Development and implementation of a process evaluation for intervention quality improvement of a community-based behavioral HIV intervention trial in Tanzania.

Aim: Process evaluations for social and behavioral interventions are increasingly important as interventions become more complex and multi-faceted. Conducting process evaluations in low-resource international settings can be challenging. Process evaluations in low-resource international settings can help inform and improve quality of ongoing intervention implementation. We conducted a process evaluation of a cluster-randomized controlled trial to assess the efficacy of a microfinance and health leadership program on sexually transmitted infections and intimate partner violence perpetration among young men in Tanzania. Subject and Methods: Our trial included 1,491 participants and the intervention lasted two years. We collected process data on microfinance loan uptake and repayment, and health leaders' health conversations with peers to monitor intervention reach and dose received. We developed a database system that allowed offline data collection and synced to a central database when internet was accessible. Research staff in the U.S. accessed data from the central database to analyze and create regular implementation reports. Results: Process graphical reports facilitated identification of implementation challenges and enabled us to resolve issues before they worsened. For example, from a group with low microfinance loan repayment we learned area participants perceived the loan to be a grant, and then we clarified the misinformation with participants. Conclusions: The process evaluation helped inform ongoing intervention implementation, including approaches to improve reach and uptake of interventions. Field staff time was protected by systemizing the sharing of data processing and analyses across the global team.

Intimate partner violence perpetration and sexual risk behaviour: Identifying shared determinants among young men in Tanzania.

In this study we examined factors that predict involvement in different patterns of sexual risk behavior and IPV perpetration among young men in Tanzania (n = 979), with a focus on identifying factors that distinguish men who engage in both behaviours from those who do not. Risk factors were drawn from three domains thought to be upstream drivers of both IPV and sexual risk: poverty, adverse childhood experiences, and inequitable gender norms. A three-step latent class analysis was used to assess whether and how factors from each domain distinguished subgroups of men whose behaviour patterns were characterised as comorbid (involvement in IPV and sexual risk behaviour), IPV-only, sexual risk only, and normative (low risk). Consistent with expectations, greater food insecurity, adverse childhood experiences, and inequitable gender norms related to violence and sexual behaviour predicted increased risk of membership in the comorbid group compared to other sub-groups. Findings support the promise of integrated prevention programmes targeting the common causes of IPV perpetration and sexual risk behaviour.

The Intersection of Intimate Partner Violence Perpetration and Sexual Risk Behavior Among Young Men in Tanzania: A Latent Class Analysis of Patterns and Outcomes.

Few studies of intimate partner violence (IPV) perpetration and sexual risk behavior among men have examined how multiple dimensions of these behaviors intersect in ways that may uniquely elevate health risks. The current study used latent class analysis to: (1) identify distinct patterns of IPV and sexual risk behavior in a sample of Tanzanian men (n = 985) and (2) examine associations between identified patterns and health outcomes. Four classes were identified: normative (64% of the sample), IPV only (14%), sexual risk only (13%), and comorbid IPV/sexual risk (5%). Compared to men in the normative subgroup, men in the comorbid group had significantly higher odds of STI infection, higher perceived HIV risk, and greater odds of substance use. Findings provide evidence that engaging in IPV and multiple sexual partnerships (i.e., a comorbid pattern) denotes elevated health risks across a range of indicators, suggesting the importance of targeted treatment and prevention efforts for men in this subgroup.

RESUMEN: Pocos estudios sobre la violencia infligida por la pareja (IPV) y las conductas sexuales de riesgo entre los hombres han examinado como las múltiples dimensiones de estas conductas pueden combinarse para elevar los riesgos de estas conductas para la salud. El estudio actual utilizó el análisis de clases latentes para: (1) identificar patrones (o clases) distintos de IPV y conductas sexuales de riesgo en una muestra de hombres de Tanzania (n = 985) y (2) examinar asociaciones entre los patrones identificados y indicadores de salud. Se identificaron cuatro clases: normativa (64% de la muestra), IPV solo (14%), riesgo sexual solo (13%) y riesgo sexual / IPV comórbido (5%). En comparación con los hombres del subgrupo normativo, los hombres del grupo comórbido tenían probabilidades significativamente más altas de infección de transmisión sexual, mayor riesgo percibido de VIH, y mayores probabilidades de consumo de sustancias (alcohol y marijuana). Los hallazgos proporcionan evidencia de que ser perpetrador de violencia en pareja y tener múltiples parejas sexuales (un patrón comórbido) es asociado con múltiples riesgos para la salud, lo que sugiere la importancia del tratamiento dirigido y los esfuerzos de prevención para los hombres en este subgrupo.

Correlates of Anxiety and Depression among Young Men Living in Dar es Salaam, Tanzania.

Depression and anxiety are important sources of morbidity globally, but we have little knowledge of risk groups and risk factors for both classes of disorders in Tanzania and other low-resource settings. We aimed to identify socio-demographic markers and risk and protective factors associated with symptoms of anxiety and depression among 1249 young men belonging to social groups known as "camps" in Dar es Salaam. Anxiety and depression were measured using the HSCL-25. Men living apart from family reported greater symptoms of anxiety and depression than men living with family, and employment was associated with a greater likelihood of clinically significant symptoms of both anxiety and depression. Childhood experience of violence was strongly associated with both anxiety and depression. Social support was associated with lower levels of anxiety and depression, and with a lower likelihood of clinically significant levels of anxiety and depression in this population. Youth not living with family and the working poor may be important populations for future investigation. Interventions targeting survivors of childhood violence and social support-based interventions should be tested to address the burden of anxiety and depression in this setting.

Results from a cluster-randomized trial to evaluate a microfinance and peer health leadership intervention to prevent HIV and intimate partner violence among social networks of Tanzanian men.

Despite calls to engage men in HIV and intimate partner violence (IPV) prevention efforts, effective approaches to reach and engage men in low-resource, high-HIV prevalence settings are limited. We identified and engaged social networks of mostly young men in a study designed to evaluate the efficacy of a combined microfinance and peer health leadership intervention to prevent HIV and IPV. We conducted a cluster-randomized trial among 60 social networks locally referred to as "camps" within Dar es Salaam, Tanzania. Camps were randomly assigned (1:1) to a microfinance and peer health leadership intervention or a control condition that received a brief delayed intervention after the study's conclusion. Allocation was not masked to participants or researchers. Behavioral assessments were conducted at baseline and 30-months post-intervention launch, with biological samples drawn at 30-months to test for sexually-transmitted infections (STIs). Primary outcomes included prevalence of STIs and past-year IPV perpetration. Secondary outcomes included STI sexual risk behaviors and past-year HIV testing. Proximal intervention targets included inequitable gender norm attitudes and hope. A modified Poisson regression approach was used to estimate intention-to-treat intervention effects on outcomes assessed at the 30-month follow-up. We enrolled 1,258 men within 60 camps. Of these men, 1,029 (81.8%) completed the 30-month follow-up. There were no differences by condition in STI prevalence, IPV perpetration, or sexual risk behaviors at the 30-month follow-up. Intervention participants reported greater levels of past-year HIV testing, controlling for baseline testing (aRR 1.13 95% CI 1.005-1.28). They also reported significantly lower levels of inequitable gender norm attitudes (adjusted effect -0.11, 95% CI -0.21-0.003). We successfully engaged and retained social networks of men in this multilevel intervention study. While we did not see an effect on the primary outcomes, our intervention successfully improved HIV testing and reduced inequitable gender norm attitudes.

Engaging Young Men as Community Health Leaders in an STI and Intimate Partner Violence Prevention Trial in Dar es Salaam, Tanzania.

BACKGROUND: This article presents lessons learned from a microfinance and health intervention for young men designed to prevent sexually transmitted infections (STI) and intimate partner violence (IPV) in Dar es Salaam, Tanzania. We describe the different strategies we used to identify and train young men to become change agents within their social networks. DESCRIPTION: A cluster-randomized trial with 60 camps was undertaken in the Kinondoni District of Dar es Salaam. A total of 170 members from 30 intervention camps were trained in March 2014 as popular opinion leaders (POLs), whom we call Camp Health Leaders (CHLs). We describe the process of nominating, training, and retaining CHLs. We also describe our monitoring process, which included the collection of weekly diaries assessing topics discussed, number of peers engaged in conversations, reactions of peers, and challenges faced. LESSONS LEARNED: POLs within naturally existing social networks can be engaged in STI and IPV prevention initiatives. Continuous efforts in retention, such as holding community advisory board (CAB) meetings, developing prevention slogans and t-shirts, and offering small grants to POL teams for intervention activities, were important to keeping POLs engaged in the intervention. Further, booster-training sessions were critical to maintain the message of the project and ensure that the challenges POLs face with implementing the programs were addressed in a timely manner. CONCLUSION: Recruiting POLs in a Tanzanian urban setting and engaging them in STI and IPV reduction through social networks is possible. Training POLs in health information and interpersonal communication is important. Utilizing booster sessions and a variety of retention strategies for POLs in programs that aim to reduce IPV and STI infections among young men is essential to maintain the health leaders' engagement in the intervention as well as intervention fidelity.

Microfinance and health interventions: Factors influencing loan repayment success with young men in Dar es Salaam, Tanzania.

Poverty is associated with numerous poor health outcomes. Youth unemployment in Tanzania is approximately 13.7%, and concentrates in urban areas. These youth lack relevant job skills and access to financial capital. Microfinance continues to be implemented globally to address poverty, and increasingly has been linked to health interventions. Men less frequently are recipients of microfinance loans. We offered microcredit to young men in an area of Dar es Salaam with high poverty as part of a randomised controlled-trial to assess the efficacy of a microfinance and health leadership intervention in preventing STI acquisition. We used mixed methods to understand predictors of successful loan repayment. Our qualitative sub-study showed that leader influence, prior business experience, personal motivation, and planning facilitated repayment. Using a modified Poisson approach, our quantitative analysis showed that successful repayment was associated with business experience, education, increasing number of children, community of residence, percentage of network members trained in business, and repayment success of peer leaders. Our results suggest that enforcing group accountability and repayment rules, offering ongoing training, and using successful entrepreneurs as role models could increase repayment success in similar populations. These strategies could provide financial opportunity for men while minimising risk for microfinance institutions.

Cluster randomized trial of comprehensive gender-based violence programming delivered through the HIV/AIDS program platform in Mbeya Region, Tanzania: Tathmini GBV study.

The Tathmini GBV study was a cluster randomized trial to assess the impact of a comprehensive health facility- and community-based program delivered through the HIV/AIDS program platform on reduction in gender-based violence and improved care for survivors. Twelve health facilities and surrounding communities in the Mbeya Region of Tanzania were randomly assigned to intervention or control arms. Population-level effects were measured through two cross-sectional household surveys of women ages 15-49, at baseline (n = 1,299) and at 28 months following program scale-out (n = 1,250). Delivery of gender-based violence services was assessed through routine recording in health facility registers. Generalized linear mixed effects models and analysis of variance were used to test intervention effects on population and facility outcomes, respectively. At baseline, 52 percent of women reported experience of recent intimate partner violence. The odds of reporting experience of this violence decreased by 29 percent from baseline to follow-up in the absence of the intervention (time effect OR = 0.71, 95% CI: 0.57-0.89). While the intervention contributed an additional 15 percent reduction, the effect was not statistically significant. The program, however, was found to contribute to positive, community-wide changes including less tolerance for certain forms of violence, more gender equitable norms, better knowledge about gender-based violence, and increased community actions to address violence. The program also led to increased utilization of gender-based violence services at health facilities. Nearly three times as many client visits for gender-based violence were recorded at intervention (N = 1,427) compared to control (N = 489) facilities over a 16-month period. These visits were more likely to include provision of an HIV test (55.3% vs. 19.6%, p = .002). The study demonstrated the feasibility and impact of integrating gender-based violence and HIV programming to combat both of these major public health problems. Further opportunities to scale out GBV prevention and response strategies within HIV/AIDS service delivery platforms should be pursued. Trial Registration: Pan African Clinical Trials Registry No. PACTR201802003124149.

Structural Network Position and Performance of Health Leaders Within an HIV Prevention Trial.

The effectiveness of peer leaders in promoting health may depend on the position they occupy within their social networks. Using sociocentric (whole network) and behavioral data from the intervention arm of a cluster-randomized HIV prevention trial in Dar es Salaam, Tanzania, we used generalized linear models with standardized predictors to examine the association between heath leaders' baseline structural network position (i.e., in-degree and betweenness centrality) and their 12-month self-reported (1) confidence in educating network members about HIV and gender-based violence (GBV) and (2) number of past-week conversations about HIV and GBV. As in-degree centrality increased, leaders reported fewer HIV-related conversations. As betweenness centrality increased, leaders reported greater number of conversations about GBV. Network position was not significantly associated with confidence in discussing either topic. Our results suggest that peer leaders who occupy spaces between sub-groups of network members may be more effective in engaging their peers in sensitive or controversial topics like GBV than more popular peer leaders.

Perpetration and Victimization of Intimate Partner Violence Among Young Men and Women in Dar es Salaam, Tanzania.

We describe and compare the baseline rates of victimization and perpetration of three forms of intimate partner violence (IPV)-psychological, physical, and sexual-among sexually active men ( n = 1,113) and women ( n = 226) enrolled in an ongoing cluster-randomized HIV and gender-based violence prevention trial in Dar es Salaam, Tanzania. IPV was measured using a modified version of the World Health Organization Violence Against Women instrument. We assess the degree to which men and women report overlapping forms of IPV victimization and perpetration. Sociodemographic and other factors associated with increased risk of victimization and perpetration of IPV are examined. Within the last 12 months, 34.8% of men and 35.8% of women reported any form of IPV victimization. Men were more likely than women to report perpetrating IPV (27.6% vs. 14.6%, respectively). We also found high rates of co-occurrence of IPV victimization and perpetration with 69.7% of male perpetrators and 81.8% of female perpetrators also reporting victimization during the last year. Among men, having ever consumed alcohol and experiencing childhood violence were associated with increased risk of most forms of IPV. Younger women were more likely to report perpetrating IPV than older women. We found evidence of gender symmetry with regard to most forms of IPV victimization, but men reported higher rates of IPV perpetration than women. Given the substantial overlap between victimization and perpetration reported, our findings suggest that IPV may be bidirectional within relationships in this setting and warrant further investigation. Implications for interventions are discussed.

Associations Between Peer Network Gender Norms and the Perpetration of Intimate Partner Violence Among Urban Tanzanian Men: a Multilevel Analysis.

Male perpetration of intimate partner violence (IPV) against women in sub-Saharan Africa is widespread. Theory and empirical evidence suggest peer networks may play an important role in shaping IPV perpetration, though research on this topic in the region is limited. We assessed the degree to which peer network gender norms are associated with Tanzanian men's perpetration of IPV and examined whether the social cohesion of peer networks moderates this relationship. Using baseline data from sexually active men (n = 1103) nested within 59 peer networks enrolled in an on-going cluster-randomized HIV and IPV prevention trial, we fit multilevel logistic regression models to examine peer network-level factors associated with past-year physical IPV perpetration. Peer network gender norms were significantly associated with men's risk of perpetrating IPV, even after adjusting for their own attitudes toward gender roles (OR = 1.53 , p = . 04). Peer network social cohesion moderated this relationship (OR = 1.50 , p = . 04); the positive relationship between increasingly inequitable (i.e., traditional) peer network gender norms and men's risk of perpetrating IPV became stronger, as peer network social cohesion increased. Characteristics of the peer network context are associated with men's IPV perpetration and should be targeted in future interventions. While many IPV prevention interventions focus on changing individual attitudes, our findings support a unique approach, focused on transforming the peer context.

Peer network influence on intimate partner violence perpetration among urban Tanzanian men.

Male perpetration of intimate partner violence (IPV) against women in Tanzania is widespread. Theory and empirical evidence suggest peer networks may play an important role in shaping IPV perpetration, although research on this topic in sub-Saharan Africa is limited. Grounded in social learning theory, social influence theory, and the theory of gender and power, the purpose of this study was to examine whether and how peer networks influence men's perpetration of IPV in Dar es Salaam, Tanzania. We conducted in-depth interviews (n = 40) with a sub-sample of 20 men enrolled in the control condition of an ongoing cluster-randomised controlled trial. We purposively sampled participants who previously reported perpetrating physical IPV. To analyse the data, we generated narrative summaries and conducted thematic and interpretative coding. We saw no evidence that men self-selected into peer networks with certain values or behaviours. Rather, men described several mechanisms through which their peers influenced the perpetration of IPV, including: (1) the internalisation of peer network norms, (2) pressure to conform to peer network norms and (3) the direct involvement of peers in shaping couple power dynamics. Our findings suggest that peer networks influence men's perpetration of IPV and should be targeted in future programmes and interventions.

Changes in Anxiety and Depression Symptoms Predict Sexual Risk Behaviors Among Young Men Living in Dar es Salaam, Tanzania.

Young men are important targets in HIV prevention in Tanzania and throughout sub-Saharan Africa. Anxiety and depression are common among youth and may be important predictors of HIV risk behaviors; evidence of these relationships in high-risk populations is needed. Using baseline and 1 year follow-up assessments from an HIV prevention trial we assessed the association between changes in symptoms of anxiety and depression and follow-up sexual risk behaviors (condom use and sexual partner concurrency) controlling for baseline sexual risk behaviors among 1113 male members of social groups known as "camps" in Dar es Salaam, Tanzania. Anxiety and depression were measured using the HSCL-25 and condom use and sexual partner concurrency were assessed through self-report. In separate models, increases in anxiety and depression were associated with sexual partner concurrency and with lower levels of condom use. In a combined model, both anxiety and depression appeared to independently affect concurrency but only depression was independently associated with condom use, with the association between anxiety and condom use being likely attributable to covariance with depression symptoms. The results of this study indicate the importance of screening and providing treatment for depression and anxiety disorders in high HIV-prevalence contexts, and the need to develop effective HIV prevention interventions targeting young men living with anxiety and depression.

Social Network Influence on HIV Testing Among Urban Men in Tanzania.

Men in sub-Saharan Africa have low HIV testing rates. Social networks exert an important influence on men's HIV-related behavior. We examined associations between network factors and HIV testing among men in Dar es Salaam, Tanzania. Data are from the baseline assessment of an HIV prevention trial with 48 primarily male networks. Among 923 sexually active men, 52 % had ever tested for HIV. In a random effects logistic regression model, men in the network core were 1.50 times more likely (p < .05) to test than those in the periphery. Percentage of women in the network was associated with men's increased HIV testing (AOR 4.24, p < .05). Perception of network HIV stigma was negatively associated with HIV testing (AOR 0.92, p < .01). Thinking at least one close friend tested for HIV was associated with increased testing (AOR 2.66, p < .001). Social network interventions are a promising approach for scaling up men's HIV testing.

Parenting practices and styles associated with adolescent sexual health in Dar es Salaam, Tanzania.

Parenting styles and practices are suggested to be important predictors of adolescent sexual health, mostly in Europe and North America. Limited research has been conducted on these processes in Sub-Saharan Africa, which has different patterns of adolescent sexual behavior and family traditions. This study qualitatively explored parenting practices and styles associated with adolescent sexual health in Tanzania, with 12 adolescents and 12 parents of adolescents. The themes we identified from the data included parental monitoring, preventive, and punitive behaviors. Parents were reported to use mostly punitive behaviors to correct or prohibit sexual behavior; parents also set clear rules about appropriate sexual behavior (e.g., modesty and abstinence). Parents were also reported to closely monitor their adolescent children's friendships and sexual behavior to minimize sexual behavior. However, some parents also engaged in positive preventive practices aimed at protecting their adolescent children.

Comparing Perceptions with Actual Reports of Close Friend's HIV Testing Behavior Among Urban Tanzanian Men.

Men have lower rates of HIV testing and higher rates of AIDS-related mortality compared to women in sub-Saharan Africa. To assess whether there is an opportunity to increase men's uptake of testing by correcting misperceptions about testing norms, we compare men's perceptions of their closest friend's HIV testing behaviors with the friend's actual testing self-report using a unique dataset of men sampled within their social networks (n = 59) in Dar es Salaam, Tanzania. We examine the accuracy and bias of perceptions among men who have tested for HIV (n = 391) and compare them to the perceptions among men who never tested (n = 432). We found that testers and non-testers did not differ in the accuracy of their perceptions, though non-testers were strongly biased towards assuming that their closest friends had not tested. Our results lend support to social norms approaches designed to correct the biased misperceptions of non-testers to promote men's HIV testing.

Evidence of social network influence on multiple HIV risk behaviors and normative beliefs among young Tanzanian men.

Research on network-level influences on HIV risk behaviors among young men in sub-Saharan Africa is severely lacking. One significant gap in the literature that may provide direction for future research with this population is understanding the degree to which various HIV risk behaviors and normative beliefs cluster within men's social networks. Such research may help us understand which HIV-related norms and behaviors have the greatest potential to be changed through social influence. Additionally, few network-based studies have described the structure of social networks of young men in sub-Saharan Africa. Understanding the structure of men's peer networks may motivate future research examining the ways in which network structures shape the spread of information, adoption of norms, and diffusion of behaviors. We contribute to filling these gaps by using social network analysis and multilevel modeling to describe a unique dataset of mostly young men (n = 1249 men and 242 women) nested within 59 urban social networks in Dar es Salaam, Tanzania. We examine the means, ranges, and clustering of men's HIV-related normative beliefs and behaviors. Networks in this urban setting varied substantially in both composition and structure and a large proportion of men engaged in risky behaviors including inconsistent condom use, sexual partner concurrency, and intimate partner violence perpetration. We found significant clustering of normative beliefs and risk behaviors within these men's social networks. Specifically, network membership explained between 5.78 and 7.17% of variance in men's normative beliefs and between 1.93 and 15.79% of variance in risk behaviors. Our results suggest that social networks are important socialization sites for young men and may influence the adoption of norms and behaviors. We conclude by calling for more research on men's social networks in Sub-Saharan Africa and map out several areas of future inquiry.

Young Men's Social Network Characteristics and Associations with Sexual Partnership Concurrency in Tanzania.

Social network influence on young people's sexual behavior is understudied in sub-Saharan Africa. Previous research identified networks of mostly young men in Dar es Salaam who socialize in "camps". This study describes network characteristics within camps and their relationship to young men's concurrent sexual partnerships. We conducted surveys with a nearly complete census of ten camp networks (490 men and 160 women). Surveys included name generators to identify camp-based networks. Fifty seven percent of sexually active men (n = 471) reported past year concurrency, measured using the UNAIDS method. In a multivariable model, men's individual concurrency was associated with being a member of a closer knit camp in which concurrency was the normative behavior. Younger men who had older members in their networks were more likely to engage in concurrency. Respondent concurrency was also associated with inequitable personal gender norms. Our findings suggest strategies for leveraging social networks for HIV prevention among young men.

Adolescents' Communication with Parents, Other Adult Family Members and Teachers on Sexuality: Effects of School-Based Interventions in South Africa and Tanzania.

Cluster-randomized controlled trials were carried out to examine effects on sexual practices of school-based interventions among adolescents in three sites in sub-Saharan Africa. In this publication, effects on communication about sexuality with significant adults (including parents) and such communication as a mediator of other outcomes were examined. Belonging to the intervention group was significantly associated with fewer reported sexual debuts in Dar es Salaam only (OR 0.648). Effects on communication with adults about sexuality issues were stronger for Dar es Salaam than for the other sites. In Dar, increase in communication with adults proved to partially mediate associations between intervention and a number of social cognition outcomes. The hypothesized mediational effect of communication on sexual debut was not confirmed. Promoting intergenerational communication on sexuality issues is associated with several positive outcomes and therefore important. Future research should search for mediating factors influencing behavior beyond those examined in the present study.

Dynamics of parent-adolescent communication on sexual health and HIV/AIDS in Tanzania.

Communication between parents and their adolescent children has been identified as one of the potential protective factors for adolescent sexual health. Qualitative exploration of sexual health communication with adolescents aged 12-15 (N = 114) and a sub-group of the parents (N = 20) was carried out. Four major themes emerged: reasons for parent-adolescent communications, or lack thereof; the focus of parental messages; the moral of the message; and the barriers to communication between parents and adolescents. Findings revealed similarities and discrepancies in views and perceptions between parents and adolescents. Adolescents and parents suggested that some sexual health communication was happening. Parents were reportedly likely to use fear to ensure that their children do not engage in risky sexual activities, while adolescents reported that conversations with their parents were mostly ambiguous and filled with warnings about the dangers of HIV/AIDS. Several communication barriers were reported by parents and adolescents. Parents of adolescents would benefit from HIV/AIDS specific communication skills.