Nothing as Practical as a Good Theory? The Theoretical Basis of HIV Prevention Interventions for Young People in Sub-Saharan Africa: A Systematic Review

Abstract

This paper assesses the extent to which HIV prevention interventions for young people in sub-Saharan Africa are grounded in theory and if theory-based interventions are more effective. Three databases were searched for evaluation studies of HIV prevention interventions for youth. Additional articles were identified on websites of international organisations and through searching references. 34 interventions were included; 25 mentioned the use of theory. Social Cognitive Theory was most prominent (n = 13), followed by Health Belief Model (n = 7), and Theory of Reasoned Action/Planned Behaviour (n = 6). These cognitive behavioural theories assume that cognitions drive sexual behaviour. Reporting on choice and use of theory was low. Only three articles provided information about why a particular theory was selected. Interventions used theory to inform content (n = 13), for evaluation purposes (n = 4) or both (n = 7). No patterns of differential effectiveness could be detected between studies using and not using theory, or according to whether a theory informed content, and/or evaluation. We discuss characteristics of the theories that might account for the limited effectiveness observed, including overreliance on cognitions that likely vary according to type of sexual behaviour and other personal factors, inadequately address interpersonal factors, and failure to account for contextual factors.

Full text

Hindawi Publishing Corporation
AIDS Research and Treatment
Volume 2012, Article ID 345327, 18 pages
doi:10.1155/2012/345327
Review Article
Nothing as Practical as a Good Theory? The Theoretical Basis of
HIV Prevention Interventions for Young People in Sub-Saharan
Africa: A Systematic Review
Kristien Michielsen,1Matthew Chersich,1, 2 Marleen Temmerman,1
Tessa Dooms,2and Ronan Van Rossem3
1International Centre for Reproductive Health, Faculty of Medicine and Health Sciences, Ghent University,
De Pintelaan 185 P3, 9000 Ghent, Belgium
2Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg 2000, South Africa
3Department of Sociology, Faculty of Political and Social Sciences, Ghent University, 9000 Ghent, Belgium
Correspondence should be addressed to Kristien Michielsen, kristien.michielsen@ugent.be
Received 29 February 2012; Revised 26 April 2012; Accepted 3 May 2012
Academic Editor: Xiaoming Li
Copyright © 2012 Kristien Michielsen et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
This paper assesses the extent to which HIV prevention interventions for young people in sub-Saharan Africa are grounded
in theory and if theory-based interventions are more effective. Three databases were searched for evaluation studies of HIV
prevention interventions for youth. Additional articles were identified on websites of international organisations and through
searching references. 34 interventions were included; 25 mentioned the use of theory. Social Cognitive Theory was most prominent
(n=13), followed by Health Belief Model (n=7), and Theory of Reasoned Action/Planned Behaviour (n=6). These cognitive
behavioural theories assume that cognitions drive sexual behaviour. Reporting on choice and use of theory was low. Only three
articles provided information about why a particular theory was selected. Interventions used theory to inform content (n=13), for
evaluation purposes (n=4) or both (n=7). No patterns of differential effectiveness could be detected between studies using and
not using theory, or according to whether a theory informed content, and/or evaluation. We discuss characteristics of the theories
that might account for the limited effectiveness observed, including overreliance on cognitions that likely vary according to type
of sexual behaviour and other personal factors, inadequately address interpersonal factors, and failure to account for contextual
factors.
1. Introduction
With an estimated 2.7 million new infections worldwide
in 2010, HIV incidence remains at very high levels [1].
Sub-Saharan Africa, accounting for 70% of these infections,
remains particularly affected. About 40% of new HIV
infections occur in the age group 15 to 24 years [1]. There-
fore, targeted prevention programmes for young people are
essential in reversing the HIV epidemic [2,3]. Over the
past decades, a considerable number of HIV prevention
interventions for young people in sub-Saharan Africa have
been developed, implemented, and evaluated. Nevertheless,
even though these interventions seem to increase knowledge
and encourage positive attitudes, radical changes in sexual
behaviour have not occurred [4,5].
Theory is said to be an essential component of successful
health promotion interventions [6,7]. Behavioural theory
can assist to understand the determinants of risky and safe
sexual behaviour [8] and hence help to identify underlying
principles about how people change their behaviour [9].
Further, it aims to explains why and how behaviours occur
and allows us to predict future behaviours by establishing
relationships between key variables. Beyond providing con-
structs, processes and hypotheses for setting up interven-
tions, theories can also provide the basis for testing the
effectiveness of interventions [10]. Furthermore, theories

2AIDS Research and Treatment
can serve as a framework for accumulating knowledge
[11]. Reviews that assessed the theoretical underpinnings
of behavioural interventions for young people worldwide
generally claim that a theoretical foundation contributes to
effectiveness [6,12–16], although a direct link has not yet
been established.
In health promotion research, a large number of theories
coexist that aim to understand health-related behaviour and
provide tools for behaviour change. The Social Learning/
Cognitive Theory (SCT), Theory of Reasoned Action/
Planned Behaviour (TRA/TPB), and Health Belief Model
(HBM) are the most dominant theories, more recently joined
by the Stages of Change (SoC) and Social Ecological Model
(SEM) [17–21].
The SCT posits that people acquire and maintain par-
ticular behavioural patterns through a constant interaction
between three factors: environment, personal factors, and
behaviour [22,23]. Behaviour is not simply the result of the
environment and the person, just as the environment is not
merely a function of the person and behaviour [17]. The
HBM is based on an understanding that a person will take a
health-related action if that person believes s/he is susceptible
to the condition (perceived susceptibility), that the condition
has serious consequences (perceived severity), that taking
action would reduce their susceptibility to the condition
or its severity (perceived benefits), and that these benefits
outweigh the cost of taking action (perceived barriers).
Action is taken more easily if the person is exposed to
factors that prompt action (cues to action) and is confident
in her/his ability to successfully perform an action (self-
efficacy) [20,24–26]. By contrast, the TRA suggests that
a person’s behaviour is determined by her/his intention
to perform the behaviour. This intention is predicated by
their attitude toward the specific behaviour and by beliefs
about whether individuals who are important to the person
approve or disapprove of the behaviour (subjective norm).
The TPB includes an additional determinant: the belief
s/he has control over a particular behaviour (perceived
behavioural control) [20,27,28]. SoC theory argues that, in
order to change a behaviour, an individual passes through
five stages: precontemplation, contemplation, preparation,
action, and maintenance [29]. People at different stages have
different informational needs and benefit from interventions
tailored to their particular stage [20]. The SEM identifies
a number of interacting levels that influence behavior
(individual, interpersonal, organizational, community, and
public policy). According to this model, behaviours are
shaped by the social environment [20,30].
These dominant theories work at various levels and
for different purposes. While the HBM and TRA/TPB are
explanatory theories operating at the individual level, the
SCT and SEM include the interpersonal and environmental
levels, respectively. The SoC theory, in turn, is a change
theory, not explaining a particular behaviour, but providing
a framework for how people alter their behaviour.
With the overarching objective of improving effectiveness
of HIV prevention interventions that target young people’s
sexual behaviour in sub-Saharan Africa, this paper examines
the extent to which these interventions are grounded in
theory, how these theories are applied and assesses if theory-
based interventions are more effective in modifying sexual
behaviour than interventions not explicitly grounded in
theory.
2. Methods
2.1. Study Eligibility, Literature Search, and Data Extraction.
We performed a systematic review to locate evaluated inter-
ventions that aim to reduce sexual risk behaviour of young
people in sub-Saharan Africa. Studies were considered eligi-
ble if they reported on the evaluation of an HIV prevention
intervention for young people on the subcontinent, had a
control group, and were published between January 1990 and
March 2012. Further, to be included, studies had to report on
the general population of young people (10–25 years) and
the intervention needed to aim to prevent HIV transmission
by reducing sexual risk taking. Searches were performed in
the online databases Medline (PubMed interface), ISI Web of
Science, and EBSCOhost. Additional articles were identified
on websites of international organisations and through
searching references of eligible articles. Data extraction
was then done in duplicate by five investigators using a
predesigned and pretested extraction sheet. Further details
of the search terms, study eligibility, and data extraction are
detailed elsewhere [4].
2.2. Study Measures. Weextracteddataoncharacteristics
of the interventions and theory use. Firstly, whether any
theory had been used and, if so, which. Secondly, for
what purpose the theory was used. We extracted full-text
descriptions of how the theory had been used, which was
later recoded into three categories: theory used to inform the
intervention (e.g., for curriculum development); theory used
to guide evaluation (e.g., to develop indicators); or both.
Thirdly, a binary variable was derived, capturing whether
an explanation was provided about why this theory was
chosen. For the studies not reporting the use of a theory,
we looked at the topics dealt with in the interventions
and the envisaged interventions’ outcomes. This gives us an
indication of the underlying theoretical assumptions used in
these interventions.
Data were also extracted on the behavioural outcomes of
the interventions: condom use (at last sex; consistency and
intention), sexual behaviour (primary abstinence; the pro-
portion of sexually active youth; recent sexual intercourse;
number of sexual partners and multiple partnerships), and
biological outcomes (HIV/STI incidence).
3. Results
1073 article titles and/or abstract were screened. After
analysis of title and abstract, we reviewed 73 full-text
publications. In total, evaluations of 34 studies met the
inclusion criteria, reported on in 38 articles. Ta ble 1 sums the
main intervention characteristics and study designs.

AIDS Research and Treatment 3
Tab le 1: Characteristics of studies included in systematic review of use of behavioural theory in HIV prevention interventions in youth in sub-Saharan Africa.
Author, year Country Year of
intervention Study design
Sample size at
baseline
(males/females)
Main intervention activities
(duration)
Intervention
setting
(urban/rural)
Theory or
theories used
Role of theory in the
study
Explanation
provided about
why theory
used?
Central Africa
Van Rossem
and Meekers
[31]
Cameroon 1996-1997 Repeat C/S,
quasiexperimental 1606 (753/757)
Behaviour change commu-
nication and promotion
through peers and in media,
condom distribution,
youth-friendly services (13
months)
Community
(urban)
Health Belief
Model
Development of
intervention and
questionnaire/
evaluation
No
Speizer et al.
[32]Cameroon 1997-1998 Repeat C/S,
quasiexperimental 802 (400/402)
Through discussion groups,
one-on-one meetings, and
health and sport association
gatherings, peer educators
informed their peers and
referred them to services.
Promotional materials were
distributed in schools and
community (18 months)
School + Com-
munity (urban)
NR, focus on
knowledge NA NA
Meekers et al.
[33]Cameroon 2000-2001
Repeat C/S, pre
post-controlling
for exposure
1956 (1056/900)
Media and interpersonal
communication campaign.
Peer education, magazine,
radio drama, radio call-in
show, media campaign,
condom promotion (12
months)
Community
(urban)
Health Belief
Model, Social
Learning
Theory, Theory
of Reasoned
Action
Development of
intervention and
questionnaire/
evaluation
No

4AIDS Research and Treatment
Tab le 1: Continued.
Author, year Country Year of
intervention Study design
Sample size at
baseline
(males/females)
Main intervention activities
(duration)
Intervention
setting
(urban/rural)
Theory or
theories used
Role of theory in the
study
Explanation
provided about
why theory
used?
Eastern Africa
Klepp et al.
[34,35]Tanzania 1990
Cohort,
randomized
schools
1063 (502/561)
Teachers provided informa-
tion, students created posters
and performed songs, poetry,
drama and role-play, small-
group discussions among stu-
dents. Interviews and panel
discussions with parents and
community members (2-3
months)
Primary school
(urban + rural)
Social Learning
Theory and
Theory of
Reasoned
Action
Development of
intervention and
questionnaire/
evaluation
No
Shuey et al.
[36]Uganda 1994–1996 Repeat C/S,
quasiexperimental 800 (398/402)
Strengthen existing school
health curriculum, meeting
with parents and community
leaders, formation of school
health clubs with peer educa-
tion, question boxes (2 years)
Primary school
(urban + rural)
Social Cognitive
Theory NR No
Kinsman et
al. [37]Uganda 1997-1998 Cohort,
quasiexperimental 2077 (920/1157) Extracurricular classes by
trained teachers (1 year)
Primary and
secondary
schools (rural)
Behaviour
Changes for
Interventions
Model
Development of
intervention and
questionnaire/
evaluation
No
Erulkar et al.
[38]Kenya 1998–2000 Repeat C/S,
quasiexperimental 1544 (792/752)
Adult counsellor in commu-
nity educating youth, referral
to youth-friendly services and
encouraging parent-child
communication (3 years)
Community
(urban + rural)
NR, focus on
values,
knowledge,
gender, and
empowerment
NA NA

AIDS Research and Treatment 5
Tab le 1: Continued.
Author, year Country Year of
intervention Study design
Sample size at
baseline
(males/females)
Main intervention activities
(duration)
Intervention
setting
(urban/rural)
Theory or
theories used
Role of theory in the
study
Explanation
provided about
why theory
used?
Ross et al.
[39],
Doyle et al.
[40]
Tanzania 1998–2002
Repeat C/S,
randomized
communities
Ross: 9219
(5103/4116)
Doyle: 13814
(7300/6514)
Participatory, teacher-led,
peer-assisted, in-school pro-
gram, youth-friendly health
services, condom promotion
and distribution, and youth
health days and video shows
in community (3 years)
School + Com-
munity (rural)
Social Learning
Theory
Development of
intervention No
Maticka-
Tyndale et al.
[41]
Kenya 2002-2003
Repeat C/S,
randomized
schools
7392 (3636/3764)
Peer education on level of
teachers and students, ques-
tion boxes, school health
clubs, information corners
and assemblies, drama,
music and literary perform-
ances (18 months)
Primary school
(urban + rural)
Social Learning
Theory and
Scripting
Theory
Development of
intervention Yes
Rijsdijk et al.
[42]Uganda 2008
Cohort,
randomized
schools
1986 (1096/889)
low-tech, computer-based,
interactive comprehensive
sex education programme,
teacher-led (6 months)
Secondary
school
(urban + rural)
Theory of
Planned
Behavior and
Health Belief
Model
Development of
intervention No
Southern Africa
Kuhn et al.
[43]
South
Africa 1990 Repeat C/S,
quasiexperimental 567 (not reported)
Intense, high-profile focus on
AIDS in the school by teach-
ers (2 weeks)
Secondary
school (urban)
NR, focus on
knowledge and
attitudes
NA NA

6AIDS Research and Treatment
Tab le 1: Continued.
Author, year Country Year of
intervention Study design
Sample size at
baseline
(males/females)
Main intervention activities
(duration)
Intervention
setting
(urban/rural)
Theory or
theories used
Role of theory in the
study
Explanation
provided about
why theory
used?
Harvey et al.
[44]
South
Africa 1993-1994
Cohort,
randomized
schools
1080 (447/633)
“Schoolopenday”with
drama, song, dance, poetry,
and posters prepared and
presented by students (3
days)
Secondary
school
(urban + rural)
Applied
behaviour
change
framework
Development of
questionnaire/
evaluation
No
Meekers [45]South
Africa 1994–1997 Repeat C/S,
quasiexperimental 226 (0/226)
Mass media campaign, peer
education and condom pro-
motion and distribution
(35 months)
Community
(urban)
Health Belief
Model
Development of
questionnaire/
evaluation
No
Fitzgerald et
al.; Stanton et
al. [46,47]
Namibia 1996
Cohort,
randomized
participants
515 (236/279)
Curriculum taught by a
teacher and out-of-school
youth (7 weeks)
Secondary
school
(urban + rural)
Social Cognitive
Theory /
Protective
Motivational
Theory
Development of
intervention and
questionnaire/
evaluation
No
Kim et al.
[48]Zimbabwe 1997-1998 Repeat C/S,
quasiexperimental 1426 (713/713)
Mass media campaign,
community drama groups,
peer educators, youth-
friendly health services (6
months)
School + Com-
munity (urban)
Steps to
Behaviour
Change
Framework
Development of
intervention No
James et al.
[49]
South
Africa 1998
Cohort,
randomized
schools
1168 (542/616) Reading of a comic book
(1 hour)
Secondary
school
(urban + rural)
Theory of
Health
Promotion and
Social Learning
Development of
intervention No

AIDS Research and Treatment 7
Tab le 1: Continued.
Author, year Country Year of
intervention Study design
Sample size at
baseline
(males/females)
Main intervention activities
(duration)
Intervention
setting
(urban/rural)
Theory or
theories used
Role of theory in the
study
Explanation
provided about
why theory
used?
Visser [50]South
Africa 1998–2000
Repeat C/S, pre
post-controlling
for exposure
873 (410/463)
Trained teachers and pro-
fessionals provide life skills
and HIV/AIDS education.
Parents included in action
committee (1 year)
Secondary
school (urban)
Health Belief
Model
Development of
intervention No
Underwood
et al. [51]Zambia 1999-2000 Repeat C/S,
quasiexperimental 921 (378/543)
Participatory developed
mass media campaign (7
months)
Community
(urban + rural)
Stage Theory of
Behaviour
Change
Development of
intervention No
Magnani et
al. [52]
South
Africa 1999–2001
Cohort, pre
post-controlling
for exposure
3052 (1375/1677) Life skills curriculum
taught by teachers (2 years)
Secondary
school (urban)
Social Learning
Theory
Development of
intervention No
Agha [53] Zambia 2000
Cohort,
randomized
schools
481 (268/213)
Peer educators using dis-
cussion and drama skits
(1 hour 45 min)
Secondary
school (urban)
NR, focus on
knowledge,
normative
beliefs, and risk
perception
NA NA
James et al.
[54]
South
Africa 2001
Cohort,
randomized
schools
936 (456/466)
Life skills intervention
taught by trained teachers
(20 weeks)
Secondary
school
(urban + rural)
Social Cognitive
Theory and
Theory of
Planned
Behaviour
Development of
questionnaire/evaluation No

8AIDS Research and Treatment
Tab le 1: Continued.
Author,
year Country Year of
intervention Study design
Sample size at
baseline
(males/females)
Main intervention activities
(duration)
Intervention
setting
(urban/rural)
Theory or
theories used
Role of theory in the
study
Explanation
provided
about why
theory used?
Plautz et
al. [55]Madagascar 2001-2002
Cohort, pre
post-controlling
for exposure
1785
(1000/785)
Youth-friendly services, mass
media, and inter-personal com-
munication by peer educators
(23 months)
Community
(urban + rural)
Social Learning
Theory, Health
Belief Model,
and Theory of
Reasoned
Action
Development of
intervention and
questionnaire/
evaluation
No
Karnell et
al. [56]South Africa 2002
Cohort,
randomized
schools
661 (324/337)
Peer educators using recorded
monologues of fictional charac-
ters, teacher support (8 weeks)
Secondary
school (urban)
Social Learning
Theory, Social
Inoculation,
Cognitive
Behaviour
Theory
Development of
intervention and
questionnaire/
evaluation
Yes
Visser [57] South Africa 2002-2003 Repeat C/S,
quasiexperimental
1918
(858/1060) Peer education (18 months) Secondary
schools (urban) Systems Theory Development of
intervention No
Jewkes et
al. [58,59]South Africa 2003-2004
Cohort,
randomized
communities
2776
(1360/1416)
Participatory learning ap-
proaches taught by facilitators,
peer group meeting, commu-
nity meeting (6–8 weeks)
Community
(rural)
Participatory
Learning
Approach and
Adult Education
Theory
Development of
intervention No

AIDS Research and Treatment 9
Tab le 1: Continued.
Author, year Country Year of
intervention Study design
Sample size at
baseline
(males/females)
Main intervention activities
(duration)
Intervention
setting
(urban/rural)
Theory or
theories used
Role of theory in the
study
Explanation
provided
about why
theory used?
Tibbits et al.
[60]
South
Africa 2004-2005
Cohort,
randomized
schools
4040 (2020/2020)
Comprehensive, risk-reduction
life skills curriculum for adoles-
cents, teacher-led (24 months)
Secondary
school, urban
Selective
optimization
with
compensation,
Self-
Determination
Theory, and
Social Cognitive
Theory
Development of
intervention Yes
Mason-Jones
et al. [61]
South
Africa 2007-2008 Cohort,
quasiexperimental 3934 (1661/2211)
Government-led peer education
project, in class standard cur-
riculum, conversations outside
class, referral (18 months)
Secondary
school (urban +
rural)
NR, knowledge
and
psychosocial
characteristics
NA NA
Baird et al.
[62]Malawi 2008-2009
Cohort,
randomized
schools
3796 (0/3796)
Monthly cash transfer pro-
gramme to reduce the risk of
STI infection (24 months)
School + com-
munity (urban
+ rural)
NR, focus on
structural factor
(poverty and
education) and
knowledge
NA NA
Burnettetal.
[63]Swaziland NR Cohort,
randomized youth 204 (101/103)
Teacher-led life-skills HIV
prevention education program,
curriculum, interactive tech-
niques, role playing, and group
discussions (13 weeks)
Secondary
school (urban)
Self-efficacy
theory and
Protection
Motivation
Theory
Development of
intervention No

10 AIDS Research and Treatment
Tab le 1: Continued.
Author, year Country Year of
intervention Study design
Sample size at
baseline
(males/females)
Main intervention activities
(duration)
Intervention
setting
(urban/rural)
Theory or
theories used
Role of theory in the
study
Explanation
provided
about why
theory used?
Western Africa
Brieger et al.
[64]
Nigeria
and Ghana 1994–1997 Repeat C/S,
quasiexperimental
1784 (not
reported)
Peer educators, promotion
of community-level net-
works, referral to services
(30 months)
School + Com-
munity (urban)
NR, focus on
knowledge and
attitudes
NA NA
Fawole et al.
[65]Nigeria 1996
Cohort, pre
post-controlling
for exposure
450 (204/246)
Education sessions by com-
munity physicians with
help of teachers (1 month)
Secondary
school (urban)
NR, focus on
knowledge and
attitudes
NA NA
Okonofua et
al. [66]Nigeria 1997-1998
Repeat C/S,
randomized
schools
1896 (877/1008)
Establishment of repro-
ductive health club in
school, health awareness
campaigns by professionals,
distribution of print mate-
rial, peer education, youth-
friendly services (11
months)
Secondary
school (urban)
NR, focus on
knowledge and
barriers
NA NA
Van Rossem
and Meekers
[67]
Guinea 1997-1998 Cohort,
quasiexperimental 2016 (925/1091)
Peer educators (discussion
and theatre), condom pro-
motion, billboards, youth-
friendly services and con-
traception distribution (8
months)
Community
(urban)
Health Belief
Model
Development of
questionnaire/
evaluation
No
Atwood et al.
[68]Liberia 2007-2008
Cohort,
randomized
schools
812 (455/357)
Curriculum-based program
by health educators (8
weeks)
Primary school
(urban)
Social Cognitive
Theory and
Theory of
Reasoned
Action
Development of
intervention No
C/S: Repeated cross-sectional design.
NR: No theory is explicitly reported, dominant constructs used in the intervention.
NA: Not applicable.

AIDS Research and Treatment 11
3.1. Theoretical Basis of the Interventions. About three quar-
ters of the studies—25 of 34—mentioned having used at least
one theory. In total, 19 different theories were mentioned
42 times. Several stated that they had applied two or more
theories, with three papers reporting that the intervention
design drew on three theories.
Of all the theories mentioned, the SCT was most
prominent (n=13). Other theories that were mentioned
more than once are the HBM (n=7) and the TRA/TPB
(n=6). Four studies mentioned using a behaviour
change framework: behaviour changes for interventions
model [37], applied behaviour change framework [44], steps
to behaviour change framework [48] and stage theory of
behaviour change [51]. Assessment of the concepts used
in the interventions not explicitly mentioning the use
of a theory indicated that they also operated from an
assumption that knowledge, attitudes, beliefs, and/or role
models determine sexual behaviour. Hence, it seems that
most interventions are implicitly or explicitly guided by
cognitive behavioural frameworks. The one exception is
Baird (2012); this intervention uses an indirect pathway to
try to influence HIV incidence, namely, through encouraging
girls’ school attendance.
Description of the main activities indicates that most
interventions use one or a combination of participatory
learning techniques, such as drama plays, poetry, songs, club
formation, peer education (role modelling), and discussions
and debates. This suggests that the learning strategies of
most interventions were based on participatory learning
approaches.
A small, but considerable proportion of interventions
[32,34–36,38–40,58,62,64] go beyond focusing on the
individual young person and facilitate community involve-
ment in the interventions. Here, the implicit theoretical
assumption is that in order to change the participants’ sexual
behaviour, the community needs to be involved (cf. SEM).
There is no clear evolution detectable over time in the
frequency of use of different theories; of the 20 studies which
began in the decade 1990–1999, 14 reported theory use, while
11 of the 14 beginning after 2000 used theory.
3.2. Use of Theory in the Research Projects. Of 25 inter-
ventions that mentioned a theory, 7 said that the theory
was used to both inform the content of the intervention
(e.g., the curriculum) and to inform the evaluation or
questionnaire design. In 13 studies, theory was reportedly
used only to inform the intervention content, and in 4
only for designing the evaluation or questionnaire. One
study mentioning theory use did not specify how this was
applied [36]. The SCT was almost exclusively used to inform
the intervention. The HBM was mostly used for evaluation
purposes, predominately in studies from Population Services
International [31,33,45,55,67], as was the TRA/TPB.
Only three articles provided information on why a
particular theory was selected [41,56,60]. Nine authors
limited themselves to a brief explanation of the theory itself
[31,37,42,45,48,50,51,63,67]. The remainder did not
provide any information on theory selection.
3.3. Theory Use and Intervention Effectiveness. Overall, the
behavioural outcomes of the 34 studies were markedly
heterogeneous, with little reduction in heterogeneity after
stratifying by theory use (Ta ble 2 ). It was not possible to
discern any patterns in differential effectiveness between the
role of theory in a study, or between studies reporting or not
reporting theory use. Nor did we find particular differences
in intervention design by theory use.
Four studies reported biological measures of intervention
effectiveness [39,40,58,59,62]. Jewkes succeeded in
reducing HSV-2 incidence. Baird’s study, not explicitly based
on theory, reported a reduced HIV incidence and HSV-
2 incidence in the intervention group as compared to the
control group, but these data were not controlled for baseline
prevalence and should be treated with some caution [62].
Since the three other studies reporting biological measures
all based their intervention on a theory, it is not possible to
compare the effectiveness of theory- and non-theory-based
interventions in changing these outcomes.
3.4. Evaluation of the Theory. Four studies refer to their
theoretical basis in their conclusions, criticizing the the-
ory, specifically “the theoretical approaches underlying the
program have built in shortcomings which could result
in the program not having significant impact on the
students’ behavioural intentions” [69]; “the discrepancies in
the findings may be substantiated by the lack of system-
atic information that was available on the empirical and
theoretical underpinnings upon which the KwaZulu-Natal
Department of Education’s program was based—a finding
similar to reports of those educational programs that were
not grounded in a theoretical understanding of adolescent
sexual behaviour [...]” [54]; “These findings present mixed
evidence regarding the relationship between self-efficacy
and outcome expectations and HIV protective behaviours
among adolescents in Swaziland.” [63]; “TPB has received
considerably more support from research for its predictive
power of safe sex behaviour than the HBM.” [42].
4. Discussion
The review found that the majority of HIV prevention
interventions targeted at youth in sub-Saharan Africa use
theory-based approaches. A wide range of theories have been
employed, but three behavioural theories predominate: SCT,
HBM, and TRA/TPB. No one theory emerged dominant, as
reporting on the choice, use, and specific evaluation of theory
was low.
4.1. Comparison with Other Reviews. Broadly, the results are
consistent with reviews of HIV risk-reduction interventions
elsewhere, though some variation in use of theory can be
noted across these reviews. Pedlow and Carey [70]reviewed
23 randomized controlled trials of HIV risk-reduction
interventions for adolescents in the United States and found
an explicit theoretical rationale in all but one study. Similar
to our review, SCT was most common (18/23). Three other
theories were used in four or more studies (TRA, HBM,

12 AIDS Research and Treatment
Tab le 2: Description of study outcomes stratified by role of theory use in each study.
Condom use at last
sex
Ever/consistently used
condom
Sexual debut,
proportion of
sexually active
youth
Sexual intercourse
in past months
Number of
sexual partners HIV incidence HSV-2 Other STIs Overview
Theory used
for
development
of
intervention
Visser, 2005◦Ross, 2007++ Visser, 2005−− Maticka-Tyndale,
2007◦Visser, 2005◦Ross, 2007◦Ross, 2007◦Ross, 2007◦44 outcomes
Magnani, 2005++ Underwood, 2006++ Magnani, 2005−− Visser, 2007++ Magnani,
2005++ Jewkes, 2008◦Jewkes, 2008++ Jewkes, 2008◦++7
Maticka-Tyndale,
2007+Kim, 2001◦Maticka-Tyndale,
2007+Kim, 2001+Ross, 2007+Doyle, 2010◦Doyle, 2010◦Doyle, 2010◦+10
Ross, 2007+Magnani, 2005++ Ross, 2007◦Visser, 2007−− ◦22
Jewkes, 2008◦Atwood 2012◦Klepp, 1997+Kim, 2001+−1
Underwood, 2006◦Kim, 2001+Atwood, 2012−− −−4
Visser, 2007◦Underwood, 2006−Doyle, 2010+
Doyle, 2010◦Atwood, 2012+
Tibbits, 2011◦Burnet, 2011◦
Doyle, 2010◦
Tibbits, 2011◦
James, 2006+Harvey, 2000++ Harvey, 2000◦James, 2006+Harvey, 2000◦12 outcomes
Meekers, 1998◦Meekers, 1998◦Van Rossem, 1999+Van Rossem,
1999◦
++1
Theory used
for
development
of evaluation
or
questionnaire
Van Rossem, 1999+Van Rossem, 1999+Meekers, 1998◦+5
◦6
−0
−−0

AIDS Research and Treatment 13
Tab le 2: Continued.
Condom use at last
sex
Ever/consistently used
condom
Sexual debut,
proportion of
sexually active
youth
Sexual intercourse
in past months
Number of
sexual partners HIV incidence HSV-2 Other STIs Overview
Van Rossem, 2000◦Van Rossem, 2000++ Fitzgerald, 1999◦Fitzgerald, 1999◦Fitzgerald,
1999◦15 outcomes
Fitzgerald, 1999◦Meekers, 2005+Van Rossem, 2000◦Van Rossem,
2000+++1
Theory used
for
development
of
intervention
and
evaluation or
questionnaire
Meekers, 2005+Fitzgerald, 1999◦Plautz, 2003−+3
Plautz, 2003◦Plautz, 2003◦ ◦10
Karnell, 2005◦ −1
−−0
Theory used,
but uncertain
in which
phase of
study
Shuey++ 1outcome
++1
Speizer+Agha, 2002◦Speizer++ Speizer−− Agha, 2002++ Baird, 2012++ Baird, 2012++ Baird, 2012◦18 outcomes
Agha, 2002◦Okonofua++ Brieger, 2001−− Agha, 2002++ Fawole, 1999◦++6
Interventions
not explicitly
based on
theory
Erulkar, 2004+Kuhn◦Fawole, 1999◦Erulkar, 2004◦Erulkar, 2004+ +4
Fawole, 1999◦Fawole, 1999◦Erulkar, 2004+◦12
Mason-Jones,
2011◦Baird, 2012◦Baird, 2012◦ −0
Mason-Jones,
2011−−
−−3
++ significant positive intervention effect on outcome variable for the whole study population.
+significant positive intervention impact on outcome variable for a subgroup of the target population, and no significant impact on the whole study population or whole population impact not reported.
◦no significant intervention impact on the outcome variable.
−significant negative intervention effect on outcome variable in a sub-group of the target population, and no significant impact on the whole study population or whole population impact not reported.
−−significant negative intervention effect on the outcome variable for the whole study population.

14 AIDS Research and Treatment
and Information-Motivation-Behavioural Skills Model). A
review on the impact of HIV and sex education programs on
youth throughout the world [6] found that more than four
fifths of the 83 interventions identified one or more theory.
SCT formed the basis for more than half (54%) of these
interventions. TRA (19%), HBM (12%), TPB (10%), and the
Information-Motivation-Behavioural Skills Model (10%)
were also commonly mentioned. Two other reviews covering
HIV, STD, or pregnancy risk-reduction interventions among
adolescents in the United States had comparable results, with
a similar distribution of theories used [12,71]. While several
new theories or integrated models have been developed since
the outbreak of HIV focussing specifically on sexual health
behaviours like condom use [8,72], they are not used in HIV
interventions for young people in sub-Saharan Africa.
4.2. Gaps in (the Use of) Theory. By focussing on cognitive
constructs of behaviour, the interventions explicitly or
implicitly start from the assumption that cognitions influ-
ence the person’s thinking and decision making, and thus
drive sexual behaviour [73]. In the remaining discussion,
we will focus on the utility of grounding HIV prevention
interventions for young people on a cognitive behavioural
framework. We attempt to identify critical areas for attention
and improvement on different levels.
Firstly, cognitive behavioural models aim to explain a
particular behaviour. The theoretical constructs that influ-
ence behavioural decisions may vary, depending on the
behaviour in question. This poses marked challenges for
HIV prevention interventions, since they generally attempt
to influence a wide range of behaviours—for example,
increasing condoms use, reducing the number of sexual
partners, minimising sexual activity, delaying the onset of
sexual debut—which are influenced by different factors.
To further complicate matters, sexual decisions may vary
depending on the reasons for sexual intercourse (ranging
between, e.g., intimacy or desire, external factors, and affect
management). These, in turn, are further influenced by
gender and psychological characteristics (e.g., depression,
self-esteem, and impulsiveness) [74]. Thus, sexual behaviour
itself is far from a uniform behaviour, but rather a collection
of several relatively distinct behaviours, that can be shaped
by different factors in different contexts. While the use of a
theoretical framework provides grip in structuring an HIV
prevention intervention, the interventionist needs to be very
clear about what behaviour they aim to alter and which
factors determine this behaviour.
Second, the applicability of cognitive behavioural models
to youth sexual behaviours may vary between development
stages. For instance, applying cognitive theory to young
people with no or limited sexual experience may be difficult.
This group may not yet have well-anchored ideas, and conse-
quently their attitudes, norms, and beliefs about safe sexual
behaviour may be less clear and stable than for their adult
counterparts [70,73]. Theories used in HIV interventions
targeted at youth could be strengthened by accounting for
the extent to which individual decision making is supported
by one’s age, gender, or other personal characteristics.
Third, these theories seem to ignore the fact that sexual
intercourse takes place between two persons, within a rela-
tionship. Sexual decisions do not depend on the individual,
but also on the sexual partner and the type of relationship.
Young people might have specific types of partners that may
influence sexual decision making. For example, relationships
with someone who is much older are risky because it
exposes the younger person (mostly girls) to a partner who
is more likely to be sexually experienced and hence more
likely to be HIV-positive [75,76]. Often, these age-disparate
relationships are transactional in nature, with money or gifts
given in exchange for sexual intercourse [75,77–81]. Also,
young people in same-age relationships might have different
types of relationships than adults. They tend to be in what
is called by Bastard et al. [82] the “courtship-seduction”
phases of relationships, in which the predominant concerns
are to “present the best image, win trust, and avoid sources
of conflict. These concerns take precedence over that of
protecting oneself from the risk of AIDS.”
Fourth, while some interventions recognize the impor-
tance of involving the community, only the SCT explicitly
stresses the influence of contextual and structural factors
on an individual’s behaviour. Even though the theory states
that the social environment is an important determinant
of the behaviour, many interventions based on SCT did
not attempt to include or influence environmental factors.
Most interventions are limited to providing information and
teaching skills. TRA/TPB implicitly includes this level by
stating that personal attitudes, and norms are influenced
by behavioural and normative beliefs in the society, which
is useful for tracking varying modes of sexual socialisation.
However, this is an indirect effect of the environment on
individual behaviour, while still ignoring the broader struc-
tural factors that shape sexual behaviour. Many recent studies
have demonstrated the contribution of structural factors
to young people’s vulnerability for HIV [75,83–85]. These
environmental aspects include both distal influences—such
as taboos on adolescent sexuality, norms and values, policies,
poverty, education as well as more proximate influences.
These include families’ opinions about adolescent relation-
ships or teachers refusing to talk about condoms. Increased
efforts in future studies to account for structural factors at
a theoretical level may improve the design of interventions
and assist in their evaluation, by understanding the possible
barriers between motivation and actual behaviour change.
According to Gielen and Sleet [86], behavioural interven-
tions can be subdivided into three categories, those aimed at
intrapersonal factors (e.g., knowledge, skills, and intentions);
interpersonal factors (including relational motivations and
social desirability); community factors (e.g., culture, gender
inequalities, poverty, and violence). We have already argued
that the most common theories used in HIV interventions
directed to youth do not adequately address interpersonal
factors, the failure to account for contextual factors further
compounds the difficulty of evaluating interventions and
understanding the possible barriers between motivation and
actual behaviour change.
Finally, while cognitive behavioural theories of change
might be successful in altering cognitions and behavioural

AIDS Research and Treatment 15
intentions, they provide insufficient directives on translating
this into actual behaviour change. Thus interventions could
be regarded as successful in having altered motivations
and intentions, even though behavioural change may not
result. Similarly, interventions based on the HBM, might
increase the perceived severity and susceptibility of a person,
and relieve barriers to behaviour change, but in itself,
might be insufficient to alter the sexual behaviour. Clearly,
motivations or beliefs about behaviour change on a cognitive
or rational level need to be accompanied by a clear strategy
for introducing a new behaviour [87].
5. Conclusion
In the end, it boils down to two key questions: what deter-
mines sexual behaviour of young people? And what frame-
works are most useful for making sense of and impacting
positively on determinants of youth sexual behaviour? Rec-
ognizing the complexity and heterogeneity of this particular
behaviour, theory can provide help in generalizing key
determinants and making them operational. Theories aim
to describe determinants and processes that account for
or guide behaviour (change) through the rationalization
of individual decisions. This aids in understanding human
behaviour, and when used appropriately, can provide a solid
grounding for program development and evaluation. The
strength of theory is to generalize and simplify complex situ-
ations. However, in the case of HIV prevention interventions
for young people, the dominant theories might oversimplify
sexual behaviour. While such cognitive behavioural models
can explain the links between intention and behaviour,
particularly at an intrapersonal level, they are less able to
account for interpersonal and contextual factors related to
the complexity of sex, the experience of youth and disparities
in social, cultural, and economic realities of youth in sub-
Saharan Africa.
Acknowledgments
K. Michielsen acknowledges the Research Foundation Flan-
ders (FWO) for financial support. The authors acknowledge
Stanley Luchters and Petra De Koker for data extraction.
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