Pregnancy and STI/HIV prevention intervention preferences of South African adolescent girls: findings from a cultural consensus modelling qualitative study

Abstract South African adolescent girls experience high rates of unintended pregnancy and sexually transmitted infections including HIV. To inform culturally-tailored dual protection interventions to prevent both unintended pregnancy and STIs/HIV, this study qualitatively examined girls’ sexual health intervention preferences. Participants were aged 14–17 years old and Sesotho-speaking (N = 25). To elucidate shared cultural beliefs, individual interviews examined participants’ perceptions about other adolescent girls’ pregnancy and STI/HIV prevention intervention preferences. Interviews were conducted in Sesotho and translated into English. Two independent coders identified key themes in the data using a conventional content analysis approach with discrepancies resolved by a third coder. Participants indicated that intervention content should include efficacious pregnancy and STI/HIV prevention methods and ways to navigate peer pressure. Interventions should be accessible, avoid criticism and provide high-quality information. Preferred intervention formats included online, SMS/text, or delivery by social workers or older, knowledgeable peers, with mixed acceptability for delivery by parents or same-age peers. Schools, youth centres and sexual health clinics were preferred intervention settings. Results highlight the importance of cultural context in tailoring dual protection interventions to address the reproductive health disparities among adolescent girls in South Africa.


Introduction
South African adolescent girls experience an elevated prevalence of both unintended pregnancy and sexually transmitted infections (STIs) including human immunodeficiency virus (HIV), with significant health disparities experienced by Black girls (Dellar, Dlamini, and Karim 2015;McHunu et al. 2012;Simbayi, Shisana, and Rehle 2014).In South Africa, HIV rates increase rapidly throughout adolescence and young adulthood.For example, in a nationally representative sample, there was an HIV prevalence rate of 5.2% among individuals aged 14-19 years and 10.2% among individuals aged 20-24 years (Simbaya et al., 2019).National data also point to high rates of sexual activity among 15-19 year-old individuals (83%), with approximately one-third using modern contraceptive methods (Chersich et al. 2017).Unintended teenage pregnancy and/or HIV carry numerous adverse health and socio-economic consequences including an elevated risk of maternal and infant mortality, decreased educational attainment, exacerbation of poverty, and perpetuation of gendered power imbalances (Breheny and Stephens 2009;Panday et al. 2009).To reduce unintended pregnancies and STI/HIV transmission and empower reproductive health decision-making, interventions that consider relevant cultural factors are urgently needed for this population.
Reproductive health counselling to promote dual protection (DP; the use of one or more methods to prevent both pregnancy and STI/HIV) is included in the Republic of South Africa's National Adolescent and Youth Policy (2017).However, rates of reported DP use among South African women, and adolescents in particular, are low (Osuafor and Maputle 2017;Toska et al. 2020;MacPhail et al. 2007).National data show that injectable contraception (e.g.depot-medroxyprogesterone) is the most commonly used contraceptive method among South African women (Chersich et al. 2017;Moodley et al. 2016).However, this method is only effective in preventing pregnancy, and despite the provision of free male and female condoms and efforts to promote their use, rates of consistent condom use among South African adolescents are low (Mathews et al. 2022;Toska et al. 2020).While there are DP interventions in the literature that have incorporated contextual considerations (e.g.social networks, negotiation skills), there have been challenges with youth engagement and implementation (Bhana, Crewe, and Aggleton 2019;Harrison et al. 2016;Mathews et al. 2022;Mturi and Bechuke 2019).
Cultural consensus modelling (CCM) is an iterative, multi-phased methodology using an ethnographic approach to develop a culturally sensitive understanding of a given topic (Brown et al. 2018).CCM is an approach whereby individuals define the boundaries regarding a set of knowledge or behaviours shared by a group (Dressler et al. 2005;Fielding-Miller et al. 2016;Weller 2007).In Phase 1 of a CCM approach, individuals respond to free listing questions about their culture rather than their behaviours, allowing individuals to draw upon shared cultural knowledge.Utilising these identified group beliefs, Phase 2 asks individuals to rate the extent to which factors identified in Phase 1 are valued to identify unique clusters of individuals (termed cultural consensus models) who place greater importance on particular factors.Phase 3 utilises qualitative interviews with key informants from Phase 2 to gather in-depth information regarding the perceived group beliefs and behaviours.Lastly, a quantitative survey is conducted (Phase 4) to determine the extent to which cultural consensus model types are associated with differences in self-reported behaviours.In this way, a CCM approach uses a rigorous, multiphase mixed methods approach to identify a set of culturally relevant beliefs for a given outcome.
CCM has been utilised to explore cultural beliefs related to various health outcomes (e.g.transactional sexual behaviours; Fielding-Miller et al. 2016).We have previously reported on the use of CCM to examine South African adolescent girls' awareness and acceptability of DP strategies (Brown et al. 2021).A singular cultural consensus model of pregnancy and STI/HIV prevention method acceptability was observed.This consensus model emphasised the use of prevention methods based on prevalent HIV-related messaging (the Abstinence, Be Faithful, and Condom Use [ABC] model), but this model displayed limited awareness of the breadth of highly efficacious, modern HIV and pregnancy (e.g.intrauterine devices) prevention methods (Brown et al. 2021).To inform future culturally tailored DP interventions for South African adolescent girls, this paper reports on the preferences identified for sexual health interventions assessed via in-depth qualitative interviews as part of our earlier CCM study (Phase 3) examining the acceptability of DP methods.

Participants
Participants were Black, Sesotho-speaking adolescent girls and young women aged between 14 and 17 (N = 25; Mean age = 15.8 years) from the Mangaung Metropolitan Municipality in the Free State Province.All participants reported being currently enrolled in government funded public schools, with the majority reporting no current employment (92%).Participants indicated that zero adults (36%), one adult (40%), two adults (20%), or three adults (4%) who resided in the household had paid employment.

Procedures
Participants were a subset from the quantitative rating survey (N = 100) carried out as part of the second phase of the parent CCM study (Brown et al. 2021) who were highly consistent with the identified consensus model of acceptable pregnancy and STI/HIV prevention methods.Participants' Phase 2 consonance scores (a measure of consistency with the identified cultural model) were rank-ordered and individuals were invited to participate by rank order.A total of six individuals declined or were unavailable to be recontacted and thus we invited the next most highly consonant individuals to participate until the final sample size of 25 was reached.Recruitment for the quantitative rating survey was conducted by Sesotho-speaking research staff through outreach efforts at community-based organisations frequented by adolescents and fliers.Eligibility for Phases 2 and 3 included being: (a) female; (b) aged 14-17 years; (c) Sesotho-speaking; and (d) a Mangaung resident.The age of the sample was selected as sexual debut often occurs between 14 and 17 years and therefore an important developmental period to target sexual health interventions.Interested individuals were informed of their eligibility for the qualitative interviews immediately following the completion of the Phase 2 rating survey and told that participation would involve a one-hour individual interview.Written parental consent and written youth assent were obtained.
Semi-structured interviews were conducted in Sesotho.Interview questions were designed to elicit participants' perceptions of acceptable DP strategies and the pregnancy and perceived STI/HIV prevention intervention preferences of other girls in their community.Thus, interview prompts were designed to elucidate shared cultural beliefs rather than individual beliefs or behaviours.All interviews were digitally recorded, transcribed verbatim, and translated into English.Study protocols were approved by the University of the Free State Institutional Review Board.

Data analytic approach
Qualitative analyses employed a conventional content analysis approach using NVivo 11 software (QSR International 2015).The analytic approach sought to (a) identify pregnancy and STI/HIV educational prevention intervention content preferences, and (b) assess the preferred format and setting for future interventions.Transcripts were annotated with notes for potential coding categories to develop the initial codebook.The initial codebook was used to code a randomly selected transcript, and the coding classification scheme was refined based on coding discrepancies and discussion of potential coding structure revisions using a standard iterative process (MacQueen et al. 1998;Taylor and Bogdan 1998).Two independent raters (TDT & AEH) then coded all transcripts using the finalised codebook to apply codes representing an identified theme or sub-theme to text segments, with representative quotations (employing pseudonyms to protect confidentiality) identified.Coding discrepancies were resolved by a third coder (JLB).

Intervention content
Girls and young women were asked to identify perceived gaps in the sexual health knowledge of peers to inform intervention content.Common themes for intervention content focused on (a) the efficacious pregnancy and STI/HIV prevention methods, and (b) navigating peer-pressure about sex.However, some participants identified that there were no gaps in sexual health knowledge present.
Including intervention content regarding efficacious pregnancy and STI/HIV prevention methods was the most common theme identified.Participants indicated a desire to learn more about STI/HIV prevention strategies, as illustrated by Addy: I think the most important topic will be pregnancy and STI and HIV prevention.
Eliza indicated that information regarding STI/HIV prevention strategies including condom use was needed since there was a perceived lack of concern for sexual health relative to other community issues.
For instance, no one is talking about condoms and why we should use them.Nobody is talking about STIs and HIV.The only thing people are talking about is crime and how to prevent it… This notion highlights the discrepancy between what some young people may view as critical issues compared to where resources are allocated.Participants who identified gaps in peers' sexual health education and knowledge expressed the belief that interventions should provide more in-depth sexual health information than they currently receive.This sentiment was exemplified by Emmie: People are no longer given deep information about these things [sexual health], they are only given average information.
Furthermore, Cora expressed a desire for future sexual health interventions to discuss STI/HIV transmission in greater detail.
We do not get topics about STIs that much…How you get infected by it and how you treat it.
The desire to learn how to navigate peer-pressure about sex was also identified.Specifically, content should focus on resisting peer pressure from friends and male adolescents to engage in sexual activity.Respondents shared that because their peers often feel pressured to engage in sexual activity, they want to learn more about interpersonal communication with friends and partners: I think they should include topics such as peer pressure, whereby they explain the bad things about it and the way it is best to stand your ground.The other thing is they should teach the best way of communicating… (Lori).
An additional theme, endorsed by a minority (n = 4) of participants, was that there were no gaps in sexual and reproductive health knowledge among peers.Participants shared that their current sexual education curriculum and knowledge about pregnancy and STI/HIV was comprehensive as stated below: I do not think so because the information we have is enough to help us regarding them [sexual health].I don't think any topics are missing that would put us into problems (Myra).

Intervention delivery format
Participants were asked to identify which delivery format(s) similar peers would prefer to receive sexual health information along with explanations for these preferences.Preferred intervention delivery formats were those that (a) were easily accessible (e.g.online, text/SMS), (b) provided high-quality information, and (c) were delivered by knowledgeable, skilled facilitators.Formats with fewer barriers that were easily accessible were more acceptable.The reported preoccupation with the quality of information was frequently mentioned and underpinned by comprehensive and accurate information.Finally, participants identified the importance of knowledgeable, skilled facilitators to deliver sexual health interventions who would ensure that confidentiality was protected and create a safe, non-judgemental environment for sexual health discussions.Preferred facilitator characteristics were being trustworthy, well-informed, and providing non-biased sexual health recommendations.

Online
Sexual health information received online was the most highly supported delivery format, due to its reported accessibility as reflected by Tina: Yes, it is very easy, because you just search for the information you need.Because everyone has a phone, and they spend most of their time on it.
Others identified the desire to avoid negative judgement through independent learning that being online affords.
So, for you to avoid being judged by someone, go to your Google, read, and understand (Sonia).
Respondents indicated that the privacy afforded by this format was beneficial due to their peers' desire to keep their engagement with DP information to themselves: Other adolescent girls were more concerned about their ability to ask questions anonymously: …on the Internet, no one knows who I am, even if I say something no one will know it was me (Lori).
The quality of online, sexual health information was identified as a strength by some, and a concern by others.Several adolescent girls reported that peers would prefer to receive DP educational programming online due to the comprehensiveness of the information available: I love it because you get all the information from it (Elsie).
They would prefer receiving it online because that is where they will receive all the information they need (Ethel).
Because the Internet gives one information beyond what one learns at school and from their parents (Josie).
However, doubts about online information's accuracy were expressed by Myra: I am saying yes because at times some information that one gets from the internet is similar to the one they received from school or LoveLife while the other one might just get you into trouble.

Text message/SMS
Most participants believed that peers would prefer to receive sexual health information via SMS or text messages for reasons similar to an online format.These included ease and accessibility, the ability to avoid negative judgement and embarrassment, and privacy.However, some participants identified ways in which SMS/text was less acceptable than online.For example, one participant described receiving DP information via text messages as 'boring'(Alex) and resulting in low engagement levels.Viola was apprehensive about the ability to save and revisit sexual health information via text/SMS, An SMS can be deleted whenever the space on your phone becomes full, whereas Jess expressed doubts regarding the information's validity due to uncertainty about its source, Because you won't know who it is from.

Parents
There was mixed support about receiving sexual health information from parents.Participants voiced concerns that parents would share only negatively biased sexual health information: …but not parents because it is not all times [when]they tell you everything.Sometimes they hide some of the information (Lissa).
Additionally, parents' discomfort discussing sex with their daughters was a barrier: It is going to be hard because some parents don't know how to talk to their children about STIs, HIV, and pregnancy (Alex).
However, most participants suggested that peers would find parent-delivered interventions unacceptable due to concern that parents would misinterpret their intentions and negatively judge them: No, because her parents will shout at her why is she asking about such information.So, no she won't even bother (Lois).
Lori's response illustrates challenges that parents and adolescents might experience with parent-delivered sexual health interventions: Both of you do not feel comfortable around each other.When you ask your parent about sex, she/he will think or feel like you want to have sex.To show that, your parent will shout at you to show that he/she does not want [to] be asked such questions…I feel bad because…she feels like I am having sex and stuff.
In contrast, several participants explained that receiving DP information from parents would be viewed favourably by peers in a context where there was a sense of openness between parents and children: Yes, they would like to get information from parents, because a parent will always sit down with you and tell them everything.They can be open to them more than people from outside (Lin).
Similarly, descriptions of parents as sincere and trustworthy sources were commonly expressed to support this format: But your parents love you and they always want the best for you, so the advice you get from them is very genuine and worthy to be taken seriously (Joan).
Parents are parents, right?She gives information so that you become a good child (Emmie).
In addition, adolescent girls' responses suggested that they equated sexual experiences with knowledge, and therefore, viewed parents as a resource for sexual education information: Because parents have been there.So, they know everything.They will say, "My child, let's sit down.This is the way things are.If you don't want to get an STI, use protection" (Mabel).
A parent is an elderly person, who was once a child too.She has children now.She knows everything about herself.So, she can explain to me about sex … You must do this…or don't do that (Tanya).

Other adults
All respondents believed that their peers would be agreeable to receiving sexual health information from adults who were not parents or guardians.Of note, several respondents explicitly referenced social workers and adults of a similar age within this category.Openness and relatability were the most common themes discussed, as illustrated: Yes, because we are almost the same age so we can talk about everything (Alex), Because they would feel free talking to them, rather than their parents (Anita).
As with parents, participants explained that their peers would vary in finding this delivery format acceptable depending on the experience and knowledge the adults possessed: We would enjoy getting information from other adults.They have experienced what we are going through, and they will teach us what they know (Viola).
Furthermore, some adolescent girls cited a preference for information provided by older young people because of their knowledge, especially relative to parents: Yes, because she will tell her the good and bad stuff and explain everything in detail (Etta), Old people [parents] lived in the olden days; they will tell you what they used to do.We don't want to know about those times, we want to know what is happening now (Eliza).

Same-aged peers
Like responses about parent facilitators, participants expressed mixed support about receiving sexual health information from same-aged peers.Importantly, participants often did not distinguish between same-aged peers relative to peers with additional training or knowledge.As such, several participants made direct reference to their 'friends' in describing their views of same-aged peers as facilitators.The most cited justification for this format was teenagers' ability to be frank and open with each other: Yes.They would like to get information from other teenagers because they might be friends and they talk about everything.She can be open to her (Lin).…because they will be feeling free because they will be talking to each other as peers and friends (Renee).
Yes, because we would all be young people.There will not be any adults so we will be free to speak (Zoe).
Others believed that their peers would appreciate the mutual exchange of information between teens: It is because they will be helping each other by having discussions (Addy).
Yes, because they are your same age group, so you advise each other (Yvonne).
Yet other participants explained that same-aged peers may provide less biased information than one's parents: I don't think it is good news all the time, but as youth, we learn from school.Our parents hide some of the information, so it's best to rely on each other as a youth (Lissa).
While some respondents described the potential for receiving unbiased information via this format, others voiced concerns about the credibility of information delivered by same-aged peers.For example, respondents reported that their peers would not prefer this delivery format due to concerns that they would receive positively biased information from other teenagers: No, I don't think you would get the correct information because they will only tell you how good it is to have sex (Etta).
Adolescent girls also expressed that other teenagers' lack of experience and knowledge would limit the accuracy and usefulness of information: Our minds are the same.We don't know anything.We are still teens.We are still children (Mabel), Because it is not going to work if you speak with your friend who is the same age as you and who is also in that stage whereby you both do crazy things.So, it is not a great idea to get advice from them because it will not be true as always (Joan).
The most cited reason for their peers' disapproval of this format was the notion that other teenagers are untrustworthy and intentionally provide misinformation: I do not think we would prefer to receive it from them because at that age we influence one another on wrong behaviour.Another problem is the fact I would not readily receive information that comes from someone my age.Most young people like deceiving and influencing each other; they use one another to feel good about themselves.So, most teenagers influence one another with bad things (Viola).

Intervention setting
Participants were asked which setting(s) their peers would feel most comfortable receiving sexual health information in, and their explanation for each.As commonly reported across intervention characteristics, the most common considerations provided were a) familiarity and accessibility, b) concerns regarding negative judgement, and c) access to trusted information.The theme of familiarity and accessibility highlighted participants' interest in locations that already provide sexual health information and resources.Responses to the negative judgement theme revealed participants' desire to access information and ask questions anonymously without fear of stigmatisation.The broader theme of access to trusted information relates to young people's preference to receive sexual health information from settings with trusted facilitators.

Clinics
Most participants shared that community clinics providing sexual health services would be the most acceptable setting to receive sexual health education.Receiving information in a setting that is familiar and accessible was an important consideration for participants.Lin shared that the clinic needed to be nearby for youth to access the information.Addy highlighted access to sexual healthcare as a major benefit of clinic settings: …if there is anyone who needs to be attended [to], they can receive any assistance.
Another reported reason clinics were perceived as ideal was having access to information anonymously, without negative judgement.
Because workers at the clinic have information, they would feel comfortable asking questions without being judged (Lori).
Yes, even at the clinics they can be interested to get programs, and others can feel free if they can talk to another person but secretly/in private (Renee).
Participants also explained that the clinic personnel were trusted sources of high-quality information: …you can get enough correct knowledge (Lin).
…one is provided with all the information that they need (Addy).

Shauna drew a the distinction between clinic nurses and parents as sources of information:
Because nurses know best, and they would feel free more than with their parents.
This response highlights the desire to receive information from reputable, unbiased sources.However, others expressed that their peers would be concerned about privacy and being negatively judged at a clinic: …many people go there to clinics.So, a person is scared that when you are at the clinic wanting those things there will be people there (Deborah).
We are usually hurt because they do not want to know our reasons for looking for information regarding teen[age] pregnancy, HIV, and STIs.So, when they approach us, they do not speak to us well and they also shout at us.As girls, we become hurt yet when we go there with a boy, they believe that we are doing a school project.If they see us as girls, they automatically assume the worst (Viola).

Schools
Most participants shared that schools were an additional setting in which their peers would feel comfortable receiving sexual health education.Similar to clinics, participants expressed confidence in receiving credible information, without negative judgment, and felt more comfortable discussing sex at school rather than at home with parents.One reason provided was that schools are designated for learning, making them a more comfortable environment: … so that they can get sex education programmes because in schools there are subjects that teach about sex and HIV (Lin).
It is because at school we will all be learning without judgement, so we believe that the things we learn that day will be employed throughout our lives (Zoe).
Participants also described feeling more comfortable at school because of the sense of community they shared with their peers: Because you have so much freedom than at home or any other place.I think it is better to be around many people than be alone (Shauna).Because they will be free at schools, and they will get more information… They will be getting more information and they will be able to talk to people and give them information (Renee).
The theme of familiarity was also expressed as sexual health topics were already being discussed in schools, sometimes as the exclusive setting for receiving sexual health information.Teachers were often cited as facilitators who adolescent girls felt comfortable receiving sexual health education from.However, gender preferences for the facilitator were not specified.

Youth centres
A minority of participants expressed that their peers would prefer youth community centres as a setting for sexual health education.One reason in support of this was that in these centres there already exists programming for sexual health education, making it a more comfortable environment: Yes, they would love that because at that time the place will have only teens and adults who are there to teach about STIs, HIV, and teen[age] pregnancy (Viola).
Another reported reason, similar to other settings, was the importance of confidentiality and comfort: …it's like volunteers.So that they speak to the youth, right?…So, they think that they can go there, they can feel safe speaking to someone that lives there where they live, they don't know me, I don't know them such things (Deborah).
The importance of feeling a sense of community with peers and having the opportunity to learn from others' experiences was another reason given to support receiving sexual health information in this setting.
So, don't end up doing something that will lead you to do what I did, because we don't know how it is going to be with you… Just join our youth.Become a team with them.Talk to each other… (Kady).
Reported reasons against this setting revolved around adolescent's lack of trust in their peers as facilitators and concerns for confidentiality.

Discussion
To inform future culturally tailored DP programmes and interventions for adolescent girls and young women in South Africa, this study employed a CCM approach to qualitatively elucidate perceptions of needed intervention content and preferred intervention formats by other girls in their community.Participants reported that sexual health interventions that provide in-depth information regarding STI/HIV and pregnancy strategies were needed.Future interventions should therefore include detailed information regarding STI/HIV transmission routes and how to navigate peer pressure to engage in sexual activity.Previous interventions highlight strategies and content to enhance sexual health self-efficacy (Harrison et al. 2016;Layzer, Rosapep, and Barr 2014;Sieving et al. 2011).Collectively, future interventions for this population should include comprehensive information regarding efficacious pregnancy and STI/HIV prevention methods and should also emphasise communication skills and strategies to navigate peer pressure.
Participants in this study noted a preference for intervention delivery formats that were accessible, avoided stigmatisation, and provided high-quality information.Preferred intervention formats included online, text/SMS, or delivery by social workers or older, knowledgeable peers, with mixed acceptability for delivery by parents or same-age peers.Consistent with respondents' desire for confidentiality and accessibility, a text message sexual/reproductive health intervention developed for Tanzanian young people shows feasibility as being adaptable for South African adolescents (L'Engle et al. 2013).Among South African adolescent girls, concerns about receiving accurate information that can be revisited should be considered in adaptation.Thus, the literature provides initial support for the potential efficacy of technology-based DP interventions tailored for adolescent girls and young women in South Africa.
While interventions delivered by older peers have shown improvements in sexual health outcomes among adolescent girls (Jewkes et al. 2006;Mbatha and Bhana 2007), peer-based interventions have been less effective in improving DP prevention behaviours (e.g.condom use, delaying the age of sexual initiation; Mason-Jones, Mathews, and Flisher 2011;Visser 2007).The desire for young people to be in groups with familiar peers and feel comfortable around them has been discussed in the literature (Mathews et al. 2022).Participants' support for 'friends' (i.e.same-aged peers) as facilitators further speaks to the potential of utilising social networks in DP interventions.
Extant sexual health interventions in South Africa, inclusive of parental involvement, found parents reporting greater perceived improvement in parent-child sex communication than adolescents and young people themselves (Armistead et al. 2014).Indeed, consistent with our findings, past qualitative data revealed that while both parents and children described discussion about sexual topics as taboo, parents (but not children) believed that these conversations would induce sexual risk behaviours (Kuo et al. 2016).These results and our current findings highlight the need for DP interventions that provide high-quality information and address the barriers facing child-parent sexual health communication (Duby et al. 2022).Integration of training for parents about how to discuss sexual health with their children could be a direction for future work.Utilising the perceived openness and security some young people feel as a strength could be critical in dissemination by supplying parents with accurate knowledge and communication skills (Duby et al. 2022).
Schools, sexual health clinics, and youth centres were preferred intervention settings.School-based sexual health interventions have a strong evidence base for improving sexual health behaviours and biological outcomes (e.g.pregnancy, STI infection) among young South Africans (Magnani et al. 2005;James et al. 2006;Jemmott III et al. 2015;Tibbits et al. 2011).However, not all school-based interventions developed for South African youth are efficacious (Mathews et al. 2012).Overall, the school setting has evidence pointing to efficacious sexual health outcomes but is not without its limitations (Harrison et al. 2016;McClinton Appollis et al. 2021).While receiving high support from youth, the literature has shown that youth centre settings may not be an appropriate means of reaching adolescent girls and young women for sexual health education and few have been implemented (Mathews et al. 2022).
The term 'adolescent/youth-friendly' care refers to an approach to care that prioritises the needs and comfort of young people themselves (Shaikh et al. 2021;Mavedzenge, Doyle, and Ross 2011).Improved outcomes (e.g.increased odds of condom use at the last sexual encounter) have been found among young people who attended clinics deemed 'adolescent-friendly' (Shaikh et al. 2021).The concept is also consistent with expressed concerns about seeking care at clinics with accessible information in a judgement-free setting.Concerns related to the adequacy of sexual health information (e.g.bias), gender inequities, negative healthcare provider attitudes as well as confidential, stigma-free contraception resources were reported concerns of the participants and are supported in the literature as contributors to sexual health disparities (Jonas et al. 2020).Few interventions have been implemented to address the social and contextual barriers that South African adolescent girls and young women are facing (Harrison et al. 2016;Jonas et al. 2020;Mathews et al. 2022).

Strengths and limitations
The study employed Cultural Consensus Modelling to determine shared cultural beliefs from the ground up (Weller 2007).Qualitative interviews were conducted with participants best aligned with the identified cultural model (Brown et al. 2021), thus providing the cultural context from within this community of South African adolescent girls.However, while they may be suggestive, the findings cannot be generalised to adolescent girls and young women in other locations or with differing characteristics.Interviews were also conducted in Sesotho and translated into English, so some nuances regarding participants' responses may have been affected in the translation process.
An additional limitation of this approach is the impact of socialisation on youth's perceived needs.Considering that the ABC model of sexual health is the dominant educational model in use locally, there may be additional needs that participants do not have awareness of that are important to identify (e.g.sexual violence prevention, sexual rights; Brown et al. 2021;Harrison et al. 2016;Bhana, Crewe, and Aggleton 2019).

Conclusions
This study examined South African adolescent girls' perceived sexual health intervention needs and clarified their beliefs around content, delivery format, and setting, to inform culturally-tailored DP interventions and programming to prevent both unintended pregnancy and STI/HIV.Participants indicated that interventions should address using efficacious pregnancy and STI/HIV prevention methods and navigating peer pressure.Adolescents reported that interventions should be accessible, avoid negative judgement, and provide high-quality information.Preferred intervention formats included online, SMS/text, or delivery by social workers or older, knowledgeable peers, with mixed acceptability for delivery by parents or same-age peers.Schools, youth centres and existing sexual health clinics were preferred intervention settings.Reported gaps in HIV and pregnancy prevention knowledge, mixed support for peer-led interventions, and majority support for a school setting differentiate this population's needs from others.Based on the findings presented, culturally tailored, multi-facetted DP interventions are needed to address the intersections of individual and structural barriers that South African adolescent girls are facing to support meaningful engagement.
Because when you google, it's not like those people look into who you are, or what you [are] googling.So, you know when you read a certain thing you are reading it alone (Deborah).