Sub-Saharan African countries face the highest rates of teenage pregnancy, early marriage, HIV, and other sexually transmitted infections (STIs) prevalence in the world. Despite decades of public health interventions and research, there is limited causal evidence regarding which types of interventions (supply side or demand side) are most effective in improving sexual and reproductive health (SRH) outcomes and why.
In Tanzania, approximately 60 percent of females report to have had sex by age 18. Yet less than 10 percent of adolescents aged 15 to 19 report using any modern contraceptive method . One possible reason for the lack of long-term improvement in sexual and reproductive health outcomes, despite decades of research and interventions, is that very few programs have addressed both supply-side constraints (e.g., lack of access to contraception) and demand-side constraints (e.g., lack of use of contraception when available), and when they have, few have targeted adolescents.
Additionally, the majority of existing supply-side and demand-side programs tend to target only females, while descriptive data suggest that males may have more control over decisions around contraceptive use. To address these evidence gaps, researchers are conducting a randomized evaluation with both male and female adolescents in Tanzania to identify the differential impacts of demand-side and supply-side interventions and to better understand the role males play in affecting SRH outcomes.
BRAC, the implementing partner of this evaluation, launched the Empowerment and Livelihood for Adolescents (ELA) program in 2008. The program provides a safe space, skills training, and microfinance to increase the social and financial empowerment of girls and young women aged 12 to 24. ELA clubs operate in Bangladesh, Uganda, Tanzania, Sierra Leone, South Sudan, and Liberia. There are nearly 150 ELA clubs operating across three regions in Tanzania (Dodoma, Iringa, and Mbeya).
BRAC is leveraging their network of ELA clubs to implement this randomized evaluation. The evaluation is divided into two components: (1) a group-randomized component to test the relative importance of various supply- and demand-side factors that affect SRH outcomes; and (2) an individual-randomized component to test the effectiveness of goal-setting in affecting SRH outcomes.
The group-randomized intervention includes the following treatment groups:
1.Female demand-side treatment: Female adolescents are offered standard SRH programming that includes improved SRH education through the ELA clubs. This will allow researchers to investigate the effectiveness of demand-side interventions related to education.
2.Female supply-side treatment: Research partners from Marie Stopes Tanzania visit the females approximately once every two months and offer them free contraceptives. This will allow researchers to understand how much of the low contraceptive rates are due to supply-side constraints.
3.Male demand-side treatment: Males control much of the power in negotiations over contraceptive use and sexual behavior. Therefore, researchers have selected males from the sexual networks of females and are offering them education around SRH and domestic violence issues through soccer clubs. The NGO implementing this arm is Grassroots Soccer. By adding male peers to the intervention, researchers will be able to test whether improving males’ knowledge of SRH results in larger improvements in female outcomes.
4. Comparison: A comparison group of adolescent females and males has been recruited from communities neighboring the intervention communities. These comparison communities come from an earlier randomized evaluation of the ELA program when the program was initially rolling out (Buehren et al., 2017).
On top of the group-randomized intervention, researchers are implementing a second individually-randomized intervention that cuts across all treatment arms. Researchers have randomly assigned individual females to one of two groups:
- Goal-setting treatment: A subsample of females from each treatment arm was selected to participate in a goal-setting exercise where they were asked to commit to remaining HIV/STI free and set three specific strategies to accomplish this goal. This treatment will allow researchers to investigate the impact of commitment to SRH on SRH outcomes.
- Comparison: The remaining girls in the parent intervention serve as a comparison group.
To assess the effectiveness of the SRH programming, researchers collected data from all groups on a range of health and behavioral indicators and are analyzing adolescents’ SRH behavior, including reported sexual activity, pregnancies, and knowledge of contraception methods. In addition, data are being gathered on other health behaviors, including drinking, smoking, socializing, and self-reported mental and physical health. Outside of health, researchers are analyzing adolescents’ economic behaviors, including savings and employment status, along with other behavioral indicators, including risk-taking and optimism. Finally, researchers will map adolescents’ social networks to better understand how adolescents’ peers may influence their decisions.
Results and Policy Implications
Evaluation ongoing, results forthcoming.