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Response to Jewkes ‘Where to for Sexual Health Education for Adolescents in Sub-Saharan Africa?’
Posted by MKV1FS on 24 Aug 2010 at 16:51 GMT
Authors: Doyle AM, Plummer ML, Obasi AIN, Makokha M, Hayes RJ, Changalucha J, Ross DA.
The Perspective by Rachel Jewkes1 on the results of the MEMA kwa Vijana long-term impact evaluation2 provides a valuable contribution to the discussion of ‘what next?’ for adolescent sexual and reproductive health (ASRH) interventions in sub-Saharan Africa. This is especially relevant given that the 2006 WHO-coordinated systematic review of ASRH interventions in developing countries3 and the recent update of this review4 highlighted the fact that, despite over 20 years of research, there is still no evidence to show that any specific behaviour change intervention has reduced HIV among young people.
The commentary suggests that advances in our understanding of adolescent interventions point to deficiencies in the overall design and content of the MEMA kwa Vijana (MkV) intervention that makes its lack of impact inevitable. Specifically, Jewkes argues that the main reason for the lack of short-term (3 years) and long-term (8 years) biological impact of the MkV intervention was that it was a largely schools-based intervention. In particular, the commentary asks important and valid questions about the role of the school context in intervention effectiveness. However, Jewkes argues that the MkV intervention was of low intensity, was largely didactic, focused predominantly on abstinence and lacked a focus on skills, gender and identity. We believe that this is a misleading overview of the MkV intervention. Furthermore, we feel that Jewkes’ commentary fails to consider important issues relating to context, cost and sustainability which must also be addressed if adolescent reproductive health interventions are to achieve the impact on HIV that is so desperately needed in sub-Saharan Africa.
Jewkes’ discussion is largely based on a comparison between the MEMA kwa Vijana intervention in Tanzania and Stepping Stones interventions in South Africa; the latter being the only intervention in sub-Saharan Africa that has shown a statistically significant improvement in any biological outcome (HSV2) within a randomised controlled trial.5 It is therefore important to consider their similarities and differences, both in terms of content and context. Both interventions were implemented and evaluated among young rural Africans, and designed to be sustainable and replicable on a large scale. However, the interventions had some critical differences, beyond the obvious difference of school and health facility (MkV) versus community (Stepping Stones) setting.
Importantly, the interventions addressed two very different constituencies of young people, especially in terms of age, formal education, cognitive development, and motivation. The MkV evaluation involved randomly selected pupils in Years 5 – 7 of rural Tanzanian primary schools, with 94% aged 14-17 years when they first received the in-school interventions. In contrast, Stepping Stones was evaluated in volunteers aged 16-23 years who were mostly attending Years 9 - 11 of South African secondary schools.6 The differences in educational foundation alone can contribute to participants having substantially different critical thinking skills, literacy, and understanding of mathematical, biological and sexual health concepts, all of which have implications both for the content and approach of programmes.
In her commentary, Jewkes stated that the MkV curriculum lacked a focus on skills-building, and particularly communication skills-building, and she referred to the curriculum as “notably limited in addressing gender relations and identities.” During MkV intervention development and pilot testing, it was found that primary school students had little correct understanding of HIV/AIDS, and their ability to grasp and meaningfully participate in interactive, skills-building exercises was extremely limited. Skills-building exercises within the final curriculum were therefore kept intentionally simple. These included participatory sessions on developing skills to refuse sex, respecting others’ decisions, and girls and boys having equal abilities (Box 1 in paper)2.7, 8 Class peer educators modelled skilled behaviours in scripted dramas; and general students practised skills in role plays. Our research with this population suggested that a more radical approach would have been neither appropriate nor effective on a large scale, whether in the school system or the community.
In her commentary, Jewkes also refers to the in-school component of the MkV intervention as “very substantially didactic”. We believe this is also misleading. It is true that, at the time of the trial, most Tanzanian primary school teachers used very didactic teaching methods. However, MkV teachers were also trained to teach the curriculum using much more interactive methods, including using questions and answers, story reading, letter reading, guided discussions, group work, disease transmission simulations, personalisation exercises, knowledge competitions, quizzes, flip chart illustrations, scripted dramas performed by trained peer educators, and role-plays in which all pupils were encouraged to participate. Those exercises may not have been as complex, subtle or participatory as many international “best practice” curricula, but they represented an unusually interactive and diverse approach to teaching for rural Tanzanian schools at the time.
Jewkes also addressed MkV intervention behaviour change goals in her commentary. She is correct that Tanzanian government and school policies stressed abstinence promotion for primary school pupils, and that this limited the extent to which both partner reduction and condom use could be promoted within MkV. The MkV curriculum (as in Box 1 in paper2) included sessions relating to partner reduction and correct condom use, but we agree that more complex, intensive promotion of both of these behavioural goals might have been more effective in reducing sexual health risk in the trial population.9 However, a critical lesson from our trial was the importance of working creatively and collaboratively when faced with such constraints. For example, although condom demonstrations and explicit illustrations were prohibited in the schools, we negotiated permission to describe condoms in class, and to demonstrate their correct use during scheduled visits of school classes to local health clinics. Furthermore, youth condom promoters and distributors were recruited and trained to promote and sell subsidised condoms to young people in the trial communities. Notably, in-depth interviews carried out in 2009 with those exposed to the in-school intervention 8-10 years previously revealed that condom use was one of the main topics that was remembered.10
Jewkes noted some other MkV programme limitations which have been described previously, including those to do with limited broader community engagement.11, 12 Within the initial MkV design, broader community activities were intentionally limited to maximise sustainability and the potential to scale-up the intervention, because interventions outside existing institutions such as schools and health facilities generally require much greater expense, given they do not work with existing infrastructure and staff. MkV succeeded in developing a relatively affordable intervention: following initial development and start-up, the intervention was estimated to cost $10/student/year, with costs estimated to drop to $1.54/student/year following intervention scale-up.13 In her commentary, Jewkes compares the MkV intervention to two community-based interventions that were likely to have required considerably higher costs per young person reached directly and had less obvious pre-existing structures in place for national scale up. While we agree that broader community intervention work would have strengthened the MkV intervention, it is important to recognise that much greater expense may be necessary to achieve this. The quality and quantity of evaluation studies has improved in the past 5 years, but data on the cost of interventions, needed urgently by policy-makers, remain rare.4
The appropriateness of schools as a focus for adolescent reproductive health interventions is central to Jewkes‘discussion. There is a critical need for improved teacher training and supervision to monitor and appropriately respond to different kinds of physical, sexual and economic abuse in sub-Saharan Africa.14-16 In our qualitative research, for example, we found corporal punishment was practised in all schools and there was evidence of sexual abuse by 1-2 male teachers in almost every school. Nonetheless, in most schools there were also a large number of teachers who strove to treat children fairly and to teach them to the best of their ability despite tremendous constraints, including putting many extra hours into teaching a new sexual health intervention. Whilst we agree that the school context and values are very important to the effectiveness of school-based interventions, we believe that the broader community context is equally or more important, particularly as contradictory norms and expectations in the broader community appear to have prevented many young people from adopting what they learnt in the MkV programme, and because adverse practices within school clearly reflect those within the wider community. This view is supported by qualitative research carried out during the first 4 years of the trial (1999-2002)9, 17 and also by more recent qualitative research following the long-term impact evaluation in 2009.10
Finally, one of the critical challenges in developing and rigorously evaluating a public health intervention is to balance its scale and intensity with what will be affordable and feasible in the local context if it is eventually scaled up. Adolescents remain a critical constituency in the landscape of HIV prevention and reproductive health. The coverage and infrastructure provided by schools means that they will remain a very important setting for sexual health interventions for this group. It is therefore important to try to improve MkV and other school-based programmes, and it is also critical that fundamental changes be made to the broader school context. However, this cannot be achieved without meaningful engagement with the wider community, whose practices determine those of the school and may constrain or enhance the ability of students to apply in real life the skills that they acquire though schools-based interventions. Interventions such as Stepping Stones may well have an important contribution to make here, particularly with older, more educated young people who are motivated to volunteer for such an intervention. Such combined intervention efforts are likely to require substantially more funding than relatively low-cost, institutional programmes like the in-school component of MkV. However, the lack of a statistically significant impact on HIV of even the Stepping Stones intervention suggests that greater investment in more complex, intensive and integrated interventions in a range of intervention settings (e.g. community, schools, health facilities, youth detention centres, mass media) and for a range of youth constituencies may be necessary to prevent HIV and improve sexual health among adolescents in sub-Saharan Africa.
1. Jewkes R. Where to for sexual health education for adolescents in sub-saharan Africa? PLoS Med. 2010;7(6):e1000288.
2. Doyle AM, Ross DA, Maganja K, Baisley K, Masesa C, Andreasen A, et al. Long-term biological and behavioural impact of an adolescent sexual health intervention in tanzania: follow-up survey of the community-based MEMA kwa Vijana Trial. PLoS Med. 2010;7(6):e1000287.
3. Ross DA, Dick B, Ferguson J. Preventing HIV/AIDS in young people: a systematic review of the evidence from developing countries. UNAIDS Inter-agency Task Team on Young People. Geneva: World Health Organization; 2006.
4. Doyle AM, Napierala Mavedzenge S, Ross DA. HIV prevention in young people in sub-Saharan Africa: a systematic review and update of the evidence (WEAC0201). XVIII International AIDS Conference (AIDS 2010); 2010; Vienna, Austria. 2010.
5. Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, et al. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial.[see comment]. BMJ. 2008;337:a506.
6. Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Khuzwayo N, et al. A cluster randomized-controlled trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behaviour amongst youth in the rural Eastern Cape, South Africa: trial design, methods and baseline findings. Tropical Medicine & International Health. 2006 Jan;11(1):3-16.
7. Obasi AIN, Chima K, Cleophas- Mazige B, Mmassy G, Makokha M, Plummer ML, et al. Good things for young people: Reproductive health education for primary schools: Teacher’s guides for Standards 5, 6 and 7, and Teacher’s resource book. 2010. http://www.memakwavijana.... (accessed July 8, 2010).
8. Obasi AIN, Chima K, Cleophas- Mazige B, Mmassy G, Makokha M, Plummer ML, et al. MEMA kwa Vijana: Elimu ya afya ya uzazi kwa schule za msingi: Kiongozi cha mwalimu: Darasa la 5, 6 na 7. Dar es Salaam: Ben and Company; 2004.
9. Plummer ML, Wight D. Why behavior change is slow: Young people's sexual relationships and HIV prevention in rural Africa. Lexington Books. Forthcoming.
10. Wamoyi J, Mshana G, Doyle AM, Ross DA. What sticks in the mind? Rural Tanzanian young people's memories of an in-school sexual and reproductive health intervention 7-9 years later (MOPE0541). XIII International AIDS Conference (AIDS 2010); 2010; Vienna, Austria. 2010.
11. Obasi AI, Cleophas B, Ross DA, Chima KL, Mmassy G, Gavyole A, et al. Rationale and design of the MEMA kwa Vijana adolescent sexual and reproductive health intervention in Mwanza Region, Tanzania. AIDS Care. 2006 May;18(4):311-22.
12. Plummer ML, Wight D, Obasi AIN, Wamoyi J, Mshana G, Todd J, et al. A process evaluation of a school-based adolescent sexual health intervention in rural Tanzania: the MEMA kwa Vijana programme. Health Education Research. [Article]. 2007 Aug;22(4):500-12.
13. Terris-Prestholt F, Kumaranayake L, Obasi AIN, Cleophas-Mazige B, Makokha M, Todd J, et al. From trial intervention to scale-up: costs of an adolescent sexual health program in Mwanza, Tanzania. Sexually Transmitted Diseases. 2006 Oct;33(10 Suppl):S133-9.
14. The Panos Institute. Beyond victims and villains: addressing sexual violence in the education sector.: The Panos Institute,; 2003. http://www.panos.org.uk/?... (accessed July 8, 2010)
15. Leach D, Fiscian V, Kadzamira EL, Machakanja P. An Investigative Study of the Abuse of Girls in African Schools. London: Department for International Development; 2003.
16. Abrahams N, Mathews S, Ramela P. Intersections of 'sanitation, sexual coercion and girls' safety in schools'. Trop Med Int Health. 2006 May;11(5):751-6.
17. Wight D, Plummer ML, Mshana G, Wamoyi J, Shigongo ZS, Ross DA. Contradictory sexual norms and expectations for young people in rural Northern Tanzania. Soc Sci Med. 2006 Feb;62(4):987-97.