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C-Channel Issue 7

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C-Channel header  March 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 to connect you with state-of-the-art research findings that may be useful in your work.

In C-Channel 7, eleven peer-reviewed articles on behavior and social change communication are summarized: three on HIV and AIDS, three on family planning and reproductive health, three on malaria, and two on the monthly topic – male circumcision. The articles cover research carried out in India, south Asia, Kenya, Mali, Nigeria, Niger and southern Africa. Additional information is available at the program’s website: www.c-changeprogram.org/

Thank you,
The Knowledge Management Team at C-Change


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


 

HIV and AIDS

1. "They have opened our mouths": Increasing women's skills and motivation for sexual communication with young people in rural South Africa

2. Couples-focused behavioral interventions for prevention of HIV: Systematic review of the state of evidence

3. Explaining adherence success in sub-Saharan Africa: An ethnographic study
 

FAMILY PLANNING/REPRODUCTIVE HEALTH

4. Birth interval and risk of stillbirth or neonatal death: Findings from rural North India

5. Improving maternal, newborn and child health in South Asia: The promise of healthy timing and spacing of pregnancy as an intervention

6. The role of individual and community normative factors: a multilevel analysis of contraceptive use among women in union in Mali
 

MALARIA

7. Access and barriers to measures targeted to prevent malaria in pregnancy in rural Kenya

8. Household possession, use and non-use of treated or untreated mosquito nets in two ecologically diverse regions of Nigeria-Niger Delta and Sahel Savannah

9. Malaria treatment-seeking behaviour and recovery from malaria in a highland area of Kenya
 

MONTHLY TOPIC MALE–CIRCUMCISION

10. Risk compensation is not associated with male circumcision in Kisumu, Kenya: A multi-faceted assessment of men enrolled in a randomized controlled trial

11. Understanding the impact of male circumcision interventions on the spread of HIV in Southern Africa
 


HIV and AIDS

1. "They have opened our mouths": Increasing women's skills and motivation for sexual communication with young people in rural South Africa

Authors: Phetla, G; Busza, J; Hargreaves, JR; Pronyk, PM; Kim, JC; Morison, LA; Watts, C; Porter, JDH
Source: AIDS Education and Prevention Dec 2008, 20(6): 504-518.

ABSTRACT

Communication between parents and young people about sex has been identified as a positive influence on young people's sexual behavior. This article presents findings from South Africa, where a social intervention to reduce levels of HIV and intimate partner violence actively promoted sexual communication between adults and young people.

We assessed this component of the program using quantitative and qualitative methods, collecting data through surveys, direct observation, interviews, and focus group discussions. Women participating in intervention activities reported sexual communication with children significantly more often than matched women in the control group (80.3% vs. 49.4%, adjusted risk ratio 1.59 (1.31-1.93)). The content of communication with young people also appears to have shifted from vague admonitions about the dangers of sex to concrete messages about reducing risks.

The congruence between these findings and existing literature on parent-child sexual communication suggests that conceptual frameworks and programs from developed settings can be adapted effectively for resource-poor contexts.

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

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2. Couples-focused behavioral interventions for prevention of HIV: Systematic review of the state of evidence

Authors: Burton, J; Darbes, LA; Operario, D
Source: AIDS and Behavior 9 Oct 2008, DOI10.1007/s10461-008-9471-4.

ABSTRACT

HIV is frequently transmitted in the context of partners in a committed relationship, thus couples-focused HIV prevention interventions are a potentially promising modality for reducing infection. We conducted a systematic review of studies testing whether couples-focused behavioral prevention interventions reduce HIV transmission and risk behavior. We included studies using randomized controlled trial designs, quasi-randomized controlled trials, and nonrandomized controlled studies. We searched five electronic databases and screened 7,628 records. Six studies enrolling 1,084 index couples met inclusion criteria and were included in this review. Results across studies consistently indicated that couples-focused programs reduced unprotected sexual intercourse and increased condom use compared with control groups. However, studies were heterogeneous in population, type of intervention, comparison groups, and outcomes measures, and so meta-analysis to calculate pooled effects was inappropriate. Although couples-focused approaches to HIV prevention appear initially promising, additional research is necessary to build a stronger theoretical and methodological basis for couples-focused HIV prevention, and future interventions must pay closer attention to same-sex couples, adolescents, and young people in relationships.

KEYWORDS: HIV, Prevention, Couples, Relationships, Systematic review

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

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3. Explaining adherence success in sub-Saharan Africa: An ethnographic study

Authors: Ware, NC; Idoko, J; Kaaya, S; Biraro, IA; Wyatt, MA; Agbaji, O; Chalamilla, G; Bangsberg, DR
Source: PLoS Med 2009, 6(1): e1000011.

BACKGROUND: Individuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). This number exceeds the levels of adherence observed in North America and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty. This paper offers an explanation and theoretical model of ART adherence success based on the results of an ethnographic study in three sub-Saharan African countries.

METHODS AND FINDINGS: Determinants of ART adherence for HIV-infected persons in sub-Saharan Africa were examined with ethnographic research methods. 414 in-person interviews were carried out with 252 persons taking ART, their treatment partners, and health care professionals at HIV treatment sites in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic activities were also conducted. Data were examined using category construction and interpretive approaches to analysis. Findings indicate that individuals taking ART routinely overcome economic obstacles to ART adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and "begging" transport funds, making "impossible choices" to allocate resources in favor of treatment, and "doing without." Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise.

CONCLUSION: Adherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities and thus preserving social capital in essential relationships.

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

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 FAMILY PLANNING/REPRODUCTIVE HEALTH

4. Birth interval and risk of stillbirth or neonatal death: Findings from rural North India

Authors: Williams, EK; Hossain, MB; Sharma, RK; Kumar, V; Pandey, CM; Baqui, AH
Source: Journal of Tropical Pediatrics Oct 2008, 54:286.

ABSTRACT

Short birth intervals have been associated with adverse birth outcomes. This study examines the association between preceding interval and risk of stillbirth or neonatal death in rural north India (n = 80 164). Adjusted odds ratios (OR) and 95% confidence interval (CI) of stillbirth and neonatal mortality were calculated. The odds of stillbirth were significantly greater among birth intervals of <18 months (OR 3.10; CI: 2.69–3.57), 18–35 months (OR 1.47; CI 1.30–1.68) and >59 months (OR 1.44; CI 1.19–1.73), compared with intervals of 36–59 months. Neonatal death was associated with birth intervals of <18 months (OR 4.12; CI 3.74–4.55) and 18–35 months (OR 1.78; CI 1.63–1.94), compared to births spaced 36–59 months. Previous history of either stillbirth or neonatal death was significantly associated with risk of stillbirth and neonatal death, respectively, as were multiple births.

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

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5. Improving maternal, newborn and child health in South Asia: The promise of healthy timing and spacing of pregnancy as an intervention

Author: Islam, A
Institute: JP Grant School of Public Health, BRAC University, Dhaka, Bangladesh
Source: 4th Public Health Association of South Africa Conference 2008.

BACKGROUND: Although tremendous progress has been made in improving health over the last fifty years, pregnancy and childbirth still remain a catastrophic experience for women in many developing countries – killing more than half a million of them annually. This is particularly so in Sub-Saharan Africa and South Asia. With about twenty-five percent of the world’s population, South Asia accounts for more than forty percent of the global maternal deaths every year. Of the 10.5 million children that die every year, mostly from preventable causes, one-third of them are in South Asia. Unless solutions are found, South Asia will fail to achieve the health-related Millennium Development Goals (MDGs).

METHODS: The paper is based on an analysis of secondary data from various research studies as well as data generated by Demographic and Health Surveys in South Asia.

RESULTS: The results indicate that a curative approach focusing primarily on availability of and access to emergency obstetric services is unlikely to achieve much success in reducing maternal, newborn and infant mortality/morbidity in South Asia. A more comprehensive approach is warranted.

CONCLUSIONS: A renewed emphasis on healthy timing and spacing of pregnancy (HTSP) as part of a broader reproductive health agenda could make significant contribution in promoting maternal, newborn and child health in South Asia and thereby help achieve the health related MDGs. For example, avoiding first pregnancy before the age of 18 and an interval of 3 to 5 years between pregnancies could reduce the maternal mortality ratio by more than 25 percent in the region. Moreover, this emphasis on HTSP could be instrumental in repositioning family planning as a critical health intervention fundamental to improving maternal, newborn and child health as part of a comprehensive Primary Health Care System.

For further information, contact the author mailto:aislam@bracuniversity.ac.bd.

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6. The role of individual and community normative factors: A multilevel analysis of contraceptive use among women in union in Mali

Authors: Kaggwa, EB; Diop, N; Storey, JD
Source: International Family Planning Perspective 5 Jun 2008, 34(2): 79-88.

CONTEXT: Unlike in other African countries, the fertility rate in Mali has remained at a relatively high rate of 6.8 births per woman. Little research exists on the role that community norms play in use of family planning, particularly in low-prevalence countries.

METHODS: Data on 7,671 women in union from the 2001 Mali Demographic and Health Survey were analyzed using multilevel modeling techniques to assess the effects of individual and community factors on the adoption of modern contraceptive methods.

RESULTS: Only 5% of women in union were using a modern contraceptive method in 2001. The odds of contraceptive use were elevated among women in the highest wealth quintile, women who approved and whose partner approved of family planning, those who had had recent discussions on family planning with their partner or others and those exposed to family planning messages (odds ratios, 1.4-2.7). At the community level, the odds of modern contraceptive use rose with the proportion of women who were exposed to family planning messages (5.5), and decreased as the mean number of births per woman rose (0.7). In the final model, which included both individual- and community-level factors, the community factors were no longer significant.

CONCLUSIONS: Because approval of family planning and discussion of family planning with partners were shown to be the factors most strongly associated with modern contraceptive use in the multilevel model, programs that seek to increase individual approval and those that teach communication between partners could be particularly helpful to increasing contraceptive use in Mali.

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

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MALARIA

7. Access and barriers to measures targeted to prevent malaria in pregnancy in rural Kenya

Authors: Gikandi, PW; Noor, AM; Gitonga, CW; Ajanga, AA; Snow, RW
Institutions: 1 Malaria Public Health and Epidemiology Group, Centre for Geographic Medicine Research-Coast, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya; 2 Centre for Tropical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
Source: Tropical Medicine & International Health 26 Feb 2008, 13(2): 208–217.

ABSTRACT

OBJECTIVES: To evaluate barriers preventing pregnant women from using insecticide-treated nets (ITN) and intermittent presumptive treatment (IPT) with sulphadoxine-pyrimethamine (SP) 5 years after the launch of the national malaria strategy promoting these measures in Kenya.

METHODS: All women aged 15–49 years were interviewed during a community survey in four districts between December 2006 and January 2007. Women pregnant in the last 12 months were asked about their age, parity, education, use of nets, ITN, antenatal care (ANC) services and sulphadoxine-pyrimethamine (SP) (overall and for IPT) during pregnancy. Homestead assets were recorded and used to develop a wealth index. Travel time to ANC clinics was computed using a geographic information system algorithm. Predictors of net and IPT use were defined using multivariate logistic regression.

RESULTS: Overall 68% of pregnant women used a net; 52% used an ITN; 84% attended an ANC clinic at least once and 74% at least twice. Fifty-three percent of women took at least one dose of IPT-SP, however only 22% took two or more doses. Women from the least poor homesteads (OR = 2.53, 1.36–4.68) and those who used IPT services (OR = 1.73, 1.24–2.42) were more likely to sleep under any net. Women who used IPT were more likely to use ITNs (OR = 1.35, 1.03–1.77), while those who lived more than an hour from an ANC clinic were less likely (OR = 0.61, 0.46–0.81) to use ITN. Women with formal education (1.47, 1.01–2.17) and those who used ITN (OR: 1.68, 1.20–2.36) were more likely to have received at least one dose of IPT-SP.

CONCLUSION: Although the use of ITN had increased 10-fold and the use of IPT fourfold since last measured in 2001, coverage remains low. Provider practices in the delivery of protective measures against malaria must change, supported by community awareness campaigns on the importance of mothers' use of IPT.

KEYWORDS: malaria, pregnancy, antenatal care, intermittent presumptive treatment, sulphadoxine-pyrimethamine, insecticide-treated nets, Kenya

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

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8. Household possession, use and non-use of treated or untreated mosquito nets in two ecologically diverse regions of Nigeria - Niger Delta and Sahel Savannah

Authors: Afolabi, BM; Sofola, OT; Fatunmbi, BS; Komakech, W; Okoh, F; Saliu, O; Otsemobor, P; 2, Oresanya, OB; Amajoh, CN; Fasiku, D; Jalingo, I
Source: Malaria Journal 2009, 8:30.

ABSTRACT

BACKGROUND: Current use of treated mosquito nets for the prevention of malaria falls short of what is expected in sub-Saharan Africa (SSA), though research within the continent has indicated that the use of these commodities can reduce malaria morbidity by 50% and malaria mortality by 20%. Governments in sub-Sahara Africa are investing substantially in scaling-up treated mosquito net coverage for impact. However, certain significant factors still prevent the use of the treated mosquito nets, even among those who possess them. This survey examines household ownership as well as use and non-use of treated mosquito nets in Sahel Savannah and Niger Delta regions of Nigeria.

METHODOLOGY: This survey employed a cross-sectional survey to collect data from households on coverage and use of mosquito nets, whether treated or not. Fever episodes in the previous two weeks among children under the age of five were also recorded. The study took place in August 1-14 2007, just five months after the March distribution of treated mosquito nets, coinciding with the second raining period of the year and a time of high malaria transmission during the wet season. EPI INFO version 2003 was used in data analysis.

RESULTS: The survey covered 439 households (HHs) with 2,521 persons including 739 under-fives, 585 women in reproductive age and 78 pregnant women in Niger Delta Region and Sahel Savannah Region. Of the 439 HHs, 232 had any mosquito nets. Significantly higher proportion of households in the Niger Delta Region had any treated or untreated mosquito nets than those in the Sahel Savannah Region. In the Niger Delta Region, the proportion of under-fives that had slept under treated nets the night before the survey exceeded those that slept under treated nets in the Sahel Savannah Region. Children under the age of five years in the Niger Delta Region were four times more likely to sleep under treated nets than those in the Sahel Savannah Region.

CONCLUSIONS: This study found that despite the fact that treated nets were distributed widely across Nigeria, the use of this commodity was still very low in the Sahel Savanna region. Future campaigns should include more purposeful social and health education on the importance and advantages of the use of treated nets to save lives in the Sahel Savannah region of Nigeria.

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

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9. Malaria treatment-seeking behaviour and recovery from malaria in a highland area of Kenya

Authors: Sumba, PO; Wong, SL; Kanzaria, HK; Johnson, KA; John, CC
Source: Malaria Journal 2008, 7:245.

ABSTRACT

BACKGROUND: Malaria epidemics in highland areas of Kenya cause significant morbidity and mortality.

METHODS: To assess treatment-seeking behaviour for malaria in these areas, a questionnaire was administered to 117 randomly selected households in the highland area of Kipsamoite, Kenya. Self-reported episodes of malaria occurred in 100 adults and 66 children.

RESULTS: The most frequent initial sources of treatment for malaria in adults and children were medical facilities (66.0% and 66.7%) and local shops (19.0% and 30.3%). Adults and children who initially visited a medical facility for treatment were significantly more likely to recover and require no further treatment than those who initially went to a local shop (adults, 84.9% v. 36.8%, P < 0.0001, and children, 79.6% v. 40.0%, P = 0.002, respectively). Individuals who attended medical facilities recalled receiving anti-malarial medication significantly more frequently than those who visited shops (adults, 100% vs. 29.4%, and children, 100% v. 5.0%, respectively, both P < 0.0001).

CONCLUSIONS: A significant proportion of this highland population chooses local shops for initial malaria treatment and receives inappropriate medication at these local shops, resulting in delay of effective treatment. Shop keeper education has the potential to be a component of prevention or containment strategies for malaria epidemics in highland areas.

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

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MONTHLY TOPIC–MALE CIRCUMCISION 

10. Risk compensation is not associated with male circumcision in Kisumu, Kenya: A multi-faceted assessment of men enrolled in a randomized controlled trial

Authors: Mattson, CL; Campbell, RT; Bailey, RC; Agot, K; Ndinya-Achola, JO; Moses, S
Source: PLoS ONE 2008, 3(6): e2443.

ABSTRACT

BACKGROUND: Three randomized controlled trials (RCTs) have confirmed that male circumcision (MC) significantly reduces acquisition of HIV-1 infection among men. The objective of this study was to perform a comprehensive, prospective evaluation of risk compensation, comparing circumcised versus uncircumcised controls in a sample of RCT participants.

METHODS AND FINDINGS: Between March 2004 and September 2005, we systematically recruited men enrolled in a RCT of MC in Kenya. Detailed sexual histories were taken using a modified Timeline Followback approach at baseline, 6, and 12 months. Participants provided permission to obtain circumcision status and laboratory results from the RCT. We evaluated circumcised and uncircumcised men's sexual behavior using an 18-item risk propensity score and acquisition of incident infections of gonorrhea, chlamydia, and trichomoniasis. Of 1780 eligible RCT participants, 1319 enrolled (response rate = 74%). At the baseline RCT visit, men who enrolled in the sub-study reported the same sexual behaviors as men who did not. We found a significant reduction in sexual risk behavior among both circumcised and uncircumcised men from baseline to 6 (p<0.01) and 12 (p = 0.05) months post-enrollment. Longitudinal analyses indicated no statistically significant differences between sexual risk propensity scores or in incident infections of gonorrhea, chlamydia, and trichomoniasis between circumcised and uncircumcised men. These results are based on the most comprehensive analysis of risk compensation yet done.

CONCLUSION: In the context of a RCT, circumcision did not result in increased HIV risk behavior. Continued monitoring and evaluation of risk compensation associated with circumcision is needed as evidence supporting its' efficacy is disseminated and MC is widely promoted for HIV prevention.

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

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11. Understanding the impact of male circumcision interventions on the spread of HIV in Southern Africa

Authors: Hallett, TB; Singh, K; Smith, JA; White, RG; Abu-Raddad, LJ; Garnett, GP
Source: PLoS ONE 2008, 3(5): e2212.

ABSTRACT

BACKGROUND: Three randomised controlled trials have clearly shown that circumcision of adult men reduces the chance that they acquire HIV infection. However, the potential impact of circumcision programmes – either alone or in combination with other established approaches – is not known and no further field trials are planned. We have used a mathematical model, parameterised using existing trial findings, to understand and predict the impact of circumcision programmes at the population level.

FINDINGS: Our results indicate that circumcision will lead to reductions in incidence for women and uncircumcised men, as well as those circumcised, but that even the most effective intervention is unlikely to completely stem the spread of the virus. Without additional interventions, HIV incidence could eventually be reduced by 25–35%, depending on the level of coverage achieved and whether onward transmission from circumcised men is also reduced. However, circumcision interventions can act synergistically with other types of prevention programmes, and if efforts to change behaviour are increased in parallel with the scale-up of circumcision services, then dramatic reductions in HIV incidence could be achieved. In the long-term, this could lead to reduced AIDS deaths and less need for anti-retroviral therapy. Any increases in risk behaviours following circumcision , i.e. ‘risk compensation’, could offset some of the potential benefit of the intervention, especially for women, but only very large increases would lead to more infections overall.

CONCLUSIONS: Circumcision will not be the silver bullet to prevent HIV transmission, but interventions could help to substantially protect men and women from infection, especially in combination with other approaches.

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.
To contact us, please send an email to c-channel@healthnet.org
Additional information about the project is available at the website www.c-changeprogram.org/