Delivery of Behavior Change
Communication (BCC) Services through TV
& Radio Channels, Print Media and IPC
Interventions
FINAL REPORT
End of Project Evaluation
January, 2009
Submitted to:
Dr. Hassan Abbas Zaheer
National Programme Manager
National AIDS Control Programme
National Institute of Health, Ministry of Health
Government of Pakistan, Islamabad
Submitted by:
SEBCON (Pvt) Limited
Socio-economic and Business Consultants, Islamabad
i
Acknowledgement
Sebcon would like to thank NACP for reposing confidence in us to perform the BCC end
of project evaluation. The feedback and guidance by NACP contributed significantly in the
successful completion of the study.
The firm is particularly appreciative of the role of the Dr. Hasan Abbas, National
Programme Manager, NACP and Dr. Amir Maqbool, NACP for their support and
professional cooperation that enabled us to successfully undertake the fieldwork and
complete the study. The NACP were responsive to the needs of the consultant and
provided regular and valuable guidance in the performance of the study.
The study would not have been possible without the cooperation of Midas. Our special
gratitude to all NGOs, their management and project staff whose prompt and full
cooperation in selecting research assistants, arranging logistic support, selecting target
communities and individuals, and collection of data greatly facilitated the completion of
the survey work.
Kamran Sadiq
Team Leader
i
Table of Contents
Executive Summary
1-7
1.0
Introduction
8
2.0
Evaluation Team
8
3.0
Survey Design
8
4.0
Survey Methodology
9
5.0
Sampling Plan
9
6.0
Data Collection
10
7.0
Internal Orientation Meeting
10
8.0
Fieldwork
10
9.0
Field Team
11
10.0
Field Work Schedule
11
11.0
Data Analysis
11
12.0
Key Findings
11
12.1.
Review of the BCC Project Design
11
12.2.
Review of the BCC Preparatory Phase
13
12.3.
Review of the BCC activities implemented.
15
12.3.1
Electronic Media
15
12.3.2
Print Media
16
12.3.3
Advocacy
17
12.3.4
Social Mobilization
17
12.3.5
Review of Management Arrangements
17
13.0
Key Findings of the Survey
19
14.0
Recommendations
61
Annexes
I.
Survey Tools
Questionnaire
Guide Lines for Key Informative Interviews
II.
Details of the media campaign implemented
ii
Abbreviations
AIDS
ANF
AJK
BCC
CDC
CSW
CPR
DoH
DFID
FATA
FCA
FBS
GoP
HMIS
HIV
IDA
IDU
IEC
IPC
KAP
MCH
MOF
MOH
MSM
NACP
NBTC
NGO
NIH
NWFP
PBTA
PHC
PLWHA
PACP
PIP
QA
Rs
RTI
STI/STD
TA
TAG
TOT
TORs
UNAIDS
UNDCP
UNDP
UNFPA
UNICEF
USD
VCT
WB
WHO
Acquired Immune Deficiency Syndrome
Anti Narcotics Force
Azad Jammu and Kashmir
Behavior Change Communication
Communicable Disease Control
Commercial Sex Workers
Contraceptive Prevalence Rate
Department of Health
Department for International Development
Federally Administered Tribal Areas
Federal Committee on AIDS
Federal Bureau of Statistics
Government of Pakistan
Health Management Information System
Human Immunodeficiency Virus
International Development Agency
Intravenous Drug User
Information Education and Communication
Inter-personal Communication
Knowledge, Attitude & Practice
Maternity & Child Health
Ministry of Finance
Ministry of Health
Men having Sex with Men
National AIDS Control Programme
National Blood Transfusion Committee
Non-Government Organization
National Institute of Health
North West Frontier Province
Provincial Blood Transfusion Authority
Primary Health Care
People Living with HIV/AIDS
Provincial AIDS Control Programme
Project Implementation Plan
Quality Assurance
Rupees
Reproductive Tract Infection
Sexually Transmitted Infection/Diseases
Technical Assistance
Technical Advisory Group
Training of Trainers
Terms of Reference
Joint United Nations Programme on HIV/AIDS
United Nations Drugs Control Programme
United Nations Development Programme
United Nations Population Fund
United Nations International Children’s Emergency Fund
U.S. Dollar
Voluntary Counseling and Testing
World Bank
World Health Organization
iii
Executive Summary
The BCC contract was signed between NACP and Midas in May 2005 after a protracted
procurement process spread over a year. The objective of the BCC project was to
“improve knowledge, skills, practices and behavior of general adult population of
Pakistan for protecting themselves and their peers against HIV/AIDS and other sexually
transmitted diseases in the period of three years”.
Evaluation Methodology
The evaluation methodology was a combination of key informant interviews, focus group
discussions (FGDs), and structured questionnaires. A total of 10 Focus Group Discussions
and 25 Key Informant Interviews were conducted. The quantitative portion of the survey
included; 400 detailed and structured interviews of households. The sampling plan was
approved by NACP prior to fieldwork. To ensure that the sampling plan was
representative, physical, social, and economic disparities of the target communities as
well as the rural and urban divide were kept in perspective. Also, while selecting the
target community for data collection, the researchers kept in perspective factors such as
variance in literacy rates and incomes (relative poverty), and kept gender balance.
Design Issues
The core indicators developed as part of the TOR are specific and relevant and are
designed to gauge the knowledge, attitudes, and perceptions of the general adult
population towards HIV modes of transmissions, stigma and discrimination, preventive
measures and major misconceptions related to HIV and AIDS.
From an evaluation perspective, it was important to establish the relationship, if any,
between the core indicators, the targets set, and the resources allocated to achieve the
targets. The overall Behavioral Change targets were quantified in the TOR whereas; the
strategy to achieve the targets was left to the consultant. However, in the absence of
specific media targets that are quantified in the TOR, competing firms were left with the
option of proposing varied strategies with major variances in the resources required to
achieve the same BCC targets.
The basis of setting the baseline and core targets is not clear. Are the targets related to
any international accepted standards that define minimum levels of awareness that
would lead to safe behavior? The TOR does not elaborate on this issue. Similarly, the
baseline figures represent the year 2004. Whereas, the BCC contract was awarded in
May 2005, therefore, the 2004 baseline figures may not have been relevant in 2005.
BCC Strategy
A 5 point communication strategy was developed by Midas with the following theme:
“HIV/AIDS Everyone’s Concern: Think-Understand-Prevent.” The 5 point strategy
entailed; advocacy, stimulate community dialogue, increase knowledge, promote
preventive and care seeking behavior, and reduce stigma. The Urdu version of the theme
was “HIV & AIDS - Hum sab ka masla he – Sonchye, Samaje, Roakye”. A second theme
was developed “HIV & AIDS - Hum sab ko bachna he – Sonchye, Samaje, Roakye.” The
theme messages were part of the logo for the BCC campaign. The theme messages ask
the target audience to acknowledge HIV & AIDS as a societal as opposed to an individual
problem and urge everyone to play a role to prevent its spread.
1
The advocacy component of the strategy entailed certain specific changes in the policy
makers’ attitude towards HIV & AIDS. To achieve this change, Midas implemented
activities at the national, provincial, district, and community levels.
The document titled “media campaign (Phase 2: February – July 2006) was produced by
Midas to showcase their plans for the BCC campaign. The plan presents a good mix of TV
spots on various TV channels, radio spots, and programmes on various FM channels and
advertisements on various leading newspapers. The plan also includes publication of
articles, features and write-ups in leading Urdu and English dailies.
Although the media strategy refers to a community based dialogue to stimulate
discussion, the media campaign document lacks a detailed strategy on interpersonal and
social mobilization activities. The strategy lacks any serious attempt to mobilize
resources and expertise of other public and private sector organizations for synergy.
Midas believes that this gap in the strategy is because the ‘scope of work did not include
mobilization of third party resources for synergy.’
Message Development
Prior to the implementation of BCC activities, the TOR specified that the consultant would
‘carry out a small but representative baseline survey to aid in the design of the
messages.’ After the award of the contract the Technical Advisory Group (TAG) and
NACP decided to conduct a baseline survey in the first year of project (Page 8, annual
report). Midas drafted the TORs for the baseline survey and shared it with NACP, Family
Health International (FHI) and HIV/AIDS Surveillance Project (HASP). The baseline TORs
were fine-tuned based on feedbacks from the respective organizations. However, as per
the unsigned minutes of a meeting held on October 5, the National Program Manager,
NACP informed the BCC team that a demographic health survey was to be conducted
soon by the Ministry of Health. Therefore, it was decided that Midas not need to carry
the baseline survey (Page 11, annual report). Instead, the findings of the demographic
health survey would be utilized to design the messages.
Upon inquiry, Midas informed the evaluation team that there is no documented evidence
of NACP’s authorization to forego the baseline survey. However, verbal authorization
made by the National Program Manager is documented in the annual report.
The activity to ‘carry out a small but representative baseline survey to aid in the design
of the messages’ is specified in the ‘scope of BCC services’ section of the contract. Since
the baseline activity was part of the TOR, any deviation from the scope of work required
a revision of the TOR that should have lead to a contract amendment to incorporate the
financial and technical implications of not implementing a key activity. This was not
done. It would have been in line with contract requirements to formalize the change in
the scope of work.
Furthermore, the impact of the demographic health survey on the message development
process is not fully discernable as the entire message development process does not
refer to the findings of the demographic health survey that was supposed to feed into
the design of the messages finally developed. Prevention or care needs of the target
audience should have received greater attention in the message design process.
Message content generally focused on the preventive side and did not elaborate on skill
enhancement to protect from HIV/STIs. Similarly, the message design and content
should have focused more on the target audience’s ideas of DISADVANTAGES or barriers
of adopting this desired behavior and popular prevention and care beliefs, concerns, and
needs of the target audience were identified during the message design process.
According to Midas, they ‘tried to make up for this deficiency by covering the issue in IPC
initiatives like theatrical performances, advocacy seminars with stakeholders, sports
activities and so on.’
2
Midas produced TV spots for the BCC campaign at two specific periods i.e, in April 2006
and again in September 2007. None of the TVCs produced in April 2006 were shared
with the respondents of the audience research conducted between March – September
2006 to gauge their knowledge, perceptions and sensitivities about HIV & AIDS based on
the new TVCs. Therefore, the fundamental concept of audience research to seek
feedback on messages designed and disseminated was lost. According to Midas, ‘the
responsibility to select TVCs to share with the respondents rested with the audience
research contractor and NACP.’
Similarly, it is difficult to comprehend how the critical findings of the audience research
conducted between March and September 2006 were factored into the TVCs that were
produced in April 2006 as the audience research report was prepared in September
2006. The National Program Manager, NACP mentions in the quarterly report (April-June
2007) that the findings would be included in the development of messages in the next
quarter.
The messages developed only encouraged people to change attitudes in a general
context. Message content generally focused on the preventive side. A pre-testing of
communication products was carried out in November 2005.
TV and radio spots were produced with the red ribboners theme aimed at engaging the
youth towards HIV & AIDS. Famous celebrities such as film actor Shan and members of
the pop group strings also make an appearance in the TV spots.
The production values of both the TV and radio spots were good. The TV spots included
animation and dramatization concerning HIV & AIDS transmission routes, preventive
measures, knowledge of HIV & AIDS. The voice over used in the TV spots is effective and
the messages came through clearly.
The actors in the TVC (Television Commercial) look the part and dramatize the
sequences well. The red ribboners TVC is especially well scripted and played out. There is
variety of TV spots, for example on blood transfusion, unsafe sex, used syringes, and
stigma. Celebrities like Shan and members of the pop group strings also feature in the
TVCs.
The messages regarding the use of condoms were limited to few print media
advertisements. The electronic media campaign was conspicuous by its absence of any
reference to the promotion of condom use. The reasons cited for limited promotion of
condoms included the social and cultural inhibitions as well as the reluctance of the
policy makers including the Ministry of Health to challenge the established media airing
norms.
Selection of Media Channels
The TV and radio channels utilized for broadcasting the TV and radio spots were
proposed by Midas and approved by TAG (Technical Advisory Group). The criteria and
appropriateness for using these channels cannot be gauged accurately as they may not
reflect the preference of the target audience i.e. the general adult population of Pakistan.
The Midas media plan suggests that a high proportion of TV spots were aired between 710 p.m., which is considered prime time. The airing plans for the radio spots are more
scattered. The airing schedule for the radio spots is distributed between morning and
evening times, and designed to complement popular programs such as cricket
tournaments.
3
Some public events organized by the firm such as the HIV & AIDS hockey tournament
and street theatre activities were covered comprehensively by leading local and national
newspapers. However, there is less focus on coverage of advocacy seminars, media
conferences, and youth an event in the national and local newspapers.
Management and Reporting
The overall quality of management and reporting by Midas for the BCC project was
inconsistent. Quarterly progress reports did not include detailed work plans. Copies of
transmission certificates that were made available to the evaluation should have,
preferably been annexed with the quarterly progress reports.
A section “Milestones for the reporting period” was added in the last 2 quarterly progress
reports. This section is a variance analysis of BCC activities, where a planned vs. actual
approach has been adopted to report the milestones approved and implemented as per
TAG meetings. This approach should have been adopted in all previous quarterly
progress reports.
Midas insists that the quarterly progress report format utilized was approved by the
NACP and any gaps in the format should have been made up by the NACP and
communicated to Midas.
It would have been preferable to back detailed activity reports with documentary
evidence to suggest that implementation of activity had actually taken place.
There was limited Coordination between the different stakeholders particularly with other
similar BCC campaigns being implemented by the provincial AIDS control programmes.
The responsibility rests with the National and Provincial AIDS Control Programmes for
failing to operationalize functional coordination mechanisms for greater impact.
The Team Leader resigned in June 2007. A reference is made to a meeting where the
replacement was approved. Upon inquiry, Midas informed the evaluation team that the
decision to confirm the replacement of the Team Leader was communicated verbally by
the National Program Manager, NACP. Again, it was the responsibility of the NACP to
seek a replacement equal or more qualified to replace the team leader through a
formalized process outlined in the contract.
Also, diligent contract management and administration demanded that the NACP should
have formalized any changes in the TOR and/or replacement of key staff should have
been documented including the appropriate approvals.
A section “Milestones for the reporting period” was added in the last 2 quarterly progress
reports. This section is a variance analysis of BCC activities, where a planned vs. actual
approach has been adopted to report the milestones approved and implemented as per
TAG meetings. This approach should have been adopted in all previous quarterly
progress reports.
Summary Findings of Impact Survey
The results of the quantitative and qualitative survey point, in general, to an increase in
the basic knowledge about HIV and AIDS.
It is pertinent to mention here that while Midas was implementing the national BCC
campaign a similar BCC campaign was being implemented by another firm under the
Punjab AIDS Control Programme. Although, the Punjab BCC campaign was mandated to
be limited to Punjab, however, their campaign also utilized public and private electronic
media channels which have national coverage. Therefore, it is safe to assume that the
4
impact measured during the survey was the result of the combined impact of the two
BCC campaigns.
A majority of respondents (97.8%) who had seen the TVC on HIV & AIDS remembered
at least one mode of transmission of HIV. This is improvement over the period the BCC
campaign was implemented.
Overall, the survey findings suggest that the awareness levels for HIV transmission
modes have improved although the awareness gap needs to be further narrowed down .
Amongst the respondents who had watched the TVC on HIV & AIDS a majority recalled
unsafe sex (34.3%) as a mode of HIV transmission followed by used syringes (33.0%)
and un-screened blood transfusions (24.4%). The least known modes of HIV
transmission were mother to child (3.1%) and unsterilized surgical equipment/blades
(2.7%). A sizeable proportion of the overall respondents (14.1%) did not know of any
HIV mode of transmission.
Overall, 85 percents of the respondents appreciated the quality of the jingle including
the message content and the melody (The jingle was produced under the BCC Punjab
program.
Awareness levels for HIV modes of transmission varied among both male and female
respondents. More male respondents (38.6%) as compared to their female counterparts
(21.6%) identified unsafe sex as a HIV mode of transmission, which is a substantial
difference. A higher proportion of female respondents compared to male respondents
recalled HIV modes of transmissions such as un-screened blood transfusions (male
16.39%, female 26.5%) and used syringes (male 25.5%, female 32.4%). The awareness
levels for modes of transmissions such as mother to child and use of unsterilized surgical
equipment/blades was low among both male and female respondents.
About 26.2 percent of the respondents who had viewed the TVC could recall one mode of
transmission for HIV. About 21 percent of the respondents who had viewed the TVC
could recall two modes of HIV transmission. TVCs on HIV & AIDS should be designed to
bring clarity and better understanding so that the recall value for all modes of
transmission for HIV is increased. A majority of respondents (73.2%) who had heard the
radio spot on HIV & AIDS could recall at least one mode of transmission for HIV & AIDS.
This again is a significant achievement of the BCC campaign.
81 percent of all respondents of the target population across all four provinces (Punjab,
NWFP, Balochistan & Sindh) and the Federal, both rural and urban had watched a TVC on
HIV & AIDS. Again, most respondents related to the message with the jingle that was
aired by the BCC Punjab program. The survey finding suggests that the TV media
campaign on HIV & AIDS was conducted intensively nationwide.
The women participants of the FGDs suggested the need to address the HIV/AIDS issue
more openly. They believed that the modes of HIV transmissions should be further
explained in detail. They also felt that more time should be allocated for HIV related
programs on the media, specifically on TV channels. The women participants also
stressed that it would be appropriate and more acceptable if a doctor or a respectable
member of the society narrated HIV & AIDS awareness messages. They also suggested
talk shows with doctors are aired, so that families could sit and watch the programmes
together.
The male participants from the FGDs highlighted the need to attach a mode of
transmission with pictures that are not confusing, i.e. a clip showing a barber shaving to
indicate that used blades should be avoided. Such additions would help the illiterate
population to better understand the messages.
5
Only a small percentage of respondents (17.4%) who had viewed the TVC on HIV &
AIDS discussed it with the members of their community. The findings suggest that the
subject of AIDS is still a taboo in society and the media campaign should encourage the
general adult population to talk about the social issues related to HIV and AIDS.
However, this may also require more focus on interactive forms of communication.
Amongst the respondents who had seen the TVC on HIV & AIDS a majority (60.9%) of
female respondents discussed it members of their community as opposed to their male
counterparts (39.1%). Future BCC activities on TV channels should focus on encouraging
men to break their silence and talk more openly about their health concerns, particularly
about HIV/AIDS and other sexually transmitted infection.
The findings of the FGDs in both the rural and urban areas suggest that there was some
improvement however the mainstream society is reluctant to discuss TVCs, radio spots
and print media campaigns on HIV/AIDS.
Summary of Recommendations
Future BCC TORs should specify the intensity of the media effort by quantifying
activity specific media outputs.
To make the TOR more specific and responsive to the social mobilization objectives,
it would be advisable to include a set of BCC effectiveness indicators such as;
number of training sessions, number of education sessions, number of media events,
number of materials produced, number of materials distributed, number of people
trained; and number of people reached.
The TOR should specify the basis of establishing the primary and secondary
indicators as well as the baseline and target figures. If the baseline figures were not
fully relevant due to delays in contract award, it would have been prudent to utilize
the provision for a baseline in the TOR which states that the consultant would ‘carry
out a small but representative baseline survey to aid in the design of the messages’
to revise the baseline figures.
Based on the findings of the survey conducted as part of this evaluation, future BCC
campaigns should focus more on the target audience’s ideas of DISADVANTAGES or
barriers of adopting this desired behavior? For example barriers such as; money,
time, convenience, comfort etc.
In addition to a combination of communication channels more emphasis should be
made on the use of interpersonal channels, traditional and folk media, and
community networks.
The variance analysis of BCC activities, where a planned vs. actual approach has
been adopted to report the milestones approved and implemented as per TAG
meetings should be adopted in all future reporting formats.
Future BCC campaigns should focus more on educating women about the dangers of
unsafe sex, while more focus should be on men with regards to used syringes as an
HIV mode of transmission.
Future BCC messaging through TV channels should focus on encouraging men to
break their silence and talk more openly about their health concerns, particularly
about HIV/AIDS and other sexually transmitted infection.
There should be a greater effort to produce TVCs that focus on individual
HIV modes of transmission in future, so that recall value is better.
6
The national and provincial AIDS Control Programs should establish BCC
coordination mechanisms for synergy and greater impact.
Contract administration by the NACP should be more diligent to ensure
implementation in accordance with the TOR and other relevant contract clauses. Any
variations in the TOR or the scope of work should be fully documented and its
technical and financial implications formalized in the contract through a contract
amendment. To cite verbal instructions as the basis of deviations from the scope of
work is a serious contract administration oversight.
In future, the budget for third party evaluations should not be part of the
contract amount of the entity to be evaluated. The present arrangement where the
evaluation payments are released by Midas creates a potential conflict of interest
situation.
7
BCC End of Project Evaluation
1.0
Introduction
The end of project evaluation of the National AIDS Control Programme’s BCC component
was conducted between July and September 2008.
The evaluation report addresses issues by responding to the following evaluation
objectives:
Objective 1: To gauge the level of knowledge of general population regarding HIV
modes of transmission and methods of prevention;
Objective 2: To measure the general population’s attitude regarding HIV/AIDS and
towards People Living with HIV/AIDS (PLWHAs);
Objective 3: To measure people’s perception about the media campaign;
Objective 4: To get feedback from the key stakeholders, decision and policy makers
regarding the effectiveness of the project; and
Objective 5: To measure the effectiveness of the implementing agency i.e. Midas Pvt.
Ltd in light with TORs of the BCC project such as
Number
Number
Number
Number
2.0
of
of
of
of
activities agreed held/accomplished or not
TV and Radio spots
press advertisements in newspapers and magazines
advocacy activities completed.
Evaluation Team
The evaluation team consisted of experienced and qualified team of consultants with
extensive experience in program/project evaluations and conducting quantitative and
qualitative surveys with focus on health awareness. Besides the Team Leader, the key
staff also included a research specialist, a BCC specialist who specializes in research and
analysis, and a field team of research associates lead by a coordinator/behavioral
sociologist.
After the initial briefings by the NACP staff, the evaluation team reviewed the project
documents. The evaluation methodology focused on “exploration” of the ‘behavior’
phenomena in the context of the quality of the BCC campaign.
The pre-dominant method used for the collection of primary data for the qualitative part
of the evaluation was the focus group discussions (FGDs), some key informants
interviews, open ended semi-structured interviews (individual and group) and review of
secondary data etc., and detailed quantitative method of data collection.
3.0
Survey Design
The survey was undertaken focusing on the target population for the BCC project that is
the general adult population and youth, which includes all strata of society, for example
male and female, literate and illiterate, and rural and urban.
8
The survey was designed to collect information and gauge the change in behavioral
patterns with respect to HIV/AIDS after the implementation of comprehensive BCC
activities implemented by Midas Pvt. Ltd during the last 2.5 years.
4.0
Survey Methodology
The evaluation methodology focused on “exploration” of the ‘behavior’ phenomena in the
context of the impact of the BCC project on the behavioral patterns of the target groups
across of Pakistan.
The pre-dominant method used for the collection of primary data for the qualitative part
of the evaluation was the focus group discussions (FGDs), some key informants
interviews, open ended semi-structured interviews (individual and group) and review of
secondary data etc. For the community based quantitative data on knowledge, attitude,
and practices detailed questionnaire was developed and data collected as per the
approved sampling plan.
The BCC end of project evaluation consisted of the following steps:
Meetings with NACP Officials;
Discussions/review of reports regarding any baseline/mapping/KAP surveys already
done;
Communication with partners/stakeholders either through telephone, email;
Preparation of detailed questionnaires and survey instruments;
Training of survey staff;
Pretesting of questionnaires;
Data collection;
Data analysis; and
Report preparation.
5.0
Sampling Plan
Table 1:
Sampling Plan 1 – Collection of Qualitative Data
Provinces/Locations
No. of Focus Group
Discussions
No. of Key Informant
Interviews
Federal
Punjab
N.W.F.P
Balochistan
Sindh
Total
2
5
5
5
5
22
5
10
10
10
10
45
Table 2:
Sampling Plan 2 – Collection of Quantitative Data
Provinces/Locations
Federal
Punjab
N.W.F.P
Balochistan
Sindh
Total Sample Size
No.
Cities/
Villages
4
4
4
4
4
20
Geographical
Coverage
Urban
Rural
2
2
2
2
2
2
2
2
2
2
10
10
No. of
Households
Sample Size
20
20
20
20
20
100
80
80
80
80
80
400
9
A total of 10 Focus Group Discussions and 25 Key Informant Interviews were conducted.
To collect quantitative data, 400 detailed and structured interviews of households was
conducted. In order to ensure that representative data is collected, physical, social, and
economic disparities of the target communities as well as the rural and urban divide was
kept in perspective while developing the sampling plan.
In addition, while selecting the target community for data collection, the researchers
kept in perspective factors such as variance in literacy rates and incomes (relative
poverty), gender balance.
6.0
Data Collection
Once the survey tools and instruments were finalized, the team of research associates
underwent a one-day internal orientation and training activity to ensure familiarization
with the overall objectives of the project, develop consistency in approach, and
familiarization on the quality control aspects of the survey.
7.0
Internal Orientation Meeting
A full day orientation meeting was held on July 26, 2008 to orient the research
associates responsible for collecting data.
The objectives of the meeting were to:
Familiarize the research associates with the objectives of the study;
Review the format of the Focus Group Discussions (FGDs) and Key Informant
Interviews and clarify any technical issues;
Finalize a check list of field work activities;
Review the sampling plan;
Identify local contacts;
Review the travel plan and time frame for conducting the study; and
Finalize all logistic arrangements and the work plan for conducting the
study.
The research associates were asked to review and give feedback on the guidelines
developed for conducting the Focus Group Discussions (FGDs) and Key Informant
Interviews. All technical issues were clarified and the research associates were instructed
to properly document all findings so that accuracy is maintained and reflected in the final
report.
The sampling plan was reviewed and discussed. To ensure the selection of representative
sampling, the research associates were advised to focus on factors such as variance in
literacy rates and incomes (relative poverty), ethic backgrounds, geographical distances
while selecting the target communities.
Local contacts were identified and the time frame for conducting the study was reviewed
and finalized. The logistic arrangements were also discussed and a final work plan was
drafted, approved and shared with the research associates.
8.0
Fieldwork
The data collected by the research associates in the field was monitored by the field
team coordinator who was responsible for achieving a minimum of 80 percent screening
response rate and a minimum 65 percent completed interview response rate. The field
team coordinator randomly visited the field to monitor the data collection process and
ensure that necessary checks are in place regarding quality control.
10
The entire team of research associates was trained in the data collection procedures
during internal orientation workshops conducted at the federal and provincial levels.
9.0
Field Team
NWFP
Inamullah Khan
Khadija Aziz
Punjab
Yasmin Bibi
Inamullah Khan
Balochistan
Jamaluddin Khan
Rukhsana Almas
Sindh
Fareeda Jamote
Jamualuddin Khan
10.0 Field Work Schedule
Province
Punjab
Sindh
Federal
Balochistan
N.W.F.P
City/Location
Rawalpindi & Jhelum
Karachi & Hyderabad
Islamabad (Golra Sharif,
Saidpur village, G-8 & G-9
Markaz)
Quetta & Mastung
Peshawar & Mardan
Dates
July 29-31,08
August 1-3,08
August 1–4, 08
August 6-8, 08
August 8-10, 08
11.0 Data Analysis
The data collected in the field was shared with the team leader, research specialist, BCC
specialist, and Field Team Coordinator/Behavioral Sociologist who jointly discussed and
finalized the survey analysis format, with relevance to behavioral issues to be addressed,
and recommendations for implementation.
Each question was coded and the consultant ensured that the data quality control
through an operational management plan which entailed at least 5 percent verification of
all households with a minimum 80 percent response rate and a minimum 65 percent
completed interview response rate. The confidentiality of the data collected was ensured
and monitored by the Field Team Coordinator. Field status reports were prepared and
shared with the NACP.
12.0 Key Findings
12.1.
Review of the BCC Project Design
Behavior Change Communications (BCC) is a tool for promoting and sustaining healthy
behavior by changing the decision and behavior of individuals and communities through
communicating messages (be it health or otherwise) via different channels (public,
private, mass media, small or medium media). Effective behavior change communication
strategies recognize the importance of the beneficiary and their role in the ownership,
development, monitoring and evaluation of health promotion, in general or HIV
prevention, AIDS care and support activities.
Effective BCC programs are designed to;
Increase awareness and knowledge of a health problem and its solution,
Demonstrate or depict healthy behavior,
Improve skills and sense of self-efficacy (that is, feeling capable of performing the
behavior),
Reinforce healthy knowledge, attitudes, and behavior,
Show the benefits of adopting healthy behavior,
11
Help shift social norms to encourage more healthy behavior,
Advocate a position on a health issue or policy,
Increase demand or support for health services,
Refute myths and correct misunderstanding,
Change perceptions of risk, and
Prompt individual and community behavior change.
The objective of the BCC project was to “improve knowledge, skills, practices and
behavior of general adult population of Pakistan for protecting themselves and their
peers against HIV/AIDS and other sexually transmitted diseases in the period of three
years”. The core indicators developed were specific and relevant and were designed to
gauge the knowledge, attitudes, and perceptions of the general adult population towards
HIV modes of transmissions, stigma and discrimination, preventive measures and major
misconceptions related to HIV and AIDS.
What is more important is the relationship between the core indicators, the BCC targets
set, and the resources allocated to achieve the targets. All the BCC targets to be
achieved have been quantified and the strategy to achieve the targets has been left to
the consultant. In the absence of clear media targets specified in the TOR, interested
consultants were left with the option of proposing varied strategies with major variances
in the resources required to achieve the same targets. Therefore in practical terms the
real strategy to achieve the media targets was left to the implementers to decide the
right media mix as well as intensity of the media campaign.
The BCC project commenced in June 2005 and in the absence of a baseline survey which
was to be conducted under the TOR, Arjumand Associates conducted an audience
research in September 2006 with the overall objective to “Identify suitable means of
information and communication to develop and disseminate messages for general adult
population”. The report was officially launched in April 2007.
The TOR specified that the consultant would ‘carry out a small but representative
baseline survey to aid in the design of the messages.’ After the award and
commencement of the BCC project, the Technical Advisory Group (TAG) and NACP
decided to conduct a baseline survey in the first year of project (Page 8, annual report).
Midas drafted the TORs for the baseline survey and shared it with the NACP, Family
Health International (FHI) and HIV/AIDS Surveillance Project (HASP). The TORs were
fine-tuned based on feedbacks from the respective organizations.
However, as per the minutes of a meeting held on October 5, the National Program
Manager, NACP informed the BCC team that a demographic health survey was to be
conducted soon by the Ministry of Health, and it was decided that Midas not need to
carry the baseline survey (Page 11, annual report). Instead, the findings of the
demographic health survey would be utilized to design appropriate messages. Upon
inquiry, Midas informed the evaluation team that the NACP’s authorization to forego the
baseline survey was verbal only and no document exists to support the change in the
TOR.
Therefore, no baseline survey was conducted as specified in the TOR.
The activity to ‘carry out a small but representative baseline survey to aid in the design
of the messages’ is a activity specified in the ‘scope of BCC services’ section of the
contract. Since the baseline activity was part of the TOR, it was prudent that any
deviation from the scope of work should have been documented leading to a contract
amendment to incorporate the financial and technical implications of not implementing
an activity. The primary responsibility for the revision of the TOR rested with the NACP.
12
Midas had developed the theme, logos and messages for the BCC campaign as early as
November 2005, when the communication material developed was pre-tested. The
theme “HIV/AIDS – Everyone’s concern – think, understand, prevent” was developed
before November 2005 and was used for the entire duration of the BCC campaign. The 5
point strategy entailed; advocacy, stimulate community dialogue, increase knowledge,
promote preventive and care seeking behavior, and reduce stigma.
Moreover, Midas produced TV spots for the BCC campaign at two specific periods i.e, in
April 2006 and again in September 2007.
The advocacy component of the strategy entailed certain specific change in the policy
makers attitude towards HIV & AIDS. To achieve this change, the consultant planned to
implement activities at the national, provincial, district, and community levels.
The document titled “media campaign (Phase 2: February – July 2006) was produced by
Midas to showcase their plans for the BCC campaign. The plan presents a good mix of TV
spots on various TV channels, radio spots, and programmes on various FM channels and
advertisements on various leading newspapers. The plan also includes publication of
articles, features and write-ups in leading Urdu and English dailies.
The impact of interpersonal communication for initiating behavior change was part of the
media effort. There was also an attempt to involve resources and expertise of other
public and private sector organizations for synergy. The media strategy refers to a
community based dialogue to stimulate discussion.
12.2. Review of the BCC Preparatory Phase
As per the decision of the NACP, the TOR specified baseline survey was not conducted.
While reviewing the message design process, the evaluation team kept the following
parameters in perspective:
Identification of the prevention or care needs of the target audience;
Have the prevention or care CONCERNS of the target audience been addressed;
Do some of the messages refer to the NEEDS of the target audience;
Do some of the messages appeal to the BELIEFS of the target group;
Do some of the messages refer to the CONCERNS of the target audience;
Which messages encourage people to change their ATTITUDES;
Which messages help people to learn SKILLS to protect them from STD/HIV
infections;
Which messages refer to the UNDESIRED BEHAVIORS;
Which messages refer to desired behaviors;
Do some of the messages refer to the target audience’s ideas of the
DISADVANTAGES or barriers of adopting this desired behavior;
Do some of the messages refer to the target audience’s ideas of the ADVANTAGES of
adopting this desired behavior;
Have the messages and materials in this intervention been pre-tested with the target
audience;
Does this intervention use a combination of communication channels.
Midas shared some documents and information that describe the message design
process. The theme for the campaign is ‘HIV & AIDS – Its everyone’s concern – Think,
Understand, Prevent. Similarly, in Urdu the theme is “HIV & AIDS - Hum sab ka masla
he – Sonchye, Samaje, Roakye”.
A second theme was developed “HIV & AIDS - Hum sab ko bachna he – Sonchye,
13
Samaje, Roakye.” The theme messages were part of the logo for the BCC campaign.
The theme messages ask the target audience to acknowledge HIV & AIDS as a societal
as opposed to an individual problem and urge everyone to play a role to prevent its
spread. The messages developed only encouraged people to change attitudes in a
general context. No specific messages were developed to focus on changing attitudes
towards HIV and AIDS.
Message content generally focused on the preventive side. For example, the following
messages help people learn skills to protect themselves from STD/HIV infections:
The messages designed did focus on the UNDESIRED BEHAVIORS with messages such
as:
a)
b)
c)
d)
Don’t let drugs ruin your life;
Avoid unsafe sex;
Don’t use unscreened blood; and
Don’t use unsterilized surgical instruments
A pre-testing of communication products was carried out in November 2005 at four
levels:
1.
2.
3.
4.
In-house pre-testing;
Pre-testing in Islamabad;
Pre-testing with stakeholders; and
Pre-testing at Provincial levels
Focus group discussions were conducted for pre-testing of the communication products
to ensure appropriateness of messages, for informational and motivational purposes, and
to identify myths, misconceptions, or beliefs about a product.
The TV and Radio spots produced by Midas cover core issues related to HIV/AIDS such
as:
Modes of transmissions;
Preventive measures;
Knowledge of HIV and AIDS; and
Stigma and discrimination;
In addition, TV and radio spots were produced with the red ribboners theme aimed at
engaging the youth towards HIV & AIDS. Famous celebrities such as film actor Shan and
members of the pop group strings also make an appearance in the TV spots.
The production values of both the TV and radio spots were good. The TV spots included
animation and dramatization concerning HIV & AIDS transmission routes, preventive
measures, knowledge of HIV & AIDS. The voice over used in the TV spots is effective and
the messages came through clearly.
The actors in the TVC (Television Commercial) look the part and dramatize the
sequences well. The red ribboners TVC is especially well scripted and played out. There is
variety of TV spots, for example on blood transfusion, unsafe sex, used syringes, and
stigma. Celebrities like Shan and members of the pop group strings also feature in the
TVCs.
One TVC on preventive measures (also features in print material ”Know HIV & AIDS”),
14
displays pictures along with messages. There are pictures of a blood bag, a couple,
surgical equipment and a syringe. All these pictures have big red crosses on them
suggesting that one should avoid sexual practices or use of blood, syringes and surgical
equipment. The text along with these pictures is technically correct.
12.3.
Review of the BCC activities implemented.
One of the key objectives of the evaluation was to measure the effectiveness of the
implementing agency i.e. Midas Pvt. Ltd in light with TORs of the BCC project such as;
number of activities agreed held/accomplished or not, number of TV and Radio spots,
number of press advertisements in newspapers and magazines, and number of advocacy
activities completed.
12.3.1
Electronic Media
As the baseline survey was not conducted, the TV and radio channels utilized for
broadcasting the TV and radio spots were proposed by Midas and approved by TAG
(Technical Advisory Group). The criteria and appropriateness for utilizing media channels
may be gauged from other surveys and polls on viewership ratings. However, in the
absence of a baseline survey that included identifying media preferences, the criteria and
appropriateness for using these channels could not be gauged accurately.
A combination of communication channels were used particularly with regard to the
choice of electronic media channels. Limited use of interpersonal channels, traditional
and folk media, and community networks were employed.
Based on the research done by Arjumand and Associates in September 2006, the peak
time for watching TV was 7-10 p.m., while the peak time for listening to radio spots was
7-9 a.m.
The media plan shared by Midas suggests that a high proportion of TV spots were aired
between 7-10 p.m., which is considered prime time. The airing plans for the radio spots
are more scattered. The airing schedule for the radio spots is distributed between
morning and evening times, and designed to complement popular programs such as
cricket tournaments.
The details of the media campaign implemented are attached in annex II.
The electronic media campaign utilized popular TV and radio channels to create HIV &
AIDS awareness across Pakistan.
Midas developed a plan of action for the first year of implementation. This plan was
executed in the first year after approval from TAG and NACP. The annual report May
2005 – April 2006 reports the approved activities vs. actual activities implemented each
quarter, along with reasons for variance.
After the first year, Midas began submitting quarterly progress reports. The progress
reports include minutes of the meetings of TAG meetings. The objective of these
meetings was to review the BCC activities carried out in the past quarter and approve
activities for upcoming quarters. These outcomes of these meetings are often
suggestions on future BCC activities and a brief review of past activities, while no specific
milestones are set to be achieved in the upcoming quarter.
There were delays in holding TAG meetings regularly to monitor the implementation of
activities as well as approving the work plans proposed by Midas. Midas contends that it
had ‘no control over scheduling and/or holding TAG meetings.’
15
Upon request, Midas did share transmission certificates with the evaluation team.
12.3.2
Print Media
Three types of press ads highlighting “Red Ribboner’s” campaign and helpline” were
published in different magazines including:
Weekly Preview (DAWN);
DAWN Young World;
Shifa News Islamabad;
DAWN;
Times;
Express;
Pakistan Observer;
Asas;
Ausaf;
Jinnah;
Al-Akhbar;
Sobh Karachi;
Nawai Pak;
Financial Post;
Medical Review;
Wahdat Peshawar;
Takbeer; and
Weekly Uns
The copies of the print advertisement have been included in the quarterly progress
report. Based on the copies of print advertisements attached in the quarterly progress
reports, local newspaper coverage improved with the course of implementation. Local
print media coverage of advocacy seminars, musical concerts, and youth events on HIV
& AIDS is adequate.
Information, Education and Communication (IEC) and promotional material including
leaflets, booklets, posters on STIs, mugs, t-shirts, key chains, red ribbons, male condom
packs, female condom purses and bags were designed and produced related to
HIV/AIDS as per the quarterly progress report.
Information, Education and Communication (IEC) and promotional material including
leaflets, booklets, guidelines, procedures and tear sheets were designed and produced
related to HIV/AIDS as per the quarterly progress report.
The following IEC material was reportedly developed:
Brochure containing messages on HIV & AIDS and Road safety (developed in
collaboration with ITP);
Brochure containing details of World AIDS Day and Red Ribboners campaign;
Mugs;
Pens;
T-shirts;
Mobile pouches; and
Red Ribbons
In the progress reports two brochures (one with ITP and the other of WAD campaign)
are attached. No pictures or designs of other IEC material such as mugs, pens, t-shirts,
mobile pouches or red ribbons are included.
16
The messages regarding the use of condoms were limited to few print media
advertisements. The electronic media campaign was conspicuous by its absence of any
reference to the promotion of condom use. The reasons cited for limited promotion of
condoms included the social and cultural inhibitions as well as the reluctance of the
policy makers including the Ministry of Health’s reluctance to challenge the established
media airing norms. According to Midas, ‘two TVCs on condom use, duly approved by
NACP, were pulled after being televised a number of times at the Ministry’s desire.’
12.3.3
Advocacy
Advocacy meetings with government officials and stakeholders were organized to
interest policy makers for helping establish more conducive environment for Behavior
Change Communication. A number of resolutions advocating the collective involvement
of the governments, donors, the civil society, youth and media were signed to join hands
in the fight against HIV & AIDS.
There was a need for follow up to facilitate subsequent policy changes that were needed
to be made to improve the policy environment for HIV and AIDS related Behavior
Change Communication. There is no evidence to suggest that any subsequent policy
changes were made to improve the environment for Behavior Change Communication.
Special events were organized for World AIDS days.
12.3.4
Social Mobilization
The media campaign document needed to lay greater stress on interpersonal social
mobilization activities. The strategy is also weak to involve resources and expertise of
other public and private sector organizations for synergy. Although the media strategy
refers to a community based dialogue to stimulate discussion, the media campaign
document lacks specific activities to promote interpersonal communication and social
mobilization. According to Midas, the ‘scope of work did not include mobilization of third
party resources for synergy.
A number of stage dramas, social mobilization events, stage theater, melas were
organized to create HIV & AIDS awareness. The interactive street theatre performances
were well documented in the annexed report, giving details of locations and
performances. Photographs of all 12 performances in different locations should have
been included in the progress reports.
12.3.5
Review of Management Arrangements
The overall quality of management and reporting by Midas for the BCC project was
patchy. Copies of transmission certificates for electronic media, as well as copies of print
advertisements were not included in the annexure of any quarterly progress report. The
transmission certificates were made available only after the evaluation team requested
Midas as proof of implementation. According to Midas, the transmission certificates were
‘not integral to quarterly reports, copies of transmission certificates were routinely
provided to NACP along with quarterly reports.’
In each quarterly progress report, the detailed are listed. Coordination mechanisms were
not fully functional between the different stakeholders particularly other similar BCC
campaigns being implemented by the provincial AIDS control programmes. The lead role
for coordination rested with the NACP.
The Team Leader resigned in June 2007. The replacement process is not fully
documented as required under the contract. According to Midas, ‘Midas performed the
contract tat the pleasure of the NACP. The decision to bring the CEO as the team leader
17
was also taken jointly with NACP.’
Diligent contract administration demanded complete adherence to the contract in general
and particularly to the Special Conditions of Contract. Such diligence would have ensured
implementation in accordance with the TOR and scope of work. Any variations in the TOR
or the scope of work should have been fully documented and its technical and financial
implications formalized in the contract through a contract amendment. To cite verbal
instructions as the basis of deviations from the scope of work is a contract administration
oversight of the NACP.
A section “Milestones for the reporting period” was added in the last 2 quarterly progress
reports. This section is a variance analysis of BCC activities, where a planned vs. actual
approach has been adopted to report the milestones approved and implemented as per
TAG meetings. This approach should have been adopted in all previous quarterly
progress reports. According to Midas, ‘the format of the quarterly report stipulated by
NACP included no provision for including upcoming quarter’s plan. We fully complied with
requisite format.’
The budget for the third party evaluation of the BCC component was included in the
Midas contract. Again, this violates the very basis third party evaluation and creates a
potential conflict of interest situation. Midas contends that ‘the TORs for the contract
were drawn by NACP, and not Midas.’
18
13.0
Key Findings of the Survey
The objective of the evaluation to gauge the level of knowledge of general population
regarding HIV modes of transmission and methods of prevention led to a quantitative
and qualitative survey.
In general, the results of the quantitative and qualitative survey point to a significant
increase in the knowledge about HIV and AIDS. It is pertinent to mention here that while
Midas was implementing the national BCC campaign a similar BCC campaign was being
implemented by another firm under the Punjab AIDS Control Programme. Therefore, it is
safe to assume that the impact measured during the survey was the result of the
combined impact of the two BCC campaigns.
Chart 1: Respondents overall knowledge of HIV transmission
modes after viewing TVC on HIV & AIDS
Amongst the respondents who had watched the TVC on HIV & AIDS a majority recalled
unsafe sex (34.3%) as a mode of HIV transmission followed by used syringes (33.0%)
and un-screened blood transfusions (24.4%). The least known modes of HIV
transmission were mother to child (3.1%) and unsterilized surgical equipment/blades
(2.7%). A sizeable proportion of the overall respondents (14.1%) did not know of any
HIV mode of transmission.
Overall, the findings suggest that the awareness levels for HIV transmission modes have
improved considerably although the awareness gap needs to be further narrowed down .
Chart 2: Gender wise knowledge of HIV modes of after viewing TVC on HIV &
AIDS
Awareness levels for HIV modes of transmission varied among both male and female
respondents. More male respondents (38.6%) as compared to their female counterparts
(21.6%) identified unsafe sex as a HIV mode of transmission, which is a substantial
difference. A higher proportion of female respondents compared to male respondents
19
recalled HIV modes of transmissions such as un-screened blood transfusions (male
16.39%, female 26.5%) and used syringes (male 25.5%, female 32.4%). The awareness
levels for modes of transmissions such as mother to child and use of unsterilized surgical
equipment/blades was very low among both male and female respondents.
Future BCC campaigns should focus more on educating women about the dangers of
unsafe sex, while more focus should be on men with regards to used syringes as an HIV
mode of transmission.
Chart 3: Percentage of respondents that remember at least one HIV mode of transmission
after viewing TVC on HIV & AIDS
A majority of respondents (97.8%) who had seen the TVC on HIV & AIDS remembered
at least one mode of transmission of HIV. This is a significant improvement over the
period the BCC campaign was implemented.
Chart 4: Percentage of respondents that recalled one HIV mode of transmission after viewing TVC
on HIV & AIDS
About 26.2 percent of the respondents who had viewed the TVC could recall one mode of
transmission for HIV. There should be a greater effort to produce TVCs that focus on
individual HIV modes of transmission in the future, so that recall value is better.
20
Chart 5: Percentage of respondents that recalled two HIV modes of transmission
After viewing TVC on HIV & AIDS
About 21 percent of the respondents who had viewed the TVC could recall two modes of
HIV transmission. TVCs on HIV & AIDS should be designed to bring clarity and better
understanding so that the recall value for all modes of transmission for HIV is increased.
Chart 6: Percentage of respondents who had heard the radio spot
and remember at least one mode of transmission for HIV
A majority of respondents (73.2%) who had heard the radio spot on HIV & AIDS could
recall at least one mode of transmission for HIV & AIDS. This again is a significant
achievement of the BCC campaign.
Chart 7: Percentage of respondents who had heard the radio spot
and remember only one mode of transmission for HIV
About 23.2 percent of the respondents who had heard the radio spot on HIV & AIDS
could recall one mode of transmission for HIV & AIDS. Messages on HIV & AIDS to be
aired on radio channels must be improved for better recall value in future BCC
campaigns.
21
Chart 8: Percentage of respondents who had heard the radio spot
and remember no mode of transmission for HIV
A majority of respondents (53.6%) who had heard the radio spot on HIV & AIDS did not
remember any modes of transmission for HIV & AIDS.
Findings from the FGDs
According to the findings of the Focus Group Discussions (FGDs) the most recalled
modes of HIV transmission, were in the following order:
1. HIV/AIDS can be transmitted through sexual relations;
2. HIV/AIDS can be transmitted by using used syringes and blades; and
3. HIV/AIDS can be transmitted by use of untested blood.
The women participants of the FGDs suggested the need to address the HIV/AIDS issue
more openly. They believed that the modes of HIV transmissions should be further
explained in detail. They also felt that more time should be allocated for HIV related
programs on the media, specifically on TV channels. The women participants also
stressed that it would be appropriate and more acceptable if a doctor or a respectable
member of the society narrated HIV & AIDS awareness messages. They also suggested
talk shows with doctors are aired, so that families could sit and watch the programmes
together.
The male participants from the FGDs highlighted the need to attach a mode of
transmission with pictures that are not confusing, i.e. a clip showing a barber shaving to
indicate that used blades should be avoided. Such additions would help the illiterate
population to better understand the messages.
The findings with regard to the evaluation objective to ‘measure the general
population’s attitude regarding HIV/AIDS and towards People Living with HIV/AIDS
(PLWHAs) are the following:
22
Chart 9: Respondents who had seen the TVC that discussed the TVC
with members of their community
Only a small percentage of respondents (17.4%) who had viewed the TVC on HIV &
AIDS discussed it with the members of their community. The findings suggest that the
subject of AIDS is still a taboo in society and the media campaign should encourage the
general adult population to talk about the social issues related to HIV and AIDS.
However, this may also require more focus on interactive forms of communication.
Chart 10: Gender wise breakdown of respondents who had seen the
TVC and discussed the TVC with members of their community
Amongst the respondents who had seen the TVC on HIV & AIDS a majority (60.9%) of
female respondents discussed it members of their community as opposed to their male
counterparts (39.1%). Future BCC activities on TV channels should focus on encouraging
men to break their silence and talk more openly about their health concerns, particularly
about HIV/AIDS and other sexually transmitted infection.
Chart 11: Breakdown of respondents by educational background who had
seen the TVC and discussed the TVC with members of their community
23
An overwhelming majority of respondents (33.3%) who had seen the TVC and discussed
it with members of their community were of the master/post graduate level, followed by
Bachelors (20.3%) and Intermediate (14.5%). This suggests that education plays a
major part in the attitude, acceptability and willingness of the respondents to spread and
share useful information HIV & AIDS with their peers and member of their communities.
Chart 12: Respondents who had heard the radio spot discussed it with
members of their community
Only a small percentage of respondents (19.6%) who had heard the radio spot on HIV &
AIDS discussed it with the members of their community.
Chart 13: Gender wise breakdown of respondents who had heard the radio
spot and discussed it with members of their community
In the case of radio spots, a majority of male respondents (63.6%) who had heard the
radio spot on HIV & AIDS had discussed it with members of their community, as opposed
to their female counterparts (36.4%).
24
Chart 14: Respondents who had read the print advertisement on HIV/AIDS and
discussed it with members of their community
A small proportion of the overall respondents (15.3%) that had read the print
advertisement on HIV & AIDS discussed it with the members of their community. It can
be implied that there are strong reservations concerning talking openly about HIV &
AIDS in society.
Findings from the FGDS
The findings of the FGDs in both the rural and urban areas suggest that there was some
improvement however the mainstream society is reluctant to discuss TVCs, radio spots
and print media campaigns on HIV/AIDS.
There were two main reasons for this:
1. People felt shy discussing HIV/AIDS with each other; and
2. People had not seen an actual HIV/AIDS patient therefore, could not relate to the
hardships faced by him.
There were no indicators set at the outset of the project, against which effectiveness
such as:







number
number
number
number
number
number
number
of
of
of
of
of
of
of
training sessions;
education sessions;
media events;
materials produced;
materials distributed;
people trained; and
people reached.
However, the trend in outputs showed that there were improvements overtime. From
this perspective, it could be concluded that the implementation improved over time, as
evidenced by the increase in the scale and scope of project activities.
The project used various methods to transmit behavior change communication messages
to their target populations. The media used included: peer educators, outreach workers,
and drama clubs, through which the direct project and wider communities were targeted
with electronic BCC messages.
The messages regarding the use of condoms were limited to few print media
advertisements. The electronic media campaign was conspicuous by its absence of any
reference to the promotion of condom use. The reasons cited for limited promotion of
25
condoms included the social and cultural inhibitions as well as the reluctance of the
policy makers to challenge the established norms of behavior.
The objective of the evaluation was to measure the people’s perception about the
media campaign
Chart 15: Overall respondents who had watched a TVC on HIV & AIDS
81 percent of all respondents of the target population across all four provinces (Punjab,
NWFP, Balochistan & Sindh) and the Federal, both rural and urban had watched a TVC on
HIV & AIDS. The survey finding suggests that the TV media campaign on HIV & AIDS
was conducted intensively nationwide.
Chart 16: Gender wise Breakdown of respondents who had watched a TVC on HIV
& AIDS
The viewer ship of the TVCs on HIV & AIDS was evenly distributed between the male
(51.2%) and female (48.8%) respondents. The finding implies that both male and
female respondents had equal access and opportunity to view the TVCs on HIV & AIDS.
A relatively small proportion (19%) of the overall respondents had not watched the TVCs
on HIV & AIDS.
Chart 17: Gender wise breakdown of respondents who had not watched a TVC on
HIV & AIDS
From the respondents who had not watched a TVC on HIV & AIDS (19%), the majority
were males (61.8 %). This implies that future BCC campaigns would have to consider
production of TVCs that are more attractive to the general male adult population.
26
Chart 18: Province wise break down of
respondents who had watched a TVC
on HIV & AIDS-Punjab
TVC on HIV & AIDS
Chart 20: Province wise break down of
respondents who had watched a TVC
on HIV & AIDS-NWFP
TVC on HIV & AIDS
Chart 19: Province wise break down of
respondents who had watched a TVC
on HIV & AIDS-Sindh
TVC on HIV & AIDS
Chart 21: Province wise break down of
respondents who had watched a TVC
on HIV & AIDS-Federal
TVC on HIV & AIDS
Chart 22: Province wise break down of
respondents who had watched a TVC
on HIV & AIDS-Balochistan
TVC on HIV & AIDS
The findings suggest that a TVC on HIV & AIDS was most viewed in the Federal Area
(92.5%) and least viewed in the province of Sindh (68.8%). The viewership of the TVC
was in the Punjab was the second lowest (72.5%), while the viewership of the TVC in
NWFP (90%) and Balochistan (81.3%) was relatively high.
27
Chart 23: Age group wise breakdown of respondents who had watched a TVC on
HIV & AIDS
The respondents of age group 16-30 years had seen the TVC on HIV & AIDS the most
(54.3%), and the viewer ship of the TVC amongst the respondents declined in the age
groups 31-40 years (36.7%), 41-50 years (6.5%) and 51-70 (2.5%). The viewer ship
among the age group 41-50 years is very low and could be targeted in future media
campaigns.
Chart 24: Gender wise breakdown of age groups of respondents who had watched
a TVC on HIV & AIDS
Similar patterns exist in relation to viewer ship of the TVC on HIV & AIDS amongst male
and female respondents of various age groups. The TVC viewer ship amongst both
genders was highest amongst the age group of 16-40 years and lowest amongst the age
group of 51-70 years.
28
Chart 25: Age group wise breakdown of respondents who had not watched a TVC
on HIV & AIDS
The most number of respondents who had not viewed the TVC on HIV & AIDS were of
the age group 16-30 years (51.3%) and the numbers declined in the age groups 31-40
years (35.5%), 41-50 years (9.2%) and 51-70 (3.9%). The findings suggest that the
respondent in the 16-30 age group are the main viewers of TV channels and media
campaigns on HIV & AIDS should specifically target this age group.
Chart 26: Gender wise breakdown of age groups of respondents who had not
watched a TVC on HIV & AIDS
A majority of male respondents (57.4%) in the age group of 16-30 years had not seen
the TVC on HIV & AIDS while a majority of female respondents (44.8%) amongst the
age group of 31-40 had not seen the TVC on HIV & AIDS.
Chart 27: Education wise breakdown of respondents who had watched a TVC on
HIV & AIDS
29
The respondents who had viewed the TVC on HIV & AIDS the most had a Master or postgraduate level education (19.1%). Intermediate (15.4%), Bachelors (13.9%), and
Matriculation (13.6%) levels of education followed this trend. Surprisingly, more illiterate
respondents (11.4%) had seen the TVC than respondents who with secondary education
(8.0%).
Chart 28: Gender wise breakdown of respondents who had watched a TVC on HIV
& AIDS and their educational background
Most male respondents who had viewed the TVC on HIV & AIDS were of master or
postgraduate degree level (22.9%) while the illiterate male respondents (7.2%) had
least viewed the TVC on HIV & AIDS. Amongst the female respondents there is a
different pattern, as most female respondents who had viewed the TVC on HIV & AIDS
were of Intermediate level (17.1%) followed by illiterate female respondents (15.8%).
The illiterate female respondents had viewed the TVC more than female respondents
who had Masters (15.2%). Bachelors (10.8%) or Matriculation (13.9%) level of
education.
Chart 29: Breakdown of frequency with which respondents had watched a TVC on
HIV & AIDS
30
Most of the respondents had viewed the TVC on HIV & AIDS once a month (34.4%). This
was followed by once a week and at various times (21.3%). Only 9.9% of the overall
respondents had viewed the TVC on HIV & AIDS once a day.
Chart 30: Gender wise breakdown of
frequency with which respondents had
watched a TVC on HIV & AIDS-Male
Chart 31: Gender wise breakdown of
frequency with which respondents had
watched a TVC on HIV & AIDS-Female
A majority of male respondents (44.6%) had viewed the TVC on HIV & AIDS once a
month, while a majority of female respondents (29.1%) had viewed the TVC at various
times. A good portion of both male (22.9%) and female (20.3%) had viewed the TVC
once a week. This implies that the BCC media campaign on HIV & AIDS was consistent
with regular airing of TVCs on TV channels.
Chart 32: Overall viewership of TVC on HIV & AIDS on various TV channels
The TVC on HIV & AIDS was most viewed on PTV (83.3%) followed by GEO (34.9%) and
Aaj News (17.3%). The TVC was least viewed on Apna channel (1.2%) and TV One
(1.2%).
31
Chart 33: Gender wise viewership of TVC on HIV & AIDS on various TV channels
A majority of both the male (43.2%) and female (40.1%) had viewed the TVC on HIV &
AIDS on PTV. The findings suggest that male respondents had viewed the TVC on
various TV channels more than the female respondents had, particularly on GEO and Aaj
news.
Chart 34: Timings when TVC on HIV & AIDS was most viewed
A majority of the overall respondents (69.8%) had viewed the TVC between 7-11 p.m.,
and the least popular time for viewing the TVC was between 7-9 a.m. (5.9%). This
suggests that future BCC TV media campaigns should consider airing TV spots between
7-11 p.m.
Chart 35: Gender wise break down of
timings when TVC on HIV & AIDS was
most viewed-Male
Chart 36: Gender wise break down of
timings when TVC on HIV & AIDS was
most viewed-Female
32
The patterns for both male and female respondents are similar for the timings when the
TVC on HIV & AIDS was most viewed. 7-11 p.m. was the most popular time for viewing
the TVC amongst both male (61.9%) and female (64.8%).
Chart 37: The most recalled slogan/theme from respondents who had seen
the TVC on HIV & AIDS
The most recalled slogan from respondents who had viewed the TVC on HIV & AIDS was
“AIDS Ek Khatarnak Bemari He” (23.1%) followed by “AIDS La Elaaj Hai” (20.7%) and
“Apne Aap ko AIDS se Bachaye” (14.5%). The BCC campaign implemented by Midas was
being complemented with the Punjab AIDS Control Program BCC campaign implemented
by another firm, the general population was exposed to a variety of slogans and
messages.
Chart 38: The most recalled slogan/theme from respondents who had seen
the TVC on HIV & AIDS – Gender wise
The male respondents were more responsive in recalling the slogans and themes of TVC
on HIV & AIDS than the female respondents.
33
Chart 39: Overall respondents who heard Radio Spot on HIV & AIDS
Only 14% percent of all respondents of the target population across all four provinces
(Punjab, NWFP, Balochistan & Sindh) and the Federal, both rural and urban had heard
the radio spot on HIV & AIDS. The survey finding suggests that the radio media
campaign on HIV & AIDS should have been conducted more intensively nationwide.
Chart
Gender
wise
Breakdown
of respondents
who heard
radio(50%)
spot onand female
The listening
of40:
radio
spots
was
evenly distributed
between
the a
male
HIV & AIDS
(50%) respondents. The finding implies that both male and female respondents had
equal access and opportunity to hear the radio spot on HIV & AIDS. A relatively large
proportion (86%) of the overall respondents had not heard the radio spot on HIV &
AIDS.
Chart 41: Gender wise breakdown of respondents who had not heard the
radio spot on HIV & AIDS
34
From the respondents who had not heard the radio spot on HIV & AIDS (86%), a slight
majority were males (53.8 %).
Chart 42: Province wise break down of
respondents who had heard a Radio spot
on HIV & AIDS-NWFP
Chart 44: Province wise break down of
respondents who had heard a Radio spot
on HIV & AIDS-Sindh
Chart 43: Province wise break down of
respondents who had heard a Radio spot
on HIV & AIDS-Punjab
Chart 45: Province wise break down of
respondents who had heard a Radio spot
on HIV & AIDS-Balochistan
Chart 46: Province wise break down of
respondents who had heard a Radio spot on HIV
& AIDS-Federal
The overall listener ship of the radio spot on HIV & AIDS was low across all provinces of
Pakistan. Listener ship in the Federal and NWFP was the lowest (8.8%), while
Balochistan (23.8%) fared a little better than Sindh (15%) and Punjab (13.8%).
35
Chart 47: Age group wise breakdown of respondents who had heard a Radio
Spot on HIV & AIDS
The respondents of age group 16-30 years had heard the radio spot on HIV & AIDS the
most (58.9%), and the listener ship of the radio spot amongst the respondents declined
in the age groups 31-40 years (32.1%), 41-50 years (8.9%).
Chart 48: Gender wise breakdown of age groups of respondents who had heard
Radio Spot on HIV & AIDS
36
Similar patterns exist in relation to listener ship of the radio spot on HIV & AIDS
amongst male and female respondents of various age groups, except age group of 4150, where a male majority (14.3%) had heard the radio spot when compared to their
female counterparts (3.6%). The listener ship of the radio spot amongst both genders
was highest amongst the age group of 16-40 years and lowest amongst the age group of
51-70 years (0%).
Chart 49: Age group wise breakdown of respondents who had not heard the radio
spot on HIV & AIDS
The most number of respondents who had not heard the radio spot on HIV & AIDS were
of the age group 16-30 years (52.9%) and the numbers declined in the age groups 3140 years (37.2%), 41-50 years (6.7%) and 51-70 (3.2%). The findings suggest that the
respondent in the 16-30 age group are the main listeners of radio channels and media
campaigns on HIV & AIDS should specifically target this age group.
Chart 50: Gender wise breakdown of age groups of respondents who had not
heard the radio spot on HIV & AIDS
A majority of male respondents (58.9%) in the age group of 16-30 years had not heard
the radio spot on HIV & AIDS while a majority of female respondents (41.5%) amongst
the age group of 31-40 had not heard the radio spot on HIV & AIDS.
37
Chart 51: Education wise breakdown of respondents who had heard a radio spot
on HIV & AIDS
The respondents who had heard the radio spot on HIV & AIDS the most had intermediate
level education (21.4%). Matriculation (19.6%), Masters (14.3%), and Bachelors
(10.7%) levels of education followed this trend. Surprisingly, the same percentage of
illiterate respondents (8.9%) had heard the radio spot as respondents who with
secondary education (8.9%).
Chart 52: Gender wise breakdown of respondents who had heard a Radio Spot on
HIV & AIDS and their educational background
A majority of male respondents who had heard the radio spot had secondary and
Intermediate level of education (32.1%). On the contrary, the majority of female
respondents who had heard the radio spot had Matriculation (25%) and Secondary
education (17.9%) backgrounds. Illiterate male respondents had heard the radio spot
more than Bachelor level students. No female respondents with primary education had
heard the radio spot on HIV & AIDS.
38
Chart 53: Breakdown of frequency with which respondents had heard a radio
spot on HIV & AIDS
A majority of participants had heard the radio spot at various times (28.6%) or did not
know the time (26.8%).
Chart 54: Overall listenership of Radio Spot on HIV & AIDS on various Radio
channels
The most widely listened to radio channel , as far as the radio spot on HIV & AIDS is
concerned was FM 101 (45.2%) followed by FM 100 (30.6%), while the share of listener
ship for all other FM channels was negligible.
Chart 55: Gender wise listener ship of Radio Spot on HIV & AIDS on various
Radio channels
A majority of both the male (43.8%) and female (46.7%) had heard the HIV & AIDS
radio spot FM 101. The findings suggest that only male respondents had heard the radio
39
spot on some FM radio channels (FM 93 and FM 99) while only female respondents had
heard it on FM 91 and FM 97. Both male (34.4%) and female (26.7%) respondents also
heard the radio spot well on FM 100.
Chart 56: Timings when Radio Spot on HIV & AIDS was most heard
A majority of the overall respondents (69.8%) had heard the radio spot between 9-11
a.m. (63.8%), and the least popular time for viewing the TVC was between 1-5 p.m.
(5.9%). Many respondents (25%) also heard the radio spot between 7-11 p.m.
Chart 57: Gender wise break
down of timings when Radio
Spot was most heard-Male
Chart 58: Gender wise break
down of timings when Radio
Spot was most heard-Female
The patterns for both male and female respondents are similar considering the timings
radio spot on HIV & AIDS was most heard. 9-11 a.m. was the most popular time for
listening to the radio spot amongst both male (61.1%) and female (66.6%).
Chart 59: The most recalled slogan/theme from respondents who had Radio Spot
on HIV & AIDS
40
The most recalled slogan from respondents who had heard the radio spot on HIV & AIDS
was “Apne Aap ko” AIDS se Bachaye” (19.6%) followed by AIDS Ek Khatarnak Bemari
He” (11%) and ”AIDS La Elaaj Hai” (5%). It is a concern that the main slogan used by
Midas during the BCC campaign “HIV & AIDS – Hum Sub Ka Masla Hai – Sochye,
Samajye, Roakye” was not recalled. Although the most recalled slogan “Apne Aap ko
AIDS se Bachaye” resembles the theme/slogan adopted at the latter stage of the BCC
campaign by Midas, “Hum Sub Ko Bachna Hai”. Moreover, as the BCC campaign
implemented by Midas was being complemented with provincial BCC campaigns, the
general population was exposed to a variety of slogans and messages.
The most recalled slogan/theme from respondents who had seen the TVC on
HIV & AIDS – Gender wise
Chart 60: The most recalled slogan/theme from respondents who had seen the
TVC on HIV & AIDS – Gender wise
A majority of male respondents (72.7%) recalled the theme/slogan “Apne Aap Ko AIDS
se Bachaye” while a majority of female respondents recalled the themes “AIDS Ek
Khatarnak Bemari He” (72.7%) and “AIDS La Elaaj Hai” (60%). Overall, female
respondents were more responsive in recalling the main themes and slogans aired by the
HIV & AIDS radio spots on various radio channels.
Chart 61: Overall respondents that had seen or read an advertisement on
HIV/AIDS in the newspapers
About 34.3% percent of all respondents of the target population across all four provinces
(Punjab, NWFP, Balochistan & Sindh) and the Federal, both rural and urban had seen or
read an advertisement on HIV & AIDS in the newspapers. The survey finding suggests
that future print media campaigns should be conducted more intensively nationwide.
41
Chart 62: Province wise breakdown of
respondents who had seen a read an
advertisement on HIV/AIDS in the
newspapers-Punjab
Chart 64: Province wise breakdown of
respondents who had seen a read an
advertisement on HIV/AIDS in the
newspapers-NWFP
Chart 63: Province wise breakdown of
respondents who had seen a read an
advertisement on HIV/AIDS in the
newspapers-Sindh
Chart 65: Province wise breakdown of
respondents who had seen a read an
advertisement on HIV/AIDS in the
newspapers-Balochistan
Chart 66: Province wise breakdown of
respondents who had seen a read an
advertisement on HIV/AIDS in the
newspapers-Federal
The overall readership of advertisement on HIV & AIDS was very low across all provinces
of Pakistan. Readership of the HIV & AIDS advertisement was by far the highest in the
Federal (54%) compared to other provinces (NWFP 22.6%%, Balochistan 19%, Punjab
17.5%, and Sindh 13.1%) where the level of readership was very low.
42
Chart 67: Gender wise breakdown of respondents who had
seen or read an advertisement on HIV/AIDS in the print media
A majority of male respondents (73.7%) had read an advertisement on HIV/AIDS in the
print media compared to their female counterparts (26.3%). The finding is a reflection of
the higher literacy rate of males and access to the print media.
Chart 68: Breakdown by age group of respondents who had read an advertisement
on HIV/AIDS
The respondents of age group 16-30 years had read the print advertisement on HIV &
AIDS the most (59.1%), and the readership of the print advertisement amongst the
respondents declined in the age groups 31-40 years (35.8%), 41-50 years (5.1%).
43
Chart 69: Gender wise breakdown by age groups of respondents who read an
advertisement on HIV/AIDS
A majority of both male (61.4%) and female (52.8%) respondents of age groups 16-30
had read an advertisement on the newspaper, followed by age groups 31-40 and 41- 50.
Chart 70: Breakdown by age group of respondents who had not read an
advertisement on HIV/AIDS
The age group of 16-30 (51.3%) was the highest for respondents who had not read an
advertisement in the print media, followed by 31-40 (36.9%), 41-50 (8%) and 51-70
(4.2%).
44
Chart 71: Gender wise Breakdown by age group of respondents who had not read
an advertisement on HIV/AIDS
Majority of male (56.3%) and female (47%) respondents of age group 16-30 had not
read an advertisement on HIV & AIDS.
Chart 72: Breakdown by education level of respondents who had read an
advertisement on HIV/AIDS
Most respondents who had read the print advertisement on HIV & AIDS were of
Master/Post Graduate level of education (32.8%) followed by , Bachelor (22.6%) and
Intermediate (18.2%).
Chart 73: Gender wise breakdown by education level of respondents who had read
an advertisement on HIV/AIDS
45
Both male and female respondents who had read the HIV & AIDS advertisement the
most were of Master/Post Graduate Level (Male 31.7%), Female 36.1%). A good
proportion of both male and female respondents from Bachelors and Intermediate
educational backgrounds had also read the print advertisement on HIV & AIDS.
Chart 74: Breakdown of the frequency with which respondents had read an
advertisement on HIV/AIDS
Most respondents (66.8%) had read the print advertisement once a month followed by,
at various times (13.6%), once a week (10.6%).
Chart 75: Gender wise breakdown of the frequency with which respondents read
the print advertisement on HIV/AIDS
A majority of male respondents (44.6%) read the print advertisement on HIV & AIDS
once a month, while a majority of female respondents (47.2%), cited at various times.
46
Chart 76: Breakdown of the percent of total (male + female) who had read the print
advertisement on HIV/AIDS in various newspapers
The majority of respondents (71.5%) had read the print advertisement on HIV & AIDS
on Jang, followed by Nawai- Waqt (37.2%), Ausaf (19.7%), The NEWS (16.1%),
Roznama Express (8%), DAWN (5.8%), The Nation (3.6%), and Pakistan (2.9%).
Chart 77: Gender wise breakdown of the respondents who had read the print
advertisement on HIV/AIDS
Both male (42%) and female (48%) respondents had seen the print advertisement on
HIV & AIDS the most on Jang. More male than female respondents read Nawai – Waqt,
Pakistan, and Ausaf. More female respondents than male had read the print
advertisement on HIV & AIDS in Jang, The NEWS, DAWN, and The Nation.
Findings from the FGDs
The main messages recalled from the TVC, radio spots and print advertisements on HIV
& AIDS, according to the respondents of the FGDs were as follows:







HIV/AIDS
HIV/AIDS
HIV/AIDS
HIV/AIDS
HIV/AIDS
HIV/AIDS
HIV/AIDS
is a dangerous disease;
is incurable;
kills;
spreads due to illicit sexual relations with women;
spreads due to re-use of syringe;
spreads due to the re-use of blades; and
spreads due to transmission of untested blood.
47
The main recall of images and photo clips regarding the electronic and print campaign on
HIV & AIDS was as follows:
1. A man with an umbrella in the rain;
2. A lady doctor showing syringes and different clinical operation instruments; and
3. Dark footage of a man and woman together.
13.0 Recommendations
For future BCC campaigns, it is advisable that the intensity of the media effort is defined
in the TOR which is relevant to the targets to be achieved. Therefore, it is advisable that
in future BCC contracts the media outputs should be activity specific and quantified.
Furthermore, to make the TOR more specific and responsive to the program objectives,
it would be advisable to include a set of BCC effectiveness indicators such as:
number
number
number
number
number
number
number
of
of
of
of
of
of
of
training sessions;
education sessions;
media events;
materials produced;
materials distributed;
people trained; and
people reached.
The TOR should specify the basis of establishing the primary and secondary indicators as
well as the baseline and target figures.
In future campaigns, it would be useful to focus more on the target audience’s ideas of
DISADVANTAGES or barriers of adopting this desired behavior? For example barriers
such as;
money
time
convenience
physical ease
mental ease
social standing
comfort
popularity
others (please specify)
Do some of the messages refer to the target audience’s ideas of the ADVANTAGES of
adopting this desired behavior?
yes or no
Here are some examples of advantages. Check those or list
others that your intervention addresses.
protected health
being “modern”
protection of family
pain reduction
fewer medical costs
peace of mind
others (please specify)
48
Future BCC campaigns should focus more on educating women about the dangers of
unsafe sex, while more focus should be on men with regards to used syringes as an HIV
mode of transmission.
Future BCC activities on TV channels should focus on encouraging men to break their
silence and talk more openly about their health concerns, particularly about HIV/AIDS
and other sexually transmitted infection.
There should be a greater effort to produce TVCs that focus on individual HIV modes of
transmission in future, so that recall value is better.
The variance analysis of BCC activities, where a planned vs. actual approach has been
adopted to report the milestones approved and implemented as per TAG meetings
should be adopted in all future reporting formats.
The national and provincial AIDS Control Programs should establish BCC coordination
mechanisms for synergy and greater impact.
Contract administration should be diligent to ensure implementation in accordance with
the TOR and other relevant contract clauses. And, any variations in the TOR or scope of
work should be fully documented and its technical and financial implications formalized in
the contract through a contract amendment. To cite verbal instructions as the basis of
deviations from the scope of work is a serious contract administration oversight.
In future, the budget for third party evaluations should not be part of the contract
amount of the entity to be evaluated. The present arrangement where the evaluation
payments are released by Midas creates a potential conflict of interest situation.
49