Structural Pathways for South African Men to Reduce Substance Abuse and HIV

Project Summary:

Young men aged 18-25 years in South Africa face the intersecting epidemics of HIV, alcohol and drug abuse, and unemployment. This R34 is designed to reduce young men’s risk by addressing three problems with existing evidence-based programs (EBP): interventions are not designed considering men’s fight-flight coping strategy; donors are unwilling to invest in substance abusing men; and existing job training does not consider young men’s poor habits. Our goal is to apply behavioral economists’ strategies to new delivery formats that are highly attractive to young men: soccer and job training. A neighborhood-level HIV prevention strategy will shape men’s positive daily routines at an organized soccer league: being on time, completing practice, arriving sober & drug free, showing sportsmanship, and being nonviolent. Employment training by artisan trainers/mentors will be contingently offered to young men who demonstrate positive habits-of-daily-living on 80% of days over two months. Young township men in two neighborhoods will be randomized to receive the intervention that includes soccer, job training, and contingency management to shape behaviors (N=1 neighborhood; n=60 males) or to receive the control condition of soccer and job training without contingency management (n=1 neighborhood; 60 males).

Assessments will be at baseline and 6 months follow-up. We hypothesize the program will significantly reduce HIV-related sexual risk acts and substance abuse, and sustain more employment. We will evaluate life goals, consistency of daily routines pro-social acts, & family relationships. We will primarily evaluate intervention feasibility and uptake, and preliminarily evaluate intervention impacts and mediating factors for reducing HIV risk acts & substance use. We will also document stakeholders’ perceptions of the program’s challenges and successes via Key informant interviews, the number of young men in shebeens over time via observations, and the key features of the social movement strategies of the Sonke Gender Justice, a men’s advocacy movement.

HIV prevention efforts for young people in Sub-Saharan Africa have largely been unsuccessful: novel, structural, community level programs that address the social determinants of HIV are needed (Fenton, 2010; NIAID, 2010; Gupta et al., 2008). In particular, young South African men face many barriers, relative to women, to access and utilize HIV prevention programs, including that:

  • Young men are more likely to have concurrent sexual partners, abuse multiple substances, drop-outof school, and be unemployed, compared to women, creating greater challenges for behavior change(Kalichman et al., 2009; Wechsberg et al., 2008).
  • Many donor agencies are only willing to invest in women (Pronyk et al., 2007; Yunus, 2003). Men havegreater interpersonal power, are considered to be substance abusers who squander money and unreliable employees, making interventions difficult (Khandker, 2005; Wong et al., 2008).
  •  Existing prevention programs are more consistent with women’s coping styles “to tend and befriend” (Taylor, 2002). Men’s coping style of fight-flight (Tyrell, 2002) is less compatible with HIV’s current arsenal of evidence-based interventions (EBI) and microfinance program support groups (Kuhanen, 2009). Men are unlikely to attend stigmatized counseling sessions, typical of EBI (Peterson, 2007).
  • The existing R3 billion spent on government job training programs in South Africa (i.e., SETA) deliver didactic lessons. Fewer than 0.9% get on-the-job training or graduate (Bennel & Segrestom, 1998; Akojee & McGrath, 2007; Ziderman, 2003). High demand for relatively low skilled labor is filled by immigrants from neighboring African countries, rather than South Africans, leading to high unemployment and civil unrest.

This R34 aims to design a structural, community-level intervention to sustain self-protective acts among young, South African men aged 18-25 years. A two-pronged intervention is planned to acquire skills-of-daily- living (through soccer) and job skills (through artisan apprenticeships). Over two years, we will demonstrate the feasibility, acceptability, and uptake of the intervention components and outcome measures. We aim to shift four behaviors of young men: to increase consistent habits-of-daily-living, provide job skills and to decrease substance use and HIV-related sexual risk. Young men will be invited to play soccer daily, with contingency management in one neighborhood and not in another neighborhood.  If youth are adherent to the program, they will be offered on-the-job-training and receive artisan tools at graduation.

We will proceed in two phases:

In Phase 1, qualitative interviews will elicit information on men’s developmental pathways. Sonke Gender Justice, a South African NGO advocating for men’s mobilization for gender equity and respect for women, will recruit and train coaches for a daily soccer program and Artisans to deliver a job training program. While soccer is intrinsically rewarding, this pilot will evaluate whether a strategy of behavioral economists (i.e., contingency management) is needed to ensure high program uptake to shape four daily routines: showing up on time, sober & drug free, completing practice, and showing sportsmanship. Coaches will not be counselors or provided with specific scripts, but will be trained in the Street Smart EBI to learn the core intervention tools to problem solve challenges of daily living; create opportunities to dramatically demonstrate key health principles; to form solid bonds with young men; and to be knowledgeable about health risks and community resources. The artisan trainers will be local entrepreneurs making an income, who will receive training and support on how to mentor youth. Artisans will be supported to shape youth’s job behaviors, similar to our successful Uganda program (Rotheram-Borus et al., 2010; Lightfoot et al., 2009).

In Phase 2, a quasi-experimental design with two neighborhoods will be implemented. Neighborhoods have been matched on size, type and quality of housing, number of shebeens (bars), and length of residence. All young men aged 18-25 years in each neighborhood will be recruited to participate in a baseline interview (n=60/neighborhood). One neighborhood will be randomized to the Contingency Management Condition (CMC; n=60 youth) and one to the Control Condition (CC; N=60 youth) and reassessed at 6 months. Coaches will implement the soccer program in both neighborhoods; youth demonstrating consistent habits at soccer for at least two months will be offered access to four months of artisan training. Stakeholder interviews (n=10 at baseline and end of program in each neighborhood) and observations at local shebeens (n= 2/month @ 5 shebeens per neighborhood) will also be conducted to monitor community-level changes over time.

The specific aims of this project are:

  1. To describe perceived challenges of emerging adulthood among young men; and to document perceptions of the program’s challenges and successes, and the key features of the social movement strategies of the Sonke Gender Justice NGO partner that are associated with men’s successes.
  2. To document the program uptake, adherence, prosocial acts, and substance free days in CM vs no-CM.
  3. To examine if young men in the CM vs. no-CM control condition demonstrate significantly:

a. Fewer HIV-related sexual risk acts, less substance use, and more employment;
b. More positive life goals; consistent, healthy daily routines; & greater social support & prosocial acts.
c. To contrast the number of men in shebeens and clean substance use screens across conditions.

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