RESUMO
Around half of adolescent pregnancies in low- and middle-income countries are unintended, contributing to millions of unsafe abortions per year. Adolescents 360 (A360), a girl-centred initiative, aimed to increase voluntary uptake of modern contraceptives among adolescents in Nigeria, Ethiopia and Tanzania. We evaluated the effectiveness and cost-effectiveness of A360 in increasing modern contraceptive use in selected geographies. We used before-and-after cross-sectional studies of adolescent girls in four settings. Two Nigerian settings had purposefully selected comparison areas. Baseline and endline household surveys were conducted. The primary study outcome was modern contraceptive prevalence rate (mCPR). Secondary outcomes mapped onto the A360 Theory of Change. Interpretation was aided by a process evaluation along with secular mCPR trends and self-reported A360 exposure data. Incremental design and implementation costs were calculated from implementer systems, site visits, surveys, and interviews. mCPR change was modelled into maternal disability-adjusted life years (DALY) averted to calculate incremental cost-effectiveness ratios. In Oromia, Ethiopia, mCPR increased by 5% points (95% CI 1-10; n = 1,697). In Nigeria, there was no evidence of an effect of A360 on mCPR in Nasarawa (risk ratio: 0·96, 95% CI: 0·76-1·21; n = 5,414) or in Ogun (risk ratio: 1·08, 95% CI: 0·92-1·26; n = 3,230). In Mwanza, Tanzania, mCPR decreased by 9% points (-17 to -0.3; n = 1,973). Incremental cost per DALY averted were $30,855 in Oromia, $111,416 in Nasarawa, $30,114 in Ogun, and $25,579 in Mwanza. Costs per DALY averted were 14-53 times gross domestic product per capita. A360 did not lead to increased adolescent use of modern contraceptives at a population level, except in Oromia, and was not cost-effective. This novel adolescent-centred design approach showed some promise in addressing the reproductive health needs of adolescents, but must be accompanied by efforts to address the contextual drivers of low modern contraceptive use.
RESUMO
Existing participatory research approaches have failed to identify innovative methods that overcome the persistent barriers to adolescent sexual and reproductive health service demand and access. Increasingly, programmers have turned to human-centered design (HCD), a problem-solving process that centers the needs, perspectives, and experiences of people, when developing solutions to complex SRH challenges. This article describes the application of a youth-engaged version of HCD as part of Adolescents 360, a transdisciplinary initiative to increase 15- to 19-year-old girls' use of modern contraception in Nigeria, Ethiopia, and Tanzania. Youth-adult design teams (including 111 "youth designers" trained in HCD methods) undertook formative research to inform the design and implementation of interventions. We reflect on the practical implications of using instrumental strategies of HCD with a youth-led participatory approach. Our experience indicates that (1) engaging youth as project partners in transdisciplinary teams requires planned and dedicated financial and human resources; (2) involving youth as action researchers can help identify opportunities to improve program empathy and responsiveness; (3) it is difficult to recruit "extreme users" as project partners because of the high competencies needed in HCD; (4) centering empathy and employing design standards during prototyping can drive decision-making and resolve questions raised by conflicting evidence claims in existing bodies of literature; and (5) testing tangible services and products in real-world settings continues long after the intervention design phase. Youth-adult partnership should continue throughout this iterative and adaptive phase to ensure that the adolescent experience of the intervention remains at the core of intervention delivery.