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C-Channel Issue 5

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C-Channel header  January 2009

Dear Colleagues,

C-Channel, the monthly e-newsletter from the C-Change program, provides peer-reviewed literature on behavior and social change communication in the health sector so that you are connected with state-of-the-art research findings. We hope these are useful in your work.

In C-Channel #5, eleven peer-reviewed articles are summarized. An examination of sexual behaviors and their effect on HIV transmission and prevalence in Africa is the focus of the first three articles. One of the sexual behaviors—multiple concurrent partnerships (MCP)—is being addressed by a C-Change country program in Lesotho. Four articles look at reproductive health (RH) and behavior change. One is a study of the sexual activity of adolescent virginity pledgers vs. nonpledgers in the U.S.; another assesses the effectiveness of using radio vs. television programming for health communication campaigns around RH problems and the HIV and AIDS epidemic in Zambia; another explores women's and couples' motivations to terminate pregnancies in Bangladesh; and the fourth examines the effects of sexual debut on a woman’s subsequent reproductive health in Haiti, particularly where there are large age differences between partners and a likely gender-based power differential. Two articles on malaria examine continued surveillance to eliminate malaria in the Gambia and the importance of effective treatment to thwart deleterious effects of malaria on children’s cognitive abilities and performance in school. The final two articles look at the impact of Internet use on adolescents uptake of health information—one in Uganda and the other in Nigeria.

Thank you,
The Knowledge Management Team at C-Change


To view archived issues, visit http://c-changeprogram.org/c-channel


HIV/AIDS

1. Concurrent sexual partnerships and the HIV epidemics in Africa: Evidence to move forward

2. Changes in sexual behaviour leading to the decline in the prevalence of HIV in Uganda: confirmation from multiple sources of evidence

3. Perceptions of risk to HIV infection among adolescents in Uganda: Are they related to sexual behaviour?
 

FAMILY PLANNING/REPRODUCTIVE HEALTH

4. Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers

5. The reach and impact of social marketing and reproductive health communication campaigns in Zambia

6. "Having another child would be a life or death situation for her": Understanding pregnancy termination among couples in rural Banglades

7. Age differences at sexual debut and subsequent reproductive health: Is there a link?
 

MALARIA

8. Changes in malaria indices between 1999 and 2007 in The Gambia: a retrospective analysis

9. Effect of intermittent preventive treatment of malaria on health and education in schoolchildren: a cluster-randomised, double-blind, placebo-controlled trial
 

COMMUNICATION AND BEHAVIOR CHANGE

10. Internet use among Ugandan adolescents: Implications for HIV intervention

11. The internet as a source of reproductive health information among adolescent girls in an urban city in Nigeria
 


HIV/AIDS

1. Concurrent sexual partnerships and the HIV epidemics in Africa: Evidence to move forward

Authors: Mah, TL; Halperin, DT
Source: AIDS and Behavior 22 July 2008, Online First.

ABSTRACT

The role of concurrent sexual partnerships is increasingly recognized as important for the transmission of sexually transmitted infections, particularly of heterosexual HIV transmission in Africa. Modeling and empirical evidence suggest that concurrent partnerships—compared to serial partnerships—can increase the size of an HIV epidemic, the speed at which it infects a population, and its persistence within a population. This selective review of the published and unpublished literature on concurrent partnerships examines various definitions and strategies for measuring concurrency, the prevalence of concurrency from both empirical and modeling studies, the biological plausibility of concurrency, and the social and cultural underpinnings of concurrency in southern Africa.

Keywords: HIV prevention, Concurrent sexual partners, Heterosexual transmission, HIV epidemiology

To link to the website containing this article, click here.

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2. Changes in sexual behaviour leading to the decline in the prevalence of HIV in Uganda: confirmation from multiple sources of evidence

Author: Kirby, D
Source: Sexually Transmitted Infections 2008, 84(2): ii35-ii41.

Objectives: To identify the changes in sexual behaviour that led to the dramatic reduction in the prevalence of HIV in Uganda in the early 1990s.

Methods: Seven different types of evidence were examined: (1) models of HIV prevalence and incidence in Kampala and other sentinel sites in Uganda; (2) reports of behaviour change in the primary newspaper in Uganda; (3) surveys with questions about perceptions of personal behaviour change; (4) large demographic and health surveys (DHS) collected in 1988/9 and 1995 and large Global Program on AIDS (GPA) surveys in 1989 and 1995 with questions about reported sexual behaviour; (5) smaller less representative surveys of reported sexual behaviour collected in other years; (6) reports of numbers of condoms shipped to Uganda; and (7) historical documents describing the implementation of HIV prevention programmes in Uganda.

Results: All seven types of data produced consistent evidence that people in Uganda first reduced their number of sexual partners prior to or outside of long-term marital or cohabiting relationships, and then increased their use of condoms with non-marital and non-cohabiting partners.

Conclusions: Consistent with basic theories about transmission of sexually transmitted infections, first reducing the number of sexual partners and breaking up sexual networks and then reducing the chances of HIV transmission with remaining casual partners by using condoms can be achieved and can dramatically reduce the sexual transmission of HIV in generalised epidemics.

To link to the website containing this article, click here. Full Text is freely available.

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3. Perceptions of risk to HIV infection among adolescents in Uganda: Are they related to sexual behaviour?

Authors: Kibombo, R; Neema, S; Ahmed, FH
Source: African Journal of Reproductive Health 2007, 11(3): 168-181. [PubMed Central]

ABSTRACT

Uganda has been hailed as a success story in the fight against HIV that has seen a reversal in prevalence from a peak of 15% in 1991 to about 6.5% currently. Since 1992, the largest and most consistent declines in HIV have occurred among the 15–19-year-olds. While many studies have examined how key behavior changes (Abstinence, Be faithful and Condom use) have contributed to the decline in HIV prevalence, few have studied the relationship between sexual behaviors and risk perception. Using data from the 2004 National Survey of Adolescents, multivariate logistic regression models were fitted to examine the strength of the association between risky sexual behavior and perceived risk among 12–19-year-old adolescents in Uganda. After controlling for other correlates of sexual behavior such as age, education, residence, region and marital status, the findings indicate highly significant positive association between perceived risk and risky sexual behavior among males but not females. The findings reveal that, regardless of their current sexual behavior, most female adolescents in Uganda feel at great risk of HIV infection. The findings also show that adolescents with broken marriages are much more vulnerable to high risk sexual behaviors than other categories of adolescents. These results further emphasize the need for a holistic approach in addressing the social, economic and contextual factors that continue to put many adolescents at risk of HIV infection.

Keywords: adolescents, HIV infection, sexual behaviour

To link to the website containing this article, click here. Full Text is freely available.

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FAMILY PLANNING/REPRODUCTIVE HEALTH

4. Patient teenagers? A comparison of the sexual behavior of virginity pledgers and matched nonpledgers

Author: Rosenbaum, JE
Source: Pediatrics January 2009, 123(1): e110-e120.

Objective: The US government spends more than $200 million annually on abstinence-promotion programs, including virginity pledges. This study compares the sexual activity of adolescent virginity pledgers with matched nonpledgers by using more robust methods than past research.

Subjects and Methods: The subjects for this study were National Longitudinal Study of Adolescent Health respondents, a nationally representative sample of middle and high school students who, when surveyed in 1995, had never had sex or taken a virginity pledge and who were >15 years of age (n = 3440). Adolescents who reported taking a virginity pledge on the 1996 survey (n = 289) were matched with nonpledgers (n = 645) by using exact and nearest-neighbor matching within propensity score calipers on factors including prepledge religiosity and attitudes toward sex and birth control. Pledgers and matched nonpledgers were compared 5 years after the pledge on self-reported sexual behaviors and positive test results for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis, and safe sex outside of marriage by use of birth control and condoms in the past year and at last sex.

Results: Five years after the pledge, 82% of pledgers denied having ever pledged. Pledgers and matched nonpledgers did not differ in premarital sex, sexually transmitted diseases, and anal and oral sex variables. Pledgers had 0.1 fewer past-year partners but did not differ in lifetime sexual partners and age of first sex. Fewer pledgers than matched nonpledgers used birth control and condoms in the past year and birth control at last sex.

Conclusions. The sexual behavior of virginity pledgers does not differ from that of closely matched nonpledgers, and pledgers are less likely to protect themselves from pregnancy and disease before marriage. Virginity pledges may not affect sexual behavior but may decrease the likelihood of taking precautions during sex. Clinicians should provide birth control information to all adolescents, especially virginity pledgers.

To link to the website containing this article, click here. Full Text is freely available.

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5. The reach and impact of social marketing and reproductive health communication campaigns in Zambia

Authors: Rossem, RV; Meekers, D
Source: BMC Public Health 2007, 7:352.

ABSTRACT

Background: Like many sub-Saharan African countries, Zambia is dealing with major health issues, including HIV/AIDS, family planning, and reproductive health. To address reproductive health problems and the HIV/AIDS epidemic in Zambia, several social marketing and health communication programs focusing on reproductive and HIV/AIDS prevention programs are being implemented. This paper describes the reach of these programs and assesses their impact on condom use.

Methods: This paper assesses the reach of selected radio and television programs about family planning and HIV/AIDS and of communications about the socially marketed Maximum condoms in Zambia, as well as their impact on condom use, using data from the 2001–2002 Zambia Demographic and Health Survey. To control for self-selection and endogeneity, we use a two-stage regression model to estimate the effect of program exposure on the behavioural outcomes.

Results: Those who were exposed to radio and television programs about family planning and HIV/AIDS were more likely to have ever used a condom (OR = 1.16 for men and 1.06 for women). Men highly exposed to Maximum condoms social marketing communication were more likely than those with low exposure to the program to have ever used a condom (OR = 1.48), and to have used a condom at their last sexual intercourse (OR = 1.23).

Conclusion: Findings suggest that the reproductive health and social marketing campaigns in Zambia reached a large portion of the population and had a significant impact on condom use. The results suggest that future reproductive health communication campaigns that invest in radio programming may be more effective than those investing in television programming, and that future campaigns should seek to increase their impact among women, perhaps by focusing on the specific constrains that prevent females from using condoms.

To link to the website containing this article, click here. Full Text is freely available.

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6. "Having another child would be a life or death situation for her": Understanding pregnancy termination among couples in rural Banglades

Authors: Gipson, JD; Hindin, MJ
Source: American Journal of Public Health Oct 2008, 98(10): 1827-32.

OBJECTIVES: We conducted a mixed-method study in rural southwestern Bangladesh, a country in which an estimated 730,000 elective pregnancy terminations occur each year, to explore women's and couples' motivations to terminate pregnancies.

METHODS: Quantitative data derived from a 1998 cross-sectional survey and a longitudinal demographic surveillance system (1998-2003) were combined with qualitative data gathered through 84 in-depth interviews conducted with 19 couples during 2004-2005.

RESULTS: Quantitative results indicated that 11% of couples reported a pregnancy termination in the study period; the rate was highest among couples who reported in 1998 that they wanted no more children (29%). Both wives' and husbands' fertility preferences independently and significantly predicted pregnancy termination. Qualitative findings showed that more than half of the participants had attempted to terminate a pregnancy at least once in their lifetime.

CONCLUSIONS: Our results highlight the importance of collecting data from both partners and the influence of husbands' fertility preferences on reproductive decisionmaking. The prevalence of reported pregnancy terminations in our population, along with the use of informal methods in termination attempts, highlights the need for continued provision of contraceptives and access to safe and affordable pregnancy termination services in this setting.

To link to the website containing this article, click here.

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7. Age differences at sexual debut and subsequent reproductive health: Is there a link?

Authors: Gómez, AM; Speizer, IS; Reynolds, H; Murray, N; Beauvais, H
Source: Reproductive Health 31 Oct 2008, 5(1): 8.

ABSTRACT

BACKGROUND: Experiences at sexual debut may be linked to reproductive health later in life. Additionally, young women with older sexual partners may be at greater risk for HIV and sexually transmitted infections. This study examines sexual debut with an older partner and subsequent reproductive health outcomes among 599 sexually experienced women aged 15-24 who utilized voluntary counseling and testing or reproductive health services in Port-au-Prince, Haiti.

METHODS: Logistic regression models, controlling for socioeconomic and demographic factors, examined whether age differences at first sex were significantly associated with STI diagnosis in the previous 12 months and family planning method use at last intercourse.

RESULTS: Sixty-five percent of women reported sexual initiation with a partner younger or less than 5 years older, 28% with a partner 5 to 10 years older, and 7% with a partner 10 or more years older. There was a trend towards decreased likelihood of recent use of family planning methods in women who had first sexual intercourse with a partner 5 to 9 years older compared to women with partners who were younger or less than 5 years older. Age differences were not linked to recent STI diagnosis.

CONCLUSION: Programs focusing on delaying sexual debut should consider age and gender-based power differentials between younger women and older men. Future research should examine whether wide age differences at sexual debut are predictive of continued involvement in cross-generational relationships and risky sexual behaviors and explore the mechanisms by which cross-generational first sex and subsequent reproductive health may be connected.

To link to the website containing this article, click here. Full Text is freely available.

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MALARIA

8. Changes in malaria indices between 1999 and 2007 in The Gambia: a retrospective analysis

Authors: Ceesay, SJ; DPhil, CC; Erskine, J; Anya, SE; Duah, NO; Fulford, AJ; Sesay, SS; Abubakar, I; Dunyo, S; Sey, O; Palmer, A; Fofana, M; Corrah, T; Bojang, KA; Whittle, HC; Greenwood, BM; Conway, DJ
Source: The Lancet 01 November 2008, 372(9649): 1545-1554.

SUMMARY

Background: Malaria is a major cause of morbidity and mortality in Africa. International effort and funding for control has been stepped up, with substantial increases from 2003 in the delivery of malaria interventions to pregnant women and children younger than 5 years in The Gambia. We investigated the changes in malaria indices in this country, and the causes and public-health significance of these changes.

Methods: We undertook a retrospective analysis of original records to establish numbers and proportions of malaria inpatients, deaths, and blood-slide examinations at one hospital over 9 years (January, 1999-December, 2007), and at four health facilities in three different administrative regions over 7 years (January, 2001–December, 2007). We obtained additional data from single sites for haemoglobin concentrations in paediatric admissions and for age distribution of malaria admissions.

Findings: From 2003 to 2007, at four sites with complete slide examination records, the proportions of malaria-positive slides decreased by 82% (3397/10861 in 2003 to 337/6142 in 2007), 85% (137/1259 to 6/368), 73% (3664/16932 to 666/11333), and 50% (1206/3304 to 336/1853). At three sites with complete admission records, the proportions of malaria admissions fell by 74% (435/2530 to 69/1531), 69% (797/2824 to 89/1032), and 27% (2204/4056 to 496/1251). Proportions of deaths attributed to malaria in two hospitals decreased by 100% (seven of 115 in 2003 to none of 117 in 2007) and 90% (22/122 in 2003 to one of 58 in 2007). Since 2004, mean haemoglobin concentrations for all-cause admissions increased by 12 g/L (85 g/L in 2000–04 to 97 g/L in 2005–07), and mean age of paediatric malaria admissions increased from 3.9 years (95% CI 3.7–4.0) to 5.6 years (5.0–6.2).

Interpretation: A large proportion of the malaria burden has been alleviated in The Gambia. Our results encourage consideration of a policy to eliminate malaria as a public-health problem, while emphasising the importance of accurate and continuous surveillance.

To link to the website containing this article, click here.

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9. Effect of intermittent preventive treatment of malaria on health and education in schoolchildren: a cluster-randomised, double-blind, placebo-controlled trial

Authors: Clarke, SE; DPhil MC; Njagi, JK; Khasakhala, L; Cundill, B; Julius Otido, J; Crudder, C; Estambale, BB; DPhil, SB
Source: The Lancet 12 July 2008, 372(9633): 127-138. [PubMed Central]

SUMMARY

Background: Malaria is a major cause of morbidity and mortality in early childhood, yet its consequences for health and education during the school-age years remain poorly understood. We examined the effect of intermittent preventive treatment (IPT) in reducing anaemia and improving classroom attention and educational achievement in semi-immune schoolchildren in an area of high perennial transmission.

Methods: A stratified, cluster-randomised, double-blind, placebo-controlled trial of IPT was done in 30 primary schools in western Kenya. Schools were randomly assigned to treatment (sulfadoxine-pyrimethamine in combination with amodiaquine or dual placebo) by use of a computer-generated list. Children aged 5–18 years received three treatments at 4-month intervals (IPT n=3535, placebo n=3223). The primary endpoint was the prevalence of anaemia, defined as a haemoglobin concentration below 110 g/L. This outcome was assessed through cross-sectional surveys 12 months post-intervention. Analysis was by both intention to treat, excluding children with missing data, and per protocol. This study is registered with ClinicalTrials.gov, number NCT00142246.

Findings: 2604 children in the IPT group and 2302 in the placebo group were included in the intention-to-treat analysis of the primary outcome; the main reason for exclusion was loss to follow-up. Prevalence of anaemia at 12 months averaged 6.3% in the IPT group and 12.6% in the placebo group (adjusted risk ratio 0.52, 95% CI 0.29–0.93; p=0.028). Significant improvements were also seen in two of the class-based tests of sustained attention, with a mean increase in code transmission test score of 6.05 (95% CI 2.83–9.27; p=0.0007) and counting sounds test score of 1.80 (0.19–3.41; p=0.03), compared with controls. No effect was shown for inattentive or hyperactive-compulsive behaviours or on educational achievement. The per-protocol analysis yielded similar results. 23 serious adverse events were reported within 28 days of any treatment (19 in the IPT group and four in the placebo group); the main side-effects were problems of balance, dizziness, feeling faint, nausea, and/or vomiting shortly after treatment.

Interpretation: IPT of malaria improves the health and cognitive ability of semi-immune schoolchildren. Effective malaria interventions could be a valuable addition to school health programmes.

To link to the website containing this article, click here. Full Text is freely available.

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COMMUNICATION AND BEHAVIOR CHANGE

10. Internet use among Ugandan adolescents: Implications for HIV intervention

Authors: Ybarra, ML; Kiwanuka, J; Emenyonu, N; Bangsberg, DR
Source: Public Library of Science Medical 2006 November, 3(11): e433.

ABSTRACT

Background: The Internet is fast gaining recognition as a powerful, low-cost method to deliver health intervention and prevention programs to large numbers of young people across diverse geographic regions. The feasibility and accessibility of Internet-based health interventions in resource-limited settings, where cost-effective interventions are most needed, is unknown. To determine the utility of developing technology-based interventions in resource-limited settings, availability and patterns of usage of the Internet first need to be assessed.

Methods and Findings: The Uganda Media and You Survey was a cross-sectional survey of Internet use among adolescents (ages 12–18 years) in Mbarara, Uganda, a municipality mainly serving a rural population in sub-Saharan Africa. Participants were randomly selected among eligible students attending one of five participating secondary day and boarding schools in Mbarara, Uganda. Of a total of 538 students selected, 93% (500) participated.

Of the total respondents, 45% (223) reported ever having used the Internet, 78% (175) of whom reported going online in the previous week. As maternal education increased, so too did the odds of adolescent Internet use. Almost two in five respondents (38% [189]) reported already having used a computer or the Internet to search for health information. Over one-third (35% [173]) had used the computer or Internet to find information about HIV/AIDS, and 20% (102) had looked for sexual health information. Among Internet users, searching for HIV/AIDS information on a computer or online was significantly related to using the Internet weekly, emailing, visiting chat rooms, and playing online games. In contrast, going online at school was inversely related to looking for HIV/AIDS information via technology. If Internet access were free, 66% (330) reported that they would search for information about HIV/AIDS prevention online.

Conclusions: Both the desire to use, and the actual use of, the Internet to seek sexual health and HIV/AIDS information is high among secondary school students in Mbarara. The Internet may be a promising strategy to deliver low-cost HIV/AIDS risk reduction interventions in resource-limited settings with expanding Internet access.

To link to the website containing this article, click here. Full Text is freely available.

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11. The internet as a source of reproductive health information among adolescent girls in an urban city in Nigeria

Author: Nwagwu, WE
Source: BMC Public Health 2007, 7:354.

ABSTRACT

Background: There exists some research evidence regarding how adolescents utilize the Internet for health information seeking purposes. The purpose of this study is to understand how in-school and out-of-school adolescent girls in Owerri, Nigeria use online resources to meet their reproductive health information needs. The result could be considered very crucial in assessing the potential role of the Internet in providing health information to adolescent girls in a typical Nigerian urban city.

Methods: A questionnaire was used to collect data from 1011 adolescent girls in selected secondary schools in the communities, and also from 134 out-of-school girls selected from the same communities.

Results: More than 73% of the girls reported having ever used the Internet; more than 74% and 68% of them being in-school and out-of-school respectively. The in-school girls (43.9%) reported having home access more than the out-of-school (5.6%) although the out-of-school have used the Internet for finding reproductive and related information more than the in-school. While parents (66.22%) and teachers (56.15%) are the two sources most used to the in-school girls, friends (63.18%) and the Internet (55.19%) were reported by the out-of-school youth as the two most used sources of information to them.

Conclusion: The Internet is not a first choice of source of reproductive health information for both the in-school and out-of-school adolescent girls in Owerri, Nigeria. The source is however, more commonly used by the out-of-school than the in-school, but the in-school have a more favorable assessment of the quality of information they obtain from the Internet.

To link to the website containing this article, click here. Full Text is freely available.

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C-Change, managed by AED, is USAID's flagship program to improve the effectiveness and sustainability of communication programs for behavior and social change in low and middle income countries.
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