Leveraging strong social ties among young men in Dar es Salaam: A pilot intervention of microfinance and peer leadership for HIV and gender-based violence prevention

Do Gender-Based Violence Interventions Consider the Impacts of Climate Change? A Systematic Review

Climate change and extreme weather events have been shown to increase incidences of gender-based violence (GBV). Numerous organizations have devoted significant time, resources, and effort to the design and implementation of interventions aimed at reducing GBV in Africa. Some interventions effectively reduce violence, but GBV persists and remains pervasive. The United Nations has called for GBV interventions that consider the impact of climate change on violence. This review aims to determine whether public health interventions intended to reduce GBV in Africa take into account the effects of climate change on the region and the population. PubMed, PsychArticles, and CINAHL databases were searched systematically in February 2023 for interventions conducted in Africa published between 2010 and 2023. There were a total of 86 articles in the final review that described 40 distinct interventions. The intervention designs included empowerment and participatory approaches (microfinance, microfinance plus, community education, and community engagement), changing social and cultural norms (community education, community engagement, and media), and school-based programs. None of the 40 interventions mentioned climate, weather, or climate change as a component of the intervention. There are several opportunities to improve existing, successful GBV interventions in order to increase their efficacy. GBV interventions could incorporate economic independence programs that do not rely on agriculture and include climate change education. These findings could facilitate the integration of two previously distinct research disciplines-climate change and GBV prevention-to inform future research and develop more effective and cost-efficient interventions.

Men's comfort in distributing or receiving HIV self-test kits from close male social network members in Dar Es Salaam, Tanzania: baseline results from the STEP project

Background

A variety of strategies have been used to reach men with HIV self-testing services, including social network-based HIV self-test kits distribution. However, few studies have assessed men’s comfort to distribute to or receive HIV self-test kits from close male friends within the same social network. In this study, we assessed men’s comfort to distribute to and/or receive HIV self-test kits from close male friends and associated factors among men who socialize in networks locally referred to as “camps” in Tanzania.

Methods

Data are from the baseline survey of a cluster-randomized controlled trial conducted in June 2019 with 18 social networks or “camps” in Dar es Salaam, Tanzania. Participants were 18-year-old or older male camp members who were HIV-negative at the time of enrolment. We used the Generalized Estimating Equations (GEE) to assess factors associated with being comfortable to distribute to and/or receive HIV self-test kits from close male members within one’s social network.

Results

Of 505 participants, 67.9% (n = 342) reported being comfortable to distribute to while 68.2% (n = 344) were comfortable to receive HIV self-test kits from their close male friends. Ever having heard about HIV self-testing (Adjusted Prevalence Ratio (Adj. PR): 1.6; 95% Confidence Interval [CI]: 1.3, 1.9), willingness to self-test for HIV in front of a sexual partner (Adj. PR: 3.0; 95%CI: 1.5, 6.1) and exposure to peer-led HIV self-testing education and promotion (Adj. PR: 1.4; 95%CI: 1.2, 1.7) were significantly associated with being comfortable to distribute HIV self-test kits to close male members within one’s social network. Similar results were observed for being comfortable to receive HIV self-test kits from a close male friend within one’s social network.

Conclusions

Overall, these findings suggest that distribution of HIV self-test kits through close male friends could improve the proportion of men reached with HIV self-testing services and improve HIV testing rates in this population where uptake remains low. However, additional promotional strategies such as peer-led HIV self-testing education are needed to raise awareness and increase the proportion of men who are comfortable to receive and/or distribute HIV self-testing kits.

Results from a cluster-randomized trial to evaluate a microfinance and peer health leadership intervention to prevent HIV and intimate partner violence among social networks of Tanzanian men

Despite calls to engage men in HIV and intimate partner violence (IPV) prevention efforts, effective approaches to reach and engage men in low-resource, high-HIV prevalence settings are limited. We identified and engaged social networks of mostly young men in a study designed to evaluate the efficacy of a combined microfinance and peer health leadership intervention to prevent HIV and IPV. We conducted a cluster-randomized trial among 60 social networks locally referred to as "camps" within Dar es Salaam, Tanzania. Camps were randomly assigned (1:1) to a microfinance and peer health leadership intervention or a control condition that received a brief delayed intervention after the study's conclusion. Allocation was not masked to participants or researchers. Behavioral assessments were conducted at baseline and 30-months post-intervention launch, with biological samples drawn at 30-months to test for sexually-transmitted infections (STIs). Primary outcomes included prevalence of STIs and past-year IPV perpetration. Secondary outcomes included STI sexual risk behaviors and past-year HIV testing. Proximal intervention targets included inequitable gender norm attitudes and hope. A modified Poisson regression approach was used to estimate intention-to-treat intervention effects on outcomes assessed at the 30-month follow-up. We enrolled 1,258 men within 60 camps. Of these men, 1,029 (81.8%) completed the 30-month follow-up. There were no differences by condition in STI prevalence, IPV perpetration, or sexual risk behaviors at the 30-month follow-up. Intervention participants reported greater levels of past-year HIV testing, controlling for baseline testing (aRR 1.13 95% CI 1.005-1.28). They also reported significantly lower levels of inequitable gender norm attitudes (adjusted effect -0.11, 95% CI -0.21-0.003). We successfully engaged and retained social networks of men in this multilevel intervention study. While we did not see an effect on the primary outcomes, our intervention successfully improved HIV testing and reduced inequitable gender norm attitudes.

Engaging Young Men as Community Health Leaders in an STI and Intimate Partner Violence Prevention Trial in Dar es Salaam, Tanzania

BACKGROUND

This article presents lessons learned from a microfinance and health intervention for young men designed to prevent sexually transmitted infections (STI) and intimate partner violence (IPV) in Dar es Salaam, Tanzania. We describe the different strategies we used to identify and train young men to become change agents within their social networks.

DESCRIPTION

A cluster-randomized trial with 60 camps was undertaken in the Kinondoni District of Dar es Salaam. A total of 170 members from 30 intervention camps were trained in March 2014 as popular opinion leaders (POLs), whom we call Camp Health Leaders (CHLs). We describe the process of nominating, training, and retaining CHLs. We also describe our monitoring process, which included the collection of weekly diaries assessing topics discussed, number of peers engaged in conversations, reactions of peers, and challenges faced.

LESSONS LEARNED

POLs within naturally existing social networks can be engaged in STI and IPV prevention initiatives. Continuous efforts in retention, such as holding community advisory board (CAB) meetings, developing prevention slogans and t-shirts, and offering small grants to POL teams for intervention activities, were important to keeping POLs engaged in the intervention. Further, booster-training sessions were critical to maintain the message of the project and ensure that the challenges POLs face with implementing the programs were addressed in a timely manner.

CONCLUSION

Recruiting POLs in a Tanzanian urban setting and engaging them in STI and IPV reduction through social networks is possible. Training POLs in health information and interpersonal communication is important. Utilizing booster sessions and a variety of retention strategies for POLs in programs that aim to reduce IPV and STI infections among young men is essential to maintain the health leaders' engagement in the intervention as well as intervention fidelity.

Microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices in economically-vulnerable African-American young adults (EMERGE): protocol for a feasibility randomized clinical trial

Background

Economic vulnerability, such as homelessness and unemployment, contributes to the HIV risk among racial minorities in the U.S., who are disproportionately infected. Yet, few economic-strengthening interventions have been adapted for HIV prevention in economically-vulnerable African-American young adults. Engaging Microenterprise for Resource Generation and Health Empowerment (EMERGE) is a feasibility randomized clinical trial of an HIV prevention microenterprise intervention with integrated text messages (“nudges”) that are informed by behavioral economic principles. The trial aims to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors.

Methods/design

In total, 40 young adults who are African-American, aged 18–24, live in Baltimore City, have experienced at least one episode of homelessness in the last 12 months, are unemployed or underemployed (fewer than 10 h per week), are not enrolled in school, own a cell phone with text messaging, and report at least one episode of unprotected or unsafe sex in the prior 12 months will be recruited from two community-based organizations providing residential supportive services to urban youth. Participants will undergo a 3-week run-in period and thereafter be randomly assigned to one of two groups with active interventions for 20 weeks. The first group (“comparison”) will receive text messages with information on job openings. The second group (“experimental”) will receive text messages with information on job openings plus information on HIV prevention and business educational sessions, a mentored apprenticeship, and a start-up grant, and business and HIV prevention text messages based on principles from behavioral economics. The two primary outcomes relate to the feasibility of conducting a larger trial. Secondary outcomes relate to employment, sexual risk behaviors, and HIV preventive practices. All participants will be assessed using an in-person questionnaire at pre-intervention (prior to randomization) and at 3 weeks post-intervention. To obtain repeated, longitudinal measures, participants will be assessed weekly using text message surveys from pre-intervention up to 3 weeks post-intervention.

Discussion

This study will be one of the first U.S.-based feasibility randomized clinical trials of an HIV prevention microenterprise intervention for economically-vulnerable African-American young adults. The findings will inform whether and how to conduct a larger efficacy trial for HIV risk reduction in this population.

Trial registration

ClinicalTrials.gov, NCT03766165. Registered on 4 December 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3529-7) contains supplementary material, which is available to authorized users.

Structural Network Position and Performance of Health Leaders Within an HIV Prevention Trial

The effectiveness of peer leaders in promoting health may depend on the position they occupy within their social networks. Using sociocentric (whole network) and behavioral data from the intervention arm of a cluster-randomized HIV prevention trial in Dar es Salaam, Tanzania, we used generalized linear models with standardized predictors to examine the association between heath leaders' baseline structural network position (i.e., in-degree and betweenness centrality) and their 12-month self-reported (1) confidence in educating network members about HIV and gender-based violence (GBV) and (2) number of past-week conversations about HIV and GBV. As in-degree centrality increased, leaders reported fewer HIV-related conversations. As betweenness centrality increased, leaders reported greater number of conversations about GBV. Network position was not significantly associated with confidence in discussing either topic. Our results suggest that peer leaders who occupy spaces between sub-groups of network members may be more effective in engaging their peers in sensitive or controversial topics like GBV than more popular peer leaders.

Mate Yako Afya Yako: Formative research to develop the Tanzania HIV self-testing education and promotion (Tanzania STEP) project for men

The purpose of this formative research, guided by the Integrated Behavioral Model, was to assess men's attitudes and personal agency towards HIV self-testing (HIVST) and confirmatory HIV testing in order to inform the development of the Tanzania STEP (Self-Testing Education and Promotion) Project, a peer-based HIV self-testing intervention for young men in Tanzania. Qualitative in-depth interviews were conducted with 23 men in Dar es Salaam, Tanzania who socialize in networks locally referred to as "camps". Men reported privacy, confidentiality, and saving time as the primary reasons for their self-testing interest. Most participants had high perceived control and self-efficacy to self-test and seek confirmatory HIV testing. Nevertheless, men reported concerns related to their ability to perform the test and the potential lack of post-test counseling. Specific recommendations for the intervention included providing HIVST education and pre-test counseling, and using mobile health (mHealth) strategies for participants to reach a healthcare professional for further assistance. The findings suggest that while HIVST is highly acceptable among men in Tanzania, future interventions will need to address the challenges that men may face with HIVST before promoting it as an alternative or supplement to facility-based HIV testing.

Microfinance and health interventions: Factors influencing loan repayment success with young men in Dar es Salaam, Tanzania

Poverty is associated with numerous poor health outcomes. Youth unemployment in Tanzania is approximately 13.7%, and concentrates in urban areas. These youth lack relevant job skills and access to financial capital. Microfinance continues to be implemented globally to address poverty, and increasingly has been linked to health interventions. Men less frequently are recipients of microfinance loans. We offered microcredit to young men in an area of Dar es Salaam with high poverty as part of a randomised controlled-trial to assess the efficacy of a microfinance and health leadership intervention in preventing STI acquisition. We used mixed methods to understand predictors of successful loan repayment. Our qualitative sub-study showed that leader influence, prior business experience, personal motivation, and planning facilitated repayment. Using a modified Poisson approach, our quantitative analysis showed that successful repayment was associated with business experience, education, increasing number of children, community of residence, percentage of network members trained in business, and repayment success of peer leaders. Our results suggest that enforcing group accountability and repayment rules, offering ongoing training, and using successful entrepreneurs as role models could increase repayment success in similar populations. These strategies could provide financial opportunity for men while minimising risk for microfinance institutions.

"Generally the young mom suffers much:" Socio-cultural influences of maternal capabilities and nutrition care in Uganda

We conducted 40 in-depth interviews and eight focus groups among mothers and fathers (n = 91) of diverse ages in western Uganda to define the relevant domains of maternal capabilities and their relationship to infant and young child feeding practices. This study was directed by a developing theory of maternal capabilities that posits that the impact of health-directed interventions may be limited by unmeasured and poorly understood maternal characteristics. Ugandan caregivers defined three major life events that constrain women's capabilities for childcare: early pregnancy, close child spacing, and polygamous marriage. Women describe major constraints in their decision-making capabilities generally and specifically to procuring food for young children. Future nutrition programs may improve their impact through activities that model household decision-making scenarios, and that strengthen women's social support networks. Findings suggest that efforts to transform gender norms may be one additional way to improve nutrition outcomes in communities with a generally low status of women relative to men. The willingness of younger fathers to challenge traditional gender norms suggests an opportunity in this context for continued work to strengthen resources for children's nutritional care.

SIGNIFICANCE

Maternal factors such as autonomy are associated with child feeding practices and nutritional status, with varying degrees depending on the definition of maternal-level constructs and context. This study describes the events and processes that constrain maternal capabilities-intrapersonal factors that shape mother's abilities to leverage resources to provide care to children-as they relate to nutrition and hygiene practices. We report community beliefs and understandings about which capabilities have meaning for child nutrition and hygiene, and develop a conceptual framework to describe how these capabilities are formed and describe implications for future nutrition programs in East Africa and similar settings.

Comparing Perceptions with Actual Reports of Close Friend's HIV Testing Behavior Among Urban Tanzanian Men

Men have lower rates of HIV testing and higher rates of AIDS-related mortality compared to women in sub-Saharan Africa. To assess whether there is an opportunity to increase men's uptake of testing by correcting misperceptions about testing norms, we compare men's perceptions of their closest friend's HIV testing behaviors with the friend's actual testing self-report using a unique dataset of men sampled within their social networks (n = 59) in Dar es Salaam, Tanzania. We examine the accuracy and bias of perceptions among men who have tested for HIV (n = 391) and compare them to the perceptions among men who never tested (n = 432). We found that testers and non-testers did not differ in the accuracy of their perceptions, though non-testers were strongly biased towards assuming that their closest friends had not tested. Our results lend support to social norms approaches designed to correct the biased misperceptions of non-testers to promote men's HIV testing.

Vijana Vijiweni II: a cluster-randomized trial to evaluate the efficacy of a microfinance and peer health leadership intervention for HIV and intimate partner violence prevention among social networks of young men in Dar es Salaam

Background

Intimate partner violence (IPV) and sexually transmitted infections (STIs), including HIV, remain important public health problems with devastating health effects for men and women in sub-Saharan Africa. There have been calls to engage men in prevention efforts, however, we lack effective approaches to reach and engage them. Social network approaches have demonstrated effective and sustained outcomes on changing risk behaviors in the U.S. Our team has identified and engaged naturally occurring social networks comprised mostly of young men in Dar es Salaam in an intervention designed to jointly reduce STI incidence and the perpetration of IPV. These stable networks are locally referred to as “camps.” In a pilot study we demonstrated the feasibility and acceptability of a combined microfinance and peer health leadership intervention within these camp-based peer networks.

Methods design

We are implementing a cluster-randomized trial to evaluate the efficacy of an intervention combining microfinance with health leadership training in 60 camps in Dar es Salaam, Tanzania. Half of the camps have been randomized to the intervention arm, and half to a control arm. The camps in the intervention arm will receive a combined microfinance and health leadership intervention for a period of two years. The camps in the control arm will receive a delayed intervention. We have enrolled 1,258 men across the 60 study camps. Behavioral surveys will be conducted at baseline, 12-months post intervention launch and 30-month post intervention launch and biological samples will be drawn to test for Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) at baseline and 30-months. The primary endpoints for assessing intervention impact are IPV perpetration and STI incidence.

Discussion

This is the first cluster-randomized trial targeting social networks of men in sub-Saharan Africa that jointly addresses HIV and IPV perpetration and has both biological and behavioral endpoints. Effective approaches to engage men in HIV and IPV prevention are needed in low resource, high prevalence settings like Tanzania. If we determine that this approach is effective, we will examine how to adapt and scale up this approach to other urban, sub-Saharan African settings.

Trial registration

Clinical Trials.gov: NCT01865383. Registration date: May 24, 2013.