Partnering to proceed: scaling up adolescent sexual reproductive health programmes in Tanzania. Operational research into the factors that influenced local government uptake and implementation

BACKGROUND: Little is known about how to implement promising small-scale projects to reduce reproductive ill health and HIV vulnerability in young people on a large scale. This evaluation documents and explains how a partnership between a non-governmental organization (NGO) and local government authorities (LGAs) influenced the LGA-led scale-up of an innovative NGO programme in the wider context of a new national multisectoral AIDS strategy. METHODS: Four rounds of semi-structured interviews with 82 key informants, 8 group discussions with 49 district trainers and supervisors (DTS), 8 participatory workshops involving 52 DTS, and participant observations of 80% of LGA-led and 100% of NGO-led meetings were conducted, to ascertain views on project components, flow of communication and decision-making and amount of time DTS utilized undertaking project activities. RESULTS: Despite a successful ten-fold scale-up of intervention activities in three years, full integration into LGA systems did not materialize. LGAs contributed significant human resources but limited finances; the NGO retained control over finances and decision-making and LGAs largely continued to view activities as NGO driven. Embedding of technical assistants (TAs) in the LGAs contributed to capacity building among district implementers, but may paradoxically have hindered project integration, because TAs were unable to effectively transition from an implementing to a facilitating role. Operation of NGO administration and financial mechanisms also hindered integration into district systems. CONCLUSIONS: Sustainable intervention scale-up requires operational, financial and psychological integration into local government mechanisms. This must include substantial time for district systems to try out implementation with only minimal NGO support and modest output targets. It must therefore go beyond the typical three- to four-year project cycles. Scale-up of NGO pilot projects of this nature also need NGOs to be flexible enough to adapt to local government planning cycles and ongoing evaluation is needed to ensure strategies employed to do so really do achieve full intervention integration

Intravaginal and Menstrual Practices among Women Working in Food and Recreational Facilities in Mwanza, Tanzania: Implications for Microbicide Trials

Intravaginal and menstrual practices may potentially influence results of trials of microbicides for HIV prevention through effects on the vaginal environment and on adherence to microbicide and placebo products. As part of the feasibility study for the Microbicides Development Programme Phase 3 trial of a vaginal microbicide in Mwanza, a variety of quantitative and qualitative methods were used to describe these practices, associations with behaviour and underlying social norms among women working in food and recreational facilities. Intravaginal cleansing by inserting fingers and either water alone or soap and water was thought necessary to remove “uchafu” (dirt), referring to vaginal secretions, including menstrual blood and post-coital discharge. Vaginal cleansing was carried out within 2 hours after 45% of sex acts. Sexual enhancement practices were less common. Intravaginal and menstrual practices and associated behaviours and demographic factors should be measured and monitored throughout microbicide trials to enable analyses of their impacts on microbicide effectiveness

Scaling up adolescent sexual and reproductive health interventions through existing government systems? A detailed process evaluation of a school-based intervention in Mwanza region in the northwest of Tanzania.

PURPOSE: There is little evidence from the developing world of the effect of scale-up on model adolescent sexual and reproductive health (ASRH) programmes. In this article, we document the effect of scaling up a school-based intervention (MEMA kwa Vijana) from 62 to 649 schools on the coverage and quality of implementation. METHODS: Observations of 1,111 students' exercise books, 11 ASRH sessions, and 19 peer-assistant role plays were supplemented with interviews with 47 ASRH-trained teachers, to assess the coverage and quality of ASRH sessions in schools. RESULTS: Despite various modifications, the 10-fold scale-up achieved high coverage. A total of 89% (989) of exercise books contained some MEMA kwa Vijana 2 notes. Teachers were enthusiastic and interacted well with students. Students enjoyed the sessions and scripted role plays strengthened participation. Coverage of the biological topics was higher than the psycho-social sessions. The scale-up was facilitated by the structured nature of the intervention and the examined status of some topics. However, delays in the training, teacher turnover, and a lack of incentive for teaching additional activities were barriers to implementation. CONCLUSIONS: High coverage of participatory school-based reproductive health interventions can be maintained during scale-up. However, this is likely to be associated with significant changes in programme content and delivery. A greater emphasis should be placed on improving teachers' capacity to teach more complex-skills-related activities. Future intervention scale-up should also include an increased level of supervision and may be strengthened by underpinning from national level directives and inclusion of behavioral topics in national examinations

Dusty discos and dangerous desires: community perceptions of adolescent sexual and reproductive health risks and vulnerability and the potential role of parents in rural Mwanza, Tanzania.

This paper presents villagers' assessments of young people's sexual and reproductive health vulnerability and of community-based interventions that may reduce both vulnerability and risk in rural Mwanza, Tanzania. The primary methods used were 28 group discussions and 18 in-depth interviews with representatives of various social groups in four villages. The majority of participants attributed young people's sexual and reproductive health risks to a combination of modernisation (and its impact on family and community life), socioeconomic conditions, social norms in rural/lakeshore communities and the difficulties parents and other adults face in raising adolescents in contemporary Tanzania. Community life has limited opportunities for positive development but contains many risky situations. Young and old agreed that parents have a strong influence on young people's health but are failing in their parental responsibility. Parents acknowledged the multiple influences on sexual risk behaviour. They expressed a need for knowledge and skills related to parenting so that they can address these influences both through family- and community-based strategies

Comparison of sexual behavior data collected using a coital diary and a clinic-based interview during a microbicide pilot study in Mwanza, Tanzania.

BACKGROUND: The performance of coital diaries (CDs) and clinic-based interviews to measure sexual behavior was compared during a pilot study for a Phase III microbicide trial. METHODS: In Mwanza, 59 women were enrolled for 4 weeks and provided with 20 placebo gels. Weekly, women were given CDs to complete daily. At the final clinic visit, women attended a face-to-face interview (Clinic FFI) about their sexual behavior, and the gel use was accounted for (gel accountability (GA)). Comparisons were made between CD, Clinic FFI, and GA data. In-depth interviews following clinic visits elicited reasons for discrepancies in reports. RESULTS: Twice as many sex acts during 1 week were recorded in the CD (median 4) compared with the clinic FFI (median 2). At the clinic FFI, more women reported using the gel for each sex act (84% vs. 40%; P < 0.001) and vaginal washing for each sex act (98% vs. 56%; P < 0.001) compared with the CD. Over 4 weeks, 16.4% of women recorded sex during menstruation in CDs compared with 1.8% at the clinic visit (P = 0.01). The median number of gels used reported in the CDs was the same as the GA (10) with 59% agreement on the number used within +/-2 gels. Reasons for misreporting during clinic FFI were reported to have been poor recall, embarrassment, or misunderstanding. Inaccuracies in CDs were attributed to misunderstanding or poor recording. CONCLUSIONS: CDs elicited higher recording of sex acts and lower reporting of gel use than clinic FFIs, which has implications for measuring adherence during clinical trials. With clear instructions and support, coital dairies should be considered in future microbicide trial design