Structural Interventions to Enable Adolescent Contraceptive Use in LMICs: A Mid-Range Theory to Support Intervention Development and Evaluation

Abstract

Enabling contraceptive use is critical for addressing high adolescent pregnancy rates in low- and middle-income countries (LMICs). Broader or ‘upstream’ determinants, such as poverty, education, and social norms, can affect the knowledge, attitudes, motivation, and ability to access and use contraception. Structural interventions aim to address these broader determinants, e.g., through poverty alleviation from livelihood training or cash transfers, increasing school participation, or changing social norms. We conducted an evidence synthesis using intervention component analysis, a case-based approach, following a systematic mapping of the evidence base. We identified 17 studies with 29 structural intervention arms, which reported adolescent contraceptive use outcomes compared to a control group or baseline. It was not possible to identify with certainty which interventions were ‘likely effective’ or ‘likely ineffective’ due to the high heterogeneity of the methods. We built on an existing framework of family planning use to propose three steps to designing interventions: (1) tailor interventions to adolescents’ life stages; (2) assess the baseline situation; and (3) select appropriate activities to match the gaps. These steps will aid developers and evaluators of structural adolescent contraceptive interventions to develop an evidence base that is of use across a wide range of settings and use scenarios.

Effect and cost-effectiveness of human-centred design-based approaches to increase adolescent uptake of modern contraceptives in Nigeria, Ethiopia and Tanzania: Population-based, quasi-experimental studies

“…Sociocultural factors remain a barrier to adolescent contraceptive use in Nasarawa, Ogun and Mwanza. For instance, in Nasarawa, one of the main reasons participants said they were not using contraception was the desire to bear children [ 25 ], reflecting established social norms [ 26 ]. In Ogun and Mwanza, A360 appeared less effective among unmarried girls perhaps because of insufficient impact on the stigma associated with premarital sex [ 27 – 29 ].…”

Can cash transfer interventions increase contraceptive use and reduce adolescent birth and pregnancy in low and middle income countries? A systematic review and meta-analysis

“…This could be through staying on longer in school, and so delaying marriage and sexual activity, and later through increased participation in the labour market, which may change preferences for early childbearing as well as their agency to control their sexual and reproductive choices. Further work is needed to understand the mechanisms through which cash transfers may exert an impact, and in particular how cash transfer interventions should be designed to correspond with appropriate life stages of recipients, and which contextual conditions best support cash transfers as an appropriate intervention to lower the age at first birth, and the extent to which [6]. While we could therefore hypothesise that cash transfers are an example of an effective upstream intervention, other features of the review need to be considered and investigated before recommendations can be made around these findings; these represent some of the limitations of the review discussed below.…”

“…Firstly, we observe little evidence that cash transfer interventions improve the uptake of contraception, although our results also suggest that the greatest intervention impacts are on pregnancy (and birth in the case of CCT). Although many studies explore contraceptive use as a (main) determinant of pregnancy and birth, structural interventions also influence the frequency of (vaginal) sexual activity [6], and cash transfer interventions may also influence the latter more than the former. A second limitation is around how much of the impact we can attribute to the cash transfer itself, given that in half of the studies, the transfer was provided alongside other intervention activities.…”

“…Our results therefore suggest that the impacts of cash transfers on contraceptive use are heterogeneous, and while suggestive of a positive impact overall, are ultimately inconclusive. Furthermore, cash transfers appear to lower the odds of contraceptive use in some settings, although the extent to which this reflects measurement error, contextual effects, or intervention design is unclear, although in the case of the study by Darney, Weaver [53] this is likely due to the level of sexual activity (see [6]).…”

“…Facilitating more extensive use of contraceptives to increase sexual and reproductive choice is dependent on ensuring a supply of contraceptives is in place as well as ensuring knowledge of and demand for contraceptives among adolescents through educational programmes [for example 5]. However, it is recognised that broader factors such as women's empowerment and education can also be major 'upstream' determinants of use [6][7][8]. For example, preventing adolescent pregnancy also involves removing barriers to making informed reproductive choices including reducing gender inequality and discrimination, and creating health promoting environments through improving education and empowerment [8].…”