Michelle R. Kaufman

Health Behavior Change Models for HIV Prevention and AIDS Care: Practical Recommendations for a Multi-Level Approach

Abstract:Despite increasing recent emphasis on the social and structural determinants of HIV-related behavior, empirical research and interventions lag behind, partly because of the complexity of social–structural approaches. This article provides a comprehensive and practical review of the diverse literature on multi-level approaches to HIV-related behavior change in the interest of contributing to the ongoing shift to more holistic theory, research, and practice. It has the following specific aims: (1) to provide a comprehensive list of relevant variables/factors related to behavior change at all points on the individual–structural spectrum, (2) to map out and compare the characteristics of important recent multi-level models, (3) to reflect on the challenges of operating with such complex theoretical tools, and (4) to identify next steps and make actionable recommendations. Using a multi-level approach implies incorporating increasing numbers of variables and increasingly context-specific mechanisms, overall producing greater intricacies. We conclude with recommendations on how best to respond to this complexity, which include: using formative research and interdisciplinary collaboration to select the most appropriate levels and variables in a given context; measuring social and institutional variables at the appropriate level to ensure meaningful assessments of multiple levels are made; and conceptualizing intervention and research with reference to theoretical models and mechanisms to facilitate transferability, sustainability, and scalability.

Sex Trafficking in Nepal: A Review of Intervention and Prevention Programs

Trafficking of girls and women for the purpose of sexual exploitation is a problem worldwide, particularly in South Asia. This review focuses on Nepal-to-India sex trafficking with an examination of current anti-trafficking intervention and prevention programs. The activities of both governmental agencies and nongovernment organizations are described and critically analyzed. Suggestions for evaluating and improving interventions, and thereby reducing the trafficking of girls and women, are discussed.

Adolescent sexual and reproductive health services and implications for the provision of voluntary medical male circumcision: Results of a systematic literature review.

Background Voluntary medical male circumcision (VMMC) is a critical HIV prevention tool. Since 2007, sub-Saharan African countries with the highest prevalence of HIV have been mobilizing resources to make VMMC available. While implementers initially targeted adult men, demand has been highest for boys under age 18. It is important to understand how male adolescents can best be served by quality VMMC services. Methods and Findings A systematic literature review was performed to synthesize the evidence on best practices in adolescent health service delivery specific to males in sub-Saharan Africa. PubMed, Scopus, and JSTOR databases were searched for literature published between January 1990 and March 2014. The review revealed a general absence of health services addressing the specific needs of male adolescents, resulting in knowledge gaps that could diminish the benefits of VMMC programming for this population. Articles focused specifically on VMMC contained little information on the adolescent subgroup. The review revealed barriers to and gaps in sexual and reproductive health and VMMC service provision to adolescents, including structural factors, imposed feelings of shame, endorsement of traditional gender roles, negative interactions with providers, violations of privacy, fear of pain associated with the VMMC procedure, and a desire for elements of traditional non-medical circumcision methods to be integrated into medical procedures. Factors linked to effective adolescent-focused services included the engagement of parents and the community, an adolescent-friendly service environment, and VMMC counseling messages sufficiently understood by young males. Conclusions VMMC presents an opportune time for early involvement of male adolescents in HIV prevention and sexual and reproductive health programming. However, more research is needed to determine how to align VMMC services with the unique needs of this population.

“My children and I will no longer suffer from malaria”: a qualitative study of the acceptance and rejection of indoor residual spraying to prevent malaria in Tanzania

BackgroundThe objective of this study was to identify attitudes and misconceptions related to acceptance or refusal of indoor residual spraying (IRS) in Tanzania for both the general population and among certain groups (e.g., farmers, fishermen, community leaders, and women).MethodsThis study was a series of qualitative, semi-structured, in-depth interviews and focus group discussions conducted from October 2010 to March 2011 on Mainland Tanzania and Zanzibar. Three groups of participants were targeted: acceptors of IRS (those who have already had their homes sprayed), refusers (those whose communities have been sprayed, but refused to have their individual home sprayed), and those whose houses were about to be sprayed as part of IRS scale-up. Interviews were also conducted with farmers, fishermen, women, community leaders and members of non-government organizations responsible for community mobilization around IRS.ResultsResults showed refusers are a very small percentage of the population. They tend to be more knowledgeable people such as teachers, drivers, extension workers, and other civil servants who do not simply follow the orders of the local government or the sprayers, but are skeptical about the process until they see true results. Refusal took three forms: 1) refusing partially until thorough explanation is provided; 2) accepting spray to be done in a few rooms only; and 3) refusing outright. In most of the refusal interviews, refusers justified why their houses were not sprayed, often without admitting that they had refused. Reasons for refusal included initial ignorance about the reasons for IRS, uncertainty about its effectiveness, increased prevalence of other insects, potential physical side effects, odour, rumours about the chemical affecting fertility, embarrassment about moving poor quality possessions out of the house, and belief that the spray was politically motivated.ConclusionsTo increase IRS acceptance, participants recommended more emphasis on providing thorough public education, ensuring the sprayers themselves are more knowledgeable about IRS, and asking that community leaders encourage participation by their constituents rather than threatening punishment for noncompliance. While there are several rumours and misconceptions concerning IRS in Tanzania, acceptance is very high and continues to increase as positive results become apparent.Swahili AbstractUsuliMalengo mahususi ya utafiti huu ni kutambua tabia na imani potofu zinazopelekea kukubali au kutakaa upuliaziaji wa dawa ya kuua mbu majumbani (IRS) katika Tanzania kwa watu wote kwa ujumla na kwa makundi maalumu ya watu (kama wakulima, wavuvi, viongozi wa jamii na wanawake).NjiaUtafiti huu ni mfululizo wa tafiti stahilifu zenye sehemu ya muundo, tafiti za kina na majadilianao ya vikundi vya walengwa yaliyofanyika Tanzania bara na Zanzibar kuanzia mwezi Oktoba, 2010 hadi mwezi Machi, 2011. Yalikuwepo makundi matatu ya walengwa: wanaokubali IRS (wale ambao nyumba zao zilikwisha kupulizwa dawa ya kuua mbu) wasiokubali (hii ni jamii iliyokwisha kupulizwa dawa na wale watu waliokataa dawa isipulizwe kwenye nyumba zao) na wale ambao nyumba zao zilikuwa zinakaribia kupulizwa dawa ikiwa ni kama sehemu ya kusambaza IRS. Usaili ulifanyika pia kwa wakulima, wavuvi, wanawake na viongozi wa jamii vile vile na kwa wanachama wa asasi zisizo za kiserikali waliokuwa wakiwajibika kwa IRS.MatokeoMatokeo yalionyesha kuwa waliokataa walikuwa ni asilimia ndogo sana ya watu wote. Walikuwa ni watu waelewa kama vile walimu, madereva, wafanyakazi katika miradi na watumishi wengine wa serikali ambao wanafuata amri kutoka kwa serikali yao au kwa wapuliza dawa lakini walikuwa na wasiwasi kuhusu mchakato huo mpaka waone matokeo yake. Waliokataa walikuwa katika maainisho matatu: 1) waliokataa kidogo mpaka wapewe maelezo; 2) waliokubali dawa ipulizwe kwenye vyumba vichache tu; 3) waliokataa katu katu. Mara kwa mara wengi wa wasailiwa waliokataa, walitoa sababu zao za kukataa nyumba zao zisipuliziwe, bila kukubali kuwa wamekataa kupuliziwa. Sababu za kukataa mwanzoni zilikuwa ni pamoja na; kutokuwa na uhakika kuhusu dawa inavyofanya kazi, kutoelewa matokeo yake, kuongezeka kwa kuenea kwa wadudu wengine. Athari nyingine mbaya zilizoonekana ni: harufu, tetesi kuhusu kemikali zinazoathiri urutubishwaji, aibu ya kutolewa vitu vyao vyenye thamani duni kutoka kwenye nyumba zao na imani kuwa dawa hiyo ilihamasishwa kisiasa zaidi.HitimishoIli kuongeza kukubalika kwa IRS, washiriki wanasisitiza zaidi kuzitoa dawa hizo kwa kuwaelimisha watu kwanza, kuhakikisha kuwa wanaonyunyuza dawa hiyo wana ujuzi wa kutosha kuhusu dawa yenyewe, kuwaomba viongozi wa jamii wawatie moyo wanajamii katika kaya zao badala ya kuwatishia na kuwalazimisha. Pamoja na kwamba kuna tetesi na watu kuelewa visivyo kuhusu IRS, kukubalika ni kukubwa na kunaendelea kuonyehsa kuwa na mafanikio chanya.

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.

Using social and behavior change communication to increase HIV testing and condom use: the Malawi BRIDGE Project

While overall HIV prevalence in Malawi has decreased, it is still high in the southern region of the country. Behavioral prevention activities are crucial to continue the reduction in HIV prevalence. Behavior change is influenced by many factors. Previous work indicates knowledge about HIV transmission, self-efficacy to protect oneself from exposure, and accurate risk perception of ones susceptibility all impact sexual behavior. The current study looks at the effects of a behavior change communication program in Malawi called the BRIDGE II Project on psychosocial and behavioral variables. The program sought to address barriers to individual action and confront societal norms related to sexual risk behavior through a mix of community-based activities and mass media messages delivered through local radio stations. Using cohort data (n = 594), we examined the effect of BRIDGE exposure on three variables that affect HIV behaviors: knowledge, self-efficacy, and risk perception, as well as two behavioral outcomes: HIV testing and condom use at last sex. Data were collected at baseline and for a midterm evaluation. Regression analyses showed exposure to BRIDGE was significantly associated with knowledge level (β = 0.20, p < .001) and self-efficacy (β = 0.35, p < .001) at midterm when controlling for baseline scores, but not risk perception. Psychosocial variables did not show a significant relationship to either behavioral outcome. However, program exposure was a significant predictor of both HIV testing in the past year (odds ratio [OR] = 1.40, p < .001) and condom use at last sex (OR = 1.26, p < .05). This study suggests such a communication intervention may play an important role in not only affecting HIV-related behaviors themselves, but also critical factors that affect HIV behaviors, including knowledge and self-efficacy. It is recommended that communication efforts around HIV risk reduction be increased.

Age Differences in Perceptions of and Motivations for Voluntary Medical Male Circumcision Among Adolescents in South Africa, Tanzania, and Zimbabwe

Abstract Background The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) have set a Fast-Track goal to achieve 90% coverage of voluntary medical male circumcision (VMMC) among boys and men aged 10–29 years in priority settings by 2021. We aimed to identify age-specific facilitators of VMMC uptake among adolescents. Methods Younger (aged 10–14 years; n = 967) and older (aged 15–19 years; n = 559) male adolescents completed structured interviews about perceptions of and motivations for VMMC before receiving VMMC counseling at 14 service provision sites across South Africa, Tanzania, and Zimbabwe. Adjusted prevalence ratios (aPRs) were estimated using multivariable modified Poisson regression models with generalized estimating equations and robust standard errors. Results The majority of adolescents reported a strong desire for VMMC. Compared with older adolescents, younger adolescents were less likely to cite protection against human immunodeficiency virus (HIV) or other sexually transmitted infections (aPR, 0.77; 95% confidence interval [CI], .66–.91) and hygienic reasons (aPR, 0.55; 95% CI, .39–.77) as their motivation to undergo VMMC but were more likely to report being motivated by advice from others (aPR, 1.88; 95% CI, 1.54–2.29). Although most adolescents believed that undergoing VMMC was a normative behavior, younger adolescents were less likely to perceive higher descriptive norms (aPR, 0.79; .71–.89), injunctive norms (aPR, 0.86; 95% CI, .73–1.00), or anticipated stigma for being uncircumcised (aPR, 0.79; 95% CI, .68–.90). Younger adolescents were also less likely than older adolescents to correctly cite that VMMC offers men and boys partial HIV protection (aPR, 0.73; 95% CI, .65–.82). Irrespective of age, adolescents’ main concern about undergoing VMMC was pain (aPR, 0.95; 95% CI, .87–1.04). Among younger adolescents, fear of pain was negatively associated with desire for VMMC (aPR, 0.89; 95% CI, .83–.96). Conclusions Age-specific strategies are important to consider to generate sustainable demand for VMMC. Programmatic efforts should consider building on the social norms surrounding VMMC and aim to alleviate fears about pain.

An assessment of HIV testing in Tanzania to inform future strategies and interventions

This study identified characteristics of Tanzanians who have never tested for HIV in order to inform localized interventions to increase HIV testing coverage and uptake. A total of 3257 randomly selected participants aged 18–49 years were surveyed in 16 Mainland regions. Those surveyed were asked about demographics, HIV risk perception, HIV testing behavior, knowledge of both their own and partners HIV status, and if they were tested with their partner. Approximately 22% of women and 46% of men reported never testing for HIV, with those who are younger (18–24 years), single/never married, living in rural areas, less educated, and having multiple sexual partners in the past year less likely to have tested. The gender differences in HIV testing behavior identified are supported by existing research. No association was found in either gender between HIV risk perception and testing, however, those least likely to test were those with multiple sex partners. These findings can help better target localized interventions focused on younger, single people, and those with multiple sex partners.

The Role of Health Systems and Policy in Producing Behavior and Social Change to Enhance Child Survival and Development in Low- and Middle-Income Countries: An Examination of the Evidence

Evidence-based behavior change interventions addressing health systems must be identified and disseminated to improve child health outcomes. Studies of the efficacy of such interventions were identified from systematic searches of the published literature. Two hundred twenty-nine of the initially identified references were judged to be relevant and were further reviewed for the quality and strength of the evidence. Studies were eligible if an intervention addressed policy or health systems interventions, measured relevant behavioral or health outcomes (e.g., nutrition, childhood immunization, malaria prevention and treatment), used at least a moderate quality research design, and were implemented in low- or middle-income countries. Policy or systems interventions able to produce behavior change reviewed included media (e.g., mass media, social media), community mobilization, educational programs (for caregivers, communities, or providers), social marketing, opinion leadership, economic incentives (for both caregiver and provider), health systems strengthening/policy/legislation, and others. Recommendations for policy, practice, and research are given based on fairly strong data across the areas of health service delivery, health workforce, health financing, governance and leadership, and research.

Effects of the Fataki Campaign: Addressing Cross-Generational Sex in Tanzania by Mobilizing Communities to Intervene

The national multimedia “Fataki” campaign aired in Tanzania from 2008 to 2011 with the goal of addressing cross-generational sex (CGS) by mobilizing communities to intervene in CGS relationships. A cross-sectional household survey was used to evaluate the campaign. Logistic regression analysis found a dose–response relationship between campaign exposure and interpersonal communication about CGS, intervening in CGS relationships, and lower CGS engagement among women. No association was found between campaign exposure and current CGS involvement among men, though longer-term data collection may be needed to assess changes in relationship patterns. Findings indicated that engaging in interpersonal communication about CGS was associated with a higher likelihood of actually intervening. Strategies to generate further discussion surrounding CGS and increase impact, such as through community-based components to supplement campaigns, are discussed.ResumenEntre 2008 y 2011, se difundió en Tanzanía la campaña nacional multimedia “Fataki” con miras a abordar el problema de las relaciones sexuales intergeneracionales (RSI) mediante la movilización de las comunidades para que intervinieran en las relaciones RSI. Se llevó a cabo una encuesta domiciliaria transversal para evaluar la campaña. El análisis de regresión logística mostró una relación dosis-respuesta entre la exposición a la campaña y la comunicación interpersonal acerca de las RSI, la intervención en las relaciones RSI y una menor participación de las mujeres en las RSI. No se encontró relación alguna entre la exposición a la campaña y la actual participación de los hombres en las RSI, si bien se necesitaría una recopilación de datos más a largo plazo a fin de analizar los cambios en los modelos de relación. Las conclusiones indicaron que la participación en la comunicación interpersonal acerca de las RSI estaba asociada a una intervención real más probable. Se examinan estrategias para generar nuevos debates entorno a las RSI y aumentar el impacto, como por ejemplo mediante componentes comunitarios que sirvan para complementar las campañas.