Additional outcomes

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Additional outcomes are summarized in Table 7.4 and described below.

7.3.1.1 Access to information: changes in knowledge

Of the nine studies reporting data on knowledge of HIV transmission and prevention, four measured increased knowledge of modes of HIV/AIDS transmission. In China, study C (7) showed large, significant differences -measured both before and after the intervention - in knowledge of modes of transmission, including sexual intercourse (77% before versus 95% after), having multiple sexual partners (69% before versus 93% after) and sharing needles for drug use (67% before versus 95% after). Similarly large differences were found for rejecting incorrect modes of transmission, and all knowledge measures were significantly different from the control group. The "Tsa Banana" campaign in Botswana (study G) (11) showed mixed results on the item, "sexually active people risk getting infected with HIV," with males showing significant improvements in knowledge (adjusted odds ratio = 3.2) and females showing no significant improvement. In Guinea, study E (9) reported levels of knowledge of transmission of 90-96% among the control groups, leaving little room for improvement in the intervention group. One study of HIV programmes in South Africa (study L) (19) reported a positive association between a low score on an AIDS knowledge index and exposure to "Soul Buddyz" (a programme within the Soul City intervention aimed at children aged 8-12 years) in South Africa.

The one study measuring knowledge of abstinence as a prevention technique, the "HEART" campaign in Zambia (study I) (13), showed significantly higher knowledge among those who had the seen the campaign compared with those who had not (66% of males exposed to the campaign versus 53% of males not exposed; 65% for females exposed versus 55% for females not exposed). Three of the five studies measuring knowledge of condoms as a prevention method showed large and significant differences between intervention and comparison groups (studies B, C and M) (6, 7, 20). The Soweto Adolescent Reproductive Health Programme (study M) (20) reported a significant jump in the knowledge that condoms can prevent HIV transmission, from 60% pre-intervention to 85% post-intervention; study C (7), "HIV Prevention and Education in Rural China" also found a substantial improvement in this type of knowledge (a change from 46% to 94% in the intervention group versus 44% to 49% for the control group).

The one study measuring a response to the statement "there is a cure for AIDS" (study L in South Africa) (17) found significant increases in disagreement with the statement post-intervention (change from 79% pre-intervention to 89% post-intervention). Of five studies reporting on responses to the statement that "you can tell someone has HIV/AIDS by the way that they look," only study C (7) in China showed a significant improvement between intervention and control groups from pre-intervention to post-intervention.

7.3.1.2 Access to skills: self-efficacy to pursue preventive behaviours

Two evaluations measured young women's self-efficacy in pursuing abstinence or refusing to have sex with someone who offered gifts. Study K (16) in Côte d'Ivoire showed significant differences in self-efficacy across those with low levels of exposure to the campaign compared with those who had high levels of exposure, while study O (22) in Ghana did not detect significant differences across levels of exposure. However, all four studies investigating self-efficacy in using condoms or convincing a sexual partner to use condoms showed significant differences between the intervention and comparison groups (7, 13, 16, 22). Those who were highly exposed to the "Stop AIDS Love Life" campaign in Ghana (study O) (22) had significantly higher scores on a scale of 1-6 measuring condom-related self-efficacy than those who were not exposed to the campaign (3.9 for males exposed to the campaign versus 2.9 for males not exposed; 3.0 for females exposed versus 1.6 for females not exposed). Similarly, those who were exposed to a campaign in Côte d'Ivoire (study K) (16) were significantly more likely to report self-efficacy in terms of consistent condom use than those who were not exposed (58% of those with no exposure used condoms consistently versus 70% of those with low exposure versus 75% of those with high exposure). In study C in China (7), both the intervention and the control groups showed increases in their confidence about their abilities to convince sexual partners to use condoms, but the increase for the intervention group was significantly larger

(83% to 92% among the intervention group versus 78% to 84% among the control group).

7.3.1.3 Access to health services: awareness and utilization

All four campaigns that measured awareness of a health product or service showed significant positive differences between interventions and controls. Variables measured included awareness of an AIDS hotline in study A (5) in Saint Vincent and the Grenadines (91% of the intervention group versus 75% of the controls), and in study I (13) in Zambia the availability of voluntary counselling and testing (79% for males in the intervention group versus 67% for male controls; 84% for females in the intervention group versus 64% for female controls) and places where condoms could be purchased (81% intervention versus 72% controls). Other variables measured included the location of condom vendors in study E in Guinea (9) (86% for males in the intervention group versus 57% for male controls; 59% for females in the intervention group versus 22% for female controls). However, awareness did not necessarily translate into utilization; no significant differences were found in the use of the AIDS hotline in Saint Vincent and the Grenadines (5), and study D in Cameroon (8) reported no significant differences in visits to health centres between the intervention and control groups. In Zimbabwe, study F (10) reported that members of intervention groups were significantly more likely to attend health centres than controls (28% versus 10%) and more likely to attend youth services (11% versus 2%). In South Africa, study J (14) reported that those exposed to the loveLife campaign were significantly more likely than those who had not been exposed to have ever been tested for HIV (16% versus 10%).

7.3.1.4 Decreasing vulnerability

Perception of personal risk

None of the four evaluations reporting data on the perception of personal risk of HIV/AIDS showed a consistent and significant difference (studies D, E, H, I) (8, 9, 12, 13).

Social norms

Eight of the 15 studies reported measures of social norms; these measures were highlighted especially by data for the broad-based media efforts of Soul City in South Africa (study L) (17) and the global Staying Alive campaign (study N) (21). Evaluation of the Soul City programme (study L) (17, 18) found significant desirable changes in all norms tested before and after the campaign, including disagreement with the expectation that a woman would have sex with a man without using a condom (59% disagreed with the statement pre-intervention and 65% disagreed post-intervention). The Soul city evaluation also found that participants disagreed with the idea that boys or men have the right to have sex with their girlfriends if they buy them gifts (65% pre-intervention versus 73% post-intervention) (17). The global Staying Alive campaign reported more varied results; positive associations with campaign exposure were shown for the importance of using a condom, discussing HIV with a sexual partner and getting tested for HIV. However, norms regarding tolerance toward people living with HIV/AIDS did not show similar positive associations (21).

After the PRISM media campaign in Guinea, young people, parents, health workers, community leaders, religious leaders and members of established social networks were significantly more likely to report that their community was open to discussing young people's reproductive health questions than the year before campaign (study E) (9). In Cameroon, study D (8) reported that the proportion of youths that often discussed sexuality or contraceptives was significantly higher among the intervention group (0.897 versus 0.774). Study K in Côte d'Ivoire (16) reported significantly higher perceptions of peer support for abstinence among those who were highly exposed to the campaign compared with those who were not exposed (62% versus 53%).

In study O in Ghana (22), the percentage of youths who believed that their friends approved of avoiding or delaying sexual activity decreased significantly from before the intervention to after the intervention (60% versus 42% for males; 61% versus 36% for females); however, those who had higher exposure to the Ghana Stop AIDS Love Life campaign were significantly more likely to believe that their friends approved of delaying or avoiding sex than those with no exposure (52% of males with high exposure versus 27% of males with no exposure; 47% of females with high exposure versus 26% of females with no exposure).

In study A (5) in Saint Vincent and the Grenadines, some measures of social norms showed improvement after a radio campaign while others did not. Although campaign listeners and non-listeners were equally likely to report that their friends, parents or most people important to them thought that they should use condoms, campaign listeners were significantly more likely than non-listeners to report that their friends used condoms (46% for listeners versus 22% for non-listeners).

7.3.1.5 Decreasing prevalence as measured by proximate behavioural determinants

Abstinence

The age of sexual debut or current or continued abstinence was evaluated for six programmes. Two showed significant effects (10, 13); two did not (20, 22); and two showed mixed results (8, 12). Study F (10) in Zimbabwe found that 53% of those in the intervention sites "said no to sex" compared with 32% in the comparison sites; however no differences were found for participants' responses to "stopped having sex due to the campaign".

Number of sexual partners

Of the five studies reporting on whether the number of sexual partners was reduced, four showed equivocal or null results (7, 8, 12, 22). However, study F in Zimbabwe (10) showed a marked change, with 20% of respondents in the intervention group reporting that they had had only one partner during the recall period compared with 2% of the control group.

Condom use

Twelve programmes reported on condom use, with eight reporting on condom use during last sexual episode. Of these eight, five showed significant differences between intervention and comparison groups (7, 9, 12, 13, 22). The largest effects were reported by study O (22) in Ghana, which found that those who were highly exposed to the campaign were several times more likely than those who were not exposed to report using a condom during the last time they had sex (males: 34% versus 10%; females: 22% versus 4%). Study E (9) found similarly strong effects (males: 48% versus 24%; females: 27% versus 3%).

Of the five programmes reporting on whether condoms had ever been used, three found significant increases (8, 9, 13). Two separate evaluations of Soul City in South Africa (study L) showed an association between consistent condom use and exposure to the programme (17-19).

Mediating factors: interpersonal communication

Nine studies reported data on whether young people discussed HIV, abstinence or condom use with peers, parents or partners. Study F (10) in Zimbabwe showed a significant difference between intervention and control groups in participants having discussions with anyone about sexually transmitted infections or AIDS (78% of intervention group versus 67% of control group). Significantly more youths who were exposed to the loveLife campaign in South Africa reported ever talking to their parents about HIV/AIDS than youths who were not exposed to the campaign (90% versus 81%) (15).

The Soul City campaign in South Africa (study L) also reported significantly more frequent discussions with "someone close" among those with access to more sources of Soul City media than among those with fewer sources (18, 19). The multicountry Staying Alive campaign (study N) calculated a network score, ranging from 0 to 6, for which respondents were assigned one point for each type of individual (parent, sibling, teacher or counsellor, doctor or nurse, sexual partner, friend or schoolmate) with whom they talked about HIV/AIDS during the previous month (21). In each of the three Staying Alive evaluation sites, those exposed to the campaign scored significantly higher than those who were unexposed (in Kathmandu: 2.26 points versus 1.30; in Sao Paulo: 0.96 versus 0.65; in Dakar 1.48 versus 1.04).

In Zambia, abstinent youths who were exposed to the HEART campaign (study I) spoke to significantly more people about abstinence than those who were not exposed (males: 2.9 for those exposed versus 2.3 for those not exposed; females: 3.8 for those exposed versus 2.2 for those not exposed) (13). Single females highly exposed to the "PL.U.S." campaign in Cote d'Ivoire (study K) were significantly more likely to discuss sexual abstinence with a parent during the previous 12 months than those who were not (33% versus 15%) (16). The PL.U.S. campaign also showed significant gains in discussions about condoms for both single males and single females: 90% of single females who were highly exposed to the campaign encouraged someone to use condoms during the previous 12 months compared with 56% of those who were not exposed to the campaign (16).

The PRISM campaign in Guinea (study E) and the Stop AIDS Love Life campaign in Ghana (study O) also showed significantly higher levels of discussion about condoms among participants in the intervention group than among the control group. Those in the PRISM intervention group were roughly twice as likely as controls to recommend condom use to someone else (males: 70% versus 31%; females: 31% versus 16%) (9). Study O, the Stop AIDS Love Life campaign, also reported large and significant differences between the proportion of participants who were highly exposed to the campaign and the proportion of those who were not exposed in terms of discussing the use of condoms to avoid AIDS and other sexually transmitted infections during the past year (males: 57% versus 16%; females: 55% versus 18%) (22). However, a radio campaign in Saint Vincent and the Grenadines (study A) did not show improvements in the proportion of adolescents and parents who discussed the use of condoms (5). Less than 2% of the sexually experienced participants in the Zimbabwe study (study F) asked a partner to use a condom as a result of the campaign (10).

Only one of the 15 studies recorded HIV prevalence (study J). The evaluation of study J in South Africa found that overall young people who participated in the programme had an adjusted odds of being HIV positive of approximately 0.60 compared with those who had not participated (15).

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