Optimising the implementation of adolescent-friendly health services and its effects on contraceptive uptake and adolescent pregnancy in rural Mozambique: an implementation research study of the S-NICE intervention.

BACKGROUND

Despite national policies promoting adolescent- and youth-friendly health services, implementation gaps hinder improvements in adolescent sexual and reproductive health outcomes in Mozambique. S-NICE is a structured, participatory decision-support intervention designed to strengthen delivery through routine data use, multisectoral coordination, and local action planning. This study evaluates the implementation and effectiveness of S-NICE in rural Sofala Province.

METHODS

A mixed methods design integrating qualitative and quantitative approaches. The effectiveness component applied a quasi-experimental Difference-in-Difference analysis comparing eight intervention and eight comparison facilities over two six-month periods. The indicators of effectiveness were the increase in new users of modern contraceptive methods among girls aged 15-19 years and a drop in rates of adolescent pregnancy measured through attendance of first antenatal care appointment. The implementation component used a multiple case-study design guided by the Consolidated Framework for Implementation Research, drawing on 68 in-depth interviews and 21 focus group discussions (n = 188 participants) across health, education, community, and adolescent stakeholders to assess intervention's acceptability and appropriateness. Implementation fidelity was assessed through structured review of workshop reports.

RESULTS

Within intervention facilities, coverage of new modern contraceptive users increased from 5.45% to 10.12% (+4.67 percentage points; p = 0.029), while adolescent pregnancy declined from 13.76% to 11.64% (-2.12 percentage points; p = 0.022). However, the difference to comparison facilities did not reach statistical significance neither for contraceptive uptake (+5.21 percentage points; p = 0.121) nor adolescent pregnancy rates (-2.43 percentage points; p = 0.090). In terms of its implementation, S-NICE demonstrated moderate-to-high fidelity and strong acceptability and appropriateness across stakeholder groups. Qualitative findings indicated that participatory workshops, data-driven decision-making, and engagement of community leaders strengthened coordination and accountability, while infrastructure constraints, staff turnover, and sociocultural norms remained persistent barriers.

CONCLUSIONS

S-NICE was associated with favourable trends in adolescent sexual and reproductive health outcomes and demonstrated strong implementation performance in routine health system settings. Although causal effects could not be conclusively established in a quasi-experimental study, our findings suggest that structured, data-driven, multisectoral implementation strategies may strengthen adolescent- and youth-friendly health services delivery in low-resource contexts. Longer-term and larger-scale evaluations are warranted to evaluate impact and assess sustainability.