Research Division Population Services International

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1 Research Division Population Services International An Evaluation of Adolescent Sexual Health Programs in Cameroon, Botswana, South Africa, and Guinea Sohail Agha PSI Research Division Working Paper No Sohail Agha, Ph.D., is Research Officer at Population Services International. PSI/Washington D.C Nineteenth Street, N.W., Suite 600 Washington D.C U.S.A. PSI/Europe Douglas St. London SW1P 4PB United Kingdom

2 Abstract Objective: Between 1994 and 1998 four social marketing adolescent sexual health (SMASH) interventions were implemented in Cameroon, Botswana, South Africa and Guinea with the objective of improving adolescent reproductive health. In each country, 8-13 months of youth-oriented activities were conducted in intervention areas. This study assesses the impact of the interventions on young adults. Design: This study utilizes a quasi-experimental design, using data from pre and post intervention surveys in intervention and control sites in each country. The revised Health Belief Model (HBM) provides the theoretical basis for this evaluation. Results: Of the four social marketing programs evaluated, the intervention in Cameroon was the only one in which changes occurred along nearly all components of the Health Belief model and among both men and women. Young men and women in Cameroon became more aware of the benefits of sexual protection, experienced a reduction in barriers to safer sex and an increase in self-efficacy. Young women reported a lower likelihood of having had sex by age 15 and young men reported fewer sexual partners. The Cameroon intervention also resulted in increased condom use and in greater use of abstinence. In contrast, the programs in Botswana, South Africa and Guinea had little or no impact on sexual behavior. Among young women in Botswana, the program had a positive impact on perceived susceptibility to sexual risk, perceived benefits of prevention and perceived barriers to safer sex. What distinguished the Cameroon program from others was that it was the only program in which mass media and interpersonal communication were able to reach a substantial proportion of the population. Conclusions: A social marketing intervention can be effective in producing improvements in attitudes and safer sex behavior of adolescents if mass-media and peer education activities reach a significant proportion of young adults.

3 Acknowledgments This research was funded by the Office of Health and Nutrition, Global Bureau, and the Africa Bureau, Health and Human Resources Division, U.S. Agency for International Development (USAID), under the terms of Cooperative Agreement No. HRN-A The opinions expressed herein are those of the authors and do not necessarily reflect the views of the U.S. Agency for International Development. Additional support was provided by PSI, which has core support from the British Department for International Development (DFID). The author is grateful to Dominique Meekers, Josselyn Neukom and Clayton Davis for their comments and suggestions at various stages of the write-up of this report, and to Cynthia Aragon for editing.

4 INTRODUCTION Larger numbers of young Africans (ages 15 to 24) are currently at risk of sexually transmitted diseases and unintended pregnancy than at any other time in the past. Women under 25 account for more than half of all new cases of HIV in Africa. Many young Africans do not recognize the dangers associated with having unprotected sexual intercourse, or misjudge their personal risk. Adolescents practice unprotected sex for a variety of reasons. In some countries, where information and counseling about family planning and protection against sexually transmitted diseases have not been provided to young people, adolescents may not correctly assess the consequences of having unprotected sexual intercourse. When they do realize the importance of contraceptive use, cultural norms may restrain them from exercising their choice: gender-based prescriptions for behavior may not allow women to be forthcoming in sexual matters. Both individual and societal openness to the threat of sexual disease can be important in determining the choices available to young adults. In many countries, sexual disease is stigmatized. Stigma associated with sex can make young men and women reluctant to propose condom use because they fear being labeled as promiscuous or HIV positive. Religious prohibitions on sexual behavior outside of marriage or on the use of contraception may also limit young peoples choices: guilt and shame about being sexually active may limit young people s access contraceptive services, even when contraceptive services are available. Likewise, service providers who are morally opposed to the practice of sex by young adults may discourage the latter from obtaining contraceptives. To increase adolescents self-confidence in their ability to obtain and use contraceptives, an increase in knowledge of contraception, improvements in beliefs and attitudes towards contraception and greater openness in discussion of contraception are important. Welldesigned adolescent sexual health interventions have the potential to bring about these Page 1

5 changes through the use of mass media and peer educators and by increasing access to reproductive health products and services. The present study assesses the performance of four adolescent interventions implemented in sub-saharan Africa. These projects were implemented under a five-year Social Marketing Adolescent Sexual Health project (SMASH) financially supported by USAID s Africa Bureau. Individual interventions were implemented for about 8 to 13 months, between 1994 and This study is unique because it uses an experimental design in multiple countries of sub-saharan Africa and presents findings within the parameters of a clearly defined theoretical framework. BACKGROUND Reviews of the literature on interventions to improve adolescent sexual health show that many adolescent interventions have had minimal impact (Kirby et al., 1994; Reitman et al., 1996; Werner-Wilson et al., 1998). Studies have shown that it is easier to increase adolescents knowledge about reproductive health than to change their attitudes, or their behavioral intentions. In general, young women are more likely to demonstrate changes in knowledge, attitudes and behavioral intent than young men (Applegate, 1998). It has been even more difficult to demonstrate that interventions have been able to produce changes in actual behavior. When changes in behavior have occurred, they have usually taken the form of the adoption of contraceptive use. Delays in sexual initiation or partner reduction have usually not been observed (Franklin et al., 1997; Werner-Wilson et al., 1998). Several explanations have been forwarded to explain why there is only limited evidence that adolescent sexual health interventions are effective in changing actual behavior. Some researchers believe that the impact of some of these interventions is limited due to the poor integration of theory in their design (Mantell et al., 1997; Applegate, 1998), while others have faulted not the intervention itself, but rather the poor design of evaluations (Brown et al., 1991). Page 2

6 Because the extent to which adolescent interventions are effective is not known (Reitman et al., 1996) and because of the need to understand factors that motivate behavior, it is important to implement theory-based sexual health interventions as well as to evaluate their performance using clearly defined assessment tools. The present study uses the expanded Health Belief Model to evaluate the degree of success or failure of social marketing interventions to improve adolescents attitudes and practices in two West African (Cameroon and Guinea) and two Southern African (Botswana and South Africa) countries. EVALUATION FRAMEWORK: THE HEALTH BELIEF MODEL The HBM is one of the most widely used models to explain individual health behaviors. It is a cognitive model that uses a cost-benefit perspective to understand preventive health behavior. The expanded HBM states that individuals evaluate their susceptibility to disease and take a preferred course of action based on their level of self-efficacy and an assessment of perceived benefits versus barriers to action (Brown et al., 1991; Mantell et al., 1997; Van Rossem and Meekers, 1999a). Although studies suggest that the HBM model is efficacious in predicting intentions and behavior in the African context (Wilson and Lavelle, 1992; Adih and Alexander, 1999), it has some weaknesses. One weakness is its assumption that individuals make rational choices in sexual behavior. First, individuals may not have a true choice between safe and unsafe sexual behavior (e.g. they may be forced to have sex). Second, some risky behaviors may be due to emotional or psychological factors that operate at the noncognitive level (Brown et al., 1991; Poppen and Reisen, 1997). Third, perceived susceptibility to sexual risk, one of the components of the HBM, has proven to be difficult to operationalize (Poppen and Reisen, 1997). In spite of these limitations, the HBM is used for this assessment because a) its components broadly reflect social marketing efforts, b) it provides an organizing framework for an evaluation of adolescent reproductive health and c) it allows the Page 3

7 examination of a range of variables that are common to several popular conceptual models. DESCRIPTION OF THE INTERVENTIONS The social marketing sexual health interventions were implemented in Cameroon, Botswana, South Africa and Guinea in different years between 1994 and The Cameroon intervention was implemented for the longest duration, 13 months, while the other programs were carried out for only about 8 to 10 months. The interventions were designed to make adolescents understand the health risks associated with unprotected sexual intercourse and to motivate them to make healthy decisions concerning sexual behavior. To make adolescents appreciate the risks associated with early sexual initiation or unprotected sex, trained peer educators held meetings with adolescents during which they discussed the advantages of abstinence, monogamy and contraceptive use. Sponsored events such as concerts and soccer games were also used to raise awareness of the potential consequences of unprotected sex. Mass-media was used to increase adolescents awareness of the need to practice abstinence, monogamy, and safe sex; to make adolescents aware of the availability of contraceptives; and to create an enabling environment for the practice of contraceptive use. At the same time, contraceptives were made available in youth-friendly outlets (outlets where providers were trained to be sensitive to the needs of young people). Table 1 shows the reach of the different components of the social marketing interventions in Cameroon, Botswana, South Africa and Guinea. Table 1 about here Mass media The ability of the interventions to influence behavior change in the intervention locations was, in part, determined by the existence of local radio stations in intervention towns and by the reach of these stations. In Cameroon, there was a local radio station that reached a Page 4

8 large segment of the population in the intervention location. As a consequence, a radio call-in show where participants discussed reproductive health issues pertinent to adolescents received an enthusiastic response from adolescents. In South Africa, there was a local radio station but its reach was limited to only about one-tenth of the population (Parker, personal communication), which lowered the impact of the massmedia efforts in South Africa. In Botswana, the program aired a radio call-in show. However, since there was no local radio station in the intervention town, adolescents in both intervention and control towns were exposed to the radio talk show. Mass-media was not used in Guinea. Sponsored events The Guinea intervention relied primarily on sponsored events such as soccer games or concerts for reaching young audiences. However, because adolescents had to be physically present to be exposed to behavior change messages, their reach was limited. In Cameroon, Botswana and South Africa, sponsored events were a less important component of the intervention. Peer education Peer education was used in all four countries. Peer-educators were given standardized training and provided refresher courses in Cameroon and Botswana (Harris, personal communication). Peer educators were able to reach a significant portion of adolescents in both Cameroon and Botswana because of the relatively small populations of the intervention towns. By contrast, the target population in Guinea and South Africa was much larger. As a result, the peer education components in Guinea and South Africa were less intensive, and less closely monitored than in the other two countries (Barnes, personal communication). Contraceptive access The interventions were also designed to increase adolescents access to contraceptives by providing subsidized condoms and other contraceptives through youth-friendly outlets. Page 5

9 DATA AND METHODS Study Design The most rigorous evaluation design is the true experiment in which individuals are randomly assigned to intervention and control groups. In many real-life situations, however, it is unethical or impractical to implement a true experiment (Jemmott and Jemmott, 1994; Fisher et al., 1998). In the case of interventions that rely on the use of mass media, for example, it is not possible to isolate individuals living in the same neighborhood so that some are randomly exposed to the intervention and others are not. Because of the practical difficulties of implementing a true experimental design, a quasiexperimental design (such as a non-equivalent control group design) is often used (Fisher et al., 1998). In such a design, towns rather than individuals are assigned to intervention and control groups. The data for this study were collected using the non-equivalent control group design. The intervention and control locations were selected on the basis of programmatic priorities and logistical considerations. In three countries (Cameroon, Botswana, and South Africa), the intervention and control locations were distinct towns. One intervention and one control town were selected in Cameroon, Botswana and South Africa. The intervention and control towns were geographically separated from each other by several hundred miles. The design of the Guinean program was different because it was a programmatic priority to conduct the intervention in the capital city. As a result, there was no comparable city that could be used as a control site. To overcome this problem, the intervention was implemented in several distinct neighborhoods in the capital city, while other neighborhoods in the same city were used as control sites. A similar procedure was used in the second largest city, Kankan. After selection of the intervention and control locations, baseline surveys of adolescents were conducted in each intervention and control town/neighborhood. Follow-up surveys were conducted after the interventions were implemented. In Cameroon, about 800 interviews with males and females aged 12 to 22 were conducted in each baseline and Page 6

10 post-intervention survey. In Botswana, about 500 interviews with males and females aged 13 to 18 were conducted in each baseline and 1200 in each post-intervention survey. About 1000 interviews with males and females aged 12 to 19 were conducted in each pre and post-intervention survey in Guinea and about 100 interviews were conducted with females 17 to 20 at each baseline and each follow-up survey in South Africa. Data on South African males are not shown because of their poor quality (for details about individual evaluations see Meekers et al., 1997; Meekers, forthcoming; Van Rossem and Meekers, 1999a; Van Rossem and Meekers, 1999b). The variables The variables used in this study serve as proxies for various indicators of the HBM. Although there is some variation in the use of dependent variables across the four countries, many of the variables used are identical and enable a relatively easy comparison across countries. Statistical Analysis A multi-variate logistic regression model was used in this study. The intervention and control locations were compared to determine whether time-trends between intervention and control locations were different. The results presented in Tables 2 through 5 show odds ratios which indicate a) the time-trends in the intervention and control towns/neighborhoods and b) whether the trends in the intervention and control towns/neighborhoods were significantly different from each other. Since a non-equivalent control group design was used, there were some differences between the age and educational levels of respondents in intervention and control locations. As is standard for analysis of a non-equivalent control group design (e.g. O Leary et al., 1997), the level of socio-demographic factors was controlled in the regression analysis. Interpretation of the tables The first two columns of Tables 2 through 5 show the relative odds that an indicator has significantly changed over time in the intervention and control sites of each country. Page 7

11 An odds ratio of greater than one indicates a significant increase in the indicator, while an odds ratio of less than one demonstrates a decrease in the indicator. The third column shows whether or not the intervention had a significant impact on the indicator. There is evidence that the intervention had an impact when the changes in the intervention location are significantly different from those in the control location. If, on the other hand, the indicators changed at the same rate in both locations, then there is no evidence that the intervention had any impact. RESULTS Impact on Risk Perception, Perceived Benefits of Safer Sex and Sexual Protection, and Barriers to Safer Sex Table 2 shows whether, relative to the control location, there was an increase in risk perception, an increase in perceived benefits of sexual protection and a decrease in barriers to safer sex among young women. The interventions in Botswana and Cameroon showed greater impact on these Health Belief indicators than those in South Africa and Guinea. In Botswana, the intervention had a net positive impact by increasing the perceived risk of pregnancy, increasing the perceived benefits of safer sex and reducing perceived barriers to safer sex. Beliefs about the benefits of protection increased more in the intervention than in the control location in Cameroon and there was some reduction in barriers to safer sex, but risk perception did not change. In South Africa, the intervention resulted in an increased awareness of the benefits of sexual protection. However, there was no reduction in barriers to safer sex. The intervention in Guinea appears to have had no impact on these Health Belief indicators. Table 2 about here Table 3 shows the impact of the intervention on perceived risk and on the benefits and barriers to protection among young men. The intervention resulted in an increased perception of the benefits of condom use and other contraceptives among young men in Page 8

12 Cameroon. The interventions in Botswana and Guinea appear to have had no impact on risk perceptions and on perceived benefits of safer sex among young men. There is also no evidence of a reduction in barriers to safer sex in Cameroon or Botswana due to the intervention. Table 3 about here Impact on Self-efficacy, Sexual Partnerships and Contraceptive Use Table 4 shows changes in self-efficacy, sexual partnerships and contraceptive use among young women. The intervention in Cameroon had a net positive impact on these indicators. There was greater self-efficacy and more contraceptive use among young women because of the intervention. The level of early sexual initiation among young women declined, consistent with an increase in the use of abstinence for pregnancy prevention. The interventions appear to have had very little impact in improving self-efficacy and in reducing sexual partnerships among women in Botswana, South Africa or Guinea. There is limited evidence that the programs increased pregnancy prevention efforts in Botswana and use of the pill in Guinea. Table 4 about here Table 5 shows changes in self-efficacy, sexual partnerships and contraceptive use among young men. Once again, the effect of the intervention was most visible in Cameroon. Because of the intervention, there was a reduction in multiple partnership, an increase in modern method use and an increase in abstinence among young men in Cameroon. Changes in Botswana and Guinea were more limited. In Botswana, the intervention resulted in a reduction in casual partnership. In Guinea, condom use increased. Table 5 about here Page 9

13 CONCLUSIONS AND IMPLICATIONS The social marketing sexual health interventions relied to different degrees on mass media, sponsored events, peer education and youth-friendly contraceptive services. While social marketing sexual health interventions were broadly similar, there were important differences between them. Some of these differences were determined by factors beyond the control of the social marketing intervention, but they did have an important impact on the outcome of the evaluation. The Cameroon intervention was implemented in a relatively small town (pop. 86,000) in which peer educators were able to reach a substantial proportion of the population. Moreover, the existence of a local radio station that had a wide reach meant that a large segment of the intervention group was exposed to the radio talk show. Thus, the Cameroon intervention was strong in both mass media and peer education components. This intervention was also longer than those in the other three countries (13 months versus about 8-10 months). The Cameroon program also had the greatest impact. Relative to the control location, there was an increase in perceived benefits, a reduction in perceived barriers and an increase in self-efficacy in the intervention location. Consistent with these changes, there was also evidence of a reduction in sexual initiation by age 15 among young women, reduction of sexual partnership among young men and an increase in abstinence and condom use (among both young men and women) because of the intervention. Because the intervention town in Botswana had a small population (pop. 30,000), peer educators were able to reach a significant proportion of adolescents through their behavior change messages. However, because the intervention location in Botswana did not have a local radio station, both intervention and control towns were exposed to the mass media. Thus, there was no net effect of the mass media in the intervention location in Botswana. The Botswana intervention produced an increased perception of risk, increased the perception of benefits and reduced barriers to safer sex, but only among women. There was also evidence of a reduction in casual partnership among young men. Page 10

14 In South Africa, the intervention was implemented in a township with a very large population (estimated between one and two million). Peer educators were unable to have a substantial impact because of the size of population. Moreover, the radio station in the intervention location was estimated to reach only a tenth of the population. The South Africa intervention was only able to produce increased awareness of the benefits of sexual protection among young women. The poor quality of data for men limited the extent to which it was possible to evaluate the full impact of this intervention. Mass media was used little in Guinea because the intervention and control sites were in the same two cities. As a result, the intervention relied primarily on sponsored events such as concerts and soccer games. Because sponsored events require physical presence of a young person for them to be exposed to the behavior change messages, their reach was limited. Some sponsored events such as soccer games were also more likely to be attended by young men than by young women. Moreover, although sponsored events were conducted in the intervention neighborhoods in the two cities, it is possible that some young persons from control neighborhoods also attended the events. Thus, dilution of the impact of the intervention due to exposure of persons in the control neighborhood is a possibility. The Guinea intervention appears to have had little or no impact on Health Belief indicators. Overall, the interventions had greater impact on young women than on young men. The interventions had greater success in raising risk perception, increasing awareness of the benefits of sexual protection and reducing barriers to safer sex among young women. This is consistent with previous studies that have shown a greater impact of sexual health interventions on the attitudes and beliefs of young women than those of young men. It is possible that the social marketing sexual health interventions were better at addressing the concerns of women than of men. A better understanding of the sexual health concerns of young men is likely to increase the effectiveness of adolescent sexual health interventions. Page 11

15 One component of the HBM, perceived susceptibility to sexual risk, only showed measurable improvement among young women in Botswana. There was no improvement in this indicator in any of the other countries or amongst young men. This may in part be due to the difficulties measuring this construct (Poppen and Reisen, 1997) or because it is difficult to change perceptions of sexual risk. The Cameroon intervention, which was the most effective across the range of Health Belief indicators, was the only one in which both mass media and peer educators were able to reach a substantial proportion of the population. This suggests that the combination of mass media and interpersonal communication are necessary to produce behavior change in social marketing interventions that target adolescents. The results from this study also suggest that social marketing interventions are likely to benefit from a greater understanding of the sexual health concerns of young men. Page 12

16 References Adih and Alexander: Determinants of Condom Use to Prevent HIV Infection Among Youth in Ghana. Journal of Adolescent Health 1999, 24: Applegate M: AIDS Education for Adolescents: A Review of the Literature. Journal of HIV/AIDS Prevention & Education for Adolescents & Children 1998, 2(1): Barnes, J. Personal communication, August Brown LK, DiClemente RJ, Reynolds LA: HIV Prevention for Adolescents: Utility of the Health Belief Model. AIDS Education and Prevention 1991, 3(1): Fisher AA, Laing J, Stoeckel J: Guidelines for overcoming Design Problems in Family Planning Operations Research. Studies in Family Planning 1985, 16(2): Franklin C, Grant D, Corcoran J, Miller PO, Bultman L: iveness of Prevention Programs for Adolescent Pregnancy: A Meta-Analysis. Journal of Marriage and the Family 1997, 59: Harris, J. Personal communication, August Janz NK, Becker MH: The Health Belief Model: A Decade Later. Health Education Quarterly 1984, 11(1): Jemmott JB III, Jemmott LS: Interventions for Adolescents in Community Settings. In DiClemente RJ, Peterson JL, eds., Preventing AIDS, Theories and Methods of Behavioral Interventions 1994: Kirby D et al.: School-based Programs to Reduce Sexual Risk Behaviors: A Review of iveness. Public Health Reports 1994, 109(3): Mantell JE, DiVittis AT, Auerbach MI: Evaluating HIV Prevention Intervention. New York: Plenum Press. 1997: Meekers D, Stallworthy G, Harris J: Changing Adolescents Beliefs about Protective Sexual Behavior: The Botswana Tsa Banana Program. PSI Research Division Working Paper No. 3. Washington DC: Population Services International Meekers D: The iveness of Targeted Social Marketing to Promote Adolescent Reproductive Health: The Case of Soweto, South Africa. Journal of HIV/AIDS Prevention and Education for Adolescents and Children, forthcoming. O Leary A, DiClemente RJ, Aral SO: Reflections on the Design and Reporting of STD/HIV Behavioral Intervention Research. AIDS Education and Prevention 1997, 9 (Suppl. A): Page 13

17 Parker W: Personal communication, August Poppen PJ, Reisen CA: Perception of Risk and Sexual Self-Protective Behavior: A Methodological Critique. AIDS Education and Prevention 1997, 9(4): Reitman D, St. Lawrence JS, Jefferson KW, Alleyne E, Brasfield TL, Shirley A: Predictors of African American Adolescents Condom Use and HIV Risk Behavior. AIDS Education and Prevention 1996, 8(6): Van Rossem R, Meekers D: An Evaluation of the iveness of Targeted Social Marketing to Promote Adolescent and Young Adult Reproductive Health in Cameroon. PSI Research Division Working Paper No. 19. Washington DC: Population Services International. 1999a. Van Rossem R, Meekers D: An Evaluation of the iveness of Targeted Social Marketing to Promote Adolescent Reproductive Health in Guinea. PSI Research Division Working Paper No. 23. Washington DC: Population Services International. 1999b. Werner-Wilson RJ, Wahler J, Kreutzer J: Independent and Dependent Variables in Adolescent and Young Adult Sexuality Research: Conceptual and Operational Difficulties. Journal of HIV/AIDS Prevention & Education for Adolescents & Children 1998, 2(3/4): Wilson D, Lavelle S: Psychosocial predictors of intended condom use among Zimbabwean adolescents. Health Education Research 1992, 7(1): Page 14

18 Table 1 Reach of Intervention Components in Cameroon, Botswana, South Africa and Guinea 1 Cameroon Botswana South Africa Guinea Mass media High Low 2 Low Not applicable 3 Sponsored events Low Low Low Moderate Peer education High High Low Moderate Youth access to contraceptive services Moderate/High Moderate /High Low/Moderate Low/Moderate 1 Assessed on the basis of project records and discussions with project staff 2 Both intervention and control groups were exposed to the radio campaign 3 Mass media was not used 15

19 Table 2 Odds Ratios of Changes in Perceived Risk, and in Perceived Benefits and Barriers to Prevention, FEMALES CAMEROON BOTSWANA SOUTH AFRICA GUINEA SUSCEPTABILITY TO RISK Sexual activity carries the risk of AIDS None None 4.02 ** 1.02 Negative None Sexual activity carries the risk of pregnancy 0.71 * 0.80 None ** Positive ** Positive 2.76 ** 1.07 Negative BENEFITS OF ABSTINENCE Protects against unwanted pregnancy 1.72 ** 5.26 ** Positive * Positive Protects against AIDS/sexual risk ** Positive * None 1.31 * 1.30 * None MONOGAMY/FIDELITY Protects against AIDS/sexual risk 0.19 ** 0.41 ** None None None CONDOM USE Protects against unwanted pregnancy ** Positive 1.75 ** 3.75 ** Positive 2.11 * 3.17 ** None 2.35 ** 2.26 ** None Protects against AIDS/sexual risk ** Positive ** Positive 2.71 ** 1.24 Negative OTHER CONTRACEPTIVES Protect against pregnancy 1.95 ** 4.48 ** Positive 0.52 ** 1.95 ** Positive 1.84 ** 1.19 None BARRIERS TO ABSTINENCE Most people my age have sex 0.58 ** 0.85 None Sex gives status None Sex leads to marriage ** Positive Opposed to sex before marriage None Positive for girls to have sex before marriage None Positive for boys to have sex before marriage None CONDOM USE Normal for a woman to propose condom use 0.32 ** 1.07 Positive If women suggest condom use, lose respect 1.91 ** 1.62 ** None Men should take responsibility for protection * None *p<.10; **p<.05; ***p<.01 16

20 Table 3 Odds Ratios of Changes in Perceived Risk, and in Perceived Benefits and Barriers to Prevention, MALES CAMEROON BOTSWANA GUINEA SUSCEPTABILITY TO RISK Sexual activity carries the risk of AIDS 0.62 ** 0.66 ** None 2.68 ** 3.02 ** None None Sexual activity carries the risk of pregnancy 1.37 * 1.36 * None 2.54 ** 1.90 ** None 3.48 ** 1.28 Negative BENEFITS OF ABSTINENCE Protects against unwanted pregnancy 4.48 ** 3.48 ** None Protects against AIDS/sexual risk 5.77 ** 5.25 ** None 1.54 ** 1.17 None MONOGAMY/FIDELITY Protects against AIDS/sexual risk None None CONDOM USE Protects against unwanted pregnancy 0.57 ** 1.39 * Positive * None 4.27 ** 2.55 ** None Protects against AIDS/sexual risk ** None 2.32 ** 1.04 Negative OTHER CONTRACEPTIVES Protect against pregnancy ** Positive None BARRIERS TO ABSTINENCE Most people my age have sex 0.73 * 0.52 ** None Sex gives status ** None Sex leads to marriage 0.19 ** 0.10 ** None Opposed to sex before marriage ** Negative Positive for girls to have sex before marriage Positive for boys to have sex before marriage CONDOM USE Normal for a woman to propose condom use 0.60 ** 0.73 ** None If women suggest condom use, lose respect None Men should take responsibility for protection Note: *p<.10; **p<.05; ***p<.01. Data for South African males is not presented because of poor quality 17

21 Table 4 Odds Ratios of Changes in Self-efficacy, Sexual Partnerships and Contraceptive Use, FEMALES CAMEROON BOTSWANA SOUTH AFRICA GUINEA SELF-EFFICACY Believes that AIDS is avoidable 0.11 ** 0.96 Positive Often discusses sexuality/contraception Positive 1.64 * 1.03 None Discussed sexual matter with partner 0.52 * 0.48 * None Discussed disease prevention with partner Negative Feel confused about sexual matters ** Positive SEXUAL PARTNERSHIPS Sexually experienced None 0.45 ** 0.44 ** None None None Had sex by age * 0.34 ** Positive None None Two or more partners during last month 2.38 ** 1.71 * None Negative Two or more casual partners in last year 1.92 * 1.98 * None Have fewer partners to protect from AIDS * Positive CONTRACEPTIVE USE Ever used condom ** Positive None 2.20 * 1.85 None 0.43 ** 0.42 ** None Used condom in last sex 2.13 ** 1.66 * None None None 0.31 * 0.80 Positive Currently using condoms for pregnancy prev ** 3.82 ** Positive 14.5 * 0.79 Negative Ever done anything to prevent pregnancy ** Positive Ever used pill None ** Positive Uses modern method for pregnancy prev ** 3.32 ** None None Uses abstinence for pregnancy prevention 0.56 ** 2.40 ** Positive *p<.10; **p<.05; ***p<.01 18

22 Table 5 Odds Ratios of Changes in Self-efficacy, Sexual Partnerships and Contraceptive Use, MALES CAMEROON BOTSWANA GUINEA SELF-EFFICACY Believes that AIDS is avoidable 0.46 ** 0.64 * None Often discusses sexuality/contraception 0.68 * 1.37 Positive 0.47 ** 0.93 None Discussed sexual matter with partner 3.92 ** 3.11 ** None Discussed disease prevention with partner Feel confused about sexual matters SEXUAL PARTNERSHIPS Sexually experienced 0.54 ** 0.44 ** None None None Had sex by age ** None 0.66 * 0.97 None Two or more partners during last month ** Positive None Two or more casual partners in last year ** Positive Have fewer partners to protect from AIDS None CONTRACEPTIVE USE Ever used condom None None ** None Used condom in last sex None None ** Positive Currently using condoms for pregnancy pre ** 2.52 ** None Ever done anything to prevent pregnancy 2.32 * 1.04 None Ever used pill * None Uses modern method for pregnancy prev ** Positive Uses abstinence for pregnancy prevention 1.99 ** 3.10 ** Positive Note: *p<.10; **p<.05; ***p<.01. Data for South African males is not presented because of poor quality 19