Daniel Wight

Process evaluation of complex interventions: Medical Research Council guidance

Process evaluation is an essential part of designing and testing complex interventions. New MRC guidance provides a framework for conducting and reporting process evaluation studies

Limits of teacher delivered sex education: interim behavioural outcomes from randomised trial

Abstract Objective: To determine whether a theoretically based sex education programme for adolescents (SHARE) delivered by teachers reduced unsafe sexual intercourse compared with current practice. Design: Cluster randomised trial with follow up two years after baseline (six months after intervention). A process evaluation investigated the delivery of sex education and broader features of each school. Setting: Twenty five secondary schools in east Scotland. Participants: 8430 pupils aged 13-15 years; 7616 completed the baseline questionnaire and 5854 completed the two year follow up questionnaire. Intervention: SHARE programme (intervention group) versus existing sex education (control programme). Main outcome measures: Self reported exposure to sexually transmitted disease, use of condoms and contraceptives at first and most recent sexual intercourse, and unwanted pregnancies. Results: When the intervention group was compared with the conventional sex education group in an intention to treat analysis there were no differences in sexual activity or sexual risk taking by the age of 16 years. However, those in the intervention group reported less regret of first sexual intercourse with most recent partner (young men 9.9% difference, 95% confidence interval −18.7 to −1.0; young women 7.7% difference, −16.6 to 1.2). Pupils evaluated the intervention programme more positively, and their knowledge of sexual health improved. Lack of behavioural effect could not be linked to differential quality of delivery of intervention. Conclusions: Compared with conventional sex education this specially designed intervention did not reduce sexual risk taking in adolescents.

A bit more truthful: the validity of adolescent sexual behaviour data collected in rural northern Tanzania using five methods.

Objective: To assess the validity of sexual behaviour data collected from African adolescents using five methods. Methods: 9280 Tanzanian adolescents participated in a biological marker and face to face questionnaire survey and 6079 in an assisted self-completion questionnaire survey; 74 participated in in-depth interviews and 56 person weeks of participant observation were conducted. Results: 38% of males and 59% of females reporting sexual activity did so in only one of the two 1998 questionnaires. Only 58% of males and 29% of females with biological markers consistently reported sexual activity in both questionnaires. Nine of 11 (82%) in-depth interview respondents who had had biological markers provided an invalid series of responses about sex in the survey and in-depth interview series. Only one of six female in-depth interview respondents with an STI reported sex in any of the four surveys, but five reported it in the in-depth interviews. Conclusion: In this low prevalence population, biological markers on their own revealed that a few adolescents had had sex, but in combination with in-depth interviews they may be useful in identifying risk factors for STIs. Self-reported sexual behaviour data were fraught with inconsistencies. In-depth interviews seem to be more effective than assisted self-completion questionnaires and face to face questionnaires in promoting honest responses among females with STIs. Participant observation was the most useful method for understanding the nature, complexity, and extent of sexual behaviour.

Limits to modern contraceptive use among young women in developing countries: a systematic review of qualitative research

BackgroundImproving the reproductive health of young women in developing countries requires access to safe and effective methods of fertility control, but most rely on traditional rather than modern contraceptives such as condoms or oral/injectable hormonal methods. We conducted a systematic review of qualitative research to examine the limits to modern contraceptive use identified by young women in developing countries. Focusing on qualitative research allows the assessment of complex processes often missed in quantitative analyses.MethodsLiterature searches of 23 databases, including Medline, Embase and POPLINE®, were conducted. Literature from 1970–2006 concerning the 11–24 years age group was included. Studies were critically appraised and meta-ethnography was used to synthesise the data.ResultsOf the 12 studies which met the inclusion criteria, seven met the quality criteria and are included in the synthesis (six from sub-Saharan Africa; one from South-East Asia). Sample sizes ranged from 16 to 149 young women (age range 13–19 years). Four of the studies were urban based, one was rural, one semi-rural, and one mixed (predominantly rural). Use of hormonal methods was limited by lack of knowledge, obstacles to access and concern over side effects, especially fear of infertility. Although often more accessible, and sometimes more attractive than hormonal methods, condom use was limited by association with disease and promiscuity, together with greater male control. As a result young women often relied on traditional methods or abortion. Although the review was limited to five countries and conditions are not homogenous for all young women in all developing countries, the overarching themes were common across different settings and contexts, supporting the potential transferability of interventions to improve reproductive health.ConclusionIncreasing modern contraceptive method use requires community-wide, multifaceted interventions and the combined provision of information, life skills, support and access to youth-friendly services. Interventions should aim to counter negative perceptions of modern contraceptive methods and the dual role of condoms for contraception and STI prevention should be exploited, despite the challenges involved.

Impediments to safer heterosexual sex: a review of research with young people

This article reviews the existing British literature on the micro-social details of young peoples heterosexual encounters, emphasizing the cultural factors which impede the adoption of health education advice. Most of the findings cited come from qualitative projects that relied primarily on detailed interviews or group discussions. Six issues are highlighted: difficulties in talking about sex; the gender-role expectations brought to an encounter; the primary function of condoms as contraceptives; problems in buying, carrying and using condoms; how the stage of a particular relationship affects behaviour, and gendered power relations. Several important issues are not addressed in the existing literature. The survey data on sexual behaviour suggest that HIV has had little impact on sexual activity, apart from a reported increase in condom use. Qualitative studies reveal the moral categories, gender-role expectations, power inbalances and other cultural factors that prevent a high level of knowledge about HIV transmission from being translated into safer heterosexual behaviour. Their findings provide important insights into how realistic and practical safer sex messages are. They suggest that to promote health in respect to HIV it is necessary not only to advocate specific precautionary behaviour, such as using condoms, but also to address wider cultural issues relating to the taboos around the discussion of sex and the empowerment of women.

Transactional sex amongst young people in rural northern Tanzania: an ethnography of young women's motivations and negotiation

BackgroundMaterial exchange for sex (transactional sex) may be important to sexual relationships and health in certain cultures, yet the motivations for transactional sex, its scale and consequences are still little understood. The aim of this paper is to examine young womens motivations to exchange sex for gifts or money, the way in which they negotiate transactional sex throughout their relationships, and the implications of these negotiations for the HIV epidemic.MethodAn ethnographic research design was used, with information collected primarily using participant observation and in-depth interviews in a rural community in North Western Tanzania. The qualitative approach was complemented by an innovative assisted self-completion questionnaire.FindingsTransactional sex underlay most non-marital relationships and was not, per se, perceived as immoral. However, womens motivations varied, for instance: escaping intense poverty, seeking beauty products or accumulating business capital. There was also strong pressure from peers to engage in transactional sex, in particular to consume like others and avoid ridicule for inadequate remuneration.Macro-level factors shaping transactional sex (e.g. economic, kinship and normative factors) overwhelmingly benefited men, but at a micro-level there were different dimensions of power, stemming from individual attributes and immediate circumstances, some of which benefited women. Young women actively used their sexuality as an economic resource, often entering into relationships primarily for economic gain.ConclusionTransactional sex is likely to increase the risk of HIV by providing a dynamic for partner change, making more affluent, higher risk men more desirable, and creating further barriers to condom use. Behavioural interventions should directly address how embedded transactional sex is in sexual culture.

Process evaluation in complex public health intervention studies: the need for guidance

Public health interventions aim to improve the health of populations or at-risk subgroups. Problems targeted by such interventions, such as diet and smoking, involve complex multifactorial aetiology. Interventions will often aim to address more than one cause simultaneously, targeting factors at multiple levels (eg, individual, interpersonal, organisational), and comprising several components which interact to affect more than one outcome.1 They will often be delivered in systems which respond in unpredictable ways to the new intervention.2 Recognition is growing that evaluations need to understand this complexity if they are to inform future intervention development, or efforts to apply the same intervention in another setting or population.1 Achieving this will require evaluators to move beyond a ‘does it work?’ focus, towards combining outcomes and process evaluation. There is no such thing as a typical process evaluation, with the term applied to studies which range from a few simple quantitative items on satisfaction, to complex mixed-method studies exploring issues such as the process of implementation, or contextual influences on implementation and outcomes. As recognised within MRC guidance for evaluating complex interventions, process evaluation may be used to ‘assess fidelity and quality of implementation , clarify causal mechanisms and identify contextual factors associated with variation in outcomes’.1 This paper briefly discusses each of these core aims for process evaluation, before describing current Medical Research Council (MRC) Population Health Sciences Research Network (PHSRN) funded work to develop guidance for process evaluations of complex public health interventions. ### Intervention implementation An important role for process evaluations is to examine the quantity and quality of what was actually implemented in practice, and why. This may inform implementation of similar interventions elsewhere, and facilitate interpretation of intervention outcomes. While notions of standardisation are central to implementation assessment, the nature of …

Rationale and design of the MEMA kwa Vijana adolescent sexual and reproductive health intervention in Mwanza Region, Tanzania

Abstract Large-scale innovative, integrated, multifaceted adolescent sexual and reproductive health (ASRH) interventions are urgently needed in sub-Saharan Africa. Implementation through schools and health facilities may maximize intervention coverage and sustainability, however the impact of the use of these structures on intervention content and delivery is not well documented. This paper describes the rationale and design of a large-scale multifaceted ASRH intervention, which was developed and evaluated over three years in rural communities in Mwanza Region, North West Tanzania. The intervention comprised community mobilization, participatory reproductive health education in primary schools, youth-friendly reproductive health services and community-based condom provision for youth. We examine the effect of socioeconomic, cultural and infrastructural factors on intervention content and implementation. This paper demonstrates the means by which such interventions can be feasibly and sustainably implemented to a high standard through existing government health and school structures. However, the use of these structures involves compromise on some key aspects of intervention design and requires the development of complementary strategies to access out-of-school youth and the wider community.

Is Parenting Associated with Teenagers' Early Sexual Risk-Taking, Autonomy And Relationship with Sexual Partners?

CONTEXT: Extensive research has explored the relationship between parenting and teenagers’ sexual risk-taking. Whether parenting is associated with wider aspects of teenagers’ capacity to form satisfying sexual relationships is unknown. METHODS: Self-reported data were collected in 2007 from 1,854 students, whose average age was 15.5 years, in central Scotland. Multivariate analyses examined associations between parenting processes and sexual outcomes (delayed first intercourse, condom use and several measures reflecting the context or anticipated context of first sex). RESULTS: Parental supportiveness was positively associated with all outcomes (betas, 0.1–0.4), and parental values restricting intercourse were positively associated with all outcomes except condom use (0.1–0.5). Parental monitoring was associated only with delayed intercourse (0.2) and condom use (0.2); parental rules about TV content were associated with delayed intercourse (0.7) and expecting sex in a relationship, rather than casually (0.8). Frequency of parental communication about sex and parental values endorsing contraceptive use were negatively associated with teenagers’ delayed intercourse (–0.5 and –0.3, respectively), and parents’ contraceptive values were negatively associated with teenagers’ expecting sex in a relationship (–0.5). Associations were partly mediated by teenagers’ attitudes, including value placed on having sex in a relationship. CONCLUSIONS: Parents may develop teenagers’ capacity for positive and safe early sex by promoting skills and values that build autonomy and encourage sex only within a relationship. Interventions should promote supportive parenting and transmission of values, avoid mixed messages about abstinence and contraception, and acknowledge that teenagers may learn more indirectly than directly from parents about sex.

Difficulty and Diversity: The context and practice of sex education

The amount and nature of sex education provided varies from school to school. Teachers regard it as fraught with difficulties. It is a sensitive subject, there is no statutory training, no set curriculum or examinations to work towards, and it is one of many areas to be dealt with in an increasingly crowded Personal and Social Education programme by teachers who often also have a guidance role and a subject commitment. Drawing on data from 25 schools in Scotland, this paper considers how teachers talk about sex education, and looks at the factors that shape provision, at the school and teacher levels. The broad priorities of the senior management team, and the views and experience of key individuals, shape programme design. Within schools, the values, experiences and characteristics of individual classroom teachers are important in understanding what sex education is actually delivered, particularly where the Guidance Team lacks cohesion.