Sexual and reproductive health and rights (SRHR) is an essential and integral component of universal health coverage that countries around the globe need to consider for attainment of the sustainable development goals (SDGs). Limited access to sexual and reproductive health (SRH) among adolescents has been reported as a challenge in many countries worldwide.¹ Lack of or inadequate SRH knowledge among adolescents has severe consequences, including but not limited to increased teenage pregnancies, early marriage and poor decision-making.²

Worldwide, teenage pregnancy remains a major concern with variations in different countries, including sub-Saharan Africa (SSA) as the most affected.^3,4,5,6,7,8 The East African region accounts for 25% of the SSAs prevalence.⁹ In Rwanda, one of the East African countries, pregnancies among young girls between 10 years and 18 years continue to be reported, with the eastern province having the highest prevalence.¹⁰ Teenage pregnancy consequently leads to school dropouts, extreme poverty, complicated pregnancies and associated risks, malnutrition as well as mental health consequences.¹¹

A recent study conducted in Rwanda about adolescent reproductive health and sources of information revealed that sexuality as a topic is considered taboo in Rwandan culture.¹² However, another study that was conducted to explore enabling and preventive factors to access to the SRH among adolescents revealed that 5% of female and 11% of male adolescents became engaged in sexual activity before the age of 15 years.¹³ This high prevalence of teenage pregnancies and adolescents’ behaviour of engaging in sexual activities suggests a need to address the problem but also calls for implementing different interventions to provide and increase access to quality sex education.

Since 2016, Rwanda has been implementing a comprehensive SRH education in primary and secondary schools together with other different interventions such as teaching in and out schooling and mobile for reproductive health (m4RH) that delivered reliable SRH information to early adolescents.¹¹ However, from statistics, it appears that most of these interventions seem to be less effective with little or no significant outcomes.¹⁴ This might be argued that many of the adolescents seek information from their peers, who might also be equipped with little or incorrect knowledge about SRH.¹⁵ This, therefore, led to the development and implementation of a Sexual and Reproductive Health Peer Education Programme (SRH PEP) conducted in the selected district of Rwanda. The selection of the district was based on the current country’s highest prevalence of teenage pregnancies in Eastern Province.¹⁶ The SRH PEP was implemented to equip adolescents with knowledge and the right attitudes about SRH in schools but also to contribute to addressing the problem. The outcomes of implementing the SRH PEP were also evaluated.

This study utilised both pre-intervention and post-intervention designs. A baseline (pre-test) survey was conducted on SRH knowledge and attitudes among adolescents before the implementation of the intervention. A post-test survey was conducted after 26 months of the implementation of the intervention.

The SRH PEP Manual was developed in 2019 in collaboration with the University of Rwanda (UR) and University College Leuven-Limberg (UCLL) staff.¹⁶ The development of the Manual undertook several steps to the final implementable Manual. The literature review process was conducted to understand the available evidence around the implementation of the SRH PEP. A local needs assessment was then conducted to ensure that the intervention was tailored to the local and adolescents’ needs. A networking event was also organised with different stakeholders, including schools’ leadership, teachers, community leaders, religious people and healthcare providers among others. The purpose of this event was to gain a comprehensive understanding of existing SRH programmes in the district or schools, the challenges faced during their implementation in the schools and the communities. The networking event was also used as an opportunity to connect with the stakeholders for programme sustainability. Baseline surveys were then conducted using mixed methods. The quantitative approach was used to examine adolescents’ knowledge and their attitudes regarding SRH, while the qualitative approach was conducted through six focus group discussions (FGDs) to obtain a deeper understanding of adolescents’ SRH needs. These were analysed and used to inform the development of the SRH PEP Manual. Lastly, the team from UR visited UCLL to discuss SRH issues and outreach programmes in Rwanda.

During the implementation of the SRH PEP, the empowerment model developed by the research team guided the process.¹⁶ With the use of the SRH PEP Manual, a 6-day workshop was conducted to train selected students to become peer educators (PEs). The goal of the workshop was to equip PEs with enough SRH knowledge and improve their personal development and group communication skills. During the workshop, evidence-based experimental learning and interactive methodologies were used. These strategies were also used to help PEs discover new information about themselves. To ensure that PEs were actively involved and retained information, active learning strategies such as role plays, simulations and educational games were utilised.¹⁷

We conducted two different trainings (training module A for UR midwifery students as facilitators and train-the-trainer module B for PEs).¹⁸ Six of the trained facilitators (midwifery students) and three staff members of UR midwifery trained the selected students at three secondary schools. In each school, we selected 12 students as PEs (six males and six females). In addition, we trained their teachers who, at the time, showed interest in learning more about SRH issues and also in implementing the SRH Module. This was not previously planned but, in the end, added value to the project for sustainability. These teachers then took up the mentorship role of the students during the project implementation. After we completed the training, we then embarked on creating a WhatsApp group among the project team, trained teachers and schools’ authorities to ensure constant communication. The project team contacted the trained peers by phone through their teachers and authorities at least twice a month to monitor any challenges and propose immediate solutions. Focus group discussions were conducted with PEs to explore their experiences as evidence that PEs improved the programme.¹⁸ After 26 months of implementing the SRH PEP, we again assessed their knowledge and attitudes.

The SRH PEP was implemented in three secondary-level high schools. However, due to unforeseen challenges faced by one school in the implementation of the project – with mentors’ relocation to other schools and repatriation of PEs to Burundi from the refugee camp,¹⁹ the post-intervention was only conducted in two schools. Therefore, 536 students aged between 13 years and 24 years from secondary school levels 2, 3, 5 and 6 participated in both the pre-survey and the post-survey. Students from secondary levels 1 and 4 were excluded because they were new to the schools and programme from primary level and other schools, respectively. The findings from the pre-test evaluations from the third school were not considered in this manuscript. After excluding the incomplete data from the total 536 students who had participated in the baseline, 508 students enrolled in the programme were included in the analysis.

A self-administered questionnaire, the World Health Organisation’s (WHO) ‘Illustrated Questionnaire for Interview Surveys with Young People’ was adapted and utilised as a data collection tool for this study.²⁰ The questionnaire consisted of 23 questions/statements on knowledge with different subscales such as four items for sexual health, eleven items on contraceptive methods and eight items on human immunodeficiency virus (HIV) and/or acquired immunodeficiency syndrome (AIDS) and sexually transmitted diseases (STDs). A score of one (1) was allocated to the correct response, whereas a score of zero (0) was given to the incorrect response. Similarly, there were 13 items for the attitudes, and a Score 1 was assigned for the positive attitude, whereas a Score 0 for the negative attitude. Higher total scores implied better knowledge and attitudes. Six students from each school were recruited for the pilot of the instrument. The findings from the pilot study yielded Cronbach’s alpha of 0.85. The students also provided their feedback to make the tool easier to complete. During the pilot study, the students were not included in the study. The final corrected tool was developed from the feedback obtained from the assessed students. Before the implementation of the project, the questionnaire was administered to all (N = 536) students.

Data were analysed using the Statistical Package for the Social Sciences (SPSS) version 25 (SPSS Inc., Chicago, IL, United States). Descriptive statistics were conducted, with frequencies and percentages used for categorical variables, and means with standard deviations calculated for continuous variables. McNemar test was used to compare categorical knowledge and attitude variables between pre-test and post-test intervention. The score changes of knowledge and attitudes as continuous variables between pre-test and post-test interventions were evaluated using paired t-test. A p-value of less than 0.05 was considered as statistically significant.

Ethical clearance to conduct this study was obtained from the University of Rwanda College of Medicine and Health Sciences Institutional Review Board (No. 158/CMHS IRB/2019). Participants aged less than 18 years old signed assent forms, and their legal guardians signed the informed consents, while those aged 18 years and more signed the informed consents.

Slightly more than half (53.7%) of the respondents were in the age range of 16 years to 18 years, with significantly more females in this age group (p = 0.001). There was nearly an equal distribution of participants for all the classes involved. Large proportion (49.0%) of students were from Protestants’ religious affiliation. About 9% were taking alcohol with more among males (p < 0.001), while smoking was only 0.4%. Approximately half of the participants (48.9%) had never engaged in conversations with their fathers about sexual matters, compared with 30.5% who had not discussed such topics with their mothers. Among the respondents, 13.8% reported having had sexual intercourse and, of these, the majority (70.6%) indicated that they had used contraceptives (Table 1).

Table 2 demonstrates the responses of adolescents to knowledge questions provided pre-education and post-education interventions. The knowledge was divided into three subscales: sexual health, contraceptive methods and HIV and/or AIDS and STDs. The knowledge had significantly improved (p < 0.01) for all statements except for two questions under the subscale of HIV and/or AIDS and STDs, which were cure of HIV and/or AIDS and availability of simple test for HIV (Table 2).

Table 3 provides the responses of adolescents to the attitudes on contraceptive methods during the pre-education and post-education interventions. The respondents demonstrated significant increase in the positive attitudes to all the statements after implementing the SRH PEP (p < 0.001).

Table 4 indicates that the mean overall knowledge scores among adolescent students had significantly increased from 15.87 before the intervention to 19.59 after the intervention (p < 0.001). Similarly, the mean knowledge score for each subscale had improved significantly after the SRH PEP (p < 0.001). A similar result was also observed for the mean attitude scores, where it significantly improved from 7.95 in the pre-intervention to 10.66 in the post-intervention (p < 0.001).

The attitude score on contraceptive was significantly higher among male students than female students (p = 0.005) before intervention; however, this difference was not significant after the intervention (p = 0.986). Students from Seniors 5 and 6 had significantly (p < 0.001) higher knowledge scores compared to those in Seniors 3 and 4 in both the pre-intervention and the post-intervention. After the intervention, the overall knowledge score was significantly higher among adolescents aged from 22 years to 24 years (p = 0.022), but there were no significant differences before the intervention (Table 5).