1. 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 Community Mobilization Adult-Child Communication Reality Radio

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

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

7. Formative research 1. Literature review of “vulnerable girls” 2. 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 Aug 2010Sep 2009 Community Mobilization Teacher Training Life Skills Economic Strengthening Reality Radio Adult-Child Communication

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: 1.Key Informants 2.Adults 3.Adolescents

12. SCI Domains – Key Informants 1) Access to health services 2) Concerns about alcohol abuse 3) Regulation of alcohol 4) Community cohesion 5) Community groups 6) Community safety 7)Economic opportunities 8)Community support 9)Gender and community 10)School safety 11)Sexual abuse concerns 12)Regulation of sexual abuse

13. Community Action (Outcome) Domains – Key Informants 1. 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?” 2. Sexual abuse action 3. Vulnerable girls support 4. 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: 1.Key Informants 2.Adults 3.Adolescents

16. SCI Domains - Adults 1) 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?” 2) Community cohesion “When conflicts or disagreements arise between community members, they are always resolved quickly.” 3) Community safety 4) Economic opportunities 5) School safety 6) Sexual abuse regulations

17. Community Action Outcome Domains - Adults 1. Community support Example: “In the last 12 months, have people in your community worked together to address HIV/AIDS?” 2. 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. Baseline Supportive Community Index (SCI) From three populations: 1.Key Informants 2.Adults 3.Adolescents

20. SCI Domains - Adolescents 1) Poverty 2) Food security 3) Home security 4) Alcohol access & regulation 5) Community cohesion 6) Community safety 7) Economic opportunities 8) School safety 9) 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