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Evaluating Structural
Interventions
Kelly Hallman
“Pushing Forward with Structural Interventions for HIV Prevention – Where Are We Now
and How Do We Move Forward”
26 July 2012, IAS Conference
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The reality
We are
hardwiredforthis
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..and WHY do you want my sex?
• Intimacy, pleasure• Evolution, childbearing
• Challenge of HIV and STIs
• How do we tackle?• How to measure intervention impact?
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Levels of “rigor”
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Common HIV prevention outcomes
• HIV
• HSV
• Condom use
• Sexual partnering
• Abstinence, frequency
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What’s common to these outcomes?
• Changes at individual-level
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…and the “enabling” environment?
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“Poverty isn’t created by poor people.
It’s created by wrong systems.
And we don’t notice it.”
- M. Yunus
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Structural change
• Transformation that alters flows in• authority• rights• resources • opportunities• information• responsibilities
• Long-term process
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Are these amenable to
study using an RCT?
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R C T• Randomized• Denial of benefits a concern• Phased-in approach
• Control• All else held constant
• Learning, mid-course correction?
• Narrow intervention• or single bundled package • or expensive multi-arm
• Trial• Limited time to measure change
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Perhaps a middle ground
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Structural factors likely to impact HIV, health, well-being
• What is the theory of change?
• Clear conceptual framework
• Causal impact hypothesis
• Identify “proximate determinants”
• Outcomes along path to desired change
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Theory Study outcomes, Study design
• Did it work?1. Structural level • Organizational theory• Systems analysis• Timeline
2. Individual level• Outcomes: Factors along pathway to
desired change• Design: e.g., case-control with careful
matching (PSM)• Timeline
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Methods
• Why did it work (or not)?
• Monitoring
• Operations research
• Institutional change theory
• Qualitative approaches• Seasonality analysis• Time use patterns• etc.
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Let us move creatively beyond….
Your study was not an
RCT!
Be gone with you!
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“The first rule of social change:
Maximize your impact without being a jerk.
If you maximize impact while being a jerk, it is not worth it.”
- Jacob Harold, Hewlett
Foundation
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The Population Council conducts biomedical, social science, and public health research. We deliver solutions that lead to more effective policies, programs, and technologies that improve lives around the world.
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Few girls under age 15 in Burkina Faso reached by peer educators
7
3033
30
0
10
20
30
40
50
60
70
80
90
100
10-14 15-19 20-24 25+
Age of girls reached by peer educators
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Yet younger girls much lower levels of HIV and SRH knowledge than older girls
15
40
2231
4759
0102030405060708090
100
Knows of STIsapart from HIV
Knows a sourcefor contraceptives
Knows ABC(abstinence, befaithful, use a
condom)
12-14 yrs
15-19 yrs
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Few girls with little schooling reached by a peer educators
27
54
19
0102030405060708090
100
None Primary Secondary orhigher
Level of schooling of girls reached by peer educators
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And …most girls in Burkina Faso have never been to school
63
11
26
0102030405060708090
100
None Primary Secondary orhigher
Level of schooling of 12-19-year-old girls
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And their levels of preventive knowledge are much lower than those who ever attended school
16
46
2941
46
63
0102030405060708090
100
Knows of STIsapart from HIV
Knows a sourcefor contraceptives
Knows ABC(abstinence, befaithful, use a
condom)
Noschooling
Everattended
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Siyakha Nentsha impact on self-reported sexual behaviors
Boys Girls
+ p<0.10; * p<0.05; ** p<0.01
Had sex past year
# of sexual partners in past
year
0tan27a566027
0tan27a566027
0tan27a566027
0tan27a566027
0tan27a566027
0tan27a566027
0tan27a566027
0tan27a566027
0tan28a566028
SN combined (v. control)
(Yt2
- Y
t1)
- (Y
c2 -
Yc1
)
Had sex past year # of sexual partners in past
year
0tan27a566027
0tan27a566027
0tan27a566027
0tan27a566027
0tan27a566027
0tan27a566027
0tan27a566027
0tan27a566027
0tan28a566028
SN combined (v. control)
*
+
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Siyakha Nentsha impact on social and economic
Boys Girls
+ p<0.10; * p<0.05; ** p<0.01
# Social grants
knowledge
Attempted to open bank ac-count in
past year
Is saving
0tan27a566027
0tan28a566028
SN combined (v. control)
# Social grants
knowledge
Attempted to open bank ac-count in
past year
Is saving
0tan27a566027
0tan28a566028
SN combined (v. control)
(Yt2
- Y
t1)
- (Y
c2 -
Yc1
)
*
*
*