Enhancing sexual and reproductive health decision-making skills in underserved communities in Ghana: A quasi-experimental study

Adolescent sexual and reproductive health (SRH) decision-making is crucial for long-term well-being. It plays a significant role in public health efforts, including reducing sexually transmitted infections (STIs) and teenage pregnancies. While cultural and socio-political influences on adolescent sexual and reproductive health (SRH) decision-making are well-documented, less is known about the effect of SRH educational materials' difficulty levels on decision-making, particularly in Ghana and Sub-Saharan Africa. This study used a quasi-experimental design to assess the effectiveness of SRH educational materials of varying difficulty levels on decision-making skills using 317 adolescents, ages 11-15. Participants were assigned to a control group or one of the three intervention arms: difficult text, simplified text-only, or picture-enhanced text. Over six weeks, weekly sessions were conducted, followed by an end-line assessment with 249 participants and an 8-week post-intervention evaluation. Data analysis employed SPSS (version 26.0) and STATA (version 15.0), utilizing difference-in-difference and high-dimension fixed-effects models, paired sample t-test, and Kendall's coefficient of concordance. Results show participants (66%) were females and were 7th graders (56%). All three treatments, difficult text (10.808 points; CI = 1.2-20.36; P = 0.027), simplified text (11.60 points; CI = 4.68-18.52; P = 0.001), and picture-enhanced text (11.145 points; CI = 3.96-18.32; P = 0.002) significantly improved adolescents' decision-making scores. After controlling for time-invariant characteristics within groups, the difficult-text material's effect on decision-making scores declined (β3 = -6.442 points; CI = -13.908 to 1.096; P = 0.094) while that of the simplified and picture-enhanced materials was maintained. The study highlights the need for well-designed materials and effective pedagogy in SRH education to enhance learning and retention. Incorporating structured reading and discussion-based sessions into the school health program is recommended to promote the real-world application of SRH information and improve long-term SRH outcomes in adolescents.