Estimating the Impact of Sexuality Education and Mobile Health Services on Reproductive Health and Empowerment Among Adolescents in Sierra Leone for the Family Planning Impact Lab (REACH)

The 60 schools in this arm are the control group. They will continue providing their standard services and functions. They will not implement the Comprehensive Sexuality Education curriculum nor will they receive mobile SRH services.

The 60 schools in this arm will implement the Comprehensive Sexuality Education (CSE) curriculum and offer a safe space for menstrual hygiene and care.

For junior secondary schools in the "CSE only" and "CSE+mobile SRH services" intervention arms, at baseline at the start of the school year, MSSL will train teachers who teach subjects in which CSE topics are included, using a standard teaching training curriculum to help mitigate the risk of variability in the quality of CSE implementation across schools. Teachers will then implement the CSE curriculum in their classes throughout the duration of the study. MSSL will provide yearly refresher teacher training throughout the study. In each school, guidance counselors will be tasked with monitoring implementation of the intervention. MSSL will provide all materials and equipment needed to teach CSE. Each school will create a "safe space" where students can go for menstrual hygiene and care.

• CSE
• Child and Adolescent Health and Life Skills (CAHLS) - name used by the Ministry of Education to refer to the CSE curriculum

The 60 schools in this arm will receive MSSL-provided mobile sexual and reproductive health (SRH) outreach services on the school premises 3 times per school year.

For junior secondary schools in the "Mobile SRH services only" and "CSE+mobile SRH services" intervention arms, MSSL will utilize three mobile clinical teams to provide direct, comprehensive SRHR services on-site at schools. Each team will be composed of two service providers trained to provide youth-friendly services, one data imputer, and a transport assistant. The team will visit each school once per quarter (3 times during the school year). A comprehensive range of youth-friendly SRH services, including contraceptive counseling, provision of LARC (implants and IUDs), short-term methods (pills, injectables and emergency contraception), condom promotion, STI services, and referrals to health facilities if needed, will be available to all students through the mobile visits.

• Mobile outreach clinics

The 60 schools in this arm will receive both interventions: they will implement the CSE curriculum (and space spaces) and will also receive MSSL-provided mobile SRH outreach services on the school premises 3 times per school year.

For junior secondary schools in the "CSE only" and "CSE+mobile SRH services" intervention arms, at baseline at the start of the school year, MSSL will train teachers who teach subjects in which CSE topics are included, using a standard teaching training curriculum to help mitigate the risk of variability in the quality of CSE implementation across schools. Teachers will then implement the CSE curriculum in their classes throughout the duration of the study. MSSL will provide yearly refresher teacher training throughout the study. In each school, guidance counselors will be tasked with monitoring implementation of the intervention. MSSL will provide all materials and equipment needed to teach CSE. Each school will create a "safe space" where students can go for menstrual hygiene and care.

• CSE
• Child and Adolescent Health and Life Skills (CAHLS) - name used by the Ministry of Education to refer to the CSE curriculum

For junior secondary schools in the "Mobile SRH services only" and "CSE+mobile SRH services" intervention arms, MSSL will utilize three mobile clinical teams to provide direct, comprehensive SRHR services on-site at schools. Each team will be composed of two service providers trained to provide youth-friendly services, one data imputer, and a transport assistant. The team will visit each school once per quarter (3 times during the school year). A comprehensive range of youth-friendly SRH services, including contraceptive counseling, provision of LARC (implants and IUDs), short-term methods (pills, injectables and emergency contraception), condom promotion, STI services, and referrals to health facilities if needed, will be available to all students through the mobile visits.

• Mobile outreach clinics

Proportion of female respondents who use, or whose partners use, modern contraceptive methods (female/male sterilization, IUD, implant, injectable, pill, emergency contraception, male/female condom, and modern fertility-awareness-based methods). Aggregated as a proportion at each round; between-arm effect estimated via difference-in-differences.

Proportion of female respondents classified as preference-concordant by the Preference-Aligned Fertility Management (PFM) indicator: using contraception and wanting to be, or not using and not wanting to be.

Proportion of female respondents who report being able to make their own decisions regarding the use of family planning, as opposed to needing permission from a parent, partner, healthcare provider, or other household authority figure.

Proportion of the baseline (JSS1-enrolled) cohort of female and male respondents no longer enrolled in / attending school at a given follow-up round. Baseline enrollment is universal by eligibility, so dropout is measured longitudinally across rounds.

Proportion of female respondents who reported a new pregnancy that was unwanted or mistimed since the previous round, based on pregnancy history and retrospective wantedness.

Among female and male respondents who report having had sex in last 6 months, proportion who report that a condom was used at last intercourse.

Modified unmet-need indicator: Proportion of sexually active non-pregnant female respondents who wish to delay or avoid pregnancy but are not using a modern contraceptive method.

Proportion of female contraceptive users who are satisfied with their method

Among female respondents using a method, proportion who discontinue (stop or have removed) their method between consecutive rounds.

Proportion of female and male respondents who got married or started cohabiting between two consecutive rounds.

Mean score on an index of 5 SRH knowledge items among female and male respondents, including potential side effects, infertility, postpartum fertility, and the fertile window.

Mean score on the 4-item DAP scale for female respondents. Items include to what extent: 1) becoming pregnant in the next 3 months makes me feel excited, 2) it would be a positive addition to my life to have a baby in the next year, 3) thinking about having a baby within the next year makes me feel stressed out, and 4) if I had a baby in the next year, it would be hard for me to manage raising the child.

Each DAP item has response options that range from 0-4. For negatively worded items, 4 is "strongly agree;" for positively worded items, 4 is "strongly disagree." Sum raw item scores and divide by 14 to obtain an average pregnancy preferences score (final range: 0-4). Higher scores reflect a higher desire to avoid pregnancy. The DAP is intended to be used as a continuous measure.

Proportion of partnered female respondents reporting any of the five reproductive-coercion behaviors on the validated 5-item short-form validated Reproductive Coercion Scale (or the mean item count).

Mean score on the validated 10-item CSESSA for female respondents. The score is calculated by summing all item values, creating a total score ranging from 0 to 100 across the partner-communication, provider-communication, and choosing/managing-a-method subscales.

Mean score out of 15 items measuring beliefs and attitudes about gender and gender norms, for female and male respondents

Proportion of female and male respondents who rated their health as very good or excellent (or mean on the ordinal scale).

Mean score on validated Cantril Self-Anchoring Ladder (present and anticipated 4-year rungs, 0-10), for female and male respondents

Mean score on validated 4-item PHQ-4 mental health scale, for female and male respondents (range 0-12). Report the mean total score and the proportion screening positive (subscale total >=3 for anxiety and for depression).Total score is determined by adding together the scores of each of the four items. Scores are rated as normal (0-2), mild (3-5), moderate (6-8), and severe (9-12).

Mean score on the validated 11-item CYRM for female and male respondents (simple sum of all 11 items, no reverse-scored items)

Mean score on validated GEAS empowerment scale and 3 subscales (5-item freedom of movement, 7-item voice and 5-item decision-making/behavioral control), for female and male respondents. Mean scores are calculated based on each set of scaled items, ranging from 1 to 4.

Mean highest school level that female and male respondents aspire to complete

Proportion of female and male respondents expressing both: 1) support for the continuation of female circumcision, and 2) intention to have a future daughter circumcised (or for boys, desire that their future wife be circumcised).

Among ever-partnered female respondents, proportion reporting any controlling, emotional, physical, sexual, or economic abuse by a current/most-recent partner, using standard DHS/WHO-style items. Reportable overall and by subdomain.

Proportion of male respondents who have witnessed physical violence by another man who would do something about it

Average number of CSE topics covered in class during the current school year as reported by female and male respondents

Proportion of female and male respondents who report that CSE classes have been useful or very useful in helping them in their personal life, by trial arm

Proportion of female and male respondents who report having attended mobile SRH services at their school or a neighboring school during the current school year

Mean score on validated PCCC scale for female respondents who attended mobile SRH services at their school or a neighboring school during the current school year, based on 4 items