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 program, including information about abstinence and condoms, to promote STI prevention and treatment among sexually experienced youth
• Youth-led reproductive health clubs distributing IEC materials and sponsoring debates, dramas, essay contests, symposia, and films related to STI prevention and treatment
• STI health awareness campaigns, mounted by each school's reproductive health club
• Peer educators providing education about methods of preventing STIs, including abstinence and condoms
• Health professionals providing information on STI prevention and treatment
• Training of peer educators
• Training of selected medical care professionals, pharmacists, and dealers in patent medicines, in STI treatment and referral for treatment, condom provision, and partner tracing and treatment
• Referral of youth for STI testing and treatment

For Use With

• Students in senior high classes 4 and 5, ages 14 through 18
• Urban youth
• Sexually experienced youth

Evaluation Methodology

• Quasi-experimental evaluation, using a randomized, controlled design with eight secondary schools in Benin City, Edo State, Nigeria (four intervention schools in the western part of the city, four control schools in the eastern part of the city) and four control secondary schools in the nearby town of Ekpoma
• Baseline survey in September 1997 among 1,896 randomly selected students in senior classes four and five in the intervention and comparison schools; follow-up survey in July 1998 among 1,885 randomly selected students in senior classes four and five in the intervention and comparison schools

Evaluation Findings

• Reduced incidence of STIs
• Increased use of condoms
• Increased partner notification of exposure to STIs—among females
• Increased use of private physicians for STI treatment

Program Description

This STI counseling and treatment program has three components that are together designed to 1) decrease adolescents' use of 'informal' sector providers who lack training in STI treatment and 2) increase students' use of trained doctors in private practice. The first component consists of school-based reproductive health clubs where adolescents can discuss reproductive health matters. The clubs offer health awareness campaigns at which health care professionals provide students with information on STI prevention and treatment. Other activities of the reproductive health clubs include distributing educational materials on STIs, organizing debates and symposia, sponsoring dramas and essay contests, and showing films on STI prevention and treatment.[11]

The second component is peer education. Members of the reproductive health clubs are chosen by their peers to be trained as peer educators. Training lasts four weeks and covers aspects of STI prevention and treatment, symptom recognition, the benefits of early treatment, the need for professional treatment, sources of professional treatment, prevention methods, the importance of partner notification, and the need to abstain from sex during treatment for STIs. Trained peer educators provide counseling to other students, either one-on-one or in groups at breaks and after school, distribute educational materials on STIs, and refer youth with symptoms of STIs to trained health care providers.[11]

The third component of the intervention consists of training for providers of formal and informal health care. Medical care practitioners, patent medicine dealers, and pharmacists (whom adolescents identify as sources of care) are trained in the diagnosis and treatment of STIs, based on the World Health Organization (WHO) syndrome management system. This system stresses condom use and partner notification and provides different protocols of care for different groups of health care providers. Pharmacists and patent medicine dealers receive training to encourage the use of condoms and to refer adolescents to trained private practitioners. Medical doctors, by contrast, receive training in standard WHO protocols for treatment of STIs in adolescents and to refer difficult cases to hospitals.*[11]

Evaluation Methodology

Preliminary studies indicated that Nigerian adolescents were often reluctant to seek medical treatment for STI symptoms and, when seeking treatment, often sought assistance from informal sector providers (patent medicine practitioners, traditional healers, pharmacists, and laboratory technicians). Assessment also showed that neither these nor medically trained health care professionals used standard protocols for diagnosing and treating STIs in adolescents. To that end, the Women's Health and Action Research Centre designed this program to increase youth's knowledge of STI symptoms, use of condoms, treatment-seeking behavior, and notification of partners regarding STI infection. The intervention also aimed to decrease the proportion of youth who experienced symptoms of STI and to decrease adolescents' use of informal and untrained providers.[11]

The study used a randomized, controlled design with randomly selected students from three study sites: one intervention and two comparison sites. Four secondary schools in Benin City were randomly chosen to participate as intervention sites, and four as comparison sites. The four intervention schools and the trained health care providers (formal and informal) were all located in the western part of Benin City. The comparison schools were in the eastern part of Benin City. Since it was impossible to restrict the influence of this community-based intervention to the specific, chosen intervention schools, researchers selected four secondary schools in nearby Ekpoma (a city demographically different from Benin City) as additional comparisons.[11]

Intervention and comparison schools included junior students (in classes one through three) and senior students (in classes four through six), ranging in age from 14 to 20. In order to assure that students would still be in school a year later at follow-up, the intervention focused on senior students in classes four and five and not on students in senior class six (who would have graduated). At the outset, all individual students gave informed consent to participate and all randomly selected students agreed to complete the pre-intervention and post-intervention survey questionnaires. At each selected intervention and comparison school, senior classes four and five comprised about 320 students; approximately 160 students were randomly chosen to participate in the pre- and post-intervention surveys. The same classes that took the pretest also took the follow-up, although individuals in the classes were re-sampled using random selection. Changes from pretest to follow-up were assessed at the school level.[11]

In total, 1,896 and 1,885 youth participated in the baseline and follow-up surveys, respectively. To ensure students' confidentiality, the questionnaires were self-completed and without any individual identifier. Surveyed youth were equally divided among the three study sites (youth in intervention schools n=643; youth in Benin comparison schools n=649; youth in Ekpoma comparison schools n=604). At baseline, significant demographic differences existed between the youth from Ekpoma (comparison) and youth from the two Benin groups of schools. Students in the two Benin City groups of schools (intervention and comparison) were demographically similar. Specifically, surveyed Ekpoma students were slightly more female and older by a mean of one year, compared to students from the two Benin City groups of schools. The predominant religious affiliation in Benin City was Pentecostal Church, compared to the Catholic Church in Ekpoma. In Benin City, Bini, Ishan, and Ibo were the predominant ethnic groups, compared to Ishan in Ekpoma. Surveyed students from Ekpoma came from families with a lower socioeconomic status (SES) than students from either group of Benin City schools (indicated by fewer household possessions and less paternal education).[11]

At baseline, significantly fewer students from the intervention schools and the Benin City comparison schools reported previous sexual intercourse, versus students from Ekpoma comparison schools (38, 34, and 53 percent, respectively). At baseline, proportions of sexually experienced students who reported never using a condom were similar (89, 89, and 85 percent, respectively). The proportions of sexually experienced students who reported having at least one STI symptom in the previous six months were significantly lower in the intervention schools and the Benin City comparison schools than in Ekpoma comparison schools (33, 31 and 42 percent, respectively). Finally, the proportions of students who reported using private doctors for STI symptoms, though more similar, were also lower in the intervention and the Benin City comparison schools than in Ekpoma: 18, 19, and 24 percent, respectively, visited a private doctor. On the other hand, the students from the two Benin City groups of schools were substantially more likely to report visiting a hospital or clinic than were youth in the Ekpoma comparison schools: 26, 22, and six percent, respectively.10 As a result, multivariate analysis controlled for age, gender, religion, ethnicity, SES, living situation, and prior sexual experience.[11]

Outcomes

• Knowledge—
  • At posttest, students from the intervention schools were significantly more likely than students in comparison schools in either city to be able to name up to six STIs. The mean number of STIs that youth could name increased by 0.47 among youth from the intervention schools and by 0.01 and by -0.16 among youth in the Benin and Ekpoma comparison schools, respectively. The effect was statistically significant for both males and females but was especially strong among female students in the intervention schools.[11]
• Behaviors—
• Increased use of condoms—From pre- to post-intervention, condom use among sexually experienced males and females increased significantly in the intervention schools (from 31 to 41 percent among males; from 30 to 37 percent among females). Among students in the combined comparison schools, reported condom use increased significantly among males (29 to 36 percent), but decreased among females (30 to 28 percent). As a result, the intervention showed a significant relative increase in condom use among youth in the intervention schools relative to the students in the two comparison groups of schools (OR=1.41). This statistically significant effect was due to the reported increase among female students (OR=1.80), rather than among male students (OR=1.13) in the intervention schools.[11]
• Increased partner notification of exposure to STI—Among females in the intervention schools, those who notified their partners that they had an STI increased significantly from five percent at pretest to 18 percent at follow-up. There was a small, but insignificant, increase in the percentage of males in the intervention schools who notified their partners that they had an STI (nine to 10 percent). The impact of the intervention was significant versus students at both comparison groups of schools among females (OR=7.1), but not among males (OR=1.3).[11]
• Increased use of private physicians for STI treatment—Among students in the intervention schools, the proportion of youth who went to private physicians for treatment for STI symptoms in the previous six months increased from 18 percent at pretest to 41 percent at follow-up (OR=3.24). A smaller, but still significant increase occurred in the proportion of students in the Benin comparison schools who sought treatment for STI symptoms from private physicians (19.0 to 29.1 percent; OR=1.75) while there was no significant change in Ekpoma (24 to 30 percent). The impact of the intervention was significant, relative to students in both the Benin and the Ekpoma comparison groups of schools (OR=1.85 and 2.31, respectively). At the same time, the decline in the proportion of students at intervention schools who sought STI treatment from pharmacists and patent medicine dealers was statistically significant (from 15 to four percent; OR=2.26), relative to students from both comparison groups of schools (OR=0.44).[11]
• Long-term impact—
• Reduced incidence of STIs**—The intervention resulted in a statistically significant reduction in STI symptoms among students in the intervention schools, relative to students at both the Benin City and Ekpoma comparison schools (OR=0.63 and 0.69, respectively) as well as to students at both groups of schools, combined (OR=0.68). Among students at intervention schools at posttest, 22 percent reported STI symptoms in the past six months, compared to 33 percent at pretest. In both comparison groups of schools, students also reported a decrease in STI symptoms (31 to 29 percent in Benin City comparison schools; 42 to 35 percent in Ekpoma). The effect of the intervention appeared stronger in males (OR=0.58) than in females (OR=0.70), when the intervention schools were compared to all comparison schools.[11]

For More Information, Contact

• Women's Health and Action Research Centre, 4 Alofoje Street, Off Uwasota Street, Box 10231, Benin City, Edo State, Nigeria; e-mail This e-mail address is being protected from spambots. You need JavaScript enabled to view it

* Prior to the launch of this school-based intervention, students identified 40 private practitioners, 36 pharmacists, and 50 patent medicine dealers as individuals to whom they went for STI treatment. Invited to participate in training to improve their services, 28 private practitioners, 29 pharmacists, and 45 patent medicine dealers received the training.[11]

** The program measured a reduction in STI symptoms. Advocates for Youth used this as a proxy for sexually transmitted infections, in keeping with the syndrome management system of the World Health Organization.