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3 year Evaluation

The impact of the interventions during the first 3 years

The impact of these interventions on HIV incidence, the prevalence genital herpes (HSV2), syphilis, chlamydia, gonorrhoea, trichomoniasis, and pregnancy, reported sexual behaviours (eg. sexual debut, condom use), and knowledge and reported attitudes related to sexual and reproductive health, was evaluated over a 3-4 year period within a cluster randomised controlled trial (1998-2002). During MkV1, the impact was evaluated within a cohort of 9645 adolescents, whose mean age was just under 16 years at recruitment in late 1998. Baseline data were collected from them in late 1998 immediately before the interventions started in the 10 intervention communities, and follow-up data were collected from the same adolescents in 2000 and again in 2001/2. The overall follow-up rate was 73%, but was higher in males (77%) than in females (69%).

This phase of the trial demonstrated:

 

Feasibility

  • The intervention programme was found to be locally appropriate and popular with both young people and implementers
    • Local government teachers and health workers could deliver the interventions to a high standard, given sufficient training and quarterly supportive supervision

Impact

The evaluation in 2001/2 showed that the intervention programme had resulted in:

  • Significant improvements in sexual and reproductive health knowledge; for example:
    • “Can a person who looks strong and healthy have HIV?”
  • “Is it possible for a girl to become pregnant the first time she makes love?”)
  • Significant improvements in reported attitudes related to sexual and reproductive health risk; for example:
    • “If a man or youth wants to have sexual intercourse (make love) with a girl, can she refuse to have sexual intercourse (make love) with him if he is older than her?”
  • Significant improvements in several reported sexual behaviours; for example:
    • A higher proportion of those who reported having had sex at the 2001/2 follow-up survey reported that they had first used a condom during follow-up (both males and females)
    • A higher proportion of those who reported having had sex at the 2001/2 follow-up survey reported that they had used a condom at their most recent sexual intercourse (only significant in males)
    • A lower proportion of males reported sexual debut during the follow-up period (males only, borderline significant)
    • A smaller proportion of males reported more than 1 sexual partner in the last 12 months (males only)
  • However, despite these encouraging results, there was no consistent impact of the intervention programme on biological indicators of the frequency of HIV, other STIs or pregnancy.

 

Potential explanations for the lack of a consistent effect on these key biological outcomes include:

1. Such interventions only really change knowledge & skills, but not risk-taking, at least in the short-term

Reported behaviour is notoriously unreliable in young people and may be subject to differential reporting bias (intervention vs comparison) in the presence of an intervention. Hence, the differences in reported sexual behaviours that were observed in the trial may have reflected knowledge of desired behaviours more than actual behaviour.

2. The interventions need more time to work

  • 40% of impact evaluation cohort only received one year of the in-school intervention.
  • The highest risk group (Year 6 at recruitment) had the least exposure to the in-school intervention (one year)
  • The duration of follow-up (3 years) may have been too short to see the impact of any improvement in young men’s risk-taking on biological outcomes in young women, due to the substantial differences in the average age of sexual partners.

3. Additional interventions may be needed

  • Additional interventions, introduced in tandem with interventions like those used in MkV1, might be needed to reach a tipping point and achieve a measurable impact on HIV, other STIs and pregnancy rates in the short to medium term.

 

Key lessons from Phase 1

  1. Considerable caution is needed when extrapolating from evidence of a beneficial impact of interventions or programmes on sexual health knowledge, attitudes & reported behaviour to health impact on HIV, STIs & unwanted pregnancy in adolescents.
  2. Future evaluations should include biological outcomes, even if this increases their size and cost.
  3. Phase 1 of the MEMA kwa Vijana Trial has shown that there is a feasible intervention programme that can induce substantial & sustained improvements in knowledge, reported attitudes, & reported behaviours.
  4. More work is needed to explore:
    • Whether, in the longer term, benefits on health outcomes can be demonstrated, if such interventions are sustained.
    • How to further enhance the interventions

 

Next steps after Phase 1

These findings and the lessons learned while implementing Phase 1 of MEMA kwa Vijana resulted in three specific next steps:

  • Rolling out of the core MEMA kwa Vijana interventions (sexual & reproductive health education within the last 3 years of primary school, and youth-friendly health services interventions) with detailed operations research to learn the lessons from this process (MkV2 Interventions Scale-up & Operations Research; 2004-2009)
  • Formative research to develop and pilot test additional interventions specifically targeting the parents of adolescents which might be introduced alongside the core MkV interventions (MkV2 Formative Research; 2006-2009)
  • A further survey within the original 20 MkV trial communities to evaluate the medium-long term impact of the interventions (MkV Trial Further Survey; 2007-2008)

These are described in other sections of this website.