Applying Intervention Mapping to develop a community-based intervention aimed at improved psychological and social well-being of unmarried teenage mothers in Uganda.

Out-of-wedlock pregnancy among adolescents in sub-Saharan Africa is a major concern, because of its association with health, social, psychological, economic and demographic factors. This article describes the development of the Teenage Mothers Project, a community-based intervention to improve psychological and social well-being of unmarried teenage mothers in rural Uganda. We used Intervention Mapping (IM) for systematically developing a theory and evidence-based comprehensive health promotion programme. A planning group consisting of community leaders, teenage mothers, staff of a community-based organization and a health promotion professional was involved in the six steps of IM: needs assessment, programme objectives, methods and applications, intervention design, planning for adoption and implementation and planning for evaluation. The programme includes five intervention components: community awareness raising, teenage mother support groups, formal education and income generation, counselling, and advocacy. The intervention components are based on a variety of theoretical methods, including entertainment education, persuasive communication, mobilization of social networks and social action. In conclusion, IM facilitated the planning group to structure the iterative, bottom-up, participatory design of the project in a real-life setting and to use evidence and theory. The article provides suggestions for the planning of support interventions for unmarried teenage mothers.

Implementation of The World Starts With Me, a comprehensive rights-based sex education programme in Uganda.

This article presents a process evaluation of the implementation of the sex education programme the World Starts With Me (WSWM) for secondary school students in Uganda. The purpose of this mixed-methods study was to examine factors associated with dose delivered (number of lessons implemented) and fidelity of implementation (implementation according to the manual), as well as to identify the main barriers and facilitators of implementation. Teachers' confidence in teaching WSWM was negatively associated with dose delivered. Confidence in educating and discussing sexuality issues in class was positively associated with fidelity of implementation, whereas the importance teachers attached to open sex education showed a negative association with fidelity. Main barriers for implementing WSWM were lack of time, unavailability of computers, lack of student manuals and lack of financial support and rewards. Other barriers for successful implementation were related to high turnover of staff and insufficient training and guidance of teachers. Teachers' beliefs/attitudes towards sexuality of adolescents, condom use and sex education were found to be important socio-cognitive factors intervening with full fidelity of implementation. These findings can be used to improve the intervention implementation and to better plan for large-scale dissemination of school-based sex education programmes in sub-Saharan Africa.

Psychosocial correlates of the motivation to abstain from sexual intercourse among Indonesian adolescents.

OBJECTIVES: Adolescents in Indonesia have limited access to sexuality education, resulting in increased risk of sexually transmitted infections and unplanned pregnancies. This study aimed to understand psychosocial correlates of sexual abstinence intentions to inform future sexuality education. METHODS: Data were collected in 79 secondary schools among 2315 students, aged 14-20 years, in Jambi, Lampung, Jakarta and Bali. A self-completed questionnaire measured attitudes, risk perception, subjective norms, perceived behavioural control and intentions towards sexual abstinence. RESULTS: Significant associations with intention to abstain from sexual intercourse were found for experience with sexual intercourse, perceived behavioural control, attitude and subjective norms of peers and parents, explaining 31% of the variance in abstinence intention. CONCLUSIONS: To promote adolescents' informed sexual decision-making, sexuality education programmes in Indonesia may benefit from addressing past sexual behaviour and perceived behavioural control, subjective norms of peers and attitudes.

Qualitative evaluation of the Teenage Mothers Project in Uganda: a community-based empowerment intervention for unmarried teenage mothers.

BACKGROUND: A large proportion of unmarried teenage mothers in Uganda face physical, psychological, and social problems after pregnancy and childbirth, such as obstetric complications, lack of education, and stigmatisation in their communities. The Teenage Mothers Project (TMP) in Eastern Uganda empowers unmarried teenage mothers to cope with the consequences of early pregnancy and motherhood. Since 2000, 1036 unmarried teenage mothers, their parents, and community leaders participated in economic and social empowerment interventions. The present study explored the changes resulting from the TMP as well as factors that either enabled or inhibited these changes. METHODS: Semi-structured interviews (N = 23) were conducted with former teenage mothers , community leaders, and project implementers, and lifeline histories were obtained from former teenage mothers (N = 9). Quantitative monitoring data regarding demographic and social characteristics of teenage mother participants (N = 1036) were analysed. RESULTS: The findings suggest that, overall, the TMP seems to have contributed to the well-being of unmarried teenage mothers and to a supportive social environment. It appears that the project contributed to supportive community norms towards teenage mothers' position and future opportunities, increased agency, improved coping with early motherhood and stigma, continued education, and increased income generation by teenage mothers. The study findings also suggest limited change in disapproving community norms regarding out-of-wedlock sex and pregnancy, late active enrolment of teenage mothers in the project (i.e., ten months after delivery of the child), and differences in the extent to which parents provided support. CONCLUSIONS: It is concluded that strengths of the community-based TMP seem to be its socio-ecological approach, the participatory planning with community leaders and other stakeholders, counselling of parents and unmarried teenage mothers, and the emphasis on education and income generation. The project can improve by earlier active participation of unmarried pregnant adolescents and increased support for parents.

Correlates of delayed sexual intercourse and condom use among adolescents in Uganda: a cross-sectional study.

BACKGROUND: Comprehensive sex education, including the promotion of consistent condom use, is still an important intervention strategy in tackling unplanned pregnancies, HIV/AIDS and sexually transmitted infections (STIs) among Ugandan adolescents. This study examines predictors of the intention to use a condom and the intention to delay sexual intercourse among secondary school students (aged 12-20) in Uganda. METHODS: A school-based sample was drawn from 48 secondary schools throughout Uganda. Participants (N = 1978) completed a survey in English measuring beliefs regarding pregnancy, STIs and HIV and AIDS, attitudes, social norms and self-efficacy towards condom use and abstinence/delay, intention to use a condom and intention to delay sexual intercourse. As secondary sexual abstinence is one of the recommended ways for preventing HIV, STIs and unplanned pregnancies among the sexually experienced, participants with and without previous sexual experience were compared. RESULTS: For adolescents without sexual experience (virgins), self-efficacy, perceived social norms and attitude towards condom use predicted the intention to use condoms. Among those with sexual experience (non-virgins), only perceived social norm was a significant predictor. The intention to delay sexual intercourse was, however, predicted similarly for both groups, with attitudes, perceived social norm and self-efficacy being significant predictors. CONCLUSIONS: This study has established relevant predictors of intentions of safe sex among young Ugandans and has shown that the intention to use condoms is motivated by different factors depending on previous sexual experience. A segmented approach to intervention development and implementation is thus recommended.

The World Starts With Me: a multilevel evaluation of a comprehensive sex education programme targeting adolescents in Uganda.

BACKGROUND: This paper evaluates the effect of the World Starts With Me (WSWM), a comprehensive sex education programme in secondary schools in Uganda. The aim of the present study was to assess the effects of WSWM on socio-cognitive determinants of safe sex behaviour (delay; condom use and non-coercive sex). METHODS: A survey was conducted both before and immediately after the intervention among students in intervention (N = 853) and comparison (N = 1011) groups. A mixed model repeated measures analysis was performed to assess the effectiveness of the WSWM programme on the main socio-cognitive determinants of safe sex behaviour at post-test. A similar post-hoc comparison was made between schools based on completeness and fidelity of implementation of WSWM. RESULTS: Significant positive effects of WSMW were found on beliefs regarding what could or could not prevent pregnancy, the perceived social norm towards delaying sexual intercourse, and the intention to delay sexual intercourse. Furthermore, significant positive effects of WSWM were found on attitudes, self-efficacy and intention towards condom use and on self-efficacy in dealing with sexual violence (pressure and force for unwanted sex). A reversed effect of intervention was found on knowledge scores relating to non-causes of HIV (petting, fondling and deep kissing). A follow-up comparison between intervention schools based on completeness of the programme implementation revealed that almost all significant positive effects disappeared for those schools that only implemented up to 7 out of 14 lessons. Another follow-up analysis on the basis of implementation fidelity showed that schools with a "partial" fidelity score yielded more significant positive effects than schools with a "full" fidelity of implementation score. CONCLUSIONS: The study showed an intervention effect on a number of socio-cognitive determinants. However, the effectiveness of WSWM could be improved by giving more systematic attention to the context in which such a programme is to be implemented. Implications for the systematic development and implementation of school-based safe sex interventions in Uganda will be discussed.