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Mohd Tohit NF, Haque M. Breaking the Cycle: Addressing Period Poverty as a Critical Public Health Challenge and Its Relation to Sustainable Development Goals. Cureus 2024; 16:e62499. [PMID: 38887745 PMCID: PMC11180967 DOI: 10.7759/cureus.62499] [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] [Accepted: 06/16/2024] [Indexed: 06/20/2024] Open
Abstract
This narrative review comprehensively examines the intricate relationship between period poverty and the Sustainable Development Goals (SDGs), positioning it as a critical public health challenge with far-reaching implications. Through an in-depth analysis of the multifaceted impact of period poverty on public health, including its effects on reproductive health, mental well-being, and economic participation, the paper underscores the urgent need to address this issue within the framework of the SDGs. An overview of existing literature on period poverty, its impact on health and well-being, and its relation to the SDGs was carried out. Different perspectives, interventions, and policy approaches to addressing period poverty were also explored. By illuminating the interplay between period poverty and various SDGs, particularly those related to gender equality, health, education, and economic empowerment, the study emphasizes the imperative of integrating menstrual health and hygiene into global development efforts. Advocating for targeted policies, funding, and advocacy, the manuscript calls for a holistic and inclusive approach to breaking the cycle of period poverty, ultimately contributing to advancing the SDGs and fostering a more equitable and healthier global society. Efforts to eradicate period poverty - providing affordable menstrual products, improving sanitation infrastructure, enhancing education, and implementing supportive policies - lead to significant progress in public health and gender equity. By prioritizing menstrual health management in public health policies, educational programs, and economic strategies, we can ensure that everyone who menstruates can do so with dignity and without limits on their potential.
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Affiliation(s)
- Nor Faiza Mohd Tohit
- Department of Community Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, MYS
| | - Mainul Haque
- Department of Research, Karnavati Scientific Research Center (KSRC) School of Dentistry, Karnavati University, Gandhinagar, IND
- Department of Pharmacology and Therapeutics, National Defence University of Malaysia, Kuala Lumpur, MYS
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Mehta SD, Nandi D, Otieno F, Zulaika G, Nyothach E, Agingu W, Bhaumik R, Mason L, van Eijk AM, Phillips-Howard PA. Increased reproductive tract infections among secondary school girls during the COVID-19 pandemic: associations with pandemic-related stress, mental health, and domestic safety. Sex Med 2024; 12:qfae045. [PMID: 39045336 PMCID: PMC11264406 DOI: 10.1093/sexmed/qfae045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 06/10/2024] [Accepted: 06/18/2024] [Indexed: 07/25/2024] Open
Abstract
Background Kenya, like many countries, shuttered schools during COVID-19, with subsequent increases in poor mental health, sexual activity, and pregnancy. Aim We sought to understand how the COVID-19 pandemic may mediate the risk of reproductive tract infections. Methods We analyzed data from a cohort of 436 secondary schoolgirls in western Kenya. Baseline and 6-, 12-, and 18-month study visits occurred from April 2018 to December 2019 (pre-COVID-19), and 30-, 36-, and 48-month study visits occurred from September 2020 to July 2022 (COVID-19 period). Participants self-completed a survey for sociodemographics and sexual activity and provided self-collected vaginal swabs for bacterial vaginosis (BV) testing, with sexually transmitted infection (STI) testing at annual visits. 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. COVID-19-related stress was measured with a standardized scale and dichotomized at the highest quartile. Mixed effects modeling quantified how BV and STI changed over time. Longitudinal mediation analysis quantified how the relationship between COVID-19 stress and increased BV was mediated. Outcomes Analysis outcomes were BV and STI. Results BV and STI prevalence increased from 12.1% and 10.7% pre-COVID-19 to 24.5% and 18.1% during COVID-19, respectively. This equated to 26% (95% CI, 1.00-1.59) and 36% (95% CI, 0.98-1.88) higher relative prevalence of BV and STIs in the COVID-19 vs pre-COVID-19 periods, adjusted for numerous sociodemographic and behavioral factors. Higher COVID-19-related stress was associated with elevated depressive symptoms and feeling less safe inside the home, which were each associated with a greater likelihood of having a boyfriend. In mediation analyses, the direct effect of COVID-19-related stress on BV was small and nonsignificant, indicating that the increased BV was due to the constellation of factors that were affected during the COVID-19 pandemic. Clinical Translation These results highlight factors to help maintain reproductive health for adolescent girls in future crises, such as anticipating and mitigating mental health impacts, domestic safety concerns, and maintaining sexual health services. Strengths and Limitations Impacts of the COVID-19 pandemic on drivers of reproductive tract health among those who did not attend school or who live in different settings may differ. Conclusions In this cohort of adolescent girls, BV and STIs increased following COVID-19-related school closures, and risk was mediated by depressive symptoms and feeling less safe in the home, which led to a higher likelihood of sexual exposures.
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Affiliation(s)
- Supriya D Mehta
- Division of Infectious Diseases, Department of Medicine, Rush University College of Medicine, Chicago, IL 60612, United States
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL 60612, United States
| | - Debarghya Nandi
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL 60612, United States
| | | | - Garazi Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L35QA, United Kingdom
| | | | - Walter Agingu
- Nyanza Reproductive Health Sciences, Kisumu 40100, Kenya
| | - Runa Bhaumik
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL 60612, United States
| | - Linda Mason
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L35QA, United Kingdom
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool L35QA, United Kingdom
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Mehta SD, Nandi D, Otieno F, Zulaika G, Nyothach E, Agingu W, Bhaumik R, Mason L, van Eijk AM, Phillips-Howard PA. Increased reproductive tract infections among secondary school girls during the COVID-19 pandemic: associations with pandemic related stress, mental health, and domestic safety. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.02.17.24302973. [PMID: 38405836 PMCID: PMC10889038 DOI: 10.1101/2024.02.17.24302973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
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.
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Affiliation(s)
- Supriya D Mehta
- Division of Infectious Diseases, Department of Medicine, Rush University College of Medicine, Chicago, IL, USA
- Division of Epidemiology & Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL, USA
| | - Debarghya Nandi
- Division of Epidemiology & Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL, USA
| | | | - Garazi Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | | | - Runa Bhaumik
- Division of Epidemiology & Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL, USA
| | - Linda Mason
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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Ssemata AS, Ndekezi D, Kansiime C, Bakanoma R, Tanton C, Nelson KA, Hytti L, Neema S, Torondel B, Seeley J, Weiss HA. Understanding the social and physical menstrual health environment of secondary schools in Uganda: A qualitative methods study. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002665. [PMID: 38019777 PMCID: PMC10686490 DOI: 10.1371/journal.pgph.0002665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Accepted: 11/05/2023] [Indexed: 12/01/2023]
Abstract
Adolescent girls face social, psychological, and physical problems managing menstruation in schools in low-resource settings. This study aimed to evaluate the social and physical menstrual health environment of secondary schools in Wakiso and Kalungu districts, Uganda, in preparation for a subsequent menstrual health intervention trial to improve education, health and wellbeing. We conducted a qualitative rapid assessment in 75 secondary schools in Uganda. This involved conducting in-depth interviews with 150 head/senior teachers and 274 students, 26 Focus Group Discussions with students, and 13 transect walks to observe school Water, Sanitation and Hygiene (WASH) facilities between May and October 2021. Due to COVID-19 related school closures, face-to-face research activities were halted and in-depth interviews were conducted over phone and replaced focus group discussions. We employed a thematic framework analysis approach using the social-ecological model (which focuses on the complex interplay between individual, interpersonal, institutional, and societal factors) to generate themes and key concepts. Participants described the social and physical menstrual health environment of secondary schools at the individual level (knowledge gaps on menstruation before menarche, negative norms and beliefs about menstrual health); interpersonal level (limited psycho-social support, myths and misconceptions about the disposal of sanitary materials and pain relief, menstrual hygiene management (MHM) support from school nurses, peers and senior teachers); institutional level (non-implementation of Government circulars on MHM, lack of school-level guidelines policies and programs on MHM and poor WASH facilities, i.e. lack of soap, safe water and unclean toilets); and societal level (MHM programmes provided by civil society groups, health workers, and students' school associations). The findings showed individual, societal and institutional burdens related to menstrual experiences. Multi-level evidence-based interventions aimed at improving the social and physical environment for menstrual health among school-going girls are needed.
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Affiliation(s)
- Andrew Sentoogo Ssemata
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Faculty of Public Health Policy, Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Denis Ndekezi
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | | | | | - Clare Tanton
- Faculty of Public Health Policy, Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Kate Andrews Nelson
- Faculty of Epidemiology and Population Health, MRC International Statistics & Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom
| | - Laura Hytti
- Faculty of Epidemiology and Population Health, MRC International Statistics & Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom
| | - Stella Neema
- Department of Sociology & Anthropology, School of Humanities and Social Sciences Makerere University, Kampala, Uganda
| | - Belen Torondel
- Faculty of Infectious and Tropical Diseases, Department of Disease Control, London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom
| | - Janet Seeley
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
- Faculty of Public Health Policy, Department of Global Health & Development, London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Helen A. Weiss
- Faculty of Epidemiology and Population Health, MRC International Statistics & Epidemiology Group, London School of Hygiene & Tropical Medicine, Keppel Street, London, United Kingdom
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Zulaika G, Nyothach E, van Eijk AM, Wang D, Opollo V, Obor D, Mason L, Chen T, Kerubo E, Oyaro B, Mwaki A, Eleveld A, Ngere I, Fwaya E, ter Kuile FO, Kwaro D, Phillips-Howard PA. 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. EClinicalMedicine 2023; 65:102261. [PMID: 37860578 PMCID: PMC10582356 DOI: 10.1016/j.eclinm.2023.102261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 09/15/2023] [Accepted: 09/22/2023] [Indexed: 10/21/2023] Open
Abstract
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.
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Affiliation(s)
- Garazi Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Elizabeth Nyothach
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Valarie Opollo
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - David Obor
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Linda Mason
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Tao Chen
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Emily Kerubo
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Boaz Oyaro
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Alex Mwaki
- Safe Water and AIDS Project (SWAP), Kisumu, Kenya
| | - Alie Eleveld
- Safe Water and AIDS Project (SWAP), Kisumu, Kenya
| | - Isaac Ngere
- Washington State University Global Health Program, Nairobi, Kenya
| | | | - Feiko O. ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), Liverpool, UK
| | - Daniel Kwaro
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
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Mehta SD, Zulaika G, Agingu W, Nyothach E, Bhaumik R, Green SJ, van Eijk AM, Kwaro D, Otieno F, Phillips-Howard P. Analysis of bacterial vaginosis, the vaginal microbiome, and sexually transmitted infections following the provision of menstrual cups in Kenyan schools: Results of a nested study within a cluster randomized controlled trial. PLoS Med 2023; 20:e1004258. [PMID: 37490459 PMCID: PMC10368270 DOI: 10.1371/journal.pmed.1004258] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Accepted: 06/07/2023] [Indexed: 07/27/2023] Open
Abstract
BACKGROUND Nonhygienic products for managing menstruation are reported to cause reproductive tract infections. Menstrual cups are a potential solution. We assessed whether menstrual cups would reduce bacterial vaginosis (BV), vaginal microbiome (VMB), and sexually transmitted infections (STIs) as studies have not evaluated this. METHODS AND FINDINGS A cluster randomized controlled trial was performed in 96 Kenyan secondary schools, randomized (1:1:1:1) to control, menstrual cup, cash transfer, or menstrual cup plus cash transfer. This substudy assessing the impact of menstrual cups on BV, VMB, and STIs, included 6 schools from the control (3) and menstrual cup only (3) groups, both receiving BV and STI testing and treatment at each visit. Self-collected vaginal swabs were used to measure VMB (16S rRNA gene amplicon sequencing), BV (Nugent score), and STIs. STIs were a composite of Chlamydia trachomatis and Neisseria gonorrhoeae (nucleic acid amplification test) and Trichomonas vaginalis (rapid immunochromatographic assay). Participants were not masked and were followed for 30 months. The primary outcome was diagnosis of BV; secondary outcomes were VMB and STIs. Intention-to-treat blinded analyses used mixed effects generalized linear regressions, with random effects term for school. The study was conducted between May 2, 2018, and February 7, 2021. A total of 436 participants were included: 213 cup, 223 control. There were 289 BV diagnoses: 162 among control participants and 127 among intervention participants (odds ratio 0.76 [95% CI 0.59 to 0.98]; p = 0.038). The occurrence of Lactobacillus crispatus-dominated VMB was higher among cup group participants (odds ratio 1.37 [95% CI 1.06 to 1.75]), as was the mean relative abundance of L. crispatus (3.95% [95% CI 1.92 to 5.99]). There was no effect of intervention on STIs (relative risk 0.82 [95% CI 0.50 to 1.35]). The primary limitations of this study were insufficient power for subgroup analyses, and generalizability of findings to nonschool and other global settings. CONCLUSIONS Menstrual cups with BV and STI testing and treatment benefitted adolescent schoolgirls through lower occurrence of BV and higher L. crispatus compared with only BV and STI testing and treatment during the 30 months of a cluster randomized menstrual cup intervention. TRIAL REGISTRATION ClinicalTrials.gov NCT03051789.
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Affiliation(s)
- Supriya D. Mehta
- Division of Infectious Disease Medicine, Rush University College of Medicine, Chicago, Illinois, United States of America
- Division of Epidemiology & Biostatistics, University of Illinois Chicago School of Public Health, Chicago, Illinois, United States of America
| | - Garazi Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Elizabeth Nyothach
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Runa Bhaumik
- Division of Epidemiology & Biostatistics, University of Illinois Chicago School of Public Health, Chicago, Illinois, United States of America
| | - Stefan J. Green
- Department of Internal Medicine and Genomics and Microbiome Core Facility, Rush University, Chicago, Illinois, United States of America
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Daniel Kwaro
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Penelope Phillips-Howard
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Rudgard WE, Saminathen MG, Banougnin BH, Shenderovich Y, Toska E. The role of structural factors for preventing HIV risk practices among adolescents in South Africa: A three-wave analysis of caregiving, education, food security, and social protection. RESEARCH SQUARE 2023:rs.3.rs-2164051. [PMID: 36798325 PMCID: PMC9934770 DOI: 10.21203/rs.3.rs-2164051/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Structural interventions are endorsed to enhance biomedical and behavioural HIV prevention programmes for adolescents. Aiming to inform future interventions, we evaluated longitudinal associations between six structural factors and five HIV risk practices in a cohort of adolescents in South Africa. METHODS We used three rounds of data between 2014-2018 on 1046 adolescents living with HIV and 483 age-matched community peers in South Africa's Eastern Cape (Observations = 4402). We used multivariable random effects within-between logistic regression to estimate sex-specific associations between six time-varying structural factors - number of social grants, education enrolment, days with enough food, caregiver supervision, positive caregiving, and adolescent-caregiver communication - and five HIV risk practices - multiple sexual partners, transactional sex, age-disparate sex, condomless sex, and sex on substances. We calculated probability differences, contrasting predicted probabilities at average and maximum values of structural factors associated with multiple risk practices. FINDINGS The sample mean age was 15.29 (SD: 3.23) years and 58% were female. In females, compared to average, maximum positive caregiving scores were associated with lower probability of transactional sex (-1.06 percentage points [ppts], 95%CI=-1.60; -0.52ppts), and age-disparate sex (-0.73ppts; 95%CI=-1.26; -0.19ppts); maximum caregiver supervision scores were associated with lower probability of multiple sexual partners (-3.11ppts; 95%CI=-3.87; -2.35ppts) transactional sex (-1.07ppts, 95%CI=-1.42; -0.71ppts), age-disparate sex (-0.67ppts; 95%CI=-1.08; -0.25ppts), condomless sex (-3.96ppts; 95%CI=-5.65; -2.26ppts), and sex on substances (-0.93ppts; 95%CI=-1.50; -0.37ppts); and, seven days with enough food was associated with lower probability of multiple sexual partners (-1.18ppts, 95%CI=-2.06; -0.30ppts), and transactional sex (-0.91ppts; 95%CI=-1.41; -0.42ppts). Relative to non-enrolment, education enrolment was associated with lower probability of age-disparate sex (-3.18ppts; 95%CI=-5.35; -1.01ppts), and condomless sex (-11.32ppts; 95%CI=-19.15; -3.49ppts). In males, compared to average, maximum caregiver supervision scores were associated with lower probability of multiple sexual partners (-2.83ppts; 95%CI=-3.66; -2.00ppts), transactional sex (-0.90ppts; 95%CI=-1.20; -0.60ppts), age-disparate sex (-0.46ppts; 95%CI=-0.77; -0.15ppts), and sex on substances (-1.42ppts; 95%CI=-2.06; -0.78ppts). No other structural factors were associated with multiple risk practices. INTERPRETATION Structural interventions to improve food security and education enrolment among adolescent girls, and positive and supervisory caregiving among adolescent girls and boys are likely to translate into crucial reductions in HIV risk.
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Affiliation(s)
| | | | | | | | - Elona Toska
- University of Cape Town Centre for Social Science Research
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Kamire V, Magut F, Khagayi S, Kambona C, Muttai H, Nganga L, Kwaro D, Joseph RH. HIV Risk Factors and Risk Perception Among Adolescent Girls and Young Women: Results From a Population-Based Survey in Western Kenya, 2018. J Acquir Immune Defic Syndr 2022; 91:17-25. [PMID: 35972852 PMCID: PMC9387564 DOI: 10.1097/qai.0000000000003021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/25/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND In sub-Saharan Africa, HIV prevalence in adolescent girls and young women (AGYW) is 2-fold to 3-fold higher than that in adolescent boys and young men. Understanding AGYW's perception of HIV risk is essential for HIV prevention efforts. METHODS We analyzed data from a HIV biobehavioral survey conducted in western Kenya in 2018. Data from AGYW aged 15-24 years who had a documented HIV status were included. We calculated weighted prevalence and evaluated factors associated with outcomes of interest (HIV infection and high risk perception) using generalized linear models to calculate prevalence ratios. RESULTS A total of 3828 AGYW were included; 63% were aged 15-19 years. HIV prevalence was 4.5% and 14.5% of sexually active AGYW had high risk perception. Over 70% of participants had accessed HIV testing and counseling in the past 12 months. Factors associated with both HIV infection and high risk perception included having an HIV-positive partner or partner with unknown status and having a sexually transmitted infection in the past 12 months. Having an older (by ≥10 years) partner was associated with HIV infection, but not high risk perception. Less than 30% of sexually active AGYW with 3 or more HIV risk factors had high perception of HIV risk. CONCLUSION Gaps in perceived HIV risk persist among AGYW in Kenya. High access to HIV testing and prevention services in this population highlights platforms through which AGYW may be reached with improved risk counseling, and to increase uptake of HIV prevention strategies.
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Affiliation(s)
- Vivienne Kamire
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kenya
| | - Faith Magut
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kenya
| | - Sammy Khagayi
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kenya
| | - Caroline Kambona
- Division of Global HIV & TB (DGHT), Center for Global Health, United States Centers for Disease Control and Prevention (CDC) Kenya
| | - Hellen Muttai
- Division of Global HIV & TB (DGHT), Center for Global Health, United States Centers for Disease Control and Prevention (CDC) Kenya
| | - Lucy Nganga
- Division of Global HIV & TB (DGHT), Center for Global Health, United States Centers for Disease Control and Prevention (CDC) Kenya
| | - Daniel Kwaro
- Kenya Medical Research Institute-Centre for Global Health Research (KEMRI-CGHR), Kenya
| | - Rachael H. Joseph
- Division of Global HIV & TB (DGHT), Center for Global Health, United States Centers for Disease Control and Prevention (CDC) Kenya
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Okello E, Rubli J, Torondel B, Makata K, Ayieko P, Kapiga S, Greco G, Renju J. Co-development and piloting of a menstrual, sexual and reproductive health intervention to improve social and psychological outcomes among secondary schoolgirls in Northern Tanzania: the PASS MHW study protocol. BMJ Open 2022; 12:e054860. [PMID: 35131831 PMCID: PMC8823075 DOI: 10.1136/bmjopen-2021-054860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Poor menstrual health negatively impacts psychosocial and physical health, and subsequently leads to poor school outcomes, but the effort to improve adolescent girls' menstrual health in Tanzania remains fragmented. This study aimed to develop and pilot a scalable, comprehensive menstrual, sexual and reproductive health (MSRH) intervention within Tanzanian government structures to improve MSRH practices and perceptions and the overall school climate to ensure the psychosocial well-being and optimal school participation and performance among secondary schoolgirls. METHODS AND ANALYSIS This study will be conducted in three phases. Phase I will be a formative research to iteratively refine an existing puberty and menstrual health intervention, and to collaboratively design strategies to embed the intervention into government structures thereby promoting scalability. In Phase II, we will pilot and evaluate the refined intervention and implementation strategies using a mixed-methods design to assess (1) feasibility, acceptability and sustainability; and (2) effect on MSRH practices and perceptions and the overall school climate. In Phase III, we will synthesise the research findings in collaboration with the national, regional and district government and non-government stakeholders. ETHICS AND DISSEMINATION This pilot study will provide evidence-based recommendations for a comprehensive, complex menstrual and puberty intervention within secondary schools in Tanzania that can be further tested for broader effectiveness across a larger population. Papers, policy briefs and both regional/international conference presentations are planned to reach academic and non-academic groups. Protocol, tools and consent have been reviewed and approved by the independent Tanzanian national ethics committee (NIMR/HQ/R.8a/Vol.IX/3647) and the LSHTM Observational/Interventions Research Ethics Committee (LSHTM Ethics Ref: 22854). The project will involve adolescents, and procedures will be followed to ensure that we obtain permission and consent of parents and guardians and assent from all adolescents below 18 years of age that will be enrolled in the study.
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Affiliation(s)
- Elialilia Okello
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania
| | - Jennifer Rubli
- Monitoring and Evaluation, Femme International, Moshi, Tanzania
| | - Belen Torondel
- Disease Control, London School of Hygiene and Tropical Medicine, London, UK
| | - Kenneth Makata
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania
| | - Philip Ayieko
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Saidi Kapiga
- Mwanza Intervention Trials Unit, National Institute for Medical Research, Mwanza Research Centre, Mwanza, Tanzania
- Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, UK
| | - Giulia Greco
- Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Jenny Renju
- Epidemiology and Biostatistics, Kilimanjaro Christian Medical University College, Moshi, Tanzania
- Population Health, London School of Hygiene and Tropical Medicine, London, UK
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10
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Zulaika G, Bulbarelli M, Nyothach E, van Eijk A, Mason L, Fwaya E, Obor D, Kwaro D, Wang D, Mehta SD, Phillips-Howard PA. Impact of COVID-19 lockdowns on adolescent pregnancy and school dropout among secondary schoolgirls in Kenya. BMJ Glob Health 2022; 7:e007666. [PMID: 35027438 PMCID: PMC8761596 DOI: 10.1136/bmjgh-2021-007666] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Accepted: 12/16/2021] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Secondary school closures aimed at limiting the number of infections and deaths due to COVID-19 may have amplified the negative sexual and reproductive health (SRH) and schooling outcomes of vulnerable adolescent girls. This study aimed to measure pandemic-related effects on adolescent pregnancy and school dropout among school-going girls in Kenya. METHODS We report longitudinal findings of 910 girls in their last 2 years of secondary school. The study took place in 12 secondary day schools in rural western Kenya between 2018 and 2021. Using a causal-comparative design, we compared SRH and schooling outcomes among 403 girls who graduated after completion of their final school examinations in November 2019 pre-pandemic with 507 girls who experienced disrupted schooling due to COVID-19 and sat examinations in March 2021. Unadjusted and adjusted generalised linear mixed models were used to investigate the effect of COVID-19-related school closures and restrictions on all outcomes of interest and on incident pregnancy. RESULTS At study initiation, the mean age of participants was 17.2 (IQR: 16.4-17.9) for girls in the pre-COVID-19 cohort and 17.5 (IQR: 16.5-18.4) for girls in the COVID-19 cohort. Girls experiencing COVID-19 containment measures had twice the risk of falling pregnant prior to completing secondary school after adjustment for age, household wealth and orphanhood status (adjusted risk ratio (aRR)=2.11; 95% CI:1.13 to 3.95, p=0.019); three times the risk of school dropout (aRR=3.03; 95% CI: 1.55 to 5.95, p=0.001) and 3.4 times the risk of school transfer prior to examinations (aRR=3.39; 95% CI: 1.70 to 6.77, p=0.001) relative to pre-COVID-19 learners. Girls in the COVID-19 cohort were more likely to be sexually active (aRR=1.28; 95% CI: 1.09 to 1.51, p=0.002) and less likely to report their first sex as desired (aRR=0.49; 95% CI: 0.37 to 0.65, p<0.001). These girls reported increased hours of non-school-related work (3.32 hours per day vs 2.63 hours per day in the pre-COVID-19 cohort, aRR=1.92; 95% CI: 1.92 to 2.99, p=0.004). In the COVID-19 cohort, 80.5% reported worsening household economic status and COVID-19-related stress was common. CONCLUSION The COVID-19 pandemic deleteriously affected the SRH of girls and amplified school transfer and dropout. Appropriate programmes and interventions that help buffer the effects of population-level emergencies on school-going adolescents are warranted. TRIAL REGISTRATION NUMBER NCT03051789.
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Affiliation(s)
- Garazi Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Elizabeth Nyothach
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Annemieke van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Linda Mason
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Eunice Fwaya
- Siaya County, Kenya Ministry of Health, Siaya, Kenya
| | - David Obor
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Daniel Kwaro
- Center for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Supriya D Mehta
- Division of Epidemiology & Biostatistics, University of Illinois at Chicago, Chicago, Illinois, USA
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11
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Stoner MCD, Edwards JK, Westreich D, Kilburn K, Ahern J, Lippman SA, Gómez-Olivé FX, Kahn K, Pettifor A. Modeling Cash Plus Other Psychosocial and Structural Interventions to Prevent HIV Among Adolescent Girls and Young Women in South Africa (HPTN 068). AIDS Behav 2021; 25:133-143. [PMID: 33475905 PMCID: PMC8292433 DOI: 10.1007/s10461-021-03158-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2021] [Indexed: 11/25/2022]
Abstract
Poverty alleviation programs can reduce HIV incidence but may have greater impacts when combined with other psychosocial interventions. We modeled the change in HIV incidence among South African adolescent girls and young women (AGYW) associated with combining a cash transfer (the South African Child Support Grant (CSG)) with other structural and behavioral interventions. We modeled observational data from the HPTN 068 study where 2328 HIV negative AGYW (13–20 years) were followed for 4 years. In a Monte Carlo simulation based on this cohort (N = 10,000), CSG receipt was not independently associated with HIV incidence. Providing the CSG combined with increasing caregiver care and reducing adolescent depression had the largest reduction in HIV incidence with the fewest number of combined interventions (RD − 3.0%; (95% CI − 5.1%, − 0.9%). Combining a monthly grant with interventions to increase caregiver care and reduce adolescent depression could substantially reduce HIV incidence above the provision of cash alone.
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Affiliation(s)
- Marie C D Stoner
- Women's Global Health Imperative, RTI International, Berkeley, CA, USA.
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA.
| | - Jessie K Edwards
- Department of Epidemiology, University of North Carolina, Chapel Hill, NY, USA
| | - Daniel Westreich
- Department of Epidemiology, University of North Carolina, Chapel Hill, NY, USA
| | - Kelly Kilburn
- Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Jennifer Ahern
- Division of Epidemiology & Biostatistics, School of Public Health, University of California, Berkeley, USA
| | - Sheri A Lippman
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Medicine, University of California, San Francisco, USA
| | - F Xavier Gómez-Olivé
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
- Epidemiology and Global Health Unit, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Audrey Pettifor
- Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA
- Department of Epidemiology, University of North Carolina, Chapel Hill, NY, USA
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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12
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Stoner MCD, Kilburn K, Godfrey-Faussett P, Ghys P, Pettifor AE. Cash transfers for HIV prevention: A systematic review. PLoS Med 2021; 18:e1003866. [PMID: 34843468 PMCID: PMC8668130 DOI: 10.1371/journal.pmed.1003866] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 12/13/2021] [Accepted: 11/11/2021] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Given the success of cash programs in improving health outcomes and addressing upstream drivers of HIV risk such as poverty and education, there has been an increasing interest in their potential to improve HIV prevention and care outcomes. Recent reviews have documented the impacts of structural interventions on HIV prevention, but evidence about the effects of cash transfer programs on HIV prevention has not been systematically reviewed for several years. METHODS AND FINDINGS We did a systematic review of published and unpublished literature to update and summarize the evidence around cash programs for HIV prevention from January 2000 to December 17, 2020. We included studies with either a cash transfer intervention, savings program, or program to reduce school costs. Included studies measured the program's impact on HIV infection, other sexually transmitted infections (STIs), or sexual behaviors. We screened 1,565 studies and examined 78 in full-text review to identify a total of 45 peer-reviewed publications and reports from 27 different interventions or populations. We did not do a meta-analysis given the range of outcomes and types of cash transfer interventions assessed. Most studies were conducted in sub-Saharan Africa (N = 23; South Africa, Tanzania, Malawi, Lesotho, Kenya, Uganda, Zimbabwe, Zambia, and eSwatini) followed by Mexico (N = 2), the United States (N = 1), and Mongolia (N = 1)). Of the 27 studies, 20 (72%) were randomized trials, 5 (20%) were observational studies, 1 (4%) was a case-control study, and 1 (4%) was quasi-experimental. Most studies did not identify a strong association between the program and sexual behaviors, except sexual debut (10/18 finding an association; 56%). Eight of the 27 studies included HIV biomarkers, but only 3 found a large reduction in HIV incidence or prevalence, and the rest found no statistically significant association. Of the studies that identified a statistically significant association with other STIs (N = 4/8), 2 involved incentives for staying free of the STI, and the other 2 were cash transfer programs for adolescent girls that had conditionalities related to secondary schooling. Study limitations include the small number of studies in key populations and examining interventions to reduce school costs and matched saving programs. CONCLUSIONS The evidence base for large-scale impacts of cash transfers reducing HIV risk is limited; however, government social protection cash transfer programs and programs that incentivize school attendance among adolescent girls and young women show the greatest promise for HIV prevention.
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Affiliation(s)
- Marie C. D. Stoner
- Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
- Women’s Global Health Imperative, RTI International, Berkeley, California, United States of America
- * E-mail:
| | - Kelly Kilburn
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
| | | | | | - Audrey E. Pettifor
- Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina, United States of America
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina, United States of America
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13
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van Eijk AM, Jayasinghe N, Zulaika G, Mason L, Sivakami M, Unger HW, Phillips-Howard PA. Exploring menstrual products: A systematic review and meta-analysis of reusable menstrual pads for public health internationally. PLoS One 2021; 16:e0257610. [PMID: 34559839 PMCID: PMC8462722 DOI: 10.1371/journal.pone.0257610] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 09/06/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Girls and women need effective, safe, and affordable menstrual products. Single-use menstrual pads and tampons are regularly provided by agencies among resource-poor populations. Reusable menstrual pads (RMPs: fabric layers sewn together by an enterprise for manufacture of menstrual products) may be an effective alternative. METHODS For this review (PROSPERO CRD42020179545) we searched databases (inception to November 1, 2020) for quantitative and qualitative studies that reported on leakage, acceptability, or safety of RMPs. Findings were summarised or combined using forest plots (random-effects meta-analysis). Potential costs and environmental savings associated with RMPs were estimated. RESULTS A total of 44 studies were eligible (~14,800 participants). Most were conducted in low- and middle-income countries (LMIC, 78%), and 20% in refugee settings. The overall quality of studies was low. RMP uptake in cohort studies ranged from 22-100% (12 studies). One Ugandan trial among schoolgirls found leakage with RMPs was lower (44.4%, n = 72) compared to cloths (78%, n = 111, p<0.001). Self-reported skin-irritation was 23.8% after 3 months among RMP-users in a Ugandan cohort in a refugee setting (n = 267), compared to 72.8% at baseline with disposable pad use. There were no objective reports on infection. Challenges with washing and changing RMP were reported in LMIC studies, due to lack of water, privacy, soap, buckets, and sanitation/drying facilities. Among 69 brands, the average price for an RMP was $8.95 (standard deviation [sd] $5.08; LMIC $2.06, n = 10, high-income countries [HIC] $10.11), with a mean estimated lifetime of 4.3 years (sd 2.3; LMIC 2.9, n = 11; HIC 4.9 years, n = 23). In 5-year cost-estimates, in LMICs, 4-25 RMPs per period would be cheaper (170-417 US$) than 9-25 single-use pads, with waste-savings of ~600-1600 single-use pads. In HICs, 4-25 RMPs would be cheaper (33-245 US$) compared to 20 single-use tampons per period, with waste-savings of ~1300 tampons. CONCLUSION RMPs are used internationally and are an effective, safe, cheaper, and environmentally friendly option for menstrual product provision by programmes. Good quality studies in this field are needed.
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Affiliation(s)
- Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Naduni Jayasinghe
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Garazi Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Linda Mason
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Holger W. Unger
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Obstetrics and Gynaecology, Royal Darwin Hospital, Darwin, Australia
- Menzies School of Health Research, Charles Darwin University, Darwin, Australia
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14
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Mehta SD, Zulaika G, Otieno FO, Nyothach E, Agingu W, Bhaumik R, Green SJ, van Eijk AM, Kwaro D, Phillips-Howard PA. High Prevalence of Lactobacillus crispatus Dominated Vaginal Microbiome Among Kenyan Secondary School Girls: Negative Effects of Poor Quality Menstrual Hygiene Management and Sexual Activity. Front Cell Infect Microbiol 2021; 11:716537. [PMID: 34621690 PMCID: PMC8490761 DOI: 10.3389/fcimb.2021.716537] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 08/30/2021] [Indexed: 01/05/2023] Open
Abstract
The vaginal microbiome (VMB) impacts numerous health outcomes, but evaluation among adolescents is limited. We characterized the VMB via 16S rRNA gene amplicon sequencing, and its association with Bacterial vaginosis (BV) and sexually transmitted infections (STIs; chlamydia, gonorrhea, trichomoniasis) among 436 schoolgirls in Kenya, median age 16.9 years. BV and STI prevalence was 11.2% and 9.9%, respectively, with 17.6% of girls having any reproductive tract infection. Three community state types (CST) accounted for 95% of observations: CST-I L.crispatus-dominant (N=178, BV 0%, STI 2.8%, sexually active 21%); CST-III L.iners-dominant (N=152, BV 3.3%, STI 9.7%, sexually active 35%); CST-IV G.vaginalis-dominant (N=83, BV 51.8%, STI 25.3%, sexually active 43%). In multivariable adjusted analyses, sexually active girls had increased odds of CST-III and CST-IV, and use of cloth to manage menses had 1.72-fold increased odds of CST-IV vs. CST-I. The predominance of L.crispatus-dominated VMB, substantially higher than observed in prior studies of young adult and adult women in sub-Saharan Africa, indicates that non-optimal VMB can be an acquired state. Interventions to maintain or re-constitute L.crispatus dominance should be considered even in adolescents.
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Affiliation(s)
- Supriya D. Mehta
- Division of Epidemiology & Biostatistics, University of Illinois at Chicago, Chicago, IL, United States,*Correspondence: Supriya D. Mehta,
| | - Garazi Zulaika
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | | | - Elizabeth Nyothach
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
| | | | - Runa Bhaumik
- Division of Epidemiology & Biostatistics, University of Illinois at Chicago, Chicago, IL, United States
| | - Stefan J. Green
- Department of Internal Medicine and Genomics and Microbiome Core Facility, Rush University, Chicago, IL, United States
| | - Anna Maria van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Daniel Kwaro
- Centre for Global Health Research, Kenya Medical Research Institute, Kisumu, Kenya
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15
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Zulaika G, Nyothach E, van Eijk AM, Obor D, Mason L, Wang D, Chen T, Kerubo E, Opollo V, Ngere I, Omondi Owino S, Oyaro B, ter Kuile FO, Kwaro D, Phillips-Howard P. Factors associated with the prevalence of HIV, HSV-2, pregnancy, and reported sexual activity among adolescent girls in rural western Kenya: A cross-sectional analysis of baseline data in a cluster randomized controlled trial. PLoS Med 2021; 18:e1003756. [PMID: 34582445 PMCID: PMC8478198 DOI: 10.1371/journal.pmed.1003756] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adolescence is a sensitive time for girls' sexual and reproductive health (SRH), as biological changes occur concurrently with heightening pressures for sexual activity. In western Kenya, adolescent girls are vulnerable to acquiring sexually transmitted infections (STIs), such as HIV and herpes simplex virus type 2 (HSV-2), and to becoming pregnant prior to reaching adulthood. This study examines associations between individual, household, and partner-related risk factors and the prevalence of sex, adolescent pregnancy, HIV, and HSV-2. METHODS AND FINDINGS We report baseline findings among 4,138 girls attending secondary school who were enrolled between 2017 and 2018 in the Cups or Cash for Girls (CCG) cluster randomized controlled trial in Siaya County, rural western Kenya. Laboratory confirmed biomarkers and survey data were utilized to assess the effects of girls' individual, household, and partner characteristics on the main outcome measures (adolescent reported sex, prior pregnancy, HIV, and HSV-2) through generalized linear model (GLM) analysis. Complete data were available for 3,998 girls (97%) with median age 17.1 years (interquartile range [IQR] 16.3 to 18.0 years); 17.2% were HSV-2 seropositive (n = 686) and 1.7% tested positive for HIV (n = 66). Sexual activity was reported by 27.3% girls (n = 1,090), of whom 12.2% had been pregnant (n = 133). After adjustment, orphanhood (adjusted risk ratio [aRR] 2.81, 95% confidence interval [CI] 1.18 to 6.71, p-value [p] = 0.020), low body mass index (BMI) (aRR 2.07; CI: 1.00 to 4.30, p = 0.051), and age (aRR 1.34, 1.18 to 1.53, p < 0.001) were all associated with HIV infection. Girls reporting light menstrual bleeding (aRR 2.42, 1.22 to 4.79, p = 0.012) for fewer than 3 days (aRR 2.81, 1.16 to 6.82, p = 0.023) were over twice as likely to have HIV. Early menarche (aRR 2.05, 1.33 to 3.17, p = 0.001) was associated with adolescent pregnancy and HSV-2-seropositive girls reported higher rates of pregnancy (aRR 1.62, CI: 1.16 to 2.27, p = 0.005). High BMI was associated with HSV-2 (aRR 1.24, 1.05 to 1.46, p = 0.010) and sexual activity (aRR 1.14, 1.02 to 1.28, p = 0.016). High levels of harassment were detected in the cohort (41.2%); being touched indecently conveyed the strongest association related to reported sexual activity (aRR 2.52, 2.26 to 2.81, p < 0.001). Study limitations include the cross-sectional design of the study, which informs on the SRH burdens found in this population but limits causal interpretation of associations, and the self-reported exposure ascertainment, which may have led to possible underreporting of risk factors, most notably prior sexual activity. CONCLUSIONS Our findings indicate that adolescent girls attending school in Kenya face frequent harassment for sex and are at high risk of pregnancy and HSV-2, with girls experiencing early menarche particularly vulnerable. Targeted interventions, such as earlier sexual education programs, are warranted to address their vulnerability to SRH harms. TRIAL REGISTRATION ClinicalTrials.gov NCT03051789.
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Affiliation(s)
- Garazi Zulaika
- Liverpool School of Tropical Medicine (LSTM), Liverpool, United Kingdom
- * E-mail: (GZ); (PPH)
| | - Elizabeth Nyothach
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | | | - David Obor
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Linda Mason
- Liverpool School of Tropical Medicine (LSTM), Liverpool, United Kingdom
| | - Duolao Wang
- Liverpool School of Tropical Medicine (LSTM), Liverpool, United Kingdom
| | - Tao Chen
- Liverpool School of Tropical Medicine (LSTM), Liverpool, United Kingdom
| | - Emily Kerubo
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | - Valarie Opollo
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | | | | | - Boaz Oyaro
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
| | | | - Daniel Kwaro
- Kenya Medical Research Institute (KEMRI), Centre for Global Health Research, Kisumu, Kenya
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