HIV Risk-Reduction Intervention among Namibian Youth - Book Report/Review Example

Research Article Critique Increased protected sex and abstinence among Namibian youth following a HIV risk-reduction intervention: a randomized, longitudinal study Bonita F. Stanton, Xiaoming Li, Joshua Kahihuata, Ann M. Fitzgerald, Simeone Neumbo, Geraldus Kanduuombe, Izabel B. Ricardo, Jennifer S. Galbraith, Nancy Terreri, Irene Guevara, Hannu Shipena, Johan Strijdom, Rebecca Clemens and R.F. Zimba The Study Purpose and background context. The purpose of this study is to evaluate an HIV risk-reduction intervention among Namibian adolescents. The background context has to do with the epidemic of AIDS in sub-Saharan Africa that calls for urgent interventions. With approximately three-quarters of the global burden of HIV, sub-Saharan Africa has many cities where the seroprevalence among young adults exceeds 30%. One such country is Namibia, which is located in south-western Africa. With a population of 1.6 million, including 11 ethnic groups, it is among the world's most sparsely populated nations. As of 1996, the national seroprevalence of HIV was estimated to be 15% among antenatal patients, with rates as high as 25% in some districts. With an average annual per capita gross national product of US$2000, biomedical prevention and treatment methods in Namibia are simply not affordable to most citizens or to the government. Significance. The study is significant in that in 1996, the Government of Namibia in partnership with UNICEF and the University of Maryland, elected to adapt an adolescent AIDS risk-reduction curriculum that had been successful in the United States. The resulting curriculum, 'My Future is My Choice' (MFMC), included 14 sessions, each 2 hours in length, to be administered over 7 weeks. The MFMC intervention was administered to adolescents throughout Namibia. Before its widespread implementation, the programme was assessed in 1996-1997 through a randomized, controlled longitudinal trial of 515 youths from 10 schools in two of Namibia's 11 districts, Caprivi and Omusati. The primary outcome measures of the intervention were abstinence and condom use. Additional risk behaviors, as well as HIV risk intentions and perceptions, were also assessed. This study reported the results of this evaluation. Theoretical model. Although no theoretical model is described as used in the study, a conceptual framework can be discerned. The study acknowledges the abundance of literature indicating behavioral interventions in Western settings that share certain common features said to change self-reported risk behaviors among targeted audiences, including adolescents. The framework of this study is that of behavioral change that involves training and practice in specific skills such as the acquisition and use of condoms, redounding to an increase of protected sex. Research design and methods. A randomized trial of a 14-session face-to-face intervention emphasizing abstinence and safer sexual practices was conducted among 515 youths (median age 17 years and median grade 11) attending 10 secondary schools located in two districts in Namibia. Youths were randomly assigned to the intervention or control condition at the level of the individual. HIV risk behaviors; intentions and perceptions were assessed at baseline; and immediately post-intervention at 6 and 12 months post-intervention. Sample characteristics and sampling. Youths from 10 schools, randomly selected from among the 161 upper/high schools in Omusati and Caprivi who were in grades 9 or 11 between ages 15 and 18 were invited to enroll. Over 80% of eligible youths enrolled. After enrolment, students attended a preliminary session to complete baseline questionnaires. They were then randomly assigned at the level of the individual based on random numbers table, to the intervention condition (e.g. participate in the MFMC programme in late 1996) or to the delay-control condition (e.g. would not receive the intervention until after the 12-month follow-up had been completed). The protocol received ethical clearance from institutional review boards at the UMD and UNICEF, Namibia. Findings and conclusions. Among all 515 youths who enrolled in the programme, rates of either abstinence or sex with a condom were not significantly different between control and intervention youths at baseline or in the follow-up period. However, analyses conducted among the subset of youths who were sexually inexperienced at baseline (n = 255) revealed that a higher percentage of intervention youths (17%) than control youths (9%, P < 0.05) remained sexually inexperienced one year later. Moreover, in the immediate post-intervention period, among baseline virgins who subsequently initiated sex, intervention youths were more likely than control youths to use a condom (18 versus 10%, P < 0.05). Additional HIV-related risk behaviors (failure to discuss previous HIV risk exposure with one's sexual partner and alcohol use), intentions to use condoms, and perceptions of the ability to use condoms were positively affected by the intervention. It is concluded that there is evidence that the 'My Future is My Choice' (MFMC) intervention is reducing HIV risk behaviors among sexually inexperienced participants aged 15-18. Related risk behaviors and perceptions are also positively impacted by the intervention. Critique The findings and threats to internal validity. One of the features of this study is that, beginning with the topic alone (sex and HIV), it is sensitive; it is rather invasive of privacy, and therefore imposing or stressful. James Neill (2003) referred to these issues as "noise" which could probably impact negatively on the measurement, confounding measurement as threat to internal validity. This refers to the degree of certainty that observed effects in an experiment are actually the result of the experimental treatment or condition (the cause), rather than intervening, extraneous or confounding variables ("Validity," UWE, 2006). Another feature of the study is that there was a randomized trial of a 14-session face-to-face intervention up to one year (Stanton, Li, Kahihuata, et al., 1998). The 14 sessions can be considered test-retests where reliability compares results from an initial test with repeated measures later on ("Validity," UWE, 2006). Referred to as an issue of Instrumentation, changes in calibration of a measurement tool or changes in the observers or scorers may produce changes in the obtained measurements (Campbell & Stanley, 1963). It is also probable that over time, the subjects may not be the same. Meaning, their frame of thinking, their rate of cooperation may have changed over time as they grew tired. Campbell and Stanley (1963) referred to this process as Maturation, or processes within the participants as a function of the passage of time. Because of the effect on measurement, reliability is compromised. Reliability is an essential pre-requisite for validity. ("Validity," UWE, 2006). On the other hand, granting that the study was able to handle the bulk of 515 participants, the findings may be said to be believable and useful to the extent that errors in ethical issues and reliability issues in re-testing may be cancelled out by the number of participants involved. The findings and threats to external validity. External Validity is concerned with the degree to which research findings can be applied to the real world, beyond the controlled setting of the research. This is the issue of generalizability ("Validity," UWE, 2006). This study published in 1998, stated that the primary outcome measures of the intervention were abstinence and condom use, and others. To evaluate this study today, available relevant literature will have to be considered. In a study of 100 Greater Windhoek youth, ages 15 to 25, and published in 2003, terms used to describe some HIV prevention strategies-such as "abstinence" or "faithfulness" were found not understood by a large majority of young adults in Namibia ("Namibia," Johns Hopkins, 2003). Five years after this 1998 'My Future is My Choice' study (Stanton, Li, Kahihuata, et al., 1998), another Namibia research ("Namibia," Johns Hopkins, 2003) said that most young people in Namibia believe that "abstinence" means "to be absent" and "faithfulness" means faith in a religious sense, not being faithful to one sexual partner. The word "monogamy" is understood by only one-quarter, with 75 percent saying they had never heard the word. This later research also had Namibia subjects of virtually the same age groups supposed to have more exposure in communication. In sum, this 'misunderstanding terms' syndrome can be counted as reactive effect of experimental arrangement, a factor that could jeopardize external validity or representativeness of the study (Campbell & Stanley, 1963). Strengths and limitations of the study. This study is pioneering and learning from another program called 'Focus on Kids.' which was developed in the USA. It has contributed in some way to HIV studies in the form of testing interventions through cultural settings not available in Africa or most other developing countries (Stanton, Li, Kahihuata, et al., 1998). As with any study based on self-report, there is concern, however, that the data may be skewed by report bias. Value of study and implications for health policy. This study provides evidence regarding several important issues relevant to controlling the HIV epidemic in Africa. In Western settings there is consensus that appropriately designed face-to-face HIV risk-reduction interventions can reduce HIV risk behaviors among adolescents. To date, such interventions are not available in Africa or most other developing countries. The study found it appealing to be able to modify successful Western interventions and use them in other cultural and geographical settings, where HIV is a major problem and where resources and time may be limited. The concern with this approach has been that the meaning of risk and protective behaviors, especially sexual practices, may differ radically between cultures, so that relevant cultural adaptations must be made. Caution is warranted, however, that the adaptation process itself does require significant time and resources. Recommendations for further study. As national implementation of 'My Future is My Choice' proceeds in Namibia, it will be important, according to this study, to try to establish biological markers to corroborate these self-reports of intervention effect. The study also recommended that intervention implementation be monitored to help ensure that these youths are given every opportunity to shape their futures or empowered, rather than having them taken away. Sex and HIV studies itself, is very sensitive and intrusive of privacy. The study also recommended that increased attention must be cast on condom availability as it may affect study time. Finally, the study said some consideration should be given to the development of gender-specific interventions or intervention components. Nothing was mentioned in the study, however, about communication problems, or whether the subjects had problems about language or understanding terms. It is obvious that a program crafted with messages sensitive to the issue of language may ensure that young people have a clear understanding of HIV transmission and prevention ("Namibia research," Johns Hopkins, 2003). This should be looked into in further researches done along HIV studies that could contribute towards an HIV/AIDS prevention strategy developed for Namibian youth. References Campbell, D.T. & Stanley, J.C. (1963, 1966). Experimental and Quasi-Experimental Designs for Research. Rand McNally, Chicago, Illinois. Namibia Research Shows Most Youth Don't Understand the Terms "Abstinence" or "Faithfulness" for HIV Prevention. Center for Communication Programs (CCP). Johns Hopkins Bloomberg School of Public Health. May 27, 2003. Retrieved October 6, 2007, from http://www.jhuccp.org/pressroom/2003/05-27.shtml Neill, James. Analysis of Professional Literature. Last updated February 21, 2003. Retrieved October 6, 2007, from http://wilderdom.com/OEcourses/PROFLIT/Class5QuantitativeResearchDesignSamplingMeasurement.htm Stanton, B.F., Li, X,., Kahihuata, J., Fitzgerald, A.M., Neumbo, S. Kanduuombe, G., Ricardo, I.B., Galbraith, J.S., Terreri, N., Guevara, I. , Shipena, H., Strijdom, J. Clemens, R. & Zimba, R.F. Increased protected sex and abstinence among Namibian youth following a HIV risk-reduction intervention: a randomized, longitudinal study. AIDS 1998, Vol. 12 No. 18:2473-2480 Validity and Reliability. Data analysis. University of the West of England (UWE). Bristol. Last updated July 13, 2006. Retrieved October 6, 2007, from http://hsc.uwe.ac.uk/dataanalysis/quantIssuesValid.asp Read More