This document outlines an adolescent HIV prevention program for schools in Geita district, Tanzania. It describes conducting a 4-year intervention rolling out to all 33 wards and schools. The intervention has two components: a classroom curriculum and a social support network for females. The classroom uses knowledge building, skills training, and self-efficacy approaches. The social support network is designed to provide instrumental, companionship, and emotional support. The research design is quasi-experimental, using pre- and post-testing to evaluate the intervention's effects on knowledge, attitudes, and risk behaviors over time.

1. Before It's Too Late 1
Before it’s too late:
An adolescent HIV Prevention programfor Geita district,
mwanza region, Northern Tanzania
Jeffrey Sheldon, M. A., Ed. m.
School of Behavioral & Organizational Sciences
Claremont Graduate University
The Claremont Colleges
25 April 2007

2. Before It's Too Late 2
OVERVIEW
• SPECIFIC AIMS: global
• SPECIFIC AIMS: students
• BACKGROUND AND SIGNIFICANCE
• TARGET POPULATION
• PRIOR INTERVENTIONS WITH ADOLESCNENTS
• THEORETICAL RATIONALE
• THE INTERVENTION
• THE SETTING
• RESEARCH DESIGN
• METHODS
• MEASURES & evaluation
• CHALLENGES
• TIMELINE
• REFERENCES

3. Before It's Too Late 3
Specific Aims: global
• help meet target of 25 % reduction in hiv prevalence in young people by 2010.
• Put HIV prevalence and risk in a different perspective within the community.
• Provide accurate information that dispels myths and inaccuracies about hiv/aids.
• Begin changing prevalent social norms and prevalent male attitudes towards women.
(Hayes et al., 2005; UNGASS, 2001)

4. Before It's Too Late 4
Specific Aims: students
• know, understand, and be aware of their own bodies.
• know, understand and be aware of developmental stages (physical, emotional, cognitive).
• know how hiv is transmitted and how hiv becomes aids if left untreated.
• know how to decrease their risk of becoming hiv infected.
• know the consequences of risky sexual behavior and alcohol and drug use are associated
with risky sexual behavior.

5. Before It's Too Late 5
Specific Aims: students
• know that oro-genital and anal sex are not safe sexual alternatives.
• know that positive and mutually fulfilling relationships can exist within a context of male
hegemony and dominance.
• be able to properly use male or female condoms.
• know where and how to acquire condoms.
• Begin to change gender role norms and stereotypes through improved female – male
dialogue.

6. Before It's Too Late 6
Specific Aims: students
• Increase adolescent male awareness that females are part of the sexual decision-making
process.
• Attenuate potential adolescent male aggressiveness and hostility towards females.
• Improve self – control in both adolescent males and females.
• Improve male – female relationships through relational skill building.
• Improve communication and negotiation skills between adolescent males and adolescent
females.

7. Before It's Too Late 7
Specific Aims: students
• Increase adolescent female awareness of choice in sexual behavior and risk taking.
• Increase self-efficacy and self-esteem.
• Establish supportive relationships between adolescent females and older, significant – other
females in their ward.
• Establish a social support network between adolescent females across villages in each ward.
• Increase adolescent female coping motives.

8. Before It's Too Late 8
Background& Significance
• Life expectancy in tanzania 44 years and falling; infant mortality rate is 99/1000 and rising
due to high rates of hiv/aids infection – women most at risk.
• 2.2 million people living with hiv/aids:
– 15 % are 15 – 24 years;
– 70.5 % are 25 – 49 years;
– 60 % of new infections in 15 – 24 years age range.;
– 13.3 % infection rate among women and climbing.
• Prevalence rate expected to increase to 16.7 % by 2010 unless…..
(aids and africa, 2003; buve et al, 2002; chnotowa, 1993; ole-nguyaine et al., 2004; somi et al., 2006; tacaids, 2003; unaids, 2004; unicef, 1999)

9. Before It's Too Late 9
Background& Significance
• Hiv infection rates higher in rural areas along truck routes and in mining communities due
to migratory populations.
• Migratory populations engage in more risky behaviors and are considered bridging
populations.
• In geita district, mwanza region 30 companies prospecting for gold.
• Hiv prevalence in geita district 13 %
– 19 % for community members.
– 16 % for women.
(bellaby, 1990; campbell, 1997; cates & dallabetta, 1999; chngalucha et al., 2002; desmond, et al., 2005; republic of tanzania, 1996, 2002)

10. Before It's Too Late 10
target population
• ADOLESCENT FEMALES AND MALES AGES 12 – 18 ATTENDING PRIMARY SCHOOL.
– LIVE IN AN AREA OF HIGH RISK;
– YOUNG WOMEN LIKELY TO ENGAGE IN RELATIONSHIPS WITH OLDER MEN;
– 14 % PREGNANCY RATE FOR ADOLESCENT FEMALES;
– 25 % - 33 % STI RATE IN MALES & FEMALES RESPECTIVELY;
– Males deny risk.;
– Girls have less exposure to accurate information;
– Males and females have different attitudes about sex;
– Knowledge gap between males and females;
– Adolescence a time of experimentation; and
– Male hegemony and dominance is the prevailing cultural norm.
(adamchak et al., 1990; desmond et al., 2005; gesovitz, 2005; gupta & weiss, 1993; haram, 2004, 2005; klepp et al., 1996, 1997; matasha et al., 1998;
nyblade et al, 2003; orubulolye et al., 1993; silberschmidt & rasch, 2001; unaids, 2004; unaids/who, 2002; unicef, 2000; vavrus, 2003)

11. Before It's Too Late 11
prior interventions withadolescents
• AarØ, L. E., et al. (2006). Promoting sexual and reproductive health in early adolescence in South Africa and Tanzania:
Development of a theory and evidence based intervention program. Scandinavian Journal of Public Health, 34, 150 – 158.
• Clark, T. S., et al. (2006). An Adolescent-targeted HIV Prevention Project Using African Professional Soccer Players as Role
Models and Educators in Bulawayo, Zimbabwe. AIDS Behavior, 10, S77 – S83.
• Gallant, M., & Maticka-Tyndale, E. (2004). School-basedHIV prevention programmes for African youth. Social Science &
Medicine, 58, 1337 – 1351.
• Klepp, K.I., et al. (1997). AIDS education in Tanzania: Promoting risk reduction among primary school children. American
Journal of Public Health, 87(12), 1931 - 1936.
• Kaljee, L. M., et al. (2005). Effectiveness of a theory–basedrisk reduction HIV prevention program for rural Vietnamese
adolescents. Aids Education and Prevention, 17(3), 185–199.
• Stanton, B. F., et al. (1998). Increased protected sex and abstinence among Namibian youth following a HIV risk-reduction
intervention: A randomized, longitudinal study. AIDS, 12, 2473 – 2480.
• Visser, M. J., & schoeman, J. B. (2004). Implementing a community intervention to reduce young people’s risks for getting HIV:
Unraveling the complexities. Journal of Community Psychology, 32(2), 145 – 165.

12. Before It's Too Late 12
theoretical rationale
• Knowledge, skill – building, self-efficacy component.
• Protection motivation theory.
– Threat appraisal.
• Intrinsic rewards;
• Extrinsic rewards;
• Perceived severity; and
• Perceived vulnerability.
– Coping appraisal
• Self-efficacy;
• Response efficacy; and
• Response costs.
(rogers, 1975)

13. Before It's Too Late 13
theoretical rationale
• Social support network for adolescent females component.
• Social support theory.
– instrumental
– Companionship
• Leisure activities
– Informational
• Get help in understanding a problem
• Receive advice on methods of coping
– Emotional
• Increases self-esteem because one is loved & accepted
(cohen&willis,1985)

14. Before It's Too Late 14
theintervention
• Interventions for adolescents as espoused in the literature not operating in geita district.
– Geita district council has established hiv/aids committees in all 33 wards.
– A community mapping exercise has been done in 16 wards.
– Two centers for Voluntary counseling & testing.
– Home based care & support available.
– Schools have integrated plans that involve councilors and school committees.

15. Before It's Too Late 15
theintervention
• socio-ecological perspective of working with wards & villages
• builds on existing hiv prevention efforts in the geita district.
• participatory rural appraisal to engage community.
• modification of the focus on kids curriculum within a socio – cultural framework.
• Creating a social support network a novel approach; different than typical peer support
used in schools in other interventions.
(Dalton et al., 2001; edwards et al., 2000; goodman, 1998, 2000; Kaljee et al., 2005; Maalim, 2006; Scheirer, 19996;., Stanton et al., 1998).

16. Before It's Too Late 16
theintervention
• Two components:
– Classroom.
– Social support network for females.
• The classroom component:
– 16, 2 hour sessions over four months.
– Knowledge.
– Skills.
– Self-esteem, Self-efficacy.
• Social Support network component:
– 2 hours per week, 8 hours per month +.
– Instilling and supporting optimism & hope.
– Supporting resistance & negotiation.
– Staving off depression.

17. Before It's Too Late 17
theintervention
• The classroom component curriculum:
– Biological facts, puberty and sexuality;
– Basic facts, reproductive biology;
– Basic facts, adolescent development;
– Basic facts, hiv/aids;
– Risk behaviors including alcohol/drug use;
– Exercising self – control;
– Intra-relationship violence;
– Communication & negotiation skills;
– A framework for decision – making;
– Male – female Relationship skill building;
– Effective & safe birth control / efficacy;
– Readjusting gender roles, power, and sexual relationships; and
– Self-esteem building.

18. Before It's Too Late 18
theintervention
• The Social support component:
– Bring adolescent females together each week to build relationships through shared activities;;
– Establish social support network for adolescent females across villages only during pilot phase;
– Establish social support network for adolescent females across wards during full
implementation;
– Establish social support relationship for adolescent females with older, significant – other female
within villages during both pilot phase and full implementation; and
– monitor and assist in maintaining networks.

19. Before It's Too Late 19
thesetting
• Geita district, mwanza region, northern tanzania

20. Before It's Too Late 20
thesetting
• 33 administrative wards:
– 29 rural, 4 mixed urban/rural.
– 21,582 = Average population / ward.
– 6 = Average # of primary schools / ward.
– 1.5 = average # of government health units / ward.
– 5 = average # villages / ward
• 163 villages.
• 4 tribes: wasukuma, wasumbwa, wazinza, & walongo.
• Population = 712,195 as of 2002 census.
• 234 public primary schools across district; 70 % of children attend primary school.

21. Before It's Too Late 21
RESEARCH DESIGN
• ONE DISTRICT, ALL WARDS, ALL SCHOOLS after 4 YEARS.
• GRADUAL ROLL OUT = 11 NEW WARDS & SCHOOLS THEREIN EACH YEAR.
• COMPARISON SCHOOLS THE PREVIOUS YEAR ARE INTERVENTION SCHOOLS THE NEXT
YEAR.
• YEAR 1: QUASI-EXPERIMENTAL, REGRESSION POINT DISPLACEMENT DESIGN (trochim& campbell,
1996)
• YEARS 2 & 3: QUASI-EXPERIMENTAL, BETWEEN GROUPS, PRE – TEST, REPEATED
MEASURES POST – TEST, DELAYED – INTERVENTION COMPARISON GROUP.
• YEAR 4: QUASI-Experimental, within groups, pre-test, repeated measures post – test, no
comparison.

22. Before It's Too Late 22
Research design
• Year 1, pilot phase
a m j j a s o n d
O1 X1 X1 X1 X1 O1 O1 O1
O2 O2 O2 O2
O3 O3 O3 O3
O4 O4 O4 O4
O5 O5 O5 O5
O6 O6 O6 O6
O7 O7 O7 O7
O8 O8 O8 O8
O9 O9 O9 O9
O10 O10 O10 O10
O11 O11 O11 O11

23. Before It's Too Late 23
Research design
a m j j a s o n d
O2 X2 X2 X2 X2 O2 O2 O2
O3 X3 X3 X3 X3 O3 O3 O3
O4 X4 X4 X4 X4 O4 O4 O4
O5 X5 X5 X5 X5 O5 O5 O5
O6 X6 X6 X6 X6 O6 O6 O6
O7 X7 X7 X7 X7 O7 O7 O7
O8 X8 X8 X8 X8 O8 O8 O8
O9 X9 X9 X9 X9 O9 O9 O9
O10 X10 X10 X10 X10 O10 O10 O10
O11 X11 X11 X11 X11 O11 O10 O11
O12 O12 O12 O12
O13 O13 O13 O13
O14 O14 O14 O14
O15 O15 O15 O15
O16 O16 O16 O16
O17 O17 O17 O17
O18 O18 O18 O18
O19 O19 O19 O19
O20 O20 O20 O20
O21 O21 O21 O21
O22 O22 O22 O22
• Year 2, Implementation phase year 1

24. Before It's Too Late 24
Research design
• Year 3, Implementation Phase year 2
A M J J A S 0 N D
O12 X12 X12 X12 X12 O12 O12 O12
O13 X13 X13 X13 X13 O13 O13 O13
O14 X14 X14 X14 X14 O14 O14 O14
O15 X15 X15 X15 X15 O15 O15 O15
O16 X16 X16 X16 X16 O16 O16 O16
O17 X17 X17 X17 X17 O17 O17 O17
O18 X18 X18 X18 X18 O18 O18 O18
O19 X19 X19 X19 X19 O19 O19 O19
O20 X20 X20 X20 X20 O20 O20 O20
O21 X21 X21 X21 X21 O21 O21 O21
O22 X22 X22 X22 X22 O22 O22 O22
O23 O23 O23 O23
O24 O24 O24 O24
O25 O25 O25 O25
O26 O26 O26 O26
O27 O27 O27 O27
O28 O28 O28 O28
O29 O29 O29 O29
O30 O30 O30 O30
O31 O31 O31 O31
O32 O32 O32 O32
O33 O33 O33 O33

25. Before It's Too Late 25
Research design
• Year 4, Implementation phase: year 3
A M J J A S O N D
O23 X23 X23 X23 X23 O23 O23 O23
O24 X24 X24 X24 X24 O24 O24 O24
O25 X25 X25 X25 X25 O25 O25 O25
O26 X26 X26 X26 X26 O26 O26 O26
O27 X27 X27 X27 X27 O27 O27 O27
O28 X28 X28 X28 X28 O28 O28 O28
O29 X29 X29 X29 X29 O29 O29 O29
O30 X30 X30 X30 X30 O30 O30 O30
O31 X31 X31 X31 X31 O31 O31 O31
O32 X32 X32 X32 X32 O32 O32 O32
O33 X33 X33 X33 X33 O33 O33 O33

26. Before It's Too Late 26
Research design
O1 X1 O1 O1 O1
11 12 13
14 15 16
11 12 13
14 15 16
11 12 13
14 15 16
11 12 13
14 15 16
11 12 13
14 15 16
O2 O2 O2 O2
21 22 23
24 25 26
21 22 23
24 25 26
21 22 23
24 25 26
21 22 23
24 25 26

27. Before It's Too Late 27
methods
• Hire qualified local talent (teachers, community health workers, et al) as facilitators/research
associates; hire in sufficient numbers for full coverage.
• Screen for character, professionalism, desire, motivation, energy.
• Three days of training = 24 hours and on-going professional development
empowerment.
• Facilitators/research associates assist in contextualizing program within the district.
• ALL MATERIALS TRANSLATED INTO SWAHILI.

28. Before It's Too Late 28
methods
• Teachers & community health workers implement curriculum & assist in social support
component with other local stakeholders.
• Use of experiential learning, and skill practice rather than rote learning.
• Multiple, multiple, multiple fidelity checks.
• Multi-tasking by program development team
– data collection (farm out analysis to unwitting grad student);
– fidelity checks;
– training & ongoing professional development;
– monitoring social support networks;
– working with funding agency, community stakeholders, schools, governing authorities,, parents,
wards & individual villages, & students.

29. Before It's Too Late 29
Measures & evaluation
• Quantitative data collected four times per year (April, July, October, & December), same
measures
• Modified Youth health risk behavior instrument (YHRBI)
– Modifications to be factor analyzed and checked for reliability/validity during pilot phase; re-modified
as necessary;
– total items ≈ 175;
– Total time ≈ 45 minutes;
– Small cash incentive in usd;
– English & swahili versions;

30. Before It's Too Late 30
Measures & evaluation
• YHRBI items
– Demographics
– Engagement in violent activities (we may drop this)
– Engagement in tobacco, alcohol, & other drugs
– Past and current relationships
– Engagement in sexual activities
– Use of condoms/other forms of birth control
– Male – female partner communication
– Condom access/birth control access & efficacy
– Attitudes & beliefs regarding hiv/aids
– Perceptions on friends’ engagement in risk activities
– Intentions to engage in risk behaviors
– Hiv/aids knowledge
– Engagement with adults in dialogue about hiv/aids
– Knowledge of anyone with hiv or aids
– Knowledge on biological aspects of puberty, sexuality, reproductive biology, birth control, & safe sex
– Readjusting gender roles, power and sex, intra-relationship violence, sexual decision – making, negotiation
skills, self esteem, self-efficacy, female – male relationship building skills.

31. Before It's Too Late 31
Data analysis
• Pilot data
– A variation of ancova model
– Bivariate pre – post distribution of scores calculated for all groups
– Regression line computed for controls only as model of predicted outcome with specific pre-test
scores
– Test whether displacement of intervention group’s score from control groups’ regression line
significant using 2 – tailed t test
• Full implementation data
– 2 – tailed, Independent sample t tests (years 2 & 3)
– 2 – tailed, Matched sample t tests (year 4)
– anova

32. Before It's Too Late 32
Measures & evaluation
• Qualitative data collected four times per year (April, July, October, & December).
– Semi - Structured interviews.
– Focus groups.
• Content analysis and converting qualitative data into quantitative data (e.g., frequencies).

33. Before It's Too Late 33
Measures & evaluation
• Adolescent female social support networks
– Effectiveness of group meetings and what they got out of them;
– Effectiveness of establishing relationships;
– Efficacy of establishing networks;
– Suitability of network matching;
– Effectiveness of communicating between villages and means of conveyance;
– Topics of discussion and types of support provided;
– Who is in the network;
– Process by which relationships forged;
– Difficulties and ease in networking;
– Durability and stability of relationships/network;
– Frequency of face to face meetings or other communications; and
– Whether networking and relationships helped delay onset of sexual intercourse, resist unwanted
and persistent male sexual advances, or negotiate safe sex.

34. Before It's Too Late 34
Measures & evaluation
• Adolescent female – older significant other support
– Effectiveness of establishing relationship;
– Efficacy of establishing relationship;
– Suitability of match;
– Effectiveness of communicating within village and means of conveyance;
– Topics of discussion and types of support provided;
– Process by which relationship forged;
– Difficulties and ease in meeting;
– Durability and stability of relationship;
– Frequency of face to face meetings or other communications; and
– Whether relationship helped delay onset of sexual intercourse, resist unwanted and persistent
male sexual advances, or negotiate safe sex.

35. Before It's Too Late 35
challenges
• The silence of those in authority
• Traditions that discourage open discussions of sexuality
• Overt & covert resistance to change
• Poverty
• Women’s low social status
• Inaccurate and incomplete information on HIV transmission
• Fears about HIV
• Stigma
• Changing female values
• 4 different ethnic groups
• Working through multiple layers of bureaucracy
• Potential for increases in risk behaviors
• Contamination from mass media campaigns
• Matching intervention groups with controls
• Inconsistent school attendance

36. Before It's Too Late 36
Timeline years 1 - 4
ProgramComponent J F M A M J J A S O N D
Contextualize issues in community through PRA X X X
Hire local teachers and community health workers and provide training X X X
Planning intervention components on the premises of local culture and context; EVALUATION DATA FROM
PREVIOUS YEAR
X X X
Random sampling and recruitment of wards and schools X X X
Obtain informed consent from parents and students X
Biological aspects of puberty and sexuality X
Basic facts about reproductive biology and HIV/AIDS/STI X
Effective and safe birth control and condom use X
Readjusting gender roles, power and sexual relationships, intra-relationship violence X X X X
Risk behaviors associated with HIV/AIDS infection - alcohol consumption, drug abuse X X
Sexual decision-making skill building X X
Self-esteem AND SELF – EFFICACY SKILL building activities X X X X
Male – female communication and negotiation skill building X X X X
Female – male relational skills building X X X X
Establish adolescent female inter-district support network X X X X
Establish older female – adolescent female social support network X X X X
Fidelity Checks and monitoring support NETWORKS F F M M M
Data collection and analysis X a a X a X a a X

37. Before It's Too Late 37
references
• Adamchak, D. J., Mbizvo, M. T. & Tawanda, M. (1990) Male knowledge of and attitudes and practices towards AIDS
in Zimbabwe. AIDS, 4, 245–250.
• AIDS and Africa (2003). African AIDS statistics - Tanzania. Retrieved January 2007 from
http://aidsandafrica.com/country.html.
• Bellaby, P. (1990). To risk or not to risk? Uses and limitations of Mary Douglas on risk acceptability for
understanding health and safety at work and road accidents. Sociological Review, 38, 465–483.
• Buve, A., Bishikwabo-Nsarhaza K., & Mutangadura, G. (2002). The spread and effect of HIV-1 infection in sub-
Saharan Africa. Lancet, 359, 2011 – 2017.
• Campbell, C. (1997). Migrancy, masculine identities and AIDS: The psychosocial context of HIV
transmission on the South African gold mines. Social Science & Medicine, 45(2), 273–281.

38. Before It's Too Late 38
references
• Cates, W., & Dallabetta, G. (1999). The staying power of sexually transmitted diseases. The Lancet, 354(S4), 2.
• Changalucha, J., Gavyole, A., Grosskurth, H., Hayes, R., & Mabey, D. (2002). STD/HIV intervention and research
programme Mwanza Region, NW Tanzania. Sexually Transmitted Infections, 78, 91 – 96.
• Chintowa, P. (1993) Talking to teens: Tanzania. Populi 20(10), 6 – 7.
• Clift, S., Anemona, A., Watson-Jones, D., Kanga, Z., Ndeki, L., Changalucha, J., Gavyole, A., & Ross, D. A. (2003).
Variations of HIV and STI prevalence within communities neighbouring new gold mines in Tanzania importance for
Intervention design. Sexually Transmitted Infections, 79, 307–312.
• Cohen, S. & Wills, T. A. (1985). Stress, social support, and the buffering hypothesis. Psychological Bulletin, 98, 310-
357.
• Cowan, F. M., Langhaug, L. F., Mashungupa, G. P., Nyamurera, T., Hargrove, J., Jaffar, S., Peeling, R. W., Brown, D.
W. G., Power, R., Johnson, A. M., Stephenson, J. M., Bassett, M. T., & Hayes, R. J. (2002). School – based HIV
prevention in Zimbabwe: Feasibility and acceptability of evaluation trials using biological outcomes. Aids, 16(12),
1673 – 1678.
• Dalton, J. H., Elias, M. J., & Wandersman, A. (2001). Community psychology, linking individuals and communities.
Belmont, CA: Wadsworth.

39. Before It's Too Late 39
references
• Ewald, J., & Närman, A. (2004). Education and poverty in Geita District. Some findings from the project
“a matter of choice” Geita District, November – December 2003. Paper presented at the BERRIPA
conference “Education and Poverty” 6 - 7 April 2004, Arusha, Tanzania.
• Gersovitz, M. (2005). The HIV epidemic in four African countries seen through the demographic and
health Surveys. Journal of African Economies, 14(2), 191–246.
• Gupta, G. R., & Weiss, E. (1993). Womens’ lives and sex; Implications for AIDS prevention. Culture,
Medicine and Psychiatry, 17(4), 399 – 412.
• Hayes, R. J., Changaluchab, J., Rossa, D. A., Gavyolec, A., Todd, J., Obasia, A. I. N., Plummer, M. L., Wight,
D., Mabey, D. C., & Grosskurth, H. (2005). The MEMA kwa Vijana project: Design of a community
randomized trial of an innovative adolescent sexual health intervention in rural Tanzania.
Contemporary Clinical Trials, 26, 430 – 442.

40. Before It's Too Late 40
references
• Haram, L. (2004) Prostitutes or modern women? Negotiating respectability in Northern Tanzania. In S.
Arnfred (Ed.) Re-thinking Sexualities in Africa. Uppsala: The Nordic Africa Institute.
• Haram, L. (2005). AIDS and risk: The handling of uncertainty in Northern Tanzania. Culture, Health
and Sexuality, 7(1): 1–11.
• Hartwig,, K. A., Eng, E., Daniel, M., Ricketts, T., & Quninne, S. C. (2005). AIDS and ‘‘shared sovereignty’’
in Tanzania from 1987 to 2000: a case study. Social Science & Medicine, 60, 1613–1624.
• Klepp, K.I., Ndeki, S.S., Leshabari, M.T., Hannan, P.J., & Lyimo, B.A. (1997). AIDS education in Tanzania:
Promoting risk reduction among primary school children. American Journal of Public Health, 87(12),
1931 - 1936.
• Klepp, K.I., Ndeki, S.S., Thuen, F., Leshabari, M., & Seha, A.M. (1996). Predictors of intention to be
sexually active among Tanzanian school children. East African Medical Journal, 73(4), 218 - 224.

41. Before It's Too Late 41
references
• Maalim A.D. (2006). Participatory rural appraisal techniques in disenfranchised communities: a Kenyan case study.
International Nursing Review, 53, 178 – 188.
• Matasha, E., Ntembelea, T. Mayaud, P., Saidi, W., Todd, J., Mujaya, B., & Tendo-Wambua, L. (1998). Sexual and
reproductive health among primary and secondary school pupils in Mwanza, Tanzania: need for intervention. AIDS
Care, 10(5), 571 – 582.
• Nyblade, L., Pande, R., Mathur, S., MacQuarrie, K., Kidd, R., Banteyerga, H., et al. (2003). Disentangling HIV and
AIDS stigma in Ethiopia, Tanzania and Zambia. Washington, DC: International Center for Research on Women.
• Ole-Nguyaine, S., Crump, J. A., Kibiki, G. S., Kiang, K., Taylor, J., Schimana, W., Bartlett, J. A., Shao, J. F., Hamilton, J.
D., & Thielman, N. M. (2004). HIV-associated morbidity, mortality and diagnostic testing opportunities among
inpatients at a referral hospital in Northern Tanzania. Annals of Tropical Medicine and Parasitology, 98(2), 171–179.
• Orubuloye, I. O., Caldwell, J. C. & Caldwell, P. (1993) African women’s control over their sexuality in an era of AIDS.
A study of the Yoruba of Nigeria. Social Science and Medicine, 37, 859–872.

42. Before It's Too Late 42
references
• republic of Tanzania (1996). Mwanzaregion socio-economic profile, 98. Dar es Salaam: The Planning
Commission Dar es Salaam and Regional Commissioner’s Office Mwanza.
• Rogers, R. W. (1975). A protection motivation theory of fear appeals and attitude change. Journal of
Psychology, 91, 93–114.
• Scheirer, M.A. (1996). A template for assessing the organizational base for program implementation. New
Directions in Evaluation, 72, 61–79.
• Silberschmidt, M. & Rasch, V. (2001). Adolescent girls, illegal abortions and ‘sugar-daddies’ in Dar es
Salaam: vulnerable victims and active social agents. Social Science and Medicine, 52, 1815–1826.
• Somi, G. R., Matee, M., Swai, R. O., Lyamuya, E. F., Killewo, J., Kwesigabo, G., Tulli, T., Kabalimu, T. K.,
Ng’ang,’ L., Isingo, R., & Ndayongeje, J. (2006). Estimating and projecting HIV prevalence and AIDS
deaths in Tanzania using antenatal surveillance data. BMC Public Health. 6(120), 1 – 6.

43. Before It's Too Late 43
references
• TACAIDS. (2003). National multi-sectoral strategic framework on HIV/AIDS: 2003–2007. Dar es Salaam:
Tanzania Commission for HIV/AIDS, The Prime Minister’s Office.
• Trochim, W. M. K., and Campbell, D. T. (1996). The Regression Point Displacement Design for
Evaluating Community-Based Pilot Programs and Demonstration Projects. Unpublished manuscript. 2 -
35.
• UNAIDS. (2001). AIDS epidemic update: December 2001. Retrieved January 2007 from
http://www.unaids.org/epidemic_update/ report_dec01.
• UNAIDS (2002). Global estimates of HIV/AIDS epidemic as of end 2001. Geneva: UNAIDS.
• UNAIDS. (2003). UNAIDS/WHO HIV/AIDS estimates as of end of December 2002. Retrieved January
2007 from http://www.unaids.org/html/pub/ Topics/Epidemiology/RegionalEstimates2002_
en_pdf.htm4.
• UNAIDS/WHO. (2002). Epidemiological fact sheets on HIV/AIDS and sexually transmitted infections:
United Republic of Tanzania,2002 update.

44. Before It's Too Late 44
references
• UNAIDS/WHO. (2005). AIDS epidemic update: December 2005. Geneva: UNAIDS and World Health Organization.
• United Nations General Assembly Special Session on HIV/AIDS. (2001). Declaration of commitment on HIV/AIDS.
Geneva: United Nations.
• UNICEF (1999). The state of the world’s children 1999. New York: UNICEF.
• UNICEF (2000) The Progress of Nations 2000. New York: UNICEF.
• Vavrus, F. (2006). Girls’ schooling in Tanzania: the key to HIV/AIDS prevention? AIDS Care, 18(8): 863 – 871.