Sexual and reproductive health

There have never been more adolescents (10-19y) in the world, and nearly 90% of them live in low and middle-income (LMICs). Major improvements in child health have resulted in a dramatic epidemiological transition, whereby mortality and morbidity rates among 1-4 year-olds have fallen dramatically. These improvements have not been mirrored among adolescents and young adults, so the scale of their burden of disease has been revealed as an important current and future public health priority. Furthermore, adolescent health and development is key to the prevention of adult non-communicable diseases (such as cardiovascular diseases and cancers), the consequences of communicable diseases (such as AIDS, sexually transmitted infections (STIs), and secondary infertility), and the health, economic and social consequences of early, unintended pregnancies and abortions. Several preventive interventions provided by health services have been shown to be effective, yet adolescents are notorious for not attending health facilities to seek care, unless they have adopted adult social roles such as being married and pregnant.

The dramatic improvements in child health over the past 2-3 decades were partly due to substantial improvements in the utilization of preventive health services such as immunization, insecticide treated nets, and early, effective treatment of diarrhoea, respiratory tract infections, septicaemia and malaria, by women and young children. Recent studies have shown that it is possible to increase young people’s attendance at health facilities by training health workers to be adolescent-friendly, in the presence of assured provision of drugs and supplies for provision of family planning services and the treatment of suspected sexually transmitted infections (STIs). However, the increases in utilization of sexual and reproductive health services by young people that were observed were modest, and started from very low rates. Much higher attendance rates will be required for substantial health effects to be observed at the population level.

Sexual and reproductive health (SRH) interventions are among the most pressing health needs of adolescents, especially unmarried adolescents. Numerous attempts have been made to make such services more accessible to adolescents either through training health workers to be more adolescent-friendly, or by providing specific services for them, such as through youth clinics, youth-friendly corners within existing clinics, or the provision of SRH services within youth centres. These attempts have rarely been effective, let alone cost-effective. This has been at least partly because of the stigma associated with unmarried adolescents or young people attending a clinic that is clearly identified with the provision of sexual and reproductive health services.

The INDEPTH Health Transitions to Adulthood Study (IHTAS) proposes to address this need through the provision of a package of adolescent health services (which will include SRH services alongside a range of other adolescent health services) the active promotion of these services within the community and performance-related incentives to the health facilities.

To test the generalizability of this approach, the effects on adolescents’ utilization of health services will be rigorously evaluated within a series of two cluster randomised plausibility trials conducted in different LMIC settings. IHTAS will also evaluate the effectiveness and cost-effectiveness of providing graded incentives to adolescents who actually avail themselves of the various components of the adolescent health services package, given the form of conditional cash transfers (CCTs).

The IHTAS is the subject of a separate outline proposal that has been shared with the Hewlett Foundation. The aim is for the main IHTAS to start in April 2014. However, this document is a proposal to the Hewlett Foundation for preliminary research that will prepare the ground for the main IHTAS trial, and will be carried out between January 2013 and March 2014.

Preliminary Research

The preliminary research will provide essential information for the further development of the proposed interventions that will be tested in the IHTAS and detailed trial protocol. This preliminary research will include six main components that will all feed into the final detailed IHTAS trial protocol:

    • HDSSs: Selection of HDSSs
    • Situation analysis: Situation analysis within the two trial HDSSs
    • Data linkage: Selection of data linkage technology
    • Performance-related incentives: Selection of the specific performance-related incentives for the health facilities
    • CCTs: Selection of the incentives to be given to the trial participants in Intervention Arm 2 of the trial
    • Fund raising: The PIs will make visits to potential funders of the main trials