Adapting a Stigma-Reduction Workshop for Adolescent Sexual and Reproductive Health and Contraceptive Stigma in Kilimanjaro,Tanzania: A Methodological Study

Abstract

Background

Although contraception is free of charge in Tanzania, adolescent girls and young women (AGYW) often avoid seeking services due to stigma and moral judgments around adolescent sexuality. Existing stigma-reduction programs in Tanzania primarily target HIV-related stigma in clinical settings and have not been tailored to the unique social context of sexual and reproductive health (SRH) and contraceptive stigma in youth populations.

Objective

This methods paper describes the design, adaptation, and implementation of a participatory stigma-reduction workshop program aimed at addressing SRH and contraceptive stigma among AGYW in Kilimanjaro, Tanzania.

Methods

The adapted intervention consisted of a three-session workshop series delivered separately to urban and rural groups of female adolescents. We adapted the Expanded Total Facility Approach Stigma-reduction Training for Health Workers, originally developed for reducing HIV-related stigma among healthcare workers, into a youth-centered, community-based workshop model. This adaptation was guided by the Health Stigma and Discrimination Framework, Stigma Power Process Model, and Participatory Action Research. Through a collaborative, iterative process with local stakeholders, the content was modified to reflect the sociocultural drivers of SRH and contraceptive stigma affecting AGYW. The adapted intervention was implemented between February and March 2025 among 40 female adolescent participants aged 15-20 years old in urban and rural Kilimanjaro. Facilitators were Tanzanian women researcher coordinators who were trained to deliver the workshops using interactive, peer-based methods. Evaluation of feasibility, acceptability, and potential efficacy used a concurrent mixed-methods approach, including pre/post questionnaires, focus group discussions, and facilitator reflection sessions that guided adaptation, ensured cultural and developmental relevance.

Conclusion

This study demonstrates the feasibility of adapting facility-based stigma interventions to community settings and younger populations. It offers a replicable model for future efforts to reduce SRH stigma through culturally grounded and participatory approaches. This paper provides a methodological framework for adapting stigma-reduction interventions using participatory and qualitative approaches in youth SRH research.

1. Introduction

Tanzania, a country in East Africa, is characterized by a diverse geography that includes coastal regions, the Serengeti plains, and the Kilimanjaro highlands. (CIA, 2025) Despite national efforts to expand sexual and reproductive health (SRH) services, Tanzania continues to report one of the highest adolescent fertility rates globally. According to the 2022 Tanzania Demographic Health Survey (DHS), adolescent fertility remains high, with 22% of girls aged 15-19 having begun childbearing, and rates exceeding 40% in certain regions (Tanzania Ministry of Health & ICF, 2022). Among sexually active unmarried adolescents aged 15-19, the unmet need for contraception remains alarmingly high and is estimated at 55% as of 2022 (Tanzania Ministry of Health & ICF, 2022). These gaps contribute to a high prevalence of unintended adolescent pregnancies.

Although contraceptive services are free of charge in public health facilities, adolescent girls and young women (AGYW) face persistent barriers to access, many of which stem from deeply rooted stigma. Adolescent SRH stigma, including that associated with contraceptive use, refers to the devaluation, shame, and mistreatment of sexually active adolescents and is a powerful social determinant of health. Adolescent SRH stigma in Tanzania is shaped by intersecting community, familial, and healthcare norms that frame adolescent sexuality, especially among unmarried adolescent women, as morally problematic (Hall et al., 2018; Logie et al., 2019, 2024). Community narratives often equate contraceptive use with promiscuity, while parents and religious leaders discourage SRH service use on moral grounds (Mushy et al., 2020). These dynamics manifest differently across settings; urban AGYW often navigate reputational risks within dense social networks, while rural AGYW face more limited access to accurate SRH information and stronger parental or community control over contraceptive decision-making (Carroll & Kapilashrami, 2020; Wamoyi et al., 2011). Healthcare providers may reinforce these norms through judgmental attitudes or service denial, creating additional barriers to care (Chelva et al., 2022; Sedekia et al., 2017). Together, these forces contribute to internalized shame, avoidance of services, and adverse outcomes such as delayed care, unintended pregnancy, unsafe abortions, and untreated STIs (Carroll & Kapilashrami, 2020; Chelva et al., 2022; Nyblade et al., 2017; Sedekia et al., 2017).

Despite wide recognition of these challenges, few SRH programs in Tanzania address stigma directly (Chandra-Mouli et al., 2014; Hartog et al., 2020; L'Engle et al., 2013). To date, no published interventions have explicitly targeted SRH and contraceptive stigma among AGYW in Tanzania, representing a critical gap in both research and practice (Banda et al., 2022; L'Engle et al., 2013).

This study responds to this gap by piloting a participatory workshop series designed to reduce SRH and contraceptive stigma among AGYW in the Kilimanjaro region. Drawing on a stigma-reduction training tool originally developed for HIV-related stigma among healthcare workers (Clay et al., 2024), the intervention was adapted to reflect adolescents’ developmental needs, cultural context, and lived experiences. A concurrent mixed-methods pilot design was used to assess feasibility, acceptability, and early signals of impact. Pilot studies play a central role in translational research by allowing for iterative refinement, identification of implementation barriers, and early insights into intervention outcomes (Thabane et al., 2010).

In this context, the pilot study served not only as a methodological test of the intervention’s adaptability but also as an opportunity to elevate the voices of AGYW and center their experiences in the design of future stigma reduction programs. This pilot phase focused on AGYW due to gendered patterns of contraceptive stigma; subsequent phases will include boys to address dyadic and community-level stigma.

This study advances the qualitative methodological literature by demonstrating a systematic, participatory adaptation of an established and evidence-based stigma-reduction intervention for a new population and stigma domain. It highlights how qualitative and participatory methods can drive iterative, culturally grounded intervention adaptation in low- and middle-income countries youth contexts.

2. Conceptual Frameworks

The development and delivery of effective SRH interventions requires grounding in robust theoretical frameworks that can inform all stages of program design, implementation, and evaluation. This study was informed by three interrelated frameworks: the Health Stigma and Discrimination Framework, the Stigma Power Process Model, and Participatory Action Research. Together, these frameworks provided a multi-level lens to understand how SRH and contraceptive stigma is produced, reinforced, and experienced by AGYW in Kilimanjaro, Tanzania. They also guided the creation of context-sensitive intervention strategies aimed at addressing stigma at both individual and structural levels.

The Health Stigma and Discrimination Framework informed both the intervention design and the analysis of study data (Stangl et al., 2019). This framework conceptualizes stigma as a dynamic process shaped by individual, interpersonal, community, and structural forces. During the adaptation phase, the framework was used to identify key drivers of stigma including cultural norms surrounding women’s sexuality, misinformation about contraceptive use, and community gossip, and to guide the development of targeted workshop activities that encouraged adolescents to reflect on and challenge these norms. The framework’s domains of stigma marking, manifestations (e.g., internalized and anticipated stigma), and outcomes also structured the intervention’s evaluation approach. Additionally, the framework was used to categorize themes during qualitative analysis of post-intervention focus group discussions (FGD). Specifically, it enabled the research team to systematically map participants’ narratives onto the framework’s domains (drivers and facilitators, manifestations, and impacts) providing a deeper understanding of the social and emotional dimensions of stigma as experienced by AGYW.

The Stigma Power Process Model conceptualizes stigma as a mechanism of social control used to maintain inequality by keeping people “down,” “in,” or “away.” (Link & Phelan, 2014) This framework informed the intervention’s focus on internalized stigma, structural inequities, and social exclusion. Through interactive activities such as storytelling and role-playing, participants were encouraged to rethink harmful beliefs, navigate power dynamics in relationships and healthcare settings, and build peer support systems.

Finally, a participatory action research approach grounded the study in adolescent-centered methods. Participatory action research emphasizes collaboration with participants to co-design interventions aligned with their lived experiences (Baum et al., 2006). Adolescents contributed through reflection sessions, and post-intervention discussion-based feedback rather than initial co-design. The participatory component consisted of three workshop sessions, four reflection sessions, and two FGDs, and the same participants took part in both activities. Their feedback was critical for guiding revisions to activity structure, language, and facilitation, and will be vital in future iterations. This approach fostered empowerment, improved contextual relevance, and provided critical insights to inform adaptation and scale-up.

Together, these frameworks guided decisions about which workshop components required modification and how to structure evaluation of the adapted intervention.

3. Methods

3.1. Study Design

The “Expanded Total Facility Approach Stigma-reduction Training for Health Workers: In-service training guide” developed by the London School of Hygiene and Tropical Medicine (LSHTM) (Clay et al., 2024; Mlunde et al., 2024), is an intervention originally designed to address HIV-related stigma among healthcare workers in Zambia, Ghana, and Tanzania. While initially intended for use within clinical settings, this study adapted the tool for a new population, AGYW, and a different stigma context: SRH and contraceptive stigma in community settings. The LSHTM framework was chosen for its participatory design and focus on addressing SRH-related stigma, including HIV, which offered a robust theoretical and practical basis for adapting the intervention to contraception and SRH stigma among adolescents. This study aimed to assess the adaptability of the LSHTM tool to broader health stigma domains and to evaluate its potential for reducing SRH and contraceptive stigma among youth outside of facility-based environments.

3.2. Study Setting and Population

The study was conducted in the Kilimanjaro Region of northern Tanzania, with urban participants recruited from the communities of Rau, Pasua, Longuo B, and Mamboleo and rural participants recruited from the communities of Chekereni and Mabogini. Our inclusion criteria focused on AGYW aged 15-20 because this age range reflects the period when SRH stigma is most acutely experienced, and when adolescents begin navigating autonomy, relationships, and contraceptive decision-making. Limiting the sample to AGYW ensured the intervention directly addressed gendered social expectations and stigma processes that disproportionately affect girls, while allowing for depth of discussion about lived experiences. Additional characteristics such as schooling status, disability, or socioeconomic position were not used as exclusion criteria in order to recruit a diverse, community-based sample reflective of the real-life heterogeneity of adolescents in Kilimanjaro.

A total of 40 participants (n=20 urban, n=20 rural) were recruited by research assistants from WEMA Health Innovation Tanzania, a local non-governmental organization dedicated to conducting research in Tanzania. Potential participants were identified and invited to participate in the study in the selected communities where the research organization has established longstanding and equitable research relationships in ongoing research over the prior decade. Community leaders were briefed and consulted on the research program if required. In addition, snowball sampling was incorporated to ensure a wide range of potential participants were reached. When a participant enrolled in the study, they were asked to refer a peer who met the study criteria.

Research assistants described to potential participants and their parents that the program is a confidential research study about adolescent-friendly SRH that includes interactive workshops and discussions about family planning, contraceptive stigma, and inequitable gender norms, as well as assessed the eligibility of potential participants in an informal conversation.

3.3. Workshop Adaptation Process

The adaptation process was carried out collaboratively by the principal investigator, Tanzanian research staff, and experienced facilitators. The team reviewed each LSHTM activity, examining where content, tone, or examples required modification to align with adolescent developmental stages, local gender norms, and community SRH contexts. Changes included simplifying technical language, incorporating scenarios familiar to adolescents, and shifting from provider-patient interactions to peer, family, and community dynamics. These decisions ensured the tool remained conceptually grounded in stigma-reduction principles while being culturally and age appropriate for AGYW in Kilimanjaro.

Four activities were selected by the research team from the LSHTM’s core curriculum for the purpose of this study: 1) Outside the Gender Box, 2) Things People Say, 3) Stigma Reflection, and 4) Challenge the Stigma, Be the Change. These activities were selected for their focus on stigma and gender transformation, as well as their generalizability to AGYW and contraceptive stigma. It was also a priority that the selected activities be highly interactive, as the research team believed this format would be more meaningful to a younger audience and would promote greater engagement. Only a subset of activities from the original curriculum was included to ensure sufficient time to complete workshop activities over the designated weekends while also allowing ample time for group reflection periods. Activities involving primarily individual exercises, such as “Values Clarification”, or information-heavy content, such as “Gender and Sexual Diversity Terminologies”, were therefore excluded. Instead, the workshop prioritized interactive, group-based activities designed to promote active engagement, facilitate deeper reflection, and create an enjoyable and supportive environment for participants.

The LSHTM sample agenda positioned the “Stigma Reflection” activity on Day 1 of workshop. However, the research team anticipated that this activity might be challenging at the outset, as it requires participants to openly discuss personal experiences related to stigma. Based on advice from local collaborators, the activity was therefore scheduled for Day 3, when participants were expected to feel more comfortable with the facilitators and their peers.

Several modifications were made to adapt the workshop activities to the study context. In the “Things People Say” activity, flipchart prompts were revised to better reflect the target populations (i.e., young people, young women, and young women who use contraception and/or engage in sexual activity). In the “Challenge the Stigma, Be the Change” activity, role-play scenarios were modified to represent the experiences of AGYW and to address stigma related to SRH and contraception. Additionally, while many of the original role-play scenarios focused on stigma within healthcare settings, these were adapted to emphasize stigma from peers and within the community, as community and self-stigma were the primary focus of the workshops.

Adaptation decisions were made through consensus during meetings, drawing on facilitators’ experiences delivering prior youth programs, cultural insight from Tanzanian staff, and feasibility considerations such as language accessibility, emotional safety, and time requirements for reflective dialogue.

3.4. Implementation and Facilitation

The stigma-reduction workshops engage participants in activities and discussions surrounding topics of general stigma, contraceptive stigma, inequitable gender norms and expectations, and SRH. These workshops were designed to immerse AGYW in interactive exercises that promote conversation and self-reflection, allowing participants to express their perceptions and experiences in a safe and confidential setting through arts-based activities, role-playing exercises, and group discussions (see supplemental information, S1, for workshop guide). Thus, fostering a deeper understanding of SRH and contraceptive stigma.

Prior to implementing the intervention, four women staff members of WEMA Health Innovation Tanzania, who were selected as the study facilitators, received training from the principal investigator. Facilitators were trained in how to conduct the workshops, proper preparation and use of materials, data collection, and how to handle difficult participant interactions. The facilitators also had prior stigma training. The principal investigator was present in Moshi during the time of workshop implementation and was made available to facilitators for follow-up meetings, questions and/or challenges with implementation. The study team ensured that only local team members were present during workshop implementation to ensure cultural safety and comfort of participants. The facilitators met with the study team following each workshop session to debrief as well as address any challenges or concerns. Additionally, rather than conduct the workshops in a hospital or research setting, we chose to implement the workshops at WEMA Health Innovation Tanzania, a local non-governmental organization offering private spaces with restricted access to ensure confidentiality. Facilitators were local women as opposed to doctors or nurses, to minimize power imbalances.

Workshops and focus groups were conducted with mixed-age groups of AGYW based on guidance from Tanzanian research staff and community partners, who explained that girls in this age range commonly interact in school, peer groups, and community settings, and are accustomed to discussing sensitive topics collectively. Mixing ages helped avoid singling out younger participants and supported natural peer-learning dynamics, where older girls often model confidence and vocabulary around SRH topics, while younger girls contribute perspectives informed by early-stage experiences.

3.5. Workshop Structure

Each participant completed a three-session stigma-reduction workshop delivered over one weekend (Table 1).

Table 1.

Breakdown of Daily Workshop Activities, Associated Themes and Timing

Activity	Theme	Time
Day 1
Introduction, Icebreakers	Welcome	1 hour
Day 2
Outside the Gender Box	Gender roles and norms	2 hours
Things People Say	Understanding stigma	1 hour
Day 3
Stigma Reflection	Understanding stigma, Building confidence	1 hour
Challenge the Stigma, Be the Change	Building confidence, Peer support	1 hour

Following each workshop activity, participants engaged in a reflective period with peers and facilitators to review the content, their thoughts and feelings, and draw connections between the activities, contraception, and stigma. Workshops were separated by participant location, with urban participants on weekend 1 (7 February 2025 to 9 February 2025) and rural participants on weekend 2 (14 February 2025 to 16 February 2025).

Because contraception-seeking, especially among unmarried girls, is highly stigmatized, facilitators emphasized that participants were not required to share personal experiences and could speak in general or hypothetical terms. Participants were reminded that they could skip any activity, step outside, or request a private conversation at any time. Confidentiality agreements were co-created with the group to ensure respect, non-judgment, and protection of peers’ stories. A detailed 3-day workshop agenda follows:

3.5.1. Day 1

Participants engaged in ice-breaker activities to introduce themselves to the group and program facilitators. Following, participants completed the required assessment tools.

3.5.2. Day 2

Day 2 engaged participants in “Outside the Gender Box” and “Things People Say” exercises.

3.5.2.1. Outside the Gender Box

This exercise was designed to help participants explore the impact of gender expectations. Participants were asked to draw images of an ‘ideal man’ and ‘ideal woman’ in their community (Figure 1), including terms reflecting characteristics that are either outside or inside of the ‘gender box’. Following, participants were given the opportunity to write examples of times in their own lives when they stepped outside of their gender box (Figure 2). The group reflected on the activity and the connection between rigid gender norms and stigma.

Figure 1.

Outside the Gender Box Activity Drawings.

Figure 2.

Participants Stepping Outside of the Gender Box.

3.5.2.2. Things People Say

This exercise was designed for participants to identify words used to stigmatize groups of people, specifically young people, young women, and young women who engage in sexual activity and/or use contraception. Participants brainstormed terms in any language, including slang and street language, and shared them with the group, using phrases such as “I am a young woman, and this is what YOU say about ME.” The activity is structured to allow participants to express stigmatizing words while attributing them to ‘people,’ rather than admitting that they may have used the words or the words have been used against them, and without identifying themselves as members of the specific group.

Participants were purposely instructed to take on a character so as not to disclose terms used by them or against them in real life. They reflected on the impact of these words on self-esteem and the link between language and stigma.

3.5.3. Day 3

Participants engaged in “Stigma Reflection” and “Challenge the Stigma, Be the Change” exercises.

3.5.3.1. Stigma Reflection

This exercise was designed to draw on participants’ own experience of being stigmatized. They were asked to think of a time when they felt isolated or rejected for being seen as different from others and how this impacted them. They had the opportunity, if willing, to share their story with the group and to reflect on how it feels to be stigmatized.

3.5.3.2. Challenge the Stigma, Be the Change

This exercise explored how participants can challenge everyday stigma in their communities through role-play scenarios, allowing them to practice their assertiveness skills.

At the conclusion of Day 3, participants completed the required assessment tools.

3.6. Evaluation Methods

The specific objectives of this study were,

1. To understand the knowledge, lived experiences, and attitudes of AGYW related to SRH, contraception, stigma, and gender norms using qualitative data collected during workshops and thematic analysis of post-intervention FGDs.

2. To assess the feasibility and acceptability of the adapted stigma-reduction workshop program, as perceived by participants and facilitators, through post-intervention FGDs.

3. To evaluate the potential efficacy of the intervention in reducing SRH and contraceptive stigma, through changes in pre- and post-intervention measures of:

a) Attitudes and beliefs towards adolescent SRH, assessed through the Adolescent SRH Stigma scale. (Hall et al., 2018)

b) Attitudes and beliefs towards contraceptive use, assessed through the Contraceptive Use Stigma scale. (Meurice et al., 2021)

c) Sexual double standard endorsement, assessed through the Global Early Adolescent Study Sexual Double Standards scale. (Moreau et al., 2019, 2021)

These quantitative tools were adapted from validated stigma scales and tested for internal consistency reliability following pre- and post-intervention data collection using Cronbach’s alpha.

3.7. Data Collection

3.7.1. Focus Group Discussions

Workshop facilitators (n=4) conducted 60-90-minute FGDs with participants (n=40, with 10 participants per FGD) 3-weeks post-workshop. FGDs followed semi-structured discussion guides organized into domains of current knowledge and attitudes, contraceptive stigma and personal experiences, stigma around sexual activity, information sources, barriers and challenges (see supplemental information, S2). Participants also discussed perceived impact and acceptability of the intervention and changes in perceptions over time.

One-week following the conclusion of workshop implementation, study facilitators participated in a 60-minute FGD led by the PI (n=4). The FGD followed a semi-structured discussion guide organized into domains of general workshop feedback, workshop content and activities, participant engagement and dynamics, workshop structure and logistics, and changes and improvements (see supplemental information, S3).

FGDs were audio recorded, and a member of the research team translated and transcribed the recordings. Two members of the research team verified accuracy of transcriptions, and once verified, digital recordings were erased. FGDs were analyzed using an inductive approach to thematic analysis, with codes refined through reflexive team discussions and iterative codebook development (Ando et al., 2014; Braun & Clarke, 2022; Roberts et al., 2019). Rigour was maintained through double-coding, codebook consensus meetings, and the use of reflexive memos.

3.7.2. Workshop Materials and Group Reflections

Following each workshop activity, participants engaged in 20-30-minute reflection periods with facilitators and peers. Facilitators asked a series of questions allowing participants to contemplate the activity and its relation to contraception and stigma. Reflection discussions were audio recorded, and a member of the research team translated and transcribed the recordings. Two members of the research team verified accuracy of transcriptions, and once verified, digital recordings were erased.

For activities that produced deliverables, such as “Outside the Gender Box”, participant drawings were photographed for study-related use (Figure 3), and all text was translated and transcribed by a member of the research team.

Figure 3.

Photograph of Participants Engaging in a Group-based Workshop Activity.

Facilitator debriefs, participant reflections, and adaptation notes were systematically documented and contributed to thematic analysis and codebook refinement.

3.7.3. Assessment Tools

Pre- and post-intervention, AGYW completed the Sexual Double Standards scale to measure contemporary sexual double standards endorsement among adolescents (Moreau et al., 2019, 2021), the Contraceptive Use Stigma scale to measure stigmatizing attitudes and beliefs regarding contraceptive use (Meurice et al., 2021), and the Adolescent SRH Stigma scale to quantitatively test a conceptual model of stigma as a barrier to family planning (see supplemental information, S4) (Hall et al., 2018). The Sexual Double Standards scale includes 6 items on a 5-point Likert (1= disagree a lot, 5= agree a lot), the Contraceptive Use Stigma scale includes 7 items on a 5-point Likert (1= strongly disagree, 5= strongly agree), and the Adolescent SRH Stigma scale includes 20 items on a 3-point Likert (Agree, Neutral, Disagree) with three subscales: stigmatizing lay attitudes, enacted stigma, and internalized stigma. Stigmatizing lay attitudes are the community beliefs that AGYW who engage in sex, pregnancy, childbearing, and abortion are “immoral”, “disrespectful”, “disobedient”, or “bad girls”. Enacted stigma is the gossip, marginalization, and mistreatment of AGYW with SRH experiences. Finally, internalized stigma is defined as the “disgrace” or “shame” felt as a result of negative attitudes and enacted stigma occurring with SRH experiences (Hall et al., 2018).

4. Implementation Insights

The implementation of the adapted stigma-reduction workshop series provided valuable insights into the feasibility, acceptability, and contextual realities of delivering participatory interventions to AGYW in northern Tanzania.

4.1. Recruitment and Participation

Recruitment through trusted community networks proved effective in reaching eligible participants and gaining consent. Participant retention was 100%, indicating the practical feasibility of the delivery model. Participants were not former beneficiaries or registered members of WEMA Health Innovation Tanzania.

4.2. Workshop Delivery and Engagement

All workshop sessions were conducted in Kiswahili and delivered by trained women facilitators who had experience working with youth. The participatory format, which included storytelling, group discussions, and arts-based activities, was well-received by participants.

Facilitator debriefs noted that participants were initially hesitant to speak about SRH issues but gradually became more open and reflective as trust developed. This suggests that the design and pacing of the intervention were appropriate for the target age group.

4.3. Cultural Relevance and Acceptability

Feedback from participants and facilitators highlighted that the workshop content was relatable, respectful, and sensitive to local cultural contexts. We believe the use of familiar scenarios, youth-centered language, and non-clinical settings helped reduce power differentials and enhance comfort among AGYW. Facilitators noted that the “Outside the Gender Box” and “Things People Say” exercises were particularly effective in initiating discussions about stigma and gender norms.

4.4. Facilitator Capacity and Support

Training facilitators in both content and adolescent-centered engagement strategies was critical to successful implementation. Facilitators emphasized the importance of creating a non-judgmental environment, responding flexibly to group dynamics, and managing disclosure of sensitive experiences. Continued mentorship and regular check-ins during implementation allowed facilitators to adapt their delivery and troubleshoot challenges in real time.

4.5. Operational Considerations

Delivering the workshop in weekend sessions allowed for intensive delivery without disrupting school schedules. However, some logistical challenges were noted, including coordinating transportation for rural participants. These were mitigated through advance planning including a transport stipend and delivery of meals/snacks during workshops but underscore the need for logistical flexibility in future scale-up.

4.6. Overall Feasibility

The study demonstrated that adapting a facility-based stigma-reduction framework for adolescents in a community setting is both feasible and acceptable. The combination of high participant retention, positive engagement, and facilitator adaptability supports the potential for this model to be replicated and scaled in similar contexts.

5. Methodological Implications and Lessons Learned

The process of adapting and implementing a stigma-reduction intervention for AGYW generated several methodological insights that may guide researchers seeking to adapt participatory interventions for new populations or settings.

First, adapting a tool originally designed for adult healthcare providers required rethinking tone, complexity, and facilitation strategies to ensure developmental and cultural appropriateness for adolescents. This illustrates the methodological importance of critically examining language, scenarios, and power dynamics embedded in existing tools when transferring them to youth contexts. Researchers should anticipate substantial modification to ensure that intervention components are meaningful, accessible, and resonant for younger participants.

Second, the adaptation process highlighted how stigma is shaped by local social environments, demonstrating the value of collecting contextual insights early in the adaptation phase. Differences between urban and rural participants underscored the methodological need to consider geographic, cultural, and relational dynamics when designing participatory intervention activities. For researchers working in diverse LMIC settings, this reinforces the importance of grounding adaptation decisions in local knowledge rather than relying solely on the original tool’s structure.

Third, the use of participatory methods showed that deeper engagement requires adequate time and flexible facilitation. From a methodological perspective, this emphasizes that participatory approaches cannot be rushed; rich, nuanced reflections emerged only when activities allowed sufficient space for dialogue, storytelling, and collective interpretation. Researchers planning similar interventions should allocate more time than initially expected and build in opportunities for iterative reflection.

Fourth, facilitator expertise was central to producing valid, trustworthy qualitative data. The ability of facilitators to navigate sensitive topics, establish trust, and support emotionally charged discussions shaped the quality of data generated and the overall success of the adaptation. Methodologically, this highlights the importance of robust facilitator training, ongoing reflexive practice, and carefully structured participant protections, particularly when working with stigmatized topics among adolescents.

Collectively, these methodological insights highlight the complexities of adapting participatory stigma-reduction tools for adolescents in LMIC contexts. They also provide a transferable framework for researchers seeking to modify existing interventions in culturally responsive, developmentally appropriate, and ethically grounded ways.

6. Researcher Positionality and Reflexivity

A research team’s positionality shapes the questions asked, the design and implementation of the study, and the interpretation of findings. To acknowledge these influences, we offer the following collective reflection.

Our author team includes researchers and practitioners from Tanzania and Canada with diverse expertise in global health, women’s health, SRH, stigma reduction, and gender equity. Team members span multiple stages of academic and professional trajectories, from graduate students and research staff to senior faculty and global health leaders. Together, we bring perspectives from clinical practice, community-based research, participatory methodologies, and policy engagement.

We represent a range of lived experiences, shaped by our identities as women, and by our different cultural, linguistic, and geographic contexts. Our team includes Canadian and Tanzanian researchers, with Tanzanian women staff contributing grounded knowledge of local health systems, cultural norms, and adolescent girls lived realities. We recognize that these positionalities influence both the power dynamics within our team and our relationships with participants. By prioritizing reflexivity and dialogue, we aimed to ensure that local expertise guided decision-making, especially in the adaptation of workshop activities and facilitation strategies.

As a collective, we share a commitment to conducting ethical, collaborative, and reciprocal research. Our approach emphasizes engaging with adolescents and communities as equal partners, ensuring that their voices and creative contributions shape both the research process and its outcomes. We view knowledge as co-created, with data owned and used not only for academic purposes but also to inform community programs and advocacy for adolescent health and empowerment in Tanzania. This commitment extends to our knowledge mobilization strategies, which include academic publications, community reports, and creative outputs designed to advance health equity and reduce stigma.

7. Limitations

The small sample size (n=40), non-random sampling approach, and lack of control group limit generalizability of the findings. The short duration of the study prevented assessment of long-term changes in stigma or behavior. Social desirability bias may have influenced both survey responses and qualitative feedback, particularly given the sensitive nature of the topics. Some subscales of the Adolescent SRH stigma scale demonstrated suboptimal internal consistency, particularly internalized stigma (α = 0.491-0.564) and stigmatizing lay attitudes (α = 0.415-0.587), which limits the interpretability of these domains. While individual item responses may still offer insight, aggregate subscale scores should be interpreted with caution. These findings highlight the need for future studies to validate and potentially refine stigma items to enhance reliability when used with adolescent populations in similar cultural contexts. Additionally, the exclusion of adolescent boys and young men represents a missed opportunity to address the gendered dimensions of stigma more holistically.

8. Conclusion

This study provides novel methodological insight into how participatory, stigma-informed frameworks can be systematically adapted for new populations and contexts. The participatory, culturally grounded approach ensured relevance and acceptability, while the flexible delivery format accommodated diverse needs.

The model offers a valuable roadmap for researchers and practitioners seeking to address SRH and contraceptive stigma in other populations and geographies. Future adaptations could extend to male participants, explore intersectional stigma, or incorporate digital tools for broader reach.

To conclude, this paper details a replicable, participatory approach to adapting stigma-reduction interventions for adolescent SRH and contraceptive stigma in Tanzania. By centering adolescent voices and local expertise, this approach holds promise for reducing stigma and promoting reproductive empowerment in diverse contexts, offering a replicable and culturally grounded model for adapting stigma-reduction interventions in diverse settings.

9. Ethical Considerations

Ethical approval was obtained from Queen’s University Health Sciences Research Ethics Board (HSREB) and the National Institute for Medical Research (NIMR) in Tanzania. Written informed consent was obtained from all participants, including separate permission for the use of photographs and participant-created artwork. All study materials, including FGD guides, reflection prompts, and consent forms, were reviewed and approved by both ethics boards. Confidentiality was ensured through the use of de-identified transcripts, unique participant IDs, secure data storage procedures, and restricted access to study files. Participants received transportation reimbursement and meals; no other incentives were provided.

Supplemental Material

Supplemental Material - Adapting a Stigma-Reduction Workshop for Adolescent Sexual and Reproductive Health and Contraceptive Stigma in Kilimanjaro, Tanzania: A Methodological Study

Supplemental Material for Adapting a Stigma-Reduction Workshop for Adolescent Sexual and Reproductive Health and Contraceptive Stigma in Kilimanjaro, Tanzania: A Methodological Study by Rachel Di Iorio, Nicola West, Anisia E. Kiwelu, Doreen A. Mruma, Elizabeth G. Ngolle, Mwasiti K. Jumanne, Carmen H. Logie, Karen Yeates in International Journal of Qualitative Methods