Cognitive mapping: Using local knowledge for planning health research

Background: Cognitive mapping is a participatory research methodology that documents, in visual form, a construct of the local environment in which people live and work. We adapted this method to provide detailed data about study locales to inform recruitment and retention strategies for HIV prevention community based clinical trials. Methods: Four cognitive mapping studies were undertaken between 2005 and 2010, in and around Johannesburg in Orange Farm, and Hillbrow. Participants included members of clinical trial Community Advisory Boards (CAB), young people recruited from schools in Hillbrow and an organization for out of school youth, and men recruited from a database of men in the community interested in taking part in research. These groups participated in reconnaissance walks and in depth interviews, and drew detailed sketch maps. Results: The cognitive maps defined the physical boundaries of the research locales, provided insights into their social histories, and identified important characteristics of the population such as movement, social and sexual networks, ethnic and other divisions. Important differences between the official cartographic maps and the cognitive maps were raised. The mapping data was applied by identifying key areas for recruitment that recruitment staff members were less familiar with and that may otherwise have been overlooked. Conclusions: Cognitive mapping is an effective, rapid and low cost method that can be used to inform recruitment and retention strategies for community-based clinical trial research. The method also provides a means for clinical trial researchers to involve the local community in research and to familiarise them with the social setting

Sticks and stones: How words and language impact upon social inclusion

Language framed as derogatory names and symbols can have implications for people and their life experiences. Within a Saussurian-inspired frame, and looking at ideas of stigma and social inclusion, this paper examines the use of language as a weapon within a social context of (changing) intent and meaning. Three examples of language use in mainstream society are analysed: \u27retarded\u27 which evolved from scientific diagnosis to insult; \u27gay\u27 as a derogatory adjective within popular culture; and, the way language around suicide is used to both trivialise and stigmatise those who are suicidal, as well as those who are bereaved

Sticks and stones: How words and language impact upon social inclusion

Language framed as derogatory names and symbols can have implications for people and their life experiences. Within a Saussurian-inspired frame, and looking at ideas of stigma and social inclusion, this paper examines the use of language as a weapon within a social context of (changing) intent and meaning. Three examples of language use in mainstream society are analysed: \u27retarded\u27 which evolved from scientific diagnosis to insult; \u27gay\u27 as a derogatory adjective within popular culture; and, the way language around suicide is used to both trivialise and stigmatise those who are suicidal, as well as those who are bereaved

Conceptualizing Community Mobilization for HIV Prevention: Implications for HIV Prevention Programming in the African Context

Introduction: Community mobilizing strategies are essential to health promotion and uptake of HIV prevention. However, there has been little conceptual work conducted to establish the core components of community mobilization, which are needed to guide HIV prevention programming and evaluation. Objectives: We aimed to identify the key domains of community mobilization (CM) essential to change health outcomes or behaviors, and to determine whether these hypothesized CM domains were relevant to a rural South African setting.Method:We studied social movements and community capacity, empowerment and development literatures, assessing common elements needed to operationalize HIV programs at a community level. After synthesizing these elements into six essential CM domains, we explored the salience of these CM domains qualitatively, through analysis of 10 key informant in-depth-interviews and seven focus groups in three villages in Bushbuckridge. Results: CM domains include: 1) shared concerns, 2) critical consciousness, 3) organizational structures/networks, 4) leadership (individual and/or institutional), 5) collective activities/actions, and 6) social cohesion. Qualitative data indicated that the proposed domains tapped into theoretically consistent constructs comprising aspects of CM processes. Some domains, extracted from largely Western theory, required little adaptation for the South African context; others translated less effortlessly. For example, critical consciousness to collectively question and resolve community challenges functioned as expected. However, organizations/networks, while essential, operated differently than originally hypothesized - not through formal organizations, but through diffuse family networks. Conclusions: To date, few community mobilizing efforts in HIV prevention have clearly defined the meaning and domains of CM prior to intervention design. We distilled six CM domains from the literature; all were pertinent to mobilization in rural South Africa. While some adaptation of specific domains is required, they provide an extremely valuable organizational tool to guide CM programming and evaluation of critically needed mobilizing initiatives in Southern Africa

Assessing risk for HIV infection among adolescent girls in South Africa: an evaluation of the VOICE risk score (HPTN 068)

INTRODUCTION: To maximize impact and minimize costs, antiretroviral pre-exposure prophylaxis (PrEP) interventions should be offered to those at highest risk for HIV infection. The risk score derived from the VOICE trial is one tool currently being utilized to determine eligibility in adolescent PrEP trials in sub-Saharan Africa. This study is aimed at evaluating the utility of the risk score in predicting HIV incidence among a cohort of adolescent girls in rural South Africa. METHODS: We utilized data from HIV Prevention Trials Network (HPTN) 068, a phase III randomized controlled trial conducted in rural Mpumalanga province, South Africa. School-attending young women aged 13 to 20 years were enrolled into the trial from 2011 to 2012 and followed for up to three years. A risk score based on individual-level risk factors measured at enrolment was calculated for HPTN 068 participants who completed a one-year follow-up visit and were HIV seronegative at enrolment. Possible scores ranged from 0 to 10. A proportional hazards model was then used to determine if risk score at enrolment was predictive of incident HIV infection at follow-up and an area under the curve analysis was used to examine the predictive ability of the score. RESULTS AND DISCUSSION: The risk score had limited variability in the HPTN 068 sample. Scores ≥5 identified 85% of incident infections from 94% of the sample, compared to the VOICE sample in which scores ≥5 identified 91% of incident infections from only 64% of participants. The risk score did not predict HIV incidence after one year of follow-up (hazard ratio = 1.029; 95% confidence interval (CI): 0.704, 1.503, p = .884) and showed poor predictive ability (area under the curve = 0.55; 95% CI: 0.44, 0.65). Certain individual risk factors that comprise the risk score may be context specific or not relevant for adolescent populations. Additional factors should be considered when assessing risk for the purposes of determining PrEP eligibility. CONCLUSIONS: The VOICE risk score demonstrated low utility to predict HIV incidence in the HPTN 068 sample. Findings highlight the need for an age and developmentally appropriate tool for assessing risk for HIV infection among adolescents. Use of the VOICE risk score for determining PrEP eligibility in younger populations should be carefully considered

Acceptability and feasibility of cash transfers for HIV prevention among adolescent South African women

Women are at increased risk of HIV infection in much of sub-Saharan Africa. Longitudinal and cross-sectional studies have found an association between school attendance and reduced HIV risk. We report feasibility and acceptability results from a pilot of a cash transfer intervention conditional on school attendance paid to young women and their families in rural Mpumalanga, South Africa for the prevention of HIV infection. Twenty-nine young women were randomised to intervention or control and a cash payment based on school attendance made over a 2-month period. Quantitative (survey) and qualitative (focus group and interview) data collection was undertaken with young women, parents, teachers and young men in the same school. Qualitative analysis was conducted in Atlas.ti using a framework approach and basic descriptive analysis in Excel was conducted on the quantitative data. Results indicate it was both feasible and acceptable to introduce such an intervention among this population in rural South Africa. There was good understanding of the process of randomisation and the aims of the study, although some rumours developed in the study community. We address some of the changes necessary to ensure acceptability and feasibility of the main trial

Investigating HIV/AIDS in southern Africa

Book Review Webb, D (1997) HIV and AIDS in Africa. Cape Town: David Philip. ISBN 0 86486 341

Adolescents and HIV in developing countries: new research directions

Adolescents are of interest in HIV/STD studies as they are a group whose behaviour places them at increased risk of HIV infection (Hein, 1992). Adolescence is a period characterised by the development and formation of sexuality, a process which frequently involves a high turn-over of sexual partners (Krahe and Reiss, 1995; Lear, 1995). Teenage experimentation with drugs and alcohol frequently leads to the adoption of high risk behaviours or engagement in unplanned episodes of casual sex (Weatherburn and Project SIGMA, 1992). In addition, adolescents are particularly vulnerable to the normative social influences of their peers (DiClemente, 1990). These influences among adolescents tend to discourage the adoption of safe sexual behaviour by encouraging negative associations to be attached to condoms and their use. While the intense influence of normative social values on adolescents makes them increasingly vulnerable to HIV infection, if HIV-preventive behaviour can be made to seem the norm, teenagers may also be readily influenced by this (Fisher, Misovich & Fisher, 1992). Finally, aspects of teenagers\u27 lives are dominated by feelings of invulnerability which allow them to take the chances they see as developmentally important (Memon, 1991; Ingham, Woodcock and Stenner, 1992). While adolescents know about HIV, most have not personalised the threat of AIDS (Edgar et al, 1992). The factors which place adolescents at risk of HIV tend to stereotype adolescence as a period of traumatic social behaviour. While much of the literature has encouraged this stereotype, adolescence should not be viewed as a completely negative developmental stage (Aggleton, 1991)

\u27I think condoms are good but, aai, I hate those things\u27: condom use among adolescents and young people in a Southern African township

Levels of heterosexually transmitted HIV infection are high amongst South African youth, with one recent survey reporting levels of 18.9% amongst 17-20 year olds and 43.1% amongst 21-25 year olds. In these groups levels of knowledge about HIV are high, but perceived vulnerability and reported condom use are low. Much existing research into youth HIV in developing countries relies on survey measures which use individual knowledge, attitudes and reported behaviour as variables in seeking to explain HIV transmission amongst this group. This paper reports on a focus group study that seeks to complement existing individual-level quantitative findings with qualitative findings highlighting community and social factors that hinder condom use amongst youth in the township of Khutsong, near Carletonville. Study informants comprised 44 young women and men in the 13-25 year age group. Data analysis highlighted six factors hindering condom use: lack of perceived risk; peer norms; condom availability; adult attitudes to condoms and sex; gendered power relations and the economic context of adolescent sexuality. Informants did not constitute a homogenous group in terms of their understandings of sexuality. While there was clear evidence for the existence of dominant social norms which place young peoples\u27 sexual health at risk, there was also evidence that many young people are self-consciously critical of the norms that govern their sexual behaviour, despite going along with them, and that they are aware of the way in which peer and gender pressures place their health at risk. There was also evidence that a minority of youth actively challenge dominant norms and behave in counter-normative and health-enhancing ways. The actively contested nature of dominant sexual norms provides a fertile starting point for peer education programmes that seek to provide the context for the collective negotiation of alternative sexual norms that do not endanger young peoples\u27 sexual health

Using Focus Group Discussion to investigate Perceptions of Sexual Risk Compensation following Posttrial HIV Vaccine Uptake Among Young South Africans

This chapter provides an overview of a research study examining the potential for risk compensation following HIV vaccination. The study made use of focus group discussions (FGDs) as the main source of data, and the chapter focuses on choices relating to data-collection method, challenges, and methods for addressing contextual and methodological challenges to FGDs