Date Published: August 1, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Kristien Michielsen, Matthew Chersich, Marleen Temmerman, Tessa Dooms, Ronan Van Rossem.
This paper assesses the extent to which HIV prevention interventions for young people in sub-Saharan Africa are grounded in theory and if theory-based interventions are more effective. Three databases were searched for evaluation studies of HIV prevention interventions for youth. Additional articles were identified on websites of international organisations and through searching references. 34 interventions were included; 25 mentioned the use of theory. Social Cognitive Theory was most prominent (n = 13), followed by Health Belief Model (n = 7), and Theory of Reasoned Action/Planned Behaviour (n = 6). These cognitive behavioural theories assume that cognitions drive sexual behaviour. Reporting on choice and use of theory was low. Only three articles provided information about why a particular theory was selected. Interventions used theory to inform content (n = 13), for evaluation purposes (n = 4) or both (n = 7). No patterns of differential effectiveness could be detected between studies using and not using theory, or according to whether a theory informed content, and/or evaluation. We discuss characteristics of the theories that might account for the limited effectiveness observed, including overreliance on cognitions that likely vary according to type of sexual behaviour and other personal factors, inadequately address interpersonal factors, and failure to account for contextual factors.
With an estimated 2.7 million new infections worldwide in 2010, HIV incidence remains at very high levels . Sub-Saharan Africa, accounting for 70% of these infections, remains particularly affected. About 40% of new HIV infections occur in the age group 15 to 24 years . Therefore, targeted prevention programmes for young people are essential in reversing the HIV epidemic [2, 3]. Over the past decades, a considerable number of HIV prevention interventions for young people in sub-Saharan Africa have been developed, implemented, and evaluated. Nevertheless, even though these interventions seem to increase knowledge and encourage positive attitudes, radical changes in sexual behaviour have not occurred [4, 5].
1073 article titles and/or abstract were screened. After analysis of title and abstract, we reviewed 73 full-text publications. In total, evaluations of 34 studies met the inclusion criteria, reported on in 38 articles. Table 1 sums the main intervention characteristics and study designs.
The review found that the majority of HIV prevention interventions targeted at youth in sub-Saharan Africa use theory-based approaches. A wide range of theories have been employed, but three behavioural theories predominate: SCT, HBM, and TRA/TPB. No one theory emerged dominant, as reporting on the choice, use, and specific evaluation of theory was low.
In the end, it boils down to two key questions: what determines sexual behaviour of young people? And what frameworks are most useful for making sense of and impacting positively on determinants of youth sexual behaviour? Recognizing the complexity and heterogeneity of this particular behaviour, theory can provide help in generalizing key determinants and making them operational. Theories aim to describe determinants and processes that account for or guide behaviour (change) through the rationalization of individual decisions. This aids in understanding human behaviour, and when used appropriately, can provide a solid grounding for program development and evaluation. The strength of theory is to generalize and simplify complex situations. However, in the case of HIV prevention interventions for young people, the dominant theories might oversimplify sexual behaviour. While such cognitive behavioural models can explain the links between intention and behaviour, particularly at an intrapersonal level, they are less able to account for interpersonal and contextual factors related to the complexity of sex, the experience of youth and disparities in social, cultural, and economic realities of youth in sub-Saharan Africa.