Effects of Sexual Health Education Intervention (PREPARE) on Proximal Determinants of Sexual Debut and Condom Use Among Primary School

Children in Dar es Salaam

Presenter: Prosper Faustine Njau (MD)Supervisor: Elia J Mmbaga (MD, MPH, Phd)

Perspective

• This intervention evaluation uses baseline and first follow-up data– Six months since

baseline survey

Research Question and Analysis Objectives• What is the effect of PREPARE intervention on proximal determinants of

sexual debut and condom use among primary school children aged 12 to 14 years in Dar es Salaam?

AIMs:1 To compare baseline socio-demographic and household characteristics of

primary school aged children from intervention and control schools in Dar es salaam

2 To compare baseline proximal determinants of sexual debut and condom use among primary school children from intervention and control school in Dar Es Salaam

3 To determine the baseline proportion of sexual debut and condom use among primary school children by intervention status in Dar Es Salaam

4 To determine the change in the determinants of sexual debut and condom use among primary school children following the PREPARE intervention

5 To determine changes in sexual behavior immediately after intervention

Materials and Analysis Plan

Data collection and analysis• Data collection– Data were collected using a self administered

questionnaire (same questionnaire at baseline and at follow-up)

• Analysis– We paired baseline and first follow-up data– All analyses were done using STATA 12; and adjusted

for clustering at school level– We used the Difference in Difference model to

determine the effect of the intervention on outcomes

Arguments for use of the difference in difference Model

• Enables us to– Compare between

groups at baseline– Compare within controls

to see the time effect– Take into account the

time effect to determine the intervention effect

Source; Impact Evaluation In Practice

Results

Sex and age distribution

• A total of 5099 students were involved in the study at baseline (BL)

• 2,488(49.4) were females

• Mean age was 12.4 years and ranged from 12 to 14

• At first follow-up, 4,609 (90.4) of the baseline

students were interviewed; 2,332 (50) were females

BL: Socio-demographic characteristicsVariable 

Controln (%)

Interventionn (%)

Chi-Square

p-value

Class Five 771 (34.6) 845(36.5) 1.66 0.19

Six 1,454 (65.5) 1471(63.5)    

Age 12yrs 1,518 (64.9) 1597 (67.5) 0.87 0.65

13yrs 607 (27.1) 608 (25.8)

14yrs 168 ( 8.0) 163 ( 6.7)

Sex Female 1270 (49.7) 1218 (49.2) 0.17 0.69

Male 1284 (50.3) 1260 (50.8)

Religion Christian 1318 (51.1) 1235 (49.3) 3.54 0.32

Muslim 1255 (48.7) 1260 (50.3)

Traditional 3 (0.1) 7 (0.3)

Other 2 (0.1) 1 (0.0)

Intervention effects on knowledge and myths

Variables Female MaleBaseline

Difference (I-C)

Difference among control

group (F1-Baseline)

Intervention Effect

Baseline Difference

(I-C)

Difference among control

group (F1-Baseline)

Intervention Effect

Knowledge            

HIV knowledge (mean difference)

0.000 -0.072** 0.083** 0.001 -0.048** 0.039

Protection knowledge (mean difference) -0.013 -0.052* 0.099** -0.002 -0.026* 0.068**Myths            

Myths – HIV (mean difference) 0.022 -0.010 -0.119** -0.045 -0.022 -0.056Myths – Condom(mean difference) 0.021 0.125** -0.152** -0.057 0.050 -0.089

* <0.05; ** <0.001

Intervention effects Condom use and delaying sex attitudes

Variables Female Male

Baseline Difference

(I-C)

Difference among control

group (F1-Baseline)

Intervention Effect

Baseline Difference

(I-C)

Difference among control

group (F1-Baseline)

Intervention Effect

Attitudes            

+ve attitude–Condom use (mean difference)

-0.099 0.041 0.160* -0.018 0.104* 0.033

-ve attitude–Condom use (mean difference)

-0.006 -0.004 0.004 0.032 0.003 -0.063

+ve attitude delayed sex initiation(mean difference)

0.014 0.060 0.205** -0.025 0.017 0.094

-ve attitude delayed sex initiation (mean difference)

-0.027 -0.061 -0.004 0.105 0.055 -0.171*

* <0.05; ** <0.001

Intervention effects: Norms and self-efficacy measures

Variables Female Male

Baseline Difference

(I-C)

Difference among

control group (F1-Baseline)

Intervention Effect

Baseline Difference

(I-C)

Difference among

control group (F1-Baseline)

Intervention Effect

Norms            Delaying sex(mean difference)

0.036 -0.014 0.207* -0.005 -0.032 0.089

Condom use(mean difference)

-0.076 -0.056* 0.230** -0.057 -0.104* 0.124

Self-Efficacy            

Delaying sex(mean difference)

0.008 0.094* 0.128* -0.038 0.096* 0.007

Condom use(mean difference)

-0.042 0.065 0.094 -0.063 0.033 0.021

* <0.05; ** <0.001

Intervention effects: Communication and intentions

Variables Female Male

Baseline Difference

(I-C)

Difference among

control group (F1-Baseline)

Intervention Effect

Baseline Difference

(I-C)

Difference among

control group (F1-Baseline)

Intervention Effect

Communication            

With parents(mean difference)

0.029 -0.031 0.094* 0.017 -0.016 -0.009

With friends(mean difference)

0.012 -0.030 0.213** 0.044 0.045 0.005

Intentions            

To have Sex(mean difference)

-0.007 0.072 0.020 0.055 0.049 0.046

To use condoms(mean difference)

-0.041 -0.132** 0.211** 0.008 -0.015 -0.009

* <0.05; ** <0.001

Intervention effects: Reported sexual activity• At baseline:– 500 (10.8% [SE 0.6, 95 CI; 9.5, 12.2]) participants

report to have ever had sex– 279 - 55.8% of the sexually active (Chi square 9.12,

p=0.03) were in the intervention schools

• At immediate follow-up:– 352 (8.6% [SE, 0.6 CI 7.3, 9.8]) of the respondents

reported incident sex initiation (4,617 naïve at BL) – 265 (74.3 %) of incident sex learners were males (Chi-

square; 127.99, df;2 p;<0.01)• There was no intervention effect on sexual activity, immediately

post intervention.

Intervention effects: Condom UseAt baseline•Among those with reported sex initiation, 152 (34.2% [SE 2.6, 95 CI 28.9, 39.4]) reported to have ever used a condom

At immediate follow-up•Among those who reported incident sex initiation, 61 (17.3% [SE 2.4 CI; 12.4, 22.4]) report to have ever used a condom

•No intervention effect noted on Condom Use

Discussion• We found PREPARE to have effect on some proximal determinants of

sexual behavior that varied by sex:– HIV (females only) and protection (males and females) knowledge and myths

(females only) reduction– In females: positive attitudes on delayed sex initiation and condom use & positive

norms related to delaying sex and condom use as well as self efficacy (SE) to delay sex though not condom use

– In males: reduction in negative attitudes towards delayed sex initiation was the only attitudinal change effected.

– In females: Increase communications with parents and peers on protection• No effects were noted on actual behaviors – expected as behaviors takes

some time to change

• Overall on the short term, the intervention seem to have more effect among girls; probably due to norms and risk perception

Limitations

• Potential information bias due to lack of specific biological markers to validate self reported sex initiation

Conclusion

• In this study we were able to explore sexual debut, condom use and proximal determinants of these sexual behaviors as purported in the theory of planned behavior

• PEPRARE intervention was found to have significant effects by improving proximal determinants of sexual debut and condom use

• The intervention seems to be working more effective on the short-term among female compared to male pupils

Recommendations

• The intervention is effective– However effects of the intervention is most evident in

females; there is a need to explore why this was the case from formative data to determine specific barriers for male pupils

• Effect on actual behavior was not observed in the first follow-up survey (six moths from baseline)– actual behavior takes some time to change, analyses

of the repeat follow-up survey is recommended to determine if the intervention had an effect on actual reported sexual behaviors

Acknowledgement

• Profs. Sylvia Kaaya & Gad Kilonzo; Dr. K. Mrumbi, Ms. Lusajo Kajula & Mrema Noel

• Dr. Elia Mmbaga – Main supervisor• Other PREPARE Dar es Salaam Team Members– Richard Rutahiwa – Admin support– Edward Lema – Data Manager