Lessons learned implementing SKILLZ Girl in a cluster randomized controlled trial in South Africa

Brief Summary

Background

Adolescent girls in South Africa face disproportionately high rates of HIV, sexually transmitted infections, and unintended pregnancy. School-based health programs are a promising strategy, but delivering them consistently at scale is challenging.

What Grassroot Soccer did

Grassroot Soccer implemented SKILLZ Girl, which is a sport-based program with weekly sessions on HIV prevention, healthy relationships, gender, and sexual and reproductive health, across peri-urban secondary schools in Cape Town with nearly 2,800 girls ages 13–17.

What the study found

Girls who attended rated the program highly, valuing the safe, girls-only space. However, overall attendance was low, with in-school delivery outperforming after-school delivery.

Why this matters

High acceptability alone isn't enough. Structural barriers like safety concerns and competing responsibilities must be addressed for school-based programs to reach girls consistently.

DETAILED SUMMARY

Importance

Adolescent girls in South Africa face a disproportionately high burden of HIV, STIs, and unintended pregnancies. School-based comprehensive sexuality education (CSE) is an important strategy to improve sexual and reproductive health, but few studies examine barriers to implementing after-school programs at scale.

Objective

To identify lessons learned while implementing a cluster-randomized controlled trial of SKILLZ Girl in South Africa with a focus on attendance, acceptability, and feasibility.

Study details

Study design: Cluster-randomized controlled trial (mixed methods data)
Data collection: Attendance registers; WhatsApp reminders; program monitoring/fidelity checks
Participants: Female learners, school grades 8–10 (approx. 13–17 years)
Implementation setting: 2800 participants from secondary schools in a single health sub-district of Cape Town, South Africa (peri-urban)
Study period: Two cohorts delivered across 2018–2019; each delivery period lasted approximately 6 months

Intervention

SKILLZ Girl: 10 weekly 45–60-minute sessions over two school terms. Sessions focused on HIV and STI prevention, gender and power, healthy relationships, self-esteem, and sexual and reproductive health.

Results

Sample: 2,791 adolescent girls enrolled; 1,344 in intervention schools and 1,447 in control schools
Attendance: Low attendance across cohorts; 41.1% attended zero sessions. Cohort 1 mean attendance: 44.2%; graduation rate: 27.8%. Cohort 2 mean attendance: 47.2%; graduation rate for in-school delivery 50.2% vs. 18.7% after school (p < 0.05).
Acceptability: 78% rated their interest in the sessions as 8–10/10; participants valued girls-only spaces and the near-peer Coach model;
- “We felt safe to talk about these things with our Coach.” (adolescent participant)
Feasibility (Implementation Barriers):
- Security concerns due to community violence
- Competing responsibilities (homework, caregiving)
- Minimal culture of after-school programming
- Early health screenings reduced incentive to attend sessions

Conclusions and implications

Results demonstrate that high acceptability alone is insufficient to overcome structural, safety, and scheduling barriers to after-school programs in low-resource settings.
Program success improved when sessions were delivered in-school, but this risks burdening school schedules.

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Citation

DOI

Year: 2023

Authors: Pike C, Coakley C, Lee D, Daniels D, Ahmed N, Hartmann M, Padian N, Bekker LG

Pike C, Coakley C, Lee D, Daniels D, Ahmed N, Hartmann M, Padian N, Bekker LG. Lessons Learned From the Implementation of a School-Based Sexual Health Education Program for Adolescent Girls in Cape Town, South Africa. Glob Health Sci Pract. 2023;11(6):e2300026. doi: 10.9745/GHSP-D-23-00026.