MEMA kwa Vijana (MkV) - “Good things for young people”
MEMA kwa Vijana (MkV), or “Good things for young people,” used a multi-sectoral approach to prevent HIV and improve sexual health for young people. The program worked in schools, health facilities, and communities to educate young people, ensure quality and youth-friendly services, and create a supportive environment for young people to make healthy choices. MkV used bio-markers to measure its long-term effectiveness, and provided policymakers with evidence and recommendations for scaling-up effective youth-targeted programming. After a pilot phase, the project was able to achieve significant scale-up and the curriculum and training materials have been adapted for other African countries.
The in-school educational program was teacher-led and peer-assisted using participatory methods including drama, stories, and games. Reproductive health services were provided in the community and focused on meeting the specific needs of youth and becoming more youth-friendly. The condom distribution was for and by youth; STI/HIV videos were shown in the communities. A week of intensive community-wide activities once a year in each community included inter-school competitions. Topics covered during the sessions were: refusal skills, self-efficacy, self-esteem, information on STI/HIV, sexuality, contraception, abstinence, access to reproductive health care, moral behavior and social values regarding sex, respecting individual rights, gender issues, and access to contraceptives.
Development of curriculum/program: Initially, a needs assessment was conducted. A collaborative approach was used to develop and pretest training and supervision guides and materials. Robust materials developed for the program include: three teacher guides and a teacher’s resource book and flip chart for use in Years 5, 6, and 7 of primary school. Training and supervision manuals were also developed for teachers, class and community peer educators, health workers, youth condom promoters and distributors, and community advisory committees. These materials were adapted for use in other countries like Zambia and Zimbabwe. Some of the materials that were adapted in other countries are MkV’s nationally approved teacher’s guides for standards 5-7 (http://www.memakwavijana.org/materials-and-resources/teachers-guides-eng...) and a teachers research book (http://www.memakwavijana.org/pdfs/Teachers-Resource-Book.pdf).
Implementation: In intervention communities, the program was implemented in 58 primary schools. During each of the 3 years, 80% of scheduled in-school sessions were taught. 3,000 condoms were distributed per year during 2000-2002.
Evaluation: Biological markers were used to evaluate sexual activity, in addition to reported sexual behaviors, at 36 and 96 months post intervention.
Policy and advocacy: The careful documentation and research components of MkV were used to provide policymakers with evidence and recommendations for designing effective interventions for preventing HIV and improving the sexual health of young people. Research found that policymakers did find some elements of MkV useful in implementing policy and providing standardized materials for adolescent sexual and reproductive health.
- Delayed initiation of sex
- Increased condom use
- Reduced number of sex partners
- Increased use of sexual health services
- Teacher-led intensive training and sessions in: refusal skills, self-efficacy, self-esteem, information on STI/HIV, sexuality, contraception, abstinence, access to reproductive health care, moral behavior and social values regarding sex, respecting individual rights, gender issues, and access to contraceptives
- Peer-assisted participatory methods including the use of drama, stories, and games
- Adequate training of educators including training and supervision manuals for teachers, class and community peer educators, health workers, youth condom promoters and distributors
- Use of biological markers to evaluate impact on sexual risk reduction at 36 and 96 months after intervention
- Pilot phase allowed for learning and revision of approach including potential size of impact (including impact on HIV, knowledge, attitudes, and behavior), cost-effectiveness, quality, cultural appropriateness of the program, and acceptability (by the community and stakeholders including policymakers, in addition to the target population)
- Over 150 teachers, 2,000 peer educators, 62 head teachers, 14 ward education coordinators, 10 district school inspectors, and 70 health workers were trained in MkV’s methodology.
- MKV’s intervention impacted the youth that had more exposure to the in-school programs and, furthermore, it was noted that the program impacted males more than females. More specifically, the intervention resulted in delayed initiation of sex among males as well as increased condom use 96 months post intervention.
- MkV’s intervention resulted in substantial improvements in knowledge and reported sexual attitudes in both males and females. For example, in a 2002 independent reproductive health examination taken by Year 7 students in trial primary schools, 84% of students in intervention communities scored 50% or more and 26% scored at least 80%. This successful outcome was in part due to intervention in early school years. As few Tanzanian youth continue their schooling beyond primary school, the program provided an effective venue for conducting adolescent sexual health programs. In addition, incorporating the peer educator component and informally educating peers facilitated open discussions about sexual activity and risk reduction.
- The intervention also delayed reported sexual debut and reduced numbers of partners. In a trial conducted in 2001-2002, males in intervention communities reported sexual debut before the age of 16 years less often than males in comparison communities. Further, surveys indicated that males reported reduced number of sexual partners in the past 12 months. Males also reported increased condom use.
- In order to minimize over-reporting of “desired” behaviors, biological markers should be integrated, in addition to reported sexual behaviors.
- In order to increase perceived susceptibility to risk, or expectations of negative outcomes from sex, interventions should allow individuals to do a personal risk assessment.
- Low expectation of long-term negative outcomes from sex amongst MkV participants was highly influenced by positive, short-term expectations, such as pleasure, material gain and/or peer esteem. The widespread practice of material exchange for sex can be an impediment to risk reduction, as it has both emotional and financial importance for girls. The MkV curriculum acknowledged the temptation and negative consequences of such material exchange in the drama serial, but it may benefit from more attention in the existing curriculum.
- It is important for teachers to incorporate the active-learning and inquiry-based teaching techniques.
- Scale up of MkV was cost effective—moving from pilot to scale up into 649 primary schools significantly reduced the costs. MkV intervention estimated that the entire annual cost of the multi-component intervention was approximately $30,000 per trial community, which included a total population of roughly 15,000 people of all ages. This equates to about $10 per young person within the target age range (12-19 years). Scale up of MkV into 649 primary schools and 179 health facilities reduced the annual costs to $1.59/student/year. Hence, the recurrent costs of in-school interventions might be quite cost-effective. Although there is typically an initial expense related to project development and teacher training, the costs of the materials required for in-school sex education are generally limited, and once the program has been developed and initiated, training of new teachers can be included into pre-service training curricula at little added expense. In addition, if the intervention was implemented entirely by government staff at the district level, costs would decrease to about $22,000 per community for the first year, and $3,600 in subsequent years ($1.20 per young person targeted).
- In order to conduct a more comprehensive analysis of costs, it would be useful to assess the HIV infections averted in a given period, in addition to program costs.
- National Institute for Medical Research, Mwanza
- London School of Hygiene and Tropical Medicine
- Medical Research Council, Glasgow
- Liverpool School of Tropical Medicine
- Adults (over 18)
- Adolescents (ages 13-17)