Discussion
WEST, EVENTS, SECONDARY
RMA, a community-based and gender-synchronized program to promote modern contraceptive use and gender equity, resulted in increased current modern contraceptive use and reduced IPV among married adolescent girls and their husbands in the Dosso region of Niger in this first randomized experimental evaluation of a program of this kind in Francophone West Africa. Overall, RMA participants had a nearly 2.3 factor higher likelihood of current modern contraceptive use after 24 months of intervention, and 0.43 factor lower likelihood of recent IPV.Only the intervention arm combining both household visits and small group sessions was effective at both increasing current modern contraceptive use and decreasing past year IPV (aIRR = 2.99, p < 0.001 and aIRR = 0.46, p = 0.052, respectively). This suggests that multi-component interventions may be necessary to concurrently shift both contraception and IPV, behaviors deeply influenced by both individual and interpersonal knowledge and behavior, as well as by gender and social norms. This is consistent with other recent experimental evidence underscoring the utility of combined individual and group activities within social and behavior change interventions [Importantly, these improvements were not uniform across different program modalities, and patterns of effects differed for contraceptive and IPV outcomes. The implementation of household visits, with or without small group discussions, appear necessary to achieve significant increases in modern contraceptive use over a 24-month period in this population. This mode of social behavioral intervention focused on increasing knowledge and dispelling misinformation regarding the nature, mechanisms, effects, and potential risks associated with different forms of modern contraception, and how they may be accessed locally. The privacy of these one-on-one, gender-matched visits allows for a dialogue that may result in greater understanding of these topics than from a group setting where the judgement of peers or fear of publicly questioning an authority figure may inhibit questions or dissenting concerns [In contrast, small group discussions were more effective at reducing recent IPV, with or without the addition of household visits. These group discussions, structured to include dialogue between peers, are well suited for examining social norms and their effects on individuals, families and the community as a whole [RMA’s observed effects on current modern contraceptive use further differed based on parity of married adolescents, with baseline nulliparous participants not significantly increasing their use of modern contraceptives, in contrast to women with one birth at baseline. As women’s social status in Niger is associated with increased childbearing, childless women may be held in lower social regard [These results must be interpreted in light of key limitations. All data was collected via respondent self-report, and is therefore subject to recall and social desirability bias, particularly when discussing sensitive topics such as IPV; this was mitigated to the extent possible by asking about current or recent events for the primary and secondary outcomes, and by conducting interviews individually and in private locations. While our treatment and control arms did not have equivalency at baseline in several assessed factors, we adjusted for these factors in multivariable analyses to provide unbiased estimates of treatment effect. Our findings are specific to the population of adolescent wives and their husbands that we studied in Dosso region, Niger; the RMA intervention should be tested elsewhere to assess validity in other contexts.