Effects of the Reaching Married Adolescents Program on Modern Contraceptive Use and Intimate Partner Violence: Results of a Cluster Randomized Controlled Trial among Married Adolescent Girls and Their Husbands in Dosso, Niger

"...advances the state of evidence regarding contraceptive use and IPV among married adolescents and their husbands in Niger, highlighting the importance of engaging male partners in such public health programs, as well as of using multiple modes of delivery of programs."

Niger has the highest rate of adolescent fertility in the world, with early marriage, early childbearing, and high gender inequity. At the community level, gender norms set expectations that men are providers and heads of household, while women's primary responsibility is to bear and raise as many children as is feasible. At the interpersonal level, power dynamics favour husbands' control over both household- and fertility-related decisions. This study assesses the impact of Reaching Married Adolescents (RMA), a gender-synchronised social behavioural intervention implemented by Pathfinder International to improve modern contraceptive use and reduce intimate partner violence (IPV) among married adolescent couples in rural Dosso region, Niger.

Based on the Theory of Reasoned Action, the RMA model included:

• Household visits to individual married adolescent girls (ages 13-19) and their husbands: Gender-matched, trained community health workers (CHWs) conducted monthly household visits that provided information and counseling on healthy timing and spacing of pregnancies and how to access and use modern contraceptive methods. This mode of intervention focused on increasing knowledge and dispelling misinformation regarding the nature, mechanisms, effects, and potential risks associated with different forms of modern contraception, and how they may be accessed locally.
• Single-sex small discussion groups: Selected female and male community members served as "mentors" and were trained to facilitate small, single-sex groups for married adolescent girls (twice monthly) and their husbands (once monthly). Content delivered in these groups included general health and life skills, reproductive health and anatomy, use of modern contraceptive methods for healthy timing and spacing of pregnancies, gender norms that impede contraceptive use and female autonomy, couple communication regarding fertility decisions, and gender-based violence.
• Village-level community dialogues: Each month, two trained facilitators at the village-level engaged community gatekeepers and key influencers (e.g., religious and community leaders, parents, and in-laws) to create an environment supportive of healthy timing and spacing of pregnancies, including modern contraceptive use among married adolescent girls and their husbands.

A cluster-randomised controlled trial (cRCT) was conducted to evaluate the effects of the RMA programme on current modern contraceptive use (primary outcome) and past year experiences of physical and sexual IPV (secondary outcome). In addition to a control arm, intervention arms included home visits (Arm 1), group discussion sessions (Arm 2), and both approaches (Arm 3). The researchers used multilevel mixed-effects Poisson regression models to assess intervention effects. Baseline and 24-month follow-up data were collected April-June 2016 and April-June 2018. At baseline, 1,072 adolescent wives were interviewed (88% participation), with 90% retention at follow-up; 1,080 husbands were interviewed (88% participation), with 72% retention at follow-up.

Women participating in the RMA intervention were more than twice as likely to report modern contraceptive use at follow-up relative to those in the control arm (adjusted incidence rate ratio (aIRR) 2.33, 95% confidence interval (CI) 1.41-3.87, p = 0.001). These intervention effects differed by intervention arm. In arm-specific analyses, women were significantly more likely to report modern contraceptive use at follow-up than control in Arms 1 and 3 (aIRR 3.65, 95% CI 1.51-8.78, p = 0.004 and aIRR 2.99, 95% CI 1.68-5.32, p < 0.001, respectively). Arm 2 participants did not have significantly different likelihood of modern contraceptive use relative to control participants.

In terms of the secondary outcome, 8.9% of all wives across study arms reported IPV within the past year at baseline, increasing slightly to 9.8% at follow-up. This increase was concentrated in the control arm (6.9% at baseline to 11.7% at follow-up), with the intervention arm remaining relatively static (9.5% at baseline to 9.2% at follow-up). This pattern over time differed by specific intervention arm: past year IPV increased from 3.9% to 9.0% in Arm 1, decreased from 10.6% to 7.2% in Arm 2, and decreased from 14.6% to 11.3% in Arm 3. Women participating in any intervention arm of RMA were slightly less likely to report past year IPV at follow-up relative to those in the control arm, though this difference was not statistically significant.

Overall, RMA participants had a nearly 2.3 factor higher likelihood of current modern contraceptive use after 24 months of intervention, and 0.43 factor lower likelihood of recent IPV. Only the intervention arm combining both household visits and small group sessions was effective at both increasing current modern contraceptive use and decreasing past year IPV (aIRR = 2.99, p < 0.001 and aIRR = 0.46, p = 0.052, respectively). This finding suggests that multi-component interventions may be necessary to concurrently shift both contraception and IPV, behaviours deeply influenced by both individual and interpersonal knowledge and behaviour, as well as by gender and social norms.

Specifically, the researchers note that the privacy of one-on-one, gender-matched visits allows for a dialogue that may result in greater understanding of modern contraceptive use topics as compared to a group setting, where the judgment of peers or fear of publicly questioning an authority figure may inhibit questions or dissenting concerns. In contrast, small group discussions were more effective at reducing recent IPV, with or without the addition of household visits. In this context, gender norms regarding control of fertility and contraceptive use decisions were examined, as well as those regarding the use of force by husbands to maintain control over wives. These group discussions, structured to include dialogue between peers, are well suited for examining social norms and their effects on individuals, families, and the community as a whole.

Notably, social norms and stigma may well affect delivery and impact of social behavioural interventions such as RMA, as those married adolescents receiving the programme who did not have children, individuals for whom the use of contraceptives is least acceptable, did not increase their contraceptive use.

In conclusion: "Identifying the modes of social and behavior change programming able to most synergistically and effectively improve contraceptive use and reduce IPV in a setting with the world's highest fertility and low levels of gender equity is a key step towards improving the health and well-being of these very young adolescent wives."