Social norms, attitudes and access to modern contraception for adolescent girls in six districts in Uganda

Adolescent utilization of sexual and reproductive health services in Gamo Zone, Southern Ethiopia. Insights from multilevel and latent class analysis

Introduction

Adolescents face unique challenges related to their sexual and reproductive health (SRH), with access to timely services being critical for positive outcomes. However, SRH service utilization among adolescents remains low. This study aimed to identify factors influencing SRH service use among adolescents in Gamo Zone, Ethiopia.

Methods

A community-based cross-sectional study involved 1172 adolescents selected through stratified sampling. Structured face-to-face interviews were employed for data collection. Multilevel mixed logistic regression was fitted to identify factors and latent class analysis was conducted to understand population heterogeneity.

Results

The findings of this study reveal that 198 (16.89%) adolescents (95% CI: 14.8%-19.2%) utilized SRH services within the past 12 months. Factors significantly associated with SRH service utilization included good knowledge about SRH rights (AOR = 4.65; 95% CI: 2.68, 8.07), belonging to one-parent families (AOR = 4.13; 95% CI: 2.39, 7.12), engaging in parental discussions regarding SRH issues (AOR = 3.17; 95% CI: 1.89, 5.29), high family support (AOR = 1.96; 95% CI: 1.09, 3.51), and enrolling in school (AOR = 0.19; 95% CI: 0.11, 0.33). Additionally, access to social media was associated with increased SRH service utilization among adolescents (AOR = 1.98; 95% CI: 1.25, 3.15). Latent class analysis identified four groups: rural school-enrolled adolescents living with parents, urban school-enrolled adolescents with both parents, urban disadvantaged female adolescents, and early adolescents with limited social media access.

Conclusions

In conclusion, our study sheds light on the utilization of SRH services among adolescents, revealing that 16.89% of the participants accessed these services within the past year. Significant factors associated with SRH service utilization included good knowledge about SRH rights, belonging to one-parent families, engaging in parental discussions regarding SRH issues, high family support, and enrollment in school. Interestingly, access to social media was also linked to increased utilization of SRH services among adolescents. Furthermore, our latent class analysis identified four distinct classes of adolescents based on socio-demographic indicators, highlighting the heterogeneity within this population. These findings underscore the importance of tailored interventions and targeted approaches to address the diverse needs of adolescents in accessing and utilizing SRH services.

Using Vignettes to Gain Insights Into Social Norms Related to Voluntary Family Planning and Gender-Based Violence in South Sudan

Social norms are the shared expectations about behaviors that are held within collective groups. These differ from attitudes and beliefs, which are individually held. In South Sudan, social norms can affect the use of voluntary family planning and reproductive health (FP/RH); some of these norms even present risks for women seeking FP/RH care and their FP/RH providers. This cross-sectional, descriptive study conducted in 5 counties in South Sudan used vignettes as a qualitative method to explore social norms related to FP/RH and decisions related to contraceptive use and gender-based violence. Participants were asked to respond to vignettes about a fictional couple during various life stages of care-seeking. Vignettes allow respondents to share their opinions and feelings without directly speaking about their own experiences. Respondents included community members, FP/RH providers, and key influencers (e.g., religious leaders, traditional leaders, elders). The study identified restrictive social norms related to FP/RH, including entrenched, dominant gender roles (i.e., requiring male consent to use contraceptives) and risk for the woman and her provider if she accesses FP/RH services. Of note, supportive social norms are gaining acceptance regarding women's voice and agency; it was found that some women can negotiate their reproductive choice with their partners and participate in planning their families, which has not always been a widely accepted norm. The use of vignettes can lead to a better understanding of the challenges and provide insights on effective implementation approaches. It is essential for programs working to promote the use of FP/RH services in South Sudan to consider the challenges presented by social norms. Findings from this study were shared with stakeholders and communities to codesign interventions aimed at increasing the use of FP/RH services. Additionally, the dialogue stimulated by this study should lead to an organic transformation toward supportive social norms through collective agency.

Family Factors and Gender Norms as Protective Factors Against Sexual Risk-Taking Behaviors Among Adolescent Girls in Southern Uganda

Adolescent girls and young women are at a higher risk for HIV infection stemming from barriers to accessing comprehensive sexual health education, unequal cultural, social, and economic statuses, limited access to education and health care services, and gender-based violence. This makes adolescent girls susceptible to high-risk sexual behaviors. This study examines the protective role of family, social support factors and gender norms against sexual risk-taking behaviors among secondary school adolescent girls in Uganda. Baseline data from the National Institute of Mental Health-funded Suubi4Her study were analyzed. A total of 1260 girls aged 14-17 years and enrolled in the first or second year of secondary school were recruited across 47 secondary schools. Hierarchical linear regression models were conducted to determine the role of family, social support factors and gender norms on sexual risk-taking behaviors. Results indicate that traditional gender norms, family care and relationships, and social support were all associated with lower levels of sexual risk-taking intentions-a proxy for engaging in sexual risk behaviors. Findings point to the need to develop family level support interventions to equip adolescent girls with adequate sexual health-related knowledge and skills to facilitate safer sexual practices and reduce high-risk sexual-taking behaviors, as they develop and transition into young adulthood.

Preference for novel biomedical HIV pre-exposure prophylaxis methods among adolescent girls and young women in Kampala, Uganda: a mixed methods study

Background

Novel HIV pre-exposure prophylaxis (PrEP) methods including a potential future HIV vaccine, will increase prevention options for adolescent girls and young women (AGYW) at high risk of HIV infection in Eastern and Southern Africa, yet data on AGYW's preferences for various PrEP methods is limited. We investigated preferences for five biomedical PrEP methods (oral, injectable, vaginal ring, implant, HIV vaccine) among 14-24-years-old AGYW in Kampala, Uganda.

Methods

From January to December 2019, we conducted a mixed methods study including 265 high-risk AGYW. After receiving two education sessions on the five PrEP methods, participants were asked about their "most preferred PrEP method." Multinomial logistic regression (oral PrEP as reference category) was used to determine participant characteristics associated with method preference. Results are presented as adjusted relative risk ratios (aRRR) with 95% confidence intervals (CI). In-depth interviews were conducted with 20 selected participants to examine reasons influencing PrEP preferences and suggestions for method improvements. Transcripts were analyzed thematically.

Results

Participants preferred methods were: HIV vaccine (34.7%), oral PrEP (25.7%), injectable PrEP (24.9%), PrEP implant (13.6%), and vaginal ring (1.1%). Preference for injectable PrEP increased with every year of age (aRRR 1.22; 95% CI 1.04-1.44) and among participants with chlamydia or gonorrhoea (aRRR 2.53; 95% CI 1.08-5.90), while it was lower among participants having sexual partner(s) living with HIV or of unknown HIV status (aRRR 0.30; 95% CI 0.10-0.91). Preference for PrEP implants also increased with age (aRRR 1.42; 95% CI 1.14-1.77) and was strong among participants having ≥10 sexual partners in the past 3 months (aRRR 3.14; 95% CI 1.16-8.55), while it was lower among those with sexual partner(s) living with HIV or of unknown HIV status (aRRR 0.25; 95% CI 0.07-0.92). PrEP method preference was influenced by product attributes and prior experiences with similar product forms commonly used in health care.

Conclusion

AGYW have varied preferences for biomedical PrEP method and those with higher sexual behavioral risk prefer long-acting methods. As we anticipate more available PrEP options, oral PrEP use should be supported among AGYW, especially for those with sexual partners living with HIV or of unknown HIV status.

Unintended pregnancies in the lives of young people in Luwero, Uganda: a narrative analysis

Using a feminist narrative approach, this article explores how unintended pregnancy can rupture young lives, and how young people respond to and navigate these ruptures. We analyse qualitative data from a longitudinal cohort study in Luwero, Uganda, focusing on narratives of a girl and a boy about their recent experiences of unintended and unwanted pregnancy during COVID-19 school closures. We argue that laws, policies and norms relating to education, sexual and reproductive health, and the family in Uganda position young people in complex and contradictory ways, that create the conditions for unintended pregnancies, and restrict the choices open to them. The analysis traces how pregnancy ruptures their everyday lives, their identities, and relationships. Their narratives reveal gendered ways in which they enact identities to manage the ruptures. Families are sites of contestation, where gender and sexuality are regulated, but are also mobilised by young people to support their efforts to repair the ruptures. Our analysis underscores the importance of working with young people to understand their positionalities, resource environments and social networks as they make and navigate decisions about pregnancy, and of addressing the structural forces that underpin the rupturing effects of pregnancy on teenage lives.

A qualitative assessment of the impact of a community-embedded intervention on beneficiaries' attitudes and beliefs about adolescent sexual reproductive health in Ebonyi State, Southeast, Nigeria

BACKGROUND

Adolescents and their communities in Ebonyi State, Nigeria have poor attitudes and beliefs towards adolescent sexual and reproductive health (SRH). This paper reports on the effects of a community-embedded intervention that focused on creating positive changes in the attitudes and beliefs of adolescents and community members to enhance adolescents' access to SRH information and services.

METHODS

This study adopted the Qualitative Impact Assessment approach to evaluate the changes in attitudes and beliefs about the SRH of adolescents from the perspectives of the beneficiaries of a community-embedded intervention namely, adolescents, parents, school teachers, and community leaders. The intervention was implemented in six local government areas in Ebonyi State, southeast Nigeria and the evaluation was undertaken four months after the implementation of the interventions commenced. Eighteen (18) interviews were conducted with 82 intervention beneficiaries including: (i) six in-depth interviews with school teachers; (ii) two sex-disaggregated FGDs with parents; (iii) two sex-disaggregated FGDs with community leaders; and (iv) eight sex-disaggregated FGDs with in school and out of school adolescents. A thematic analysis of data was performed with the aid of NVivo software, version 12.

RESULTS

The community-embedded intervention led to changes in individual attitudes and beliefs, as well as changes in community norms and values concerning adolescent SRH. Adolescents reported that following the community-embedded SRH intervention, they have become more comfortable discussing openly SRH issues with their peers, and they could more easily approach their parents and initiate SRH discussions. The parents of adolescents reported that following the intervention, they have become more willing to discuss sensitive SRH issues with adolescents, and frequently make out time to do so. It was also reported that parents no longer use euphemisms to describe sexual body parts, and community leaders now believe that it is all right to discuss SRH with adolescents. Hence, initiating or having SRH discussions with adolescents is no longer misconceived as encouraging sex, and menstruation in unmarried adolescents is no longer viewed as a sign of promiscuity. Respondents also highlighted changes in community norms of, (i) gendered parental communication of SRH matters, as both mothers and fathers have started discussing SRH issues with their adolescent boys and girls; and (ii) public shaming and discipline of pregnant teenage girls are on the decline.

CONCLUSION

The community-based intervention had a positive impact on individual attitudes and beliefs, as well as community and societal values and norms about adolescent SRH. Interventions that take into account community norms and values regarding adolescent SRH should be prioritized to enable the achievement of the SRH-related target of SDG 3.

Exploring a syndemic of poverty, cumulative violence, and HIV vulnerability among refugee youth: multi-method insights from a humanitarian setting in Uganda

Synergistic associations between social inequities and HIV vulnerabilities - known as a syndemic - are understudied with youth in humanitarian settings. We explored refugee youths' HIV prevention needs in Bidi Bidi Refugee Settlement, Uganda. This multi-methods study involved 6 focus groups and 12 in-depth individual interviews (IDI) with refugee youth (n = 60) aged 16-24, and IDI with refugee elders (n = 8) and healthcare providers (n = 8). We then conducted cross-sectional surveys with refugee youth (16-24 years) (n = 115) to assess: poverty, recent sexual and gender-based violence (SGBV), and condom engagement motivation (CEM) (wanting to learn about condoms for HIV prevention). Multivariable logistic regression was used to estimate adjusted odds ratios for associations between poverty and SGBV with CEM. Qualitative narratives revealed poverty and trauma elevated substance use, and these converged to exacerbate SGBV. SGBV and transactional sex increased HIV vulnerabilities. Among survey participants, poverty and recent SGBV were associated with reduced odds of CEM. The interaction between poverty and recent SGBV was significant: the predicted probability of CEM among youth who experienced both poverty and SGBV was almost half than among youth who experienced poverty alone, SGBV alone, or neither. Findings signal the confluence of poverty, violence, and substance use elevate refugee youth HIV vulnerabilities.

Personal, Interpersonal, and Sociocultural Factors of Condom Use in Rural Indigenous Nahuas Adolescents in Mexico

The goal of this research was to determine the personal, interpersonal, and sociocultural predictors of condom use among rural Indigenous adolescents. Predictor variables were selected from Bandura's Social Cognitive Theory and Leininger's Transcultural Theory. The sample consisted of 419 Nahuas adolescents randomly selected from the total number of neighborhood blocks in a rural community in Puebla, Mexico. The instruments had acceptable psychometric characteristics (Cronbach alpha and validity scores). Multiple linear regression models were used. Results: 56.8% of participants were female, and 50.40% were students. Mean age was M = 17.5 (SD = 0.97), and the majority (63%) identified as Catholic. Age at menarche/first ejaculation (β = -1.2, p = 0.038), attitude toward condom use (β = 0.13, p < 0.001), ethnic identity (β = 0.21, p < 0.001), and ability to negotiate condom use (β = 0.13, p = 0.003) predicted (R² = 22.3) condom use. This study provided a basis for integration of the cultural values of Indigenous adolescents within interventions for sexual health promotion.

Exploring the Role of Norms and Habit in Explaining Pro-Environmental Behavior Intentions in Situations of Use Robots and AI Agents as Providers in Tourism Sector

In a pandemic situation, with climate change around the world, studies analyzing changes in travel patterns are welcome. This study combines three theories to propose a model on pro-environmental behavior intentions, namely, the theory of planned behavior, value–belief–norm theory and habit theory. This study aims to examine the role of social norms, personal norms and habit strength to explain pro-environmental behavior intentions. The authors collected 316 usable questionnaires from tourists in the well-known touristic Belem location in Lisbon. Personal norms were revealed to have the strongest association with pro-environmental behavior intentions, followed by habit strength. The study also identified different broad challenges to encouraging sustainable behaviors and use these to develop novel theoretical propositions and directions for future research. Finally, the authors outlined how practitioners aiming to encourage sustainable consumer behaviors can use this framework to achieve better results.