Where to for Sexual Health Education for Adolescents in Sub-Saharan Africa?

Abstract

Sub-Saharan Africa remains the global hub of the HIV epidemic. Seventy percent of new HIV infections occur in the region. And because the sexually transmitted epidemic starts among women and men in their teenage years [1], promoting the sexual health of adolescents is a substantial health priority. In light of this, the findings of the MEMA kwa Vijana trial in Tanzania [2] and the long-term follow up of participants in its school-based intervention, published this week in PLoS Medicine [3], are very disappointing. The key questions we have to ask now are: In light of current knowledge about behaviour change, are these findings surprising? And, what are the implications for the next generation of sexual health interventions? In the 15 years since the process of developing the MEMA kwa Vijana intervention began, understanding of adolescent behaviour change has deepened (not least from this study) to the point where it seems less than surprising that this intervention was unsuccessful. At the time of its design, a major concern was that good behaviour change intentions would be undermined by poor services from clinics and untreated sexually transmitted infections. However, it now seems that the biggest threat to such interventions comes from the context of delivery in the school environment and the constraints thus entailed. Social science research from the MEMA kwa Vijana team now indicates that the school-based intervention was being implemented in a context of massive gender and status power differentials between teachers and learners, which provided the opportunity for rape, harassment, economic exploitation, and beating of learners, thus severely undermining positive messages from the programme [4]. Broader community engagement with the programme was very limited and, because it was delivered in schools, it had to be tailored to the constraints of the classroom. As a result, the curriculum was delivered in 12 lessons per year of 40 minutes each, for a maximum of 3 years [3]. In practice, for many this was probably much less than 8 hours of intervention, and was at most 24 hours for the two-thirds of learners who attended all lessons over all 3 years [3]. This intervention was thus low intensity, particularly if compared, for example, to the 50 hours of an intervention like Stepping Stones (the author adapted Stepping Stones for South Africa) [5] or the 5-day Men As Partners program [6]. Furthermore, the Department of Education in Tanzania prohibited condom promotion and demonstrations in school and demanded a focus on abstinence, a strategy that has been shown to be ineffective [7]. Teachers had only short training in delivering the intervention, and since they were unfamiliar with participatory methods, it was very substantially didactic [8]. There were also some notable omissions in the curriculum. It lacked a focus on skills building, particularly communication skills, which are recognised now as essential for good practice [8],[9]. It was also notably limited in addressing gender relations and identities.