1 Introduction

Adolescent girls and young women in sub-Saharan Africa experience disproportionate rates of morbidity and mortality, in large part driven by HIV [1–4]. Age-disparate transactional sex is a major contributor to this high HIV prevalence [5, 6], as it has been found to co-occur with risky sexual behaviours such as unprotected sex and mixing sex and alcohol [7]. Age-disparate transactional sex is defined as occurring when an adolescent girl and man at least 5–10 years older have sex with the implicit understanding that material support or other benefit will be given in return [8]. These relationships are also associated with other harmful sexual and reproductive health outcomes including sexual violence, unplanned and early pregnancy and unsafe abortion [7]. Adolescent pregnancy, in turn, has been associated with higher rates of maternal and perinatal mortality, in addition to other negative outcomes for babies and young mothers [9].

The link between age-disparate transactional sex and educational attainment, defined as “the highest level of education completed by a person” [10], although established in the literature has received less attention. We know that for adolescent girls in sub-Saharan Africa there is a complex and important relationship between educational attainment, money and HIV, and that age-disparate transactional sex relationships seem to play a key role in consolidating these relationships [11–13], but the nuances of these associations are less clear. Remaining in school for instance, has been found to be a key protective factor for HIV [14–17], with in-school girls less likely to engage in sex, including age-disparate sex, than their out-of-school peers [18]. Education, however, is not in itself a ‘silver bullet’ for girls’ sexual and reproductive health outcomes. A recent systematic review and meta-analysis examining the effects of education interventions on sexual and reproductive health in low- and middle-income countries found inconclusive results, and the authors highlighted the need to better understand in which circumstances and contexts schooling is beneficial [19]. For instance, there is evidence from a four-country study in sub-Saharan Africa that some adolescent girls may engage in age-disparate transactional sex to pay for school fees, school materials, and transport to school, and once they have engaged in premarital sex, they are at a higher risk of leaving school due to pregnancy or early/forced marriage [18]. In Tanzania, there is also evidence that inequitable gender norms are reproduced within schools, such as between students and teachers, and reports indicate that many in-school adolescent girls face sexual harassment and abuse from male peers and teachers [20, 21].

Widespread investment in girls’ education following the introduction of the Millennium Development Goals and the Sustainable Development Goals, for example through the introduction of fee-free primary school across sub-Saharan Africa, has improved adolescent girls’ access to primary education. Gender inequitable norms, however, have played a large role in upholding persisting attainment disparities between adolescent girls and boys in secondary and tertiary education [16, 18, 22]. Educational attainment for Tanzanian adolescent girls is particularly low; they have one of the lowest transition rates from primary to secondary school in sub-Saharan Africa [23], and of those adolescent girls who do enrol in secondary education, only 27% complete it [24].

In 2017 a controversial and highly contested new education policy in Tanzania led to the introduction of mandatory pregnancy testing and expulsion of pregnant girls [25]. This policy was challenged in 2021 when six girls who were expelled from school because they were pregnant filed a lawsuit against the Tanzanian Government, leading the Ministry of Education to ban pregnancy tests in schools, and require schools to allow pregnant and married adolescent girls and young women to continue with their education [26]. The enforcement and implementation of these new policies on schools, and their long-term impact have yet to be seen; including on the educational attainment of adolescent girls, as well as their HIV status and overall sexual and reproductive health. However, they show a step in the right direction to alleviate the gendered educational gap in Tanzania.

Amid the current state of flux in national gendered educational policies, there exists a critical need for research that evaluates interventions designed to address and rectify inequitable gender norms within the realm of education [27, 28]. A recent literature review identified fourteen interventions in sub-Saharan Africa (ranging from material support to community-based interventions) that demonstrated promise in increasing adolescent girl’s educational attainment [29]. The primary aim of most of these interventions was HIV prevention, and educational outcomes were secondary. Findings suggested that material support interventions were most successful, while less is known about interventions aimed at changing attitudes and behaviours [29]. Importantly, none of the interventions included in the review aimed to change gender norms, and none were conducted in Tanzania [29]. While some promising interventions are currently being evaluated in the country, most notably the USAID funded Waache Wasome or “Let them Learn” project [30], a gap persists in gender norms interventions promoting adolescent girl’s educational attainment.

The current study evaluates the Learning Initiative on Norms, Exploitation and Abuse (LINEA) radio drama intervention, which is the first, to our knowledge, with the primary goal of preventing age-disparate transactional sex. Formative research informing intervention development suggested that risk of engaging in age-disparate transactional sex relationships related to girls’ motivations and beliefs about education. Wamoyi and colleagues found that age-disparate transactional sex caused interesting tensions between Tanzanian adolescent girl’s short-term and long-term aspirations [27], whereby adolescent girls’ participation in age-disparate transactional sex tended to reflect their short-term aspirations, which included dressing well and appearing attractive to men and their peers [27, 28, 31]. This was in direct contradiction with their long-term educational goals, which were linked to wealth, respect, freedom and independence, and were conversely put at risk by the sexual and reproductive health consequences of engaging in age-disparate transactional sex at an early age, in particular due to unplanned pregnancy [27].

In developing the LINEA intervention, we chose to use an entertainment-education or ‘edutainment’ approach, mixing important health messages with entertaining content in the form of a radio drama. We utilised this approach as it has proven successful in promoting a wide range of health behaviours across large and varied audiences [32], including sexual and reproductive health in the United States [33] and gender-based violence in rural Senegal [34]. The edutainment approach is evidence-based and grounded in social science theory, in particular Albert Bandura’s social cognitive theory, which suggests that audience members are more likely to engage in new behaviours, or modify existing behaviours in line with those performed by characters if they like the characters or identify with them [35]. Edutainment is considered to be successful because it role models positive behaviours and the beneficial consequences that result from them, rather than lecturing against negative behaviours, as is common in more traditional, didactic programming [32].

In this paper we explore the potential of the LINEA radio drama intervention to help adolescent girls refocus on and prioritise their long-term aspirations of building a better future. This reinforces the more direct intervention messaging about age-disparate transactional sex, as reported in our companion paper [36], by highlighting that any benefits from age-disparate transactional sex are short-term, and that age-disparate transactional sex can lead to multiple long- and short-term harms to girls’ education and aspirations, in addition to health-related problems. Findings are from an exploratory, mixed-methods evaluation of a condensed, radio drama-only version of the full LINEA intervention (comprised of curriculum and radio drama components). Data was collected in Shinyanga region, Tanzania from September-December 2021, and found encouraging shifts in knowledge, behaviours, and attitudes, beliefs and social norms linked directly to age-disparate transactional sex [36]. In the current paper we report additional results from the qualitative data on indications of desirable change that while not linked directly to age-disparate transactional sex, were still in line with the goal of promoting adolescent girl’s sexual and reproductive health: 1) adolescent girl’s focus on long-term educational goals, and 2) shifts towards more gender equitable attitudes about work. A forthcoming process evaluation paper is also planned, which will include evidence of unintended consequences from the radio drama.

This study was a collaboration between the Tanganyika Christian Refugee Service (TCRS) and Amani Girls Organization (AGO) in Tanzania, and the London School of Hygiene & Tropical Medicine (LSHTM) in the UK. The ultimate aim of this study was to inform a cluster randomised controlled trial (cRCT) of the LINEA intervention planned for 2023–2026 in Mwanza, Tanzania.

2 Methods

3 Results

We begin this section by describing the study participants. We then present evidence of additional results [to complement our primary findings [36]] from the evaluation of the LINEA radio drama that related to underlying attitudes, beliefs and social norms that helped create an enabling environment for preventing age-disparate transactional sex: 1) adolescent girls focusing on long-term educational goals, and 2) increased gender equitable attitudes about work among adolescent girls and women and men caregivers. While the first theme was specific to adolescent girls, the second theme arose among adolescent girls, women caregivers and men caregivers, however, we did not find evidence of any notable differences between them. Thus, findings from all three groups are reported together.

3.1 Study participants

Of the 81 participants recruited, 59 (73%) partook in endline IDIs. Drop-out rates were highest among adult participants, the most common reasons being busy schedules and work-related travel. We analysed 104 transcripts collected at midline and endline from these 59 participants. Endline transcripts were available from 23 adolescent girls, 18 women and 18 men, and midline transcripts were available from a sub-sample of these participants: 16 adolescent girls, 16 women and 13 men (Table 1). The majority of adolescent girl participants were 15 years old (n = 10), while women’s ages ranged from 31-years to 77-years, and men’s ages ranged from 25-years to 76-years.

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Table 1. Number of transcripts analysed for this study from midline and endline in-depth interviews (IDIs) with 81 adolescent girls, women caregivers and men caregivers.

https://doi.org/10.1371/journal.pgph.0002527.t001

4 Discussion

The findings of this study highlight the potential of the LINEA radio drama to promote educational aspirations and gender equitable attitudes about work among adolescents and their caregivers in Tanzania. Given the low rates of secondary school completion among Tanzanian adolescent girls [21, 22] and the high prevalence of gender inequitable norms and sexual violence in the study region [47], these outcomes are particularly pertinent. Past literature has demonstrated that educational attainment is a protective factor for age-disparate transactional sex [18], and evidence from this study suggests that the LINEA radio drama has the potential to not only prevent age-disparate transactional sex directly [36], but to also impact important, related contextual factors that drive it: 1) adolescent girls’ focus on long-term educational goals and 2) adolescent girls and caregivers increased gender-equitable attitudes about work. Thus, by preventing age-disparate transactional sex, which is a key driver of HIV and unintended pregnancy, the LINEA radio drama holds promise in contributing to decreasing the morbidity and mortality of adolescent girls in Tanzania [5, 7].

Despite education already being highly encouraged in the intervention community, we found that the radio drama gave adolescent girls the motivation to persevere, especially when they experienced setbacks. Previous research suggests that when adolescent girls and young women focus on long-term aspirations, such as educational attainment, it can influence them to make safer sexual decisions [27]. Thus, interventions such as the LINEA radio drama can leverage these aspirations to deter engagement in age-disparate transactional sex, and guide them towards making sexual decisions that align with their evolving capacities [54]. Although pregnant students are now legally able to remain in school in Tanzania [26], delaying first sexual experiences is still essential, as the responsibilities of caring for a child can be a significant barrier for pregnant adolescent girls and adolescent mothers to continue their education [50]. Stigma and discrimination at the institutional and individual levels in schools also present significant barriers for adolescent girls who wish to continue with their education despite being pregnant or having a child [55, 56]. Moreover, delayed first sex is expected to contribute to decreased HIV, as older adolescents are more likely to negotiate condom use due to more equitable power dynamics vis a vis their sexual partners, and better knowledge about HIV [57]. Therefore, findings from this exploratory study suggest that the LINEA radio drama could also contribute towards a set of initiatives to prevent HIV infections among this particularly affected group.

Our study also revealed evidence of more gender-equitable attitudes about work among adolescent girls, and women and men caregivers, creating an enabling environment for changes in gender norms linked to education and employment. The radio drama helped participants accept women working in traditionally male-dominated professions, and motivated women to start small businesses to support their daughters, indicating a departure from traditional male provider norms, and the expectation that adolescent girls provide for themselves once they reach a certain age or leave school. These findings suggest that marketing strategies that encourage women to enrol in traditionally male-dominated vocational trainings could be effective in increasing women’s participation in these sectors, thereby contributing to the shift towards more equitable gender norms. Gender equitable norms have been associated with increased empowerment and improved health outcomes for both women and men [58]. Furthermore, evidence from a cash transfer programme evaluation in Tanzania suggests that improved economic circumstances lead to decreased engagement in transactional sex for survival [59]. However, the effectiveness of cash-transfers in preventing such relationships in the general population remains inconclusive [e.g. 60], suggesting that the LINEA radio drama could be an important complement to interventions that addresses structural factors such as poverty in driving age-disparate transactional sex. Findings from this study also highlight the potential of the LINEA radio drama to have broader impacts beyond preventing age-disparate transactional sex, by challenging attitudes that promote sexual and gender-based violence more generally and fostering more gender-equitable communities.

While this exploratory evaluation suggests that the LINEA radio drama shows promise, more rigorous evaluation is needed to determine causal impact, as well as whether our findings from IDIs with members of the poorest households and who have a family member living with a disability in Shinyanga region, North-western Tanzania are transferable to other populations and regions across Tanzania. The results from this study suggest that the cRCT evaluating LINEA planned from 2023–2026 in Mwanza region should also incorporate educational aspirations and gender equitable attitudes about work as secondary outcomes, and should elucidate if changes reported in motivation and attitudes in this study are consistent with changes in social norms and reported behaviours, as evidence suggest the latter are harder to change [42, 43].

5 Conclusions

This study makes a unique contribution to the literature by providing evidence on the impacts of an edutainment age-disparate transactional sex intervention on educational aspirations, and gender-equitable attitudes about work in Tanzania. This evidence provides insight into how future sexual and reproductive health interventions can be optimized to target these important outcomes, which are closely related to HIV, morbidity and mortality for adolescent girls in sub-Saharan Africa [9, 14, 15, 18]. This study also highlights the potential wide-reaching impacts of the LINEA radio drama to prevent age-disparate transactional sex in particular. If proven effective in the forthcoming cRCT, the LINEA radio drama has the potential to be easily and cost-effectively scaled up to increase adolescent girl’s motivation to pursue their education and create more gender-equitable communities across Tanzania.

Acknowledgments

We would like to thank the adolescent girls and their caregivers for their support and participation in this study. We are also grateful to the fieldwork teams from TCRS and AGO who implemented the intervention and conducted the interviews.