Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention

doi:10.4236/wja.2011.12008

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World Journal of AIDS, 2011, 1, 43-49

doi:10.4236/wja.2011.12008 Published Online June 2011 (http://www.SciRP.org/journal/wja)

Cameroonian Preadolescents’ Perspectives of an

HIV Prevention Intervention

Comfort Enah, Linda Moneyham, Gwendolyn Childs, Carrie Ann Gakumo

School of Nursing, University of Alabama, Birmingham, USA.

Email: [email protected]

Received April 30th, 2011; Revised May 20th, 2011; Accepted May 27th, 2011.

ABSTRACT

Purpose: Determining and incorporating the perspective of the target population is important to the developments of

effective and sustainable HIV prevention efforts. Cameroonian preadolescent females remain at high risk for contract-

ing HIV and have not benefitted from targeted HIV prevention efforts. In this report, findings are presented from data

collected from 60 Cameroonian preadolescent females; ages 10 - 12 years; following their completion of an HIV pre-

vention intervention. Methods: The theory-based intervention utilized the World Health Organization’s Responsible

Behavior: Delaying Sex curriculum which had been tailored for the target population with the assista nce of Cameroo-

nian experts. The data reported here were collected as part of a questionn a ire participan ts comp leted po st-in terventio n.

Results: With only a few exceptions, participants perceived the intervention to be appropriate and relevant. No signifi-

cant differences were found in participants’ assessment of the intervention across different ages and ethnic groups.

Discussion: Evaluating the appropriateness of interventions to the developmental level, gender, and culture of partici-

pants is an essential step in developing effective and sustainable interventions. Findings in this study are encouraging

and indicate that interventions adapted with the assistance of local experts can be perceived relevant and appropriate

by participants.

Keywords: HIV Prevention, Adolescent He alth, Intervention Research, Participants’ Perspectives, Cameroon, Africa

1. Introduction

According to the 2009 AIDS epidemic update by the

Joint programs on AIDS [1], sub-Saharan Africa remains

the most heavily affected region in the world, accounting

for over 68% of new infection in recent years. In addition,

women and girls in sub-Saharan Africa continue to be

disproportionately affected by HIV/AIDS [1]. While

tremendous strides have been made in improving access

to HIV treatment, the epidemic continues to outpace the

response. Although there are numerous evidence-based

preventio n interventions with demonstrated effectiv eness,

most have been developed in western countries with cul-

tures and other characteristics distinctly different from

sub-Saharan Africa. In addition, few HIV prevention

interventions have been designed specifically for young

adolescent females.

In recent years, considerable progress has been made

in identifying factors that contribute to the transmission

of the disease in countries that are disproportionately

affected by HIV/AIDS such as Cameroon, Africa. Sev-

eral approaches have been used in Sub-Saharan Africa in

an attempt to decrease HIV infection rates in adolescents.

Included in these strategies are peer education, social

marketing, mass media awareness campaigns, voluntary

testing and counseling, and school-based programs [2].

School-based approaches are often advocated because of

the ability to reach large numbers of adolescents in a

short period of time in an environment suitable for

learning and evaluation. It is generally recommended that

school-based primary disease prevention interventions

should begin at the primary school level because school

attendance drops dramatically in most countries in this

region as students transition from primary, secondary,

high school and college levels [3]. The focus of HIV

prevention efforts on primary school students is limited,

however, by the “one size fits all” approach to interven-

tions targeting adolescents. Little consideration has been

given to the developmental differences of younger and

older adolescents, as well as their level of engagement in

sexual activity. Key to intervention effectiveness is the

match between the in terven tion an d the target p opu latio n .

Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention

As part of a larger study to assess the potential efficacy

of an HIV prevention intervention tailored for use with

Cameroonian preadolescents [4,5] we explored the ac-

ceptability and relevance of the intervention to primary

school age Camero onian girls.

The magnitude of the impact of AIDS in Sub-Saharan

Africa is unparalleled in human history. In this region of

the world, the disease will cripple the economies of many

countries if urgent preventative interventions are not im-

plemented [1,6]. The disease is a threat to people in the

most productive phases of their lives, with devastating

effects on families and entire cultures and popu lations [6].

In Cameroon, a third of those who are infected are aged

14 - 19 [7]. Among young people, the full impact of

AIDS is hidden by the lengthy incubation period of the

disease. Those diagnosed in youn g adulthood were likely

infected during their adolescent and preadolescent years

[8]. There is growing recognition of the need to target

young adolescents and preadolescents for HIV preven-

tion efforts prior to their engagement in sexual activity

[9,10].

There is increasing recognition of the need to target

HIV prevention efforts in Camero on on females. Females

in Cameroon are at increased risk of being infected be-

cause they initiate sexual activity at an earlier age than

their male counterparts; they also tend to initiate sexual

activity with older men who have higher infection rates

than younger males [11,12]. In addition, many females

engage in sexual relationships for economic benefits, due

in part to the generally lower socio-economic status of

women. In Cameroon men are more likely to complete

high school, attend college and subsequently get better

paying jobs than women. Women also tend to get mar-

ried at younger ages than men. In addition, cultural

norms dictate that the man is the head of the household

and the decision-maker. All these factors translate to a

subordinate role for women and the economic depend-

ence of many females on their husband or sexual partners

[1,12-14].

There is a paucity of HIV prevention intervention

studies focusing on preadolescents or young adolescents

in Cameroon. Although two intervention studies con-

ducted in Cameroon have been reported [15,16], there

are no known efforts to tailor HIV prevention interven-

tions to be culturally sensitive, gender specific, and de-

velopmentally appropriate for u se with Cameroonian pr e-

and young adolescents. Considering that most HIV pre-

vention interventions were developed in the western

world, assessment of the relevance and acceptability of

such interventions strategies is key to maximizing their

effectiveness for specific populations such as Cameroo-

nian preadolescents. The aim of the research reported

here was to assess the perceived relevance and accept-

ability of an HIV prevention intervention to preadoles-

cent Cameroonian females.

2. Methods

We analyzed post intervention data from a one group

pretest posttest design study. The focus of the larger

study was to determine the feasibility of recruiting and

enrolling Cameroonian girls in HIV prevention studies,

estimate the efficacy of the intervention, and assess cul-

tural sensitivity of the intervention and study protocols.

The findings reported here focus on the analysis of rele-

vance and acceptability of the intervention to participants.

Approval for the study was obtained from the primary

author’s institutional review board and the board of edu-

cation of the school in Cameroon. In addition, parents

provided written informed consent and participants pro-

vided written assent to participate in the study.

Setting and Sample: The study was conducted in a

public school located in a university town which is also

the capital of the South W est Province of Cameroon. The

town is also located in one of the provinces with the

highest HIV/AIDS prevalence rates in Cameroon. All

female students attending the school, aged 10 - 12, who

could read and write, were considered eligible for the

study. Sixty girls, who constituted 100% of those eligible,

participated in the study.

Procedures: The study was advertized on school bul-

letin boards and flyers were distributed to all students

attending the school. Consent forms were sent home with

eligible students for their parents to complete. Transpor-

tation was provided to and from the school. The study

was implemented on a Saturday so as to allow partici-

pants to participate in all school activities during week-

days.

All parental consent and student assent forms were

collected and reviewed for completeness when student

arrived at the study site. At the beginning of the day, par-

ticipants completed a brief survey which in cluded demo-

graphic characteristics and correlates of HIV risks in

preadolescence. Participants took about 10 minutes to

complete the questionnaire. Because the questionnaire

focused on sensitive issues related to sexual behavior,

strategies to encourage open and honest responses were

implemented [17]. Strategies used in this study included:

1) explaining the importance of honest responses to

questions because there were no right or wrong responses;

2) assuring participants that their responses would be

kept confidential; 3) using code numbers instead of

names on questionnaires; and 4) asking participants to

deposit completed questionnaires in a sealed box instead

of directly to the investigator.

The Intervention: The intervention was a day long

workshop that was delivered in a group format. The

Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention

workshop topics are outlined in Table 1. At the begin-

ning of the intervention a lecture on bodily changes dur-

ing puberty and HIV information such as nature of the

HIV virus, modes of transmission and groups at risk in

Cameroon was presented. The second part included spe-

cific units that focused on values clarification and build-

ing of specific HIV prevention behavioral skills. Each

unit incorporated small group activities and a discussion.

These units were completed in small groups of 10 stu-

dents each. The investigator moved from group to group

encouraging participation, answering questions, and fa-

cilitating activities. After each unit was completed,

groups shared a summary of their discussions and activi-

ties with other participants and answered questions.

The intervention was built on the World Health Or-

ganization’s (1994) Responsible Behavior: Delaying Sex

curriculum, which allows content and protocols to be

tailored to the specific needs, culture, and gender of the

target population [18]. This curriculum includes a

teacher’s guide, students’ guide, and a sample of ques-

tions that can be used to evaluate the curriculum. The

primary investigator, a nativ e of Cameroon, worked with

local experts to adapt the intervention so that it matched

the culture, age, and ge nder of participan ts. The interven-

tion was extended with the addition of the theme: Be

Proud! Be Responsible! [19], to enhance personal, gen-

der, and cultural pride. Activities in the intervention

aimed at influencing attitudes, control beliefs, and be-

havioral norms about delaying sex, which are antece-

dents of intention and behavior. As part of the interven-

tion participants were assisted in preparing planned cul-

turally appropriate responses that could be used when

they were faced with pressures to have sex. Examples of

planned responses included refusing (“No, I am leaving”),

delaying (“Let me think about it and we can talk again

tomorrow”), and bargaining (“I won’t do that but maybe

we can do…”). Interactive activities that were also part

of the intervention included: affirmations, life mapping,

the use of role-plays, decision making in real-life sce-

narios, assertive communication scenarios, question and

answer sessions, and group discussions (See Table 1)

Measures: A questionnaire administered prior to and

immediately after the workshop intervention was used to

measure demographic data and study variables. The

relevance and acceptability of the intervention was as-

sessed using 10 items developed specifically for use in

the study with the help of a panel of seven Cameroonian

health educators and teachers. The items were statements

about the intervention that included understanding of the

intervention, ease of reading the items, comfort with

content, missing content, likelihood of recommending

the intervention to others, and suggestions for modifying

the intervention. For each item, participants completed

Table 1. Outline of intervention workshop curriculum guide.

Section Content

Theme: Be proud! Be Responsible! Target Variable

Section 1 Lecture: Introduction, bodily changes during puberty, and HIV prevention

information Lecture Knowledge and

Attitudes

Section 2 HIV prevention: Delaying Sexual intercourse

Unit 1 Activity: Discuss a variety of reasons for delaying sex until older or married Attitudes and Norms

Unit 2 Activity: Discussing the decisions to delay or not to delay: Why young people make

these decisions and the consequences, life mapping, and affirmations Norms and behavior

control

Unit 3 Activity: Students practice responding to typical arguments that are used to pressure

girls to have sex Subjective norms and

behavior control

Unit 4 Make students aware that they are not alone in delaying sex and providing guidelines

to assist students Subjective norms

Unit 5 Activity: Students practice guidelines for delaying sex in role-plays. Use guidelines

provided in previous unit. Facilitator communicate that delaying sex is not always

easy but specific behaviors skills can help

Behavior control

Unit 6 Activity Expressing Affections without sex: Students discuss ways to demonstrate

affection that do not include sex. Behavior control

Unit 7 Activity: Deciding how far to go ahead of time Behavior control

Unit 8 Discuss passive, assertive, and aggressive behaviors Behavior control

Unit 9 Activity: Learning to be assertive: students practice assertive communication Behavior control

Unit 10 Activity: Responding to persuasion: Using the Refuse, Delay, Bargain approach.

Student practice using this approach in role-plays Behavior control

Unit 11 Activity: Dealing with threats of violence: Discuss potential compromising situa-

tions, incentives for sex from older persons, threats of violence Behavior control

Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention

two tasks. First, participants responded “yes” or “no” as

to whether the item was true. Second, participants were

asked to provide written comments about the aspect of

the intervention addressed in the item. The items were

administered immediately following completion of the

intervention.

Data Management and Analysis: Descriptive statistics

were used to summarize responses to sociodemographic

items and the yes/no responses to the 10 items assessing

the relevance and acceptability of the intervention. To

explore differences in perceptions of appropriateness of

the intervention, Fisher-exact tests were conducted to

assess differences in responses to yes/no items in relation

to differences in age, living conditions, educational level

of parents, household income, and provinces or origin.

The content of the written responses to each of the 10

items were analyzed and categorized into common

themes related to the acceptability and relevance of the

intervention

3. Results

The sociodemographic characteristics of participants are

summarized in Table 2. The age of students ranged from

10 - 12 years with a mean age of 10.5. The majority of

participants lived with both parents (66.7%). All partici-

pants reported they had not yet engaged in sexual activity.

The literacy rate for participant’s parents (98%) was

much higher than the national reported adu lt literacy rate

of approximately 77% [20].

Participants hailed from eight different English-

speaking areas of Cameroon, and the majority (85%) was

from English speaking provinces. Reported household

incomes for the majority of participants (64%) were

higher than national median incomes and most students

(61.7%) had at least one member of their household who

held a college degree.

The responses to the 10 items assessing the interven-

tion are summarized in Table 3 . The majority of the par-

ticipants (78%) reported favorable perceptions of the

intervention. There were no significant differences in

responses to the 10 items due to age or ethnicity. How-

ever a trend was noted in rating of the intervention con-

tent, with participants from the No rwest Province report-

ing less understanding of content (50%) as compared to

Table 2. Sample characteristics (N = 60).

Variable N %

Age

10 years old 34 56.7

11 years old 21 35

12 years old 5 8.3

Living with

Both parents 40 66.7

One parent 9 45

Grand parents 6 10

Other relatives 5 8.3

Monthly Household Income

Below 50,000 CFA 20 33.3

50,000 CFA - 100,000 CFA 8 13.3

100,000 CFA - 200,000 CFA 12 20

Above 200,000 CFA 19 31.7

Unreported 1 1.7

Highest Educational level in Household

No Formal Education 1 1.7

Primary School 4 6.7

Secondary School 8 13.3

High School 6 10

University or Above 37 61.7

Other (Professional Diploma) 4 6.7

Table 3. Summary of responses to relevance and acceptability items.

Item Frequency (Percentages)

Yes No

1. Comfort with content 44 (73.3%) 15 (25%)

2. Study help change mind 41 (68.3%) 12 (28.3%)

3. Expected content not covered 7 (11.6%) 52 (86.7%)

4. Some content should be left out 6.7 (40.2%) 52 (86.7%)

5. Learned new skill 44 (73.3%) 16 (26.7%)

6. Would recommend study to others 43 (71.7%) 16 (26.7%)

(Note: Total sample was 60).

Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention 47

participants from other provinces (81% - 88%); they

were also less likely to agree to having learned new skills

(60%) than participants from other provinces (83% -

89%) Twenty five percent of the participants reported not

feeling comfortable with the topics covered in the inter-

vention. However, participants failed to explain what

specifically made them uncomfortable. Among those

who provided explanations, their discomfort was associ-

ated with discussions of sexual behavior in general. Most

participants indicated that the content of the intervention

was sufficient. However, sixteen percent of the partici-

pants indicated that there was additional content that

should be included in the intervention, including infor-

mation about the progress being made toward the devel-

opment of an HIV vaccine and current treatment modali-

ties. A small portion of participants (6.7 %) indicated that

certain content should be omitted howev er; they failed to

provide specific information on what content this might

be.

In general, most participants (78%) reported that they

had learned new skills, and would try to share skills th ey

had learned with family members. They also indicated

that they would recommend the intervention to others

because they had learned new skills that would be useful

to other people they knew.

4. Discussion

This was the first study that had directly assessed the

relevance and acceptability of school-based HIV preven-

tative interventions to preadolescents Cameroonian fe-

males. Considering that most HIV prevention interven-

tions were developed for use with Western populations

and do not target preadolescents, assessments of the

relevance and acceptability of such interventions are

warranted. In this study, most participants, including the

youngest age group perceived the intervention appropri-

ate. The impact of HIV/AIDS in Cameroon and the lack

of age appropriate interventions that equip these students

to protect themselves from the disease might have con-

tributed to this positive perception. Participants were

highly likely to have known at a personal level people

who were suffering from or had died from the disease.

To date, HIV preventative strategies in the country have

focused almost exclusively on media campaigns promot-

ing condom use and HIV testing. The relevance of the

intervention to the target population likely resulted from

the inclusion of strategies for protecting oneself from the

disease. The importance preadolescent females and their

parents attached to protection from the disease was evi-

dent in the 100% positive resp onse of parents to allo wing

their children to take part in the study.

Findings in this study which suggest that the interven-

tion was contextually appropriate are consistent with

findings in other school-based studies in sub-Saharan

Africa [21-24]. In these studies western change theories

were integrated with qualitative information from local

experts and the resulting interventions were perceived

contextually relevant. In line with these studies, a num-

ber of steps were taken in the process of developing the

intervention to ensure that students in Cameroon would

be able to understand the content. Evaluation of interv en-

tion content and strategies by teachers involved in the

educational system in Cameroon during the adaptation

phase and the resulting modifications made from this

evaluation contributed to the perceived appropriateness

from even the youngest of participants. Furthermore,

participants were aware that th e primary investigator was

native to the region, and this may have added to positive

perceptions of the intervention.

When responses on appropriateness of the interv ention

were examined by age, no relationship was found be-

tween age and perceived appropriateness. It is worth

noting that the majority of the participants (58.3%) were

10 year-olds, and proportionately more 10 year-old par-

ticipants than older participants thought the intervention

was appropriate. The proportionately more favorable

perceptions from 10 year-old students might be a devel-

opmental or a social desirability issue or simply due to

chance since the difference among age groups were not

significant.

The responses on appropriateness of the intervention

were also examined by ethnicity. Participants were from

two major English speaking ethnic regions or provinces

of the country; the Northwest and Southwest provinces.

A few of the participants (15%) were from various other

provinces in the country and were all grouped under

“other”. In general, students from all ethnic divisions

considered the in tervention and its components appropri-

ate. However there were some non-significant differ-

ences between participants from different ethnic regions

in their responses to some of the items concerning ap-

propriateness of the intervention. More participants (81%)

from the Southwest province reported that they under-

stood the content of the study than participants from the

Northwest province (50%) while more participants from

the Northwest province (83%) reported having learned

new skills than participan ts from the Southwest provin ce

(60%). These findings have to be interpreted with caution

considering the convenience sample and the relatively

small number of participants (20%) from the Northwest

province. These differences might be a reflection of

variations in cultural norms related to sexuality issues

between the two regions. In at least one descriptive study

[10] conducted in the Northwest Province, researchers

examining socio-cultural factors associated with risky

sexual behaviors found differences among participants

Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention

from different provinces which were attributed to differ-

ences in sexual permissiveness among ethnic groups. In

the same study, participants from the Northwest Province

were found to have initiated sexual activity earlier than

their counterparts from other provinces [10]. Regional

differences were also observed in a study on early initia-

tion of sexual activity [25]. The percentage of women

who were sexually active in adolescence and before mar-

riage varied from 8% in some regions of the country to

69% in other regions [25]. Reports could not be found in

the literature that provided any specific difference in

cultural practices in these provinces that could account

for the difference. Further exploration of these differ-

ences is warranted.

It must be noted that the choice of measures for ap-

propriateness of the intervention might have influenced

results obtained. The choice of a yes/no response format

has the advantage of being more appealing to participants

because it demands less concentration, but variability in

the responses is also lost by using this format [26] The

open-ended sections of the questions added to elicit more

in depth information were often not used by participants.

For those who used it, responses were often brief or

cryptic and provided little to understanding participants’

perceptions. Face to face interviews would have been a

better approach in eliciting more in depth information. In

addition because of the sensitive nature of the topic of

the intervention, the age, and gender of participants the

influence of social desirability bias cannot be ruled out.

In all, HIV infections pose a serious threat to the

health of young Cameroonians. The prevalence rate con-

tinues to rise at an alarming rate in this population. Ex-

perts have identified equipping pre-adolescent females

with skills necessary to reduce their vulnerability as an

effective strategy towards reversing the epide mic. Evalu-

ating the appropriateness of interventions to the devel-

opmental level, gender, and culture of participants is an

essential step in developing effective and sustainable

interventions. Find ings in this study ar e encouraging and

indicate that the intervention was appropriate from the

participants’ perspective. However these results need to

be interpreted with caution because the small sample size

and the convenien ce sampling approach used. In addition,

there are limits to generalizability of the findings as the

intervention was tailored based on knowledge of the de-

velopmental level and culture of participants. In spite of

the limitations, findings and practical lessons learned

from the study could inform other more rigorously de-

signed HIV preventions interventions studies in Camer-

oon or studies targeting preadolescents.

REFERENCES

[1] Joint United Nations Program on HIV/AIDS, “AIDS

Epidemic,” Update December 2009, Retrieved 21 January

2010.

http://data.unaids.org/pub/Report/2009/JC1700/Epi/Updat

e/2009/en.pdf

[2] Joint United Nations Program on HIV/AIDS, “Epidemi-

ological Fact Sheet on HIV and AIDS, Core Data on

Epidemiology and Response, Cameroon,” 2008.

http://apps.who.int/globalatlas/predefinedReports/EFS200

8/full/EFS2008_CM.pdf

[3] United Nations Children’s Fund, “Information on STI and

HIV/AIDS.”

www.unicef.org/wcaro/WCARO_Cameroon_Pub_KitPT

ME-en.pdf

[4] C. Enah, “An Intervention to Increase Intentions and Be-

havioral Skills to Postpone Sexual Activity in Cameroo-

nian Preadolescent Female Students,” Dissertation Ab-

stracts International 65/05, 2342B, 2004.

[5] C. Enah, M. Sommers, L. Moneyham, C. Long and G.

Childs, “Piloting and HIV Prevention Intervention for

Cameroonian Girls,” Journal of Nurses in AIDS Care,

Vol. 21, No. 6, 2010, pp. 512-521.

doi:10.1016/j.jana.2010.02.011

[6] World Health Organization, “HIV/AIDS Epidemiological

Surveillance Report for the WHO African Region,” 2007.

http://www.afro.who.int/aid/publications/index.html

[7] World Health Organization, “2006 AIDS Epidemic Up-

date,” 2006.

http://www.who.int/hiv/mediacentre/04_sub_saharan_Afr

ica_2006_EpiUpdate_eng.pdf

[8] G. Burkholder, L. Harlow and J. Washkwich, “Social

Stigma, HIV/AIDS Knowledge, and Sexual Risk,” Jour-

nal of Applied Biobehavioral Research, Vol. 4, No. 1,

1999, pp. 27-44.

doi:10.1111/j.1751-9861.1999.tb00053.x

[9] P. T. Tebon, “Cameroon National Composite Policy In-

dex Report 2008,” 2008.

http://data.unaids.org/pub/report/2008/Cameroon_2008_n

cpi_en.pdf

[10] M. Sommer, “An Overlooked Priority: Puberty in

Sub-Saharan Africa,” American Journal of Public Health,

Vol. 101, No. 6, 2011, pp. 979-981.

doi:10.2105/AJPH.2010.300092

[11] Joint United Nations Program on HIV/AIDS, “Report on

the HIV/AIDS Epidemic,” 26 February 2007.

http: www.unaids.html

[12] M. Rwenge, “Sexual Risk Behaviors among Young Peo-

ple in Bamenda, Cameroon,” International Family Plan-

ning Perspectives, Vol. 26, No. 3, 2000, pp. 188-123,

130.

[13] D. Meekers and A. Calves, “Main Girlfriends, Girlfriends,

Marriage, and Money: The Social Context of HIV Risk

Behavior in Sub-Saharan Africa,” Health Transitions Re-

view, Vol. 7 (Supplement), 1997, pp. 361-375.

[14] N. Lydie, N. Robinson, B. Ferry, E. Akam, M. De Loen-

zien, L. Zekeng and S. Abega, “Adolescent Sexuality in

Yaoundé, Cameroon,” Journal of Biosocial Sciences, Vol.

36, No. 5, 2004, pp. 597-616.

Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention

[15] J. Speizer, B. Taambashe and S. Tegang, “An Evaluation

of the ‘Entre Nous Jeunes’ Peer-Educator Program or

Adolescents in Cameroon,” Studies in Family Planning,

Vol. 32, No. 4, 2001, pp. 339-351.

doi:10.1111/j.1728-4465.2001.00339.x

[16] D. Meekers, S. Agha and M. Klein, “The Impact on

Condom Use of the ‘100% Jeune’ Social Marketing Pro-

gram in Cameroon,” Journal of Adolescent Health, Vol.

36, No. 6, 2005, p. 530.

doi:10.1016/j.jadohealth.2004.10.012

[17] B. Mensch, P. Hewett and A. Erulkar, “The Reporting of

Sensitive Behavior among Adolescents: A Methodologi-

cal Experiment in Kenya,” Demography, Vol. 40, No. 2,

2003, pp. 247-268.doi:10.1353/dem.2003.0017

[18] World Health Organization, “Responsible behavior: De-

laying Sex,” In Curriculum Planners’ Handbook, WHO/

UNESCO, Geneva, 1994.

[19] L. Jemmott, J. Jemmott and K. McCaffee, “Be Proud! Be

Responsible! Strategies to Empower Youth to Reduce

Their Risk of AIDS,” Columbia University School of

Nursing, New York, 1996.

[20] World Health Organization, “2006 AIDS Epidemic Up-

date,” 2006.

http://www.who.int/hiv/mediacentre/04_sub_saharan_Afr

ica_2006_EpiUpdate_eng.pdf

[21] J. Jemmott, L . Jemmott, A. O’Leary, Z. Ngwane, L. Icard,

S. Bellamy, et al., “School-Based Randomized Controlled

trial of an HIV/STD Risk Reduction Intervention for

South African Adolescents,” Archives of Pediatric Medi-

cine, Vol. 164, No. 10, 2010, pp. 923-929.

doi:10.1001/archpediatrics.2010.176

[22] A. Karnell, P. Cupp, R. Zimmerman, S. Feist-Price and T.

Bennie, “Efficcacy of an American Alcohol and HIV

Curriculum Adapted for Use in Aouth Africa: Results of a

Pilot Study in Five Townships,” AIDS Education and

Prevention, Vol. 18, No. 4, 2006, pp. 295-310.

doi:10.1521/aeap.2006.18.4.295

[23] M. Fitzgerald, B. Stanton, N. Terreri, H. Shipena, X. Li, J.

Kahihuata, et al., “Use of Western-Based HIV Risk-

Reduction Interventions Targeting Adolescents in an Af-

rican Setting,” Journal of Adolescent Health, Vol. 25,

1999, pp. 52-61.

doi:10.1016/S1054-139X(98)00120-7

[24] K. Klepp, S. Ndeki, M. Leshabari, P. Hannan and B. Ly-

imo, “AIDS Education in Tanzania: Promoting Risk Re-

duction among Primary School Children,” American

Journal of Public Health, Vol. 87, No. 12, 1997,

1931-1936.doi:10.2105/AJPH.87.12.1931

[25] B. Kuate-Defo, “Premarital Sexual Intercourse during

Adolescence: Trends and Determinants of Regional Dif-

ferences,” In: B. Kuate-Defo, Ed., Sexuality and Repro-

ductive Health during Adolescence in Africa with Special

Reference to Cameroon, University of Ottawa Press, Ot-

tawa, 1998, pp. 121-140.

[26] R. Devellis, “Scale Development: Theory and Applica-

tions,” Sage Publications, Newbury Park, 1991.