Geita District Mwanza Region Northern Tanzania April 2007 J Sheldon

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Geita District Mwanza Region Northern Tanzania April 2007 J Sheldon

  1. 1. Before it’s too late: An adolescent HIV Prevention program for Geita district, mwanzaregion, Northern Tanzania Jeffrey Sheldon, M. A., Ed. m. School of Behavioral & Organizational Sciences Claremont Graduate University The Claremont Colleges 25 April 2007 Before Its Too Late 1
  2. 2. OVERVIEW • SPECIFIC AIMS: global • SPECIFIC AIMS: students • BACKGROUND AND SIGNIFICANCE • TARGET POPULATION • PRIOR INTERVENTIONS WITH ADOLESCNENTS • THEORETICAL RATIONALE • THE INTERVENTION • THE SETTING • RESEARCH DESIGN • METHODS • MEASURES & evaluation • CHALLENGES • TIMELINE • REFERENCES Before Its Too Late 2
  3. 3. Specific Aims: global • help meet target of 25 % reduction in hiv prevalence in young people by 2010. • Put HIV prevalence and risk in a different perspective within the community. • Provide accurate information that dispels myths and inaccuracies about hiv/aids. • Begin changing prevalent social norms and prevalent male attitudes towards women. (Hayes et al., 2005; UNGASS, 2001) Before Its Too Late 3
  4. 4. Specific Aims: students • know, understand, and be aware of their own bodies. • know, understand and be aware of developmental stages (physical, emotional, cognitive). • know how hiv is transmitted and how hiv becomes aids if left untreated. • know how to decrease their risk of becoming hiv infected. • know the consequences of risky sexual behavior and alcohol and drug use are associated with risky sexual behavior. Before Its Too Late 4
  5. 5. Specific Aims: students • know that oro-genital and anal sex are not safe sexual alternatives. • know that positive and mutually fulfilling relationships can exist within a context of male hegemony and dominance. • be able to properly use male or female condoms. • know where and how to acquire condoms. • Begin to change gender role norms and stereotypes through improved female – male dialogue. Before Its Too Late 5
  6. 6. Specific Aims: students • Increase adolescent male awareness that females are part of the sexual decision-making process. • Attenuate potential adolescent male aggressiveness and hostility towards females. • Improve self – control in both adolescent males and females. • Improve male – female relationships through relational skill building. • Improve communication and negotiation skills between adolescent males and adolescent females. Before Its Too Late 6
  7. 7. Specific Aims: students • Increase adolescent female awareness of choice in sexual behavior and risk taking. • Increase self-efficacy and self-esteem. • Establish supportive relationships between adolescent females and older, significant – other females in their ward. • Establish a social support network between adolescent females across villages in each ward. • Increase adolescent female coping motives. Before Its Too Late 7
  8. 8. Background & Significance • Life expectancy in tanzania 44 years and falling; infant mortality rate is 99/1000 and rising due to high rates of hiv/aids infection – women most at risk. • 2.2 million people living with hiv/aids: – 15 % are 15 – 24 years; – 70.5 % are 25 – 49 years; – 60 % of new infections in 15 – 24 years age range.; – 13.3 % infection rate among women and climbing. • Prevalence rate expected to increase to 16.7 % by 2010 unless….. (aids and africa, 2003; buve et al, 2002; chnotowa, 1993; ole-nguyaine et al., 2004; somi et al., 2006; tacaids, 2003; unaids, 2004; unicef, 1999) Before Its Too Late 8
  9. 9. Background & Significance • Hiv infection rates higher in rural areas along truck routes and in mining communities due to migratory populations. • Migratory populations engage in more risky behaviors and are considered bridging populations. • In geita district, mwanza region 30 companies prospecting for gold. • Hiv prevalence in geita district 13 % – 19 % for community members. – 16 % for women. (bellaby, 1990; campbell, 1997; cates & dallabetta, 1999; chngalucha et al., 2002; desmond, et al., 2005; republic of tanzania, 1996, 2002) Before Its Too Late 9
  10. 10. target population • ADOLESCENT FEMALES AND MALES AGES 12 – 18 ATTENDING PRIMARY SCHOOL. – LIVE IN AN AREA OF HIGH RISK; – YOUNG WOMEN LIKELY TO ENGAGE IN RELATIONSHIPS WITH OLDER MEN; – 14 % PREGNANCY RATE FOR ADOLESCENT FEMALES; – 25 % - 33 % STI RATE IN MALES & FEMALES RESPECTIVELY; – Males deny risk.; – Girls have less exposure to accurate information; – Males and females have different attitudes about sex; – Knowledge gap between males and females; – Adolescence a time of experimentation; and – Male hegemony and dominance is the prevailing cultural norm. (adamchak et al., 1990; desmond et al., 2005; gesovitz, 2005; gupta & weiss, 1993; haram, 2004, 2005; klepp et al., 1996, 1997; matasha et al., 1998; nyblade et al, 2003; orubulolye et al., 1993; silberschmidt & rasch, 2001; unaids, 2004; unaids/who, 2002; unicef, 2000; vavrus, 2003) Before Its Too Late 10
  11. 11. prior interventions withadolescents • AarØ, L. E., et al. (2006). Promoting sexual and reproductive health in early adolescence in South Africa and Tanzania: Development of a theory and evidence based intervention program. Scandinavian Journal of Public Health, 34, 150 – 158. • Clark, T. S., et al. (2006). An Adolescent-targeted HIV Prevention Project Using African Professional Soccer Players as Role Models and Educators in Bulawayo, Zimbabwe. AIDS Behavior, 10, S77 – S83. • Gallant, M., & Maticka-Tyndale, E. (2004). School-based HIV prevention programmes for African youth. Social Science & Medicine, 58, 1337 – 1351. • Klepp, K.I., et al. (1997). AIDS education in Tanzania: Promoting risk reduction among primary school children. American Journal of Public Health, 87(12), 1931 - 1936. • Kaljee, L. M., et al. (2005). Effectiveness of a theory–based risk reduction HIV prevention program for rural Vietnamese adolescents. Aids Education and Prevention, 17(3), 185–199. • Stanton, B. F., et al. (1998). Increased protected sex and abstinence among Namibian youth following a HIV risk-reduction intervention: A randomized, longitudinal study. AIDS, 12, 2473 – 2480. • Visser, M. J., & schoeman, J. B. (2004). Implementing a community intervention to reduce young people’s risks for getting HIV: Unraveling the complexities. Journal of Community Psychology, 32(2), 145 – 165. Before Its Too Late 11
  12. 12. theoretical rationale • Knowledge, skill – building, self-efficacy component. • Protection motivation theory. – Threat appraisal. • Intrinsic rewards; • Extrinsic rewards; • Perceived severity; and • Perceived vulnerability. – Coping appraisal • Self-efficacy; • Response efficacy; and • Response costs. (rogers, 1975) Before Its Too Late 12
  13. 13. theoretical rationale • Social support network for adolescent females component. • Social support theory. – instrumental – Companionship • Leisure activities – Informational • Get help in understanding a problem • Receive advice on methods of coping – Emotional • Increases self-esteem because one is loved & accepted (cohen & willis, 1985) Before Its Too Late 13
  14. 14. the intervention • Interventions for adolescents as espoused in the literature not operating in geita district. – Geita district council has established hiv/aids committees in all 33 wards. – A community mapping exercise has been done in 16 wards. – Two centers for Voluntary counseling & testing. – Home based care & support available. – Schools have integrated plans that involve councilors and school committees. Before Its Too Late 14
  15. 15. the intervention • socio-ecological perspective of working with wards & villages • builds on existing hiv prevention efforts in the geita district. • participatory rural appraisal to engage community. • modification of the focus on kids curriculum within a socio – cultural framework. • Creating a social support network a novel approach; different than typical peer support used in schools in other interventions. (Dalton et al., 2001; edwards et al., 2000; goodman, 1998, 2000; Kaljee et al., 2005; Maalim, 2006; Scheirer, 19996;., Stanton et al., 1998). Before Its Too Late 15
  16. 16. the intervention • Two components: – Classroom. – Social support network for females. • The classroom component: – 16, 2 hour sessions over four months. – Knowledge. – Skills. – Self-esteem, Self-efficacy. • Social Support network component: – 2 hours per week, 8 hours per month +. – Instilling and supporting optimism & hope. – Supporting resistance & negotiation. – Staving off depression. Before Its Too Late 16
  17. 17. the intervention • The classroom component curriculum: – Biological facts, puberty and sexuality; – Basic facts, reproductive biology; – Basic facts, adolescent development; – Basic facts, hiv/aids; – Risk behaviors including alcohol/drug use; – Exercising self – control; – Intra-relationship violence; – Communication & negotiation skills; – A framework for decision – making; – Male – female Relationship skill building; – Effective & safe birth control / efficacy; – Readjusting gender roles, power, and sexual relationships; and – Self-esteem building. Before Its Too Late 17
  18. 18. the intervention • The Social support component: – Bring adolescent females together each week to build relationships through shared activities;; – Establish social support network for adolescent females across villages only during pilot phase; – Establish social support network for adolescent females across wards during full implementation; – Establish social support relationship for adolescent females with older, significant – other female within villages during both pilot phase and full implementation; and – monitor and assist in maintaining networks. Before Its Too Late 18
  19. 19. the setting • Geita district, mwanza region, northern tanzania Before Its Too Late 19
  20. 20. the setting • 33 administrative wards: – 29 rural, 4 mixed urban/rural. – 21,582 = Average population / ward. – 6 = Average # of primary schools / ward. – 1.5 = average # of government health units / ward. – 5 = average # villages / ward • 163 villages. • 4 tribes: wasukuma, wasumbwa, wazinza, & walongo. • Population = 712,195 as of 2002 census. • 234 public primary schools across district; 70 % of children attend primary school. Before Its Too Late 20
  21. 21. RESEARCH DESIGN • ONE DISTRICT, ALL WARDS, ALL SCHOOLS after 4 YEARS. • GRADUAL ROLL OUT = 11 NEW WARDS & SCHOOLS THEREIN EACH YEAR. • COMPARISON SCHOOLS THE PREVIOUS YEAR ARE INTERVENTION SCHOOLS THE NEXT YEAR. • YEAR 1: QUASI-EXPERIMENTAL, REGRESSION POINT DISPLACEMENT DESIGN (trochim & campbell, 1996) • YEARS 2 & 3: QUASI-EXPERIMENTAL, BETWEEN GROUPS, PRE – TEST, REPEATED MEASURES POST – TEST, DELAYED – INTERVENTION COMPARISON GROUP. • YEAR 4: QUASI-Experimental, within groups, pre-test, repeated measures post – test, no comparison. Before Its Too Late 21
  22. 22. Research design • Year 1, pilot phase a m j j a s o n dO1 X1 X1 X1 X1 O1 O1 O1O2 O2 O2 O2O3 O3 O3 O3O4 O4 O4 O4O5 O5 O5 O5O6 O6 O6 O6O7 O7 O7 O7O8 O8 O8 O8O9 O9 O9 O9O10 O10 O10 O10O11 O11 O11 O11 Before Its Too Late 22
  23. 23. Research design • Year 2, Implementation phase year 1 a m j j a s o n dO2 X2 X2 X2 X2 O2 O2 O2O3 X3 X3 X3 X3 O3 O3 O3O4 X4 X4 X4 X4 O4 O4 O4O5 X5 X5 X5 X5 O5 O5 O5O6 X6 X6 X6 X6 O6 O6 O6O7 X7 X7 X7 X7 O7 O7 O7O8 X8 X8 X8 X8 O8 O8 O8O9 X9 X9 X9 X9 O9 O9 O9O10 X10 X10 X10 X10 O10 O10 O10O11 X11 X11 X11 X11 O11 O10 O11O12 O12 O12 O12O13 O13 O13 O13O14 O14 O14 O14O15 O15 O15 O15O16 O16 O16 O16O17 O17 O17 O17O18 O18 O18 O18O19 O19 O19 O19O20 O20 O20 O20O21 O21 O21 O21O22 O22 O22 O22 Before Its Too Late 23
  24. 24. Research design • Year 3, Implementation Phase year 2 A M J J A S 0 N DO12 X12 X12 X12 X12 O12 O12 O12O13 X13 X13 X13 X13 O13 O13 O13O14 X14 X14 X14 X14 O14 O14 O14O15 X15 X15 X15 X15 O15 O15 O15O16 X16 X16 X16 X16 O16 O16 O16O17 X17 X17 X17 X17 O17 O17 O17O18 X18 X18 X18 X18 O18 O18 O18O19 X19 X19 X19 X19 O19 O19 O19O20 X20 X20 X20 X20 O20 O20 O20O21 X21 X21 X21 X21 O21 O21 O21O22 X22 X22 X22 X22 O22 O22 O22O23 O23 O23 O23O24 O24 O24 O24O25 O25 O25 O25O26 O26 O26 O26O27 O27 O27 O27O28 O28 O28 O28O29 O29 O29 O29O30 O30 O30 O30O31 O31 O31 O31O32 O32 O32 O32O33 O33 O33 O33 Before Its Too Late 24
  25. 25. Research design • Year 4, Implementation phase: year 3 A M J J A S O N DO23 X23 X23 X23 X23 O23 O23 O23O24 X24 X24 X24 X24 O24 O24 O24O25 X25 X25 X25 X25 O25 O25 O25O26 X26 X26 X26 X26 O26 O26 O26O27 X27 X27 X27 X27 O27 O27 O27O28 X28 X28 X28 X28 O28 O28 O28O29 X29 X29 X29 X29 O29 O29 O29O30 X30 X30 X30 X30 O30 O30 O30O31 X31 X31 X31 X31 O31 O31 O31O32 X32 X32 X32 X32 O32 O32 O32O33 X33 X33 X33 X33 O33 O33 O33 Before Its Too Late 25
  26. 26. Research design O1 X1 O1 O1 O111 12 13 11 12 13 11 12 13 11 12 13 11 12 1314 15 16 14 15 16 14 15 16 14 15 16 14 15 16 O2 O2 O2 O221 22 23 21 22 23 21 22 23 21 22 2324 25 26 24 25 26 24 25 26 24 25 26 Before Its Too Late 26
  27. 27. methods • Hire qualified local talent (teachers, community health workers, et al) as facilitators/research associates; hire in sufficient numbers for full coverage. • Screen for character, professionalism, desire, motivation, energy. • Three days of training = 24 hours and on-going professional development empowerment. • Facilitators/research associates assist in contextualizing program within the district. • ALL MATERIALS TRANSLATED INTO SWAHILI. Before Its Too Late 27
  28. 28. methods • Teachers & community health workers implement curriculum & assist in social support component with other local stakeholders. • Use of experiential learning, and skill practice rather than rote learning. • Multiple, multiple, multiple fidelity checks. • Multi-tasking by program development team – data collection (farm out analysis to unwitting grad student); – fidelity checks; – training & ongoing professional development; – monitoring social support networks; – working with funding agency, community stakeholders, schools, governing authorities,, parents, wards & individual villages, & students. Before Its Too Late 28
  29. 29. Measures & evaluation • Quantitative data collected four times per year (April, July, October, & December), same measures • Modified Youth health risk behavior instrument (YHRBI) – Modifications to be factor analyzed and checked for reliability/validity during pilot phase; re-modified as necessary; – total items ≈ 175; – Total time ≈ 45 minutes; – Small cash incentive in usd; – English & swahili versions; Before Its Too Late 29
  30. 30. Measures & evaluation • YHRBI items – Demographics – Engagement in violent activities (we may drop this) – Engagement in tobacco, alcohol, & other drugs – Past and current relationships – Engagement in sexual activities – Use of condoms/other forms of birth control – Male – female partner communication – Condom access/birth control access & efficacy – Attitudes & beliefs regarding hiv/aids – Perceptions on friends’ engagement in risk activities – Intentions to engage in risk behaviors – Hiv/aids knowledge – Engagement with adults in dialogue about hiv/aids – Knowledge of anyone with hiv or aids – Knowledge on biological aspects of puberty, sexuality, reproductive biology, birth control, & safe sex – Readjusting gender roles, power and sex, intra- relationship violence, sexual decision – making, negotiation skills, self esteem, self-efficacy, female – male relationship building skills. Before Its Too Late 30
  31. 31. Data analysis • Pilot data – A variation of ancova model – Bivariate pre – post distribution of scores calculated for all groups – Regression line computed for controls only as model of predicted outcome with specific pre-test scores – Test whether displacement of intervention group’s score from control groups’ regression line significant using 2 – tailed t test • Full implementation data – 2 – tailed, Independent sample t tests (years 2 & 3) – 2 – tailed, Matched sample t tests (year 4) – anova Before Its Too Late 31
  32. 32. Measures & evaluation • Qualitative data collected four times per year (April, July, October, & December). – Semi - Structured interviews. – Focus groups. • Content analysis and converting qualitative data into quantitative data (e.g., frequencies). Before Its Too Late 32
  33. 33. Measures & evaluation • Adolescent female social support networks – Effectiveness of group meetings and what they got out of them; – Effectiveness of establishing relationships; – Efficacy of establishing networks; – Suitability of network matching; – Effectiveness of communicating between villages and means of conveyance; – Topics of discussion and types of support provided; – Who is in the network; – Process by which relationships forged; – Difficulties and ease in networking; – Durability and stability of relationships/network; – Frequency of face to face meetings or other communications; and – Whether networking and relationships helped delay onset of sexual intercourse, resist unwanted and persistent male sexual advances, or negotiate safe sex. Before Its Too Late 33
  34. 34. Measures & evaluation • Adolescent female – older significant other support – Effectiveness of establishing relationship; – Efficacy of establishing relationship; – Suitability of match; – Effectiveness of communicating within village and means of conveyance; – Topics of discussion and types of support provided; – Process by which relationship forged; – Difficulties and ease in meeting; – Durability and stability of relationship; – Frequency of face to face meetings or other communications; and – Whether relationship helped delay onset of sexual intercourse, resist unwanted and persistent male sexual advances, or negotiate safe sex. Before Its Too Late 34
  35. 35. challenges • The silence of those in authority • Traditions that discourage open discussions of sexuality • Overt & covert resistance to change • Poverty • Women’s low social status • Inaccurate and incomplete information on HIV transmission • Fears about HIV • Stigma • Changing female values • 4 different ethnic groups • Working through multiple layers of bureaucracy • Potential for increases in risk behaviors • Contamination from mass media campaigns • Matching intervention groups with controls • Inconsistent school attendance Before Its Too Late 35
  36. 36. Timeline years 1 - 4Program Component J F M A M J J A S O N DContextualize issues in community through PRA X X XHire local teachers and community health workers and X X Xprovide trainingPlanning intervention components on the premises of local X X Xculture and context; EVALUATION DATA FROM PREVIOUS YEARRandom sampling and recruitment of wards and schools X X XObtain informed consent from parents and students XBiological aspects of puberty and sexuality XBasic facts about reproductive biology and HIV/AIDS/STI XEffective and safe birth control and condom use XReadjusting gender roles, power and sexual relationships, X X X Xintra-relationship violenceRisk behaviors associated with HIV/AIDS infection - alcohol X Xconsumption, drug abuseSexual decision-making skill building X XSelf-esteem AND SELF – EFFICACY SKILL building activities X X X XMale – female communication and negotiation skill building X X X XFemale – male relational skills building X X X XEstablish adolescent female inter-district support network X X X XEstablish older female – adolescent female social support X X X XnetworkFidelity Checks and monitoring support NETWORKS F F M M MData collection and analysis X a a X a X a a X Before Its Too Late 36
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