Maria Elena Figueroa

Using Health Education Theories to Explain Behavior Change: A Cross-Country Analysis:

Scholars within the fields of public health, health education, health promotion, and health communication look to specific theories to explain health behavior change. The purpose of this article is to critically compare four health theories and key variables within them with regard to behavior change in the area of reproductive health. Using cross-country analyses of Ghana, Nepal, and Nicaragua (data sets provided by the Center for Communication Programs, Johns Hopkins University), the authors looked at the Health Belief Model, Theory of Reasoned Action, Extended Parallel Process Model, and Social Cognitive Theory for these two defined objectives. Results show that all four theories provide an excellent fit to the data, but that certain variables within them may have particular value for understanding specific aspects of behavior change. Recommendations for the selection of theories to use as guidelines in the design and evaluation of reproductive health programs are provided.

Microbiologic effectiveness of boiling and safe water storage in South Sulawesi, Indonesia

In Indonesia, where diarrhea remains a major cause of mortality among children <5 years, the government promotes boiling of drinking water. We assessed the impact of boiling on water quality in South Sulawesi. We surveyed randomly selected households with at least one child <5 years old in two rural districts and tested source and stored water samples for Escherichia coli contamination. Among 242 households, 96% of source and 51% of stored water samples yielded E. coli. Unboiled water samples, obtained from 15% of households, were more likely to yield E. coli than boiled samples [prevalence ratios (PR) = 2.0, 95% confidence interval (CI) 1.7-2.5]. Water stored in wide-mouthed (PR = 1.4, 95% CI = 1.1-1.8) or uncovered (PR = 1.8, 95% CI = 1.3-2.4) containers, or observed to be touched by the respondents hands (PR = 1.6, 95% CI = 1.3-2.1) was more likely to yield E. coli. A multivariable model showed that households that did not boil water were more likely to have contaminated stored water than households that did boil water (PR = 1.9, 95% CI = 1.5-2.3). Although this study demonstrated the effectiveness of boiling in reducing contamination, overall impact on water quality was suboptimal. Future studies are needed to identify factors behind the success of boiling water in Indonesia to inform efforts to scale up other effective water treatment practices.

Voluntary medical male circumcision among adolescents: a missed opportunity for Hiv behavioral interventions

Objective: Voluntary medical male circumcision (VMMC) is one of the first opportunities for adolescent males in African countries to interact with the healthcare system. This study explored the approaches used during adolescent VMMC counseling and whether these strategies maximize broader HIV prevention opportunities. Methods: Qualitative interviews were conducted with 92 VMMC clients ages 10–19 years in South Africa (n = 36), Tanzania (n = 36), and Zimbabwe (n = 20) and 33 VMMC providers across the three countries. Discussions explored HIV prevention counseling, testing, and disclosure of results. Audio recordings were transcribed, translated into English, and coded thematically by two individuals. Results: Male adolescents in all three countries reported that limited information was provided about HIV prevention and care, and adolescents were rarely provided condoms. Although VMMC protocols require opt-out HIV testing, adolescents recounted having blood taken without knowing the purpose, not receiving results, nor completely understanding the link between VMMC and HIV. Most males interviewed assumed they had tested negative because they were subsequently circumcised without knowing test results. Providers reported spending little time talking about HIV prevention, including condom use. They admitted that younger adolescent clients often receive little information if assumed they are not sexually active or too young to understand and instead discussed nonsexually transmitted routes of HIV. Conclusion: In the sites of the three countries studied, HIV prevention and care messages were inconsistent and sometimes totally absent from VMMC counseling sessions. VMMC appears to be a missed opportunity to engage in further HIV prevention and care with adolescents.

Household water treatment and safe storage

In this chapter we present an exchange systems approach to evaluate the potential of water markets to provide sustainable and equitable access for all. The approach is sourced from marketing theory, which in turn is constructed on a social exchange and general systems theory platform (Bagozzi, 1978; Layton, 2007). The exchange systems concept offers a systemic view of exchange that allows for the integration of broader economic and social considerations into the design of water markets. We illustrate different types of exchange systems to offer the reader a broader perspective on water markets. Such a perspective can enable new thinking in how water provision systems can contribute to improved human health. We begin with a general introduction to the marketing exchange concept and subsequently trace its evolution to exchange systems.

The effect of a joint communication campaign on multiple sex partners in Mozambique: the role of psychosocial/ideational factors

Abstract Mozambique is one of the countries in sub-Saharan Africa most affected by the HIV epidemic. Multiple and concurrent sexual partnerships (MSP/CP) have been recognized as one of the key drivers in the rapid spread of HIV in the region. Though HIV prevention programs have been successful in increasing condom use and HIV testing, reducing the practice of MSP/CP has been more difficult. Grounding their interventions in social and behavior change theory, four organizations in Mozambique joined efforts to implement a year-long, multimedia national campaign for HIV prevention with emphasis on the reduction of MSP/CP. Evaluating its impact and identifying the factors that hinder or contribute to its success are critical to building effective programs in the future. With data from a 2011 population-based survey of 1427 sexually active women and men, multivariate causal attribution (MCA) analysis was used to estimate the impact of the campaign in the four regions of Mozambique with the highest levels of HIV prevalence. The analysis tested the psychosocial pathways through which the campaign was expected to affect MSP. The results indicate that exposure (recall) was high; 81.2% of the respondents could recall one or more of the communication campaign components. The campaign had a significant indirect impact on MSP through its negative effect on attitudes that favor MSP, and its positive effect on knowledge and discussion of MSP risk with sex partner. This study demonstrates the value of identifying appropriate psychosocial factors and using them to design the campaign communication strategy, and evaluate the causal pathways by which it has an impact. The campaign was successful in changing MSP behavior by working through two psychosocial variables.

Impacts of four communication programs on HIV testing behavior in South Africa

This paper aims to evaluate the impacts of four communication programs on promoting HIV testing behavior among sexually active individuals in South Africa. The four programs, implemented by Johns Hopkins Health and Education in South Africa, are aimed to promote HIV prevention behaviors, as well as gender-based violence prevention, tuberculosis screening and treatment, and reduction of alcohol consumption. Launched between 2009 and 2010, they all promoted HIV testing. Data came from the population-based Third National AIDS Communication Survey 2012; 6004 men and women who had sex within the last 12 months were included in the analysis. Multiple causal attribution analysis is used to justify causal reference and estimate the impact of communication programs. Findings indicate significant direct and indirect effects of the programs on HIV testing behavior. Indirect effects worked through increasing ones likelihood of perceiving that their friends were tested and the probability of talking about HIV testing with sex partners and friends, which in turn increased the likelihood of HIV testing. Findings suggest multiple angles from which communication programs can promote HIV testing. The study also demonstrates the use of multiple statistical techniques for causal attribution in a post-only design, where randomization is not possible.

Use of SMS-Based Surveys in the Rapid Response to the Ebola Outbreak in Liberia: Opening Community Dialogue

During an emerging health crisis like the 2014 Ebola outbreak in West Africa, communicating with communities to learn from them and to provide timely information can be a challenge. Insight into community thinking, however, is crucial for developing appropriate communication content and strategies and for monitoring the progress of the emergency response. In November 2014, the Health Communication Capacity Collaborative partnered with GeoPoll to implement a Short Message Service (SMS)–based survey that could create a link with affected communities and help guide the communication response to Ebola. The ideation metatheory of communication and behavior change guided the design of the survey questionnaire, which produced critical insights into trusted sources of information, knowledge of transmission modes, and perceived risks—all factors relevant to the design of an effective communication response that further catalyzed ongoing community actions. The use of GeoPoll’s infrastructure for data collection proved a crucial source of almost-real-time data. It allowed for rapid data collection and processing under chaotic field conditions. Though not a replacement for standard survey methodologies, SMS surveys can provide quick answers within a larger research process to decide on immediate steps for communication strategies when the demand for speedy emergency response is high. They can also help frame additional research as the response evolves and overall monitor the pulse of the situation at any point in time.

Effectiveness of Community Dialogue in Changing Gender and Sexual Norms for HIV Prevention: Evaluation of the Tchova Tchova Program in Mozambique

Structural HIV prevention interventions have gained prominence as ways to address underlying social and cultural factors that fuel the HIV epidemic. Identifying theories that explain how structural interventions are expected to change such factors can substantially increase their success. The Tchova Tchova community dialogue program, a theory-based intervention implemented in 2009–2010 in the provinces of Zambezia and Sofala, Mozambique, aimed to change gender and sexual norms for HIV prevention. Through facilitated sessions, the program sparked critical thinking and open dialogue among participants. This article measures the program’s effectiveness based on a sample of 462 participants and 453 nonparticipants. The results show that the program was successful in producing changes in three of the underlying structural factors of HIV: gender attitudes, gender roles, and HIV stigma. The program was also successful in changing other factors associated with HIV infection, including HIV prevention knowledge, discussion of HIV between sex partners, and having multiple sex partners.

A Theory-Based Socioecological Model of Communication and Behavior for the Containment of the Ebola Epidemic in Liberia

The Ebola virus disease that emerged in the West African countries of Liberia, Sierra Leone, and Guinea in 2014 created an unprecedented public health emergency that caught national and international organizations off guard. Despite available guidelines to respond to public health emergencies, coordinated action to control the disease only came almost 6 months after what is now considered the first human contact with the virus. Theory-based frameworks, like the ideation model and the pathways framework, are important tools for guiding research and the design of communication activities and strategies to effectively impact on the more likely determinants of the intended behavior. By using theory, these frameworks increase the chances that localized research and communication interventions can effectively change desired behaviors and their behavioral determinants. In an outbreak situation such frameworks are all the more important, when time is of the essence and lives are on the line.

The multidimensional nature of HIV stigma: evidence from Mozambique

HIV stigma continues to be a major challenge to addressing HIV/AIDS in various countries in sub-Saharan Africa, including Mozambique. This paper explores the multidimensional nature of HIV stigma through the thematic analysis of five qualitative studies conducted in high HIV prevalence provinces in Mozambique between 2009 and 2012. These studies included 23 interviews with people living with HIV (PLHIV) (10 women and 13 men); 6 focus groups with 32 peer educators (24 women and 8 men) working for community-based organisations (CBOs) providing services to PLHIV; 17 focus groups with community members (72 men and 70 women); 6 interviews (4 women and 2 men) with people who had family members living with HIV/AIDS; 24 focus groups (12 with men and 12 with women) and 6 interviews with couples. Our findings indicate that HIV stigma is a barrier to HIV testing and counselling, status disclosure, partner notification, and antiretroviral therapy (ART) access and adherence, and that moral stigma seems to be more common than physical stigma. Additionally, the findings highlight that HIV stigma is a dynamic social process that is conceptualised as being tied to personal responsibility. To effectively diminish HIV stigma in Mozambique, future interventions should address moral stigma and re-conceptualise HIV as a chronic disease.