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

Go Girls! Initiative: Goal & Social-ecological conceptual framework

GOAL: To reduce HIV prevalence among adolescent girls aged 10-17 in Botswana, Malawi & Mozambique

Social ecology & combined preventionSE 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

Model 1:

Individual & community level

Life SkillsOut-of-school

Community Mobilization

Adult-Child Communication

Reality Radio

Model 2:

Multi-level: individual, community & structural approach

School Personnel Training

Economic Strengthening

Extended families:Adult-child communicationEconomic strengthening

GGI’s whole-

community approach Safe schools:

Teacher training

Girls: School-based and community-based life skills

Communities:Community mobilizationRadio program

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

Evaluation timelineBase-line

Endline

Aug 2010Sep 2009

Community Mobilization

Teacher Training

Life Skills

Economic Strengthening

Reality Radio

Adult-Child Communication

Supportive Community IndexWhat 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

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

Baseline Supportive Community Index (SCI)

From three populations:1. Key Informants2. Adults3. Adolescents

SCI Domains – Key Informants1) Access to health

services2) Concerns about

alcohol abuse3) Regulation of alcohol4) Community cohesion5) Community groups6) Community safety

7) Economic opportunities

8) Community support9) Gender and community10)School safety11)Sexual abuse concerns12)Regulation of sexual

abuse

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 action3. Vulnerable girls support4. Community health

“In the last year, has the impact of HIV/AIDS on the community improved, worsened, or stayed the same?”

Correlation of the SCI and Community Action – Key InformantsBotswana (n=21)

Range: 67-146Correlation = 0.79

Malawi (n=40)Range: 60-135Correlation = 0.73

Mozambique (n=82)Range: 43-138Correlation = 0.55

Baseline Supportive Community Index (SCI)

From three populations:1. Key Informants2. Adults3. Adolescents

SCI Domains - Adults1) 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 safety4) Economic opportunities5) School safety6) Sexual abuse regulations

Community Action Outcome Domains - Adults

1. Community supportExample: “In the last 12 months, have people in your community worked together to address HIV/AIDS?”

2. Vulnerable girls supportExample: “In the last 12 months, has any

action been taken in the community to improve the well-being of adolescent girls?”

SCI and Outcome - AdultsLinear Regression

Main predictor: SCIage, 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

Baseline Supportive Community Index (SCI)

From three populations:1. Key Informants2. Adults3. Adolescents

SCI Domains - Adolescents1) Poverty 2) Food security3) Home security4) Alcohol access & regulation5) Community cohesion6) Community safety7) Economic opportunities8) School safety9) Sexual abuse regulations

Outcome Variable - Adolescents

Sexual experience “Have you ever had sexual intercourse?”

SCI and Sex - AdolescentsLogistic Regression

Main predictor: SCIAge, current schooling status, orphan status, &

residenceBotswana (n=560)

OR = 0.81; p = 0.000Malawi (n=752)

OR = 0.93; p = 0.041Mozambique (n=427)

OR = 0.91; p = 0.017

Measuring Structural ChangeMeasurement of the SCI at 2 time points

BaselineEndline

Comparing changeAnalyze the % change in community aggregate

scores

Hypothesis+ % SCI change SCI Model II > SCI Model I

ConclusionsSCI is strongly associated with hypothesized

outcomesIn 3 countriesIn 3 populations

Cross-country validation of the SCI

ImplicationsMost 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 countriesAs well as measuring the structural change

through the SCIFuture researchers and programs can use

these tools to design and test structural level interventions

Contact detailsCarol Underwood, PhDJohns Hopkins Bloomberg School of Public HealthCenter for Communication Programs111 Market Place, Suite 310Baltimore, MD 21202, USATel: 410-659-6300 Fax: 410-659-6266

Web: http://www.jhuccp.org

Email: cunderwo@jhuccp.org