Replicating impact of a primary school HIV prevention programme: primary school action for better health, Kenya.

School-based programmes to combat the spread of HIV have been demonstrated to be effective over the short-term when delivered on a small scale. The question addressed here is whether results obtained with small-scale delivery are replicable in large-scale roll-out. Primary School Action for Better Health (PSABH), a programme to train teachers to deliver HIV-prevention education in upper primary-school grades in Kenya demonstrated positive impact when tested in Nyanza Province. This article reports pre-, 10-month post- and 22-month post-training results as PSABH was delivered in five additional regions of the country. A total of 26 461 students from 110 primary schools in urban and rural, middle- and low-income settings participated in this repeated cross-sectional study. Students ranged in age from 11 to 16 years, were predominantly Christian (10% Muslim), and the majority were from five different ethnic groups. Results demonstrated positive gains in knowledge, self-efficacy related to changes in sexual behaviours and condom use, acceptance of HIV+ students, endorsement of HIV-testing and behaviours to post-pone sexual debut or decrease sexual activity. These results are as strong as or stronger than those demonstrated in the original impact evaluation conducted in Nyanza Province. They support the roll-out of the programme across Kenyan primary schools.

Adherence practices among people living with HIV.

This paper offers a critique of patient-deficit models of adherence by examining the articulation of dosing schedules and food prohibitions with the structure of everyday lives. Interviews with 31 men and 4 women taking HAART show that doses associated with regular daily life events are most consistently taken, but many individuals rework official dosing guidelines around timing and food consumption. Barriers to adherence often arise from conflicting demands imposed by work schedules, different medications, food prohibitions, and even outright discrimination as in the case of US immigration policy. Adherence may be the outcome of compromises made in an effort to solve contradictory demands, and may be situational and related to the qualities of particular drugs, as much as to personality traits. Autobiographical narratives that give order to one's sense of self provide foundations upon which adherence decision making occurs. Finally, perceptions of drug effectiveness may lead to self-reinforcing adherence practices.

Exotic dancing and health.

The health and safety of women who work as exotic dancers are firmly embedded within the social organization of the strip club and the broader social, economic and political context of the work of exotic dancing. Exotic dancers in this study expressed health concerns associated with: the effects of costuming and appearance requirements; dirty work environments; problems due to stigmatization, sexual harassment and assault; and police disinterest or victim blaming. The balance between benefits and hazards related to exotic dancing is influenced not only by the personal choices made by dancers, but also by the organization of the strip club and the broader context within which exotic dancing takes place.

Social and cultural vulnerability to sexually transmitted infection: the work of exotic dancers.

This article examines the social and cultural factors that influence the vulnerability of female exotic dancers to sexually transmitted infections. Results are based on a qualitative, exploratory study using observations in 10 clubs and in-depth interviews with 30 dancers in southern Ontario. The social and cultural context within which exotic dancing takes place contributes to a chronic state of sexual harassment and sexual assault in the strip clubs. Women are pressured by economics and by their customers to engage in sex for pay. The defence mechanisms that some women use to deal with these work conditions also contribute to women's vulnerability. The social structure of strip clubs and their policies toward employees and customers can either reduce or exacerbate the vulnerability of dancers. Workplace policies and health and safety standards appear to be the most effective ways to decrease the vulnerability of dancers. Public health units can work with employers and dancers to establish workplace policies and programmes that contribute to the health and wellbeing of dancers.

Relaying the message of safer sex: condom races for community-based skills training.

This paper describes a community-based HIV prevention program designed to improve confidence in condom use skills by giving community members 'hands-on' experience in using condoms correctly. A condom race activity which had been effective in increasing condom skills confidence among university students in the US was modified and implemented with the general population in rural Northeast Thailand. In addition to providing training in condom use skills, the condom race was part of an integrated condom promotion and distribution campaign which responded to needs identified by the community, built upon the credibility and influence of local leaders and peers, and extended access to condoms into rural communities. Local leaders who had participated in a training-of-trainers program organized condom races in their communities, serving as positive role models for community acceptance of condom use. The condom race stimulated community discussion about condoms and increased participants' feelings of self-efficacy in correct condom use. Participation in the condom race activity was particularly empowering to women, who reported increased confidence in their ability to use condoms and to suggest using condoms with their partners after the race.

PIP: Incorrect condom use results in decreased confidence in the ability to use condoms and the perception that condoms are less effective in disease prevention. A community-based HIV prevention program in northeast Thailand sought to improve condom use skills and confidence through "hands-on" experience. Teams of men and women from rural villages participated in a relay race by properly putting a condom on a penis model while blindfolded, then removing the condom and passing the model and blindfold on to the next player on the team. The race coincided with the introduction of condom boxes at local shops. Trained village leaders were responsible for organizing the race in collaboration with local public health officials. To assess program impact, 160 interviews were conducted in 8 villages 6 weeks after the races. About 50% of those interviewed had attended the races and 22.7% of men and 14.9% of women had participated. Over 75% were aware condoms were now available in shops and 28.4% of men and 7.9% of women had accessed condoms through the boxes. A separate set of interviews held immediately before and after the race with 164 participants from 29 villages revealed significant changes--especially among women--in confidence in condom use self-efficacy and the ability to discuss condom use with a partner. Overall, the race created an environment of social support for condom use in rural communities in Northeast Thailand by stimulating community discussion.

Cattle markets and local festivals: development of HIV/AIDS prevention interventions for specific risk situations in rural northeast Thailand.

In rural Northeast Thailand, risk of sexual transmission of HIV is popularly perceived to be site-specific. Risk of HIV transmission in local scenarios like cattle markets and village festivals has not been adequately addressed. This paper assesses the use of community consultation and formative research to overcome prevailing assumptions about HIV risk by involving community members in the process of identifying risks and developing HIV prevention strategies. This participatory approach can be used to develop prevention programs that are responsive to the specific context of risk behavior in rural environments.

Toward reducing the spread of HIV in northeastern Thai villages: evaluation of a village-based intervention.

This paper presents results of the evaluation of an intervention designed for northeastern Thai villages and particularly for village women. The intervention was based on established principles of behavior change, social learning theory, and community health promotion, and it was grounded in elicitation research. A total of 600 women and 479 men and 12 villages participated in the evaluation which used data collected from face-to-face knowledge, attitude, practices (KAP) surveys, focus groups, and village meetings in a quasi-experimental pre- and post-control group design. Eight of the nine outcome goals set for the intervention were achieved with significant increases in married women taking the initiative in reducing the risk posed to them by the sexual activities of their husbands.

PIP: This paper describes and evaluates a 1994 intervention designed to reduce HIV transmission among villagers in northeastern Thailand. The report opens with an introduction which describes the progression of HIV/AIDS in the country. The HIV prevention intervention is then described as consisting of 1) an agreement between intervention providers and village leaders to establish a partnership to introduce the intervention and train volunteers as facilitators, 2) broadcast of a 5-day motivational audio-drama over village loudspeakers, and 3) a village meeting to institute village discussions of AIDS and plan further village strategies. Outcome goals for women, for men, and for the village as a whole included 1) villager identification of the program as a major source of information, 2) increased risk awareness, 3) increased reporting of risk-reduction behavior, 4) increased communication about HIV/AIDS, 5) identification with characters in audio-drama, 6) identification of HIV/AIDS as a community concern, and 7) creation by the villagers of additional strategies. Description of the evaluation methodology includes data collection from KAP interviews and focus groups and a sample survey. Results are presented for each of the preliminary goals, and it is concluded that the project intervention was successful. Modifications were made based on the evaluation results, and the strategy was adapted for large-scale intervention. Using a strategic approach guided by established theories of behavior change and community development ensured that the program was sensitive to the sociocultural framework presented by the targeted village.

Contexts and patterns of men's commercial sexual partnerships in northeastern Thailand: implications for AIDS prevention.

Results of an exploratory research project elaborating the contexts, patterns and specific scenarios of the commercial sexual activity of northeastern Thai men are reported. Data were collected using face-to-face surveys, focus groups, key informant interviews and observations in 32 northeastern villages (n = 744 men), 18 migrant labour camps housing sugarcane workers (n = 219 men), and five cattlemarkets in northeast Thailand. Fifty percent of married men and 43% of single men had visited female sex workers (FSW). Female sex worker visits occurred primarily prior to marriage, though 13% of married men had purchased sexual services within the past year. Nonmarital sexual activity was set within the socio-cultural frameworks of poverty, circular migration, a large commercial sex sector, and a belief system about men's sexuality and men's and women's gender roles. Sexual services were typically purchased as part of friendship group partying (paiy tiaow) and generally included heavy alcohol consumption. The most common scenario for visiting FSWs involved brothels, though cattlemarkets, festivals, and migrant labour situations were also scenarios for FSW contact. These each had unique characteristics that affected the likelihood that condoms would be used. The further the specifics of a scenario (as evaluated by men) diverged from those of brothel contact with an FSW, the less likely men were to identify this as having the potential for HIV transmission and the less likely they were to use a condom. AIDS prevention campaigns must be developed that are sensitive to the socio-cultural framework, contexts and specific scenarios within which nonmarital sexual contacts occur.

Evaluation of HIV/AIDS education initiatives among women in northeastern Thai villages.

A longitudinal, naturalistic experimental design was used in an evaluation of the effects of an HIV/AIDS educational pamphlet controlling for secular trends (most specifically media coverage of HIV/AIDS) in Northeastern Thailand. Nine hundred and fifty-four women from 18 villages completed KAP interviews either in the autumn of 1991 or 1992 with HIV/AIDS education pamphlets distributed to every household in 12 of these villages in the spring of 1992. Pamphlets influenced women's perceptions of personal risk from casual sources and the degree to which they volunteered that condoms were a means of prevention of HIV transmission. Both results were related to the content and style of presentation of information about sources of risk and about condoms in the pamphlets. Secular trends and an increase in communication between villagers had a significant influence on knowledge, perceived efficacy of self protection, readiness to use condoms, and perception of levels and sources of personal risk.

Canadian ethnocultural communities facing AIDS: overview and summary of survey results from phase 111

This paper describes the survey results reporting demographic profiles, behaviours, opinions beliefs, attitudes and intentions related to condom use for three Canadian ethnocultural communities (Latin American, English-speaking Caribbean and South Asian) participating in the Ethnocultural Communities facing AIDS Study. Specific recommendations are presented for HIV-prevention programming based on the research results (AU).

Understanding use of condoms among Canadian ethnocultural communities: methods and main findings of the survey

The aim of this study was to understand the intention to use a condom for each instance of sexual intercourse with a new partner in three of Canada's non-dominant ethnocultural communities: Latin American (N=346), English-speaking Caribbean (N=358), and South Asian (N=355). All respondents were recruited from multiple ethnocultural venues using predetermined sampling frames and quotas for each community. Anonymous questionnaire assessing culturally specific theoretical constructs were completed. This paper presents the methodology and the main findings. The high quality of the results of this study demonstrate the advantage of establishing strong partnerships with members of communities being studied (AU)

Many voices: sociocultural results of the ethnocultural communities facing AIDS study in Canada

This paper presents the results of Phase 11 of the Ethnocultural Communities facing AIDS Study, the sociocultural investigation of factors contributing to risk behaviour associated wih HIV/AIDS in six ethnocultural communities in Canada in three urban sites. In Vancouver, the South Asian and Chinese communities were studied, the Horn of Africa and English-speaking Caribbean communities in Toronto and the Latin American and Arab-speaking communities in Montreal. Results demonstrated that there are common elements across these ethnocultural communities that increase the risk for HIV transmission. HIV/AIDS awareness and prevention in ethnocultural communities must address sociocultural differences, particularly sex role differences between men and women in terms of power within relationships to negotiate for safer sexual practices (AU).

HIV/AIDS in the context of culture: selection of ethnocultural communities for study in Canada.

This article reports on the methodology used to select six ethnocultural communities invited to participate in subsequent phases of the project on HIV/AIDS in the context of culture in Canada. Selection was based on quantitative data on demography, qualitative assessment of ethnocultural cohesion; and quantitative data and qualitative data of exposure to risk for sexually transmitted disease. A principle of partnership insured that the final selection was completed by interaction between the investigators and the National Advisory Committee representing ethnocultural communities in Canada. The six communities asked to participate in Phase II of the study were: in Montreal, the Latin American and the Arabic-speaking communities; in Toronto, the English-speaking Caribbean communities and communities from the Horn of Africa; in Vancouver, the Chinese and the South Asian communities. The results are significant for the future both of research on ethnicity in Canada and of control of HIV and AIDS.

Participatory aspects in the qualitative research design of phase II of the ethnocultural communities facing AIDS study.

This paper describes the steps taken in generating and implementing a qualitative research design for Phase II of the Ethnocultural Communities Facing AIDS Study. Theoretically framed by the macro-level, sociocultural model of health behaviour developed by Kleinman, the methodological procedures are an adaptation of Scrimshaw's Rapid Assessment Procedures (RAP) and a participatory approach involving stakeholders from each ethnocultural community. Qualitative data-on behaviours conducive to HIV transmission in six ethnocultural communities in Canada-were elicited using a combination of key communicator interviews, focus groups, and participant observation techniques. Data were analyzed using systematic content analysis techniques. Inter-rater reliability checks and procedures of triangulation demonstrated the validity of evidence generated. A commitment to research partnership with community persons, and an accountability loop that provided assurances of how the data would be scientifically represented, were critical elements in the process of design construction.

Overview of the Canadian study on the determinants of ethnoculturally specific behaviours related to HIV/AIDS.

Canada's population is composed of heterogenous ethnocultural communities. There is a need for information and educational initiatives on HIV and AIDS directed specifically at these communities. For such interventions to be effective we must determine the existing personal and sociocultural factors related to HIV transmission. There has been little such research in Canada. In this supplement we report on various aspects of a study conducted between May 1992 and December 1994 to determine the factors related to HIV transmission in several ethnocultural communities. This paper describes some innovative aspects of the project: the conceptual framework, the community participatory model, the use of a multi-method research design, and the ongoing communication strategy. The combination of these elements makes the study unique. The value of the study lies not only in the information obtained but also in the model it provides for future research in other settings.

Many voices--sociocultural results of the ethnocultural communities facing AIDS study in Canada.

This paper presents the results of Phase II of the Ethnocultural Communities Facing AIDS Study, the sociocultural investigation of factors contributing to risk behaviour associated with HIV/AIDS in six ethnocultural communities in Canada in three urban sites. In Vancouver, the South Asian and Chinese communities were studied, the Horn of Africa and English-speaking Caribbean communities in Toronto and the Latin American and Arabic-speaking communities in Montreal. Results demonstrated that there are common elements across these ethnocultural communities that increase the risk for HIV transmission. HIV/AIDS awareness and prevention in ethnocultural communities must address sociocultural differences, particularly sex role differences between men and women in terms of power within relationships to negotiate for safer sexual practices.

Understanding use of condoms among Canadian ethnocultural communities: methods and main findings of the survey.

The aim of this study was to understand the intention to use a condom for each instance of sexual intercourse with a new partner in three of Canada's non-dominant ethnocultural communities: Latin American (N = 346), English-speaking Caribbean (N = 358), and South Asian (N = 355). All respondents were recruited from multiple ethnocultural venues using predetermined sampling frames and quotas for each community. Anonymous questionnaires assessing culturally specific theoretical constructs were completed. This paper presents the methodology and the main findings. The high quality of the results of this study demonstrate the advantage of establishing strong partnerships with members of communities being studied.

PIP: During April-May 1994, in Canada, 346 members of the Latin American community aged 18-49, 358 members of the English-speaking Caribbean community aged 16-49, and 355 members of the South Asian community aged 18-45 completed a questionnaire developed by the Research Group on Psychosocial Aspects of Health Behavior at Laval University in Quebec. This study aimed to identify the variables influencing intention to use a condom for each instance of sexual intercourse with a new partner in three nondominant ethnocultural communities. 81% of Latin Americans, 75% of the Caribbeans, and 71% of the South Asians intended to use a condom for each instance of sexual intercourse with a new partner during the next 3 months. Yet, among people who had had sex with a new partner in the last year, only 30% of Latin Americans, 28% of the Caribbeans, and 47% of South Asians always used a condom. Significant predictors of intent to use a condom in each instance of sexual intercourse with a new partner were personal normative belief (a measure of the personal feelings of moral obligation or responsibility to use or refuse to use a condom), perceived behavioral control, and role beliefs (p .0001). For the Latin American community, these three constructs explained 70.7% of the variance (partial R2 = 51.1% for personal normative belief, 10% for role beliefs, and 4.1% for perceived behavioral control). For the English-speaking Caribbean community, they explained 51% of the variance (partial R2 = 35.7% for personal normative belief, 11.9% for perceived behavioral control, and 3.5% for role beliefs). For the South Asian community, they accounted for 76% of the variance (partial R2 = 63.5% for perceived behavioral control, 9.4% for personal normative belief, and 3.1% for role beliefs). These findings serve as a basis for recommendations for the prevention of HIV transmission among the participating ethnocultural communities.

Canadian ethnocultural communities facing AIDS: overview and summary of survey results from phase III.

This paper describes the survey results reporting demographic profiles, behaviours, opinions, beliefs, attitudes, and intentions related to condom use for three Canadian ethnocultural communities (Latin American, English-speaking Caribbean and South Asian) participating in the Ethnocultural Communities Facing AIDS Study. Specific recommendations are presented for HIV-prevention programming based on the research results.

Multisectoral strategy for AIDS prevention at community level.

In north-east Thailand a five-act drama is broadcast on the village sound system to catalyse involvement in planning and carrying out AIDS prevention activities. Each community's own suggestions for an effective strategy are presented to the relevant government and nongovernmental agencies for endorsement and support.

PIP: The multisectoral AIDS prevention strategy (MAPS) was implemented in four northeastern provinces of Thailand where a very developed infrastructure for health, education, and social welfare exists. (MAPS entails use of integrated government and nongovernmental AIDS-related services to conduct community-defined initiatives.) An audio-drama was used to introduce MAPS at the community level. It included risks, precautions, local beliefs, and modes of personal interaction pertaining to prevention of the spread of AIDS. The five-act audio-drama was entitled On the Brink and was broadcast over each of the 43 communities' public address systems. It revolved around the needs of married women in relation to AIDS prevention and addressed how men and rural people in general are involved. The stages of the MAPS program were a pre-drama subdistrict meeting, a week of drama in the communities, a post-drama community meeting to discuss a community AIDS strategy, a post-drama subdistrict meeting to present and consolidate the strategy, and implementation of the strategy. Three teams implemented MAPS. The post-drama community meetings began with games and a quiz on AIDS with small prizes to encourage participation in discussions. Identified local HIV risk situations included brothels, cattle auctions, certain festivals during which prostitution occurs, and intravenous drug use among young men. The first priority identified in all the subdistricts was open and free availability of condoms (e.g., available where alcohol is sold). Other suggested interventions were publicity about the danger of commercial sex work and training for women whose husbands travel in developing sexual negotiation skills. During the post-drama subdistrict meeting, an AIDS implementation committee was chosen to coordinate AIDS prevention activities conducted by both the government and nongovernmental organizations' staff in the subdistrict.

Alternative cut-point scores for the CAST-6.

Alternative cut-point scores for the CAST-6, a shortened version of the Children of Alcoholics Screening Test, are examined in three samples: outpatient substance abusers, outpatient psychiatric patients, and medical students. Hit rates for identification are maximized with a lower cut-point for medical students and a higher cut-point for a sample of individuals seeking outpatient treatment for substance abuse. Either cut-point yields equivalent results in an outpatient psychiatric sample.