nothingaspracticalasagoodtheory?thetheoreticalbasisof...

Hindawi Publishing CorporationAIDS Research and TreatmentVolume 2012, Article ID 345327, 18 pagesdoi:10.1155/2012/345327

Review Article

Nothing as Practical as a Good Theory? The Theoretical Basis ofHIV Prevention Interventions for Young People in Sub-SaharanAfrica: A Systematic Review

Kristien Michielsen,1 Matthew Chersich,1, 2 Marleen Temmerman,1

Tessa Dooms,2 and Ronan Van Rossem3

1 International Centre for Reproductive Health, Faculty of Medicine and Health Sciences, Ghent University,De Pintelaan 185 P3, 9000 Ghent, Belgium

2 Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg 2000, South Africa3 Department of Sociology, Faculty of Political and Social Sciences, Ghent University, 9000 Ghent, Belgium

Correspondence should be addressed to Kristien Michielsen, [email protected]

Received 29 February 2012; Revised 26 April 2012; Accepted 3 May 2012

Academic Editor: Xiaoming Li

Copyright © 2012 Kristien Michielsen et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

This paper assesses the extent to which HIV prevention interventions for young people in sub-Saharan Africa are groundedin theory and if theory-based interventions are more effective. Three databases were searched for evaluation studies of HIVprevention interventions for youth. Additional articles were identified on websites of international organisations and throughsearching references. 34 interventions were included; 25 mentioned the use of theory. Social Cognitive Theory was most prominent(n = 13), followed by Health Belief Model (n = 7), and Theory of Reasoned Action/Planned Behaviour (n = 6). These cognitivebehavioural theories assume that cognitions drive sexual behaviour. Reporting on choice and use of theory was low. Only threearticles provided information about why a particular theory was selected. Interventions used theory to inform content (n = 13), forevaluation purposes (n = 4) or both (n = 7). No patterns of differential effectiveness could be detected between studies using andnot using theory, or according to whether a theory informed content, and/or evaluation. We discuss characteristics of the theoriesthat might account for the limited effectiveness observed, including overreliance on cognitions that likely vary according to typeof sexual behaviour and other personal factors, inadequately address interpersonal factors, and failure to account for contextualfactors.

1. Introduction

With an estimated 2.7 million new infections worldwidein 2010, HIV incidence remains at very high levels [1].Sub-Saharan Africa, accounting for 70% of these infections,remains particularly affected. About 40% of new HIVinfections occur in the age group 15 to 24 years [1]. There-fore, targeted prevention programmes for young people areessential in reversing the HIV epidemic [2, 3]. Over thepast decades, a considerable number of HIV preventioninterventions for young people in sub-Saharan Africa havebeen developed, implemented, and evaluated. Nevertheless,even though these interventions seem to increase knowledge

and encourage positive attitudes, radical changes in sexualbehaviour have not occurred [4, 5].

Theory is said to be an essential component of successfulhealth promotion interventions [6, 7]. Behavioural theorycan assist to understand the determinants of risky and safesexual behaviour [8] and hence help to identify underlyingprinciples about how people change their behaviour [9].Further, it aims to explains why and how behaviours occurand allows us to predict future behaviours by establishingrelationships between key variables. Beyond providing con-structs, processes and hypotheses for setting up interven-tions, theories can also provide the basis for testing theeffectiveness of interventions [10]. Furthermore, theories

2 AIDS Research and Treatment

can serve as a framework for accumulating knowledge[11]. Reviews that assessed the theoretical underpinningsof behavioural interventions for young people worldwidegenerally claim that a theoretical foundation contributes toeffectiveness [6, 12–16], although a direct link has not yetbeen established.

In health promotion research, a large number of theoriescoexist that aim to understand health-related behaviour andprovide tools for behaviour change. The Social Learning/Cognitive Theory (SCT), Theory of Reasoned Action/Planned Behaviour (TRA/TPB), and Health Belief Model(HBM) are the most dominant theories, more recently joinedby the Stages of Change (SoC) and Social Ecological Model(SEM) [17–21].

The SCT posits that people acquire and maintain par-ticular behavioural patterns through a constant interactionbetween three factors: environment, personal factors, andbehaviour [22, 23]. Behaviour is not simply the result of theenvironment and the person, just as the environment is notmerely a function of the person and behaviour [17]. TheHBM is based on an understanding that a person will take ahealth-related action if that person believes s/he is susceptibleto the condition (perceived susceptibility), that the conditionhas serious consequences (perceived severity), that takingaction would reduce their susceptibility to the conditionor its severity (perceived benefits), and that these benefitsoutweigh the cost of taking action (perceived barriers).Action is taken more easily if the person is exposed tofactors that prompt action (cues to action) and is confidentin her/his ability to successfully perform an action (self-efficacy) [20, 24–26]. By contrast, the TRA suggests thata person’s behaviour is determined by her/his intentionto perform the behaviour. This intention is predicated bytheir attitude toward the specific behaviour and by beliefsabout whether individuals who are important to the personapprove or disapprove of the behaviour (subjective norm).The TPB includes an additional determinant: the beliefs/he has control over a particular behaviour (perceivedbehavioural control) [20, 27, 28]. SoC theory argues that, inorder to change a behaviour, an individual passes throughfive stages: precontemplation, contemplation, preparation,action, and maintenance [29]. People at different stages havedifferent informational needs and benefit from interventionstailored to their particular stage [20]. The SEM identifiesa number of interacting levels that influence behavior(individual, interpersonal, organizational, community, andpublic policy). According to this model, behaviours areshaped by the social environment [20, 30].

These dominant theories work at various levels andfor different purposes. While the HBM and TRA/TPB areexplanatory theories operating at the individual level, theSCT and SEM include the interpersonal and environmentallevels, respectively. The SoC theory, in turn, is a changetheory, not explaining a particular behaviour, but providinga framework for how people alter their behaviour.

With the overarching objective of improving effectivenessof HIV prevention interventions that target young people’ssexual behaviour in sub-Saharan Africa, this paper examinesthe extent to which these interventions are grounded in

theory, how these theories are applied and assesses if theory-based interventions are more effective in modifying sexualbehaviour than interventions not explicitly grounded intheory.

2. Methods

2.1. Study Eligibility, Literature Search, and Data Extraction.We performed a systematic review to locate evaluated inter-ventions that aim to reduce sexual risk behaviour of youngpeople in sub-Saharan Africa. Studies were considered eligi-ble if they reported on the evaluation of an HIV preventionintervention for young people on the subcontinent, had acontrol group, and were published between January 1990 andMarch 2012. Further, to be included, studies had to report onthe general population of young people (10–25 years) andthe intervention needed to aim to prevent HIV transmissionby reducing sexual risk taking. Searches were performed inthe online databases Medline (PubMed interface), ISI Web ofScience, and EBSCOhost. Additional articles were identifiedon websites of international organisations and throughsearching references of eligible articles. Data extractionwas then done in duplicate by five investigators using apredesigned and pretested extraction sheet. Further detailsof the search terms, study eligibility, and data extraction aredetailed elsewhere [4].

2.2. Study Measures. We extracted data on characteristicsof the interventions and theory use. Firstly, whether anytheory had been used and, if so, which. Secondly, forwhat purpose the theory was used. We extracted full-textdescriptions of how the theory had been used, which waslater recoded into three categories: theory used to inform theintervention (e.g., for curriculum development); theory usedto guide evaluation (e.g., to develop indicators); or both.Thirdly, a binary variable was derived, capturing whetheran explanation was provided about why this theory waschosen. For the studies not reporting the use of a theory,we looked at the topics dealt with in the interventionsand the envisaged interventions’ outcomes. This gives us anindication of the underlying theoretical assumptions used inthese interventions.

Data were also extracted on the behavioural outcomes ofthe interventions: condom use (at last sex; consistency andintention), sexual behaviour (primary abstinence; the pro-portion of sexually active youth; recent sexual intercourse;number of sexual partners and multiple partnerships), andbiological outcomes (HIV/STI incidence).

3. Results

1073 article titles and/or abstract were screened. Afteranalysis of title and abstract, we reviewed 73 full-textpublications. In total, evaluations of 34 studies met theinclusion criteria, reported on in 38 articles. Table 1 sums themain intervention characteristics and study designs.

AIDS Research and Treatment 3

Ta

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.[4

8]Z

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1997

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13)

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mu

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Ch

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k

Dev

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men

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tion

No

Jam

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al.

[49]

Sou

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98C

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t,ra

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miz

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No


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1785

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56]

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.[58

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.[6

0]So

uth

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-200

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]So

uth

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-200

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s

NA

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Bai

rdet

al.

[62]

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awi

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-200

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NA

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Bu

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al.

[63]

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204

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3.1. Theoretical Basis of the Interventions. About three quar-ters of the studies—25 of 34—mentioned having used at leastone theory. In total, 19 different theories were mentioned42 times. Several stated that they had applied two or moretheories, with three papers reporting that the interventiondesign drew on three theories.

Of all the theories mentioned, the SCT was mostprominent (n = 13). Other theories that were mentionedmore than once are the HBM (n = 7) and the TRA/TPB(n = 6). Four studies mentioned using a behaviourchange framework: behaviour changes for interventionsmodel [37], applied behaviour change framework [44], stepsto behaviour change framework [48] and stage theory ofbehaviour change [51]. Assessment of the concepts usedin the interventions not explicitly mentioning the useof a theory indicated that they also operated from anassumption that knowledge, attitudes, beliefs, and/or rolemodels determine sexual behaviour. Hence, it seems thatmost interventions are implicitly or explicitly guided bycognitive behavioural frameworks. The one exception isBaird (2012); this intervention uses an indirect pathway totry to influence HIV incidence, namely, through encouraginggirls’ school attendance.

Description of the main activities indicates that mostinterventions use one or a combination of participatorylearning techniques, such as drama plays, poetry, songs, clubformation, peer education (role modelling), and discussionsand debates. This suggests that the learning strategies ofmost interventions were based on participatory learningapproaches.

A small, but considerable proportion of interventions[32, 34–36, 38–40, 58, 62, 64] go beyond focusing on theindividual young person and facilitate community involve-ment in the interventions. Here, the implicit theoreticalassumption is that in order to change the participants’ sexualbehaviour, the community needs to be involved (cf. SEM).

There is no clear evolution detectable over time in thefrequency of use of different theories; of the 20 studies whichbegan in the decade 1990–1999, 14 reported theory use, while11 of the 14 beginning after 2000 used theory.

3.2. Use of Theory in the Research Projects. Of 25 inter-ventions that mentioned a theory, 7 said that the theorywas used to both inform the content of the intervention(e.g., the curriculum) and to inform the evaluation orquestionnaire design. In 13 studies, theory was reportedlyused only to inform the intervention content, and in 4only for designing the evaluation or questionnaire. Onestudy mentioning theory use did not specify how this wasapplied [36]. The SCT was almost exclusively used to informthe intervention. The HBM was mostly used for evaluationpurposes, predominately in studies from Population ServicesInternational [31, 33, 45, 55, 67], as was the TRA/TPB.

Only three articles provided information on why aparticular theory was selected [41, 56, 60]. Nine authorslimited themselves to a brief explanation of the theory itself[31, 37, 42, 45, 48, 50, 51, 63, 67]. The remainder did notprovide any information on theory selection.

3.3. Theory Use and Intervention Effectiveness. Overall, thebehavioural outcomes of the 34 studies were markedlyheterogeneous, with little reduction in heterogeneity afterstratifying by theory use (Table 2). It was not possible todiscern any patterns in differential effectiveness between therole of theory in a study, or between studies reporting or notreporting theory use. Nor did we find particular differencesin intervention design by theory use.

Four studies reported biological measures of interventioneffectiveness [39, 40, 58, 59, 62]. Jewkes succeeded inreducing HSV-2 incidence. Baird’s study, not explicitly basedon theory, reported a reduced HIV incidence and HSV-2 incidence in the intervention group as compared to thecontrol group, but these data were not controlled for baselineprevalence and should be treated with some caution [62].Since the three other studies reporting biological measuresall based their intervention on a theory, it is not possible tocompare the effectiveness of theory- and non-theory-basedinterventions in changing these outcomes.

3.4. Evaluation of the Theory. Four studies refer to theirtheoretical basis in their conclusions, criticizing the the-ory, specifically “the theoretical approaches underlying theprogram have built in shortcomings which could resultin the program not having significant impact on thestudents’ behavioural intentions” [69]; “the discrepancies inthe findings may be substantiated by the lack of system-atic information that was available on the empirical andtheoretical underpinnings upon which the KwaZulu-NatalDepartment of Education’s program was based—a findingsimilar to reports of those educational programs that werenot grounded in a theoretical understanding of adolescentsexual behaviour [. . .]” [54]; “These findings present mixedevidence regarding the relationship between self-efficacyand outcome expectations and HIV protective behavioursamong adolescents in Swaziland.” [63]; “TPB has receivedconsiderably more support from research for its predictivepower of safe sex behaviour than the HBM.” [42].

4. Discussion

The review found that the majority of HIV preventioninterventions targeted at youth in sub-Saharan Africa usetheory-based approaches. A wide range of theories have beenemployed, but three behavioural theories predominate: SCT,HBM, and TRA/TPB. No one theory emerged dominant, asreporting on the choice, use, and specific evaluation of theorywas low.

4.1. Comparison with Other Reviews. Broadly, the results areconsistent with reviews of HIV risk-reduction interventionselsewhere, though some variation in use of theory can benoted across these reviews. Pedlow and Carey [70] reviewed23 randomized controlled trials of HIV risk-reductioninterventions for adolescents in the United States and foundan explicit theoretical rationale in all but one study. Similarto our review, SCT was most common (18/23). Three othertheories were used in four or more studies (TRA, HBM,


Ta

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2008

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and Information-Motivation-Behavioural Skills Model). Areview on the impact of HIV and sex education programs onyouth throughout the world [6] found that more than fourfifths of the 83 interventions identified one or more theory.SCT formed the basis for more than half (54%) of theseinterventions. TRA (19%), HBM (12%), TPB (10%), and theInformation-Motivation-Behavioural Skills Model (10%)were also commonly mentioned. Two other reviews coveringHIV, STD, or pregnancy risk-reduction interventions amongadolescents in the United States had comparable results, witha similar distribution of theories used [12, 71]. While severalnew theories or integrated models have been developed sincethe outbreak of HIV focussing specifically on sexual healthbehaviours like condom use [8, 72], they are not used in HIVinterventions for young people in sub-Saharan Africa.

4.2. Gaps in (the Use of) Theory. By focussing on cognitiveconstructs of behaviour, the interventions explicitly orimplicitly start from the assumption that cognitions influ-ence the person’s thinking and decision making, and thusdrive sexual behaviour [73]. In the remaining discussion,we will focus on the utility of grounding HIV preventioninterventions for young people on a cognitive behaviouralframework. We attempt to identify critical areas for attentionand improvement on different levels.

Firstly, cognitive behavioural models aim to explain aparticular behaviour. The theoretical constructs that influ-ence behavioural decisions may vary, depending on thebehaviour in question. This poses marked challenges forHIV prevention interventions, since they generally attemptto influence a wide range of behaviours—for example,increasing condoms use, reducing the number of sexualpartners, minimising sexual activity, delaying the onset ofsexual debut—which are influenced by different factors.To further complicate matters, sexual decisions may varydepending on the reasons for sexual intercourse (rangingbetween, e.g., intimacy or desire, external factors, and affectmanagement). These, in turn, are further influenced bygender and psychological characteristics (e.g., depression,self-esteem, and impulsiveness) [74]. Thus, sexual behaviouritself is far from a uniform behaviour, but rather a collectionof several relatively distinct behaviours, that can be shapedby different factors in different contexts. While the use of atheoretical framework provides grip in structuring an HIVprevention intervention, the interventionist needs to be veryclear about what behaviour they aim to alter and whichfactors determine this behaviour.

Second, the applicability of cognitive behavioural modelsto youth sexual behaviours may vary between developmentstages. For instance, applying cognitive theory to youngpeople with no or limited sexual experience may be difficult.This group may not yet have well-anchored ideas, and conse-quently their attitudes, norms, and beliefs about safe sexualbehaviour may be less clear and stable than for their adultcounterparts [70, 73]. Theories used in HIV interventionstargeted at youth could be strengthened by accounting forthe extent to which individual decision making is supportedby one’s age, gender, or other personal characteristics.

Third, these theories seem to ignore the fact that sexualintercourse takes place between two persons, within a rela-tionship. Sexual decisions do not depend on the individual,but also on the sexual partner and the type of relationship.Young people might have specific types of partners that mayinfluence sexual decision making. For example, relationshipswith someone who is much older are risky because itexposes the younger person (mostly girls) to a partner whois more likely to be sexually experienced and hence morelikely to be HIV-positive [75, 76]. Often, these age-disparaterelationships are transactional in nature, with money or giftsgiven in exchange for sexual intercourse [75, 77–81]. Also,young people in same-age relationships might have differenttypes of relationships than adults. They tend to be in whatis called by Bastard et al. [82] the “courtship-seduction”phases of relationships, in which the predominant concernsare to “present the best image, win trust, and avoid sourcesof conflict. These concerns take precedence over that ofprotecting oneself from the risk of AIDS.”

Fourth, while some interventions recognize the impor-tance of involving the community, only the SCT explicitlystresses the influence of contextual and structural factorson an individual’s behaviour. Even though the theory statesthat the social environment is an important determinantof the behaviour, many interventions based on SCT didnot attempt to include or influence environmental factors.Most interventions are limited to providing information andteaching skills. TRA/TPB implicitly includes this level bystating that personal attitudes, and norms are influencedby behavioural and normative beliefs in the society, whichis useful for tracking varying modes of sexual socialisation.However, this is an indirect effect of the environment onindividual behaviour, while still ignoring the broader struc-tural factors that shape sexual behaviour. Many recent studieshave demonstrated the contribution of structural factorsto young people’s vulnerability for HIV [75, 83–85]. Theseenvironmental aspects include both distal influences—suchas taboos on adolescent sexuality, norms and values, policies,poverty, education as well as more proximate influences.These include families’ opinions about adolescent relation-ships or teachers refusing to talk about condoms. Increasedefforts in future studies to account for structural factors ata theoretical level may improve the design of interventionsand assist in their evaluation, by understanding the possiblebarriers between motivation and actual behaviour change.

According to Gielen and Sleet [86], behavioural interven-tions can be subdivided into three categories, those aimed atintrapersonal factors (e.g., knowledge, skills, and intentions);interpersonal factors (including relational motivations andsocial desirability); community factors (e.g., culture, genderinequalities, poverty, and violence). We have already arguedthat the most common theories used in HIV interventionsdirected to youth do not adequately address interpersonalfactors, the failure to account for contextual factors furthercompounds the difficulty of evaluating interventions andunderstanding the possible barriers between motivation andactual behaviour change.

Finally, while cognitive behavioural theories of changemight be successful in altering cognitions and behavioural


intentions, they provide insufficient directives on translatingthis into actual behaviour change. Thus interventions couldbe regarded as successful in having altered motivationsand intentions, even though behavioural change may notresult. Similarly, interventions based on the HBM, mightincrease the perceived severity and susceptibility of a person,and relieve barriers to behaviour change, but in itself,might be insufficient to alter the sexual behaviour. Clearly,motivations or beliefs about behaviour change on a cognitiveor rational level need to be accompanied by a clear strategyfor introducing a new behaviour [87].

5. Conclusion

In the end, it boils down to two key questions: what deter-mines sexual behaviour of young people? And what frame-works are most useful for making sense of and impactingpositively on determinants of youth sexual behaviour? Rec-ognizing the complexity and heterogeneity of this particularbehaviour, theory can provide help in generalizing keydeterminants and making them operational. Theories aimto describe determinants and processes that account foror guide behaviour (change) through the rationalizationof individual decisions. This aids in understanding humanbehaviour, and when used appropriately, can provide a solidgrounding for program development and evaluation. Thestrength of theory is to generalize and simplify complex situ-ations. However, in the case of HIV prevention interventionsfor young people, the dominant theories might oversimplifysexual behaviour. While such cognitive behavioural modelscan explain the links between intention and behaviour,particularly at an intrapersonal level, they are less able toaccount for interpersonal and contextual factors related tothe complexity of sex, the experience of youth and disparitiesin social, cultural, and economic realities of youth in sub-Saharan Africa.

Acknowledgments

K. Michielsen acknowledges the Research Foundation Flan-ders (FWO) for financial support. The authors acknowledgeStanley Luchters and Petra De Koker for data extraction.

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