HIV prevention for young people in Sub-Saharan Africa : effectiveness of interventions and areas for improvement: evidence from Rwanda

These conclusions and recommendations mainly affect five parties: researchers, intervention managers, evaluators, funders and scientific journal editors. Given the absence of a vaccine or a cure, the focus remains on preventing HIV transmission. By analysing existing data on the determinants of the complex sexual behaviour of young people and their causal pathways, and by gathering additional information, researchers should make unprecedented efforts to develop alternative and more effective interventions. Accepting the complexity of sexual behaviour of young people, also means dealing with a considerable degree of uncertainty and flexibility. Intervention development, implementation and evaluation are to be considered inseparable: results of effectiveness evaluations should be considered of little use if no information is provided on the intervention or its implementation and vice versa. Since the evaluation should be an integral part of the intervention, intervention managers and evaluators need to work in close collaboration, without suspicion. Donors have to accept that a complex intervention cannot be designed beforehand, but requires a process approach that maps risky behaviours, dominant predictors, causal pathways and key stakeholders. This pre-intervention research should be considered a fundamental part of the intervention and donors should be aware that effectiveness depends on this phase, hence funding should be made available. In this process, reality, and not morality, should be at the forefront: young people should be approached as responsible individuals who are able to make their own decisions and need to be made competent to ensure their choice to (not) have sexual intercourse is made autonomous, without coercion or regret and with the necessary in-depth knowledge of risks. This requires a change in attitudes of all stakeholders involved. A complex intervention approach also means that the intervention is monitored and can be changed during its course, resulting in the need for flexible, mixed and triangulated evaluation approaches (“combination evaluation”) and flexible funding strategies. Scientific journals have the responsibility to make innovative approaches public, even though they might not be considered most rigorous by current scientific standards, as well as allow for elaborate reports on intervention development and implementation. We are convinced this can be done if all parties remain conscious of the ultimate objective; eradicating HIV among the important and vulnerable population of young people

Factors influencing abortion decision-making processes among young women

Background: Decision-making about if and how to terminate a pregnancy is a dilemma for young women experiencing an unwanted pregnancy. Those women are subject to sociocultural and economic barriers that limit their autonomy and make them vulnerable to pressures that influence or force decisions about abortion. Objective: The objective of this study was to explore the individual, interpersonal and environmental factors behind the abortion decision-making process among young Mozambican women. Methods: A qualitative study was conducted in Maputo and Quelimane. Participants were identified during a cross-sectional survey with women in the reproductive age (15-49). In total, 14 women aged 15 to 24 who had had an abortion participated in in-depth interviews. A thematic analysis was used. Results: The study found determinants at different levels, including the low degree of autonomy for women, the limited availability of health facilities providing abortion services and a lack of patient-centeredness of health services. Conclusions: Based on the results of the study, the authors suggest strategies to increase knowledge of abortion rights and services and to improve the quality and accessibility of abortion services in Mozambique

Adult and young women communication on sexuality : a pilot intervention in Maputo-Mozambique

Background: Communication on sexuality within the family has been considered a determinant factor for the sexual behaviour of young women, contributing to delaying sexual initiation. Taking into account that young women are increasingly exposed to sexualized messages, they need clear, trustful and open communication on sexuality more than ever. However, in Mozambique, communication about sexuality is hampered by strict social norms. This paper evaluates the case of an intervention aimed at reducing the generational barrier for talking about sexuality and to contribute to better communication within the family context. Methods: The intervention consisted of three weekly one-hour coached sessions in which female adults and young interacted about sexuality. Realist evaluation was used as a framework to assess context, mechanisms, and outcomes of the intervention. Interviews were conducted among 13 participants of the sessions. Result: The interaction sessions were positively appreciated by the participants and contributed to change norms and attitudes towards communication on sexuality within families. Recognition of similarities and awareness of differences were key in the mechanisms leading to these outcomes. This was reinforced by the use of visual materials and the atmosphere of respect and freedom of speech that characterized the interactions. Limiting factors were related to the long-standing taboo on sexuality and existing misconceptions on sexuality education and talks about sex. Conclusion: By elucidating mechanisms and contextual factors our study adds knowledge on strategies to improve transgenerational communication about sexuality

Implementation of an HPV vaccination program in Eldoret, Kenya: results from a qualitative assessment by key stakeholders

Background: Cervical cancer strikes hard in low-resource regions yet primary prevention is still rare. Pilot projects have however showed that Human Papillomavirus (HPV) vaccination programs can attain high uptake. Nevertheless, a study accompanying a vaccination demonstration project in Eldoret, Kenya, revealed less encouraging outcomes: uptake during an initial phase targeting ten schools (i.e., 4000 eligible girls), was low and more schools had to be included to reach the proposed number of 3000 vaccinated girls. The previously conducted study also revealed that many mothers had not received promotional information which had to reach them through schools: teachers were sensitized by health staff and asked to invite students and parents for HPV vaccination in the referral hospital. In this qualitative study, we investigate factors that hampered promotion and vaccine uptake. Methods: Focus group discussions (FGD) with teachers (4) and fathers (3) were organized to assess awareness and attitudes towards the vaccination program, cervical cancer and the HPV vaccine, as well as a FGD with the vaccinators (1) to discuss the course of the program and potential improvements. Discussions were recorded, transcribed, translated, and analyzed using thematic analysis In addition, a meeting with the program coordinator was set up to reflect upon the program and the results of the FGD, and to formulate recommendations for future programs. Results: Cervical cancer was poorly understood by fathers and teachers and mainly linked with nonconforming sexual behavior and modern lifestyle. Few had heard about the vaccination opportunity: feeling uncomfortable to discuss cervical cancer and not considering it as important had hampered information flow. Teachers requested more support from health staff to address unexpected questions from parents. Non-uptake was also the result of distrust towards new vaccines. Schools entering the program in the second phase reacted faster: they were better organized, e.g., in terms of transport, while the community was already more familiarized with the vaccine. Conclusions: Close collaboration between teachers and health staff is crucial to obtain high HPV vaccine uptake among schoolgirls. Promotional messages should, besides providing correct information, tackle misbeliefs, address stigma and stress the priority to vaccinate all, regardless of lifestyle. Monitoring activities and continuous communication could allow for detection of rumors and unequal uptake in the community

Barriers to sexuality education for children and young people with disabilities in the WHO European region : a scoping review

While sexuality education can support children and young people with disabilities in their sexual development and contribute to their wellbeing, challenges to its provision exist. This study identifies barriers to sexuality education for children and young people with disabilities in the WHO European Region via a scoping review of research published since 2006. Using the PRISMA-ScR Guidelines and predefined selection criteria, 14 studies were selected for inclusion. Together, these studies identified seven barriers to sexuality education for children and young people with disabilities, including the social misperception of people with disabilities as asexual and in need of protection which, combined with limited support for educators, resulted in noncomprehensive and normative sexuality education. Educators seemed inclined to redirect responsibility for sexuality education to others, and diversity among children and young people with disabilities, as well as cultural and religious diversity, makes it difficult to define a general approach. Finally, competing priorities related to the general health and wellbeing of children and young people with disabilities may appear to render sexuality education less important. We identify gaps in the research and highlight implications for the reduction of the barriers to sexuality education for children and young people with disabilities within the WHO European Region

Sexuality education : what is it?

This policy brief developed by the European Expert Group on Sexuality Education provides an overview of key issues in sexuality education. It focuses primarily on sexuality education in Europe and Central Asia but is also relevant to countries outside of these regions

Limited effectiveness of HIV prevention for young people in sub-Saharan Africa: studying the role of intervention and evaluation

On average, 2,500 young people (15-24 years) get -infected with HIV every day; 80% of which live in sub-Saharan Africa. Since no cure or vaccine is available, reducing sexual risk behaviour in this group is crucial in tackling the epidemic. The general objective of this doctoral study was to improve the effectiveness of HIV prevention interventions for young people in sub-Saharan Africa. First, we assessed the overall effectiveness of such interventions (systematic literature review, meta-analysis). Secondly, we evaluated a school-based peer-led HIV prevention interventions in Rwanda (longitudinal, non-randomized controlled trial), to get insight into how interventions are developed, implemented and evaluated. While the first two objectives demonstrated limited effectiveness, the third objective aimed to identify reasons for this limited effectiveness: a) baseline characteristics of -respondents that predict participation were identified (using data from objective 2); b) we studied determinants of young people\u27s sexual behavior using a qualitative \u27mailbox study\u27 that assessed the spontaneous thoughts of Rwandan adolescents on sexuality; c) we assessed the role of one specific structural factor: -education (literature review and analysis of existing datasets); d) we assessed the theoretical underpinnings of existing HIV prevention interventions for young people in sub-Saharan Africa (literature review). Based on these studies, we discuss two main reasons for the observed limited effectiveness: factors associated with the intervention (strong focus on cognitions and moral, and implementation issues), and with evaluation (design, power, indicators). Recommendations for improving interventions, evaluations and for further research are provided

Reducing HIV/AIDS in young people in Sub-Sahara Africa: gaps in research and the role of theory

This paper discusses the role of education in preventing HIV in children and young people in sub-Sahara Africa and presents the results of policy advisory research conducted on behalf of the Belgian Development Cooperation. The research consisted of a literature review and a field study in Rwanda. Relative to the high number of HIV prevention activities in sub-Sahara Africa, there is a limited number of scientific data on HIV risk reduction interventions for young people in this region. Longitudinal studies are especially scarce. Preliminary results show that many interventions have only a marginal impact on reducing sexual risk behaviour. Factors influencing programme effectiveness include the consistency and accuracy of messages and information, the provision of life-skills, social support and access to contraceptives, the intensity and duration of the programme, the training of the facilitators and the age of the target population. The HIV/ AIDS pandemic has a potentially devastating impact on the education sector. Because few countries have monitoring systems in place that quantify the absenteeism, morbidity and mortality of teachers and students infected with or affected by HIV/AIDS, there is only anecdotal evidence available for illustrating this impact. The final section discusses the current gaps in research and the important role of theory in increasing the impact and improving the evaluations of HIV/AIDS education interventions

Effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda: results from a non-randomized controlled trial

Background: While the HIV epidemic is levelling off in sub-Saharan Africa, it remains at an unacceptably high level. Young people aged 15-24 years remain particularly vulnerable, resulting in a regional HIV prevalence of 1.4% in young men and 3.3% in young women. This study assesses the effectiveness of a peer-led HIV prevention intervention in secondary schools in Rwanda on young people’s sexual behavior, HIV knowledge and attitudes. Methods: In a non-randomized longitudinal controlled trial, fourteen schools were selected in two neighboring districts in Rwanda Bugesera (intervention) and Rwamagana (control). Students (n= 1950) in eight intervention and six control schools participated in three surveys (baseline, six and twelve months in the intervention). Analysis was done using linear and logistic regression using generalized estimation equations adjusted for propensity score. Results: The overall retention rate was 72%. Time trends in sexual risk behavior (being sexually active, sex in last six months, condom use at last sex) were not significantly different in students from intervention and control schools, nor was the intervention associated with increased knowledge, perceived severity or perceived susceptibility. It did significantly reduce reported stigma. Conclusions: Analyzing this and other interventions, we identified several reasons for the observed limited effectiveness of peer education: 1) intervention activities (spreading information) are not tuned to objectives (changing behavior); 2) young people prefer receiving HIV information from other sources than peers; 3) outcome indicators are not adequate and the context of the relationship in which sex occurs and the context in which sex occurs is ignored. Effectiveness of peer education may increase through integration in holistic interventions and redefining peer educators’ role as focal points for sensitization and referral to experts and services. Finally, we argue that a narrow focus on sexual risks will never significantly turn the tide