Participant characteristics
All 95 HOPE participants who enrolled during the CHARISMA enrollment period agreed to participate in CHARISMA; an additional 5 HOPE participants enrolled after the CHARISMA enrollment period had closed and did not participate in CHARISMA. Ninety-two of the 95 CHARISMA participants completed a questionnaire. At enrollment in CHARISMA, the average age of the respondents was 30 (Table 1), with a range of 21 to 48. Over two-thirds had at least a secondary school education. Thirty-four percent lived with a partner, 65% did not live with a partner, and only 17% were married. Twelve percent reported that their partner had slapped, hit or beaten them in the 12 months before enrollment. Fewer than half (44.6%) earned their own income.
Table 1
Participant characteristics at enrollment (n = 92)
|
Mean (SD)
|
Age
|
30 ± 7.0
|
|
N (%)
|
Highest level of education
|
|
Primary school
|
3 (3.3)
|
Secondary school, not complete
|
24 (26.1)
|
Secondary school, complete
|
44 (47.8)
|
Any college or university
|
21 (22.8)
|
Living with primary partner
|
|
No primary partner
|
1 (1.1)
|
Lives with partner
|
31 (33.7)
|
Does not live with partner
|
60 (65.2)
|
Marital Status
|
|
Currently married
|
16 (17.4)
|
Not currently married
|
76 (82.6)
|
Any physical or sexual violence, past 12 monthsa
|
11 (11.96)
|
Slapped, hit, or beaten by partner
|
10 (10.87)
|
Kicked, dragged, or pushed by partner
|
7 (7.61)
|
Forced to have sex by partner
|
3 (3.26)
|
Participant earns own income
|
|
Yes
|
41 (44.6)
|
No
|
51 (55.4)
|
Total
|
92 (100.0)
|
Note. SD = standard deviation |
a Aggregate measure that includes report of one or more of the below experiences |
Acceptability of CHARISMA
As shown in Table 2, all 92 participants who completed the questionnaire were administered the HEART tool and received the healthy relationships counseling module. Participants received supplemental counseling modules based on HEART tool recommendations and counselor assessments. Most participants (n = 54) received the IPV module; fewer received the partner communication module (n = 30) or the ring disclosure module (n = 27). Participants generally found the questions in the HEART tool easy to answer (69.6% very easy and 19.6% somewhat easy). Only a quarter of participants (25%) found the questions to be highly relevant, but an additional 61% found them somewhat relevant, and a large majority (79.3%) reported that they were very helpful. When asked why they found the HEART helpful, the primary reason participants gave was that it helped them to understand problems in their relationships and, in some cases, motivated them to make changes. As one participant said, “[The questions] were helpful because they sort of made me realize the issues I am going through, and I was able to get counseling afterwards.” (Lindiwe, age 22). A secondary reason participants said the HEART was helpful was that it gave them a new perspective on gender roles: “It helped me in understanding…that men and women are equal and that we need to share in duties in the house.” (Ndondoloza, age 22)
Staff estimated that the HEART took 20 to 30 minutes on average to complete. Most participants (60.9%) thought that it took about the right amount of time, but 25.0% thought it took too long (Table 2). Participants had strong preferences for how they would like to answer the HEART questions in the future, with slightly more strongly preferring administration by a counselor (41.3%) than strongly preferring self-administration by computer (35.9%). For those who preferred a computer, reasons included that they would be able to answer the questions more honestly without being judged and they would have more control over the pacing (going faster, repeating questions, or going back to revise responses to earlier questions). As one respondent said, “I feel that discussing my personal issues with a stranger is not okay, and with a computer I will be able to say everything that is personal without being shy” (Siphokazi, age 25). For women who preferred a counselor, reasons included that they appreciated the sympathy and human touch of a counselor, and that a counselor could answer questions and provide advice. As one respondent said, “Anything that you find hard to understand can be explained better by a counsellor than a computer” (Thembekile, age 24).
For the healthy relationships, partner communication, and ring disclosure counseling modules, nearly all participants (93–100%) that received those modules thought they were highly or somewhat relevant (Table 2); fewer participants (78%) thought that the IPV module was relevant. A large majority (82.6–90.0%) said that the healthy relationships, partner communication, and ring disclosure modules were very helpful; a slightly smaller majority (72.7%) said that the IPV module was very helpful. In response to open-ended questions about the counseling modules, participants said that the modules increased their awareness of harmful dynamics in their relationships, improved their communication with their partners, and helped them talk to their partners about their ring use. Table 3 provides illustrative quotes to demonstrate participant reactions to each counseling module type. Most women who received the IPV counseling said that it empowered them, but some said that it was not relevant to them.
Staff estimated that, on average, counseling at enrollment took 30–40 minutes. Most participants thought the counseling modules were about the right length (68.5–83.3%, depending on the module; Table 2). Nearly all participants (94% or more) rated the counselors as “great” or “good” in terms of their respect and caring, listening skills, confidentiality, and knowledge (not shown). Many more participants said that they would strongly prefer to receive the counseling modules in-person (40.7–55.6%) than said they would strongly prefer a hypothetical computer-based version of the counseling (22.2–29.6%). The reasons for their preferences were similar to the reasons they gave for completing the HEART with a counselor as compared with by themselves.
Table 2
Participants’ reactions to CHARISMA components
|
HEART
(n = 92)
|
Healthy relationships counseling module
(n = 92)a
|
Supplemental counseling modules
|
Partner communication (n = 30)a
|
Ring disclosure
(n = 27)a
|
IPV
(n = 54)a
|
Ease of understanding (HEART questions only)
|
|
|
|
|
|
Very easy
|
69.6%
|
NA
|
NA
|
NA
|
NA
|
Somewhat easy
|
19.6%
|
NA
|
NA
|
NA
|
NA
|
Somewhat difficult
|
9.7%
|
NA
|
NA
|
NA
|
NA
|
Very difficult
|
1.1%
|
NA
|
NA
|
NA
|
NA
|
Relevance
|
|
|
|
|
|
Highly relevant
|
25.0%
|
54.3%
|
56.7%
|
66.7%
|
47.3%
|
Somewhat relevant
|
60.9%
|
39.1%
|
43.3%
|
25.9%
|
30.9%
|
Not very relevant
|
14.1%
|
6.5%
|
0.0%
|
7.4%
|
21.8%
|
Helpfulness
|
|
|
|
|
|
Very helpful
|
79.3%
|
82.6%
|
90.0%
|
88.9%
|
72.7%
|
Somewhat helpful
|
18.5%
|
17.4%
|
10.0%
|
7.4%
|
20.0%
|
Not helpful
|
2.2%
|
0.0%
|
0.0%
|
3.7%
|
7.3%
|
Length
|
|
|
|
|
|
Too long
|
25.0%
|
18.5%
|
13.3%
|
7.4%
|
11.1%
|
About right
|
60.9%
|
68.5%
|
83.3%
|
77.8%
|
74.1%
|
Not long enough
|
14.1%
|
13.0%
|
3.3%
|
14.8%
|
14.8%
|
Preference for computer or counselor administration
|
|
|
|
|
|
Strongly prefer computer
|
35.9%
|
27.2%
|
26.7%
|
22.2%
|
29.6%
|
Somewhat prefer computer
|
2.2%
|
2.2%
|
3.3%
|
3.7%
|
3.7%
|
No preference
|
13.0%
|
16.3%
|
20.0%
|
18.5%
|
18.5%
|
Somewhat prefer a counselor
|
7.6%
|
4.4%
|
6.7%
|
0.0%
|
7.4%
|
Strongly prefer a counselor
|
41.3%
|
50.0%
|
43.3%
|
55.6%
|
40.7%
|
a All 92 participants received the healthy relationships counseling module and at least one other counseling module. |
Table 3
Participant reactions to counseling modules
Healthy Relationships Counseling
▪ I liked that I was able to talk to a stranger about my relationship because he or she will not be judgmental or take sides. (Zanele, age 30)
▪ Talking to the counselor made me see things in a different angle, it made me realize that there are some things that I was doing towards my partner unaware that they are not right. (Nozizwe, age 22)
Partner Communication Counseling
▪ I liked the module because it worked for me greatly. I was just a person who would keep quiet whenever I do not like something that my partner does. This module encouraged me to talk to my partner about what I don’t like…in a constructive manner. (Duduzile, age 39)
▪ I liked that the counsellor touched on anger issues affecting communication in our relationship and how to calm down even when angry and talk things out instead of adding fuel in the fire. (Kholwa, age 26)
Ring Disclosure Counseling
▪ I liked that they gave me ideas on ring disclosure and it worked—my partner now knows I’m using the ring and he doesn’t have a problem with it. (Mbalenhle, age 27)
IPV Counseling
▪ It made me realize that I don’t have to let anyone control me and to stay in an abusive relationship (Sihle, age 24)
▪ I did not like that the tool chose for me this module while I was not going through any abuse in my relationship. (Unathi, age 31)
|
Perceived impact of CHARISMA
A large majority of participants agreed or strongly agreed that CHARISMA had helped them to improve their relationships (91%) and to use the ring more consistently (88%; Fig. 1). Smaller majorities also agreed or strongly agreed that it had helped them use the ring more consistently (75%) and reduce conflict with their partners (62%), and that it helped their partner be more supportive of their ring use (51%).
In regard to ring disclosure, 35 participants (38%) said that when they enrolled in HOPE their partner did not know that they were using the ring or that they did not know if he knew (not shown). Of those 35, 12 (34%) reported that they had since told their partner that they were using the ring, and nine (75%) of them said that CHARISMA had been either very helpful (58.3%) or somewhat helpful (16.7%) in helping them talk to their partner about it (Table 4). Twenty-three participants had still not disclosed their ring use to their partner at the time of the survey, and 19 (82.6%) of this subset reported that CHARISMA had been either very helpful (65.2%) or somewhat helpful (17.4%) in helping them feel comfortable keeping their ring use a secret from their partner.
In regard to IPV, 13 participants (14%) said that their partner was controlling or abusive when they enrolled in HOPE and CHARISMA. Seven (53.9%) of these said that their partner was no longer controlling or abusive at the time of the survey (6 or more months after enrollment), and three (23.1%) said that they were no longer with that partner. One participant (7.7%) responded that her partner was still abusive, but she had some strategies and information that made her feel safer than before. Only 2 of the participants (15.4%) in abusive or controlling relationships at enrollment said that their relationship had not changed six months later. Of the 11 participants who said that their relationship had changed, eight (72.7%) said that CHARISMA had had a “big” effect in bringing about that change.
Table 4
Impact of CHARISMA on ring disclosure and IPV among select subgroups
Population subgroup
|
Measure
|
n (%)
|
Participants who disclosed ring use to partner after enrollment (n = 12)
|
Helpfulness of CHARISMA in talking to partner about ring use
|
|
Very helpful
|
7 (58.3)
|
Somewhat helpful
|
2 (16.7)
|
Made no difference
|
3 (25.0)
|
Participants who had not disclosed ring use to partner at time of interview (n = 23)
|
Helpfulness of CHARISMA in helping participant feel comfortable keeping ring use a secret from partner
|
|
Very helpful
|
15 (65.2)
|
Somewhat helpful
|
4 (17.4)
|
Made no difference
|
4 (17.4)
|
Participants whose partner was controlling or abusive at enrollment (n = 13)
|
Status of relationship at time of interview
|
|
No longer with that partner
|
3 (23.1)
|
Still with that partner, but he is no longer controlling or abusive
|
7 (53.9)
|
Still with that partner and he is still controlling or abusive, but have some strategies and information that make me feel safer than before
|
1 (7.7)
|
Relationship has not changed
|
2 (15.4)
|
Participants whose relationship was controlling or abusive at enrollment and whose relationship status had changed at time of interview (n = 11)
|
How much of an effect CHARISMA had in bringing about that change in the relationship
|
|
A big effect
|
8 (72.7)
|
A medium effect
|
2 (18.2)
|
A small effect
|
0 (0.0)
|
No effect
|
1 (9.1)
|
Factors affecting the feasibility of charisma
Facilitators
Factors that facilitated CHARISMA implementation and effectiveness included the longitudinal design of CHARISMA, the use of lay counselors, and implementation of CHARISMA at Wits RHI as part of the existing HOPE study.
Staff thought that the fact that CHARISMA had multiple visits over time was important in enhancing rapport between clinic staff and participants, which could increase the effectiveness of the intervention. Staff observed that some participants were reluctant to open up about difficulties in their relationships during the enrollment visit but became more comfortable over time, and more open or honest in subsequent visits. Also, staff said that IPV is normalized in South Africa, so it can take time for participants to begin to recognize IPV in their relationship and be ready to take action on it; therefore, the ongoing support is important to help them reach that stage.
As noted previously, one way in which CHARISMA differed from the Safe & Sound intervention was that CHARISMA used lay counselors instead of nurses to administer the intervention. Clinic supervisors thought that the lay counselors were perceived by study participants as attentive and caring people and relatable, as was confirmed by the participant survey results. Supervisors also noted that use of lay counselors facilitated hiring, because many people in Johannesburg are certified HIV counselors, a key qualification for the position, and a large pool of candidates had basic, related skills and training. Finally, supervisors commented that lay counselors are a lower wage category of staff to hire than nurses, which reduces the overall cost of the intervention and could make it the approach more feasible to fund and implement in a public health clinics in the future.
Staff noted that implementation of CHARISMA at the Wits RHI clinic as part of the HOPE study facilitated implementation in several ways. Because nearly all of the CHARISMA staff had worked on ASPIRE, the clinical trial of the dapivirine ring that preceded HOPE, they had seen the need for an intervention like CHARISMA, which added to their motivation and commitment to the work. Further, counseling staff were hired solely to work on CHARISMA and to offer HIV pre- and post-test counseling; as a result, they did not have multiple competing work priorities, as might be the case in a public health clinic. Finally, staff said that the quality of care in the Wits RHI clinic was very high and very personal, and because participants had been coming to the clinic for years (since enrollment in the ASPIRE trial, which began in November 2012), they felt comfortable there and trusted in the confidentiality of the services.
Challenges
Challenges to implementation included the length of time required to administer CHARISMA, counselor stress from hearing participants’ traumatic stories (vicarious trauma), limited male partner engagement, participants’ lack of follow-through on referrals, and external contextual factors.
The staff noted that the CHARISMA intervention was lengthy to administer. From start to finish (including time for the participant to enter the clinic and sign in, introductions, overview of CHARISMA, informed consent, administration of the HEART, provision of counseling, discussion of referrals, and signing out), staff estimated that the intervention typically took 1.5 to 2 hours at the enrollment visit, and 45 minutes to an hour for the month 1 visit (including sign-in, follow-up counseling, discussion of referrals, and sign-out). In the absence of further intervention streamlining, this could present an important barrier to successfully implementing the intervention in a public health clinic.
Staff commented that hearing difficult stories about participants’ experiences with IPV was stressful for the counselors. To address the stress, clinic supervisors were available to any of the counselors who needed to talk, and the team met regularly to process the issues they were dealing with and support each other. The counselors felt that this helped them regulate their emotions, build skills, and feel more cohesive as a team. Counselors were also able to take a break after any counseling sessions that were particularly stressful. Counselors thought that these measures were insufficient, however, to enable them to fully deal with the stress and symptoms of vicarious trauma. To provide additional support, the project hired a psychologist, who began holding bi-monthly group debriefing sessions with the team and was also available for individual counseling sessions when needed. At the time of the KIIs, the psychologist had been assisting for only two weeks, but the staff perceived her as helpful.
Engaging participants’ male partners was challenging. By Month 6, male partners of just 14 participants (14.7%) had come to the clinic. Forty-four percent of participants in the survey said they had not invited their partners to come to the clinic. In responses to an open-ended question about why they had not invited their partner to the clinic, the reason mentioned most frequently was that he was too busy to come. Other reasons included that he lived or worked too far away, she did not see any reason for him to come, or that he did not know she was in the study. The community outreach component of CHARISMA reached over 10,000 men, but none of the women participating in CHARISMA said that their partners had participated in any of these activities. Efforts to invite the participants’ male partners to the community outreach events were hampered by the need to preserve the confidentiality of the participants and by challenges in coordination between the organizations responsible for the clinic and community components of CHARISMA. However, this did not hinder the intervention delivered directly to the female CHARISMA participants.
Relatively few participants followed through on referrals from clinic staff to outside organizations. Twenty-nine participants (31.5%) reported that they had received a referral for services outside the clinic, and 10 (34.5% of those who received a referral) said that they had gone for the services. The primary reasons given for not following through on a referral were that they did not think they had a problem, the problem had been resolved, they knew how to resolve the problem, or they did not have time. Staff surmised that participants may be willing to tell their story or receive services and care in the research clinic, which is a familiar place, but may not be willing to do so at an unfamiliar place. In addition, staff thought that in cases where participants’ problems involved their partners, they might feel like they were betraying their partner if they followed through on the referral. The staff tried to help overcome the barriers by offering transportation and accompaniment to the referral organizations, but this was often insufficient to overcome the participants’ reluctance to seek outside organizations’ assistance.
Several external contextual factors posed challenges to the successful implementation of CHARISMA. As previously mentioned, staff commented that IPV is so common that it is normalized in Johannesburg, so it can take time to help women (and their partners) see it as a problem, or as addressable. Staff also noted that people of some cultures in South Africa do not talk about their problems, so some participants may have been reluctant to speak openly with counselors. Staff believed that the intensive nature of the intervention, with more than one session, was key to overcoming these barriers and making intervention impact feasible. Finally, staff commented that another challenge was the lack of formal commitment in many of the women’s relationships (only 17% were married, and 34% were cohabiting), which may have made male partners less willing to work to improve the relationship and limited the women’s ability to insist that they do so.