---
title: "Barriers to Adolescent Pregnancy Prevention in LMICs: Implementers’ Perspectives"
id: "plos-one-23-exploring-barriers-to-implementing-adolescent-pregnancy-prevention"
canonical_url: "https://medichelpline.com/clinical-feed/plos-one-23-exploring-barriers-to-implementing-adolescent-pregnancy-prevention"
content_type: "clinical_feed_article"
specialty: "Pediatrics"
source_name: "PLOS ONE (Medicine)"
source_url: "https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0360943"
published_at: "2026-10-23T14:00:00.000Z"
evidence_level: "Journal Feed"
license: "CC-BY-NC-4.0 / Informational Use"
---
# Barriers to Adolescent Pregnancy Prevention in LMICs: Implementers’ Perspectives
## Provenance & Clinical Metadata
- **Canonical URL:** https://medichelpline.com/clinical-feed/plos-one-23-exploring-barriers-to-implementing-adolescent-pregnancy-prevention
- **Specialty:** [Pediatrics](https://medichelpline.com/clinical-feed/pediatrics.md)
- **Primary Source:** PLOS ONE (Medicine)
- **Source URL:** [Original Journal Publication](https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0360943)
- **Published At:** 2026-10-23T14:00:00.000Z
- **Evidence Rating:** Journal Feed
## Executive GIST (TL;DR)
- Investigators conducted a qualitative exploratory study interviewing 19 programme implementers working across 24 low- and middle-income countries to identify implementation barriers to adolescent pregnancy prevention. - Data were collected through virtual in-depth individual interviews between August and October 2024 and organized with Dedoose for thematic analysis; the study used purposive and snowball sampling. - Experts reported seven interrelated implementation challenges that limited **adolescent pregnancy** prevention programmes’ reach, acceptability, and sustainability. - The cohort described adolescent engagement as tied to perceived usefulness and, at times, to material or social incentives; stigma and confidentiality concerns pushed youth toward private information-seeking. - Gendered power dynamics reduced boys’ participation and constrained girls’ agency; household poverty, material insecurity, and transactional marriage practices (for example, bride price) promoted early unions and childbearing. - Program legitimacy was undermined by cultural taboo, religious opposition, contraception myths, and normalization of violence, which limited community support and open discussion of **sexual and reproductive health (SRH)**. - Operational barriers included bureaucratic delays, weak institutional backing, school resistance, unstable policy environments, and donor-dependent financing, all of which hampered continuity and scale-up. - The study team noted that effective programmes must go beyond information provision: they require relevance to adolescents, confidentiality safeguards, attention to gendered power, community gatekeeper engagement, and stronger enabling implementation conditions. - The authors reported no specific funding and made underlying data available via Figshare; they considered thematic sufficiency reached by the 19th interview but acknowledged that local nuances and country-level differences were not exhaustively captured.
## Clinical Analysis & Structured Key Points
Exploring barriers to implementing adolescent pregnancy prevention interventions in low- and middle-income countries: Perspectives from international experts | PLOS One Browse Subject Areas ? Click through the PLOS taxonomy to find articles in your field. For more information about PLOS Subject Areas, click here . Article Authors Metrics Comments Media Coverage Reader Comments Figures Figures Abstract Background Adolescent pregnancy remains a significant public health concern, particularly in low- and middle-income countries (LMICs). Although various interventions have been implemented to address this issue, many have failed to achieve positive outcomes due to numerous barriers. Objective To explore the barriers to implementing adolescent pregnancy prevention interventions in LMICs. Methods This qualitative exploratory study involved 19 adolescent pregnancy prevention program implementers across 24 LMICs. Data were collected through virtual in-depth individual interviews, organized using Dedoose software, and analyzed thematically. Results Findings highlighted seven interrelated challenges shaping programme reach, acceptability, and sustainability. Experts reported that adolescents’ engagement depended on perceived usefulness and, at times, material or social benefits of attendance, while stigma made participation social risky and encouraged private information-seeking. Prevention efforts were further constrained by gendered allocation and unequal decision-making power, which limited boys’ participation and girls’ agency. Separately, poverty, household material insecurity, and transactional marriage practices such as bride price contributed to early unions and subsequent childbearing, while programme legitimacy is challenged by taboo, religious opposition, contraception myths, and the normalization of violence. Finally, implementation was hindered by administrative delays, weak institutional backing, school-level resistance, and unstable or poorly enforced policy environments, limiting continuity and scale-up of interventions. Conclusion Effective teenage pregnancy prevention in LMICs requires more than delivering sexual and reproductive health (SRH) information; programmes must be designed to feel relevant to adolescents while reducing stigma and protecting confidentiality to support genuine engagement. Interventions also need to address gendered power dynamics and gatekeeper control, alongside community-level legitimacy barriers such as taboo, religious opposition, contraception myths, and normalized violence. Sustainable impact will depend on enabling implementation conditions, including reduced bureaucratic delays, stronger institutional and school support, coherent policies, reliable financing beyond donor cycles, and better data to guide targeted action. Citation: Nkurunziza A, Nkurikiyintwali JMV, Ndayisenga JP, Kasine Y, Twagirayezu I, Uwera YDN (2026) Exploring barriers to implementing adolescent pregnancy prevention interventions in low- and middle-income countries: Perspectives from international experts. PLoS One 21(10): e0360943. https://doi.org/10.1371/journal.pone.0360943 Editor: Mudasir Mustafa, University of West Florida, UNITED STATES OF AMERICA Received: February 27, 2026; Accepted: October 2, 2026; Published: October 23, 2026 Copyright: © 2026 Nkurunziza et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Data Availability: The data underlying the results presented in the study are available from FIGSHARE https://doi.org/10.6084/m9.figshare.31434898 . Funding: The author(s) received no specific funding for this work. Competing interests: The authors have declared that no competing interests exist. Introduction Adolescents make up a significant portion of the global population, with most residing in low- and middle-income countries (LMICs) [ 1 ]. Adolescent pregnancy remains a major global health and development challenge, carrying far-reaching health, social, and economic consequences for adolescents and their communities, including adverse health outcomes, heightened vulnerability to unemployment, and disrupted educational trajectories (World Health Organization [ 2 ]. The WHO defines adolescent pregnancy as pregnancy occurring among girls aged 10–19 years [ 2 , 3 ]. While fertility rates among adolescents aged 15–19 have declined globally, progress has been uneven: adolescent birth rates in LMICs remain approximately four times higher than those in high-income regions, underscoring persistent and profound inequities [ 4 , 5 ]. As of 2019, it was estimated that each year, around 21 million pregnancies occurred among adolescents aged 15–19 in LMICs, with nearly half of these pregnancies being unintended and leading to approximately 12 million births [ 6 ]. Moreover, despite improvements in some settings, projections indicate that adolescent pregnancies may rise again by 2030, driven largely by the rapid growth of adolescent populations in many LMICs and the resulting demographic momentum. Trends in adolescent birth rates have varied across regions, with Southern Asia experiencing the steepest decline, while reductions have been slower in Latin America and the Caribbean (LAC) and sub-Saharan Africa (SSA) [ 7 , 8 ]. Although all regions have seen decreases, SSA and LAC still report the highest rates globally, at 97.9 and 51.4 births per 1,000 women, respectively, in 2023. Global efforts have focused on improving the sexual and reproductive health rights (SRHR) of adolescents. However, progress has been uneven across countries, largely due to restrictive social norms that limit girls’ and women’s autonomy, gender stereotypes that discourage their participation in education and decision-making, and power imbalances that reduce their access to resources, opportunities, and health services in many LMICs. In these regions, inadequate infrastructure, widespread poverty, and high rates of gender-based violence have significantly hindered adolescents from accessing essential SRH services [ 1 ]. In response to these persistently high rates, numerous interventions have been implemented to prevent adolescent pregnancy across LMICs, including cash transfer programs, school-based education curricula, life-skills training, contraceptive provision initiatives, peer education programs, and mass media campaigns [ 9 ]. However, available evidence suggests that many initiatives do not consistently achieve their intended outcomes, even when they are designed to address key drivers of adolescent pregnancy. Importantly, while some studies have documented barriers encountered by those delivering interventions, these insights remain dispersed across contexts and intervention types, limiting the field’s ability to draw coherent, implementation-relevant lessons. There is therefore a critical need to systematically examine the barriers faced by key stakeholders involved in delivering adolescent pregnancy prevention interventions in LMICs. To our knowledge, no study has comprehensively examined this issue, making this research timely and significant. By synthesizing implementers’ perspectives, this study aims to strengthen understanding of real-world implementation constraints and to inform the design of more feasible, acceptable, and sustainable strategies for policymakers, practitioners, and researchers seeking to improve adolescent sexual and reproductive health outcomes in LMICs. Materials and methods Study design This study employed a descriptive exploratory qualitative research design, which is particularly effective for gaining a comprehensive understanding of a specific area of interest [ 10 ]. This approach was appropriately selected to facilitate an in-depth exploration of the barriers experienced by stakeholders involved in implementing interventions aimed at addressing adolescent pregnancy in LMICs. Population and sampling Purposive and snowball sampling was used to invite experts involved in the implementation of interventions aimed at preventing adolescent pregnancies across in LMICs. Eligible participants included individuals who had been involved in designing, implementing, or evaluating sexual and reproductive health interventions specifically targeting adolescent pregnancies in LMICs. Only those who had worked on such interventions for a minimum period of six months and were able to communicate in English and French were included. The study initially aimed to recruit approximately 25 participants. Sample adequacy was assessed in relation to the study’s exploratory objective and the recurrence and depth of cross-cutting implementation concepts. Because participants represented diverse geographical, professional, and programme contexts, this assessment was made at the level of overarching programmatic and implementation barriers rather than within individual countries or regions. By the 19 th interview, the major categories were recurring across participants’ accounts, and the later interviews primarily elaborated existing categories or provided context-specific examples rather than introducing substantively new overarching categories. The dataset was therefore considered to have achieved conceptual or high-level thematic sufficiency for addressing the study objective. This determination does not imply that localized cultural meanings, intervention-specific experiences, or country- and region-level differences were exhaustively captured. Data collection instrument An interview guide consisting of open-ended questions was developed by members of the research team based on literature [ 11 – 13 ]. Team members had extensive experience in qualitative research and reproductive health interventions. The interview guide included the following questions: Could you briefly describe your background and experience in implementing adolescent pregnancy prevention interventions in LMICs? Based on your experience, what are the main barriers to implementing adolescent pregnancy prevention interventions in LMICs? What strategies have been used to address or overcome these implementation barriers? How have local context, culture, policies, and health system infrastructure influenced intervention implementation? What are the key components of effective adolescent pregnancy prevention interventions in LMICs? What recommendations would you offer to policymakers, practitioners, and program implementers to improve the implementation, scalability, and sustainability of these interventions? Is there anything else you would like to add regarding barriers or facilitators to implementing adolescent pregnancy prevention interventions in LMICs? Data collection procedures Data collection was conducted between August and October 2024. Recruitment began with a targeted Google search designed to identify professionals with documented experience in the development, implementation, or evaluation of adolescent pregnancy prevention interventions in LMICs. The search combined topic-related terms, including “adolescent pregnancy prevention,” “teenage pregnancy prevention,” “adolescent sexual and reproductive health,” “youth sexual and reproductive health,” and “youth-friendly sexual and reproductive health services,” with role-related terms such as “programme implementer,” “programme manager,” “technical advisor,” “researcher,” “monitoring and evaluation specialist,” and “sexual and reproductive health advisor.” These terms were combined with geographical identifiers, including “LMIC,” “low- and middle-income countries,” regional terms such as “sub-Saharan Africa,” “Latin America,” and “Asia,” and the names of individual countries. Publicly available staff directories, project webpages, reports, and publication author affiliations were reviewed. Potential participants were screened to confirm that they had been involved in designing, implementing, or evaluating a relevant intervention for at least six months before they were contacted by email. Since many researchers did not respond to our emails despite two reminders, we expanded our recruitment efforts by reaching out through platforms used by individuals who had implemented these interventions. Additionally, we connected with the study participants who helped link us with potential participants meeting the inclusion criteria. Those who agreed to participate were invited to take part in virtual semi-structured interviews. All interviews were conducted by the research team members via video conferencing (Zoom), and field notes were taken during and after each session. Data collection was concluded once saturation was reached. At the end of each interview, participants received a $20 CAD gift card as a token of appreciation to cover their time and internet expenses. Data analysis All interviews were audio-recorded and transcribed verbatim by members of the research team. Interviews conducted in French were subsequently translated into English by bilingual members of the research team prior to analysis. Field notes were incorporated into the transcripts, which were then uploaded into Dedoose software to facilitate coding. Guided by thematic analysis framework [ 14 – 16 ], transcripts were thematically coded, and relationships between codes were identified. The research team members collaboratively reviewed the codes and held regular meetings to address and resolve any inconsistencies. Descriptive and explanatory accounts were developed to understand how context and setting influenced intervention implementation. Themes and categories were continuously compared and refined to ensure they accurately represented the data. Rigor To ensure rigor, the study adhered to Lincoln and Guba’s four criteria [ 17 ]: credibility, dependability, confirmability, and transferability. Credibility was enhanced through prolonged engagement with participants, literature-informed interview guides, experienced data collectors, integration of field notes, conceptual sufficiency and regular team meetings. Dependability was maintained through an audit trail and team-based coding. The research team members conducted and transcribed the interviews, which enhanced the credibility and dependability of the findings by ensuring consistency in data collection and a deeper familiarity with the data. Confirmability was supported by reflexivity and routine debriefing sessions, while transferability was ensured through purposive sampling. Ethical considerations Ethical approval for the study was obtained from the University of Rwanda, College of Medicine and Health Sciences Institutional Review Board (Approval Notice: No 508/CMHS IRB/2024). Individuals who expressed interest after receiving the invitation email were provided with a detailed information letter and given adequate time to review it. They were also encouraged to ask any questions prior to providing consent. Those who agreed to participate signed an informed consent form. Participants’ rights, including confidentiality and voluntary participation, were fully respected and protected throughout the study. Findings Socio-demographic data Across the 19 study participants, the sample was nearly gender-balanced (10 female, 9 male) and represented a wide range of countries and settings, primarily across Africa, with additional participants from Latin America and Asia and one participant reporting work across multiple countries. Ages ranged from 27 to 60 years (mean ≈ 37.1 years), and professional experience ranged from 5 to 20 years (mean ≈ 11.1 years), indicating a generally mid- to senior-level workforce. Educational attainment was high overall, with 11 participants holding a master’s degree, 7 holding a bachelor’s degree, and 1 holding a PhD. Participants’ roles spanned clinical and leadership positions, including midwives, nurse-midwives, lecturers/university faculty, community health workers, program managers, executive directors, and SRH/youth health advisors ( Table 1 .). Download: PNG larger image TIFF original image Table 1. Socio-demographic data of the study participants (N = 19). https://doi.org/10.1371/journal.pone.0360943.t001 Themes The thematic findings are organized into seven interconnected areas that reflect how expert implementers understand the realities of preventing teenage pregnancy in LMICs. First, experts highlighted that adolescents’ engagement is shaped by the extent to which interventions are perceived as useful and, in some instances, by what adolescents can gain from attending. Second, they described how stigma makes participation in SRH programmes socially risky, prompting some adolescents to avoid services and instead seek information privately, including through online sources. Third, experts emphasized that prevention efforts are constrained by gendered expectations and unequal decision-making power, which often limit girls’ agency and reduce boys’ participation. Fourth, they noted that limited autonomy and gatekeeping by parents, partners, and other authority figures restrict adolescents’ practical access to interventions. Fifth, implementers explained how economic pressure and entrenched social norms normalize early marriage and early childbearing, lowering the perceived need for prevention and reducing programme uptake. Sixth, they reported that interventions frequently face legitimacy challenges rooted in taboo, religious opposition, contraception myths, and the normalization of violence, all of which can generate community resistance. Finally, experts identified systemic implementation constraints, including administrative delays, weak institutional backing, school gatekeeping, and unstable policy environments that undermine the continuity, scale-up, and sustainability of pregnancy prevention programmes. Theme 1: Engagement is not synonymous with uptake: Relevance and transactional participation. Experts described a recurring mismatch between what programs are designed to achieve and why some adolescents show up. Several implementers observed that attendance does not always signal interest in pregnancy prevention or SRH learning; rather, participation can be driven by social and material benefits. One expert explained that adolescents could appear disengaged from the intended goals of the intervention but still attend because the program offered a space to connect with peers or access tangible support: However, they would still attend the interventions often not for the intended purpose, but to socialize, receive financial incentives, or access food. (P4). In contrast, other adolescents were perceived as not engaging because they did not see additional value in the intervention, especially when SRH topics had already been covered elsewhere. This “we’ve heard it before” perception was described as a barrier to sustained participation and deeper engagement: Some adolescents believe they have already received sufficient sexual health education in school and therefore do not see the value in engaging in further discussions on the topic. (P12). Together, these accounts highlight that implementers are not only trying to reach adolescents, but also trying to make prevention content feel timely, relevant, and worth the effort of participation. Theme 2: Stigma makes SRH participation socially risky, pushing adolescents toward private information-seeking. A strong thread across experts’ accounts was that adolescents often avoid SRH interventions not because they reject the information, but because participation can expose them to judgment. One implementer noted that adolescents may fear being labeled as sexually active simply for attending a program: Adolescents do not want to attend some programs/interventions because of stigma. They do not want anyone to know that they are getting SRH information. (P3) In response to this social risk, experts reported that som
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