This document outlines an adolescent HIV prevention program for schools in Geita district, Tanzania. It describes conducting a 4-year intervention rolling out to all 33 wards and schools. The intervention has two components: a classroom curriculum and a social support network for females. The classroom uses knowledge building, skills training, and self-efficacy approaches. The social support network is designed to provide instrumental, companionship, and emotional support. The research design is quasi-experimental, using pre- and post-testing to evaluate the intervention's effects on knowledge, attitudes, and risk behaviors over time.
Geita District Mwanza Region Northern Tanzania April 2007 J Sheldon
1. Before It's Too Late 1
Before it’s too late:
An adolescent HIV Prevention programfor Geita district,
mwanza region, Northern Tanzania
Jeffrey Sheldon, M. A., Ed. m.
School of Behavioral & Organizational Sciences
Claremont Graduate University
The Claremont Colleges
25 April 2007
2. Before It's Too Late 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
3. Before It's Too Late 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)
4. Before It's Too Late 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.
5. Before It's Too Late 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.
6. Before It's Too Late 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.
7. Before It's Too Late 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.
8. Before It's Too Late 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)
9. Before It's Too Late 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)
10. Before It's Too Late 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)
11. Before It's Too Late 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-basedHIV 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–basedrisk 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.
12. Before It's Too Late 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)
13. Before It's Too Late 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)
14. Before It's Too Late 14
theintervention
• 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.
15. Before It's Too Late 15
theintervention
• 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).
16. Before It's Too Late 16
theintervention
• 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.
17. Before It's Too Late 17
theintervention
• 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.
18. Before It's Too Late 18
theintervention
• 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.
19. Before It's Too Late 19
thesetting
• Geita district, mwanza region, northern tanzania
20. Before It's Too Late 20
thesetting
• 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.
21. Before It's Too Late 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.
22. Before It's Too Late 22
Research design
• Year 1, pilot phase
a m j j a s o n d
O1 X1 X1 X1 X1 O1 O1 O1
O2 O2 O2 O2
O3 O3 O3 O3
O4 O4 O4 O4
O5 O5 O5 O5
O6 O6 O6 O6
O7 O7 O7 O7
O8 O8 O8 O8
O9 O9 O9 O9
O10 O10 O10 O10
O11 O11 O11 O11
27. Before It's Too Late 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.
28. Before It's Too Late 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.
29. Before It's Too Late 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;
30. Before It's Too Late 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.
31. Before It's Too Late 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
32. Before It's Too Late 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).
33. Before It's Too Late 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.
34. Before It's Too Late 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.
35. Before It's Too Late 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
36. Before It's Too Late 36
Timeline years 1 - 4
ProgramComponent J F M A M J J A S O N D
Contextualize issues in community through PRA X X X
Hire local teachers and community health workers and provide training X X X
Planning intervention components on the premises of local culture and context; EVALUATION DATA FROM
PREVIOUS YEAR
X X X
Random sampling and recruitment of wards and schools X X X
Obtain informed consent from parents and students X
Biological aspects of puberty and sexuality X
Basic facts about reproductive biology and HIV/AIDS/STI X
Effective and safe birth control and condom use X
Readjusting gender roles, power and sexual relationships, intra-relationship violence X X X X
Risk behaviors associated with HIV/AIDS infection - alcohol consumption, drug abuse X X
Sexual decision-making skill building X X
Self-esteem AND SELF – EFFICACY SKILL building activities X X X X
Male – female communication and negotiation skill building X X X X
Female – male relational skills building X X X X
Establish adolescent female inter-district support network X X X X
Establish older female – adolescent female social support network X X X X
Fidelity Checks and monitoring support NETWORKS F F M M M
Data collection and analysis X a a X a X a a X
37. Before It's Too Late 37
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