Science and Success in Developing Countries: Holistic Programs That Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections

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Executive Summary [HTML] [PDF]

Program Components

• Comprehensive HIV prevention program to increase knowledge and reduce sexual risk-taking behaviors
• Muslim religious leaders focusing on community-based HIV and AIDS prevention
• Curriculum on HIV prevention, developed by Uganda's ministry of health and made culturally appropriate for Muslims by Islamic Medical Association of Uganda (IMAU)
• Three-day training workshops for imams (mosque leaders) and selected community volunteers, called Family AIDS Workers (FAWs)
• Follow-up training of imams and FAWs
• HIV prevention education of the community's households by the FAWs
• Regular visits by the imams to the households
• Periodic on-site checks and group discussions with imams and FAWs by trainers from IMAU

For Use With

• Male and female Muslim youth
• Muslim families in rural communities
• Muslim communities in rural trading centers

Evaluation Methodology

• Quasi-experimental evaluation over two years, using experimental and comparison groups in two districts with large Muslim populations
• Baseline surveys of members of randomly chosen Muslim families living near randomly selected mosques in the experimental and comparison areas (n=1,907); follow-up survey of members of randomly chosen Muslim families living near randomly selected mosques in the experimental and comparison areas (n=1,826); data from focus group discussions and key informant interviews

Evaluation Findings

• Reduced number of sex partners
• Increased use of condoms—males

Program Description

This program provides culturally appropriate, HIV prevention education to Muslim families living in rural communities and trading centers in Uganda. The program, Family AIDS Education & Prevention through Imams, is based on the assumption that the imam, the mosque leader, is the usual teacher of family values and behavior, including those related to sexuality. The Islamic Medical Association of Uganda (IMAU) has adapted a curriculum originally developed by Uganda's Ministry of Health. The adapted curriculum provides information on a variety of topics in relation to HIV and AIDS, including values clarification, basic facts, risk perceptions, prevention information, safer sex, gender, and adolescence. The curriculum also includes information addressing practices common in Uganda's Muslim communities—practices such as 1) circumcision and 2) ablution of the dead. Each topic is tied to specific objectives related to HIV risk reduction.[18]

IMAU teaches top Muslim leaders about HIV and AIDS among Muslims within Uganda and enlists their support for an intensive HIV and AIDS prevention effort. These religious leaders then select imams and community volunteers. IMAU trainers conduct three-day workshops for imams and their lay assistants, called Family AIDS Workers or FAWs, using guided discussion to work through the culturally appropriate curriculum. A year later, IMAU trainers conduct a second set of three-day workshops at which imams and FAWs discuss their experiences and learn additional information. After each set of workshops, the imams and FAWs train families in their communities, using the same curriculum and a similar teaching method. Each imam supervises five FAWs. The imam visits a household, introduces the FAW, and makes periodic follow-up visits. Each FAW repeatedly visits and educates a few households. In this way, families learn one or two new topics each month and revisit topics and issues previously discussed.* In addition, imams discuss HIV and AIDS during religious gatherings. IMAU trainers periodically visit the imams and FAWs, assisting them with issues that have arisen and giving imams and FAWs a chance to discuss their progress.[18]

Evaluation Methodology

A cross-sectional baseline survey—in March, 1992, of respondents (n=1,907) living around randomly selected mosques—identified topics for intensive education among Muslim families in northeastern Uganda. Such topics included risks of: 1) mother-to-child HIV transmission (at birth or through breastfeeding); 2) using the same razor to circumcise many male infants; and 3) ritually washing the dead (ablution). The baseline survey provided 1) the needs assessment for adapting the HIV/AIDS educational program and 2) baseline data for later comparison with follow-up data.

Imams at about 200 mosques in two districts—Mpigi and Iganga—with large populations of Muslims were chosen for the pilot intervention. Twenty-three IMAU trainers delivered the HIV prevention curriculum to imams and their lay assistants, the FAWs, at three-day workshops. Outcome measures included correct knowledge of HIV transmission and prevention, use of condoms, number of sexual partners, and risk perception of practices such as circumcision and ablution of the dead. Only half of Iganga district received the program. The other half of Iganga district provided a comparison site, enabling evaluators to assess the impact of the program itself, apart from other, nationwide efforts to control and prevent HIV and AIDS.[18]

At follow-up, the questionnaire included the same questions as the baseline survey, with some questions added or modified. For example, due to extensive polygamy in the communities, questions about number of sexual partners needed revising to obtain more accurate and informative answers about extra-marital sexual partners. At both baseline and follow-up, 21 mosques were selected from each district, with 12 selected at random from among rural mosques and nine selected at random from among mosques in trading centers. Individual respondents (n=1,826) were then selected as follows. One index household, of which the head was Muslim, was randomly selected at each mosque. Fifteen households in concentric distribution around the index household and in which the head was Muslim, were then enrolled into the survey. Members of the household were eligible for the survey if they were 15 years or older and if they had been resident in the household for the past 12 months. Some respondents may have been surveyed at both baseline and follow-up, but there was no effort to resurvey the same respondents.[18]

At baseline and follow-up, respectively, 63 and 68 percent of respondents were female; 40 and 47 percent were ages 15 to 24; 93 and 97 percent were Muslim; and 52 and 61 percent had a primary education. Unexposed respondents were less likely to be educated, but analysis showed educational level to have no effect on outcomes. Baseline data for all three areas—intervention and comparison—were combined to provide uniform baseline values.[18]

In addition, evaluators obtained qualitative data through focus group discussions and interviews with key informants. Nine focus group discussions were held: three each in Mpigi, the intervention area of Iganga, and the non-intervention area of Iganga. In each location, the three focus group discussions consisted of: 1) adult married males, ages 25 to 40; 2) adult married females, ages 20 to 29; and 3) unmarried females, ages 15 to 19. All of these participants (n=75) were from rural areas. Focus groups, with gender-specific moderators, used a story and asked questions about the story to guide discussion. Evaluators also interviewed 25 key informants, including FAWs, imams, imams' assistants, county sheiks, and district kadhis. They were asked how the community responded to the project, the strengths and weaknesses of the project, and the community's response to an anticipated condom availability and sales program.[18]

Outcomes

• Knowledge—
  • Between baseline and follow-up, a statistically significant proportion of respondents in the intervention areas showed increases in correct knowledge of:
    • Sexual transmission of HIV (from 86 to 97 percent); among respondents from the comparison area, proportions rose only from 86 to 90 percent.[18]
    • Mother-to-child transmission (from one to 10 percent); among respondents from the comparison area, proportions rose only from one to two percent.[18]
    • Risk of non-sterile, skin-piercing instruments (from 36 to 80 percent); among respondents in the comparison area, proportions rose only from 36 to 51 percent.[18]
    • Condoms as protective against HIV (64 to 82 percent); among respondents from the comparison area, proportions dropped from 64 to 60 percent.[18]
• Attitudes—
  • A statistically significant proportion of respondents from the intervention areas showed increased perception of risks posed by traditional Muslim practices:
    • Proportions who viewed as risky the circumcising of several male infants with the same razor rose from 45 to 78 percent while remaining unchanged at 45 percent among those from the comparison area.[18]
    • Proportions of respondents from the intervention areas who perceived risk from ablution of the dead rose from 27 to 60 percent while dropping from 27 to 24 percent among those from the comparison area.[18]
• Behaviors—
  • Reduced number of sex partners—Between baseline and follow-up, a statistically significant proportion of responding youth from the intervention areas reported a reduced number of sex partners versus responding youth from comparison areas.
    • Among males ages 15 to 24 from the intervention areas, the proportion reporting two or more partners fell from 45 percent at baseline to 32 percent at follow-up while rising from 45 to 59 percent among male youth from the comparison area.
    • Among females ages 15 to 24 from the intervention areas, the proportion reporting two or more partners fell from 13 percent at baseline to six percent at follow-up while rising from 13 to 16 percent among female youth from the comparison area.[18]
  • Increased use of condoms—Instruction about the importance of using condoms was included in the program only in the second year, when imams acknowledged that condoms were an HIV prevention tool that could not be ignored. Reports of ever use rose from 15 percent at baseline to 25 percent at follow-up among males from the intervention areas; reports of ever use of condoms also rose among males from the comparison areas (from 15 to 21 percent). The comparative rise, though slight, was statistically significant for males from the intervention areas.[18]

For More Information, Contact

• Islamic Medical Association of Uganda, P.O. Box 2773, Kampala, Uganda; e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it

*FAWs receive two hens, to generate income to replace earnings lost during their voluntary work in HIV prevention education. Imams receive a bicycle to facilitate their visiting individual families.