How can structural interventions enable adolescent contraceptive use in low- and middle-income countries?

Helen Burchett is an Associate Professor at the London School of Hygiene & Tropical Medicine (LSHTM) and a MARCH Centre member. She has a particular research interest in the interplay between context, interventions and people, to understand how or why interventions may, or may not, work.

Helen’s recent research focused on adolescent contraceptive use in low- and middle-income countries (LMICs). With her colleagues, she mapped the existing evidence and proposed three steps to designing effective structural adolescent contraceptive interventions.
Women queuing for contraceptives in Malawi. Credit: FCDO

What is a ‘structural intervention’ and why focus on them?

Reducing adolescent childbearing is a global priority and contraception is one of the ways of doing this. When we started this project, we had a broad remit of looking at adolescent contraceptive interventions in LMICs. We recognised that many factors can affect whether an adolescent wants, and feels able, to use contraception, including gender inequality, fertility norms and poverty. Structural interventions aim to address these broad factors e.g. by reducing poverty or changing gender norms.

We realised that although sex education campaigns had often been evaluated and their findings pooled in systematic reviews, there was less understanding of which structural interventions worked, in which contexts or for whom.

Who was involved in the research team?

I worked with colleagues within LSHTM (Rebecca French) as well as the EPPI-Centre at UCL and the International Center for Reproductive Health, Mozambique.

What did you find?

We found forty intervention evaluations. What was interesting was that almost half had not been published in academic journals. We only found these by handsearching the websites of international non-governmental organisations (NGOs) and other global organisations for evaluation reports.

Poverty reduction and economic empowerment interventions were the most common – such as conditional or unconditional cash or food transfers, vocational training or microfinance. There were also evaluations of a range of activities aiming to increase participation of girls in schooling, or interventions that aimed to change social norms within communities.

However, when we looked at a subset of controlled studies with contraceptive outcomes in more detail, we could not categorise them as most or least effective, because there was so much variation in the study designs and methods used to evaluate interventions. Instead, we conducted an analysis of the whole subset of studies, using an existing framework of family planning created by the International Centre for Research on Women (ICRW).

From this analysis, we proposed three steps to designing interventions that will aid developers and evaluators of structural adolescent contraceptive interventions to develop an evidence base that is of use across a wide range of contexts:

  1. Tailor interventions to adolescents’ life stages
  2. Assess the baseline situation
  3. Select appropriate activities to match the gaps

What are the next steps?   

Next, we need people to try out these three steps, to see if they are helpful for the development of appropriate and effective interventions. We think it is important for those working in this field to discuss the evaluation challenges we identified, so that we can try to reach a consensus around what measures and study designs to use. This will make it easier for the comparison and pooling of future studies.

What is CEDIL and how can we learn more?

CEDIL stands for the Centre for Excellence in Development Impact and Learning. It was funded by the Foreign, Commonwealth & Development Office (FCDO) to support innovations in impact evaluations and evidence synthesis in international development and funded this research. Projects range from being a year to 3 years or more, and most have finished or are finishing soon, since it ends in 2023. Details of the projects funded can be found on the CEDIL website.


Read Helen's paper on structural adolescent contraceptive interventions in LMICs.

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