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Kunesh J, Hémono R, Gatare E, Kayitesi L, Packel L, Hope R, McCoy SI. Age-disparate relationships at first sex and reproductive autonomy, empowerment, and sexual violence among adolescent girls and young women in Rwanda. SSM Popul Health 2024; 25:101617. [PMID: 38426029 PMCID: PMC10901839 DOI: 10.1016/j.ssmph.2024.101617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 12/28/2023] [Accepted: 01/29/2024] [Indexed: 03/02/2024] Open
Abstract
Background Age-disparate relationships (ADR) place adolescent girls and young women (AGYW) at higher risk of unprotected sex and HIV infection; few studies have investigated ADR at first sex in sub-Saharan Africa. This study investigates ADR at first sex and its association with reproductive autonomy, reproductive empowerment, contraception coercion, and consent at first sex among female Rwandan youth. Methods Cross-sectional data from a randomized trial (n = 5768) of in-school youth ages 12-19 at enrollment were analyzed with focus on those who reported sexual activity (n = 1319). General estimating equation linear models and Poisson models were used to estimate linear coefficients and prevalence ratios (PR), with 95% confidence intervals (CIs) estimated using robust standard errors. Results Females reported a significantly higher average partner age gap than males by 2.43 years (2.90 years vs. 0.46 years, 95% CI: 2.01, 2.86). Overall, 23.4% (n = 102) of sexually active AGYW engaged in an ADR at first sex. The prevalence of non-consensual first sex was 60% higher among AGYW reporting ADR at first sex compared to AGYW reporting similar-aged partners (adjusted PR = 1.59, 95% CI: 1.25, 2.02). No association was found between ADR at first sex and reproductive autonomy, reproductive empowerment, or contraception coercion. Conclusions Our results suggest a high prevalence of sexual violence among AGYW engaging in first sex with an age-disparate partner. However, we did not find evidence that ADR at first sex affects reproductive autonomy or empowerment within the first few years of sexual initiation. Further research is needed to explore the impact of ADR at first sex and longer-term trajectories of sexual behavior, empowerment and autonomy.
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Affiliation(s)
- Jacqueline Kunesh
- University of California, Berkeley Division of Epidemiology and Biostatistics, School of Public Health, 2121 Berkeley Way, Berkeley, CA, 94720, USA
| | - Rebecca Hémono
- University of California, Berkeley Division of Epidemiology and Biostatistics, School of Public Health, 2121 Berkeley Way, Berkeley, CA, 94720, USA
| | - Emmyson Gatare
- Food and Agriculture Organization of the United Nations (FAO), Rome, Italy
| | - Laetitia Kayitesi
- Youth Development Labs (YLabs), 3130 Shattuck Avenue, Berkeley, CA, 94705, USA
| | - Laura Packel
- University of California, Berkeley Division of Epidemiology and Biostatistics, School of Public Health, 2121 Berkeley Way, Berkeley, CA, 94720, USA
| | - Rebecca Hope
- Youth Development Labs (YLabs), 3130 Shattuck Avenue, Berkeley, CA, 94705, USA
| | - Sandra I. McCoy
- University of California, Berkeley Division of Epidemiology and Biostatistics, School of Public Health, 2121 Berkeley Way, Berkeley, CA, 94720, USA
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Vizheh M, Zurynski Y, Braithwaite J, Rapport F. Determinants of women's agency in accessing and utilising reproductive healthcare services; a systematic review. CULTURE, HEALTH & SEXUALITY 2024; 26:248-264. [PMID: 37078806 DOI: 10.1080/13691058.2023.2200814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 04/05/2023] [Indexed: 05/03/2023]
Abstract
Women's agency is vital to access and use reproductive healthcare services, particularly in contexts where patriarchal beliefs and cultural norms limit women's desire to act on their goals or affect their access to essential resources. However, less is known about what resources enable women to exercise agency to access these services. A comprehensive systematic review was conducted to summarise existing evidence on the determinants of women's agency in accessing and using reproductive healthcare services. Various determinants were identified, including individual characteristics; household structure; reproductive health-related determinants; social relations; and economic factors. These determinants of women's agency in accessing reproductive healthcare services were strongly associated with social norms and cultural beliefs. Several gaps in the literature included inconsistent definitions and measurement of women's agency; lack of considering cultural sensitivities and socially acceptable practices in the conceptualisation and measurement of women's agency; a narrow focus on services related predominantly to pregnancy and birth, with other aspects of services including sexual health and safe abortion being largely unreported. The literature focused on developing countries in Africa and Asia, leaving a significant gap in knowledge about women's agency to access services in other geographical areas or among immigrant or refugee populations living in developed countries.
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Affiliation(s)
- Maryam Vizheh
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
| | - Yvonne Zurynski
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
- National Health and Medical Research Council, Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
- National Health and Medical Research Council, Partnership Centre for Health System Sustainability, Australian Institute of Health Innovation, Macquarie University, Sydney, Australia
| | - Frances Rapport
- Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Sydney, Australia
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Groenewald C, Isaacs N, Qoza P. Hope, agency, and adolescents' sexual and reproductive health: A mini review. FRONTIERS IN REPRODUCTIVE HEALTH 2023; 5:1007005. [PMID: 36874262 PMCID: PMC9982081 DOI: 10.3389/frph.2023.1007005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 01/30/2023] [Indexed: 02/19/2023] Open
Abstract
Availability of and access to services that promote sexual and reproductive health (SRH) amongst adolescent girls have become a global priority. Yet, while researchers have explored factors that influence the uptake of SRH services in low-and-middle income countries, the roles that "agency" and "hope" play in adolescent SRH is less understood. To study this, this mini review systematically reviewed the literature across three databases, EBSCO-host web, Pubmed and South Africa (SA) epublications, for the period of January 2012 to January 2022. Findings showed that a paucity of studies identified the link between agency, hope and adolescent SRH respectively. Our review included 12 articles and found no studies that focused on hope and its role in adolescent SRH or seeking SRH services. However, the literature revealed the complexities of adolescent SRH agency and autonomy where female adolescents had limited autonomy to make SRH decisions. Limited access to adolescent friendly SRH services was also found to restrict girls' agency to prevent unintended pregnancies or to take up SRH support. Given the paucity of research, empirical studies are needed to further understand the extent to which hope, agency and other subjective factors implicate adolescent SRH in the African context.
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Affiliation(s)
- Candice Groenewald
- Centre for Community-Based Research, Human Sciences Research Council, Pretoria, South Africa.,Psychology Department, Rhodes University, Grahamstown, South Africa
| | - Nazeema Isaacs
- Impact Centre, Human Sciences Research Council, Cape Town, South Africa
| | - Phiwokazi Qoza
- Centre for Community-Based Research, Human Sciences Research Council, Pretoria, South Africa
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Gutin SA, Harper GW, Moshashane N, Ramontshonyana K, Stephenson R, Shade SB, Harries J, Mmeje O, Ramogola-Masire D, Morroni C. Relationship, partner factors and stigma are associated with safer conception information, motivation, and behavioral skills among women living with HIV in Botswana. BMC Public Health 2021; 21:2231. [PMID: 34879845 PMCID: PMC8653588 DOI: 10.1186/s12889-021-12268-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 11/16/2021] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND A significant proportion (20-59%) of people living with HIV in sub-Saharan Africa desire childbearing, are of reproductive age, and are in sero-different relationships (~50%). Thus it is plausible that some portion of new HIV transmissions are due to attempts to become pregnant. Safer conception (SC) methods that effectively reduce the risk of HIV transmission exist and can be made available in resource-constrained settings. Few studies in the region, and none in Botswana, have quantitatively examined the correlates of information, motivation, and behavioral skills for SC uptake. METHODS We surveyed 356 women living with HIV from 6/2018 to 12/2018 at six public-sector health clinics in Gaborone, Botswana. Participants were 18-40 years old, not pregnant, and desired future children or were unsure about their childbearing plans. We examined correlates of SC information, motivation, and behavioral skills using nested linear regression models, adjusting for socio-demographic, interpersonal, and structural variables. RESULTS Knowledge of SC methods varied widely. While some SC methods were well known (medical male circumcision by 83%, antiretroviral therapy for viral suppression by 64%), most other methods were known by less than 40% of participants. Our final models reveal that stigma as well as relationship and partner factors affect SC information, motivation, and behavioral skills. Both internalized childbearing stigma (ß=-0.50, 95%CI:-0.17, -0.02) and perceived community childbearing stigma were negatively associated with SC information (ß=-0.09, 95%CI:-0.80, -0.21). Anticipated (ß=-0.06, 95%CI:-0.12, -0.003) and internalized stigma (ß=-0.27, 95%CI:-0.44; -0.10) were associated with decreased SC motivation, while perceived community childbearing stigma was associated with increased SC motivation (ß=0.07, 95%CI:0.02, 0.11). Finally, internalized childbearing stigma was associated with decreased SC behavioral skills (ß=-0.80, 95%CI: -1.12, -0.47) while SC information (ß=0.24, 95%CI:0.12, 0.36), motivation (ß=0.36, 95%CI:0.15, 0.58), and perceived partner willingness to use SC (ß=0.47, 95%CI:0.36, 0.57) were positively associated with behavioral skills CONCLUSIONS: Low SC method-specific information levels are concerning since almost half (47%) of the study participants reported they were in sero-different relationships and desired more children. Findings highlight the importance of addressing HIV stigma and partner dynamics in interventions to improve SC information, motivation, and behavioral skills.
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Affiliation(s)
- Sarah A Gutin
- Center for AIDS Prevention Studies, Division of Prevention Science, University of California, San Francisco, 550 16th Street, 3rd Floor, 94143, San Francisco, CA, USA.
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA.
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa.
| | - Gary W Harper
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
| | - Neo Moshashane
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Kehumile Ramontshonyana
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
| | - Rob Stephenson
- Department of Systems, Population and Leadership, School of Nursing, University of Michigan, MI, Ann Arbor, USA
- The Center for Sexuality and Health Disparities, School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Starley B Shade
- Department of Epidemiology & Biostatistics School of Medicine, University of California, San Francisco, CA, San Francisco, USA
| | - Jane Harries
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
| | - Okeoma Mmeje
- Department of Health Behavior and Health Education, School of Public Health, University of Michigan, 1415 Washington Heights, MI, 48109, Ann Arbor, USA
- Department of Obstetrics and Gynecology, University of Michigan Medical School, MI, Ann Arbor, USA
| | - Doreen Ramogola-Masire
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Chelsea Morroni
- Women's Health Research Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, 7925, Observatory, Cape Town, South Africa
- Botswana Harvard AIDS Institute Partnership Princess Marina Hospital, Private Bag BO 320, Gaborone, Botswana
- MRC Centre for Reproductive Health, University of Edinburgh, 47 Little France Crescent, EH16 4TJ, Edinburgh, United Kingdom
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Feld H, Barnhart S, Wiggins AT, Ashford K. Social support reduces the risk of unintended pregnancy in a low-income population. Public Health Nurs 2021; 38:801-809. [PMID: 33938034 PMCID: PMC8419072 DOI: 10.1111/phn.12920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 04/06/2021] [Accepted: 04/07/2021] [Indexed: 11/29/2022]
Abstract
Almost half of all pregnancies (45%) in the United States (US) are unintended, with the highest concentration in women with low incomes. Targeted research is warranted to identify risk and protective factors that influence pregnancy intention to improve maternal/child health. PURPOSE To identify individual and interpersonal level associations to pregnancy intention to use as leverage points to build resilience. METHOD A cross-sectional, secondary analysis of Medicaid eligible pregnant women in Kentucky (n = 309). RESULTS Sixty-two percent reported their current pregnancy was unintended. Older age, partnered, negative drug screen, and increased social support were associated with decreased odds of unintended pregnancy. For every 1 unit increase of belonging and tangible social support, women were 13% and 14% (respectively) less likely to have an unintended pregnancy (OR = 0.87, 95% CI = 0.78-0.97, p = .011, OR = 0.86, 95% CI = 0.77-0.95, p = .005). A positive drug screen was associated with an almost three-fold increase in the odds of unintended pregnancy (OR = 2.88, 95% CI = 1.49-5.58, p = .002). CONCLUSION Public health nurses can play a critical role in reducing unintended pregnancy rates by promoting social support, inclusion, and acceptance. There remains a critical need to identify barriers and facilitators to pregnancy planning for persons who use illicit drugs.
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Affiliation(s)
- Hartley Feld
- College of Nursing, University of Kentucky, Lexington, KY, USA
| | - Sheila Barnhart
- College of Social Work, University of Kentucky, Lexington, KY, USA
| | | | - Kristin Ashford
- College of Nursing, University of Kentucky, Lexington, KY, USA
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Karp C, Wood SN, Galadanci H, Sebina Kibira SP, Makumbi F, Omoluabi E, Shiferaw S, Seme A, Tsui A, Moreau C. 'I am the master key that opens and locks': Presentation and application of a conceptual framework for women's and girls' empowerment in reproductive health. Soc Sci Med 2020; 258:113086. [PMID: 32521413 PMCID: PMC7369639 DOI: 10.1016/j.socscimed.2020.113086] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 04/30/2020] [Accepted: 05/22/2020] [Indexed: 11/18/2022]
Abstract
RATIONALE A renewed focus on women's and girls' empowerment in the era of Sustainable Development Goals reflects the belief that empowerment is central to health and development. Sexual and reproductive health (SRH) outcomes, including pregnancy and contraceptive use, may contribute to and result from empowerment. However, enhanced understanding of how women become empowered for SRH requires clear conceptualization of empowerment. OBJECTIVE We aimed to assess the applicability of a proposed framework for women's and girls' SRH empowerment (WGE-SRH) in sub-Saharan Africa. We sought to understand what shapes and motivates preferences for childbearing and contraception, exploring how women and girls navigate external pressures or rewards to exercise and achieve their reproductive goals. METHODS Grounded in the WGE-SRH framework, we conducted a qualitative study in four distinct contexts (Ethiopia, Kano and Anambra States in Nigeria, and Uganda). We implemented and analyzed 120 in-depth interviews and 38 focus group discussions with 440 women and men and translated results to refine the WGE-SRH framework. RESULTS Findings demonstrate the salience of women's internal motivations, including the social value and joys of motherhood, in shaping existence of reproductive choices. However, existence of choice was limited by couples' economic situations, pressures from providers, partners, and family members, and women's fears of contraceptive side effects or relationship dissolution. Despite these constraints, many found ways to exercise their reproductive choices through negotiation with partners, third party involvement in reproductive discussions, non-verbal communication, and covert use of contraception. CONCLUSIONS The WGE-SRH framework is useful for exploring SRH empowerment, embracing the multilevel, dynamic nature of empowerment, as a process transitioning from existence of choice (autonomy) to exercise of choice (self-efficacy, decision-making, negotiation), and, ultimately, to achievement of choice. Future research and programs related to SRH empowerment should distinguish between existence and exercise of choices to promote the health and well-being of women and girls.
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Affiliation(s)
- Celia Karp
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA.
| | - Shannon N Wood
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Hadiza Galadanci
- Center for Advanced Medical Research and Training, Bayero University Kano, Nigeria
| | - Simon Peter Sebina Kibira
- Department of Community Health and Behavioral Sciences, School of Public Health, Makerere University, Uganda
| | - Fredrick Makumbi
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Uganda
| | | | - Solomon Shiferaw
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Ethiopia
| | - Assefa Seme
- Department of Reproductive Health and Health Service Management, School of Public Health, Addis Ababa University, Ethiopia
| | - Amy Tsui
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA
| | - Caroline Moreau
- Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, USA; Soins et Santé Primaire, CESP Centre for Research in Epidemiology and Population Health U1018, Inserm, F-94805, Villejuif, France
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