The Role of Theory−based HIV and Sexual Health Interventions in Enhancing Positive Sexual Behaviour Outcomes and Reducing Risk Factors among Young People in Sub−Saharan Africa. A Scoping Review Protocol

Bright Mukanga^1*, Myra Taylor² and Siyabonga Blessing Dlamini^1,2
*Correspondence: Bright Mukanga, Department of Public Health, University of KwaZulu-Natal, Glenwood, Durban, South Africa, Email:

Keywords

Theory-based interventions • Sexual behaviour • HIV • Risk factors • Young people • Sub-sahara Africa

Abbreviations

Mesh: Medical Subject heading, PRISMA: Preferred reporting items for systematic reviews and misanalyses, RCT: Randomised controlled trial, SSA: Sub-saharan Africa, HIV: Human immunodeficiency virus, PYD: Positive youth development, SCT: Social cognitive theory, HBM: Health belief model, SRH: Sexual and reproductive health, CINAHL: Cumulative index to nursing and allied health literature, AGYW: Adolescent girls and young women, SoC: Stages of change, TPB: Theory of planned behaviour

Introduction

Sub-Saharan Africa (SSA) has been the epicentre of HIV transmission for decades now [1], accounting for about 70% of the 34.2 million people infected with HIV globally [2]. Young people, especially adolescent girls aged 15-24 years, are disproportionately affected by the pandemic and account for 34% of all new HIV infections representing a growing population in need of Sexual and Reproductive Health (SRH) services [3]. Estimates indicate that of the nearly 290,000 new HIV infections in Eastern and Southern Africa among young people aged 15 to 24 years old, two-thirds occurred among adolescent girls and young women (AGYW) [4]. While HIV-related deaths declined by 48% between 2005 and 2017, AIDS-related deaths among all adolescents and young people increased by 50% to approximately 55,000 deaths [5]. Young people’s vulnerability to HIV is compounded by a range of biological, behavioural, social, structural, and gender dynamics [6,7]. Further, young people’s access to HIV and sexual and reproductive health (SRH) services is limited, and community stigma and human rights violations are widespread in SSA [5]. Predictors of sexual risk behaviours among young people in SSA include early marriages and sexual initiation for young girls which are forced and not voluntary, substance abuse, age at first sex, low parental education, peer influence, age-disparate relationships, punitive laws criminalising homosexuality which prevent young people from seeking treatment from health centres [8,9], gender discrimination, and economic disadvantage [10,11]. Given this, it is projected that new adolescent infections will increase by 13% annually leading to 3.5 million new infections by 2030 if interventions to address the drivers of HIV among young people are not scaled up [12]. Therefore, tailored HIV prevention programmes are essential in reversing the HIV epidemic among young people because they are contextual and can address structural factors that influence young people’s sexual risk behaviour [13].

For several decades, HIV prevention programmes have been developed and implemented in SSA to reduce vulnerabilities and sexual risk behaviour among young people [5]. These include preventive education in schools such as comprehensive sexuality education [14], services offered at youthfriendly centres such as free condom distribution, counselling, HIV testing, and initiatives that enhance the utilization of SRH services [15]. These have mainly focused on increasing levels of sexual health knowledge, abstinence, delaying sexual debut, increasing condom use and reducing the number of sexual partners, changing attitudes, improving access to sexual and reproductive health services, and enhancing sexual health efficacy [2].

Also, many individual level health promotion interventions that are based on existing theories of behavior change have been used in developing, implementing, and evaluating behavior change for HIV-related interventions [16]. These interventions seek to understand the context of health-related behaviors and provide a theoretical framework for planning behavior change programmers [17]. Because they have a theoretical foundation, theory-based interventions provide a basis for understanding how cognitive abilities predict sexual behavior and are considered to be more efficacious than those that are not theory-based [13-18]. Additionally, theory when used to inform behavior change can aid in understanding factors influencing risky and safe sexual behavior and can be effective in establishing principles and address the dynamics of behavior change [19]. Besides providing theoretical underpinnings for behavioral interventions, behavioral theories can provide a framework for evaluating HIV prevention interventions [18]. However, reviews of individual level theory-based HIV interventions have revealed that the success of these models is constrained by their inability to explicitly consider high-level behavioral connections [20]. The common theories and approaches used in HIV interventions include the I-Change model (ICM) [21], the Social Learning /Cognitive theory (SCT), the Theory of Reasoned Action/Planned Behaviour (TRA/TPB), the Stages of Change (SoC), the Social Ecological Model (SEM), the Health Belief Model (HBM) [13], and positive youth development (PYD) [22]. SCT posits that there is a reciprocal influence between behavioral patterns and the surrounding environment, a phenomenon referred to as reciprocal determinism [23]. SCT emphasizes efficacy expectations and outcome expectancies as influenced by the surrounding environment [10]. It assumes that behavior is not simply the result of the environment and the person, just as the environment is not merely a function of the person and behavior [13].

The HBM is a value expectancy theory used to predict health-seeking behavior and has six main constructs [24]. It assumes that a person takes health-related action if that person believes that he/she is susceptible to the condition (perceived susceptibility), the condition has serious consequences (perceived severity), and that taking action would reduce their susceptibility to a certain condition (perceived benefits) and that these benefits outweigh the cost of taking action (Perceived barriers) and that action is taken more easily if the person is exposed to factors that prompt action (Cues to action) and is confident in his /her abilities to successfully act (self-efficacy) [13].

The TRA/TPB is an explanatory theory that postulates that a person's behavior is determined by his/her intention to perform the behavior. It asserts that behavioral intention is influenced by attitudes, subjective norms, and perceived behavioral control [19-25]. The Sock model stipulates that behavior change is a continuous process and that an individual passes through five stages: pre-contemplation, contemplation, preparation, action, and maintenance [26]. The ICM model is an explanatory model which postulates that the effects of pre-motivational factors (Knowledge, behavioral cognizance, risk perception and cue) on behavior, is mediated by motivational factors such as attitude, self-efficacy, social influence, and intention [21]. Because of the numerous theoretical constructs that exist and overlap in different models, the I-change model takes an integrated approach to behavior change and offers a socio-ecological framework for understanding health behavior [27].

Despite their effectiveness in understanding cognitive sexual health behavior, HIV prevention interventions that are only based on cognitive behavioral theories have small and short-term effects because they do not consider the multiplicity of environmental and structural factors that drive sexual behavior [10]. As such, recent literature supports a social ecological approach to understanding the multiple influences and predictors of risk sexual behaviors. The SEM posits that health seeking behavior is shaped by an allay of structural factors other than those at an individual level [28,29].

Important to note is the fact that sexual behavior is a collection of several distinct behaviors [30], therefore, no single theory can address all these behavioral characteristics [13]. For instance, factors that influence sexual behavior might be at community and structural levels, which can include gender discrimination and stigma, and existing health policies [29]. Hence, the planning of theory-based HIV interventions should be done following the type of behavior being measured. Additionally, Michelson K, et al. [13], assert that not all theories are suitable for all age groups of young people which can vary between their developmental stages. This can pose a great challenge in identifying attitudes and beliefs in young people who have not fully identified cognitive behaviors. As such, theory-based interventions should take a targeted approach and should be assessed for their suitability in assessing cognitive behavior outcomes as influenced by one’s age, gender, and other personal characteristics [15].

As such, most interventions among young people in developed countries have taken an integrated approach to HIV prevention where positive youth development (PYD) programmers have been incorporated into existing theorybased interventions [31]. PYD is an approach to HIV prevention among young people which includes several programmers and policy initiatives that focus on building young people's skills and competencies [32]. PYD fosters youth agency through programmers such as education that enhance interpersonal skills. Unlike theory-based interventions which focus on single-problem behavior, the concept of PYD takes a comprehensive approach to behavior change and fosters a supportive environment to prepare young people for successful adulthood [33]. It is argued that because many behavioral problems have common predictors, measuring a single behavioral problem may not be efficacious in addressing the multi-determinism of sexual behavioral risk factors [22]. However, there is limited literature on the effects of positive youth development in reducing sexual risk behaviors among young people in lowincome countries [33].

Considering this, this review seeks to provide a critical narrative synthesis and map evidence on the role of theory-based HIV and sexual health interventions in enhancing positive sexual outcomes and reducing risk factors among young people aged 10-24 years of age in Sub-Saharan Africa. The review will describe, contextualize and appraise various theory-based HIV prevention interventions regarding their efficacy in reducing sexual risk behaviors among young people. Additionally, the review will seek to establish the theoretical foundation of various HIV prevention interventions among young people in SSA.

Methods

The scoping review will adopt a framework proposed by Arksey and O'Malley, which outlines five stages in the organization and development of the review process [34]. These stages include (1) identifying the research question, (2) identifying relevant studies, (3) study selection, (4) charting the data, and (5) collating, summarizing, and reporting the results. Further, we will seek to report the findings from our scoping review using the Preferred Reporting Items for Systematic Reviews (PRISMA) and Meta-Analysis Extension for Scorpion Reviews (Figure 1).

Review process

Framework stage 1: Identifying the research question: This stage was informed by the scanning of existing published scholarly literature. This guided the development of the research questions for the scoping review. Considering this, the broad research question that this review will seek to answer is: “What is the role of theory-based HIV and sexual health interventions in enhancing positive sexual behavioral outcomes and reducing risk factors among young people in SSA?’’. Guided by the main research question, the review will seek to provide a narrative synthesis of the efficacy of theory-based HIV and sexual health interventions in enhancing positive sexual behavior outcomes and reducing risky sexual behaviors among young people aged 10-24 years of age. Further, the review will seek to appraise and characterize various behavioral theories that are applied in HIV/AIDS interventions. The review will also seek to establish the theoretical basis of the current HIV prevention interventions among young people in SSA.

Framework stage 2: Identification of relevant studies: Searching of electronic databases of existing published literature will be done to identify relevant studies to include in this review. The search will also be extended to published systematic reviews. These electronic databases will include PubMed, Scopus, MEDLINE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science, Google Scholar, ProQuest One Academic and EMBASE. In addition, all reference lists in the articles identified in the databases will be included to identify additional relevant studies. The review will also include relevant grey literature such as Grey Literature Report, OpenGrey, and Web of Science, and Conference Proceedings to identify studies, reports, and conference abstracts that we will apply to this review. The inclusion criteria that will guide the protocol will be as follows: (1) Language of publication: English, (2) Timeframe: Articles not more than 10 years old after publication, (3) Study setting: SSA, (4) types of articles: randomized controlled trials, interventional studies including quasi-experimental designs, reports, qualitative studies, and literature reviews. Articles will be excluded if they do not meet the above criteria. The search terms will be agreed upon by the search team and a librarian will be consulted to aid in the selection of appropriate search terms. The review will utilise the following keywords that will be used to search for articles in the various electronic databases: sexual, health, theory, HIV, interventions, behaviour, young people, adolescents, teenagers, youth, SSA, role, enhancing, and risk. Further, we will adopt a search string that will combine keywords and Medical Subject Headings (MeSH) [35], which will include, Theory-based, Sexual health, Sub Sahara Africa, HIV interventions, Sexual Health interventions, and risky behavior. All the review articles will be screened for their titles, abstracts, and index terms. The articles which will be retrieved will be imported into reference management software, namely EndNote. EndNote reference manager will be used for removing duplications and managing records and organizing the final list of references which will be included in the review.

Framework stage 3: Study selection: The review will adopt two levels of screening; this will be at the title stage where two review members will independently screen the title and abstract of all retrieved articles for inclusion, based on the set of already established inclusion criteria. These inclusion criteria will be developed using the population-concept-context (PPC) framework (Table 1). The second level of screening will involve a full-text review, where a sample of the retrieved articles will again be independently screened by two review team members. This will enhance consistency in the applicability of the eligibility criteria for inclusion in the review [36]. If the article is determined to be relevant by both members of the review team, it will be included in the full-text review. Advancement to the next stage of screening will be determined by reaching an agreement percentage of 80% and above. Any agreement on certain articles which is less than this will need the inclusion and exclusion criteria to be clarified by the three members of the review team. All duplicates from different databases will be removed using the EndNote reference manager. Titles and abstracts will be screened to ascertain whether they meet the established inclusion criteria by a member of the review team. The full-text articles of those meeting the title and abstract criteria will then be retrieved. At this stage, if there are any disagreements about the eligibility of the selected articles, this will be discussed between two reviewers until a consensus is reached through the engagement of the third reviewer. This review will adopt the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow chart (Figure 1).

Framework stage 4: Charting the data: Data will be extracted from the retrieved articles and will include the author, year of publication, and study objectives. Our data extraction framework will aid in assessing the eligibility criteria for inclusion. The assessment criteria for each article will be based on the study population characteristics, setting, length of the interventions, types of outcomes assessed, and information on the effectiveness of the theorybased HIV interventions [35].

Framework stage 5: Collating, summarizing and reporting the results: Through the numerical analysis, the review will compile a summary of findings on the role of theory-based HIV and sexual health interventions in enhancing positive sexual behavior outcomes and reducing risky behaviors among young people in SSA. This will be done using a thematic construction that will be used to build a narrative based on the objectives of this review. The review will provide a narrative synthesis of the theoretical foundations of HIV prevention interventions among young people in SSA. Most importantly, the numerical analysis of the data from different articles will provide a narrative synthesis to help appraise the efficacy of various theory-based HIV interventions among young people. Also, the narrative synthesis of the findings will be essential in assessing the role of theory-based HIV and sexual health interventions in enhancing positive sexual behaviour outcomes and reducing risk factors among young people in Sub-Sahara Africa.

Discussion and Conclusion

This scoping review aims to assess the role of theory-based HIV and sexual health interventions in enhancing positive sexual behaviors and reducing risk behaviors among young people aged 10-24 years in Sub-Sahara Africa. Findings from this review will be essential in establishing the role of theorybased HIV prevention interventions in enhancing positive sexual behaviors and reducing risk factors among young people in Sub-Saharan Africa. Additionally, results from this scoping review will provide key insights and can guide future HIV programmer developers in developing effective theory-based HIV interventions among young people in SSA. In informing policy change and practice, the findings may act as a backdrop to many HIV programmers that seek to integrate positive youth development programmers into existing theory-based HIV interventions in Sub-Saharan Africa. The limitation of this review is that we only included articles and review papers published in English which is likely to contribute to selection bias.

Acknowledgments

Not applicable.

Authors Contributions

The authors contributed to the development of the research questions, the methods and the drafting and editing. All authors have approved the final manuscript.

Funding

The project was supported by the Health Economics and HIV/AIDS Research Division (HEARD) based at the University of KwaZulu-Natal, Durban, South Africa.

Availability of Data and Materials

Not applicable.

Ethics Approval and Consent to Participate

Not applicable.

Consent for Publication

Not applicable.

Conflicts of Interest

The authors declared that they have no competing interests.

References

1. Joshi, Keya, Justin Lessler, Oluwasolape Olawore and Gideon Loevinsohn, et al. "Declining HIV incidence in sub‐Saharan Africa: A systematic review and meta‐analysis of empiric data." J Int AIDS Soc 24 (2021): e25818.

Google Scholar, Crossref, Indexed at

2. https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-017-4729-2
3. McCarraher, Donna R., Catherine Packer, Sarah Mercer and  Alexis Dennis, et al. "Adolescents living with HIV in the Copperbelt Province of Zambia: Their reproductive health needs and experiences." PloS one 13 (2018): e0197853.

Google Scholar, Crossref, Indexed at

4. https://www.unaids.org/en/resources/fact-sheet
5. Govender, Kaymarlin, Wilfred GB Masebo, Patrick Nyamaruze and Richard G. Cowden, et al. "HIV prevention in adolescents and young people in the Eastern and Southern African region: A review of key challenges impeding actions for an effective response." The Open AIDS Journal 12 (2018): 53.

Google Scholar, Crossref, Indexed at

6. Harrison, Abigail, Christopher J. Colvin, Caroline Kuo and Alison Swartz, et al. "Sustained high HIV incidence in young women in Southern Africa: Social, behavioral and structural factors and emerging intervention approaches." Current Hiv/aids Reports 12 (2015): 207-215.

Google Scholar, Crossref, Indexed at

7. Santelli, John S., Zoe R. Edelstein, Sanyukta Mathur and Ying Weim, et al. "Behavioral, biological and demographic risk and protective factors for new HIV infections among youth, Rakai, Uganda." J Acquir Immune Defic Syndr (1999) 63 (2013): 393.

Google Scholar, Crossref, Indexed at

8. Hagopian, Amy, Deepa Rao, Aaron Katz and Sallie Sanford, et al. "Anti-homosexual legislation and HIV-related stigma in African nations: What has been the role of PEPFAR?." Glob Health Action 10 (2017): 1306391.

Google Scholar, Crossref, Indexed at

9. Laar, Amos and Debra DeBruin. "Key populations and human rights in the context of HIV services rendition in Ghana." BMC Int Health Hum Rights 17 (2017): 1-10.

Google Scholar, Crossref, Indexed at

10. Bauman, Laurie J., Dana Watnick, Ellen Johnson Silver and  Angelic Rivera, et al. "Reducing HIV/STI risk among adolescents aged 12 to 14 Years: A randomized controlled trial of project prepared." Prev Sci (2021): 1-13.

Google Scholar, Crossref, Indexed at

11. Widman, Laura, Sophia Choukas-Bradley, Seth M. Noar and Jacqueline Nesi, et al. "Parent-adolescent sexual communication and adolescent safer sex behavior: A meta-analysis." JAMA Pediatr 170 (2016): 52-61.

Google Scholar, Crossref, Indexed at

12. Hosek, Sybil and Audrey Pettifor. "HIV prevention interventions for adolescents  ." Current HIV/AIDS Reports 16 (2019): 120-128.

Google Scholar, Crossref, Indexed at

13. Michielsen, Kristien, Matthew Chersich, Marleen Temmerman and Tessa Dooms, et al. "Nothing as practical as a good theory? The theoretical basis of HIV prevention interventions for young people in Sub-Saharan Africa: A systematic review." AIDS Res Treat 2012 (2012).

Google Scholar, Crossref, Indexed at

14. Wangamati, Cynthia Khamala. "Comprehensive sexuality education in sub-Saharan Africa: Adaptation and implementation challenges in universal access for children and adolescents." Sex Reprod Health Matters 28 (2020): 1851346.

Google Scholar, Crossref, Indexed at

15. Badru, Titilope, Jefferson Mwaisaka, Hadiza Khamofu and  Chinedu Agbakwuru, et al. "HIV comprehensive knowledge and prevalence among young adolescents in Nigeria: Evidence from Akwa Ibom AIDS indicator survey, 2017." BMC Public Health 20 (2020): 1-10.

Google Scholar, Crossref, Indexed at

16. https://europepmc.org/article/med/31332401
17. Simoni, Jane M., Keshet Ronen and Frances M. Aunon. "Health behavior theory to enhance eHealth intervention research in HIV: Rationale and review." Current HIV/AIDS Reports 15 (2018): 423-430.

Google Scholar, Crossref, Indexed at

18. Latifi, Arman, Effat Merghati-Khoei, Davood Shojaeizadeh and Saharnaz Nedjat, et al. "Theory-based interventions in STIs/HIV Prevention: A systematic review of the literature in Iran." Med J Islam Repub Iran 31 (2017): 131.

Google Scholar, Crossref, Indexed at

19. Farahani, Farideh Khalajabadi, Fatemeh Darabi and Mehdi Yaseri. "The effect of theory-based HIV/AIDS educational program on preventive behaviors among female adolescents in Tehran: A randomized controlled trial." J Reprod Infertil 21 (2020): 194.

Google Scholar, Indexed at

20. Kaufman, Michelle R., Flora Cornish, Rick S. Zimmerman and Blair T. Johnson. "Health behavior change models for HIV prevention and AIDS care: practical recommendations for a multi-level approach." J Acquir Immune Defic Syndr (1999) 66 (2014): S250.

Google Scholar, Crossref, Indexed at

21. Kasten, Stefanie, Liesbeth van Osch, Math Candel and Hein de Vries. "The influence of pre-motivational factors on behavior via motivational factors: A test of the I-Change model." BMC Psychol 7 (2019): 1-12.

Google Scholar, Crossref, Indexed at

22. Bonell, Chris, Kate Hinds, Kelly Dickson and James Thomas, et al. "What is positive youth development and how might it reduce substance use and violence? A systematic review and synthesis of theoretical literature." BMC public health 16 (2015): 1-13.

Google Scholar, Crossref, Indexed at

23. Bandura, Albert. "Social cognitive theory and exercise of control over HIV infection." Preventing AIDS: Theories and methods of behavioral interventions (1994): 25-59.

Google Scholar

24. Joorbonyan, Hoda, Mohtasham Ghaffari and Sakineh Rakhshanderou. "Peer-led theoretically Desinged HIV/AIDS prevention intervention among students: A case of health belief model." BMC Public Health 22 (2022): 1-10.

Google Scholar, Indexed at

25. Mo, Phoenix KH, Joseph TF Lau, Meiqi Xin and Vivian WI Fong. "Understanding the barriers and factors to HIV testing intention of women engaging in compensated dating in Hong Kong: The application of the extended Theory of Planned Behaviour." PloS one 14 (2019): e0213920.

Google Scholar, Crossref, Indexed at

26. Huan, Xiping, Weiming Tang, Giridhara R. Babu and Jianjun, et al. "HIV risk-reduction counselling and testing on behavior change of MSM." PloS one 8 (2013): e69740.

Google Scholar, Crossref, Indexed at

27. Cheung, Kei Long, Sander Matthijs Eggers and Hein de Vries. "Combining the integrated-change model with self-determination theory: Application in physical activity." Int J Environ Res Public Health 18 (2021): 28.

Google Scholar, Crossref, Indexed at

28. Ezenwaka, Uchenna, Chinyere Mbachu, Nkoli Ezumah and Irene Eze, et al. "Exploring factors constraining utilization of contraceptive services among adolescents in Southeast Nigeria: an application of the socio-ecological model." BMC Public Health 20 (2020): 1-11.

Google Scholar, Crossref, Indexed at

29. Frew, Paula M., Kimberly Parker, Linda Vo and Danielle Haleyolin, et al. "Socioecological factors influencing women’s HIV risk in the United States: qualitative findings from the women’s HIV SeroIncidence study (HPTN 064)." BMC Public health 16 (2016): 1-18.

Google Scholar, Crossref, Indexed at

30. Srahbzu, Mengesha and Enguday Tirfeneh. "Risky sexual behavior and associated factors among adolescents aged 15-19 years at governmental high schools in Aksum Town, Tigray, Ethiopia, 2019: an institution-based, cross-sectional study." Biomed Res Int 2020 (2020).

Google Scholar, Crossref, Indexed at

31. Mukanga, Bright, Myra Taylor and Siyabonga Blessing Dlamini. "The role of theory-based HIV and sexual health interventions in enhancing positive sexual behaviour outcomes and reducing risk factors among young people in Sub-Saharan Africa. A scoping review protocol." (2023).

Google Scholar, Crossref, Indexed at

32. Romer, Daniel and David Hansen. "Positive youth development in education." In The palgrave handbook of positive education, Cham: Springer International Publishing (2021): 75-108.
33. Catalano, Richard F., Martie L. Skinner, Gina Alvarado and Chisina Kapungu, et al. "Positive youth development programs in low-and middle-income countries: A conceptual framework and systematic review of efficacy." J Adolesc Health 65 (2019): 15-31.

Google Scholar, Crossref, Indexed at

34. Arksey, Hilary and Lisa O'Malley. "Scoping studies: Towards a methodological framework." Int J Soc Res Methodol 8 (2005): 19-32.

Google Scholar, Crossref, Indexed at

35. Dlamini, Siyabonga B., Benn Sartorius and Themba Ginindza. "Mapping the evidence on interventions to raise awareness on lung cancer in resource poor settings: A scoping review protocol." Syst Rev 8 (2019): 1-5.

Google Scholar, Crossref, Indexed at

36. Babatunde, Gbotemi Bukola, B. Schmidt, Netsai Bianca Gwelo and Olagoke Akintola. "Defining, conceptualising and operationalising community empowerment: A scoping review protocol." BMJ open 12 (2022): e056152.

Google Scholar, Crossref, Indexed at