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 education and HIV/STI prevention curriculum, designed to encourage 1) delayed initiation of sex and 2) reductions in sexual risk-taking among sexually experienced youth
• Six sessions, one per week, each lasting two to six hours, conducted over six consecutive weeks
• Experiential activities, including role-plays, debates, songs, and story-telling along with lectures and videos
• Demonstration on the proper use of condoms
• Referral of students for reproductive and sexual health care

For Use With

• Urban youth, ages 13 through 20
• High school youth
• Youth living in poverty

Evaluation Methodology

• Quasi-experimental evaluation using randomized, control design in four urban high schools in an older, poorer, local government area (LGA) of Ibadan, Lagos State, Nigeria
• Random selection of 20 to 25 students from two arms each of senior classes 1, 2, and 3 in each of the four schools
• Baseline and follow-up surveys in January and February 1996 and at six months post-intervention in August 1996
• Baseline survey among 450 randomly selected students from senior classes 1, 2, and 3 in intervention and comparison schools; follow-up survey among 433 students who completed the baseline survey

Evaluation Findings

• Delayed initiation of sexual intercourse
• Reduced number of sex partners
• Increased use of condoms

Program Description

The program is specifically designed to address HIV/STI related knowledge, attitudes, and behaviors among high school youth in urban Nigeria. Based on behavior change theory, the program attempts to change behaviors within the community by helping members to understand that a problem (HIV and AIDS) exists. Through education, the program works to address youth's lack of knowledge, improve sexual health attitudes, and reduce sexual risk-taking behaviors. The comprehensive health education program, developed in conjunction with health education experts from the Department of Preventive & Social Medicine at the University of Ibadan, includes six HIV education sessions, implemented in classrooms by a physician and two experienced teachers. Sessions, each lasting two to six hours, occur once each week during six consecutive weeks.[15]

The program uses experiential activities, including role-plays, stories, songs, debates, and essays, as well as films and more traditional lectures. The program also includes a demonstration on the proper use of condoms. To address the differing needs of students, each class level (1, 2, or 3) receives the program separately. During and after the program's end, the reproductive health educators continue making themselves available to refer requesting students and/or teachers—in a sympathetic and nonjudgmental manner—to appropriate clinical care services.[15]

Evaluation Methodology

High school students in the southeast local government area (LGA) of Ibadan were surveyed on their attitudes, knowledge, and behaviors related to HIV and AIDS and other sexually transmitted infections (STIs). Results indicated that most students (83 percent) knew about the sexual transmission of HIV, but few knew about other transmission routes. Knowledge was higher among older than younger youth. Twenty percent felt that HIV and AIDS was not a medical problem in Nigeria, and 83 percent said they would dislike being around anyone with HIV or AIDS. At the same time, average age for first sex was 15.8 for males and 16.3 for females; 35 percent of surveyed students had ever sex; and 27 percent had sex in the month preceding the survey. Of the sexually experienced students, 68 percent of males and 32 percent of females reported having had multiple sexual partners (mean number=1.76). Among youth who reported sex in the previous month, only 20 percent reported consistent use of condoms. These findings informed the development of a school-based health education curriculum designed to positively affect students' HIV/STI knowledge, attitudes, and behaviors. At the same time, findings constituted the baseline survey for the intervention that followed.[15]

Eleven mixed-sex public schools in the target LGA were divided into two groups, based on geographic location. Two adjacent schools in one group were chosen as the intervention schools; two comparison schools were randomly chosen from the other group. From senior high classes 1, 2, and 3 in each school, two arms (each consisting of 20 to 25 students) were randomly chosen to participate in the study of the intervention's effectiveness. All students in the selected arms participated in the study.[15]

The baseline questionnaire was administered in Yoruba, the native language of the target youth (total n=450; n=233 students in intervention schools; n=217 students in comparison schools). Evaluation was carried out six months after the intervention, using an adjusted version of the pretest (n=433; n=223 intervention youth; n=210 comparison youth; 17 students were lost to follow-up). At baseline, the intervention and comparison groups were matched, with no statistical differences in their mean age, gender, class, religion, or parental background. For example, mean age of the intervention students was 17.6 years and of the comparison students, 17.8 years. Females constituted 53 percent of the intervention students and 57 percent of the comparisons. Ninety-eight and 99.5 percent, respectively, were Yoruba; 55 and 51 percent, respectively, were Muslim. Thirty-three percent of the intervention students had mothers with no education versus 30 percent of comparison students. There were no significant differences between intervention and comparison students in terms of HIV knowledge and awareness at baseline. Also at baseline, no statistically significant differences existed in the proportion of students who were sexually active: 33 and 39 percent of intervention and comparison youth, respectively, had ever had sexual intercourse. Similarly, among sexually experienced youth the mean age at first sex was 16.2 and 15.9 years, respectively, among intervention and comparison youth, while 53 and 43 percent, respectively, reported use of a condom at most recent sexual intercourse, and 12 and 11 percent, respectively, reported consistent use of condoms. Finally, four percent and two percent, respectively, reported a past medical history of STI.[15]

Outcomes

• Knowledge—
  • At six months post-intervention, knowledge about methods of transmission of HIV as well as knowledge of prevention methods had increased significantly more among intervention than comparison students. For example, 95 percent of intervention youth knew that HIV could be transmitted from a pregnant woman to her unborn child, versus 43 percent of comparison youth. Ninety-two percent of intervention youth knew that an HIV-infected person could look completely healthy, versus 41 percent of comparison youth. Ninety-six percent of intervention youth knew that using condoms decreases the risk of HIV transmission, versus 63 percent of comparison youth.[15]
• Attitudes—
• Awareness of HIV and AIDS and attitudes towards those living with HIV or AIDS were significantly improved among intervention youth, versus comparison youth at six months post-intervention. For example, 93 percent of intervention youth felt that HIV was a problem in Nigeria, versus 57 percent of comparison youth. Among intervention youth, 79 percent felt they could touch and care for someone living with AIDS, versus 14 percent of comparison youth.[15]
• Behaviors—
• Delayed initiation of sexual intercourse—Evaluation found a statistically significant difference in the proportions of students who reported never having had sexual intercourse. At six-month follow-up, 76 percent of intervention students reported no sexual experience, versus 62 percent of comparison students. At the same time, the change from baseline to follow-up was substantial among intervention youth (from 67 to 76 percent) while remaining virtually unchanged among comparison youth (from 61 to 62 percent).[15]
• Reduced number of sex partners—At six-month follow-up, there was a statistically significant difference in the mean number of sexual partners reported by the sexually experienced intervention youth versus sexually experienced comparisons (1.060 and 1.312, respectively).[15]
• Increased use of condoms—A higher proportion of sexually experienced intervention students than comparisons reported condom use at last intercourse (54 versus 43 percent). Similarly, 20 percent of the sexually experienced intervention students reported consistent condom use versus 13 percent of the comparison students.[15]

Note: Evaluation also found that the recent history of STIs decreased among intervention youth (from four percent at baseline to two percent at six-month follow-up) while rising among comparison youth (from two to three percent). This finding was not statistically significant. Evaluation also found a greater reduction in the proportion of intervention students who engaged in sexual intercourse in the month preceding the post-test survey versus comparison students even though the proportions decreased in both groups between baseline and follow-up. This change was also not statistically significant. Nevertheless, evaluators assessed these changes—along with the increased condom use and reduced number of sex partners (reported above)—as indicating a substantial and significant improvement in safer sex behaviors among intervention students, versus comparison students.[15]

For More Information, Contact

• Department of Preventive and Social Medicine, College of Medicine, University of Ibadan, PMB 5017 GPO, Ibadan, Nigeria