Acceptability and challenges of introducing an educational audio-drama about gender violence and HIV prevention into schools in Botswana: an implementation review.

Structural interventions for HIV prevention are typically complex and evaluation should include measurement of implementation. In a trial of a structural intervention for HIV prevention in Botswana we trained teachers to use an audio-drama about gender violence and HIV (BVV). We measured the use of BVV by the trained teachers, and the factors related. In three-day workshops we trained guidance teachers in primary and secondary schools to use the 8-episode BVV audio-drama, that covers gender, gender violence and HIV. One to two years later, two interviewers visited schools and administered an electronic questionnaire to the head teacher and to the BVV-trained teacher. Most teachers (70%, 72/103) had used the BVV materials and reported a positive response from students. Primary school teachers were less likely to have used BVV (adjusted odds ratio (ORa) 0.24, 95% cluster adjusted confidence interval (CIca) 0.07-0.88). Teachers in schools with a working MP3 player were more likely to have used BVV (ORa 3.75, 95% CIca 1.11-12.70). Implementation was much lower in one district (ORa 0.12, 95% CIca 0.04-0.36), related to language constraints. The main difficulty was lack of time, especially in primary schools. These findings could inform rollout of the BVV programme in schools. Abbreviations: BVV: Beyond Victims and Villains audio-drama; CI: Confidence interval; OR: Odds ratio.

Can social network analysis help to include marginalised young women in structural support programmes in Botswana? A mixed methods study.

BACKGROUND: In Botswana, one fifth of the adult population is infected with HIV, with young women most at risk. Structural factors such as poverty, poor education, strong gender inequalities and gender violence render many young women unable to act on choices to protect themselves from HIV. A national trial is testing an intervention to assist young women to access government programs for returning to education, and improving livelihoods. Accessing marginalised young women (aged 16-29 and not in education, employment or training) through door-to-door recruitment has proved inefficient. We investigated social networks of young women to see if an approach based on an understanding of these networks could help with recruitment. METHODS: This mixed methods study used social network analysis to identify key young women in four communities (using in-degree centrality), and to describe the types of people that marginalised young women (n = 307) turn to for support (using descriptive statistics and then generalized linear mixed models to examine the support networks of sub-groups of participants). In discussion groups (n = 46 participants), the same young women helped explain results from the network analysis. We also tracked the recruitment method for each participant (door to door, peers, or key community informants). RESULTS: Although we were not able to identify characteristics of the most central young women in networks, we found that marginalised young women went most often to other women, usually in the same community, and with children, especially if they had children themselves. Rural women were better connected with each other than women in urban areas, though there were isolated young women in all communities. Peer recruitment contributed most in rural areas; door-to-door recruitment contributed most in urban areas. CONCLUSIONS: Since marginalised young women seek support from others like themselves, outreach programs could use networks of women to identify and engage those who most need help from government structural support programs. Methods that rely on social networks alone may be insufficient, and so a combination of approaches, including, for instance, peers, door-to-door recruitment, and key community informants, should be explored as a strategy for reaching marginalised young women for supportive interventions.

Access of choice-disabled young women in Botswana to government structural support programmes: a cross-sectional study.

Structural factors like poverty, poor education, gender inequality, and gender violence are important in the HIV epidemic in southern Africa. Such factors constrain many people from making choices to protect themselves against HIV. The INSTRUCT cluster randomised controlled trial of a structural intervention for HIV prevention includes workshops for young women which link them with existing government structural support programmes. Fieldworkers identified all young women aged 15-29 years in each intervention community, not in school and not in work, interviewed them, and invited them to a workshop. Choice-disability factors were common. Among the 3516 young women, 64% had not completed secondary education, 35% did not have enough food in the last week, 21% with a partner had been beaten by their partner in the last year, and 8% reported being forced to have sex. Of those aged 18 and above, 45% had applied to any government support programme and 28% had been accepted into a programme; these rates were only 33% and 10% when Ipelegeng, a part-time minimum wage rotating employment scheme with no training or development elements, was excluded. Multivariate analysis considering all programmes showed that women over 20 and very poor women with less education were more likely to apply and to be accepted. But excluding Ipelegeng, young women with more education were more likely to be accepted into programmes. The government structural support programmes were not designed to benefit young women or to prevent HIV. Our findings confirm that programme use by marginalised young women is low and, excluding Ipelegeng, the programmes do not target choice disabled young women.

The Inter-ministerial National Structural Intervention trial (INSTRUCT): protocol for a parallel group cluster randomised controlled trial of a structural intervention to reduce HIV infection among young women in Botswana.

BACKGROUND: Wide recognition that structural factors are important in the HIV epidemic has not generated much evidence of impact of structural interventions. Few randomised controlled trials of structural interventions for HIV prevention have an HIV endpoint, and most of those did not show a significant impact. It has proved difficult to prevent new HIV infections in Botswana, especially among young women, many of whom are unable to act on HIV preventive choices. Proposed by a government think tank in Botswana, the Inter-ministerial National Structural Intervention trial (INSTRUCT) tests whether addressing social and economic factors, including gender inequality, gender violence, poverty, and poor access to education, can lower HIV infection rates among young women. Focussed on increasing access by marginalised young women to government support programs, the intervention seeks to change their structural position, reducing their vulnerability to transactional sex, and thus to HIV infection. METHODS: This parallel group cluster randomised controlled trial compares HIV rates among young women in districts with and without the structural interventions. The 30 administrative districts in the country, stratified by HIV prevalence and development status, will be randomly assigned to 5-district implementation waves. The intervention in the first-wave districts will include: (i) recruiting and preparing vulnerable young women to apply to government support programs, (ii) making the support programs more accessible to young women by engaging local program officers and young women in co-evaluation of programs and co-design of solutions; and (iii) generating an enabling environment for change in communities through an audio-drama edutainment program. In year five, an impact survey will measure HIV rates among vulnerable young women (15-29 years) in a random sample of communities in the five intervention districts and in the five second-wave (control) districts. Fieldworkers will undertake rapid HIV screening and interview young women and young men, collecting information on secondary outcomes of attitudes and behaviours. DISCUSSION: This is the first step in a planned stepped-wedge design that will roll out the intervention, modified as necessary, to all districts. Strong government commitment provides an important opportunity to reduce new HIV cases in Botswana, and guide prevention efforts in other countries. TRIAL REGISTRATION: Registration number: ISRCTN 54878784 . Registry: ISRCTN. Date of registration: 11 June 2013.

HIV-sensitive social protection for unemployed and out-of-school young women in Botswana: An exploratory study of barriers and solutions.

Promotive social protection programs aim to increase income and capabilities and could help address structural drivers of HIV-vulnerability like poverty, lack of education and gender inequality. Unemployed and out-of-school young women bear the brunt of HIV infection in Botswana, but rarely benefit from such economic empowerment programs. Using a qualitative exploratory study design and a participatory research approach, we explored factors affecting perceived program benefit and potential solutions to barriers. Direct stakeholders (n = 146) included 87 unemployed and out-of-school young women and 59 program and technical officers in five intervention districts. Perceived barriers were identified in 20 semi-structured interviews (one intervention district) and 11 fuzzy cognitive maps. Co-constructed improvement recommendations were generated in deliberative dialogues. Analysis relied on Framework and the socioecological model. Overall, participants viewed existing programs in Botswana as ineffective and inadequate to empower vulnerable young women socially or economically. Factors affecting perceived program benefit related to programs, program officers, the young women, and their social and structural environment. Participants perceived barriers at every socioecological level. Young women's lack of life and job skills, unhelpful attitudes, and irresponsible behaviors were personal-level barriers. At an interpersonal level, competing care responsibilities, lack of support from boyfriends and family, and negative peer influence impeded program benefit. Traditional venues for information dissemination, poverty, inequitable gender norms, and lack of coordination were community- and structural-level barriers. Improvement recommendations focused on improved outreach and peer approaches to implement potential solutions. Unemployed and out-of-school young women face multidimensional, interacting barriers that prevent benefit from available promotive social protection programs in Botswana. To become HIV-sensitive, these socioeconomic empowerment programs would need to accommodate or preferentially attract this key population. This requires more generous and comprehensive programs, a more client-centered program delivery, and improved coordination. Such structural changes require a holistic, intersectoral approach to HIV-sensitive social protection.

Community views of inter-generational sex: findings from focus groups in Botswana, Namibia and Swaziland.

Inter-generational sex is an important driver of the AIDS epidemic in Southern Africa, contributing to the high incidence of HIV among young women. We conducted 12 focus group discussions with women aged 15-24 years and 11 with men aged 40-55 years in urban and rural locations in Botswana, Namibia and Swaziland. There was consensus that inter-generational sex is commonplace. The young women were clear they had sex with older men to get money and material goods. In urban sites, they spoke about requirements for a "modern" lifestyle and to keep up with their friends, but in rural sites they also said they needed money for school fees, food and household goods. Young women used disparaging names for the older men and they were well aware of the risk of HIV from inter-generational sex. They believed older men were more risky than younger men: They were more likely to be infected and it was harder to negotiate use of a condom with them. They were willing to take the risk to get what they wanted; some also had a fatalistic attitude. Older men described sexual motivation and blamed young women for seducing them. They believed there was a higher risk of HIV from younger women, because they have more partners and do not insist on using a condom. But this did not deter them from taking the risk. Older men and young women discount the risks of inter-generational sex against short-term benefits. Isolated efforts to increase risk awareness are unlikely to be effective. Making older men aware they are ridiculed by young women may be a promising approach, combined with interventions that give alternatives to young women and increase their self-worth.

A role for traditional doctors in health promotion: experience from a trial of HIV prevention in Botswana.

Traditional doctors have been largely ignored in HIV prevention, particularly primary prevention. As part of a structural intervention programme to reduce HIV risk among young women in Botswana, we trained 147 traditional doctors in four districts as well as government health education assistants (HEAs) and teachers to run discussion groups in the community and schools, using an evidence-based eight-episode audio-drama, covering gender roles, gender violence, and how these are related to HIV risk. One year later, we contacted 43 of the 87 trained traditional doctors in two districts. Most (32) were running discussion groups with men and women, with links to the local HEAs and teachers. They were adept at recruiting men to their groups, often a challenge with community interventions, and reported positive changes in attitudes and behaviour of group participants. Traditional doctors can play an important role in primary prevention of gender violence and HIV.

Reaching marginalized young women for HIV prevention in Botswana: a pilot social network analysis.

Almost one-fifth of Botswana's population is infected with HIV. The Inter-Ministerial National Structural Intervention Trial is a trial to test the impact on HIV rates of a structural intervention that refocuses government structural support programs in favor of young women. Ensuring that the intervention reaches all vulnerable young women in any given community is a challenge. Door-to-door recruitment was inefficient in previous work, so we explored innovative ways to reach this population. We sought to understand the support networks of marginalized young women, and to test the possibility of using social networks to support universal recruitment in this population. Ego-centric and sociometric analyses were used to describe the support networks of marginalized young women. Marginalized young women go to other women and relatives for support, and they communicate face to face rather than using social media. Network maps show how young women were connected to each other. Lessons from the pilot include a better understanding of how to use social networks as a recruitment method, such as the time required and the types of community members that can help. Social networks could help reach other hard-to-reach populations.