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Zimbabwe: A Decade of HIV Prevention Research

Zimbabwe: A Decade of HIV Prevention Research. Danuta Kasprzyk, PhD and Daniel Montaño, PhD University of Connecticut, CHIP March 17, 2011. University of Zimbabwe. Overview. Zimbabwe Background Behavior Change Research: Applying the Integrated Behavioral Model (IBM) CPOL

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Zimbabwe: A Decade of HIV Prevention Research

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  1. Zimbabwe: A Decade of HIV Prevention Research Danuta Kasprzyk, PhD and Daniel Montaño, PhD University of Connecticut, CHIP March 17, 2011 University of Zimbabwe

  2. Overview • Zimbabwe Background • Behavior Change Research: Applying the Integrated Behavioral Model (IBM) • CPOL • Male Circumcision • Strategies to Improve Family Functioning Among Families with HIV Positive Parents • Family Health Study

  3. Zimbabwe: Basic demographics • 11.39 Million people • Median Age: 17.6 (M=16.3; F=18.8) • 5.95 Million 15-49 year olds • 41% children under 5 years of age • 70% live in rural areas • 70% of population is women and children • Two majority ethnic groups • 70% Shona; 30% Ndebele • English, Shona and Ndebele are the official languages 2007 – 2008 UN estimates/CIA Factbook estimates

  4. Zimbabwe: Basic demographics • Annual population growth = 0.6 • Adult Literacy 90%: • women 87.6%; • men 93.7% • Percent of primary school enrollment • boys 88%, • girls 87% • Per capita expenditure on health = $146 US 2007 – 2008 UN estimates/CIA Factbook estimates

  5. Zimbabwe: Public Health Indicators Statistics from ZDHS/Multiple Indicator Monitoring Survey 2009/Maternal and Perinatal Mortality Study; * 2007 data

  6. HIV prevalence (%) in adults (15–49) in Africa, 2007

  7. The Zimbabwe AIDS Epidemic • First reported case: 1984 • Prevalence peaked in 1998 at over 30% • 1.1 M PLWHA (2009 est.) • 10% children; 60% women • ~1.3 million orphans • ~135,000 new infections/year

  8. Zimbabwe HIV Prevalence Overall Adult 2005 (ZDHS) Urban: 17% Rural: 15% Total Prevalence % <15.2 15.2 – 16.7 16.7 – 18.4 18.5 – 19.7 >19.7

  9. Zichire Origin • ZiCHIRe formed in July 2000 after obtaining funding to join NIMH Collaborative HIV/STD Prevention Trial • We operate with a formal Memorandum of Understanding with Battelle and University of Zimbabwe (UZ) • 2 collaborating institutions: • Battelle, Centers for Public Health Research and Evaluation • UZ, Medical School, Department of Community Medicine • UZ, Department of Psychology

  10. University of Zimbabwe Zichire office

  11. Research in Zimbabwe • Ten studies conducted since 2000 • RCT HIV/STD Prevention Trial, 8 yrs, NIMH • Alcohol and risky behavior, 4 yrs, NIAAA • Male Circumcision uptake in, 4 yrs, NIMH • Family Health Study: psychosocial support intervention, 6 yrs, NINR • Neuro-cognitive effects of HIV, UW grant, Pilot study • STD Etiology Study, pilot, NIMH • UNICEF: Male Champions rapid assessment evaluation • CDC: • Mopani Junction Radio Drama formative research and pilot impact evaluation • Young Adult Survey development • Health educational pamphlet design technical assistance

  12. Behavior change research:Application of the Integrated Behavioral Model (IBM)

  13. Origin and Application of the IBM • In USA • Project SAFER • In Zimbabwe • Project SAFER • CPOL Trial • Male Circumcision

  14. Intention to Perform the Behavior Integrated Behavioral Model Experiential Attitude Feelings about Behavior Attitude Other Factors Instrumental Attitude Behavioral Beliefs Injunctive Norm Normative Beliefs – Others’ expectations Perceived Norm Normative Beliefs – Others’ behavior Descriptive Norm Control Beliefs Perceived Control Personal Agency Efficacy Beliefs Self-Efficacy

  15. HIV/STD Prevention Trial • NIMH funded, Multi-national Collaborative 2-armed RCT to test HIV/STD prevention intervention • First multi-national test of the Community Popular Opinion Leader (CPOL) Model Intervention: • Multi-site: Conducted in 5 countries • China/UCLA; India/JHU; Peru/UCSF-UCLA; Russia/Medical College of WI; Zimbabwe/Battelle India China Peru Peru

  16. HIV/STD Prevention Trial • Accrued cohort through purposive selection of approximately 185 individuals (30 Growth Points) • Conduct Baseline (N=5,547) • Personal Interview Assessment: • Demographic, Behavioral Risk, IBM • Health Assessment, including STD symptoms • Biologic samples (Bacterial and Viral STDs) • Implement intervention (15 growth points randomly assigned) • Follow-ups at 12 and 24 months (30 growth points)

  17. People shopping at Gokwe Growth Point Shops at Dema Growth Point Growth Point Recruitment Sites Local women selling vegetables outside a store at Nedziwa Growth Point Men drinking Chibuku at a bottle store in Mamina Growth Point

  18. .

  19. CPOL Behavioral Intervention • Diffusion of Innovation Theory • Uses Community Popular Opinion Leaders • Deliver persuasive messages to peers to encourage behavior change • Opinions and behavior diffuse through community to become norm • CPOLs trained to have conversations with peers • Focus on effective conversation skill training • Use self as example of behavior change • Assumes CPOLs will target the right issues • Attitudes, norms, self efficacy

  20. Application of IBM: Original intent • Apply IBM to: • Inform content of CPOLs’ messages • Structure CPOL conversations with community members • Measure intermediate outcomes • Determine whether behavior change can be explained by change in IBM constructs • Collaborative Trial decisions: • These plans were not implemented across 5 study sites

  21. Additional NIAAA funding • Allowed us to apply the IBM to: • Identify appropriate targets for intervention messages • Assess whether those targets were impacted • Qualitative elicitation interviews to identify: • Underlying issues/beliefs for each IBM construct • 8 behaviors: condom use with different partners, monogamy, talking to partners about sex, sex in context of alcohol use, transactional sex • Develop culturally appropriate IBM construct measures for each behavior

  22. Final IBM Survey • Measured constructs for each behaviour • Behavioural intention/motivation • Attitude: 9-14 behavioural beliefs • Perceived Norm: 4-6 normative beliefs • All three measured with 5-pt Strongly disagree – Strongly agree • Self-Efficacy: 6-11 self-efficacy beliefs • 5-pt Certain I could not – Certain I could • Translated and back-translated to Shona and Ndebele • Conducted survey – Baseline, 12-mo, 24-mo

  23. Results: STI Incidence CPOL Trial Main Outcome Results Results: Unprotected sex

  24. CPOL Trial Results Summary • Equal change in behavior in both Intervention and Control sites • Unprotected sex with non-spousal/live-in partners reduced by 33% • Incidence in combined STD/HIV outcome declined equally • CPOL Intervention did not add anything over and above the counseling and testing intervention • Why no differential effect?

  25. IBM Analysis • Computed model constructs – mean of beliefs underlying construct • Correlation of constructs with Intention • Correlation to identify construct beliefs that best explain Intention and behavior: • Behavioral beliefs underlying Attitude • Normative beliefs underlying Perceived Norm • Efficacy beliefs underlying Self-Efficacy

  26. Condom Use – Steady Partner

  27. beta .16** .17** .49** .69 Correlations IBM Constructs with Intention to Use Condoms with Steady Condom Use - Steady (n=2,212) r Attitude .46 Perceived Norm .49 Self Efficacy .65 Multiple R All correlations significant with p < 0.01; Multiple R significant with p < 0.01; ** beta weight significant with p < 0.01

  28. Behavioral Beliefs: Rs with Condom Use Motivation (Steady Partner) All correlations significant with p < 0.001

  29. Normative Beliefs: Rs with Condom Use Motivation (Steady Partner) All correlations significant with p < 0.001

  30. Efficacy Beliefs: Rs with Condom Use Motivation (Steady Partner) All correlations significant with p < 0.001

  31. Was there differential impact? • Computed change score for each measure • 24-month minus Baseline • Tested for significant difference: • Intervention vs. Control • If constructs were targeted appropriately, expected greater change for Intervention vs Control

  32. Differential Change (Steady Partner Condom Use)

  33. Differential ChangeBehavioral Beliefs (Steady Partner Condom Use)  

  34. Differential ChangeNormative Beliefs (Steady Partner Condom Use)

  35. Differential ChangeEfficacy Beliefs (Steady Partner Condom Use) 

  36. Sticking to one Partner - Monogamy

  37. Behavioral Beliefs: Rs with Monogamy Motivation All correlations significant with p < 0.004, except *

  38. Normative Beliefs: R with Monogamy Intention All correlations significant with p < 0.001

  39. Efficacy Beliefs: Rs with Monogamy Intention All correlations significant with p < 0.001

  40. Differential Change – Monogamy

  41. Differential Change Behavioral Beliefs (Monogamy)

  42. Differential Change Normative Beliefs (Monogamy)

  43. Differential Change Efficacy Beliefs (Monogamy)

  44. Impact and Process Evaluation • CPOLs had conversations • CPOLs expressed frustration: • Did not know what to target in conversations • Data shows CPOLs did not target/impact critical beliefs • Training successful in motivating conversations and conversation skills • Not successful in teaching CPOLs how to target and change beliefs shown to be key in changing behavior

  45. Enhanced CPOL Intervention • IBM complements CPOL • CPOL provides channel of persuasive communication • IBM provides behavioral theory to identify targets of persuasive messages • Train CPOLs in IBM conceptualization • Train CPOLs to have guided conversations • Use IBM conversation guide to systematically identify beliefs to target for each person • Target issues identified • Train CPOLs to develop messages for target beliefs identified in this research

  46. Enhanced CPOL intervention • Used in roll-out to comparison sites • Trainers and CPOLs extremely positive • CPOLs understood IBM conceptualization • Expressed greater confidence in: • Having targeted conversations with peers • Having an impact on behavior • Not evaluated

  47. Closing the Gap in Male Circumcision UptakeEnvironmental and Behavioral Factors Shaping Male Circumcision Decisions in ZimbabweFunded by: National Institute of Mental Health

  48. Why Circumcision: Ecological Studies Caldwell  Strong potential impact

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