Rise

Adolescent pregnancy remains a major public health and development challenge in sub-Saharan Africa. In Zambia, early childbearing is common and closely linked with school dropout, poverty, and limited opportunities for girls (1). The Research Initiative to Support the Empowerment of girls (RISE), coordinated by the University of Bergen and the University of Zambia, was a large cluster randomized trial designed to evaluate comprehensive community- and school-based strategies to reduce the risk of adolescent pregnancy and support girls’ education. The intervention packages were developed based on WHO’s recommendations for research on prevention of early childbearing and marriage (2), systematic review of the literature (3), and formative research (4). The main trial findings were published in 2024 (5).

Key study findings

The trial was conducted in 157 rural schools in Zambia and almost 5000 girls participated. It estimated the effect of two interventions provided for two years: (i) economic support to adolescent girls and their families, and (ii) a combined package of economic support, comprehensive sexuality education (CSE) through youth clubs, and community dialogue meetings. The primary outcomes were adolescent childbearing and completion of lower secondary school. The combined package of interventions had an 18% effect in reducing early childbearing and substantially increased (26% increment) the proportion of girls sitting for their grade 9 examinations. Economic support alone tended to give slightly smaller effects. Further analysis suggested that combining economic support with CSE and community engagement can reduce girls’ risk of early pregnancy during the period when the support is provided, but that the effects quickly wane when the support ends.

Sub-studies contributing additional scientific and program-relevant information

The RISE trial has also stimulated a number of sub-studies that address specific questions such as the effects on sexual behaviour, adolescent survey methodology, and healthcare expenditures.

One paper examined the effects of the intervention packages on secondary outcomes related to sexual and reproductive health (SRH) (6). The investigators found that economic support lowered self-reported sexual activity at the end of the two-year intervention period. The addition of CSE and community dialogue improved knowledge regarding contraceptives and reduced unprotected sexual activity overall and increased the use of contraceptives among those who reported to have recently been sexually active. 

A methodological sub-study explored how best to interview adolescent girls on sensitive topics such as sex and pregnancy (7). It found that while adolescents were often uncomfortable with very direct questions, strategies such as building trust, using indirect wording, putting questions into a context of romantic relationships, and combining face-to-face interviews with Audio Computer-Assisted Self Interviewing could improve the reliability and validity of self-reported data. These findings have implications for how adolescents should be interviewed about sensitive SRH issues.

Another substudy investigated whether the RISE cash transfer intervention had broader impacts on healthcare utilisation and catastrophic health expenditures for households (8). While no major changes were observed in overall healthcare use, the intervention reduced inequalities in healthcare access between wealth groups. 

Policy implications

These findings provide important insights for global debates on the integration of cash transfers, school-based sexuality education and efforts to change community norms. Taken together, the RISE trial and its sub-studies indicate that comprehensive school- and community-based interventions may not be sufficient to achieve more than modest reductions in adolescent pregnancy rates when offered for a short period of time. However, financial support, CSE and community dialogue can reduce barriers to education and equip adolescent girls with knowledge and life skills for better SRH and social outcomes. 

Overall Impact Summary

The RISE trial has made an important contribution to evidence-based strategies for reducing the risk of adolescent pregnancy and improving girls’ education in contexts where too early childbearing is common and there are substantial barriers to secondary school enrolment and discussing SRH with adolescents. The findings and those of similar studies clearly indicate that removing economic barriers to schooling can allow more children to complete basic education, but that direct effects of financial support on early childbearing are limited to the active support period.

References

1.            Zambia Statistics Agency, Ministry of Health (MOH) Zambia, IICF. Zambia Demographic and Health Survey 2018. (external link) Lusaka, Zambia, and Rockville, Maryland, USA: Zambia Statistics Agency, Ministry of Health, ICF; 2019.

2.            WHO. WHO guidelines on preventing early pregnancy and poor reproductive health outcomes among adolescents in developing countries (external link). World Health Organization; 2011.

3.            Sandøy IF, Mudenda M, Zulu J, Munsaka E, Blystad A, Makasa MC, et al. Effectiveness of a girls’ empowerment programme on early childbearing, marriage and school dropout among adolescent girls in rural Zambia: study protocol for a cluster randomized trial (external link). Trials. 2016;17(1):588.

4.            Blystad A, Moland KM, Munsaka E, Sandøy I, Zulu J. Vanilla bisquits and lobola bridewealth: parallel discourses on early pregnancy and schooling in rural Zambia. (external link) BMC Public Health. 2020;20(1):1485.

5.            Sandøy IF, Mudenda M, Hegdahl HK, Zulu JM, Grønvik T, Munsaka E, et al. Effectiveness of economic support, comprehensive sexuality education and community dialogue on early childbearing and sitting for grade nine exams among adolescent girls in rural Zambia: a cluster randomised trial. (external link) eClinicalMedicine. 2024;78:102934.

6.            Hegdahl HK, Musonda P, Svanemyr J, Zulu JM, Grønvik T, Jacobs C, et al. Effects of economic support, comprehensive sexuality education and community dialogue on sexual behaviour: Findings from a cluster-RCT among adolescent girls in rural Zambia. (external link) Soc Sci Med. 2022;306:115125.

7.            Isaksen K, Sandøy I, Zulu J, Melberg A, Kabombwe S, Mudenda M, et al. Interviewing adolescent girls about sexual and reproductive health: a qualitative study exploring how best to ask questions in structured follow-up interviews in a randomized controlled trial in Zambia. (external link) Reprod Health. 2022;19(1):9.

8.            Mori AT, Mudenda M, Robberstad B, Johansson KA, Kampata L, Musonda P, et al. Impact of cash transfer programs on healthcare utilization and catastrophic health expenditures in rural Zambia: a cluster randomized controlled trial. (external link) Frontiers in Health Services. 2024;Volume 4 - 2024.

Principal Investigator:
Ingvild Fossgard Sandøy, University of Bergen, Norway

Co-Principal Investigator:
Patrick Musonda, University of Zambia, Zambia