Promoting sexual and reproductive health among adolescents in southern and eastern Africa (PREPARE): project design and conceptual framework

Background: Young people in sub-Saharan Africa are affected by the HIV pandemic to a greater extent than young people elsewhere and effective HIV-preventive intervention programmes are urgently needed. The present article presents the rationale behind an EU-funded research project (PREPARE) examining effects of community-based (school delivered) interventions conducted in four sites in sub-Saharan Africa. One intervention focuses on changing beliefs and cognitions related to sexual practices (Mankweng, Limpopo, South Africa). Another promotes improved parent-offspring communication on sexuality (Kampala, Uganda). Two further interventions are more comprehensive aiming to promote healthy sexual practices. One of these (Western Cape, South Africa) also aims to reduce intimate partner violence while the other (Dar es Salaam, Tanzania) utilises school-based peer education. Methods/design: A modified Intervention Mapping approach is used to develop all programmes. Cluster randomised controlled trials of programmes delivered to school students aged 12–14 will be conducted in each study site. Schools will be randomly allocated (after matching or stratification) to intervention and delayed intervention arms. Baseline surveys at each site are followed by interventions and then by one (Kampala and Limpopo) or two (Western Cape and Dar es Salaam) post-intervention data collections. Questionnaires include questions common for all sites and are partly based on a set of social cognition models previously applied to the study of HIV-preventive behaviours. Data from all sites will be merged in order to compare prevalence and associations across sites on core variables. Power is set to .80 or higher and significance level to .05 or lower in order to detect intervention effects. Intraclass correlations will be estimated from previous surveys carried out at each site. Discussion: We expect PREPARE interventions to have an impact on hypothesized determinants of risky sexual behaviour and in Western Cape and Dar es Salaam to change sexual practices. Results from PREPARE will (i) identify modifiable cognitions and social processes related to risky sexual behaviour and (ii) identify promising intervention approaches among young adolescents in sub-Saharan cultures and contexts.publishedVersionPeer Reviewe

Effects of PREPARE, a Multi-component, School-Based HIV and Intimate Partner Violence (IPV) Prevention Programme on Adolescent Sexual Risk Behaviour and IPV : Cluster Randomised Controlled Trial

Young South Africans, especially women, are at high risk of HIV. We evaluated the effects of PREPARE, a multi-component, school-based HIV prevention intervention to delay sexual debut, increase condom use and decrease intimate partner violence (IPV) among young adolescents. We conducted a cluster RCT among Grade eights in 42 high schools. The intervention comprised education sessions, a school health service and a school sexual violence prevention programme. Participants completed questionnaires at baseline, 6 and 12 months. Regression was undertaken to provide ORs or coefficients adjusted for clustering. Of 6244 sampled adolescents, 55.3 % participated. At 12 months there were no differences between intervention and control arms in sexual risk behaviours. Participants in the intervention arm were less likely to report IPV victimisation (35.1 vs. 40.9 %; OR 0.77, 95 % CI 0.61-0.99; t(40) = 2.14) suggesting the intervention shaped intimate partnerships into safer ones, potentially lowering the risk for HIV

Intimate partner violence among adolescents in South Africa and Tanzania

Background The aims of this dissertation were to study intimate partner violence among adolescents in Tanzania and South Africa, particularly prevalences and associated factors. Furthermore, to examine the relation between violent attitudes and violent behaviour, and the importance of the Theory of Planned Behaviour in predicting sexual debut. Intimate partner violence is the most common form of violence against women and girls. About one third of all women worldwide will experience violence from an intimate partner at least once in their lifetime. This has many negative effects on the physical, mental and reproductive health of women, among which a heightened risk for infection with HIV. This is especially worrying given the high prevalence of HIV in sub-Saharan Africa. Infection can be direct, through sexual violence and rape. Infection can also be indirect: for example, a culture of masculinity that condones male control of women, male sexual entitlement, patriarchy, and perceived low female status, all contribute to ‘justifying’ violence against women, thereby increasing chances of HIV infection. With a few exceptions, the majority of studies from Africa on violence against intimate partners, concerns people from college age and onwards, and are cross-sectional in nature. Various social cognition models like the Theory of Planned Behaviour have been used in such research. On the one hand these models have shown to be useful in various Africa settings; on the other hand there is also resistance against use of such Western models in the ‘global south’. The current prospective, longitudinal study will contribute to expanding knowledge on intimate partner violence among adolescents (12-15 year olds), including the usefulness of social cognition models, specifically in Tanzania and South Africa. Methods The three papers in this study were based on data material from survey data collections done in the SATZ study research project, a large-scale randomised controlled trial done in Tanzania and South Africa(n=15,864) between 2002-2006. Analyses in the first two papers were carried out with SPSS version 15.0, and included descriptive statistics, cross-tabulations, factor analyses, logistic regressions and general linear modelling. Analyses in paper III were done in SPSS version 19.0 and Mplus version 6, and included multi-group structural equation modelling, in addition to descriptive statics. All analyses were adjusted for cluster effects. Measurement included scales on intimate partner violence (Straus’ Revised Conflict Tactics Scales, CTS2), sexual debut, attitude towards violence, social cognition scales, and sociodemographic variables. Results Paper I. Violence was prevalent in all sites: depending on site and gender, 10.2-37.8% has been victim, 3.1-21.8% perpetrators, and 8.6-42.8% has been both victim and perpetrator. Being male was associated with perpetration in all sites, while being female was associated with victimization in Dar es Salaam and Mankweng (yet in Cape Town victimization was also associated with being male). In all sites higher age and low socioeconomic status was associated with all types of violence. In Cape Town, being religious and having parents with higher education was protective against all types of violence. However no clear subgroups were defined as being at much higher risk, so violence control policies should target young adolescents across geographic, economic and social groups. Paper II. We found that results were consistent with the notion of a bi-directional attitudes-behaviour interrelationship in Cape Town (and to some extent Mankweng). In Dar es Salaam attitudes predicted behaviour prospectively, but prediction in the opposite direction was not confirmed. Paper III. The results showed that the Theory of Planned Behaviour predictors did not have strong predictive power. Controlling for sociodemographic factors did not change the predictive power much, nor when violence was added to the model. However, violence did predict sexual debut directly, and explained variance in sexual debut was substantially higher when violence was added to the model. Discussion This study shows that intimate partner violence is highly prevalent, already at a young age, in relationships between young people in South Africa and Tanzania. To some extent this study found support for including individual attitude-and behaviour change approaches in intervention efforts: in paper II we found that in Cape Town (and to some extent Mankweng) there was a bidirectional relationship between attitudes and behaviour (attitudes towards violence and being a perpetration), while in Dar es Salaam attitudes predicted behaviour prospectively. In paper III support was found for prediction of intentions by attitudes (and to some extent behaviour by intentions). Still, the social cognition model could only explain a limited amount of explained variance; therefore there is a need to look into other environmental influences. We emphasize the need to focus on violence in the wider community at the larger social and structural level, beyond the individual level. Future research and interventions should include both sexes, since both are part of the dynamic that keeps violence going, and target young people, preferably before they become involved in (sexual) relationships. Interventions should be adjusted to the cultural and social settings where they take place, using an ecological approach where the individual is targeted, as well as their surroundings at the interpersonal, community, and structural level

A movie map conversion study: a case study of 'Pride & Prejudice' in the East midlands of England

Background: Fostering adolescents’ communication on sexuality issues with their parents and other significant adults is often assumed to be an important component of intervention programmes aimed at promoting healthy adolescent sexual practices. However, there are few studies describing the relationship between such communication and sexual practices, particularly in sub-Saharan Africa. This study examined the relationships between adolescents’ communication with significant adults and their condom use in three sites in this region. Methods: Data stem from a multi-site randomized controlled trial of a school-based HIV prevention intervention implemented in Cape Town and Mankweng, South Africa and Dar es Salaam, Tanzania. Only data from comparison schools were used. The design is therefore a prospective panel study with three waves of data collections. Data were collected in 2004 from 6,251 participants in 40 schools. Associations between adolescents’ communication with adults about sexuality issues and their use of condoms were analysed cross-sectionally using analysis of variance, as well as prospectively using multiple ordinal logistic regression analysis. Results: Cross-sectional analyses showed that consistent condom users had significantly higher mean scores on communication (across topics and communication partners) than both occasional users and never-users, who had the lowest scores. After controlling for condom use at the first data collection occasion in each model as well as for possible confounders, communication scores significantly predicted consistent condom use prospectively in all three ordinal logistic regression models (Model R² = .23 to .31). Conclusion: The findings are consistent with the assertion that communication on sexuality issues between adolescents and significant adults results in safer sexual practices, as reflected by condom use, among in-school adolescents. The associations between communication variables and condom use might have been stronger if we had measured additional aspects of communication such as whether or not it was initiated by the adolescents themselves, the quality of advice provided by adults, and if it took place in a context of positive adult-adolescent interaction. Studies with experimental designs are needed in order to provide stronger evidence of causality

Effect of the PREPARE intervention on sexual initiation and condom use among adolescents aged 12-14: A cluster randomised controlled trial in Dar es Salaam, Tanzania

Background: Unsafe sexual practices continue to put adolescents at risk for a number of negative health outcomes in Tanzania. While there are some effective theory-based intervention packages with positive impact on important mediators of sexual behaviours, a context specific and tested intervention is urgently needed in Tanzania. Purpose: To develop and evaluate an intervention that will have a significant effect in reducing sexual initiation and promoting condom use among adolescents aged 12–14 in Dar es Salaam, Tanzania. Design: A school-based Cluster Randomised Controlled Trial was conducted during 2011–2014 in Kinondoni Municipality. Methods: A total of 38 public primary schools were randomly selected, of which half were assigned to the intervention and half to the control group based on their size and geographic location. Participants were interviewed using a self-administered questionnaire at baseline before the PREPARE intervention and then, 6 and 12 months following intervention. The primary outcomes were self-reported sex initiation and condom use during the past 6 months. Data analysis was done using Generalized Estimating Equation (GEE) modelling controlling for repeated measures and clustering of students within schools. Results: A total of 5091 students were recruited at baseline, and interviewed again at 6 (n = 4783) and 12 months (n = 4370). Mean age of participants at baseline was 12.4 years. Baseline sociodemographic, psychometric and behavioural characteristics did not significantly differ between the two study arms. The GEE analysis indicated that the intervention had a significant effect on sexual initiation in both sexes after controlling for clustering and correlated repeated measures. A significantly higher level of action planning to use condoms was reported among female adolescent in the intervention arm than those in the control arm (p = 0.042). An effect on condom use behaviour was observed among male adolescent (p = 0.004), but not among female (p = 0.463). Conclusions: The PREPARE intervention had an effect in delaying self-reported sexual initiation among adolescents aged 12–14 in Dar es Salaam Tanzania. The intervention positively influenced action planning to use condoms for both sexes and increased actual condom use among male adolescents only. Future interventions addressing adolescent sexual and reproductive health should focus on impacting mediators of behaviour chang