Study setting
The data we report on were collected as part of a cluster randomised control trial (RCT) to test the efficacy of soccer and vocational training as contexts to deliver male-specific, HIV prevention programmes [28]. This intervention was staged in Khayelitsha and Mfuleni, two peri-urban settlements situated on the outskirts of Cape Town, South Africa. Khayelitsha has a conservatively estimated population of 420000 [28], and is one of the most impoverished areas in Cape Town, with a median annual household income of ~R20 000 (~US$1340), and half of its residents living in informal housing [29]. Khayelitsha is comprised of five major peri-urban settlements with both formal and informal housing. Mfuleni is located close to Khayelitsha, and is a relatively new peri-urban settlement, with an estimated population of 52300 [30]. Although reliable annual household income estimates are unavailable, the nature of housing and living conditions in Mfuleni is similar to those in Khayelitsha.
We identified 24 neighbourhoods of similar size (approximately 450–600 households) that was separated by buffer areas or at least 1 km of highways, railways, and rivers. Neighbourhoods were matched based on factors reflecting income (i.e. percentage of informal dwellings, availability of water and toilets on-site) and on density, ratio of dwellings to shebeens (informal bars), and access to day-care and healthcare clinics.
Recruitment and randomization
Neighbourhoods were recruited in triplets, i.e. three neighbourhoods were enrolled at the same time. The assessment team then recruited the next triplet. In this cluster randomised controlled design, the UCLA team randomised neighbourhoods within matching triads and randomly assigned to one of three conditions: soccer league (SL), soccer league and vocational training (SL + V), and a control condition (CC). For this analyses, we will only be looking at those assigned to SL and SL + V conditions. There were a total of four waves of 150 recruited participants a month at the time of this analyses; recruitment for this study was ongoing at the time of this paper.
Description of intervention
The SL group received soccer training for a 12-month period. On a weekly basis, participants attended 2 days of soccer practice, and one match day. The practices and matches were facilitated by soccer coaches, who were positive role models selected from the community and were trained in the foundational skills and theory common across evidence-based psychotherapeutic interventions and adolescent HIV prevention programs. The training included life skills in specific content areas (i.e., the core messages delivered during the intervention), including reducing alcohol/drug use, increasing HIV testing, optimizing the utilisation of healthcare facilities, fostering healthy daily routines, building friendship networks that are not based on shared risk behaviours, and managing money. The content areas were frequently rehearsed with role-plays during soccer practices so that the coaches could deliver the health messages on a regular basis.
For the SL + V condition, the SL condition described above was replicated for a six-month period. Thereafter, all young men were offered vocational training through two local organisations: Silulo Ulutho Technologies and Zenzele Training and Development. Through these organisations, young men were offered accredited training programmes in either computer courses, woodwork, or wielding. In addition, training was offered in a mentor-mentee environment, to enable participants to develop the necessary interpersonal skills required for employment.
Finally, the CC participants did not receive any intervention content, but routinely received flyers with picture stories regarding HIV prevention strategies and how to access these resources locally.
At the outset of the study, the fieldworkers and recruiters were blinded to intervention assignment.
Participants
To be recruited into the study, participants were required to be unemployed young men; aged 18–29 years old; and in the preceding 2 months slept at least 4 nights per week in a dwelling within the neighbourhood they were recruited for at least 2 months prior to recruitment. In addition, participants were required to speak isiXhosa or English, and was not be under the influence of substances at time of recruitment. In keeping with the study design of a cluster RCT, all young men in a neighbourhood were assigned to the same condition. All young men assigned to the SL and SL + V were followed-up for the first 6 months. For this analysis, we focused primarily on the two intervention arms where soccer was implemented.
Data collection
Baseline data were collected from a clustered sample of 729 young men who were assigned to either SL or SL + V conditions. Demographic characteristics included age, highest grade of school completed (years), relationship status, household monthly income, type of housing, presence of electricity in home, water access on the property, flushable toilets on premises, and presence of electrical source for cooking. Living with parents and partners were also recorded. Furthermore, we asked men about their chronic illnesses (e.g., HIV), social support, levels of gangsterism (i.e. number of arrests, number of prison sentences and gang membership), group violence involvement, and substance use [e.g. alcohol, marijuana (dagga), methaqualone (mandrax), and methamphetamine (tik)].
Depressive symptoms
The Center for Epidemiologic Studies Depression Scale (CES-D) was administered [31]. A cut-off of ≥16 was used to indicate depressed mood.
Perceived stress scale
The Perceived Stress Scale (PSS) was administered to measure the perception of stress [32]. A cut-off of 13 or higher was used to indicate high perceived stress.
Substance Use was self-reported if the participant used alcohol and/or used dagga, mandrax, or tik in the last 6 months. For alcohol consumption, binge drinking was asked if the participant consumed 6 drinks or more on one occasion on a daily or almost daily basis.
Problematic drinking was determined on whether the participant experienced heavy episodic drinking (six or more drinks in a single day) at least once a month over a specified timeframe, and responded yes to at least one of the following three questions: [1] Have close friends or relatives worried or complained about your drinking? [2]; Do you sometimes take a drink in the morning when you first get up? [3]; Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
Aggregate substance use was calculated to measure the levels of substance by severity, i.e. alcohol, dagga, mandrax, and tik use. If a participant reported alcohol use, this was multiplied by 1; subsequently, if a participant reported dagga use, this response was multiplied by 2; and lastly, self-report use of mandrax or tik was multiplied by 3. Thereafter, these responses were summed up by each of these substances to create this aggregate variable of substance use.
Aggregate gangsterism
Similar to above, measures of gangsterism was calculated by severity, i.e. arrests, prison sentences, and gang memberships. If a participant reported being arrested, this was multiplied by 1; if a participant reported whether they were given a prison sentence, this response was multiplied by 2; and lastly, membership with a gang was multiplied by 3. Thereafter, these responses were summed up by each of these substances to create this aggregate variable of gangsterism.
Lastly, practice records were kept of the young men’s attendance at the weekly soccer practices over a period of 6 months. In both intervention arms, participants were expected to attend 72 soccer practises and matches over a period of 6 months. Rates and patterns of attendance at soccer practices were mapped over time, based on date at which participants were recruited into the intervention. The rates and patterns of practises were used to determine intervention adherence and consistency of intervention engagement.
Intervention adherence
A measure of extent of participation in soccer practices. The measure is an index (i.e. value from 0 to 1) that reflects the number of soccer practices attended (numerator) over the total number of scheduled practices over the observed period (denominator).
Consistency of intervention engagement
A measure of the regularity of attendance at soccer practices. The measure is an index (i.e. value from 0 to 1) which reflects the number of weeks during which at least 1 soccer practice was attended of the total number of weeks during which soccer practices were scheduled (numerator) compared to the total number of weeks during which soccer practices where scheduled over the observed period (denominator).
Data analysis
Univariate descriptive analysis was used to describe the neighbourhood and individual sample socio-demographics, general health, social support, gangsterism, and substance use. Soccer attendance rates were summarized by month and graphed across time, based on when the intervention was initiated. A post-hoc analysis was done to determine if the level of adherence and consistency of engagement were associated with the time of entry into the intervention. Given these findings, we adjusted for entry of level for the study in the multivariate models to determine if higher indexes of adherence and/or consistency of engagement with the intervention were associated with socio-behavioural demographics and risk behaviours, such as hazardous substance use, gangsterism, and criminal activity. All data analysis was performed in R version 3.0.1. results are reported as adjusted odds ratios (aORs) and the significance level for all analysis was set to alpha = 0.05.