Adolescents in Tanzania are at risk of contracting HIV and other sexually-transmitted infections. But large-scale adolescent sexual and reproductive health (ASRH) programmes are uncommon in sub-Saharan Africa. Schools provide an opportunity to reach large numbers of young people at relatively low cost. But how effective are school-based programmes?

Dealing with private and sensitive topics, ASRH programmes are easily weakened by poor teacher training, lack of awareness of the programmes’ importance and limited time for delivery. Research looks at supporting factors and barriers for ASRH in rural primary schools in Mwanza Region, Tanzania, through three years of participant observation in nine villages. It reveals great challenges to ASRH programmes, such as:

• low school enrolment, inconsistent attendance and high drop-out rates
• severe resource constraints
• problematic teacher to pupil relationships, including authoritarian teaching methods and corporal punishment
• practices, such as mandatory pregnancy examinations, which lead to pupils’ secrecy about sexual activity
• sexual abuse of schoolgirls by teachers
• tensions between teachers and villagers
• low teacher wages leading to pupil exploitation or demanding of bribes.

A related study evaluated an ASRH intervention, MEMA kwa Vijana (MkV), comparing 62 primary schools in ten intervention communities with 63 schools in ten control communities where the ASRH intervention was not taking place. The trial involved 9,645 primary school children aged at least 14 years at the start. It included a teacher-led, peer-assisted course, training of youth-friendly health workers and youth condom promotion and distribution.

In the MkV trial’s final survey, higher percentages of participants in intervention communities reported better attitudes and behaviours than control groups, but there was no consistent biological impact . Were these outcomes due to poor implementation, limitations of the programme or external factors? Participant observation researchers found that high quality teacher and community peer educator training courses were run across all districts, and that programme implementation, completeness of delivery and participant engagement and satisfaction were also good.

The programme was strong in addressing some key issues, but more limited in addressing others. For example, programme participants had far better ASRH knowledge than students in comparison schools. However, the programme only seemed to marginally affect some widespread and problematic attitudes and practices in youth sexual relationships, such as negative perceptions of condoms, the exchange of sex for money, and having secretive, concurrent relationships. Programme success was further blocked by the other contextual factors identified above.

These findings suggest that, despite great resource limitations, it is feasible to implement ASRH interventions through existing government structures when they are incorporated into the school curriculum. But sexual behaviour change can be an unwelcome, complex and long-term process, requiring great self-motivation and social reinforcement. Together, these studies suggest that school-based ASRH programmes must be adapted to the realities of the local setting by:

• simplification of the subject matter
• intensive focus on problematic practices in youth sexual relationships
• training on active teaching methods
• improvement of teacher to pupil and teacher to community relationships
• close supervision and appropriate responses to abuse or exploitation.

Source(s):
‘Are Schools a Good Setting for Adolescent Sexual Health Promotion in Rural Africa? A Qualitative Assessment from Tanzania’, Health Education Research, by M. Plummer, D.Wight, A. I. N. Obasi, J. Wamoyi, G. Mshana, J. Todd, B. C. Mazige, M. Makokha, R. J. Hayes and D. A. Ross, forthcoming 2007
‘A Process Evaluation of a School-Based Adolescent Sexual Health Intervention in Rural Tanzania: the MEMA Kwa Vijana Programme’, Health Education Research, by M. Plummer, D.Wight, A. I. N. Obasi, J. Wamoyi, G. Mshana, J. Todd, B. C. Mazige, M. Makokha, R. J. Hayes and D. A. Ross, forthcoming 2007

Funded by: UK Medical Research Council. British Academy, European Commission, Development Cooperation Ireland, UNAIDS, UK Department for International Development (DFID)

id21 Research Highlight: 2 March 2007

Further Information:
Mary Plummer
Department of Epidemiology and Population Health
London School of Hygiene and Tropical Medicine
London
WC1E 7HT
UK

Contact the contributor: mary.plummer@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

National Institute for Medical Research, Tanzania

Medical Research Council, UK

Other related links:
African Medical and Research Foundation Tanzania

Educating girls as a ‘social vaccine’ against HIV

'Growing threat: HIV and adolescents in Ethiopia'

'Barriers to adolescent contraceptive use in South Africa'

'Talking freely about sexuality in Zambia'