Evaluating the effects of a multi-level intervention on young women’s contraceptive use: sexual and reproductive health results of a cluster-randomized factorial-design study in Tshwane, South Africa

Abstract

In South Africa, adolescent girls and young women (AGYW) are engaged in early, condomless, and unprotected (from pregnancy) sex, which puts them at risk of unintended pregnancies and sexually transmitted infections. At the individual, interpersonal, and structural levels, AGYW experience barriers to their access to and use of contraception and condoms. This study employed a cluster-randomised factorial design to examine the impact of a multi-level intervention on contraceptive use behaviours among 802 women ages 16-24 in Tshwane, South Africa. The two intervention components were the Young Women's Health CoOp (YWHC), an intervention to increase participants' knowledge and skills, and a stigma and discrimination (S&D) reduction training at the facility level. Study facilities were randomised into the four study arms: YWHC only; S&D only; both YWHC and S&D; and control (standard of care). The study demonstrated that AGYW in the YWHC arm (RRR: 2.45; 95% CI: 1.05-5.70, p = 0.038) and those in the YWHC and S&D arm (RRR: 3.65; 95%CI: 1.56-8.50, p = 0.003) were more likely to have started a contraceptive method than to remain a non-user compared to those in the control arm over the 9-month follow-up period. However, those in the S&D training-only arm had lower odds of adopting a method over the follow-up period (OR: 0.63; 95% CI: 0.41-0.97, p = 0.037). These results demonstrate the importance of supporting AGYW with tailored messaging in a safe environment as part of sexual and reproductive health services.