Science and Success in Developing Countries: Holistic Programs That Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections

Full Study Report [HTML] [PDF]
Executive Summary [HTML] [PDF]

Program Components

• Comprehensive sexual health program, including messages to encourage 1) delay in the initiation of sex and 2) reductions in sexual risk-taking behaviors among sexually experienced youth
• Youth-developed and youth-targeted campaign messages disseminated at live events, on radio talk shows, in brochures, and by peer educators
• Peer education
• Horizon Jeunes youth clubs
• Distribution of information, education, and communication (IEC) products, such as brochures
• Youth-targeted distribution of condoms and oral contraceptives
• Training of health care providers in making services youth-friendly
• Involvement of parents and community leaders, including local health and education officials
• Integration within a nationwide social marketing program
• Mass media advertising

For Use With

• Urban youth
• Male and female youth, ages 12 to 22
• In- and out-of-school youth

Evaluation Methodology

• Quasi-experimental evaluation design, using baseline and post-intervention surveys at least 14 months apart in two small cities in Cameroon: Edéa, the intervention site, and Bafia, the comparison site
• Baseline survey among randomly selected youth ages 12 to 22 in each city (n=1,606; n=805 in Edéa; n=801 in Bafia); follow-up survey among randomly selected youth ages 12 to 22 in each city (n=1,633; n=811 in Edéa; n=822 in Bafia)
• Sales data and data on health center visits for family planning

Evaluation Findings

• Delayed initiation of sexual intercourse
• Increased abstinence among sexually experienced youth
• Reduced number of sexual partners—males
• Increased use of contraception—males
• Increased use of condoms—females

Program Description

Horizon Jeunes is an adolescent reproductive health program implemented within and integrated into a larger, nationwide, social marketing program. Horizon Jeunes is based on the revised health belief model and aims to increase adolescents' awareness and use of preventive behaviors and sexual health products and services. In particular, the intervention encourages adolescents to delay the initiation of sex and to use condoms to prevent HIV and STIs when they do choose to initiate sex. It also encourages sexually active youth to use modern contraceptive methods and to abstain in order to prevent unintended pregnancy.[9,10]

The program includes peer educators, trained in the techniques of social marketing and of interpersonal communication to promote behavior change. Peer educators also function as mobile distributors of the Prudence Plus condoms promoted in the nationwide social marketing campaign. Pharmacies sell Novelle oral contraceptives, also promoted in the nationwide social marketing campaign. The project educates youth about the availability of the condoms and oral contraceptives and works to increase providers' willingness to serve unmarried young women. Peer educators lead in the creation of school-based youth clubs that distribute project materials to club members. Radio spots advertise events organized by Horizon Jeunes and also carry informative commercials with sexual health information for youth. Talk shows address sexual health topics of interest to youth, including HIV and AIDS, other STIs, unwanted pregnancy, abstinence, fidelity, condom use, and parent-child communication about sexuality. Finally, promotional events—such as condom demonstrations at night clubs, presentations at local soccer games, and theatrical sketches on reproductive health—provide ongoing reinforcement of messages promoting safer sexual behaviors among youth. Other components of the program target parents, teachers, and community leaders and include meetings between adults, peer educators, and youth.[9,10]

Evaluation Methodology

The project was evaluated using a quasi-experimental research design. Data were collected at baseline and post-intervention in two cities: Edéa, the intervention site, and Bafia, the comparison site. Edéa is a cosmopolitan city of about 86,000 people, located about 40 miles from Douala and on the main road to Yaoundé. Bafia is a city of about 73,000 people, about 80 miles north of Yaoundé and sufficiently far from the intervention site to prevent spillover of the intervention. Bafia is situated on another main road, between Yaoundé and Bafoussam. Both Edéa and Bafia have populations of mixed ethnicity: Bakoko and Bassa in Edéa, and Bafia and Yambassa in Bafia; these indigenous groups do not dominate in either town. In both sites, the population is fairly evenly divided between Muslims, Christians, and animists. Both have government-run hospitals, clinics, and family planning and AIDS service centers. At the same time, Edéa is a cosmopolitan city with an industrial center that attracts substantial numbers of immigrants; Bafia is an agricultural town with no industry and little immigration. Because of this, evaluation controlled for differences in characteristics between the samples.[9,10]

Researchers obtained baseline data during July and August 1996 and follow-up data in October and November 1997, using the same technique to randomly identify survey participants. Using multistage sampling, 30 clusters of households were drawn in each site, with individual households randomly selected in each cluster. Within each household, researchers randomly chose one individual age 12 to 22, using the last birthday technique. During home visits, researchers obtained informed consent from both the head of household and the prospective respondent and conducted the interview. At baseline, 1,606 youth were surveyed (n=805 in the intervention site; n=801 in the comparison site); at follow-up, 1,633 youth were surveyed (n=811 in the intervention site; n=822 in the comparison site). Total refusal rate was approximately eight percent. Samples obtained at baseline and follow-up were independent of one another, and the evaluation examined aggregate changes in behaviors by comparing all respondents living in the intervention site (regardless of exposure to the program) with all respondents living in the comparison site.[9,10]

Researchers observed significant group differences on all demographic variables. For example at follow-up, the males in the comparison city were about one year younger than comparison city males at baseline (16.5 versus 17.9 years at baseline). At followup, a larger proportion of females in the comparison city were married or cohabiting than were females in the intervention city at followup or in either city at baseline. Youth in the comparison city, at baseline and follow-up, were significantly more Muslim and less Christian than those in the intervention city at either time, and respondents in the comparison city were also less likely to attend school. Finally, males at baseline were more likely to report being divorced or widowed than males at follow-up. Thus, analysis controlled for differences in age, religion, marital status, education, type of school, employment status, parity, and fertility intentions.[9,10]

Outcomes

• Knowledge—
  • The intervention had a significant effect on knowledge of condoms for birth control among both male and female youth. The proportion of male youth in the intervention community who knew of the benefits of condoms for birth control increased from 65 to 71 percent between baseline and follow-up, while the proportion declined from 55 to 42 percent among males in the comparison town. Among intervention site females, the proportion knowing about condoms for birth control rose from 39 to 74 percent, versus a slight increase from 36 to 44 percent among females in the comparison town.[10]
  • The intervention also significantly increased male and female youth's knowledge of oral contraceptives—from 13 to 39 percent of intervention city males, versus a change from nine to 11 percent of comparison city males; and from 23 to 60 percent of intervention city females, versus a change from 14 to 25 percent of comparison city females.[10]
  • The intervention significantly increased male youth's knowledge of the intrauterine device (IUD) and injectable contraception (rising from four to 27 percent) versus little change among males in the comparison community (from three to eight percent).[10]
• Attitudes—
  • The proportion of male respondents who considered themselves at risk for STIs or HIV/AIDS increased significantly in both intervention and comparison sites between 1996 and 1997, and increased significantly more among males in the intervention site (13 to 50 percent versus 18 to 26 percent among comparison site males).[10]
  • The intervention significantly increased females' awareness of their own responsibility to use protection during sex; the proportion of intervention city females who saw themselves as responsible for protection rose from 74 percent at baseline to 84 percent at follow-up, versus a slight decline from 76 to 74 percent among comparison site females.[10]
• Behaviors—
• Delayed initiation of sexual intercourse—Among male youth in the intervention site, the proportion of respondents who initiated sexual intercourse prior to age 15 decreased significantly (down from 29 percent in 1996 to 19 percent in 1997); little change occurred among males in the comparison site (25 to 22 percent). There was also a significant decline (from 10 to four percent) in the proportion of intervention site females who initiated sex prior to age 15 while proportions rose from eight to 13 percent among comparison site females.[10]
• Increased abstinence for pregnancy prevention among sexually experienced youth—The intervention resulted in a statistically significant positive change in the use of abstinence for pregnancy prevention among young women (odds ratio [OR]=2.40) and among young men, (OR=3.10) in the intervention city.[9]
• Reduced number of sex partners—The intervention resulted in a statistically significant reduction in the proportion of young men in the intervention site reporting two or more sexual partners in the past month (down from 30 to 15 percent; OR=0.36) while the proportion of males in the comparison site reporting two or more partners in the past month rose from 29 to 35 percent.[9,10]
• Increased use of contraception—The intervention resulted in a statistically significant increase in the proportion of young men in the intervention city who reported using modern methods of contraception to prevent pregnancy (OR=11.05). Among males, the proportion reporting use of the IUD or injectable contraceptives increased significantly more rapidly in the intervention site (from three to 28 percent) than in the comparison site (from three to five percent).[9,10]
• Increased use of condoms—The intervention resulted in a significant positive change in young women's ever use of condoms, rising from 58 to 76 percent (OR=2.27) between 1996 and 1997 and of their using condoms to prevent pregnancy (rising from 21 to 52 percent between 1996 and 1997; OR=3.82). Among females in the comparison site, ever use dropped slightly (from 53 to 50 percent) and use for family planning rose far less (from 19 to 33 percent) than among females in the intervention site.[9,10]

For More Information, Contact

• Population Services International, 1120 19th Street NW, Suite 600, Washington, DC 20036; e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it