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

1. 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 FaustineNjau (MD) Supervisor: Elia J Mmbaga (MD, MPH, Phd)

2. Perspective • This intervention evaluation uses baseline and first follow-up data • Six months since baseline survey

3. 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: • To compare baseline socio-demographic and household characteristics of primary school aged children from intervention and control schools in Dar es salaam • To compare baseline proximal determinants of sexual debut and condom use among primary school children from intervention and control school in Dar Es Salaam • To determine the baseline proportion of sexual debut and condom use among primary school children by intervention status in Dar Es Salaam • To determine the change in the determinants of sexual debut and condom use among primary school children following the PREPARE intervention • To determine changes in sexual behavior immediately after intervention

4. Materials and Analysis Plan

5. 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 clusteringat school level • We used the Difference in Difference model to determine the effect of the intervention on outcomes

6. 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

7. Results

8. 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

9. BL: Socio-demographic characteristics

10. Intervention effects on knowledge and myths * <0.05; ** <0.001

11. Intervention effects Condom use and delaying sex attitudes * <0.05; ** <0.001

12. Intervention effects: Norms and self-efficacy measures * <0.05; ** <0.001

13. Intervention effects: Communication and intentions * <0.05; ** <0.001

14. 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.

15. Intervention effects: Condom Use At 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

16. 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

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

18. 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

19. 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

20. 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