title: Reaching the hard to reach: longitudinal investigation of adolescents' attendance at an after-school sexual and reproductive health programme in Western Cape, South Africa.
abstract: BACKGROUND
  Adolescents need access to effective sexual and reproductive health (SRH) interventions, but face barriers accessing them through traditional health systems. School-based approaches might provide accessible, complementary strategies. We investigated whether a 21-session after-school SRH education programme and school health service attracted adolescents most at risk for adverse SRH outcomes and explored motivators for and barriers to attendance.
  
  
  METHODS
  Grade 8 adolescents (average age 13 years) from 20 schools in the intervention arm of an HIV prevention cluster randomised controlled trial in the Western Cape Province of South Africa, were invited to participate in an after-school SRH program and to attend school health services. Using a longitudinal design, we surveyed participants at baseline, measured their attendance at weekly after-school sessions for 6 months and surveyed them post-intervention. We examined factors associated with attendance using bivariate and multiple logistic and Poisson regression analyses, and through thematic analysis of qualitative data.
  
  
  RESULTS
  The intervention was fully implemented in 18 schools with 1576 trial participants. The mean attendance of the 21-session SRH programme was 8.8 sessions (S.D. 7.5) among girls and 6.9 (S.D. 7.2) among boys. School health services were visited by 17.3 % (14.9 % of boys and 18.7 % of girls). Adolescents who had their sexual debut before baseline had a lower rate of session attendance compared with those who had not (6.3 vs 8.5, p < .001). Those who had been victims of sexual violence or intimate partner violence (IPV), and who had perpetrated IPV also had lower rates of attendance. Participants were motivated by a wish to receive new knowledge, life coaching and positive attitudes towards the intervention. The unavailability of safe transport and domestic responsibilities were the most common barriers to attendance. Only two participants cited negative attitudes about the intervention as the reason they did not attend.
  
  
  CONCLUSIONS
  Reducing structural barriers to attendance, after-school interventions are likely to reach adolescents with proven-effective SRH interventions. However, special attention is required to reach vulnerable adolescents, through offering different delivery modalities, improving the school climate, and providing support for adolescents with mental health problems and neurodevelopmental academic problems.
  
  
  BACKGROUND
  Current Controlled Trials ISRCTN56270821 ; Registered 13 February 2013.
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, PO Box 19070, Tygerberg, Cape Town, 7505, South Africa. cathy.mathews@mrc.ac.za.|Adolescent Health Research Unit, Division of Child & Adolescent Psychiatry, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa. cathy.mathews@mrc.ac.za.
authors.forename: Catherine
authors.initials: C
authors.lastname: Mathews
authors.affiliation: Department of Health Promotion, Caphri Research Institute, Maastricht University, POB 616 6200 MD, Maastricht, The Netherlands. m.eggers@maastrichtuniversity.nl.
authors.forename: Sander Matthijs
authors.initials: SM
authors.lastname: Eggers
authors.affiliation: Adolescent Health Research Unit, Division of Child & Adolescent Psychiatry, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa. petrus.devries@uct.ac.za.|Division of Child & Adolescent Psychiatry, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa. petrus.devries@uct.ac.za.
authors.forename: Petrus J
authors.initials: PJ
authors.lastname: de Vries
authors.affiliation: Adolescent Health Research Unit, Division of Child & Adolescent Psychiatry, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa. amanda.mason-jones@york.ac.uk.|Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, York, YO10 5DD, UK. amanda.mason-jones@york.ac.uk.
authors.forename: Amanda J
authors.initials: AJ
authors.lastname: Mason-Jones
authors.affiliation: Health Systems Research Unit, South African Medical Research Council, PO Box 19070, Tygerberg, Cape Town, 7505, South Africa. lorainejoytownsend@gmail.com.|Adolescent Health Research Unit, Division of Child & Adolescent Psychiatry, University of Cape Town, 46 Sawkins Road, Rondebosch, Cape Town, 7700, South Africa. lorainejoytownsend@gmail.com.
authors.forename: Loraine
authors.initials: L
authors.lastname: Townsend
authors.affiliation: Department of Health Promotion and Development, University of Bergen, Bergen, Norway. LeifEdvard.Aaro@fhi.no.|Division of Mental Health, Norwegian Institute of Public Health Division of Mental Health, P.O Box 4404, Nydalen, Oslo, NOR-0403, Norway. LeifEdvard.Aaro@fhi.no.
authors.forename: Leif Edvard
authors.initials: LE
authors.lastname: Aarø
authors.affiliation: Department of Health Promotion, Caphri Research Institute, Maastricht University, POB 616 6200 MD, Maastricht, The Netherlands. hein.devries@maastrichtuniversity.nl.
authors.forename: Hein
authors.initials: H
authors.lastname: De Vries
mesh_terms: D000293:Adolescent; D005260:Female; D006293:Health Promotion / Q000458:organization & administration*; D006301:Health Services Needs and Demand; D006801:Humans; D008297:Male; D008507:Medically Underserved Area; D009042:Motivation; D034121:Reproductive Health Services / Q000458:organization & administration*; D012572:School Health Services / Q000458:organization & administration*; D012736:Sex Education / Q000458:organization & administration*; D012742:Sex Offenses; D013019:South Africa