Understanding motives for intravaginal practices amongst Tanzanian and Ugandan women at high risk of HIV infection: the embodiment of social and cultural norms and well-being.

Some types of intravaginal practices (IVP) may increase the risk for HIV acquisition. This is particularly worrisome for populations with dual high prevalence of HIV and IVP. Women involved in transactional sex are at increased risk for HIV infection in sub-Saharan Africa. Social, cultural and economic influences are strong drivers of IVP in this population. To explore this, we carried out a qualitative research study to investigate the drivers and motivations for using IVP within a large observational study of women at high risk of HIV in Tanzania and Uganda from September 2008 to September 2009. Of the 201 women selected, 176 women took part in a semi-structured in-depth interview. Additionally, in Tanzania, eight focus group discussions among study participants and community members were carried out to obtain information on community norms and expectations. IVP were motivated by overlapping concerns with hygiene, morality, sexual pleasure, fertility, relationship security, and economic security. These motives were driven by the need to meet cultural and social expectations of womanhood, and at the same time attend to personal well-being. Among women involved in transactional sex in East Africa, interventions aimed at modifying or eliminating IVP should attend to local cultural and social norms as well as the individual as an agent of change.

Vaginal practices among women at high risk of HIV infection in Uganda and Tanzania: recorded behaviour from a daily pictorial diary.

BACKGROUND: Intravaginal practices (IVP) are highly prevalent in sub-Saharan African and have been implicated as risk factors for HIV acquisition. However, types of IVP vary between populations, and detailed information on IVP among women at risk for HIV in different populations is needed. We investigated IVP among women who practice transactional sex in two populations: semi-urban, facility workers in Tanzania who engage in opportunistic sex work; and urban, self-identified sex workers and bar workers in Uganda. The aim of the study was to describe and compare IVP using a daily pictorial diary. METHODOLOGY/PRINCIPAL FINDINGS: Two hundred women were recruited from a HIV prevention intervention feasibility study in Kampala, Uganda and in North-West Tanzania. Women were given diaries to record IVP daily for six weeks. Baseline data showed that Ugandan participants had more lifetime partners and transactional sex than Tanzanian participants. Results from the diary showed that 96% of Tanzanian participants and 100% of Ugandan participants reported intravaginal cleansing during the six week study period. The most common types of cleansing were with water only or water and soap. In both countries, intravaginal insertion (e.g. with herbs) was less common than cleansing, but insertion was practiced by more participants in Uganda (46%) than in Tanzania (10%). In Uganda, participants also reported more frequent sex, and more insertion related to sex. In both populations, cleansing was more often reported on days with reported sex and during menstruation, and in Uganda, when participants experienced vaginal discomfort. Participants were more likely to cleanse after sex if they reported no condom use. CONCLUSIONS: While intravaginal cleansing was commonly practiced in both cohorts, there was higher frequency of cleansing and insertion in Uganda. Differences in IVP were likely to reflect differences in sexual behaviour between populations, and may warrant different approaches to interventions targeting IVP. Vaginal practices among women at high risk in Uganda and Tanzania: recorded behaviour from a daily pictorial diary.

Vaginal practices diary: development of a pictorial data collection tool for sensitive behavioral data.

BACKGROUND: Intravaginal practices (IVP) are highly prevalent behaviors among women at increased risk for HIV in sub-Saharan Africa. IVP data collected by face-to-face interviews (FTFI) may be subject to recall or social desirability bias. Daily self-administered diaries may help to decrease bias associated with FTFI. IVP data from a diary and FTFI were compared during a multisite microbicide feasibility study in Tanzania and Uganda. METHODS: In all, 200 women were recruited and given diaries to complete daily for 6 weeks. Data obtained in the diary were compared with data from the FTFI during clinical visits to assess the consistency of reporting of IVP between the data collection methods. RESULTS: In Tanzania, proportions of overall vaginal cleansing and insertion were similar for the FTFI and the diary, but the diary indicated higher frequency of cleansing and use of a cloth or other applicator. In Uganda, proportions of overall vaginal cleansing were similar for FTFI and the diary, but the diary indicated higher frequency of cleansing, use of soaps and cloths for cleansing, and insertion. Most of the inconsistencies between the 2 data collection methods were from reported frequency of IVP or IVP related to sexual intercourse. CONCLUSIONS: The comparison of FTFI and the vaginal practice diary suggests that recall of IVP may be improved by a daily self-administered diary, especially for frequency of cleansing and cleansing in proximity to sexual intercourse. The vaginal practices diary can provide a more detailed understanding of IVP and aid in the interpretation of findings from FTFI.

Scaling up adolescent sexual and reproductive health interventions through existing government systems? A detailed process evaluation of a school-based intervention in Mwanza region in the northwest of Tanzania.

PURPOSE: There is little evidence from the developing world of the effect of scale-up on model adolescent sexual and reproductive health (ASRH) programmes. In this article, we document the effect of scaling up a school-based intervention (MEMA kwa Vijana) from 62 to 649 schools on the coverage and quality of implementation. METHODS: Observations of 1,111 students' exercise books, 11 ASRH sessions, and 19 peer-assistant role plays were supplemented with interviews with 47 ASRH-trained teachers, to assess the coverage and quality of ASRH sessions in schools. RESULTS: Despite various modifications, the 10-fold scale-up achieved high coverage. A total of 89% (989) of exercise books contained some MEMA kwa Vijana 2 notes. Teachers were enthusiastic and interacted well with students. Students enjoyed the sessions and scripted role plays strengthened participation. Coverage of the biological topics was higher than the psycho-social sessions. The scale-up was facilitated by the structured nature of the intervention and the examined status of some topics. However, delays in the training, teacher turnover, and a lack of incentive for teaching additional activities were barriers to implementation. CONCLUSIONS: High coverage of participatory school-based reproductive health interventions can be maintained during scale-up. However, this is likely to be associated with significant changes in programme content and delivery. A greater emphasis should be placed on improving teachers' capacity to teach more complex-skills-related activities. Future intervention scale-up should also include an increased level of supervision and may be strengthened by underpinning from national level directives and inclusion of behavioral topics in national examinations.

A process evaluation of the scale up of a youth-friendly health services initiative in northern Tanzania.

BACKGROUND: While there are a number of examples of successful small-scale, youth-friendly services interventions aimed at improving reproductive health service provision for young people, these projects are often short term and have low coverage. In order to have a significant, long-term impact, these initiatives must be implemented over a sustained period and on a large scale. We conducted a process evaluation of the 10-fold scale up of an evaluated youth-friendly services intervention in Mwanza Region, Tanzania, in order to identify key facilitating and inhibitory factors from both user and provider perspectives. METHODS: The intervention was scaled up in two training rounds lasting six and 10 months. This process was evaluated through the triangulation of multiple methods: (i) a simulated patient study; (ii) focus group discussions and semi-structured interviews with health workers and trainers; (iii) training observations; and (iv) pre- and post-training questionnaires. These methods were used to compare pre- and post-intervention groups and assess differences between the two training rounds. RESULTS: Between 2004 and 2007, local government officials trained 429 health workers. The training was well implemented and over time, trainers' confidence and ability to lead sessions improved. The district-led training significantly improved knowledge relating to HIV/AIDS and puberty (RR ranged from 1.06 to 2.0), attitudes towards condoms, confidentiality and young people's right to treatment (RR range: 1.23-1.36). Intervention health units scored higher in the family planning and condom request simulated patient scenarios, but lower in the sexually transmitted infection scenario than the control health units. The scale up faced challenges in the selection and retention of trained health workers and was limited by various contextual factors and structural constraints. CONCLUSIONS: Youth-friendly services interventions can remain well delivered, even after expansion through existing systems. The scaling-up process did affect some aspects of intervention quality, and our research supports others in emphasizing the need to train more staff (both clinical and non-clinical) per facility in order to ensure youth-friendly services delivery. Further research is needed to identify effective strategies to address structural constraints and broader social norms that hampered the scale up.

Scaling up a school-based sexual and reproductive health intervention in rural Tanzania: a process evaluation describing the implementation realities for the teachers.

Little is known about the nature and mechanisms of factors that facilitate or inhibit the scale-up and subsequent implementation of school-based adolescent sexual and reproductive health (ASRH) interventions. We present process evaluation findings examining the factors that affected the 10-fold scale-up of such an intervention, focussing on teachers' attitudes and experiences. Qualitative interviews and focus group discussions with teachers, head teachers, ward education coordinators and school committees from eight schools took place before, during and after intervention implementation. The results were triangulated with observations of training sessions and training questionnaires. The training was well implemented and led to some key improvements in teachers' ASRH knowledge, attitudes and perceived self-efficacy, with substantial improvements in knowledge about reproductive biology and attitudes towards confidentiality. The trained teachers were more likely to consider ASRH a priority in schools and less likely to link teaching ASRH to the early initiation of sex than non-trained teachers. Facilitating factors included teacher enjoyment, their recognition of training benefits, the participatory teaching techniques, support from local government as well as the structured nature of the intervention. Challenges included differential participation by male and female teachers, limited availability of materials and high turnover of trained teachers.

Partnering to proceed: scaling up adolescent sexual reproductive health programmes in Tanzania. Operational research into the factors that influenced local government uptake and implementation.

BACKGROUND: Little is known about how to implement promising small-scale projects to reduce reproductive ill health and HIV vulnerability in young people on a large scale. This evaluation documents and explains how a partnership between a non-governmental organization (NGO) and local government authorities (LGAs) influenced the LGA-led scale-up of an innovative NGO programme in the wider context of a new national multisectoral AIDS strategy. METHODS: Four rounds of semi-structured interviews with 82 key informants, 8 group discussions with 49 district trainers and supervisors (DTS), 8 participatory workshops involving 52 DTS, and participant observations of 80% of LGA-led and 100% of NGO-led meetings were conducted, to ascertain views on project components, flow of communication and decision-making and amount of time DTS utilized undertaking project activities. RESULTS: Despite a successful ten-fold scale-up of intervention activities in three years, full integration into LGA systems did not materialize. LGAs contributed significant human resources but limited finances; the NGO retained control over finances and decision-making and LGAs largely continued to view activities as NGO driven. Embedding of technical assistants (TAs) in the LGAs contributed to capacity building among district implementers, but may paradoxically have hindered project integration, because TAs were unable to effectively transition from an implementing to a facilitating role. Operation of NGO administration and financial mechanisms also hindered integration into district systems. CONCLUSIONS: Sustainable intervention scale-up requires operational, financial and psychological integration into local government mechanisms. This must include substantial time for district systems to try out implementation with only minimal NGO support and modest output targets. It must therefore go beyond the typical three- to four-year project cycles. Scale-up of NGO pilot projects of this nature also need NGOs to be flexible enough to adapt to local government planning cycles and ongoing evaluation is needed to ensure strategies employed to do so really do achieve full intervention integration.