Study from Tanzania offers lessons on how to improve the health of adolescent girls around the world
Being a teenager anywhere is a challenge. This is especially true in sub-Saharan Africa, where adolescents have some of the world’s highest rates of HIV infection, unwanted teenage pregnancies and intimate partner violence.
In Tanzania, for example, around 60% of adolescent girls are sexually active by the age of 18. Less than 10% of girls aged 15-19 use any type of modern contraceptive. A staggering 15 to 24 year olds in three will experience intimate partner violence.
There have been decades of public health interventions and research in the countries of sub-Saharan Africa. But we still have a lot to learn about how to improve adolescent sexual and reproductive health. Most traditional family planning and sexual and reproductive health programs target married adults or the elderly and often focus exclusively on women.
In our recent research, we sought to identify interventions that could improve the sexual and reproductive health of girls and young women aged 11 to 22. We have partnered with BRAC, an international development organization operating in 11 countries, including Tanzania.
One of our main findings was that two interventions significantly reduced intimate partner violence. The first was to engage and inspire adolescents and young men to make better sexual and reproductive health choices. The second was the empowerment of adolescent girls and young women. We did this using a goal setting exercise focused on maintaining good health.
Both approaches are inexpensive and easy to replicate and scale. But they are not often used for sexual and reproductive health interventions. Our research provides new information on strategies that can be used to improve the lives of adolescents in sub-Saharan Africa and around the world.
Our partner, BRAC, designs scalable, proven solutions that empower people to lift themselves out of poverty and realize their potential. Among its initiatives are the adolescent empowerment and livelihood clubs. These provide social and economic empowerment and education for young people in fun environments in eight countries.
We implemented three additional interventions in 150 of the clubs across Tanzania in a randomized controlled trial. This research method provides a rigorous design to identify causal impacts and determine which interventions are effective and which are not.
Between 2016 and 2020, we worked with around 4,500 adolescents (3,000 women and 1,500 men). We analyzed the results of the following three interventions:
a goal setting activity for adolescent girls and young women to stay healthy and safe from sexually transmitted infections and HIV. This allowed us to estimate the role of behavioral factors that affect commitment to safe sexual behavior and mate selection.
a football-based health behavior change and empowerment program for male partners of adolescent girls and young women. This allowed us to test whether adolescent sexual and reproductive health outcomes improved when men were included in the intervention.
access to free modern contraceptives. This allowed us to test whether their access – without changing other norms of behavior – had a significant impact.
The results were surprising. We believe they are important for policy makers, civil society organizations and the general public.
What we found
First, we found that providing male partners with a football-based health program that educated them and encouraged them to make better sexual and reproductive health choices reduced female reports of intimate partner violence. In collaboration with BRAC, we offered this intervention by partnering with Grassroot Soccer. It is a non-profit adolescent health organization that uses football to educate, inspire and engage young people in developing countries.
The reduction in intimate partner violence associated with the soccer-based health intervention appears to be driven by a change in men’s attitudes toward intimate partner violence in the communities where Grassroot Soccer operated. In addition, we have observed a reduction in sexual activity in these communities. Women reported fewer partners and spent less time with male partners.
Second, we found that adolescent girls who participated in the goal setting activity reported a decrease in intimate partner violence. We asked adolescent girls to identify two or three specific strategies to achieve the goal of staying healthy and safe from sexually transmitted infections and HIV.
The reduction in intimate partner violence due to goal setting activity has been driven by improvements in the reported quality of partners, as well as an increase in the sense of self-action of young women. We measured the quality of partners based on partner’s age, education level, and contraceptive use. These are all factors that correlate with risky sexual activity.
In the arms of goal setting and football treatment, we found that the impacts were greatest in women who were already sexually active at the start of the study.
Third, we found that simply having access to free contraceptives did not have a significant impact on sexual and reproductive health outcomes. This may be because accessing modern contraceptives without changing the norm through education is not effective – but more study is needed on this issue.
We have learned a number of key lessons from our results. First, the participation of adolescents and young men reduces intimate partner violence and changes men’s attitudes towards violence against women.
Second, the adolescents benefited from participating in an activity that encouraged forward-looking behavior. It heightened their sense of personal free will to make better choices in the present time around sex.
Third, offering contraception alone, without focusing on changing the behavior of women and men, will not necessarily improve adolescent sexual and reproductive health.