Adaptation of a gender-transformative sexual and reproductive health intervention for adolescent boys in South Africa and Lesotho using intervention mapping

Figures & data

Table 1. Demographic characteristics of project advisory group members and focus group participants

Project Advisory Group
Lesotho	Age Range	Gender	Representatives	Geography
Adolescent	13–17	N = 9 (5 female; 4 male)	4 Youth NGO; 2 secondary school students; 3 community members	6 urban; 3 peri-urban
Community	18+	N = 8 (4 female; 4 male)	2 NGO; 2 health workers; 1 teacher; 1 principal; 1 caregiver; 1 community leader	6 urban; 1 peri-urban; 1 rural
Expert	18+	N = 13 (8 female; 5 male)	6 Ministry of Education and Training; 4 NGO; 2 Ministry of Health, 1 UNICEF;	13 urban
South Africa	Age Range	Gender	Representatives	Geography
Adolescent	13–17	N = 8 (5 female; 3 male)	8 community members	8 peri-urban
Community	18+	N = 7 (5 female; 2 male)	2 social workers; 2 teachers; 2 caregivers; 1 community leader	7 peri-urban
Expert	18+	N = 8 (5 female; 3 male)	5 Western Cape Education Department; 2 NGO; 1 Department of Health	13 urban
Focus Group Participants
Lesotho	Mean Age	Gender	Representatives	Geography
Adolescent	16.1	N = 28 (15 female; 13 male)	18 secondary school students; 10 community members	24 urban; 4 peri-urban
Adult	44.2	N = 12 (6 female, 6 male)	3 caregivers; 2 councillors; 2 pastors, 2 teachers; 1 police officer; 1 village health worker; 1 community leader	12 urban
South Africa	Mean Age	Gender	Representatives	Geography
Adolescent	14.6	N = 27 (14 female; 13 male)	27 secondary school students	27 peri-urban
Adult	42.0	N = 10 (8 female; 2 male)	2 teachers; 2 caregivers; 2 nurses; 2 community leaders; 1 NGO; 1 social worker	10 peri-urban

Figure 1. Modified intervention Mapping process

Table 2. Codes, themes and sub-themes from focus group discussions

Focus Group Themes and sub-themes	Illustrative Participant Quotes
Theme 1: Unequal gender norms promote sex without a condom
Codes: - Boys carry condoms, girls do not - Boys make sexual decisions - Adolescent pregnancy is stigmatised for girls and a status symbol for boys -Boys do not like using condoms because they reduce pleasure	- ‘boys are very naughty, we have that rulership, we tell ourselves that I’m going to rule this girl’ (adolescent, male, South Africa) - ‘so if the man feels like it is time, the woman doesn’t have a say; so they just do it; get pregnant and the rest is history’ (adolescent, female, Lesotho) - ‘it is always the case that boys [rather than girls] take protection’ (adolescent, female, Lesotho)
Sub-theme: Transactional sex – material needs and power
Codes: - Some girls have sex for money to make ends meet - Some girls engage in transactional sex for material goods from older men ‘blessers’ - Girls are unable to request condom use in transactional relationships - Unequal power relations	- ‘due to poverty in their homes, they need to make a living out of prostitution’ (adolescent, female, Lesotho) - ‘the blesser does not want to use a condom and because she wants the money and she knows that she will get the money, she will then allow that’. (adult, female, South Africa)
Theme 2: Peer Influences on sexual behaviour
Codes: -Perceived norms (everyone is having sex) -Peer pressure (better having sex without condom) - Early sexual experience seen as a sign of maturity and masculinity for boys - Having multiple partners is a status symbol for boys	- ‘one friend will be telling the other about sex, and they will be curious to feel how it is’. (adolescent, female, Lesotho) - ‘for us boys when we talk, you will hear them saying: “if you can sleep with that girl, you are a top dog” and they get respect from that’ (adolescent, male, Lesotho) - ‘it’s status when they talk, when someone is telling the other one that I have this number of girls’ (adult, female, South Africa)
Sub-theme: Substance use leads to unprotected/condomless sex
Codes: - Drinking and taverns are a common part of life - Substance use as a reason for unprotected/condomless sex - Sexual assault when under the influence of substances	- ‘there is no one that does not go [to] the tavern, there is no one that stops the children to not go around at night’ (adult, male, South Africa) - ‘when [a] young person uses alcohol, they may engage in activities that could lead to unplanned pregnancy’ (adolescent, female, Lesotho) - ‘even if she does not want to but because she is drunk she will not have the strength to fight him off, and end up doing it’ (adolescent, male, South Africa)
Theme 3: Access and Barriers to Condoms and Other Contraception
This theme consisted of three sub-themes: 1) Stigma in the community; 2) adults talking about sex is culturally taboo; and 3) Misconceptions about condoms and other contraception
Sub-theme: Stigma in the community around adolescent sexuality
Codes: -Adolescents know where to access (knowledge and availability not a barrier) - Stigma as a barrier to access - Fear of clinic staff - Fear of being caught carrying condoms	- ‘imagine getting in here going to ntate [sir] there to ask for condoms, he is going to ask me so many questions’. (adolescent, male, Lesotho) - ‘They are afraid to be looked in a bad manner because the nurses sometimes have no patience, they talk in a bad way’ (adolescent, female, Lesotho)
Sub-theme: Adults talking about sex is taboo
Codes: - Adult-child talking about sex is taboo, sinful, perverted - Talking about sex promotes sex - Parents do not have SRH knowledge themselves - Teachers uncomfortable teaching relationships and sexuality education	‘it goes back in the day when for us Basotho, it was a taboo to sit your child down and talk to them about sex’ (adult, female, Lesotho) ‘it is like a sin to introduce a sex topic to the child’ (adult, male, Lesotho) ‘if you tell a child that there is something called sex, they will feel eager and want to try it’ (adult, female, Lesotho) ‘it is still hard for us to talk to our children about sex because it was never done to us’ (adult, female, South Africa) ‘At school, there is a teacher that teaches Life Orientation. He skips the part about reproduction all the time’ (adult, female, South Africa
Sub-theme: Misconceptions about condoms and other contraception
Codes: - Condoms waste time - Condoms are a ‘bad omen’ (bad luck for current relationships and the future fertility) - Condoms reduce male pleasure - Female contraception causes infertility	-‘[Condoms] are a bad omen, and they delay [men] to do their stuff [referring to sexual climax]’ (adolescent, male, Lesotho) - ‘there is no way you can eat a lollipop with is cover’ (adolescent, male, Lesotho) - ‘some are hearing other children’s opinions about contraceptives maybe say it is not right one day when you are married you might not get children in future’ (adolescent, female, South Africa)
Theme 4: Lack of diversions for adolescents – activities for idle hands
Codes: - Idle adolescents - Not enough programmes - Adults reported there was nothing else exciting for young people to do (e.g. community, after-school programmes etc.) and that was part of the reason why they engaged in substance misuse and unprotected/condomless sex	- ‘there should be something that keeps one busy, because if someone idles, they get to have a lot [of bad] thoughts’ (adult, male, Lesotho) - ‘there must be a programme that will look after children after school so that they do not walk around in the streets, so that the streets can be quiet while the children are in that programme’ (adult, female, South Africa)
Theme 5: Responses to the JACK intervention
Codes: - Opportunities for discussion and self-reflection welcomed - Interactive modality and story-line of film acceptable - Adolescents did not want to complete the homework exercise with parents/caregivers - All other activities acceptable with minor contextual modifications - Parent/caregiver animated films acceptable - Delivery by older peers rather than teachers -Mixed views about whether should be delivered in schools or community settings - Potential parental resistance to JACK in Lesotho	- ‘I [am] able to tell other people about new things that I learned, maybe they also did not know about it and they will get to know it and have more knowledge’ (adolescent, male, Lesotho) - ‘is better because they [characters in the IVD] discuss the issue, unlike here, here we do not discuss, when there is something bothering you, you keep it to yourself’ (adolescent, female, South Africa) - ‘where those questions pop up, I am able to empathise with the characters as to what I would do while in a similar situation’ (adolescent, female, Lesotho) - ‘it is not easy for me to watch it [the If I Were Jack IVD] with an adult’. (adolescent, male, Lesotho) - ‘it is nice, I liked it, things that are written here, I liked most of what is on this paper’ (adolescent, female, South Africa) -“if it is ‘delivered by someone older, there might be some resistance and it might bore them; but if it is delivered by their peers, it is easy for the message to cut across’ (adult, male, South Africa) - “I think if parents are involved, it would be just to teach them how to talk to their child, and when things like this one have happened, they should be able to address them together with their child.’ (adult, female, Lesotho) - “Whenever something new comes up [in relation to sex and HIV], it is not often that it gets a good reception [from parents]. All you need to know is that there will be some resistance at first, but that doesn’t say if they refuse; you will have failed. (adult, female, Lesotho)

Figure 2. Logic model of the problem

Table 3. Intervention adaptation plan

ORIGINAL INTERVENTION	PLANNED ADAPTATIONS
INTERVENTION GOALS
‘To reduce unintended pregnancy and promote sexual health and wellbeing’	Change goals to directly highlight aims to reduce HIV/STI rates and gender inequalities in SRH, as well as unintended pregnancy. ‘To reduce unintended early pregnancy, HIV and STI rates and gender inequalities in sexual and reproductive health’
INDIVIDUAL LEVEL DETERMINANTS TARGETED BY THE INTERVENTION
FOR ADOLESCENTS: Knowledge Skills Beliefs about consequences Self-efficacy Gender role norms Normative beliefs	Add: ‘Beliefs about barriers to condom use and contraception’
ENVIRONMENTAL LEVEL DETERMINANTS TARGETED BY THE INTERVENTION
FOR PARENTS/CAREGIVERS AND EDUCATORS: Knowledge Skills Self-efficacy	Add: ‘Beliefs about speaking to young people about SRH’
INTERVENTION INPUTS AND ACTIVITIES
FOR ADOLESCENTS: Interactive video drama (IVD) Group activities Homework activity FOR PARENTS/CAREGIVERS: Animated films Parent/Caregiver factsheet FOR EDUCATORS: Training Materials	Amendments: IVD uses local actors and is filmed in local areas. All activities and materials are contextually appropriate (e.g. mention local statistics and services) Activities increase current focus on gender inequalities, consensual sex and substance use An activity that focuses on transactional sex is added Activities are amended to mention appropriate local barriers to condom/contraception use and misconceptions about condoms and other contraceptives Lesotho materials are amended to account for the criminalisation of abortion An activity focused on the dangers of unsafe abortion is added for both countries An activity targeting LGBTQI adolescents is added Homework activity is replaced with an individual activity that helps young people to safely identify an older trusted adult that they could speak to about SRH Parent/caregiver activities are amended to address local concerns, particularly addressing cultural taboo relating to adults speaking to children about SRH and increasing knowledge that talking about SRH does not encourage sex Parent/caregiver/educator materials refer to SRH education rather than relationships and sexuality education All online activities are coupled with paper versions for those with no internet access All activities should refer to SRH rather than ‘sex’ or sexuality as this is more taboo
PERFORMANCE OBJECTIVES (INTERVENTION OUTPUTS)
FOR ADOLESCENTS: Knowledge: Know how to prevent Unintended Early Prgnancy (UEP)/HIV/STIs; discounting myths about condoms; know it is good to wait until ready to have sex; know where to access contraception/safe abortion and find sexual health information and support; know that condoms prevent UEP/HIV/STIs. Skills: communicating with peers, partners and adults (health professionals, teachers); using condoms and other methods of contraception Beliefs about consequences: Believing that when a person is ready and prepared, relationships, sex and pregnancy can be positive experiences; believing that UEP/HIV could be a challenging experience which would impact on current life and future goals and plans; believing in the need to take action in order to avoid negative consequences Self-efficacy: Communicating with peers, partners and adults (parents, educators, health professionals); obtaining condoms/contraception; negotiating condom use; using condoms/contraception correctly; in SA obtaining safe abortion. Feeling confident about being able to communicate about sex and UEP, say no to sex, and obtain and use contraception Normative beliefs: Believing that peers are not having sex; Believing that peers always use contraception when they have sex; Believing that peers should not pressure others to have sex. Gender role norms: believing that both men and women have roles and responsibilities in avoiding UEP/HIV; both men and women should carry condoms; sexual pleasure is not a human right; consensual sexual relationships; ‘real’ men respect women’s sexual decisions; planning for and expecting positive sexual experiences.	Add: Knowledge: know what is consensual and non-consensual sex; know about the possible negative consequences of transactional sex; know how to evaluate relationships; know where to seek help for unhealthy or abusive relationships. For Lesotho, remove ‘know where to access abortion’. For both countries; know about the risks of unsafe abortion and know about post-abortive care. Skills: communicate expectations with sexual partners; avoiding or leaving unhealthy relationships Beliefs about consequences: believing that unhealthy relationships will impact negatively on current life and future goals Believing that gender equal relationship can be happy and fulfilling Self-efficacy: Confidence in ability to communicate personal expectations, preferences and limits Normative beliefs: Add – Believing that peers are not having sex until they feel ready; believing that peers always use condoms when they have sex, even in monogamous/steady relationships; believing that peers should not pressure others to not use condoms, believing that sexual partners should not pressure each other not to use condoms; believing that condom use is not a sign of a distrust in relationships. Gender role norms: Add – Believing that women have the right to make decisions about sex; believing that women have the right to refuse sex; believing that women have the right to request the use of condoms and to refuse sex if condoms are not available; believing that women in transactional relationships have the right to refuse sex without condoms; believing that using condoms does not emasculate men.
BEHAVIOURAL OUTCOMES
Delayed age of sexual initiation Avoidance of unprotected/condomless sex Condom use Contraceptive use Gender equality	Add: Safe abortion/post-abortive care Healthy relationships Testing for HIV/STIs/pregnancy Asserting gender equal relationships
THEORETICAL FOUNDATIONS
Theory of Planned Behaviour Transtheoretical Model of Behaviour Change Social Cognitive Theory Social norms Theory Socio-cultural influences (gender, religion, social class) Gender-transformative theory	Consider/Add: Theories of stigma Theories of power
DELIVERY METHODS
Delivered by trained teachers Delivered in Post-primary schools	Change: Delivery by trained young adult facilitators Deliver in schools and community settings Consider/Add: Drama narration versions of films delivered via local radio

Figure 3. Emerging theory of change model

Data availability statement

Data are stored at Queen’s University Belfast. Because the data consists of interviews with sensitive personal information, data will not be shared.