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Evaluation of complex sexual and reproductive health educational interventions targeting young people in low- and middle-income countries

Olena Ivanova (UGent)
(2022)
Author
Promoter
(UGent) and Sónia Dias
Organization
Abstract
Attention to young people’s health has been increasing globally with a special focus dedicated to their sexual and reproductive health (SRH). Low- and middle-income countries (LMICs) carry the highest burden of HIV, early pregnancies, early marriage and other relevant issues among young people. Improving SRH outcomes and services among young people in LMICs is of critical importance for global and public health. Over the last decades, many SRH interventions, have been designed and implemented. The scope of these interventions is broad, thus, this thesis specifically looks at the SRH interventions with a focus on SRH promotion through education. SRH educational interventions are often complex (i.e., containing multiple activities and targeting variability of outcomes) and contextdependant, especially because of the sensitivity of the young people’s sexuality. Complexity thinking is not new to public health and health promotion sciences; however, it is often nominally mentioned without recognizing its importance for intervention design and evaluation processes. Evaluating complex interventions in complex systems (i.e., schools or health care centers) and showing their effectiveness is methodologically challenging, as well as resource-demanding. However, without suitable and well-planned evaluation, it is very difficult to demonstrate effectiveness and identify interventions that are having a substantial impact on SRH outcomes of young people. The overarching research aim within this PhD dissertation was to contribute to the scientific knowledge on evaluation approaches for complex SRH educational interventions for young people in LMICs. To answer thesis objectives, a diversity of study designs was chosen. Firstly, to synthetise the evidence on the evaluation designs used for complex SRH interventions, a systematic literature review was performed looking at existing evaluation designs applied to sexuality education in LMICs, their benefits and limitations. This review adhered to PRISMA guidelines, searched two data bases and brought findings together using descriptive narrative synthesis. Secondly, different evaluation designs were applied to three SRH interventions for young people in five countries. These interventions focused strongly on SRH promotion and educational component: 1) the ELIMIKA project (Kenya) represented a pilot digital platform providing evidence-based information on SRH and interaction between peers and health care providers for HIV-positive youth; 2) the CERCA project (Ecuador, Bolivia and Nicaragua) delivered educational messages through peer-to-peer education, schools and health care provides to prevent teenage pregnancies; 3) the sexuality education program (CSE Uganda) provided comprehensive lessons in schools for young adolescents. To bring these single evaluations together and learn from them, a meta-evaluation approach was employed, looking at interventions’ effectiveness and methodological soundness, process understanding and involvement of main stakeholders, costs-assessment and utility of results. Findings of this doctoral dissertation have been published in five peer-reviewed articles. In brief, systematic review findings pointed out the dominance of the method-driven evaluation designs for sexuality education interventions with a focus on “gold standard” - randomized controlled trial, with all its limitations in real-world settings; lack of data triangulation and use of mixed method approach; and scarcity of theory-driven evaluations. Moreover, the results of this thesis show the evolution of the PhD candidate’s evaluation thinking - from conservative quantitative approach applied to digital intervention for HIV-positive young people in Kenya to comprehensive combination of effectiveness and process evaluation for school-based sexuality education in Uganda. The ELIMIKA study applied pre-post-test design using questionnaire to assess the effectiveness, however, it suffered from short implementation time and high lost to follow-up. Post-hoc CERCA process evaluation used qualitative approach to shed light on the limited effectiveness of the original evaluation and reflect on different stages of the intervention - from design to additional outcomes. Meanwhile, CSE Uganda combined pre-post-survey in intervention and control groups with process evaluation. Additionally, the meta-evaluation of these three evaluation studies highlighted that all interventions had limited effectiveness; they partially involved main stakeholders in the development and execution of the evaluation; two of them explored the fidelity and quality of the implementation; they all lacked costs assessments and mostly showed good utility in sensitizing and raising awareness among stakeholders around SRH issues. Finally, in the discussion chapter, the impact of intervention’s and context’s complexities on evaluations is explored with providing a description of available alternative evaluation theories and methods. Based on the accumulated experience and literature, an evaluation framework is suggested, which combines context, intervention and evaluation features, and can provide guidance for future evaluation studies of complex SRH programs. There is still a number of research gaps and recommendations that could be addressed in future studies: effective integration of economic evaluations into complex interventions and systems; exploration and testing of alternative evaluation designs, especially in challenging settings, such as humanitarian disasters or during epidemics; and capacity- and resource-adequate programming for measuring long-term SRH outcomes. In conclusion, acknowledging and mapping complexity in the evaluation of SRH interventions for young people in LMICs is challenging, but necessary to better understand how intervention works, why and for whom.
Wereldwijd is de aandacht voor de gezondheid van jongeren toegenomen, in het bijzonder voor hun seksuele en reproductieve gezondheid (SRG). Jongeren in lage- en midden-inkomslanden (LMIC's) dragen de grootste last van hiv, tienerzwangerschappen, kind huwelijken en gedwongen huwelijken en andere relevante problemen. Het verbeteren van de SRG-resultaten en -diensten onder jongeren in LMIC's is van cruciaal belang voor de maatschappelijke gezondheid. De laatste decennia zijn er veel SRG-interventies voor jongeren ontworpen en geïmplementeerd. Deze thesis focust specifiek op SRG-interventies via educatie. SRG-interventies zijn vaak complex (d.w.z. ze bevatten meerdere activiteiten en richten zich op verschillende uitkomsten) en context-afhankelijk, vooral vanwege de gevoeligheid van het onderwerp “seksualiteit van jonge mensen”. Complexiteit denken is niet nieuw binnen maatschappelijke gezondheid en gezondheidsbevordering; echter, het wordt vaak enkel vermeld zonder het belang ervan te erkennen voor het ontwerpen, opzetten en evalueren van interventies. Het evalueren van complexe interventies in complexe systemen (bv. scholen) en het aantonen van hun effectiviteit is methodologisch een uitdaging, en vergt ook veel middelen. Zonder een geschikte en goed geplande evaluatie is het zeer moeilijk om de effectiviteit aan te tonen en interventies te identificeren die een substantiële impact hebben op de SRG-resultaten van jongeren. Het overkoepelende onderzoeksdoel van deze thesis is om bij te dragen aan de wetenschappelijke kennis over het evalueren van complexe SRG-interventies via educatie voor jongeren in LMICs. Om de doelstellingen van het proefschrift te beantwoorden, werden verschillende studies opgezet. Ten eerste, om de wetenschappelijke evidentie rond evaluatie van complexe SRG-interventies te synthetiseren, werd een systematisch literatuuronderzoek uitgevoerd waarbij gekeken werd naar bestaande evaluatiebenaderingen toegepast op seksuele en relationele vorming in LMICs, hun voordelen en beperkingen. Deze review volgde de PRISMA-richtlijnen, doorzocht twee wetenschappelijke databanken en bracht de bevindingen samen met behulp van een beschrijvende narratieve synthese. Ten tweede werden verschillende evaluatiedesigns toegepast op drie SRGinterventies voor jongeren in vijf landen. Deze interventies waren sterk gericht op SRG-promotie via educatie: 1) het ELIMIKA-project (Kenia) ontwikkelde een digitaal platform dat evidence-based informatie over SRG verspreidde over leven met HIV en interactie tussen jongeren met HIV en gezondheidswerkers stimuleerde; 2) het CERCA-project (Ecuador, Bolivia en Nicaragua) gebruikte educatieve boodschappen via peer-to-peer onderwijs, scholen en ezondheidszorgverstrekkers ter preventie van tienerzwangerschappen; 3) het programma voor seksuele en relationele vorming (CSE Uganda) ontwikkelde een lessenpakket voor lagere scholen. Om deze afzonderlijke evaluaties samen te brengen en er lessen uit te trekken, werd een meta-evaluatie-aanpak gehanteerd, waarbij werd gekeken naar de doeltreffendheid en methodologische degelijkheid van de interventies, het inzicht in het proces en de mate van betrokkenheid van de stakeholders, de kosteneffectiviteit en de bruikbaarheid van de resultaten. De bevindingen van deze doctoraatsthesis zijn gepubliceerd in vijf peer-reviewed artikels. De systematische review vond een dominantie van methode-gedreven evaluatiedesigns voor seksuele en relationele vormingsinterventies voor jongeren in LMICs, met een focus op de "gouden standaard" - gerandomiseerde gecontroleerde trials, met al de bijkomende beperkingen in realworld settings; gebrek aan data triangulatie en mixed methoden; en beperkte aandacht voor theorie-gedreven evaluaties. Verder tonen de resultaten van dit proefschrift de evolutie aan van het evaluatiedenken van de promovendus - van een conservatieve kwantitatieve benadering toegepast op een digitale interventie voor hiv-positieve jongeren in Kenia tot een uitgebreide combinatie van effectiviteits- en procesevaluatie voor schoolgebaseerde seksuele voorlichting in Oeganda. In de ELIMIKA-studie werd een pre-post-test design toegepast, gebruik makend van een vragenlijst om de effectiviteit te beoordelen, maar de studie had te lijden onder de korte implementatietijd en het hoge verlies aan follow-up. De post-hoc CERCA-procesevaluatie maakte gebruik van een kwalitatieve benadering om licht te werpen op de beperkte doeltreffendheid van de oorspronkelijke evaluatie. CSE Uganda combineerde pre- en postonderzoek in interventie- en controlegroepen met een procesevaluatie. Bovendien bleek uit de meta-evaluatie van deze drie evaluatiestudies dat alle interventies een beperkte doeltreffendheid hadden; ze de belangrijkste stakeholders gedeeltelijk betrokken bij de ontwikkeling en uitvoering van de evaluatie; twee van de interventies onderzochten de kwaliteit van de implementatie; ze hadden geen kostenevaluatie en de meeste interventies bleken goed bruikbaar in het sensibiliseren en sensibiliseren van de stakeholders rond SRGproblemen. Ten slotte wordt in het discussiehoofdstuk de impact van de complexiteit van de interventie en de context op evaluaties verkend met een beschrijving van beschikbare alternatieve evaluatietheorieën en -methoden. Op basis van de verzamelde ervaring en literatuur wordt een evaluatieraamwerk voorgesteld, dat context-, interventie- en evaluatiekenmerken combineert, en een leidraad kan zijn voor toekomstige evaluatiestudies van complexe SRG-programma's. De conclusie is dat het erkennen en in kaart brengen van de complexiteit van de evaluatie van SRG-interventies voor jongeren in LMICs een uitdaging is, maar een noodzakelijke voorwaarde is om beter te begrijpen hoe interventies werken, waarom en voor wie.

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Citation

Please use this url to cite or link to this publication:

MLA
Ivanova, Olena. Evaluation of Complex Sexual and Reproductive Health Educational Interventions Targeting Young People in Low- and Middle-Income Countries. Ghent University. Faculty of Medicine and Health Sciences, 2022.
APA
Ivanova, O. (2022). Evaluation of complex sexual and reproductive health educational interventions targeting young people in low- and middle-income countries. Ghent University. Faculty of Medicine and Health Sciences, Ghent, Belgium.
Chicago author-date
Ivanova, Olena. 2022. “Evaluation of Complex Sexual and Reproductive Health Educational Interventions Targeting Young People in Low- and Middle-Income Countries.” Ghent, Belgium: Ghent University. Faculty of Medicine and Health Sciences.
Chicago author-date (all authors)
Ivanova, Olena. 2022. “Evaluation of Complex Sexual and Reproductive Health Educational Interventions Targeting Young People in Low- and Middle-Income Countries.” Ghent, Belgium: Ghent University. Faculty of Medicine and Health Sciences.
Vancouver
1.
Ivanova O. Evaluation of complex sexual and reproductive health educational interventions targeting young people in low- and middle-income countries. [Ghent, Belgium]: Ghent University. Faculty of Medicine and Health Sciences; 2022.
IEEE
[1]
O. Ivanova, “Evaluation of complex sexual and reproductive health educational interventions targeting young people in low- and middle-income countries,” Ghent University. Faculty of Medicine and Health Sciences, Ghent, Belgium, 2022.
@phdthesis{8750637,
  abstract     = {{Attention to young people’s health has been increasing globally with a special focus dedicated to
their sexual and reproductive health (SRH). Low- and middle-income countries (LMICs) carry the
highest burden of HIV, early pregnancies, early marriage and other relevant issues among young
people. Improving SRH outcomes and services among young people in LMICs is of critical importance
for global and public health. Over the last decades, many SRH interventions, have been designed and
implemented. The scope of these interventions is broad, thus, this thesis specifically looks at the SRH
interventions with a focus on SRH promotion through education. SRH educational interventions are
often complex (i.e., containing multiple activities and targeting variability of outcomes) and contextdependant,
especially because of the sensitivity of the young people’s sexuality. Complexity thinking
is not new to public health and health promotion sciences; however, it is often nominally mentioned
without recognizing its importance for intervention design and evaluation processes. Evaluating
complex interventions in complex systems (i.e., schools or health care centers) and showing their effectiveness is methodologically challenging, as well as resource-demanding. However, without suitable and well-planned evaluation, it is very difficult to demonstrate effectiveness and identify interventions that are having a substantial impact on SRH outcomes of young people. 
The overarching research aim within this PhD dissertation was to contribute to the scientific knowledge on evaluation approaches for complex SRH educational interventions for young people in LMICs. To answer thesis objectives, a diversity of study designs was chosen. Firstly, to synthetise the evidence on the evaluation designs used for complex SRH interventions, a systematic literature review was performed looking at existing evaluation designs applied to sexuality education in LMICs, their benefits and limitations. This review adhered to PRISMA guidelines, searched two data bases and brought findings together using descriptive narrative synthesis. Secondly, different evaluation designs were applied to three SRH interventions for young people in five countries. These interventions focused strongly on SRH promotion and educational component: 1) the ELIMIKA project (Kenya) represented a pilot digital platform providing evidence-based information on SRH and interaction between peers and health care providers for HIV-positive youth; 2) the CERCA
project (Ecuador, Bolivia and Nicaragua) delivered educational messages through peer-to-peer education, schools and health care provides to prevent teenage pregnancies; 3) the sexuality education program (CSE Uganda) provided comprehensive lessons in schools for young adolescents.
To bring these single evaluations together and learn from them, a meta-evaluation approach was employed, looking at interventions’ effectiveness and methodological soundness, process understanding and involvement of main stakeholders, costs-assessment and utility of results.
Findings of this doctoral dissertation have been published in five peer-reviewed articles. In brief, systematic review findings pointed out the dominance of the method-driven evaluation designs for sexuality education interventions with a focus on “gold standard” - randomized controlled trial, with all its limitations in real-world settings; lack of data triangulation and use of mixed method approach; and scarcity of theory-driven evaluations. Moreover, the results of this thesis show the evolution of the PhD candidate’s evaluation thinking - from conservative quantitative approach applied to digital intervention for HIV-positive young people in Kenya to comprehensive combination of effectiveness and process evaluation for school-based sexuality education in Uganda. The ELIMIKA study applied pre-post-test design using questionnaire to assess the effectiveness, however, it suffered from short implementation time and high lost to follow-up. Post-hoc CERCA process evaluation used qualitative approach to shed light on the limited effectiveness of the original
evaluation and reflect on different stages of the intervention - from design to additional outcomes. Meanwhile, CSE Uganda combined pre-post-survey in intervention and control groups with process evaluation. Additionally, the meta-evaluation of these three evaluation studies highlighted that all
interventions had limited effectiveness; they partially involved main stakeholders in the development and execution of the evaluation; two of them explored the fidelity and quality of the implementation; they all lacked costs assessments and mostly showed good utility in sensitizing and raising awareness among stakeholders around SRH issues. 
Finally, in the discussion chapter, the impact of intervention’s and context’s complexities on evaluations is explored with providing a description of available alternative evaluation theories and methods. Based on the accumulated experience and literature, an evaluation framework is suggested, which combines context, intervention and evaluation features, and can provide guidance for future evaluation studies of complex SRH programs. There is still a number of research gaps and recommendations that could be addressed in future studies: effective integration of economic evaluations into complex interventions and systems; exploration and testing of alternative evaluation designs, especially in challenging settings, such as humanitarian disasters or during epidemics; and capacity- and resource-adequate programming for measuring long-term SRH outcomes. In conclusion, acknowledging and mapping complexity in the evaluation of SRH interventions for young people in LMICs is challenging, but necessary to better understand how intervention works, why and for whom.}},
  author       = {{Ivanova, Olena}},
  language     = {{eng}},
  pages        = {{IX, 147}},
  publisher    = {{Ghent University. Faculty of Medicine and Health Sciences}},
  school       = {{Ghent University}},
  title        = {{Evaluation of complex sexual and reproductive health educational interventions targeting young people in low- and middle-income countries}},
  year         = {{2022}},
}