A Review of Interventions Addressing Structural Drivers of Adolescents' Sexual and Reproductive Health Vulnerability in sub-Saharan Africa: Implications for Sexual Health Programming

"Whilst the number of interventions aimed at addressing the structural drivers of risk among young people are on the rise, there is a need for interventions to have a clear focus, indicate the pathways of risk they are trying to address and have a rigorous evaluation strategy to assess whether and how they work to reduce young people's vulnerability to HIV."

Published in the Reproductive Health Journal, this article provides a review of selected interventions in sub-Saharan Africa (sSA) designed to address structural drivers of adolescents' sexual and reproductive health (SRH) risk and to explore pathways of influence. The review provides a narrative summary of fifteen interventions, ten of which are published in peer-reviewed publications, and five grey literature publications, and highlights some of the lessons learned. Most of these interventions are located in Southern Africa, with fewer in East and West Africa.

The article adopted a definition of "structural drivers of HIV/AIDS" that conceptualises this as "'physical, social, cultural organizational, community, economic, legal or policy aspects of the environment that influence the risk and vulnerability environment and thus acting as barriers to, or facilitators of, HIV prevention and treatment behaviour.'" The authors set out to review interventions that attempted to tackle structural risk determinants related to SRH and HIV/AIDS such as gender norms, inequities, and poverty among young people aged 14 to 24 years. The analysis was based on a literature review, and the fifteen interventions had either HIV or HIV risk outcomes (such as condom use, multiple partners, intimate partner sexual violence, intergenerational sex, and sexually transmitted infections), and broader behaviour change and interaction skills. Recognising that the most-at-risk population is young women, many of the reviewed interventions focused on adolescent girls.

The article firstly discusses six interventions focusing on economic drivers of SRH risks, grouped under those that work towards economic empowerment of women and others that combine economic empowerment with school attendance. These were: Shaping the Health of Adolescents in Zimbabwe (SHAZ!), Intervention with Microfinance for AIDS and Gender Equity (IMAGE), The Tap and Reposition Youth (TRY) (Kenya), incentivising safer sex, the combined Stepping Stones and Creating Futures intervention, and Survival Skills Training for Orphans (SSTOP). One lesson learned from the economic empowerment interventions "is that microcredit without proper mentorship might not be the best intervention for most adolescents. While girls may grapple with loan repayment, they may also be made vulnerable to HIV infection."

The authors then review interventions focusing on social norms around gender inequality, gender violence, and child socialisation, structured according to: gender empowerment and safe spaces for young people; comprehensive sexuality and behaviour change communication (BCC); and parenting and socialisation.

In relation to gender empowerment and safe spaces, the review discusses the Binti Pamoja Centre, Siyekha nentsha, and the Vitu NEWALA project. In the discussion on interventions that focused on comprehensive sexuality and BCC strategies, the review looks at the Girls Power Initiative (GPI), Soul Buddyz, and the One Love campaign by the Soul City Institute for Health and Development Communication and Stepping Stones. These three interventions focused on information provision for social change using approaches such as mass media, social mobilisation, advocacy, and participatory activities. "Qualitative evaluations from these interventions show positive results. For example, the Girls Power Initiative through its skills training activities economically empowered women to reduce the likelihood of transactional sex. GPI reported that their behaviour change communication model reduced the likelihood that young women will engage in transactional sex. The Soul City Institute's interventions were noted to have impacted social norms especially those related to sexual behaviour."

Related to parenting and socialisation, the review states that "although socialisation is a key component for the transmission of important social norms, there are a few interventions with an explicit focus on improving parent-child relationships (communication and other dimensions of parenting) from sSA." The review looks at two interventions that focused on parenting as a key mechanism of socialisation: Families Matter! and the Mema Kwa Jamii project (Good Things for Communities project).

Reflecting on the interventions overall, the review notes that they all use a wide variety of strategies to address multiple structural factors. However, very few of these have been evaluated to better understand what works and what doesn't. Comprehensive sexuality education and BCC can help to influence social and gender norms, which are some of the key structural drivers of young people's risk. Combining economic empowerment and social support, such as within families and through safe spaces, can also help to reduce risk. However, programmes that have a flexible design and phased approach that takes into account the various structural factors are likely to have the most impact. Moreover, monitoring and evaluation is vital for assessing impact and learning in order to make future programmes better.