Scaling-up Normative Change Interventions for Adolescent and Youth Reproductive Health: An Examination of the Evidence

Blesser relationships among orphaned adolescent girls in contexts of poverty and gender inequality in South African townships

The term blesser has become part of South Africa's contemporary lexicon, replacing the older terminology of 'sugar daddy.' While much recent literature has focused on the blesser phenomenon, the voices of orphaned adolescent girls on their entanglement in blesser relationships have had insufficient attention. Using the theory of gender and power as an analytical lens, this qualitative study analyses the visual and textual data generated by orphaned adolescent girls on their relationships with blessers. To generate data, the participants used photovoice to represent their relationships with older male sexual partners in their resource-poor South African township neighbourhoods. Our analysis reveals a set of factors that render orphaned adolescent girls vulnerable to age-disparate relationships, such as the structural dimensions of their lives, including their status as orphaned girls, heteropatriarchy, age-based hierarchies, and poverty in their households and communities. On the other hand, our analysis explores the less understood area of the relative agency, intentionality, and proactive approach that orphaned girls take to initiating and negotiating blesser relationships. The findings have implications for further research that will expand our understanding of girls' agency-and the structural limits to that agency-in adverse socio-cultural circumstances. Such research holds potential for interventions that might enable orphaned girls to better advocate for themselves in the context of unequal power relations.

Use of contraceptives, empowerment and agency of adolescent girls and young women: a systematic review and meta-analysis

INTRODUCTION

The evidence on adolescent empowerment, which involves access to personal and material resources for reproductive autonomy and economic equity, is limited. This systematic review assesses the use of contraceptives in empowering and strengthening the agency and vice versa among adolescents and young women.

METHODS

We ran the searches in six electronic databases: Cochrane Database of Systematic Reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL), The Campbell Library, MEDLINE (PubMed), EMBASE, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Web of Science. The methodological quality of studies was assessed using ROBINS-I and ROB-II tools as appropriate. Meta-analysis was performed using Review Manager 5.4.

RESULTS

Forty studies that assessed the impact of empowerment on contraceptive use were included. Of these, 14 were non-randomised studies for intervention (NRSIs), and the remaining 26 were randomised controlled trials (RCTs). The results from RCTs show a significant effect of the sexual and reproductive health empowerment in increasing ever use of contraception (RR 1.22; 95% CI 1.02, 1.45; n=9; I²=77%; GRADE: Very Low), and insignificant effect on unprotected sex (RR 0.97; 95% CI 0.74, 1.26; n=5; I²=86%; GRADE: Very Low) and adolescent pregnancy (RR 1.07; 95% CI 0.61, 1.87; n=3; I²=36%; GRADE: Very Low). None of the studies assessed impact of contraceptive use on empowerment.

CONCLUSIONS

Empowerment of adolescents and young women certainly improves contraceptive use in the immediate or short-term period. However, more robust studies with low risk of bias, longer-term outcomes, and impact of contraceptive use on empowerment and agency-strengthening are required. To increase contraceptive use uptake, tailored policies and delivery platforms are necessary for youth in low- and middle-income countries.

Gender-transformative programmes: a framework for demonstrating evidence of social impact

Ample evidence has demonstrated that gender inequality and restrictive gender norms wield significant influence over health outcomes. While gender-transformative programmes have grown with the aim of challenging these norms and promoting gender equality, their effectiveness in driving sustainable norm change remains a subject of debate. This paper introduces a comprehensive analytical framework designed to assess the impact of these programmes.Drawing from extensive literature reviews of rigorously evaluated health programmes, this framework identifies four key dimensions that are instrumental in determining a programme's potential for transformative change. These dimensions are multiplicative effect, sustainability, spread and scalability. Multiplicative effect emphasises the interconnected nature of societal systems, positing that altering one element can trigger cascading effects throughout the entire system. Sustainability recognises that change within a system is less likely to revert once the structure has shifted. Programmes that facilitate norm change are more likely to sustain the changes brought about by their interventions. Spread acknowledges the importance of engaging entire networks that share the targeted norms. Successful programmes should demonstrate evidence of gender-related outcomes extending beyond the immediate beneficiaries, progressively diffusing through the broader population. Finally, scalability emphasises the need to bring gender-transformative initiatives to a larger scale to effect broader norm change.By aligning programme design and evaluation with these four dimensions, the proposed framework provides a standardised approach for assessing gender-transformative programmes. It shifts the focus from individual-level change to systemic transformation, bridging the gap between programmatic aspirations and the ability to measure genuine progress.

Maintaining Program Fidelity in a Changing World: National Implementation of a School-Based HIV Prevention Program

Large-scale, evidence-based interventions face challenges to program fidelity of implementation. We developed implementation strategies to support teachers implementing an evidence-based HIV prevention program in schools, Focus on Youth in The Caribbean (FOYC) and Caribbean Informed Parents and Children Together (CImPACT) in The Bahamas. We examined the effects of these implementation strategies on teachers' implementation in the subsequent year after the initial implementation during the COVID-19 pandemic. Data were collected from 79 Grade 6 teachers in 24 government elementary schools. Teachers completed training workshops and a pre-implementation questionnaire to record their characteristics and perceptions that might affect their program fidelity. School coordinators and peer mentors provided teachers with monitoring, feedback, and mentoring. In Year 1, teachers on average taught 79.3% of the sessions and 80.8% of core activities; teachers in Year 2 covered 84.2% of sessions and 72.9% of the core activities. Teachers with "good" or "excellent" school coordinators in the second year taught significantly more sessions on average (7.8 vs. 7.0, t = 2.04, P < 0.05) and more core activities (26.3 vs. 23.0, t = 2.41, P < 0.05) than teachers with "satisfactory" coordinators. Teachers who had a "good" or "satisfactory" mentor taught more sessions than teachers who did not have a mentor (7.9 vs. 7.3; t = 2.22; P = 0.03). Two-level mixed-effects model analysis indicated that teachers' program fidelity in Year 1, confidence in the execution of core activities, and school coordinators' performance were significantly associated with Year 2 implementation dose. Implementation of FOYC + CImPACT was significantly associated with improved student outcomes. Teachers maintained high fidelity to a comprehensive HIV prevention program over 2 years during the COVID-19 pandemic. Future program implementers should consider additional implementation support to improve the implementation of school-based programs.

Use of contraceptives and associated factors among male adolescents in rural secondary schools, Coast Region, Tanzania: a school-based cross-sectional study

BACKGROUND

Teenage pregnancy is still one of the reproductive health concerns facing adolescents in Tanzania. The problem has been associated with physiological, psychological, and social changes and increases the risk of unsafe abortion and adverse maternal, fetal, and neonatal outcomes among adolescents. Low utilization of contraceptive methods among adolescents is one of the key causes. The strategy of involving male adolescents in sexual and reproductive health programs can increase the rate of contraceptive use among adolescents, thereby preventing teenage pregnancy.

OBJECTIVE

To examine factors associated with the uptake of contraceptives among male secondary school adolescent students.

METHODS

This was a cross-sectional study conducted in rural secondary schools in Kisarawe District, Coast Region, Tanzania. Multi-stage sampling methods were used to recruit participants. Descriptive and multiple regression analyses were conducted to assess the prevalence and factors associated with contraceptive use. 95% confidence interval and p-value < 0.05 were considered statistical significance. Univariate and multivariate logistic regression were tested for the Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) respectively.

RESULTS

The study involved 422 male students with the majority of them 58.1% aged 17-19 years, 50.2% were Muslim, 76.3% were studying in government schools, 62.3% were from households size of 4-6 members, 87.4% were not in a relationship, and 64.2% were living with both parents. Less than half (38.9%) of male students reported ever having sex in their lifetime, and among them, very few (29.8%) used any method of contraceptive. The reported lowest age for the first sex was 10 years. The male condom was the most method used (69.4%) and Pharmacy/Chemist Shops were the common source of contraceptive services (55.1%). Students who had adequate knowledge of contraceptives were more likely to report the use of contraceptive methods compared to those who had inadequate knowledge (AOR = 2.704, 95% CI: 1.220-5.995, p = 0.014). Participants in Private schools were 4.3 times more likely to report the use of contraceptives than those in government schools (AOR = 4.347, 95% CI: 1.758-10.762, p = 0.01). Students in a relationship were 3.5 times more likely than those not in a relationship to report the use of a contraceptive method (AOR = 3.51, 95% CI: 1.421-8.670, p = 0.006).

CONCLUSION

The study found the low use of contraceptives among male adolescents who ever had sex in their lifetime. Thus, it's suggested that age-tailored comprehensive sexual and reproductive health education should start to be taught from a very young age as adolescents initiate sex at an early age. Also, Teenage pregnancy prevention programs should involve males as the key players during the development and implementation of the program as most of the decisions among partners are from men.

Trends and determinants of unmet need for modern contraception among adolescent girls and young women in Tanzania, 2004-2016

Unintended pregnancy at a young age can lead to poor reproductive health, social and economic outcomes. The high rate of unintended teenage pregnancies in Tanzania is indicative of inadequate availability and uptake of modern contraception. Determining trends and determinants of unmet need for modern contraception among adolescent girls and young women (AGYW) in Tanzania will help address the burden of unintended pregnancies. An analytical cross-sectional study design was conducted using secondary data from three consecutive Tanzania Demographic and Health Surveys (TDHS) 2004/05, 2010 and 2015/6 among AGYW in need of modern contraception. Data analysis considered the complex survey design. Poisson regression model was used to determine factors associated with unmet need for modern contraception. We observed a steady decline in unmet need for modern contraception among sexually active AGYW in need of modern contraception from 31.8% in 2004/05 to 27.5% in 2015/16 survey. In the multivariable analysis, higher prevalence of unmet need for modern contraception was observed among adolescents, participants with at least one live birth, from poor wealth tertile, and those sexually active during the past four weeks compared to their counterparts. Despite declining levels, the unmet need for modern contraception among AGYW in Tanzania remains high. AGYW under 19 years, those from poor households, and those who are postpartum are most at risk. Greater efforts in empowering and educating AGYW at risk on their reproductive health rights and needs will further the uptake of modern contraceptive use, reduce the rates of unintended pregnancies, lower the adolescent fertility rate as a result lower unmet need for modern contraception.

Decomposing the Gap in Contraceptive Use Among Female Adolescents and Young Women Aged 15-24 in India: An Analysis of Appended Datasets of NFHS-4 and 5

PURPOSE

Owing to the reproductive health needs of the budding adolescent and young population, the present study aims to determine the factors associated with and decomposing the gap in contraceptive use among adolescents and young women in India.

DESIGN

Cross sectional design.SettingThe present study is based in India using the appended datasets (IV and V rounds) of the Indian Demographic Health Survey (DHS), also known as National Family Health Survey (NFHS) conducted in 2015-16 and 2019-21.

SAMPLE

The adequate sample size was 475,294 adolescents and young women in NFHS-4 and 229,705 in NFHS-5, totaling 704,999 adolescents (appended for NFHS-4 and 5) for the present study.

MEASURES

Sociodemographic, sexual and reproductive history and contraceptive measures.

ANALYSIS

Descriptive statistics, chi-square tests, and a binary logistic regression model were executed. Additionally, a decomposition technique called Fairlie decomposition was employed to identify the primary causes of the difference in the prevalence of contraceptive use between the two survey periods.

RESULTS

Almost 96% of young women aged 15-24 knew about contraception, but only 12% used it. Regression analysis revealed that contraceptive use was associated with higher age (AOR 1.09), higher education (AOR 1.28), married adolescents (AOR 4.08), richest wealth quantile (AOR 2.95), joint decision making (AOR 4.40), knowledge of ovulatory cycle (AOR 1.47), interaction with a health worker about any methods of family planning (AOR 3.29) and three and above children ever born (AOR 18.54). Decomposition analysis showed that factors like decision-making of contraception, age, interaction with family planning worker, the intention of last pregnancy, place of residence and age at first sex contributed to increasing the probability of contraceptive use from NFHS-4 to 5.

CONCLUSION

A target-based approach dedicated to understanding the mindset of adolescents and keeping up with their unique needs is the need of the hour.

Understanding how social norms influence access to and utilization of adolescent sexual and reproductive health services in Northern Nigeria

Background

This study explored the influence of social norms on the access and utilization of sexual and reproductive health services by adolescents. Apart from individual and environmental barriers, social norms influence contraceptive decisions and ultimately sexual and reproductive health outcomes. Social norms that shape group behavior describe acceptable standards of behavior and evoke sanctions when such behavior standards are not adhered to. Sexually active adolescents in Nigeria have a relatively low level of modern contraceptive use being influenced by social norms. Scaling up adolescent reproductive health interventions that integrate normative change for a wider impact of programs remains challenging.

Methods

Using data from 18 communities, 188 married and unmarried adolescents (F52% and M48%) and 69 (F37%; M63%) reference group participants were purposively sampled and participated in a social norms exploration intervention study conducted through focus group discussion and in-depth interviews between October and November 2019. The Advancing Learning and Innovation on Gender Norms (ALIGN) Social Norms Exploration Tool (SNET) was adapted for the data collection into discussion guides and vignettes. Pilot testing of the tools informed review and validation prior to actual data collection.

Findings

Low contraceptive uptake by adolescents was characterized by early and forced marriage in childhood; a prominent practice enshrined in social norms around girl-childchastity, family honor, and disapproval of pre-marital sex and pregnancy out of wedlock.

Conclusion

The understanding of harmful social norms, normative change actors, and potential norm-shifting factors for contraceptive decisions by adolescents is essential for effective adolescent sexual and reproductive health interventions for wider impact and adaptive programming in behavior change interventions for improving the access to and utilization of modern contraceptives by adolescents for improved sexual health outcomes, the attainment of the Family Planning (FP) 2030 commitment and universal health coverage policy.

Disparity in spectrum of infectious diseases between in-school and out-of-school children, adolescents, and youths in China: findings from a successive national surveillance from 2013 to 2021

Background

An accelerated epidemiological transition, economic development and urbanization have brought rapid reductions but a potential disparity in infectious diseases burdens in-school and out-of-school children, adolescents, and youths in China. This paper assesses the disparity in spectrum of infectious diseases between two groups, and described disparity's variation by age, year and province, and determined the priority diseases.

Methods

A total of 7,912,274 new incident cases (6,159,021 in school and 1,753,253 out of school) aged 6-21 years across 43 notifiable infectious diseases have been collected based on China's Notifiable Infectious Disease Surveillance System from 2013 to 2021. All infectious diseases are categorized into seven categories: vaccine preventable, bacteria, gastrointestinal and enterovirus, sexually transmitted and bloodborne, vectorborne, zoonotic, and quarantinable diseases. We used the index of incidence rate ratio (IRR) of by specific disease, category, year, and age to assess the disparity between those out-of-school and in-school, and determine their separate priority diseases.

Findings

From 2013 to 2021, a small disparity of notifiable infectious diseases existed with higher average yearly incidence for out-of-school children, adolescents, and youth than that in-school (327.601 v.s. 319.677 per 100,000, IRR = 1.025, 95%CI: 1.023-1.027, standardized IRR = 1.169, 95%CI: 1.155-1.183), and it gradually narrowed by surveillance years with IRR from 1.351 in 2013 to 1.015 in 2021 due to large decreased disparity in compulsory education stage group. Such disparity was mainly driven by sexually transmitted and bloodborne diseases, bacteria diseases, vectorborne diseases, quarantinable diseases and zoonotic diseases. However, vaccine preventable diseases, gastrointestinal and enterovirus diseases showed higher incidence of infectious diseases for those in-school than that out-of-school, particularly for seasonal influenza, mumps and hand-foot-and-mouth disease. Meanwhile, such disparity is obvious in most of ages and in eastern and coastal regions of China, and the narrowing trend is attributed to six categories diseases, except for sexually transmitted and bloodborne diseases with gradually widened disparity between two groups with surveillance years with IRR from 22.939 in 2013 to 23.291 in 2021 due to large disparity for those who have completed compulsory education.

Interpretation

A huge achievement has been achieved in reducing the burden and disparity of infectious diseases between out-of-school and in-school children, adolescents, and youths in China, particularly for the compulsory education stage population. The priorities for the coming decades will be to extend successful strategies to a broad scope and promote education, particularly for the investment of social health resources and the improvement of personal health literacy in the non-compulsory education stage. This should involve extending the years of compulsory school, improving sex health education, strengthening monitoring, expanding immunization programs coverage and prioritizing the prevention and control of sexually transmitted diseases and tuberculosis among out-of-school population.

Funding

National Natural Science Foundation of China and Beijing Natural Science Foundation.

Accelerated institutionalization of an adolescent sexual and reproductive health (ASRH) intervention in Tanzania: Findings from a mixed-methods evaluation

Introduction

From 2018 to 2020, Adolescents 360 (A360), aiming to increase demand for and voluntary uptake of modern contraception among adolescent girls 15–19 years, designed and scaled an intervention in Tanzania (Kuwa Mjanja) to 13 regions through project-funded expansion. In 2020, the project began to develop a strategy for its follow-on phase, focusing on program sustainability. In this process, funder priorities led to a decision to exit A360's programming in Tanzania over a 15-month exit period. A360 elected to pursue a process of expedited institutionalization of Kuwa Mjanja into government systems during this period.

Materials and methods

The institutionalization process was facilitated in 17 local government authorities in Tanzania. Quantitative and qualitative data were gathered and analyzed including time-trend analysis of routine performance data, statistical analysis of two rounds of client exit interviews, and thematic analysis of qualitative research.

Results

The sociodemographic characteristics of adolescent girls reached under government-led implementation were comparable to those reached by A360-led implementation. Intervention productivity decreased under government-led implementation but remained consistent. Adopter method mix shifted slightly toward greater long-acting and reversible contraceptive uptake under a government-led model. Factors that enabled successful institutionalization of Kuwa Mjanja included the presence of youth-supportive policies, the establishment of school clubs which provided sexual and reproductive health education, commitment of government stakeholders, and appreciation of adolescent pregnancy as a problem. Some intervention components were important for program effectiveness but proved difficult to institutionalize, primarily because of resource constraints. Lack of adolescent sexual and reproductive health (ASRH)-focused targets and indicators disincentivized Kuwa Mjanja implementation.

Discussion

There is significant potential in operationalizing user-centered ASRH models within government structures, even in a narrow time frame. A360 saw similar performance under government-led implementation and fidelity to the unique experience that the program was designed to deliver for adolescent girls. However, beginning this process earlier presents greater opportunities, as some aspects of the institutionalization process that are critical to sustained impact, for example, shifting government policy and measurement and mobilizing government resources, require heavy coordination and long-term efforts. Programs pursuing institutionalization in a shorter time frame would benefit from setting realistic expectations. This may include prioritizing a smaller subset of program components that have the greatest impact.

Development of the SPREAD framework to support the scaling of de-implementation strategies: a mixed-methods study

OBJECTIVE

We aimed to increase the understanding of the scaling of de-implementation strategies by identifying the determinants of the process and developing a determinant framework.

DESIGN AND METHODS

This study has a mixed-methods design. First, we performed an integrative review to build a literature-based framework describing the determinants of the scaling of healthcare innovations and interventions. PubMed and EMBASE were searched for relevant studies from 1995 to December 2020. We systematically extracted the determinants of the scaling of interventions and developed a literature-based framework. Subsequently, this framework was discussed in four focus groups with national and international de-implementation experts. The literature-based framework was complemented by the findings of the focus group meetings and adapted for the scaling of de-implementation strategies.

RESULTS

The literature search resulted in 42 articles that discussed the determinants of the scaling of innovations and interventions. No articles described determinants specifically for de-implementation strategies. During the focus groups, all participants agreed on the relevance of the extracted determinants for the scaling of de-implementation strategies. The experts emphasised that while the determinants are relevant for various countries, the implications differ due to different contexts, cultures and histories. The analyses of the focus groups resulted in additional topics and determinants, namely, medical training, professional networks, interests of stakeholders, clinical guidelines and patients' perspectives. The results of the focus group meetings were combined with the literature framework, which together formed the supporting the scaling of de-implementation strategies (SPREAD) framework. The SPREAD framework includes determinants from four domains: (1) scaling plan, (2) external context, (3) de-implementation strategy and (4) adopters.

CONCLUSIONS

The SPREAD framework describes the determinants of the scaling of de-implementation strategies. These determinants are potential targets for various parties to facilitate the scaling of de-implementation strategies. Future research should validate these determinants of the scaling of de-implementation strategies.

Some Interventions to Shift Meta-Norms Are Effective for Changing Behaviors in Low- and Middle-Income Countries: A Rapid Systematic Review

Social-norms approaches are increasingly included in behavior-change programming. Recent reviews categorize a large number of norms-shifting programs but do not synthesize evidence about effectiveness. To inform the design of social and behavior-change programs in low- and middle-income countries in response to time-sensitive demands, this rapid systematic review examines the evidence for the effectiveness of interventions that use norms-based approaches to change behavior. Nine indexes and eight websites were electronically searched for both systematic reviews and primary studies. Abstracts and full texts were screened to include: documents published in 2010 and later; documents evaluating the effectiveness of programs that include norms-based approaches; documents measuring behavioral outcomes; and documents employing quantitative analysis of concurrent treatment and comparison groups. Data collected include participant age cohort, program name and duration, scope of norms, intervention activities, category of behavioral outcome, and statement of findings for the main behavioral outcome(s). Primary studies were appraised based on identification strategy. Search and screening yielded 7 systematic reviews and 29 primary studies covering 28 programs. Across the primary studies, the programs are highly heterogeneous, and the findings are mixed, with some strong positive effects and many marginal or null effects on behavior change. Taken together, the evidence shows that meta-norms-based approaches can be part of effective programs but do not assure that programs will change behaviors. Program designers can draw some general conclusions from this review but can also use it to locate specific studies relevant to their evidence needs.

Exploring and Monitoring Privacy, Confidentiality, and Provider Bias in Sexual and Reproductive Health Service Provision to Young People: A Narrative Review

Purpose: Poor privacy and confidentiality practices and provider bias are believed to compromise adolescent and young adult sexual and reproductive health service quality. The results of focus group discussions with global youth leaders and sexual and reproductive health implementing organizations indicated that poor privacy and confidentiality practices and provider bias serve as key barriers to care access for the youth. Methods: A narrative review was conducted to describe how poor privacy and confidentiality practices and provider bias impose barriers on young people seeking sexual and reproductive health services and to examine how point of service evaluations have assessed these factors. Results: 4544 peer-reviewed publications were screened, of which 95 met the inclusion criteria. To these articles, another 16 grey literature documents were included, resulting in a total of 111 documents included in the review. Conclusion: Poor privacy and confidentiality practices and provider bias represent significant barriers for young people seeking sexual and reproductive health services across diverse geographic and sociocultural contexts. The authors found that present evaluation methods do not appropriately account for the importance of these factors and that new performance improvement indicators are needed.

Correlates of Sexual Risky Behaviours, HIV Testing, and HIV Testing Intention among Sexually Active Youths in Northern Tanzania

Background:

HIV testing services are important entry-point into the HIV cascade to care and treatment in order to slow down the spread of HIV infection. Over half of all new HIV infections in Sub-Saharan Africa occur among young people under the age of 25, particularly women. The study aimed to determine factors influencing young people's decision to undergo HIV testing services in Northern Tanzania.

Methods:

A total of 536 sexually active participants aged 15 to 24 years old completed a semi-structured questionnaire based on the Health Belief Model (HBM) and the Theory of Planned Behaviour (TPB).

Results:

Males compared to femaleparticipants were significantly younger at first age of sexual intercourse (15.4 vs. 16.7 years; p = .001). Out of 536 participants, 418(78%) reported inconsistent condom use, and 203/303(67%) were those practicing casual sex. Only, 189/536(35.3%) of the participants reported to have had an HIV-test. Age, socioeconomic status, perceived HIV severity, attitudes and social approval regarding testing and beliefs about testing procedures and perceived barriers to testing were significant predictors of HIV testing (R² =.22). Age, unsafe casual sex, perceived severity, HIV-testing attitudes, self-efficacy, social approval, cues for actions and perceived quality of testing procedures were significant and positively related to HIV-testing intentions, while perceived barriers to testing were negatively related (R² = .36).

Conclusion:

The integrated constructs of HBM and TPB provides a framework for identifying correlates of HIV testing behaviours and HIV testing intentions among sexually active youths. Future behaviour change interventions should focus on reduction of sexually risky behaviours, increasing perceived HIV severity, enhance positive attitudes and social approvals on testing, reduce misconceptions about testing procedures, alleviation of perceived barriers to testing and improve testing self-efficacy among sexually active youths in this setting.

Breast and Cervical cancer disparities in Alabama: current scenario, ongoing efforts to reduce the disparity gaps, and what more we could be doing

Over the years, we have made considerable progress in our understanding of the biology of various cancers leading to advancements in their management strategies. Consequently, we have witnessed steady improvements in survival rates of cancer patients post-diagnosis. The progress; however, has been slow for some cancer types and the advances in cancer care have not benefited all the communities equally in the United States. The state of Alabama has one of the most diverse demographics in the country and as a result, we witness significant health disparities among our populations. Breast and cervical cancers are the two major cancer types that disparately affect the women in our state. Here, we describe the extent of disparities in the diagnosis and death rates from these cancers in the state of Alabama and discuss potential underlying causes affecting the health outcomes. We also discuss ongoing efforts undertaken to reduce the disparity gaps and provide a perspective for addressing these disparities more effectively.

Scaling Up Public Health Interventions: Engaging Partners Across Multiple Levels

Advancing the science of intervention scale-up is essential to increasing the impact of effective interventions at the regional and national levels. In contrast with work in high-income countries (HICs), where scale-up research has been limited, researchers in low- and middle-income countries (LMICs) have conducted numerous studies on the regional and national scale-up of interventions. In this article, we review the state of the science on intervention scale-up in both HICs and LMICs. We provide an introduction to the elements of scale-up followed by a description of the scale-up process, with an illustrative case study from our own research. We then present findings from a scoping review comparing scale-up studies in LMIC and HIC settings. We conclude with lessons learned and recommendations for improving scale-up research. Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Supporting the implementation of guidelines to prevent mother-to-child-transmission of HIV in Malawi: a multi-case study

BACKGROUND

High HIV infection and fertility rates contributed to over 12,000 children acquiring HIV from their mothers in 2011 in Malawi. To prevent mother-to-child transmission of HIV, Malawi adopted the Option B+ guidelines, and for three years, the University of North Carolina (UNC) Project provided support to strengthen guideline implementation in 134 health centres. Little is known about how implementation support strategies are delivered in low resource countries or contextual factors that may influence their delivery. The limited descriptions of support strategies and salient contextual factors limits efforts to replicate, target, and further refine strategies. Guided by the Interactive Systems Framework for Dissemination and Implementation, this study describes factors influencing implementation of support strategies and how they impacted health center staff capacity to implement Option B+ in Malawi.

METHODS

A qualitative multi-case study design was applied. Data were collected through site visits to 4 heath centres (2 low- and 2-high performing centres). We interviewed 18 support providers and recipients between October 2014 and October 2015. Data were analysed using content, thematic, and cross-case analysis.

RESULTS

Four categories of strategies were used to support Option B+ guidelines implementation: training, technical assistance (TA), tools, and resources. All heath-centres implemented Option B+ guidelines for care provided between the antenatal and labor and delivery periods. Gaps in Option B+ implementation occurred during community activities and during post-delivery care, including gaps in testing of children to ascertain their HIV status at 6 weeks, 12 months, and 24 months. Salient contextual factors included staffing shortages, transportation challenges, limited space and infrastructure, limited stocks of HIV testing kits, and large patient populations.

CONCLUSIONS

Understanding factors that influence implementation support strategies and delivery of the Option B+ guidelines, such as availability of staff and other materials/drug resources, is critical to designing effective implementation support for low resource settings.

"Spoiled" girls: Understanding social influences on adolescent contraceptive decision-making in Kenya

OBJECTIVES

Despite significant public health emphasis on unintended pregnancy prevention among adolescent girls and young women in Sub-Saharan Africa, there is a gap in understanding how adolescents' own reproductive priorities and the social influences on their decision-making align and compete. We examined the social context of contraceptive decision-making among Kenyan female adolescents.

METHODS

Using community-based sampling, we conducted 40 in-depth interviews and 6 focus group discussions among sexually-active or partnered adolescent girls and young women aged 15-19 in the Nyanza region of Kenya. We analyzed the data in Dedoose using an inductive, grounded theory approach, and developed a conceptual model from the data illustrating social influences on adolescent contraceptive decision-making.

RESULTS

Participants viewed adolescent pregnancy as unacceptable, and described severe social, financial, and health consequences of unintended pregnancy, including abortion under unsafe conditions. Yet, their contraceptive behaviors often did not reflect their desire to delay pregnancy. Contraceptive decision-making was influenced by multiple social factors, centering on the intersecting stigmas of adolescent female sexuality, pregnancy, and contraceptive use, as well as unequal power in sexual relationships. To prioritize pregnancy prevention, adolescents must navigate conflicting social norms and power dynamics, and put their perceived future fertility at risk.

CONCLUSIONS

Contraceptive decision-making among Kenyan female adolescents is strongly influenced by opposing social norms within families, communities, and sexual relationships, which compel them to risk stigma whether they use a contraceptive method or become pregnant as adolescents. These findings put into perspective adolescents' seemingly incongruent pregnancy preferences and contraceptive behaviors. Interventions to address adolescent unintended pregnancy should focus on supporting adolescent decision-making agency, addressing fertility-related contraceptive concerns, and promoting innovative contraceptive access points rather than increasing contraceptive prevalence.

Delaying sexual onset: outcome of a comprehensive sexuality education initiative for adolescents in public schools

BACKGROUND

A common risk behavior in adolescence is the early initiation of unprotected sex that exposes adolescents to an unplanned pregnancy or sexually transmitted infections. Schools are an ideal place to strengthen adolescents' sexual knowledge and modify their behavior, guiding them to exercise responsible sexuality. The purpose of this article was to evaluate the knowledge of public secondary school teachers who received training in comprehensive education in sexuality (CES) and estimate the counseling's effect on students' sexual behavior.

METHODS

Seventy-five public school teachers were trained in participatory and innovative techniques for CES. The change in teacher knowledge (n = 75) was assessed before and after the training using t-tests, Wilcoxon ranks tests and a Generalized Estimate Equation model. The students' sexual and reproductive behavior was evaluated in intervention (n = 650) and comparison schools (n = 555). We fit a logistic regression model using the students' sexual debut as a dependent variable.

RESULTS

Teachers increased their knowledge of sexuality after training from 5.3 to 6.1 (p < 0.01). 83.3% of students in the intervention school reported using a contraceptive method in their last sexual relation, while 58.3% did so in the comparison schools. The students in comparison schools were 4.7 (p < 0.01) times more likely to start sexual initiation than students in the intervention schools.

CONCLUSION

Training in CES improved teachers' knowledge about sexual and reproductive health. Students who received counseling from teachers who were trained in participatory and innovative techniques for CES used more contraceptive protection and delayed sexual debut.

Norms and sexual relations among adolescents in the context of an intervention trial in rural Zambia

High levels of adolescent pregnancy and child marriage rates in low- and middle-income countries is an issue of concern to many stakeholders, including in Zambia where almost one-third of women give birth before age 18. The aim of this paper is to explore and analyse social norms concerning adolescents' sexual behaviour within the context of an intervention trial in rural communities in southern Zambia. It is based on a qualitative study applying individual interviews, focus group discussions and participatory research methods. We apply the distinction between injunctive and descriptive norms to demonstrate that adolescent girls are caught between conflicting norms. Injunctive norms express that premarital sex, contraceptive use, and discussions about sex between adults and youths are socially condemned. At the same time poor girls are reported to feel pressure towards having sexual relations for the economic benefits such relations can bring, and this practice is considered so common that it amounts to a descriptive norm. Norms and structural conditions combine to create a disabling and disempowering environment for adolescent sexual and reproductive health, which limits girls' agency and exposes them to unwanted pregnancies.

Improving use of maternal care services among married adolescent girls: an intervention study in rural India

This study examined the effect of the Safe Adolescent Transition and Health Initiative (SATHI) programme on the use of maternal care services among rural, pregnant adolescents in India. This was an intensive community-based, multi-site intervention project conducted in Maharashtra state between 2008 and 2011. Its aims were to improve the reproductive health of married adolescent girls and avert the adverse consequences of early motherhood. It had a quasi-experimental, case-control, pre-post design to enable rigorous evaluation. This study used cross-sectional data from 644 married girls aged under 19 years at baseline and 802 at endline to assess the maternal care outcomes of antenatal care, delivery and postnatal services and nutrition during pregnancy. Difference-in-differences analysis showed that all outcomes improved significantly in the study sites between baseline and endline, and the improvement in study sites was significantly larger than in the control sites. Multivariate analysis showed a statistically significant dose-response effect of intervention participation for antenatal care, pregnancy nutrition and postnatal care. Study participation was not statistically significantly associated with higher rates of safe or institutional delivery. The analysis suggests that training and supporting community health workers to work with married adolescent girls using interpersonal communication and interacting frequently with them and their families and communities can significantly improve the use of maternal care services among this population. With almost a million community health workers and 200,000 auxiliary nurse midwives at the community level providing primary level care in India, this intervention offers a proven strategy to replicate and scale-up to reach large numbers of married adolescent girls who do not currently use maternal care services.

Scaling Up a Strengthened Youth-Friendly Service Delivery Model to Include Long-Acting Reversible Contraceptives in Ethiopia: A Mixed Methods Retrospective Assessment

BACKGROUND

Donor funded projects are small scale and time limited, with gains that soon dissipate when donor funds end. This paper presents findings that sought to understand successes, challenges and barriers that influence the scaling up and sustainability of a tested, strengthened youth-friendly service (YFS) delivery model providing an expanded contraceptive method choice in one location - the YFS unit - with additional units in Amhara and Tigray, Ethiopia.

METHODS

This retrospective mixed methods study included interviews with key informants (KIs) (qualitative arm) and analysis of family planning (FP) uptake statistics extracted from the sampled health facilities (quantitative arm). A multistage convenience purposive sampling technique was adopted to randomly select 8 health facilities aligned with respective woredas, zones and regional health bureaus (RHBs). A semi-structured interview guide soliciting information on 6 scaling-up elements (stakeholder engagement, roles and responsibility, policy environment, financial resources, quality of voluntary FP services and data availability and use) guided the interviews. Fifty-six KI interviews were conducted with policy-makers, program managers, and clinic staff. Recurring themes were triangulated across administrative levels and implementing partners. Relevant FP data (acceptor status, age and method uptake) were extracted from the 8 sampled health facilities for a thirteen-month period. Qualitative findings triangulated with FP service statistics assessed the influence of the 6 scaling-up elements with trends in long-acting reversible contraceptive (LARC) uptake before and after training.

RESULTS

Our findings depict that respondents were knowledgeable and supportive of an expanded method mix. Statistically significant increases in long-acting contraceptive uptake were noted at 2 of the 8 health centers. Fidelity to the tested model was operationally constrained; respondents frequently mentioned trained staff absences and turnover as obstacles in offering quality FP services.

CONCLUSION

Despite conducive policy environment, supportive stakeholders, favorable environment, and financial support for trainings, statistically significant increases in LARC uptake occurred at only 2 of the 8 health centers; indicating the influence of weak health systems, poor quality of voluntary FP services and a ceiling effect. Scale-up processes must consider potential bottlenecks of weak health systems and availability of financial resources by addressing these as crucial elements in any systematic scale-up framework.

Reproductive health education program for Mexican women

Objective: Improve knowledge, attitudes and reproductive behaviours through an educational intervention aimed at reproductive health in two groups of Mexican women. Materials and methods: We carried out an education program targeting two segments, indigenous women and marginalised adolescents, with a pre-test, immediate post-test and post-test six months after it was carried out. Instruments used: a reproductive health history was established (pre-test and post-test six months) and a questionnaire of knowledge, attitude and conduct related to reproductive health and condom use (pre-test, immediate post-test and post-test six months). Results: Improved test scores in reproductive health and condom use - knowledge, attitude and conduct, were notable in the group of indigenous women (p < .05). However, in the group of adolescents there was a significant increase (p < .05) only in reproductive health - knowledge and attitude; in condom usage, increase was only noted in knowledge and conduct, not in attitude (pre-test vs immediate post-test). Six months after post-test results there was a decrease in test scores in comparison with the immediate post-test results. They were however, higher than the pre-test scores. Conclusions: Both groups significantly increased short-term knowledge, attitude and conduct related to reproductive health and condom use through the implementation of an education program. Results show that this education program can contribute to the development of an effective education program.