CHAPTER TWO
2.5 Programmes and their effectiveness in promoting safer sexual behaviours
2.5.1 Programmes’ effectiveness in promoting safer sexual behaviours among adolescents Adolescents constitute one of the high-risk groups as far as HIV infection is concerned
However, because they are more likely than adults to adopt and maintain safer behaviour, this group is also key to halting the HIV/AIDS pandemic (UNICEF/UNAIDS/WHO, 2002). This can only be achieved by designing effective interventions targeted at adolescents of all categories, and meeting their risk-reduction needs by using a multi-disciplinary approach.
Studies have consistently proven that HIV knowledge does not translate into safer sexual behaviours in adolescents (Agius, Dyson, Pitts, Mitchell, & Smith, 2006; Martiniuk, O'Connor,
& King, 2003; Olayinka & Osho, 1997). Therefore, interventions have to go beyond merely providing information to adolescents, and should rather teach them the skills to negotiate and adopt safer sexual behaviours, as well as increase their self-efficacy.
Meanwhile, many stakeholders in Africa and elsewhere are apprehensive about providing adolescents with comprehensive sexuality education because they fear it will make them more promiscuous, and thus advocate an abstinence-only education (AOE) approach (Brocato, 2005), as is being promoted by the US government. However, US medical professional organisations oppose the idea of the AOE approach on ethical grounds, namely that it deliberately withholds or
102 distorts potentially life-saving information about contraception use and STI prevention (Santelli et al., 2006a, 2006b). However, the organisations support comprehensive sexuality education that includes information about abstinence and accurate information about contraception, human sexuality and STIs.
Brocato (2005) states that comprehensive sexuality education programmes are made up of age- appropriate, medically accurate information on a broad set of topics related to sexuality, including human development, reproductive health, relationships, body image, gender roles, abstinence, contraception, and STIs, including HIV/AIDS. They also teach skills necessary for communication, decision-making and negotiation, as well as provide information. In addition, these programmes promote gender equality, self-esteem building and respecting the rights of others.
Findings of a recent review of AOE and comprehensive sexuality education programmes designed to promote abstinence from sexual intercourse concluded that the latter demonstrates efficacy in delaying initiation of intercourse as well as promotes other protective behaviours such as condom use (D.B. Kirby, Laris, & Rolleri, 2007). The review found no evidence that AOE programmes demonstrate efficacy in delaying sexual initiation. In another study on comprehensive sexuality education, Dilorio, Resnicow, McCarty, De, Dudley, Wang, and Denzmore (2006) reported no difference among the study and control groups in terms of abstinence rates, but there were increases in HIV knowledge and condom use in the study groups.
In contrast, a study in the US involving seventh graders found that an AOE programme was effective in delaying sexual initiation (Weed, Ericksen, Lewis, Grant, & Wibberly, 2008).
Similarly, a longitudinal study of adolescents (12-16 years) revealed that a private pledge not to have sex until one is older reduced the likelihood of engaging in sexual intercourse and oral sex, while there was no association between a formal pledge and sexual behaviour (Bersamin, Walker, Waiters, Fisher, & Grube, 2005).
Comprehensive sexuality education programmes have been shown to be more effective in either delaying sexual debut or promoting safe sex in younger adolescents than in older sexually active
103 adolescents (Maticka-Tyndale, Wildish, & Gichuru, 2007a; Rusakaniko et al., 1997; Siegel, Aten, & Enaharo, 2001). This is an indication for that sexuality education should be introduced early in adolescence, before the onset of risky behaviours. In that way, adolescents‘ sexual debut could be delayed, and they could also be equipped to practise safe sex.
According to D. Kirby et al. (1994), characteristics of effective school-based sexual health interventions include:
Having clear and specific outcome behaviours
Using social learning theories as theoretical approaches for programme development
Involving students in experiential activities to personalise relevant basic information
Addressing social or media influences on sexual behaviours
Designing their content to reinforce group-specific values and norms
Providing opportunities to model and practise communication and negotiation skills A current review of school-based sexual health interventions in SSA revealed that such interventions were most effective in changing knowledge, followed by attitudes (Paul- Ebhohimhen, Poobalan, & van Teijlingen, 2008). Behavioural intentions were next, whereas the least significant changes were in actual behaviour. The study also found that:
Behavioural change in relation to abstinence was easier to effect among baseline virgins, while condom use appeared to be the more practicable sexual risk protective behaviour for adolescents who are already sexually active.
In addition, the authors emphasise that future interventions must take into account the duration of the study and monitor the progress of interventions, as well as address the following aspects:
Socio-economic status and religious affiliation to ensure better programme generalisability to other settings
Programmes should be conducted during school hours to allow opportunity for interactions between researchers and stakeholders
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Facilitators should be trained to deal with the particular sexual health intervention under evaluation instead of relying on their knowledge and perception of the same in order to effectively conduct the intervention and its monitoring
Studies should be based on both theoretical and research-based evidence from systematic reviews, qualitative studies and discrete choice experiments to allow for appropriate evaluation
Tactical communication of the goals of an intervention to stakeholders helps to ensure smooth delivery of interventions. For example, portraying an intervention as ‗a means of preventing STIs and HIV/AIDS‘ rather than as ‗providing sex education‘
Use of factorial designs to vary different programme components could highlight the strengths and weaknesses associated with using different media and facilitators in intervention design and delivery
Greater effectiveness is associated with using skills-based content in interventions, namely involving active participation of students and more lengthy interventions and offering the opportunity for repeated exposure to the same theme
Studies should be designed to report long-term (≥ one year) outcomes in order to reduce limitations in the long-term evidence regarding their effectiveness in preventing STI/HIV in SSA and to determine whether certain outcomes routinely demonstrate a delayed effect (i.e. a statistically significant outcome having not yet been reached)
Conducting more focused (e.g. limiting the types of schools, content of intervention and outcomes measured) interventions could be more informative in terms of drawing associations between both the internal and external validity of a study
Sub-analysis of outcomes based on pre-intervention sexual history helps in the development of group-specific interventions
105 2.5.2 Programmes’ effectiveness in promoting safer sexual behaviours among adolescents with disability
People with disability have almost been forgotten in the fight against HIV/AIDS. Intervention studies targeting PWD, particularly adolescents are sparse. Little is known about the relationship between HIV/AIDS and persons with pre-existing disability, and the available data are mainly exploratory and descriptive in nature. However, the basic principles and guidelines for standard sexuality and HIV/AIDS education for adolescents, as outlined above, can also be adapted for adolescents with disability. In addition, few studies have demonstrated the effectiveness of peer education among in-school deaf in Nigeria and video AIDS prevention training in persons with mild/moderate intellectual disability (Osowole & Oladepo, 2000; Samowitz et al., 1989).
Furthermore, provision of HIV prevention education to individuals with intellectual disability is more challenging than educating other PWD because cognitive impairments are likely to lead to unsafe sexual practices unless safe sex is repeatedly reinforced (Health and Disability Working Group, 2002). The need to provide concrete examples, use anatomically correct models and simple, unambiguous words has also been emphasised.
Moreover, sex education programmes for PWID should provide skills in the interpersonal domain in addition to sexuality information because these people have been found to lack knowledge about sex and intimacy (McCabe, Cummins, & Reid, 1994). Such programmes should also provide skills on how to recognise sexual abuse (Duke, 2006).
Di Giulio (2003) argues that persons with physical disability who are fully included in mainstream education can benefit from the standard sexuality and HIV education, and such opportunity provides them an added benefit of affirming their status as full sexual beings.
However, Di Giulio (2003) adds that in order for sexuality education for youth with disability to be comprehensive, such education must in addition to the standard information and skills include information and skills relevant to their specific disability. She states:
106 This would include but not limited to, addressing issues about how a particular disability may impact on sexual function, the suitability of particular contraceptive methods for people with different disabilities, and prevention of sexual exploitation and abuse.
Furthermore, Groce (2004b) proposes a general guideline for designing interventions for PWD as follows:
TYPE I: PWD being reached with HIV/AIDS messages as members of the general population with little or no additional adaptation or expense
TYPE II: Adapting HIV/AIDS outreach campaigns to ensure inclusion of PWD as members of the general population, with low to moderate additional expense
TYPE III: Making disability-specific adaptations to existing materials and developing new materials to reach individuals with disability outside the bounds of the general population, targeting harder-to-reach individuals and populations. This involves moderate to high cost