Adolescents in Botswana face extraordinary reproductive health challenges. Teen pregnancy forces girls to leave school after which few resume their education. Botswana has the second highest HIV prevalence in the world, with incidence increasing rapidly at ages 15-19, peaking at 40.2% prevalence by ages 30-34. STIs are prevalent despite the availability of free health care. Traditional sex education, provided in now banned village initiation schools, is no longer available and parents are uncomfortable discussing reproductive health within the family. In an earlier R34 award, guided by a Community Advisory Board and Adolescent Advisory Group, we conducted formative interviews, assessed the psychometric adequacy of the proposed measures, and adapted and assessed the feasibility and acceptability of interventions for youth and their parents. We now propose to conduct a 3-arm randomized controlled trial with 500 families, with a male and with a female adolescent age 13-18. Arm 1 (N = 200) will receive the parent intervention ?Families Matter 2!? (FM2!) and their adolescent will participate in ?Living as a Safer Teen? (LAST). In Arm 2 (N = 200), parents receive FM2! Only and six months later their adolescents will receive LAST allowing us to assess the impact of the parent program alone and potential boost in outcomes when adolescents are also engaged in intervention. Arm 3 (N = 100), the comparison arm, will be the current, widely-delivered program in Botswana. Each adolescent and parent dyad will complete ACASI assessments in English or Setswana at baseline, post-intervention, 6- and 12-month follow-ups on family communication, parenting practices, knowledge of sexual development, and sexual behavior. Youth will also complete psychosocial measures assessing attitudes toward condoms, perceived barriers to sexual safety, attitudes toward transactional sex, acceptance of gender violence, and self-efficacy. Gonorrhea, chlamydia, herpes simplex virus type 2 (HSV2), and human immunodeficiency virus (HIV) will be tested at baseline and 12-month follow-up for adolescents. A pilot trial affirmed the feasibility of recruiting parent(caretaker)/adolescent dyads and retention exceeded 95% for both parents and adolescents. While the pilot trial was underpowered, results suggest that the interventions improved family communication, child management skills, knowledge of sexual development, attitudes toward contraception; lowered tolerance for intergenerational transactional sex and gender violence; and lowered sexual risk behavior of both parents and adolescents in the intervention arm. In addition, youths who were abstinent upon entering the pilot intervention appear to have delayed sexual debut more successfully than the comparison arm. This study addresses the highest priority in Botswana?s current national strategic plan. If the results provide strong evidence of effectiveness, the Ministries of Education, Health, Youth & Culture, National AIDS Coordinating Agency, and the Office of the President have committed to its dissemination throughout Botswana.
This application proposes to deliver and evaluate a pilot-tested multi-level reproductive health intervention for Batswana adolescents and their parents. The study will evaluate interventions designed to improve reproductive health outcomes for adolescents and their families that are designed to have high public health impact. Program impact will be evaluated with cognitive, behavioral, biomedical and cost effectiveness endpoints from baseline across the following year and the results have broad applicability throughout sub-Saharan Africa.
