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Randomized Controlled Trial
. 2023 Feb 16;23(1):348.
doi: 10.1186/s12889-023-15023-0.

Comprehensive sexuality education linked to sexual and reproductive health services reduces early and unintended pregnancies among in-school adolescent girls in Zambia

Michael T Mbizvo  1 , Kondwani Kasonda  2 , Nelly-Claire Muntalima  2 , Joseph G Rosen  2 , Sophie Inambwae  2 , Edith S Namukonda  2 , Ronald Mungoni  2 , Natasha Okpara  2 , Chifundo Phiri  2 , Nachela Chelwa  2 , Chabu Kangale  2
Affiliations
Randomized Controlled Trial

Comprehensive sexuality education linked to sexual and reproductive health services reduces early and unintended pregnancies among in-school adolescent girls in Zambia

Michael T Mbizvo et al. BMC Public Health. .

Abstract

Background: Advancing the health of adolescents, particularly their sexual and reproductive health, including HIV prevention and care, is a development imperative. A critical part for improving their wellbeing and economic development is the social status accorded to adolescent girls and young women (AGYW). However, AGYW in many countries including Zambia, encounter health challenges that stem from gender inequalities, lack of empowerment, inaccurate knowledge on sexuality, and poor access to sexual and reproductive health (SRH) services and information. Addressing the knowledge gaps through comprehensive sexuality education (CSE) and improving access to SRH services and appropriate information, should reduce school attrition from early and unintended pregnancies (EUP) and enhance realization of their full potential.

Methods: The aim was to reduce EUP and improve SRH outcomes among AGYW in Zambia through provision of CSE linked to receptive SRH services. A 3-Arm randomized control study collected cross-sectional data at baseline, midline and Endline. Schools where CSE was being routinely provided were randomized into a non-intervention arm (arm1), an intervention arm in which information on available SRH services was provided in schools by health workers to complement CSE, (arm 2), and arm 3 in which pupils receiving CSE were also encouraged or supported to access pre-sensitized, receptive SRH services.

Results: Following 3 years of intervention exposure (CSE-Health Facility linkages), findings showed a significant decline of in-school pregnancies amongst AGYW in both intervention arms, with arm two exhibiting a more significant decline, having recorded only 0.74% pregnancies at endline (p < 0.001), as well as arm 3, which recorded 1.34% pregnancies (p < 0.001). No significant decline was recorded in the CSE only control arm. Trends in decline of pregnancies started to show by midline, and persisted at endline (2020), and when difference in differences test was applied, the incident rate ratios (IRR) between the none and exposed arms were equally significant (p < 0.001).

Conclusion: Linking provision of CSE with accessible SRH services that are receptive to needs of adolescents and young people reduces EUP, which provides the opportunity for higher retention in school for adolescent girls.

Keywords: Adolescent girls and young women; Adolescent sexual and reproductive health; Comprehensive sexuality education; Early and unintended pregnancies; Sub-Saharan Africa.

Plain language summary

Among Zambia’s key health and development challenges, are high rates of EUP, and disproportionately higher HIV rates among AGYW. Pregnancy among girls in school poses a challenge. CSE programmes are part of available armamentarium to improve knowledge on the risks. Poor SRH places a heavy strain on health systems and undermines sustainable development efforts. In response to these challenges, we initiated implementation research to develop and test a model linking CSE programs in schools with access to SRH services and information. Research was conducted in 23 schools and their local catchment health care facilities in two North Western province districts of Zambia. Following baseline data collection, schools were selected to ensure comparability of indicators such as reported pregnancy rates, CSE, and subsequently randomized into three study arms, with the first arm continuing standard instruction of CSE (control). The second arm was designed to bring information on available SRH services to schools, including raising awareness through health fares and clubs. In the third arm, health providers were trained to be more receptive to ASRH health needs, in addition to encouraging teachers to introduce students to health services. Pregnancies declined in all intervention arms at endline, with marked reductions in intervention Arm 2 which recorded 0.74% of in school pregnancies (p < O.001), followed by arm 3, with 1.34% (p < 0.001). The decline in intervention arms was more than 50% in intervention arms, as compared with control arm, and significantly lower, as a proportion of AGYW in arm 2, followed by arm 3.

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Conflict of interest statement

The authors of this manuscript have no conflict of interest to declare.

Figures

Fig. 1
Fig. 1
Distribution of schools in study districts
Fig. 2
Fig. 2
Summary schema of the study design
Fig. 3
Fig. 3
Protocol conceptual framework developed to guide the overall study conceptualization and implementation
Fig. 4
Fig. 4
Cumulative number of school-level pregnancies, by year and study arm
Fig. 5
Fig. 5
Schematic description of pregnancies over time in each arm, from which difference in difference tests were conducted
See this image and copyright information in PMC

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