1. Evaluating Structural Interventions Kelly Hallman “Pushing Forward with Structural Interventions for HIV Prevention – Where Are We Now and How Do We Move Forward” 26 July 2012, IAS Conference

2. The reality We are hardwired for this

3. ..and WHY do you want my sex? Intimacy, pleasure Evolution, childbearing Challenge of HIV and STIs How do we tackle? How to measure intervention impact?

4. Levels of “rigor”

5. Common HIV prevention outcomes HIV HSV Condom use Sexual partnering Abstinence, frequency

6. What’s common to these outcomes? Changes at individual-level

7. …and the “enabling” environment?

8. “Poverty isn’t created by poor people. It’s created by wrong systems. And we don’t notice it.” - M. Yunus

10. Structural change Transformation that alters flows in authority rights resources opportunities information responsibilities Long-term process

11. Are these amenable to study using an RCT?

12. R C T Randomized Denial of benefits a concern Phased-in approach Control All else held constant Learning, mid-course correction? Narrow intervention or single bundled package or expensive multi-arm Trial Limited time to measure change

13. Perhaps a middle ground

14. Structural factors likely to impact HIV, health, well-being What is the theory of change? Clear conceptual framework Causal impact hypothesis Identify “proximate determinants” Outcomes along path to desired change

15. Theory Study outcomes, Study design Did it work? 1.Structural level Organizational theory Systems analysis Timeline 2.Individual level Outcomes: Factors along pathway to desired change Design: e.g., case-control with careful matching (PSM) Timeline

16. Methods Why did it work (or not)? Monitoring Operations research Institutional change theory Qualitative approaches Seasonality analysis Time use patterns etc.

17. Let us move creatively beyond…. Your study was not an RCT! Be gone with you!

18. “The first rule of social change: Maximize your impact without being a jerk. If you maximize impact while being a jerk, it is not worth it.” - Jacob Harold, Hewlett Foundation

19. The Population Council conducts biomedical, social science, and public health research. We deliver solutions that lead to more effective policies, programs, and technologies that improve lives around the world.

20. Few girls under age 15 in Burkina Faso reached by peer educators

21. Yet younger girls much lower levels of HIV and SRH knowledge than older girls

22. Few girls with little schooling reached by a peer educators

23. And …most girls in Burkina Faso have never been to school

24. And their levels of preventive knowledge are much lower than those who ever attended school

25. Siyakha Nentsha impact on self-reported sexual behaviors Boys Girls + p<0.10; * p<0.05; ** p<0.01 * +

26. Siyakha Nentsha impact on social and economic Boys Girls + p<0.10; * p<0.05; ** p<0.01 * * *