Demographic characteristics of the quantitative sample (Table 2): Of the 4399 AGYW who completed the household survey, 56.7% were between the ages of 15 and 19 years old and the remaining 43.3% were 20-24 years of age. Almost half (48.4%) of AGYW living in the districts where the intervention was implemented, indicated that they had participated in at least one of the intervention components. Study laboratory tests found 12.4% of participants testing HIV positive of which 61% reported to have already known their status. Among AGYW who were HIV positive, almost 4.5% of them were recently infected. More than half of AGYW (56.2%) reported that they were in school at the time the survey was conducted. More than half (53.2%) of AGYW who had ever had sex (N=3009) reported that they had ever been pregnant. Most AGYW (61.9%) reported that they had high social support from their parents. The majority of AGYW (67.3%) reported they had a boyfriend in the past 12 months. Almost a third (29.6%) of survey participants reported they had experienced IPV and/or sexual violence in the past 12 months.
Factors associated with participation in the combination HIV prevention intervention
Table 3 presents the participation rates and the associated factors, stratified by age group. Among AGYW in both age groups combined, fewer participants who were HIV positive (43.3%; as per study laboratory tests), reported they had participated in at least one of the intervention components compared with those who were HIV negative (49.1%; p value=0.001). The age-stratified results do not show an association between HIV status and participation in the intervention. No associations were found between AGYW’s socioeconomic status and their participation in the intervention. In both age groups, a greater proportion of AGYW who were in school at the time of the survey participated in the intervention compared with those who were not in school. Among both age groups, fewer AGYW who had ever been pregnant had participated in at least one of the intervention components compared with those who were never pregnant. No associations were found regarding social support from parents and participation rates. A greater portion of AGYW in both age groups who reported to have had a boyfriend in the past 12 months participated in the interventions compared with those who did not have a boyfriend in the past 12 months. Those aged 20-24-years-old who had experienced IPV and/or sexual violence in the past 12 months reported higher participation rates (43.2%) than those who did not experience IPV and/or sexual violence (38.8%, p value = 0.034), while no associations were found among 15-19-year-olds.
A total of 185 AGYW who were recipients of the intervention were interviewed and included in focus group discussions (as seen in Table 4 below). One AGYW intervention recipient refusal was received due to the parental consent being declined. Nineteen of the 185 AGYW participated in SIDIs and 2 were lost to follow up when researchers were unable to contact them. In-depth interviews and FGDs were also conducted with 13 intervention implementers and 13 intervention facilitators.
Demographic characteristics of the AGYW who participated in the intervention qualitative sample: The median age of AGYW living in the communities in which the intervention was implemented was 17 years (Interquartile range (IQR) 15-24). The most commonly spoken language was isiXhosa (40.5%), followed by isiZulu (21.6%).
Participation in the intervention: Facilitators and Barriers reported by AGYW and intervention implementers and facilitators
Themes which emerged from the qualitative data were coded and grouped into facilitators and barriers to participation which were encountered by AGYW, intervention implementers and facilitators of the combination HIV prevention intervention. The facilitators to participation included motivation towards participation in the interventions. Barriers included misguided expectations about financial rewards or job opportunities; competing responsibilities, interests or activities; family responsibilities including childcare; inappropriate incentives; inability to disrupt the school curriculum and difficulties with conducting interventions after school hours due to safety concerns; miscommunication about meetings; as well as struggles to reach out-of-school AGYW. These findings were then grouped into the following levels of influence which are presented below: 1) Individual; 2) Interpersonal; 3) Organisational; and 4) Community.
A key facilitator for AGYW’s recruitment into intervention components related to motivation. At the individual level, participation was enabled when AGYW felt motivated to attend. AGYW respondents expressed self-motivation driven by curiosity and an active interest in extra-curricular activities at school.
I love exploring things. If there is something happening at school, I go and find out what is happening, that is how I joined RISE. (AGYW 15-18yrs, Eastern Cape)
Altruism, community mindedness, and the desire to help other AGYW in their communities were also motivating factors for attendance.
We felt that since we are young girls in our community…we have children and there is more to… learn from RISE. So that we can also help other kids… So that’s how we started. Then we asked for information on how RISE works, how do we attend, and what do you do in your meetings so we can attend. (AGYW 19-24yrs, North West)
Even with RISE, nobody ever told me to go and join or how it will help me, I just joined it on my own… because I am a person who especially loves to work with other youth people. (AGYW 19-24yrs, KwaZulu-Natal)
Perceived benefits of the intervention also provided motivation. Some AGYW joined the intervention because they were struggling with peer pressure and they perceived that they might get support to cope through the intervention.
I joined RISE due to peer pressure because I had many friends and they were involved in drugs, and I learned from RISE about how to deal with substances and pressure and I decided to stop going to friends and associated myself with those who were not on drugs. (AGYW 15-18yrs, Eastern Cape)
Perceived benefits also included the fun activities organised for participants, for when trips or outings were planned, some AGYW were motivated to attend on those days:
Not all of us were attending, because others didn’t come, they were not serious…(they) will only come if we are going somewhere out of (place name), that’s when they will come…they just want a ride obviously, they want to see places (AGYW 19-24yrs, North West)
Intervention facilitators also reported that they thought the certificates AGYW were given after completion of the sessions acted as a motivator for participants:
Another thing that attracts them is because we award them with certificates after finishing the sessions… So, we tell them that if you were bunking (also known as skipping school) and have not attended 16 session or plus, you don’t get the certificate, so I think it is the main thing that attracts them maybe to finally come to the sessions. (Intervention Facilitator, KwaZulu-Natal)
Individual level motivation was shown to be important not only for AGYW intervention recipients, but also for intervention facilitators. When participants did not attend the sessions, intervention facilitators reported they felt demotivated because they had already spent money traveling to the venue. However, they weighed their disappointment against the potential benefits of reaching even one or two participants.
Sometimes, honestly speaking sometimes when I am supposed to secure appointments with RISE I feel that, you know what, maybe I must not go…but, at the same time, the two that come makes a difference…That’s what I always say… at least they tried and whatever they need to discuss you can still discuss it. I am not going to say because the other eighteen did not come, I won’t support these kids. But it demoralizes that one comes from (place name) going to, for example, (place name). I pay R8.00 (approximately US$ 0.46), for transport instead of using the money for bread…And they do not come, at all! (Intervention Facilitator, North West)
Material incentives were used as an approach to keep young women motivated to attend and participate in the intervention components. AGYW in KwaZulu-Natal reported that they were given sanitary towels, umbrellas, and water bottles when they participated in the KGIS programme. Facilitators in North West reported giving mugs, glasses, and selfie sticks after three months of attendance in the intervention. WOW members in the Western Cape received a cash incentive, R300 (approximately US$ 17.37) for recruiting 15 participants. Some AGYW reported that they valued the incentives.
Some participants felt that the opportunity to learn and be part of a group was sufficient motivation to attend, and that the provision of incentives and refreshments was an added bonus.
(They) only (gave us) knowledge, and to get us away from thinking bad things, to gather together. (AGYW 19-24yrs, KwaZulu-Natal)
Some intervention facilitators reported that incentives facilitated participation in the intervention.
What we found very difficult… People who are not working, when you call them they expect you to give them something for their time… They are not going to just give you their time for free, that’s where the headache was with RISE out-of-school…. then we found that there is money for refreshments so we used that as the bribe as per session…. it worked… It kept them coming and then we had incentives as well. (Intervention Facilitator, Eastern Cape)
Money is a challenge, cause when we don’t have money to buy them snacks they don’t come. (Intervention Facilitator, Eastern Cape)
However, in some instances even when incentives were provided, AGYW were insufficiently motivated to attend.
The RISE Club… it’s a cool idea, it just doesn’t take off in every school. We also then offer incentives for the club attendees. So if you attend 3 sessions… either we will give you cup or umbrella, or earphones, so they get a little incentive at the end of the 3 sessions… also… you get say R200 (approximately US$ 11.58) per session and then at the end some of them accumulate it, they can buy something to eat or they can do their own stationary for the project... (but) the club idea never takes off. (Western Cape, Intervention Implementer)
The intervention implementers and facilitators felt that some of the gifts provided to AGYW participants were inappropriate, or even counter-productive. For example, providing school going learners with earphones as an incentive, was viewed as potentially detrimental to their education, as they would be distracted in class.
Most of our incentives are not good for the children. Just like earphones, you can’t give earphones to the school kids because she needs to listen towards what the teacher are saying. (Intervention Implementer, KwaZulu-Natal)
Other incentives that were felt to be inappropriate included selfie-sticks and glass mugs. More useful and contextually relevant incentives would have been items such as toiletries, or vouchers to enable AGYW to purchase necessary toiletries.
We do give them incentives but that’s not what they need. We give them airtime, we give them water bottles but that’s not something that they need because they can take that bottle and throw it away. They need something like roll on, sprays, toiletries something that they can use. (Intervention Facilitator, Eastern Cape)
Like for instance for incentives we had earphones… We had… selfie stick… I don’t see why do you need that thing, your phone has selfie mode, so why need a stick I don’t know… I wish we could have incentives that make sense…Why can’t you give me a Spar voucher for R100 (approximately US$ 5.79), where I can go and buy myself toiletries? (Intervention Facilitator, Eastern Cape)
Suggestions were made by AGYW themselves about what incentives would make them more likely to attend the interventions, such as organising outings, or providing programme branded t-shirts so that they can be identified by others and also promote the intervention to others:
Most girls are not eager to come and attend, they need nice things like going out on trips. (AGYW 15-18yrs, Mpumalanga)
We want things that are visible like maybe getting a t-shirt and show it. When someone sees it, I will then explain about how I got it from this group. (AGYW 15-18yrs, Mpumalanga)
The availability of intervention participants to attend sessions was an individual-level barrier that was cited for retention. Intervention implementers and facilitators explained that retaining AGYW in the intervention proved to be challenging for reasons including time constraints and lack of availability, and AGYW’s competing responsibilities, interests, or activities, which made it difficult for AGYW to attend meetings consistently:
There’s been poor attendance… I’m losing hope because people have other commitments, such as going to school, jobs, others have boyfriends… So for me to get a hold of them… It’s getting tougher, but at the end of the month… I do end up finding them. (Intervention facilitator, North West)
Sometimes the girls are completing other things or maybe they just needed to eat lunch or something. So then attendance dropped, that’s the challenge, the biggest challenge of RISE is that they get recruited they start up with a bang and they will start up with 25 in a class and by the end of the quarter they down to 8 or 9 or 10. (Intervention implementers, Cape Town)
It seemed that AGYW had a misguided expectation that the intervention would provide them with what they felt was their most important needs, such as employment opportunities or money, but were later disillusioned when they found they would not receive them, and this led them to no longer be motivated to attend.
When I joined RISE, the moment you hear woman empowerment you thought like that… like maybe it does more maybe they will take us as woman, they will give us small jobs maybe we cut trees and then they pay us that small money. (AGYW 19-24yrs, North West)
The intervention implementers reiterated this saying that some of these young women have children to support and come from child headed household and need money to put food on the table and therefore desire quick fixes to their economic difficulties. Participants wanted to know how they would benefit from attending the clubs, specifically if they would be paid for attendance:
The hype is always high, everyone wants to be part of the club right… sometimes most of them they get disappointed that they are not giving them a daily job so they start falling off and going because the dynamic and the challenges they are faced with…Some they stay here because they can see the bigger picture, there’s just going to be a struggle it going to take long but at the end of the day there’s light at the end of the tunnel. These are the girls that are having children, they need to feed them these are the girls that are child headed families, they need to put bread on the table. So they want something that is quick quick that can give them money. (Intervention implementer, North West)
The provision of incentives and payment was a particularly important motivator for attendance that took place in the “out-of-school” clubs. Intervention facilitators found recruiting outside of the school more challenging than in schools.
In school they are bound by being within the school grounds and they can’t leave, while with the out-of-school if they don’t feel like attending, they won’t (Intervention facilitator, KZN)
Factors at the interpersonal level which AGYW felt facilitated participation and attendance included having good facilitators that the AGYW felt they could be open with:
When we joined RISE Club we did not open up completely because we were under the impression that she (the facilitator) is an adult and will not understand what we were going through and we limited ourselves. She told us to open up because while we were at RISE Club we are all the same and experiencing the same things including her so we must talk and learn to be confident in speaking. (AGYW 15-18yrs, Eastern Cape)
Intervention implementers and facilitators described interpersonal barriers to participation among AGYW who are in the older age group (19-24 years), as many had conflicting obligations, limiting their availability to dedicate time to attend intervention activities. Even those AGYW who they wanted to attend, often experienced challenges related to childcare and parenting responsibilities.
If you have got a big number of people with children and on the day that you decide to do you RISE Out-of-school Clubs they won't have a baby sitter but also they can't afford one…They are not gonna come, if they sacrifice 2 weeks or 3 weeks over a period of their time knowing that at the end they will have outcomes they do that… (Intervention implementer, Eastern Cape)
(She) will have an issue about the baby, or she should go and collect her sister, such excuses things like that... (Intervention facilitator, KwaZulu-Natal)
Also described were instanced of resistance from family members towards the AGYW participating in interventions.
You find that a child is interested but the parent won’t allow her to attend (Intervention facilitator, KwaZulu-Natal)
Additionally, some participants were prevented from attending due to resistance from boyfriends.
Some girls could not come to the training and when we ask around what happened you will get answers like the boyfriend did not want them to attend… (Intervention implementer, North West)
On the organisational level, it proved to be challenging for intervention implementers to target specific school-going AGYW of certain ages because ages and grades do not always correlate and learners are therefore not all the same age in each grade, making intervention activities hard to implement. Intervention implementers suggested it would be better to invite the whole grade regardless of their ages because all the girls in their community are at risk.
(Schools would say) “The mere fact that we are based in this community in this area all of our girls are at risk so we can’t hand pick individuals from classes, we going to give you the whole grade 9”. So, in none of our school did we have the hand-picked. Everybody gave us the whole class, the whole grade. (Intervention implementer, Western Cape)
Safety was also a concern in some schools and learners needed to be transported to and from school. The intervention implementers and facilitators were then unable to have classes after school hours and had to conduct them during interval (recess), but this became a problem because some would want to eat lunch and if the intervention did not feed them then that would discourage them from coming:
The biggest challenge was safety in our communities the kids are living in high risk communities so after they get transported in and out-of-school and if you after school programmes they miss their transports, so that’s why it shifted to interval but if you are then taking interval away and not giving them something to eat... (Intervention implementer, Cape Town)
Furthermore, there were challenges with communication reported by existing members, who said they were not informed about the meetings, and then subsequently reprimanded for their absence.
Some of us you don’t inform us, and then afterwards you say we don’t attend meetings, and then we get shocked. I just heard you now complaining that we don’t want to do it. You didn`t even tell me about it, or to show that there is a project. There was a certain meeting where you were just reprimanding me. That like, “you never show up for meetings. You only show up when (facilitator’s name) comes.” Whereas for some of us when there is a meeting, we don’t get told. (AGYW 15-18yrs, North West)
Communication about school-based intervention activities was often provided to learners at morning assembly, which means that those AGYW who arrived at school late were not aware of the activities being offered.
Most of the learners, they are clueless about what is happening here at school, because they are coming late at school, where most of the things are announce in assembly, and that affect(s) them. (AGYW 15-18yrs, Western Cape)
Suggestions made by AGYW to resolve communication challenges included providing intervention participants with a few days warning, and regular reminders.
On the community level, intervention facilitators expressed that recruitment for out-of-school AGYW was more challenging than recruiting AGYW in schools, some went door-to-door themselves and others appointed others to recruit for them.
In the community, I recruited children myself, I had to go door-to-door looking for these kids, if I happen to know that, a particular house has a child that has dropped out-of-school…that I know is within this age group. That is how I recruited out-of-school. (Intervention facilitators, KwaZulu-Natal)
Intervention implementers adapted their recruitment methods to be responsive to specific communities.
Suggestions for improving recruitment were also made by AGYW, such as holding events in the community to attract and promote the interventions which will give participants an opportunity to ask questions about the intervention.
We know that like young woman we love having fun, when you pass by and hear sound of music from the hall, obviously you will come because you want to see what’s happening and then when you enter you will maybe see the (organisation) flag, posters from (the organisation), and then you will seek more information about what (the organisation) is actually doing… (AGYW 19-24yrs, North West)
Maybe it can do, I don’t know an event or something…there’s a RISE event, this is what happens maybe at the hospital or clinic, they’ll come with their own gazebos and setup for testing…”there’s a RISE event over there, they’re even testing”, and so on, you see. (AGYW 19-24yrs, North West)
Intervention facilitators did however say that they had awareness campaigns in the communities to promote the interventions where a participant who completed the course would come and speak about the benefits of the intervention:
You find that we do awareness campaigns, a child who has been attending the programme that has just been finished, goes and speaks to other kids, and it shows that those kids have changed from what she was (Intervention facilitator, KwaZulu-Natal)