Capitalising on aspirations of adolescent girls and young women to reduce their sexual health risks: Implications for HIV prevention

Qualitative evaluation of an edutainment intervention to prevent age-disparate transactional sex in Tanzania: Changes in educational aspirations and gender equitable attitudes towards work

Age-disparate transactional sex is a major contributor to the disproportionate rates of HIV experienced by adolescent girls in sub-Saharan Africa, and a key driver of unintended adolescent pregnancy. This paper comprises one element of the impact evaluation of the Learning Initiative on Norms, Exploitation and Abuse (LINEA) radio drama intervention to prevent age-disparate transactional sex. It provides new insights into the radio drama's influence on distal drivers of age-disparate transactional sex identified in formative research: girls' own educational aspirations, and gendered attitudes towards work. The intervention, which targeted adolescent girls and their caregivers in the Shinyanga Region of Tanzania, uses an edutainment approach to prevent transactional sex between girls aged 12-16 years and men at least 5-10 years older. We distributed the 39-episode radio drama on USB flash drives to 331 households and conducted longitudinal in-depth interviews with 59 participants. We conducted a thematic analysis of endline (December 2021) transcripts from 23 girls, 18 women caregivers, and 18 men caregivers of girls (n = 59), and midline (November 2021) transcripts from a sub-sample of these participants: 16 girls, 16 women and 13 men (n = 45). Findings suggest the radio drama created an enabling environment for preventing age-disparate transactional sex by increasing girls' motivation to focus on their studies and remain in school. There was also strong evidence of increased gender-equitable attitudes about work among girls and women and men caregivers. These supported women joining the workforce in positions traditionally reserved for men and challenging the male provider role. Our findings suggest that the LINEA radio drama can supplement interventions that address structural drivers of age-disparate transactional sex. The radio drama may also have impacts beyond preventing age-disparate transactional sex, such as reducing girls' HIV morbidity and mortality, and challenging attitudes that promote sexual and gender-based violence to foster more gender-equitable communities across Tanzania.

Barriers to family planning through structural health vulnerabilities: findings from case studies from rural Uganda

The burden of maternal mortality in sub-Saharan Africa is the highest in the world. As high fertility rates present an increased risk to women's health, programmes and services have been put in place to increase access to family planning. Several studies have identified sociocultural factors as limiting access to family planning, including male resistance and women's low decision-making power. However, these studies have often used a behavioural approach that anchors barriers to access in women's attitudes or motivations. In 2019, a qualitative evaluation of a family planning programme using a behavioural approach was conducted in rural Uganda, focusing on women's attitudes and unmet needs. With hindsight, we realised that our evaluation was insufficient to adequately capture barriers that extend beyond women's motivations. This paper shares three case studies that we analysed using a structural health vulnerabilities approach. Our analysis highlights political, economic, social and cultural structures that can impede access to family planning. Using a structural health vulnerabilities approach, we identify structural barriers which have their roots in the local realities women face and propose context-specific structural recommendations. Finally, we contrast our initial results with findings the case studies presented to highlight the relevance of taking structural vulnerabilities into account in future family planning programme evaluation and women's sexual and reproductive health studies.

Shifting social norms to prevent age-disparate transactional sex in Tanzania: what we can learn from intervention development research

This paper reflects on the development process (2015-2020) of the Learning Initiative for Norms, Exploitation, and Abuse (LINEA) Intervention. The LINEA Intervention is a multi-component social norms intervention to prevent age-disparate transactional sex in Tanzania. This paper aims to: (1) critically reflect on the LINEA Intervention development process by retrospectively comparing it with a pragmatic, phased framework for intervention development in public health, the Six Essential Steps for Quality Intervention Development (6SQuID); and (2) discuss the usefulness and applicability of this framework to guide intervention development for gender-based violence prevention. This paper contributes to a growing field of intervention development research to improve the designs of interventions to prevent gender-based violence. Findings showed that the LINEA Intervention development approach mostly aligned with the steps in 6SQuID framework. However, the LINEA Intervention development process placed particular emphasis on two phases of the 6SQuID framework. First, the LINEA Intervention development process included significant investment in formative research, feasibility testing, and refinement; and second, the LINEA Intervention was informed by a clearly articulated behavior change theory-social norms theory. Beyond the 6SQuID framework the LINEA Intervention development process: (i) followed a non-linear, iterative process; (ii) applied ongoing feasibility testing to refine the intervention, and (iii) relied on co-development with local implementers and participants. This paper suggests future components for a robust intervention development process, highlighting beneficial additions to the 6SQuID approach, a well-recognized intervention development sequence. Particularly useful additions include incorporating sufficient time, flexibility, and resources to foster meaningful collaborations and iteration on the intervention design.

A mixed-methods, exploratory, quasi-experimental evaluation of a radio drama intervention to prevent age-disparate transactional sex in Tanzania

INTRODUCTION

Age-disparate transactional sex (ADTS) is associated with HIV, unintended pregnancy, school dropout and violence, yet few interventions have successfully prevented it, and none have set ADTS prevention as their primary outcome. This exploratory evaluation aimed to assess indications of change after exposure to the Learning Initiative on Norms, Exploitation and Abuse (LINEA) intervention, a mass-media, gender-transformative social norms intervention aimed at preventing ADTS in Tanzania.

METHODS

In a condensed implementation 331 participants were instructed to listen to the LINEA radio drama over seven weeks, and 60 were randomly allocated to household discussion sessions about content. In-depth interviews (n = 81) from girls aged 12-16 years, and women and men caregivers were collected at baseline (September 2021), midline (November) and endline (December 2021). Surveys were conducted (n = 120) at baseline and endline using the Norms and Attitudes on ADTS Scale (NAATSS) and the Gender Roles and Male Provision Expectations (GRMPE) scale. Interviews were thematically analyzed using a framework approach. Age-stratified linear regression models adjusted for baseline scores were used to measure association between the intervention and endline scale scores.

RESULTS

Longitudinal data were available from 59 qualitative (73%) and 95 quantitative participants (79%). Qualitative evidence revealed the drama facilitated family conversations about adolescent challenges, allowing caregivers to advise daughters. Some girls gained confidence to refuse men's gifts, learning that accepting them could necessitate sexual reciprocation. Some caregivers felt increased responsibility for supporting girls in the community to avoid ADTS. Blame for ADTS shifted for some from girls to men, suggesting increased understanding of inequitable power dynamics and reductions in victim blaming. Marginal quantitative evidence revealed that highly exposed girls had improved gender equitable beliefs on the GRMPE (β = -6.26; 95% CI: -12.94, 0.42). Moderately exposed men had increased gender inequitable norms on the NAATSS subscale (β = 0.42 95% CI: 0.05, 0.79), but there was no effect in highly exposed men.

CONCLUSIONS

Given the small sample results should be interpreted cautiously. Our initial findings indicate high engagement with the LINEA intervention shows promise in shifting knowledge, behaviors, and attitudes, beliefs and social norms driving ADTS in Shinyanga, Tanzania, supporting a robust impact evaluation.

Impact of the DREAMS Partnership on social support and general self-efficacy among adolescent girls and young women: causal analysis of population-based cohorts in Kenya and South Africa

INTRODUCTION

The Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) Partnership aimed to influence psychosocial processes that promote empowerment among adolescent girls and young women (AGYW), and reduce HIV incidence. We estimated the impact of DREAMS on aspects of AGYW's collective and individual agency (specifically, social support and self-efficacy), in three settings where DREAMS was implemented from 2016 until at least end 2018.

METHODS

Research cohorts of ~1500 AGYW aged 13-22 were randomly selected from demographic platforms in Kenya (Nairobi; Gem) and South Africa (uMkhanyakude) and followed up from 2017 to 2019. Social support was based on questions about female networks and access to safe places to meet with peers; general self-efficacy was measured using a scale previously validated in other settings. We conducted multivariable logistic regression, and estimated the causal effect of invitation to DREAMS on each outcome in 2018 and 2019 by comparing counter-factual scenarios in which all, vs no, AGYW were DREAMS invitees.

RESULTS

In Nairobi, Gem and uMkhanyakude, respectively, 74%, 57% and 53% were invited to DREAMS by 2018. Social support was higher among DREAMS invitees versus non-invitees (eg, adjusted OR 2.0 (95% CI 1.6 to 2.6), Gem, 2018). In 2018, DREAMS increased social support in all settings and age groups, for example, from 28% if none were DREAMS invitees to 43% if all were invitees (+15% (95% CI 10% to 20%)) in Gem. Effects were strongest in Kenya, but weakened in 2019, particularly among older AGYW. In uMkhanyakude, DREAMS invitees had greater self-efficacy compared with non-invitees in 2018 (+9% (95% CI 3% to 13%), 2018) but less so in 2019. In Kenyan settings, there was weak evidence for impact on self-efficacy among younger AGYW in Gem (+6% (95% CI 0% to 13%)) and older AGYW in Nairobi (+9% (95% CI -3% to +20%)) in 2019.

CONCLUSIONS

DREAMS impacted on social support and, less consistently, on self-efficacy. Weakening effects over time may reflect changes in access to safe spaces and social networks as AGYW age and change circumstances, and withdrawal of DREAMS from uMkhanyakude in 2018, highlighting the importance of programme sustainability and improving programming for older participants.