Behavioural Intervention for Adolescent Uptake of Family Planning: A Randomized Controlled Trial, Uganda

"A behavioural change intervention designed to target identified barriers can increase adolescents' uptake of family planning counselling and services."

Negative stereotypes and social stigma around contraception and sexual relationships can inhibit uptake of family planning (FP). To address such barriers in light of unmet need for FP in Uganda, ideas42 partnered with MSI Reproductive Choices and Marie Stopes Uganda (MSUG) to explore the behavioural dimensions of adolescent girls' access to FP services and to design and test an intervention targeting the behavioural challenges that contribute to unmet need and inhibit adolescent uptake in Uganda. This randomised controlled trial (RCT) evaluated the impact of the intervention.

The study was conducted in a network of 151 social franchise clinics ("BlueStar clinics"), which deliver sexual and reproductive health services in (generally low-income) urban and peri-urban communities in Uganda. Community health mobilisers distribute youth vouchers free to girls and young women under 25 years and sell paid discount vouchers to women of all ages for 2000 Ugandan shillings (about US$0.55).

The core intervention is a peer-referral system that formalises word-of-mouth means of advocating for FP and is intended to reduce stigma about contraceptive use and normalise information-sharing among adolescents. Grounded in behavioural design, the approach began with diagnosis of the barriers preventing uptake of the behaviour (e.g., social stigma surrounding FP that leads adolescents to overestimate the unpleasantness and visibility of the uptake process), identified through clinic-based observations and qualitative interviews with married and unmarried adolescents, service providers, community health mobilisers, and local nongovernmental organisation staff. The intervention was refined through collaboration and testing with users, resulting in a multicomponent health behaviour intervention that involved:

• Refer-a-friend (RAF) - This component invites girls aged 15-19 who use contraceptives or have received FP counseling to give a RAF card to a friend who is not currently using contraceptives, spurring a conversation about why girls like them may choose to use contraceptives. The friend redeems her card at network clinics for two colourful friendship wristbands (one for her and one for the friend who referred her) and free contraceptive counselling. Those clients in turn receive a new RAF card to give to another friend, empowering them to give advice in a way that can build their confidence and solidify their motivation to access FP services when needed.
• Clinic environment materials - Intended to convey the message to girls that they belong, these materials include posters displaying redeemed RAF cards, posters signed by service providers, and service provider name tags.
• Youth-friendly services (YFS) training - Providers from a subset of clinics received a 3-day training on provision of YFS, designed by MSI for the Uganda context and facilitated by a member of MSU's Youth Team. This training focuses on caregiving that respects young clients' dignity, privacy, and autonomy to make an informed choice. The training also builds service providers' confidence and reaffirms a commitment to serve youth.

For the RCT, BlueStar clinics were randomised into control (56 clinics) and intervention groups (60 clinics). All intervention clinics received the core intervention (RAF and clinic materials), while a subset of clinics also received the YFS training. The researchers collected clinics' routine data on monthly numbers of visits by adults and adolescents over a 15-month baseline and 6-month intervention period, 2018-2020. (In April 2020, a decision was made to pause the programme (until August 2020) due to restrictions on travel and public activity during the COVID-19 pandemic. However, the network clinics remained open to provide essential services. During the pause, girls could redeem RAF cards, but staff halted the card distribution.)

The study found that mean monthly proportion of visits by adolescents increased from 13.7% to 22.8% (P < 0.001) in intervention clinics and from 15.5% to 19.2% (P < 0.001) in control clinics before and after the intervention. However, only the intervention clinics recorded a significant increase in the mean monthly number of adolescent FP visits, from 17.2 (standard deviation (SD): 22.0) to 23.4 (SD: 31.2; P < 0.001) before and after the intervention. In control clinics, the mean monthly numbers of visits by adolescents were 21.5 (SD: 27.0) and 22.7 (SD: 34.5) before and after the intervention, respectively (P = 0.54).

Multivariate regression analysis found significant effects of the intervention on primary outcomes in the pooled intervention group compared with control. Mean monthly visits by adolescents increased by 45% (incidence rate ratio (IRR): 1.45; 95% confidence interval (CI): 1.14-1.85), or over 5 additional adolescent clients per clinic per month. The mean adolescent proportion of total clients improved by 5.3 percentage points (95% CI: 0.02-0.09). Within treatment arms, clinics receiving the training in YFS provision showed the strongest effects: a 62% increase (IRR: 1.62; 95% CI: 1.21-2.17) in adolescent clients, or over 7 additional adolescents per clinic per month, relative to the control group.

In short, despite interruption due to the COVID-19 pandemic, this RCT found a significant effect of the peer-referral intervention on both of the primary outcomes: average monthly number of visits by adolescents and proportion of total visits by adolescents. The magnitude of the effects was reduced when data were included from the months when the programme was paused; nevertheless, the data still showed a significant impact of the intervention. Furthermore, the researchers received positive feedback during a process evaluation (published elsewhere) from service providers, community mobilisers, and clients, who said they wanted the intervention to continue.

As reported ideas42 reports, MSUG is taking steps to re-launch the programme within the 60 BlueStar clinics where the pilot took place, as well as to expand the programme to an additional 23 clinics they have identified as having the greatest need. Once the intervention is implemented at all 116 BlueStar clinics, MSUG plans to adapt the programme for other service delivery channels within Uganda.

Indeed, the researchers conclude that, "The behavioural diagnosis underlying this intervention identified barriers to adolescent uptake that may be relevant beyond the study network and beyond Uganda, suggesting these designs might be adapted to similar settings where family planning services are available but similar barriers inhibit girls' access."

Editor's note: Click here for a related programme brief [PDF] and design guide [PDF].