Building on tradition: using the ADAPT-ITT model to develop a sexual health intervention from initiation rites of passage for rural young women in Southern Malawi.

Introduction: Young rural women are disproportionately affected by negative sexual and reproductive health (SRH) outcomes. However, few sexual health interventions for rural girls document the systematic process of leveraging the cultural tradition and integrating participant input in the development of SRH interventions. Aligning health interventions with familiar cultural practices increases both cultural congruency and relevance. This study aimed to adapt the Yao traditional initiation ceremonies for girls who have attained puberty ( Methods: This study employed an Ethnographic Participatory Action Research design, guided by the ADAPT-ITT [Assessment, Decision, Administration, Production, Topical Experts, Integration, Training, and Testing] model. This framework facilitated an iterative process of inquiry and intervention development. We conducted semi-structured in-depth interviews with purposively sampled women from three generations (young women aged 16-24 years, mothers, and grandmothers), traditional and religious SRH counselors, and participant observations of the traditional initiation rites ceremonies ( Results: Findings revealed important community assets including rich indigenous knowledge and a well-structured system for socializing girls and young women on sexuality and expected behaviors across different life stages, deeply rooted in the rituals and traditions of the Yao culture. Older women demonstrated remarkable depth of knowledge, creativity, and commitment in supporting the SRH of young women. At the same time, the study identified critical needs, including misinformation about SRH and women's reproductive physiology that promoted sexual activity during peak fertility periods. These identified assets and needs were collectively leveraged to co-create a culturally grounded SRH intervention for girls who reached menarche which the participants named: Partnership in Action: Health Improvement Intervention (PAHII). After one year of implementation, a descriptive evaluation of PAHII showed a 51.9% reduction in pregnancies and an 82.8% increase in the number of young women using family planning methods. Discussion: Findings support the importance of adapting culturally accepted traditional education, upholding healthy cultural practices, and leveraging deeply rooted values in research and interventions development and implementation. Further research is needed to examine the effectiveness of this sexual health intervention tailored for rural young women on a larger scale.