Categories of interventions

School-based interventions can be categorized according to at least three different dimensions. These are described below. (In reviews of school-based interventions, whether the school was primary, secondary or post-secondary might be considered important. However, in this review, all of the studies of interventions in primary schools were conducted in Africa and the age range of the youths who participated - 10 to 18 years - was within the age range of youths in secondary schools in other developing countries - 10 to 25 years. Thus, studies were not grouped by school level in this review.)

5.1.3.1 Curriculum-based versus non-curriculum-based

Curriculum-based interventions are often more intensive and more structured than non-curriculum-based interventions. In addition, curriculum-based interventions are more likely to be based on theory and previous research and may have been extensively pilot-tested and sanctioned by the appropriate authorities. The curricula serve to guide and inform the educators, and their use may overcome or ameliorate some of the educators' personal prejudices or limitations in teaching skills. These characteristics may enhance the effectiveness of these interventions.

Non-curriculum-based interventions include a variety of activities such as one-on-one spontaneous or opportunistic counselling about sexual activity and HIV while the student is on school grounds, school health fairs, dramas that present stories about HIV during school assemblies, the use of posters or leaflets, or combinations of these. Some of these activities may be easier to implement in schools, at least initially, because they may not require that teachers be trained. In addition, some people have argued that spontaneous one-on-one interaction between educators and youths may be more effective, given the personal nature of sexual behaviour. However, such interactions require a degree of sensitivity, skill and empathy that may be beyond the scope of many implementers or may necessitate a high level of training.

5.1.3.2 Interventions with and without characteristics of effective curriculum-based interventions

There are a variety of other characteristics of interventions, especially curriculum-based interventions, that may affect their effectiveness (for example, the focus of the activities, the information provided and the instructional methods implemented).

In developed countries, there have been at least 65 evaluations of curriculum-based sex education and HIV education interventions, and there have also been additional studies of non-curriculum-based interventions. Reviews of these studies have identified some of the characteristics of interventions believed to be important in producing behavioural change (12, 14, 17-21).

While these characteristics of effective interventions have not been derived from interventions used primarily in developing countries, they nevertheless provide a potential set of guidelines that can be used to assess these interventions in developing countries. The most recent set of characteristics identified by Kirby et al. (12) is based on the greatest number of studies and includes some studies from developing countries. That review identified 17 characteristics that appear to distinguish effective programmes and that describe programme development, the curricula and programme implementation. These characteristics are described in Box 5.1.

Box 5.1

Characteristics of effective curriculum-based programmes

Developing the curriculum

1. Involve multiple people with different backgrounds in theory, research and sex/HIV education.

Content

Curriculum goals and objectives

1. Focus on clear health goals, such as theprevention of STIsa and HIV and/or pregnancy.

Implementation

1. Secure at least minimal support from appropriate authorities, such as ministries of health, school districts or community organizations.

2. Assess relevant needs and assets of target group.

2. Focus narrowly on specific behaviours leading to these health goals (such as abstaining from sex or using condoms or other contraceptives); give clear messages about these behaviours; and address situations that might lead to them and how to avoid them.

2. Select educators with desired characteristics, train them and provide monitoring, supervision and support.

3. Use a logic model approach to develop the curriculum that specifies the health goals, the behaviours affecting those health goals, the risk and protective factors affecting those behaviours, and the activities addressing those risk and protective factors.

4. Design activities consistent with community values and available resources (such as staff time, staff skills, facility space and supplies).

3. Address multiple sexual-psychosocial risk and protective factors affecting sexual behaviours (such as knowledge, perceived risks, values, attitudes, perceived norms and self-efficacy).

Activities and teaching methods

4. Create a safe social environment in which youths can participate.

3. If needed, implement activities to recruit and retain youths and overcome barriers to their involvement (for example, publicize the programme, offer food or obtain consent from youths or parents).

4. Implement virtually all activities as designed.

5. Pilot-test the program.

5. Include multiple activities to change

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