A health promotion approach to emergency management: effective community engagement strategies from five cases.

Community engagement is crucial for controlling disease outbreak and mitigating natural and industrial disasters. The COVID-19 pandemic has reconfirmed the need to elevate community engagement to build equity, trust and sustained action in future health promotion preparedness strategies. Using the health promotion strategy of strengthening community action enhances the opportunity for better outcomes. There is, therefore, a need to improve our understanding of community engagement practices during crises, scale-up good community engagement initiatives, and improve and sustain people-centered approaches to emergency responses. This paper presents five case studies from the United States, Singapore, Sierra Leone, Kenya and South Africa that demonstrate the potential strengths that can be nurtured to build resilience in local communities to help mitigate the impact of disasters and emergencies. The case studies highlight the importance of co-developing relevant education and communication strategies, amplifying the role of community leaders, empowering community members to achieve shared goals, assessing and adapting to changing contexts, pre-planning and readiness for future emergencies and acknowledgement of historic context.

Sociocognitive Predictors of Condom Use and Intentions Among Adolescents in Three Sub-Saharan Sites.

Many HIV intervention programs in sub-Saharan Africa have applied social cognitive theories such as the theory of planned behavior. However, a recent sub-Saharan African review was unable to show increased effectiveness for theory-based interventions. This study assessed whether the predictive value of attitudes, subjective norms, self-efficacy, and intention was similar to studies in Europe and the U.S., and whether there were differences between three sub-Saharan sites. Longitudinal multigroup structural equation modeling was used to assess whether attitudes, subjective norms, and self-efficacy predicted condom use intentions and condom use (after 6 months) among adolescents in three sites, namely Cape Town (South Africa; N = 625), Dar es Salaam (Tanzania; N = 271), and Mankweng (South Africa; N = 404). Condom use intentions were predicted by subjective norms and self-efficacy in all three sites. Attitudes were not related to intentions in Dar es Salaam and were moderately related to intentions in Cape Town and Mankweng. The proportions of explained variance in intentions and behavior were decent (37-52 and 9-19%, respectively). Although significant differences in predictive value were found between sites and in comparison to European and U.S. studies, intentions could adequately be explained by attitudes, subjective norms, and self-efficacy. However, the limited proportions of variance in behavior explained by intentions could signify the importance of contextual and environmental factors. Future studies are recommended to use an integrative approach that takes into account both individual and contextual factors, as well as social and environmental differences.

Social Cognition Variables and Victimization as Predictors of Sexual Debut Among Adolescents in South Africa and Tanzania: A Multi-group SEM Analysis.

Early sexual debut is common in South Africa and Tanzania, with potentially negative reproductive health outcomes. The role of violence as a predictor of sexual debut was studied, in a context of predictors borrowed from social cognition models. Data were taken from cluster-randomized trials of school-based HIV prevention interventions in three sites in South Africa and Tanzania. Analyses consisted of descriptive statistics and multi-group structural equation modelling. The basic model functioned fairly well for Cape Town, but less well for Mankweng and Dar es Salaam (low R(2) values). Attitudes were the strongest predictor of intention. Adding socio-demographic variables to the model did not reduce the associations much and neither did subsequent inclusion of violence. Sexual debut was strongly associated with victimization; adding violence also substantially increased R(2) for sexual debut. Besides social cognition factors, intimate partner violence should be addressed in future research on reproductive health interventions for adolescents.

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.

Promoting sexual and reproductive health among adolescents in southern and eastern Africa (PREPARE): project design and conceptual framework.

BACKGROUND: Young people in sub-Saharan Africa are affected by the HIV pandemic to a greater extent than young people elsewhere and effective HIV-preventive intervention programmes are urgently needed. The present article presents the rationale behind an EU-funded research project (PREPARE) examining effects of community-based (school delivered) interventions conducted in four sites in sub-Saharan Africa. One intervention focuses on changing beliefs and cognitions related to sexual practices (Mankweng, Limpopo, South Africa). Another promotes improved parent-offspring communication on sexuality (Kampala, Uganda). Two further interventions are more comprehensive aiming to promote healthy sexual practices. One of these (Western Cape, South Africa) also aims to reduce intimate partner violence while the other (Dar es Salaam, Tanzania) utilises school-based peer education. METHODS/DESIGN: A modified Intervention Mapping approach is used to develop all programmes. Cluster randomised controlled trials of programmes delivered to school students aged 12-14 will be conducted in each study site. Schools will be randomly allocated (after matching or stratification) to intervention and delayed intervention arms. Baseline surveys at each site are followed by interventions and then by one (Kampala and Limpopo) or two (Western Cape and Dar es Salaam) post-intervention data collections. Questionnaires include questions common for all sites and are partly based on a set of social cognition models previously applied to the study of HIV-preventive behaviours. Data from all sites will be merged in order to compare prevalence and associations across sites on core variables. Power is set to .80 or higher and significance level to .05 or lower in order to detect intervention effects. Intraclass correlations will be estimated from previous surveys carried out at each site. DISCUSSION: We expect PREPARE interventions to have an impact on hypothesized determinants of risky sexual behaviour and in Western Cape and Dar es Salaam to change sexual practices. Results from PREPARE will (i) identify modifiable cognitions and social processes related to risky sexual behaviour and (ii) identify promising intervention approaches among young adolescents in sub-Saharan cultures and contexts. TRIAL REGISTRATIONS: Controlled Trials ISRCTN56270821 (Cape Town); Controlled Trials ISRCTN10386599 (Limpopo); Clinical Trials NCT01772628 (Kampala); Australian New Zealand Clinical Trials Registry ACTRN12613000900718 (Dar es Salaam).

Condom use and sexuality communication with adults: a study among high school students in South Africa and Tanzania.

BACKGROUND: Fostering adolescents' communication on sexuality issues with their parents and other significant adults is often assumed to be an important component of intervention programmes aimed at promoting healthy adolescent sexual practices. However, there are few studies describing the relationship between such communication and sexual practices, particularly in sub-Saharan Africa. This study examined the relationships between adolescents' communication with significant adults and their condom use in three sites in this region. METHODS: Data stem from a multi-site randomized controlled trial of a school-based HIV prevention intervention implemented in Cape Town and Mankweng, South Africa and Dar es Salaam, Tanzania. Only data from comparison schools were used. The design is therefore a prospective panel study with three waves of data collections. Data were collected in 2004 from 6,251 participants in 40 schools. Associations between adolescents' communication with adults about sexuality issues and their use of condoms were analysed cross-sectionally using analysis of variance, as well as prospectively using multiple ordinal logistic regression analysis. RESULTS: Cross-sectional analyses showed that consistent condom users had significantly higher mean scores on communication (across topics and communication partners) than both occasional users and never-users, who had the lowest scores. After controlling for condom use at the first data collection occasion in each model as well as for possible confounders, communication scores significantly predicted consistent condom use prospectively in all three ordinal logistic regression models (Model R(2) = .23 to .31). CONCLUSION: The findings are consistent with the assertion that communication on sexuality issues between adolescents and significant adults results in safer sexual practices, as reflected by condom use, among in-school adolescents. The associations between communication variables and condom use might have been stronger if we had measured additional aspects of communication such as whether or not it was initiated by the adolescents themselves, the quality of advice provided by adults, and if it took place in a context of positive adult-adolescent interaction. Studies with experimental designs are needed in order to provide stronger evidence of causality.

Associations between attitudes toward violence and intimate partner violence in South Africa and Tanzania.

Attitude change approaches are common in the prevention of intimate partner violence (IPV) among adolescents. This study examined associations between perpetration or victimization and attitudes toward IPV with data from a longitudinal randomized controlled trial (RCT) of an HIV prevention intervention among school students in three sites in South Africa and Tanzania. Data analyses were confined to students from the control group only, and to those with experience with romantic relationships. Boys and those more involved with violence reported more violence-supportive attitudes. For Cape Town (and to some extent Mankweng), the results of prospective prediction are consistent with the notion of a bidirectional attitudes-behavior interrelationship. For Dar es Salaam attitudes predicted behavior prospectively; however, prediction in the opposite direction was not confirmed. These results indicate that attitude change strategies may be useful complementary to structural approaches also in global South settings, although their effectiveness may vary.

Community influences on adolescents' use of home-brewed alcohol in rural South Africa.

BACKGROUND: Alcohol represents a major public health challenge in South Africa, however little is known about the correlates of alcohol use among rural adolescents. This article examines community influences on adolescents' use of home-brewed alcohol in a rural region of South Africa. METHOD: A total of 1600 high school adolescents between 11 and 16 years of age participated in this study. Seven hundred and forty (46.3%) were female and 795 (49.7%) were male. Data on gender were missing for 65 students (4.0% of the sample). The age range was 11-29 years (mean age 16.4 years; Standard deviation = 2.79). A survey questionnaire on adolescent risk behavior that examined adolescents' use of alcohol and various potential community influences on alcohol use was administered. Factor analysis was used to group community-level variables into factors. Multiple logistic regression techniques were then used to examine associations between these community factors and adolescents' use of home-brewed alcohol. RESULTS: The factor analysis yielded five community-level factors that accounted for almost two-thirds of the variance in home-brewed alcohol use. These factors related to subjective adult norms around substance use in the community, negative opinions about one's neighborhood, perceived levels of adult antisocial behavior in the community, community affirmations of adolescents, and perceived levels of crime and violence in the community (derelict neighborhood). In the logistic regression model, community affirmation was negatively associated with the use of home-brew, whereas higher scores on "derelict neighborhood" and "adult antisocial behavior" were associated with greater odds of drinking home-brew. CONCLUSION: Findings highlight community influences on alcohol use among rural adolescents in South Africa. Feeling affirmed and valued by the broader community appears to protect adolescents against early alcohol use. In contrast, perceptions of high levels of adult anti-social behavior and crime and violence in the community are significant risks for early alcohol initiation. Implications of these findings for the prevention of alcohol use among adolescents in rural communities are discussed.

Pilot Health Promoting Hospital in rural South Africa: evidence-based approach to systematic hospital transformation.

This project aimed at transforming a rural District Hospital in the Limpopo Province of South Africa into a Health Promoting Hospital according to standards developed by WHO-Europe. The intervention used a diagnostic approach and baseline needs assessment of hospital staff, patients, and their relatives to identify health education and promotion needs. Activities included empowerment training and skills development, implementation of health education and promotion activities, and the integration of health-promoting standards and values in the hospital structure and culture. The project indicated applicability of the model in a resource-limited setting, based on staff empowerment, local leadership, and stakeholder engagement.

The association between students' perceptions of a caring teacher and sexual initiation. A study among South African high school students.

This paper has the following aims: (i) to explore the extent to which students who received an intervention involving HIV/AIDS and sexuality perceived that their teacher cared for their health and well-being, (ii) to investigate the characteristics of students who reported to have caring teachers and (iii) to document the association between students' perceptions of care and reported onset of sexual activity. Data were obtained from the second follow-up survey of a prospective study carried out among high school students in South Africa (Cape Town and Mankweng). We analyzed data from 3483 students who met the inclusion criteria. Students from the intervention group perceived greater care from teachers than students in the control group. Female students and students from Cape Town perceived having received more care, and their perception of care was associated with the number of lessons received, how often students expressed their opinions in class and how often teachers talked about HIV/AIDS, condoms and abstinence. Students who perceived that their teacher cared for their health and well-being were less likely to initiate sexual intercourse. This is the first paper to demonstrate the salience of the concept of care in studies of school-based HIV/AIDS prevention programs in sub-Saharan Africa.

An HIV/AIDS knowledge scale for adolescents: item response theory analyses based on data from a study in South Africa and Tanzania.

A 14-item human immunodeficiency virus/acquired immunodeficiency syndrome knowledge scale was used among school students in 80 schools in 3 sites in Sub-Saharan Africa (Cape Town and Mankweng, South Africa, and Dar es Salaam, Tanzania). For each item, an incorrect or don't know response was coded as 0 and correct response as 1. Exploratory factor analyses based on polychoric correlations showed two separate factors for all sites. Two-parameter item response theory (IRT) analysis (bifactorial multiple indicators multiple causes confirmatory factor analysis models) consistently showed a general first factor and a second 'method' factor. One single global latent variable seemed to sufficiently well capture most of the systematic variation in knowledge. Some items did not discriminate well between levels of the underlying knowledge latent variable and information values were highest for low levels of knowledge. The scale might be improved by adding items, in particular items that are more difficult to answer. Some differential item functioning effects related to site and socioeconomic status were identified. Scores on the latent knowledge variable were particularly low among females in Dar es Salaam and Mankweng, and were negatively associated with socioeconomic status. This study illustrates advantages of using IRT analysis instead of more conventional approaches to examining psychometric properties of knowledge scales.

Advances in health promotion in Africa: promoting health through hospitals.

A district hospital in a rural area of the Limpopo Province in South Africa has recently been launched as a 'Health Promoting Hospital', based on the principles of the Ottawa Charter and according to standards developed by WHO-Europe. The initiative was conceived as a project in partnership with stakeholders from the local community and is considered a pilot by Provincial health authorities, representing an advance in health promotion practice in the region. The project was designed as a research intervention, guided by the principles of critical action research integrated with the Precede-Proceed model for the systematic evaluation of health promotion and education. This commentary reports on the process undertaken in successfully transforming this community-based hospital into a Health Promoting Hospital by integrating the concept, values and standards of health promotion into its structure and culture, thereby creating a healthy setting and promoting the health and wellbeing of the hospital's staff, its patients, and their relatives.

Parental education as an indicator of socioeconomic status: improving quality of data by requiring consistency across measurement occasions.

AIMS: Adolescents' reports of parents' education are sometimes used as indicators of socioeconomic status in surveys of health behaviour. The quality of such measurements is questionable. We hypothesized that consistent reporting of parents' education across measurement occasions in prospective panel studies indicates a higher quality of data than single or inconsistent reports. METHODS: A multi-site, prospective panel study (three measurement occasions) was carried out among adolescents in Cape Town and Mankweng (South Africa), and Dar es Salaam (Tanzania). Analyses were based on data from students participating at baseline and with a valid code for school number (n = 15,684). RESULTS: For Cape Town and Dar es Salaam students, the associations between parents' education and an alternative indicator of socioeconomic status (both measured at baseline) increased with increasing consistency of reports about parents' education across measurement occasions. For Cape Town, the associations of father's education with a range of behavioural and social cognition variables were significantly stronger among ;;consistent'' than among other students. The pattern was the same for mother's education, but with fewer significant interaction effects. CONCLUSIONS: Requiring consistency of reports across data-collection occasions may, under the right combination of circumstances, make a difference. Insignificant and "close to zero'' associations may turn out to be at least moderately strong and statistically significant. When applying indicators of socioeconomic status, such as parents' highest level of completed education, it is most advantageous to use data from prospective panel studies, and to check for consistency of answers across measurement occasions.

Teachers' confidence in teaching HIV/AIDS and sexuality in South African and Tanzanian schools.

AIMS: This study aimed to investigate how confident and comfortable teachers at Tanzanian and South African urban and rural schools are in teaching HIV/AIDS and sexuality. It also aimed at identifying factors associated with teacher confidence and investigated how reported confidence was associated with the implementation of educational programmes on HIV/AIDS and sexuality. METHODS: A survey was conducted among South African grade 8 and 9 Life Orientation teachers, and among science teachers for grade 5 to 7 in public primary schools in Tanzania. Teachers' confidence levels were measured on a four-item scale (0-3). RESULTS: A total number of 266 teachers participated in a survey in 86 schools in South Africa and Tanzania. Overall, teachers report to be rather confident in teaching HIV/AIDS and sexuality. Tanzanian teachers reported higher levels of confidence then did their South Africa colleagues (2.1 vs. 1.8; p < 0.01). Confidence in teaching was significantly associated with the numbers of years teaching HIV/AIDS and sexuality, formal training in these subjects, experience in discussing the topics with others, school policy and priority given to teaching HIV/AIDS and sexuality at school. Finally, confidence in teaching remained positively associated with self-reported successful implementation of school-based programmes after adjusting for gender, age, religion and numbers of years teaching HIV/AIDS and sexuality. CONCLUSIONS: Across urban and rural sites in South Africa and Tanzania teachers reported to be fairly confident in teaching HIV/AIDS and sexuality. Further strengthening of their confidence levels could, however, be an important measure for improving the implementation of such programmes.

Sociodemographic variations in communication on sexuality and HIV/AIDS with parents, family members and teachers among in-school adolescents: a multi-site study in Tanzania and South Africa.

AIMS: To identify with whom in-school adolescents preferred to communicate about sexuality, and to study adolescents' communication on HIV/AIDS, abstinence and condoms with parents/guardians, other adult family members, and teachers. METHODS: Data were obtained from a baseline questionnaire survey carried out in South Africa (Cape Town and Mankweng) and Tanzania (Dar es Salaam) in early 2004. We analysed data for 14,944 adolescents from 80 randomly selected schools. The mean ages were as follows: Cape Town, 13.38 years (standard deviation (SD) 1.15); Mankweng, 13.94 years (SD 1.35); and Dar es Salaam, 12.94 years (SD 1.31). RESULTS: Adolescent females preferred to receive sexuality information from their mothers, while among males there was a higher preference for fathers in two sites. Thirty-seven per cent, 41% and 29% reported never or hardly ever communicating about sexuality with parents, other adult family members, and teachers, respectively. "Silence'' was more prevalent in Dar es Salaam than in the other two sites. The odds of "never or hardly ever'' communicating with parents in Dar es Salaam were higher among girls than among boys (p < 0.01). For the two South African sites, boys had significantly higher odds of experiencing silence than did girls (both p < 0.001), and socioeconomic status was positively associated with parent-adolescent sexuality communication. In the logistic regression models, explained variation (Nagelkerke's R(2)) across sites ranged from 0.013 to 0.032. CONCLUSIONS: In all three sites, a substantial proportion of adolescents reported not communicating with their parents about HIV/AIDS, abstinence, or condoms. The low proportion of explained variation in sexuality communication implies that silence is common across sociodemographic subgroups.

Correlates of intention to use condoms among Sub-Saharan African youth: the applicability of the theory of planned behaviour.

AIMS: To test the applicability of an extended version of the theory of planned behaviour for the study of condom use intentions among large samples of young people in South Africa and Tanzania. METHODS: Baseline data of a randomized controlled trial of school-based HIV/AIDS prevention programmes were used. The setting comprised secondary schools in the regions of Cape Town, Polokwane and Dar es Salaam. Participants were 15,782 secondary school students. The main measures were scales for intentions, knowledge, risk perceptions, attitudes, perceived social norms and perceived self-efficacy regarding condom use. RESULTS: Seven variables accounted for 77% of the variance in intentions to use condoms: attitudes (beta = 0.17), injunctive norms (beta = 0.27), self-efficacy (beta = 0.41), gender (lower condom use intentions among females), being a student at the Dar es Salaam site (lower scores than students in Cape Town and Polokwane), socioeconomic status (higher intentions with higher status), and access to condoms (higher intentions with higher access). CONCLUSIONS: Our results are comparable to those of studies conducted in Europe and the USA. Social cognition models such as the theory of planned behaviour are applicable in understanding the correlates of condom use intentions in African contexts.

Dating violence among school students in Tanzania and South Africa: prevalence and socio-demographic variations.

AIMS: Widespread adolescent dating violence (DV) in Sub-Saharan Africa calls for immediate action, particularly since it is linked to the spread of HIV/AIDS. This article presents prevalence and demographic correlates of DV among school students in Cape Town and Mankweng (South Africa) and Dar es Salaam (Tanzania). METHODS: Data were derived from the baseline data collection of a multi-site randomized controlled trial of an HIV prevention intervention among young adolescents. The results were confined to students who reported previously or currently being in a relationship (n = 6,979). Multiple logistic regression analysis with demographic predictors was employed, controlled for cluster effect. RESULTS: Within our sample 10.2%-37.8% had been victims, 3.1%-21.8% had been perpetrators, and 8.6%-42.8% had been both (percentages dependent on site and gender). Before controlling for other factors, religion was a protective factor against violence in Cape Town. After controlling for other factors, a higher age and lower socioeconomic status were associated with belonging to any of the three groups of violence. Being male in all sites was associated with perpetration; being female with victimization (except in Cape Town where the converse finding was obtained). Higher parental education in Cape Town was protective against all types of violence. Ethnicity and living with biological parents were not associated with violence. CONCLUSIONS: DV is prevalent and widespread in the study sites. Violence control policies and interventions should target young adolescents. Since there was not one clearly defined subgroup identified as being at high risk, such programmes should not be limited to high risk groups only.

Social outcome expectations regarding delayed sexual debut among adolescents in Mankweng, South Africa.

AIMS: To describe outcome expectations related to delayed sexual transition, to examine the dimensionality and internal consistency of such expectations, and to examine variations in social outcome expectations across subgroups defined by demographic variables, indicators of socioeconomic status and predictors related to school and educational ambitions. METHODS: Data stem from a survey among school students (grades 8-12) in Mankweng, Limpopo, South Africa (n = 5,697). A five-item scale of outcome expectations was analysed with frequency and percentage distributions, principal components analysis, Cronbach's alpha, and general linear model procedures, while controlling for the cluster nature of the sample (school classes). RESULTS: Four items formed a component on negative social outcome expectations (SOE) related to delayed sexual transition. The internal consistency of the SOE scale proved adequate. Negative SOEs increased with age, were higher among males than females, and decreased with father's education. Negative expectations were high among students who had repeated a school year due to failing exams, among those who did not expect to complete schooling up until grade 12, and among students who reported absence from school. DISCUSSION: Negative social outcome expectations related to delayed sexual transition have elsewhere been shown to be important in predicting actual transition. The present study shows that there is considerable room for positive changes in such expectations. Negative SOEs may contribute to explaining demographic and socioeconomic variations in sexual transition. CONCLUSIONS: Social outcome expectations deserve more attention in programmes aimed at promoting sexual- and reproductive health.