Adaptation and Evaluation of a Multi-Component School-Based Sexual Reproductive Health Intervention Safer Choices Programme in Rural KwaZulu-Natal, South Africa - A Process Evaluation.

introductionWe co-adapted and evaluated a multi-component whole-school health-promotion Safer Choices programme to improve sexual and reproductive health (SRH) and uptake of HIV-prevention among learners in rural uMkhanyakude district, KwaZulu-Natal, South Africa.

methodsFrom January 2023 to June 2025, we used the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) to guide and document Safer Choices adaptations. We used participatory qualitative approaches and a process evaluation to assess intervention acceptability and feasibility. Co-adapting involved a 3-day workshop with 16 learners aged 15-19 (Grade 9-10), four discussions with school leadership and two focus group discussions (FGDs) with parents/guardians, to understand the context and social validity of the programme. Intervention acceptability was assessed through five in-depth interviews with teachers/school leadership and three with peer leaders, two workshops with intervention and clinical delivery teams, two FGDs with community members and five with learners. Interactions were audio-recorded, transcribed and analysed using thematic analysis.

resultsSchools were described as learning spaces providing opportunities for health promotion through health and well-being lessons. Teachers and parents/guardians noted a need for Safer Choices to provide SRH/HIV services in schools, as most learners were already sexually active. Provision of mobile SRH/HIV services in schools was perceived to be feasible if negotiated with the school and HIV-status neutral services were provided to minimize stigma. Adaptations to Safer Choices were focused on optimizing intervention delivery or emphasizing social validity of the programme. During implementation of Safer Choices, myths and misconceptions around HIV and pregnancy were addressed. Challenges such as no electricity and large classes made it difficult to deliver Safer Choices. Peer navigators (lay youth-workers) were engaged to help deliver the intervention.

conclusionsIn a context of high sexual risk and vulnerability, it was feasible to co-adapt and deliver the Safer Choices programme, which provided accurate and accessible SRH information and services to address adolescent SRH needs of learners in our rural schools. Adaptation challenges included balancing fidelity to intervention with both the "real-world" context and the practicality of peer navigators supporting intervention delivery. These results suggest that optimizing the impact necessitates appropriately resourcing school-based interventions to address the challenges of programming in rural settings.