Does a School-based Intervention Increase Girls' Sexual and Reproductive Health Attitudes and Intentions? Results from a Mixed-methods Cluster-randomized Trial in Burkina Faso

"The (re)solve intervention showed promise for supporting adolescent girls in 4eme and 3eme to use contraception and potentially avoid pregnancies in two large cities in Burkina Faso. This is an important contribution to the field, which has little evidence on successful school-based SRH [sexual and reproductive health] programming for adolescents in sub-Saharan Africa..."

Adolescent girls in Burkina Faso face unintended pregnancy risk due to low levels of contraceptive use. The (re)solve project was designed to address contraceptive misperceptions and increase girls' perceptions of their pregnancy risk, primarily through a participatory game (La Chance) and a health passport aimed at easing health facility access. The primary objective of the school-based intervention was to demystify and normalise contraception as a valid option of pregnancy prevention for girls. This paper shares the results of an impact evaluation using a mixed-methods cluster randomised control trial design to evaluate (re)solve's impact on girls' intentions to use contraception, among other outcomes.

As detailed at Related Summaries, below, the (re)solve intervention was informed by several processes that generated data and insights on young women's barriers to contraceptive use and nonuse in Burkina Faso. This research highlighted, for example, the attitudes, beliefs, and norms that interfere with the decision-making process along the pathway from intention formation (e.g., the decision to avoid pregnancy by using contraception) to follow-through (e.g., the decision to get a contraceptive at a clinic). The combined insights from segmentation analysis and behavioural diagnosis into individual, social, and structural barriers served as primary inputs into the design of the intervention.

The programme team implemented (re)solve in 16 randomly selected secondary schools - 8 each in Bobo-Dioulasso (Bobo) and Ouagadougou (Ouaga) - in 4ème and 3ème (grades 9 and 10). In each location, they trained 16 community-based facilitators to lead the board games and distribute the passports and identified 18 health facilities (9 each in Bobo and Ouaga) to participate. A total of 3,120 girls in grades 3ème and 4ème played La Chance between December 2019 and March 2020. Facilitators distributed 11,908 passports to girls in this timeframe. Also, posters that matched the design of the board game that were displayed in participating schools and health facilities advertising puberty-related, non-contraceptive counseling and services for girls. Providers and staff trained in youth-friendly services also wore matching name tags to help them be easily identifiable to girls visiting the facilities.

Thirty-two schools were randomly allocated intervention or control. The evaluation included quantitative longitudinal surveys at baseline (N = 2,372) and endline (N = 2,072) and qualitative in-depth interviews (IDIs) with girls in the intervention group at baseline (N = 41) and endline (N = 48) and with implementation staff (N = 35) and experts (N = 14) at endline. The research team collected baseline data between November 2019 and January 2020, after a 7-day training in Ouagadougou for the research partners. After a refresher training, the research team collected midline data in January and February 2020. The research team collected endline data in July 2020. They used generalised estimating equations (GEE) analysis for the main analysis.

The study found that girls in the intervention schools shifted their contraceptive intention and attitudes in desired ways, more than control-school girls. For example, there was an absolute shift between baseline and endline of 21.1 in the community-level prevalence in the intervention schools of girls reporting they had the confidence to get and use contraception, as compared to a shift of only 10.8 among control-school girls. (re)solve had a positive effect on girls' intention to use contraception (adjusted odds ratio (aOR) = 1.59, 95% confidence interval (CI) 0.97-2.61), though this finding did not reach statistical significance. When the researchers restricted the sample among girls who went to a health facility in the intervention group, they found that girls in the intervention schools were about twice as likely to express an intention to use contraception in the next 3 months compared to all girls in the control schools (aOR = 2.02, 95% CI 1.08-3.77). The impact was particularly large among girls who had never had sex, girls who attended public schools, and girls in 3ème.

Notably, an unexpectedly large percentage of intervention-school girls (365 of 809, or 45.1%) intended to go to a facility but had not yet gone because of obligations or restrictions such as school duties, COVID-19 pandemic-related restrictions, or a lack of means, transport, or support.

Qualitative findings suggest that, overall, girls enjoyed playing La Chance, asking questions, and learning through gameplay and facilitated dialogue. They also reported positive experiences at the (re)solve health facilities. Furthermore, the intervention seems to have positively shifted attitudes and facility-seeking behaviours for many girls. For example, at baseline, a number of girls expressed concerns that contraception would be ineffective or would have lasting negative consequences, including trouble conceiving later, but at endline, most girls articulated that modern methods of contraception could successfully and reliably prevent pregnancy and sexually transmitted infections (STIs).

However, both quantitative and qualitative data indicate that, at endline, many girls still cited the role of misinformation and fear - especially of a link between contraception, particularly implants, and permanent infertility - which "remain a significant barrier to contraceptive use" in this mostly young, sexually naïve population. ("The sticky belief that contraceptives causes infertility is usually grounded in deeper social norms around proving fertility after marriage and the importance of parenthood....It is unsurprising that fear of future infertility would be resilient to a time-bound behavioral intervention such as" (re)solve.)

In short, this study found an increase in intervention-school girls' intention to use contraception in the near future - the primary outcome for the evaluation - compared to control-school girls, although the relationship was not statistically significant. The researchers noted improvements over time in other key outcomes. "The well-received solutions appear to pique girls' curiosity about SRH, including contraceptives. Behavior change, such as getting girls to use contraception, or even to hold an intention to do so, is not an overnight process. However, even with this light-touch interventions, we can expect modest behavior change.... [I]nterventions like (re)solve may 'prime the pump' for behavior change and increasing girls' use of contraception."