Research question
This is feasibility and acceptability study is part of our preparation for a large community randomized evaluation of a complex multi-component intervention package to reduce HIV risk in rural youth. The proposed intervention will be delivered in communities and secondary schools throughout the Hlabisa sub-district surrounding the Africa Centre’s surveillance area. We are undertaking the feasibility study specifically answer two research questions. The first involves the content of the community intervention component. In this part of the study we are seeking to learn whether a series of facilitated traditional meetings designed to mobilize and ‘conscientise’ disparate parts of the school-community are feasible and acceptable, and whether they can produce a sense of community ownership and community will that in turn seeks to address some of the social and structural determinants of youth HIV risk, such that it enhance the effects of our school-based curricula. The second research question involves identifying the behaviours most closely associated with HIV risk in rural community youth. These data will enable accurate power calculations for the trial in a population group whose HIV incidence and prevalence data have up to now been largely estimated from older populations. Answering the first question involves a programme of primarily qualitative research involving focus groups and in-depth interviews. While answering the second involves an HIV sero-prevalence and behavioural survey conducted among grade 8 and 9 learners (the first 2 years of secondary school, aging around 15/16 years old) in the 49 secondary schools across the sub-district.
Rationale
The Africa Centre’s HIV surveillance data suggest that HIV prevalence among secondary school aged young people is low, but incidence rises quickly after young people leave secondary school. Interventions that seek to address the social and structural determinants of HIV risk, as well as the individual-level behavioural determinants are needed to prepare young people and to reduce new infections among what is effectively the next generation of HIV-positive adults. In South Africa, the first generation of HIV prevention interventions targeting youth were low threshold and primarily educational, focused on improving basic knowledge and understanding of HIV, the main transmission routes and behavioural prevention strategies (e.g. condom use). In contrast, a second generation of targeted interventions aimed to reduce behavioural risks for HIV, including both sexual and social behaviours (e.g. alcohol and substance use) with some consideration of social and structural drivers of HIV transmission. The so-called third generation of HIV prevention interventions aims to combine these approaches and address social and structural determinants, while at the same time equipping individuals with appropriate social, educational and personal skills to limit their personal risk. Umthombo Wentsha (Fountain for Youth) is an intervention that will involve a multi-component, multi-level school and community intervention package.
Preliminary results
Answering the first of our research questions involves a mixed method qualitative study in two school communities that employs focus groups and participatory action research tools. The first stage is a ‘listening’ phase with focus groups undertaken with seven different school sub-communities (e.g. structural and emotional stakeholders, parents, teachers, etc.) at each of our two sites. The second stage is an ‘action’ phase and involves facilitating school sub-communities in participatory planning meetings where they develop, implement and monitor a local youth HIV prevention action plan. Our initial work suggests that each of our schools has a very different material base and ‘local-cultural’ capacity to engage positively with youth and HIV prevention. However, school communities are all concerned and have shown significant willingness to mobilize and to participate in intervention efforts that aim to protect their youth. However, the different levels of the school community have different stakes in this process and different conceptions of youth and the level and sort of community change required to support prevention among their local young people. The district-wide HIV seroprevalence and behavioural survey are currently in the planning stage and should be ready to enter the field before the middle of the year. In this part of the feasibility study we are also testing the acceptability of two significant methodological innovations the use of microcapillary blood collection and the use of mobile telephones and SMS messaging as the self-reported data collection tools.
Policy implications
Potential policy implications even of this feasibility and acceptability work are significant. At the national level the South African Government has been frequently criticized for delivering ‘too little, too late’ in relation to the HIV crisis among the country’s youth. To date HIV prevention targeting this group has been largely centralised, with individual communities having only limited opportunity to contribute to development of local action plans. By exploring with the communities their willingness to be mobilised by the crisis of HIV and youth, and working with them to devise local action plans, we will also be able to assess school-community’s capacity to be ‘owners’ and custodians of specific prevention activities and implementers of intervention components (for example, can community members be custodians of ensuring condom availability). This will provide important insight to policy-makers about policy new ways in which policy, practice and implementation can be conceived.