title: Scaling up adolescent sexual and reproductive health interventions through existing government systems? A detailed process evaluation of a school-based intervention in Mwanza region in the northwest of Tanzania.
abstract: OBJECTIVE
  There is little evidence from the developing world of the effect of scale-up on model adolescent sexual and reproductive health (ASRH) programmes. In this article, we document the effect of scaling up a school-based intervention (MEMA kwa Vijana) from 62 to 649 schools on the coverage and quality of implementation.
  
  
  METHODS
  Observations of 1,111 students' exercise books, 11 ASRH sessions, and 19 peer-assistant role plays were supplemented with interviews with 47 ASRH-trained teachers, to assess the coverage and quality of ASRH sessions in schools.
  
  
  RESULTS
  Despite various modifications, the 10-fold scale-up achieved high coverage. A total of 89% (989) of exercise books contained some MEMA kwa Vijana 2 notes. Teachers were enthusiastic and interacted well with students. Students enjoyed the sessions and scripted role plays strengthened participation. Coverage of the biological topics was higher than the psycho-social sessions. The scale-up was facilitated by the structured nature of the intervention and the examined status of some topics. However, delays in the training, teacher turnover, and a lack of incentive for teaching additional activities were barriers to implementation.
  
  
  CONCLUSIONS
  High coverage of participatory school-based reproductive health interventions can be maintained during scale-up. However, this is likely to be associated with significant changes in programme content and delivery. A greater emphasis should be placed on improving teachers' capacity to teach more complex-skills-related activities. Future intervention scale-up should also include an increased level of supervision and may be strengthened by underpinning from national level directives and inclusion of behavioral topics in national examinations.
authors.affiliation: Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, United Kingdom. jenny_komrower@yahoo.co.uk
authors.forename: Jenny R
authors.initials: JR
authors.lastname: Renju
authors.forename: Bahati
authors.initials: B
authors.lastname: Andrew
authors.forename: Lemmy
authors.initials: L
authors.lastname: Medard
authors.forename: Coleman
authors.initials: C
authors.lastname: Kishamawe
authors.forename: Michael
authors.initials: M
authors.lastname: Kimaryo
authors.forename: John
authors.initials: J
authors.lastname: Changalucha
authors.forename: Angela
authors.initials: A
authors.lastname: Obasi
mesh_terms: D000293:Adolescent; D000294:Adolescent Behavior / Q000523:psychology*; D016497:Adolescent Health Services / Q000458:organization & administration*; D005178:Faculty / Q000458:organization & administration*; D005260:Female; D015658:HIV Infections / Q000517:prevention & control; D006801:Humans; D007398:Interpersonal Relations; D008297:Male; D015397:Program Evaluation; D018456:Reproductive Medicine / Q000458:organization & administration; D040242:Risk Reduction Behavior; D019035:Rural Health Services / Q000458:organization & administration; D012572:School Health Services / Q000458:organization & administration*; D012736:Sex Education / Q000379:methods*; D012749:Sexually Transmitted Diseases / Q000517:prevention & control*; D013636:Tanzania / Q000453:epidemiology