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Prevention of HIV/AIDS among Young People in Bangladesh

A Collaborative Project between National AIDS/STD Programme, Ministry of Health & Family Welfare and Save the Children- USA, Funded by GFATM


Survey conducted and report prepared by ICDDR,B Dr. Charles P. Larson, Director, HSID and Project Director, GFATM 905 Consortium Dr. Nafisa Lira Huq, Operation Researcher, HSID, ICDDR,B Livia Ottisova, BA Technical Reviewed by: Dr. S. M. Mustafa Anower, Director, Center for Medical Education and Line Director, National AIDS/STD Program & SBTP Dr. Md. Hanif Uddin, Program Manager, National AIDS/STD Programme Dr. Nizam Uddin Ahmed, Director, HIV/AIDS Program and South Asia Program Advisor, Save the Children - USA Dr. Md. Mozammel Hoque, Deputy Program Manager, National AIDS/STD Programme Dr. Kazi Belayet Ali, Program Manager, HIV/AIDS Program, Save the Children - USA Dr. Fadia Sultana, Manager, Response and Coordination, Save the Children - USA Dr. Lima Rahman, Deputy Program Manager, Save the Children - USA ABM Kamrul Ahsan, Deputy Program Manager, Save the Children - USA Shaikh Masudul Alam, Deputy Program Manager, Save the Children - USA Published by: National AIDS/STD Program and Save the Children - USA with ICDDR,B Layout Design and Desktop Publishing: Nahid Ad. & Printing First Print: June 2007


ACKNOWLEDGEMENTS This investigation was funded through the Global Fund to Fight AIDS, Tuberculosis and Malaria supported "Project on Prevention of HIV/AIDS among Young People in Bangladesh" under the stewardship of Ministry of Health and Family Welfare, Government of Bangladesh and under the Management of Save the Children - USA, Bangladesh. We thank Professor Nihar Ranjan Sarker, Department of Psychology, Dhaka University, Dr. Mahbubur Rahman, Department of Anthropology, Independent University of Bangladesh, Dr. S. M. Mustafa Anower, Director, Center for Medical Education and Line Director, National AIDS/STD Programme (NASP) & SBTP, Directorate General of Health Services Dr. Md. Hanif Uddin, Programme Manager, National AIDS/STD Programme, Dr. Md. Mozammel Hoque, Deputy Programme Manager, National AIDS/STD Programme, Dr. Nizam Uddin Ahmed, Director, HIV/AIDS Program and South Asia Program Advisor, Save the Children USA, Dr. Lubana Ahmed, Programme Manager, Access Program, Dr. Kazi Belayet Ali, Program Manager, HIV/AIDS Program, Save the Children USA, Dr. Fadia Sultana, Manager, Coordination and Response, Dr. Lima Rahman, Deputy Program Manager, and Shaikh Masudul Alam, Deputy Program Manager, HIV/AIDS, SC-USA for their review of the report and valuable comments. We also acknowledge the support of the.


Dr. S. M. Mustafa Anower Director, Center for Medical Education and Line Director, National AIDS/STD Programme & SBTP Directorate General of Health Services Mohakhali, Dhaka

FOREWORD

The HIV/AIDS pandemic has now entered South Asia and though in Bangladesh the spread of HIV/AIDS has largely been limited to high risk or marginalized groups but we are not far away from the epidemic among the general population. Recognizing this threat, the Government of Bangladesh has made HIV/AIDS prevention among youth, aged 15 to 24 years, a priority. It is widely acknowledged at present day that for HIV/AIDS prevention among youth, a comprehensive strategy is needed that range from messages containing abstinence to condom promotion. We all know that advocacy of abstinence is widely accepted in Bangladesh and relatively easy to promote but the challenge for HIV/AIDS prevention lies in messages related to sexuality and condom promotion. This study addressed the specific points of these challenges through measuring community readiness in the context of Bangladesh. Beside this measurement critically analysis of the societal factors responsible for youth risky behavior is the added benefit for designing a culturally fit HIV prevention for the youth of Bangladesh. I express my sincere thanks to the scientists and the study team of ICDDR, B for their earnest effort in conduction of this study. Special thanks to Save the Children, USA as supporting through their management activities to this package in the conduction of this research.


Dr. Md. Hanif Uddin Programme Manager National AIDS/STD Programme Directorate General of Health Services Ministry of Health and Family Welfare

FOREWORD

Surrounded by high HIV/AIDS prevalent neighboring countries Bangladesh is still in a position of low prevalence. As per evidence we came to know about the risky behavior of youth for contracting HIV/AIDS and if this continue, it is certain that we will soon face the epidemic. Thus to remain low prevalent this is the optimal time to decide on prevention of HIV epidemic among youth. There are many factors for youth's risk taking behavior but factors within community are the supreme. Prevention approach targeted individual behavior change often shaped by the norms and culture of community where they are residing. Understanding the norms and factors responsible for this shaping is essential for best culturally fitted prevention activity. No matter whether prevention approach is health care focus or school based or media related. The information of this study provides the insights of communities acceptance, disapprove and views of HIV/AIDS prevention in various aspects. Therefore it would be in great help to design the feasible HIV/AIDS prevention programs through all the reachable methods to youth. My heartiest gratitude to the research team of ICDDR,B responsible for this study for their hard endeavor. I would also like to thank HIV/AIDS team members of Save the Children, USA for the necessary support as managing agency.


Kelland Stevenson Country Director Save the Children - USA

FOREWORD

HIV/AIDS is now one of the most important global issues as it has serious consequences over the social, economical and cultural context of any country. This issue is not confined to a single or a group of countries; it is now the common issues of all the counties of the world. Bangladesh is also no exception in this regard. Though Bangladesh is still a low prevalent country for HIV/AIDS, however the risky behaviors related to HIV/AIDS infection are highly prevalent. This is a great challenge to combat HIV/AIDS in Bangladesh as the prevention programme needs the wide participation and open views of the people. This study reveals the level of knowledge and preparedness of the community to address HIV/AIDS. I hope this study will guide us to plan new activities and develop messages to combat HIV/AIDS according to the level of community readiness. I express my heartiest thank to the professionals and scientists of ICDDR,B to carry out the study. I also thank Save the Children- USA for their continuous support and hard work as the management agency.


Dr. Nizam Uddin Ahmed Director, HIV/AIDS Program and South Asia Program Advisor Save the Children - USA

FOREWORD

Recognizing the threat of HIV/AIDS epidemic in Bangladesh, the Government of Bangladesh has made HIV/AIDS prevention among youth, aged 15 to 24 years, a priority (GFATM, 2004). Within the context of the GFATM HIV/AIDS Youth Prevention Project in Bangladesh, several interventions are planned. It is well understood that the effectiveness of these interventions will be influenced by the selected content (evidence-based) and institutional capacities, and organizational integrity. What is less well recognized is the potential impact communities can have on program effectiveness and the ultimate spread of HIV/AIDS among youth in Bangladesh. Given its relatively conservative religious and cultural norms (Caldwell et al., 1999), Bangladeshi society is expected to resist the introduction of HIV/AIDS prevention messages addressing sexual behavior and the use of condoms. How well prepared communities are to adopt and work with HIV/AIDS prevention programs can be conceptually described as "community readiness". This investigation therefore has addressed the measurement and description of community readiness. The validated measure of community readiness, proof of its utility and adaptability to intervention programs will form the foundation for more effective community and public health partnerships and, in the end, more effective HIV/AIDS prevention efforts. The information of this study provides the insights of communities acceptance, disapprove and views of HIV/AIDS prevention in various aspects. Therefore it would be in great help to design the feasible HIV/AIDS prevention programs through all the reachable methods to youth. Above all, my heartfelt thank goes to National AIDS/STD Programme of Directorate General of Health Services for their continued support in completing the study. My heartiest gratitude to the research team of ICDDR, B responsible for this study and for their hard endeavor.


Acronyms AIDS GFATM GOB HIV ICDDR, B MOHFW NASP NGO RH RO RTI SES SRH STD STI SW WHO YFHS

Acquired Immuno Deficiency Syndrome Global Fund to fight AIDS, Tuberculosis and Malaria Government Of Bangladesh Human Immuno-deficiency Virus International Centre for Diarrhoeal Disease Research, Bangladesh Ministry of Health and Family Welfare National AIDS/STD Program Non-Government Organization Reproductive Health Research Officer Reproductive Tract Infection Socio Economic Status Sexual and Reproductive Health Sexually Transmitted Disease Sexually Transmitted Infection Sex Worker World Health Organization Youth Friendly Health Services


Table of Contents Executive Summery Introduction Methods Results Discussion Reference Table 1. Stages of community readiness to change Table 2. Study populations Table 3. Scoring instructions at each successive stage of community readiness Table 4. Scoring of community group attitudes towards mass media HIV/AIDS awareness campaigns, premarital sex and sale of condoms to unmarried youth Table 5. Male youth assumptions about the sexual activity of their peers Figure 1. Schematic representation of the potential influence (effect modification) of community readiness on the success of HIV/AIDS prevention interventions Figure 2. Selection of communities Figure 3. Community readiness results: Mirsarai Figure 4. Community readiness results in Abhoynagar Figure 5. Community readiness results: Hobiganj Figure 6. Businessmen in 3 communities in Hobiganj Figure 7. Teacher groups in three communities in Hobiganj Figure 8. Community readiness: Overall scores by sub-district Figure 9. Attitude of community groups towards HIV/AIDSmass media awareness, premarital sex, and condom purchases to unmarried range 0 [unacceptable] to 4 [acceptable/tolerated] Figure 10. Key informant readiness: Abhoynagar Figure 11. Key informant readiness: Mirsarai Figure 12. Key informant readiness: Hobiganj Figure 13. Key informant attitudes by location towards HIV/AIDS mass media awareness campaigns, premarital sex and condom sales to unmarried youth Figure 14. Key informant attitudes by profession towards HIV/AIDS mass media awareness campaigns, premarital sex and condom sales to unmarried youth

1 5 7 11 18 21 22 23 23

24 25

26 26 27 27 28 28 29 29

30 30 31 31

32

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Executive summary Recognizing the threat of HIV/AIDS epidemic in Bangladesh, the Government of Bangladesh has made HIV/AIDS prevention among youth, aged 15 to 24 years, a priority (GFATM, 2004). Within the context of the GFATM HIV/AIDS Youth Prevention Project in Bangladesh, several interventions are planned. It is well understood that the effectiveness of these interventions will be influenced by the selected content (evidence-based) and institutional capacities, and organizational integrity. What is less well recognized is the potential impact communities can have on program effectiveness and the ultimate spread of HIV/AIDS among youth in Bangladesh. Given its relatively conservative religious and cultural norms (Caldwell et al., 1999), Bangladeshi society is expected to resist the introduction of HIV/AIDS prevention messages addressing sexual behavior and the use of condoms. How well prepared communities are to adopt and work with HIV/AIDS prevention programs can be conceptually described as "community readiness". This investigation therefore has addressed the measurement and description of community readiness. The validated measure of community readiness, proof of its utility and adaptability to intervention programs will form the foundation for more effective community and public health partnerships and, in the end, more effective HIV/AIDS prevention efforts. The study design was descriptive in nature using qualitative and quantitative methods. Data collection was initiated in April, 2005 and ended in December, 2005.The study was carried out in three sub-districts, Abhoynagar (Jessore district), Mirsarai (Chittagong district) and Madhabpur (Hobigang district). The first two sub-districts are ICDDR,B field sites where we are well known and trusted. The third site is in Sylhet Division. It was selected because it is considered the most conservative area of Bangladesh in terms of societal norms. For purposes of group discussions, five community groups were drawn from both formal and informal organizations: union parishad members of development committees, businessmen, teachers, drug vendors, and religious leaders (imams). Either on the basis of formal appointment or acknowledged leadership in the community, key informants representing each of the community groups were interviewed. Females and males youth were grouped on the basis of marital status, age and schooling for group

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discussion using vignette. Male youth in-depth interviews were conducted among males 20-24 years in five groups: students, loiterers, farmers, small businessmen and youth working in the transport sector. The community readiness assessment was derived from the proceedings of a semi-structured interview that included open-ended questions addressing 6 stages of the community readiness model. The questions were created to elicit information on how each community group was understanding and acting on information about the imminent HIV epidemic as it affected youth in Bangladesh. Rather than placing each group at one stage only, they received a score from 0 (no indication) to 4 (high activity) to indicate their functioning at each stage. The same scoring guidelines were used for the community groups and key informants. Questions were also added to determine community group attitudes towards youth sexuality and HIV/AIDS prevention and answers were used to score the group on a scale ranging from 0 to 4 points. Vignettes based upon hypothetical situations were prepared and selectively presented on the basis of gender, age and marital status. The topics covered by the vignettes included peer pressure, condom purchases, access to reproductive health information, health care seeking, partner pressure, extramarital relationship. The elicited responses were sub-grouped under societal norms, perceived vulnerability, supports and decision-making. Male in-depth interviews covered HIV/AIDS risk behaviors, the perceived influence of communities on these behaviors and in what manner communities could be involved in HIV/AIDS prevention and sexual practices. The results of the community readiness showed that there is some variation by type of group, however the overall trend in all three sub-districts is remarkably similar. Awareness of the HIV/AIDS epidemic and the appreciated vulnerability of Bangladesh youth is consistently high and above 3. This is also the case for knowledge about routes of transmission. At the fourth stage of community readiness, namely discussing what the organization can do to prevent the epidemic taking hold in their community, the data indicate that, with the exception of the Union Parishad and imams, little or no planning was being done in any of the sub-districts studied. Finally, none of the organizations interviewed had begun serious preparation by taking decisions or identifying resources, and no activities had been initiated. With the exception of imams, these groups were quite supportive of mass media

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HIV/AIDS awareness campaigns. These attitudes were much more intolerant to premarital sexuality or condom availability. Premarital sex among youth was viewed as intolerable and immoral, and requiring punishment. Making condoms available was viewed as encouraging premarital sex. Uniformly, it was stated that unmarried male youth should not be persuaded to go to a brothel because of the negative social stigma associated with going to a "bad place". But on the other hand it was also generally accepted that succumbing to peer pressure is influenced by youthful sexuality and curiosity, which is a strong drive for youth to join their friends. It was generally agreed that unmarried male youth would be uncomfortable when purchasing condoms because they fear acquiring a bad reputation. As mentioned almost invariably by all groups, unknown providers are the safest and easiest to purchase from. The groups (male and female) mentioned some societal problems for access to reproductive health information. As with condoms, there is fear of being questioned by service providers and for seeking health care for any reproductive health problem. That would lead to suspicions in the community, and the inference that they are sexually active. Out of 5 respondents for each category per site, 6 loiterers, businessmen and youth working in the transport sector in Mirsarai and Abhoynagar were engaged in sex, either with girlfriend or CSW. Engaging in sex was comparatively low among youth in Hobiganj, except among transport workers. All youth working in the transport sector in Hobiganj had sex with sex workers. Condom use was more frequent among youth in Mirsarai and Abhoynagar. Among nine sexually active youth in Hobiganj only one used condoms. Suggested prevention strategies from youth included community participation in the form of awareness raising. Male youth suggested prevention strategies included the need for the community elite to be involved in dissemination of information about HIV and prevention. Although they stated that information should include messages on abstinence, they requested condom promotion and access. They felt this required community permission to make condoms available from a nonjudgmental outlet. The findings reveal that community groups hold similar positive attitudes toward mass media messages about HIV prevention and similar negative

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attitudes toward access to condoms by unmarried youth. Although aggregate results seem to indicate broad similarities among groups with respect to readiness for change, in-depth analyses of one site shows a degree of heterogeneity between groups as to their stages of readiness. This variability holds considerable promise for the future of community-led prevention activities, as leaders at high levels of readiness can introduce and encourage innovative ideas and facilitate the community's progression through the various stages. Nevertheless, our findings indicated that the various groups have not yet formed links with each other to openly discuss their knowledge or opinions on the oncoming epidemic. Youth, on the other hand, think that sexual activity is common among their male peers, but that adult initiatives to adopt a preventive message would not likely succeed because they would arouse community conflict and suspicion. Strategies to overcome barriers to community-wide communication and to prepare for preventive activities are now needed.

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INTRODUCTION It is now widely acknowledged that the HIV/AIDS pandemic has arrived in South Asia (UNAIDS, 2002). In Bangladesh the spread of HIV/AIDS has largely been limited to high risk or marginalized groups, in particular injection drug users (Government of Bangladesh, 2004-2005). Nonetheless, unless effective prevention strategies are implemented, the epidemic will soon enter the general population. Recognizing this threat, the Government of Bangladesh has made HIV/AIDS prevention among youth, aged 15 to 24 years, a priority (GFATM, 2004). Strategies that have been considered and are in varied stages of implementation include mass media awareness campaigns, school health education, youth friendly health services, sensitization of community leaders and condom promotion. These are consistent with the internationally applied "A,B,C" strategies of abstinence, being faithful, and condom promotion. Advocacy of abstinence is widely accepted in Bangladesh and relatively easy to promote, while public discourse on sexuality is not and condom promotion is restricted to married couples. Given its relatively conservative religious and cultural norms (Caldwell et al., 1999), Bangladeshi society is expected to resist the introduction of HIV/AIDS prevention messages addressing sexual behavior and the use of condoms. Yet, unless various interest groups within the society accept such messages, they will stop needed information and condoms from reaching youth. The groups include religious leaders, teachers, health professionals , and civil society. So far, together they have created a consensus about prescriptive norms of sexuality for youth, such as that unmarried youth should not be able to purchase or access condoms. Consequently, most interested parties [or health organizations] feel that to begin preventive activities for youth will require a working partnership with organizations at the community level. This study is aimed at assessing how ready are various community organizations to facilitate HIV preventive activities. How well prepared communities are to adopt and work with HIV/AIDS prevention programs can be conceptually described as "community readiness". This concept builds upon the work of Prochaska and others (Prochaska Redding, & Evers, 2002; Warren, 1978) who have characterized the stages an individual passes through in the process of changing health behavior, such as cessation of smoking. Many interventions place the burden

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of change on individuals. The ineffectiveness of these interventions led researchers to examine the role of communities and their influence on the prevention of problem youth behaviors such as substance abuse. It was found that communities can have a profound, positive influence on prevention outcomes, but only if they are ready (Slater, 2005). Adapting the Readiness-to-Change framework to populations, researchers developed a parallel conceptual framework for change in community norms in support of health behaviors (Oetting, 1994). The stages of readiness of a community organization to act on behalf of HIV prevention include awareness of the country's vulnerability, knowledge of transmission, knowledge of prevention, planning to act, preparation to act, and initiation of activities. Although the framework emerged out of public health efforts to deal more effectively with substance abuse and heart disease in developed countries (Edwards, 2000), it can be usefully applied with some modification to the Bangladesh context. Within the context of the GFATM HIV/AIDS Youth Prevention Project in Bangladesh, several interventions are planned. It is well understood that the effectiveness of these interventions will be influenced by the selected content (evidence-based) and institutional capacities, and organizational integrity. What is less well recognized is the potential impact communities can have on program effectiveness and the ultimate spread of HIV/AIDS among youth in Bangladesh (refer to Figure 1). Yet numerous studies have demonstrated that refusal to accept new practices and norms among certain segments of the population can defeat the best planned interventions (e.g. West et al., 1999) and innovations (Rogers, 1975). Community readiness strategies have not been tested in South Asia. This includes the absence of a validated measure of community readiness, proof of its utility and adaptability to intervention programs, and evidence that enhancing community readiness results in improved public health outcomes. This investigation therefore has addressed the measurement and description of community readiness as outlined in Table 1. To evaluate the readiness to change of various community groups, both members and key informants of groups were interviewed and rated for their activities at each stage. Attitudes toward specific preventive strategies, such as mass media messages and condom access for youth, were assessed. Finally, with the help of vignettes and in-depth interviews, youth discussed community barriers to preventive strategies. It is anticipated that this work will form the foundation for more effective community and public health partnerships and, in the end, more effective HIV/AIDS prevention efforts.

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METHODS Study design: The study design was descriptive in nature using a multimethod, multi-informant approach. Qualitative and quantitative methods were applied to collect information from members of community groups, key informants and youth in rural settings of Bangladesh. Data collection was initiated in April, 2005 and ended in December, 2005. Study sites: The study was carried out in three sub-districts, Abhoynagar (Jessore district), Mirsarai (Chittagong district) and Madhabpur (Hobigang district). The first two sub-districts are ICDDR,B field sites where we are well known and trusted. Abhoynagar is considered a relatively high and Mirsarai a low coverage area in terms of public health services. The third site is in Sylhet Division. It was selected because it is considered the most conservative area of Bangladesh in terms of societal norms. It is also a lower coverage area. Each sub-district in Bangladesh is divided into unions, which are again divided into wards (typically 9 wards per union), with each ward made up of 2 or 3 villages that contain a population of about 2,500 individuals per village. The lowest level of government administration is the union parishad (development committee), which is an elected body. Information about the degree of organization and functional status of government services in the unions was provided by sub-district government officials. Unions were stratified into high, middle and low categories and one union from each strata was randomly selected. This was followed by random selection of 1 ward from each union (refer to Figure 2). Study populations (refer to Table 2) Community groups: For purposes of group discussions, five community groups were drawn from both formal and informal organizations: union parishad members of development committees, businessmen, teachers, drug vendors, and religious leaders (imams). Union parishad members were interviewed as a group following consent from the respective chairman. The research officers used a reputational recruitment method to recruit the businessmen (Finnegan, 1989). The headmaster of the available secondary school in the selected ward was approached to form a teacher group. All drug vendors in a ward were requested to join a discussion group; thus a census of the drug shops or small pharmacies was conducted. The imams of larger mosques from the 3 unions in a sub-district made up the religious leaders group. A total of 13 community group sessions were held in each sub-district.

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Key informants: Either on the basis of formal appointment or acknowledged leadership in the community, key informants representing each of the community groups were interviewed as is summarized in table 2. This included the chairman of the union parishad, the chairman of the ward business committee, a secondary school headmaster, an acknowledged spokesperson for drug vendors in a ward, and the unofficial but recognized senior imam in a union. Youth Groups: Vignettes were developed for male and female youth group sessions. In each ward females were grouped on the basis of marital status, age and schooling (unmarried students, unmarried non-students, married 1518 and married 19-24 years of age), while males were grouped on the basis of marriage, age, schooling and employment (unmarried students 15 to 18 or 19 to 24 years of age, unemployed non-students [loiterers], and farmers 19-24 years). All females were recruited at the household level as were male students under 18 years of age. Households and farmers were selected using EPI cluster sampling methods (Bennett et al). Students above 18 years and loiterers were purposively selected from shops, fields or roads. Written consent was obtained from all participants as well as from parents/guardians of youth under 18. Male youth in-depth interviews: These were conducted among males 20-24 years in five groups: students, loiterers, farmers, small businessmen and youth working in the transport sector. Enrollment of students, loiterers and farmers was done by the techniques that applied for the vignettes groups. Businessmen were selected from small shops run by youth, and youth working in the transport sector were purposively selected from the taxi or rickshaw stands of the selected wards. Measures Community Readiness: The community readiness assessment was derived from the proceedings of focus group discussions and semi-structured interviews that included open-ended questions addressing 6 stages of the community readiness model. Stages beyond these six were not expected or observed given the recent epidemic status of Bangladesh. The questions were created to elicit information on how each community group was understanding and acting on information about the imminent HIV epidemic as it affected youth in their community. These included questions on awareness of HIV/AIDS and its spread, the HIV pandemic, the Bangladesh country situation, perception of youth risk taking behavior as a problem in

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the community, ownership of the problem, awareness of prevention methods, organizational responses to HIV, and actual community-based activities, such as a prevention plan, working strategies on a plan, action taken by groups in community and networks among groups and external relations. Rather than placing each group at one stage only, they received a score from 0 (no indication) to 4 (high activity) to indicate their functioning at each stage. The same scoring guidelines were used for the community groups and key informants (Table 3). Transcripts of the tape-recorded group sessions and key informant interviews were prepared in Bangla. These were then translated into English. One Bangla speaking and one English speaking rater scored each session. These scores were then compared and where differences occurred a consensus was reached between the two raters. A finer-grained methodology was utilized to code the group discussions in one of the communities, with a view to analyze the degree of agreement and disagreement among group members. Transcripts from the FGDs were analyzed by assigning a stage (1-6) to each meaningful statement and a level (0-4) indicating the extent to which the statement indicated achievement of that stage. For instance, a statement indicating a high level of understanding HIV prevention would receive a score of Stage 3 (Knowledge of Prevention), Level 4. Frequencies of statements for each Stage - Level were tallied and the modal level was computed to represent the Stage of Readiness to Change for that group. Community Attitudes: Questions were also added to determine community group attitudes towards youth sexuality and HIV/AIDS prevention. For example, sexual activity among youth, recognition of such behavior as a problem for the community and willingness to accept sex education or easy access to condoms were explored. Answers were used to score the group on a scale ranging from 0 to 4 points, as outlined in Table 4. If there were divergent attitudes within a group, they were scored at a point midway between. Youth perspectives Vignettes: Vignettes based upon hypothetical situations were prepared and selectively presented on the basis of gender, age and marital status (see Appendix 1). The topics covered by the vignettes included peer pressure to visit a sex worker (males), social barriers to condom purchases (males), placing a reproductive health information poster in schools (males and females), barriers to seeking health care for reproductive health problems

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(males and females), females pressured by a partner to have sex (females), and a husband involved in an extramarital relationship (females). For instance, posting HIV/AIDS posters in the local secondary school was applicable to unmarried youth; condom purchase and peer pressure to visit brothels were for the unmarried males. Common to all youth was a vignette addressing health care seeking behavior for a sexual health problem. The field research officers narrated each vignette to the appropriate youth groups. Afterwards participants were asked what the person ought, could, and would do and were then encouraged to elaborate the story as it might occur in real life. Similar to the community readiness component, Bangla transcripts of the group sessions were prepared from tape recordings and field notes. These were then summarized and translated into English. The elicited responses were sub-grouped under societal norms, perceived vulnerability, supports and decision-making. Male in-depth interviews: These interviews covered HIV/AIDS risk behaviors, the perceived influence of communities on these behaviors and in what manner communities could be involved in HIV/AIDS prevention. Inquiries about sexual practices began with "other youth" and were followed by personal experiences. We also inquired about condom purchases and anticipated or actual difficulties of doing so. Data on peer and personal sexual practices with a girlfriend or commercial sex worker were quantified. Respondents were stratified in the following manner: students, farmers, loiterers, transport workers (rickshaw pullers, bus fare collectors), and employed youth (small businesses). Conduct of Study The field research team responsible for data collection was made up of a coinvestigator and four field research officers, all with a masters degree in a social science and training plus experience in qualitative methods of data collection. One sub-district site at a time was completed, in the following order; Mirsarai, Abhoynagar and Hobiganj. Each sub-district required 4 to 6 weeks to complete. In each site, prior to the start of data collection, the study team and principal investigator met with local government and nongovernment representatives (health, education, religion, youth groups) at which time the purpose of the study and the data collection methods were explained.

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RESULTS Community readiness The results of the aggregate community readiness ratings based upon community group discussions are summarized by sub-district in Figures 3 to 5. Separate curves are presented for each community group interviewed. There is some variation by type of group, however the overall trend in all three sub-districts, as summarized in Figure 8, is remarkably similar. Scores range from 0 to 4 for each step along the readiness scale. It can be seen that awareness of the HIV/AIDS epidemic and the appreciated vulnerability of Bangladeshi youth is consistently high and above 3. This is also the case for knowledge about routes of transmission. It is in knowledge about HIV prevention that disparities between sub-districts and professional groups begin to appear. In Aboynagar and Mirsarai, Union Parishad, businessmen and imams had the highest scores for preventive knowledge, whereas in Hobiganj it was Union Parishad members, teachers and imams who had the most knowledge of prevention. Drug sellers, who have a pivotal role in HIV prevention, did not rank highest for understanding HIV prevention. At the fourth stage of community readiness, namely discussing what the organization can do to prevent the epidemic taking hold in their community, the data indicate that, with the exception of the Union Parishad and imams, little or no planning was being done in any of the sub-districts studied. Finally, none of the organizations interviewed had begun serious preparation by taking decisions or identifying resources, and no activities had been initiated. The expectation that the conservative Hobiganj communities would be less ready did not, in fact, result. As seen in Figure 5, the Union Parishad and imams were higher in planning. The finer, statement-by-statement analysis of discussions from the Hobiganj subdivision revealed considerable variation of modal stage-levels in each group. For example the businessmen scored high on Stage 2 (Knowledge of Transmission), reaching Levels 3 and 4, and are ready to work on Knowledge of Prevention (Figure 6). On the other hand, teachers reached relatively high levels of Stage 3 (Knowledge of Prevention), indicating they are ready to work towards Stage 4 (Planning) (Figure 7). Results also confirmed that none of the groups had begun serious planning or preparation for HIV prevention by taking decisions or identifying resources, and that no activities had been initiated.

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Illustrative comments emerging from the community group interviews include the following; "If water passage is obstructed from its natural flow one day it will be polluted. Young age is like that, if they don't have any place to express their sexual urge they will do it in an undesired way." (Madrasa teacher, Abhoynagar ) "[Unmarried boys] will never have the courage to get condoms from me...." (Drug Vendor, Hobiganj) "We should go out and tell them about the available preventive measures." (Union Parishad Member, Hobiganj) Most groups mentioned the availability of and relatively unrestricted access to commercial sex workers and pornographic videos as risk factors in their communities. Common preventive strategies suggested by the group members included closing brothels, restricting women's movements, and maintaining religious rules. Community Attitudes Figure 9 summarizes the attitudes expressed by community professional groups towards specific activities relevant to the spread of HIV among youth in Bangladesh. With the exception of imams, these groups were quite supportive of mass media HIV/AIDS awareness campaigns. These attitudes were much more intolerant of premarital sexuality or condom availability. Premarital sex among youth was viewed as intolerable and immoral, and requiring punishment. Punishment was seen by some as a way to encourage abstinence by setting an example of what would happen to those who engage in premarital sex. This was not the case for extramarital sex, which seems to be much more tolerated. Nearly all groups recognized that condoms would prevent HIV infection and eventually save lives. Nonetheless, acceptance of condom availability for unmarried youth was uniformly low. Making condoms available was viewed as encouraging premarital sex. Youth Vignettes Vignette # 1 [unmarried and married males, all ages]: An unmarried, male youth pressured by friends to visit a brothel sex worker.

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Uniformly, it was stated that unmarried male youth should not be persuaded to go to a brothel because of the negative social stigma associated with going to a "bad place". This included fear of punishment. Other reasons given to not adhere to peer pressure included that Islam forbids sex before marriage and vulnerability to becoming infected with HIV. Many were concerned about parents' strict values against premarital sex and parental punishment for this. While discussing the practical situation of refusing friends, peer pressure was acknowledged to be an important influence. "If friends pressure us, we can't avoid them." (Student and loiterer, unmarried, 15-16 years Hobiganj) "We don't want to make them unhappy. But before making a decision we should be very careful". (Student,19-22 years Abhoynagar) It was also generally accepted that succumbing to peer pressure is influenced by youthful sexuality and curiosity, which is a strong drive for youth to join their friends. In reality, few youth had actually experienced this type of pressure. However, those who did admitted they were positively influenced and did have sex with a sex worker, facilitated by the rationalization that sex workers are low cost and attractive, it is a special event, or they were out for an adventure. Vignette # 2 [unmarried and married male, all ages]: Barriers to purchasing a condom for an unmarried male. It was generally agreed that unmarried male youth would be uncomfortable when purchasing condoms because they fear acquiring a bad reputation. Buying condoms could lead to their being labeled as 'bad boy' in their community. "Younger boys use condoms as a balloon, but adults use it for sex. He is not a young child, so the shopkeeper will conclude he is buying the condom to have sex." (Loiterer, 16-18 years, Mirsarai) They are also intimidated by a provider's/vendor's questioning. "Why are you buying it, where are you going, are you going to have sex?" Many providers might have a moral responsibility to disclose to parents on an unmarried male's purchase of condoms (or attempted purchase). This would lead to punishment and family discord.

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As mentioned almost invariably by all groups, unknown providers are the safest and easiest to purchase from. Vignette # 3 [unmarried males and females]: Whether a poster advertising health services for STIs or reproductive health problems should be placed in a school. Consistently, all the groups (male and female) understood the importance of access to reproductive health information. Nonetheless, they raised problems if such a poster were placed in a school. Opposition groups would be formed in the village and pressure placed on headmasters to remove them. It was also mentioned that such a poster would create an embarrassing situation between males and females or younger and older students. "The Headmaster will conclude that young students who have received reproductive health counseling about safe sex will be more likely to become sexually active."( Non schooling, 15-19, Hobiganj) The reaction among females included shame and fear of being teased by the boys. This had actually happened following the distribution of reproductive health booklets in the past. "After reading a booklet on reproductive health the boys teased the girls, laughed at them, and drew pictures and bad words on walls and in bathrooms. Some parents were very upset, thus most of us didn't show them to parents. That's why teachers will not allow a poster". ( School going, female, 15-19 years, Mirsarai) When asked how to create a supportive environment for such information, they recommended community involvement that implicated the local elite, union parishads, teachers, and school governing bodies. Male youth also mentioned that the willingness to admit such a poster basically depends on the risk and benefit perception of the community. "If a headmaster permitted the poster he might be threatened, or dismissed from his position." (Farmer, 21-23 years Abhoynagar) Vignette # 4 [unmarried males and females]: Barriers to seeking care for reproductive health problems for an unmarried youth. In general, both males and females said they did not feel free to seek health

14


care for reproductive health problems. As with condoms, there is fear of being questioned by service providers and exposure - members of the community would come to know because one of them would be present in the health facility and spread the word. Seeking health care for any reproductive health problem would lead to suspicions in the community, and the inference that they are sexually active. The most common fear among male youth was that the provider would disclose to others their health problem and this would lead to punishment and a bad reputation. Almost all female groups mentioned their inability to go to a health facility alone. Seeking care alone may lead to the spread of negative rumors in their community. Vignette # 5 [Unmarried females]: Unmarried female is pressured by male partner to have sex Sex by an unmarried woman was viewed by the females as unacceptable, regardless of the male's feelings. They think that it is most important for an unmarried girl to remain a virgin before marriage because sex before marriage would lead to adverse consequences. They might become pregnant unwillingly, or infected by HIV, thus making it difficult for them to remain living in the community. Females were clear that such refusal would lead to a breakdown of the relationship; rather than risk this conflict they suggested they would adopt tricky techniques to avoid such pressure. Importantly, females expressed strong support for community values condemning premarital sex. "The punishment system is good, other girls will learn a lesson from this. Whatever our parents do for us is good." (Non school going , 15-19 years, unmarried Hobiganj ) Vignettes # 6 [Married females]: Husband's extramarital sex Young married women generally said that because of their lack of control over their husband's activities and inability to negotiate with him, they would not be able to stop their husband's extramarital sexual activities. The penalty of starting an argument about the husband's sexual behavior might be divorce or violence. Support from the husband's friend or sister-in-law might help to change the situation. Some married women said they have confidence in their ability to prevent their husband from such a relationship. Some young married women were open about their husband's extramarital

15


sexual activities. One woman mentioned that separation from family for a long time for work contributes to a husband's extramarital relationship. They mentioned that such behavior is also placing them at risk for getting an infection and seeking health care for an infection often needs approval from the husband. Also some would avoid seeking care because they think that they would have to admit their husband's extramarital relationship to the provider or they themselves would get a bad reputation. Male Youth In-Depth Interviews (Refer to Table 5) Just under 60% of male youth in Mirsarai reported that 'sex with a girlfriend' and 'sex with a CSW' were two common behaviors among their peer groups. Some 58% and 48% of youth in Abhoynagar thought that 'sex with a girlfriend' and 'sex with a CSW', respectively, were very common behaviors among their peers. In contrast, 20% and 32% of youth in Hobiganj mentioned that 'sex with a girlfriend' and 'sex with a CSW', respectively were very common behaviors. A relatively higher proportion of youth in Hobiganj in comparison to the other two sites believed that these two behaviors were uncommon among their peers. Out of 5 respondents for each category per site, 6 loiterers, businessmen and youth working in the transport sector in Mirsarai and Abhoynagar were engaged in sex, either with girlfriend or CSW. Engaging in sex was comparatively low among youth in Hobiganj, except among transport workers. All youth working in the transport sector in Hobiganj had sex with sex workers. Condom use was more frequent among youth in Mirsarai and Abhoynagar. Among nine sexually active youth in Hobiganj only one used condoms. Youth were aware that anyone who has sex with a girlfriend or sex worker is potentially at risk for being infected with HIV. Some youth viewed HIV as a risk only in relation to sex workers but not girlfriends. Many knew that condoms could protect them from HIV. There were mixed opinions as to the availability of condoms for unmarried men: some thought condoms could be easily purchased because businessmen would be eager to make a sale, whereas others felt that unmarried men would not be able to purchase condoms. "If the shop owner knows me he will ask questions. He might tell others and this will brand me as a bad person". (Farmer, unmarried, 19-20 years, Hobiganj) Fear of being exposed by the provider and acquiring a bad reputation was frequently mentioned.

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Youth also indicated that the type of provider affected how they would be treated when they ask to obtain condoms. A young provider was expected to have a more friendly attitude towards the request, and an unknown provider might not be expected to divulge the request to others, but a known provider was expected to question the youth. Several youth mentioned the effects of punishment for premarital sex. Some youth thought that it was effective in reducing premarital sex, but many said it would not stop sexual activity. Youth considered this behavior as natural at this age and believed that men's sexual drive cannot be stopped by any means. "My community can't do anything. I should correct myself, it is my body." (Farmer, 20-24 years unmarried, Mirsarai ) "Punishment can stop it [premarital sex] only for the time being." ( Loiterer, 16-19 years, Mirsarai) Suggested prevention strategies included community participation in the form of awareness raising. They suggested that the community elite be better informed about high risk sexual practices,, the consequences of HIV/AIDS and disease prevention. Other suggested prevention strategies included the need for the community elite to be involved in dissemination of information about HIV and prevention. They also suggested that family members, such as sisters- and brothers-in-law, be recruited to inform young people. Although they stated that information should include messages on abstinence, they requested condom promotion and access. They felt this required community permission to make condoms available from a non-judgmental outlet. "If communities promote only abstinence, we will not listen. The community should support use of condom." (Student, 22 years, Mirsarai) "Whatever the community does to reduce this behavior and save youth from HIV/AIDS, some will be influenced but some will not because they have become addicted to this. They should be told about condoms." ( Loiterer, 22 years, Mirsarai)

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DISCUSSION Although not all community groups accept the vulnerable position of their youth they do have adequate knowledge of the transmission and prevention of HIV/AIDS. However, most of the groups have done little to plan for the epidemic and have not made concrete preparations. They hold similar positive attitudes toward mass media messages about HIV prevention and similar negative attitudes toward access to condoms by unmarried youth. However, although there is tacit agreement to support this position, the groups have not yet formed links with each other to openly discuss their knowledge or opinions on the oncoming epidemic. Youth, on the other hand, think that sexual activity is common among their male peers, but that adult initiatives to adopt a preventive message would not likely succeed because they would arouse community conflict and suspicion. Strategies to overcome barriers to community-wide communication and to prepare for preventive activities are now needed. Community Readiness to Change Discussions with group members and key informants revealed that most have not discussed with each other information on HIV transmission and prevention strategies. None denied the impending epidemic and the need to protect youth. Yet in each sub-district, there were one or two groups who had higher preventive discussion scores, and others who had discussed mostly modes of transmission but little on prevention. The in-depth analysis of group discussions in Hobigang also revealed a considerable degree of variability in readiness for change. This indicates that already, there are some leaders who have high levels of knowledge with respect to transmission and prevention of HIV and are ready to consider implementing prevention strategies in their communities. These "early adaptors" (Rogers, 1983) are central to the process of community-wide change, as they are able to introduce and promote innovative ideas from higher levels and facilitate the community's progression through stages of readiness. Specifically, our results indicated that most commonly to reach the planning stage were the Union Parishad members and the Imams. Teachers and drug sellers, the two pivotal groups for implementing HIV prevention activities, had low scores on the Planning stage. As found elsewhere (e.g. Feinberg et al., 2004), these groups adopted the fairly conventional approach of pursuing

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their usual roles (called "business as usual") despite recognition of the need for a new strategy to confront the epidemic. Their leaders had not taken a divergent position or called for a re-thinking of the norms. Only a few had discussed plans for taking a public stand. In particular, Imams planned to speak out on the need for abstinence and sex segregation before marriage. The groups had not organized meetings with each other to form any kind of coalition or cohesive approach to the epidemic. This would be the next step, along with an open discussion among groups on various public health strategies. Attitudes toward Preventive Strategies The groups explicitly accepted the conventional rules of abstinence among unmarried youth and no condom access, but extramarital sex among married males and condom access. They were generally in favor of mass media messages about HIV and abstinence. Thus, building community cohesion among groups for a mass media strategy could be the first step. Planning and preparing organizational support for a mass media campaign would encourage leadership, decision-making, and resource allocation on a generally accepted strategy. Leadership is needed to raise the issue of sex worker and condom access. At the moment, most groups seem to support exposure and punishment of those who contravene the rules against access to condoms for premarital sex. Youth Identified Community Barriers to Prevention Young people identified community conflict as the most important barrier to introducing innovative strategies. Because of the relatively homogeneous acceptance of rules about sexual activities of married and unmarried youth, anyone taking a public action that differed would generate conflict. For example, by permitting a poster on STI and reproductive health services, the headmaster's intentions would be suspect and his position challenged. Likewise, drug sellers and health providers were expected to feel compelled to inform on an unmarried young person's request for condoms or services. Presumably most had learned this lesson by observing or hearing about another person's punishment and the bad reputation that followed, with implications for their future arranged marriage. Other social barriers to prevention included the difficulty of young women to protect themselves from a partner's infection through explicit talk. The need to avoid conflict in a relationship meant that they could not refuse. School girls felt unable to stop the teasing from boys that results when sex information is made public.

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Likewise, young men would have trouble refusing the encouragement of their peers to attend a brothel for fear of jeopardizing their relationship. Despite strong societal pressure to remain abstinent before marriage, young people find it difficult to take a personal stand against peers who confront them with sexual opportunities. Youth groups will have to be included in any coalition among organizations involved in designing HIV prevention activities. They will have to be given voice equal to other partners. Limitations of the study The study is a first attempt at assessing the levels of community readiness for adopting HIV prevention strategies in Bangladesh. The measurement strategy was thus multi-method and multi-informant. Although effort was made to score group and informant discussions in a reliable and consensual manner, further refinements to the procedure will be made in the future. The stages themselves were modified to fit the current HIV context in Bangladesh, where there was little denial of the problem but different levels of knowledge in preparation for prevention. The sequential nature of the stages and their completeness has yet to be evaluated. Future research will be needed to foster communication among groups, encourage leadership initiatives, and provide the input for groups to start planning and preparation. The original contribution of study is in providing a framework for evaluating the role of social organizations in facilitating or impeding public health activities to prevent HIV. Because shared social norms are strong and deviation from them brings severe consequences in small communities, partnerships for change will be necessary. Thus, identifying readiness for change among community groups will help to identify the input needed to move forward.

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REFERENCE Bennett S, Woods T, Liyanage WM, Smith DL. A simplified general method for cluster-sample surveys of health in Developing countires. World Health Statistics Quarterly 1991;44:98-106. Caldwell B. Pieris I. Barkat-e-Khuda. Caldwell J. Caldwell P. Sexual regimes and sexual networking: the risk of an HIV/AIDS epidemic in Bangladesh. Social Science & Medicine 1999;48:1103-16. Edwards RW, Jumper-Thurman P, Plested BA, Oetting ER, Swanson L. Community readiness: research to practice. J Community Psychol 2000;28:291-307. Fineberg, ME, Greenberg MT, Osgood DW. Readiness, functioning, and perceived effectiveness in community prevention coalitions: a study of communities that care. American J of Community Psych 2004;33:163-176. Finnegan JR, Bracht NF, Viswaneth K. Community power and leadership analysis in lifestyle campaigns. In CT Salmon (ed). Information Campaigns: Balancing social values and social change. Newbury Park, CA: Sage, 1989, pp 54-84. GFATM: Prevention of HIV/AIDS among Youth and Adolescents in Bangladesh. Under Grant No BAN-202-G01-H-00 supported by The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) received by Ministry of Health and Family Welfare (MOHFW), The Government of the People's Republic of Bangladesh Government of the People's Republic of Bangladesh. National HIV Serological Surveillance, 2004-2005 Bangladesh. Sixth Round technical Report. Kalichman SC, Somlai A, Sikkema K. Community involvement in HIV/AIDS prevention. In N Schneiderman, MA Speers, JM Silva, H Tomes, JH Gentry. Integrating behavioral and social sciences with public health., pp.159-175. American Psychological Assoc: Washington. Oetting ER, Donnermeyer JF, Plested BA, Edwards RW, Kelly K, Beauvais F.

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Assessing community readiness for prevention. Int J Addictions 1995;30:65983. Prochaska JO, Redding CA, Evers KE. The transtheoretical model and stages of change. In K Glanz, BK Rimer, FM Lewis (Eds.), Health behavior and health education: Theory, research and practice, pp. 99-120. San Francisco: JosseyBass, 2002. Rogers, E. (1983). Diffusion of Innovations. New York, NY: Free Press. Slater MD, Edwards RW, Plested BA, et al. Using community readiness key informant assessments in a randomized group prevention trial: Impact of a participatory community-media intervention. J Community Health 2005;30:39-53. UNAIDS (2002) Report on the global HIV/AIDS epidemic. Geneva: Joint UN Programme on HIV/AIDS. Warren R. The community in America (3rd ed.). Chicago:Rand McNally, 1978. Table 1. Stages of community readiness to change

Stage 1. Vulnerability 2.Knowledge 3. Prevention 4. Planning 5. Preparation 6. Implementation 7. Stabilization

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Description Aware of the HIV/AIDS epidemic, that it can spread to Bangladesh and into their own community Knowledge about routes of HIV/AIDS spread and the current situation in Bangladesh Correct knowledge about how to prevent HIV/AIDS and recognizes the need for prevention Discussing HIV/AIDS prevention with others and promoting the need for it Acknowledge the need for a plan and began developing a plan Support for and active participation in the implementation of HIV/AID prevention interventions Interventions in place with monitoring, adjustments and signs of sustainability


Table 2. Study populations

Participants

Source

Teachers

Wards

Businessmen

Wards

Drug vendors

Wards

Union Parishad

Unions

Imams Youth

Sub-districts Wards Wards Wards

Type of Interview

# per Sub-district

Group Headmasters Group Chairperson Group Spokesperson Group Chairman Group Spokesperson Groups male female Interviews male

3 3 3 3 3 3 3 3 1 3 15 12 25

Table 3. Scoring instructions at each successive stage of community readiness Stage 1: Vulnerability [0] HIV/AIDS not a problems, people spreading false information/lies [1] Spread of HIV/AIDS a problem elsewhere, not Bangladesh [2] HIV/AIDS a problem, including Bangladesh, but not in my/our community [3] HIV/AIDS a problem, including my/our community, but among high risk people only (“bad� people, drug users, promiscuous, sex workers) [4] HIV/AIDS a problem, including my/our community and in the general population Stage 2: Knowledge of Transmission [0] Unaware of HIV/AIDS [1] Aware of HIV/AIDS, but unaware of its spread (epidemic) [2] Aware of HIV/AIDS, aware of its spread (epidemic), but not how [3] Aware of HIV/AIDS, aware of its spread (epidemic), and how it spreads [4] Aware of HIV/AIDS, aware of its spread (epidemic), how it spreads and know current situation in Bangladesh

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Stage 3: Knowledge of Prevention [0] No ideas / nothing can be done [1] Have ideas, but incorrect/regressive [2] Have correct ideas / knowledge about HIV/AIDS prevention [3] Have correct ideas / knowledge about HIV/AIDS prevention and discussing HIV/AIDS prevention with others [4] Have correct ideas / knowledge about HIV/AIDS prevention and having formal discussions about what could be done Stage 4: Planning [0] No awareness of the need for a plan and no indication of planning [1] Awareness of the need for a plan, but no indication of planning [2] Awareness of the need for a plan and have decided they need/should have a plan [3] Debating, convincing or actually working on a plan [4] Detailed or fully developed a plan Stage 5: Preparation (decisions, resources) [0] No preparation [1] Planned activities presented/discussed in community [2] Identify key participants and responsibilities [3] Prepare for implementation of a planned set of activities [4] Agreed upon implementation strategy(ies) begun Stage 6: Initiation [0] Nothing initiated [1] Concrete action(s) taken by a single group [2] Concrete action (s)taken by more than one group [3] Groups planning coordination of activities [4] Coordinated, concrete actions by more than one group

24


Table 4. Scoring of community group attitudes towards mass media HIV/AIDS awareness campaigns, premarital sex and sale of condoms to unmarried youth. Mass media HIV/AIDS awareness 0 unacceptable 1 prefer not 2 ambivalence 3 acceptable 4 acceptable + support condoms Premarital sex: 0 no tolerance, punishment 1 no tolerance, no punishment 2 ambivalence 3 tolerated 4 tolerated + support condoms Sale of condoms to unmarried youth 0 absolutely not 1 prefer not 2 ambivalence 3 acceptable 4 acceptable + promote Table 5. Male youth assumptions about the sexual activity of their peers.

Sex with girlfriend Very common Common Uncommon Sex with CSW Very common Common Uncommon

Mirsarai n= 17 59% 41% 0% n=27 59% 37% 4%

Abhoynagar n=24 58% 38% 4% n=25 48% 52% 0%

Hobiganj n=25 20% 60% 20% n=25 32% 60% 8%

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Program content Agency/Institution capacity & organization

Individual HIV/AIDS

practices

Prevention

HIV/AIDS spread

interventions/ program

Community Readiness/ Support

Community practices . risk lowering environments . tolerance, stigmatization . active participation

Figure 1. Schematic representation of the potential influence (effect modification) of community readiness on the success of HIV/AIDS prevention interventions. Rural Study Sites ( Mirsarai, Abhoynagar & Hobiganj)

Listing of unions and Stratification by level of organization (high, middle & low)

Random selection of 1 union/strata (n=3/site)

Random selection of 1 ward/union

Figure 2. Selection of communities

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4 UP

3.5

Businessmen Teachers

3

Drug sellers

2.5

Imams

2 1.5 1 0.5 0 Vulnerability

Knowledge

Prevention

Planning

Preparation

Figure 3. Community readiness results: Mirsarai

4 UP Teachers Drug sellers Imams

3.5 3 2.5 2 1.5 1 0.5 0 Vulnerability Knowledge

Prevention

Planning

Preparation

Initiation

Figure 4. Community readiness results in Abhoynagar

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4 UP Businessmen Teachers Drug sellers Imams

3.5 3 2.5 2 1.5 1 0.5 0 Vulnerability

Knowledge

Prevention

Planning

Preparation

Figure 5. Community readiness results: Hobiganj

Modal Level score

4 Community 1 Community 2 Community 3

3 2 1

In iti

at io

n

n ra tio Pr ep a

Pl an ni ng

n io re w

K no

K no w

re

V ul n

Tr an sm

Pr ev en t

i ss

er ab

io n

le

0

Figure 6. Businessmen in 3 communities in Hobiganj.

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Modal Level score

4 Community 1 Community 2 Community 3

3 2 1

In i

tia tio

n

n Pr ep ar at io

ni ng Pl an

n io Pr ev en t re w

K no

K no

w

re

Tr an s

V ul

m

i ss

ne ra b

io n

le

0

Figure 7. Teacher groups in three communities in Hobiganj.

4 Abhonagar Mirsarai Hobiganj

3.5 3 2.5 2 1.5 1 0.5 0 Vulnerability

Knowledge

Prevention

Planning

Preparation

Figure 8. Community readiness: Overall scores by sub-district

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4 Mass Media

Premar. Sex

Condom avail.

3.5 3 2.5 2 1.5 1 0.5 0 UP

en e ssm

in Bus

ers

ch Tea

g Dru

ers se l l

ms Ima

Figure 9. Attitude of community groups towards HIV/AIDS mass media awareness, premarital sex, and condom purchases to unmarried range 0 [unacceptable] to 4 [acceptable/tolerated]

4 3.5 UP Chair 3

Businessmen

2.5

Headmaster

2

Drug sellers Imams

1.5 1 0.5 0 Vulnerability

Knowledge

Prevention

Planning

Preparation

Figure 10. Key informant readiness: Abhoynagar

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4 UP Chair Businessmen Headmaster Drug sellers Imams

3.5 3 2.5 2 1.5 1 0.5 0 Vulnerability

Knowledge

Prevention

Preplanning

Plannig

Figure 11. Key informant readiness: Mirsarai

4 UP Chair

3.5

Businessmen 3

Headmaster Drug sellers

2.5

Imams

2 1.5 1 0.5 0 Vulnerability

Knowledge

Prevention

Planning

Preparation

Figure 12. Key informant readiness: Hobiganj

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4 Mirsarai 3.5

Abhoynagar

3

Hobibang

2.5 2 1.5 1 0.5 0 Mass Media

Premarital Sex

Condom Sales

Figure 13. Key informant attitudes by location towards HIV/AIDS mass media awareness campaigns, premarital sex and condom sales to unmarried youth.

4 Mass Media

Premarital Sex

Condom Sales

3.5 3 2.5 2 1.5 1 0.5 0 UP Chair

Businessman

Headmaster

Drug Seller

Imam

Figure 14. Key informant attitudes by profession towards HIV/AIDS mass media awareness campaigns, premarital sex and condom sales to unmarried youth.

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Appendix. Youth group vignettes Community Dynamics study ICDDR,B GFATM Prevention of HIV/AIDS in Youth Project Vignettes/FGDs for Unmarried Female Interviewer Guideline 1.

Introduction + Informed consent

2.

Obtain/record baseline information

3.

Orientation + reassurance about confidentiality Vignettes/FGDs for female Warm up and explanation: Introduction and purpose

4. 5. 6. 7.

Thanks for coming Consent taken after explaining the purpose and procedure of the study Tell me little about your life style, school/ work place How do you spend your leisure time

The discussion leader will introduce the vignettes by saying: "I'm going to read you short stories about things that happened to some young people in another village of Bangladesh. After each story, I'm going to ask you some questions about what you think. There aren't 'right' answers to these questions; I just want to know what you think. It's good if different people have different answers. I would be happy to hear from all of you." Vignette 1: Parents pressure boy/girl to marry early Sabina (Faysal) is 16 (19) years old. Her (his) parents have arranged for her (him) to marry a boy (girl) and the wedding is planned for six months from

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now. She (he) doesn't feel ready to get married yet, but her (his) parents want this very much. What could Sabina (Faysal) do to avoid this marriage? What would be some reasons for Sabina to agree to the marriage? What would other people in the village think if she (he) refused to get married? What advice would her (his) friends give her (him)? Do you know anyone this happened to? What did they do? Vignette 2: Boy pressures girl to have sex Aminur is 20 years old and Nazmun is 16. For the last year Aminur has been talking to Nazmun, and they like each other. He is a nice looking boy from a good family. They have held hands in the past, and even kissed a couple of times. Now Aminur is asking Nazmun to have sex with him (should use an appropriate expression here). She doesn't want to, but he is putting pressure on her and saying that they will get married some day. Nazmun is not sure what to do. She likes Aminur and would like to marry him, so she does not want him to get angry with her. On the other hand, she is afraid of what might happen if they have sex. Do you think Nazmun should have sex with Aminur? In reality, do you think that they would have sex? What would happen if they had sex? If they didn't have sex? What could she tell him to convince him to wait? How would he react? Who might Nazmun go to for advice? Factors in family/community influencing youth's behavior Has anything like this happened to someone you know? What happened at the end?

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What would be your parents'/community's reaction if they discover someone to have this incident How do you describe your parents'/community's value regarding premarital sexual activity Do you respect your parents'/community's ideals and opinions about sex Vignette 3: Students want to put a poster in school advertising a clinic for adolescents The health clinic in the village has decided to offer special services for young people. They have some hours where they will only see young patients, and they want young people to feel free to come to them for any health issue, for example, contraception. Some high school students want to put posters in their school advertising these services, so that all the students will know about them. However, some people in the village are not happy that the clinic is offering these services to young people. The school principal is worried that it is not a good idea to have these posters in the school. What could be some reasons that the school principal would not allow the posters? What could the students say to convince him? Is there anyone who could convince the principal to allow the posters? What would happen if the students put up posters even though the principal forbids them to? What would happen if the school principal allowed the posters even though some people in the village don't approve of the clinic? Vignette 4: For non school going groups, replace poster vignettes Rita/Shumon has a health problem. Girls: very month when she gets her menstruation she experiences a lot of cramps/pain.

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Boys: He has gone to see a sex worker and now he has pain when the urinates. He is worried he has caught a disease. S/he could like to get treatment for their problem but s/he is not sure where to go? S/he would like to get help, is there someone s/he would talk to? From where s/he could get help? Would there be any problems for seeking treatment? Is there somewhere s/he could get treatment? What might the provider say? What might people in the community say if they see her/him going to a health facility? What might her/his parents say if they find her/him? Social barriers for seeking care for a RH problem Has anything like this ever happened in your school? If your community approves a clinic for youth RH problem, do you think that unmarried girl/boy can avail health care for RH problem What problems he/she might face (probe problems from provider's side and community side)

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Community Dynamics study ICDDR,B GFATM Prevention of HIV/AIDS in Youth Project Vignettes/FGDs for Unmarried male youth Interviewer Guideline 1.

Introduction + Informed consent

2.

Obtain/record baseline information

3.

Orientation + reassurance about confidentiality

Warm up 8. 9.

Thanks for coming Consent taken after explaining the purpose and procedure of the study 10. Tell me little about your life style, school/ work place 11. How do you spend your leisure time The discussion leader will introduce the vignettes by saying: "I'm going to read you short stories about things that happened to some young people in another village of Bangladesh. After each story, I'm going to ask you some questions about what you think. There aren't 'right' answers to these questions; I just want to know what you think. It's good if different people have different answers. I would be happy to hear from all of you." Vignette 1: Parents pressure boy/girl to marry early Sabina (Faysal) is 16 (19) years old. Her (his) parents have arranged for her (him) to marry a boy (girl) and the wedding is planned for six months from now. She (he) doesn't feel ready to get married yet, but her (his) parents want this very much. What could Sabina (Faysal) do to avoid this marriage? What would be some reasons for Sabina to agree to the marriage?

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What would other people in the village think if she (he) refused to get married? What advice would her (his) friends give her (him)? Do you know anyone this happened to? What did they do? Vignette 2, Male: Boy pressured by friends to visit a sex worker Naushad has two friends, Motiur and Mahmud. For Naushad's twentieth birthday, Motiur and Mahmud want to bring him to see a prostitute (use appropriate expression). Naushad has heard a lot of things about this place, and he is worried he might get an illness or that other people might find out. At the same time, he is curious and he doesn't want to say 'no' to his friends. What should Naushad do? In reality, do you think Naushad will go with his friends? Why or why not? What could he tell them if he decides he doesn't want to go? What would Naushad's parents think if they found out he visited a prostitute? What would other people in the village think if they found out? Factors in family/community influencing youth's behavior In your community do boys pressurized others for this kind of situation Has anything like this happened to someone you know? Do you know how this pressure was handled Vignette 3: Social barriers for condom purchase Raju is often pressurized by his friends to visit a brothel. He has some interest about it but he knows that this type of relationship might put him at risk to sexually transmitted diseases. He is also aware about condom, which can protect him from diseases. One day he decided to go to a brothel but before going there he wants to purchase a condom. He was hesitant to ask the

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provider about condom and also afraid of what might happen if someone find him purchasing condom. Why he is hesitant about purchasing condom What questions the provider might ask before selling condom Do you think that the provider will disclose this to others, and then what will happen If his parents knows this what would be their reaction Vignette 4: Students want to put a poster in school advertising a clinic for adolescents The health clinic in the village has decided to offer special services for young people. They have some hours where they will only see young patients, and they want young people to feel free to come to them for any health issue, for example, contraception. Some high school students want to put posters in their school advertising these services, so that all the students will know about them. However, some people in the village are not happy that the clinic is offering these services to young people. The school principal is worried that it is not a good idea to have these posters in the school. What could be some reasons that the school principal would not allow the posters? What could the students say to convince him? Is there anyone who could convince the principal to allow the posters? What would happen if the students put up posters even though the principal forbids them to? What would happen if the school principal allowed the posters even though some people in the village don't approve of the clinic? Vignette 5: For non school going groups, replace poster vignettes Rita/Shumon has a health problem.

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Girls: very month when she gets her menstruation she experiences a lot of cramps/pain. Boys: He has gone to see a sex worker and now he has pain when the urinates. He is worried he has caught a disease. S/he could like to get treatment for their problem but s/he is not sure where to go? S/he would like to get help, is there someone s/he would talk to? From where s/he could get help? Would there be any problems for seeking treatment? Is there somewhere s/he could get treatment? What might the provider say? What might people in the community say if they see her/him going to a health facility? What might her/his parents say if they find her/him? Social barriers for seeking care for a RH problem Has anything like this ever happened in your school? If your community approves a clinic for youth RH problem, do you think that unmarried girl/boy can avail health care for RH problem What problems he/she might face (probe problems from provider's side and community side) In the peer pressure vignette, a hypothetical situation was placed where on the birthday occasion of a youth his two friends proposed him to see a sex worker. The youth is worried about disease on the other hand he is curious about the place. In the condom vignette it was described that a youth wants to visit a brothel and as he is aware about the risk of sexually transmitted disease and condom as disease prevention he wants to purchase a condom,

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but is afraid of community's reaction. To advertise the reproductive health services some high school students want to put posters in school premises. Some villagers are against it which worry the headmaster of that particular school. Another vignette created a situation where male and female youth has reproductive health problem and they want to receive treatment for their health problem. In the next vignette a situation was described where a female is pressured by her partner to have sex. She doesn't want to make her partner unhappy on the other hand she is thinking about the consequences of sexual relationship. In the last vignette married female is assuming that her husband is responsible for her itching problem which he received from a sex worker. She wants to bring him back and treat her itching problem but fear and shyness is working in her. In a situation where a youth is facing pressure from friend to visit a brothel the groups were asked that what morality is working in him against that visit, is it possible to adhere to friends' pressure, reasons behind it and what would be the consequences of disclosure of the event in his community. Condoms purchasing vignette focused on the situation that makes him hesitant while purchasing condom, questions raised by providers, the events that would happen after disclosure his condom purchase. In the reproductive health information related poster vignette the groups discussed the reasons for not allowing the posters in a school premise by the headmaster, what would happen if it is hanged against headmaster's or other people's wish and what are ways to convince the headmaster for hanging the poster. The common vignettes i.e. health care seeking for STI or RH problem, discussion was mainly focused on youth's ability to seek care and the reasons that act as barriers for not seeking health care. Similar to peer pressure vignettes if a girl face pressure from her male partner to have sex what morality would act for not having sex and the consequences of such an event were discussed. Only for the married females their husband's extramarital behavior was discussed. In this vignette the decision making power of a wife in terms of bringing change in husband's behavior, seeking health care if her husband infects her with STI were discussed. After discussing the hypothetical situation, youth were asked whether they faced peer pressure in their real life, if so how did they manage the situation, did he buy condoms and during buying what problems he faced, are there any events in their community about partner's pressure on girls to have sex, did they face problems while seeking health care and we also asked directly about husband's extramarital relationship.

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An Assessment of Community Readiness for HIV/AIDS Prevention Interventions in Rural Bangladesh  

An Assessment of Community Readiness for HIV/AIDS Prevention Interventions in Rural Bangladesh

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