Inter-ministerial national structural intervention trial (INSTRUCT) : protocol for a parallel group cluster randomised controlled trial of a structural intervention to reduce HIV infection among young women in Botswana

Young women continue to bear the brunt of new HIV infections. Many are unable to act on HIV preventive choices. Proposed by a government think tank, the Inter-ministerial National Structural Intervention trial (INSTRUCT) tests whether addressing social and economic factors, including gender inequality, gender violence, poverty, and poor access to education, can lower HIV infection rates. This trial is intended as first phase of a larger stepped-wedge trial towards an approach that will increase access of marginalised young women in Botswana to government structural support programs

The Inter-ministerial National Structural Intervention trial (INSTRUCT): protocol for a parallel group cluster randomised controlled trial of a structural intervention to reduce HIV infection among young women in Botswana

Abstract Background Wide recognition that structural factors are important in the HIV epidemic has not generated much evidence of impact of structural interventions. Few randomised controlled trials of structural interventions for HIV prevention have an HIV endpoint, and most of those did not show a significant impact. It has proved difficult to prevent new HIV infections in Botswana, especially among young women, many of whom are unable to act on HIV preventive choices. Proposed by a government think tank in Botswana, the Inter-ministerial National Structural Intervention trial (INSTRUCT) tests whether addressing social and economic factors, including gender inequality, gender violence, poverty, and poor access to education, can lower HIV infection rates among young women. Focussed on increasing access by marginalised young women to government support programs, the intervention seeks to change their structural position, reducing their vulnerability to transactional sex, and thus to HIV infection. Methods This parallel group cluster randomised controlled trial compares HIV rates among young women in districts with and without the structural interventions. The 30 administrative districts in the country, stratified by HIV prevalence and development status, will be randomly assigned to 5-district implementation waves. The intervention in the first-wave districts will include: (i) recruiting and preparing vulnerable young women to apply to government support programs, (ii) making the support programs more accessible to young women by engaging local program officers and young women in co-evaluation of programs and co-design of solutions; and (iii) generating an enabling environment for change in communities through an audio-drama edutainment program. In year five, an impact survey will measure HIV rates among vulnerable young women (15–29 years) in a random sample of communities in the five intervention districts and in the five second-wave (control) districts. Fieldworkers will undertake rapid HIV screening and interview young women and young men, collecting information on secondary outcomes of attitudes and behaviours. Discussion This is the first step in a planned stepped-wedge design that will roll out the intervention, modified as necessary, to all districts. Strong government commitment provides an important opportunity to reduce new HIV cases in Botswana, and guide prevention efforts in other countries. Trial registration Registration number: ISRCTN 54878784. Registry: ISRCTN. Date of registration: 11 June 2013

Community views of inter-generational sex : findings from focus groups in Botswana, Namibia and Swaziland

The young women in the study were clear that sex with older men was about material gain. Some said they felt they had no choice. Older men reported sexual gratification as a key motivator. Persuading young girls not to engage sexually with older men will be difficult unless prevention programmes also target older men. Prevention programmes designed simply to increase knowledge of the risks of inter-generational sex are unlikely to be effective. More promising approaches might include making older men aware of the ridicule they attract from the young women, and helping young women to find alternative ways of financial support

Can social network analysis help to include marginalised young women in structural support programmes in Botswana? A mixed methods study

Background: In Botswana, one fifth of the adult population is infected with HIV, with young women most at risk. Structural factors such as poverty, poor education, strong gender inequalities and gender violence render many young women unable to act on choices to protect themselves from HIV. A national trial is testing an intervention to assist young women to access government programs for returning to education, and improving livelihoods. Accessing marginalised young women (aged 16–29 and not in education, employment or training) through door-to-door recruitment has proved inefficient. We investigated social networks of young women to see if an approach based on an understanding of these networks could help with recruitment. Methods: This mixed methods study used social network analysis to identify key young women in four communities (using in-degree centrality), and to describe the types of people that marginalised young women (n = 307) turn to for support (using descriptive statistics and then generalized linear mixed models to examine the support networks of sub-groups of participants). In discussion groups (n = 46 participants), the same young women helped explain results from the network analysis. We also tracked the recruitment method for each participant (door to door, peers, or key community informants). Results: Although we were not able to identify characteristics of the most central young women in networks, we found that marginalised young women went most often to other women, usually in the same community, and with children, especially if they had children themselves. Rural women were better connected with each other than women in urban areas, though there were isolated young women in all communities. Peer recruitment contributed most in rural areas; door-to-door recruitment contributed most in urban areas. Conclusions: Since marginalised young women seek support from others like themselves, outreach programs could use networks of women to identify and engage those who most need help from government structural support programs. Methods that rely on social networks alone may be insufficient, and so a combination of approaches, including, for instance, peers, door-to-door recruitment, and key community informants, should be explored as a strategy for reaching marginalised young women for supportive interventions

Framework overview of main factors affecting program benefit per method and participant group.

Framework overview of main factors affecting program benefit per method and participant group.</p

Promotive social protection programs that enhance livelihood and capabilities in Botswana.

Promotive social protection programs that enhance livelihood and capabilities in Botswana.</p

Socioecological model of barriers that impede benefit from promotive social protection programs by unemployed and out-of-school young women in Botswana.

Socioecological model of barriers that impede benefit from promotive social protection programs by unemployed and out-of-school young women in Botswana.</p

Deliberative dialogue: Pattern matching tables, selection & improvement recommendations.

Deliberative dialogue: Pattern matching tables, selection & improvement recommendations.</p

FCM coding tree: Why young women do not benefit from programs.

FCM coding tree: Why young women do not benefit from programs.</p