The Women's Health and Action Research Centre (WHARC) created the STI Counseling and Treatment Programme in response to studies indicating that Nigerian adolescents are often reluctant to seek medical treatment for sexually transmitted infection (STI) symptoms or, if they do seek help, rely on informal sector providers (patent medicine practitioners, traditional healers, pharmacists, and laboratory technicians). Assessment has also showed that neither these nor medically trained health care professionals tend to use standard protocols for diagnosing and treating STIs in adolescents.

In this context, an initiative was developed to reach out to sexually experienced 14- to 18-year-old Nigerians in senior high classes. The primary goal was to decrease adolescents' use of informal sector providers who lack training in STI treatment and to increase their use of trained doctors in private practice. Other aims included increasing young people's knowledge of STI symptoms, use of condoms, treatment-seeking behaviour, and notification of partners regarding STI infection. The intervention also aimed to decrease the proportion of youth who experienced symptoms of STI.

In brief, the initiative involves:

1. school-based reproductive health clubs that offer health awareness campaigns at which health care professionals provide students with information on STI prevention and treatment. Other activities include distributing educational materials on STIs, organising debates and symposia, sponsoring dramas and essay contests, and showing films on STI prevention and treatment.
2. trained peer educators who provide counseling to other students, distribute educational materials on STIs, and refer youth with symptoms of STIs to trained health care providers.
3. a training system for providers of formal and informal health care.

Four secondary schools in the western part of Benin City were randomly chosen to participate as intervention sites; the 4 comparison schools were in the eastern part of Benin City. Since it was impossible to restrict the influence of this community-based intervention to the specific, chosen intervention schools, researchers selected 4 secondary schools in nearby Ekpoma (a city demographically different from Benin City) as additional comparisons. At each selected intervention and comparison school, senior classes 4 and 5 comprised about 320 students; approximately 160 students were randomly chosen to participate in the pre- and post-intervention surveys.

The study used a randomised, controlled design with randomly selected students from 3 study sites: one intervention and two comparison sites. In total, 1,896 and 1,885 youth participated in the baseline (September 1997) and follow-up survey (July 1998), respectively. To ensure students’ confidentiality, the questionnaires were self-completed and without any individual identifier. At baseline, students in the two Benin City groups of schools (intervention and comparison) were demographically similar. However, significant demographic differences existed between the youth from Ekpoma (comparison) and youth from the two Benin groups of schools. For example, at baseline, fewer students from the intervention schools and the Benin City comparison schools reported previous sexual intercourse, versus students from Ekpoma comparison schools (38%, 34%, and 53%, respectively).To adjust for these and other differences, multivariate analysis controlled for age, gender, religion, ethnicity, socio-economic status (SES), living situation, and prior sexual experience.

At post test, students from the intervention schools were significantly more likely than students in comparison schools in either city to be able to name up to 6 STIs. The mean number of STIs that youth could name increased by 0.47 among youth from the intervention schools and by 0.01 and by -0.16 among youth in the Benin and Ekpoma comparison schools, respectively. The effect was statistically significant for both males and females but was especially strong among female students in the intervention schools.

From pre- to post-intervention, condom use among sexually experienced males and females increased significantly in the intervention schools (from 31% to 41% among males; from 30% to 37% among females). Among students in the combined comparison schools, reported condom use increased significantly among males (29% to 36%), but decreased among females (30% to 28%). As a result, the intervention showed a significant relative increase in condom use among youth in the intervention schools relative to the students in the two comparison groups of schools (OR=1.41). This statistically significant effect was due to the reported increase among female students (OR=1.80), rather than among male students (OR=1.13) in the intervention schools.

Among females in the intervention schools, those who notified their partners that they had an STI increased significantly from 5% at pretest to 18% at follow-up. There was a small, but insignificant, increase in the percentage of males in the intervention schools who notified their partners that they had an STI (9% to 10%). The impact of the intervention was significant versus students at both comparison groups of schools among females (OR=7.1), but not among males (OR=1.3).

Among students in the intervention schools, the proportion of youth who went to private physicians for treatment for STI symptoms in the previous 6 months increased from 18% at pretest to 41% at follow-up (OR=3.24). A smaller, but still significant, increase occurred in the proportion of students in the Benin comparison schools who sought treatment for STI symptoms from private physicians (19.0% to 29.1%; OR=1.75) while there was no significant change in Ekpoma (24% to 30%). The impact of the intervention was significant, relative to students in both the Benin and the Ekpoma comparison groups of schools (OR=1.85 and 2.31, respectively). At the same time, the decline in the proportion of students at intervention schools who sought STI treatment from pharmacists and patent medicine dealers was statistically significant (from 15% to 4%; OR=2.26), relative to students from both comparison groups of schools (OR=0.44).

Finally, the proportions of students who reported using private doctors for STI symptoms, though more similar, were also lower in the intervention and the Benin City comparison schools than in Ekpoma: 18%, 19%, and 24%, respectively, visited a private doctor. On the other hand, the students from the two Benin City groups of schools were substantially more likely to report visiting a hospital or clinic than were youth in the Ekpoma comparison schools: 26%, 22%, and 6%, respectively.

The intervention resulted in a statistically significant reduction in STI symptoms among students in the intervention schools, relative to students at both the Benin City and Ekpoma comparison schools (OR=0.63 and 0.69, respectively) as well as to students at both groups of schools, combined (OR=0.68). Among students at intervention schools at posttest, 22% reported STI symptoms in the past 6 months, compared to 33% at pretest. In both comparison groups of schools, students also reported a decrease in STI symptoms (31% to 29% in Benin City comparison schools; 42% to 35% in Ekpoma). The effect of the intervention appeared stronger in males (OR=0.58) than in females (OR=0.70), when the intervention schools were compared to all comparison schools.

Sue Alford, MLS, Nicole Cheetham, MHS, and Debra Hauser, MPH, "Science and Success in Developing Countries: Holistic Programs that Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections" [PDF] (Advocates for Youth, 2005).