Gender-transformative, community-based intervention and changes in long-acting reversible contraceptive use among adolescent girls and young women in underserved districts of Mozambique

Gender-transformative, community-based intervention and changes in long-acting reversible contraceptive use among adolescent girls and young women in underserved districts of Mozambique | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Gender-transformative, community-based intervention and changes in long-acting reversible contraceptive use among adolescent girls and young women in underserved districts of Mozambique Baltazar Chilundo, Luc Van Der Veken, Artur Sulemane, Mohamad Ibrahim Brooks, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8869107/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Modern contraceptive use among adolescents in Mozambique remains constrained by limited access and restrictive gender norms that reduce girls and young women’s autonomy over reproductive decision-making. Evidence on large-scale gender-transformative interventions that influence modern contraceptive and long-acting reversible contraceptive (LARC) uptake among adolescent girls and young women (AGYW) remains limited. The IMPACTO project (2018–2024) implemented a multi-level intervention across underserved districts of Manica and Tete provinces combining gender-transformative community strategies with youth-responsive service strengthening. This study assessed changes in modern contraceptive use and LARC uptake following implementation. Methods A repeated cross-sectional household survey was conducted at baseline (2018–2019) and endline (2023) across nine underserved districts in central Mozambique. AGYW aged 15–24 years and men aged 18–49 years were selected using a random walk household sampling approach. Data were collected using tablet-based questionnaires capturing contraceptive use, attitudes toward family planning services, gender norms, household decision-making, gender-based violence (GBV) attitudes, and awareness of abortion legislation. Differences in proportions between baseline and endline were assessed using chi-square tests, and 95% confidence intervals were estimated. Results A total of 4,861 respondents participated at baseline and 5,028 at endline. Modern contraceptive use among sexually active AGYW increased from 43.3% to 56.4% (p<0.0001). Implant use rose substantially from 3.0% to 15.4%, representing a four-fold rise in LARC uptake. Improvements were observed in contraceptive attitudes, gender-equitable norms among AGYW (17.4% to 41.8%) and men (33.1% to 49.3%), joint household decision-making (16.0% to 65.0%) and reductions in early marriage and GBV. Awareness of abortion decriminalization increased from 10.9% to 40.7%. Descriptive parallel improvements across behavioural, normative, and structural indicators were consistent with the intervention’s theory of change. Conclusions A gender-transformative community intervention combined with youth-responsive service strengthening was associated with substantial increases in modern contraceptive use and a pronounced shift toward LARC methods use among AGYW in underserved districts of Mozambique. Improvements in service delivery alone are unlikely to result in equitable access to highly effective contraception for adolescents without concurrent transformation of social and gender norms. Adolescent girls and young women Modern contraceptive prevalence Long-acting reversible contraceptives Gender norms Gender-transformative intervention Male engagement Household decision-making Mozambique Family planning programme evaluation BACKGROUND Mozambique continues to face high rates of adolescent pregnancy and early childbearing, which remain closely associated with unmet need for modern contraception and limited reproductive autonomy among adolescent girls and young women (AGYW) (1–6). National survey data indicate that more than half of young women aged 15–24 have begun childbearing, particularly in rural provinces such as Manica and Tete where access to youth-responsive contraceptive services is constrained and social norms discourage contraceptive use prior to first birth (6–8). Despite national commitments to expand family planning services, adolescents in Mozambique face persistent barriers to contraceptive uptake, including limited decision-making power, fear of infertility, stigma associated with premarital sexual activity, and partner opposition (9,10). Evidence from sub-Saharan Africa shows that these barriers are strongly shaped by restrictive gender norms that position men as gatekeepers of reproductive decisions and limit AGYW’s ability to seek contraception independently (10–12). Moreover, qualitative evidence from sub-Saharan Africa indicates that social norms constrain open communication between parents and adolescents, often leaving young people without supportive dialogue at home and influencing how they seek information and make decisions about contraception and sexual behaviour (13). Such norms reduce early adoption of modern methods and contribute to reliance on short-acting or no contraception among young women (11,14). LARC methods such as implants and intrauterine devices (IUDs), are highly effective in preventing unintended pregnancy among adolescents. However, uptake remains limited in many rural African settings due to persistent myths, misinformation, and sociocultural resistance (11,15). Evidence suggests that strengthening service availability alone is insufficient to increase LARC uptake without addressing gender norms and broader social determinants that influence contraceptive decision-making (16–18). Gender-transformative interventions that engage both women and men have demonstrated potential to improve reproductive communication and contraceptive behaviours, yet large-scale population-level evidence remains limited (11,14,19–22). Mozambique’s 2014 abortion law reform expanded legal access under specified conditions; however, awareness remains low and stigma persists, reflecting broader gaps in reproductive rights knowledge that intersect with limited contraceptive agency (4,23). The Supporting Family Planning and Abortion Services Project (IMPACTO), implemented between 2018 and 2024 across nine underserved districts of Manica and Tete provinces, Mozambique, combined community-based, gender-transformative strategies with strengthening of youth-responsive contraceptive services. The intervention sought to address normative and structural barriers to modern contraception, promote equitable gender attitudes supporting reproductive autonomy, and improve awareness of reproductive rights. To clarify the multi-level nature of the intervention, Table 1 summarizes the principal components implemented across community, institutional, and health-system levels, targeting AGYW, men, community leaders, and service providers. This paper presents findings from a repeated cross-sectional evaluation of IMPACTO, focusing on changes in modern contraceptive use and shifts toward LARC uptake among AGYW in underserved districts of central Mozambique. Table 1: Key Components of the IMPACTO Intervention (2018–2024) Intervention domain Target group Key activities Intended mechanism of change Small-group empowerment curriculum AGYW (15–24 years) Structured 12-session curriculum addressing gender roles, power dynamics, sexual and reproductive health and rights (SRHR), contraception, consent, and decision-making; integration of civic action module Increase SRHR knowledge; build self-efficacy; strengthen agency and negotiation capacity Civic action and leadership training AGYW Provincial and district-level civic training workshops; advocacy skill-building; participation in Community Leadership Committees (CLC), Co-Management Committees (CMC), school councils, radio programs, and public forums Foster “power within”; increase public participation; strengthen accountability mechanisms Male engagement sessions Adult men; fathers; partners Small-group dialogues on masculinity, shared decision-making, contraception, prevention of early marriage and gender-based violence (GBV) Shift restrictive gender norms; increase support for women and girl’s contraceptive autonomy Social Analysis and Action methodology Community leaders (CLC, CMC), influencers Structured six-session dialogue cycles to examine harmful norms, early marriage, GBV, and SRHR; development of community action plans Transform normative environment; legitimize AGYW participation; reduce social barriers Community sensitization and mass communication Community members Radio programs; community dialogues; household visits; advocacy events (e.g., 16 Days of Activism) Reduce myths and stigma; normalize contraception and gender equality Youth-responsive service strengthening Health authorities; facility-based staff and providers; Community Health Workers Training on gender-sensitive, youth-responsive contraception and safe abortion care; LARC provision; expansion of services in hard-to-reach areas; community outreach events Improve quality, availability, and acceptability of contraceptive services GBV and early marriage prevention Community leaders; families Legal awareness (abortion law, and child, early and forced marriage legislation); engagement with police and judicial system; survivor referral strengthening Strengthen protective environment; enhance reproductive autonomy MATERIALS and METHODS Study design and study setting This study used a repeated cross-sectional, population-based survey design to assess changes in modern contraceptive uptake and related determinants following implementation of the IMPACTO project in underserved areas of Manica and Tete provinces, Mozambique. Baseline data were collected between December 2018 and February 2019, and endline data between November and December 2023. The design allowed comparison of contraceptive behaviours and associated gender and social indicators at population level in project-supported areas. The surveys were conducted in nine districts where IMPACTO was implemented: i) Manica Province: Chimoio City, Gondola, Macate, Manica, Vanduzi; and ii) Tete Province: Cidade de Tete, Moatize (Town and District), Doa, Mutarara. These districts are socioeconomically disadvantaged with high poverty levels and limited access to basic services, and characterized by high adolescent fertility, early marriage, limited contraceptive access, and strong sociocultural barriers to SRHR, particularly for adolescents and youth. Study population, sample size, and sampling strategy The study included two respondent groups: AGYW aged 15–24 years and men aged 18–49 years. Eligibility criteria required residence within the selected localities and provision of informed consent prior to participation. The survey sample was powered to detect a minimum 10-percentage point change in modern contraceptive prevalence between baseline and endline at the provincial level. The sample size was calculated using the formula: n = D [(Zα + Zβ)² × (P1(1 − P1) + P2(1 − P2)) / (P2 − P1)²] Assuming a design effect (D) of 2 to account for cluster sampling, baseline prevalence (P1) of 50%, endline prevalence (P2) of 60%, a two-tailed α of 0.05, and statistical power of 90%, the minimum required sample was 1,066 respondents per province. To produce a self-weighted dataset and avoid the need for sampling weights during analysis, the sample size was adjusted proportionally according to the population size of the project catchment areas in each province. The IMPACTO intervention covered districts representing an estimated population of 1,086,557 in Manica and 1,056,488 in Tete, yielding a provincial ratio of approximately 1.03. Based on this proportional adjustment, the survey targeted 1,096 households in Manica and 1,066 households in Tete, for a total of 2,162 households across both provinces. Proportional allocation was also applied to selected localities to ensure that the sample mirrors the population distribution. A non-probability random walk household sampling method was employed across 116 randomly selected localities within the nine districts. In each locality, the geographic centre was identified with the assistance of a community informant. Male and female enumerators then proceeded in opposite randomly selected directions, approaching households systematically along their paths. Households were included when at least one eligible AGYW (female enumerator path) or one eligible man (male enumerator path) was present. This sampling strategy was adopted to ensure broad geographic coverage in underserved and resource-constrained areas where reliable household listings were not available. Measures and data collection The primary outcomes focused on contraceptive behaviour among AGYW. These included current use of modern contraceptive methods among sexually active, non-pregnant AGYW, shifts in contraceptive method-mix distinguishing short-acting from LARC methods, and implant use as the principal indicator of LARC uptake. Secondary measures captured determinants and contextual factors associated with contraceptive behaviour. These included knowledge and awareness of contraceptive methods, attitudes toward contraceptive safety and eligibility, gender norms assessed using adapted Gender Equitable Men (GEM) scales (24) among both AGYW and men, household decision-making dynamics, attitudes toward GBV and awareness of GBV-related legislation, and knowledge of the legal status of abortion in Mozambique. Data were collected using structured questionnaires programmed into the CommCare mobile platform and administered through tablets by trained enumerators. Enumerators were sex-matched to respondents and deployed outside their own communities to minimize social desirability and interviewer bias. Comprehensive training was conducted prior to fieldwork and covered research ethics, informed consent procedures, contraceptive and reproductive health concepts, gender norms, and digital data collection protocols. Data analysis Data were exported from CommCare and analyzed using SPSS and Excel. Descriptive statistics were calculated for all key indicators. Differences in proportions between baseline and endline were assessed using chi-square tests, and 95% confidence intervals were estimated. Analyses were stratified by province and sex where relevant. Gender norms were assessed using an adapted version of the GEM scale (24). Responses to individual GEM items were coded and summed to generate a composite score, which was categorized into tertile equity levels (e.g., low-, medium-, and high-equity) based on distributional cut-offs established prior to analysis. For reporting purposes, high-equity scores were compared between survey rounds to assess shifts in gender attitudes. Indicators with sufficient denominators were tested for statistical significance at α=0.05. Post-hoc power calculations were conducted for primary outcomes. RESULTS Characteristics of the study population The surveys included 4,861 respondents at baseline and 5,028 at endline across nine rural districts in Manica and Tete provinces. AGYW comprised 2,392 at baseline and 2,517 at endline, and men 2,469 and 2,511 respectively. The majority of respondents lived in rural areas (>70% AGYW; >80% men). Most AGYW were married or in union (>80%), and approximately half had at least one child. Youth-responsive service strengthening: Changes in modern contraceptive use and method mix Following implementation of the IMPACTO intervention, substantial improvements were observed in modern contraceptive uptake among sexually active, non-pregnant AGYW across both provinces. Modern contraceptive prevalence increased from 43.3% at baseline (n=1,707) to 56.4% at endline (n=1,733), representing a 13.1-percentage point increase (95% CI: 9.8–16.4; χ²=59.6; p<0.0001). Post-hoc statistical power exceeded 99%, confirming adequate sample size to detect this change. Non-use declined from 56.7% to 43.6%, indicating broad uptake across project areas. Changes in LARC uptake LARC use among AGYW increased from 3.9% to 16.0% (difference = +12.1 percentage points; 95% CI: 10.1–14.1; χ² = 147.5; p < 0.0001), primarily driven by implant adoption (3% → 15.4%). This represents a more than four-fold increase in LARC use. The magnitude of change indicates strong behavioural shift toward highly effective methods. Injectable use also increased (15.8% → 23.9%), while condom reliance declined. Given the large sample of contraceptive users, the observed LARC increase is statistically robust and consistent across provinces. Community norm transformation: Shifts in contraceptive attitudes linked to uptake Significant improvements were observed in beliefs known to influence contraceptive demand and acceptability among AGYW between baseline and endline (Table 2). The proportion of AGYW agreeing that modern contraception is safe for women who have not yet had children increased markedly from 24.5% at baseline to 46.3% at endline, representing a statistically significant change of +21.8 percentage points (95% CI: 19.2–24.4; p<0.0001). Similarly, agreement that spacing births through contraception improves maternal and child health increased from 54.1% to 63.4% (+9.3 percentage points; 95% CI: 6.5–12.0; p99%), confirming the robustness of the observed attitudinal shifts. These findings suggest a substantial reduction in fertility-related fears and increased normative acceptance of modern contraceptive use, which likely contributed to the rise in overall contraceptive uptake and LARC adoption among AGYW. Table 2: Changes in contraceptive attitudes associated with demand and uptake among AGYW (both provinces) Indicator Baseline Endline Difference 95% CI p-value Contraception safe for nulliparous women 24.5% 46.3% +21.8 pp 19.18–24.38 <0.0001 Contraceptive spacing improves maternal/child health 54.1% 63.4% +9.3 pp 6.55–12.03 <0.001 Gender norm transformation Substantial improvements were observed in gender-equitable attitudes among both AGYW and men between baseline and endline, as measured using adapted GEM scales (24). The proportion of AGYW with high-equity GEM scores increased from 17.4% at baseline to 41.8% at endline (difference = +24.4 percentage points; 95% CI: 21.7–27.1; χ² = 365.4; p < 0.0001), while men with high-equity GEM scores rose from 33.1% to 49.3% (difference = +16.2 percentage points; 95% CI: 13.5–18.9; χ² = 137.6; p < 0.0001). These shifts represent a significant movement away from restrictive norms that traditionally limit women’s autonomy over reproductive decision-making. Household agency and structural determinants Marked improvements were observed across structural indicators that directly affect AGYW’s autonomy and ability to adopt and sustain contraceptive use. The proportion of AGYW reporting joint decision-making over household expenditures increased significantly from 16.0% at baseline to 65.0% at endline (difference = +49.0 percentage points; 95% CI: 46.4–51.6; χ² = 1,115; p < 0.0001), indicating a substantial shift in relational power dynamics within households. At the same time, the prevalence of early marriage among AGYW declined significantly from 49.5% to 24.1% (difference = −25.4 percentage points; 95% CI: −28.2 to −22.6; χ² = 370.5; p < 0.0001). Experience of GBV among AGYW in the previous 12 months also decreased significantly from 13.4% to 5.3% (p<0.0001). Lower exposure to violence reflects improved safety and reduced coercive control, which are critical conditions for women’s ability to make independent reproductive decisions and access contraception without fear or restriction. All three indicators were highly powered (>99%), reinforcing their statistical robustness and supporting the conceptual pathway through which gender-transformative programming contributed to enhanced agency and an enabling environment for modern contraceptive, particularly LARC, uptake. Changes in abortion law awareness as part of reproductive choice context Awareness among AGYW that abortion is legally permitted in Mozambique increased significantly from 10.9% at baseline to 40.7% at endline (difference = +29.8 percentage points; 95% CI: 27.6–32.4; χ² = 584.2; p < 0.0001). This improvement reflects enhanced dissemination of reproductive rights information within project areas. Although stigma surrounding abortion remained prevalent, increased legal awareness is important within the broader reproductive choice continuum, as it signals greater knowledge of available options and rights related to unintended pregnancy. These findings complement the observed rise in contraceptive uptake by indicating progress in AGYW’s overall awareness of reproductive autonomy and legal protections. Summary of key changes across study outcomes Table 3 presents a synthesis of the principal behavioural and structural outcomes observed between baseline and endline across both provinces, highlighting statistically significant improvements in modern contraceptive use, LARC uptake, gender norms, and related determinants influencing reproductive agency among AGYW. Table 3: Summary of key outcomes observed between baseline and endline (both provinces) Domain Indicator Baseline Endline Change Significance Contraceptive Use Modern contraceptive prevalence (AGYW) 40.0% 56.0% +16 pp p<0.0001 LARC use Implant use (AGYW) 3.0% 15.4% +12.4 pp p<0.0001 Total LARC use (AGYW) 3.9% 16.0% +12.1 pp p<0.0001 Attitudes Contraception safe for nulliparous women 24.5% 46.3% +21.8 pp p<0.0001 Birth spacing improves maternal/child health 54.1% 63.4% +9.3 pp p<0.001 Gender Norms High GEM (AGYW) 17.4% 41.8% +24.4 pp p<0.0001 High GEM (Men) 33.1% 49.3% +16.2 pp p<0.0001 Agency Joint household decision-making 16.0% 65.0% +49 pp p<0.0001 Protection AGYW reporting GBV (12 months) 13.4% 5.3% −8.1 pp p<0.0001 Social Context Early marriage among AGYW 49.5% 24.1% −25.4 pp p<0.0001 Rights Awareness Abortion law awareness (AGYW) 11.0% 41.0% +30 pp p<0.0001 Changes in normative and agency factors alongside modern contraceptive uptake To further contextualize the observed increase in modern contraceptive and LARC uptake among AGYW, descriptive comparisons were conducted examining selected attitudinal, agency, and gender norm indicators across survey rounds (Table 4). These indicators correspond to key domains of the IMPACTO intervention and represent potential pathways through which gender-transformative programming may influence contraceptive behaviour. Although these descriptive findings do not establish causal relationships, the parallel improvements across behavioural and normative domains are consistent with the intervention’s multi-level theory of change. Table 4: Changes in selected attitudinal, agency, and gender norm indicators among AGYW and men, baseline and endline Modern Contraceptive Use (baseline) Modern Contraceptive Use (endline) Contraceptive Attitude – AGYW* Birth spacing improves maternal/child health - AGREE 54.1% (1,295/2,392) 63.4% (1,597/2,517) Birth spacing improves maternal/child health - DISAGREE 11.6% (277/2,392) 8.3% (209/2,517) Agency - AGYW** Makes household decision-making - JOINTLY or SELF 50.8% (868/1,707) 58.6% (1015/1,733) Makes household decision-making - HUSBAND 31.9% (545/1,707) 25.7% (446/1,733) Gender norms - AGYW GEM scale - HIGH equity 13.4% (321/2,392) 38.7% (973/2,517) GEM scale - LOW equity 23.0% (550/2,392) 8.3% (205/2,517) Gender norms - MEN GEM scale - HIGH equity 33.1% (818/2,469) 49.2% (1,235/2,511) GEM scale - LOW equity 13.6% (335/2,469) 7.6% (191/2,511) Note: Contraceptive attitude* was measured as the proportion of AGYW who agreed that using contraception for spacing pregnancies improves the health of the mother and baby. Agency** was constructed as a composite indicator based on five decision-making domains: (1) use of household income; (2) visits to family members; (3) ability to work outside the home; (4) use of contraceptives; and (5) access to health services or medical treatment. Improvements in modern contraceptive use occurred alongside substantial shifts in attitudinal and normative indicators. Agreement that birth spacing improves maternal and child health increased from 54.1% to 63.4% among AGYW. The proportion reporting joint or self-household decision-making increased from 50.8% to 58.6%, while husband-only decision-making declined. High-equity GEM scores increased markedly among AGYW (13.4% to 38.7%) and men (33.1% to 49.2%). Although these descriptive findings do not establish causality, the parallel improvements in normative, attitudinal, and agency indicators alongside increases in modern contraceptive and LARC uptake are consistent with the intervention’s theory of change. DISCUSSION This evaluation provides population-level evidence that a multi-level, gender-transformative, community-based intervention was associated with substantial increases in modern contraceptive use and a marked shift toward LARC uptake among AGYW in underserved districts of Mozambique. The observed increase in implant use, together with improvements in gender norms, agency, and contraceptive attitudes, reinforces growing evidence that demand-side and structural barriers are central determinants of adolescent contraceptive behaviour in low-resource settings (9,11,16). Gender norms and male engagement as drivers of contraceptive behaviour Restrictive gender norms have been widely documented as barriers to AGYW’s contraceptive autonomy across sub-Saharan Africa (10–12,14). Norms that position men as gatekeepers of reproductive decision-making, alongside parental and community expectations surrounding early marriage and childbearing, can limit early contraceptive initiation and reduce acceptance of modern methods, particularly LARCs (12,14). The substantial rise in high-equity GEM scores among both AGYW and men observed in this evaluation reflects meaningful shifts toward equitable attitudes and aligns with systematic evidence demonstrating that gender-transformative programming can improve women’s reproductive agency and contraceptive uptake when male partners and communities are actively engaged (19–22). Improved male support and declining acceptance of violence likely contributed to an enabling environment for AGYW to seek and sustain contraceptive use. Reducing demand-side barriers and structural constraints to support LARC uptake The four-fold increase in implant use represents a major shift toward highly effective contraception among AGYW. Prior studies have shown that adolescents rarely adopt LARCs in contexts where myths about infertility and sociocultural resistance persist (11,16,17). The marked improvement in attitudes regarding contraceptive safety for nulliparous women indicates reduced perceived barriers to LARC eligibility, which likely facilitated greater uptake. Concurrent improvements in joint household decision-making, reductions in early marriage, and declines in GBV further demonstrate strengthened agency and diminished structural constraints that traditionally limit adolescent reproductive autonomy (3–5,12,19). Together, these shifts provide a coherent pathway linking gender norm transformation to increased adoption of LARCs. These shifts align with increases in high-equity GEM scores among both AGYW and men, reflecting movement away from norms that reinforce male dominance and restrict women’s independent health decision-making. Gender-equitable attitudes among AGYW are associated with enhanced negotiation capacity and greater likelihood of initiating contraception prior to first birth, while improved attitudes among men may contribute to more supportive relational environments and reduced resistance to women’s contraceptive use. Taken together, these behavioural, normative, and structural changes provide a coherent explanatory pathway for the observed rise in modern contraceptive prevalence and LARC adoption. The findings reinforce growing evidence that addressing gender norms and demand-side barriers is critical for expanding adolescent access to highly effective contraceptive methods in underserved settings. Broader reproductive rights awareness and programme implications Increased awareness of abortion legality reflects expanded exposure to reproductive rights information, complementing improvements in contraceptive empowerment despite persistent stigma (4,23). The findings highlight that strengthening youth-responsive services alone is insufficient to expand LARC uptake in socially constrained environments. Integrating gender-transformative, community-based strategies within family planning programmes can accelerate modern contraceptive adoption and shift adolescents toward more effective methods in underserved settings. Limitations and contribution The repeated cross-sectional design without a comparison group limits causal inference, and the random walk sampling restricts generalizability. Self-reported contraceptive use may also be subject to desirability bias. Nevertheless, large sample sizes, high statistical power, and consistent changes across behavioural and structural indicators strengthen confidence in programme-associated effects. This study contributes rare large-scale African evidence demonstrating that gender-transformative approaches can significantly drive LARC uptake among AGYW in high-deprivation contexts. The magnitude and consistency of change across modern contraceptive uptake, gender equitable attitudes, household decision-making, and rights awareness strongly align with the IMPACTO conceptual framework, which hypothesized that transforming social and gender norms would increase AGYW’s agency and enable greater utilization of sexual and reproductive health services. The parallel improvements observed across normative, attitudinal, and agency indicators strengthen the plausibility of the intervention’s hypothesized pathways linking social norm transformation to contraceptive behaviour change. CONCLUSIONS AND IMPLICATIONS The IMPACTO intervention was associated with substantial increases in modern contraceptive use and a pronounced shift toward LARC adoption among AGYW in underserved districts of Mozambique. The four-fold rise in implant uptake suggests that addressing gender norms, household power dynamics, and structural barriers alongside youth-responsive service strengthening can accelerate access to highly effective contraception among adolescents. Programmatic implications Integrating gender-transformative, community-based strategies within family planning programmes may enhance adolescents’ contraceptive autonomy and reduce resistance to LARC adoption in socioeconomically deprived settings. Policy implications Scaling similar multi-level approaches within Mozambique’s national family planning strategy could contribute to sustained reductions in adolescent pregnancy and improved equity in access to long-acting methods. Academic implications This study contributes rare population-level evidence from sub-Saharan Africa demonstrating that transforming gender norms and social determinants is closely aligned with increased LARC uptake, reinforcing the importance of integrating gender and structural analysis into contraceptive research and programme evaluation. LIST OF ABBREVIATIONS Abbreviation Full term AGYW Adolescent Girls and Young Women CLC Community Leadership Committee CMC Co-Management Committee GBV Gender-Based Violence GEM Gender Equitable Men IMPACTO Supporting Family Planning and Abortion Services Project IUD Intrauterine Device LARC Long-Acting, Reversible Contraceptive SRHR Sexual and Reproductive Health and Rights Declarations ACKNOWLEDGMENTS The authors gratefully acknowledge Global Affairs Canada for financial support, as well as the Ministry of Health, Directorate of Public Health, and the provincial health authorities of Tete and Manica for their support in both the implementation of the IMPACTO project and the evaluation activities. We extend our sincere appreciation to Pathfinder International and local partner staff for their collaboration, and to all study participants including health professionals, adolescent girls and young women, men, and community leaders whose participation made this study possible. AUTHORS’ CONTRIBUTION BC led the writing of the manuscript for publication, LV coordinated implementation of the IMPACTO project, AS conducted the design and coordinated the evaluations with support from MB. JF, LV, MB, and KH provided internal review of the manuscript. FUNDING Both implementation and evaluation reported in this publication were supported by Global Affairs Canada. The content is solely the responsibility of the authors and does not necessarily represent the official views of Global Affairs Canada or Pathfinder International. DATA AVAILABILITY All data and materials are accessible upon request from the corresponding author. COMPETING INTERESTS The authors declare no competing interests. CONSENT FOR PUBLICATION N/A ETHICAL APPROVAL AND PARTICIPANTS CONSENT Ethical approval was obtained from the Mozambican Ministry of Health Institutional Review Board (Ref: 434/CNBS/18; amended 2023). 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Available from: https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-023-02361-8 Blanc AK. The Effect of Power in Sexual Relationships on Sexual and Reproductive Health: An Examination of the Evidence. Stud Fam Plann [Internet]. 2001 Sep [cited 2026 Jan 19];32(3):189–213. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1728-4465.2001.00189.x Usonwu I, Ahmad R, Curtis-Tyler K. Parent–adolescent communication on adolescent sexual and reproductive health in sub-Saharan Africa: a qualitative review and thematic synthesis. Reprod Health [Internet]. 2021 Dec [cited 2026 Feb 2];18(1):202. Available from: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-021-01246-0 Macia M, Maharaj P, Gresh A. Masculinity and male sexual behaviour in Mozambique. Cult Health Sex [Internet]. 2011 Nov [cited 2026 Jan 19];13(10):1181–92. Available from: http://www.tandfonline.com/doi/abs/10.1080/13691058.2011.611537 Chola L, McGee S, Tugendhaft A, Buchmann E, Hofman K. Scaling Up Family Planning to Reduce Maternal and Child Mortality: The Potential Costs and Benefits of Modern Contraceptive Use in South Africa. Bammann K, editor. PLOS ONE [Internet]. 2015 Jun 15 [cited 2026 Jan 19];10(6):e0130077. Available from: https://dx.plos.org/10.1371/journal.pone.0130077 Engelbert Bain L, Amu H, Enowbeyang Tarkang E. Barriers and motivators of contraceptive use among young people in Sub-Saharan Africa: A systematic review of qualitative studies. Darteh EKM, editor. PLOS ONE [Internet]. 2021 Jun 4 [cited 2026 Jan 20];16(6):e0252745. Available from: https://dx.plos.org/10.1371/journal.pone.0252745 Dasa TT, Kassie TW, Roba AA, Wakwoya EB, Kelel HU. Factors associated with long-acting family planning service utilization in Ethiopia: a systematic review and meta-analysis. Contracept Reprod Med [Internet]. 2019 Dec [cited 2026 Jan 20];4(1):14. Available from: https://contraceptionmedicine.biomedcentral.com/articles/10.1186/s40834-019-0095-z Ninsiima LR, Chiumia IK, Ndejjo R. Factors influencing access to and utilisation of youth-friendly sexual and reproductive health services in sub-Saharan Africa: a systematic review. Reprod Health [Internet]. 2021;18(1):135–135. Available from: https://doi.org/10.1186/s12978-021-01183-y Ruane-McAteer E, Amin A, Hanratty J, Lynn F, Corbijn Van Willenswaard K, Reid E, et al. Interventions addressing men, masculinities and gender equality in sexual and reproductive health and rights: an evidence and gap map and systematic review of reviews. BMJ Glob Health [Internet]. 2019 Sep [cited 2026 Jan 20];4(5):e001634. Available from: https://gh.bmj.com/lookup/doi/10.1136/bmjgh-2019-001634 Ruane-McAteer E, Gillespie K, Amin A, Aventin Á, Robinson M, Hanratty J, et al. Gender-transformative programming with men and boys to improve sexual and reproductive health and rights: a systematic review of intervention studies. BMJ Glob Health [Internet]. 2020 Oct [cited 2026 Jan 20];5(10):e002997. Available from: https://gh.bmj.com/lookup/doi/10.1136/bmjgh-2020-002997 Aventin Á, Robinson M, Hanratty J, Keenan C, Hamilton J, McAteer ER, et al. Involving men and boys in family planning: A systematic review of the effective components and characteristics of complex interventions in low‐ and middle‐income countries. Campbell Syst Rev [Internet]. 2023 Mar [cited 2026 Jan 20];19(1):e1296. Available from: https://onlinelibrary.wiley.com/doi/10.1002/cl2.1296 Castro A, Kabra R, Coates A, Kiarie J. Successful strategies that address gender-related barriers and promote bodily autonomy within efforts to scale up and sustain postpregnancy contraception: a scoping review. BMJ Glob Health [Internet]. 2025 Feb [cited 2026 Jan 20];10(2):e016638. Available from: https://gh.bmj.com/lookup/doi/10.1136/bmjgh-2024-016638 Assembleia da República. Lei n.o 35/2014 de 31 de Dezembro: Código Penal Despenalização do Aborto Seguro. 2014. UN Women. Making Women Count First Edition, December 2013 [Internet]. UN Women Multi Country Office for India, Bhutan, Sri Lanka and Maldives; 2013 [cited 2026 Jan 20]. Available from: http://www.unwomensouthasia.org Additional Declarations No competing interests reported. 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National survey data indicate that more than half of young women aged 15\u0026ndash;24 have begun childbearing, particularly in rural provinces such as Manica and Tete where access to youth-responsive contraceptive services is constrained and social norms discourage contraceptive use prior to first birth (6\u0026ndash;8).\u003c/p\u003e\n\u003cp\u003eDespite national commitments to expand family planning services, adolescents in Mozambique face persistent barriers to contraceptive uptake, including limited decision-making power, fear of infertility, stigma associated with premarital sexual activity, and partner opposition (9,10). Evidence from sub-Saharan Africa shows that these barriers are strongly shaped by restrictive gender norms that position men as gatekeepers of reproductive decisions and limit AGYW\u0026rsquo;s ability to seek contraception independently (10\u0026ndash;12).\u0026nbsp;Moreover, qualitative evidence from sub-Saharan Africa indicates that social norms constrain open communication between parents and adolescents, often leaving young people without supportive dialogue at home and influencing how they seek information and make decisions about contraception and sexual behaviour\u0026nbsp;(13). \u0026nbsp;Such norms reduce early adoption of modern methods and contribute to reliance on short-acting or no contraception among young women\u0026nbsp;(11,14).\u003c/p\u003e\n\u003cp\u003eLARC methods such as implants and intrauterine devices (IUDs), are highly effective in preventing unintended pregnancy among adolescents. However, uptake remains limited in many rural African settings due to persistent myths, misinformation, and sociocultural resistance (11,15). Evidence suggests that strengthening service availability alone is insufficient to increase LARC uptake without addressing gender norms and broader social determinants that influence contraceptive decision-making (16\u0026ndash;18). Gender-transformative interventions that engage both women and men have demonstrated potential to improve reproductive communication and contraceptive behaviours, yet large-scale population-level evidence remains limited (11,14,19\u0026ndash;22).\u003c/p\u003e\n\u003cp\u003eMozambique\u0026rsquo;s 2014 abortion law reform expanded legal access under specified conditions; however, awareness remains low and stigma persists, reflecting broader gaps in reproductive rights knowledge that intersect with limited contraceptive agency (4,23).\u003c/p\u003e\n\u003cp\u003eThe Supporting Family Planning and Abortion Services Project (IMPACTO), implemented between 2018 and 2024 across nine underserved districts of Manica and Tete provinces, Mozambique, combined community-based, gender-transformative strategies with strengthening of youth-responsive contraceptive services. The intervention sought to address normative and structural barriers to modern contraception, promote equitable gender attitudes supporting reproductive autonomy, and improve awareness of reproductive rights.\u003c/p\u003e\n\u003cp\u003eTo clarify the multi-level nature of the intervention, Table 1 summarizes the principal components implemented across community, institutional, and health-system levels, targeting AGYW, men, community leaders, and service providers.\u003c/p\u003e\n\u003cp\u003eThis paper presents findings from a repeated cross-sectional evaluation of IMPACTO, focusing on changes in modern contraceptive use and shifts toward LARC uptake among AGYW in underserved districts of central Mozambique.\u003c/p\u003e\n\u003cp\u003eTable 1: Key Components of the IMPACTO Intervention (2018\u0026ndash;2024)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntervention domain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTarget group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eKey activities\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntended mechanism of change\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003eSmall-group empowerment curriculum\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eAGYW (15\u0026ndash;24 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eStructured 12-session curriculum addressing gender roles, power dynamics, sexual and reproductive health and rights (SRHR), contraception, consent, and decision-making; integration of civic action module\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eIncrease SRHR knowledge; build self-efficacy; strengthen agency and negotiation capacity\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003eCivic action and leadership training\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eAGYW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eProvincial and district-level civic training workshops; advocacy skill-building; participation in Community Leadership Committees (CLC), Co-Management Committees (CMC), school councils, radio programs, and public forums\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eFoster \u0026ldquo;power within\u0026rdquo;; increase public participation; strengthen accountability mechanisms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003eMale engagement sessions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eAdult men; fathers; partners\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eSmall-group dialogues on masculinity, shared decision-making, contraception, prevention of early marriage and gender-based violence (GBV)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eShift restrictive gender norms; increase support for women and girl\u0026rsquo;s contraceptive autonomy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003eSocial Analysis and Action methodology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eCommunity leaders (CLC, CMC), influencers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eStructured six-session dialogue cycles to examine harmful norms, early marriage, GBV, and SRHR; development of community action plans\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eTransform normative environment; legitimize AGYW participation; reduce social barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003eCommunity sensitization and mass communication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eCommunity members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eRadio programs; community dialogues; household visits; advocacy events (e.g., 16 Days of Activism)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eReduce myths and stigma; normalize contraception and gender equality\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003eYouth-responsive service strengthening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eHealth authorities; facility-based staff and providers; Community Health Workers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eTraining on gender-sensitive, youth-responsive contraception and safe abortion care; LARC provision; expansion of services in hard-to-reach areas; community outreach events\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eImprove quality, availability, and acceptability of contraceptive services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 23px;\"\u003e\n \u003cp\u003eGBV and early marriage prevention\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 18px;\"\u003e\n \u003cp\u003eCommunity leaders; families\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 35px;\"\u003e\n \u003cp\u003eLegal awareness (abortion law, and child, early and forced marriage legislation); engagement with police and judicial system; survivor referral strengthening\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 22px;\"\u003e\n \u003cp\u003eStrengthen protective environment; enhance reproductive autonomy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"MATERIALS and METHODS","content":"\u003ch2\u003eStudy design and study setting\u003c/h2\u003e\n\u003cp\u003eThis study used a repeated cross-sectional, population-based survey design to assess changes in modern contraceptive uptake and related determinants following implementation of the IMPACTO project in underserved areas of Manica and Tete provinces, Mozambique. Baseline data were collected between December 2018 and February 2019, and endline data between November and December 2023. The design allowed comparison of contraceptive behaviours and associated gender and social indicators at population level in project-supported areas.\u003c/p\u003e\n\u003cp\u003eThe surveys were conducted in nine districts where IMPACTO was implemented: i) Manica Province: Chimoio City, Gondola, Macate, Manica, Vanduzi; and ii) Tete Province: Cidade de Tete, Moatize (Town and District), Doa, Mutarara.\u003c/p\u003e\n\u003cp\u003eThese districts are socioeconomically disadvantaged with high poverty levels and limited access to basic services, and characterized by high adolescent fertility, early marriage, limited contraceptive access, and strong sociocultural barriers to SRHR, particularly for adolescents and youth.\u003c/p\u003e\n\u003ch2\u003eStudy population, sample size, and sampling strategy\u003c/h2\u003e\n\u003cp\u003eThe study included two respondent groups: AGYW aged 15\u0026ndash;24 years and men aged 18\u0026ndash;49 years. Eligibility criteria required residence within the selected localities and provision of informed consent prior to participation.\u003c/p\u003e\n\u003cp\u003eThe survey sample was powered to detect a minimum 10-percentage point change in modern contraceptive prevalence between baseline and endline at the provincial level. The sample size was calculated using the formula:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003en = D [(Z\u0026alpha; + Z\u0026beta;)\u0026sup2; \u0026times; (P1(1 \u0026minus; P1) + P2(1 \u0026minus; P2)) / (P2 \u0026minus; P1)\u0026sup2;]\u003c/p\u003e\n\u003cp\u003eAssuming a design effect (D) of 2 to account for cluster sampling, baseline prevalence (P1) of 50%, endline prevalence (P2) of 60%, a two-tailed \u0026alpha; of 0.05, and statistical power of 90%, the minimum required sample was 1,066 respondents per province.\u003c/p\u003e\n\u003cp\u003eTo produce a self-weighted dataset and avoid the need for sampling weights during analysis, the sample size was adjusted proportionally according to the population size of the project catchment areas in each province. The IMPACTO intervention covered districts representing an estimated population of 1,086,557 in Manica and 1,056,488 in Tete, yielding a provincial ratio of approximately 1.03. Based on this proportional adjustment, the survey targeted 1,096 households in Manica and 1,066 households in Tete, for a total of 2,162 households across both provinces.\u003c/p\u003e\n\u003cp\u003eProportional allocation was also applied to selected localities to ensure that the sample mirrors the population distribution. A non-probability random walk household sampling method was employed across 116 randomly selected localities within the nine districts. In each locality, the geographic centre was identified with the assistance of a community informant. Male and female enumerators then proceeded in opposite randomly selected directions, approaching households systematically along their paths. Households were included when at least one eligible AGYW (female enumerator path) or one eligible man (male enumerator path) was present.\u003c/p\u003e\n\u003cp\u003eThis sampling strategy was adopted to ensure broad geographic coverage in underserved and resource-constrained areas where reliable household listings were not available.\u003c/p\u003e\n\u003ch2\u003eMeasures and data collection\u003c/h2\u003e\n\u003cp\u003eThe primary outcomes focused on contraceptive behaviour among AGYW. These included current use of modern contraceptive methods among sexually active, non-pregnant AGYW, shifts in contraceptive method-mix distinguishing short-acting from LARC methods, and implant use as the principal indicator of LARC uptake.\u003c/p\u003e\n\u003cp\u003eSecondary measures captured determinants and contextual factors associated with contraceptive behaviour. These included knowledge and awareness of contraceptive methods, attitudes toward contraceptive safety and eligibility, gender norms assessed using adapted Gender Equitable Men (GEM) scales (24) among both AGYW and men, household decision-making dynamics, attitudes toward GBV and awareness of GBV-related legislation, and knowledge of the legal status of abortion in Mozambique.\u003c/p\u003e\n\u003cp\u003eData were collected using structured questionnaires programmed into the CommCare mobile platform and administered through tablets by trained enumerators. Enumerators were sex-matched to respondents and deployed outside their own communities to minimize social desirability and interviewer bias. Comprehensive training was conducted prior to fieldwork and covered research ethics, informed consent procedures, contraceptive and reproductive health concepts, gender norms, and digital data collection protocols.\u003c/p\u003e\n\u003ch2\u003eData analysis\u003c/h2\u003e\n\u003cp\u003eData were exported from CommCare and analyzed using SPSS and Excel. Descriptive statistics were calculated for all key indicators. Differences in proportions between baseline and endline were assessed using chi-square tests, and 95% confidence intervals were estimated. Analyses were stratified by province and sex where relevant. Gender norms were assessed using an adapted version of the GEM scale (24). Responses to individual GEM items were coded and summed to generate a composite score, which was categorized into tertile equity levels (e.g., low-, medium-, and high-equity) based on distributional cut-offs established prior to analysis. For reporting purposes, high-equity scores were compared between survey rounds to assess shifts in gender attitudes.\u003c/p\u003e\n\u003cp\u003eIndicators with sufficient denominators were tested for statistical significance at \u0026alpha;=0.05. Post-hoc power calculations were conducted for primary outcomes.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003ch2\u003eCharacteristics of the study population\u003c/h2\u003e\n\u003cp\u003eThe surveys included 4,861 respondents at baseline and 5,028 at endline across nine rural districts in Manica and Tete provinces. AGYW comprised 2,392 at baseline and 2,517 at endline, and men 2,469 and 2,511 respectively. The majority of respondents lived in rural areas (\u0026gt;70% AGYW; \u0026gt;80% men).\u003c/p\u003e\n\u003cp\u003eMost AGYW were married or in union (\u0026gt;80%), and approximately half had at least one child.\u003c/p\u003e\n\u003ch2\u003eYouth-responsive service strengthening: Changes in modern contraceptive use and method mix\u003c/h2\u003e\n\u003cp\u003eFollowing implementation of the IMPACTO intervention, substantial improvements were observed in modern contraceptive uptake among sexually active, non-pregnant AGYW across both provinces.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eModern contraceptive prevalence increased from 43.3% at baseline (n=1,707) to 56.4% at endline (n=1,733), representing a 13.1-percentage point increase (95% CI: 9.8\u0026ndash;16.4; \u0026chi;\u0026sup2;=59.6; p\u0026lt;0.0001). Post-hoc statistical power exceeded 99%, confirming adequate sample size to detect this change. Non-use declined from 56.7% to 43.6%, indicating broad uptake across project areas.\u003c/p\u003e\n\u003ch2\u003eChanges in LARC uptake\u003c/h2\u003e\n\u003cp\u003eLARC use among AGYW increased from 3.9% to 16.0% (difference = +12.1 percentage points; 95% CI: 10.1\u0026ndash;14.1; \u0026chi;\u0026sup2; = 147.5; p \u0026lt; 0.0001), primarily driven by implant adoption (3%\u0026nbsp;\u0026rarr;\u0026nbsp;15.4%). This represents a more than four-fold increase in LARC use. The magnitude of change indicates strong behavioural shift toward highly effective methods. Injectable use also increased (15.8%\u0026nbsp;\u0026rarr;\u0026nbsp;23.9%), while condom reliance declined. Given the large sample of contraceptive users, the observed LARC increase is statistically robust and consistent across provinces.\u003c/p\u003e\n\u003ch2\u003eCommunity norm transformation: Shifts in contraceptive attitudes linked to uptake\u003c/h2\u003e\n\u003cp\u003eSignificant improvements were observed in beliefs known to influence contraceptive demand and acceptability among AGYW between baseline and endline (Table 2). The proportion of AGYW agreeing that modern contraception is safe for women who have not yet had children increased markedly from 24.5% at baseline to 46.3% at endline, representing a statistically significant change of +21.8 percentage points (95% CI: 19.2\u0026ndash;24.4; p\u0026lt;0.0001). Similarly, agreement that spacing births through contraception improves maternal and child health increased from 54.1% to 63.4% (+9.3 percentage points; 95% CI: 6.5\u0026ndash;12.0; p\u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eBoth indicators were highly powered (\u0026gt;99%), confirming the robustness of the observed attitudinal shifts. These findings suggest a substantial reduction in fertility-related fears and increased normative acceptance of modern contraceptive use, which likely contributed to the rise in overall contraceptive uptake and LARC adoption among AGYW.\u003c/p\u003e\n\u003cp\u003eTable\u0026nbsp;2: Changes in contraceptive attitudes associated with demand and uptake among AGYW (both provinces)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"102%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIndicator\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEndline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDifference\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003e95% CI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eContraception safe for nulliparous women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+21.8 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e19.18\u0026ndash;24.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eContraceptive spacing improves maternal/child health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+9.3 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e6.55\u0026ndash;12.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003eGender norm transformation\u003c/h2\u003e\n\u003cp\u003eSubstantial improvements were observed in gender-equitable attitudes among both AGYW and men between baseline and endline, as measured using adapted GEM scales (24). The proportion of AGYW with high-equity GEM scores increased from 17.4% at baseline to 41.8% at endline (difference = +24.4 percentage points; 95% CI: 21.7\u0026ndash;27.1; \u0026chi;\u0026sup2; = 365.4; p \u0026lt; 0.0001), while men with high-equity GEM scores rose from 33.1% to 49.3% (difference = +16.2 percentage points; 95% CI: 13.5\u0026ndash;18.9; \u0026chi;\u0026sup2; = 137.6; p \u0026lt; 0.0001). These shifts represent a significant movement away from restrictive norms that traditionally limit women\u0026rsquo;s autonomy over reproductive decision-making.\u003c/p\u003e\n\u003ch2\u003eHousehold agency and structural determinants \u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eMarked improvements were observed across structural indicators that directly affect AGYW\u0026rsquo;s autonomy and ability to adopt and sustain contraceptive use. The proportion of AGYW reporting joint decision-making over household expenditures increased significantly from 16.0% at baseline to 65.0% at endline (difference = +49.0 percentage points; 95% CI: 46.4\u0026ndash;51.6; \u0026chi;\u0026sup2; = 1,115; p \u0026lt; 0.0001), indicating a substantial shift in relational power dynamics within households.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAt the same time, the prevalence of early marriage among AGYW declined significantly from 49.5% to 24.1% (difference = \u0026minus;25.4 percentage points; 95% CI: \u0026minus;28.2 to \u0026minus;22.6; \u0026chi;\u0026sup2; = 370.5; p \u0026lt; 0.0001).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eExperience of GBV among AGYW in the previous 12 months also decreased significantly from 13.4% to 5.3% (p\u0026lt;0.0001). Lower exposure to violence reflects improved safety and reduced coercive control, which are critical conditions for women\u0026rsquo;s ability to make independent reproductive decisions and access contraception without fear or restriction.\u003c/p\u003e\n\u003cp\u003eAll three indicators were highly powered (\u0026gt;99%), reinforcing their statistical robustness and supporting the conceptual pathway through which gender-transformative programming contributed to enhanced agency and an enabling environment for modern contraceptive, particularly LARC, uptake.\u003c/p\u003e\n\u003ch2\u003eChanges in abortion law awareness as part of reproductive choice context\u003c/h2\u003e\n\u003cp\u003eAwareness among AGYW that abortion is legally permitted in Mozambique increased significantly from 10.9% at baseline to 40.7% at endline (difference = +29.8 percentage points; 95% CI: 27.6\u0026ndash;32.4; \u0026chi;\u0026sup2; = 584.2; p \u0026lt; 0.0001). This improvement reflects enhanced dissemination of reproductive rights information within project areas. Although stigma surrounding abortion remained prevalent, increased legal awareness is important within the broader reproductive choice continuum, as it signals greater knowledge of available options and rights related to unintended pregnancy. These findings complement the observed rise in contraceptive uptake by indicating progress in AGYW\u0026rsquo;s overall awareness of reproductive autonomy and legal protections.\u003c/p\u003e\n\u003ch2\u003eSummary of key changes across study outcomes\u003c/h2\u003e\n\u003cp\u003eTable 3\u0026nbsp;presents a synthesis of the principal behavioural and structural outcomes observed between baseline and endline across both provinces, highlighting statistically significant improvements in modern contraceptive use, LARC uptake, gender norms, and related determinants influencing reproductive agency among AGYW.\u003c/p\u003e\n\u003cp\u003eTable 3: Summary of key outcomes observed between baseline and endline (both provinces)\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eDomain\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eIndicator\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEndline\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eChange\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSignificance\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eContraceptive Use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eModern contraceptive prevalence (AGYW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e40.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e56.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+16 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eLARC use\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eImplant use (AGYW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e15.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+12.4 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eTotal LARC use (AGYW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e3.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+12.1 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eAttitudes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eContraception safe for nulliparous women\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e46.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+21.8 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eBirth spacing improves maternal/child health\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+9.3 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003eGender Norms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh GEM (AGYW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41.8%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+24.4 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHigh GEM (Men)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e49.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+16.2 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eAgency\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eJoint household decision-making\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e16.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+49 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eProtection\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAGYW reporting GBV (12 months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.4%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5.3%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026minus;8.1 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSocial Context\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eEarly marriage among AGYW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e49.5%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24.1%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026minus;25.4 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eRights Awareness\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eAbortion law awareness (AGYW)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e41.0%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e+30 pp\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ep\u0026lt;0.0001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eChanges in normative and agency factors alongside modern contraceptive uptake\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo further contextualize the observed increase in modern contraceptive and LARC uptake among AGYW, descriptive comparisons were conducted examining selected attitudinal, agency, and gender norm indicators across survey rounds (Table 4). These indicators correspond to key domains of the IMPACTO intervention and represent potential pathways through which gender-transformative programming may influence contraceptive behaviour. Although these descriptive findings do not establish causal relationships, the parallel improvements across behavioural and normative domains are consistent with the intervention\u0026rsquo;s multi-level theory of change.\u003c/p\u003e\n\u003cp\u003eTable 4: Changes in selected attitudinal, agency, and gender norm indicators among AGYW and men, baseline and endline\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"bottom\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eModern Contraceptive Use (baseline)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eModern Contraceptive\u0026nbsp;Use (endline)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eContraceptive Attitude \u0026ndash; AGYW*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Birth spacing improves maternal/child health - AGREE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e54.1% (1,295/2,392)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e63.4% (1,597/2,517)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Birth spacing improves maternal/child health - DISAGREE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e11.6% (277/2,392)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.3% (209/2,517)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eAgency - AGYW**\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Makes household decision-making - JOINTLY or SELF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e50.8% (868/1,707)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e58.6% (1015/1,733)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Makes household decision-making - HUSBAND\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e31.9% (545/1,707)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e25.7% (446/1,733)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender norms - AGYW\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;GEM scale - HIGH equity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.4% (321/2,392)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e38.7% (973/2,517)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;GEM scale - LOW equity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e23.0% (550/2,392)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e8.3% (205/2,517)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender norms - MEN\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;GEM scale - HIGH equity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e33.1% (818/2,469)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e49.2% (1,235/2,511)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;GEM scale - LOW equity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e13.6% (335/2,469)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e7.6% (191/2,511)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eNote: Contraceptive attitude* was measured as the proportion of AGYW who agreed that using contraception for spacing pregnancies improves the health of the mother and baby. Agency** was constructed as a composite indicator based on five decision-making domains: (1) use of household income; (2) visits to family members; (3) ability to work outside the home; (4) use of contraceptives; and (5) access to health services or medical treatment.\u003c/p\u003e\n\u003cp\u003eImprovements in modern contraceptive use occurred alongside substantial shifts in attitudinal and normative indicators. Agreement that birth spacing improves maternal and child health increased from 54.1% to 63.4% among AGYW. The proportion reporting joint or self-household decision-making increased from 50.8% to 58.6%, while husband-only decision-making declined. High-equity GEM scores increased markedly among AGYW (13.4% to 38.7%) and men (33.1% to 49.2%).\u003c/p\u003e\n\u003cp\u003eAlthough these descriptive findings do not establish causality, the parallel improvements in normative, attitudinal, and agency indicators alongside increases in modern contraceptive and LARC uptake are consistent with the intervention\u0026rsquo;s theory of change.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis evaluation provides population-level evidence that a multi-level, gender-transformative, community-based intervention was associated with substantial increases in modern contraceptive use and a marked shift toward LARC uptake among AGYW in underserved districts of Mozambique.\u003c/p\u003e\n\u003cp\u003eThe observed increase in implant use, together with improvements in gender norms, agency, and contraceptive attitudes, reinforces growing evidence that demand-side and structural barriers are central determinants of adolescent contraceptive behaviour in low-resource settings (9,11,16).\u003c/p\u003e\n\u003ch2\u003eGender norms and male engagement as drivers of contraceptive behaviour\u003c/h2\u003e\n\u003cp\u003eRestrictive gender norms have been widely documented as barriers to AGYW’s contraceptive autonomy across sub-Saharan Africa (10–12,14). Norms that position men as gatekeepers of reproductive decision-making, alongside parental and community expectations surrounding early marriage and childbearing, can limit early contraceptive initiation and reduce acceptance of modern methods, particularly LARCs (12,14). The substantial rise in high-equity GEM scores among both AGYW and men observed in this evaluation reflects meaningful shifts toward equitable attitudes and aligns with systematic evidence demonstrating that gender-transformative programming can improve women’s reproductive agency and contraceptive uptake when male partners and communities are actively engaged (19–22). Improved male support and declining acceptance of violence likely contributed to an enabling environment for AGYW to seek and sustain contraceptive use.\u003c/p\u003e\n\u003ch2\u003eReducing demand-side barriers and structural constraints to support LARC uptake\u003c/h2\u003e\n\u003cp\u003eThe four-fold increase in implant use represents a major shift toward highly effective contraception among AGYW. Prior studies have shown that adolescents rarely adopt LARCs in contexts where myths about infertility and sociocultural resistance persist (11,16,17). The marked improvement in attitudes regarding contraceptive safety for nulliparous women indicates reduced perceived barriers to LARC eligibility, which likely facilitated greater uptake. Concurrent improvements in joint household decision-making, reductions in early marriage, and declines in GBV further demonstrate strengthened agency and diminished structural constraints that traditionally limit adolescent reproductive autonomy (3–5,12,19). Together, these shifts provide a coherent pathway linking gender norm transformation to increased adoption of LARCs. These shifts align with increases in high-equity GEM scores among both AGYW and men, reflecting movement away from norms that reinforce male dominance and restrict women’s independent health decision-making. Gender-equitable attitudes among AGYW are associated with enhanced negotiation capacity and greater likelihood of initiating contraception prior to first birth, while improved attitudes among men may contribute to more supportive relational environments and reduced resistance to women’s contraceptive use.\u003c/p\u003e\n\u003cp\u003eTaken together, these behavioural, normative, and structural changes provide a coherent explanatory pathway for the observed rise in modern contraceptive prevalence and LARC adoption. The findings reinforce growing evidence that addressing gender norms and demand-side barriers is critical for expanding adolescent access to highly effective contraceptive methods in underserved settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBroader reproductive rights awareness and programme implications\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIncreased awareness of abortion legality reflects expanded exposure to reproductive rights information, complementing improvements in contraceptive empowerment despite persistent stigma (4,23). The findings highlight that strengthening youth-responsive services alone is insufficient to expand LARC uptake in socially constrained environments. Integrating gender-transformative, community-based strategies within family planning programmes can accelerate modern contraceptive adoption and shift adolescents toward more effective methods in underserved settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations and contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe repeated cross-sectional design without a comparison group limits causal inference, and the random walk sampling restricts generalizability. Self-reported contraceptive use may also be subject to desirability bias. Nevertheless, large sample sizes, high statistical power, and consistent changes across behavioural and structural indicators strengthen confidence in programme-associated effects. This study contributes rare large-scale African evidence demonstrating that gender-transformative approaches can significantly drive LARC uptake among AGYW in high-deprivation contexts. The magnitude and consistency of change across modern contraceptive uptake, gender equitable attitudes, household decision-making, and rights awareness strongly align with the IMPACTO conceptual framework, which hypothesized that transforming social and gender norms would increase AGYW’s agency and enable greater utilization of sexual and reproductive health services.\u003c/p\u003e\n\u003cp\u003eThe parallel improvements observed across normative, attitudinal, and agency indicators strengthen the plausibility of the intervention’s hypothesized pathways linking social norm transformation to contraceptive behaviour change.\u003c/p\u003e"},{"header":"CONCLUSIONS AND IMPLICATIONS","content":"\u003cp\u003eThe IMPACTO intervention was associated with substantial increases in modern contraceptive use and a pronounced shift toward LARC adoption among AGYW in underserved districts of Mozambique. The four-fold rise in implant uptake suggests that addressing gender norms, household power dynamics, and structural barriers alongside youth-responsive service strengthening can accelerate access to highly effective contraception among adolescents.\u003c/p\u003e\n\u003ch2\u003eProgrammatic implications\u003c/h2\u003e\n\u003cp\u003eIntegrating gender-transformative, community-based strategies within family planning programmes may enhance adolescents\u0026rsquo; contraceptive autonomy and reduce resistance to LARC adoption in socioeconomically deprived settings.\u003c/p\u003e\n\u003ch2\u003ePolicy implications\u003c/h2\u003e\n\u003cp\u003eScaling similar multi-level approaches within Mozambique\u0026rsquo;s national family planning strategy could contribute to sustained reductions in adolescent pregnancy and improved equity in access to long-acting methods.\u003c/p\u003e\n\u003ch2\u003eAcademic implications\u003c/h2\u003e\n\u003cp\u003eThis study contributes rare population-level evidence from sub-Saharan Africa demonstrating that transforming gender norms and social determinants is closely aligned with increased LARC uptake, reinforcing the importance of integrating gender and structural analysis into contraceptive research and programme evaluation.\u003c/p\u003e"},{"header":"LIST OF ABBREVIATIONS","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 458px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFull term\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eAGYW\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 458px;\"\u003e\n \u003cp\u003eAdolescent Girls and Young Women\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eCLC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 458px;\"\u003e\n \u003cp\u003eCommunity Leadership Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eCMC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 458px;\"\u003e\n \u003cp\u003eCo-Management Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eGBV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 458px;\"\u003e\n \u003cp\u003eGender-Based Violence\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eGEM\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 458px;\"\u003e\n \u003cp\u003eGender Equitable Men\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eIMPACTO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 458px;\"\u003e\n \u003cp\u003eSupporting Family Planning and Abortion Services Project\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eIUD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 458px;\"\u003e\n \u003cp\u003eIntrauterine Device\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eLARC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 458px;\"\u003e\n \u003cp\u003eLong-Acting, Reversible Contraceptive\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 118px;\"\u003e\n \u003cp\u003eSRHR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 458px;\"\u003e\n \u003cp\u003eSexual and Reproductive Health and Rights\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003eACKNOWLEDGMENTS\u003c/p\u003e\n\u003cp\u003eThe authors gratefully acknowledge Global Affairs Canada for financial support, as well as the Ministry of Health, Directorate of Public Health, and the provincial health authorities of Tete and Manica for their support in both the implementation of the IMPACTO project and the evaluation activities. We extend our sincere appreciation to Pathfinder International and local partner staff for their collaboration, and to all study participants including health professionals, adolescent girls and young women, men, and community leaders whose participation made this study possible.\u003c/p\u003e\n\u003cp\u003eAUTHORS\u0026rsquo; CONTRIBUTION\u003c/p\u003e\n\u003cp\u003eBC led the writing of the manuscript for publication, LV coordinated implementation of the IMPACTO project, AS conducted the design and coordinated the evaluations with support from MB. JF, LV, MB, and KH provided internal review of the manuscript.\u003c/p\u003e\n\u003cp\u003eFUNDING\u003c/p\u003e\n\u003cp\u003eBoth implementation and evaluation reported in this publication were supported by\u0026nbsp;Global Affairs Canada. The content is solely the responsibility of the authors and does not necessarily represent the official views of\u0026nbsp;Global Affairs Canada\u0026nbsp;or Pathfinder International.\u003c/p\u003e\n\u003cp\u003eDATA AVAILABILITY\u003c/p\u003e\n\u003cp\u003eAll data and materials are accessible upon request from the corresponding\u003c/p\u003e\n\u003cp\u003eauthor.\u003c/p\u003e\n\u003cp\u003eCOMPETING INTERESTS\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCONSENT FOR PUBLICATION\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN/A\u003c/p\u003e\n\u003cp\u003eETHICAL APPROVAL AND PARTICIPANTS CONSENT\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from the Mozambican Ministry of Health Institutional Review Board (Ref: 434/CNBS/18; amended 2023). All procedures were conducted in accordance with the ethical standards of the institutional research committee and with the 1964 Declaration of Helsinki and its later amendments. Written informed consent was obtained from all participants prior to data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. Adolescent Health in Mozambique. 2018. \u003c/li\u003e\n\u003cli\u003eAndrade EP, Villalba JP, Souza Li LFR de. Manual T\u0026eacute;cnico Para O Cuidado \u0026Agrave; Sa\u0026uacute;de Do Adolescente Na Aten\u0026ccedil;\u0026atilde;o B\u0026aacute;sica Equipe T\u0026eacute;cnica Respons\u0026aacute;vel Pelo Manual [Internet]. 2019. 1 p. Available from: http://ipads.org.br/cidadaniajovem/wp-content/uploads/2020/08/MANUAL-T\u0026Eacute;CNICO-SA\u0026Uacute;DE-ADOLESCENTE-DIGITAL.pdf\u003c/li\u003e\n\u003cli\u003eKok MC, Kakal T, Kassegne AB, Hidayana IM, Munthali A, Menon JA, et al. Drivers of child marriage in specific settings of Ethiopia, Indonesia, Kenya, Malawi, Mozambique and Zambia \u0026ndash; findings from the Yes I Do! baseline study. BMC Public Health [Internet]. 2023 Apr 28 [cited 2026 Jan 19];23(1):794. Available from: https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-023-15697-6\u003c/li\u003e\n\u003cli\u003eGriffin S, Melo MD, Picardo JJ, Sheehy G, Madsen E, Matine J, et al. The Role of Gender Norms in Shaping Adolescent Girls\u0026rsquo; and Young Women\u0026rsquo;s Experiences of Pregnancy and Abortion in Mozambique. Adolescents [Internet]. 2023 Jun 14 [cited 2026 Jan 19];3(2):343\u0026ndash;65. Available from: https://www.mdpi.com/2673-7051/3/2/24\u003c/li\u003e\n\u003cli\u003eNhampoca JM, Maritz JE. Early marriage, education and mental health: experiences of adolescent girls in Mozambique. Front Glob Womens Health [Internet]. 2024 Jun 12 [cited 2026 Jan 19];5:1278934. Available from: https://www.frontiersin.org/articles/10.3389/fgwh.2024.1278934/full\u003c/li\u003e\n\u003cli\u003eInstituto Nacional de Estat\u0026iacute;sticas. Inqu\u0026eacute;rito Demogr\u0026aacute;fico e de Sa\u0026uacute;de 2022\u0026ndash;23 em Mo\u0026ccedil;ambique (IDS 2022\u0026ndash;23). Maputo Mo\u0026ccedil;amb E Rockv Md EUA [Internet]. 2024;24:71\u0026ndash;5. Available from: http://www.ncbi.nlm.nih.gov/pubmed/14170994\u003c/li\u003e\n\u003cli\u003eUNICEF, UNFPA \u0026amp; CECAP. Child marriage and adolescent pregnancy in Mozambique: causes and impact. Maputo, Mozambique: The UNICEF Mozambique, UNFPA and Coliga\u0026ccedil;\u0026atilde;o para a Elimina\u0026ccedil;\u0026atilde;o e Preven\u0026ccedil;\u0026atilde;o dos Casamentos Prematuros; 2015. \u003c/li\u003e\n\u003cli\u003eCEPSA. Adolescentes e Jovens em Mo\u0026ccedil;ambique: uma Perspectiva Demogr\u0026aacute;fica e de Sa\u0026uacute;de. Boaventura M. Cau Carlos Arnaldo. Maputo, Mozambique: Centro de Estudos de Popula\u0026ccedil;\u0026atilde;o e Sa\u0026uacute;de; 2014. 240 p. \u003c/li\u003e\n\u003cli\u003eChandra-Mouli V. What Does Not Work in Adolescent Sexual and Reproductive Health: A Review of Evidence on Interventions Commonly Accepted as Best Practices. Glob Health Sci Pract. 2015;3(3):333\u0026ndash;40. \u003c/li\u003e\n\u003cli\u003eMISAU-DNSP. Estrat\u0026eacute;gia Nacional de Planeamento Familiar 2023-2030. Minist\u0026eacute;rio da Sa\u0026uacute;de (MISAU) Direc\u0026ccedil;\u0026atilde;o Nacional de Sa\u0026uacute;de P\u0026uacute;blica (DNSP); 2023 Dec. \u003c/li\u003e\n\u003cli\u003eMohamed S, Chipeta MG, Kamninga T, Nthakomwa L, Chifungo C, Mzembe T, et al. Interventions to prevent unintended pregnancies among adolescents: a rapid overview of systematic reviews. Syst Rev [Internet]. 2023 Oct 19 [cited 2026 Jan 19];12(1):198. Available from: https://systematicreviewsjournal.biomedcentral.com/articles/10.1186/s13643-023-02361-8\u003c/li\u003e\n\u003cli\u003eBlanc AK. The Effect of Power in Sexual Relationships on Sexual and Reproductive Health: An Examination of the Evidence. Stud Fam Plann [Internet]. 2001 Sep [cited 2026 Jan 19];32(3):189\u0026ndash;213. Available from: https://onlinelibrary.wiley.com/doi/10.1111/j.1728-4465.2001.00189.x\u003c/li\u003e\n\u003cli\u003eUsonwu I, Ahmad R, Curtis-Tyler K. Parent\u0026ndash;adolescent communication on adolescent sexual and reproductive health in sub-Saharan Africa: a qualitative review and thematic synthesis. Reprod Health [Internet]. 2021 Dec [cited 2026 Feb 2];18(1):202. Available from: https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-021-01246-0\u003c/li\u003e\n\u003cli\u003eMacia M, Maharaj P, Gresh A. Masculinity and male sexual behaviour in Mozambique. Cult Health Sex [Internet]. 2011 Nov [cited 2026 Jan 19];13(10):1181\u0026ndash;92. Available from: http://www.tandfonline.com/doi/abs/10.1080/13691058.2011.611537\u003c/li\u003e\n\u003cli\u003eChola L, McGee S, Tugendhaft A, Buchmann E, Hofman K. Scaling Up Family Planning to Reduce Maternal and Child Mortality: The Potential Costs and Benefits of Modern Contraceptive Use in South Africa. Bammann K, editor. PLOS ONE [Internet]. 2015 Jun 15 [cited 2026 Jan 19];10(6):e0130077. Available from: https://dx.plos.org/10.1371/journal.pone.0130077\u003c/li\u003e\n\u003cli\u003eEngelbert Bain L, Amu H, Enowbeyang Tarkang E. Barriers and motivators of contraceptive use among young people in Sub-Saharan Africa: A systematic review of qualitative studies. Darteh EKM, editor. PLOS ONE [Internet]. 2021 Jun 4 [cited 2026 Jan 20];16(6):e0252745. Available from: https://dx.plos.org/10.1371/journal.pone.0252745\u003c/li\u003e\n\u003cli\u003eDasa TT, Kassie TW, Roba AA, Wakwoya EB, Kelel HU. Factors associated with long-acting family planning service utilization in Ethiopia: a systematic review and meta-analysis. Contracept Reprod Med [Internet]. 2019 Dec [cited 2026 Jan 20];4(1):14. Available from: https://contraceptionmedicine.biomedcentral.com/articles/10.1186/s40834-019-0095-z\u003c/li\u003e\n\u003cli\u003eNinsiima LR, Chiumia IK, Ndejjo R. Factors influencing access to and utilisation of youth-friendly sexual and reproductive health services in sub-Saharan Africa: a systematic review. Reprod Health [Internet]. 2021;18(1):135\u0026ndash;135. Available from: https://doi.org/10.1186/s12978-021-01183-y\u003c/li\u003e\n\u003cli\u003eRuane-McAteer E, Amin A, Hanratty J, Lynn F, Corbijn Van Willenswaard K, Reid E, et al. Interventions addressing men, masculinities and gender equality in sexual and reproductive health and rights: an evidence and gap map and systematic review of reviews. BMJ Glob Health [Internet]. 2019 Sep [cited 2026 Jan 20];4(5):e001634. Available from: https://gh.bmj.com/lookup/doi/10.1136/bmjgh-2019-001634\u003c/li\u003e\n\u003cli\u003eRuane-McAteer E, Gillespie K, Amin A, Aventin \u0026Aacute;, Robinson M, Hanratty J, et al. Gender-transformative programming with men and boys to improve sexual and reproductive health and rights: a systematic review of intervention studies. BMJ Glob Health [Internet]. 2020 Oct [cited 2026 Jan 20];5(10):e002997. Available from: https://gh.bmj.com/lookup/doi/10.1136/bmjgh-2020-002997\u003c/li\u003e\n\u003cli\u003eAventin \u0026Aacute;, Robinson M, Hanratty J, Keenan C, Hamilton J, McAteer ER, et al. Involving men and boys in family planning: A systematic review of the effective components and characteristics of complex interventions in low‐ and middle‐income countries. Campbell Syst Rev [Internet]. 2023 Mar [cited 2026 Jan 20];19(1):e1296. Available from: https://onlinelibrary.wiley.com/doi/10.1002/cl2.1296\u003c/li\u003e\n\u003cli\u003eCastro A, Kabra R, Coates A, Kiarie J. Successful strategies that address gender-related barriers and promote bodily autonomy within efforts to scale up and sustain postpregnancy contraception: a scoping review. BMJ Glob Health [Internet]. 2025 Feb [cited 2026 Jan 20];10(2):e016638. Available from: https://gh.bmj.com/lookup/doi/10.1136/bmjgh-2024-016638\u003c/li\u003e\n\u003cli\u003eAssembleia da Rep\u0026uacute;blica. Lei n.o 35/2014 de 31 de Dezembro: C\u0026oacute;digo Penal Despenaliza\u0026ccedil;\u0026atilde;o do Aborto Seguro. 2014. \u003c/li\u003e\n\u003cli\u003eUN Women. Making Women Count First Edition, December 2013 [Internet]. UN Women Multi Country Office for India, Bhutan, Sri Lanka and Maldives; 2013 [cited 2026 Jan 20]. Available from: http://www.unwomensouthasia.org\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"contraception-and-reproductive-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"carm","sideBox":"Learn more about [Contraception and Reproductive Medicine](http://contraceptionmedicine.biomedcentral.com)","snPcode":"40834","submissionUrl":"https://submission.nature.com/new-submission/40834/3","title":"Contraception and Reproductive Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Adolescent girls and young women, Modern contraceptive prevalence, Long-acting reversible contraceptives, Gender norms, Gender-transformative intervention, Male engagement, Household decision-making, Mozambique, Family planning programme evaluation","lastPublishedDoi":"10.21203/rs.3.rs-8869107/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8869107/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003cbr\u003e\nModern contraceptive use among adolescents in Mozambique remains constrained by limited access and restrictive gender norms that reduce girls and young women’s autonomy over reproductive decision-making. Evidence on large-scale gender-transformative interventions that influence modern contraceptive and long-acting reversible contraceptive (LARC) uptake among adolescent girls and young women (AGYW) remains limited. The IMPACTO project (2018–2024) implemented a multi-level intervention across underserved districts of Manica and Tete provinces combining gender-transformative community strategies with youth-responsive service strengthening. This study assessed changes in modern contraceptive use and LARC uptake following implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003cbr\u003e\nA repeated cross-sectional household survey was conducted at baseline (2018–2019) and endline (2023) across nine underserved districts in central Mozambique. AGYW aged 15–24 years and men aged 18–49 years were selected using a random walk household sampling approach. Data were collected using tablet-based questionnaires capturing contraceptive use, attitudes toward family planning services, gender norms, household decision-making, gender-based violence (GBV) attitudes, and awareness of abortion legislation. Differences in proportions between baseline and endline were assessed using chi-square tests, and 95% confidence intervals were estimated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003cbr\u003e\nA total of 4,861 respondents participated at baseline and 5,028 at endline. Modern contraceptive use among sexually active AGYW increased from 43.3% to 56.4% (p\u0026lt;0.0001). Implant use rose substantially from 3.0% to 15.4%, representing a four-fold rise in LARC uptake. Improvements were observed in contraceptive attitudes, gender-equitable norms among AGYW (17.4% to 41.8%) and men (33.1% to 49.3%), joint household decision-making (16.0% to 65.0%) and reductions in early marriage and GBV. \u0026nbsp;Awareness of abortion decriminalization increased from 10.9% to 40.7%. Descriptive parallel improvements across behavioural, normative, and structural indicators were consistent with the intervention’s theory of change.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003cbr\u003e\nA gender-transformative community intervention combined with youth-responsive service strengthening was associated with substantial increases in modern contraceptive use and a pronounced shift toward LARC methods use among AGYW in underserved districts of Mozambique. Improvements in service delivery alone are unlikely to result in equitable access to highly effective contraception for adolescents without concurrent transformation of social and gender norms.\u003c/p\u003e","manuscriptTitle":"Gender-transformative, community-based intervention and changes in long-acting reversible contraceptive use among adolescent girls and young women in underserved districts of Mozambique","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-06 12:06:03","doi":"10.21203/rs.3.rs-8869107/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-04-28T22:00:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"67658065575847273188581478915482897200","date":"2026-04-07T10:46:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"147520800688618876596787144729959646827","date":"2026-04-07T06:01:44+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-31T15:28:23+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-20T08:57:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-18T17:35:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"Contraception and Reproductive Medicine","date":"2026-02-13T07:59:27+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"contraception-and-reproductive-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"carm","sideBox":"Learn more about [Contraception and Reproductive Medicine](http://contraceptionmedicine.biomedcentral.com)","snPcode":"40834","submissionUrl":"https://submission.nature.com/new-submission/40834/3","title":"Contraception and Reproductive Medicine","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6d95b92e-359c-41e9-b3d3-1d4d780f91b0","owner":[],"postedDate":"April 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-06T12:06:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-06 12:06:03","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8869107","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8869107","identity":"rs-8869107","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}