Effectiveness of sakshyam kishor kishori intervention on family planning (FP) uptake among married adolescent girls in selected districts of Nepal

Abstract

Executive Summary:

Adolescence is a stage of transition from childhood to adulthood when young people experience changes in puberty whilst not yet having the maturity or assuming the roles and responsibilities of adults. An adolescent is any person between 10 and 19 years of age and in this age group, the sexual and reproductive health needs mostly differ from those of adults. In Nepal, adolescents comprise 24% of the total population and adolescents often face family pressure for early marriage and childbearing which puts them at increased risk of maternal deaths and pregnancy related health consequences. Despite continuous efforts from governmental and non-governmental sectors in preventing early marriage and early childbearing, Nepal falls among the countries which have high adolescent fertility rates and high adolescent maternal death rates. Access to family planning (FP) services has become a critical public health need for delaying the first child, preventing premature maternal deaths, and improving neonatal health outcomes. However, Nepal lacks evidence on the interventions that can be effective in increasing uptake of FP services and preventing adolescent pregnancies. In this context, this study attempted to test the effectiveness of the Sakshyam Kishor Kishori intervention on improving knowledge, attitude, self-efficacy and use of FP services among married adolescents. Methodology A mixed-method, quasi-experimental study covering four districts, with Sarlahi and Arghakhanchi as the intervention districts and Sunsari and Pyuthan as control districts. The study primarily assessed changes in contraceptive use, intention to use FP and self-efficacy through baseline and the endline surveys amongst 15-19 year old married adolescent girls in the study sites. Knowledge of FP, perceived risks, perceived benefits, and perceived barriers were further assessed as secondary outcome variables. In the baseline survey, 3,634 participants with 1,812 in intervention and 1,822 in control districts were interviewed, using a structured questionnaire between November and January 2019. After baseline data collection, the Sakshyam Kishor Kishori intervention was rolled out for a period of 11 months from January 2020 to November 2020 in the intervention districts. Sakshyam Kishor Kishori intervention used five key strategies: empowering adolescents, informing adolescents about FP services, engaging them in raising awareness at community level, strengthening service delivery through advocacy and capacity development, and delivering FP services to adolescents in and out of schools through mobile camps. Data collection for the endline survey was completed November to December 2020. In the endline, 3,680 participants, 1,840 each from both the intervention and control districts completed the quantitative survey. Alongside the survey, qualitative assessments were conducted to assess the perceived effectiveness and potential areas of improvement in the intervention. A total of 117 qualitative interviews were conducted among different categories of beneficiaries (65 interviews), the programme implementors (44 interviews) and local leaders (8 interviews) during the process.

Results: By the time of the endline survey, 24.8% of the participants in intervention districts had been reached by the Sakshyam Kishor Kishori intervention. Respondents’ knowledge score (total: 28 points) increased by 1.27 points in control districts and 4.65 points in intervention districts from baseline to endline survey. Intervention districts gained additional 3.38 points in knowledge score during the intervention period which was statistically significant at p< 0.05 indicating that intervention was effective in improvingknowledgeofFPinthestudy.Similarly, perceptionofriskscore(total: 40points)decreased by 1.19 points in control districts, but it remained stable in intervention districts. Despite this, the difference in change of perception of risk score from baseline to endline survey, in intervention and control districts was statistically significant. Intervention was also found to be effective in improving perception about the benefit of using FP services and self-efficacy in use of FP services. The perception of benefit score (total: 35 points) and self-efficacy score (total: 30 points) improved by additional 1.08 points and 1.15 points respectively in intervention districts. However, intervention did not have statistically significant improvement in the use of contraceptives. As COVID-19 pandemic prevailed for most of the implementation period, the effect of the pandemic over the effectiveness of the intervention was adjusted and the analysis was re-run. After adjustment for impact of COVID-19, the intervention was found effective in overcoming barriers to FP services as well. Although reluctance was seen in early stage of the intervention, the programme gradually gained confidence of the participants and was well accepted in later stages of the intervention, as revealed by qualitative component of the study. Participants shared that it was relatively easy to comprehend and receive the message, ask questions, contact, or visit tutors for information at flexible time when both participants and tutors are of same age. Lack of knowledge, poverty, distance to health facilities, feeling of shame, pressure from family members and their attitude, fear of side effects and the fear that they may have to compromise with their privacy were the major concerns from participants relating to FP service use, which were addressed by five key strategies of Sakshyam Kishor Kishori intervention. Participants shared that, after the intervention, they were able to talk confidently about FP services with their family members and health workers. Parents of the adolescent participants also noticed changes in their children and shared that they are now more informed about health issues like menstruation and able to talk about it with their parents and family. Apart from benefiting direct beneficiaries, the intervention also benefitted a wider segment of the community, increasing understanding about FP services, child spacing and the appropriate age for marriage. Participants shared that engaging girls below the age of adolescence too could help them prepare for the transition to adolescence, with the accompanying bodily changes. According to participants, more engagement of adolescent boys could further improve the effectiveness of intervention.

Conclusion: The intervention was found effective in improving knowledge of FP, perception of the risk and benefits of using/not using FP services, overcoming barriers to FP services and self-efficacy in use of FP services. However, the effect of intervention may take slightly longer period to influence indicators like contraceptive prevalence rate.