Is a search for game changers preventing us from focusing on the necessary tasks of systems strengthening and norm change to facilitate adolescent contraceptive use?

Abstract

With a keen awareness of the size and health needs of the global adolescent population, governments, nongovernment organizations and the technical and funding agencies that support them continue to seek innovative answers to persistent programming challenges to increasing contraceptive use among sexually active adolescents. Adolescents 360 (A360) is a project implemented by Population Services International (PSI) and partners with funding from the Bill and Melinda Gates Foundation (BMGF) and the Children’s Investment Fund Foundation (CIFF). The first phase of the project was implemented from 2016 – 2020 in Ethiopia, Nigeria, and Tanzania. A360 hypothesized that human centered design (HCD) could catalyze new insights into identifying and solving problems that limit adolescents’ use of contraception. Despite initial promising results, A360 demonstrated very limited impact on modern contraceptive uptake among adolescents. The authors of this commentary were members of a technical advisory group to A360 and are uniquely positioned to provide insights on this project to complement those of A360’s staff and evaluators, which are already in the public arena. Our analysis suggests that all stakeholders should take steps to rebalance their programs and investments to not only seek new solutions (i.e. game changers), but to also invest in the institutionalization of the solutions that have been generated over the past 40 years, prioritizing those that have shown evidence of effectiveness (i.e. adolescent responsive health service delivery) and those that demonstrate significant promise (i.e. social norm change).

Introduction

This commentary discusses a set of lessons learned from the work of the A360 Project – a well-resourced, multi-country and multi-year initiative working to improve adolescent sexual and reproductive health (ASRH)—that organizations and agencies that provide technical and financial support to implement ASRH programs could use to inform their work. It responds to the growing consensus that it is important to draw out and share not only what has worked, but also what has not, in ASRH programs, so that others can build on this learning. In other words, it responds to an imperative for learning and sharing [1, 2].

Independent interim and final evaluations of the A360 Project included process, outcome and costing analyses, and are available in the public arena [3, 4]. These reports describe how A360 performed in relation to its objectives, provide plausible explanations for where it performed well and where it did not, identified gaps between proposed and actual performance, and suggested possible ways of addressing them. A360 staff who oversaw the execution of the Project, and the outcome evaluation team have published their findings in peer-reviewed journals [5, 6]. A360 reported on the achievements of the Project, the opportunities it used, and the challenges it faced, while the evaluation team pointed out precisely where the Project’s performance did or did not achieve its targets and discussed the reasons for the same.

This commentary does not seek to reiterate the findings of the evaluation reports and the peer-reviewed journal publications. Instead, its intended audience is the wider ASRH community – researchers, programmers, and technical and financial supporters – and the opportunity to use the learnings generated by this well-resourced, multi-country, multi-year Project. The commentary cites specific evaluation findings and proposes “dos” and “don’ts” for future programming backed by research evidence, and practical experience.

All three authors of this commentary were members of a technical advisory group (TAG) established by A360 to provide support and guidance to the design and implementation of the Project. Each of us have over 25 years of ASRH work experience in low- and middle-income countries (LMICs). All three of us have reviewed A360’s plans and reports (prioritizing the findings of the mid-term and final evaluations) and have met with A360 staff on numerous occasions. We believe that we have a sound understanding of the Project’s efforts.

We have prepared this commentary with great appreciation for the significant investment in ASRH made by the donors and the implementers. We have empathy for all who contributed to the Project goal of improving the SRH of adolescent girls by increasing their contraceptive use. Our aim is not to criticize any individual or organization; rather, we believe that A360’s efforts are relevant to many other ASRH programs and projects that are grappling with many of the same questions and challenges tackled by the Project, namely, to translate innovative ideas into action, while being responsive to differing social, cultural, and economic contexts. We hope that our suggested dos and don’ts will help those working in—and supporting – ASRH work in LMICs design and execute better projects and programs.

We begin with some information on the context in which A360 was conceived and operationalized, and about the Project itself. We then present comments and observations that were provided to A360 in our role as the Technical Advisory Group. We wrap up by discussing our three main reflections on future directions for ASRH programming.

The context in which A360 was conceived

There has been keen awareness of the need to address adolescent pregnancy and childbearing around the world for over 50 years [7]. The consequences of adolescent pregnancy and childbearing and their effect on the ability of countries to achieve key health, social and development outcomes were acknowledged as a global priority at the 1994 International Conference on Population and Development (ICPD). This public attention enabled international organizations and local champions to press governments to pay attention to ASRH and to mobilize resources to implement programs and policies. Six years later, the Millennium Development Goals (MDG) were announced, and Goal 5 (to reduce maternal mortality) and Goal 6 (to prevent HIV infection and HIV-related mortality) provided new impetus for ASRH programs and policies. However, the MDGs initially paid little attention to adolescents despite advocacy from United Nations agencies and international organizations that noted more robust programmatic and policy attention to adolescents and young people was needed to achieve these two goals [8].

By the start of the second decade of the 2000s, clear evidence had accrued of the nature and scale of SRH risks and problems faced by adolescents, as well as an improved understanding of the determinants of those problems. These included their lack of access to evidence-based information and education as well as counseling and health services, yet there was still limited global and country level investment in ASRH. ASRH champions from the global to the local levels worked together to raise the alarm that make the case of omitting adolescents from programs designed to achieve MDG Goals 5 and 6 had significant implications not only for the health and wellbeing of adolescents, but also for efforts to reduce maternal and child morbidity and mortality [8].

UN agencies and partners began to formulate responses; for example, UNAIDS called for a global effort to address HIV in adolescents, and the Global Fund for AIDS, Tuberculosis and Malaria dedicated resources to enable countries to develop programs to prevent HIV infection in adolescent girls in sub-Saharan Africa; Girls Not Brides advocated for child marriage to be prioritized on the global agenda; and UNESCO and UNAIDS jointly supported regional commitments to provide adolescents with SRH information and services in Latin American and Eastern and Southern Africa [9]. Nevertheless, ASRH advocates and program implementers remained frustrated, impatient, and even outraged that adolescents still were not adequately benefiting from the significant investments in and actions to achieve the MDGs. It was in this climate of urgency that A360 was conceived [8, 9].

Technical and funding agencies began to look for new – and disruptive—ways to analyze problems in context, yield new insights, and pursue innovation while centering on the real-life experiences of clients and end-users [10]. One such methodology believed to show significant promise to improve ASRH, and specifically adolescent contraceptive use, was human centered design (HCD). A number of agencies have endorsed – and even required—the use of HCD methodologies in their awards, and A360 was one such investment, supported by the Bill and Melinda Gates Foundation (BMGF) and the Children’s Investment Fund Foundation (CIFF).

About A 360

A360 was designed by Population Services International (PSI), the Center for the Developing Adolescent, IDEO, and Society for Family Health Nigeria with the goal of increasing voluntary uptake of modern contraception among unmarried and married adolescent girls in Ethiopia, Northern Nigeria, Southern Nigeria, and Tanzania, “…reimagining and redefining the way sexual and reproductive health (SRH) programs are designed and delivered for adolescent girls and young women” [11]. The first phase of A360 was implemented from 2016–2020.

A360 eschewed standard programming design efforts, instead adopting an approach driven by principles of HCD, with adolescents, young people and adults from a range of disciplines collaborating to envision, design, and implement what were anticipated to be more responsive, sustainable, and scalable SRH programs that successfully increased adolescent contraceptive use. A360’s designers hypothesized that “a fusion of disciplines, prioritizing meaningful engagement of young people…would catalyze novel and successful approaches…” leading to population level changes in modern contraceptive prevalence rates (mCPR) among adolescents in the four project geographies. HCD was central to A360’s design aspirations, championed as an innovative methodology generating new insights to improve adolescent contraceptive use, as perhaps not previously revealed by traditional methods of inquiry and design [3].

A360’s donors were careful to dedicate significant resources for evaluation to examine implementation efforts and measure the effect of HCD-generated solutions on adolescent contraceptive use. ITAD coordinated the evaluation and conducted process evaluations at midline and endline, while the London School of Tropical Medicine and Hygiene (LSTMH) conducted the outcome evaluation. Avenir Health undertook a cost-effectiveness analysis.

The 2018 midline reported impressive increases in the numbers of contraceptive adopters¹ and adolescent girls, their families, and communities expressed satisfaction with A360’s activities. With what appeared to be highly persuasive findings in hand, A360 began disseminating their experiences, although it was still too soon to know if there was any outcome level evidence that could be attributed to A360 (e.g., increases in adolescent mCPR or decreases in adolescent childbearing). Given persistently high rates of unmet need for contraception among adolescents, A360 was likely optimistic about these preliminary results. Some urged caution, however, citing significant weaknesses in health systems, as well as provider biases against providing adolescents with contraception, which would likely pose challenges to A360’s ability to sustain and advance what appeared to be promising approaches [3].

The midline evaluation suggested that A360 should also develop strategies to address the “harmful community myths, misconceptions and stigma around contraception for adolescent girls.” In response, A360 implemented “light touch” community engagement approaches and activities which included aspirational messaging, life skills education, and vocational skills development provided by community mobilizers and educators. These activities were proposed as a way to encourage adolescent girls to visit health facilities where they could also then learn about contraception. A360 considered that such activities could “circumnavigate…stigma,” by avoiding direct reference to contraception, and could mitigate negative attitudes among community members and providers that could limit adolescent contraceptive uptake and sustained use. Less emphasis on contraception was also thought to encourage adolescent attendance at A360 organized events, especially those that highlighted entrepreneurship and employment [3]. The final evaluation observed, however, that these activities only appeared to “attract more than empower” adolescent girls [4].

“(A)lthough A360 succeeded in reaching…girls with modern contraception in often innovative ways, the evaluation cannot definitively conclude that A360 revolutionized ASRH programming in the way it was initially designed to do” [4].

The endline findings did not reflect the midline’s optimistic tone, with results described as a “mixed bag.” The process evaluation reported that there had been more adolescent contraceptive adopters than initially projected, and that adolescent girls and communities liked the activities implemented by A360. In contrast, the outcome evaluation revealed that the changes in adolescent mCPR were limited and inconsistent across the project sites. An increase in mCPR was detected only in Oromia, Ethiopia, which reported a five percent increase among married adolescents, but in Nasarawa and Ogun States in Nigeria there was no change in adolescent mCPR, and in Ilemela, Tanzania (where A360 had added a vocational and life skills interventions) there was a nine percent decrease, even though girls cited approval of the skills development activities [4]. It is also important to note that in Ethiopia, A360 was implemented on the heels of a national program which had already achieved population level increases in adolescent contraceptive use [4].

Insights from A 360’s evaluations that have wider relevance

The TAG originally identified 10 insights culled from A 360’s evaluation reports that appear to have limited the ability of the Project to achieve more significant contraceptive use results among adolescents. Although the evaluations were specific to A360, it is our collective opinion that the findings mirrored the decisions and actions of many other projects. This includes the tendency to implement interventions that while popular, have been shown to be ineffective, and to deliver proven interventions in ways that compromise their effectiveness [12, 13].

In Table 1 (below) we share our observations on nine of the 10 insights that we gleaned from the evaluation reports (the tenth was related to cost, which this commentary does not address). Against each insight, we describe what we believe to be specific limitations of A360’s approach and categorize these actions as “do not.” We then suggest alternative responses to the insight that are based on evidence and research as well as the TAG members’ collective expertise in ASRH and categorize these as “do.” We believe these observations have relevance for the entire ASRH community as it continues to develop and implement programs to improve contraceptive use among sexually active adolescents, as well as other priority adolescent health initiatives.

Table 1 TAG recommendations to A360

Discussion

The world has made progress in increasing the uptake of contraception by adolescents and in reducing unmet need, although this progress has been slow and uneven [26]. Looking ahead towards the 2030 target date of the Sustainable Development Goals (SDGs), we have three reflections on future ASRH programming and policies.

First, this commentary is about phase one of A360, which was implemented from 2016–2020. The Project has moved on to a subsequent phase, building on the lessons it learned in the first phase [5]. Although the Project did not achieve what it initially intended, it makes a valuable contribution to the field in highlighting the significant challenges in integrating new programmatic approaches into weak health and other systems, and in overcoming powerful social and cultural attitudes and norms which contribute to poor ASRH. The Project has also shown that even with the injection of substantial resources and the promotion of new design methodologies, significant improvements in contraceptive uptake and continuation cannot be achieved without strengthening faltering delivery systems and shifting restrictive—and sometimes harmful – norms.

Second, a small but growing number of countries have moved ASRH services from projects to sustained programs by integrating adolescent friendly health service elements into national health systems [27, 28]. USAID’s High Impact Policy brief, Adolescent responsive contraceptive systems: Institutionalizing adolescent-responsive elements to expand access and choice [29] discusses how countries did this by working incrementally to pass supportive laws and policies; making health facilities more welcoming of adolescent clients; improving the skills of the health workforce; ensuring that age-and sex-disaggregated data is gathered, analyzed and used; and providing dedicated financing for the provision of these services. They also worked to build social acceptance for adolescent contraceptive use through coordinated communication efforts and campaigns from the national to the local levels. Chile, Ethiopia, and Thailand are three examples of what can be achieved when good science is combined with strong leadership and management. They challenge and inspire other countries to do what is feasible and urgently needs to be done – now.

Third, several countries, including the countries in which phase one of A360 was implemented, have set out national policy, program and budgetary commitments to improve adolescent outcomes; for example, improving access to and uptake of contraception by adolescents through  making commitments to FP2030 [30, 31]. or to end child marriage as part of the Global Programme to Accelerate an End to Child Marriage [32]. Supporting countries develop and achieve sound commitments to adolescents and SRH may be better use of available resources than aspirational projects that are not always fully aligned with wider national efforts. From research and programmatic experience, we know that there are a multiplicity of determinants (prioritizing both protective and risk factors) at the individual, interpersonal, family, community, organizational and social levels that influence adolescent health and wellbeing. The same determinants may operate at multiple levels and often in combination with each other, amplifying their effects. This reinforces our understanding that ASRH interventions should work at all levels of the socio-ecological framework, and that interventions should be delivered with quality – and importantly at scale –- while leaving no one behind. Collaboration and collective action across sectors to deliver multisectoral and/or integrated programming is crucial [22].

Conclusion

The thirty years since ICPD has shown us how challenging it is to implement and sustain ASRH programs and policies, particularly in terms of creating adolescent responsive systems and facilitating family, community and societal support for ASRH. Bolstering weak systems and encouraging sectors to work together is slow and painstaking, with limited evidence of what works to guide efforts. Building community support for the sensitive topic of ASRH through dialogues with skeptical family and community leaders is also demanding, time consuming, and non-linear. It is tempting to bypass these two challenges altogether, use token approaches, or search for catalytic  solutions. Our experience has taught us, however, that there is no alternative to the slow and tedious tasks of system strengthening and norm changing. Nevertheless, available evidence suggests that these efforts are doable and worth doing, even in resource constrained and conservative contexts.