Carol Underwood, Ph.D. & Hilary Schwandt, Ph.D. Johns Hopkins University

1. Validation of the Supportive Community Index: survey research on Girls’ Vulnerability to HIV/AIDs from Botswana, Malawi, and Mozambique Carol Underwood, Ph.D. & Hilary Schwandt, Ph.D. Johns Hopkins University

2. Go Girls! Initiative: Goal & Social-ecological conceptual framework GOAL: To reduce HIV prevalence among adolescent girls aged 10-17 in Botswana, Malawi & Mozambique

3. Social ecology & combined prevention • SE approach posits interrelated roles of intrapersonal, interpersonal, institutional, community, and structural levels • SE interventions encompass the three elements of combined prevention – biomedical (individual level), behavioral (individual & social normative), and structural interventions

4. Model 1:Individual & community level Life Skills Out-of-school Adult-Child Communication Community Mobilization Reality Radio

5. Model 2:Multi-level: individual, community & structural approach School Personnel Training Economic Strengthening

6. GGI’s whole-community approach Communities: Community mobilization Radio program Safe schools: Teacher training Girls: School-based and community-based life skills Extended families: Adult-child communication Economic strengthening

7. Formative research • Literature review of “vulnerable girls” • Qualitative study to examine community perspectives’ of “vulnerable girls” Results informed and helped to refine 3 indices in advance of the baseline survey

8. Evaluation timeline Sep 2009 Aug 2010 Community Mobilization Teacher Training Life Skills Adult-Child Communication Economic Strengthening Reality Radio

9. Supportive Community Index • What is it? • A community/structural level measurement tool • How can it be utilized? • Measure the level, and change in, community/structural support in a community – emphasizing vulnerable girls’ support • Why is it important? • Communities/structures have a large impact on individual behaviors yet they are rarely addressed or evaluated • Measurement allows for evaluation of structural interventions

10. Why focus on structural factors? • Research shows that structural factors – access to educational, employment, & financial opportunties as well as policies that affect the distribution of resources – are key to HIV reduction • Yet, structural interventions lag behind biomedical and individual-level behavioral interventions • Nonetheless, community members prioritize structural interventions • Practitioners argue that structural effects are difficult to measure

11. Baseline Supportive Community Index (SCI) From three populations: Key Informants Adults Adolescents

12. SCI Domains – Key Informants • Access to health services • Concerns about alcohol abuse • Regulation of alcohol • Community cohesion • Community groups • Community safety • Economic opportunities • Community support • Gender and community • School safety • Sexual abuse concerns • Regulation of sexual abuse

13. Community Action (Outcome) Domains – Key Informants • Alcohol action “In the past 12 months, has the community taken any action to address the issue of outlets selling alcohol to people younger than 18 years?” • Sexual abuse action • Vulnerable girls support • Community health “In the last year, has the impact of HIV/AIDS on the community improved, worsened, or stayed the same?”

14. Correlation of the SCI and Community Action – Key Informants • Botswana (n=21) • Range: 67-146 • Correlation = 0.79 • Malawi (n=40) • Range: 60-135 • Correlation = 0.73 • Mozambique (n=82) • Range: 43-138 • Correlation = 0.55

15. Baseline Supportive Community Index (SCI) From three populations: Key Informants Adults Adolescents

16. SCI Domains - Adults • Alcohol regulation “How likely do you think it is that an adolescent younger than 18 years of age will obtain alcohol in this community if he or she tries?” • Community cohesion “When conflicts or disagreements arise between community members, they are always resolved quickly.” • Community safety • Economic opportunities • School safety • Sexual abuse regulations

17. Community Action Outcome Domains - Adults • Community support Example: “In the last 12 months, have people in your community worked together to address HIV/AIDS?” • Vulnerable girls support Example: “In the last 12 months, has any action been taken in the community to improve the well-being of adolescent girls?”

18. SCI and Outcome - Adults • Linear Regression • Main predictor: SCI • age, marital status, parity, and residence • Botswana (n=530) • β = 0.22; 95% CI (0.17, 0.27)* • Malawi (n=615) • β=0.17; 95% CI (0.14, 0.21)* • Mozambique (n=529) • β=0.14; 95% CI (0.095, 0.18)* *p = 0.000

19. BaselineSupportive Community Index (SCI) From three populations: Key Informants Adults Adolescents

20. SCI Domains - Adolescents • Poverty • Food security • Home security • Alcohol access & regulation • Community cohesion • Community safety • Economic opportunities • School safety • Sexual abuse regulations

21. Outcome Variable - Adolescents Sexual experience “Have you ever had sexual intercourse?”

22. SCI and Sex - Adolescents • Logistic Regression • Main predictor: SCI • Age, current schooling status, orphan status, & residence • Botswana (n=560) • OR = 0.81; p = 0.000 • Malawi (n=752) • OR = 0.93; p = 0.041 • Mozambique (n=427) • OR = 0.91; p = 0.017

23. Measuring Structural Change • Measurement of the SCI at 2 time points • Baseline • Endline • Comparing change • Analyze the % change in community aggregate scores • Hypothesis • + % SCI change • SCI Model II > SCI Model I

24. Conclusions • SCI is strongly associated with hypothesized outcomes • In 3 countries • In 3 populations • Cross-country validation of the SCI

25. Implications • Most behavior change research and programs focus on the individual – ignoring the structures outside the individual influence • GGI (research & program) has been designed with a community and structural level focus • GGI is implementing a structural level intervention in three countries • As well as measuring the structural change through the SCI • Future researchers and programs can use these tools to design and test structural level interventions

26. Contact details Carol Underwood, PhD Johns Hopkins Bloomberg School of Public Health Center for Communication Programs 111 Market Place, Suite 310 Baltimore, MD 21202, USA Tel: 410-659-6300 Fax: 410-659-6266 Web: http://www.jhuccp.org Email: cunderwo@jhuccp.org