There were two groups – intervention and control – to whom the program was delivered in small groups. Outcomes were assessed at baseline, before the program, and again at 3-month and 6-month follow-ups. Data were collected between 2006 and 2008.
Participants, Recruitment and Randomization
The investigative team distributed flyers and display posters announcing the project at strategic locations in the military establishments including such places as apartments, storefronts, clinics, and recreational areas informing enlisted women about the study and requesting their participation. Information about the study was also distributed through established ethno-cultural and civic organizations in the military. The flyers listed the study inclusion criteria: (1) 18 years of age or older; (2) self-reported unprotected vaginal intercourse with two or more different partners in the past six months, or having been diagnosed and treated for a sexually transmitted disease in the last year; (3) residence at the study sites; (4) ability to communicate in English Language; and (5) willingness to sign an informed consent for study participation. The flyer also listed the collaborating community-based organization’s telephone number that prospective participants could call to obtain additional information or schedule an appointment to participate in the study. Eligible participants were asked to visit the study recruitment center where non-military project staff (health educators) introduced the study aims and procedures to the participants.
A convenience sampling approach was used for participants’ recruitment – those selected for participation were encouraged to invite their friends to participate. A total sample of 386 female enlisted personnel from two permanent military bases in Southwestern Nigeria was initially recruited for this study. After the screening process, 346 of the participants met the inclusion criteria for participation in the study (). They were randomly assigned to one of two groups. Specifically, 174 females were assigned to the intervention group and received a 5-session, small group, videotape-based HIV prevention intervention, based on the IMB model, and 172 were assigned to the 5-session, HIV education comparison group, using a concealment of allocation technique.
Flowchart of the Distribution and Retention of Study Participants in Intervention and Control Groups
Intervention and Control Conditions
For brevity, we will refer to the participants assigned to the motivational skills-building intervention as intervention group (or participants) and those assigned to the HIV education (only) condition as control or comparison group. The participants met twice a week, and the sessions were delivered in 90-minute blocks by two facilitators.
Videotape-based HIV Prevention Intervention
Formative research to develop intervention material
As suggested by the IMB model, a qualitative phase that included focus groups and personal interviews was conducted to adapt Kalichman et al.’s intervention (1999b)
and to elicit the target population’s level of HIV prevention information, motivation, and behavioral skills. We conducted six focus groups (N=36) and 20 one-to-one interviews with women in the Nigerian Army to elicit information on how to produce a video-based intervention that is feasible, efficacious, and acceptable in modifying HIV risk behaviors. Responses suggested that the intervention should address issues related to the three “Ws” (war, wine, and women) of the Nigerian Army, as well as situational factors that encourage coercive sex by senior officers. The participants emphasized the fact that alcohol and drug use increases the likelihood of HIV transmission among the Nigerian Army, coupled with a lack of knowledge on correct condom use. Furthermore, the women suggested that the intervention videos should incorporate local actors for cultural acceptability, and that participants’ recruitment and retention could be bolstered by senior military administrators participating as project consultants in the study, and by providing the participants with incentives such as telephone calling cards, condoms, and mall gift certificates. These suggestions and the changes made allowed the investigators to focus their intervention on the peculiar HIV risk dynamics experienced by female enlisted personnel who were serving in the Nigerian Army.
The model given by Mathews et al. (2002)
was used for adapting themes that emerged from the qualitative study into the videotape production. Focus groups were conducted with the women, which enabled them to view and comment on the contents of the original videotapes that were used for a similar study in the United States. These provided feedback on integrating the findings from the qualitative study into the intervention. The Principal Investigator, the two US-based behavioral scientists who served as project consultants and the local Nigerian health educators teamed up with a local video production company in Nigeria to develop the video tapes. This company had more than 10 years’ experience in developing educational videos in Nigeria. The team hired local actors to portray the major themes identified from the qualitative studies through dramatic narratives.
The new video tapes produced depicted risk scenarios and emphasized issues identified in the qualitative studies such as recognizing triggers that promote alcohol and drug use and other risky sexual practices in the Nigerian Army, and also introduced methods of risk avoidance and risk management. The finished product was pilot-tested for appropriateness and cultural sensitivity using 20 enlisted women, who were excluded in the main intervention study. The community-based organization’s staff also conducted mock sessions with their peers, and with a sample of the proposed study participants, to help identify strengths and weaknesses in the intervention as well as intervention implementation.
Implementation of the Intervention
The HIV prevention intervention comprised five sessions of 90 minutes each (). Each session consisted of videotape presentations, modeling, practice sessions and corrective feedback, and group sessions. The two facilitators did the modeling; supervised the practice sessions, and provided corrective feedback to study participants. The first session focused on HIV education/risk sensitization and situation cue identification and management. Similarly, the following sessions used videotapes, modeling, and discussion to address triggers, risk avoidance and risk management. In particular, they addressed the use of male and female condoms, communication with one’s partner, and substance use. For example, in Session 4, sexual assertiveness was modeled and discussed on the videotape using different models and situation contexts. The participants were then asked to practice assertiveness responses to male silhouette figures presented in videotape vignettes constructed from formative study data. This was followed by a discussion of socio-cultural issues that affect sexuality in Nigeria such as the differing cultural and religious backgrounds, cross-cultural sex role norms, polygamy, extramarital sexual relationship, transactional and coercive sex, rape, gender inequalities in income and wealth among other issues. Understanding these factors was very critical for the design of a culturally and contextually tailored intervention for the reduction of sex-related health risks among Nigerian military personnel.
HIV Prevention Intervention Sessions
Video-Based Education Control Condition
The comparison condition was a purely didactic and discussion approach devoid of any motivational and skills building content. Five sessions of 90 minutes each were used for the delivery of educational information and discussion among participants in the control group. The facilitators provided information on common misperceptions about HIV/AIDS, information on where individuals could go to receive voluntary HIV/AIDS counseling and testing, and information on the HIV/AIDS epidemic in Nigeria. The facilitators also discussed the cultural and social factors that can contribute to HIV risk (e.g., being sexually active with multiple wives and not adopting safer sex practices, and sharing scarification instruments without their being thoroughly cleaned before reuse). The session concluded with the facilitators discussing with participants some of the environmental barriers to HIV prevention (e.g., poverty, limited access to care, lack of condoms) and steps that participants can take to overcome these barriers. The study used different facilitators for the intervention and control conditions.
Training of Program Facilitators
The groups were facilitated by two female commissioned officers with minimal training in counseling and facilitator techniques, who were trained using the model of Rotheram-Borus & Leonard (2000)
. Specifically, the facilitators attended a 12-hour course that trained individuals to be local HIV prevention instructors. The course, which had been developed by the Institute for Health Research and Development in Nigeria and used, previously to train health care providers, was given at the Institute by Certified Health Education Specialists. In addition, the facilitators participated in a 3-day intensive workshop on the delivery of the videotape-based intervention organized by the project investigators.
Measures and Data Collection Procedure
Assessments were administered by research assistants during group sessions with the eight participants and two female commissioned officers who served as facilitators. The assistant used overhead projection transparencies of the items to walk the participants through the measures. This procedure has been found to be particularly effective in eliciting accurate responses to HIV risk assessments among populations with a low level of literacy (Kalichman et al., 1999b
; Kalichman et al, 2007
). Participants provided self-report of their HIV/AIDS-related knowledge and sexual behaviors at baseline, 3 and 6 months after completing the intervention. The measures were in English language; and each assessment took an average of 40 minutes to complete. Measures included socio-demographic characteristics, HIV/AIDS-related knowledge, condom use, negative condom attitudes, HIV preventive behaviors, behavioral intentions, substance use and sexual behaviors and Safer Sex Self-efficacy. The participants were reimbursed $10 for completing the baseline assessment, $15 for completing each of the 3-month and 6-month follow up assessments. The exchange rate during the period of the study was $1 to ₦150; the incentive amounts offered to participants could pay for a good dinner in a standard restaurant in Nigeria.
Participants reported their age, marital status, race/ethnicity, religion, level of education, employment status, annual income, sexual relationships, and personally knowing someone with HIV/AIDS.
A 10-item test was used to assess HIV risk and prevention-related knowledge. The items elicited information about modes of HIV transmission, knowledge of condom use, and AIDS-related knowledge. The response format was Yes, No, Don’t know. Example items include “Can a woman give the AIDS virus to a man?” (yes), “Can you get AIDS by touching a person with AIDS?” (no). Each correct answer received 1 point; an incorrect response or “don’t know” response received 0 point, for a range of 0 to 10 (alpha 0.74). On the basis of their scores, participants were dichotomized as having poor knowledge (0–5) or good knowledge (6–10).
Condom use was measured with a 21-item scale that attempts to capture participants’ knowledge and use of condom during sexual intercourse. Example of items in the scale include: “I have seen or heard about latex condom”, I have used latex condom”, and “I plan to use latex condom within the next month.” Responses to each item were either no (0) or yes (1) with a score range of 0–21 and alpha 0.67.
Negative Condom Attitudes
The negative condom attitudes scale included 22 statements such as: “Female condoms take away pleasure,” “male condoms reduce the fun of sex,” “I would be embarrassed to buy condoms,” and “male condoms are a hassle to use” all examples were reversed scored. The response format was a four-point scale ranging from 1 (strongly disagree) to 4 (strongly agree). Ratings were summed for a composite score, in which low scores represented positive attitudes and high scores negative attitudes toward condoms (range = 17–74). The internal consistency was 0.58.
HIV Preventive Behaviors
HIV preventive behavior was defined as the ability of participants to practice HIV protective behaviors and assertive skills, and was assessed using a six-item scale involving self-efficacy for condom use, HIV testing, and substance use prior to sexual intercourse. Examples of items are: In the past three months you have: “talked with sex partner about using male condoms for safer sex”, “did not have sex because you did not have a condom”, “talked with sex partner about getting tested for the HIV”, drank less or used drugs less before having sex to be safe. Participants responded with the best estimate of number of times an event occurred within the past three-months. High values indicated more favorable HIV preventive behaviors (alpha 0.78).
Behavioral Risk Avoidance Intentions
HIV risk avoidance intentions were measured using a 10-item scale. Participants were asked to imagine a situation in which they might be tempted or pressured to engage in unprotected sexual intercourse with a person they desired and to respond to each risk-reduction intention item accordingly. Sample items in the scale included: “I will keep a male condom nearby”, “I will remind myself to use a female condom during sex”, and “I will tell my partner I don’t want to have sex unless we use a condom”. Participants responded on a six-point scale ranging from 1 (definitely will not do) to 6 (definitely will do). Responses were summed to provide behavioral intentions score with a range of 10–60 (alpha 0.68). Higher scores indicated more likelihood to engage in actions that reduce HIV-related sexual risk.
Substance use and Sexual Behaviors
Drug use was classified into major substances with which ingestion could result in behavioral impairment and altered mentation. These agents were assessed in relation to sexual encounters and included alcohol, marijuana, cocaine, amphetamines, and ecstasy. Participants were asked to respond to the questions by stating the number of times that they engaged in the act during the past three months. Two items concerned use of substances and three items sexual behaviors. Questions included: In the past three months, “how many times have you used alcohol before sex?”, “how many times have you used drugs before sex?”, “how many times have you had vaginal sex without condom?” and “how many sex partners have you had?”
Safer Sex Self-efficacy
Participants risk reduction skills were assessed using questions that attempted to determine the level of confidence participants had in practicing safer sex in difficult situations in the past 3 months. Items included having confidence to suggest condom use with new and regular sexual partners, when drinking or using drugs, having satisfactory sex with condom and knowing how to use condom correctly. The participants initially responded on a four-point scale ranging from 1 (strongly disagree) to 4 (strongly agree). These were further categorized into two response groups as follows: “have confidence” (>=3 points) and “do not have confidence” (<= 2 points) in practicing safer sex.
Human Subjects Protection and Ethical Considerations
Appropriate steps were taken to ensure the protection of participants given the possibility of coercion in a military establishment. The research protocol was reviewed and approved by appropriate Institutional Review Boards in the United States and Nigeria. The women were informed verbally and in writing that their participation was voluntary, and that failure to complete all phases of the study or refusal to participate would not jeopardize their eligibility for benefits, to which they were otherwise eligible at the Armed Forces Program on AIDS Control or the collaborating community-based organization. The participants were also told that they reserved the right not to answer a question, if they so desired. In order to protect against the disclosure of sensitive personal information, the participants were required to sign a contract that they would not share others’ personal information with anyone outside the group. In addition, study data were collected by non-military project staff and military personnel did not have access to the study data. The study data were stored in a password protected computer file at the collaborating community-based organization, accessible only to the project Principal Investigator and Program Director.
Data analyses were based on 346 female participants who provided data at baseline, 3-month and 6-month follow-up assessments. All participants that dropped out of the study at each level of assessment () were excluded from data analysis at that point. Chi-square tests of independence were conducted to determine if the participants in the intervention and control conditions differed with respect to ten socio-demographic characteristics at baseline. Initial analysis indicated that personally knowing someone with HIV differed at baseline (p<0.001), and was a potential covariate for the behavioral outcomes. We used analysis of covariance with condition (intervention, control) as the between-subjects variable and baseline along with knowing someone with HIV as covariates to analyze the following five outcomes at 3- and 6-months: HIV/AIDS-related knowledge, condom use, negative condom attitudes, HIV preventive behaviors, and behavioral intentions.
We used McNemar’s chi-square test to analyze change in substance use and safer sex self-efficacy. Odds ratio (OR) was also calculated to estimate intervention effects for all outcomes of interest. For sexual risk behaviors, ORs of 1.0 favor the intervention group in reducing HIV transmission risk and indicated a protective effect. For protective sex behavior (e.g., condom use), ORs of 1.0 favor the intervention group relative to the comparison group and indicate a protective effect. All tests were two-tailed and used p < 0.05 as the cut-off for statistical significance. For all analyses, cell sizes varied slightly because of attrition and missing data. All statistics were performed using SPSS software (version 16.0; SPSS Inc., Chicago, USA).