Impact of a behaviour change intervention model for promotion of condoms amongst young adult males in an occupational setting

Evidence and gap map report: Social and Behavior Change Communication (SBCC) interventions for strengthening HIV prevention and research among adolescent girls and young women (AGYW) in low- and middle-income countries (LMICs)

Background

Adolescent girls and young women (AGYW), aged 15-24 years, are disproportionately affected by HIV and other sexual and reproductive health (SRH) risks due to varying social, cultural, and economic factors that affect their choices and shape their knowledge, understanding, and practices with regard to their health. Socio-Behavioral Change Communication (SBCC) interventions targeted at strengthening the capabilities of individuals and their networks have supported the demand and uptake of prevention services and participation in biomedical research. However, despite growing global recognition of the domain, high-quality evidence on the effectiveness of SBCC remains scattered. This evidence and gap map (EGM) report characterizes the evidence base on SBCC interventions for strengthening HIV Prevention and Research among AGYW in low- and middle-income countries (LMICs), identifying evidence gaps and outlining the scope of future research and program design.

Objectives

The objectives of the proposed EGM are to: (a) identify and map existing EGMs in the use of diverse SBCC strategies to strengthen the adoption of HIV prevention measures and participation in research among AGYW in LMICs and (b) identify areas where more interventions and evidence are needed to inform the design of future SBCC strategies and programs for AGYW engagement in HIV prevention and research.

Methods

This EGM is based on a comprehensive search of systematic reviews and impact evaluations corresponding to a range of interventions and outcomes-aimed at engaging AGYW in HIV prevention and research - that were published in LMICs from January 2000 to April 2021. Based on guidance for producing a Campbell Collaboration EGM, the intervention and outcome framework was designed in consultation with a group of experts. These interventions were categorized across four broad intervention themes: mass-media, community-based, interpersonal, and Information Communication and Technology (ICT)/Digital Media-based interventions. They were further sub-categorized into 15 intervention categories. Included studies looked at 23 unique behavioral and health outcomes such as knowledge attitude and skills, relationship dynamics, household dynamics, health care services, and health outcomes and research engagement. The EGM is presented as a matrix in which the rows are intervention categories/sub-categories, and the columns are outcome domains/subdomains. Each cell is mapped to an intervention targeted at outcomes. Additional filters like region, country, study design, age group, funding agency, influencers, population group, publication status, study confidence, setting, and year of publication have been added.

Selection Criteria

To be eligible, studies must have tested the effectiveness of SBCC interventions at engaging AGYW in LMICs in HIV prevention and research. The study sample must have consisted of AGYW between the ages of 15-24, as defined by UNAIDS. Both experimental (random assignment) and quasi-experimental studies that included a comparison group were eligible. Relevant outcomes included those at the individual, influencer, and institutional levels, along with those targeting research engagement and prevention-related outcomes.

Results

This EGM comprises 415 impact evaluations and 43 systematic reviews. Interventions like peer-led interactions, counseling, and community dialogues were the most dominant intervention sub-types. Despite increased digital penetration use of media and technology-driven interventions are relatively less studied. Most of the interventions were delivered by peers, health care providers, and educators, largely in school-based settings, and in many cases are part of sex-education curricula. Evidence across geographies was mostly concentrated in Sub-Saharan Africa (70%). Most measured outcomes focused on disease-related knowledge dissemination and enhancing awareness of available prevention options/strategies. These included messaging around consistent condom use, limiting sexual partners, routine testing, and awareness. Very few studies were able to include psychographic, social, and contextual factors influencing AGYW health behaviors and decisions, especially those measuring the impact of social and gender norms, relationship dynamics, and household dynamics-related outcomes. Outcomes related to engagement in the research were least studied.

Conclusion

This EGM highlights that evidence is heavily concentrated within the awareness-intent spectrum of behavior change and gets lean for outcomes situated within the intent-action and the action-habit formation spectrum of the behavior change continuum. Most of the evidence was concentrated on increasing awareness, knowledge, and building risk perception around SRH domains, however, fewer studies focused on strengthening the agency and self-efficacy of individuals. Similarly, evidence on extrinsic factors-such as strengthening social and community norms, relationships, and household dynamics-that determine individual thought and action such as negotiation and life skills were also found to be less populated. Few studies explore the effectiveness of these interventions across diverse AGYW identities, like pregnant women and new mothers, sex workers, and people living with HIV, leading to limited understanding of the use of these interventions across multiple user segments including key influencers such as young men, partners, families, religious leaders, and community elders was relatively low. There is a need for better quality evidence that accounts for the diversity of experiences within these populations to understand what interventions work, for whom, and toward what outcome. Further, the evidence for use of digital and mass-media tools remains poorly populated. Given the increasing penetration of these tools and growing media literacy on one end, with widening gender-based gaps on the other, it is imperative to gather more high-quality evidence on their effectiveness. Timely evidence generation can help leverage these platforms appropriately and enable intervention designs that are responsive to changing communication ecologies of AGYW. SBCC can play a critical role in helping researchers meaningfully engage and collaborate with communities as equal stakeholders, however, this remains poorly evidenced and calls for investigation and investment. A full list of abbreviations and acronyms are available in Supporting Information: Appendix F.

Systematic Review of Peer-Reviewed Literature on Global Condom Promotion Programs

Background: Globally, 1.7 million people were newly infected with HIV in 2018. Condoms are inexpensive, cost-effective, reduce HIV/STI incidence, morbidity, mortality, and unintended pregnancies, and result in health care cost savings. Given the rapid increase in at-risk adolescent and young adult (AYA) populations in countries with high HIV/STI prevalence as well as the reductions in donor support, promoting consistent condom use remains crucial. We synthesized all peer-reviewed literature on condom promotion programs with a focus on promotion in low and lower middle income (LMIC) countries and with AYA users. Methods: We systematically reviewed the published literature. Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methods, we identified 99 articles published between 2000-2019. Results: Condom promotion programs were generally effective in changing attitudes, social norms, and beliefs in favor of condom use, and 85% demonstrated positive effects on multiple condom use measures. Programs targeting AYA were at least equally as effective as those targeting others and often showed greater use of best practices, such as mass media (66%) and audience segmentation (31%). We also saw differences between programs in the intervention strategies they used and found greater effects of marketing strategies on AYA compared to the overall sample. Conclusion: Condoms remain essential to prevention, and donor support must be maintained to combat the HIV/STI epidemic.

Do HIV prevention interventions in Asia lead to increase in condom utilization?: A meta-analysis study

This meta-analytic review synthesizes the findings of published independent studies that assessed the effectiveness of HIV prevention interventions in promoting condom usage in Asia. We focused on 20 studies that used randomized control studies to establish whether HIV prevention interventions lead to increased condom utilization. As compared with the average control group client, we found that 68% of the clients who participated in an intervention group increased their condom usage. The effectiveness of HIV prevention intervention is not related to country and rural-urban contexts, to male-female samples, to the type of outcome measured, or the timing of the latest follow-up assessment. The implications of these findings are that policy-makers, health administrators, and international donors should view behavioral HIV prevention interventions as an effective approach through which to increase condom usage in order to reduce the HIV infection rate in Asia.

A cross-sectional study to evaluate factors related to condom use with commercial sexual partners in workers from Ecuadorian companies

Background

Unprotected intercourse with sex workers is one of the major risk factors for HIV infection. Consistent condom use is a prerequisite to lower the incidence of HIV.

Methods

We assessed the prevalence of condom use and its determinants among company workers engaged with commercial sexual partners in Ecuador. The study was based on a random sample of 115 companies and 1,732 workers stratified by province and working sector and utilized the “Behavioral Surveillance Surveys – Adult questionnaire” developed by Family Health International.

Results

Of the 1,561 sexually active workers, 311 (19.9 %) reported having intercourse with sex workers. Among them 25.9 % did not use a condom at the last sexual intercourse. As for condom use frequency over the last 12 months, 29/208 (13.9 %) reported never, 23 (11.1 %) sometimes, 24 (11.5 %) almost every time and 132 (63.5 %) every time. Factors adversely affecting condom use frequency over the last 12 months were female gender (OR = 4.56, 95 % CI: 1.45-14.4), older age (OR = 1.07, 95 % CI: 1.03-1.10), low educational level (OR = 4.69, 95 % CI: 1.95-11.3) and married workers living with spouse (OR = 7.66, 95 % CI: 3.08-19.1). By contrast, factors such as age at first sexual intercourse, job category, HIV transmission and prevention measure knowledge, single workers, previous exposure to HIV intervention programs and having a casual sexual partner were not affecting condom use frequency. When considering condom use during the last sexual intercourse or during the past 12 months with commercial sexual partners, results were similar.

Conclusions

Workers with low education, older age, female gender and those married living with their spouse should be targeted for specific educational interventions.