Abstract
BackgroundFew of the many behavioral sexual health interventions in Africa have been rigorously evaluated. Where biological outcomes have been measured, improvements have rarely been found. One of the most rigorous trials was of the multi-component MEMA kwa Vijana adolescent sexual health programme, which showed improvements in knowledge and reported attitudes and behaviour, but none in biological outcomes. This paper attempts to explain these outcomes by reviewing the process evaluation findings, particularly in terms of contextual factors.MethodsA large-scale, primarily qualitative process evaluation based mainly on participant observation identified the principal contextual barriers and facilitators of behavioural change.ResultsThe contextual barriers involved four interrelated socio-structural factors: culture (i.e. shared practices and systems of belief), economic circumstances, social status, and gender. At an individual level they appeared to operate through the constructs of the theories underlying MEMA kwa Vijana - Social Cognitive Theory and the Theory of Reasoned Action – but the intervention was unable to substantially modify these individual-level constructs, apart from knowledge.ConclusionThe process evaluation suggests that one important reason for this failure is that the intervention did not operate sufficiently at a structural level, particularly in regard to culture. Recently most structural interventions have focused on gender or/and economics. Complementing these with a cultural approach could address the belief systems that justify and perpetuate gender and economic inequalities, as well as other barriers to behaviour change.
Highlights
Few of the many behavioral sexual health interventions in Africa have been rigorously evaluated
Anti-retroviral treatment has dramatically improved and extended lives, unpredictable funding, weak health systems, and problems with side effects, adherence, and resistance mean that prevention remains crucial [2,3], as it is does with respect to other sexually transmitted infections (STIs) and unwanted pregnancies (e.g. [4,5])
Since the identification of HIV/AIDS, a vast number of programmes have been implemented in sub-Saharan Africa to reduce sexual risk behaviours
Summary
Few of the many behavioral sexual health interventions in Africa have been rigorously evaluated. One of the most rigorous trials was of the multi-component MEMA kwa Vijana adolescent sexual health programme, which showed improvements in knowledge and reported attitudes and behaviour, but none in biological outcomes. In recent years seven trials of behavioural sexual health programmes have used HIV as an outcome [6]. They all show that, despite improvements in knowledge and sometimes attitudes and reported behaviour, there were no improvements in biological outcomes, with one exception where herpes simplex virus 2, but not HIV, was lower in the intervention group [7]
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