Actual Versus Perceived HIV Testing Norms, and Personal HIV Testing Uptake: A Cross-Sectional, Population-Based Study in Rural Uganda

Misperception of Norms About Intimate Partner Violence as a Driver of Personal IPV Attitudes and Perpetration: A Population-Based Study of Men in Rural Uganda

Intimate partner violence (IPV) against women is a global public health problem. Conceptual frameworks suggest misperceived norms around IPV might drive perpetration of violence against women in southern and eastern Africa. We conducted a cross-sectional, population-based survey of all men residing in a rural parish in southwest Uganda, eliciting their endorsement of IPV in five hypothetical scenarios and their reported frequency of perpetration of violence against their wife/main partner. They also reported their perceptions about the extent to which most other men in their villages endorsed and/or perpetrated IPV, which we compared against the population data to measure the primary explanatory variable of interest: whether individuals misperceived norms around IPV. We fitted multivariable Poisson regression models specifying personal IPV endorsement and IPV perpetration as the outcomes. Overall, 765 men participated in the study (90% response rate): 182 (24%) personally endorsed IPV, and 78 of 456 partnered men (17%) reported perpetrating one or more acts of IPV at least once per month. Although most men neither endorsed nor reported perpetrating IPV, 342 (45%) men mistakenly thought that most other men in their villages endorsed IPV and 365 (48%) men mistakenly thought that most other men perpetrate IPV at least monthly. In multivariable regression models, men who misperceived most men to endorse IPV were more likely to endorse IPV themselves (adjusted relative risk [aRR] = 2.44; 95% CI [1.66, 3.59]; p < .001). Among partnered men, those who misperceived IPV perpetration to be normative were more likely to perpetrate IPV themselves (aRR = 4.38; [2.53, 7.59]; p < .001). Interventions to correct misperceived norms about IPV may be a promising method for reducing violence against women in rural Uganda.

Factors associated with intention of HIV testing among Asian American men: a path analysis

Research has pointed to myriad cultural and socio-psychological factors associated with HIV testing, such as acculturation, social norms about HIV testing, masculinity, homonegativity, and constructs from the Theory of Planned Behavior. However, the interrelationships of these factors on the intentions of HIV testing among the population of Asian American men remains unknown. A dataset of 425 Asian American men in the U.S., collected online with convenience sampling method during 2020-2021, was analyzed to test a conceptual framework that aimed to fill this gap. Results from a path model with two endogenous variables (homonegativity and HIV testing intention) indicated that perceived social norms about HIV testing, attitude about HIV testing, and perceived HIV risk had directandindirect relationships with the intentions of HIV testing in the study population. However, social norms about HIV testing and perceived HIV risk showed stronger direct effects (standardized estimates = 0.37 and 0.34, respectively, p-value < 0.001). Additionally, we found that the relationships of these factors with HIV testing intention were also mediated by homonegativity. Findings from this study advance our understanding of pathways of associations between a host of cultural and socio-psychological factors with HIV testing intention among an understudied population - Asian American men. Our results will help inform the development of future intervention programs to increase HIV testing in this population.

Water Treatment Practices and Misperceived Social Norms among Women Living with Young Children in Rural Uganda

Access to water safe for consumption is critical for health and well-being, yet substantial structural barriers often necessitate household action to make water safer. Social norms about water treatment practices are understudied as a driver of personal water treatment practice. This study assesses reported and perceived water treatment practices among women in a rural, water insecure setting. We used cross-sectional data from a population-based study of women living with children under 5 years old across eight villages in southwest Uganda. Participants reported their typical household water treatment practices and what they perceived to be the common practices among most other women with young children in their own village. Modified multivariable Poisson regression models estimated the association between individual behavior and perceptions. Of 274 participants (78% response rate), 221 (81%) reported boiling water and 228 (83%) reported taking at least one action to make water safer. However, 135 (49%) misperceived most women with young children in their village not to boil their water, and 119 (43%) misperceived most to take no action. Participants who misperceived these norms were less likely to practice safe water treatment (e.g., for boiling water, adjusted relative risk = 0.80; 95% CI 0.69-0.92, P = 0.002), adjusting for other factors. Future research should assess whether making actual descriptive norms about local water treatment practices visible and salient (e.g., with messages such as "most women in this village boil their drinking water") corrects misperceived norms and increases safe water treatment practices by some and supports consistent safe practices by others.

Using group norms to promote acceptance of HIV testing during household tuberculosis contact investigation: A household-randomized trial

Background

HIV status awareness and linkage to care are critical for ending the HIV epidemic and preventing tuberculosis (TB). Among household contacts of persons with TB, HIV greatly increases the risk of incident TB and death. However, almost half of household contacts in routine settings decline HIV test offers during routine contact investigation. We evaluated a brief social-behavioral norming intervention to increase acceptance of HIV testing during household TB contact investigation.

Methods

We carried out a household-randomized, controlled trial to evaluate the effect of the norming strategy among household contacts of persons with pulmonary TB in Kampala, Uganda ( ClinicalTrials.gov # NCT05124665 ). Community health workers (CHW) visited homes of persons with TB to screen contacts for TB symptoms and offer free, optional, oral HIV testing. Households were randomized (1:1) to usual care or the norming strategy. Contacts were eligible if they were ≥ 15 years old, self-reported to be HIV-negative, and living in a multi-contact household. The primary outcome, the proportion of contacts accepting HIV testing, was analyzed using an intention-to-treat approach, using a mixed-effects model to account for clustering by household. We assessed HIV testing yield as a proportion of all contacts tested.

Results

We randomized 328 contacts in 99 index households to the norming strategy, of whom 285 (87%) contacts were eligible. We randomized 224 contacts in 86 index households to the usual strategy, of whom 187 (84%) contacts were eligible. Acceptance of HIV testing was higher in the intervention arm (98% versus 92%, difference +6%, 95%CI +2% to +10%, p=0.004). Yield of HIV testing was 2.1% in the intervention arm and 0.6% in the control arm (p=0.22).

Conclusion

A norming intervention significantly improved uptake of HIV testing among household contacts of persons with TB.

Funding/Support

This work was supported by the Center for Interdisciplinary Research on AIDS (P30MH062294) and the Fogarty International Center of the National Institutes of Health (R21TW011270). The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH or other sponsors.

Male circumcision uptake and misperceived norms about male circumcision: Cross-sectional, population-based study in rural Uganda

Background

Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circumcision for human immunodeficiency virus (HIV) and sexually transmitted infection (STI) prevention. The prevalence of male circumcision in Uganda nearly doubled from 26% in 2011 to 43% in 2016, but remains below the 2020 target level. Little is known about how common male circumcision is perceived to be, how accurate such perceptions are, and whether they are associated with men's own circumcision uptake.

Methods

We conducted a cross-sectional study of all adult residents of eight villages in Rwampara District, southwestern Uganda in 2020-2022. We elicited their perceptions of the adult male circumcision prevalence within their village: >50% (most men), 10% to <50% (some), <10%, (few to none), or do not know. We compared their perceived norms to the aggregated prevalence of circumcision reported in these villages. We used a modified multivariable Poisson regression model to estimate the association between perceived norms and personal circumcision uptake among men.

Results

We surveyed 1566 participants (91% response rate): 698 men and 868 women. Among the men, 167 (27%) reported being circumcised, including 167/444 (38%) men <50 years of age. Approximately one-fourth of the population (189 (27%) men and 177 (20%) women) believed that few to no men in their own village had been circumcised. In a multivariable regression model, men who underestimated the prevalence of male circumcision were less likely to be circumcised themselves (adjusted relative risk (aRR) = 0.51; 95% confidence interval (CI) = 0.37-0.83).

Conclusions

In this population-based study in rural Uganda, one-fourth of men underestimated the prevalence of male circumcision. Men who underestimated the extent of circumcision uptake were themselves less likely to be circumcised. If the observed association is causal and underestimates within the population contribute to low uptake, then interventions correcting these misperceived norms could increase uptake of voluntary medical male circumcision.

Cigarette smoking and misperceived norms among adults in rural Uganda: a population-based study

BACKGROUND

Little is known about perceived norms about cigarette smoking in Uganda or the extent to which perceptions drive personal cigarette smoking behaviour.

METHODS

We conducted a cross-sectional study in 2016-2018 that targeted all adults who resided within eight villages in Rwampara District, southwestern Uganda. Personal cigarette smoking frequency was elicited by self-report. We also asked participants what they believed to be the cigarette smoking frequency of most other adult men and women in their villages (i.e., perceived norms). Frequent cigarette smoking was defined as 4+ times/week. We compared perceived norms to cigarette smoking frequency reports aggregated at the village level. We used multivariable Poisson regression to estimate the association between perceived norms and personal cigarette smoking behaviour.

RESULTS

Among 1626 participants (91% response rate), 92 of 719 men (13%) and 6 of 907 women (0.7%) reported frequent smoking. However, 1030 (63%) incorrectly believed most men in their villages smoked cigarettes frequently. Additionally, 116 (7%) incorrectly believed that most women in their villages smoked cigarettes frequently. These misperceptions were pervasive across social strata. Men who misperceived frequent cigarette smoking as the norm among other men in their villages were more likely to smoke frequently themselves (adjusted relative risk=1.49; 95% CI, 1.13 to 1.97).

CONCLUSIONS

Most adults overestimated cigarette smoking frequency among village peers. Men who incorrectly believed that frequent smoking was the norm were more likely to engage in frequent smoking themselves. Applying a 'social norms approach' intervention by promoting existing healthy norms may prevent smoking initiation or motivate reductions in smoking among men in rural Uganda.

Perceived norms about male circumcision and personal circumcision status: a cross-sectional, population-based study in rural Uganda

Introduction

Over the past decade, 15 high-priority countries in eastern and southern Africa have promoted voluntary medical male circucmsion for HIV and STI prevention. Despite male circumcision prevalence in Uganda nearly doubling from 26% in 2011 to 43% in 2016, it remained below the target level by 2020. Little is known about perceived norms of male circumcision and their association with circumcision uptake among men.

Methods

We conducted a cross-sectional study targeting all adult residents across eight villages in Rwampara District, southwestern Uganda in 2020-2022. We compared what men and women reported as the adult male circumcision prevalence within their village (perceived norm: >50% (most), 10% to <50% (some), <10%, (few), or do not know) to the aggregated prevalence of circumcision as reported by men aged <50 years. We used a modified multivariable Poisson regression model to estimate the association between perceived norms about male circumcision uptake and personal circumcision status among men.

Results

Overall, 167 (38%) men < 50 years old were circumcised (and 27% of all men were circumcised). Among all 1566 participants (91% response rate), 189 (27%) men and 177 (20%) women underestimated the male circumcision prevalence, thinking that few men in their own village had been circumcised. Additionally, 10% of men and 25% of women reported not knowing the prevalence. Men who underestimated the prevalence were less likely to be circumcised (aRR = 0.51, 95% CI 0.37 to 0.83) compared to those who thought that some village men were circumcised, adjusting for perceived personal risk of HIV, whether any same-household women thought most men were circumcised, and other sociodemographic factors.

Conclusions

Across eight villages, a quarter of the population underestimated the local prevalence of male circumcision. Men who underestimated circumcision uptake were less likely to be circumcised. Future research should evaluate norms-based approaches to promoting male circumcision uptake. Strategies may include disseminating messages about the increasing prevalence of adult male circumcision uptake in Uganda and providing personalized normative feedback to men who underestimated local rates about how uptake is greater than they thought.

How informal healthcare providers improve uptake of HIV testing: qualitative results from a randomized controlled trial

OBJECTIVE

Uganda is HIV-endemic with a prevalence of 5.7%. Lack of epidemic control has been attributed to low engagement with HIV testing. Collaborating with informal healthcare providers, such as traditional healers, has been proposed as a strategy to increase testing uptake. We explored acceptability and implementation of an HIV testing program where traditional healers delivered point-of-care testing and counseling to adults of unknown serostatus (clinicaltrials.gov NCT#03718871).

METHODS

This study was conducted in rural, southwestern Uganda. We interviewed participating traditional healers ( N  = 17) and a purposive sample of trial participants ( N  = 107). Healers were practicing within 10 km of Mbarara township, and 18+ years old. Participants were 18+ years old; sexually active; had received care from participating healers; self-reported not receiving an HIV test in prior 12 months; and not previously diagnosed with HIV infection. Interviews explored perceptions of a healer-delivered HIV testing model and were analyzed following a content-analysis approach.

RESULTS

Most participants were female individuals ( N  = 68, 55%). Healer-delivered HIV testing overcame structural barriers, such as underlying poverty and rural locations that limited use, as transportation was costly and often prohibitive. Additionally, healers were located in villages and communities, which made services more accessible compared with facility-based testing. Participants also considered healers trustworthy and 'confidential'. These qualities explain some preference for healer-delivered HIV testing, in contrast to 'stigmatizing' biomedical settings.

CONCLUSION

Traditional healer-delivered HIV testing was considered more confidential and easily accessible compared with clinic-based testing. Offering services through traditional healers may improve uptake of HIV testing services in rural, medically pluralistic communities.

Perceptions About Local ART Adherence Norms and Personal Adherence Behavior Among Adults Living with HIV in Rural Uganda

Although misperceived norms often drive personal health behaviors, we do not know about this phenomenon in the context of antiretroviral therapy (ART) adherence. We conducted a cross-sectional study including all persons living with HIV (PLWH) on ART across eight villages in one parish in a rural region of southwestern Uganda. We used surveys to measure personal reports of ART adherence (not missing any doses of ART in the past 7 days was considered optimal adherence whereas missing doses was considered suboptimal adherence) and perceived norms about the local ART adherence norm (whether or not each individual thought 'most other PLWH on ART in this parish' missed any doses in the past 7 days). Multivariable Poisson regression models were used to estimate the association between perceived norms and personal adherence. Among 159 PLWH on ART (95% response rate), 142 (89%) reported no missed doses. However, 119 (75%) thought most individuals in this population of PLWH on ART were sub-optimally adherent. This misperception about the local ART adherence norm was prevalent in every subgroup of PLWH. Misperceiving the local ART adherence norm to be sub-optimal adherence was associated with a reduced likelihood of optimal adherence among married PLWH (adjusted relative risk [aRR] = 0.83; 95% confidence interval [CI] 0.71-0.97). The association was similar but imprecisely estimated for all PLWH (aRR = 0.91; 95% CI 0.82-1.01). Interventions to correct misperceived ART adherence norms as a stand-alone intervention or as a complement to other adherence promotion programs may influence ART adherence behavior and perhaps reduce HIV-related stigma.

Assessing a norming intervention to promote acceptance of HIV testing and reduce stigma during household tuberculosis contact investigation: protocol for a cluster-randomised trial

INTRODUCTION

HIV status awareness is important for household contacts of patients with tuberculosis (TB). Home HIV testing during TB contact investigation increases HIV status awareness. Social interactions during home visits may influence perceived stigma and uptake of HIV testing. We designed an intervention to normalise and facilitate uptake of home HIV testing with five components: guided selection of first tester; prosocial invitation scripts; opt-out framing; optional sharing of decisions to test; and masking of decisions not to test.

METHODS AND ANALYSIS

We will evaluate the intervention effect in a household-randomised controlled trial. The primary aim is to assess whether contacts offered HIV testing using the norming strategy will accept HIV testing more often than those offered testing using standard strategies. Approximately 198 households will be enrolled through three public health facilities in Kampala, Uganda. Households will be randomised to receive the norming or standard strategy and visited by a community health worker (CHW) assigned to that strategy. Eligible contacts ≥15 years will be offered optional, free, home HIV testing. The primary outcome, proportion of contacts accepting HIV testing, will be assessed by CHWs and analysed using an intention-to-treat approach. Secondary outcomes will be changes in perceived HIV stigma, changes in perceived TB stigma, effects of perceived HIV stigma on HIV test uptake, effects of perceived TB stigma on HIV test uptake and proportions of first-invited contacts who accept HIV testing. Results will inform new, scalable strategies for delivering HIV testing.

ETHICS AND DISSEMINATION

This study was approved by the Yale Human Investigation Committee (2000024852), Makerere University School of Public Health Institutional Review Board (661) and Uganda National Council on Science and Technology (HS2567). All participants, including patients and their household contacts, will provide verbal informed consent. Results will be submitted to a peer-reviewed journal and disseminated to national stakeholders, including policy-makers and representatives of affected communities.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT05124665.

High School Students' Perceptions of School Personnel's Intentions to Help Prevent Teen Sexual and Dating Violence: Associations with Attitudes and Intended Behaviors. JOURNAL OF INTERPERSONAL VIOLENCE 2022;37:NP5471-NP5494. [PMID: 35369777 DOI: 10.1177/0886260520960115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Adolescents are at high risk for sexual and dating violence (SDV) at school, indicating need for both adolescents and school personnel to engage in bystander behavior to prevent SDV. Adolescents' perceptions of social norms about bystander behavior, including their perceptions about social norms among school personnel, may impact adolescents' own SDV attitudes and intended bystander behavior. Based on social norms theory, the current research examines adolescents who underestimate, accurately perceive, and overestimate school personnel's reactive (responding to a current situation) and proactive (spreading messaging about prevention) bystander behaviors. High school students (N = 3,404; mean age = 15.7; 87.2% White; 87% heterosexual) and school personnel (N = 1,150) from 25 schools completed surveys. Adolescents who underestimated school personnel's reactive and proactive bystander behavior had more accepting attitudes towards violence and less bystander behavior intentions. Correcting misperceived norms about bystander behavior may improve students' own bystander behavior.

Perceived and misperceived norms about khat and/or cannabis use among adults in southwest Uganda

BACKGROUND

Studies from high-income contexts have found evidence that norms about substance use are misperceived. The accuracy of perceived norms about khat and cannabis use in Uganda have not previously been described.

METHODS

We conducted a population-based study targeting all resident adults across eight villages in southwestern Uganda. Personal khat and/or cannabis use frequency was based on self-report. We measured perceived norms about substance use by eliciting individuals' perceptions about how often most other adult men and most other adult women in their villages used these substances. We compared perceived norms to aggregated village rates of use to assess the extent to which norms were misperceived. We used multivariable Poisson regression to estimate correlates of misperceived norms.

RESULTS

Among 1626 participants (91% response rate), only 29 men (4%) and 9 women (1%) reported any lifetime use of khat and/or cannabis. However, 695 participants (43%) did not think lifetime abstinence was the norm among men in their villages, and 256 participants (16%) did not think lifetime abstinence was the norm among women. Moreover, 219 participants (13%) incorrectly believed most men in their village regularly used khat and/or cannabis (≥4 times per week). Misperceived norms were present across subgroups and were correlated with larger social networks, symptoms of depression, loneliness, and younger age.

CONCLUSION

In this study of all adults across 8 villages in rural Uganda, many participants misperceived norms about khat and/or cannabis use. Providing accurate information about prevailing norms in the local population may help prevent initiation of khat and/or cannabis use among adults in this context.

Overestimation of alcohol consumption norms as a driver of alcohol consumption: a whole-population network study of men across eight villages in rural, southwestern Uganda

BACKGROUND AND AIMS

Little is known about how perceived norms about alcohol consumption may influence high alcohol consumption rates in Uganda. This study estimated the accuracy of perceived norms about men's alcohol consumption and estimated the association between perceived norms and personal alcohol consumption.

DESIGN

Cross-sectional, whole-population, sociocentric social network study.

SETTING

Eight rural villages in Rwampara District, southwestern Uganda in 2016-18.

PARTICIPANTS

A total of 719 men aged 18 years and older (representing 91% of permanent resident men).

MEASUREMENTS

Self-reported frequent (≥ 4 days per week) and heavy alcohol consumption (six or more drinks on one occasion, more than three occasions of intoxication, or spending an excessive amount on alcohol). Participants also reported whether they thought most other men in their village engaged in frequent and heavy alcohol consumption (perceived norms). Using the network study design, we calculated alcohol consumption behavior within villages and social networks. Perceived norms were compared with aggregated self-reports. Multivariable Poisson regression models were used to estimate the association between perceived norms and individual behavior.

FINDINGS

Throughout villages, frequent and heavy alcohol consumption ranged from 7 to 37%. However, 527 (74%) participants perceived, contrary to fact, that most other men in their villages frequently consumed alcohol, and 576 (81%) perceived that most others heavily consumed alcohol. Overestimation of alcohol consumption by others was pervasive among socio-demographic subgroups and was present irrespective of the actual consumption behavior at the village level and within social networks. Men who misperceived these alcohol consumption behaviors as being common were more likely to engage in frequent [adjusted relative risk (aRR) = 3.98; 95% confidence interval (CI) = 1.69-9.34) and heavy (aRR = 4.75; 95% CI = 2.33-9.69) alcohol consumption themselves.

CONCLUSIONS

Most men in eight rural Ugandan villages incorrectly thought that frequent and heavy alcohol consumption were common among men in their villages. These misperceived norms had a strong positive association with individual drinking behavior.

Normative vs personal attitudes toward persons with HIV, and the mediating role of perceived HIV stigma in rural Uganda

BACKGROUND

HIV stigma has well-documented negative impacts on HIV testing, transmission risk behavior, initiation of and adherence to antiretroviral therapy, and retention in care. We sought to assess the extent to which anticipated HIV stigma is based on misperceptions of normative attitudes toward persons with HIV, and to determine whether persons with HIV have stronger misperceptions compared with HIV-negative persons or persons of unknown serostatus. We also sought to estimate the association between normative attitudes about persons with HIV and personal attitudes about persons with HIV, and to determine the extent to which anticipated stigma mediates this association.

METHODS

We conducted a whole-population survey of 1776 persons living in 8 rural villages in southwestern Uganda. Negative attitudes toward persons with HIV, and anticipated stigma, were measured using a newly validated 15-item scale measuring multiple dimensions of HIV stigma, including social distance, blaming attitudes, and concerns about reciprocity. We used multivariable regression to estimate the association between normative attitudes about persons with HIV and personal attitudes toward persons with HIV, and to determine the extent to which perceptions of normative attitudes (anticipated stigma) mediated this association.

RESULTS

Study participants believed that negative attitudes toward persons with HIV were more pervasive than they actually are. Perceptions of the extent to which these negative attitudes are normative mediated more than one-third of the association between normative attitudes and their personal attitudes. In contrast to what we originally hypothesized, persons with HIV were less likely to misperceive these norms and perceived normative attitudes to be less stigmatizing than did others in the general population.

CONCLUSIONS

Interventions designed to accurately describe normative attitudes toward persons with HIV may reduce HIV stigma without directly focusing on the educational components that are typically embedded in anti-stigma interventions.

HIV testing and ethnicity among adolescent girls and young women aged 15-24 years in Ghana: what really matters?

Despite the high prevalence of HIV among adolescent girls and young women (AGYW) aged 15-24 years in Ghana, HIV testing remains low among this population. The objective of this study was to examine the relationship between ethnicity and HIV testing among AGYW in Ghana. The 2014 Ghana Demographic and Health Survey data were used and analyses were restricted to 3325 female participants aged 15-24 years. Chi-squared tests and a logistic regression model were used to assess the association between ethnicity and HIV testing. Furthermore, the PEN-3 cultural model informed the conceptual framework that explained the relationship between ethnicity and HIV testing behaviour. Results from the bivariate analysis showed an association between ethnicity and HIV testing among AGYW (p<0.05). However, when controlling for other behavioural and socioeconomic determinants of HIV testing in the logistic regression, there was no association between ethnicity and HIV testing. The significant predictors of HIV testing were marital status, having multiple sexual partners, and condom use. The AGYW who were married (adjusted odds ratio [aOR] = 4.56, CI: 3.46-6.08) or previously married (aOR = 4.30, CI: 2.00-9.23) were more likely to test for HIV compared with those who were never married. Having multiple sexual partners (aOR = 0.41, CI: 0.20-0.85) and condom use (aOR = 0.56, CI: 0.38-0.84) were associated with lower odds of HIV testing. The results provide evidence that ethnicity is not associated with HIV testing among AGYW in Ghana, as the bivariate association was attenuated when other behavioural and socioeconomic determinants of HIV testing were accounted for. These findings highlight the importance of considering individual-level factors, community-level factors, and other socio-cultural factors as they really matter in the development of HIV prevention programmes for adolescent girls and young women in Ghana.

Sexual Mixing and HIV Transmission Potential Among Greek Men Who have Sex with Men: Results from SOPHOCLES

HIV incidence among men who have sex with men (MSM) in Greece remains unchanged despite effective response to a recent outbreak among people who inject drugs (PWID). Network factors are increasingly understood to drive transmission in epidemics. The primary objective of the study was to characterize MSM in Greece, their sexual behaviors, and sexual network mixing patterns. We investigated the relationship between serostatus, sexual behaviors, and self-reported sex networks in a sample of MSM in Athens, Greece, generated using respondent driven sampling. We estimated mixing coefficients (r) based on survey-generated egonets. Additionally, multiple logistic regression was used to estimate adjusted odds ratios (AOR) and to assess relationships between serostatus, sexual behaviors, and sociodemographic indicators. A sample of 1,520 MSM participants included study respondents (n = 308) and their network members (n = 1,212). Mixing based on serostatus (r = 0.12, σr = 0.09-0.15) and condomless sex (r = 0.11, σr = 0.07-0.14) was random. However, mixing based on sex-drug use was highly assortative (r = 0.37, σr = 0.32-0.42). This study represents the first analysis of Greek MSM sexual networks. Our findings highlight protective behavior in two distinct network typologies. The first typology mixed assortatively based on serostatus and sex-drug use and was less likely to engage in condomless sex. The second typology mixed randomly based on condomless sex but was less likely to engage in sex-drug use. These findings support the potential benefit of HIV prevention program scale-up for this population including but not limited to PrEP.

Social and provider networks and women's contraceptive use: Evidence from Madagascar

OBJECTIVES

Women may differ by whether they rely on health providers and/or social ties for seeking information and advice about family planning. It is unknown whether these differences matter for contraceptive outcomes. This study assessed the association between women's family planning (FP) network (social and/or provider ties) and contraceptive use.

STUDY DESIGN

This cross-sectional, egocentric network study was conducted among reproductive-age women (n = 193) in rural Madagascar. Data included socio-demographics and contraceptive use. Respondents listed who they relied on for contraceptive information, advice or guidance and provided ties' gender, age, relationship, and perceived support of contraceptive use. The primary outcome was current contraceptive use. Predictors included having a FP network (0/1) and FP network composition (no network, social ties only, provider ties only, both provider and social ties), respectively. Analyses were conducted using a generalized linear model specifying a Poisson distribution, with covariate adjustment and cluster robust standard errors.

RESULTS

Having a network of individuals to turn to for contraceptive information compared to having no FP network was positively associated with contraceptive use (adjusted relative risk [aRR] 4.4, 95% confidence interval [CI] 2.00-9.87). Having a social network, a provider network, or a combination of social and provider network were all positively associated with contraceptive use (aRR 4.30 [CI 1.92-9.66], aRR 4.46 [CI 2.04-9.75], aRR 4.72 [CI 1.93-11.50], respectively), compared to having no FP network.

CONCLUSIONS

Contraceptive use was higher among women who relied on social ties, provider ties or both for contraceptive information and advice, compared to women with no FP network. These findings suggest that FP interventions should use a multicomponent approach taking into account both social and provider networks.

IMPLICATIONS

It is unknown whether differences in whether women rely on social ties (friends, partner, family members) vs. providers for contraceptive information and advice affect contraceptive outcomes. Women are just as likely to use contraception whether they rely on social ties, provider ties, or both for contraceptive information and advice.

"When you have a high life, and you like sex, you will be afraid": a qualitative evaluation of adolescents' decision to test for HIV in Zambia and Kenya using the health belief model

Background

HIV testing among adolescents is significantly lower than among adults and many adolescents living with HIV do not know their status. Adolescent perceptions of HIV testing are poorly understood and may negatively affect testing uptake. Using a qualitative design, this study sought to explore perceptions about HIV testing and treatment among adolescents living with HIV and adolescents of unknown HIV status in Lusaka, Zambia and Kenya.

Methods

Study participants were adolescents aged 15–19 years old. The adolescents living with HIV were recruited from HIV support groups at health facilities. Adolescents of unknown HIV status were recruited from existing adolescent groups within the community. In both Zambia and Kenya, four focus group discussions (FGDs) were conducted with adolescents living with HIV and four FGDs were conducted with adolescents whose HIV status was unknown, for a total of 16 FDGs. FGDs consisted of 6–12 participants, a moderator, and a note-taker. FGDs were audio-recorded, transcribed, and translated into transcripts. Transcripts were coded in the qualitative analysis software program MAXQDA v. 12. Data reduction and summary tables were generated to help identify themes across the two study population groups. Data were interpreted within the health belief model.

Results

Adolescents discussed the challenges of facing a positive HIV test result, including fear of a positive result and need to change their lifestyle, fear of social isolation, and perception of the lost opportunity to achieve future dreams. Most adolescents of unknown status were not as aware of the benefits of learning their HIV status, nor were they aware of the ability to live a long and healthy life on ART. HIV-positive adolescents reported that the messages targeted towards adolescents focus on the need to remain HIV-negative, as opposed to the benefits of knowing one’s status. Adolescents described age and requirements for parental permission as a significant limitation in their ability to access HIV testing.

Conclusions

Adolescents require more information about the benefits of testing early and the ability to live a long and healthy life on ART. Educating adolescents that HIV testing is a normative behavior among their peers could strengthen HIV testing among adolescents.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10391-x.

The association between men's family planning networks and contraceptive use among their female partners: an egocentric network study in Madagascar

Background

Ensuring women have information, support and access to family planning (FP) services will allow women to exercise their reproductive autonomy and reduce maternal mortality, which remains high in countries such as Madagascar. Research shows that women’s social networks - their ties with partners, family members, friends, and providers - affect their contraceptive use. Few studies have considered the role of men’s social networks on women’s contraceptive use. Insofar as women’s contraceptive use may be influenced by their male partners, women’s contraceptive use may also be affected by their partner’s social networks. Men may differ by the types of ties they rely on for information and advice about FP. It is unknown whether differences in the composition of men’s FP networks matter for couples’ contraceptive use. This study assessed the association between men’s FP networks and couples’ contraceptive use.

Methods

This egocentric network study was conducted among married/partnered men (n = 178) in rural Madagascar. Study participants listed who they relied on for FP information and advice, including health providers and social ties. They provided ties’ gender, age, relationship, and perceived support of contraceptive use. The primary outcome was couples’ contraceptive use, and explanatory variables included FP networks and their composition (no FP network, social-only network, provider-only network, and mixed network of social and provider ties). Analyses used generalized linear models specifying a Poisson distribution, with covariate adjustment and cluster robust standard errors.

Results

Men who had FP networks were 1.9 times more likely to use modern contraception as a couple compared to men with no FP network (95% confidence interval [CI] 1.64–2.52; p ≤ 0.001). Compared to men with no FP network, men were more likely to use modern contraception if they had a social-only network, relative risk (RR) = 2.10 (95% CI, 1.65–2.68; p ≤ 0.001); a provider-only network, RR = 1.80 (95% CI, 1.54–2.11; p ≤ 0.001); or a mixed network, RR = 2.35 (95% CI, 1.97–2.80; p ≤ 0.001).

Conclusions

Whether men have a FP network, be it provider or social ties, distinguishes if couples are using contraception. Interventions should focus on reaching men not only through providers but also through their social ties to foster communication and support for contraceptive use.

Perceived HIV stigma and HIV testing among men and women in rural Uganda: a population-based study

BACKGROUND

Stigma is a formidable social structural barrier to HIV testing, and yet the effect of stigma on HIV testing is rarely examined at the community level. We aimed to examine the geospatial relationships of perceived HIV stigma and HIV testing among men and women living in rural Uganda.

METHODS

Women and men (aged ≥18 years or emancipated minor) residing in rural areas of Uganda who self-identified as HIV negative completed interviews that included measures of HIV testing history and how participants perceived HIV stigma. We used geospatial cluster analyses to identify areas of higher perceived stigma and lower perceived stigma and the geographical dispersion of these areas. We used Poisson regression models stratified by gender to test individual-level and community-level perceived stigma in relation to frequency of HIV testing in the previous 2 years.

FINDINGS

Between Nov 25, 2015, and May 26, 2017, we interviewed 9740 participants (4359 [45%] men and 5381 [55%] women]), among whom 940 (9%) had never been tested for HIV, and among those who had been tested, 1131 (12%) had not been tested in the previous 2 years. Men (3134 [72%] of 4359) were less likely to have been tested in the past 2 years than women (4535 [84%] of 5381) were (p<0·001). We used Poisson regression models, reporting B coefficients, to test study hypotheses regarding the effects of individual-level and community-level stigma on HIV testing frequency counts. Multilevel modelling showed that women showed significant individual-level (B=-0·173, p<0·001) and community-level (B=-0·223, p<0·001) associations between lower stigma predicting higher rates of HIV testing. For men, lower individual-level perceived stigma was also associated with higher testing frequency (B=-0·030, p=0·018), whereas higher community-level perceived stigma was associated with higher testing frequency (B=0·077, p=0·008).

INTERPRETATION

Our results suggest that perceived HIV stigma at the community level exerts a differential influence on testing for women and men. HIV testing campaigns that are targeted to men and women in rural Uganda will require gender tailoring to fit local contexts.

FUNDING

US National Institute of Mental Health.

The Influence of Social Networks on Antiretroviral Therapy Initiation Among HIV-Infected Antiretroviral Therapy-Naive Youth in Rural Kenya and Uganda

BACKGROUND

HIV-infected youth in sub-Saharan Africa are less likely to initiate antiretroviral therapy (ART) than older adults.

SETTING AND METHODS

Adult (≥15 years) residents enumerated during a census in 32 communities in rural Kenya and Uganda named social contacts in 5 domains: health, money, emotional support, food, and free time. Named contacts were matched to other enumerated residents to build social networks among 150,395 adults; 90% were tested for HIV at baseline. Among youth (15-24 years) who were ART naive at baseline (2013-2014), we evaluated whether having ≥1 network contact who was HIV infected predicted ART initiation within 3 years and modification of this association by age and strength of contact, using logistic regression with robust standard errors.

RESULTS

Among 1120 HIV-infected youth who were ART naive at baseline, 805 remained alive and community residents after 3 years. Of these, 270 (33.5%) named at least one baseline HIV-infected contact; 70% (569/805) subsequently initiated ART. Youth with ≥1 HIV-infected same-age baseline contact were more likely to initiate ART [adjusted odds ratio (aOR), 2.95; 95% confidence interval (CI): 1.49 to 5.86] than those with no HIV-infected contact, particularly if the contact was a strong tie (named in >1 domain; aOR, 5.33; 95% CI: 3.34 to 8.52). When nonhousehold contacts were excluded, having an HIV-infected same age contact who was a strong tie remained associated with ART initiation (aOR, 2.81; 95% CI: 1.76 to 4.49).

CONCLUSIONS

Interventions that increase and strengthen existing social connections to other HIV-infected peers at the time of HIV diagnosis may increase ART initiation among HIV-infected youth.

Using Social Networks to Understand and Overcome Implementation Barriers in the Global HIV Response

BACKGROUND

Despite the development of several efficacious HIV prevention and treatment methods in the past 2 decades, HIV continues to spread globally. Uptake of interventions is nonrandomly distributed across populations. Such inequality is socially patterned and reinforced by homophily arising from both social selection (becoming friends with similar people) and influence (becoming similar to friends).

METHODS

We conducted a narrative review to describe how social network analysis methods-including egocentric, sociocentric, and respondent-driven sampling designs-provide tools to measure key populations, to understand how epidemics spread, and to evaluate intervention take-up.

RESULTS

Social network analysis-informed designs can improve intervention effectiveness by reaching otherwise inaccessible populations. They can also improve intervention efficiency by maximizing spillovers, through social ties, to at-risk but susceptible individuals. Social network analysis-informed designs thus have the potential to be both more effective and less unequal in their effects, compared with social network analysis-naïve approaches. Although social network analysis-informed designs are often resource-intensive, we believe they provide unique insights that can help reach those most in need of HIV prevention and treatment interventions.

CONCLUSION

Increased collection of social network data during both research and implementation work would provide important information to improve the roll-out of existing studies in the present and to inform the design of more data-efficient, social network analysis-informed interventions in the future. Doing so will improve the reach of interventions, especially to key populations, and to maximize intervention impact once delivered.

Norms and Attitudes about Being an Active Bystander: Support for Telling Adults about Seeing Knives or Guns at School among Greater London Youth

A detailed understanding of the factors associated with support among youth for reporting a knife or gun at school to an adult is essential to inform violence prevention initiatives. However, no studies have empirically assessed attitudes about support for reporting among secondary school students in Greater London nor perceived norms about such support among peers. Thus, this study explores whether students misperceive peer norms about support for telling adults about seeing weapons at school. Anonymous surveys were completed by 7401 youth (52% female; 43% White; mean age 11.8 years) in school years 4-11 in 45 school cohorts in a greater London borough between 2007 and 2012. Students reported both personal support about reporting weapons to several categories of adults and whether they perceived most other students at their school to support reporting weapons to adults in each category. Most students (64-78% on average) in most cohorts personally thought that students should report seeing a weapon at school to head teachers, police/security guard, teachers/counselors, and parent/other adult relatives. However, 34-44% of students erroneously thought that the majority of their peers did not support reporting to these adults. Perceived norms predicted personal support for reporting, adjusting for the prevalence of actual support at one's school and other factors. Pervasive norm misperceptions about reporting may contribute to a less safe environment.

"What would the neighbors do?" Measuring sexual and domestic violence prevention social norms among youth and adults

There is growing attention to how social processes in communities may contribute to domestic and sexual violence (DSV) and be a target for prevention efforts. Three main variables are collective efficacy and descriptive and injunctive norms. To date, few measures exist that assess these variables in the specific context of violence prevention. The current study sampled 3,866 adults and high-school youth in four communities in northern New England. Exploratory and confirmatory factor analyses examined the psychometrics of the scales. Scales reflecting collective efficacy, indirect public, and direct individualized descriptive norms, public and personal injunctive norms, and youth perceptions of adults' prevention actions demonstrated robust factor structures and adequate reliability and validity. These measures may prove useful for a diverse audience (e.g., practitioner, researchers) for assessing the effectiveness of community-level DSV prevention strategies.

Portrayals of mental illness, treatment, and relapse and their effects on the stigma of mental illness: Population-based, randomized survey experiment in rural Uganda

BACKGROUND

Mental illness stigma is a fundamental barrier to improving mental health worldwide, but little is known about how to durably reduce it. Understanding of mental illness as a treatable medical condition may influence stigmatizing beliefs, but available evidence to inform this hypothesis has been derived solely from high-income countries. We embedded a randomized survey experiment within a whole-population cohort study in rural southwestern Uganda to assess the extent to which portrayals of mental illness treatment effectiveness influence personal beliefs and perceived norms about mental illness and about persons with mental illness.

METHODS AND FINDINGS

Study participants were randomly assigned to receive a vignette describing a typical woman (control condition) or one of nine variants describing a different symptom presentation (suggestive of schizophrenia, bipolar, or major depression) and treatment course (no treatment, treatment with remission, or treatment with remission followed by subsequent relapse). Participants then answered questions about personal beliefs and perceived norms in three domains of stigma: willingness to have the woman marry into their family, belief that she is receiving divine punishment, and belief that she brings shame on her family. We used multivariable Poisson and ordered logit regression models to estimate the causal effect of vignette treatment assignment on each stigma-related outcome. Of the participants randomized, 1,355 were successfully interviewed (76%) from November 2016 to June 2018. Roughly half of respondents were women (56%), half had completed primary school (57%), and two-thirds were married or cohabiting (64%). The mean age was 42 years. Across all types of mental illness and treatment scenarios, relative to the control vignette (22%-30%), substantially more study participants believed the woman in the vignette was receiving divine punishment (31%-54%) or believed she brought shame on her family (51%-73%), and most were unwilling to have her marry into their families (80%-88%). In multivariable Poisson regression models, vignette portrayals of untreated mental illness, relative to the control condition, increased the risk that study participants endorsed stigmatizing personal beliefs about mental illness and about persons with mental illness, irrespective of mental illness type (adjusted risk ratios [ARRs] varied from 1.7-3.1, all p < 0.001). Portrayals of effectively treated mental illness or treatment followed by subsequent relapse also increased the risk of responses indicating stigmatizing personal beliefs relative to control (ARRs varied from 1.5-3.0, all p < 0.001). The magnitudes of the estimates suggested that portrayals of initially effective treatment (whether followed by relapse or not) had little moderating influence on stigmatizing responses relative to vignettes portraying untreated mental illness. Responses to questions about perceived norms followed similar patterns. The primary limitations of this study are that the vignettes may have omitted context that could have influenced stigma and that generalizability beyond rural Uganda may be limited.

CONCLUSIONS

In a population-based, randomized survey experiment conducted in rural southwestern Uganda, portrayals of effectively treated mental illness did not appear to reduce endorsement of stigmatizing beliefs about mental illness or about persons with mental illness. These findings run counter to evidence from the United States. Further research is necessary to understand the relationship between mental illness treatment and stigmatizing attitudes in Uganda and other countries worldwide.

TRIAL REGISTRATION

The experimental procedures for this study were registered with ClinicalTrials.gov as "Measuring Beliefs and Norms About Persons With Mental Illness" (NCT03656770).

HIV voluntary counselling and testing and behaviour changes among youths in Nigeria

Voluntary counselling and testing (VCT) for HIV has been promoted as a strategy to prevent HIV pandemics by changing sexual behaviour. Despite the provision of VCT in countries with generalized or high-burden epidemics, including Nigeria, the extent of its influence on behavioural change remains a conjecture. The main objective of this study was to examine the influence of HIV VCT on sexual behaviour changes among youths in Nigeria. The study utilized 2013 Nigeria Demographic and Health Survey (NDHS) data. Data were analysed from a nationally representative sample drawn from 8046 females and 6031 males aged 15-24 giving a total sample of 14,077 never-married youths. Descriptive and analytical analyses were carried out, including multivariate logistic regression. The study found a low uptake of HIV VCT and regional variation in behavioural changes between female and male youths. Voluntary HIV counselling and testing was found to be a protective factor for condom use at last sex for female youths, but significantly reduced the likelihood of primary sexual abstinence for both females and males, as well as having a single sexual partner for female youths. After controlling HIV VCT with other variables, certain socioeconomic factors were found to be significantly associated with behavioural changes. Thus, the attitudes of most Nigerian youths towards voluntary HIV counselling and testing needs to be improved through socioeconomic factors for healthy sexual activity. To achieve this, government and non-governmental organizations, as well as religious leaders and policymakers, should engage in appropriate and long-term activities directed at the sexual health needs of never-married youths, through voluntary HIV counselling and testing, to encourage them to change their sexual behaviour.

Social norms, misperceptions, and mosquito net use: a population-based, cross-sectional study in rural Uganda

BACKGROUND

Mosquito net use is an essential part of malaria prevention. Although previous research has shown that many people sleep under a mosquito net in endemic areas, it is unknown whether people underestimate how common it is to sleep under a net every night. Furthermore, perceived social norms about whether most others sleep under a mosquito net every night may contribute to personally sleeping under a net, given decades of research showing that people often mimic others' behaviours.

METHODS

Population-based data were collected from 1669 adults across eight villages in one rural parish in southwestern Uganda. Individuals' perception about whether most adults in their community sleep under a mosquito net every night was compared with whether daily mosquito net use was the actual norm in their community to identify the extent of norm misperception. The association between whether an individual perceived daily mosquito net use to be the norm and personal mosquito net use was assessed while adjusting for the ratio of nets:people in the household and other factors.

RESULTS

Although the majority (65%) of participants reported sleeping under a mosquito net every night (and 75% did so among the 86% of people with at least one net), one-quarter of participants thought that most adults in their community did not sleep under a mosquito net every night. Another 8% were unsure how many nights per week most adults in their community sleep under a mosquito net. Participants who perceived that daily mosquito net use was the norm were 2.94 times more likely to report personally sleeping under a mosquito net every night (95% CI 2.09-4.14, p < 0.001) compared to participants who thought doing so was not normative, adjusting for other factors.

CONCLUSIONS

Results suggest an opportunity for anti-malarial interventions to reduce misperceptions about mosquito net use norms and emphasize the commonness of daily mosquito net use in malaria-endemic regions. If people correctly perceive most others to sleep under a net every night, then they may personally do so when possible and support others to do so too.

The social network context of HIV stigma: Population-based, sociocentric network study in rural Uganda

RATIONALE

HIV-related stigma profoundly affects the physical and social wellbeing of people living with HIV, as well as the community's engagement with testing, treatment, and prevention. Based on theories of stigma elaborating how it arises from the relationships between the stigmatized and the stigmatizer as well as within the general community, we hypothesized that social networks can shape HIV-related stigma.

OBJECTIVE

To estimate social network correlates of HIV-related stigma.

METHODS

During 2011-2012, we collected complete social network data from a community of 1669 adults ("egos") in Mbarara, Uganda using six culturally-adapted name generators to elicit different types of social ties ("alters"). We measured HIV-related stigma using the 9-item AIDS-Related Stigma Scale. HIV serostatus was based on self-report. We fitted linear regression models that account for network autocorrelation to estimate the association between egos' HIV-related stigma, alters' HIV-related stigma and alters' self-reported HIV serostatus, while adjusting for egos' HIV serostatus, network centrality, village size, perceived HIV prevalence, and sociodemographic characteristics.

RESULTS

The average AIDS-Related Stigma Score was 0.79 (Standard Deviation = 0.50). In the population 116 (7%) egos reported being HIV-positive, and 757 (46%) reported an HIV-positive alter. In the multivariable model, we found that egos' own HIV-related stigma was positively correlated with their alters' average stigma score (b=0.53; 95% confidence interval [CI] 0.42-0.63) and negatively correlated with having one or more HIV-positive alters (b=-0.05; 95% CI -0.10 to -0.003).

CONCLUSION

Stigma-reduction interventions should be targeted not only at the level of the individual but also at the level of the network. Directed and meaningful contact with people living with HIV may also reduce HIV-related stigma.

Repeat HIV testing practices in the era of HIV self-testing among adults in KwaZulu-Natal, South Africa

Repeat HIV testing is important in high HIV burden communities to enable sustainability of prevention initiatives; however, an understanding of repeat testing practices is limited. Additional HIV testing approaches may be required to increase testing. HIV self-testing is an additional testing approach, but knowledge on its potential for repeat testing is limited. This study explored repeat HIV testing practices and uptake of HIV self-testing among repeat testers, following exposure to HIV self-testing. HIV testing practices were explored at two time points. During Phase 1, eighty in-depth interviews were conducted among 40 consenting adults, and 30 telephonic contacts were completed during Phase 2. Framework analysis was used to analyse the transcripts from the in-depth interviews. The practice of repeat HIV testing is primarily influenced by HIV status awareness and risk exposure. Thirteen regular testers and one HIV naïve tester at baseline had undergone repeat testing through the use of a traditional testing approach such as HIV counselling and testing as reported in Phase 2. HIV self-testing has a role among repeat testers, but affordability and access are barriers.

Smoking cessation after engagement in HIV care in rural Uganda

People living with HIV (PLWH) are more likely to smoke compared to HIV-uninfected counterparts, but little is known about smoking behaviors in sub-Saharan Africa. To address this gap in knowledge, we characterized smoking cessation patterns among people living with HIV (PLWH) compared to HIV-uninfected individuals in rural Uganda. PLWH were at least 40 years of age and on antiretroviral therapy for at least three years, and HIV-uninfected individuals were recruited from the clinical catchment area. Our primary outcome of interest was smoking cessation, which was assessed using an adapted WHO STEPS smoking questionnaire. We fit Cox proportional hazards models to compare time to smoking cessation between PLWH pre-care, PLWH in care, and HIV-uninfected individuals. We found that, compared to HIV-uninfected individuals, PLWH in care were less likely to have ever smoked (40% vs. 49%, p = 0.04). The combined sample of 267 ever-smokers had a median age of 56 (IQR 49-68), 56% (n = 150) were male, and 26% (n = 70) were current smokers. In time-to-event analyses, HIV-uninfected individuals and PLWH prior to clinic enrollment ceased smoking at similar rates (HR 0.8, 95% CI 0.5-1.2). However, after enrolling in HIV care, PLWH had a hazard of smoking cessation over twice that of HIV-uninfected individuals and three times that of PLWH prior to enrollment (HR 2.4, 95% CI 1.3-4.6, p = 0.005 and HR 3.0, 95% CI 1.6-5.5, p = 0.001, respectively). In summary, we observed high rates of smoking cessation among PLWH after engagement in HIV care in rural Uganda. While we hypothesize that greater access to primary care services and health counseling might contribute, future studies should better investigate the mechanism of this association.

A Critical Appraisal of the Social Norms Approach as an Interventional Strategy for Health-Related Behavior and Attitude Change

The Social Norms Approach is a widely used intervention strategy for promoting positive health-related behaviors. The Approach operates on the premise that individuals misperceive their peers' behaviors and attitudes, with evidence of under- and over-estimations of behaviors and peer approval for a range of positive and negative behaviors respectively. The greater these misperceptions, the more likely an individual is to engage in negative behaviors such as consuming heavier amounts of alcohol and other substances and reduce positive behaviors such as eating healthily and using sun protection. However, there are many complexities associated with the use of social norms feedback in interventions and empirical studies. Many social norms interventions do not attempt to change misperceptions of social norms or measure changes in normative perceptions pre- and post-intervention. This has led to a conflation of generic social norms interventions with those that are explicitly testing the Approach's assumptions that it is misperceptions of peer norms which drive behavior. The aim of the present review was to provide a critical appraisal of the use of the Social Norms Approach as an intervention strategy for health-related behaviors, identify the current issues with its evidence base, highlight key opportunities and challenges facing the approach, and make recommendations for good practice when using the approach. There are three core challenges and areas for improved practice when using the Social Norms Approach. Firstly, improvements in the methodological rigor and clarity of reporting of 'social norms' research, ensuring that studies are testing the approach's assumption of the role of misperceptions on behaviors are differentiated from studies investigating other forms of 'social norms.' Secondly, the need for a more explicit, unified and testable theoretical model outlining the development of normative misperceptions which can be translated into interventional studies. Finally, a need for a more robust evaluation of social norms interventions in addition to randomized controlled trials, such as the inclusion of process evaluations, qualitative studies of participant experiences of social norms feedback, and alternative study designs better suited for real-world public health settings. Such improvements are required to ensure that the Social Norms Approach is adequately tested and evaluated.

The interaction between HIV testing social norms and self-efficacy on HIV testing among Chinese men who have sex with men: results from an online cross-sectional study

BACKGROUND

Increasing human immunodeficiency virus (HIV) testing is critical for HIV control. This study aimed to evaluate the interaction between social norms and self-efficacy on HIV testing among Chinese men who have sex with men (MSM).

METHODS

We conducted an online survey in eight Chinese cities in Shandong and Guangdong Provinces in July 2016. We included participants who were born as a male, at least 16 years old, currently living in one of the designated cities, and had ever engaged in anal sex with a man. We collected information regarding socio-demographics, high-risk behaviors, and history of HIV and other STI testing. We coded sensitivity to social norms using six items asking participants about their perceived social norm regarding HIV testing. We coded HIV testing self-efficacy using a separate six-item scale. We interpreted higher mean scores as higher sensitivity to social norms and higher self-efficacy, respectively. We conducted logistic regressions to evaluate the interaction between self-efficacy and social norms on HIV testing.

RESULTS

A total of 2105 men completed the survey. The mean age of the participants was 25.97 ± 6.42 years. Over four-fifths (85.9%) of participants were unmarried, 22.7% were students, and 64.6% at least had a college degree. 62.5 and 32.6% of participants ever and tested HIV in the last three months, respectively. With respect to uptake of HIV testing in the last three months, the adjusted odds ratio was 1.01(95% CI: 0.96-1.06) for higher sensitivity to social norms and 1.09 (95% CI: 1.05-1.14) for higher self-efficacy, with an interaction effect of 1.02 (95% CI: 1.01-1.03), respectively. With respect to uptake of lifetime HIV testing, the adjusted odds ratio was 1.03(95% CI: 0.99-1.07) for higher sensitivity to social norms and 1.15 (95% CI: 1.11-1.19) for higher self-efficacy, with an interaction effect of 1.02 (95% CI: 1.01-1.04), respectively.

CONCLUSIONS

Our survey demonstrated that there is a significant association between the uptake of HIV testing with sensitivity to the social norm, higher self-efficacy, as well as the interaction between them. Tailored studies for improving HIV testing among MSM in China can combine these two interventions together.

Sexual and Social Network Correlates of Willingness to Self-Test for HIV Among Ever-Tested and Never-Tested Men: Implications for the Tanzania STEP Project

We examined factors associated with HIV self-testing (HIVST) willingness among male ever-testers and never-testers who participated in a midpoint survey of a cluster randomized controlled HIV prevention trial in Dar es Salaam. Linear mixed binary logistic regression models were constructed to examine factors (demographic, HIV risk behavior, and sexual/social network) associated with willingness to self-test. Sixtyseven percent of 301 never-testers were willing to self-test for HIV compared to 72% 577 of ever-testers. Among never-testers, having discussed testing for HIV with a sexual partner was the only factor associated with HIVST willingness (2.36, 95% CI: 1.35-4.15). For evertesters, younger men were less willing to self-test than older men while men with higher education were more willing to self-test than less educated men. Having a moderate/great HIV risk perception decreased the odds of HIVST willingness relative to no risk perception (0.40, 95% CI 0.23-0.70) for ever-testers. Discussing HIV testing with a sexual partner and having been encouraged to test for HIV by a friend were associated with higher odds of being willing to self-test (2.22, 2.23; 95% CI 1.34-3.67, 1.14-4.39, respectively) among ever-testers. These findings suggest that HIVST willingness is highly acceptable among both male ever-testers and never-testers.

Outcomes and Experiences of Men and Women with Partner Notification for HIV Testing in Tanzania: Results from a Mixed Method Study

A growing evidence base supports expansion of partner notification in HIV testing services (HTS) in sub-Saharan Africa. In 2015, a cross-sectional study was conducted in Njombe region, Tanzania, to evaluate partner notification within facility-based HTS. Men and women newly diagnosed with HIV were enrolled as index clients and asked to list current or past sexual partners for referral to HTS. Successful partner referral was 2.5 times more likely among married compared to unmarried index clients and 2.2 times more likely among male compared to female index clients. In qualitative analysis, male as well as female index clients mentioned difficulties notifying past or casual partners, and noted disease symptoms as a motivating factor for HIV testing. Female index clients mentioned gender-specific challenges to successful referral. Women may need additional support to overcome challenges in the partner notification process. In addition to reducing barriers to partner notification specific to women, a programmatic emphasis on social strengths of males in successfully referring partners should be considered.