Effect of the PREPARE Intervention on Sexual Initiation and Condom Use among Adolescents Aged 12-14: A Cluster Randomised Controlled Trial in Dar es Salaam, Tanzania

"...the intensive and multifaceted intervention programme used in this study that covered teacher centred class room teaching, peer-education and youth friendly clinic visits may partly explain the observed positive change..."

Data from 2011-2012 indicate that the prevalence of HIV infection among young people in Tanzania is high, with female adolescents (4.4%) having twice as high HIV prevalence as compared to their male counterparts (1.7%). Studies that have examined effects of interventions based on Social Cognitive Theory indicate that sexual and reproductive behavioural interventions among young people are effective, especially when targeting young adolescents before they become sexually active. Such interventions have been found to produce more impact when they are broad and target many aspects of adolescent's life, including school and home environments, policies related to health, and adolescent wellbeing. The PREPARE intervention aimed to impact key mediators of the behaviour change process such as self-efficacy, social norms, attitudes, and action planning. This paper presents results of the effects of the PREPARE intervention in delaying early sexual initiation and promoting condom use among school-based adolescents aged 12-14 years in Dar es Salaam, Tanzania.

PREPARE [full title: Promoting sexual and reproductive health among adolescents in southern and eastern Africa - mobilising schools, parents and communities] was developed based on findings from previous studies in the geographical area and a formative phase, which, according to researchers, made it population specific and culturally sensitive. The school-based intervention consisted of 3 components, one implemented by teachers, one by peer educators, and one by healthcare providers during adolescents' visits to youth-friendly health service clinics. Specifically, 3 peer-led lessons taught over 8 hours and 6 teacher-led lessons taught over 11 hours were conducted. The teacher-led lessons were integrated in the primary school science curriculum; peer-led lessons were part of an after-school life skills training curriculum and were designed to be interactive (with teachers were available to offer support when needed). The third component intended to link adolescents to information and services that may foster healthy sexuality.

Thirty-eight public primary schools in the Kinondoni Municipality of Dar es Salaam were selected for this study, which was a cluster randomised controlled trial (RCT) with 5,091 adolescents: 2,503 from intervention schools and 2,588 in the control. Participants in both arms were followed for 12 months, with data collection waves at baseline and 6 and 12 months.

The PREPARE intervention had an effect in delaying self-reported sexual initiation among both male and female adolescents. The effect was observed immediately after the intervention and was sustained over 12 months: For males, the incidence of sexual initiation in the intervention arm decreased from 11.5/100 person years at risk (PYAR) at month 6 to 7.3/100 PYAR at the 12 month follow-up. For the control arm, the incidence of sexual initiation at 6 months was 13.2/100 PYAR and 10.9/100 PYAR at 12 months. The rate of sexual initiation at 12 months following the PREPARE intervention was almost 2 times higher among the control schools as compared to the intervention schools [adjusted relative risk (ARR) = 1.9, p = 0.027]. Similarly, females from the control arm were 1.6 times more likely to initiate sex as compared to those from the intervention arm.

The intervention also positively influenced action planning to use condoms for both sexes, with a significantly higher level of action planning to use condoms reported among female adolescents in the intervention arm than those in the control arm (p = 0.042). An effect on condom use behaviour was observed among male adolescents (p = 0.004), but not among female adolescents (p = 0.463). (In analysing this finding, the researchers point out that male condoms are the most available, and condom use among females in the African cultural setting may also require successful negotiation with a male partner. "Interventions should address...interpersonal factors such as communication with partners to be able to achieve the desired effect...")

In conclusion: "Future interventions addressing adolescent sexual and reproductive health issues should be culturally sensitive and adopt broader approaches which impact underlying mediators of behavioural changes to be able to facilitate actual behavioural change."