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Quasi-Experimental Evaluation of a National Primary School HIV Intervention in Kenya
Global Health Sciences Literature Digest
Published April 26, 2007
Journal Article

Maticka-Tyndale E, Wildish J, Gichuru M. Quasi-Experimental Evaluation of a National Primary School HIV Intervention in Kenya. Eval Program Plann 2007 May; 30(2):172-186. (No abstract available.)

Objective

This evaluation examined the impact of a primary school HIV-education initiative on the knowledge, self-efficacy, and sexual and condom-use activity of upper primary school students in Kenya.

Study Design

This evaluation used a quasi-experimental, mixed qualitative-quantitative pre- and 18-month post-design comparing intervention and matched control schools.

Setting

Forty pair schools in Nyanza Province, Kenya, matched for school district and academic standing, were evaluated. Nyanza Province, located in western Kenya and bordering Lake Victoria, was chosen because of the high HIV prevalence in the region.

Participants

The sample included nearly equal proportions of males and females, with 46.6% males in the control schools, and 51.9% in the intervention schools. The median age of all participants was just over 14 years. The dominance of Christian religions, Luo and Kisii ethnic groups, and low SES reflect the regional profile. Approximately half of the youth reported they were sexually experienced at baseline. Patterns of sexual experience were similar for males and females and increased with age from 37.5% of 11-12-year-olds to over 60% of 16-17-year-olds.

Intervention

Primary School Action for Better Health (PSABH) provided in-service training for primary-school teachers and student-peer supporters to deliver an HIV education intervention to upper primary-school youth (most between 11 and 16 years of age) as part of the regular school curriculum. The pedagogy of PSABH was based on social learning theory with role modeling, practice of desired behaviors, and activities for building self-efficacy, together with didactic instructions. Input for materials reflected pre-program focus groups with youth and interviews with teachers and community leaders. The teaching and learning materials used in PSABH included a training manual, Q&A booklet, and School Health Club Activity Kit (available on the web: www.psabh.info). After sensitization of each participating community to the need for an HIV prevention program in the primary school, the head teacher, a senior classroom teacher, and one community representative from each intervention school were trained in two-week-long residential sessions. Four peer-supporters and another teacher participated in a final week-long residential training session. Teachers were trained to train colleagues in their home schools, to infuse and integrate HIV education throughout classroom subjects, and to provide guidance and counseling on HIV-related topics. In addition, teachers and pupil peer-supporters learned to use anonymous question boxes, school health clubs, information corners, and other school activities such as assemblies, drama, music, and literary performances to facilitate learning about HIV and AIDS. Program content addressed HIV transmission, prevention, and progression strategies and skill-building for resisting the social, cultural, and interpersonal pressures to engage in sexual intercourse, sessions to combat stigmatization of people living with or affected by HIV, and care of people with AIDS. Teacher resistance to discussing condom use was addressed. Pupil questioning was actively encouraged through use of an anonymous question box and in the activities in school health clubs and classrooms. Ministry of Health (MoH) and PSABH trainers worked with local health workers to train them in communicating with youth about sexuality and condoms. The health workers were encouraged to visit schools in their regions for this purpose, and supported in the endeavor. Unlike many school-based interventions that are designed for limited time periods during the school year, PSABH activities and lessons were designed to be ongoing components of the school curriculum, with education officers trained to monitor the PSABH activities in their schools, along with their regular monitoring functions.

Data were collected before and 18 months after the first teacher-training session. The head or deputy head teacher and a classroom teacher completed surveys, as did as all students in attendance on data collection days. Sixteen focus groups were held pre-intervention, and eight were held post-intervention, with a total of 160 girls and 160 boys from 24 participating schools. Forty-eight interviews were held with teachers from the same schools. Schools selected to provide focus group participants represented intervention and control sites, each of the two dominant ethnic groups (Luo and Kisii), and schools with high and low academic performance.

Primary Outcomes

Outcomes were measured as program effects (being in an intervention versus a control school) and exposure effects (having high versus low exposure using a cutoff of exposure to six of the 12 program components, at least one of which had to be the question box or school health club). Outcomes were studied in three areas: 1) Knowledge about HIV transmission and prevention (measured as pass/fail based on responding correctly to nine or more of 18 true/false items); 2) Abstinence and condom self-efficacy (measured based on responses of definitely yes or yes compared to responses of not sure, no, and definitely no accompanying each of the following statements: Abstinence: I can: (a) say "no" to sex; (b) have a boyfriend or girlfriend for a long time and not play sex. Condom: (a) A condom should be used each time you play sex; (b) I can tell my boyfriend or girlfriend about using condoms; (c) If I must play sex I can make sure a condom is used); and 3) Pupil behaviors (measured as yes/no responses that in the past year a respondent had: (a) helped a friend avoid a situation where they might become involved in sexual intercourse; (b) asked a question in the school question box; (c) asked a teacher a question about HIV or AIDS; (d) spoken to a parent about HIV, AIDS or sexuality). Students were also asked whether they had: (a) engaged in sexual intercourse in the past three months; and (b) used a condom (boys) or made sure a condom was used (girls) at last intercourse. Additionally, timing of sexual initiation was measured based on the length of time students had been sexually active.

Results

At the 18-month post-program data-collection period, adjusted odds ratios showed that pupils in intervention schools were over three times as likely as those in control schools to report high levels of exposure to overall teaching about HIV and AIDS (p<0.001). Male pre-program virgins demonstrated significant knowledge gains that could be ascribed to the program (AOR=1.59, 95% CI=1.01-2.50; p<0.05). A program effect on communication with teachers was found for both boy and girl pre-program virgins (AOR 1.88, 95% CI=1.28-2.77 and AOR 2.82, 95% CI 2.01-3.96, respectively; p<0.001). For self-efficacy and sexual behaviors, there were statistically significant program effects increasing the likelihood that sexually experienced girls reported they could "say 'no' to sex" (AOR=1.84, 95% CI=1.01-3.19; p<0.01) and could "have a boyfriend and not play sex" (AOR=1.59, 95% CI=1.01 – 2.54; p<0.05). A program exposure effect for "have a girlfriend and not play sex" was also seen in sexually experienced boys (AOR=1.46, 95% CI=1.08-1.96; p<0.01). There was an unexpected reduction in condom self-efficacy for sexually experienced girls (AOR=0.57, 95% CI=0.33-0.98; p<0.05). Boys demonstrated more program-related gains in condom self-efficacy. As with girls, these gains were more common among virgins than sexually experienced boys.

Conclusion

The authors conclude that the results of this evaluation, together with teacher and school enthusiasm for the intervention (evidenced in the rapid uptake of program components), demonstrates that local concerns and challenges to intervention delivery can be met. The evaluation results were used to expand the program to a national level, and as of June 2006, 11,000 Kenyan schools had PSABH trained teachers and the infrastructure was mobilized to deliver the program to the remaining schools by the end of 2008.

Quality Rating

There is no accepted quality-scoring tool for quasi-experimental evaluations. Some of the limitations include: 1) the cross-sectional sample made it difficult to assess the durability of the program's effect for pupils once they left school; 2) the introduction of previously out-of-school youth at the beginning of the second year of the program made it difficult to assess the impact they may have had on the program and outcomes; 3) the reliance on self-reported outcome measures may have introduced bias; and 4) there was absence of blinding. Additionally, pupil exposure is coincident with ongoing development, thus limiting the interpretation of exposure effects.

In Context

Results from this evaluation are similar to those from other school-based programs in sub-Saharan Africa, including greater gains overall for sexually inexperienced than experienced youth, and greater gains related to abstinence for girls and condom use for boys.(1)

Programmatic Implications

The high rates of sexual activity in primary school youth, coupled with the high prevalence of HIV in the region, indicate a strong need for effective prevention programs targeting this population. The results of this evaluation show that a school-based prevention program built on knowledge of local contexts and maximizing local infrastructures can be delivered at a national level and can reach a large majority of youth. The unmet needs of sexually active girls, however, indicate the importance of improving and refining these types of educational programs.

References

  1. Gallant M, Maticka-Tyndale E. School-based HIV prevention programmes for African youth. Soc Sci Med 2004 Apr;58(7):1337-51. Review.