Elsevier

Social Science & Medicine

Volume 58, Issue 7, April 2004, Pages 1337-1351
Social Science & Medicine

School-based HIV prevention programmes for African youth

https://doi.org/10.1016/S0277-9536(03)00331-9Get rights and content

Abstract

The high rate of HIV infection among youth in Africa has prompted both national and international attention. Education and prevention programmes are seen as the primary way of decreasing this rate. This paper reviews 11 published and evaluated school-based HIV/AIDS risk reduction programmes for youth in Africa. Most evaluations were quasi-experimental designs with pre–post test assessments. The programme objectives varied, with some targeting only knowledge, others attitudes, and others behaviour change. Ten of the 11 studies that assessed knowledge reported significant improvements. All seven that assessed attitudes reported some degree of change toward an increase in attitudes favourable to risk reduction. In one of the three studies that targeted sexual behaviours, sexual debut was delayed, and the number of sexual partners decreased. In one of the two that targeted condom use, condom use behaviours improved. The results of this review suggest that knowledge and attitudes are easiest to change, but behaviours are much more challenging. The article provides details about programmes and identifies characteristics of the most successful programmes. Clearly, however, more research is needed to identify, with certainty, the factors that drive successful school-based HIV/AIDS risk reduction programmes in Africa.

Introduction

The pandemic proportions of AIDS and the devastation it is wreaking in sub-Saharan Africa are widely acknowledged. What is not as often acknowledged is its impact on youth. With over 80% of those currently living with AIDS aged between 15 and 24 and three-quarters of these youth living in sub-Saharan Africa, it is not an exaggeration to say that youth in sub-Saharan Africa must become a focus for prevention efforts if the problem is to be controlled (UNAIDS, 2001). In countries with the highest rates of infection, AIDS not only constitutes a health crisis, but a crisis that threatens to dismantle the social fabric, as the next generation of workers, parents, and leaders is lost. This has prompted the call by the United Nations for a 20–25% reduction in HIV prevalence among youth by the year 2010 (UNAIDS, 2001).

Several strategies suggested for decreasing infection rates include, among others, social marketing of condoms, peer education for groups with highest infection rates (such as sex workers), mass media concerning social and cultural customs that expose participants to heightened risk (such as wife inheritance or circumcision ceremonies), voluntary counselling and testing for those who believe themselves to be infected, and school-based programmes. Of these strategies, school-based HIV prevention programming, starting as early as primary school, has been viewed as a necessary step to protect the general population from further infection (Barnett, de Koning, & Francis, 1995; Finger, Lapetina, & Pribila, 2002; Grunsheit, 1997; Kaaya Mukoma, Flisher, & Klepp, 2002b; World Bank, 1993).

Four reasons are commonly articulated in support of this position. First, given that 70% of children enter primary school and 67% of primary school entrants in sub-Saharan Africa reach grade 5 (UNICEF, 2001), primary schools are the single location where the largest proportion of young people (approximately 50%) can be reached. Second, studies in different locations support the conclusion that most youth in sub-Saharan Africa initiate sexual activity while they are still of school age, whether or not they are in school (Kaaya et al., 2002a; WHO, 1992). Third, the importance of initiating prevention programming in primary schools is evident from the conclusions of reviews of interventions demonstrating that those conducted prior to sexual debut are the most effective in reducing rates of sexually transmitted infections (e.g., Grunsheit, 1997). Finally, schools provide an established venue for intervention (Barnett et al., 1995). Their location is known, they are sustained within the community, their hours and mode of operation are known, they have established mechanisms for introduction of new programmes and accessing students, and the size of the target population is known. In addition, schools are linked to communities through families, and other community organizations, extending their reach and enhancing local ownership of interventions. It is for these reasons that Stover and colleagues’ recent assessment of the effectiveness of AIDS reduction strategies identified school-based programmes as a necessary basis for other programmes (Stover et al., 2002).

This paper critically reviews and synthesizes the results of 11 evaluated programmes designed to reduce HIV transmission to youth and delivered in sub-Saharan African schools. Several similar reviews have been published in recent years. The most comprehensive have focused exclusively on programmes in wealthy nations, particularly the United States (e.g., Kirby, 2000). Those that included programmes from developing nations either had a meagre representation from sub-Saharan Africa (e.g., 2 in Merson, Dayton, & O’Reilly, 2000), or described outcomes of a wide range of programmes uncritically, without considering whether the design and conduct of the evaluation supported the conclusions drawn by the authors (e.g., Finger et al., 2002; Grunsheit, 1997; Kaaya et al., 2002b). This article differs from these earlier reviews in two ways. First, it includes a larger number of sub-Saharan African programmes than any of the previous reviews. Second, it provides critical commentary on the evaluation procedures and analyses, interpreting reported results within the context of the quality of the research design.

Section snippets

Method

Evaluated prevention programmes were located by searching literature databases such as Psychological Literature (PsychLit), Population Information Program, Sociological Abstracts, and MEDLINE; the tables of contents of journals that published articles evaluating HIV/AIDS interventions between 1994 and 2002; and publication lists from international organizations such as the United Nations Joint Commission on HIV/AIDS and the World Health Organization Global Programme on AIDS. To be included in

Interventions

The published articles provided little information about the content and characteristics of the interventions. Notably missing, e.g., was information about whether activities included skills building or practice sessions, both of which have been shown to increase programme effectiveness (Kirby, 2000). In the absence of explicit information on message content, the messages conveyed in the programmes were deduced from the content of questions used in evaluation instruments. The appropriateness of

Evaluation designs

There was considerable variation in the form and quality of evaluations (see Table 2). One study used an experimental design with random assignment; the remainder used quasi-experimental designs, most including a control group (n=8). In all but one case, control and experimental groups completed surveys before and after the intervention. Both longitudinal panel (n=7) and repeated cross-sectional (n=4) designs were used.

Longitudinal panel designs permitted the tracking of changes in responses of

Knowledge

It is well recognized that although knowledge is not sufficient to affect behaviour change, it may be a necessary condition. The importance of knowledge justified its measurement in all programmes and the singular focus on knowledge in three programmes. There was great variation in the knowledge that was assessed as well as the method and quality of assessment, making direct comparison of areas of knowledge improvement in different programmes difficult. Despite this diversity, results of all

Discussion and conclusions

HIV prevention programmes in wealthier countries can build on a foundation of knowledge established as a result of numerous, well-resourced programmes and evaluations (see Centers for Disease Control and Prevention (CDC), 1999 for an overview). From this body of literature, Kirby (2000) identified specific characteristics that contribute to the effectiveness of programmes. While there are still too few evaluations of programmes to confirm with confidence the components of successful programmes

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