Cambodia Sentinel Survey 2008: Media and Discussion, Knowledge, Attitudes and Practices About Sexual Matters, HIV and AIDS, Risks, Condoms, VCCT (HIV Testing), People Living with HIV and Men who have Sex with Men

This 203-page report from the Research and Learning Group (R&L) of the BBC World Service Trust (hereafter, "the Trust") details a quantitative sentinel survey of young Cambodians' HIV and AIDS knowledge, attitudes, and practice (KAP). It was conducted as part of a 3-year project, launched in October 2006, to focus on HIV prevention through behaviour change communications (BCC) using mass media. The overall project goal is to create an enabling environment for prevention of sexual transmission, measured through increased exposure to HIV and AIDS media. In addition to mass media, the strategy also uses niche media to reach most-at-risk populations (MARPs) such as men who have sex with men (MSM) and entertainment workers.

Specifically, a number of television and radio outputs are being produced and broadcast:

• Television: 21 TV spots, 3 documentaries ("niche media") - each geared toward specific audiences, such as people living with HIV (PLHIV), MSM, and those seeking voluntary and confidential counselling and testing for HIV (VCCT) - and 1 drama feature film.
• Radio: 18 radio spots and 3 weekly radio phone-in programmes: Real Men (intended for rural males 20-29 years old), Really (intended for urban youth, 15-24 years old), and Hip Hop Girls (intended for urban females 15-19 years old).

In its Cambodian HIV and AIDS KAP studies, the Trust has consistently applied a survey methodology using cross-sectional household-based surveys since 2004. The 2008 Sentinel Study total sample size is 1,368 young people aged 15-29 from 6 locations: Phnom Penh, Kandal, Kampong Speu, Kampong Chhnang, Battambang, and Siem Reap. Face-to-face interviews, each lasting 50-90 minutes, were conducted in the Khmer language in August 2008 (in private locations, with the informed consent of respondents, and with male interviewers interviewing male respondents and female interviewers interviewing females).

Excerpts from the Key Findings and Recommendations sections of the Executive Summary follow:

Key Findings

Profile of the Study Population

"...Overall, four in ten respondents (42%) reported that they had ever had sex. Nearly the same proportion, (39%), of all respondents were sexually active, that is, they reported having had at least one sexual partner in the past year.

Media Consumption

...Only 10% reported no radio or television use in the past month. Eight in ten (81%) were television viewers (had watched TV in the past month); and radio listening (had listened to radio in the past month) had increased from 57% in 2007 to 65% in 2008. More than half (55%) reported using both radio and television. Virtually all (98%) had access to a mobile telephone, and, while only 7% had ever used the internet, this was nearly double the level of internet use reported in 2007.

HIV and AIDS in the Media

Nearly all (92%) respondents reported that they seen or heard something about HIV and AIDS in the media in the past year, an increase from 2007. Eight in ten (86%) had seen something about HIV and AIDS on television and 73% had heard something on the radio, an increase since 2007.

BBC World Service Trust Outputs

A selection of TV spots that had been produced and broadcast since the 2007 Sentinel Study were included in this study: 89% of respondents had seen at least one of the TV spots, accounting for nearly all (98%) respondents who reported watching television. On average, respondents recalled 4 (out of a possible 8) spots.

Audiences for the Trust's three radio phone-in programmes - Really, Real Men and Hip Hop Girls - increased since 2007. Overall, 34% of respondents had listened to the Really programme, 21% to Real Men and 11% to Hip Hop Girls. Considering that just two-thirds of respondents are radio listeners, and the leading stations manage to capture about 25% of the audience share, this is a very strong performance by these three programmes...

Interpersonal Communication: 'Talking About...'

...In the entire sample, recent (in the past month) talking about sexual matters (39%) and ever having talked to a PLHIV (39%) were the most common, followed by HIV and AIDS (36%), condoms (35%), and HIV testing (20%).

Males discussed all topics more than females; single sexually active males discussed all topics the most.

There were decreases in 'never talking' about various HIV and AIDS related topics. However, most respondents reported that discussions were not recent (i.e. they occurred more than a month ago)...

In the total sample and among both target subgroups, there were substantially lower levels of 'never talking' about various HIV and AIDS related topics among those who were not exposed to Trust outputs. Similarly, recent (in the past month) discussion was higher among those who had higher levels of exposure.

Sexual Matters and Practices

...As in 2007, the data also indicate that three distinct types of sexual relationships continue to exist between young Cambodian men and women: wife/spousal, sweetheart and paid sex workers. Male premarital sex was with sweetheart and sex worker partners. A third of single males and one in five single females reported having a sweetheart at the time of the survey. However, only two single women reported ever having had sex, reflecting the importance placed on a woman's virginity until marriage, but also suggesting possible under-reporting due to this prevailing attitude.

The data also support the Trust's assertion in 2007 that it is a widespread but not universal practice in Cambodia for men to have extramarital relationships, multiple partners and/or to pay for sex. The majority of married males, and all married women reported being monogamous with their spouse. Slightly more than a third (37%) of married males reported ever having extramarital sex, about 15% of all married men in the past year. About one in ten married males also had a sweetheart and/or a sex worker partner in the past year. Seven in ten (70%) of sexually active single males reported they had a sex with a paid sex worker in the past year.

Condoms

Knowledge that condoms can prevent HIV was close to universal, and other attitudes indicated social support for discussing and using condoms. Nevertheless condoms did still seem to be linked to sex work [..."likely a legacy of early, successful, responses to HIV and AIDS in Cambodia, which focused on promoting '100% condom use' with sex workers"], and there was nearly a third of the population who never talked about condoms.

...As in 2007, only about a half of sexually active respondents reported ever using a condom. Nearly a third of the sexually active respondents used condoms consistently (i.e. they reported having done so the last time they had sex). Consistent condom use was much more common among men than women.

Looking just at those who had ever used a condom, consistent condom use was higher: two-thirds of males and nearly half of females who had ever used a condom reported they had used one the last time they had sex. This suggests that once condom use is initiated, it is widely sustained. Condom use varied considerably across the three main types of relationships:

• Consistent condom use with spouses was reported at very low levels by both married males and females.
• Condoms use with sweethearts has become more common ('always' - 49% 2007; 65% 2008).
• Virtually all males who had a sex worker partner in the past year used a condom the last time they had sex with them.
  

In the total sample and among both target subgroups, there were substantially lower levels of condom use by those who were not exposed to the Trust outputs. Many differences were statistically significant, indicating the positive relationship between exposure to mass media with prevention information and condom use.

HIV and AIDS Risks

This study found high knowledge about HIV and AIDS risk reduction, particularly the use of condoms which increased to 97%. Other key methods known were not using contaminated injecting equipment, having only one partner and avoiding the blood and pus of PLHIV.

Since 2007, never talking about HIV and AIDS risks decreased from 25% to 21%, and was significantly lower among those who had been exposed to mass media outputs. Overall, there was strong support expressed for talking about HIV and AIDS. For a minority, embarrassment and fear were barriers to talking about HIV and AIDS, but at less so than in 2007. These barriers were less common among those who had been exposed to Trust outputs.

Risk Perception

As in 2007, a fifth of respondents reported that they felt they had some chance of contracting HIV. Among those who felt they were at some risk, using contaminated injecting equipment, lack of trust in their partner and not using condoms were the main reasons given...

VCCT (HIV Testing)

Overall, HIV testing levels were steady: 23% of respondents reported they had been tested for HIV antibodies. However, interest in being tested for HIV declined significantly from 43% in 2007 to 33% in 2008.

Never talking about HIV testing also decreased to 40%, and...exposure to the Trust outputs was associated with higher levels of talking about HIV testing in the past month.

Having been tested for HIV in the past was associated with wanting to be tested for HIV... ...[M]ore respondents who considered themselves to be at some risk wanted to be tested, compared to those who thought they were at no risk. Nevertheless, half (51%) of those who assessed themselves to be at some risk of contracting HIV did not want to be tested.

HIV testing was not associated with exposure to the BBC World Service Trust outputs, but expressing interest in being tested for HIV was higher (42%) among those with high exposure to Trust outputs.

Stigma and Discrimination

...Only a few report trying to avoid physical contact with PLHIV, and among those exposed to the Trust outputs the levels were significantly lower. Nevertheless, there was an increased response that 'avoiding the blood or pus of PLHIV' was a way to prevent HIV infection, which needs to better understood.

...In this study, only one married male reported he had ever had sex with a man. This practice was considered unacceptable by nearly all respondents, with no variations across any profiles. The stigma associated with MSM may therefore account for the underreporting of this practice among respondents...

Recommendations

Mass Media to Promote HIV Prevention Mass Media in General

• Mass media is strongly recommended as an effective method to continue communication about HIV and AIDS.
• To ensure reaching as many young Cambodians as possible a variety of programme outputs that meet their tastes and lifestyles is needed.
• As such, a multi-format, multi-media approach is recommended: looking generally at the recall of HIV and AIDS information in the media over the past year, the reach of television formats (86%) was greater than radio (73%), but many respondents had encountered HIV and AIDS information on both television and radio (67%).
• Consider extending the variety of programmes and platforms with some longer-format television outputs."