Evaluation of the TCE Programme in Mpumalanga and Limpopo Evaluation Report Prepared by Feedback Research and Analytics (Pty) Ltd Evaluation Team Terence Beney Donna Podems Trish Heimann Moketi Mokone Cherie Cawood David Khanyile April 2013 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Humana People to People South Africa Evaluation of the TCE Programme in Mpumalanga and Limpopo Evaluation Report Comissioned by PactSouth Africa under Associate Award No. 027A0070 This report is made possible by the generous support of the American people through the President's Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Agency for International Development (USAID), under the terms of Associate Award No. 674-A-00-08-00001 with PACT. The contents and opinions expressed herein do not necessarily reflect the views of PEPFAR, USAID or the United States Government. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Acknowledgements We gratefully acknowledge the contributions to the evaluation of the following: All Humana People to People staff who coordinated all of the logistics for the front-end study and who assisted the Fieldwork team to locate households. PACT SA staff, who provided us with invaluable support, in particular Rita Sonko, Addis Berhanu and Daniel Bakken. The FHI and USAID teams who attended the presentation to report on the findings and who provided their inputs and insights to enable finalization of the report. The participants of the survey, interviews and focus groups who took time to provide us data that enabled us to respond to the Terms of Reference questions. Research conducted for PACT SA by Feedback Research and Analytics 4th Floor Campus Building 999 Hilda Street, Hatfield, 0082 Pretoria South Africa P O Box 14775 Hatfield 0028 Tel: +27 12 430 2009 This project was managed by Trish Heimann Tel: +27 83 779 4855 Email: trish@solverconsult.com Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Table of Contents Table of Contents .................................................................................................................................. 4 List of Tables ......................................................................................................................................... 5 1 Executive Summary .......................................................................................................................i 1.1 Purpose and Objectives of the Evaluation ................................................................................................. i 1.2 Methodology .............................................................................................................................................. i 1.3 Findings ..................................................................................................................................................... i 1.4 Conclusions .............................................................................................................................................. ii 1.5 Recommendations to Humana .................................................................................................................iii 1.6 Recommendations to USAID and FHI 360 .............................................................................................. iv 2 Introduction ...................................................................................................................................1 2.1 Purpose of the Evaluation.........................................................................................................................1 2.2 Overview of the Programme .....................................................................................................................1 2.3 Structure of the Report..............................................................................................................................3 3 Purpose and Objectives of the Evaluation .................................................................................4 3.1 Overview...................................................................................................................................................4 3.2 Evaluation Questions................................................................................................................................4 3.3 Intended Users of the Evaluation..............................................................................................................5 4 Methodology..................................................................................................................................6 4.1 Evaluation Design.....................................................................................................................................6 4.2 Data Collection Components ....................................................................................................................6 4.3 Sampling...................................................................................................................................................8 4.4 Analytical Strategies .................................................................................................................................9 4.5 Recruitment and Training of Fieldworkers ................................................................................................9 4.6 Ethical Considerations ............................................................................................................................ 10 4.7 Challenges and Limitations to the Evaluation ......................................................................................... 11 5 Understanding the TCE Programme .........................................................................................13 5.1 TCE According to Humana ..................................................................................................................... 13 5.2 Clarifying the TCE Programme Theory of Change ................................................................................. 18 6 Profiling the Treatment and Comparison Communities .........................................................20 6.1 Background on the Selected Sites.......................................................................................................... 20 6.2 Weighting for Equivalence ...................................................................................................................... 23 6.3 Final Sample Size................................................................................................................................... 25 7 Findings .......................................................................................................................................26 7.1 Programme Effectiveness from Programme Records and Previous Evaluations ................................... 26 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics 7.2 Changes in Knowledge, Attitudes and Behaviour................................................................................... 27 7.3 Additional Beneficial Outcomes of the TCE Programme......................................................................... 36 7.4 Social Change Aspects of the TCE Programme..................................................................................... 38 7.5 Social and Economic Distortions in the Wake of TCE............................................................................. 41 7.6 The Influence of the Implementation Context ......................................................................................... 42 7.7 Sustainability........................................................................................................................................... 43 7.8 Assessing the Validity of the Theory of Change ..................................................................................... 44 7.9 Reasonably Assessing Contribution ....................................................................................................... 46 8 Conclusions.................................................................................................................................49 9 Recommendations ......................................................................................................................51 9.1 Recommendations to Humana ............................................................................................................... 51 9.2 Recommendations to USAID and FHI 360 ............................................................................................. 52 9.3 Recommendations to the National Department of Health....................................................................... 52 ANNEXURE A: Community Selection Protocol................................................................................54 ANNEXURE B: Summary of completed surveys and focus groups ..............................................57 ANNEXURE C: Instruments................................................................................................................59 ANNEXURE D: Weighting of samples to ensure equivalence ........................................................92 List of Tables Table 1: Water and sanitation in sampled communities .......................................................................23 Table 2: Profile of sampled participants before weighting of data to ensure equivalent samples .......24 Table 3: Profile of comparison and treatment communities after weighting of data to ensure equivalent samples ...............................................................................................................................24 Table 4: Number of Household Composition Forms and Participant Surveys completed per site .......25 Table 5: TCE benchmarks and achievements per implementation site (provided by Humana People to People). .................................................................................................................................................27 Table 6: Key differences in knowledge between treatment and comparison groups ...........................28 Table 7: Knowledge regarding condom use .........................................................................................28 Table 8: Comparing sexual behaviour across treatment and comparison groups ...............................29 Table 9: Testing behaviour....................................................................................................................31 Table 10: Health and help seeking behaviours .....................................................................................32 Table 11: Levels of support received ....................................................................................................35 Table 12: Humana TCE's contribution to measured effects ................................................................. 47 Table 13: Evaluation scorecard against TCE objectives ......................................................................49 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Table 14: Located households and participants surveyed – Quantitative data collection ...................57 Table 15: Stakeholder focus groups held - Qualitative data collection .................................................58 Figure 1: Aims of the TCE programme ................................................................................................. 14 Figure 2: TCE Compliance Score Card elements .................................................................................14 Figure 3: TCE project activities ............................................................................................................15 Figure 4: TCE Programme Theory of Change .....................................................................................19 Figure 6: Statistical regression model of predictors of changed behaviour ..........................................36 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page i 1 Executive Summary 1.1 Purpose and Objectives of the Evaluation The purpose of this study is to determine whether the Humana TCE programme has made a significant impact on communities where it has been implemented in terms of improving knowledge about HIV and AIDS, attitudes of personal empowerment and healthy behaviour within the context of the epidemic, and changing sexual and health seeking behaviours. The evaluation also sets out to identify any additional effects, both positive and negative, and whether positive impacts are likely to be sustained over time. 1.2 Methodology The evaluation employed integrated mixed methods, with an embedded quasi-experimental cluster design as its foremost feature, comparing the effects of the TCE programme on outcomes of interest across matched treatment and comparison communities. Community level findings are an aggregate of findings from individual and household level clusters. As a contingency to mitigate the risk of matched communities being found to be non￾equivalent on key variables with confounding potential, provision was made for propensity score matching of individual respondents to the household survey. The primary data collection method was a household survey, supported by interviews and focus groups with stakeholders of interest, and observations made during site visits. 1.3 Findings 1.3.1 The Effect of TCE on Knowledge, Attitudes and Behaviour  Members of treatment communities are significantly better informed concerning true vectors of transmission, as well as the availability of clinical and other HIV and AIDS related services.  The household survey revealed no statistically significant differences in reported sexual behaviour between treatment and control groups. However raw means on condom use do favour the treatment communities.  Although no significant difference was observed in sexual behaviour between treatment and comparison groups, there was a distinct and significant difference in health seeking behaviour. Members of treatment communities are significantly more likely to have gone for VCT; two thirds of treatment group respondents claim to know their HIV status and moreover attribute this to the Humana TCE programme.  There was also significant differences in the sharing of testing information between partners, with treatment groups far more likely to demonstrate the sharing of statuses, primarily reporting that respondents themselves shared their status, but also that respondents partners’ shared their status.  In a regession model that attempted to identify predictors of behaviour, attitudes reflecting a shared burden of responsibility for sexual behaviour between genders, a regard for gender equality. Attitudes reflecting a traditional perception of women’s roles had a negative impact on behaviour. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page ii  In the regression model on behaviour exposure to the TCE intervention also emerged as a very strong predictor of changed behaviour, confirming the effectiveness of the intervention. 1.3.2 The Social Change Effects of TCE  Qualitative evidence indicates that there are additional benefits derived by the community from TCE, including most apparently the augmentation of its social capital. The intervention acts as a social resource to meet numerous needs, and performs a networking function facilitating acces to existing resources and services.  The evidence on the effect of TCE in reducing stigma and addressing gender disparities is ambivalent. 1.3.3 The Sustainability of TCE Effects  There is insufficient evidence to make a pronouncement on the sustainability of measured effects after TCE has exited a community. However, it can be stated that despite the substantial efforts made to address sustainability through the programme, the community has no confidence in their own capacity to continue the efforts in terms of TCE activities after the programme has exited.  A firm conclusion on sustainability can only be satisfactorily determined through an impact evaluation of Humana TCE. 1.3.4 Implementation Challenges  Thjs evaluation found that the registering of households is not implemented using a consistent method. The challenges in the context – different systems of mapping households across different authorities, and the informal nature of housing in some areas – renders the current household registering process ineffective. The result is that the household register cannot be used to independently verify programme fidelity and performance.  Past RDQAs conducted by FHI 360, found that while the design of the household register was problematic, it was consistently implemented in the locations monitored and that the data were verified internally at three reporting levels. FHI 360 has made several recommendations about the design and use of the register to Humana and Humana is presently piloting the Soweto Care System database in an attempt to improve their household registering process and systems. 1.4 Conclusions Humana TCE is undoubtedly effective in increasing knowledge about HIV and AIDS, improving attitudes of personal responsibility, and significantly improving health seeking behaviours amongst beneficiaries. It achieves these results through a robust theory of change, programme design that relies on innovative behaviour change and monitoring mechanisms, and a compelling message of assuming personal responsibility for your behaviour, your status, your health and that of other members in your community. However, despite this apparently comprehensive programme design and strong effects on every other measure, the key objective of changing sexual behaviour elusive. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page iii Perceptions of the effectiveness of Humana TCE are at risk of being undermined by a system that makes it difficult for independent evaluators to validate households reached. While Humana TCE is designed to ensure the sustainability of effects, the removal of the mechanisms of realising effects – including organisational infrastructure, the extrinsic motivation (financial reward) and the intrinsic motivation (the TCE identity) for taking action - poses a potential risk to sustainability. Although the underlying theory of change appears sound and has proven effective in realising the majority of intended outcomes, the complete test of its validity and sustainability depends on a comprehensive impact evaluation that adopts as a key objective the assessment of sustainability. 1.5 Recommendations to Humana 1.5.1 Programme Design  Changing sexual behaviour: The TCE experience with introducing effective behaviour change mechanisms for health seeking behaviour, combined with the emerging body of knowledge on sexual behaviour change, holds promise. Three broad recommendations can be made in this regard: o Improving TCE effectiveness with regard to sexual behaviour should incorporate the innovative thinking in terms of accountability mechanisms that already work with health seeking behaviour in TCE. o The emerging research shows that different approaches work for different groups. Improving effectiveness on changing sexual behaviour may require a focus on a particular demographic e.g. youth, and on a limited outcome e.g. delaying sexual debut. o The regression model demonstrates that a set of progressive attitudes towards the role and status of women in the community generally and sexual relationships specifically predicts more responsible behaviours. Including an engendered perspective on education interventions in TCE is therefore recommended. 1.5.2 Programme Implementation  Managing household register and beneficiary data: The entire basis for credible pronouncements on programme fidelity and performance going forward depends on reliable, independently useable, programme records. It is essential that the problems with this data be corrected. Two recommendations are made in this regard: o Households need to be registered using a method independent the conflicting methods used by local authorities, and independently verifiable. It is recommended that a GPS system be introduced and employed as the basis for the household register at all Humana sites. o All existing household register and beneficiary data needs to captured in electronic format on an electronic platform implemented across the entire Humana organisation. A great deal of routine data is collected and can be enrmously useful to monitor and evaluate performance internally, as well as inform independent external evaluations. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page iv  Improving prospects for sustainability: While the evaluation is not in a position to make conclusive pronouncements on sustainability, it may be worth acting on the identified risks to sustainability in the following ways: o Address the FOs identity insecurities by introducing emblems to replace their TCE uniforms. This may serve to enhance their confidence in assuming their role as passionates, and the confidence of the community in the fact that sustainable social capital has been built through TCE. o Planning more deliberately to ensure the availability of resources for passionates on programme exit. Designate a lcation within a field – the house of a passionate – at which condoms, information producst and support (for HCT, PMTCT and PLWHA) continue to be available. This will require engaging a source for providing these items before programme exit. 1.6 Recommendations to USAID and FHI 360  Provide funding for equipment and technical assistance to implement and train Humana staff on a GPS based household register.  Provide funding for equipment and technical assistance to implement and train Humana staff on an organisation wide electronic platform for managing beneficiary data and programme records.  Provide technical assistance to research and design components for the TCE programme that will support achieving the sec=xual behaviour change objectives of the programme.  Fund an impact assessment that will provide evidence for a clear pronouncement on the sustainability of the positive programme effects measured in this evaluation. 1.6.1 Recommendations to the National Department of Health This evaluation confirms a that a perceived lack of confidentiality is a crucial hinderance to people accessing HIV services. Two recommendations are made to departments of health in this regard:  Layout of clinics: It is worthwhile for the Department of Health to look into the layout of clinics to minimise possible discrimination of community members who go to collect condoms or who go for HCT.  Confidentiality: This was a key finding and a concern across all stakeholder groups in all treatment sites (including youth, adult females and males, traditional healers, local leaders). Interventions to ensure that clinic staff maintain confidentiality of community members – from ethics education to disciplinary action – must be instituted.  Outreach HIV services: Evidence from community members suggests that testing and counseling services delivered through a mobile clinic staffed with personel not from the local community are more likely to be utilised than the local facility. Outreach services should be a key component of all HIV services planning. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 1 2 Introduction According to the World Bank, the prevalence of HIV in South Africa for people aged 15-49 was 17.3% in 2011, the fourth highest prevalence rate in the world behind Swaziland (26.0%), Botswana (23.4%) and Lesotho (23.3%)1 . As a result, many organizations and donors have responded in support of the South African government’s efforts, providing means to address the HIV&AIDS epidemic. The responses range from biomedical to social prevention and mitigation programmes, including the administration of antiretroviral medications, prevention of mother to child transmission, voluntary male circumcision, encouraging HIV counselling and testing (HCT), and sexual responsibility programmes improving consistency of condom use, delaying sexual debut, encouraging fidelity and the reduction of multiple concurrent partnerships. Accumulating a reliable evidence based understanding of the types of interventions that bring about sustainable change, and how they affect these changes, continues to be a priority for all institutions involved in HIV and AIDS programming. Donors in particular demand evidence that the projects that they are asked to fund make a difference in people’s lives and are likely to produce sustainable results. 2.1 Purpose of the Evaluation Pact SA commissioned Feedback Research & Analytics (FeedbackRA), in partnership with Epicentre, to conduct an evaluation of the Humana People to People Total Control of the Epidemic (TCE) programme. The purpose was to determine the difference this particular programme has made in the lives of those individuals and communities targeted and the likelihood of positive changes persisting after the Humana project has ended and exited beneficiary communiities. A more detailed discussion of the evaluation purpose and objectives follows in section 3. 2.2 Overview of the Programme 2.2.1 About the Funder Through its Umbrella Grants Management (UGM) Programme funded by PEPFAR, FHI 360 has become a leader in providing institutional capacity building, technical assistance and grant administration to primarily indigenous organizations implementing HIV/AIDS programmes in South Africa. FHI 360-UGM partner organizations work at national, provincial and local levels and deliver important HIV and AIDS services throughout South Africa. Partners work to provide critical support to orphans and vulnerable children, to prevent the spread of HIV through community mobilization efforts, to support survivors of gender-based violence and to increase access to voluntary counselling and testing. These vital efforts contribute to the reduction of HIV and AIDS in South Africa and mitigate its impact in communities around the country. Humana People to People is one of FHI360’s current project partners2 . 1 World Bank Indicators, 2011, bit.ly/WlqdaM 2 UGM Brochure (no date) Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 2 2.2.2 About Humana People to People Humana people to people in South Africa (HPP-SA) is a section 21 non-profit company registered in 1995 and founded to respond to the socio-economic needs of underprivileged South Africans. Humana People to People South Africa is a member of the international Humana People to People movement operating 225 projects in 40 countries around the world. One of their flagship interventions is the Total Control of the Epidemic programme. 2.2.3 About the Total Control of the Epidemic Programme “Only the people can liberate themselves from the HIV and AIDS epidemic” Humana People to People responded to the epidemic in South Africa by creating the “Total Control of the Epidemic” (TCE) programme in 2000. The TCE programme is a grassroots one-on-one communication and mobilization programme that has run since 2002 with the aim of reaching every person in a community with information, education, and HIV counselling and testing. The aim of creating TCE was to mobilize people for action, so that they could take control of HIV&AIDS and help each other to deal with the consequences of the epidemic. This principle of communities and individuals assuming responsibility and gaining control over the epidemic is captured in the TCE slogan “only the people can liberate themselves from the HIV and AIDS epidemic” 3 . The ultimate goal of the TCE programme is to contribute to the reduction in the incidence of HIV infections. The anticipated outcomes of the TCE programme are articulated in terms of changes in knowledge, attitudes, behaviours and skills.  Changed attitudes and behaviour of community members and members of most at risk groups, manifest as: o community members consistently use HIV prevention services; o community members have undertaken HCT and know their HIV status; o community members avoid risky sexual behaviour and use condoms correctly and consistently; o community members no longer discriminate against PLWHA.  Increased knowledge around HIV transmission and HIV and AIDS prevention and treatment;  The capacity of local leaders built regarding HIV and AIDS prevention, care and support and stigma reduction; and local leaders develope facilitation and counselling skills. A more thorough discussion of the TCE programme and its underlying theory of change follows in section 5. 3 HSRC Report on Impact Evaluation of the TCE Programme in South Africa, 2010 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 3 2.3 Structure of the Report The report begins with a description of the purpose and objectives of the evaluation, followed by an overview of the methodology as a response to the evaluation objectives and programme implementation context. A thorough description of the programme theory of change and implementation mechanisms follows in order to situate the implication of findings for programme design and implementation. A section on the implementation context is included in order to further support the interpretation of findings and the logic of the recommendations flowing from those findings. In addition a description of the programme cntext serves to qualify the methodological choices made in order to execute the evaluation. The findings chapter follows, presenting evidence for responses to the evaluation questions, arranged by evaluation questions to the extent that findings allow for such a presentation logic. The report concludes with a brief summary of key findings and a set of recommendations focussed on programme implementation and design. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 4 3 Purpose and Objectives of the Evaluation 3.1 Overview The purpose of this evaluation is to determine whether the TCE programme has made a significant impact on communities where it has been implemented in terms of its intended programmatic outcomes, as well as more broadly. Specifically, the evaluation sets out to assess:  The extent to which the TCE programme led to changes in knowledge, attitudes and behaviour with regards to the HIV and AIDS epidemic, as well as the extent to which Humana TCE is responsible for measured effects in a multi-intervention environment;  Whether the capacity of local leaders has been built to facilitate HIV and AIDS prevention in their communities;  What additional impacts, both positive and detrimental, that may be attributed to the Humana TCE programme; The evaluation is not focused exclusively on outcomes and impacts however, but attempts to obtain an evidence based understanding of how outcomes and impacts were affected in context. Such an informed understanding would provide a robust basis for programme adjustment, future programme design, and inform the prognosis for the sustainability of observed programme effects, particularly those that are positive. The evaluation purpose and objectives are operationalised in the evaluation questions presented in Section 3.2. 3.2 Evaluation Questions The evaluation prioritises two questions posited to obtain evidence of observed effects: 1. How effective was the programme in bringing about attitude, knowledge and behaviour change for reducing risk to HIV infections among targeted populations? 2. Did the programme result in a significant impact in the uptake of HIV services by the targeted populations? Included are evaluation questions to identify additional effects of interest: 3. Did the TCE programme contribute to any additional beneficial outcomes and social change? 4. Did the TCE programme contribute to any unintended consequences detrimental to individuals, groups within communities, or communities? 5. Are there any discernible effects on health outcomes in the TCE implementation communities? The evaluation also sets out to explain the mechanisms leading to the effects observed by responding to the following questions: 6. Was the Theory of Change informing the TCE programme adequate for realising programme outcomes in the programme context? Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 5 7. What was the level of programme fidelity in implementation? Were deviations from planning responsive to context or a result of inadequate implementation? 8. What contextual factors enabled or constrained programme implementation and the achievement of intended outcomes? Finally, the evaluation attempts to delineate the contribution of Humana TCE to the observed effects by situating it in a multi-programme environment: 9. What is the programming landscape with regards to HIV & AIDS in each of the treatment and comparison communities? 10. What was the TCE contribution to the cumulative effect of all programming in the beneficiary communities? 3.3 Intended Users of the Evaluation By virtue of having commissioned,this evaluation, USAID and FHI 360 are considered the primary users of this evaluation. In addition to providing a means for accountability, the utility of the evaluation for funder (FHI 360) and donor (USAID) is the contribution it makes to their understanding of what works in prevention, and as such it is likely to support future funding decisions regarding similar programming. It also tests the efficacy of an evaluation approach to large-scale prevention programmes, and in so doing can inform future evaluation decisions. This evaluation is intended to demonstrate the extent to which the TCE is effective in achieving its objectives, and explicating the mechanisms by which it exerts impact. The evaluation is therefore intended to inform programme adjustment and design decisions for Humana TCE specifically. Humana People to People is also considered a primary user of this evaluation Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 6 4 Methodology 4.1 Evaluation Design The evaluation employed integrated mixed methods, with an embedded quasi-experimental cluster design as its foremost feature. It was designed to obtain comparative measures of effects of the TCE programme on outcomes of interest - changes in knowledge, attitudes and behaviour – across matched treatment and comparison communities. Community level findings are an aggregate of findings from individual and household level clusters, which were randomly seected. Communities exposed to the TCE programme (treatment communities) were selected and compared to communities with similar characteristics that were not exposed to the TCE programme (comparison communities). Three treatment communities were selected and matched to three comparison communities, with four sites located in Mpumalanga and two sites in Limpopo. Matching was based on a review of community characteristics, guided by a community selection protocol that controlled for known vectors of the HIV and AIDS epidemic, and other variables that influence incidence and prevalence, as described in the literature. In the instance of this evaluation the community selection protocol was impemented as a guide rather than a systematic selection tool. The community selection protocol is presented in Annexure A. As a contingency to mitigate the risk of matched communities being found to be non￾equivalent on key variables with confounding potential, provision was made for propensity score matching of individual respondents to the household survey. Treatment and comparison groups could then be devised statistically based on a scale of exposure to Humana TCE. 4.2 Data Collection Components The evaluation consisted of three data collection components, namely a front-end analysis involving site visits and interviews; a household survey; and a support study to the household survey consisting of interviews and focus group discussions with a purposive selection of key informants. 4.2.1 The Front-End Analysis A front-end analysis was conducted that involved visits to the selected sites, engagement with community leaders, and initial focus groups and interviews with key informants, including Humana TCE staff and field officers implementing the programme in treatment sites. In addition to obtaining the necessary access for fieldwork in through consultation with relevant authorities, the purpose of the front-end analysis was twofold: to support site selection for the household survey; and to generate primary data for understanding the implementation context and documenting the Theory of Change. Treatment sites were identified in collaboration with Humana, and matched to comparison communities that were selected on the basis of community typologies, initially prepared from secondary data sources (primarily StatsSA Community Survey and Census data) and informed by Humana’s knowledge of its operational areas. These typologies, and the appropriatness of matched comparison communities, were verified on the front-end analysis site visits. The verification process resulted in a replacement of one comparisoin community initially matched to a treatment site. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 7 Interviews conducted with programme staff generated primary data to inform the documenting of the TCE theory of change, the initial versions of which were based on programme documentation and an earlier evaluation of TCE conducted by the HSRC in 2010. The interviews with programme staff were supplemented by interviews with key informants to generate a primary data set on the nature of the implementation contexts of TCE. The description of contexts arrived at during the evaluation and informing the interpretation of findings were based on these and later interviews and focus group discussion, as well as data from secondary sources (primarily StatsSA Community Survey and Census data). Finally, the front-end analysis guided the development of the household survey instruments. 4.2.2 The Household Survey A household survey was conducted as the primary data gathering effort of the evaluation. Individual respondents within households were randomly selected on site, while participating households were randomly selected from programme household registers. The survey collected data on knowledge, attitudes and behaviour of household members with regards to the HIV and AIDS epidemic, as well as control data on household characterisitics and the programming environment in the community. Two instruments were employed during the household survey:  A household survey was administered to the head of the household in at least 50 households in each community. The instrument was used to gather data to determine equivalence of matched communities and control for confounding variables. In addition household level data provided an overview of services available to and accessed by the community. Variables included number and gender of household members, the dominant language(s), educational attainment, employment status, morbidity and mortality; as well as services accessed such as HIV Counselling and Testing (HCT), tuberculosis (TB) services, prevention of mother to child transmission (PMTCT) services, other medical services, social protection, material support (clothing, food, donations), psychosocial and educational support.  A participant survey was administered to at least one individual residing in a sampled household (18 to 65 years of age), in addition to the head of household. The criteria for inclusion was exposure to the TCE programme for those in the treatment sites and non-exposure to the TCE programme for those in the comparison sites. The participant survey focussed on obtaining knowledge, attitude and behaviour data, with less emphasis on household level and control data. 4.2.3 The Support Study Interviews and focus groups were held with various stakeholders and key informants at treatment sites. Focus groups included adult female and male focus groups held with community members recruited from the household survey; traditional leaders/Indunas; traditional healers; school teachers; clinic staff; and youth in schools. This data collection round allowed for the exploration of questions regarding programme fidelity, mechanisms of change, contextual variables enabling or constraining programme efficacy, unintended consequences of the programme, programme contributions to social change, and the sustainability of programme effects. In addition this component allowed for triangulation of findings across multiple data sets, confirming or contesting findings established through the household survey. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 8 4.3 Sampling 4.3.1 Considerations in the Selecting Matched Sites There were two important considerations guiding the selection of communities. The first was that the treatment and comparison communities participating in the study present similar characteristics with respect to a set of key identified criteria. These criteria covered basic geographic and demographic variables such as size, rural versus urban, as well as socio￾economic conditions such as access to basic services (water and sanitation, electricity, health facilities and education). Similarities between treatment and comparison communities with respect to HIV/AIDS prevalence, was also relevant. Desktop research and interviews with community leaders in selected areas, provided an initial indication of similarities between communities to motivate matching of treatment and comparison communities. Questions pertaining to socio-economic conditions were also included in the household survey and quantitative analysis further determined the extent to which matched communities are similar. A profile of communities is presented in the Findings Chapter. The second important consideration was that the communities being compared must differ with respect to the implementation of the TCE programme – a treatment community that had been subjected to the TCE programme was matched to a comparison community that had not been exposed. The communities evaluated (treatment sites) were communities in which the intervention had been completed from 2009 to 2011. 4.3.2 The Sampling Process To sample households in the three treatment sites, Feedback randomly sampled 46% of the fields (the geographic unit that Humana designates as an area of operation), or 24 fields out of a total of 52 fields at each site. The initial sampling strategy for treatment sites included the selection of random households by physically counting each household (captured in hard copy registers) for each field and randomly sampling four households within each field using a randomisation formula in MSExcel. Household information was then manually captured for each randomly sampled household and included a household number, name of the head of the household, the members of the household and recorded the number of visits that this household had received from the TCE workers. These forms were given to the field teams to assist with the household identification and participant verification to ensure that the right participants were enrolled into the survey. The methodology was changed when it became evident that the TCE registers could not lead the survey team to the selected households. The field teams continued to recruit participants from the selected villages within each site but upon reaching the selected village they identified the boundaries and then randomly selected multiple rows of houses from which they visited the first three to four eligible households in a row of households. This process was followed in such a way so that households across the whole village were represented in the study. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 9 To sample the comparison sites, Districts provided a list of Wards . In Polokwane, Limpopo, two villages were randomly selected from a total of five wards. In Mpumalanga, the comparison sites (Matsula A and Matsulu B) each included one Ward and all villages were included in each comparison site. The households for the comparison sites were randomly sampled from the municipal household lists and corresponding maps provided by each District. The samples were selected by identifying the total number of households according to the Municipal maps and households provided for each site and using excel to identify every nth household to include as part of the sample. The target was to reach 50 households and 100 participants in each selected site with the assumption that there will be on average two eligible members in each household. . Feedback RA oversampled the households for three reasons: (1) to enable households to be replaced should members not be available, (2) should there be refusal of the household to participate or (3) should TCE participants no longer be living in the selected household. 4.4 Analytical Strategies The quantitative data obtained from the household survey effort was subjected to a number of analytical strategies: 1. Treatment communities were treated as a single treatment community, and compared to a single comparison community constituted by combining all comparison communities. This improved the external validity of measured effects by increasing sample size. Comparison of results across matched pairs was reserved for addressing the possibility of measuring no effects across the combined treatment and comparison groups, should this occur. 2. The primary analytical strategy involved a statistical comparison of means across survey items representing variables of interest, in order to identify any significant differences between treatment and comparison communities. 3. In addition a regression model was developed from the accumulated quantitative data in order to provide an indication of the best predictors of behaviour change. 4. Propensity score matching based on a scale of exposure to Humana TCE was conducted to inform the regression model. 5. Clear differences in the equivalence between treatment and comparison communities (gender and age were particularly notable in this regard) were controlled for through a statistical weighting technique before any analysis was conducted. Qualitative data was subjected to thematic analysis and used as a secondary data source for either corroborating or contesting the quantitative findings. Because the evaluation was designed to ensure the validity and reliability of quantitative data the latter take priority in guiding interpretation and positing of findings. 4.5 Recruitment and Training of Fieldworkers To recruit field workers, local organizations in each site were contacted to obtain a list of suitable candidates. In all sites, local leaders from the Municipality also provided names of candidates whom they wished to include as part of the fieldwork team. The criteria for recruitment of fieldworkers included: (1) their ability to speak the local language(s), (2) have at least a matric and (3) experience in interviewing or counselling. The fourth criteria required that community members have no prior involvement in the TCE programme. This criteria was to ensure that no bias influenced the data collection process. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 10 Lists of candidates were obtained and reviewed. Candidates with suitable qualifications and experience were identified and short-listed. Identified candidates were scheduled for assessment tests and candidates who passed the tests were scheduled for interviews. All field workers were suitable to work in the areas in which they were placed. The field workers spoke the local language, had knowledge of the area and were trained and competent in data collection. 4.6 Ethical Considerations Feedback RA submitted an application to the HSRC Research Ethics Committee for ethics review and obtained permission for the research. The process took two months to conclude. A request was made to the relevant provincial Departments of Health Research and Ethics Committee and the research was approved with no issues of ethical consideration identified. This took three weeks to finalise. District Municipalities provided letters of support to access all treatment sites and we encountered no challenges accessing the treatment sites. . Access into comparison sites was a challenge. This process to obtain approval to comparison sites (which was eventually received) took approximately three months and required continuous engagement with the comparison sites’ District Municipalities. After we obtained letters of support District Municipalities were supportive of the research. he Feedback RA and Epicentre Fieldwork team used an inclusive approach to identify and select field workers. Ward Counsellors were provided the opportunity to select community members with appropriate qualifications to be screened and interviewed In terms of ethical considerations relating to participants, the evaluation process included: Voluntary participation: participants were informed that their participation in this study was strictly voluntary and that they were free to withdraw from the study at any time. Psychological risks: there was no psychological risk to participants in participating in the study. Participants were able to refuse to answer any questions. The fieldwork team provided a contact list of local services for each site in the event that participants may have required additional care and support as a result of being surveyed or interviewed. Benefits to participants: there were no direct benefits for participants participating in the study. Confidentiality was maintained and researchers ensured privacy during data collection sessions. Informed consent: following careful explanation of the survey, the fieldwork team gave eligible participants the consent form to read or, if necessary, the consent form was read to the participant by research staff. The research team fully addressed any questions raised by eligible participants. All participants had to sign a consent form to indicate that they understood and agreed to all of the items contained in the consent. Protection of privacy of individuals: a private space was used to administer the surveys and conduct the focus groups. The interviews were conducted face to face with no other persons in the space/room other than the fieldworker and the participant(s). Only the fieldworker and focus groups participants were present for the focus group. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 11 4.7 Challenges and Limitations to the Evaluation The following challenges imposed limitations on the intended timeliness of the evaluation process, as well as the reliability and the utility of results. In most instances the limitatoins were addressed to preserve the integrity of the evaluation, and these mitigation strategies are described here. Where no mitigation was introduced it is explicitly stated. Under both eventualities the reader needs to consider whether and to what extent the ultimate reliability and utility of findings is affected. 4.7.1 Challenges with Implementing the Evaluation Design  Equivalence of treatment and comparison communities: The complexities of context renders a matching evaluation design strategy problematic. Despite efforts to control for non-equivalence through a very systematic and theoretically grounded community selection process, it was necessary to resort to statistical weighting for a more credible comparative analysis of treatment versus control conditions. In addition propensity score matching was used to create statistical treatment and comparison groups for the regression modelling exercise. 4.7.2 Challenges with Sampling  Sampling limitations: Humana maintained a list of all households and community members reached by means of Household Registers that were only available in hard copy. Because these registers were kept in the Pietermaritzburg office and there were in excess of 150 registers per site, it was not feasible to include the full list of households in the random sampling process.  Locating sampled households: It became evident early in the data collection that it was impossible to find the selected households using the Humana household registers. o There were no maps of the area with Household numbers indicated to enable the sampled households to be located, especially in the more rural areas like Driekoppies in Mpumalanga and Moletjie in Limpopo. There are also no GPS coordinates provided. In addition, maps at the Municipality level had changed and were different to those held by Eskom. o Because the system of registering households appears to be inconsistently implemented and highly dependent on Field Officers in their particular fields, it was extremely difficult for the evaluators to locate many cases without field support from Humana. o Household numbers were not displayed outside the dwelling in most villages. o Many households did not know their household number and referred to Eskom numbers instead of municipal numbers when referring to their house number. Community members did not know each other’s household numbers either, which made locating of households extremely difficult. o Household numbers were not assigned in any structured way in the community. Household numbers were allocated based on when the structure was built rather than in a consecutive manner based on location. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 12 o Some households were found to have more than one number:- a plot number and a house number. This was not consistent in villages and as a result, some community members knew their plot number while others knew the house number (depending on the leadership status in the area - Kgosi or municipality). 4.7.3 Challenges with the Data Collection Process  Fieldworkers for the household survey: It would have been ideal to have one team trained to complete data collection at all sites in each province. This would have simplified recruitment, training and data collection. However, for this study there was a strong need from the community stakeholders to have their own local people involved in the survey (to benefit their community members). This complicated recruitment and training as it required more field workers to be selected, recruited and trained then initially planned. Furthermore, due to the distances between sites and language requirements, it was not possible to have one team trained to complete data collection at all sites. 4.7.4 Challenges to the Comprehensiveness of the Evaluation  Scope of the evaluation: Some key variables of interest were ommitted from investigation, most notably adherence to treatment and voluntary male circumcision in terms of health seeking behaviour, and the extent to which counseling and testing was undertaken as partners. While VMC was not explicitly included in TCE programming originally and did not feature as a consideration during data collection design, adherence to treatment has been a focus of TCE for some time and the trio strategy is anecdotally successful. The ommission was an oversight in the evaluation design. Consequently some important conclusions on health seeking behaviour could not be posited.  Analytical limitations: Unfortunately the study could not control for the HIV status of respondents, which would offer additional key insights into the potential motivators for health seeking behaviour. The limitation is due to inconsistent or non-responses on the HIV status item. In adition some disaggregations were not executed, notably by age groups, which is becoming increasingly important. The data set is being adjusted to address the latter and the functionality introduced to run such analyses, however those results will not be available for this report. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 13 5 Understanding the TCE Programme This section provides an overview of the TCE programme based on a desktop review of programme documents, as well as interviews and focus groups held with TCE staff and field officers. Section 5.1 presents the TCE programme according to Humana, describing the programme purpose; its implementation through organisational structure, activities and monitoring mechanisms; and the provisions made in the programme design for the sustainability of its outcomes. Section 5.2 clarifies the programme theory of change and the associated logic model based on a distillation and analysis of programme documents, and the views and perspectives of Humana staff, field officers and passionates in each of the treatment communities. 5.1 TCE According to Humana This section describes the TCE programme model interms of its objectives, the activities implemented to achieve those objectives, how the organisation and its human resources are structured to execute activities effectively, and how programme fidelity is monitored. In addition TCE is designed to proactively address the risks to sustainability of the results achieved in communities, and those elements are described here. 5.1.1 The Purpose of Humana TCE “To get every person in every field and area in control of the HIV/AIDS epidemic.” The overall goal of the Humana TCE programme is to mobilise and empower communities to take control of the HIV and AIDS epidemic in the lives of each community member. This overarching goal is achieved through the realisation of five supporting objectives that focus on changing sexual and health seeking behaviours, facilitating access to health services, and engaging with every member of a beneficiary community (see When an individual can answer yes to points 1-4 (60 points), it can be said that the individual is in control of HIV/AIDS in his or her own life. The TCE Compliance Score Card is used to estimate an individual’s compliance with the TCE programme. A minimum of 85 points is required in order to be considered TCE Compliant. Figure 1: Aims of the TCE programme). Empowerment from a TCE standpoint however is operationalised as a programme result realised on an individual level: “when individuals can answer yes to the first four aspects of TCE Compliance Score card, they are in control of HIV and AIDS in their lives”. To be declared TCE Compliant means that the individual meets the demands of taking control of HIV/AIDS in his or her life. In the process of becoming TCE compliant, the individual needs to make a decision about HIV prevention in his or her own life and take action to adapt to an HIV risk free lifestyle. For an HIV negative person this means behaving in such a way as to remain HIV free, while for and HIV positive person the emphasis is on remaining healthy and not transmitting the virus to others. The different criteria to be scored on the card are listed in Figure 2: TCE Compliance Score Card elements. When an individual can answer yes to points 1-4 (60 points), it can be said that the individual is in control of HIV/AIDS in his or her own life. The TCE Compliance Score Card is used to estimate an individual’s compliance with the TCE programme. A minimum of 85 points is required in order to be considered TCE Compliant. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 14 Figure 1: Aims of the TCE programme Figure 2: TCE Compliance Score Card elements Overall Aim Every single person in an area of operation with information, education, mobilization and basic counseling Aims of the TCE project Mobilize communities to prevent HIV and increase access to care, treatment and support programs Increase HIV knowledge and promote abstinence, being faithful to one partner and condom use (ABCs) Increase HIV testing, prevention of mother to child transmission, antiretroviral and IPT programs, and condom use Meet everybody in the community individually Strengthen referral networks 1. Know all about it An individual has knowledge of the HIV virus and AIDS 10 Points 2. Know how to avoid being infected An individual has knowledge of sexual life, STD's, and strategy for abstinence and/or condom use 10 Points 3. Getting tested An individual knows their status and acts accordingly. if the individual has not been tested, he/she behaves as if s/he is HIV positive 10 Points 4. Making sure not to spread the virus Individual does not engage in sexual intercourse or does so only when using a condom 30 Points 5. 25 Points HIV negative individuals Have decided to stay negative HIV positive individuals Take proper care of themselves and their health Unknown HIV status Act as if HIV positive in all aspects 6. Being part of the TCE movement An individual participates actively in the TCE Movement 15 Points Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 15 5.1.2 Programme Activities The TCE programme pursues its purpose through various activities that contribute to the total control of the HIV/AIDS epidemic and reduction in the rate of new infections amongst the targeted communities. These activities are represented in Figure 3: TCE project activities, and detailed in the discussion following. Figure 3: TCE project activities Door-to-door campaigns: These campaigns allow for the registration of every household in the TCE area, identifies every member of that household and informs them about TCE, HIV/AIDS, healthcare services, access to information and referral services. The field officer follows up with these households throughout the three-year period to ensure full understanding of the epidemic, HCT, referrals and mobilization. These campaigns aim to ensure that everyone in the household is TCE compliant and that ‘at risk groups’ are identified and follow-ups are made. The unique person-to-person approach of the programme ensures that people are reached at a level that enables them to listen and ask questions in order to thoroughly understand. During each visit, the field officer ensures that the TCE scorecard is worked through with the aim of each household member to become TCE compliant. Condom distribution and outlets: The TCE programme maintains that ‘condoms are the single, most efficient, available technology to reduce sexual transmission of HIV’. Therefore, TCE informs about the correct use of condoms though practical demonstrations and provides the community with access to condoms. There are condom outlets established throughout communities in local shops, clubs, clinics and centres where community members can have easy access to them. The condoms are provided in large quantities. Project activities Door-to-door mobilization and person-to-person education, counseling and referals to district HIV and AIDS programs, using individualized risk￾reduction plans. Monitoring adherence to treatment, Workshops in schools, churches, clinics, and work Peer educators distribute pamphlets, condoms, act as role models Develop volunteer base for sustainability Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 16 The HIV Counselling and Testing (HCT) Programme: This programme has the objective of ensuring that everyone in the TCE area gets counselling and testing. TCE staff train their Field Officers in counselling and invite qualified nurses from the Department of Health to assess whether they qualify as lay-counsellors. The Field Officers in turn train the Passionates to mobilise the community for testing. TCE staff organize mobile testing facilities with the Department of Health or other NGOs in the community so that there is easy access to testing during community workshops, talk shows or sports tournaments. Referrals and Follow up: TCE does referrals to the nearest clinics and hospitals for PMTCT, TB prevention, social services, HCT, CD4 count and STIs treatment. TCE also focuses on the systematic tracking of patients on treatment to ensure they receive the necessary care and support. Field Officers also identify and track defaulters together with the local health authorities. Community Outreach and awareness campaigns: Comprehensive community outreach campaigns have as their primary objective to educate and equip everyone in the community about HIV and AIDS, getting tested, living with the virus and how to access condoms and healthcare facilities. The main objective is to ensure that everyone in the community is TCE compliant, which refers to limiting the spread of HIV and AIDS. The campaigns also reach out to pregnant mothers to introduce them to PMTCT Programmes in local clinics. Youth are reached through life skills lessons at schools which aim to address issues such as peer pressure, attitudes and making the right choices. Local leaders introduce TCE to the school principals and propose to have the TCE school programme in specific schools, conducting lessons for 29 weeks on different topics. Themes covered include teenage pregnancy, HIV and AIDS and related issues. 5.1.3 Organisational Structure Programme activities are executed through a leadership and structure that mimics a military organisational arrangement. One TCE area is a geographical area of 100,000 people, which is divided into small geographic units called fields. In such an area, 50 Field Officers are recruited, trained and deployed, each to a field with 2000 people. Over a period of three years, the task of the Field Officer is to go from house to house and reach every single person on a one-to-one basis. In each field the TCE Field Officer along with local volunteers will campaign and mobilise the population to fight the epidemic in a variety of ways until the epidemic is under control. While each Field Officer is assigned 2000 people to reach, there is a mechanism at the household level whereby each client is supported by two other people (one being a family member (passionate) and the other being the Field Officer). TCE has structures for meetings where Field Officers in groups of ten (called a Patrol) and groups of fifty (called a Troop) meet bi-weekly to report and evaluate their work and performance. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 17 A Patrol Leader has leadership of nine other Field Officers in sharing experiences. A Troop Commander has the daily leadership of 50 Field Officers, including reporting, planning, and accounting. The Division Commander leads 250 Field Officers. The task for the leadership is to ensure that Field Officers are informed, educated, equipped, willing and mobilized to do their door-to-door campaigns. 5.1.4 Programme Monitoring Programme progress and programme fidelity are both subject to systematic monitoring. Programme Progress: Humana implements TCE in a selected community over a three year concerted action effort. The Perpendicular Estimate System (PES) has been created as a basic tool for the TCE Field Officer to estimate the status of the TCE Programme in achieving its goal - Total Control of the Epidemic - for every single person in the Field and for the Field as a whole. The accumulated results of the PES system provides an indication of the TCE Compliance status of the entire community. Programme Fidelity: The household register is a the master record of reach into a community and is used as the basis for monitoring the extent to which field officers are implementing TCE according to plan. It falls to a contingent of Humana TCE staff known as Special Forces to implement programme fidelity monitoring, based on household register data, and following a multi-pronged process as described below.  Special Forces provide three to five support visits per week where they visit households with Field Officers. The purpose is to monitor the effectiveness in the way the Field Officers implement household visits.  Special Forces conduct three to five surprise visits per week. These are scheduled as part of the weekly plan. Surprise visits work in such a way that the Special Forces person checks the WAR room to determine where a Field Officer plans to work, s/he then goes to the area and asks community members in the area whether they have seen the TCE person and would track the Field Officer to monitor whether s/he is where they claimed they would be.  Special Forces conduct internal impact assessments where they randomly select three to five households per week and visit these to check whether the Field Officer spoke to the people and to determine what was learnt.  Validating of household visits occurs quarterly where Field Officers count each other’s registers. The activity is supervised by a Troop Commander or Special Forces person.  Counting and questioning is done weekly where the Patrol Leader will share with the full team how many households were reached in total and highlight key achievements in performance such as identifying a Field Officer who exceeded his/her targets to mobilize others for testing. Random questions and checking of household registers is also done at this meeting. It should also be noted that based on RDQA recommendations from FHI 360, Humana is piloting a Sweto Care System database in which on a weekly basis data capturers enter the household registry data and they database entries are then checked by other Humana staff with the original registry entries. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 18 5.1.5 Ensuring Sustainability The TCE programme is designed as a temporary action implemented in a target community as a concerted effort over a 3 year campaign period. Humana is intensely conscious of the risks to sustainability of the effects it achieves in that time once it exits a community. Consequently the programme design incorporates features that attempt to directly address and mitigate the risks to sustainability. These features focus on whole community mobilisation, but also consider strategies for transitioning of field officers. Whole community mobilisation: In addition to reaching every member of a community and attaining community level TCE compliance, the programme attempts to recruit various community member groupings into specific activities to address the effects of HIV and AIDS. The TRIO system links community members who go on to ARV treatment with two passionates - community members who have taken the sixth step of the TCE Compliance Score card - to support individual on treatment with adherence. A passionate could be a friend, family member, or neighbour, who will monitor the individual’s intake of ARV on a daily basis. In addition to supporting adherence, passionates are mobilised to support home based care activities, to start income generating activities to support the sick and their families, and generally to advocate amongst community members for the achievment of TCE goals. In addition local leadership is seen as the cornerstone of programme effectiveness and sustainability, and are included in implementaion from programme initiation. Leadership endorses TCE and facilities implementation. Local leaders continue to work with TCE throughout the three year period. The local leaders are recruited to work as WAR (Ward Activity Room) leaders. A WAR is a clinic, school, chiefs house or church, where Field Officers keep their attendance registers and sign in and out of work daily from these WAR rooms. Field officer transition: Field officers are recriuted from the local community, receive training, are mentored and gain work experience throughout a 3 year action. Humana maintans that the training and work experience improve the prospects of field officers, and there is anecdotal evidence of employability post TCE implementation. In addition Humana has had success in some target communities in facilitating the transition of field officers into the employ of the Provincial Departments of Health or local government as community workers. 5.2 Clarifying the TCE Programme Theory of Change The following section presents a distillation of the theory of change based on a programme document review and substantially influenced by the interviews with TCE personnel and Field Officers who implemented TCE from 2009 to 2011 in the three treatment sites4 . The extent to which Humana TCE is successful in achieving programme objectives is a test of the validity of the theory of change in context. This evaluation explicates the theory of change in order to offer a preliminary assessment of the theory of change informing programme design, and to make any recommendations for adjusting programme design if necessary. 4 A focus group was arranged with Field Officers in the TCE offices in Mpumalanga and in Limpopo Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 19 5.2.1 Principles Underlying the Humana TCE Theory of Change It is apparent that there are three key assumptions informing the design of Humana TCE. The most prevalent is the emphasis on personal accountability for change. The Compliance Scorecard is emblematic of this emphasis, as is the primary programme delivery mechanism – multiple personal engagements between the fieldworker and a programme beneficiary, during which the basis for engagement is the accounting for agreed acts representing progress on a journey of change. The second assumption is that thorough and sustained change requires a changed community environment. Numerous Humana objectives and activities are driven by this assumption, including the emphasis on winning over community leaders and reaching every community member. Programme staff at every level are keenly aware of the potential of stigma and discrimination to derail the achievement of total control over the epidemic, and the conversion of an entire community to the cause is informed by this awareness. The most obvious manifestation of this underlying assumption is the overarching programme strategy, which is an overwhelming and sustained campaign at a community level, systematically planned and executed, over a prescribed period of time. The third principle is the perspective that resources for addressing the epidemic are available to communities but are under-utilised. The emphasis on facilitating access to treatment and referrals to other service providers are key elements of the TCE strategy and illustrative of this principle. The theory of change implied by these principles and manifest in the programme design is summarised in Figure 4. Figure 4: TCE Programme Theory of Change If you have •A concerted campaign reaching every member of a community face-to-face within a short period of time •With knowledge about HIV/AIDS •A mechanism for promoting and tracking behaviour change and accountability •And that facilitates access o services Then •Each individual could gain control of the epidemic in their lives •By knowing their status •Committing to actions that will keep them healthy •And committing to actions that will keep the virus from being transmitted And Then •There will be an increased and conistent uptake of HIV services in the community •There will be a shift towards more sexually responsible behaviour •Communities will gain total control over the epidemic •And prevalence will ultimately be reduced Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 20 6 Profiling the Treatment and Comparison Communities A reasonable degree of equivalence is necessary to ensure that the quasi-experimental design maintains its integrity. Any potential systematic differences between communities that might confound comparability of results must be eliminated to the extent possible. The front end study confirmed that the selected treatment site (Tzaneen) and matched comparison site (Moletje in Polokwane) in Limpopo were suitable. It further confirmed that treatment site one (Tonga) and matched comparison site one (Matsulu A) in Mpumalanga were well matched. However, treatment site two (Driekoppies) was matched with Umjindi as comparison site two and, as a result of the front end study interviews, was deemed unsuitable as a match because the community in Umjindi had already been exposed to the TCE programme. Consequently Matsulu B was identified as a more suitable comparison site two and included in the evaluation. This section provides a brief description of the socio-economic dynamics of each of the sites within their respective municipalities and provinces, discusses further challenges with matching and the mitigation strategies adopted to improve the integrity of the sample. 6.1 Background on the Selected Sites 6.1.1 The Mpumalanga Matched Communities The two treatment sites (Tonga and Driekoppies) and their matched comparison sites (Matsulu A and B) are located within Mpumalanga Province in one of the three provincial Districts, namely, Ehlanzeni. The unemployment rate in Mpumalanga is officially 16%, while 44% of households in the province are living in poverty. HIV prevalence is 21%. Driekoppies (treatment community one) is a very small coomunity in Mpumalanga, commonly identified with the proximate Driekoppies Dam. Driekoppies is classified as rural, and is serviced with electricity, a clinic and schools. The hospital and police station are about 10km away and offices for social workers and social grants are about 13km from the community. There are reportedly high levels of sexual abuse and rape in the community5 . Tonga (treatment community two) is classified as a semi-rural area. There is a police station, magistrates court, home affairs offices, SASA offices, offices for child-abuse and a centre to address all abuse issues. The municipality’s population trends young, with a substantial proportion of school-going age. However, beyond the age of twenty years, many leave to further their education and to search for better work opportunities. The unemployment rate in Tonga is 25%. In 2001, 24% of households had no formal income, while 60% earned an annual household income of less than R20 0006 . 5 Source: IDP 2012-2013 6 Source: IDP 2012-2013 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 21 Matsulu B and Matsulu A (comparison sites two and one respectively) are wards located within Mbombela Local Municipality, one of the municipalities located in Ehlanzeni District Municipality. The municipality had an estimate of 137,353 households in 2007. The number of unemployed residents is estimated to be 52,290 and 41% of the community earn an income of less than R1600 per month. Only 11.5% of the community earn more than R3500 per month. HIV/Aids is the predominant challenge of the area and according to the Department of Health survey (2009), Mbombela had an HIV/AIDS prevalence of 43%7 . The following graphically depicts the selected sites within Mpumalanga. The front-end study identified the following similarities between the matched sites of Tonga and Matsulu A as well as Driekoppies and Matsulu B8 :  Tonga and Matsulu A are not strictly urban, but reflect the suburban characteristics typical of medium sized townships. Driekoppies and Matsulu B are both more rural than Tonga and Matsulu A  SiSwati is the main language spoken in all four areas.  Conditions and access to roads and Infrastructure are similar for matched communities. In Tonga and Matsulu A, roads are in relatively good condition, although some are not tarred. In Driekoppies and Matsulu B roads are generally in a poor condition. 7 Source: IDP 2012-2017 8 Findings are presented from interviews with municipalities and local stakeholders familiar with the sites, as well as from desktop review Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 22  The larger of households have pit toilets. In Tonga and Matsulu A the pit toilets are in a reasonably good condition and households are steadily moving away from pit toilets to septic tanks. Pit toilets in Driekoppies and Matsulu B are generally in poor condition.  Water supply is a major challenge for both matched pairs.  There is a demand for housing and both areas are experiencing a housing backlog.  HIV prevalence is relatively high with Tonga at 47.3% and Matsulu A at 42.4%.  Driekoppies and Matsulu B both experience more than 35 % unemployment rate. 6.1.2 The Limpopo Matched Communities In Limpopo Province, the third treatment site (Tzaneen) is in one of the five District Municipalities (Mopani) and it’s matched comparison site (Moletjie) is in another District Municipality (Capricorn). Limpopo consists of 25 local municipalities. The Population of the province is estimated at 5.2m of which 54.6% is women, 45.4% is men and youth at 39.4%. The unemployment rate is estimated at 26,8%, the HIV infection is at 21.5%9 . The Greater Tzaneen Municipality had a total population of 375,588 in 200110. According to the Statistics South Africa 2007 Community Survey, the unemployment figure within Greater Tzaneen Municipality was 20%. Twenty nine percent (29%) of the total population in the municipality does not have any source of income. Seventy percent (70%) of the income earned by households is below the minimum living levels (R 9,600 per annum). There is a high level of HIV prevalence (figures could not be identified for the Municipality)11 . The Polokwane Municipality, located within the Capricorn District is 23% urbanised and 71% still rural. The Moletjie Cluster is one of the four clusters within the Municipality. The Polokwane municipal area is home to approximately 561 772 people12 . The general education levels are low and poverty is a major problem in the area. Polokwane is an area with limited water resources and electrification is a challenge in some areas. The front-end study identified the following similarities between Tzaneen (the treatment site) and Moletjie (the comparison site):  Both are rural;  There are areas that are semi-urban and both sites have a mixture of deep rural and peri-urban;  Road conditions for both sites have tarred areas in peri-urban areas with poor road conditions in deep rural areas; and  Most households have pit toilets in both sites 9 STATS SA. 2010. Quarter 1 statistics 10 Census Statistics South African of 2001 11 Integrated Development Plan. 2012/2013 12 Statssa: Community Survey, 2007 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 23 6.2 Weighting for Equivalence The household survey further profiled sampled participants to determine the equivalence of the matched communities. In terms of access to basic services, almost all participants had electricity in their households (97% of comparison and 98% of treatment communities). The majority had a traditional pit latrine in terms of the toilet facility in their household (79% of comparison and 77% of treatment communities). The main source of drinking water differed slightly between the comparison and treatment communities as follows: Table 1: Water and sanitation in sampled communities Comparison Treatment Main source of drinking water Piped into dwelling 16% 35% Piped into yard 61% 50% Public tap/standpipe 15% 4% However, findings showed that overall, there were marked differences between samples on age and gender variables. In comparison sites the number of participants below the age of 29 years was much higher and participants above the age of 51 years was much higher than for treatment sites. In terms of gender, comparison sites had 59% of females in the sampled sites compared to 80% females surveyed in treatment sites. Table 2illustrates differences and similarities between sites before weighting of the data. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 24 Table 2: Profile of sampled participants before weighting of data to ensure equivalent samples Due to the variances between the treatment and comparison communities, the data was weighted to eliminate outliers in terms of gender and age so that statistical analysis could be run on equivalent samples. As Stats SA data does not report to this level and AMPS data is not available per town it was decided to weight the two samples to an overall demographic. The sections that follow present analysis from both quantitative and qualitative findings in response to the key evaluation questions. Error! Not a valid bookmark self-reference. illustrates the profile of the comparison and treatment sites overall after weighting of the data. The weighting process is detailed in Annexure C. Table 3: Profile of comparison and treatment communities after weighting of data to ensure equivalent samples Comparison Treatment Languages Swazi 54% 65% Sepedi 44% 5% Age Under 30 27% 35% 30 to 44 35% 33% 45 to 59 27% 26% Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 25 60+ 11% 7% Mean 39.9 38 Gender Female 59% 69% Male 42% 31% Degree of Urbanisation Rural 67% 60% Urban 33% 40% 6.3 Final Sample Size The following table illustrates the number of Household Composition Forms and Participant Surveys completed in each site. A total of 366 Household Composition Forms and 611 Participant Surveys were completed for this study. Table 4: Number of Household Composition Forms and Participant Surveys completed per site Household Survey Final number of participants surveyed Type of group Site Completion of Household Composition Form Participation in the survey Comparison Community 3 Moletjie 70 120 Treatment Community 3 Tzaneen 50 99 Comparison Community 2 Matsulu B 59 101 Treatment Community 2 Tonga 52 91 Comparison Community 1 Matsulu A 61 99 Treatment Community 1 Driekoppies 74 101 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 26 7 Findings The findings are considered in light of the evaluation questions posed for this study. Quantitative and qualitative findings, as well as experiences in the field, were triangulated to respond to each question. This section provides a discussion in response to each of the evaluation questions. 7.1 Programme Effectiveness from Programme Records and Previous Evaluations In 2010 the HSRC conducted an evaluation of the Humana TCE in a single matched community pair, one treatment and the other a control. A survey of a representative sample of respondents from each community provided the primary data set for analysis. The headline findings included:  93.8% of treatment community respondents said the programme had increased resolve to get tested  94.2% of treatment community respondents said Humana TCE helped them take control of the epidemic  90.2% of treatment community respondents said it had impacted their sexual behaviour and practices While these results represent self-reported change in attitudes, and only imply a change in behaviour, a key measure of behaviour in the evaluation did demonstrate a significant difference across treatment and control communities. A significantly larger proportion of the treatment community respondents (62.3%) reported actually being tested, compared with respondents in the control area (55%). If these impacts are indicative of the effectiveness of Humana TCE across communities they should be replicated to some extent in the current evaluation. Implementation records from the sites included in this evaluation suggest that, at least as far as reach is concerned, Humana TCE is positioned to realise similar effects. Table 4: Number of Household Composition Forms and Participant Surveys completed per site, shows the numbers reached through the TCE programme in the communities included in the sample for this evaluation. Of particular interest are the numbers visited and registered, the indicators of progress through the TCE programme, and specific health seeking behaviours monitored. The numbers of people visited and registered for the TCE programme are noteworthy. When compared to the number of visits recorded it is apparent that programme participants are being visited multiple times, an approximate mean of 3 visits per programme participant, though the actual distribution of visits per individual cannot be determned from the summary. A review of progress through the programme milestones however provides some interesting insights: over 70% of people registered on the programme prepare an indvidual PES plan, over 65% become TCE compliant, and approximately 6% are recorded as being active as passionates. In addition field officers succeed in directly facilitating access to testing and PMTCT services. These initial figures from routine programme data demonstrate strong reach and promise significant outcomes. The evaluation performs as an indirect verification of the reach data to some extent, and tests the expectations of effect that they reflect. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 27 Table 5: TCE benchmarks and achievements per implementation site (provided by Humana People to People). 7.2 Changes in Knowledge, Attitudes and Behaviour How effective was the programme in bringing about attitude, knowledge and behaviour change for reducing risk to HIV infections among targeted populations? 7.2.1 Knowledge Household survey results indicated that while individuals in the treatment group remain vulnerable to myths concerning transmission – such as contracting the virus through witchcraft or the sharing of utensils – the conclusive finding is that there is a significant difference in knowledge favouring the treatment group. Members of treatment communities are better informed concerning true vectors of transmission, as well as the availability of clinical and other HIV and AIDS related services. The finding suggests a greater depth of knowledge regarding HIV and AIDS related matters in the treatment communities, as opposed to the comparison communities. The key results on knowledge, with statistical significance, are presented in Table 6. There is no statistically discernible difference in knowledge regarding condom use between treatment and comparison communities. Total proportions reporting appropriate condom use across both treatment and comparison communities are high. This represents a positive finding in that knowledge about the benefits and appropriate use of condoms is ubiquitous. An increase in knowledge in treatment communities is consistently confirmed in the qualitative data, emerging as a persistent theme, specifically amongst traditional healers and youth. While it is tenuous to attribute increase in knowledge on transmission vectors to Humana TCE - simply because those messages are now commonly heard across multiple sources – it is plausible to posit that knowledge on clinical and treatment issues is attributable to Humana TCE. NO 12 main figures of TCE CAMPAIGN GOALS TO DATE TOTAL ACHIEVED CAMPAIGN GOALS TO DATE TOTAL ACHIEVED CAMPAIGN GOALS TO DATE TOTAL ACHIEVED 1 Visited and registered 1. time 102,000 103,053 100,000 101,419 100,000 105,543 2 Total number of visits 306,000 321,271 300,000 361,400 300,000 361,825 3 Mobilized for HIV Testing 20,400 22,708 20,000 20,175 20,000 18,537 4 Active as TCE Passionates 5,100 7,634 5,000 6,578 5,000 11,299 5 Made an individual PES plan 71,400 83,983 70,000 88,250 70,000 72,754 6 TCE Compliance 66,300 78,374 65,000 72,798 65,000 67,744 7 Lessons given 6,732 7,586 6,600 7295 6,450 11,848 8 People in lessons 102,000 99,921 100,000 93,689 97,750 164,381 9 Condoms distributed 4,080,000 5,393,909 4,000,000 4,712,842 4,060,000 6,081,280 10 Pregnant mothers mobilized for PMTCT 5,100 4,817 5,000 4,779 4,910 3,749 11 Households registered 18,360 19,837 18,000 18,160 18,000 24,134 12 Registered in non-HH register 0 80 0 53 0 222 13 Mothers enrolled for PMTCT 0 506 0 374 0 311 Driekoppies Tonga Tzaneen Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 28 Table 6: Key differences in knowledge between treatment and comparison groups Knowledge Item Response Mean Treatment Comparison Transmission through sharing of utensils YES 36% 14% Transmission through witchcraft YES 14% 6% Transmission during delivery YES 84% 65% Transmission during breast feeding YES 87% 77% Drugs help HIV infected people live longer YES 84% 71% The individual has heard of VCT service YES 89% 50% Table 7: Knowledge regarding condom use Knowledge Item Response Mean Treatment Comparison OK to reuse condoms after washing YES 5% 3.1% NO 95% 96.9% Condoms protect against STDs YES 95.5% 96.1% NO 4.5% 3.9% Condoms contain HIV YES 3.3% 5.8% NO 96.7% 94.2% Its embarrassing to buy condoms YES 8.6% 4.8% NO 91.4% 95.2% Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 29 The rationale for this conclusion is the following: survey results demonstrate that while comparison groups focussed on the importance of condom use and abstinence, treatment groups were far more likely to say the main messages were to get tested for HIV, avoid sex with multiple partners and those who inject drugs intravenously, to not discriminate against others with AIDS and that there are anti-retroviral drugs available that extend the life expectancy of those living with HIV. Emphasis on this breadth of knowledge is not as common as an emphasis on basic knowledge about transmission and condom use, and Humana TCE is the foremost source of knowledge on HIV and AIDS in treatment communities (40% of treatment group respondents attribute knowledge gained to Humana, with the next highest attribution given to radio, with 21% of responses). In addition interviewees and focus group respondents from treatment communities expressed uncommon knowledge themes, supporting the plausibility of such a conclusion. Breadth of knowledge "The treatment boosts the immune system" (Youth) "We are now able to differentiate between TB and the traditional illness" (Traditional Healers) 7.2.2 Sexual Behaviour The household survey revealed no statistically significant differences in reported sexual behaviour between treatment and control groups. However raw means on condom use do favour the treatment communities. The substantial difference in having younger partners is explained to some extent by the fact that comparison groups have more male respondents, even after weighting. Both groups were equally likely to engage in unprotected sex, have multiple sexual partners, have inter-generational sexual relations, pay for sex and have sex while intoxicated. However there is a significant difference between the responses of treatment and comparison groups when asked whether only the partner was intoxcated at last sexual encounter. The result favouring the comparison community may be partly attributable to the influence of TCE, but must be qualified by the observation that the comparison groups has more males in it, even after weighting. It is conceivable that the indicator reflects the power differential in sexual relationships, and that women might be compelled to meet the sexual demands of male partners. Table 8: Comparing sexual behaviour across treatment and comparison groups Behaviour Treatment Comparison Used a condom at last sexual encounter 59% 58% Always use a condom during sex 56% 49% Limit sex to one partner 59% 60% Have a partner who is more than 10 years younger 2% 10% Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 30 Behaviour Treatment Comparison Have sexual partner who is more than 10 years older 18% 19% Have paid for sex in the past 3% 4% Drunk at last sexual encounter 22% 23% Only partner drunk at last sexual encounter 27% 12% For the most part focus groups and interviews reflected these patterns of sexual behaviour. Of interest however is that male focus groups claimed a general increase in condom use, which they attribute to the Humana TCE programme. This evidence may corroborate the finding implied by the raw means score from the household survey, however the difference in means does not pass tests for statistical significance. Increased condom use "People are using more condoms then they did before" (Male focus group) "There has been an increase in the correct use of condoms" (Male focus group) Although not measured through the participant survey, reduced pregnancy in schools was highlighted across youth focus groups and teachers interviewed in all treatment sites. At best this result in the qualitative data suggests an hypothesis that requires further testing and corroboration from additional evidence. 7.2.3 Improvements in Health and Help Seeking Behaviour Did the programme result in a significant impact in the uptake of HIV services by the targeted populations? Although no significant difference was observed in sexual behaviour between treatment and comparison groups, there was a distinct and significant difference in testing behaviour (see Table 9: Testing behaviour). Two thirds of treatment group respondents claim to know their HIV status and moreover attribute this to the Humana TCE programme. There were also significant differences in the sharing of testing information between partners, with treatment groups far more likely to demonstrate the sharing of statuses, primarily reporting that respondents themselves shared their status, but also that respondents partners’ shared their status. This latter result is exceptionally noteworthy, considering the very poor results in respondent’s partners sharing their status in the comparison group. It is also reasonable to attribute this result to Humana TCE. It possibly indicates the tacit influence of the programme at community level, but more likely the sensitisation of respondents to the necessity of, as well as their right to, obtaining that information from partners, and acting based on that knowledge. However this result and its interpretation would require a qualification – data on the extent to which VCT was undertaken as partners. Unfortunately this data was not collected in the household survey. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 31 The qualitative data support the finding that there is a significant increase in testing for HIV by treatment groups, as well as in the uptake of PMTCT services, and accessing other services such as psychosocial and material support (see Table 10: Health and help seeking behaviours). Qualitative findings support the significant differences found in quantitative findings in terms of the uptake of HIV services by the targeted communities. Focus groups referred specifically to the ‘increased referral to clinics for HCT in general and to the increase in PMTCT. These two themes were highlighted across all treatment sites. Moreover treatment group members are far more likely to access other areas of social support than members of comparison groups. This is in part directly attributable to Humana TCE and their provision of services, and TCE referral of clients to other service providers. It is not possible to distinguish to what extent an increase in health seeking behaviour has prompted an increase in help seeking behaviour more generally, but this too seems a plausible hypothesis, ripe for testing. Table 9: Testing behaviour Behaviour Treatment Comparison Know if last sexual partner was tested 49% 17% Last sexual partner disclosed test results 19% 0% Told partner you were tested 75% 16% Never been tested 12% 22% HCT Testing "We normally invite TCE to come and test them before their graduation (from training to be a traditional healer)" (Traditional healers). Increase in PMTCT "Children are safe from HIV because of PMTCT" (Female Focus group) "More woman at child bearing age test for HIV as they are encouraged to test through PMTCT" (Male focus group) "People who are pregnant are testing for HIV" (Female Focus group) In addition the qualitative findings reflect the claim in the treatment communities that there is an increase in the use of ARTs. While the household survey did not collect data on ART adherence, the body of evidence as a whole would tend to support the plausibility of increased ART use and improved adherence, because it demonstrates as significant difference between treatment and comparison communities on health seeking behaviours the programme focuses on. However, the qualitative data also reflects a persistent deficit in some health seeking behaviours, including adherence. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 32 Increased use of ART "Some of the facilities even run short of the ARVs due to the increased uptake" (Male focus group) “TCE was effective - a lot of patients have come in for testing" (Clinic) "The clinic is calling us more so we know more children are going for testing" (School teachers) "The key change is children and adults coming to be tested" (Local Aids Council) "More people are testing for HIV now than they did three years ago" (Male Focus group) Table 10: Health and help seeking behaviours Behaviour Treatment Comparison Received medical support 57% 50% Received VCT 82% 42% Received PMTCT 28% 15% Received material support 10% 3% Received psychosocial support 34% 24% Community has access to support services 72% 53% 7.2.4 Persistent Deficits in Sexually Responsible and Health Seeking Behaviour The positive findings on health seeking behaviours moderates the impression given in the focus group and interview data that health seeking behaviour is low. What the qualitative data does indicate is that despite progress in treatment communities a deficit in health seeking behaviour persists and that community members are keenly aware of such behaviour. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 33 Lack of health seeking and sexually responsible behaviour emerged in four themes: non￾disclosure and disregard for others, late uptake of treatment, a tendency to test when already ill, and reluctance to adhere to treatment. Rather than invalidating the positive findings of the household survey, these data suggest a generalised sensitisation to health seeking behaviour and an accompanying inclination to note when there is a deficit in this regard amongst fellow community members. Data on adherence was not collected in the household survey and the effectiveness of TCE activities to ensure adherence could not be convincingly assessed. Therefore the import of the qualitative data on adherence is not clear. What is apparent from the limited evidence is that adherence continues to be perceived as a concern in treatment communities - as it is generally in HIV and AIDS programming - and as such offers an endorsement of TCE activities that attempt to address the lack of adherence prevalent in treatment communities. Lack of adherence to treatment "There are community members who still feel uncomfortable about taking treatment" (Male focus group) Similarly the emphasis of TCE on individuals knowing their status and assuming personal responsibility for their sexual behaviour is legitimised by the characterisation of irresponsible sexual behaviour by focus group participants and interviewees as wilful non-disclosure and negligent disregard for the well-being of others. Irresponsible sexual behaviour "HIV positive people... Adopt an attitude that says that they are not going to die alone...The king does not die alone, but dies together with his soldiers” (Female focus group) “Those who are already infected tend not to disclose to their partners and the community" (Female Focus group) While responses on adherence and sexual behaviour confirm what is already known and validate current programmematic strategies, something new might be learned from the data on belated testing and treatment. Themes concerning late testing and late uptake in treatment co-occur with a concern for maintaining confidentiality and explain these behaviours to some extent. They are therefore both an endorsement of TCE activities, as well as suggestive of how programme outcomes might be improved. Late uptake of treatment "Some people ... Only start taking it (treatment) when it is too late" (Male focus group) "The majority of people only test when they are very sick" (Male focus group) Reluctance to test and seek treatment is mitigated in circumstances where confidentiality is assured. Thus a preference for mobile clinics was expressed when discussing testing and treatment, because confidentiality is more likely to be preserved when community members are not being served by a clinic staffed with neighbours, acquaintances and relations. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 34 Maintaining confidentiality "It was easier to test at the tent than the clinic... Confidentiality was maintained" (Female focus group) "If mobile clinics come to the community people get tested" (Caregivers) "Ninety nine percent of people now go and get tested when the mobile clinic comes (Caregivers) Contrastingly, reluctance to test and seek treatment is exacerbated in circumstances where confidentiality is undermined. Two such circumstances were identified by focus group participants and interviewees. Firstly, respondents suggested that clinic staff and nurses specifically are not maintaining confidentiality. In fact high levels of distrust of nurses was frequently expressed. Secondly, the layout at clinics and the processing of patients for testing is perceived by community members to encourage stigmatisation and discrimination. Clinic layout and patient processing "The division at the clinics with the section for HIV/AIDS ... makes people uncomfortable about collecting their treatment" (Female Focus group) “The position where condoms are placed in the clinics (often at the back) discourages youth to go since they will be seen” (Youth) Having community members test and go to a specific door afterwards for counselling should they be HIV positive, also discourages them from going for being tested. “When they test positive, they have to go to the other room and if negative they walk out of the back door” (Clinic) 7.2.5 Attitudes In addition to investigating attitudes towards PLWHA (see ) and attitudes towards sexual responsibility and health seeking behaviours, the evaluation considered additional attitudes that the literature indicates may be predictive of sexual behaviour. The household survey measured attitudes in 4 categories: 1) attitudes towards sexual license for men, 2) attitudes towards promiscuous or sexually risky behaviour, attitudes towards the role of women in sexual relationships including 3) expectations of a traditional conservatism versus equality for women, and 4) attitudes towards the burden for sexual responsibility being placed on women. The only significantly measureable difference in attitudes in these domains between treatment and comparison groups is a higher likelihood that treatment group members would grant sexual license to men. The result is perhaps explained by the fact that without weighting the treatment group is predominantly female and more rural, suggesting the possibility of a more traditional inclination towards gender roles. While not producing particularly useful results when testing for a difference in means, the attitudinal scale did offer some interesting insights when employed in a regression analysis of predictors of behaviour (see 7.2.6). Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 35 7.2.6 Cumulative Personal Change A multiple regression analysis was run between overall behaviour (sexually responsible and health seeking) as the dependent variable on the one hand, and independent factors including knowledge, attitudes as described in the preceding section, propensity for exposure to the programme, expressed on a level of support scale. Statistical details of the model are represented in Table 11: Levels of support received, and Figure 5: Statistical regression model of predictors of changed behaviour. While the r squared is low, due to limited variance in the behavioural metric (specifically the component on sexually responsible behaviour), the results are nevertheless valid and useful. The regression model indicates that an attitude that insists on women assuming a traditionally conservative role impacts negatively on responsible sexual and health seeking behaviours. This may reflect a power disparity in sexual relations that grants men license to act out high risk sexual behaviours while denying women in relationship with such men the right to seek testing, treatment or insist on disclosure of partner’s status. The power disparity also curtails the potential for indirect effects that a programme such as TCE might exert on non-participants. With participation of women generally higher than men (despite additional effort at recruiting male participants) female participants act as the link between programme and non-participating male members of the household. The effectiveness of women in influencing their male household members is likely dependent on the extent to which their status is non-traditional (in a culturally patriarchal system). This finding is further corroborated by the more interesting findings on the predictive power of certain attitudes. Attitudes reflecting an inclination to accept a shared burden of responsibility for appropriate sexual behaviour across genders, and a regard for gender equality, both positively impacted behaviour. This result triangulates with the finding on the first factor, and accentuates the importance of redressing power disparities in sexual relations. It would appear that empowering women through TCE is likely to result in improved performance of the programme on measures of behaviour change. The level of exposure to TCE however is a strong predictor of positive behaviour. This is a self-evident finding: TCE holds beneficiaries accountable for engaging in health seeking behaviours. Based on the results of difference in means testing reported earlier it is unlikely that exposure to TCE predicts any significant improvements in sexually responsible behaviour however, other than potentially more consistency in the appropriate use of condoms. Table 11: Levels of support received None One to three Four and above Count Count Count Capricorn 135 117 Matsulu A 36 68 42 Matsulu B 31 113 30 Driekoppies 1 49 33 Tonga 16 26 44 Tzaneen 79 42 Support_level Comparison Comparison Area_2 Treatment Area_2 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 36 Figure 5: Statistical regression model of predictors of changed behaviour 7.3 Additional Beneficial Outcomes of the TCE Programme Did the TCE programme contribute to any additional beneficial outcomes and social change? Additional beneficial outcomes identified from the TCE programme include: (1) increased collaboration amongst stakeholders, (2) support provided to HIV negative as well as HIV positive community members, (3) being visible, present and available when needed by the community, (4) being a trustworthy source as a platform for sharing in confidence, and (5) how the Field Officers interacted in the community. These themes are further described below. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 37 7.3.1 Improved Collaboration Amongst Stakeholders Qualitative data recognised the positive role Humana assumes in communities through TCE in facilitating collaboration between key groups, such as clinic staff and the Local Aids Council. Examples of collaboration cited include Humana’s facilitation of large community campaigns that would include multiple organisations in a concerted information sharing and treatmet delivery effort. For instance community campaigns were arranged where stalls were erected by various organisations and service providers at a community site, information was disseminated, HCT promoted, and counselling provided. Examples were also given of TCE staff referring programme participants to complementary services. In this and other ways, the TCE programme is seen as playing a role in strengthening collaboration amongst community stakeholders. A local Aids Council member stated, “Through them [TCE] the relationship has been built between us and the other stakeholders" 7.3.2 A Visible, Reliable, and Accessible Social Resource Participants in all communities mentioned that the red t-shirts allowed the community members to easily identify the presence of the Field Officers. The visibility and presence of TCE Field Officers suggested that they were available to support community members. The following two quotes suggest the importance of the red t-shirt and visible presence. Accessible social resource “The presence of TCE has provided significant changes in the community" (Female focus group) “It is the people in the community with the red t-shirts that helped us and gave us information” (youth) "I cannot trust the teacher, I only trust the people with the red t-shirts" (Youth) "People prefer us (to the nurses) - it’s a trust aspect" (Field Officers) Participants, mainly the youth, indicated their trust in TCE Field Officers. The first quote also identifies the importance of the red t-shirts, as this is how the youth identifies the TCE Field Officer. The second quote demonstrates a common understanding of the Field Officers, who often reported that community members, including the youth, tended to trust the Field Officer more than the clinic nurses. Participants described the positive experience they had when dealing with Field Officers. Most participants mentioned the compassion, passion, and respect that they had for the community members and for their work. Passionate involvement "The job they [Field Officers] are doing is in their veins, they love the job" (Youth) Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 38 "They were so passionate as if they were real nurses ... All of them treated us with respect" (Clinic staff) Focus group participants in particular emphasised the role that TCE Field Officers played in providing emotional and other support, particularly to both positive and negative youth, as well as care and support for PLWHA. The following quotes illustrate the type of support that was considered invaluable to many community members: Emotional support and advice "Even if you are in a huge problem, they [TCE] are there to advise us" (Youth) "I sometimes have family issues at home but she [Field Officer] was there to support me" (Youth) Care and support for PLWHA "[TCE] provided care to those who are bed ridden" (Female focus group) "They [TCE] helped those who needed to be assisted like cleaning for them, bathing them and changing them" (Male focus group) The dynamics of stigma continue to exercise a negative influence on programme implementation, and this is reflected in some focus group observations concerning Field Officer’s support to especially PLWHA. Because the TCE programme provided so much care and support to PLWHA some participants tended to avoid Field Officers for fear of community members assuming they were HIV positive, and as a result finiding themeselves stigmatised. 7.4 Social Change Aspects of the TCE Programme The introduction chapter illustrated that some of the anticipated outcomes of the TCE programme included the desire for community members to no longer discriminate against PLWHA and for the capacity of local leaders to be built regarding HIV and AIDS prevention, care and support and stigma reduction. Findings are presented in regard to these intended social changes. 7.4.1 Discrimination and Stigma Reduction Initially the household survey data appears to indicate that treatment communities are more likely to be prejudicial towards PLWHA. However a closer review of the scale in the light of programmatic emphases in Humana TCE suggests other interpretations. The programme emphasises assuming personal responsibility for behaviour and the right to keep your status confidential. Seen in this light the results suggest that discrimination against PLWHA is low in both treatment and comparison communities. However a firm conclusion on these results cannot be convincingly posited, due to the unexpected inappropriateness of the scale in the programme context. Qualitative findings show that there were mixed perceptions amongst participants in all sites when it came to discrimination – some participants reported it as present and others said that it had decreased. The following quotes represent the perception of discrimination being present in treatment communities. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 39 Discrimination is still rife: "There is still a problem of discrimination and stigmatization" (Female focus group). "There is still high stigma around HIV/AIDS" (Male focus group) "They (the clinic) don’t allow us to get condoms because we are young" (Youth) Fear of discrimination: "If someone has an HIV test and comes back knowing he/she is HIV positive, they don’t know how their family will view them" (Youth) Fear of disclosure: "Youth are scared to go there (clinics) if they have STIs and private things because these people (nurses) really talk" (Youth) "Nurses communicate with each other if someone has HIV/AIDS" (64) "nurses disclose and don’t keep their confidentiality" (Youth) Other qualitative data indicated that discrimination had been reduced as a direct result of the TCE programme and increased disclosure across the treatment sites. Reduced discrimination "TCE changes one’s attitude" (School teachers) "TCE has made people to love their neighbours and that this (HIV) can happen to anyone in the community" (Male focus group) "Because of the knowledge they [community members] get from the clinic and those doing door to door so that is why it [discrimination] has reduced" (Traditional healers) "Family members are accepting their sick members" (Female focus group) Increased disclosure "There are more people who are comfortable disclosing their HIV status" (Male focus group) "When TCE was there people were no longer hiding" (Traditional healers) 7.4.2 Building the Capacity of Local Leadership In its deliberate focus on building the capacity of local leaders to support prevention efforts and the effective response of communities to the epidemic more generally, TCE appears to have an emphatically positive influence of the role of traditional healers. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 40 Qualitative findings clearly identify Traditional Healers as local leaders who have increased their knowledge and changed their behaviours as an outcome of the TCE programme. Traditional Healers across all treatment sites indicated having learned from the TCE programme, as noted by one Traditional Healer, "We are now able to differentiate between TB and the traditional illness" (Tonga and Driekoppies Traditional Healer). The main social changes include Traditional Healers’ requirement of clients to get tested before treating them. A measure of effect in this regard should be included in the household survey for future evaluations of TCE. Traditional healers mobilised "Every client who visits us has to be tested" (Traditional Healer) "We mobilize the client for HCT before treated" (Traditional Healer) 7.4.3 Addressing Gender Based Disparities The qualitative data supports the possible interpretation of household survey data that females are more inclined to engage in health seeking behaviours. Male focus groups identified that males were more reluctant than females to be tested for HIV. The following two quotes illustrate this finding "The fear of testing and knowing ones status makes men vulnerable - this is driven by a fear of HIV" (Male focus group) "Men are generally resistant to test for HIV" (Male focus group) Some qualitative data suggested that males, once identified as HIV positive, are also more resistant to taking treatment. As one female interviewee noted, "There are generally fewer men who collect treatment from the clinics than woman." (Female focus group) These qualitative findings are supported by the nature of the research samples. The treatment group is over-represented by females, suggesting that women are more amenable to participation in a prevention programme such as Humana TCE, and by extension to engage in health seeking behaviour. Data also suggested that women are more vulnerable to stigmatisation than men. Stigmatisation for women was perpetuated by men, as men tended to blame women for getting infected. For example, they blamed women for getting drunk and engaging in unsafe sex. "Woman are weak when under the influence of alcohol and thus get vulnerable" (Male focus group) Women are not just rendered vulnerable to stigmatisation by the power disparities in sexual relationships, but it was also indicated that they are at greater risk of infection as a result. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 41 "Men control when, where and how sex occurs as they tend to have power and money" (Male focus group) Interestingly no responses were volunteered on the extent to which TCE has promoted change in gender disparities. It would be hasty to draw conclusions from this gap in the data, however it should be noted because of the strong correlations between attitudes towards women’s pace in society and sexual and jhealth seeking behaviours emerging from the data as a whole. It would also be important to more data deliberately exploring these correlations in future evaluations of Humana. 7.5 Social and Economic Distortions in the Wake of TCE Did the TCE programme contribute to any unintended consequences detrimental to individuals, groups within communities, or communities? The most obvious distortions emerging from the qualitative data are associated with local TCE staff, specifically field officers, and these have implications for sustainability of programme effects. Field Officers interviewed across the sites identified several changes brought about by the end of the programme as being problematic, related specifically to resources and identity. Discontinuation of the stipend was a highly anxiety provoking change for Field Officers. They now perceive themselves to be abandoned to the ‘spiral of poverty’, from which they had expereinced temporary relief due to being ‘employed’ through the TCE programme. As one Field Officer stated what many others reflected upon, "We are not happy the time TCE closed... We had jobs and now we don’t have jobs" In addition to stipends FOs benefit from a number of training interventions that equip them for their role in TCE. There is anecdotal evidence that the training and work experience has improved the employment prospects of FOs, and a number have transitioned into related work, in the employ of provincial health departments or halth NGOs. The extent to which this mitigates the effects of their TCE income being discontinued is not clear from this evaluation, and would be better addressed in a subsequent impact assessment of the TCE programme. Field Officers also expressed feeling ill equipped to continue with their work as Passionates. Resources for conducting their work have been removed. Specifically, the structures that were institutionalised to drive the outreach were dissolved post-implementation. Besides the stipends being provided to Field Officers during the three-year programme being eliminated, Field Officers access to condoms, pamphlets and support (such as regular meetings between Field Officers, Troop Commanders and Division Commanders to share experiences and provide numbers reached) that is needed to continue driving activities is no longer available. An important theme emerging from the focus group discussions in this regard is that Field Officers had felt empowered by their very visible identity as TCE staff. The removal of the emblem of identity – their red t-shirts – left them feeling, at least in the immediate wake of programme exit, disempowered. While there may be additional, wider distortions associated with the implementation and the exit of programme with such a broad reach in a community, these did not emerge from the data specifically. It may be worth including a more deliberate attempt to explore such potential distortions in future TCE evaluations. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 42 7.6 The Influence of the Implementation Context What contextual factors enabled or constrained programme implementation and the achievement of intended outcomes? Focus group participants were asked about what places individuals in their community at risk of getting HIV. Alcohol, culture, poverty, informal prostitution and unprotected sex were all highlighted by participants as factors placing individuals in the community at risk of HIV/Aids. Alcohol was highlighted as the major risk factor, followed by culture, poverty and then informal prostitution. Having unprotected sex was not mentioned as often by those interviewed, but is often associated with informal prostitution and poverty as well as alcohol. The following paragraphs elaborates further on the prevalent themes. 7.6.1 Alcohol Participants across treatment sites and amongst most stakeholder groups highlighted alcohol as a theme. Participants indicated that alcohol leads to informal prostitution because young girls go to the taverns or shebeens without money and men offer to buy them drinks, expecting sex in return. This was analysed from a gender perspective above (e.g. blaming women) however these quotes also illustrate the role of alcohol in spreading HIV. “There are mis-perceptions that if a person buys another a drink, they can have sex with them” (police officer?) "They like going to the tavern and when they arrive they don’t have any money and a guy offers some of them a drink - I take his offer and when I am drunk he takes me to have sex without playing it safe" (Youth) Alcohol is further related to unprotected sex due to the effect of alcohol on behaviour. Qualitative data suggest that people become negligent when intoxicated and fail to use a condom. 7.6.2 Poverty Focus group participants highlighted poverty as being a key risk factor in that it leads to informal prostitution as a means of income. Some data also suggested that there is a financial benefit associated with having unprotected sex when taking part in informal prostitution. It appears that women ‘woman are paid more for sex when they don’t use condoms. Poverty also results in men having to leave their wives to go and work far from home resulting in men acquiring sexual partners in their area of work and as is known, having more than one sexual partner places individuals at a higher risk of contracting HIV/AIDS. 7.6.3 Cultural Practices Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 43 Certain cultural practices are a risk factor relating to HIV and AIDS. Various myths and practices were mentioned by participants. A few examples of how culture was used to explain the spread and fear of HIV and AIDS are provide below. "Some of the issues that makes HIV to spread is ... Traditions and culture" (Traditional healer) "Some people conduct ancestral rituals for people who are HIV positive or have AIDS instead of taking them to the doctors, clinics or hospitals" (Female Focus group) "Some still consult traditional healers together with the treatment and thus do not take the treatment correctly" (Female focus group) 7.7 Sustainability The evaluation was not positioned to collect sufficient evidence to make a pronouncement on the sustainability of Humana TCE outcomes. An impact evaluation conducted in communities in which Humana TCE had been implemented a number of years previously would be required to posit credible findings on sustainability. The evaluation could collect evidence concerning the mechanisms integrated into the programme design in order to ensure sustainability, as well as the identifiable risks to sustainability inherent in the programme design and implementation context. 7.7.1 Mechanisms for Ensuring Sustainability TCE adopts an explicit exit strategy for each of its ‘actions’ in order to ensure a smooth transition for communities to a post TCE condition. In addition the programme has a number of mechanisms embedded in its design to ensure sustainability. The most prominent is the mandating of community members known as ‘passionates’ to continue with prevention activism once TCE has exited from the community. The programme takes care to equip community leaders with the capacity to provide prevention related care and support, and attempts to build a referral network during implementation that connects various social service providers to coordinate a community rooted response to the epidemic and other social needs. There are even efforts made to transition local Humana TCE staff into government employ locally. Importantly it should be noted that TCE’s theory of change is based on a set of assumptions that should result in a tipping point at which an entire community is not only sensitised but converted to the cause, with a concomitant change in the balance of individual behaviour that will stay and ultimately reverse prevalence. Change, under these circumstances, should theoretically proceed driven by its own momentum. Participants across treatment sites indicated a perceived sustainability of TCE, as quoted, "They are still following what they have learnt" (Caregivers, Traditional Healers). However, measuring sustainability goes beyond perceptions. 7.7.2 Risks to Sustainability The primary risks to sustainability are inherent in the elimination of the proven mechanisms driving change, among which are the material incentives for action and the sense of identity empowering TCE field workers with tacit intrinsic motivation. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 44 There is insufficient evidence to state that there are no more effects after the TCE programme has left a community. However, it can be stated that the evidence from focus groups and interviews suggests that the community has no confidence in their ability to continue a programme of prevention efforts after TCE has exited. Passionates who were Field Officers during TCE implementation were intrinsically motivated through their identity as TCE agents. The removal of their red t-shirts permanently is emblematic of the relinquishing of that identity, and they express a sense of disempowered and inability to continue with post-programme efforts. In addition community members attribute authority and credibility to the institutionally endorsed identity of TCE agents. As soon as the programme completes the three years, the community’s faith in the capacity of individuals to institute mechanisms to perpetuate or sustain change is undermined. The removal of red t-shirts was again invoked by respondents as symbolic of the removal of identity, mandate and credibility to continue in their role as leaders of prevention efforts in their communities. It is apparent from the qualitative data that in the absence of formal, institutional mechanisms treatment communities do not consider themselves equipped post TCE to institute their own mechanisms. In focus groups, participants highlighted that TCE provided indispensable resources for the work of prevention. Participants wanted to have TCE back in their communities and to have permanent structures to provide the support and resources required to ensure sustainability. As quoted: Provision of resources with presence of TCE "TCE provided them (learners) with resources (condoms, pamphlets)..." (School teacher) "They (TCE) were working hard ... Supplying us with condoms" (Road and Transport worker) Permanent TCE structures "If only we could have fixed people for a fixed clinic as permanent" (Clinic) "In each community build something that is TCE" (school teachers) Loss of support and resources "We will not manage to do that extended job that they have been doing" (Traditional healers) "We don’t have resources like testing kits" (NGO) 7.8 Assessing the Validity of the Theory of Change Was the Theory of Change informing the TCE programme adequate for the realising of programme outcomes in the programme context? What was the level of programme fidelity in implementation? Were deviations from planning responsive to context or a result of inadequate implementation? Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 45 To fully respond to this question, this section re-visits the key assumptions informing the TCE programme design, and presents evidence on their validity. It then reports on key implementation challenges that would undermine the testing of the theory of change and therefore any conclusions on its validity. 7.8.1 The Evidence for the Assumptions A Mechanism to Change Behaviour: The main objective of the TCE programme as described by Humana is “to get every person in every field and area in control of the HIV/AIDS epidemic”. Taking control of HIV and AIDS is dependent on having suficient knowledge concerning the epidemic, and taking personal responsibility for sexual and health seeking behaviours. The emphasis on personal responsibility is one of the two primary assumptions of efficacy informing programme design. Humana TCE is distinctive in that it introduces a specific mechanism to implement behaviour change through personal responsibility – the PES plan, the scorecard monitoring the implementation of the personal plan, and the milestone of TCE compliance. The behaviour monitoring mechanisms are a significant programming innovation and its effectiveness is partially vindicated by evaluation results – members of treatment communities are far more likely to have engaged in the health seeking behaviours specified as milestones in the scorecard – testing and counseling specifically. Unfortunately, and this is not a challenge unique to TCE but a common finding across prevention interventions, even the behaviour monitoring innovations introduced through TCE have no measureable effect on changing sexual behaviour. A Mechanism for Sustaining Change: The second primary assumption informing programme design is that by reaching an entire community within a short period of time a tipping point can be reached that shifts the shared consensus on what is acceptable behaviour. In this way changes in sexual ad health seeking behaviours can be sustained independent of an exteral intervention. As discussed in the section on sustainability (see section 7.7), the TCE theory of change and programme design implements multile mechanisms to ensure the sustainability of programme effects. Together with ubiquitous it is reasonable to assume that everything possible has beend done to support the sustainability of results. This assumption remains untested because TCE has yet to be sujected to a proper impact evaluation. The conclusion then is that the emerging evidence endorses the TOC in part, but it needs strengthening on terms of changing sexual behaviour, and it requires testing in terms of sustainability. 7.8.2 Risks to Perceptions of Implementation Fidelity Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 46 The programme objective of reaching every person in a community is enabled by a systematic clustering approach that is a innovative feature of the programme design. The result is that programme performance in terms of reach is very compelling. However the experience of the evaluation field team suggests that reach was not ubiquitous. Households were repeatedly encountered that claimed not to have been visited and individuals were not reached through the door-to-door campaigns (there were many who were visited by the fieldwork team but were not exposed to TCE). A possible interpretation in this regard is that in implementation TCE assumes a strong home-based care focus – the field work team suggests that Field Officers would visit households in an area repeatedly with many surrounding households that may have needed intervention not being visited. It is quite likely however that the problem is systems related. The household register is a document for monitoring field officers and monitoring the programme implementation. Special Forces reportedly use the household Register to track down the performance and effectiveness of each Field Officer (see section 5.1.4.). However, despite a thorough verification process implemented by Humana, the inconsistent and outdated methods for maintaining the household register meant that not only was independent verification of the household register data impossible without Field Officer support, but there was no way of explaining discrepancies in household register data versus what was encountered in the field. There is also the challenge of neither Field Officers nor Field Commanders being able to point out a particular area (location) in which sampled households are located for the Feedback research team of fieldworkers to visit. This implies flaws in the household location tracking system. It should be noted that, in an RDQA conducted by FHI 360 where TCE was being implemented, of 22 randomly selected households from the Household Register that were visited, and physically identified by the appropriate Field Officer, all were found to be visited by the Field Officer for the time period queried. While the accuracy of the data in the household register was confirmed in the FHI 360 RDQA, problems with the registry design as well as confidentiality issues were acknowledged and recommendations for addressing these were proposed (echoed in the recommendations of this evaluation). Based on FHI 360 recommendations, Humana has moved forward with piloting the Soweto Care System database which consolidates all data on a household and makes retrieving and verifying household data more timely and reliable. However, as long as household data cannot be independently used and verified the conclusive testing of the compelling theory of change implicit in the TCE programme design cannot be convincingly tested. 7.9 Reasonably Assessing Contribution What is the programming landscape with regards to HIV & AIDS in each of the treatment and comparison communities? What was the TCE contribution to the cumulative effect of all programming in the beneficiary communities? Communities such as those in which Humana TCE is implemented are frequently beneficiaries of numerous interventions. It is critical to build a case for contribution of the specific programme to measured changes that are likely the result of concerted efforts executed by multiple institutions through multiple programmes. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 47 In the household survey respondents were asked to indicate the sources of various types of social services, including health services. Specifically they were requested to indicate which organisations provided them with the service, and which organisation facilitated access to the service. It is overwhelmingly clear that Humana TCE played the dominant role in both providing and facilitating access to the services that resulted in the changes measured during this evaluation. Based on these results it is reasonable to conclude that the programmes contribution to measured effects is substantial. The household survey results were corroborated by the focus groups and interviews. Focus group participants recognized TCE and did not really know about other organisations that can render anything similar, except for the home-based caregivers. People know more about TCE than any other organization. Table 12: Humana TCE's contribution to measured effects Services provided or access facilitated Source Treatment Comparison Which organisation provided VCT? TCE 68% 4% Clinic 24% 67% Other 8% 29% Which organisation assisted you to access VCT? TCE 71% 9% Clinic 12% 49% Other 17% 42% Which organisation provided PMTCT? TCE 70% 0% Clinic 24% 80% Other 6% 20% Which organisation assisted you to access PMTCT? TCE 51% 0% Clinic 15% 32% Other 34% 68% Which organisation provided you with other TCE 32% 0% Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 48 support services? Clinic 34% 81% Other 34% 29% The prominence of Humana in target communities is illustrated by the citing of the TCE programme most often when survey respondents were asked about the source of support received. In comparison communities it is the health facility that is cited most frequently, even though the types of support inquired after in the household survey are not restricted to health services. Not only does there appear to be no organisation with an equivalent prominence in the treatment or control communities, but it is further evident that while Humana does not offer all services or indeed provide them, it acts as an effective mechanism for access, directly and substantially augmenting numbers accessing services. There is ample evidence across all data sets to demonstrate that where the effects discussed were measured Humana’s contribution to their magnitude is significant and indispensable. It is apparent from this that Humana is effective. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 49 8 Conclusions Humana TCE is undoubtedly effective in increasing knowledge about HIV and AIDS, improving attitudes of personal responsibility and significantly improving health seeking behaviours amongst beneficiaries. It achieves these results through a robust theory of change and programme design that relies on innovative behaviour change and monitoring mechanisms and a compelling message of assuming personal responsibility for behaviour, status, one’s own health and that of other members in one’s community. Despite this apparently comprehensive programme design and strong effects on every other measure, the key objective of changing sexual behaviour however remains elusive. Perceptions of the effectiveness of Humana TCE are at risk of being undermined by an inconsistent system for registering households reached. This flaw is severe in that, despite robust internal mechanisms for monitoring programme fidelity, and data quality assessments confirming accuracy of household register data, the integrity of programme record keeping and monitoring can be brought into question due to the fact that independent verification, without significant support from programme staff to locate beneficiary househholds for example, is not possible. While Humana TCE is designed to ensure the sustainability of effects, the removal of the mechanisms of realising effects – including organisational infrastructure, the extrinsic motivation (financial reward) and the intrinsic motivation (the TCE identity) for taking action - poses a potential risk to sustainability. It should be emphasised that the testing of sustainability was beyond the scope of this evaluation and should be considered for inclusion in future evaluation efforts. While the underlying theory of change appears sound and has proven effective in realising outcomes, the complete test of its validity depends on a comprehensive impact evaluation that adopts as a key objective the assessment of sustainability. This is critical because sustainability of effects is arguably the most prominent promise of this exceptionally effective intervention. While the evaluation focussed on and arranged findings according to specified evaluation questions, table presents an evaluation scorecard that summarises the evaluation scope and findings from the perspective of stated TCE objectives. Table 13: Evaluation scorecard against TCE objectives Humana Objective Evaluated Performance Notes Change in attitude and behaviour of community members and most at risk groups Attitudes Health Seeking Behaviour Sexual Behaviour The evaluation differentiates between sexual and health seeking behaviour. It does not disaggregate by MARPS. Community members consistently use HIV prevention services Treatment communities significantly more likely to access health and other services. VMC and ART adherence not in household Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 50 survey data. Community members have undertaken HCT and know their HIV status Treatment community members significantly more likely to have gone for VCT/HCT Community members avoid risky sexual behaviour and use condoms correctly and consistently; No significant difference between treatment and comparison communities in this regard. Community members no longer discriminate against PLWHA Mixed, inconclusive results Increase in knowledge around HIV transmission and HIV and AIDS prevention and treatment Treatment community members test significanty better on knowledge items than comoparison community members. The capacity of local leaders is built regarding HIV and AIDS prevention, care and support and stigma reduction Not directly investigated, inconclusive results. Local leaders have developed facilitation and counselling skills Not directly investigated, inconclusive results. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 51 9 Recommendations 9.1 Recommendations to Humana 9.1.1 Programme Design  Changing sexual behaviour: TCE demonstrates a challenge common across even successful prevention programmes – very liitle change is shown in sexual behaviour. There is an emerging body of research on what works in programmes, especially youth focussed programmes, that could be used to revisit programme design. The TCE experience with introducing effective behaviour change mechanisms for health seeking behaviour, combined with the emerging body of knowledge on sexual behaviour change, holds promise. Three broad recommendations can be made in this regard: o Improving TCE effectiveness with regard to sexual behaviour should incorporate the innovative thinking in terms of accountability mechanisms that already work with health seeking behaviour in TCE. o The emerging research shows that different approaches work for different groups. Improving effectiveness on changing sexual behaviour may require a focus on a particular demographic e.g. youth, and on a limited outcome e.g. delaying sexual debut. A tailored component in TCE is somewhat contrary to the broader, all-inclusive, theory of change, but may be necessary to begin making progress on this front. o The regression model demonstrates that a set of progressive attitudes towards the role and status of women in the community generally and sexual relationships specifically predicts more responsible behaviours. Including an engendered perspective on education interventions in TCE is therefore recommended. 9.1.2 Programme Implementation  Managing household register and beneficiary data: The entire basis for credible pronouncements on programme fidelity and performance going forward depends on reliable, independently useable, programme records. It is essential that the problems with this data be corrected. Two recommendations are made in this regard: o Households need to be registered using a method independent the conflicting methods used by local authorities, and independently verifiable. It is recommended that a GS system be introduced and employed as the basis for the household register at all Humana sites. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 52 o All existing household register and beneficiary data needs to captured in electronic format on an electronic platform implemented across the entire Humana organisation. A great deal of routine data is collected and can be enrmously useful to monitor and evaluate performance internally, as well as inform independent external evaluations. Unfortunately the lack of uniform platform and the consistent electronic capture of data undermines the utility of the large and potentially invaluable volumes of data. It also significantly increases the effort required to verify the quality of the data, as well as identify and correct the causes of quality deficits consistently and timeously.  Improving prospects for sustainability: While the evaluation is not in a position to make conclusive pronouncements on sustainability, it may be worth acting on the identified risks to sustainability in the following ways: o Address the FOs identity insecurities by introducing emblems to replace their TCE uniforms. This may serve to enhance their confidence in assuming their role as passionates, and the confidence of the community in the fact that sustainable social capital has been built through TCE. o Planning more deliberately to ensure the availability of resources for passionates on programme exit. Designate a lcation within a field – the house of a passionate – at which condoms, information producst and support (for HCT, PMTCT and PLWHA) continue to be available. This will require engaging a source for providing these items before programme exit. 9.2 Recommendations to USAID and FHI 360  Provide funding for equipment and technical assistance to implement and train Humana staff on a GPS based household register.  Provide funding for equipment and technical assistance to implement and train Humana staff on an organisation wide electronic platform for managing beneficiary data and programme records.  Provide technical assistance to research and design components for the TCE programme that will support achieving the sec=xual behaviour change objectives of the programme.  Fund an impact assessment that will provide evidence for a clear pronouncement on the sustainability of the positive programme effects measured in this evaluation. 9.3 Recommendations to the National Department of Health This evaluation confirms a that a perceived lack of confidentiality is a crucial hinderance to people accessing HIV services. Two recommendations are made to departments of health in this regard:  Layout of clinics: It is worthwhile for the Department of Health to look into the layout of clinics to minimise possible discrimination of community members who go to collect condoms or who go for HCT. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 53  Confidentiality: This was a key finding and a concern across all stakeholder groups in all treatment sites (including youth, adult females and males, traditional healers, local leaders). Interventions to ensure that clinic staff maintain confidentiality of community members – from ethics education to disciplinary action – must be instituted.  Outreach HIV services: Evidence from community members suggests that testing and counseling services delivered through a mobile clinic staffed with personel not from the local community are more likely to be utilised than the local facility. Outreach services should be a key component of all HIV services planning. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 54 ANNEXURE A: Community Selection Protocol Community Selection Criteria To ensure equivalence and the integrity of the quasi-experimental design, all the selection criteria in the table following should be met. However it may prove difficult to obtain evidence from an authoritative source to confirm equivalence on all the listed criteria. It may be sufficient to obtain confirmation of equivalence against the listed criteria from a panel of key informants, but some objective evidence is preferred. To accommodate decision-making in the likely absence of objective evidence the criteria are presented in a hierarchy. The extent to which the meeting of equivalence criteria is essential is a matter of judgement for each evaluation instance where this protocol might be replicated. It is also important to remember that, provided the sample is large enough, statistical solutions can be applied to the sample and the data to compensate for a lack of group equivalence in the research design. The Limpopo treatment community will be compared with the comparison community in Limpopo. The Mpumalanga treatment communities will be compared with the comparison communities in Mpumalanga. Findings for each provinces will be compared across provinces to determine whether the differences between treatment and comparison communities are similar across both provinces: Please complete the following table by responding to each of the Level questions: Level 1 Criteria Yes/No Provide reason where applicable Evidence 1. The selected communities must each be identifiable as a community. It should be possible to geographically delineate each community and there should be some authoritative consensus on their classification as a community. 2. Both communities should be classified similarly with regards to their degree of urbanization. The two communities should be of similar size as measured by number of households. 3. The two communities should be similar in terms of their language, cultural and ethnic diversity or homogeneity. There should be no glaring systematic difference in this regard. 4. The communities should share a similar rate of employment. 5. The communities should share a similar level of income per household. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 55 Level 2 Criteria Yes/No Provide reason where applicable Evidence 1. There should be no significant differences between communities in the makeup and size of households. 2. The two communities should have a similar level of access to basic services including water and sanitation, electricity supply, refuse removal and disposal, education and any key social welfare services supplied by the state. 3. The nature and state of housing should be similar in the two participating communities. 4. Key health indicators such as infant and maternal mortality rates should be similar. 5. The susceptibility of the two communities to HIV and AIDS should be similar as measured at a higher societal but not necessarily at community level. In other words if the district in which the first community is located has a 10% seroprevalence rate, then the comparison community should fall within a district with a 10% seroprevalence rate. Level 3 Criteria Yes/No Provide reason where applicable Evidence 1. The communities should have a similar security profile. There should be no significant systematic difference in terms of social conflict or levels of crime. 2. There should be no significant cultural, values or belief based differences between the two communities that might influence community members’ perspectives on sexual behaviour, HIV and AIDS, circumcision and the rights of women and children. 3. The two communities should share similar distributions in terms of adult literacy and highest levels of education. 4. There should be similar proportions of Most At Risk Populations in both communities participating in the study. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 56 5. There should be no significant differences in the nature and prevalence of substance abuse across the two communities. There should be no significant differences in migratory patterns of the two communities. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 57 ANNEXURE B: Summary of completed surveys and focus groups Table 14 summarises the number of households located and sampled per site and the number of participants surveyed. Table 14: Located households and participants surveyed – Quantitative data collection Province Site location Type of site Number of house￾holds sampled House￾hold compo￾sition forms completed Number of Partici￾pants who con￾sented Number participa nts recruited and question naire complet ed Notes Mpumalanga Tonga Treat￾ment 192 54 90 90 Oversampling was applied. Mpumalanga Driekoppies Treat￾ment 160 68 105 105 Oversampling and alternative method was used. Mpumalanga Matsulu A Com￾parison 125 61 99 99 Despite oversampling, the target was reached on the first sample. Mpumalanga Matsulu B Com￾parison 125 59 101 101 Oversampling and alternative method was used. Limpopo Tzaneen Treat￾ment 100 50 100 100 Alternative sampling method was used. Limpopo Moletjie Com￾parison 120 70 120 120 Alternative sampling method was used. Annexure A provides further detail on households and community members participating in this evaluation13 . 13 Note: This table is generated from the field reports and may differ from the final analysis Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 58 Table 15 below provides an indication of the focus groups held with various stakeholders. Table 15: Stakeholder focus groups held - Qualitative data collection Province Site Number of participants Stakeholder group Gender (male/female/mixed) Mpumalanga Tonga 4 Adult community members recruited from hh surveys completed Female Mpumalanga Tonga & Driekoppies 5 Traditional healers Mixed Mpumalanga Tonga 5 Adult community members recruited from hh surveys completed Male Mpumalanga Tonga 7 Traditional leaders / Indunas Male Mpumalanga Tonga 5 Local leaders – Ward Counsellors Mixed Mpumalanga Umjindi 6 High School – Grade 11 Mixed (2 boys, 4 girls) Mpumalanga Umjindi 4 Local Aids Council Mixed Mpumalanga Driekoppies 6 Adult community members recruited from hh surveys completed Female Mpumalanga Driekoppies 5 Adult community members recruited from hh surveys completed Male Mpumalanga Driekoppies 7 High School – Grade 10 and Grade 11 Mixed (2 boys, 5 girls) Mpumalanga Umjindi 5 School teachers Mixed Limpopo Tzaneen 5 Traditional leaders / Indunas Male Limpopo Tzaneen 4 Traditional healers Female Limpopo Tzaneen 10 High School – Grade 11 mixed gender Limpopo Tzaneen 9 Youth club Soccer youth club - males Limpopo Tzaneen 7 Youth club Netball youth club - females Limpopo Tzaneen 4 Adult community members recruited from hh surveys completed Male Limpopo Tzaneen 4 Adult community members recruited from hh surveys completed Female Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 59 ANNEXURE C: Instruments FINAL FOCUS GROUP GUIDE Overall guidance INTRODUCTION Feedback Research & Analytics has been appointed to conduct an evaluation of an HIV-related program. During the discussion we would like to explore your views to better understand changes in attitude and behaviour of community members and most at risk groups; the level of increase in knowledge around HIV transmission, prevention and treatment as a result of HIV prevention and education programs, as well as whether the capacity of local leaders has been built regarding HIV and AIDS prevention, care and support and stigma reduction. Section 5 should be completed only for treatment group participants We do not expect you to reveal private personal information about yourself. We are interested in hearing your frank views and opinions in response to the questions. CONFIDENTIALITY Information you provide in this discussion is strictly confidential. No names will be used in reporting research findings. Quotes will be anonymous and general themes will be reported on. The discussion group is a safe environment for you to share your perceptions and experience. We also ask that each of you respect the confidentiality of the group. Thank you for taking the time to be interviewed. Before we start, I have an information sheet for each of you and you must sign consent so that we can proceed with the discussion (read introduction and obtain signed consent) Consent signed YES………………01 NO…………….. 02 Information sheet provided to FG participants YES………………01 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 60 NO…………….. 02 Interviewer: Date of interview: Type of group (code) Number of participants Community (Tzaneen, Tonga, Driekoppies, Mankweng, Matsulu A, Matsulu B) Province Probe for examples or stories during discussion. HIV/AIDS in the community 1. A discussion about HIV and AIDS in your community (risky behaviour and prevention)? (10 minutes) a) What puts individuals in your community at risk of getting HIV? Probe for reasons and examples. (Probe further for alcohol, Multiple and Concurrent Partners, violence, poverty, transactional sex, intergenerational sex, condom use, etc. based on themes discussed) b) Are there any differences in risky behaviour between men and women? (Probe on differences in engaging in risky behaviour as well as the reasons given for why these differences exist) c) What are the best ways to prevent HIV? In your view, do most people in the community apply these ways to prevent HIV? (Interviewer to collect some stories to describe the reality within the community) 2. A discussion to better understand attitudes and knowledge as well as contributors and hindering factors around HIV services in the community? (40-50 minutes) The following table to guide the conversation – it is important for the moderator to gather stories and probe two to three times to ensure detail is captured for the reality experienced in the community Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 61 What services do community members need when it comes to HIV-related matters? (Tick services that are spoken about in each column – do not probe yet for these services) (a) HIV Counselling and Testing (b) PMTCT (c) Support received by having someone to talk to, learn from for HIV or get info/condoms (d) Going for Anti￾Retroviral Treatment (ART) for those who are HIV positive (e) Support received by becoming part of an HIV-related support group (f) Support received by someone taking community members for testing and/or treatment (g) Other_____ ___ 201 There are some services that you haven’t mentioned such as…. (Moderator to do a quick check of services not mentioned and probe. Does your community make use of … (Tick services the group agrees exist) 202 Knowledge: Do people test even when they are healthy? Do people Make use of PMTCT services when they are pregnant? N/A Do people who know their status know about ART? N/A N/A 203 What is the general attitude of your community towards making use of (a)? ..undertaking HIV Counselling and Testing? Make use of PMTCT services when they are pregnant? ART for those who are HIV positive 204 Behaviours: Do members of your community generally.. ..know their HIV status in your community? ..make use of PMTCT services when ..have someone to talk to who helps in the ..belong in a support group to support PLWHA Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 62 What services do community members need when it comes to HIV-related matters? (Tick services that are spoken about in each column – do not probe yet for these services) (a) HIV Counselling and Testing (b) PMTCT (c) Support received by having someone to talk to, learn from for HIV or get info/condoms (d) Going for Anti￾Retroviral Treatment (ART) for those who are HIV positive (e) Support received by becoming part of an HIV-related support group (f) Support received by someone taking community members for testing and/or treatment (g) Other_____ ___ they are pregnant? community? or to support each other in any other way? 205 Change in behaviour over time: If you think back to 2009 and 2010 and compare the number people in your community going for/receiving (a).. .. Has the level of … (a) decreased or increased in the last three years? (show a level with your hand and determine what the journey in the community has been from 2009 until now) Tell me about this change (the reasons for the change should be probed – ask for stories to demonstrate why the change) ASK QUESTIONS FOR (b), (c), (d), (e) 206 What are the benefits of (a) as experienced by the community? ASK THE SAME FOR (b), (c), (d), (e) 207 What factors prevent community members from Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 63 What services do community members need when it comes to HIV-related matters? (Tick services that are spoken about in each column – do not probe yet for these services) (a) HIV Counselling and Testing (b) PMTCT (c) Support received by having someone to talk to, learn from for HIV or get info/condoms (d) Going for Anti￾Retroviral Treatment (ART) for those who are HIV positive (e) Support received by becoming part of an HIV-related support group (f) Support received by someone taking community members for testing and/or treatment (g) Other_____ ___ receiving (a)? Determine the difficulties and probe further to gain a good understanding of each of the challenges/difficulties These could be related to accessibility, fear, structural aspects, etc.) ASK THE SAME FOR (b), (c), (d), (e) 208 Has there ever been anything that encouraged community members to… ASK THE SAME FOR (b), (c), (d), (e) undertake HIV Counselling and Testing to know their HIV status? a) Have you or your friends been prompted to test for HIV or go to a clinic or a temporary tent for HIV-related services? Give details, stories, examples. Probe for who prompted them to go, how they experienced it. b) Have you ever belonged to a support group of any kind that had anything to do with HIV and AIDS prevention or care – this could have been a cultural or sports group, a discussion group, a group that encourages others to take their medication, etc. Probe and explore who started the support group, gather stories with examples. c) Have you or your friends ever had any HIV-related programs in your community from 2009 to 2012? Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 64 Name of program/NGO (a) NGO/PROGRAM A (b) NGO/PROGRAM B (c) NGO/PROGRAM C (d) NGO/PROGRAM D (e) NGO/PROGRAM E (f) NGO/PROGRAM F (i) What is the name of the program/NGO that came to your community? (ii) What did this program/NGO do (their core services) (iii) In what way were their services valuable to you and your friends? (iv) What would you do to make the (PROGRAM A) better so that it meets the needs of communities in a better way? (v) Do you have any other comments you wish to make about the program/NGO 3. Think about those community members who are HIV positive … (5-10 minutes)? a) Are people living with HIV in this community discriminated against? If so, in what way? b) Has discrimination of PLWHA decreased or increased in the last three years? (show a level with your hand and determine what the journey in the community has been from 2009 until now) c) Has there ever been anything that encouraged community members to stop discriminating against PLWHA? Explore the responses and probe further based on responses (probe programs should these be mentioned – capture the stories) FOR MANKWENG AND MATSULU ONLY… (TZANEEN, TONGA AND DRIEKOPPIES TO COMPLETE SECTION 5 4. Concluding remarks That is the end of the discussion. Is there anything else you would like to add or say about TCE? Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 65 5. Exploring effectiveness of the TCE program (20 minutes) FOR TZANEEN, TONGA AND DRIEKOPPIES ONLY a) Have you heard of the Total Control of the Epidemic (TCE) program run by Humana (the people with the red t-shirts and barrettes? b) What did this program do? c) Are there other programs in your community that serve the same purpose? (list each program and describe the differences between TCE and all other programs that exist) d) In your opinion, did people change their behaviours when the TCE people (with the red t-shirts) talked to them? e) What types of behaviours changed due to TCE people with red t-shirts visiting your community (probe for participants to describe the changes they noticed around them) f) What other beneficial outcomes did the TCE program bring about? (probe in the areas of information about HIV, going for VCT, perceptions of PLWHA, support groups, community mobilization and care of OVC) g) Are there any other aspects that you or your community have benefitted from as a result of the TCE program? h) Have there been any detrimental effects of the TCE program for you or your community? Explore i) Let us pretend for a few minutes that you are a president and I implement TCE for you in your country. What is it that TCE must do to be a better program for communities? (If they indicate to come back to their community, explain that they as president only have a certain amount of funds and that the aim is to reach all communities in South Africa. Probe what else could be done) j) How can we ensure that the efforts by TCE are continued in your community? (make participants aware that there is no more money from TCE and probe efforts that could be continued by the community itself – this could include any local support existing in the community) k) Is there anything else you would like to add or say about TCE? That is the end of the discussion. Thank you for your participation. Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 66 Household number Number of times follow up was made on original household? Participant number Questionnaire no. Interviewer number Date of interview Team number Quality controlled (Epi-centre): Original household or contingency household: Original ……….01 Contingency …02 Follow-up required (Feedback): HOUSEHOLD COMPOSITION FORM TCE HIV PREVENTION PROGRAM - HOUSEHOLD SURVEY NOTE 1 TO INTERVIEWER: YOU MUST WEAR YOUR TAG IDENTIFYING YOU AS A FEEDBACK RESEARCH & ANALYTICS RESEARCHER CONDUCTING A HOUSEHOLD SURVEY. ENSURE YOU INTRODUCE YOURSELF USING THE INFORMATION SHEET THAT YOU WILL LEAVE WITH THE PERSON(S) INTERVIEWED. NOTE 2: THE COMPOSITION FORM IS COMPLETED FIRST. QUESTIONS 101 AND 102 ARE KEY TO DETERMINE WHETHER YOU CONTINUE COMPLETION OF THE COMPOSITION FORM – THERE SHOULD BE TWO PERSONS IN THE HOUSEHOLD WHO ARE ELIGIBLE TO COMPLETE A PARTICIPANT SURVEY. IF THERE IS ONLY ONE PERSON IN THE HOUSEHOLD, YOU IDENTIFY A REPLACEMENT HOUSEHOLD. NOTE 3: CIRCLE RESPONSE CODES NOTE 4: ONCE THE COMPOSITION FORM IS COMPLETED, DETERMINE WHETHER THE SAME PERSON IS ELIGIBLE TO COMPLETE THE PARTICIPANT SURVEY. THE SECOND PERSON IN THE HOUSEHOLD ONLY COMPLETES THE PARTICIPANT SURVEY. 101 How many people 18 years and above live in this household? If two or more continue to 102. If only one person, end the interview 102 How many of these persons are male and how many are female? MALE………………01 FEMALE……………..02 Thank you for your time. We must have two persons in this household who are eligible to be interviewed as part of our study. Because that is not the case, I need to end the interview with you. Thank you very much for your time. 103 ONLY FOR TREATMENT SITES (TZANEEN, TONGA AND DRIEKOPPIES) Do you know how many people 18 years and above in this household have been visited by a TCE person with a red t-shirt and a red barrette? YES………………01 NO…………….. 02 NOT SURE………03 CAPTURE NUMBER OF PEOPLE IN THE HOUSEHOLD……. If only one person, end the interview. Thank you for your time. We must have two persons in this household who have been visited by a TCE person for us to conduct an interview in this household as part of our study. Because that is not the case, I need to end the interview with you. Thank you very much for your time. 104 Do you have 45 minutes for me to go through this part of the survey? YES………………01 NO…………….. 02 If yes, skip to 107 105 If no… is there someone else in your household who can complete the survey now? YES………………01 NO…………….. 02 Name of person…………………….. 106 If no… when can I come back to interview you? DATE……………… TIME…………….. 107 Before we start, I have an information sheet for you and you must sign consent so that we can proceed with the discussion (read introduction and obtain signed consent Consent signed YES………………01 NO…………….. 02 Information sheet provided to interviewee YES………………01 NO…………….. 02 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 67 10.1.1 Section A Household Details Complete the following household information: 201 Province: 202 Area: Tzaneen…………………01 Capricorn…………………02 Tonga…………………03 Driekoppies…………………04 Matsulu…………………05 203 Village/location name: 204 Urban / rural / deep rural / semi-rural: Urban…………………02 Semi-urban…………………03 Rural…………………04 Deep rural…………………05 Other…………………06 (specify)___________________ 205 Languages spoken in this household: English…………………01 Afrikaans…………………02 Ndebele …………………03 Sepedi…………………04 Xhosa …………………05 Venda …………………06 Tswana …………………07 Southern Sotho ………08 Zulu …………………09 Swazi …………………10 Tonga …………………11 206 Language requested for interview: 207 Participant age: 208 Participant gender: 10.1.2 Section B Household Descriptives ……………………..Circle the relevant answer QUESTION CODING CATEGORIES SKIP 301 What is the main source of drinking water for members of your household? PIPED INTO DWELLING . . . . . . . . . . 11 PIPED TO YARD/PLOT . . . . . . . . . . 12 PUBLIC TAP/STANDPIPE . . . . . . . . 13 TUBE WELL OR BOREHOLE . . . . . .21 DUG WELL PROTECTED WELL . . . . . . . . . . . . 31 UNPROTECTED WELL . . . . . . . . . .32 WATER FROM SPRING PROTECTED SPRING . . . . . . . . . . 41 UNPROTECTED SPRING . . . . . . . .42 RAINWATER . . . . . . . . . . . . . . . . . . 51 TANKER TRUCK . . . . . . . . . . . . . . . 61 CART WITH SMALL TANK . . . . . . . 71 SURFACE WATER (RIVER/DAM/ LAKE/POND/STREAM/CANAL/ IRRIGATION CHANNEL) . . . . . . . . 81 BOTTLED WATER . . . . . . . . . . . . . . 91 OTHER(SPECIFY) 96 ___________ _____________________ 302 What kind of toilet facility do members of your household usually use? FLUSH TOILET ………………….01 POUR FLUSH TOILET . . . . . . . .02 TRADITIONAL PIT LATRINE … 03 VENTILATED IMPROVED PIT LATRINE (VIP) . . . . . . . . . . . . 04 NO FACILITY/BUSH/FIELD . . . . 05 OTHER(SPECIFY) 96 ________________________________ 303 Does your household have electricity? YES………………01 NO…………….. 02 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 68 10.1.3 Section C Household register … Describe the members in your household by completing the following table (TABLE 400) IF 5YRS OR OLDER IF 18YRS OR OLDER IF AGE 0-17YRS PERS ON NO. USUAL RESIDENTS REL’SHIP TO HEAD OF HH GENDER AGE MARITAL STATUS EDUCATION EMPLOYMEN T STATUS SICK PERSONS SURVIVORSHIP AND RESIDENCE OF BIOLOGICAL PARENTS Name of person who usually lives in your household starting with head of household What is the relationship of (name) to the head of the household (USE CODES) Is (name) male or female? 1=male; 2=female How old is (name) in years? (What is (name)’s current marital status Has (name) ever attended school? IF NO, SKIP TO (11) Y=1; N=2 What is the highest level of school (name) comple ted? (USE CODE S) Did (name) attend school during this year? Y=1; N=2 DK=98 Is (name) engaged in any paid work? If yes, what kind of employment or business? (USE CODES) Has (name) been very sick for at least 3 months during 2009, 2010 or 2011 so that (name) was too sick to work or do normal activities? Y=1; N=2 DK=98 Is (name)’s natural mother alive? (IF NO OR DK, SKIP) Does (name)’s natural mother usually live in this househol d? Y=MOTH ER’S LINE NO.; N=00 Is (name) ’s natural mother sick? Y=1; N=2 DK=98 Is (name)’s natural father alive? (IF NO OR DK, SKIP) Does (name)’s natural father usually live in this household? Y=FATHE R’S LINE NO.; N=00 Is (name)’s natural father sick? Y=1; N=2 DK=98 (1) (2) (3) (4) (5) (6) (7) (8) code (9) (10) (11) (12) (13) (14) (15) (16) (17) 01 02 03 04 05 06 07 08 09 CODES FOR Q(3): RELATIONSHIP TO HOUSEHOLD HEAD CODES FOR EMPLOYMENT STATUS 01- 01- HEAD 02- WIFE/HUSBAND / PARTNER BY MARRIAGE 03- SON/ DAUGHTER 04- SON-IN-LAW/ DAUGHTER-IN -LAW 05- GRANDCHILD 06- PARENT 07- PARENT-IN-LAW 08- BROTHER/SISTER 09- NIECE/NEPHEW BY BLOOD 10- NIECE/NEPHEW BY MARRIAGE 11- CO-WIFE 12- OTHER RELATIVE 13- ADOPTED/FOSTER/STEP CHILD 14- NOT RELATED 98- DON’T KNOW (DK) CODES FOR Q(6): MARITAL STATUS 1=MARRIED/ LIVING TOGETHER 2=DIVORCED/ SEPARATED 3=WIDOWED 4=NEVER MARRIED AND NEVER LIVED TOGETHER CODES FOR Q(8): EDUCATION 02- 01- NO SCHOOLING 03- 02- LESS THAN GRADE 8 04- 03- LESS THAN GRADE 12 05- 04- GRADE 12 (NOT COMPLETE) 06- 05- GRADE 12 (WITHOUT EXEMPTION) 07- 06- GRADE 12 (WITH EXEMPTION) 08- 07- A DIPLOMA WITH LESS THAN GRADE 12 09- 08- A CERTIFICATE WITH LESS THAN GRADE 12 10- 09- A DEPLOMA WITH GRADE 12 11- 10- A CERTIFICATE WITH GRADE 12 12- 11- BACHELOR DEGREE 13- 12- HONOURS DEGREE 14- 13- HIGHER DEGREE 15- 14- POST-GRADUATE DIPLOMA CODES FOR Q(10): EMPLOYMENT STATUS 16- 01- PERMANENT PAID EMPLOYEE 17- 02- TEMPORARY PAID EMPLOYEE 18- 03- SELF EMPLOYED 19- 04- WORKING EMPLOYER 20- 05- PAID VOLUNTEER 21- 06- UNPAID VOLUNTEER 07- UNEMPLOYED (18) Who else is available either 15- 18years (any gender) or above 18 years (another gender to you) who is available to answer some questions after our interview? (INSERT PERSON NO.) Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 69 10.1.4 Section D morbidity and treatment support Please complete for each sick person in your household? QUESTION CODING CATEGORIES SKIP 501 How many sick people aged 18-64 years (IF NONE, RECORD 00) (IF OO, SKIP TO 514) ENTER IN QUESTION 502 THE LINE NUMBER AND NAME OF EACH SICK PERSON AGE 18-64, BEGINNING WITH THE FIRST SICK PERSON LISTED TABLE 400 (THE HOUSEHOLD SCHEDULE). IF THERE ARE MORE THAN 3 SICK PEOPLE, USE ADDITIONAL QUESTIONNAIRE(S). READ THE INTRODUCTION THAT FOLLOWS. THEN ASK QUESTIONS 502 - 505 AS APPROPRIATE FOR EACH OF THE PERSONS AGED 18-64 REPORTED AS HAVING BEEN VERY SICK. You told me that in your household one (some) of the members of your household has(ve) been very sick during 2009, 2010, 2011 or 2012. We are interested in learning about the care and support that they may have received for that/each of those persons. 502 NAME AND LINE NUMBER FROM COLUMN 1 AND 2 OF THE HH SCHEDULE (TABLE 400) First sick person line number (insert code from first column) Name_____________ Second sick person line number (insert code from first column) Name_____________ Third sick person line number (insert code from first column) Name_____________ 503 Did (name) spend one night or more in a health facility during (NAME's) illness? YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 504 If yes, how many nights? 505 What illness did (NAME) have? (USE CODES – PROBE FOR THE MOST DOMINANT DISEASE) CODES FOR Q(505): ILLNESS FEVER, MALARIA 01 DIARRHOEA 02 STOMACH ACHE 03 FLU 07 VOMITING 04 UPPER RESPIRATORY (SINUSES) 05 LOWER RESPIRATORY (CHEST, LUNGS) 06 ASTHMA 08 HEADACHE 09 SKIN PROBLEM 10 DENTAL PROBLEM 11 EYE PROBLEM 12 EAR/NOSE/THROAT 13 BACKACHE 14 BURN 22 WOUND 24 HEART PROBLEM 15 BLOOD PRESSURE 16 PAIN WHEN PASSING URINE 17 DIABETES 18 MENTAL DISORDER 19 TB 20 SEXUALLY TRANSMITTED 21 BURN 22 FRACTURE 23 WOUND 24 UNSPECIFIED LONG￾TERM ILLNESS 27 HIV/AIDS 28 TYPHOID 29 POISONING 25 PREGNANCY RELATED 26 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 70 Medical Treatment Support 506 In 2009, 2010, 2011 or 2012, has your household received any medical support such as medical tests, medical care, supplies or medicine? YES………………01 NO…………….. 02 Don’t know………98 If NO, skip to 514 507 For which members of your household did you receive medical treatment or support? 508 NAME AND LINE NUMBER FROM COLUMN 1 AND 2 OF THE HH SCHEDULE (TABLE 400) First person line number (insert code from first column) Name_____________ Second person line number (insert code from first column) Name_____________ Third person line number (insert code from first column) Name_____________ 509 Who provided these services for (NAME)? (PROBE TO IDENTIFY THE TYPES OF ORGANISATIONS AND TICK THE APPROPRIATE CODE/CODES) (IF THEY CANNOT REMEMBER THE NAME, PROBE AN IDENTIFIER, EG. A PERSON WITH A RED T-SHIRT AND BARRET, A HOME-BASED CARE-GIVER, ETC.) NAME OF ORGANISATION NAME OF ORGANISATION NAME OF ORGANISATION 510 A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ 511 Who else supported the person to access medical services? (PROBE TO IDENTIFY THE TYPES OF ORGANISATIONS AND TICK THE APPROPRIATE CODE/CODES) (IF THEY CANNOT REMEMBER THE NAME, PROBE AN IDENTIFIER, EG. A PERSON WITH A RED T-SHIRT AND BARRET, A HOME-BASED CARE-GIVER, ETC.) NAME OF ORGANISATION NAME OF ORGANISATION NAME OF ORGANISATION 512 A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ 513 How far did they/you travel to get to these services? Service comes to us …. 1 Less than 2 KM …. 2 More than 2 KM but less Service comes to us …. 1 Less than 2 KM …. 2 More than 2 KM but less Service comes to us …. 1 Less than 2 KM …. 2 More than 2 KM but less Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 71 than 5 KM ………… 3 More than 5 KM but less than 10 KM ……… 4 More than 10 KM … . 5 than 5 KM ………… 3 More than 5 KM but less than 10 KM ……… 4 More than 10 KM … . 5 than 5 KM ………… 3 More than 5 KM but less than 10 KM ……… 4 More than 10 KM … . 5 Services of Interest 514 In 2009, 2010, 2011 or 2012, has anyone in your household received voluntary counselling and testing? YES………………01 NO…………….. 02 Don’t know………98 If NO, skip to 522 515 Which members of your household? 516 NAME AND LINE NUMBER FROM COLUMN 1 AND 2 OF THE HH SCHEDULE (TABLE 400) First person line number (insert code from first column) Name___________ __ Second person line number (insert code from first column) Name___________ __ Third person line number (insert code from first column) Name____________ _ 517 Who provided these services for (NAME)? (PROBE TO IDENTIFY THE TYPES OF ORGANISATIONS AND TICK THE APPROPRIATE CODE/CODES) (IF THEY CANNOT REMEMBER THE NAME, PROBE AN IDENTIFIER, EG. A PERSON WITH A RED T-SHIRT AND BARRET, A HOME-BASED CARE-GIVER, ETC.) NAME OF ORGANISATION NAME OF ORGANISATION NAME OF ORGANISATION 518 A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ 519 Who else supported the person to access VCT services? (PROBE TO IDENTIFY THE TYPES OF ORGANISATIONS AND TICK THE APPROPRIATE CODE/CODES) (IF THEY CANNOT REMEMBER THE NAME, PROBE AN IDENTIFIER, EG. A PERSON WITH A RED T-SHIRT AND BARRET, A HOME-BASED CARE-GIVER, ETC.) NAME OF ORGANISATION NAME OF ORGANISATION NAME OF ORGANISATION Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 72 520 A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ 521 How far did they/you travel to get to these services? Service comes to us …1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 Service comes to us …1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 Service comes to us …1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 522 In 2009, 2010, 2011 or 2012, has anyone in your household received care for Tuberculosis? YES………………01 NO…………….. 02 Don’t know………98 If NO, skip to 530 523 Which members of your household? 524 NAME AND LINE NUMBER FROM COLUMN 1 AND 2 OF THE HH SCHEDULE (TABLE 400) First person line number (insert code from first column) Name___________ __ Second person line number (insert code from first column) Name___________ __ Third person line number (insert code from first column) Name____________ _ 525 Who provided these services for (NAME)? (PROBE TO IDENTIFY THE TYPES OF ORGANISATIONS AND TICK THE APPROPRIATE CODE/CODES) (IF THEY CANNOT REMEMBER THE NAME, PROBE AN IDENTIFIER, EG. A PERSON WITH A RED T-SHIRT AND BARRET, A HOME-BASED CARE-GIVER, ETC.) NAME OF ORGANISATION NAME OF ORGANISATION NAME OF ORGANISATION 526 A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ 527 Who else supported the person to access TB services? (PROBE TO IDENTIFY THE TYPES OF NAME OF ORGANISATION NAME OF ORGANISATION NAME OF ORGANISATION Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 73 ORGANISATIONS AND TICK THE APPROPRIATE CODE/CODES) (IF THEY CANNOT REMEMBER THE NAME, PROBE AN IDENTIFIER, EG. A PERSON WITH A RED T-SHIRT AND BARRET, A HOME-BASED CARE-GIVER, ETC.) 528 A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ 529 How far did they/you travel to get to these services? Service comes to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 Service comes to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 Service comes to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 530 In 2009, 2010, 2011 or 2012, has anyone in your household received PMTCT services? YES………………01 NO…………….. 02 Don’t know………98 If NO, skip to Section E 531 Which members of your household? 532 NAME AND LINE NUMBER FROM COLUMN 1 AND 2 OF THE HH SCHEDULE (TABLE 400) First person line number (insert code from first column) Name___________ __ Second person line number (insert code from first column) Name___________ __ Third person line number (insert code from first column) Name____________ _ 533 Who provided these services for (NAME)? (PROBE TO IDENTIFY THE TYPES OF ORGANISATIONS AND TICK THE APPROPRIATE CODE/CODES) (IF THEY CANNOT REMEMBER THE NAME, PROBE AN IDENTIFIER, EG. A PERSON WITH A RED T-SHIRT AND BARRET, A HOME-BASED CARE-GIVER, ETC.) NAME OF ORGANISATION NAME OF ORGANISATION NAME OF ORGANISATION 534 A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation A: ____________ B: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 74 C: ____________ C: ____________ C: ____________ 535 Who else supported the person to PMTCT services? (PROBE TO IDENTIFY THE TYPES OF ORGANISATIONS AND TICK THE APPROPRIATE CODE/CODES) (IF THEY CANNOT REMEMBER THE NAME, PROBE AN IDENTIFIER, EG. A PERSON WITH A RED T-SHIRT AND BARRET, A HOME-BASED CARE-GIVER, ETC.) NAME OF ORGANISATION NAME OF ORGANISATION NAME OF ORGANISATION 536 A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ A: ____________ B: ____________ C: ____________ C: ____________ C: ____________ 537 How far did they/you travel to get to these services? Service comes to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 Service comes to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 Service comes to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 10.1.5 Section E mortality Complete the following table (Table 600) describing anyone in your household who has died in the last five years. Name of person Age at death Gender Year they passed away Relationship to Head of Household Cause of death (1) (IF NO-ONE=00) (2) (3) (4) (5) (USE CODES) (6) (USE CODES) ….years old MALE………………01 FEMALE…………….. 02 CODES FOR Q(5): RELATIONSHIP TO HOUSEHOLD HEAD CODES FOR EMPLOYMENT STATUS CODES FOR Q(6): CAUSE OF DEATH Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 75 22- 01- HEAD 02- WIFE/HUSBAND / PARTNER BY MARRIAGE 03- SON/ DAUGHTER 04- SON-IN-LAW/ DAUGHTER-IN -LAW 05- GRANDCHILD 06- PARENT 07- PARENT-IN-LAW 08- BROTHER/SISTER 09- NIECE/NEPHEW BY BLOOD 10- NIECE/NEPHEW BY MARRIAGE 11- CO-WIFE 12- OTHER RELATIVE 13- ADOPTED/FOSTER/STEP CHILD 14- NOT RELATED 98- DON’T KNOW (DK) 1= MALARIA 2=PNEMONIA 3=AIDS 4=TETANUS 5=TB 6=MALNUTRITION 7=ANAEMIA 8=CHILD BIRTH/PREGNANCY 9=SUDDEN DEATH 10=ASTHMA 11=CANCER 12=URINARY OBSTRUCTION 13=POISINING 14=SUICIDE 15=ACCIDENT 16=MEASLES 17=OTHER (SPECIFY…._ 98=DON’T KNOW 10.1.6 Section F Social Protection 701 Who in the household receives a grant? (COMPLETE 702) What type of grant? (COMPLETE 703) 702 Person A line number (insert code from first column, Table 400) Name___________ Person B line number (insert code from first column, Table 400) Name___________ Person C line number (insert code from first column, Table 400) Name___________ Person D line number (insert code from first column, Table 400) Name___________ 703 GRANT FOR OLDER PERSONS……………01 DISABILITY GRANT….….. 02 WAR VETERANS GRANT……03 CHILD GRANT FOR FOSTER CARE……. 04 CARE DEPENDENCY GRANT… 05 CHILD SUPPORT GRANT……………… 06 GRANT IN AID (for older persons needing help)………………… 07 GRANT FOR OLDER PERSONS……………01 DISABILITY GRANT….….. 02 WAR VETERANS GRANT……03 CHILD GRANT FOR FOSTER CARE……. 04 CARE DEPENDENCY GRANT… 05 CHILD SUPPORT GRANT……………… 06 GRANT IN AID (for older persons needing help)………………… 07 GRANT FOR OLDER PERSONS……………01 DISABILITY GRANT….….. 02 WAR VETERANS GRANT……03 CHILD GRANT FOR FOSTER CARE……. 04 CARE DEPENDENCY GRANT… 05 CHILD SUPPORT GRANT……………… 06 GRANT IN AID (for older persons needing help)………………… 07 GRANT FOR OLDER PERSONS……………01 DISABILITY GRANT….….. 02 WAR VETERANS GRANT……03 CHILD GRANT FOR FOSTER CARE……. 04 CARE DEPENDENCY GRANT… 05 CHILD SUPPORT GRANT……………… 06 GRANT IN AID (for older persons needing help)………………… 07 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 76 HIV/AIDS GRANT….. 08 OTHER (SPECIFY)….. HIV/AIDS GRANT….. 08 OTHER (SPECIFY)….. HIV/AIDS GRANT….. 08 OTHER (SPECIFY)….. HIV/AIDS GRANT….. 08 OTHER (SPECIFY)….. 10.1.7 Section G Material Support Material support refers to clothing, food or other donations 801 In 2009, 2010, 2011 or 2012, did anyone in your household receive any material support such as clothing, food or other donations? YES………………01 NO…………….. 02 Don’t know………98 If NO, skip to 806 802 Which members of your household? (COMPLETE 803) 803 NAME AND LINE NUMBER FROM COLUMN 1 AND 2 OF THE HH SCHEDULE (TABLE 400) First person line number (insert code from first column) Name___________ __ Second person line number (insert code from first column) Name___________ __ Third person line number (insert code from first column) Name____________ _ 804 From whom was support received? A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation D: A tent put up by the Civil Society Organisation NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ 805 How far did you travel to get to these services? Service came to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 Service came to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 Service came to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 77 806 Can people in your community get material support services? YES………………01 NO…………….. 02 DON’T KNOW…..03 YES………………01 NO…………….. 02 DON’T KNOW…..03 YES………………01 NO…………….. 02 DON’T KNOW…..03 807 From whom can they receive such support? A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation D: A tent put up by the Civil Society Organisation NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ 808 How far would you travel to get to these services? Service came to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 Service came to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 Service came to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 10.1.8 Section H Household Economic Strengthening Household economic strengthening refers to interventions that support people in starting their own business, participating in community interventions that create provision for the household, creating your own food supply and other activities that strengthen your ability as a household to earn income. 901 In 2009, 2010, 2011 or 2012, did anyone in your household receive any support to improve your ability as a household to earn an income material support such as clothing, food or other donations? YES………………01 NO…………….. 02 Don’t know………98 If NO, skip to 907 902 Which members of your household? (COMPLETE 903) 903 NAME AND LINE NUMBER FROM COLUMN 1 AND 2 OF THE HH SCHEDULE (TABLE 400) First person line number (insert code from first column) Name___________ __ Second person line number (insert code from first column) Name___________ __ Third person line number (insert code from first column) Name____________ _ Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 78 904 From whom was support received? A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation D: A tent put up by the Civil Society Organisation NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ 905 What type of support was received? (open-ended question) 906 How far did you travel to get to these services? Service came to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 Service came to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 Service came to us …. 1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………………3 More than 5 KM but less than 10 KM ….……………… 4 More than 10 KM …….. 5 907 Can people in your community get such support services? YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 908 If yes, from whom? A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation D: A tent put up by the Civil Society Organisation NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ 909 How far did you travel to get to these services? Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 10.1.9 Section I Social Support This refers to support such as help in household work, training for a caregiver, training to become a volunteer, legal services and similar social support Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 79 1001 In 2009, 2010, 2011 or 2012, did anyone in your household receive any social support such as help in household work, training for a caregiver, training to become a volunteer, legal services and similar social support? YES………………01 NO…………….. 02 Don’t know………98 If NO, skip to 1007 1002 Which members of your household? (COMPLETE 1003) 1003 NAME AND LINE NUMBER FROM COLUMN 1 AND 2 OF THE HH SCHEDULE (TABLE 400) First person line number (insert code from first column) Name___________ __ Second person line number (insert code from first column) Name___________ __ Third person line number (insert code from first column) Name____________ _ 1004 From whom was support received? A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ 1005 What type of support was social support was received? (open-ended question) 1006 How far did you travel to get to these services? Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 1007 Can people in your community get such support services? YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 1008 If yes, from whom? A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation D: A tent put up by the Civil Society Organisation NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ 1009 How far would you travel to get to these services? Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 80 than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 10.1.10 section J Psychosocial Support This refers to support such as having someone available to talk to, having someone assist you with anything related to going for VCT, PMTCT or TB testing, checking on whether medication is taken and other similar activities. 1101 In 2009, 2010, 2011 or 2012, did anyone in your household receive any psycho￾social support such having someone available to talk to, having someone assist you with anything related to going for VCT, PMTCT or TB testing, checking on whether medication is taken, becoming part of an HIV-related support group and other similar activities? YES………………01 NO…………….. 02 Don’t know………98 If NO, skip to 1102 Which members of your household? (COMPLETE 1103) 1103 NAME AND LINE NUMBER FROM COLUMN 1 AND 2 OF THE HH SCHEDULE (TABLE 400) First person line number (insert code from first column) Name___________ __ Second person line number (insert code from first column) Name___________ __ Third person line number (insert code from first column) Name____________ _ 1104 From whom was support received? A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation D: A tent put up by the Civil Society Organisation NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ 1105 What type of support was psycho￾social support was received? (open-ended question) 1106 How far did you travel to get to these Service came to us ….1 Less than 2 KM …. 2 Service came to us ….1 Less than 2 KM …. 2 Service came to us ….1 Less than 2 KM …. 2 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 81 services? More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 1107 Can people in your community get such support services? YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 1108 If yes, from whom? A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation D: A tent put up by the Civil Society Organisation NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ 1109 How far did you travel to get to these services? Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 10.1.11 Section K Educational Support This refers to provision of pamphlets and information as well as talks relating to HIV and AIDS 1201 In 2009, 2010, 2011 or 2012, did anyone in your household receive any pamphlets and information as well as talks relating to HIV and AIDS? YES………………01 NO…………….. 02 Don’t know………98 If NO, skip to 1202 Which members of your household? (COMPLETE 1203) 1203 NAME AND LINE NUMBER FROM COLUMN 1 AND 2 OF THE HH SCHEDULE (TABLE 400) First person line number (insert code from first column) Name___________ Second person line number (insert code from first column) Name___________ Third person line number (insert code from first column) Name____________ Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 82 __ __ _ 1204 From whom was support received? A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation D: A tent put up by the Civil Society Organisation NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ 1205 What type of support was received? (open-ended question) 1206 How far did you travel to get to these services? Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 Service came to us ….1 Less than 2 KM …. 2 More than 2 KM but less than 5 KM ……………3 More than 5 KM but less than 10 KM ………… 4 More than 10 KM ….. 5 1207 Can people in your community get such support services? YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 1208 If yes, from whom? A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation D: A tent put up by the Civil Society Organisation NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ 1209 From whom was support received? A: Government facility (hospital) B: Government facility (clinic) C: Civil Society Organisation D: A tent put up by the Civil Society Organisation NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ NAME OF ORGANISATION: A: ____________ B: ____________ C: ____________ C: ____________ D: ____________ CONCLUDING REMARKS 1301 Are you willing to now complete a 20 minute participant form? YES………………01 NO…………….. 02 If yes, move to 1303 If no, move to 1302 1302 Thank you for your time in completing the household information. Who in your household (18 NAME………………01 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 83 years or older) is available to complete a 20 minute participant form with me? R10 voucher provided to interviewee: NAME…………….. 02 NAME………………03 NAME…………….. 04 YES………………01 NO…………….. 02 1303 Thank you for being willing to continue with the participant form? Before I proceed with your participant form, could you please tell me who else in your household (18 years or older) is available to complete a 20 minute participant form with me? NAME………………01 NAME…………….. 02 NAME………………03 NAME…………….. 04 Ensure at least two persons can complete the participant form 1304 ONLY FOR TREATMENT SITES (TZANEEN, TONGA AND DRIEKOPPIES) NOTE TO INTERVIEWER: This question will assist you to prioritise who to speak to in the household (interview those listed under (A), then (B), then (C), then (D) – maximum of the top four to be interviewed Could you please tell me who in your household.. (A) IS OR WAS AT SOME POINT ACTIVE AS A PASSIONATE IN THE COMMUNITY? (NAME)………………01 (NAME)………………02 (B) IS OR WAS TCE COMPLIANT? (NAME)………………01 (NAME)………………02 (C) KNOWS THEIR STATUS? (NAME)………………01 (NAME)………………02 (D) HAS MORE INFORMATION AND UNDERSTANDING OF HIV DUE TO TCE? (NAME)………………01 (NAME)………………02 1305 After completing your interview, may I proceed with interviewing the (name the top participants listed)? YES………………01 NO…………….. 02 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 84 Household number Questionnaire no. Participant number Date of interview Interviewer number Quality controlled (Epi-centre): Team number Follow-up required (Feedback): PARTICIPANT FORM - HOUSEHOLD SURVEY TCE HIV PREVENTION PROGRAM INSTRUCTION TO INTERVIEWER: THIS FORM IS COMPLETED ONLY AFTER COMPLETION OF THE COMPOSITION FORM Note 1: (TREATMENT SITES ONLY – TZANEEN, TONGA AND DRIEKOPPIES): Ensure you interview the HH survey participant who have had the most exposure to TCE based on inputs provided to question 1304 (start with those listed in (A), then (B), etc. Do not interview anyone in Tzaneen, Tonga and Driekoppies who has not been exposed to TCE. Note 2: (COMPARISON SITES ONLY – MANKWENG, MATSULU A AND MATSULU B): Should a HH survey participant have had exposure to TCE, do not continue the interview. Note 3: At least two eligible participants should complete this form in each household. Eligible participants meet the age criteria (18 years and older) and quota’s provided by Humana for gender breakdown reached (60% female and 40% male) 1401 Are you willing to complete a 20 minute participant form? YES……………… 01 YES, BUT NOT RIGHT NOW…….02 NO…………….. 03 If yes, move to 1404 If yes, but not now, move to 1403 If no, move to 1402 1402 If no… End the interview and move to the next person 1403 If yes, but not right now… When can I come back to interview you? DATE……………… TIME…………….. 1404a ONLY FOR TREATMENT SITES (TZANEEN, TONGA AND DRIEKOPPIES) NOTE TO INTERVIEWER: This question will assist you to clarify the level of exposure of the participant to TCE and to determine whether you continue the interview Could you please tell me... MARK THE HIGHEST RESPONSE (i) WERE YOU AT SOME POINT ACTIVE AS A PASSIONATE IN THE COMMUNITY THROUGH THE TCE PROGRAM? YES………………01 NO…………….. 02 (ii) WERE YOU TCE COMPLIANT? YES………………01 NO…………….. 02 (iii) DID YOU KNOW YOUR STATUS AS A RESULT OF TCE? YES………………01 NO…………….. 02 (iv) DID YOU HAVE MORE INFORMATION AND UNDERSTANDING OF HIV DUE TO TCE? YES………………01 NO…………….. 02 If no exposure to TCE, end the interview 1404b Are there members in your household who you believe have had more exposure to TCE than you have had? YES………………01 NAME A: ____________ NAME B: ____________ NAME C: ____________ NAME D: ____________ NO…………….. 02 If there are at least two other members in the HH with more exposure who are available, end the interview and ask to speak to (A), (B), etc. 1404c ONLY FOR COMPARISON SITES (MANKWENG, MATSULU A & MATSULU B) NOTE TO INTERVIEWER: This question will assist you to determine whether you continue the interview Could you please tell me, have you ever been visited by a TCE person with a red t-shirt and a red barrette YES………………01 NO…………….. 02 If yes, end the interview 1405 Thank you for being willing to complete the participant form with me? Before we start, I have an information sheet for you and Consent signed YES………………01 NO…………….. 02 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 85 you must sign consent so that we can proceed with the discussion (read introduction and obtain signed consent Information sheet provided to interviewee YES………………01 NO…………….. 02 10.1.12 Section L knowledge, attitude and practice In the questions below I would like to determine your knowledge, attitude and practice relating to HIV and AIDS QUESTION CODING CATEGORIES SKIP 1501 Have you ever heard of an illness called AIDS? YES………………01 NO…………….. 02 (If no, skip to 1122) 1502 Can people reduce their chance of getting the HIV virus by having just one uninfected sex partner who has sexual intercourse with no other partners? YES………………01 NO…………….. 02 DON’T KNOW…..98 1503 Can people get the HIV virus from mosquito or other insect bites? YES………………01 NO…………….. 02 DON’T KNOW…..98 1504 Can people reduce their chance of getting the HIV virus by using a condom every time they have sex? YES………………01 NO…………….. 02 DON’T KNOW…..98 1505 Can people get the HIV virus by sharing utensils with a person who has AIDS? YES………………01 NO…………….. 02 DON’T KNOW…..98 1506 Can people get the HIV virus because of witchcraft or other supernatural means? YES………………01 NO…………….. 02 DON’T KNOW…..98 1507 Is it possible for a healthy-looking person to have the HIV virus? YES………………01 NO…………….. 02 DON’T KNOW…..98 1508 Do you think that your chances of getting AIDS are small, moderate or great or is there no risk at all? YES………………01 NO…………….. 02 DON’T KNOW…..98 1509 Do you think you can get HIV if you help someone who is bleeding and you touch their blood? YES………………01 NO…………….. 02 DON’T KNOW…..98 1510 From which source have you learned most about HIV and AIDS? (RECORD ONLY ONE RESPONSE) RADIO . . . . . . . . . . . . . . . . . . . . . . . . . A TELEVISION . . . . . . . . . . . . . . . . . . B FILM . . . . . . . . . . . . . . . . . . . . . . . . . C DRAMA . . . . . . . . . . . . . . . . . . . . . . . D NEWSPAPERS/MAGAZINES ……….E BROCHURES . . . . . . . . . . . . . . . . F POSTERS . . . . . . . . . . . . . . . . . . . . . G BILLBOARDS . . . . . . . . . . . . . . . . H COMMUNITY NOTICES . . . . . . . I FAMILY . . . . . . . . . . . . . . . . . . . . . . . J FRIENDS . . . . . . . . . . . . . . . . . . . . . K PEERS . . . . . . . . . . . . . . . . . . . . . . . L HEALTH WORKERS . . . . . . . . . . . M TEACHERS . . . . . . . . . . . . . . . . . . . . . N POLITICAL LEADERS . . . . . . . . . O TRADITIONAL LEADERS . . . . . . . P RELIGIOUS LEADERS . . . . . . . . . Q INTERNET…………………………. R TCE PEOPLE WITH RED T-SHIRTS AND RED BARRETS……………………………. S OTHER X (SPECIFY) . . . . . . . . . . . . . . . . . . . . . 1511 What are the three most important messages you have learned about HIV and AIDS from this resource? (RECORD ONLY ONE RESPONSE) ABSTAIN FROM SEX . . . . . . . . . . .A USE CONDOMS . . . . . . . . . . . . . . . .B LIMIT SEX TO ONE PARTNER/STAY FAITHFUL TO ONE PARTNER……… C LIMIT NUMBER OF SEXUAL PARTNERS . . . D FOLLOW THE ABC'S . . . . . . . . . . . E AVOID SEX WITH PROSTITUTES…F AVOID SEX WITH PERSONS WHO…G HAVE MANY PARTNERS………….H AVOID SEX WITH HOMOSEXUALS…….I AVOID SEX WITH PERSONS WHO……..J INJECT DRUGS INTRAVENOUSLY…….K AVOID BLOOD TRANSFUSIONS...............L ANTI-RETROVIRAL DRUGS AVAILABLE….M PREVENT MOTHER-TO-CHILD TRANSMISSION….N AVOID DISCRIMINATION AGAINST PERSONS LIVING WITH AIDS……. O Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 86 ANYONE CAN GET AIDS…………P GET TESTED FOR AIDS (HIV)…….Q AIDS IS A KILLER…………………..R DON'T TAKE CHANCES…………….S OTHER ………X (SPECIFY)……………………………………………… 1512 Can the virus that causes AIDS be transmitted from a mother to her baby: During pregnancy? During delivery? By breastfeeding? Yes=1 No=2 DK=98 During pregnancy? YES………………01 NO…………….. 02 DON’T KNOW…..98 During delivery? YES………………01 NO…………….. 02 DON’T KNOW…..98 By breastfeeding? YES………………01 NO…………….. 02 DON’T KNOW…..98 1513 Are there any drugs that a doctor or nurse can give to a woman infected with the HIV virus to reduce the risk of transmission to the baby? YES………………01 NO…………….. 02 DON’T KNOW…..98 1514 Have you heard of any special drugs that people infected with the HIV virus can take to help them live longer? YES………………01 NO…………….. 02 If no, skip to 1122 1515 What drugs do you know about? PROBE: Any other drugs? RECORD ALL MENTIONED. ANTI-RETROVIRAL DRUGS (ARVs) A SEPTRIN/COTRIMOXAZOLE B HERBAL DRUGS . . . . . . . . . . . . . . . . C OTHER DRUGS X (SPECIFY) DON'T KNOW . . . . . . . . . . . . . . . . . . Z 1516 For how long should a person with the HIV virus take ARVs? LESS THAN ONE YEAR . . . . . . . . . 1 ONE YEAR OR MORE . . . . . . . . . . . 2 REST OF LIFE . . . . . . . . . . . . . . . . . . 3 OTHER 96 (SPECIFY)…………………………… DON'T KNOW . . . . . . . . . . . . . . . . . . 98 1517 How old should a person be before being taught about using a condom to prevent HIV and AIDS? OPEN ENDED 1518 Have you ever heard of VCT? YES………………01 NO…………….. 02 NOT SURE…..98 1519 If a trained counsellor came to your home and offered you free HIV counselling and testing, would you be willing to have an HIV test done in your home? YES………………01 NO…………….. 02 NOT SURE…..98 1520 Have you received any support from someone who came to your home and encouraged you to go for VCT? If so, who was it? YES………………01 Name of organisation (identifier)____________________________ NO…………….. 02 NOT SURE…..98 1521 What else have you received from this person that has made a positive change in your life? RECORD ALL MENTIONED. SOMEONE TO TALK TO………01 SOMEONE TO SUPPORT ME WHEN GOING FOR HIV AND AIDS RELATED SERVICES……..02 PROVIDING THE CORRECT INFORMATION AND KNOWLEDGE ON HIV AND AIDS……….03 BECOMING PART OF A SUPPORT GROUP………04 BECOMING A PASSIONATE…………………05 OTHER 06 (SPECIFY)……………. …………………………………….. 1522 Have you ever used a condom? YES………………01 NO…………….. 02 NOT SURE…..98 1523 It is okay to re-use a condom after washing it? YES………………01 NO…………….. 02 NOT SURE…..98 1524 Condoms protect against sexually transmitted diseases YES………………01 NO…………….. 02 NOT SURE…..98 1525 Condoms contain HIV YES………………01 NO…………….. 02 NOT SURE…..98 1526 Buying/getting condoms is embarrassing YES………………01 NO…………….. 02 NOT SURE…..98 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 87 10.1.13 Section M STIGMA 1601 Would you buy fresh vegetables from a vendor who has the HIV virus? YES………………01 NO…………….. 02 NOT SURE…..98 1602 If a member of your family got infected with the virus that causes AIDS, would you want it to remain a secret or not? YES, REMAIN A SECRET………………01 NO…………….. 02 DK/NOT SURE…..98 1603 If a teacher has the HIV virus, should she be allowed to continue teaching in the school? SHOULD BE ALLOWED . . . . . . . . . 1 SHOULD NOT BE ALLOWED ……..2 DK/NOT SURE/DEPENDS . . . . . . . 98 1604 If a relative of yours became sick with the virus that causes AIDS, would you be willing to care for her or him in your own household? YES………………01 NO…………….. 02 DK/NOT SURE…..98 1605 Do you personally know someone who has been denied involvement in social events, religious services, or community events in the last 12 months because he or she is suspected to have the HIV virus or has the HIV virus? YES………………01 NO…………….. 02 1606 Do you personally know someone who has been verbally abused or teased in the last 12 months because he or she is suspected to have the HIV virus or has the HIV virus? YES………………01 NO…………….. 02 Do you agree or disagree with the following statements… 1607 People with the HIV virus should be ashamed of themselves AGREE………………01 DISAGREE…………….. 02 DK/NO OPINION …..98 1608 People with the HIV virus should be blamed for bringing the disease into the community AGREE………………01 DISAGREE…………….. 02 DK/NO OPINION …..98 10.1.14 Section N TRANSACTIONAL SEX INSTRUCTION TO INTERVIEWER: MAKE SURE THESE QUESTIONS ARE ASKED IN A PRIVATE PLACE AND NO ONE ELSE IS PRESENT, ANDNO ONE ELSE CAN HEAR THE QUESTIONS BEING ASKED Now I would like to ask you some questions about your recent sexual activity. Let me assure you once again that your answers are completely confidential. Your personal information will be separated from your responses so that no one will be able to link your responses to you. 1701 In the last 12 months, were you paid / did you pay anyone in exchange for having sexual intercourse? YES………………01 NO…………….. 02 (IF NO, SKIP TO 1401) 1702 In the last 12 months, were you given anything (clothes, food, gifts) / did you give anyone anything (clothes, food, gifts) in exchange for having sexual intercourse? YES………………01 NO…………….. 02 (IF NO, SKIP TO 1401) 1703 Did you know if the person with whom you had sex that time had ever been tested for the HIV virus? YES………………01 NO…………….. 02 1704 Did that person tell you the result of their HIV test? YES………………01 NO…………….. 02 (IF NO, SKIP TO 1306) 1705 Did the test show that the person had the HIV virus? YES………………01 NO…………….. 02 1706 Did you tell this person your HIV status? YES………………01 NO…………….. 02 1707 The last time you were paid or paid someone in exchange for sexual intercourse, was a condom used? YES………………01 NO…………….. 02 1708 The last time you were given anything (clothes, food, gifts) or gave anything (clothes, food, gifts) to someone in exchange for sexual intercourse, was a condom used? YES………………01 NO…………….. 02 1709 Was a condom used during sexual intercourse every time you were paid or paid someone in exchange for having sexual intercourse in the last 12 months? YES………………01 NO…………….. 02 1710 Was a condom used during sexual intercourse every time you were you were given anything (clothes, food, gifts) or gave anything (clothes, food, gifts) to someone in exchange for having sexual intercourse in the last 12 months? YES………………01 NO…………….. 02 10.1.15 Section o partnering Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 88 1801 Are you currently married or living together with a man as if married? YES, CURRENTLY MARRIED………………01 YES, CURRENTLY WITH A MAN…………. 02 NO, NOT IN UNION…………….. 03 (IF YES (01 OR 02), SKIP TO 1404) 1802 Have you ever been married or lived together with a man as if married? YES, FORMELY MARRIED…………………… 01 YES, LIVED WITH A MAN ………………02 NO…………….. 03 (IF NO (03), SKIP TO 1308) 1803 What is your marital status now -are you widowed, divorced or separated? WIDOWED……………………………………… 1 DIVORCED……………………………………… 2 SEPARATED…………………………………… 3 (SKIP TO 1308) (SKIP TO 1308) (SKIP TO 1308) 1804 Is your husband or partner living with you or is he staying elsewhere? LIVING TOGETHER…………………………… 1 STAYING ELSEWHERE……………………… 2 1805 Does your husband/partner have other wives or does he live with other women as if married? YES………………01 NO…………….. 02 DK……………….03 1806 Including yourself, in total, how many wives or other partners does your husband live with now as if married? IF DON'T KNOW RECORD 98 Other wives/partners = _______________ 1807 How old was your husband or partner at his last birthday? IF DON'T KNOW RECORD 98 Age at last birthday: First husband/partner = _______________ Second husband/partner = _____________ Third husband/partner = _______________ 1808 When was the last time you were tested for the HIV virus? WITHIN THE LAST 3 MONTHS………………… 1 MORE THAN 3 MONTHS AGO BUT LESS THAN A YEAR AGO…………………… 2 MORE THAN A YEAR AGO…………………… 3 CAN'T REMEMBER…………………………….. 4 NEVER BEEN TESTED…………………………. 5 1809 Do you know your status? YES………………01 NO…………….. 02 1810 Are you willing to tell us your status? If yes… YES, I AM HIV NEGATIVE………………01 YES, I AM HIV POSITVE…………………02 NO, I AM NOT WILLING TO SHARE MY STATUS…………………..…………….. 03 1811 In total how many different people have you had sexual intercourse with in the last 12 months? IF NONE, RECORD 00 NUMBER OF SEXUAL PARTNERS___________ IF '00' SKIP TO 644 RECENT SEXUAL HISTORY… COMPLETE THE QUESTIONS BELOW: LAST SEXUAL PARTNER SECOND TO LAST SEXUAL PARTNER THIRD TO LAST SEXUAL PARTNER 1912 When was the last time you had sexual intercourse? DAYS……………………... 1 WEEKS……………………. 2 MONTHS………………….. 3 YEARS……………………….4 DAYS……………………... 1 WEEKS……………………. 2 MONTHS………………….. 3 YEARS……………………….4 DAYS……………………... 1 WEEKS……………………. 2 MONTHS………………….. 3 YEARS……………………….4 1913 FOCUS ON LAST SEXUAL PARTNER AND COMPLETE 1913-1926 The last time you had sexual intercourse (with the last, second to last, third to last), sexual partner, was a condom used? YES………………01 NO…………….. 02 DON’T REMEMBER….03 YES………………01 NO…………….. 02 DON’T REMEMBER….03 YES………………01 NO…………….. 02 DON’T REMEMBER….03 1914 Was a condom used every time you had sexual intercourse with the (last, second to last, third to last) partner in the past 12 months? YES………………01 NO…………….. 02 DON’T REMEMBER….03 YES………………01 NO…………….. 02 DON’T REMEMBER….03 YES………………01 NO…………….. 02 DON’T REMEMBER….03 1915 What was your relationship to this (second, third) person with whom you had sexual intercourse? HUSBAND………….. 1 LIVE-IN PARTNER…………2 BOYFRIEND BUT NOT LIVE￾IN…. 3 CASUAL ACQUAINTANCE. 4 PROSTITUTE………………. 5 OTHER …………………….6 (SPECIFY) ………………………………… HUSBAND………….. 1 LIVE-IN PARTNER…………2 BOYFRIEND BUT NOT LIVE￾IN…. 3 CASUAL ACQUAINTANCE. 4 PROSTITUTE………………. 5 OTHER …………………….6 (SPECIFY) ………………………………… HUSBAND………….. 1 LIVE-IN PARTNER…………2 BOYFRIEND BUT NOT LIVE￾IN…. 3 CASUAL ACQUAINTANCE. 4 PROSTITUTE………………. 5 OTHER …………………….6 (SPECIFY) ………………………………… 1916 Do you currently have a relationship with this sexual partner? YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 1917 How long have you had or did you have a sexual relationship with this person? DAYS……………………... 1 WEEKS……………………. 2 MONTHS………………….. 3 YEARS……………………….4 DAYS……………………... 1 WEEKS……………………. 2 MONTHS………………….. 3 YEARS……………………….4 DAYS……………………... 1 WEEKS……………………. 2 MONTHS………………….. 3 YEARS……………………….4 1918 Do you know if this person was ever tested for HIV virus? YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 89 NOT SURE….03 NOT SURE….03 NOT SURE….03 1919 Did this person tell you the result of their test? YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 1920 Did the result of the test show that the person had the HIV virus? YES………………01 NO…………….. 02 NO RESPONSE….03 YES………………01 NO…………….. 02 NO RESPONSE….03 YES………………01 NO…………….. 02 NO RESPONSE….03 1921 Did you share the results of your AIDS test with this partner? YES………………01 NO…………….. 02 NEVER BEEN TESTED….03 YES………………01 NO…………….. 02 NEVER BEEN TESTED….03 YES………………01 NO…………….. 02 NEVER BEEN TESTED….03 1922 Is this person older than you, younger than you, or about the same age as you? OLDER…………………….. 1 YOUNGER………………… 2 ABOUT THE SAME AGE…. 3 DON'T KNOW…………….. 4 OLDER…………………….. 1 YOUNGER………………… 2 ABOUT THE SAME AGE…. 3 DON'T KNOW…………….. 4 OLDER…………………….. 1 YOUNGER………………… 2 ABOUT THE SAME AGE…. 3 DON'T KNOW…………….. 4 1923 Would you say this person is ten or more years older /younger than you or less than ten years older / younger than you? TEN OR MORE YEARS OLDER............ 1 LESS THAN TEN YRS OLDER….......... 2 TEN OR MORE YEARS YOUNGER............. 3 LESS THAN TEN YRS YOUNGER….......... 4 UNSURE HOW MUCH…… 5 TEN OR MORE YEARS OLDER............ 1 LESS THAN TEN YRS OLDER….......... 2 TEN OR MORE YEARS YOUNGER............. 3 LESS THAN TEN YRS YOUNGER….......... 4 UNSURE HOW MUCH…… 5 TEN OR MORE YEARS OLDER............ 1 LESS THAN TEN YRS OLDER….......... 2 TEN OR MORE YEARS YOUNGER............. 3 LESS THAN TEN YRS YOUNGER….......... 4 UNSURE HOW MUCH…… 5 1924 Do you and your partner drink any alcohol? YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 YES………………01 NO…………….. 02 1925 The last time you had sexual intercourse with this person, did you or this person drink alcohol? YES………………01 NO…………….. 02 IF NO SKIP TO 2001 YES………………01 NO…………….. 02 IF NO SKIP TO 2001 YES………………01 NO…………….. 02 IF NO SKIP TO 2001 1926 Were you or your partner drunk at the time? If yes, who was drunk? RESPONDENT ONLY…….. 1 PARTNER ONLY…………. 2 BOTH RESPONDENT AND PARTNER……………. 3 NEITHER…………………… 4 RESPONDENT ONLY…….. 1 PARTNER ONLY…………. 2 BOTH RESPONDENT AND PARTNER……………. 3 NEITHER…………………… 4 RESPONDENT ONLY…….. 1 PARTNER ONLY…………. 2 BOTH RESPONDENT AND PARTNER……………. 3 NEITHER…………………… 4 GO BACK TO 1912 FOR THE NEXT PARTNER OR, IF NO MORE PARTNERS GO TO THE NEXT QUESTION (2001) Please tell me if you strongly agree , somewhat agree, somewhat disagree , strongly disagree with the following statements. strongly agree somewhat agree somewhat disagree strongly disagree 2001 a. It is ok for girls to initiate sexual activity 1 2 3 4 1 2 3 4 b. Once you have sex with a partner it's difficult to say no in the future 1 2 3 4 1 2 3 4 c. Parents have different expectations from girls vs. boys 1 2 3 4 1 2 3 4 d. In general, boys and girls want the same thing out of a relationship 1 2 3 4 1 2 3 4 e. Boys depend on girls for information about sexual health 1 2 3 4 1 2 3 4 f. there is a double standard for boys and girls when it comes to sex, that it is ok for boys to have a lot of partners but not for girls 1 2 3 4 1 2 3 4 g. it is easier for girls to say NO to sex than it is for boys 1 2 3 4 1 2 3 4 h. Most people have sex before they are really ready 1 2 3 4 1 2 3 4 i. Oral sex is not as big of a deal as sexual intercourse 1 2 3 4 1 2 3 4 j. A man can be sexually satisfied with one wife and no other sexual partner 1 2 3 4 1 2 3 4 k. A woman can be sexually satisfied with one husband and no other sexual partners 1 2 3 4 1 2 3 4 l. a woman should be a virgin when she marries 1 2 3 4 1 2 3 4 m. It is acceptable for a man to force a woman to have sex 1 2 3 4 1 2 3 4 n. A man feels proud if he has multiple sex partners 1 2 3 4 1 2 3 4 o. Usually people do not plan to have sex, it just happens 1 2 3 4 1 2 3 4 p. It is acceptable for a married man to have sexual relations outside marriage 1 2 3 4 1 2 3 4 q. It is acceptable for a married woman to have sexual relations outside marriage 1 2 3 4 1 2 3 4 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 90 r. Sex before marriage is acceptable if the couple loves each other 1 2 3 4 1 2 3 4 s. Men need sex more frequently than women do 1 2 3 4 CONCLUDING REMARKS TREATMENT SITE PARTICIPANTS COMPLETE (1201); COMPARISON SITE PARTICIPANTS COMPLETE (1202) 2101a ONLY FOR TREATMENT SITES (TZANEEN, TONGA AND DRIEKOPPIES) NOTE TO INTERVIEWER: This question will assist you to determine whether the participant is suitable for a Focus Group interview Do you have any comments about TCE or the people with the red t-shirts and barrettes that you would like to share? Capture comments made… IS THIS A GOOD CANDIDATE? A good candidate is someone who is talkative and wants to share more about TCE or about his/her/community challenges or successes around HIV and AIDS YES………………01 NO…………….. 02 2101b ONLY FOR TREATMENT SITES (TZANEEN, TONGA AND DRIEKOPPIES) A group discussion will be held after all the surveys are completed. I am not saying that someone will call you, but should there be an opportunity for you to be part of a group discussion where you can talk about HIV in your community and programs that have helped you deal with HIV related matters, would you be willing to participate? YES………………01 CONTACT NUMBER:______________ NO…………….. 02 2102a ONLY FOR COMPARISON SITES (MANKWENG, MATSULU A & MATSULU B) NOTE TO INTERVIEWER: This question will assist you to determine whether the participant is suitable for a Focus Group interview Do you have any comments about HIV in your community and programs that have helped you deal with HIV related matters? Capture comments made… IS THIS A GOOD CANDIDATE? A good candidate is someone who is talkative and wants to share more about relevant programs and/or about his/her/ community challenges/successes around HIV and AIDS YES………………01 NO…………….. 02 2102b ONLY FOR COMPARISON SITES (MANKWENG, MATSULU A & MATSULU B) A group discussion will be held after all the surveys are completed. I am not saying that someone will call you, but should there be an opportunity for you to be part of a group discussion where you can talk about HIV in your community and programs that have helped you deal with HIV related matters, would you be willing to participate? YES………………01 CONTACT NUMBER:______________ NO…………….. 02 2102 Thank you for your time… R10 voucher provided to interviewee? YES………………01 NO…………….. 02 Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 91 INTERVIEWER'S OBSERVATIONS TO BE FILLED IN AFTER COMPLETING INTERVIEW COMMENTS ABOUT RESPONDENT: COMMENTS ON SPECIFIC QUESTIONS: ANY OTHER COMMENTS: SUPERVISOR'S OBSERVATIONS NAME OF THE SUPERVISOR: DATE: COMMENTS: Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 92 ANNEXURE D: Weighting of samples to ensure equivalence Profile before weighting (Unweighted data) Comparison Treatment Afrikaans .6% English .5% Sepedi 37% 4% Sepedi, Tsonga 1% Southern Sotho 1% Swazi 61% 71% Tonga 1% Tsonga 22% Zulu 1% Zulu, Tsonga 1% <= 29.0 36% 16% 30.0 - 38.0 24% 26% 39.0 - 50.0 23% 25% 51.0+ 17% 33% Age Mean 37.1 44.3 Female 59% 80% Male 41% 20% People over 18 in househod Mean 3.3 3.6 Number of males Mean 2 2 Number of females Mean 2.0 2.1 Deep rural .5% 15.9% Rural 58% 61% Semi-urban 36% 19% Urban 5% 4% Gender Urbanised or rural Categories Languages spoken Age (grouped) Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 93 Profile after weighting (Weighted data) Comparison Treatment Swazi 54% 65% Sepedi 44% 5% Zulu 1% 0% English 1% 0% Tonga 0% 0% Afrikaans 0% 0% Sepedi, Tsonga 0% 0% Southern Sotho 0% 1% Tsonga 0% 28% Zulu, Tsonga 0% 0% Under 30 27% 35% 30 - 44 35% 33% 45 - 59 27% 26% 60+ 11% 7% @207_Participantage Mean 39.9 38.0 @101_Howmanypeopleabove 18yearsliveinhousehold Mean 3 3 @103_Capturenumberofpeop leinthehousehold Mean 3 2 @102_Numberofmales Mean 2 2 @102_Numberoffemales Mean 2.1 2.1 Female 69% 59% Male 31% 41% Rural 67% 60% Urban 33% 40% Categories Languages_spoken Age_2 Gender Urbanised_or_rural Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics Page 94 Categories: Total Categories: Total Female Male Count Count Count Unweighted Count Count Unweighted Count Rural 41 24 Rural 65 41 41 24 Urban 12 15 Urban 21 12 29 15 Rural 57 23 Rural 76 57 39 23 Urban 31 12 Urban 44 31 23 12 Rural 49 12 Rural 71 49 17 12 Urban 19 13 Urban 29 19 23 13 Rural 22 6 Rural 27 22 7 6 Urban 8 3 Urban 13 8 4 3 Categories: Comparison Categories: Comparison Female Male 1 2 Count Unweighted Count Count Unweighted Count Rural (1-2) 23 18 1.8 1.3 Rural 41 23 23 18 Urban (3-4) 9 14 1.3 1.1 Urban 12 9 15 14 Rural (1-2) 19 16 3.0 1.4 Rural 57 19 22 16 Urban (3-4) 14 11 2.2 1.1 Urban 31 14 12 11 Rural (1-2) 21 5 2.3 2.4 Rural 48 21 12 5 Urban (3-4) 10 10 1.9 1.3 Urban 19 10 13 10 Rural (1-2) 5 1 4.4 6.0 Rural 22 5 6 1 Urban (3-4) 5 1 1.6 3.0 Urban 8 5 3 1 Categories: Treatment Categories: Treatment Female Male 1 2 Count Unweighted Count Count Unweighted Count Rural (1-2) 18 6 1.3 3.0 Rural 23 18 18 6 Urban (3-4) 3 1 3.0 14.0 Urban 9 3 14 1 Rural (1-2) 38 7 0.5 2.3 Rural 19 38 16 7 Urban (3-4) 17 1 0.8 11.0 Urban 14 17 11 1 Rural (1-2) 28 7 0.8 0.7 Rural 22 28 5 7 Urban (3-4) 9 3 1.1 3.3 Urban 10 9 10 3 Rural (1-2) 17 5 0.3 0.2 Rural 5 17 1 5 Urban (3-4) 3 2 1.7 0.5 Urban 5 3 1 2 Between 45 - 59 60+ Weights to overall Weights to overall Gender Female Male Gender Female Male Age_2 Under 30 Between 30 - 44 Between 45 - 59 60+ Gender Female Male Age_2 Under 30 Between 30 - 44 Between 45 - 59 60+ Age_2 Under 30 Between 30 - 44 Gender Age_2 Under 30 (1-2) Between 30 - 44 (3 - 5) Between 45 - 59 (6-7) 60+ (8) Gender Age_2 Under 30 (1-2) Between 30 - 44 (3 - 5) Between 45 - 59 (6-7) 60+ (8) Gender Age_2 Under 30 Between 30 - 44 Between 45 - 59 60+ Humana TCE Programme Evaluation April 2013 Feedback Research and Analytics This report is made possible by the generous support of the American people through the President's Emergency Plan for AIDS Relief (PEPFAR) and the U.S. Agency for International Development (USAID), under the terms of Associate Award No. 674-A-00-08-00001 with PACT. The contents and opinions expressed herein do not necessarily reflect the views of PEPFAR, USAID or the United States Government