ABSTRACT
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.
ABSTRACT
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.
ABSTRACT
BACKGROUND: Intimate partner violence (IPV) and sexually transmitted infections (STIs), including HIV, remain important public health problems with devastating health effects for men and women in sub-Saharan Africa. There have been calls to engage men in prevention efforts, however, we lack effective approaches to reach and engage them. Social network approaches have demonstrated effective and sustained outcomes on changing risk behaviors in the U.S. Our team has identified and engaged naturally occurring social networks comprised mostly of young men in Dar es Salaam in an intervention designed to jointly reduce STI incidence and the perpetration of IPV. These stable networks are locally referred to as "camps." In a pilot study we demonstrated the feasibility and acceptability of a combined microfinance and peer health leadership intervention within these camp-based peer networks. METHODS DESIGN: We are implementing a cluster-randomized trial to evaluate the efficacy of an intervention combining microfinance with health leadership training in 60 camps in Dar es Salaam, Tanzania. Half of the camps have been randomized to the intervention arm, and half to a control arm. The camps in the intervention arm will receive a combined microfinance and health leadership intervention for a period of two years. The camps in the control arm will receive a delayed intervention. We have enrolled 1,258 men across the 60 study camps. Behavioral surveys will be conducted at baseline, 12-months post intervention launch and 30-month post intervention launch and biological samples will be drawn to test for Neisseria gonorrhea (NG), Chlamydia trachomatis (CT), and Trichomonas vaginalis (TV) at baseline and 30-months. The primary endpoints for assessing intervention impact are IPV perpetration and STI incidence. DISCUSSION: This is the first cluster-randomized trial targeting social networks of men in sub-Saharan Africa that jointly addresses HIV and IPV perpetration and has both biological and behavioral endpoints. Effective approaches to engage men in HIV and IPV prevention are needed in low resource, high prevalence settings like Tanzania. If we determine that this approach is effective, we will examine how to adapt and scale up this approach to other urban, sub-Saharan African settings. TRIAL REGISTRATION: Clinical Trials.gov: NCT01865383 . Registration date: May 24, 2013.
