Scaling up and Learning the Lessons
Since 2004, the second phase of MkV (MkV2) has supported the Government of Tanzania’s National Multi-sectoral Strategic Framework by providing technical assistance and capacity building at the regional and district level to enable MoHSW and MoEVT implementers to scale up the MkV interventions through local government structures in all schools and health facilities in four target districts (Geita, Kwimba, Misungwi, Sengerema) of Mwanza Region.The MkV interventions are:
- Teacher-led, peer-assisted adolescent sexual and reproductive health sessions in Standards 5-7 of 620 primary schools
- Youth-friendly reproductive health services in 177 health facilities
- the coverage
- the quality
- and the impact of the interventions.
The process evaluation has examined the factors both internal to intervention design and external environmental factors. Additional research focused on the design and pilot testing of a community intervention that addresses parenting, adolescent sexual and reproductive health and community risks through participatory learning and training of parents/adult caregivers.
Fig 1 below summarises how all the MkV2 research reports listed in the bibliography come together to give a complete picture of factors that influence the scaling up of ASRH programmes in Tanzania.
The numbers in brackets refer to the number of the research report presented in section 2.
Annotated bibliography of MkV research reports
1. Andrew B, Renju J, Kishamawe C and Obasi A, 2008. Impact of MEMA kwa Vijana, phase 2 on knowledge, attitudes and reported behaviour among primary school pupils in Mwanza Region. MEMA kwa Vijana Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
As part of MkV2 the districts have led a series of 14-day training sessions with 1860 science teachers covering ASRH, life skills and teaching skills. This paper presents the findings from a pupil survey that was conducted to assess if, when delivered at scale through government systems, the intervention can still impact upon pupils’ knowledge, attitudes and self efficacy. The quasi-experimental sequential cross sectional study took place in 78 rural primary schools (37 -control and 41-intervention) and involved 7432 pupils (3559-intervention and 3873-control). Additional qualitative and quantitative research took place to assess the integrity of the intervention implementation. Analysis of the survey findings were ongoing at the time of production of this report. A full report can be made available; please contact Dr. Angela Obasi, MkV2 co-principle investigator:
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2. Makokha M, 2008. What MEMA kwa Vijana has to offer the education sector AIDS response in Tanzania: A comparative review. Research report from National Institute for Medical Research and the Liverpool School of Tropical Medicine. Research conducted by an independent consultant.
The review aimed to assess whether the package of MkV education materials adds value to the provision of sexual and reproductive health education in the new primary school syllabi. The review compared the package of MkV materials and the new primary school syllabi incorporating SRH topics, related teacher training modules and textbooks supporting the delivery of syllabi. Analysis was done looking at factors that might affect the uptake of MkV materials at the textual, technical and national level. The review suggests that MkV does add value to the new syllabi. From a technical point of view, MkV possesses a depth of experience crystallised in its robust, evidence-based range of knowledge products that along with the materials includes critical research findings. These are consistent with and complementary to the priorities articulated by the MOE in its strategic plan for HIV and AIDS (2003-2007). The review recommends opening up MkV to formal collaboration with entities within MOE, reviewing what aspects of the MkV package and experience are of most interest to different stakeholders, and to employing task-oriented working groups to adapt and integrate these into the MOE programme.
3. Medard L and Renju J, 2005. Process evaluation report: findings from the District Trainers and Supervisors (Health) MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
The evaluation aimed to discuss and document the district led MEMA kwa Vijana phase 2 (MkV2) teacher training from the perspective of the trainers themselves. Four focus group discussions (FGDs) with 18 district trainers and supervisors (DTS) took place to discuss their experiences of training 212 health workers from 92 health facilities (50% of all health facilities in the four districts); each DTS completed a timesheet detailing their actual time commitment to the programme. The DTS reported positive experiences within the programme, recognizing and appreciating the shift of the programme from NGO-led and research focused (during phase 1) to a district led programme (during phase 2). In the first year of implementation DTS reported to have spent an average of 2 hours/person preparing and approximately 130 hours training (average of 8 days/person). The DTS recognized the importance of proper planning and commended the support from the Region and AMREF. They reported to be motivated by programme outcomes on health workers, the relationship they had forged with AMREF and the financial incentive to conduct the training. The FGDs enabled the DTS to openly discuss the challenges and successes and to make various recommendations for the next year’s implementation.
4. Munishi G, 2007. Challenges and opportunities for MkV2 integration into the National level policy process, A National level policy study. MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine. Research conducted by Prof. G. Munishi from the University of Dar es Salaam, 2007.
The study aimed to examine the strategies required for MEMA kwa Vijana (MkV) to scale up its products. A well placed senior policy consultant conducted 20 key informant interviews in 10 ministerial sectors and organizations with special relevance to MkV and adolescent sexual and reproductive health (ASRH). Case studies from other projects and programmes that have been scaled up nation-wide were studied to identify appropriate and effective strategies and necessary conditions for scale up. The study suggests that whilst MkV’s focus at district level has yielded valuable information, it has limited contact with policy making institutions. Despite this, key Ministries still recognize the valuable operational and research work that MkV has done at district level. The study highlights the need for clearer communication between MkV teams and national ministries to ensure its activities are better known nationally in policy-making circles. The MkV research should be shared in order to contribute to improving planning and performance of ASRH interventions. The study concludes by stating seven clear recommendations (involving communication strategies with national level policy makers and partners) in order to increase the profile of the programmes work and findings.
5. Nyalali K and Renju J, 2005. Process evaluation report: findings from the District Trainers and Supervisors (Education) MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
The evaluation aimed to discuss and document the district led MEMA kwa Vijana (MkV) teacher training from the perspective of the trainers themselves. Four focus group discussions (FGDs) with 32 district trainers and supervisors (DTS) took place to discuss their experiences of training 511 teachers from 179 primary schools (25% of schools from the four districts); each DTS completed a timesheet detailing their actual time commitment to the programme. The DTS reported positive experiences within the programme, recognizing and appreciating the shift of the programme from NGO-led (during phase 1) to district led. In the first year of implementation DTS reported to have spent 89 hours preparing and approximately 450 hours training (average of 20 days/person). The DTS recognized the importance of proper planning and commended the support from the regional trainers and supervisors (RTS) and AMREF. Further they valued the role of the ward education coordinator (WEC) as supervisors and trainers in the programme. They reported to be motivated by programme outcomes on both the teachers and the pupils. The FGDs allowed the DTS to openly discuss the challenges and successes and to make various recommendations for the next year’s implementation.
6. Renju J, 2008a. Factors that facilitated or inhibited the scaling up of an innovative adolescent sexual and reproductive health school programme in rural Mwanza Region, Tanzania. MEMA kwa Vijana, Research report from National Institute for Medical Research and Liverpool School of Tropical Medicine.
The study aimed to assess the coverage and quality of the implementation of MEMA kwa Vijana phase 2 (MkV2) in the school; to document any effect the introduction of MkV2 has had on the experience of being a teacher and on teaching overall; to document any effect the introduction of MkV2 has had on the school as a whole and finally to examine the effect of environmental and social factors within the school on the quality and impact of the intervention. A total of 110 interviews, 42 group discussions, 16 school environment observations,11 MkV class sessions observations, observations of 1,111 pupils’ exercise books and assisted self-completed questionnaires with 96 pupils were conducted in 18 schools with respondents from within and outside of the school before and after the intervention. By training seven regional government officials, fifty one district officials and 103 Ward Education Coordinators the programme has reached 1,611 teachers and approximately 101,244 pupils as part of a phased 3.5 year scale up (2004-2008). The study has shown that ASRH programmes can be scaled up to reach large number of pupils through existing government systems. This paper presents various factors that facilitated and inhibited the implementation of the programme. Overall the study suggests that the programme was well accepted, appreciated and effective at improving teachers and pupils sexual and reproductive health knowledge, attitudes and self-efficacy.
7. Renju J, 2008b. The effect of scaling up an ASRH intervention on the coverage and quality of its implementation in health facilities, lessons from MEMA kwa Vijana (phase 2). MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
The study aimed to assess coverage and quality of the implementation of MEMA kwa Vijana phase 2 (MkV2) in the health facility; to document any effect that MkV2 has had on the Health Worker (HW) and on the provision of youth friendly services (YFS) as a whole and to identify and examine the effect of any environmental and social factors on the quality and impact of the intervention. Eighteen interviews and 3 group discussions were conducted with trained and non-trained HWs from 8 HUs. The study describes key findings concerning the differences in the training manuals used in 2005 and 2006/7 and the coverage and impact of the intervention on the health workers. Whilst it is clear that MkV training has had significant effects at different levels, this study corroborated other findings (report #8) by showing that despite improvements in HW knowledge and attitudes, there were many other contextual factors that affected the provision of YFS. Further HWs believed that young peoples’ inappropriate health seeking behaviour, a lack of knowledge and life skills, low demand for services and various underlying social norms that influence young people also prevented young people from benefiting from improved services.
8. Renju J, Andrew A and Medard L, 2008a. An assessment of a youth-friendly health service programme using a simulated patient study and health worker interviews. MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
This study was designed to provide a true insight into how young people are treated in rural health units (HUs) in the districts in which MEMA kwa Vijana (MkV) works and to inform the Council Health Management teams (CHMT) so as to ensure that their plans reflect the needs of the young people within their districts. A trained simulated patient (SP) visited 16 HUs with one of three scenarios (condom request, family planning advice and sexual transmitted infection concerns). Tape recorders and debriefs were used to capture each interaction that took place between SPs entering and leaving the HU. Interviews were conducted with 30 Health Workers (HWs) working in the same departments that the SPs visited. Overall the study showed that the MkV training increased HW’s knowledge, attitudes and perceived self-efficacy. However it also showed that this does not always culminate into overall changes in the youth friendliness of the services. The study highlights various key factors that could explain this disconnect, breaking the factors down into different levels: programmatic, structural and socio-economic. The findings were presented to the CHMT and a series of recommendations were drawn, the CHMT (facilitated by AMREF) then reviewed their Council Comprehensive Health Plan (CCHP).
9. Renju J & Nyalali K, 2008a; Scaling up ASRH education through widespread teacher training; training evaluation report, MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
The study aimed to evaluate and document the district led MEMA kwa Vijana (MkV) teacher training in order to identify key facilitating and inhibitory factors. The results are based on 58 person-days observations of 34% of training sessions, 40 District trainers and supervisors (DTS), 21 Ward Education coordinators (WECs), 465 teachers and meetings with five AMREF staff and three Regional Trainers and Supervisors (RTS). The observations highlighted many positive effects of the training cascade from region to classroom. AMREF and the RTS motivated and provided key technical assistance throughout the training. The DTS were able to implement the training to a consistent level; the study also suggested positive improvements over time in their confidence and ability. The WECs were capable, enthusiastic and in touch with the needs of the communities; however they still needed support in more technical areas. The involvement of other key district officials during the planning and local health workers during the training facilitated the implementation of the intervention. The findings were triangulated with other studies (report #1, #4, #6, #11, #12 & #15) to further investigate the various different factors that facilitated or challenged the scaling up of adolescent sexual and reproductive health education through existing government systems.
10. Renju J & Nyalali K, 2008b; Scaling up youth friendly health services through wide spread health worker training; training evaluation report. MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
The study aimed to evaluate and document the district led health worker training and to identify key facilitating and inhibitory factors for Ministry of Health and Social Welfare-led training. The results are drawn from 34 person-days observations, of 50% of training sessions, 100% of DTS (24), 46% of all trained health workers (197), five meetings with AMREF project officers, seven with AMREF technical assistants and three with regional trainers and supervisors (RTS). The observations highlighted many positive effects of the training cascade adopted in MEMA kwa Vijana phase 2 (MkV2). AMREF and the RTS motivated and provided key technical assistance throughout the training. The DTS were generally able to implement the training to a consistent level; the study also suggests positive improvements over time in their confidence and ability (both logistical and technical). The observations highlighted various other factors that challenged the implementation of the programme. The findings of this study were triangulated with other studies (report #3, #7, #8, #11, #12 & #15) in order to further investigate the various different factors that facilitated or challenged the scaling up of youth friendly health services through existing government systems.
11. Renju J, Andrew B and Medard L, 2008b. A study assessing the integration of an innovative adolescent sexual and reproductive health programme into existing local government structures. MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
The study aimed to assess the districts’ uptake of MEMA kwa Vijana (MkV) activities into their routine plans and budgets; this is a companion report to another MkV research report (report #12). The study is based on a model that details various stages of behaviour change as a progression towards realizing integration in partner districts. Seventeen in-depth interviews with district heads of selected departments (HoDs) and participatory workshops involving 52 MkV2 district implementers took place. According to the model all the districts have understood and accepted MkV2, however at the time of the study no district was really undertaking activities independently with all of them relying on the presence of the technical assistant and/or AMREF to different extents. Programmes of this nature need more time to work and from the onset should have a clear and progressive exit strategy to work towards. Further attention needs to be paid to the districts routine planning and budgeting cycles so as to ensure that activity plans and evidence are presented at times when decisions are being made. The study highlights important issues in building capacity within existing government systems in order to provide large scale ASRH services in rural communities in Africa.
12. Renju J and Liviga A, 2008. Supporting districts in scaling up an innovative sexual and reproductive health project. An assessment of the Technical Assistant Model adopted in MEMA kwa Vijana phase 2. MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
The study aimed to assess the districts’ uptake of MEMA kwa Vijana (MkV) activities into their routine plans and budgets; this is a companion report to another MkV research report (report #11). The study is based on a model that details various stages of behaviour change as a progression towards realizing integration in partner districts. Forty two in-depth interviews took place with regional, district, researchers and programme officials. This study has shown that the district based technical assistant has been instrumental in the acceptance, uptake and implementation of the MkV2 project activities. However, according to the model at the time of the study no district was really undertaking activities independently with all of them relying on the presence of the technical assistant and/or AMREF to different extents. The model is relatively novel in its approach for districts and for the NGO and various challenges were faced. The MkV2 experience has shown that in order to overcome such obstacles time, flexibility and forward planning are needed. Programmers and NGOs must be well informed of government policies and processes and the planning processes must take into account government timelines. The study highlights important issues in building capacity within existing government systems in order to provide large scale ASRH services in rural communities in Africa.
13. Renju J and Haule B, 2006. Review of the National Multisectoral Strategic framework in District supported to implement the MEMA kwa Vijana intervention. MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
The second phase of MEMA kwa Vijana (MkV2) was designed with an aim to strengthen and support the National Multisectoral Strategic Framework (NMSF) (2004-2007). This study aimed to collect information to assess the awareness, understanding, acceptance and implementation level of the NMSF at the district in order to inform the National NMSF review. A policy review was followed by 41 in-depth key informant interviews with regional and districts officials. The study highlighted various key findings into the operational implementation of such all encompassing strategies; lack of ownership or motivation to implement, lack of understanding of the term “multisectoral” and confusion over the roles of key implementers. However, the study concluded that the strategy had been very useful in terms of guiding the multisectoral AIDS responses across different sectors. The researchers noted positive changes over time in people’s understanding and acceptance of the strategy. However it recommended that future policies/strategies should ensure more community involvement in the formulation/review to ensure more commitment, involvement and ownership. On a macro level, this review provides a useful insight into how new national strategies should be introduced to the implementers and what support mechanisms need to be in place to enable implementation to take place as planned.
14. Renju J, 2007. Process evaluation report of a national meeting that took place as part of the MEMA kwa Vijana programme. MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
Ensuring translation of research findings into policy and practice was an important goal of MkV2. This study took place in order to identify factors that facilitated or inhibited engagement of national level policy makers in an AMREF led national workshop focusing on adolescent sexual and reproductive health (ASRH). The study adopted a variety of methods: documentation of the preparations; meeting observations; informal interviews outside sessions and a post-workshop evaluation form. The study highlighted various factors that facilitated the engagement of national level policy makers: previous interaction with the project or project implementers; contact from senior level AMREF officials; a high-level Guest of Honour; requesting participants’ views in advance and throughout workshop; cost sharing; convenient timing; potential participants identified point persons and personal correspondence. The study also highlights other key factors that appeared to inhibit or reduce the engagement of key persons. Overall the workshop increased the profile of ASRH and the evidence and experiences of MkV with key stakeholders. The involvement of key policy makers and influencers is a fluid activity that must be continuous throughout all stages of programme implementation.
15. Renju J, Nyalali K and Medard L, 2006; A baseline report assessing the youth friendliness of rural health facilities and ASRH understanding and acceptance in rural primary schools. MEMA kwa Vijana, Research report from National Institute for Medical research and Liverpool School of Tropical Medicine.
The study aimed to capture the physical and social environment of the schools and health facilities prior to receiving the second phase of the MEMA kwa Vijana intervention (MkV2). Twenty focus group discussions with primary school teachers (164) and 70 interviews with school leadership and health facility personnel were conducted. The study found that only 34% of teachers were female; 87% of teachers had completed secondary education; 46% of teachers reported having had some training in HIV-related issues and 60% said they had taught pupils about it. Most of the study schools had insufficient teachers (72%); learning materials (83%); and toilets (72%) to meet national targets and teachers reported that many of their pupils had started having sex in standard five to seven. The respondents perceived that a lack of education within rural communities impairs their ability to recognize the importance of attending school. Forty five percent of health workers (HWs) had completed secondary level education; 60% of HWs reported to have received some training in HIV-related issues, but only 5% in youth friendly services (YFS). This large baseline study provided important information that was used to inform the programme, future research and the development of a community intervention. A large follow up study took place in these same schools and health facilities (report #6 and #7).