Posted by Maria Codina on July 9, 2019 at 2:00 pm
School-based sexuality education in Tanzania often does not meet learners’ needs. This paper reflects on the findings of a study that compared two secondary school-based sexuality education programmes: the Dance4Life sexuality education edutainment approach implemented by Restless Development, a non-governmental organisation (intervention), and an HIV prevention education approach implemented by the government (comparison), to understand into what extent a peer-led edutainment approach can be beneficial in increasing young people’s empowerment, as measured by knowledge, life skills and self-efficacy, ultimately contributing to improved sexual and reproductive health outcomes. Findings from an exploratory quantitative and qualitative study among secondary school students aged 14-24 years from four intervention schools (n=96) and two comparison schools (n=49) indicate that a peer-led edutainment approach can increase students’ knowledge levels of HIV and AIDS and contraception and their life skills, such as the ability to solve problems and to make informed decisions, higher self-esteem and confidence. These findings support the growing body of literature that a peer-led edutainment approach and implementation fidelity can improve the effectiveness of school-based sexuality education in Tanzania.
Key words: peer education, comprehensive sexuality education, edutainment, empowerment, secondary schools, Tanzania.
Since the 1994 International Conference on Population and Development (ICPD), many interventions have been developed and implemented to realise young people’s sexual and reproductive health and rights worldwide (Fathalla 2015; Haberland and Rogow 2015; Chandra-Mouli, Lane, and Wong 2015). Nowadays, there is ample knowledge about which type of interventions work and which do not. However, evaluation studies show that sexual and reproductive health interventions for young people are often not effective because they do not reach their intended target groups or lack implementation fidelity (Chandra-Mouli, Lane, and Wong 2015).
Comprehensive sexuality education is one of the interventions that has been proven to be effective in advancing young people’s sexual and reproductive health and rights, provided that it is implemented well (Kirby 2008). Traditionally, many school-based sexuality education programmes tend to focus mainly on the dissemination of knowledge. In addition, the content of comprehensive sexuality education programmes is often considered controversial by sex educators and in communities (Green et al. 2017; Helleve et al. 2009; Ahmed et al. 2009; de Haas and Hutter 2019). As a result, the information delivered regularly does not meet the needs of the learners, as learners feel that the topic of sexuality is portrayed negatively and that the topics relevant to sexually active learners are not being discussed (Pound, Langford, and Campbell 2016; de Haas, Hutter, and Timmerman 2017). As such, practice shows that many sexuality education programmes do not meet the international standards for ‘comprehensive’ sexuality education, especially where it concerns inclusion of young people’s sexual and reproductive rights (UNESCO 2018).
Taking these considerations into account, the knowledge provided could be complemented with activities that focus on young people’s own motivations and feelings. This ‘innerwork’ is important as it enables young people to understand themselves, their peers, and how they influence each other. This helps them to make their own choices, which is an important step towards developing empowerment (Taylor and Murphy 2014, 22).
Empowerment can be understood as ‘a social process of recognizing, promoting and enhancing people’s abilities to meet their own needs, solve their own problems and mobilize the necessary resources in order to feel in control of their own lives’ (Gibson 1991, 359). This definition suggests an individual understanding of empowerment, whereas empowerment can also be understood at the collective or community level and in interaction with others and the social context (Spencer 2014; Cense 2019). Although there is little supporting empirical evidence, the development of individual empowerment is generally understood to positively contribute to young people’s health (Spencer, Maxwell, and Aggleton 2008).
Accordingly, Haberland and Rogow (2015) emphasize the need for including an empowerment approach to comprehensive sexuality education programmes to increase their effectiveness. Such ‘empowerment approaches’ emphasize the role of gender and power, by helping learners to critically reflect on socially-constructed gender norms and social inequities. These critical reflections are considered to empower learners as they ‘adopt more egalitarian attitudes and relationships’, which will instigate behaviour change, such as delay of first sexual debut and use of condoms and other contraception, resulting in better sexual and reproductive health outcomes (Haberland and Rogow 2015, S17).
Globally, sexuality education is implemented by a variety of stakeholders and at multiple levels. At the national level, many governments have policies or curricula in place that address young people’s sexual and reproductive health. These programmes often concern teacher-led school-based HIV prevention and life skills building of young people. Pound, Langford, and Campbell (2016) found that teachers are often seen as a valuable source to deliver school-based sexuality education but that students might not find teachers appropriate facilitators because of their familiarity with the students and potential lack of confidentiality. In addition, students can perceive teachers as moralistic or judgemental, especially where it concerns young people’s sexual practices.
In contrast to teachers, students feel that peer educators might be better able to create a safe space through engaging activities and by the sense of affinity students have with their peers. As a result, peer educators can create an egalitarian relationship that allows for open conversations. Despite the perceived benefits of peer educators teaching school-based sexuality education, peer educators might be a less sustainable and cost-effective option compared to teachers, as new peer educators need to be trained regularly (Pound, Langford, and Campbell 2016). It is also suggested that peer educators may be the ones benefiting most from peer-led sexuality education (Chandra-Mouli, Lane, and Wong 2015).
Tanzania has one of the youngest populations in the world, with 63 percent of the population aged 24 or below (United Republic of Tanzania 2013). A range of sexual and reproductive health initiatives are being undertaken targeting this group. These initiatives are developed and implemented by the Tanzanian government and civil society organizations, and target both in- and out-of-school young people, using a myriad of approaches. The latest governmental guidelines for implementing HIV prevention and life skills education in secondary schools were published in 2002. The guidelines emphasize the provision of life skills, counselling services and knowledge. The knowledge component captures basic knowledge on HIV and AIDS and sexually transmitted infections, and a ‘responsible behaviour approach’, which emphasises abstinence and delay of sexual debut (United Republic of Tanzania 2002, 11). Condom education to students is also encouraged, although the distribution of condoms in primary and secondary schools is not permitted (United Republic of Tanzania 2002).
More recently, the Tanzanian government published ‘National guidelines for the management of HIV and AIDS’, which briefly mentions that young people should be educated about HIV prevention and that they ‘should be encouraged to abstain from sexual activity until they can make responsible decisions’ (United Republic of Tanzania 2015, 107). These guidelines reflect findings from Mkumbo (2010), who found that young people in Tanzania are interested to learn about topics such as sexual decision-making, sexual pleasure and contraception, but that only the topic of HIV and AIDS and sexually transmitted infections is covered by the Tanzanian school curriculum.
Although there is a window of interpretation to what age young people are able to make ‘responsible decisions’, it can be concluded that abstinence is the main focus of school-based sexuality education provided by the Tanzanian government (Obasi et al. 2006). However, in general, abstinence-only programmes are considered less effective than comprehensive sexuality education programmes in delaying young people’s onset of sexual intercourse and increasing their contraceptive use (Kirby 2008).
In addition to the governmental programme, the Tanzanian-based non-governmental organisation Restless Development implemented the Dance4Life programme, which adopted a more positive, comprehensive and empowering peer-led approach to sexuality education in Tanzanian secondary schools by incorporating edutainment. Edutainment means that entertainment is used to support education (Aksakal 2015), for example by making use of music, dance and youth culture during sessions. The programme theorized that young people would be more engaged when these elements are incorporated and consequently, by improving young people’s sexual and reproductive health and rights and reducing stigma, they become empowered to make safe sexual choices ultimately leading to positive health outcomes, such as fewer HIV infections, unplanned pregnancies and sexual violence.
This paper aims to reflect on the added value of the Dance4Life edutainment approach compared to the governmental approach to sexuality education, to understand to what extent a peer-led edutainment approach can increase young people’s empowerment, as measured by knowledge, life skills and self-efficacy (Cattaneo and Goodman 2015), ultimately contributing to improved sexual and reproductive health outcomes
Study setting and participants
This paper reflects on the findings of an exploratory mixed-methods comparative study, which was conducted in the districts Iringa Rural (Iringa region) and Wanging’ombe (Njombe region) in Tanzania at the end of 2015. The study was conducted in four co-educational secondary intervention schools and two co-educational secondary comparison schools. The intervention schools concerned 96 students in Form 1-4 who had been exposed to the Dance4Life programme since 2010; the comparison schools concerned 49 students participating in the government HIV prevention programme. The participating 71 male and 74 female students were aged 14-24 years; on average they were 16 years old.
The intervention programme: Dance4Life
The Tanzanian-based non-governmental organisation Restless Development is a youth-led development agency that seeks to place young people at the forefront of change and development. It has implemented the Dance4Life programme from 2010 until 2016 in 20 secondary schools in the regions of Iringa and Njombe. The programme took a 4-step approach: (1) inspire, e.g. through music and dance; (2) educate, e.g. through 15 hours of comprehensive sexuality education lessons; (3) activate, e.g. young people create awareness about, and acquire support for, sexual and reproductive health and rights in their communities; and (4) celebrate, e.g. to recognize the actions taken in celebration together with decision makers and other stakeholders (Dance4Life 2013a).
The programme had a twofold implementation strategy, firstly, through the Heart Connection Tour (HCT) team, which consisted of young volunteers trained to support and integrate dance, music, testimonies and drama through youth culture, to inspire young people to get engaged in the comprehensive sexuality education component of the programme (Dance4Life 2013b). Secondly, through Dance4Life volunteer peer educators, trained on comprehensive sexuality education and placed in communities where they facilitated comprehensive sexuality education initiatives in in- and out-of-school settings. The HCT volunteers were responsible for the ‘inspire’ step, and the volunteer peer educators for the remaining steps.
The comparison programme: the government HIV prevention programme
The HIV prevention programme implemented by the Tanzanian government educates students in primary (Class 5-7) and secondary school (Form 1-6) about HIV, AIDS and sexually transmitted infections. This HIV prevention programme is integrated in the core school curriculum through subjects such as Biology, Civics and Kiswahili. The knowledge and life skills lessons are delivered by teachers who, at the time of research, had not received additional training for teaching this programme. However, they are supported by peer educators who are trained within the school by school guardians or counsellors to lead group discussions with their peers (United Republic of Tanzania 2002).
Sample characteristics and measures
The participants filled in a questionnaire which included closed-ended questions on the following topics: student background characteristics, mode of sexuality education and satisfaction, knowledge about HIV and AIDS and modern contraceptive methods, and life skills and self-efficacy. To gather qualitative data, eight focus group discussions and ten semi-structured interviews were conducted. Sampling for participants for the focus group discussions was convenience-based: those students in the intervention and comparison schools who had been randomly excluded from the quantitative questionnaire were asked if they would be willing to participate in a focus group discussion. The discussion guide covered students’ perceptions on how sexuality education was implemented in secondary schools and what they had learned from it, components of sexuality education they enjoyed most, and how the sexuality education had changed their personal values and life skills. Focus group discussions were also conducted with a group of Dance4Life volunteers and the HCT team. These focus group discussions explored their preparation to facilitate sexuality education, their perceptions on expected changes from students upon going through sexuality education, and the influence of these changes on student and community attitudes and behaviour. In addition, semi-structured interviews were conducted with teachers to understand their perceptions on the different approaches and the impact they noticed.
This section provides an excerpt of the findings. Details of the data collection, analysis and results of the study are described in the research report ‘A comparative study on the effects of an edutainment approach on Sexual and Reproductive Health and Rights in Southern Highlands of Tanzania’, written by Francis Omondi and Kennedy Oulu (2015) and commissioned by Dance4Life and Restless Development.
Mode of sexuality education and satisfaction
Most of the intervention students indicated that sexuality education was conducted in their school compared with a third of the comparison students. While lectures were part of the sexuality education lessons in both intervention and comparison schools, students from the intervention schools also mentioned dance, drama and a mixture of dance, music and drama. In comparison, none of the students from comparison schools mentioned dance, drama or a mixture of dance, music and drama.
When asked who facilitated sexuality education in their schools, many of the intervention students mentioned peer educators compared with only a few of the comparison students, despite peer educators being an integral part of the government programme. All intervention school students affirmed that they were happy with the way sexuality education was conducted in their school compared with two third of the students in the comparison schools.
Findings from the focus group discussions with students, and interviews with head teachers/guidance and counselling teachers, indicated that teachers in comparison schools had not been trained to provide guidance and counselling on sexuality issues. Accordingly, the focus group discussion with students from one of the comparison schools indicated that the interest of students on sexual and reproductive health and rights was not equally met by the information they received, and that there were little opportunities for them to ask their own questions: ‘We have a lot of interest, but […] we are only taught about primary health and family planning, when we don’t even have families to plan yet!’.
Participants from the intervention schools, who indicated they participated in dance, poetry, culture or music sessions, were also asked how comfortable they felt when they interacted with the volunteer peer educators. Most of them felt very comfortable and this result was also reflected in the focus group discussions in which a volunteer peer educator indicated that students felt more at ease now to ask questions, including about condoms:
‘They [students] have become interested in these issues and ask a lot of questions. They come to me and they want to know how they can deal with and solve their problems, and they are open to us. Students sometimes cannot talk about some things, they could not even mention condoms. But now after talking with and educating them, they find it easy to talk about it. (Dance4Life volunteer peer educator at one of the intervention schools).’
In addition, most of the intervention students stated that their participation in dance, poetry, culture or music as part of the sexuality education lessons was (very) interactive and that the environment where they were participating was safe and allowed them to enjoy and speak freely.
Knowledge, life skills and self-efficacy
Participants from the intervention schools indicated higher levels of knowledge about modern contraceptive methods compared with their counterparts from the comparison group. They also indicated a higher increase in their life skills compared to those from comparison schools. These life skills included the ability to solve problems, improved self-esteem, improved confidence, improved ability to make informed decisions, and improved ability to communicate clearly. During the focus group discussions, various students from the intervention schools stated that through the sexuality education they had received, they now felt confident and able to talk freely in front of their peers, as illustrated by this quote: ‘After participating in the [sexuality education] sessions, we now have the confidence to talk freely in front of our fellow students’. A teacher from one of the intervention schools indicated a change in the way students related to each other as a result of the sexuality education they had received: ‘They [students] now relate positively in a way that shows they can manage risks and are assertive’.
Students from intervention schools also showed higher – though not significant – levels of self-efficacy in relation to sexual and reproductive health issues compared to students from the comparison schools. An interview with a teacher in one of the intervention schools did indicate that students were now more aware of their sexual and reproductive health and were embracing HIV testing as a result: ‘They [students] have become aware and have embraced HIV testing in the school for students, who feel this is important for them.’
This paper aims to reflect on the findings of a study that compared the governmental approach to sexuality education with the Dance4Life peer-led edutainment approach to understand into what extent a peer-led edutainment approach can be beneficial in increasing young people’s empowerment, as measured by knowledge, life skills and self-efficacy, to ultimately contribute to improved sexual and reproductive health outcomes.
The findings show that students in the intervention schools had more knowledge of modern contraception and experienced an increase in a variety of life skills due to their sexuality education. In addition, positive but not significant differences were found in relation to students’ self-efficacy to purchase and use condoms. The government’s policy to promote abstinence among young people, may have affected the discussions of condom use in both intervention and comparison schools. However, the qualitative findings do suggest that condoms were discussed in the intervention schools. In addition, another school-based intervention, using interactive peer-led sessions among young people in Tanzania, did observe increased intentions to condom use and even increased condom use uptake among men (Mmbaga et al. 2017).
Although the focus of this study was to compare both approaches, it is important to be mindful about how to interpret the differences found between the two programmes. First of all, the findings show that only a third of students in the comparison schools stated that they received sexuality education in their schools, which raises questions about how widespread the government programme was being implemented. Another finding shows that sexuality education in the comparison schools was usually taught by non-trained teachers, and without the intended support of trained peer educators, whereas in the interventions schools it was taught by trained volunteer peer educators. This suggests that sexuality education in the intervention schools may have had more implementation fidelity than the comparison schools. Therefore, the findings demonstrate the importance of implementation fidelity of school-based sexuality education programmes, including training for sexuality educators and peer educators (Chandra-Mouli, Lane, and Wong 2015; Chandra-Mouli et al. 2017).
Taking these considerations into account, Spencer, Maxwell, and Aggleton (2008, 350) note that empowerment is a complex concept that may not naturally lead to safer sexual behaviours because ‘high levels of self-esteem, knowledge and confidence’ could also lead to choices of engaging in ‘risky’ sexual practices. Therefore, Spencer (2014) distinguishes various forms of empowerment, to better capture such dynamics and complexities in the relationship between empowerment as a process and as an outcome, and to acknowledge the role of power in empowerment. She indicates that dominant perspectives on empowerment often approach young people’s health in a normative way by looking at ‘risky’ behaviours and negative health outcomes and with little attention for the context in which these practices take place. Rather, she advocates to acknowledge young people’s own, more positive, perceptions of what constitutes their health, and their abilities to prioritise their own concerns in health interventions and to challenge existing structural power relations in society. These structural power relations may limit young people’s abilities to develop empowerment, adopt safe sexual practices, and have positive health outcomes.
Such discussions require a safe, enabling space for participation and interaction, which is usually not provided in the teacher-centred, autocratic teaching styles oftentimes adopted in school-based sexuality education (Helleve et al. 2011). In the intervention, the use of peer educators and an edutainment approach – consisting of a mixture of dance, music, poetry and drama – aimed to create this interactive, participatory and safe environment in which young people feel encouraged to discuss their concerns and to challenge and debate social and gender norms. The findings confirm that students in the intervention schools felt comfortable in their interactions with the peer facilitator and were able to speak freely.
In countries like Tanzania, where national policies may not allow education about contraception in schools, the development of other competencies can serve as mediating factors for health promoting behaviours. For example, Green et al. (2017) study the role of so-called ‘youth assets’ in advancing young people’s sexual and reproductive health outcomes. These ‘youth assets’ may include ‘aspirations for the future, self-confidence’ and ‘the ability to make responsible choices’ (Green et al. 2017, 679). Green et al. (2017, 683) concluded that ‘positive youth development programs that can help youth build assets’ can improve young people’s reproductive health behaviours even when they do not receive sexuality education. The most common goals that effective programmes in their study focused on were social bonding, building competencies, belief in the future and self-determination. Almost all of the programmes provided young people the opportunity to engage in real life situations and enabled them to engage with their parents in order to strengthen support.
Based on our findings in this study, and in support of the growing body of literature on effective approaches to sexuality education in restrictive cultural and policy contexts, we recommend that the delivery of sexuality education to young people, especially in secondary schools, integrates peer-led education and interactive methods such as dance, music and drama in a manner that is engaging, participatory, comfortable and inspiring for young people. The relevance and suitability for the youth-culture and age range is paramount. As a result of this study, Dance4Life has updated their intervention approach, they used to implement the sexuality education content – the ‘educate’ step – separately from the edutainment part – ‘inspire’, ‘activate’, and ‘celebrate’. The new Dance4Life Empowerment Model integrates sexual and reproductive health content and skills building, after realising that their edutainment approach creates the safe, enabling space which is necessary for young people to feel comfortable to discuss their concerns and thus develop empowerment. In line with Spencer (2014), Haberland and Rogow (2015) and Green et al. (2017), the focus is now more on positive youth development and gender empowering elements, such as challenging gender and power norms, rather than knowledge building itself. At the same time, the curriculum is contextualized incorporating the possibilities and limitations of the local context.
While comprehensive sexuality education remains one of the proven interventions to advance young people’s sexual and reproductive health and rights, more research is needed to develop the body of evidence on effective sexual and reproductive health and rights interventions for young people (UNESCO 2018). Such research is especially needed in countries like Tanzania where national regulations do not support the teaching of comprehensive sexuality education in schools.