Impact of COVID-19 lockdowns on adolescent pregnancy and school dropout among secondary schoolgirls in Kenya

Long-term impacts of a cash plus program on marriage, fertility, and education after six years in pastoralist Kenya: A cluster randomized trial

Background

Preventing early marriage by increasing girls education has shown promise. We assessed the effects of a two-year cash plus program on marriage and fertility in a pastoralist setting in Northeastern Kenya, six years after it began.

Methods

A prospective 80-cluster randomized trial followed 2,147 girls 11-14 years old starting in 2015, re-interviewing 94.2% in 2021. Interventions included community dialogues (violence prevention), a conditional cash transfer (education), health and life skills training (health), and financial literacy (wealth creation). Villages were randomized to one of four study arms: (1) violence prevention only (V-only); (2) + education (VE); (3) + health (VEH); or (4) + wealth creation (VEHW). We used analysis of covariance to estimate intent-to-treat impacts of each study arm with an education component, as well as a pooled (weighted average) study arm combining VE, VEH and VEHW, in reference to V-only, four years after the intervention ended when girls were 17-20 years old.

Findings

Base specification estimates show reductions in the primary outcomes, though none statistically significant in the full sample. Estimates with extended controls are larger and the pooled study arm had significantly lower marriage and pregnancy. There are considerably larger statistically significant effects for the baseline out-ofschool subsample. Pooled estimates indicate 18.2 percentage point lower marriage compared to V-only and 15.1 percentage point lower pregnancy. For the same group pooled estimates indicate a 27.9 percentage point increase in current enrollment (compared to 7.1% in V-only) and a 1.8 grades increase (compared to 1.2 in V-only).

Conclusion

This study shows the potential for interventions in early adolescence with an education component to delay marriage and fertility into late adolescence and early adulthood in a marginalized and socially conservative setting with low education and high rates of child marriage.

"He'll come with some sugar." A qualitative study exploring the drivers and consequences of schoolgirls transactional sex behaviours

Intoduction

Transactional sex (TS) is common in areas of sub-Saharan Africa, motivated by reasons beyond financial support. Through this qualitative study we sought to understand the motivation driving TS among adolescent schoolgirls in rural western Kenya where rates are reportedly high. Identifying and understanding drivers within the local context is necessary for implementation of successful public health policy and programming to reduce the associated harms impacting health and wellbeing.

Methods

To understand the drivers of sexual behaviors, individual views, and socio-cultural norms, we spoke with schoolgirls, male peers, parents and teachers. The three latter groups may influence, encourage, and shape girls' views and behaviors and thus contribute to the perpetuation of cultural and societal norms.

Results

One hundred and ninety-nine participants took part across 20 FGDs; 8 comprised of schoolgirl groups, and 4 each of schoolboy, parent or teacher groups. Through thematic analysis, poverty emerged as the key driver of TS and a normative behaviour amongst secondary school girls. Subthemes including parental influence, need for menstrual pads, pressure from boda boda drivers, peer pressure, and blame were part of a complex relationship linking poverty with TS.

Discussion

We conclude that whilst TS is perceived as inevitable, normal and acceptable it is not really a choice for many girls. Exploring ways to encourage communication between families, including around menstruation, may help enable girls to ask for help in acquiring essential items. In addition, education at a community level may shift social norms over time and decrease the prevalence of age-disparate TS among schoolgirls and older, wealthier men in the community.

The downstream effects of COVID-19 on adolescent girls in the Peruvian Amazon: qualitative findings on how the pandemic affected education and reproductive health

Due to COVID-19, schools were closed to mitigate disease spread. Past studies have shown that disruptions in education have unintended consequences for adolescents, including increasing their risk of school dropout, exploitation, gender-based violence, pregnancy and early unions. In Peru, the government closed schools from March 2020 to March 2022, declaring a national emergency that affected an estimated 8 million children. These closures may have unintended consequences, including increased adolescent pregnancy, particularly in Peru's rural, largely indigenous regions. Loreto, located in the Peruvian Amazon, has one of the highest adolescent pregnancy rates in the country and poor maternal and child health outcomes. The underlying causes may not be fully understood as data are limited, especially as we transition out of the pandemic. This qualitative study investigated the downstream effects of COVID-19 on adolescent education and reproductive health in Loreto's districts of Nauta and Parinari. In-depth interviews (n=41) were conducted with adolescents and community leaders. These were held in June 2022, 3 months after the reinstitution of in-person classes throughout Peru. Focus group discussions (FGDs) were also completed with community health workers and educators from the same study area in October 2022 to supplement our findings (3 FGDs, n=15). We observed that the economic, educational and health effects of the COVID-19 pandemic contributed to reduced contraceptive use, and increased school abandonment, early unions and adolescent pregnancy. The interplay between adolescent pregnancy and both early unions and school abandonment was bidirectional, with each acting as both a cause and consequence of the other.

Impact of COVID-19 on school attendance in South Africa. Analysis of sociodemographic characteristics of learners

The outbreak of COVID-19 had resulted in the complete closure of schools in nearly all countries across the globe. However, reopening after prolonged closure may adversely affect the school attendance of learners, with long-term implications for life outcomes. Given the limited studies on the subject, this study aims at examining the impact of COVID-19 on the school attendance of learners in South Africa and how this outcome is exacerbated by underlying socioeconomic factors using National Income Dynamics Study-Coronavirus Rapid Mobile Survey data (NIDS-CRAM). The findings reveal that COVID-19 has led to a sharp drop of 48.2% in the school attendance of learners following the reopening of schools after the state of national disaster-based lockdown. The study has demonstrated that the impact of COVID-19 on the school attendance of learners varies according to socioeconomic factors such as gender, race, geographical area, family size, and the economic status of the learners' parents and provincial location. Sociodemographic characteristics such as African race, coloured race, Asian race, female gender, rural location, large household size, and Eastern Cape are associated with lower school attendance among learners. Based on these findings, educational-based policy needs to include these sociodemographic factors to promote a high school attendance rate among learners. This may include a shift from a blanket approach to geographical, racial, family, and gender-based interventions.

Sexual and Reproductive Health Outcomes Among Adolescent Females During the COVID-19 Pandemic

BACKGROUND AND OBJECTIVES

Coronavirus disease 2019 (COVID-19) posed a significant threat to adolescents' sexual and reproductive health. In this study, we examined population-level pregnancy and sexual health-related care utilization among adolescent females in Ontario, Canada during the pandemic and evaluated relationships between these outcomes and key sociodemographic characteristics.

METHODS

This was a population-based, repeated cross-sectional study of >630 000 female adolescents (12-19 years) during the prepandemic (January 1, 2018-February 29, 2020) and COVID-19 pandemic (March 1, 2020-December 31, 2022) periods. Primary outcome was pregnancy; secondary outcomes were contraceptive management visits, contraception prescription uptake, and sexually transmitted infection (STI) management visits. Poisson models with generalized estimating equations for clustered count data were used to model pre-COVID-19 trends and forecast expected rates during the COVID-19 period. Absolute rate differences between observed and expected outcome rates for each pandemic month were calculated overall and by urbanicity, neighborhood income, immigration status, and region.

RESULTS

During the pandemic, lower-than-expected population-level rates of adolescent pregnancy (rate ratio 0.87; 95% confidence interval [CI]:0.85-0.88), and encounters for contraceptive (rate ratio 0.82; 95% CI:0.77-0.88) and STI management (rate ratio 0.52; 95% CI:0.51-0.53) were observed. Encounter rates did not return to pre-pandemic rates by study period end, despite health system reopening. Pregnancy rates among adolescent subpopulations with the highest pre-pandemic pregnancy rates changed least during the pandemic.

CONCLUSIONS

Population-level rates of adolescent pregnancy and sexual health-related care utilization were lower than expected during the COVID-19 pandemic, and below-expected care utilization rates persist. Pregnancy rates among more structurally vulnerable adolescents demonstrated less decline, suggesting exacerbation of preexisting inequities.

Safeguarding in practice: anticipating, minimising and mitigating risk in teenage pregnancy research in urban informal settlements in Nairobi, Kenya

Safeguarding challenges in global health research include sexual abuse and exploitation, physical and psychological abuse, financial exploitation and neglect. Intersecting individual identities (such as gender and age) shape vulnerability to risk. Adolescents, who are widely included in sexual and reproductive health research, may be particularly vulnerable. Sensitive topics like teenage pregnancy may lead to multiple risks. We explored potential safeguarding risks and mitigation strategies when studying teenage pregnancies in informal urban settlements in Nairobi, Kenya. Risk mapping was initiated by the research team that had prolonged engagement with adolescent girls and teen mothers. The team mapped potential safeguarding risks for both research participants and research staff due to, and unrelated to, the research activity. Mitigation measures were agreed for each risk. The draft risk map was validated by community members and coresearchers in a workshop. During implementation, safeguarding risks emerged across the risk map areas and are presented as case studies. Risks to the girls included intimate partner violence because of a phone provided by the study; male participants faced potential disclosure of their perceived criminal activity (impregnating teenage girls); and researchers faced psychological and physical risks due to the nature of the research. These cases shed further light on safeguarding as a key priority area for research ethics and implementation. Our experience illustrates the importance of mapping safeguarding risks and strengthening safeguarding measures throughout the research lifecycle. We recommend co-developing and continuously updating a safeguarding map to enhance safety, equity and trust between the participants, community and researchers.

Increased reproductive tract infections among secondary school girls during the COVID-19 pandemic: associations with pandemic related stress, mental health, and domestic safety

Background

Kenya, like many countries, shuttered schools during COVID-19, with subsequent increases in poor mental health, sexual activity, and pregnancy. We sought to understand how the COVID-19 pandemic may mediate risk of reproductive tract infections. We hypothesized that greater COVID-19 related stress would mediate risk via mental health, feeling safe inside the home, and sexual exposure, given the pandemic mitigation-related impacts of school closures on these factors.

Methods

We analyzed data from a cohort of 436 girls enrolled in secondary school in rural western Kenya. Baseline, 6-, 12-, and 18- month study visits occurred April 2018 - December 2019 (pre-COVID), and 30-, 36-, and 48- month study visits occurred September 2020 - July 2022 (COVID period). At study visits, participants self-completed a survey for sociodemographics and sexual practices, and provided self-collected vaginal swabs for Bacterial vaginosis (BV) testing, with STI testing at annual visits. COVID-related stress was measured with a standardized scale and dichotomized at highest quartile. Mixed effects modeling quantified how BV and STI changed over time, and longitudinal mediation analysis quantified how the relationship between COVID-19 stress and increased BV was mediated.

Findings

BV and STI prevalence increased from 12.1% and 10.7% pre-COVID to 24.5% and 18.1% during COVID, respectively. This equated to a 26% (95% CI 1.00 - 1.59) and 36% (95% CI 0.98 - 1.88) increased relative prevalence of BV and STIs, respectively, in the COVID-19 period compared to pre-COVID, adjusted for numerous sociodemographic and behavioral factors. Higher COVID-related stress was associated with elevated depressive symptoms and feeling less safe inside the home, which were each associated with increased likelihood of having a boyfriend. In longitudinal mediation analyses, the direct effect of COVID-related stress on BV was small and non-significant, indicating increased BV was due to the constellation of factors that were impacted during the COVID-pandemic.

Conclusions

In this cohort of adolescent girls, BV and STIs increased following COVID-related school closures. These results highlight modifiable factors to help maintain sexual and reproductive health resiliency, such as anticipating and mitigating mental health impacts, domestic safety concerns, and maintaining sexual health services to prevent and treat reproductive tract infections.

Associations of formal childcare use with health and human capital development for adolescent mothers and their children in South Africa: A cross-sectional study

AIM

This study aims to investigate associations of formal childcare with maternal and child outcomes in a large sample of adolescent mothers.

BACKGROUND

Forty percent of adolescent girls in Africa are mothers. Increasing evidence shows positive impacts of formal childcare use for adult women, but no known studies in the Global South examine associations for adolescent mothers and their children.

METHODS

We interviewed 1046 adolescent mothers and completed developmental assessments with their children (n = 1139) in South Africa's Eastern Cape between 2017 and 2019. Questionnaires measured childcare use, maternal and child outcomes and socio-demographic background variables. Using cross-sectional data, associations between formal childcare use and outcomes were estimated in multivariate multi-level analyses that accounted for individual-level and family-level clustering.

RESULTS

Childcare use was associated with higher odds of being in education or employment (AOR: 4.01, 95% CIs: 2.59-6.21, p < .001), grade promotion (AOR: 2.08, 95% CIs: 1.42-3.05, p < .001) and positive future ideation (AOR: 1.58, 95% CIs: 1.01-2.49, p = .047) but no differences in mental health. Childcare use was also associated with better parenting on all measures: positive parenting (AOR: 1.66, 95% CIs: 1.16-2.38, p = .006), better parental limit-setting (AOR: 2.00, 95% CIs: 1.37-2.93, p < .001) and better positive discipline (AOR: 1.77, 95% CIs: 1.21-2.59, p = .003). For the children, there were no differences in temperament or illness, but a significant interaction showed stronger associations between childcare use and better cognitive, language and motor scores with increasing child age (AOR: 5.04, 95% CIs: 1.59-15.96, p = .006).

CONCLUSIONS

Adolescent mothers might benefit substantially from formal childcare, but causal links need to be explored further. Childcare use was also associated with improved parenting and better child development over time, suggesting positive pathways for children. At an average of $9 per month, childcare provisions for adolescent mothers may offer low-cost opportunities to achieve high returns on health and human capital outcomes in Sub-Saharan African contexts.

Factors associated with adolescent pregnancy in Maharashtra, India: a mixed-methods study

Reducing the adolescent birth rate is paramount in achieving the health-related Sustainable Development Goals, given that pregnancy and childbirth are the leading cause of mortality among young women aged 15-19. This study aimed to explore predictors of adolescent pregnancy among girls aged 13-18 years in Maharashtra, India, during the COVID-19 pandemic. Using a mixed-methods approach, primary data were gathered from two regions in Maharashtra between February and April 2022. Quantitative data from face-to-face interviews with 3049 adolescent girls assessed various household, social, and behavioural factors, as well as the socioeconomic and health impacts of COVID-19. Qualitative data from seven in-depth interviews were analysed thematically. The findings reveal that girls from low socioeconomic backgrounds face a higher likelihood of adolescent pregnancy. Multivariable analysis identified several factors associated with increased risk, including older age, being married, having more sexual partners, and experiencing COVID-19-related economic vulnerability. On the other hand, rural residence, secondary and higher secondary education of the participants, and higher maternal education were associated with a decreased likelihood of adolescent pregnancy. In the sub-sample of 565 partnered girls, partner's emotional abuse also correlated with higher rates of adolescent pregnancy. Thematic analysis of qualitative data identified four potential pathways leading to adolescent pregnancy: economic hardships and early marriage; personal safety, social norms, and early marriage; social expectations; and lack of knowledge on contraceptives. The findings underscore the significance of social position and behavioural factors and the impact of external shocks like the COVID-19 pandemic in predicting adolescent pregnancy in Maharashtra, India.Plain Language Summary: Adolescent pregnancy is an important health issue for young girls. In South Asia, one out of every five adolescent girls becomes a mother before turning 18, and in India, around 9% of girls aged 15-19 get pregnant yearly. This study focused on understanding the factors associated with adolescent pregnancy in Maharashtra, India, especially after the COVID-19 pandemic. We collected information from both urban and rural areas in Maharashtra. A total of 3049 adolescent girls participated in a survey, and seven girls participated in detailed interviews. Our analysis showed that factors like older age, being married, having multiple sexual partners, and experiencing economic difficulties due to COVID-19 increased the chances of adolescent pregnancy. On the other hand, living in rural areas, higher education for both the girls and their mothers reduced the likelihood of adolescent pregnancy. Qualitative analysis revealed that economic challenges, concerns about safety and societal norms, early marriage, societal expectations, and lack of knowledge about contraceptives could contribute to adolescent pregnancy in Maharashtra.

Key normative, legal, and policy considerations for supporting pregnant and postpartum adolescents in high HIV-burden settings: a critical analysis

Rates of adolescent pregnancy within sub-Saharan Africa are increasing. Adolescent mothers ages 10-19 years face a distinct set of risks to their own and their children's health, compounded by many economic, social, and epidemiological challenges, such as living with HIV. In navigating this complex developmental period, many adolescent mothers face structural barriers impeding safe transitions to adulthood and motherhood. Drawing on existing literature and emerging data, we outline three normative, legal, and policy issues - violence and gender inequity, access to sexual and reproductive health services, and access to social and structural supports - which affect the health, wellbeing and development of adolescent mothers and their children. We also highlight emergent evidence about programming and policy changes that can better support adolescent mothers and their children. These key proposed responses include removing barriers to SRH and HIV service integration; ensuring implementation of return-to-school policies; and extending social protection systems to cater for adolescent mothers. Despite ongoing global crises and shifts in funding priorities, these normative, legal, and policy considerations remain critical to safeguard the health and wellbeing of adolescent mothers and their children.

Assessing the health, social, educational and economic impact of the COVID-19 pandemic on adolescents in low- and middle-income countries: a rapid review of the literature

COVID-19 has caused profound health, social, educational and economic devastation around the world, especially among the lives of adolescents in low- and middle-income countries. This paper looks at a wide array of outcomes impacting adolescents' daily lives including health (mental, physical, sexual and reproductive health, vaccine perceptions and overlap between these topics), social relationships (family and peer), education and socio-economic disparities. Both scientific and grey literature between December 2019 and February 2022 were sought from PubMed, Google Scholar and organisations conducting research among adolescents, and coded. A total of 89 articles were included, 73% of which were peer-reviewed; 37% of the articles were from WHO's Western Pacific region; 62% of the articles were cross-sectional; 75% were quantitative. Three major topics emerged in more than half the articles: mental health (72%), education (61%) and socio-economic ramifications (55%). However, there were regional differences in topics and many of them overlapped. The results indicate that, where there has been research, almost all findings have been linked to worse mental health during the pandemic. Overall, remote education was seen as a negative experience. The ramification of school closures on future aspirations, in particular early school leaving, highlights the importance of prioritising education during future pandemics based on the situation within the country. Gender and other disparities have made marginalised adolescents vulnerable to the economic ramifications of containment measures. Given the risks identified, there is a pressing need to put adolescents at the centre of establishing priorities for their health agenda for post-pandemic recovery.

Qualitative perspectives on COVID-19, interpersonal violence, and interventions to improve well-being from adolescent girls and young women in Kisumu, Kenya

Introduction

Adolescent girls and young women (AGYW) face a high burden of gender-based violence (GBV) worldwide. The COVID-19 pandemic and associated policies led to global increases in GBV, decreased access to resources, and disruptions of pathways to care. We aimed to understand the effects of COVID-19 on AGYW affected by GBV in Kisumu, Kenya, as well as to identify possible interventions to mitigate those effects.

Methods

Focus group discussions (FGDs) were conducted with AGYW aged 15-25 with a history of exposure to GBV. AGYW were split into age-matched groups; aged 15-19 for younger groups and 19-25 for older groups. Discussions focused on how COVID-19 affected experiences of GBV, access to care services, economic and social outcomes, and opportunities for interventions to mitigate negative impacts of COVID-19 and violence.

Results

Five FGDs with 46 AGYW were completed in June-September 2021. AGYW described increases in all types of GBV, particularly sexual abuse and intimate partner violence. Early marriage and subsistence transactional sex also increased. AGYW described violence as both a cause and effect of poor economic, social and health consequences related to the pandemic. Notably, AGYW emphasized stress, lack of mental health support and increased substance use as risk factors for violence, and discussed the deleterious mental health effects of violence-particularly in the wake of disruption of mental health services. COVID-19 disrupted referrals to violence-related services, and reduced access to both medical services and psychosocial services. AGYW believed that interventions focused on improving mental health as well as economic empowerment would be the most feasible and acceptable in mitigating the negative effects of COVID-19 and related exacerbations in violence.

Discussion

AGYW reported increases in almost all forms of GBV during the pandemic, with related exacerbation in mental health. Concurrently, AGYW endorsed decreased access to care services. As there is no evidence that violence and mental health challenges will quickly resolve, there is an urgent need to identify and implement interventions to mitigate these negative effects.

Menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls in western Kenya: a cluster randomised controlled trial

Background

High rates of sexual and reproductive health (SRH) harms and interrupted schooling are global challenges for adolescent girls, requiring effective interventions. We assessed the impact of menstrual cups (MCs) or cash transfers conditioned on school attendance (CCTs), or both, on SRH and schooling outcomes in western Kenya.

Methods

In this cluster-randomised Cups or Cash for Girls (CCG) trial, adolescent girls in Forms two and three at 96 secondary schools in Siaya County (western Kenya) were randomised to receive either CCT, MC, combined CCT and MC, or control (1:1:1:1) for an average of 30 months. The CCT intervention comprised 1500KES (US$15 in 2016) via a cash card each school trimester. All four treatment groups received puberty and hygiene training. Assenting girls with parent or guardian consent who were post-menarche, not pregnant, area residents, not boarding, and had no disabilities precluding participation were eligible. Socio-behavioural risk factors and incidence of HIV and herpes simplex virus type 2 (HSV-2) were measured annually. School retainment and adverse events were monitored throughout. The primary outcome comprised a composite of incident HIV, HSV-2 and/or all-cause school dropout by school exit examination. The primary analysis was by intention-to-treat (ITT) using generalised linear mixed models, controlling for a priori selected baseline covariates. The trial is registered with ClinicalTrials.gov, NCT03051789.

Findings

Between February 28, 2017 and June 30, 2021, 4137 girls (median age 17.1 [interquartile range (IQR): 16.3-18.0]) were enrolled and followed annually until completion of secondary school (median 2.5 years [IQR: 2.4-2.7]); 4106 (99.3%) contributed to the ITT analysis. No differences in the primary composite outcome between intervention and control groups were seen (MC: 18.2%, CCT: 22.1%, combined: 22.1%, control: 19.6%; adjusted risk ratio [aRR]: 0.97, 95% confidence interval 0.76-1.24; 1.14, 0.90-1.45; and 1.13, 0.90-1.43, respectively). Incident HSV-2 occurred in 8.6%, 13.3%, 14.8%, and 12% of the MC, CCT, combined and control groups, respectively (MC: RR: 0.67, 0.47-0.95, p = 0.027; aRR: 0.71, 0.50-1.01, p = 0.057; CCT: aRR: 1.02, 0.73-1.41, p = 0.92; combined aRR: 1.16, 0.85-2.58, p = 0.36). Incident HIV was low (MC: 1.2%, CCT: 1.5%, combined: 1.0%, and control: 1.4%; aRR: 0.88, 0.38-2.05, p = 0.77, aRR: 1.16, 0.51-2.62, p = 0.72, aRR: 0.80, 0.33-1.94, p = 0.62, respectively). No intervention decreased school dropout (MC: 11.2%, CCT: 12.4%, combined: 10.9%, control: 10.5%; aRR: 1.16, 0.86-1.57; 1.23, 0.91-1.65; and 1.06, 0.78-1.44, respectively). No related serious adverse events were seen.

Interpretation

MCs, CCTs, or both, did not protect schoolgirls against a composite of deleterious harms. MCs appear protective against HSV-2. Studies of longer follow-up duration with objective measures of health impact are needed in this population.

Funding

Department of Health and Social Care, the Foreign, Commonwealth & Development Office, the Medical Research Council and Wellcome.

Interventions to prevent unintended pregnancies among adolescents: a rapid overview of systematic reviews

Risks associated with unintended pregnancy include unsafe abortions, poor maternal health-seeking behaviour, poor mental health, and potentially, maternal and infant deaths. Adolescent girls with unintended pregnancies are particularly vulnerable as they are at higher risk of eclampsia, premature onset of labour, and increased neonatal morbidity and mortality. Unintended pregnancy, with the right combination of interventions, can be avoided. Evidence-based decision-making and the need for a robust appraisal of the evidence have resulted in many systematic reviews. This review of systematic reviews focuses on adolescent pregnancy prevention and will seek to facilitate evidence-based decision-making. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR 2 criteria. We identified three systematic reviews from low- and middle-income countries and high-income counties and included all socioeconomic groups. We used vote counting and individual narrative review summaries to present the results. Overall, skill-building, peer-led and abstinence programmes were generally effective. Interventions focused on information only, counselling and interactive sessions provided mixed results.In contrast, exposure to parenting and delaying sexual debut interventions were generally ineffective. Adolescent pregnancy prevention interventions that deploy school-based primary prevention strategies, i.e. strategies that prevent unintended pregnancies in the first place, may effectively reduce teenage pregnancy rates, improve contraceptive use, attitudes and knowledge, and delay sexual debut. However, the included studies have methodological issues, and our ability to generalise the result is limited.

A positive consequence of the COVID-19 pandemic: how the counterfactual experience of school closures is accelerating a multisectoral response to the treatment of neglected tropical diseases

Global access to deworming treatment is one of the public health success stories of low-income countries in the twenty-first century. Parasitic worm infections are among the most ubiquitous chronic infections of humans, and early success with mass treatment programmes for these infections was the key catalyst for the neglected tropical disease (NTD) agenda. Since the launch of the 'London Declaration' in 2012, school-based deworming programmes have become the world's largest public health interventions. WHO estimates that by 2020, some 3.3 billion school-based drug treatments had been delivered. The success of this approach was brought to a dramatic halt in April 2020 when schools were closed worldwide in response to the COVID-19 pandemic. These closures immediately excluded 1.5 billion children not only from access to education but also from all school-based health services, including deworming. WHO Pulse surveys in 2021 identified NTD treatment as among the most negatively affected health interventions worldwide, second only to mental health interventions. In reaction, governments created a global Coalition with the twin aims of reopening schools and of rebuilding more resilient school-based health systems. Today, some 86 countries, comprising more than half the world's population, are delivering on this response, and school-based coverage of some key school-based programmes exceeds those from January 2020. This paper explores how science, and a combination of new policy and epidemiological perspectives that began in the 1980s, led to the exceptional growth in school-based NTD programmes after 2012, and are again driving new momentum in response to the COVID-19 pandemic. This article is part of the theme issue 'Challenges and opportunities in the fight against neglected tropical diseases: a decade from the London Declaration on NTDs'.

Naïve, uninformed and sexually abused: circumstances surrounding adolescent pregnancies in Malawi

BACKGROUND

Pregnancy and childbearing in adolescence could negatively affect girls' health and socio-economic wellbeing across the life course. Previous studies on drivers of adolescent pregnancy in Africa have not fully considered the perspectives of parents/guardians vis-à-vis pregnant and parenting adolescents. Our study addresses this gap by examining pregnant and parenting adolescents' and parents/guardians' narratives about factors associated with early and unintended pregnancy.

METHODOLOGY

The descriptive study draws on qualitative data collected as part of a larger mixed-methods cross-sectional survey on the lived experiences of pregnant and parenting adolescents. Data were collected between March and May 2021 in Blantyre, Malawi, using semi-structured interview guides. We interviewed 18 pregnant and parenting adolescent girls, 10 parenting adolescent boys, and 16 parents/guardians of pregnant and parenting adolescents. Recorded interviews were transcribed verbatim into the English language by bilingual transcribers. We used the inductive-thematic analytical approach to summarize the data.

FINDINGS

The data revealed several interconnected and structural reasons for adolescents' vulnerability to early and unintended pregnancy. These include adolescents' limited knowledge and access to contraceptives, poverty, sexual violence, school dropout, COVID-19 school closures, and being young and naively engaging in unprotected sex. While some parents agreed that poverty and school dropout or COVID-19 related school closure could lead to early pregnancies, most considered stubbornness, failure to adhere to abstinence advice and peer influence as responsible for adolescent pregnancies.

CONCLUSION

Our findings contribute to the evidence on the continued vulnerability of girls to unintended pregnancy. It highlights how parents and adolescents hold different views on reasons for early and unintended pregnancy, and documents how divergent views between girls and their parents may contribute to the lack of progress in reducing adolescent childbearing. Based on these findings, preventing unintended pregnancies will require altering community attitudes about young people's use of contraceptives and engaging parents, education sector, civil society organizations and community and religious leaders to develop comprehensive sexuality education programs to empower in- and out-of school adolescents.

COVID-19 impacts on healthcare access in sub-Saharan Africa: an overview

This overview aimed to describe the situation of healthcare access in sub-Saharan Africa, excluding South Africa, during the COVID-19 pandemic. A PubMed^® search from March 31, 2020, to August 15, 2022, selected 116 articles. Healthcare access and consequences of COVID-19 were assessed based on comparisons with months before its onset or an identical season in previous years. A general reduction of healthcare delivery, associated with the decline of care quality, and closure of many specialty services were reported. The impact was heterogeneous in space and time, with an increase in urban areas at the beginning of the pandemic (March-June 2020). The return to normalcy was gradual from the 3^rd quarter of 2020 until the end of 2021. The impact of COVID-19 on the health system and its use was attributed to (a) conjunctural factors resulting from government actions to mitigate the spread of the epidemic (containment, transportation restrictions, closures of businesses, and places of entertainment or worship); (b) structural factors related to the disruption of public and private facilities and institutions, in particular, the health system; and (c) individual factors linked to the increase in costs, impoverishment of the population, and fear of contamination or stigmatization, which discouraged patients from going to health centers. They have caused considerable socio-economic damage. Several studies emphasized some adaptability of the healthcare offer and resilience of the healthcare system, despite its unpreparedness, which explained a return to normal activities as early as 2022 while the COVID-19 epidemic persisted. There appears to be a strong disproportion between the moderate incidence and severity of COVID-19 in sub-Saharan Africa, and the dramatic impact on healthcare access. Several articles make recommendations for lowering the socioeconomic consequences of future epidemics to ensure better management of health issues.

Population Estimates of HIV Risk Factors to Inform HIV Prevention Programming for Adolescent Girls and Young Women

Violence Against Children and Youth Survey (VACS) data from seven countries were analyzed to estimate population-level eligibility for the President's Emergency Plan for AIDS Relief (PEPFAR) Determined, Resilient, Empowered, AIDS-Free, Mentored, and Safe (DREAMS) HIV prevention program for adolescent girls and young women (AGYW). The prevalence of overall eligibility and individual risk factors, including experiences of violence, social, and behavioral risks differ across countries and age groups. A large proportion of AGYW across all countries and age groups examined have at least one risk factor making them eligible for DREAMS. Experiencing multiple risks is also common, suggesting that researchers and programs could work together to identify combinations of risk factors that put AGYW at greatest risk of HIV acquisition, or that explain most new HIV infections, to more precisely target the most vulnerable AGYW. The VACS provides important data for such analyses to refine DREAMS and other youth programming.

Mental health and psychological well-being of Kenyan adolescents from Nairobi and the Coast regions in the context of COVID-19

BACKGROUND

Despite the high burden of mental health problems during adolescence and its associated negative consequences, it has remained neglected especially in sub-Saharan Africa. The 2019 novel Coronavirus disease (COVID-19) pandemic has placed additional stress on adolescent mental health. However, there are few studies documenting the burden of mental health problems and even fewer mental health services in the region. In relation to the limited body of knowledge, the present study aims to determine the psychological well-being of adolescents and to assess the risks and associated factors of mental health problems among adolescents in the context of COVID-19 pandemic in Kenya.

METHODS

We conducted a cross-sectional survey in 2022 among adolescents aged 13-19 years living in Nairobi, and the Coast region of Kenya. We utilized standardized psychological assessment tools including the Patient Health Questionnaire, Generalized Anxiety Scale, Strengths and Difficulties Questionnaire, The World Health Organization- Five Well-Being Index Scale, and the Pandemic Anxiety Scale, to evaluate the psychological wellbeing of the adolescents. A linear regression model was used to evaluate the correlates associated with quality of life, pandemic anxiety, and emotional and behavioural problems among adolescents. Subsequently, a logistic regression model was used to assess factors associated with depression and general anxiety disorders. Variables with a p-value < 0.25 in the univariate model were included in the multivariable regression model.

RESULTS

The results are based on 797 participants who met the inclusion criteria. We found the prevalence of depression to be relatively higher among out-of-school adolescents at 36.0% compared to school-going adolescents at 20.6%. Furthermore, out-of-school adolescents had significantly higher anxiety scores when compared to their school-going counterparts (27.7% vs 19.1%) respectively. In-school adolescents had a better quality of life scores, lower pandemic anxiety scores, and lower emotional and behavioral problems scores compared to their out-of-school counterparts. Key risk factors associated with depression include; being out-of-school (OR = 1.96 (95% CI 1.33- 2.88) p-value = 0.001), loneliness (OR = 10.68 (95% CI 4.49-22.86) p-value < 0.001), and living in an unsafe neighborhood (OR = 2.24 (95% CI 1.52-3.29) p-value < 0.001). An older age (OR = 1.16 (95% CI 1.03-1.30) p-value = 0.015), being out-of-school (OR = 1.81 (95% CI 1.19-2.77) p-value = 0.006), and living in an unsafe neighborhood (OR = 2.01 (95% CI 1.33-3.04) p-value = 0.001 were key factors associated with anxiety. Furthermore, key factors positively correlated with quality of life include; high socioeconomic status (ß (Std.Err) = 0.58 (0.14) p-value < 0.001, talking to friends often (ß (Std.Err) = 2.32 (0.53) p-value < 0.001, and being close to parents (ß (Std.Err) = 1.37 (0.62) = 0.026.

CONCLUSION

Our findings imply that mental health support services targeting adolescents in the country should be prioritized, especially for those who are out-of-school.

Fertility and contraceptive dynamics amidst COVID-19: who is at greatest risk for unintended pregnancy among a cohort of adolescents and young adults in Nairobi, Kenya?

OBJECTIVES

Among youth in Nairobi, we (1) characterised fertility and contraceptive use dynamics by gender; (2) estimated pregnancy prevalence over the pandemic; and (3) assessed factors associated with unintended pandemic pregnancy for young women.

DESIGN

Longitudinal analyses use cohort data collected at three timepoints prior to and during the COVID-19 pandemic: June to August 2019 (pre-pandemic), August to October 2020 (12-month follow-up) and April to May 2021 (18-month follow-up).

SETTING

Nairobi, Kenya.

PARTICIPANTS

At initial cohort recruitment, eligible youth were aged 15-24 years, unmarried and residing in Nairobi for at least 1 year. Within-timepoint analyses were restricted to participants with survey data per round; trend and prospective analyses were restricted to those with complete data at all three timepoints (n=586 young men, n=589 young women).

PRIMARY AND SECONDARY OUTCOME MEASURES

Primary outcomes comprised fertility and contraceptive use for both genders, and pregnancy for young women. Unintended pandemic pregnancy (assessed at 18-month follow-up) was defined as a current or past 6-month pregnancy with intent to delay pregnancy for more than 1 year at 2020 survey.

RESULTS

While fertility intentions remained stable, contraceptive dynamics varied by gender-young men both adopted and discontinued coital-dependent methods, whereas young women adopted coital-dependent or short-acting methods at 12-month follow-up (2020). Current pregnancy was highest at 2020 (4.8%), and approximately 2% at 2019 and 2021. Unintended pandemic pregnancy prevalence was 6.1%, with increased odds for young women recently married (adjusted OR (aOR)=3.79; 95% confidence interval (CI) 1.83-7.86); recent contraceptive use was protective against unintended pandemic pregnancy (aOR=0.23; 95% CI 0.11-0.47).

CONCLUSIONS

Current pregnancy in Nairobi was highest at the height of the COVID-19 pandemic (2020), and subsided to pre-pandemic levels by 2021 data collection; however, requires further monitoring. New marriages posed considerable risk for unintended pandemic pregnancy. Contraceptive use remains a crucial preventive strategy to averting unintended pregnancy, particularly for married young women.

Impact of COVID-19 on Adolescent HIV Prevention and Treatment Services in the AHISA Network

We investigated perceived impacts of COVID-19 on the delivery of adolescent HIV treatment and prevention services in sub-Saharan Africa (SSA) by administering a survey to members of the Adolescent HIV Prevention and Treatment Implementation Science Alliance (AHISA) from February to April 2021. We organized COVID-19 impacts, as perceived by AHISA teams, under three themes: service interruptions, service adjustments, and perceived individual-level health impacts. AHISA teams commonly reported interruptions to prevention programs, diagnostic testing, and access to antiretroviral therapy (ART). Common service adjustments included decentralization of ART refills, expanded multi-month ART distribution, and digital technology use. Perceived individual-level impacts included social isolation, loss to follow-up, food insecurity, poverty, and increases in adolescent pregnancies and sexually transmitted infections. The need for collaboration among stakeholders were commonly cited as lessons learned by AHISA teams. Survey findings highlight the need for implementation science research to evaluate the effects of pandemic-related HIV service adaptations in SSA.

School attendance and sexual and reproductive health outcomes among adolescent girls in Kenya: a cross-sectional analysis

BACKGROUND

Given the high burden of adverse sexual and reproductive health outcomes (SRH) and low levels of school attendance among adolescent girls in Kenya, this study sought to elucidate the association between school attendance and SRH outcomes among adolescent girls in Homa Bay and Narok counties.

METHODS

This study uses baseline quantitative data from the mixed-methods evaluation of the In Their Hands (ITH) program which occurred between September to October 2018 in Homa Bay and Narok counties. In total, 1840 adolescent girls aged 15-19 years participated in the baseline survey, of which 1810 were included in the present analysis. Multivariable logistic regression models were used to assess the association between school attendance (in- versus out-of-school) and ever having sex, condom use during last sex, and ever pregnant, controlling for age, orphan status, income generation, religion, county, relationship status, and correct SRH knowledge.

RESULTS

Across the 1810 participants included in our study, 61.3% were in-school and 38.7% were out-of-school. Compared to adolescent girls who were in-school, those out-of-school were more likely (AOR 5.74 95% CI 3.94, 8.46) to report ever having sex, less likely (AOR: 0.21, 95% CI 0.16, 0.31) to have used a condom during their last sexual intercourse, and more likely (AOR: 6.98, 95% CI 5.04, 9.74) to have ever been pregnant.

CONCLUSIONS

School attendance plays an integral role in adolescent girls' SRH outcomes, and it is imperative that policy actors coordinate with the government and community to develop and implement initiatives that support adolescent girls' school attendance and education.

The role of social norms on adolescent family planning in rural Kilifi county, Kenya

PURPOSE

Despite Kenya's encouraging progress in increasing access to modern contraception among youth, several barriers remain preventing large-scale efforts to reduce demand-side unmet need for family planning. Shifting social norms around the use and acceptability of modern contraception may represent a potent target for future interventions. However, the structure of normative influence on individual modern contraceptive use among youth needs to be determined. Therefore, our aim was to estimate the influence of individual and group-level normative influence on modern contraceptive use among adolescents from two villages in rural Kenya.

METHODS

Trained enumerators collected data from individuals aged 15-24 who provided oral informed consent, or parental informed consent, in two villages in rural Kilifi county. Participants completed a questionnaire related to modern contraceptive use and were asked to nominate one to five people (referents) with whom they spend free time. The enumerators photographed each individual who nominated at least one referent using Android phones and matched them with their nominated referents. Using this social network data, we estimated group-level normative influence by taking an average of referents' modern contraception use. We then explored associations between descriptive norms, injunctive norms, and network modern contraceptive use on individual modern contraceptive use, controlling for known confounders using logistic regression models. We also conducted sensitivity analyses to test a pattern of differential referent influence on individual modern contraceptive use.

RESULTS

There was a positive association between pro-modern contraception descriptive and injunctive norms and individual modern contraception use (adjusted Odds Ratio (aOR) = 1.29, 95% confidence interval (CI) = 1.05-1.6, and aOR = 1.31, CI = 1.06-1.62, respectively). Network modern contraceptive use was associated with individual use in the bivariate model (aOR = 2.57, CI = 1.6-4.12), but not in the multivariable model (aOR = 1.67, CI = 0.98-2.87). When stratified by sex and marital status, network modern contraceptive use was associated with individual modern contraceptive use among female participants (aOR = 2.9, CI = 1.31-6.42), and unmarried female participants (aOR = 5.26, CI = 1.34-20.69), but not among males. No interactive effects between norms variables were detected. Sensitivity analyses with a different estimate of network modern contraceptive use showed similar results.

CONCLUSIONS

Social norms are multilevel phenomena that influence youth modern contraceptive use, especially among young women in rural Kenya. Unmarried women with modern contraceptive users in their social network may feel less stigma to use contraception themselves. This may reflect gendered differences in norms and social influence effects for modern contraceptive use. Future research should investigate group-level normative influence in relation to family planning behaviors.

[Impact of COVID-19 on public health in sub-Saharan Africa]

Objective

This work aimed to assess the impact of COVID-19 on healthcare supply in sub-Saharan Africa except South Africa.

Method

A search through PubMed® between April 2020 and August 2022 selected 135 articles. The impact of COVID-19 was assessed on comparisons with the months prior to the onset of COVID-19 or an identical season in previous years.

Results

The decline of health services, associated with a reduction in their quality, and the closure of specialized health units have been reported. Many control programs and public health interventions have been interrupted, with the risk of an increase of the corresponding diseases. Social disorganization has generated mental health issues among the population, including health personnel. The impact was heterogeneous in space and time. The main causes were attributed to containment measures (transport restrictions, trade closures) and the lack of human and material resources. The increase in costs, in addition to the impoverishment of the population, and the fear of being contaminated or stigmatized have discouraged patients from going to health centres. The studies mention the gradual return to normal after the first epidemic wave and the resilience of the healthcare system.

Conclusion

Several articles make recommendations aimed at reducing the impact of future epidemics: support for community workers, training of health workers and reorganization of services to improve the reception and care of patients, technological innovations (use of telephones, drones, etc.) and better information monitoring.

A case for vaccinating adolescent girls for protection against COVID-19 during pregnancy and childbirth in resource-limited settings

The coronavirus disease 2019 (COVID-19) pandemic has had severe implications worldwide, including increased adverse maternal and neonatal health outcomes. Vaccination is one way of protecting against these adverse health outcomes. However, in some low-resource settings, vaccine inequity has led to poor uptake of COVID-19 vaccination. There are very high rates of adolescent pregnancy in low-resource settings, which are likely to become even higher as we begin to see the full effects of COVID-19 lockdown measures, including school closures. Although the benefits of COVID-19 vaccination in adolescents are debated, we propose that adolescent girls should be prioritised in COVID vaccination roll out in low-resource settings. This is to provide protection from severe COVID-19 disease in pregnancy, preventing adverse maternal and neonatal health outcomes.

Association between public health emergencies and sexual and reproductive health, gender-based violence, and early marriage among adolescent girls: a rapid review

BACKGROUND

As COVID-19 continues to impact lives and livelihoods around the world, women and girls are disproportionately affected. Crisis situations and related response measures, such as lockdowns, school closures, and travel restrictions, often exacerbate the adversities and human rights violations faced by adolescent girls. We conducted a rapid review to synthesise evidence on the impact of public health emergencies (PHEs) related to gender-based inequalities among adolescent girls.

METHODS

We systematically searched five major databases. Records were imported into the online screening tool Rayyan, and 10% of the records were triple screened for eligibility. We included qualitative, mixed-methods, and quantitative studies that assessed the relationship between PHEs and any of the following outcomes: (1) gender-based violence, (2) early/forced marriage, and (3) sexual and reproductive health. Due to the heterogeneity of included study designs, no meta-analysis was performed, and studies were summarised narratively.

FINDINGS

Out the initial 6004 articles, 11 studies met our eligibility criteria. Five of these assessed the impact of natural disasters and six were focused on consequences of the COVID-19 pandemic. Seven studies focused on the impact of PHEs on gender-based violence, three focused on sexual and reproductive health, and only one study looked at early marriage. The main impacts highlighted by the studies included (1) increases in physical, psychological, and sexual abuse, (2) increase in the occurrence of teenage pregnancy, (3) poor menstruation hygiene management, and (4) occurrence of early marriages. Mechanisms underlying these impacts were PHE-specific response strategies like home confinement, closure of schools, the worsening of families' financial situation such as the inability to pay for school fees or day-to-day living costs, and the disempowerment of and increased workloads for adolescent girls.

CONCLUSION

Although evidence on the impact of COVID-19 on gender-based violence, sexual and reproductive health, and especially forced or early marriage of adolescent girls is limited, results from studies on other PHEs indicate that during crises, these detrimental outcomes are exacerbated. Findings from our review have important implications for policies and programs providing life skills training, financial literacy training, credit support, and safe spaces for adolescent girls.

Living with COVID-19 and preparing for future pandemics: revisiting lessons from the HIV pandemic

In April, 2020, just months into the COVID-19 pandemic, an international group of public health researchers published three lessons learned from the HIV pandemic for the response to COVID-19, which were to: anticipate health inequalities, create an enabling environment to support behavioural change, and engage a multidisciplinary effort. We revisit these lessons in light of more than 2 years' experience with the COVID-19 pandemic. With specific examples, we detail how inequalities have played out within and between countries, highlight factors that support or impede the creation of enabling environments, and note ongoing issues with the scarcity of integrated science and health system approaches. We argue that to better apply lessons learned as the COVID-19 pandemic matures and other infectious disease outbreaks emerge, it will be imperative to create dialogue among polarised perspectives, identify shared priorities, and draw on multidisciplinary evidence.

Prevalence and correlates of teenage pregnancy among in-school teenagers during the COVID-19 pandemic in Hoima district western Uganda-A cross sectional community-based study

BACKGROUND

The COVID-19 pandemic related restrictions and lockdown measures had compromised the routine delivery and access of sexual and reproductive health and rights services to the population including the teenage girls. However, the teenage pregnancy rates during COVID-19 pandemic period were poorly documented. This study aimed at determining the prevalence and the factors associated with teenage pregnancy among in-school teenage girls during the COVID-19 pandemic period in Hoima District Uganda.

METHODS

This was a descriptive cross-sectional study that employed quantitative research methods. A total of 314 in-school teenage girls aged 13-19 years were selected using a multi-stage sampling techniques. Interviewer-administered questionnaires were used to collect the data from the participant's homes during the period December 2021-January 2022. Data analysis was done using univariate, bi-variate, and multivariate.

RESULTS

The prevalence of teenage pregnancy among the in-school teenage girls in Hoima district Uganda was 30.6% [96/314]. Higher teenage pregnancy rates were prevalent among the unmarried teenage girls [aOR: 9.6; 95%CI: 4.64-19.87; p = 0.000], teenage girls studying from boarding schools [aOR 2.83, 95%CI 1.36-5.86, p = 0.005], contraceptive non-users [aOR: 2.54; 95%CI: 1.12-5.4; p = 0.015] and teenage girls involved in sex trade [aOR 3.16, 95%CI 1.5-6.7, p = 0.003]. The factors associated with the reduced likelihood for teenage pregnancy included being an adult teenage girl aged 18-19 years [aOR: 0.15; 95%CI: 0.07-0.32; p = 0.000] and not receiving sex education during the period [aOR 0.36, 95%CI 0.13-0.62, p = 0.024].

CONCLUSION

The results indicated that 3 out of 10 in-school teenage girls from Hoima district Uganda got pregnant during the COVID-19 pandemic period of 2021. Teenage pregnancy was prevalent among teenage girls who don't use modern contraceptive methods and those involved in sex trade. Teenage pregnancy was however, less prevalent among adult teenage girls aged 18-19 years. The findings point to the need for health stakeholders to innovate creative policies, contingency plans and programmes aimed at delaying age for sexual activities, increasing contraceptive use and minimizing pregnancy risk from sex trade among in-school teenage girls during COVID-19 pandemics.

How has the COVID-19 pandemic affected young people?-Mapping knowledge structure and research framework by scientometric analysis

Since the outbreak of COVID-19, there has been a large body of literature focusing on the relationship between the COVID-19 pandemic and young people. The purpose of this study is to explore the current research status and the specific mechanism of COVID-19's effects on young people based on related literature. This paper mainly used VOS viewer and CiteSpace software to conduct a scientometric analysis of 5,077 publications retrieved from the Web of Science database. The results show that the main contributors to the field were mainly from North America and Europe, and the trend of research focus was from shallow to deep. The five main research areas in the field were summarized by keyword clustering analysis as follows: lifestyle changes due to lockdown; changes in stress and emotions; psychological illness and trauma; risk perception and practice toward the epidemic; interventions and social support. Finally, they were linked by four pathways to form a framework that integrates the relationships between the five domains and between elements within each of them, revealing the mechanism of COVID-19's effect on young people. In addition, less studied but promising elements are also presented in the framework, such as research on special groups (disadvantaged socioeconomic groups and sexual minority youth) and extreme suicidal tendencies that deserve our further attention.

Adolescent pregnancy in the time of COVID-19: what are the implications for sexual and reproductive health and rights globally?

The COVID-19 pandemic has aggravated pre-existing challenges associated with adolescents’ sexual and reproductive health and rights (SRHR). Evolving evidence suggest that it could adversely impact the progress made towards improving sexual and reproductive health outcomes among young people. The pandemic has stalled achievements in reducing adolescent pregnancy and child marriage by reinforcing contextual and structural determinants of these reproductive health outcomes, especially among girls. The pandemic has increased disruptions to schooling, decreased access to sexual and reproductive health services and compounded pre-existing socio-economic vulnerabilities. The consequences of neglecting adolescent sexual and reproductive health services over the past 2 years, to focus on COVID-19, continue to emerge. This commentary argues for targeted and responsive approaches to adolescent SRHR that tackle preventable consequences resulting from inequities faced by adolescents globally, particularly girls.

COVID-19, nutrition, and gender: An evidence-informed approach to gender-responsive policies and programs

In addition to the direct health impacts of COVID-19, government and household mitigation measures have triggered negative indirect economic, educational, and food and health system impacts, hitting low-and middle-income countries the hardest and disproportionately affecting women and girls. We conducted a gender focused analysis on five critical and interwoven crises that have emerged because of the COVID-19 crisis and exacerbated malnutrition and food insecurity. These include restricted mobility and isolation; reduced income; food insecurity; reduced access to essential health and nutrition services; and school closures. Our approach included a theoretical gender analysis, targeted review of the literature, and a visual mapping of evidence-informed impact pathways. As data was identified to support the visualization of pathways, additions were made to codify the complex interrelations between the COVID-19 related crises and underlying gender relations. Our analysis and resultant evidence map illustrate how underlying inequitable norms such as gendered unprotected jobs, reduced access to economic resources, decreased decision-making power, and unequal gendered division of labor, were exacerbated by the pandemic's secondary containment efforts. Health and nutrition policies and interventions targeted to women and children fail to recognize and account for understanding and documentation of underlying gender norms, roles, and relations which may deter successful outcomes. Analyzing the indirect effects of COVID-19 on women and girls offers a useful illustration of how underlying gender inequities can exacerbate health and nutrition outcomes in a crisis. This evidence-informed approach can be used to identify and advocate for more comprehensive upstream policies and programs that address underlying gender inequities.

Impact of the COVID-19 pandemic on access to and utilisation of services for sexual and reproductive health: a scoping review

Introduction

The COVID-19 pandemic has negatively impacted health systems globally and widened preexisting disparities. We conducted a scoping review on the impact of the COVID-19 pandemic on women and girls’ access to and utilisation of sexual and reproductive health (SRH) services for contraception, abortion, gender-based and intimate partner violence (GBV/IPV) and sexually transmitted infections (STIs).

Methods

We systematically searched peer reviewed literature and quantitative reports, published between December 2019 and July 2021, focused on women and girls’ (15–49 years old) access to and utilisation of selected SRH services during the COVID-19 pandemic. Included studies were grouped based on setting, SRH service area, study design, population and reported impact. Qualitative data were coded, organised thematically and grouped by major findings.

Results

We included 83 of 3067 identified studies and found that access to contraception, in-person safe abortion services, in-person services for GBV/IPV and STI/HIV testing, prevention and treatment decreased. The geographical distribution of this body of research was uneven and significantly less representative of countries where COVID-19 restrictions were very strict. Access was limited by demand and supply side barriers including transportation disruptions, financial hardships, limited resources and legal restrictions. Few studies focused on marginalised groups with distinct SRH needs.

Conclusion

Reports indicated negative impacts on access to and utilisation of SRH services globally, especially for marginalised populations during the pandemic. Our findings call for strengthening of health systems preparedness and resilience to safeguard global access to essential SRH services in ongoing and future emergencies.

Contraceptive method use trajectories among young women in Kenya: A qualitative study

Background

Many young women experience important key life transitions during adolescence and early adulthood, such as initiation of sexual activity, first use of contraceptives, marriage, and childbirth. For young women to be able to plan and manage their lives, it is critical to understand how these life events intersect and shape their contraceptive decision-making. This study aims to explore young women's contraceptive method use trajectories, including the factors that influence contraceptive decision-making throughout adolescence and youth.

Methodology

In 2019, the Full Access, Full Choice project (FAFC), implemented by the University of North Carolina at Chapel Hill and the African Institute for Development Policy, conducted 30 in-depth interviews with young women aged 18-24 years in three counties in Kenya (Nairobi, Mombasa and Migori). Eligible respondents had used two or more modern contraceptive methods. Interview guides utilized a modified life history approach to capture details about respondents' contraceptive use and life experiences from the time they first used contraception until the time of interview.

Results

We identified five separate contraceptive use trajectories based on the occurrence and timing of marriage, childbirth, and contraceptive method choice as well as various influences on contraceptive decision-making. The majority of respondents began their contraceptive journey by using male condoms or emergency contraception, but subsequent contraceptive decisions were varied across trajectories and influenced by different factors. For many women, the initiation of a non-coitally dependent method occurred after the birth of a child; for some, this was the first method used. Once women transitioned to using a non-coitally dependent method such as injectables or implants, many cycled through different methods to find one that had fewer side effects or provided the desired duration of protection.

Discussion

This study highlights the nuanced needs of young women throughout their adolescent and youth years in Kenya. This suggests that programs and policies need to encompass young women's diversity of experiences and motivations to best serve them.

Returning to school after COVID-19 closures: Who is missing in Malawi?

During the early stages of the COVID-19 pandemic, almost all countries implemented school closures to prevent disease transmission. However, prolonged closures can put children at risk of leaving school permanently, a decision that can reduce their long-term potential and income. This study investigated the extent to which the COVID-19 pandemic and associated school closures reduced school attendance in Malawi, a low-income African country. We used longitudinal data from a cohort of adolescents interviewed before (2017/18; at age 10-16) and after (2021; at age 13-20) the pandemic school closures. Of those students who had been attending school prior to school closures, we find that 86% returned when schools re-opened. Dropouts were more pronounced among older girls: over 30% of those aged 17-19 did not return to school. This resulted in further lowering the gender parity index to the greater disadvantage of girls. We also found that students already lagging behind in school were more likely to dropout. Thus, our data suggest that the COVID-19 pandemic has magnified gender inequalities in schooling, at least partially erasing recent progress towards inclusive education. Urgent investments are needed to find and re-enroll lost students now, and to create more resilient and adaptable educational systems before the next pandemic or other negative shock arrives.

Food security reduces multiple HIV infection risks for high-vulnerability adolescent mothers and non-mothers in South Africa: a cross-sectional study

INTRODUCTION

Adolescent girls and young women, including adolescent mothers, in Southern Africa have high HIV seroconversion and transmission. We need to know which risks drive HIV infections, and what can reduce these risks.

METHODS

We interviewed 1712 adolescent girls and young women (11-23 years), including 1024 adolescent mothers who had conceived before age 20 and had a living child, from two health municipalities of South Africa's Eastern Cape Province between March 2018 and July 2019. Recruitment was through multiple community, school and health facility channels. Associations between adolescent motherhood and seven HIV risk behaviours (multiple sexual partners, transactional sex, age-disparate sex, condomless sex, sex on substances, alcohol use and not in education or employment) were investigated using the generalized estimating equations method for multiple outcomes specified with a logit link and adjusting for nine covariates. Using the same model, we investigated associations between having enough food at home every day in the past week (food security) and the same seven HIV risk behaviours. When we found evidence of moderation by HIV status, we report stratum-specific odds ratios.

RESULTS

Mean age was 17.51 years (SD: 2.54), 46% participants were living with HIV. Compared to non-mothers, adolescent mothers had lower odds of alcohol use (AOR = 0.47, 95% CI = 0.29-0.75), but higher odds of multiple sexual partners (AOR = 1.93, 95% CI = 1.35-2.74), age-disparate sex (HIV-uninfected AOR = 1.73, 95% CI = 1.03-2.91; living with HIV AOR = 5.10, 95% CI = 2.98-8.73), condomless sex (AOR = 8.20, 95% CI = 6.03-11.13), sex on substances (AOR = 1.88, 95% CI = 1.10-3.21) and not in education/employment (HIV-uninfected AOR = 1.83, 95% CI = 1.19-2.83; living with HIV AOR = 6.30, 95% CI = 4.09-9.69). Among non-mothers, food security was associated with lower odds of multiple sexual partners (AOR = 0.45, 95% CI = 0.26-0.78), transactional sex (AOR = 0.32, 95% CI = 0.13-0.82) and not in education/employment (AOR = 0.48, 95% CI = 0.29-0.77). Among adolescent mothers, food security was associated with lower odds of transactional sex (AOR = 0.17, 95% CI = 0.10-0.28), age-disparate sex (AOR = 0.66, 95% CI = 0.47-0.92), sex on substances (AOR = 0.51, 95% CI = 0.32-0.82), alcohol use (AOR = 0.45, 95% CI = 0.25-0.79) and not in education/employment (AOR = 0.56, 95% CI = 0.40-0.78).

CONCLUSIONS

Adolescent motherhood is associated with multiple vulnerabilities to HIV infection and transmission. Social protection measures that increase food security are likely to reduce HIV risk pathways for adolescent girls and young women, especially adolescent mothers.

Digital health systems strengthening in Africa for rapid response to COVID-19

The COVID-19 pandemic has painfully exposed the constraints of fragile health systems in low- and middle-income countries, where global containment measures largely set by high-income countries resulted in disproportionate collateral damage. In Africa, a shift is urgently needed from emergency response to structural health systems strengthening efforts, which requires coordinated interventions to increase access, efficiency, quality, transparency, equity, and flexibility of health services. We postulate that rapid digitalization of health interventions is a key way forward to increase resilience of African health systems to epidemic challenges. In this paper we describe how PharmAccess' ongoing digital health system interventions in Africa were rapidly customized to respond to COVID-19. We describe how we developed: a COVID-19 App for healthcare providers used by more than 1,000 healthcare facilities in 15 African countries from May-November 2020; digital loans to support private healthcare providers with USD 20 million disbursed to healthcare facilities impacted by COVID-19 in Kenya; a customized Dutch mobile COVID-19 triage App with 4,500 users in Ghana; digital diaries to track COVID-19 impacts on household expenditures and healthcare utilization; a public-private partnership for real-time assessment of COVID-19 diagnostics in West-Kenya; and an expanded mobile phone-based maternal and child-care bundle to include COVID-19 adapted services. We also discuss the challenges we faced, the lessons learned, the impact of these interventions on the local healthcare system, and the implications of our findings for policy-making. Digital interventions bring efficiency due to their flexibility and timeliness, allowing co-creation, targeting, and rapid policy decisions through bottom-up approaches. COVID-19 digital innovations allowed for cross-pollinating the interests of patients, providers, payers, and policy-makers in challenging times, showing how such approaches can pave the way to universal health coverage and resilient healthcare systems in Africa.