A review of HIV risk reduction interventions for youth in sub-Sahara Africa: a theoretical critique and the “relational-situational factor”

Abstract

Background: Through rationalizing sexual behavior, theories can serve as a solid ground for HIV risk-reduction interventions. Studies have shown that theory-based interventions are more effective. This review makes suggestions for improving the (use of) theory in HIV risk- reduction interventions among young people in sub-Sahara Africa. Methods: Online databases and websites of international organizations were searched for evaluations of HIV risk reduction interventions for youth in sub-Sahara Africa. Reference lists of selected articles and recent reviews were examined to identify additional studies. 39 articles, reporting on 36 interventions, met the inclusion criteria. Results: There are few published evaluations of HIV-prevention programs, relative to the size of the problem. Long-term impact (>1 year) is measured by only 1 study. Twelve theories were referred to 28 times in 23 articles. Social Cognitive Theory (10) and Health Belief Model (5) dominate. There is no direct link between theory and the impact of interventions. Eleven articles measure all constructs of the theory on which the intervention is based, unfortunately using a variety of indicators giving proof of a poor conceptualization of theoretical constructs. None of the articles studied correlations between measured theoretical determinants and reported behavior, a missed chance for insights in the validity/utility of theories for sexual behavior of African youth. Gaps in measuring the outcome of behavioral interventions include: correct condom use is never assessed and concepts can be interpreted subjectively. Gaps in theory are: absence of specific theoretical concepts or measures for adolescents and ignorance of the relational-situational factor and the social context. As a result, sexual behavior of young people in sub-Saharan Africa cannot be predicted, nor changed by the current dominant constructs of health psychological theories. Conclusions: Efforts should be intensified to incorporate relational-situational aspects and social context in behavioral theory. Current behavioral theories could benefit from complementation with sociological theories.