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Preventing HIV and Teen Pregnancy in Kenya: The Roles of Teacher Training and Education Subsidies
Last registered on July 19, 2016

Pre-Trial

Trial Information
General Information
Title
Preventing HIV and Teen Pregnancy in Kenya: The Roles of Teacher Training and Education Subsidies
RCT ID
AEARCTR-0001432
Initial registration date
July 19, 2016
Last updated
July 19, 2016 8:21 PM EDT
Location(s)
Region
Primary Investigator
Affiliation
Stanford University
Other Primary Investigator(s)
PI Affiliation
MIT, J-PAL
PI Affiliation
Harvard University
Additional Trial Information
Status
Completed
Start date
2003-02-01
End date
2011-03-31
Secondary IDs
Abstract
A seven-year randomized evaluation suggests education subsidies reduce adolescent girls’ dropout, pregnancy, and marriage but not sexually transmitted infection (STI). The government’s HIV curriculum, which stresses abstinence until marriage, does not reduce pregnancy or STI. Both programs combined reduce STI more, but cut dropout and pregnancy less, than education subsidies alone. These results are inconsistent with a model of schooling and sexual behavior in which both pregnancy and STI are determined by one factor (unprotected sex), but consistent with a two-factor model in which choices between committed and casual relationships also affect these outcomes.
Registration Citation
Citation
Duflo, Esther, Pascaline Dupas and Michael Kremer. 2016. "Preventing HIV and Teen Pregnancy in Kenya: The Roles of Teacher Training and Education Subsidies." AEA RCT Registry. July 19. https://doi.org/10.1257/rct.1432-1.0.
Former Citation
Duflo, Esther, Pascaline Dupas and Michael Kremer. 2016. "Preventing HIV and Teen Pregnancy in Kenya: The Roles of Teacher Training and Education Subsidies." AEA RCT Registry. July 19. https://www.socialscienceregistry.org/trials/1432/history/9462.
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Experimental Details
Interventions
Intervention(s)
This evaluation tested two interventions to reduce risky sexual behavior: training teachers on the existing HIV curriculum, and reducing the costs of schooling by providing free uniforms. The 328 study schools were randomly assigned to one of four groups of about 82 schools. Each of the four groups of schools received a different set of programs:

In groups 2 and 4, three teachers were trained on HIV/AIDS and on how to teach the HIV curriculum. The curriculum covers facts about the disease, and encourages abstinence until marriage and faithfulness afterwards. It also teaches life skills, such as how to say "no" to unwanted or unsafe sexual relations.

In groups 2 and 3, children already enrolled in sixth grade classes were given a free uniform. Implementers also announced that students still enrolled in school the following year would be eligible for a second uniform, and distributed uniforms again the following year.

All in all, group 1 received no program at all and thus served as the comparison group, group 2 received the teacher training program only, group 3 schools received the uniforms program only, and group 4 schools received both programs.

To evaluate the impact of the two programs on sexual behavior and sexual health, survey data was collected on youths' sexual behavior. Such survey data can be subject to reporting biases, however. It was therefore important to complement this data with an objective measure of the incidence of unprotected sex, which is the main mode of HIV transmission in Kenya. Two such measures were considered: (1) childbearing rates and (2) sexually transmitted infection rates. Childbearing rates were monitored regularly between 2003 and 2010. STI infection rates (specifically, Herpes and HIV infection rates) were measured during a long-term follow-up in 2009-2010.
Intervention Start Date
2003-02-01
Intervention End Date
2004-11-30
Primary Outcomes
Primary Outcomes (end points)
- Duration of student enrolment in school
- Incidence of teen marriage
- Incidence of teen pregnancy
- HSV2 infection
Primary Outcomes (explanation)
Secondary Outcomes
Secondary Outcomes (end points)
Secondary Outcomes (explanation)
Experimental Design
Experimental Design
We study two programs implemented through a partnership between the non-governmental organization ICS Africa, the Kenyan Ministry of Education, the Kenya Institute of Education, and the Kenya National AIDS Control Council. The first program reduced the cost of education by providing free school uniforms. The second program trained teachers on how to deliver the national HIV/AIDS prevention curriculum to upper primary school students. We also evaluate a small add-on component to the government-run teacher training designed to foster the discussion of condoms, in order to check whether an explicit discussion of condoms in a curriculum otherwise focused on abstinence and fidelity could affect behavior.

The study took place in all 328 public primary schools in 7 divisions of 2 districts of Western Kenya: Butere-Mumias and Bungoma. None of these schools had participated in any prior randomized evaluation that we know of. All schools agreed to participate. Schools were stratified and assigned to one of four arms using a random number generator: (i) Control (82 schools); (ii) Stand-alone education subsidy program (83 schools); (iii) Stand-alone HIV education program (83 schools); (iv) Joint program (80 schools). Between February and July 2003, ICS distributed free school uniforms to boys and girls enrolled in sixth grade at the onset of the school year (January). In fall 2004, ICS distributed a second uniform to the same students, if they were still enrolled in the same school (regardless of their grade). It was announced at the onset of the program that students still enrolled in the same school would be eligible for a second uniform after 18 months. The total education subsidy, delivered over two years, amounted to just around $12 per student, or 2.5 percent of average annual household income in the study area at the time.

In 2002 the Kenya government started a large-scale effort to train teachers on HIV education, based in part on data suggesting that in the absence of training, many teachers were uncomfortable teaching the official HIV/AIDS curriculum. In 2003, ICS Africa helped implement the national training program for 184 primary schools by providing logistical and financial support. The 184 schools selected for the HIV Education program were asked to send three upper primary teachers to participate in a five-day training program. The training sessions were conducted jointly by one facilitator from the AIDS Control Unit of the Ministry of Education (MoE), two facilitators from the Kenya Institute of Education (KIE), and one trained staff member from ICS Africa. Teacher training included basic facts on HIV/AIDS, a condom demonstration, information on voluntary counseling and testing, and HIV/AIDS education methodology. Because training was primarily done by MoE and KIE staff and was based on the officially approved curriculum, the content should be similar to that delivered in other parts of Kenya. At the same time, since the sessions were facilitated and observed by ICS Africa and members of the research team, we do know they were well run and teacher attendance was good.

In addition to receiving training on how to deliver HIV information in the classroom, teachers were advised to set up health clubs to deliver HIV information outside of the classroom. Since the curriculum leaves almost no space for teachers to provide information about condoms, we were interested in testing whether exploiting the existing window to the maximum extent possible would affect the impact of teacher training on student knowledge and behavior. This is important for policy, since only an intervention taking place within the existing curriculum could be potentially scaled up (if effective) without major rethinking. From the perspective of understanding adolescent behavior, it was also important to try to generate exogenous variation in awareness of condoms (a potential way to protect oneself against both STI and pregnancy) without affecting access to condoms. Thus, during the school year 2005, two years after the implementation of the education subsidy and HIV education teacher training, a random subset of schools that had participated in the teacher training were sampled for an additional intervention called “critical thinking” (CT). This add-on was targeted at students in seventh and eighth grades in 2005 (many of whom, given the high repetition rate, were in sixth grade in 2003, i.e., in our study cohort). Schools sampled for CT were encouraged to organize a debate on the motion, “School children should be taught how to use condoms,” a motion suggested in the official Facilitators’ Handbook (KIE 1999, p. 66). The debate was followed by an essay competition on the theme: “Discuss ways in which you can protect yourself from HIV infection now and at later ages in your life.” Both debates and essay writing are established practices in Kenyan schools, and teachers agreed to organize these activities in 95 percent of sampled schools. At the time, none of these schools had previously organized a debate or essay competition on these specific topics, which suggests that these topics were most likely never discussed in non-CT schools, and thus the CT encouragement appears to have created the intended exogenous gap in students exposure.
Experimental Design Details
Randomization Method
Randomization done in office by a computer
Randomization Unit
School
Was the treatment clustered?
Yes
Experiment Characteristics
Sample size: planned number of clusters
328 schools
Sample size: planned number of observations
19,289 students
Sample size (or number of clusters) by treatment arms
Control group 1: 82 schools received no program at all
Treatment group 2: 83 received the teacher training program only,
Treatment group 3: 83 schools received the uniforms program only, and
Treatment group 4: 80 schools received both programs
Minimum detectable effect size for main outcomes (accounting for sample design and clustering)
IRB
INSTITUTIONAL REVIEW BOARDS (IRBs)
IRB Name
KEMRI/National Ethics Review Committee
IRB Approval Date
2002-08-07
IRB Approval Number
KEMRI/RES/7/3/1
IRB Name
MIT Committee on the Use of Humans as Experimental Subjects (COUHES)
IRB Approval Date
2006-12-21
IRB Approval Number
0612002039
Post-Trial
Post Trial Information
Study Withdrawal
Intervention
Is the intervention completed?
Yes
Intervention Completion Date
November 30, 2004, 12:00 AM +00:00
Is data collection complete?
Yes
Data Collection Completion Date
March 31, 2011, 12:00 AM +00:00
Final Sample Size: Number of Clusters (Unit of Randomization)
328 schools
Was attrition correlated with treatment status?
No
Final Sample Size: Total Number of Observations
19,289 pupils
Final Sample Size (or Number of Clusters) by Treatment Arms
Control group 1: 82 schools received no program at all Treatment group 2: 83 received the teacher training program only, Treatment group 3: 83 schools received the uniforms program only, and Treatment group 4: 80 schools received both programs
Data Publication
Data Publication
Is public data available?
Yes
Program Files
Program Files
Yes
Reports and Papers
Preliminary Reports
Relevant Papers
Abstract
A seven-year randomized evaluation suggests education subsidies reduce adolescent girls’ dropout, pregnancy, and marriage but not sexually transmitted infection (STI). The government’s HIV curriculum, which stresses abstinence until marriage, does not reduce pregnancy or STI. Both programs combined reduce STI more, but cut dropout and pregnancy less, than education subsidies alone. These results are inconsistent with a model of schooling and sexual behavior in which both pregnancy and STI are determined by one factor (unprotected sex), but consistent with a two-factor model in which choices between committed and casual relationships also affect these outcomes.
Citation
Duflo, Esther, Pascaline Dupas, and Michael Kremer. 2015. "Education, HIV, and Early Fertility: Experimental Evidence from Kenya." American Economic Review, 105(9): 2757-97.