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Promoting sexual- and reproductive health among adolescents in southern and eastern Africa – mobilising parents, schools, and communities

Final Report Summary - PREPARE (Promoting sexual- and reproductive health among adolescents in southern and eastern Africa – mobilising parents, schools, and communities)

Executive Summary:
Eight universities and research institutes (four African and four European) from six countries have been involved in the PREPARE study. During the PREPARE study, four different school- and community-based interventions aiming at promoting healthy sexual practices (preventing sexually transmitted diseases including HIV/AIDS) or predictors of such practices targeting adolescents aged 12-14 were developed, implemented and evaluated in four sites in sub-Saharan Africa. In Western Cape (South Africa) there was a broad out-of-school intervention including a violence prevention component. In Mankweng (Limpopo Province, South Africa) there was an emphasis on changing culture-specific beliefs among students through a curriculum-base intervention which took place during school hours. In Dar es Salaam (Tanzania) there was a broad intervention in schools with an emphasis on peer education approaches. In Kampala (Uganda) the aim was to improve and increase adolescent-parent communication on sexuality issues through an intervention which involved parents as well as school students. In all four sites schools were randomly allocated to intervention group and control group. Baseline data collections and one or two follow up data collections (two in Dar es Salaam and Cape Town) were carried out. The total number of students who participated in the study was 12635. In all sites significant effects were observed on relevant outcome variables. In Cape Town (after six months) and Limpopo there were significant effects on a range of social cognition outcomes (hypothesized mediators of programme effects on behavioural outcomes). In Kampala the intervention resulted in more frequent and more high-quality communication between students and their parents/guardians on sexuality issues. Effects on reported sexual behaviours were found in Dar es Salaam. Important products of the study are intervention materials and programmes and well tested high quality instruments (questionnaires and scales) for data collections. Results from the study are published in international scientific journals and presented at scientific conferences.
Dissemination seminars for ministries, NGOs and stakeholders have been held at all African sites participating in the study. Further analyses of data, publishing of results and dissemination activities will continue during the next few years.

Project Context and Objectives:
The overall purpose of this research project was to develop interventions which were effective in reducing the spread of sexually transmitted diseases (including HIV) and unwanted pregnancies by changing sexual- and reproductive behaviours among adolescents in selected sites in Sub-Saharan Africa. We applied an integrated community prevention approach with schools as an important gateway. This necessitated the development of new, innovative intervention methods.
The main aim of the PREPARE project was to develop new and innovative programs for the promotion of healthy sexual practices among adolescents in their early adolescence (in school grades corresponding to the age groups 12-14 years) using schools as a gateway to delivery.

Objectives:
# To carry out formative studies among adolescents in all four African sites in order to develop specific intervention components.
# To examine content and design of materials used in previous interventions in light of new research evidence and relevant theory in order to identify and improve sub-optimal elements and aspects;
# Based on the outcomes of 1 and 2, to design and implement new, comprehensive ‘best practice’ programs for promotion of healthy sexual behaviour among adolescents to be tested in two sites (Cape Town and Dar es Salaam), using schools as the gateway for delivery;
# Design and implement more focused interventions to be administered in two sites, one on parent-child communication and parental support for healthy sexual behaviour (Makerere) and the other one on culture-specific norms, attitudes and beliefs (Limpopo);
# To revise existing scales and instruments for data collection and develop new ones in order to meet the evaluation needs of the new best practice intervention programmes and the focused efficacy studies;
# To evaluate the intervention programmes through a combination of quantitative and qualitative approaches.

Project Results:
The most important research findings from the PREPARE projects came out of the cluster RCT design used to evaluate the four interventions. Formative research was used to inform intervention development in each site. This formative research included qualitative interviews (focus group interviews and individual interviews). The implementation process was also carefully monitored in each site by checklists and interviews.

Formative research and intervention effects

Cape Town
Formative research
The SATZ materials were reviewed, and also the Respect4U materials in our development of the PREPARE curriculum. Respect4U is a manualized intervention for Grade 8 students, mapped on to the Grade 8 curriculum which aims to reduce intimate partner violence and sexual risk behaviour (http://www.mrc.ac.za/gender/respect4u.htm. ). A curriculum which focuses on an individual’s motivation and skills only is insufficient when features of the environment limit the ability to take individual action in response to what is learned. This was evidenced by the failure of the SATZ Cape Town intervention to impact on adolescent risk behavior in Cape Town. Therefore the Western Cape PREPARE project aimed to change the school environment in two aspects. Firstly, we aimed to increase adolescent access to sexual- and reproductive health services including condoms, contraception, STI management and pregnancy tests through the establishment of a school-based health service (SBHS). Secondly, we aimed to change the school environment by reducing sexual violence and increasing feelings of safety by creating a school climate of intolerance towards violence. This was to be achieved through a partnership between teachers, students, parents and police officers focusing on the implementation of a school safety audit, raising awareness of relevant laws concerning sexual violence, and of existing services within the community where support was provided.

We used many of the SATZ questionnaire items in the PREPARE questionnaire. Also, “Sexual Decision Making” was one of the eight sections of the PREPARE curriculum. In this section we included 2 lessons from the SATZ curriculum. These lessons focussed on condom skills development and learning to identify behaviours that put one at risk for HIV, STIs and pregnancy.
The condom skills lesson had not been adequately implemented in the SATZ intervention because it was difficult for many teachers to accept. In PREPARE, both of the lessons were implemented by the PREPARE school nurse. We derived many of the PREPARE sessions from the Respect4U programme.
We pilot tested two versions of the questionnaire and conducted group cognitive interviews with the participants to hear from adolescents completing the survey about their thought processes during reading and answering questions. For each item we probed to gather information on clarity, appropriateness, and whether it elicited the requisite response. We conducted a test retest study and computed the psychometric properties of the scales to assist with scale development. Six representative public high schools in Cape Town (South Africa) were selected, that were suitable and willing to establish partnership with the Cape Town team, in order to develop specific intervention components. Principals, teachers, parents, students, health workers and police officers in the school communities agreed to participate in the project. Pre-research meetings took place at each school to introduce the project to the principal and teachers. Class lists were provided of students who had agreed to take part in the study and a random sample of students was chosen. A meeting was then planned to meet the students to obtain written consent and to plan the interviews.

Between September and December 2010, a total of 55 individual interviews with students (N=27), school principals (N=6), Life Orientation teachers (N=6), social workers based at the school (N=4), parents (N=7) and police officers (N=5) were conducted. The interviewee chose the language of the interview (English, Afrikaans or isiXhosa). Each interview was held either at the school or at the interviewee’s home, in a separate room. The interviews took between 1 hour and 1.5 hours, and each interview was followed up by a telephone call about 3 weeks after the actual interview to hear whether the interviewee had any comments, remarks or concerns. At the end of phase 1, all schools remained enthusiastic about continuing their involvement in the PREPARE project. All interviews were transcribed and if necessary translated in English.
Results from interviews showed the need for a multi-faceted community-based approach. Harmful social conditions play a major role in the perpetuation of violence, drug use, and sexual risk behaviour. The work that police officers and health workers were doing in schools, was used to build on for the development of the PREPARE intervention. Strengthening of linkages between schools and health care services is key. The interviews showed that there is a need for nurses to come to schools to provide services at the school e.g. contraception, advice on sexuality and violence etc.
Involving the parents in crucial. A parent’s effect on a student’s well-being cannot be underplayed.
This information lead to greater efforts that were made to link parents to the school, through for example parent meetings, and students’ Photovoice project. In addition, there is a lack in policies on how to deal with young people reporting violence and/or abuse at home. Initiatives were taken to strengthen the development and implementation of policies.

2. Pre- and post-training: nurses, police & school personnel, and programme facilitators:
The aim was to evaluate the effectiveness of the training. Participants completed open-ended questionnaires before and after attending the training. The questionnaires were designed to explore expectations about training, beliefs and values (about teenage sexuality, school health services, corporal punishment and community violence), service provision, skills required / acquired during training, comments on the PREPARE curriculum, expected difficulties, and appropriateness of services, topics and content of the curriculum.

3. Programme facilitators’ daily logs:
The aim was to explore intervention feasibility and to assess intervention fidelity from the perspective of the facilitators. They completed structured forms for each session that enquired about which parts of individual sessions and activities were implemented or not, reasons for nonimplementation, challenges and enablers encountered, learner responses, and comments and suggestions.

4. Observations of facilitators during implementation:
The aim was to assess intervention fidelity through unannounced observations of sessions. The evaluators used a structured score sheet that assessed evaluators’ perceptions of facilitators’ skills, coverage of content and activities, interaction dynamics with learners and general comments.
Evaluations were done independently by two evaluators and each facilitator was observed twice.

5. Learner evaluations:
The aim was to assess intervention fidelity and acceptability from the perspective of the learners who completed open-ended questionnaires on completion of randomly selected sessions. The questionnaires were designed to elicit learners’ opinions about the facilitator, the session content, the learning methods and materials, the most and least enjoyed parts of session, and suggestions for changes.

6. Post-intervention interviews with nurses, school principals and staff, and programme facilitators: The aim was to assess the feasibility and acceptability of the school health services, and the PREPARE intervention from the perspectives of the nurses, school personnel and facilitators.
Interviews were recorded and transcribed, or comprehensive notes were taken during and immediately after interviews.

7. Photo-voice:
Photo-voice was a study done in 10 of 20 interventions schools. It aimed at investigating issues of safety and unsafety in and around the school environment and to facilitate dialogue amongst the key stakeholders about these issues. Twenty learners (10 boys and 10 girls) were randomly selected from a group of learners who volunteered to participate in the photo-voice program. These learners were then given cameras to tell their stories through photography/picture taking about what makes them feel safe and/or unsafe within their school environments. At the end of the study a photo exhibition and forum meeting was held where key stakeholders were invited and learners presented their stories.
A week after the forum meeting, a focus group discussion was held with participants to evaluate the program. The program was implemented by trained facilitators. Eight of the ten schools completed the program up to the end. In all the schools learners expressed more feelings of being unsafe than being safe. Most common forms of violence that were reported, which were similar across all the schools, included physical, emotional, and sexual violence, bullying, and gangsterism. Violence is very common in South African schools, particularly within communities with high incidences of violence. Occurrence of sexual violence within school environments needs attention. Photo-voice has shown to be a great method in raising awareness about violence issues within these schools.
To date most of the qualitative data from Cape Town are yet to be analysed or reported on, which is expected to be done in the coming months.

Attendance in an after school intervention
Since the Western Cape Department of Health decided that interventions like PREPARE should not be allowed to take place during school hours, the plans for the Cape Town intervention had to be changed accordingly. It should be mentioned that originally the Western Cape Department of Education had confirmed by letter that the intervention could take place in school during school hours. But this decision was changed at a later stage. Data collections could, however, take place during school hours.
As previously reported, this opened up for new research opportunities. One important research question that could now be addressed was the issue of to what extent young adolescents would attend an after-school sexual and reproductive health programme. This has been dealt with in a publication by Catherine Mathews and associates (submitted for publication).
As planned, all students in grade 8 (average age 13 years) from 20 schools in the intervention arm of PREPARE were invited to participate in the after school programme. Considerable efforts were made to motivate student participation. To encourage attendance, each student was offered refreshments at each session and small stationary gifts at selected sessions. They gave R50.00 (US $5) supermarket gift voucher and certificate for those who attended at least 15 sessions. Each participant had a “loyalty card” which was stamped at each session or nurse consultation.
Participants were surveyed at baseline, and attendance was registered at each of the 21 weekly sessions over six months.

It turned out that 33.6 per cent of the students followed at least 50 percent of the sessions. Another 44 per cent attended between one and half of the sessions. Since there are no previous studies of this kind, it is difficult to know to what extent these are fine attendance rates. Still it is our impression that in the context of public schools in the Cape Town area, this level of attendance is quite high.
Further analyses focussed on characteristics of attenders and non-attenders. Did the intervention reach those students who are most likely to practice unsafe sex and thereby putting themselves at risk?
Considering all hypothesized risk markers, vulnerable adolescents had a lower rate of attendance at the educational sessions. They were accessed less by adolescents who had already had their sexual debut, compared with those who had not. They were attended less by adolescents who had been victims of interpersonal violence (bivariate analyses), victims of sexual violence (bivariate analyses), and perpetrators of IPV (bi- and multivariate analyses) compared to those who did not report these experiences. Early sexual initiation is a risk factor for STIs. Adolescents exposed to sexual violence and IPV are vulnerable to STIs and poor sexual and reproductive health outcomes. The education sessions were accessed less by participants with poorer scores on the mental health assessment and who had attempted self-harm, and adolescents who felt less connected to school.
Furthermore it turned out that girls were more likely than boys to attend the sessions. This is a positive finding in light of the fact that adolescent girls in South Africa (and in sub-Saharan Africa in general) are more at risk than boys of being infected with sexually transmitted diseases including HIV/AIDS. Girls are also at high risk of interpersonal violence and violence from intimate partners. Programmes to promote healthy sexual practices should preferably be carried out at school during school hours. Even when considerable efforts are made to motivate student participation, a substantial proportion of students do not participate at all or participate in less than half of the sessions (66.4 per cent in the Cape Town PREPARE intervention). And there is a tendency that students most at risk of interpersonal violence and sexually transmitted disease infections do not attend to the same extent as low risk students.

Effects of the Cape Town PREPARE intervention
Details about the Cape Town PREPARE intervention was described in the conceptual paper by Aarø and associates published in BMC Public Health in 2014. A total of 3454 students at 40 schools (20 in the intervention arm and 20 in the control arm) were involved in the study in Cape Town.

Twenty one sessions dealt with a large number of topics related to sexuality and violence. Activities which took place during the intervention included worksheets, classroom discussions, photo-novella, and students cooperating on constructing assertive messages. The curriculum focused on changing the unequal position of women and men in relationships and in society, and ideologies of male superiority that legitimise control of women by men. Some lessons focussed on sexual decision making within relationships. The intervention also aimed at increasing access to sexual- and reproductive health services and by attempting to change the school environment by reducing sexual violence and increasing feelings of safety by creating a school climate of intolerance towards violence.
Analyses of 28 social cognition sumscores and 14 behaviour variables at baseline did not reveal any significant differences between students in the intervention group and students in the control group.
This is most satisfactory and indicates that the process of randomly allocating schools to the two groups was quite successful.
Intervention took place during the six months period between baseline and the first follow up data collection. The first follow up data collection showed a number of significant “effects” of the intervention among attenders: Higher levels of knowledge regarding condom use and knowledge about HIV/AIDS and more positive attitudes (higher levels of “pros” and a lower level of “cons”) towards delaying sexual debut. There was also a significant reduction in “been bullied”. Among students who had attended 50 per cent of the sessions or more, significance was obtained for another seven outcomes. One of these outcomes was an increase in proportion who reported to have had their sexual debut. This latter finding may be explained as a selection effect. Students who were on the edge of having their sexual debut may have been more motivated to participate in an intervention intended to promote healthy sexual practices.
Many of the “effects” found among attenders were washed out when we examine all students in the intervention schools (including non-attenders). Three outcomes remained significant, namely knowledge about condom use, knowledge about HIV/AIDS and “been bullied”.

After 12 months (second follow-up data collection) only one effect remained significant for all students combined (including non-attenders), namely knowledge about condom use. Among the attenders there were two significant outcomes: Knowledge about condom use and knowledge about HIV/AIDS. Among those who attended 50 per cent or more of the sessions, another two oucome variables obtained significance: attitudes towards condom use (“cons”) and attitudes towards delaying sex (“cons”). Significance was not obtained for any of the behavioural outcomes after 12 months, not for the group as a whole, not for the attenders and not for those who attended half of the sessions or more.

To the extent that results from the PREPARE intervention can be compared with the results of the SATZ intervention, the results are more positive this time. But the effects of the PREPARE intervention are still not impressive. More analyses of data and elaboration of findings are needed in order to draw more firm conclusions. At this moment it seems that the PREPARE intervention in Cape Town needs further improvements before the programme can be recommended for use on a wider scale. It is also quite important to test out the programme when it is delivered at school, within school hours, and for all students.
The Cape Town team invested a lot of efforts in developing a strong intervention programme, in motivating students to participate in the intervention programme, and they carried out a study of high scientific quality. Although it opened up for some new research opportunities, the decision made by the Western Cape Department of Education that the intervention could not take place in school during school hours, was not particularly helpful.

Dar es Salaam
Formative research
The SATZ teacher’s and student’s manuals were reviewed, alongside 18 other classroom based methods and available text books in Tanzania to ensure gaps in these documents were filled while ensuring curriculum requirements were met. The PREPARE programme development was further informed through findings from the formative phase (literature review and primary qualitative data collection) stakeholder panels and working groups feed-back, framing of programme development using intervention mapping to map proximal learning objectives to theory, strategies and evaluation items and refined using the findings from piloting.
We used the evidence-based SATZ learners and teachers guides based on desk-top review findings, as a base document and developed these with more up to date content on scenarios from learners FGDs and IDIs, and refined strategies based on theories of change for class-room based content; we developed the peer-educators manual to complement the class room content and used theories for behavior change to inform strategies, focusing use of what were familiar media (local drama and dance and Swahili poetry (ngonjera) for activities to develop skills for healthy sexuality and HIV transmission avoidance content. For both class room and after-school weekly peer-educator led content we added a lesson planning guide, formatted to reflect lesson planning guides used by the Ministry of Education and Vocational Training in primary schools.

Pilot testing showed the need for adjustments in the methods, approaches, tools, and time constraints in the delivery in the classrooms and in the material itself. Additionally, it showed a need for cross disciplinary meetings between science teachers and teacher counsellors who were to lead the peer educators.
In Dar es Salaam, a number of procedures and techniques were employed in monitoring and evaluating the intervention. The process involved observation of implemented activities to evaluate implementation fidelity (content and teaching strategies) and extent of learners active participation, teacher’s feedback using a once weekly feed-back phone-call system where progress reports, challenges and solutions were shared with the program lead, random selection of 10% of learners workbooks per class to assess completion of assignments; and conducting post-intervention interviews (Key Informant Interviews (KIIs) and Focus Group Discussions (FGDs)) to assess how well or not the programme was received, what was useful for changing behaviours from the perspective of learners and receive perspectives from implementers on areas for programme improvement.
• Project Month 31-32: Each session of the intervention was observed at least twice, a total of 35 classroom sessions were observed. For the peer led component of the program, a total of 16 sessions were observed and four out of 19 YFS visits were observed.
• Project Month 33-36: A total of 68 scheduled interviews have been conducted (Learners FGDs n=19 [152 learners], Implementing teachers FGDs n=5 [30 teachers], Peer leaders FGDs n=5 [30 peer leaders], Parents FGDs n=2 [16 participants] and Academic coordinator FGDs n=2 [16 participants]; 9 KIIs with municipal education officer, the municipal academic coordinator for primary schools, municipal social welfare officer, 2 each implementing nurses, assistant medical officers and clinical officers from youth friendly services). An iterative process was used to collect data and develop a code book with codes and their descriptors. The qualitative data had been transcribed in word and translated from Swahili to English, uploading narratives into NVivo, validating the code book and coding the narratives is pending resources to purchase the NVivo 10 software.

• 5229 workbooks were distributed to learners in the 19 IV schools. Of those returned, 523 were randomly selected (10% per class) from implementing teachers, and have been linked by ID number with baseline data. The process of data entry was completed in project month 39 and analysis of workbooks is ongoing.
• During the period of intervention, implementers were called every end of the week. The main objective of these calls was to monitor weekly implementation of the three programs as well as to explore challenges faced and how the facilitating teachers and counsellors had resolved problems.

Effects of the Dar es Salaam PREPARE intervention
Details about the Dar es Salaam PREPARE intervention are presented in the conceptual paper published in BMC Public Health 2014 (Aarø et al., 2014). A total of 5091 students at 38 public schools in Dar es Salaam were involved in the Dar es Salaam PREPARE study.

In summary, the Dar es Salaam PREPARE intervention consisted of three components, one implemented by teachers, one by peer educators, and one was implemented by health care personnel during adolescents’ visits to youth friendly health service clinics. Three peer-led sessions taught over 8 hours and six teacher-led sessions taught over 11 hours were conducted. The teacher-led sessions were integrated in the primary school science curriculum and taught as 16 interactive teaching and learning sessions suited for large classes with some didactic lessons, each session lasting for 40 - 80 minutes. Peer-led lessons were implemented over nine weeks (once a week), each session lasting 60–90 minutes. The sessions which were part of the after-school life skills training curriculum, were designed to be interactive and teachers were available to offer support when needed.

The third component intended to link adolescents to information and services that will foster healthy sexuality. This component therefore promoted collaboration between schools and youth friendly health services, and increased the possibilities for access to sexuality and reproductive health information and services for young adolescents. Visits to health facilities were made and feedback sessions were conducted following the visits to gain views of adolescents on their experience of the services offered by the clinics.
Assessment of the intervention fidelity was done where members of the study team observed and rated approximately 25% of the teachers’ intervention sessions using a fidelity observation instrument that was developed by the study evaluation team. In addition, teachers, observers and peer educators recorded the tasks accomplished in each intervention session as well as time spent on each task. Data on the experiences, impressions of the flow, content and acceptance of the sessions were also collected.
Participants were selected from two streams of standard 5 and 6 in each school both for the intervention and control schools. Data were collected using a Swahili self-administered paper questionnaire administered in class under supervision of project staff. Teachers were not present during the administration of the questionnaire. The questionnaire collected information on sociodemographic characteristics of the participants, and various behavioural and social cognition measures relevant for the study. Repeated call-backs were done to those schools where a large number of participants were not available during initial data collection. Data were collect at baseline, 6 and 12 months following the intervention.
As already mentioned, a total of 5091 adolescents (aged 12 to 14) from 38 public primary schools in Kinondoni Municipality in Dar es salaam were recruited in this study. Of those who participated, 2503 (49.2%) were randomly allocated to the intervention arm and the rest allocated to the control arm.
No significant differences between intervention and control school students at baseline were found on demographic factors. Two significant differences were found on social cognition factors and behavioural variables. Among intervention school students the level of communication on sexuality issues with parents and friends was marginally higher. On the other hand, the socioeconomic status indicator (number of assets scale) showed a slightly higher mean among control group students. On all other variables tested, the differences were insignificant. The randomization procedure seems to have functioned reasonably well.
An extended generalized estimating equation modelling was performed to examine the effect of the PREPARE intervention on the mean score for action planning and actual behaviour variables while controlling for clustering effects.
There was an increase in means for action plan to delay sex and action plan to use condom among males during the period of 12 months of follow up for both intervention and control group and this changes did not differ significantly between the two groups. Sexual initiation decreased significantly among males in the intervention group as compared to those in the control group. Moreover, reported condom use increased significantly in both the intervention and the control arm, however, the increase was significant in the intervention group as compared to the control group.

With regards to female adolescents, action plan to use condom and sexual initiation were observed to have increased significantly in the intervention group as compared to the control groups. When this reporting takes place, analyses of effects on social cognition outcomes have not yet been completed.
The results for Dar es Salaam are highly encouraging since positive intervention effects were found on sexual transmission (debut) as well as on action planning for condom use (females) and reported condom use (males). The effects are clearly stronger than was the case during the SATZ intervention.
The relative risk for sexual transition was 1.9 for males and 1.6 for females in the control group in contrast to the intervention group. The intervention effects of the Dar es Salaam intervention may warrant nation-wide implementation of the programme.

Kampala
Formative research
In Kampala, qualitative studies were conducted during the formative phase and the intervention phase, as follows:
1. During the formative phase of PREPARE, qualitative data was collected using FGDs (Focus Group Discussions) and interviews with key informants, in order to: (i) describe adolescents and parents’ perceptions regarding parent child-communication on SRH issues, (ii) describe the school administrators’ perceptions about parent-child communication on SRH issues, (iii) to explore the content of parent-child communication on SRH, and (iv) explore how factors limiting parent-child communication could be addressed. The findings of the study were used in designing messages for inclusion in the intervention study as well as the design of research tools. Qualitative data from the formative phase of the study has been used to put together a draft manuscript that is soon ready for submission to a peer-reviewed journal.
2. In the development of the classroom based interventions we used FGDs in collection of data from adolescents regarding delayed sexual debut and use of condoms, this information was used in the development of the lesson plans for the classroom based component. Checklists were used to monitor implementation of the intervention in classrooms. After the intervention qualitative data was collected using FGDs and key informant interviews to: (i) assess adequacy and utility of the intervention, (ii) assess the level of satisfaction with the interventions. FGDs were conducted with students and parents in each of the schools and teachers were asked to write down their experience with the intervention. The findings of this study will be disseminated in a publication. Qualitative data from the post-intervention phase will be analysed in the coming month, and form the basis of another publication.

Effects of the Kampala PREPARE intervention
Details about the Kampala PREPARE intervention are presented in the conceptual paper published in BMC Public Health 2014 (Aarø et al., 2014).
The study involved 1502 students at 22 senior secondary schools in Kampala and Wakiso districts.
Eligible schools were restricted to public day schools attended by both boys and girls. After matching of schools, 11 schools were randomly allocated to the intervention condition and the other 11 schools served as controls. Sub-samples of students (and their parents/caregivers) were randomly selected from each school for inclusion in the Kampala PREPARE study.
The PREPARE Kampala intervention focussed on communication about sexuality issues between adolescents and their parents/caregivers. The intervention had three components: (i) classroom-based activities (sexual- and reproductive health issues integrated in English and Cristian Religious Education lessons), (ii) homework (involving a discussion between adolescents and their parents about a specific sexuality related topic), and (iii) a parent component (workshops for parents and a brochure targeting parents).
All the outcome variables were sumscores related to various aspects of such communication and included measures of: Communication frequency, degree of comfort (as opposed to discomfort) associated with communicating across generations on sexuality issues, assessment of how valuable such communication was perceived, amount of “danger” messages communicated by parents/caregivers, parental warmth, parental knowledge of child’s routine activities, legitimacy of parental authority regarding adolescent’s choice of boyfriend/girlfriend and alcohol use, and finally, legitimacy of parental authority regarding choice of leisure-time activities. All scales were constructed to be comparable (same number of items, same content, identical wording as far as practically possible) across generations.
Indicators of each domain were analysed with principal components analysis in order to secure unidimensionality of the items to be used in each sumscore. And the Cronbach’s alpha values were examined. Alpha values proved to be acceptable to quite high, ranging from .59 to .90 for parents/caregivers and from .64 to .91 among the adolescents.
Most parents/caregivers who participated in the study were female. The proportion of female caregivers in the intervention group was higher (65.1%) compared to those in the comparison group (57.1%) (p<.01). The mean age of parents/caregivers in both groups was approximately 40 years, and slightly more than two thirds of the parents/caregivers reported that they were Christians. More parents/caregivers in the intervention group (34.3%) had completed higher education compared to (21.5%) of the caregivers in the comparison group who had completed higher education. There was no difference between the groups with regard to mean number of possessions at home.

Analyses of differences in communication sumscores between intervention group and control group students and parents/caregivers at baseline revealed four significant differences (p<.05). Students in the intervention group had a higher mean score on parental warmth than students in the control group. Parents had higher mean score on monitoring of their children’s activities. Parents in the intervention group had higher mean score on legitimacy of parental authority with regard to deciding when the students can have boyfriend/girlfriend and with regard to alcohol use. Among students there was also a significant difference on this sumscore, but in the opposite direction. Instead of using regression analysis-based techniques to analyse intervention effects, it was decided to use a differences of differences approach, which is found to be more valid when there are significant differences between intervention group and control group at baseline.
Differences between the intervention group and the control group with regard to changes in scores on key variables were examined. Out of eight differences tested for adolescents and parents/guardians separately, six were significant (p<.05) for parents and four for adolescents. Significant effects in the desired directions for both adolescents and parents/caregivers were found for communication frequency, comfort of communication on sexuality issues, how valuable the communication was perceived, and “danger” communication. Two variables obtained significance among parents/caregivers only; knowledge of child’s routine activities and legitimacy of parental authority.
Significant effect sized varied from .17 to .47.

These results are most encouraging. The programme should be further refined, based on the implementation experiences, and may deserve countrywide dissemination in Uganda and perhaps beyond.

Limpopo
Formative research
The SATZ questionnaire was reviewed during the formative phase. Some questions were adopted or modified and included in the PREPARE survey among 1200 respondents. During intervention programme development, SATZ materials such as Teachers Manual and Learners Workbook were reviewed.
The Teacher Training took similar form as it was in SATZ. PREPARE focused on Life Orientation Teachers as well. Some knowledge-based chapters on HIV and AIDS were adopted from the SATZ material.
The pilot testing results were used to modify the instruments and intervention materials by incorporating views from schools and older adolescents for test in younger adolescents. In Limpopo, each Life Orientation teacher was given a checklist to indicate topics/Units of the intervention delivered. In addition, a project team member was assigned to each school and observed 40% of the delivery. Students’ workbooks were also checked to ensure fidelity. At the end of the intervention, we collected all the Learners’ workbooks and randomly selected 20% per school and examined/checked for completeness/response directions. Twenty male and 20 female students who participated in the intervention were interviewed and asked to complete a key tasks checklist.

Teachers, observers and students’ assessments of delivery were compared and students’ interviews were subjected to thematic analysis designed to detect informational, belief, motivational and confidence in changes in knowledge regarding HIV and AIDS misconceptions and possible behaviour skills changes.
An important element in the Limpopo arm of PREPARE was a survey among school students. The original sampe was 1200 students. After exclusion of students in order to obtain a more narrow (and relevant) age range, the sample consisted of 893 students. Measures were designed to investigate relationships between beliefs about condoms, HIV/AIDS and interpersonal relationships and two dependent measures, namely, motivation to use condoms and reported condom use. Hierarchical multiple regression showed that 10% of the variance in reported condom use was accounted for by condom use motivation and age. We then examined the correlates of condom use motivation.
Hierarchical multiple regression showed that 11 variables accounted for 49% of the variance in condom use motivation. The model corresponded closely to a modified theory of planned behaviour (TPB). Almost one third of the variance was accounted for by condom self-efficacy. In addition, attitudes towards condoms and, injunctive norms also accounted for significant proportions of the variance. Other cognitions including susceptibility to HIV and attribution of HIV infection to asexual sources such as witchcraft, spirits or supernatural forces added to the variance explained indicating that an expanded model of modifiable cognitions may be optimal when designing HIV preventive interventions among young South Africans. Beliefs to be targeted by the PREPARE intervention in Limpopo were to a large extent based on this survey, and so were instruments for evaluation of the intervention. A publication based on this early stage survey has been submitted and resubmitted (Devine-Wright and associates). The following intervention targets were identified:

Information
• A minority of young people are having sex.
• HIV is a primarily a sexually transmitted disease (including correction of misconceptions).
• Condom use is safe (including correction of misconceptions) .
• Consistent condom prevents sexual transmission of HIV.
• Anal sex is unusual and very risky.

Motivation
• Having sex is not so important for a young person.
• Young people in S Africa can avoid HIV infection (including correction of misconceptions).
• Others are using condoms – why aren’t you?
• It is not OK to force someone you know to have sex (with or without a condom).

Behavioural skills
• Carry a condom if you want to have sex.
• It is good to ask a sexual partner to use a condom.
• Unprotected sex does not mean commitment or love. Say, “No-condom-no-sex”.

Effects of the Limpopo PREPARE intervention
Details about the Limpopo PREPARE intervention are presented in the conceptual paper published in BMC Public Health 2014 (Aarø et al., 2014).
Discussions between teachers and public health specialists led to an integration of the 12 messages above into a programme which also focused on identifying and changing culture-specific beliefs which may undermine HIV-preventive information, motivation and action. The intervention targets identified through the IMB elicitation research were integrated into pre-existing health education programmes in schools which also focused on self-esteem and biological aspects of disease transmission.
Life-Orientation teachers already working in Limpopo schools were trained to deliver the intervention. The training for teachers in intervention schools took place over two weekends and was evaluated in terms of increased confidence in delivering intervention unit contents. Each 3 hour unit was divided into 3–10 key tasks to be completed by the teacher.
The programme was delivered in 5 three-hour school “units” over 5 weeks to grade 8 children who are typically aged 12–14. An overview of topics covered, objectives and sample activities is shown in Table 1 and teacher and student manuals for the intervention are available as online supplements to this article.

The first unit focused on personal and social identity including relationship with peers, experiences of violence and traditional and culture-specific religious beliefs. This unit also explored health motivation and motivation related to achievements and goals in life.

The second unit explored social identity in relation to what others are doing and thinking, especially in relation to sexual behaviour. Normative feedback was used to clarify that most young people of this age were not having sex or engaging in HIV-risk activities. The unit involved discussion of maintaining “girlfriend/boyfriend” status and “being in love” without becoming sexually active. This unit also explored gift giving as normative pressure on girls to have sex and how this can be resisted.

The third unit dealt with more difficult topics including coercive sex and sex and violence. Teachers endorsed girls’ right to wear “sexy” clothes and their right to say “no”. The unit also emphasised the need to be assertive and to protect against male violence. A series of culture-specific beliefs which may undermine anti-violence, contraceptive and HIV-preventive motivations were identified, named and challenged.

The fourth unit covered is contraceptives and HIV-preventive behavioural skills. This unit emphasized the availability and safety of condom use and advocated getting and carrying condoms when thinking about sex and using condoms during sex. The unit also explored monogamy and the advantages of being faithful to one partner. Specific condom use behavioural skills were discussed and anti-condom culture-specific beliefs named and challenged.

Finally, the fifth unit explored social identity construction and social influence processes including religious and peer influence. The importance of friends, community and family were acknowledged and the relationship between these social values and sexual behaviour and HIV prevention was explored.
To ensure delivery fidelity, a delivery checklist assessing whether each key task is delivered was developed for each unit. These checklists were completed by intervention teachers after each session and by researchers who observed 20% of intervention sessions. Twenty young men and 20 young women who participated in the intervention were interviewed at the end of the intervention and asked to complete the key tasks checklist. Teachers, observers and students’ assessments of delivery were compared and student interviews were subjected to thematic analysis designed to detect informational, belief, motivational and confidence in behaviour skills changes. Control schools were offered the PREPARE intervention once the evaluation was completed.

The evaluation questionnaire was based on the questionnaires tested during our elicitation research and tailored to assess change across the 12 intervention targets. Some parts of the questionnaire (standard core items) are identical to parts of questionnaires used in other sites that belong to the PREPARE project.

The Limpopo instrument assessed:
• Demographic and socio-economic characteristics (7 items);
• Experiences of bullying (3 items) and drinking (1 item);
• Knowledge and experience of HIV/AIDS (3 items);
• General beliefs e.g. about the future, religious beliefs, other people (11 items);
• Beliefs about HIV/AIDS (16 items), HIV primary prevention behaviours (11 items) and HIV secondary prevention behaviours (10 items);
• Beliefs about and attitudes towards condoms (38 items);
• Intentions related to future sexual practices (13 items);
• Beliefs, attitudes and descriptive norms in relation to sex (14 items);
• Recent sexual experiences (7 items);
• Previous sexual experiences (6 items);
• Recent use of condoms, experiences of and attitudes towards pressure, coercion and violence in relation to sex
• Self-efficacy in relation to condom use (7 items);
• Beliefs about HIV (9 items)
• Experience of completing the questionnaire (1 item).

Similar to the other sites, schools (n=24) were matched and within each pair one school was placed in the intervention group and the other one in the control group. There were twelve schools in each group. The numbers of students were 1585 in the intervention group and 1003 in the control group (total: 2588 students).
Since it turned out that there were a few significant differences between the intervention school students and the control school students at baseline, it was decided to use the differences between differences approach to estimating intervention effects.
Of 41 differences tested, eight were statistically significant (p<.05) and another eight were of borderline significance (p-value between .05 and .10.). All significant or borderline significant effects were in the desired direction. The effect sizes were generally small. Among the significant differences the effect sizes varied between .10 and .23 (plus or minus). Significant and positive effects (effects in the desired direction) were found for preparing for condom use, self-efficacy with regard to carrying condoms, condom use self-efficacy, condom use as a signal of trust, appreciation of boyfriend or girlfriend’s condom use, other condom-related beliefs, culture-specific beliefs (misconceptions) regarding how one might be infected, and culture-specific beliefs (misconceptions) regarding how one might stop the virus from spreading in the body. Borderline significant effects were found for positive attitudes towards abstinence, beliefs regarding the HIV virus, expectations with regard to being faithful in the future, attitudes towards condom use (condom use is important), carrying condoms means asking for sex, OK to carry condoms, infections happen by pure chance, and self-efficacy with regard to getting hold of and using condoms.
The intervention effects found in Limpopo are not impressive, but still encouraging for an intervention which is strongly integrated into normal curricula and delivered as a universal intervention (an intervention targeting all). It should be considered to build on experiences from the intervention which was carried out in Limpopo, adjust the programme according to these experiences, and make the programme available at schools throughout the Limpopo region.

Conclusions from other PREPARE publications
Already in 2011 Bastien and associates published a review of studies of parent-child communication about sexuality and HIV/AIDS in sub-Saharan Africa. The review included studies carried out in the period 1980-2011. Twenty three relevant studies were identified. Overall, findings demonstrate that discussions tend to be authoritarian and uni-directional, characterized by vague warnings rather than direct, open discussion. Moreover, parents and young people report a number of barriers to open dialogue, including lack of knowledge and skills, as well as cultural norms and taboos. Findings are less clear when it comes to associations between parental communication and adolescent sexual activity and contraception use. However, nascent indications from intervention research suggest positive findings with increases in frequency and comfort of discussions, among other outcomes.
This review was particularly important for the planning of the Kampala intervention, which addressed several of the problems identified in the review by Bastien and associates.
In another review from 2012 Bastien and associates examined use of Herpes simplex virus type 2 infection as a biomarker for sexual debut among young people in sub-Saharan Africa. This was important since use of biomarkers was considered relevant also for the PREPARE study. Based on our findings, use of HSV-2 as a biomarker for sexual debut was not recommended. This was due to its low transmission probabilities and the fact that HSV-2 prevalence is not 100% among potential sexual partners. No other useful biomarker relevant for PREPARE was identified, and it was concluded that there is a need to validate alternative biological measures. This review was particularly important for the planning of the interventions in Cape Town and Dar es Salaam, since behavioural outcomes of the interventions were aimed at in both sites.
De Koker and associates Published another review in 2014. This one was about intervention for preventing intimate partner violence. Eight articles reporting on six randomized controlled trials were retrieved. Four interventions contained both school and community components. We found positive intervention effects on IPV perpetration (three studies) and IPV victimization (one study). Compared with the studies with no effects on IPV, the effective interventions were of longer duration, and were implemented in more than one setting. There were quality issues in all six trials. It was concluded that Interventions targeting perpetration and victimization of IPV among adolescents can be effective. Those interventions are more likely to be based in multiple settings, and focus on key people in the adolescents’ environment. Future trials should assess perpetration and victimization of IPV among male and female adolescents with and without prior experiences with IPV, taking gender differences into account. This review was particularly important for the planning of the intervention in Cape Town, since this intervention included an violence prevention component.
A fourth review was produced by Mason-Jones and associates and published in 2012. This one focussed on the role of school-based health care in adolescent sexual, reproductive and mental health. Twenty seven studies were identified and reviewed. All studies, except one, was from North America, which to some extent limited the relevance of the review for sub-Saharan Africa. Only three measured adolescent sexual, reproductive, or mental health outcomes related to SBHC and none of the studies were randomized controlled trials. The remaining studies explored accessibility of services and clinic utilization or described pertinent contextual factors. It was concluded that there is a paucity of high quality research which evaluates SBHC and its effects on adolescent sexual, reproductive, and mental health. However, there is evidence that SBHC is popular with young people, and provides important mental and reproductive health services. Services also appear to have cost benefits in terms of adolescent health and society as a whole by reducing health disparities and attendance at secondary care facilities. However, clearer definitions of what constitutes school based health care and more high quality research is needed. This review was particularly important as a background for the interventions in Dar es Salaam and Cape Town, since both interventions included use of youth friendly health services.
A fifth review has been submitted by McClinton Appollis and associates. It is about adolescents’ and adults’ experiences of being surveyed about violence and abuse. Thirty publications met their inclusion criteria. Their results suggested that, whilst there were reports of discomfort, upset and other negative emotions, there were also reports of benefit, which accompanied such studies. In spite of the theoretical risk of ‘re-traumatization’, the majority of papers reviewed indicated that the risk/benefit ratio of asking sensitive questions regarding trauma and abuse was not unfavourable.
Although there have not been many studies investigating regrets of participation in sensitive research, the limited evidence about regrets suggested that, in spite of the sensitive nature, almost all participants did not regret participation. This review was particularly relevant for the planning of data collections in Cape Town, since reports about victimization was an important part of the questionnaires used in the baseline data collection as well as in the two follow up data collections.

Lessons learned and Recommendations
Cape Town:
In the Cape Town 6 month follow-up findings we showed that we impacted some of the theorized mediators of sexual risk behaviour in the desired direction. However this was not enough to change sexual behaviours. This suggests that there must be other barriers which were not targeted, that are serving to prevent participants changing their behaviour. Further research to identify and intervene on those barriers is necessary. It is possible that our intervention to change the school and social environment was not of sufficient strength and intensity and that it did not adequately influence those factors which constrain adolescents’ own decisions about sexual behaviour.
It is also important to improve on educational approaches and to apply these in interventions which take place in school during school hours. Even stronger emphasis on student involvement and mobilization of support from parents (consistent with experiences from the Kampala intervention) may contribute to stronger effects on social cognition factors as well as on behaviour.
In the 12 month follow up for most of the theorized mediators there were no differences between intervention and control arms. This suggests that we need to find ways to reinforce the changes and maintain the improvements over time. Adopting more formal strategies to integrate the intervention in the school's own intramural and extramural curriculum would be one way to do this. We were constrained due to the limitations imposed on us by the Department of Education.

Generally, establishing partnerships with Departments of Health and Education from the start of projects is of vital importance, as well as involving teachers and students in every step of intervention development.
Kampala:
It is possible to integrate sexual and reproductive health topics in the standard secondary school syllabus.
Lessons on sexual-related topics should be examinable in order for students, teachers and parents to take them seriously. There is a need to lobby the MoE/Curriculum development Centre to incorporate these topics in English and CRE during the next review cycle of secondary school curriculum.
There are still challenges when it comes to condom education with parents and teachers being reluctant to discuss condoms and condom use with adolescent children. Alternative ways of communicating this information need to be explored. E.g. peer- to-peer approaches. The results from the PREPARE Kampala intervention are most encouraging, and the programme deserves to be further refined and disseminated more widely.

Limpopo:
Culture-specific misconceptions regarding how HIV/AIDS spreads and how it can be prevented are widespread in the Limpopo province. Through the intervention it was shown that such beliefs can be changed through well planned, school-based programmes. Targeting such beliefs and misconceptions is important not only in Limpopo, but in several parts of sub-Saharan Africa. The intervention effects demonstrated in the PREPARE Limpopo intervention were rather modest. Efforts should therefore be made to improve the intervention package by for instance involving parents more strongly and by baking the belief change efforts into a more strongly community-oriented programme.
From the perspective of the PREPARE project as a whole we would like to point out that having PREPARE teams well-grounded in their respective country profiles and aware of relevant demographics, morbidity, and mortality statistics in each site was particularly useful.
It is important to build upon the strong engagement and continuously growing network involving European and African partners; likewise, utilisation of their achievements as a foundation for continued, strengthened, and sustainable work beyond the PREPARE project.
Incorporating both formative and summative evaluation strategies from the outset proved to be a good approach. Adopting an integrative approach to improve the research (both in terms of content and format) is essential for successful and sustainable capacity building. Finding out what you did well, or not so well, as well as tracking progress of local teams and resulting efforts is crucial.
Providing communication and ongoing support beyond the concrete research project enhanced sustainability and contributed to multiplication of efforts.

Dar es Salaam:
1) Fully piloting an intervention on a small scale and in a collaborative manner with stakeholders helps identify and correct potential barriers to implementation. Further, collaboration allows stakeholders to start developing a sense of ownership of the programme and therefore possibly leading to adoption.
2) Use of pilot rapid adapters as facilitators for teacher and peer-leader training in the main intervention, was cost effective and provided a powerful team for supervision and a brief midintervention retraining session with teachers.
3) Maintaining a working relationship with control schools enabled sharing of teaching materials (student, peer-led and teachers manuals and session planning sheets) by allowing trained teachers from intervention sites to build implementation capacity for delayed intervention schools to implement the PREPARE intervention.
4) Assuming locally available resources in schools will suffice for implementation of an interactive teaching and learning curriculum, where the norm is learning by rote is erroneous. In addition to creating and facilitating availability of teaching and learning resources, PREPARE also packaged all materials (except flip chart stands) in a plastic box, that allowed safe keeping and minimizing damage and loss while utilizing minimal space.
5) While carrying out the study in both semi-urban and urban settings across a municipality meant a richness of data, it unfortunately added to the costs of the programme. Visits to and from schools, many with poor accessibility by road, for sending intervention materials and conducting surveys greatly increased transport costs.

Intervention outcomes and next steps:
1) Theory led interventions that target comprehensively, proximal predictors for safe sex including knowledge and attitudes; coupled with building skills and elf-efficacy for specific healthy sexual behaviors (delaying sex initiation, using condoms consistently) can be effectively implemented by teachers amongst young adolescents.
2) While results of the findings of the PREPARE intervention were well received by key stakeholders in Dar es Salaam, models for approaching scale-up of effective school-based sexuality and sexual health education interventions for young adolescents in the Tanzanian context are needed.
3) The importance of cost analyses of such interventions in a low income context is high if findings are to influence policy and planning.

Potential impact and main dissemination activities and exploitation results
In all sites the results have been or are in the process of being communicated to ministries of health and ministries of education, NGOs, other important stakeholders as well as to the general public.
Since a number of positive outcomes of the interventions have been reported, we expect the PREPARE interventions to be utilized by relevant ministries in their future work with schools and communities. Results from the PREPARE study have already been presented at international conferences, a number of papers have already been published or submitted, and more papers will be submitted. The data that are available will be utilized in a number of new articles during the next couple of years. Analyses of possible mediators and moderators of intervention effects will be highlighted.
An advantage of school-based interventions, like the ones we delivered in Dar es Salaam, Limpopo and Kampala, targeting adolescents at an age when most of them are still school students, is that young people from all population segments are involved. This is important from a social inequality perspective. Since children also from low SES segments are involved, they may benefit from such interventions just as well as children from well educated, high income families. This kind of interventions therefore has the potential of contributing to reducing socioeconomic inequalities in health.

Potential Impact:
In all sites the results have been or are in the process of being communicated to ministries of health and ministries of education, NGOs, other important stakeholders as well as to the general public.
Since a number of positive outcomes of the interventions have been reported, we expect the PREPARE interventions to be utilized by relevant ministries in their future work with schools and communities. Results from the PREPARE study have already been presented at international conferences, a number of papers have already been published or submitted, and more papers will be submitted. The data that are available will be utilized in a number of new articles during the next couple of years. Analyses of possible mediators and moderators of intervention effects will be highlighted.

An advantage of school-based interventions, like the ones we delivered in Dar es Salaam, Limpopo and Kampala, targeting adolescents at an age when most of them are still school students, is that young people from all population segments are involved. This is important from a social inequality perspective. Since children also from low SES segments are involved, they may benefit from such interventions just as well as children from well educated, high income families. This kind of interventions therefore has the potential of contributing to reducing socioeconomic inequalities in health.

List of Websites:

http://org.uib.no/prepare/