The Need to Promote Behaviour Change at the Cultural Level: One Factor Explaining the Limited Impact of the MEMA kwa Vijana Adolescent Sexual Health Intervention in Rural Tanzania

Published in the BMC Public Health Journal, this article discusses the MEMA kwa Vijana adolescent sexual health programme, exploring why such initiatives have had little impact in reducing the prevalence of HIV. According to the article, few of the many behavioural sexual health interventions in Africa have been rigorously evaluated, and, where biological outcomes have been measured, improvements have rarely been found. One of the most rigorous trials was of the multi-component MEMA kwa Vijana adolescent sexual health programme, which showed improvements in knowledge and reported attitudes and behaviour, but none in biological outcomes. This paper reviews the process evaluation findings, particularly in terms of contextual factors, and suggests that one important reason for this failure is that the intervention did not operate sufficiently at a structural level, particularly in regard to culture.

The paper explains that recent trials of behavioural sexual health programmes have used HIV as an outcome. Unfortunately, they all show that, despite improvements in knowledge and sometimes attitudes and reported behaviour, there were no improvements in biological outcomes, with one exception where herpes simplex virus 2, but not HIV, was lower in the intervention group. The multi-component MEMA kwa Vijana programme was evaluated through a large randomised controlled trial, which found no improvements in a range of biological outcomes. The trial was complemented by a large-scale, primarily qualitative, process evaluation.

MEMA kwa Vijana consisted of four components: limited community mobilisation; a teacher-led, peer-assisted curriculum of 10-15 40-minute sessions per year for the three upper years of primary school; training and supervision of health facility clinicians to encourage youth friendliness; and the marketing of subsidised condoms by out-of-school youth.

Both the qualitative process evaluation and the biological trial outcomes showed that, despite the school component of MEMA kwa Vijana being delivered, and engaged in by pupils, largely as intended, sexual risk behaviours were not reduced. This was attributed to various factors:

• Economic barriers - women's lower social status and economic dependence; sex as an important economic resource for women/girls; and poor quality of education and health services.
• Social status/esteem-related barriers - low status of youth; sexuality and norms around masculinity.
• Cultural barriers - contradictory sexual norms, secrecy, rapid partner change, and concurrency; negative condom beliefs and attitudes; low salience of, and perceived susceptibility to, HIV/AIDS; limited agency and short-term decision making.

On the other hand, the review found that schooling protected against sexual risks in several ways, highlighting the potential of interventions to prolong formal education. The small minority of youth with strong educational ambitions were more averse to sexual risk, perhaps because they were more future-oriented. As well, parents’ close supervision of, and connection with, their children have been associated with children’s healthier behaviours. Harnessing parental concern in other ways might make interventions more meaningful and effective.

According to the paper, the results suggest that while behavioural interventions often try to modify individual participants' attitudes and norms, interventions have not sufficiently reflected awarenesss of local community norms and culture. Changing these community norms will require more than a behavioural intervention for individual youth. Highlighting the significance of culture involves seeing it as structural, in that it constitutes an underlying pattern of the social system largely beyond individuals' control. Culture is dynamic and malleable, but to modify it involves recognising two essential features: that it is a shared way of thinking and a system of beliefs.

The paper states that the broad implications for future behavioural sexual health interventions are twofold: First, interventions are most likely to be effective if multi-level: addressing individual factors but also collective and structural barriers to behaviour change. Second, within these multi-level interventions there is a need to highlight the cultural level. For new norms to endure and generate different patterns of behaviour, they need to be confirmed and reinforced through social interaction. Therefore, the broader the group involved within a community, the more opportunity there is for such social interactions to occur, and their repetition sustains the impact of the original intervention.

The process evaluation findings suggest three cultural goals for interventions:

• Seek greater openness about sexual relationships so that risks can be discussed with parents, relationships can be strengthened through social endorsement, and partners become more accountable, which means tackling the culture of discretion.
• Develop stronger relationships that precede unprotected sex so that partners are more compatible and more able to resolve problems rather than change partners.
• Develop acceptable forms of masculinity for young men in which sexual experience is not a core component, for instance drawing on their love of sport or roles as fathers.

The findings also suggest three other kinds of structural level goals for adolescent HIV prevention interventions in Africa:

• Train and monitor teachers to: have supportive relationships with pupils, boost pupil confidence, encourage critical thinking, challenge dominant gender norms, and refrain from engaging in physical or sexual abuse.
• Ensure that all young women complete primary school, even if they become pregnant, and the majority go on to secondary schooling, for example through conditional cash transfers.
• Deliver income-generating or cash transfer schemes for young women to reduce their need for transactional sex and facilitate the selection of safer partners.

The paper concludes that the findings show that, at an individual level, social norms are extremely important, but these are elements of a broader culture which is shared, is made up of systems of belief, and should be regarded as structural. Preventative interventions need to address behaviour change at multiple levels simultaneously, including the oft neglected but very important level of culture.