Measuring the medium-term impact of school-based interventions as girls transition into adulthood

The World Bank has used cross-sectional studies to evaluate the benefits of maintaining schooling on adolescent girls and young women's (AGYW) sexual and reproductive health and productivity. These suggest that most gains are due to supporting AGYW to complete secondary education, with each additional year of secondary education estimated to reduce child marriage and teen pregnancy by 7.5%, and 6.5%, respectively. They also noted that AGYW completing secondary school earn up to 5-fold more, have a one-third reduction in total fertility, increased contraception use by a third, and a ~25% reduction in child stunting compared with AGYW with no education. However, few longitudinal studies have validated these effects, or examined effects of school interventions as AGYW reach adulthood. One study in Malawi, which gave cash to schoolgirls demonstrated an immediate effect of the intervention on reducing HIV and the herpes simplex virus (HSV-2), but detected no gains compared with controls 2 years after the intervention ended. A Kenyan study providing cash and HIV education in primary school followed AGYW to beyond school completion and found fertility rates did not catch up to rates in AGYW not receiving interventions, suggesting fertility was not 'bottled-up' during intervention and then released. These conflicting findings require validation with other studies. Our UK funded trial among 4138 Kenyan secondary schoolgirls, providing cash, a menstrual cup, or both, examined if interventions reduce school dropout, HIV, HSV-2, and sexual and reproductive harms compared with AGYW not provided interventions. As this trial finishes, we now aim to follow-up all participants to evaluate the medium-term impact of prior school interventions on AGYW's health and social equity as they transition to adulthood, and to measure the medium-term cost benefits from the prior trial interventions. The study will follow-up AGYW over 33 months, with two separate surveys with additional data captured through antenatal clinic (ANC) and hospital record reviews. We will use a socio-behavioural survey questionnaire, and HIV/HSV-2 testing, through house-to-house interviews. Every effort will be made to locate girls who have migrated to maximise representativeness across prior trial arms. Health and employment outcomes generated will be used to examine the return on investment and other cost-benefits. We will also conduct qualitative research to provide data to contextualise outcomes. Critical outcomes of interest will focus on: (1) Health - HIV/HSV-2 status, fertility; maternal and neonatal outcomes; sexual and reproductive health and risk behaviours, risk of intimate-partner violence; ability to access and use health facilities; infant, child and maternal mortality. Effects of COVID-19 on these outcomes will also be assessed. (2) Financial and social equity - girls type of employment, and income achieved. We will engage with communities for feedback on their perceptions of the trial, its' value in supporting girls' health, wellbeing, and schooling, and whether outcomes measured align with their perceived needs. We will continue to work with our Ministry of Health partners, expanding to other community-based partners who will support the study design, methods used, interpretation of findings, and inputting of findings into policy and programme guidelines. The research will be disseminated widely through research and social media platforms. The study will support capacity building, through one to one mentoring, workshops to develop new skills, and by utilising data generated for post-graduate studies and co-authored publications.

This research will follow-up adolescent girls and young women (AGYW) enrolled in a prior school-based randomised-controlled trial to measure if prior interventions providing a statistically significant effect have a sustained, complementary, or lag effect on sexual and reproductive health (SRH), mental health, and social equity as AGYW transition to adulthood after trial closure. It will examine if gains are lost if outcomes converge to those of AGYW who received no prior interventions. If the trial has a non-significant effect, the follow-up will evaluate if positive lag effects occur. Additional outcomes such as mental health, community perceptions of trial outcomes, continued use and safety of menstrual cups, and COVID-19 impacts will be evaluated. We aim to re-enrol 3,719 participants (90% of original cohort) and conduct two annual biomarker and socio-behavioural surveys over 3 years. Measures will evaluate if prior interventions effect the prevalence of HIV, HSV-2, gender-based violence, age at first marriage, age-equitable partners/husbands, age at first birth, contraceptive use and fertility, stunting of infants, and other maternal health outcomes, mental health and empowerment e.g. employment, partners' educational level, income, and decision-making. Antenatal records will be interrogated to capture maternal and newborn outcomes. Focus group discussions and in-depth interviews will provide contextual data to interpret quantitative findings. Cost-benefits analyses and returns on investment of prior trial interventions on health and social equity will be measured. Building capacity e.g. enhancing mental health research, will be integral to project success. Outcomes will contribute evidence for decision-making on investments to support gender equality for AGYW. Findings, methods, and tools will be widely disseminated to inform the community, researchers, and stakeholders.