Formative Work and Community Engagement Approaches for Implementing an HIV Intervention in Botswana Schools

Abstract

Providing adolescents with evidence-based sexual risk reduction interventions is critical to addressing the HIV/AIDS epidemic among adolescents in sub-Saharan Africa. Project AIM (Adult Identity Mentoring) is an innovative, evidence-based, youth development intervention that is being evaluated for the first time in Botswana through a 3-year (2015–2017), 50-school cluster randomized controlled trial, including testing for herpes simplex virus type 2 as a sexual activity biomarker. Conducting a trial of this magnitude requires the support and collaboration of government and community stakeholders. All school staff, including teachers, must be well informed about the study; dedicated staff placed at each school can help to improve school and community familiarity with the study, improve the information flow, and relieve some of the burden study activities places on schools.

In Botswana, HIV prevalence among adolescents aged 15 to 24 years is 4% for males and 11% for females.¹ To combat the epidemic among adolescents, life-skills education has been implemented as part of the curricula in schools.² Life-skills–based programs for HIV prevention aim to enhance adolescents’ prevention knowledge, help them develop healthy attitudes, and provide them with skills to avoid risky sexual behavior.^3,4 However, these programs have not demonstrated consistent effects in preventing risky sexual behavior.^3–5

The limited impact of life-skills-based programs on sexual behavior may be explained by adolescents feeling unmotivated to make positive behavioral choices. As adolescents develop, many begin to recognize that their circumstances and environment may restrict their future opportunities.⁶ Sexual risk behaviors may occur as a reaction to a pessimistic view of one’s future or as a means of asserting oneself as an adult.^7,8 To augment life-skills education, the research team and community stakeholders identified Project AIM (Adult Identity Mentoring) for use in Botswana to address motivational and structural barriers to risk reduction behaviors, such as hopelessness and economic risk, and to offer alternative avenues for defining adult identities.

AIM is an evidence-based, youth development intervention that delays sexual initiation, reduces risky behaviors, and promotes school attendance among adolescents typically of middle-school age (11–14 years).^7,9 AIM is a Centers for Disease Control and Prevention (CDC) High-Impact HIV Prevention Program¹⁰ and is on the US Office on Adolescent Health’s list of evidence-based pregnancy prevention interventions.¹¹ (Table A, available as a supplement to the online version of this article at http://www.ajph.org, provides a list and description of Project AIM sessions.)

IMPLEMENTATION OF PROJECT AIM IN BOTSWANA

AIM is being implemented as part of a longitudinal cluster randomized controlled trial (RCT) to determine its effectiveness among junior secondary school students in eastern Botswana (Forms 1, 2, and 3), or roughly the equivalent to middle-school students (seventh, eighth, and ninth grades) in the United States. The study is being conducted in 50 junior secondary schools and consists of 2 arms: control (receiving life skills) and intervention (receiving AIM plus life skills). We assessed outcomes using self-report behavioral survey data and herpes simplex virus type 2 (HSV-2) incidence as a biomarker for sexual activity. We describe the formative work and community engagement processes used to prepare for the RCT and challenges encountered.

Formative Work

We tested the AIM curriculum and theoretical underpinnings for relevance and applicability with form 1 and 2 students at 3 junior secondary schools.¹² We conducted 20 focus groups and 7 in-depth interviews with junior secondary school students and staff, parents, and community leaders to understand adolescents’ future identifications and factors that contribute to adolescents’ HIV risk, to assess the acceptability of trial procedures,^12–14 and to inform the adaptation of study information sheets and consent forms.¹³ All activities were conducted with nontrial junior secondary schools in urban, peri-urban, and rural areas. The core elements of AIM were both relevant and acceptable to Botswana youths,¹² and we made minor changes to the session format (50–40 minutes; 12–14 sessions) to accommodate the school schedule. Content (e.g., pictures, future careers, examples of luminaries and their legacies) were culturally tailored for Botswana. Although English is the primary language of instruction in schools, sometimes Setswana is also used. As a result, we translated key terms (e.g., legacy, safeguard, future) in the AIM curriculum into Setswana to help increase students’ comprehension of key concepts. Parents, students, and school staff also recommended that study information and consent forms be prepared in both English and Setswana.

Community Engagement Process and Challenges

Launching the RCT in Botswana schools required the approval and support of many key stakeholders: the Ministry of Education and Skills Development (MoESD), Ministry of Health (MOH), youth-serving organizations, chiefs, schools, parents, and students. In the following paragraphs, we describe the strategies used to engage these stakeholders (see Table B, available as a supplement to the online version of this article at http://www.ajph.org) and the challenges encountered during this process.

Ministries, youth-serving organizations, and chiefs.

Meetings were held with MoESD and MOH officials and chiefs to solicit their support and approval to conduct the RCT, and strong partnerships were formed between the research team and MoESD. To provide ongoing input on study activities, stakeholders formed a technical working group, which consisted of representatives from youth-serving organizations working in the study communities, the MOH, and the MoESD. Arranging meetings with these stakeholders was a lengthy process and required plenty of follow-up, and the composition of meeting members changed frequently, all of which needed to be factored into the study timeline.

Schools.

To coordinate study logistics, staff held informational meetings with senior school administration and guidance and counseling teachers at each of the 50 schools. Fact sheets, frequently asked questions, and information shared with senior management about the study and scheduled activities were often not communicated to the teachers, who work most closely with the students. The research team’s failure to directly engage the teachers was problematic and created many barriers. In some instances, inadequate communication resulted in study activities being rescheduled because of teachers’ reluctance to excuse students from class. The guidance and counseling teachers at each school served as the study point of contact, and study-related duties placed an additional burden on them. Even though study staff provided thorough information, school administration and guidance and counseling teachers had difficulty understanding many of the study procedures (e.g., randomization, the need for multiple assessments, and the purpose of HSV-2 testing) and responding to parents’ and students’ inquiries.

To overcome these challenges, a study staff member (called an “AIM ambassador”) was placed at each school to assist with study coordination, respond to inquiries, and relieve some of the burden placed on the guidance and counseling teachers. Every AIM ambassador completed a thorough training and was well versed in all aspects of the study. Ambassadors had a visible presence at the school, attended school staff meetings to explain the study to other teachers, and were able to address concerns and discuss upcoming study activities in real time. To encourage further engagement, 2 teachers from each of the 50 schools attended a workshop, allowing them to increase their understanding of the study, discuss their roles in the RCT, and address any outstanding concerns. Together, these engagement strategies helped the researchers develop a solid relationship with the schools, which helped set the foundation for successful research implementation.

Parents, students, and community.

AIM ambassadors conducted information sessions during student orientation at all 50 schools, which were well attended by parents and students. Study staff conducted additional informational sessions during parent–teacher association or special meetings organized by study staff. Despite these targeted efforts, enrollment was very low in some schools because of low rates of return of parent permission forms. To overcome this challenge, ambassadors created a strong presence in the surrounding communities and helped increase familiarity with the study. In many communities, the ambassadors collaborated with chiefs to host a Kgotla meeting (a community meeting presided over by the chief) specifically targeting parents of the study-eligible students. This strategy was especially effective in engaging parents in rural communities, where Kgotla meetings are well attended. The chiefs’ presence at these meetings helped win the support of parents, which resulted in increased study enrollment and smoother execution of study activities.

CONCLUSIONS

In addition to conducting formative work to ensure that materials are culturally appropriate and study approaches are feasible, careful planning and multiple strategies are needed to successfully engage key stakeholders to implement a school-based study or program. The presence of dedicated staff at each school helps to develop a solid relationship with the schools and establish feedback mechanisms for addressing concerns that arise at the school and community level. We believe our community engagement approaches and experience will be helpful to other researchers planning to conduct similar activities in sub-Saharan Africa.