SKILLZ ATTENDANCE
SE
HOLIDAYS
In cohort 1, 9 schools received the intervention program, with sessions delivered after school as intended. Mechanisms to support attendance, identified through the literature and the study team's experience of SKILLZ delivery, included providing refreshments, offering optional free transport home after sessions, and engaging a school-appointed “teacher champion” at each school (Comparison of Mechanisms of Support Offered to Schools Receiving SKILLZ in 2 CohortsSent session reminders to schoolProvided refreshmentsProvided transportEngaged teacher championProvided certificate upon graduation (communicated in advance to participants)Used preferential program delivery during school class time, during lunchtime, or after schoolSent session reminders to school and directly to participants via WhatsAppProvided refreshmentsProvided transportEngaged teacher championProvided certificate and medal provided upon graduation (communicated in advance to participants)Despite this positive feedback, cohort 1 showed a mean attendance rate of 44.20% (standard error [SE]: 5.22%; 95% confidence interval [CI]=33.18%, 55.22%) and only 27.79% graduated from the program. Safety concerns linked to high levels of community unrest, violence, and gang activity were commonly reported as a reason for non- or infrequent attendance. To mitigate some of these known concerns, private transportation was offered. However, this option was not always sufficient if the driver could not take the learner directly to their place of residence. This differs from other similar settings in Cape Town where SKILLZ has been delivered and where private transportation arrangements were able to mitigate safety concerns and allow for high attendance. Participants also described competing priorities (e.g., homework and household responsibilities, such as caring for a younger sibling) as a common barrier to attendance after school. Low attendance at other after-school programs in the participating schools was found to be widespread, with little to no culture supporting attendance. School records showed that although 7 of the 9 cohort 1 schools had existing after-school programs other than SKILLZ, only 2 of those schools reported high attendance at after-school programs. Notably, the culture of after-school programming has not previously presented such significant challenges regarding low and nonattendance when delivered in similar settings.Despite participants having positive feedback about the program sessions, cohort 1 had a mean attendance rate of 44%.An assessment conducted after the conclusion of cohort 1 explored alternative delivery models, including in-school sessions (either during class periods or lunchtimes), weekends, and school holidays. Although the latter options were found unequivocally unfavorable to participants, in-school delivery during free class periods or lunchtime periods was perceived as acceptable and led to more than 90% in attendance when piloted in cohort 1 schools. These findings motivated an adaption to allow cohort 2 schools to choose between in-school or after-school session delivery based on the school's preference, alongside the introduction of other additional attendance support mechanisms (Nine new intervention schools were engaged in cohort 2, of which 5 schools opted to receive an in-school program (3 during class time and 2 during lunch time) and 4 selected after-school delivery. Compared to cohort 1, cohort 2 intervention schools did not show a significant improvement in attendance, with a mean attendance rate of 47.17% (SE: 4.90%; 95% CI=36.81%, 57.52%) and a mean difference in attendance rate of 2.97% (Overall, the school-informed modifications made to support SKILLZ delivery in cohort 2 did not elevate attendance to levels comparable with other SKILLZ programs. A key difference in this study compared to other SKILLZ programs was the provision of a health care screening visit at the beginning of the program before any SKILLZ sessions were delivered. In other SKILLZ programs, health care screenings were offered midway or toward the end of the intervention as a means of incentivizing attendance and reinforcing health promotion messaging. Health care access for adolescents in South Africa has been well described as suboptimal, limited by inconvenient clinic opening times and adolescent perceptions of unfriendly health care staff.School-informed modifications made to support SKILLZ delivery in cohort 2 did not elevate attendance to levels comparable with other SKILLZ programs.An SRH program for adolescent girls in Zambia showed a similarly low attendance rate, where only 30% of participants attended more than half of the sessions.