1. Conceptual Mapping of the Limpopo Intervention Charles Abraham Hans Onya, and Leif Edvard Aarø PREPARE Bergen Meeting, May 6 th 2014

2. Research Aim To identify modifiable cognitions (i.e., beliefs and attitudes) likely to promote condom use motivation and condom use among school students in South Africa, particularly in the Mankweng district. In particular to test the capacity of an extended TPB model including culture-specific beliefs about condoms, HIV/AIDS and interpersonal relationships to explain motivation to use condoms and reported condom use amongst South African secondary school students.

3. T HEORY OF P LANNED B EHAVIOUR (TPB ) Intention Attitude Subjective Norm Perceived Behavioural Control Behaviour Ajzen (1991) Organizational Behavior and Human Decision Processes

4. Preparatory and Pilot Work Narrative review of the literature Thematic analysis of transcripts of 6 focus group and 9 interviews and with school students from the Mankweng district of South Africa. Development and analyses of a pilot questionnaire tested in two schools in Mankweng district with students aged between 12-15 years using both an English (N=183) and a Northern Sotho (N=166) version.

5. Survey Used to Design Intervention Targets and Evaluation Questionnaire 200 items., administered in 9 secondary schools. Between 105 and 215 respondents in each school. 1166 young people completed the questionnaire. Our interest was in identifying intervention targets for grade 8 school students – leaving 893 students aged 12-17 years. Modifiable cognitions correlated with condom use and condom use motivation were identified and became intervention targets.

6. FORMATIVE STUDY OUTCOME - C HANGE T ARGETS I 1. A minority of young people are having sex. Delay sexual debut 2. Having sex is not so important for a young person. 3. HIV is a primarily a sexually transmitted disease. 4. Condom use is safe. 5. Consistent condom use is important as it prevents sexual transmission of HIV.

7. 6.Young people in S Africa can avoid HIV infection. 7. Carry a condom if you want to have sex. 8. It’s good to ask any sexual partner to use a condom. 9. Unprotected sex does not mean commitment or love. So no- condom-no-sex. 10. Others are using condoms – why aren’t you? 11. Anal sex is unusual and unprotected anal sex is a very high-risk activity. 12. It is not OK to force someone you know to have sex (with or without a condom) FORMATIVE STUDY OUTCOME - C HANGE T ARGETS II

8. C ULTURE S PECIFIC BELIEFS In addition the intervention was designed to change a series of culturally-specific beliefs.

9. I NTERVENTION 12 intervention schools 12 control schools Aimed to recruit 1200 from each at baseline and immediate follow up

10. R ESULTS

11. B ELIEFS ABOUT HIV-AIDS LINKS AND VIEWS ON SEXUAL FIDELITY AND HIV- PROTECTION ControlInterventionDifference Significance (p=) HIV is a virus causing AIDS 4.02 4.170.15.02 Can protect against HIV by being faithful or abstaining 3.403.540.14.02 Behavioural predition – Will be faithful 3.453.630.18.03

12. N ORMATIVE B ELIEFS AND A TTITUDES C ONCERNING A BSTINENCE FROM S EXUAL I NTERCOURSE ControlInterventionDifference Significance (p=) Abstinence - descriptive norm 3.363.480.12.06 Abstinence - injunctive norm 3.553.720.17.02 Abstinence – negative attitudes towards 2.262.140.12.01 Abstinence – positive attitudes towards 3.533.730.20.03

13. ControlInterventionDifference Significance (p=) Carrying condoms means asking for sex 3.142.98-0.16.03 - OK to carry condoms 2.892.900.01.86 Could and will carry condoms 3.553.780.23.02 C ONDOM C ARRYING B ELIEFS

14. ControlInterventionDifference Significance (p=) Suggesting condoms communicates something good 3.263.410.15.01 Suggesting condoms commnicates something bad 2.532.41-0.12.00 Saying no to sex without condom when offered gift 3.543.770.23.06 Preparing for condom use (talking about, having, carrying) 1.841.960.12.14 B ELIEFS A BOUT S UGGESTING C ONDOM USE

15. N ORMATIVE B ELIEFS C ONCERNING C ONDOM U SE ControlInterventionDifference Significance (p=) Subjective norms condom use 3.433.540.11.11 Injunctive norm against condom use 2.412.27-0.14.05

16. ControlInterventionDifference Significance (p=) Condom SE own skills3.653.750.10.24 Condom sS negotiations3.113.210.10.07 Condom SE Use difficult - easy 3.243.370.13.12 C ONDOM U SE - R ELATED S ELF E FFICACY

17. ControlInterventionDifference Significance (p=) Condoms are safe 3.113.160.05.26 Condom use is important 3.553.670.12.05 Behavioural prediction - Will use condom 3.603.660.06.64 C ONDOM U SE B ELIEFS AND MOTIVATION

18. ControlInterventionDifferenceSig’ (p=) HIV infection mechanisms (8 items) 1.991.82-0.17.00 protection from HIV 2.67 2.55-0.12.03 Can stop spread in body 2.852.63-0.22.01 C ULTURE -S PECIFIC B ELIEFS

19. ControlInterventionDifference Significance (p=) Attitude (positive) towards partner violence 2.632.49-0.14.03 It is Illegal for man to hit a woman 3.053.07.02. 86 B ELIEFS ABOUT V IOLENCE

20. How often used a condom during sex last 6 weeks? Responses coded as... Never=0, Once=1, A few times=3, Most weeks=5, Most days=20 Selecting those who reported to have had intercourses ”a few times” (vagnial or anal) and controlling for condom use at baseline as well as number of vaginal and anal intercourses at baseline...... The number of times using condoms during last 6 weeks is 2:1 higher in the intervention group (p=.033).

21. Conclusion Need more time to examine the results in detail and plan their presentation.... Nonetheless findings indicate that the intervetnion changed some – but not all – the modifiable correlates of condom use that it was designed to target – and promoted condom use among sexually-active particiapnts.

22. C.Abraham@Exeter.ac.uk Questions?