The World Starts With Me: Using Intervention Mapping for the Systematic Adaptation and Transfer of School-Based Sexuality Education from Uganda to Indonesia

This paper describes the use of a systematic approach to programme adaptation using "Intervention Mapping (IM)", a protocol for the development of evidence-based behaviour change interventions.  This case study shows the use of IM to adapt the school-based sexuality education programme "The World Starts With Me (WSWM)”, an HIV/AIDS prevention and sexuality education programme, from its original application in Uganda to application in Indonesia.

Challenges in this process include the identification of WSWM core elements that relate to the programme's effectiveness while making changes that enhance acceptance in the new context and for the new priority group. [Footnotes have been removed by the editor throughout.]

The WSWM programme was originally developed in 2002 by SchoolNet Uganda in collaboration with two Dutch organisations, Rutgers WPF and Butterfly Works. The IM approach helped to systematically address the complexity and challenges of programme adaptation and to find a balance between preservation of essential programme elements (i.e., logic models - "A logic model sets out how an intervention (such as a project, a program, or a policy) is understood or intended to produce particular results." Wikipedia) that may be crucial to the programme's effectiveness, including key objectives and theoretical behaviour change methods, and the adaptation of the programme.

"WSWM is a computer-based programme complemented with teacher-led activities. A meta-analysis shows that computer technology-based programmes have similar efficacy to more traditional human-delivered interventions with regard to increased condom use and reducing sexual activity, numbers of sex partners and incident sexually transmitted infections (STIs). Given their low cost to deliver, ability to customize intervention content, flexible dissemination channels and attractiveness to young people, computer technology-based interventions represent a promising strategy to deliver HIV/AIDS risk reduction programmes. In addition, computer assignments make interventions such as WSWM a student-driven programme, unburdening teachers from initiating discussions about sensitive issues such as sexuality."

IM steps, taken from the IM toolkit, used specifically for adaptation include:

• Step 1. Needs assessment/situation analysis - Planners use a logic model to analyse causes of sexual and reproductive health problems, including behaviours and their determinants in at-risk groups.
• Step 2. Performance objectives and change objectives - Three foci are:

1. selected health-promoting behaviours of the at-risk population (for example, sexually active young people use condoms correctly and consistently) and of relevant ‘actors’ in the environment (for example, health care providers provide condoms to young people);
2. performance objectives of each behaviour (for example, negotiating condom use with a sexual partner, obtaining condoms, taking condoms along, correct use of condoms, maintained condom use); and
3. selected change objectives, i.e., describing change in behavioural and environmental determinants (for example, desired change in beliefs, attitudes, perceived social norms, self-efficacy, and skills that are needed to accomplish the performance objectives.)

• Step 3. Theoretical behaviour change methods and practical applications - The Indonesian planning group analysed the original theoretical methods and practical applications, including participatory methods, to identify whether they would fit with the Indonesian youth and in the Indonesian school setting. (Cultural acceptance of such things as a condom demonstration were analysed and, in this case, deferred to an out-of-school organisation.)
• Step 4. Programme production - Among other things, planners considered age, gender, literacy, ethnicity, and urban/rural residence in adapting the programme, including characters, games, and other visuals, and, in particular, languages, some of which did not have words for former taboos. Local "street" language was used in some cases; in other cases, English was used. Pre-testing was done.
• Step 5. Planning adoption and implementation - Planners analysed the willingness of intended adopters and implementers of the new programme and modified the programme to obtain fidelity across adoption, implementation, and maintenance. Organisational readiness was assessed, and new performance objectives added for the Ministry of Education.
• Step 6. Planning for evaluation - Evaluation planning included an effectiveness questionnaire and a process evaluation design. A process evaluation result, for example, included: "Despite more in-depth training for Indonesian teachers than in Uganda, the process evaluation in Indonesia showed that the support and training for teachers do not meet their needs to be able to deal with conflicting norms in society and the school environment related to sexuality."

The study concludes that the adaptation process resulted in changes to the WSWM programme, including objectives, practical applications, and programme materials, but differences dominated the process of analysis, catalysing adaptive changes which may have jeopardised core elements, while some differences went unaddressed and may have jeopardised uptake. However, "IM provided a useful, in-depth framework.... [and] resulted in an adapted programme that was well accepted by decision makers and is being implemented with good reach into the priority population and good fidelity to the intended theoretical methods and practical applications."