If I Were Thabo: Optimisation and feasibility trial of a gender transformative sexual and reproductive health intervention in South Africa and Lesotho

Research on adolescent sexual and reproductive health (SRH) in sub-Saharan Africa is heavily focused on preventing unintended pregnancies and preventing HIV infection. However, very little of this work focuses on, and actively targets, boys and young men. Gender-transformative approaches, or approaches that seek to shift gender norms and power relations, have been hailed as one way to disrupt underlying factors that can lead to poor health outcomes and drive HIV infection and adolescent pregnancy. Applying a gender-transformative approach in South Africa and Lesotho, across two low-resource settings with very high rates of both HIV and adolescent pregnancy, our research aims to meet an urgent need for localised solutions and do so in an innovative and inclusive way.

The aim of this study is to address the evidence gap by adapting the If I Were Jack programme for use in South Africa and Lesotho, under the name If I Were Thabo. The original programme, developed in the UK, is a group-based intervention delivered to adolescents in educational settings, which includes a culturally sensitive interactive film about an adolescent who discovers that his girlfriend is unexpectedly pregnant, and a guided discussion about how participants would feel and react in his position. The programme is accompanied by educational materials and sessions for adolescents' caregivers, and has been shown to be acceptable and cost-effective in its current form. We propose to adapt the programme in two LMICs, South Africa and Lesotho, in partnership with adolescents, parents, teachers, community members and local experts. We will target adolescents aged 13-14, an age range where there is still potential to prevent sexual risk-taking before the majority of adolescents are sexually active, and before the increase in pregnancy and STIs reported in later adolescence.

To develop and test the intervention, the proposed study will involve two phases. First, we will work with adolescents, their parents and caregivers, teachers, health professionals and other key community members to adapt and optimise the programme materials from the UK for use in South Africa and Lesotho. This will involve co-producing locally relevant and appropriate intervention materials in each site. Adolescents will work with researchers and filmmakers to write, cast and develop new films in each site, and advise on the acceptability of text-based material, and their caregivers will be consulted on caregiver-targeted information. Teachers, community group facilitators and healthcare professionals will provide feedback on materials designed for programme facilitators. In addition, we will ask adolescents and their caregivers to give feedback on some of the research tools that will be used in the next phase.

Next, we will run a pilot of the programme within a feasibility cluster randomised trial to assess if the intervention implementation and evaluation design is feasible in both countries. As a part of this phase we will survey adolescents in schools and community groups, half of whom will be randomly chosen to receive the intervention and the other half of whom will continue with 'normal practice'. We will assess whether the questionnaires capture the necessary information on SRH outcomes for this group, including intentions relating to adolescent pregnancy, and HIV and STI infection. We will also evaluate whether the processes needed to implement the programme work well. After programme completion, we will interview adolescents and other stakeholders about their opinions of the programme and whether it is feasible to deliver in schools and community groups, and what will hinder or help the implementation in the two settings. Based on these results, we will decide if it will be feasible to do a larger trial of the intervention in both sites to see if the programme is effective in improving SRH for adolescents in these countries.

A key social determinant of sexual and reproductive health-related (SRH) morbidity and mortality in Southern Africa is unequal gender norms. The importance of working with men as well as women using Gender-Transformative (GT) approaches, in order to reduce gender inequality and improve SRH outcomes for all is well-recognised. However, a recent systematic review showed that only 8% of SRH interventions that target adolescent men are GT.

We aim to develop and feasibility test a co-produced relationships and sexuality education intervention, If I Were Thabo, for 13-14 years old adolescents, to address gender inequality as a social determinant of SRH.

The study will be conducted in the Eastern Cape, South Africa, and Maseru District, Lesotho, two countries where adolescent pregnancy and HIV rates are among the highest in the world. There are two phases to the project; a development phase followed by a cluster randomised feasibility trial. The aim of the development phase is to work with stakeholders to co-produce and optimise intervention materials and outcome measures for use in the trial. This will involve working with adolescents, their caregivers, teachers and other stakeholders to develop materials for the feasibility testing phase. The aim of the feasibility trial is to determine the value and feasibility of conducting an effectiveness trial of Thabo in schools and community groups in LE and SA. To achieve this we will implement the Thabo intervention in both settings using a cluster randomised design in 10 clusters, and measure baseline, 3 month and 9 month outcomes. We will measure self-reported engagement in unprotected sex as the primary outcome. Secondary outcomes will include knowledge, attitudes, skills, intentions relating to avoiding adolescent pregnancy, and self-reported HIV and STI diagnosis. Qualitative interviews, focus groups and observational data will be gathered to assess acceptability, feasibility, fidelity and barriers to the programme.

The study seeks to involve multiple countries, disciplines and stakeholders (SDG 17) in order to develop globally relevant solutions to challenges relating to adolescent health (SDG 3), gender equality, and the empowerment of women and girls (SDG 5). At this early stage, since the project involves the development and feasibility testing of a universally delivered relationships and sexuality education intervention for adolescents, the initial range of beneficiaries--and associated impact--is limited to local areas in two countries, South Africa and Lesotho. With this immediate scope, the proposed intervention has the potential to improve sexual, physical, and mental health in adolescents in the short- and long-term, and contribute to their future productivity and earning potential, impacting the wellbeing and prosperity of individuals and communities. At the same time, we regard this study as an opportunity to gather evidence and lessons that will actively, directly inform future efforts to expand and further adapt this intervention for broader audiences in similar high-need regions.

Our strategy for impact involves four categories of potential users and beneficiaries. Programme developers and implementers in health, education and civil society will be important beneficiaries of this research, as it advances local knowledge, evidence, and implementation experience with regard to adolescent health. By fostering relationships with multiple nongovernmental and government partners from the region, as well as larger global coordinating bodies such as WHO and UNICEF, we will strengthen channels for communication and dissemination. We aim to share both preliminary findings as well as lessons from our project methodology and process data and evaluation.

We will also work with a range of local stakeholders throughout the project to maximise acceptability, context-appropriateness, capacity, and cultural relevance. These local stakeholders may include parents, community leadership, and key service providers for adolescents (nurses, teachers, and/or counsellors). By ensuring local engagement as well as organising forums for interaction and discussion, the proposed study and its core team will visibly and meaningfully commit to co-producing this intervention with all relevant parties. These stakeholders will have the ability to gain additional knowledge and skills related to adolescent sexual and reproductive health, as well as related to their own health and wellbeing. Furthermore, these engagements may lead to continued collaboration amongst diverse stakeholders that encourage positive home, school, and community climates, and elevate key issues around sexual health that can be integrated into ongoing service delivery and educational settings.

We also acknowledge the personal, developing expertise that male and female adolescents have about their own sexual and reproductive health, and will ensure that these voices remain central to the project. Participating in this project will ideally influence their own sense of empowerment around sexual health and relationships, as well as foster good health practices and ways of engaging with others over both the short and long term. Furthermore, adolescent participation provides a key platform for young people to develop leadership skills, as well as helping to facilitate conversations across generational and gender divides.

Finally, early career researchers and more established academics will benefit from engaging in this project, with stated goals of publishing articles in open-access journals as well as attending and presenting at international conferences. These channels of impact will benefit both individuals' academic careers and their respective institutions, as well as the larger scholarly community, which can build upon this work.