Why don't urban youth in Zambia use condoms? The influence of gender and marriage on non-use of male condoms among young adults

Condom use increased after a peer group intervention implemented by community volunteers in Malawi

BACKGROUND

HIV prevention remains a global priority, especially in sub-Saharan Africa. Our research team previously developed an evidence-based peer group program for HIV prevention called Mzake ndi Mzake (Friend to Friend). A community-engaged collaboration adapted the program for community ownership and implementation. Here we report whether this HIV prevention program, implemented by community volunteers, increased condom use among sexually active individuals in rural Malawi.

METHODS

Three communities sequentially rolled out the program. Effectiveness was evaluated using a stepped wedge design. Repeated surveys 11-13 months apart were conducted between 2016 and 2019. At Time 1, no community had offered the intervention. At Time 2, the first community had offered the intervention and two had not (control group). At Time 3, two communities had offered the intervention and one had not (control group). We used two condom use indicators; condom use frequency in the last 2 months (N = 771) and condom use at last sex (N = 880). The analytical sample included all sexually active persons answering that question at one or more time points. Mixed-effects cumulative logit and Generalized Estimating Equation (GEE) models were used to model the two condom indicators over time, controlling for demographic factors, UNAIDS HIV knowledge, safer sex self-efficacy and partner communication.

RESULTS

This peer group intervention implemented by trained community volunteers increased both condom use indicators at Times 2 and 3. In the final adjusted models with non-significant factors removed, condom use in the last two months increased for the intervention group vs. control group [Time 2: Adjusted Odds Ratio (AOR) = 1.59 (1.15, 2.21); Time 3: AOR 2.01 (1.23, 3.30)]. Similarly, condom use at last sex increased for the intervention group vs. control group [Time 2: AOR = 1.48 (1.08, 2.03); Time 3: AOR 1.81 (1.13, 2.90)]. Other significant predictors of greater condom use were also described. Although the intervention increased UNAIDS HIV knowledge, knowledge did not predict condom use.

CONCLUSIONS

In this community-engaged implementation study, an evidence-based peer group program for HIV prevention increased condom use when delivered by trained community volunteers. Community ownership and program delivery by trained volunteers offer an innovative and cost-effective strategy to address ongoing HIV prevention needs without overburdening healthcare systems in sub-Saharan Africa.

TRIAL REGISTRATION

Clinical Trials.gov NCT02765659 Registered May 6, 2016.

A non-latex condom has no influence on male physiological sexual arousal

Background/Objective

Men do not use external condoms for several reasons, which can result in public health problems. One of these is related to Condom-Associated Erectile Problems. This study aimed to examine the sexual arousal response of heterosexual men when using an external condom made of synthetic resin type AT-10.

Method

A total of 82 Colombian young men (Mage = 23.17 years, SD = 3.04, age range = 18-30) participated in this experimental study. Two random groups (experimental and control; n = 41 each) were compared. The experimental group used condoms, whereas the control group did not. Fit and feel condom perceptions, initial erectile scores, age, and substance use were controlled for. Erection was measured while viewing a sexual video by using penile plethysmography and subjective arousal.

Results

The results, obtained from comparing the experimental group (using pre-erection condoms) with the control group (not using condoms), revealed no significant difference in both subjective and physiological sexual arousal. This suggests that pre-erection condoms do not have an effect on the erectile response.

Discussion

More research is needed in this area to provide treatment and clinical interventions or sexual and reproductive education to mitigate the occurrence of sexual dysfunction, unplanned pregnancies, or sexually transmitted infections. Also, research addresses public health issues related to the prevention and/or intervention of sexual risk behaviors and sexual dysfunctions, highlighting their significance in sexual education and clinical practice.

Condom use increased after a peer group intervention implemented by community volunteers in Malawi

Background

HIV prevention remains a global priority, especially in sub-Saharan Africa. Our research team previously developed an evidence-based peer group program for HIV prevention called Mzake ndi Mzake (Friend to Friend). A community-engaged collaboration adapted the program for community ownership and implementation. Here we report whether this HIV prevention program, implemented by community volunteers, increased condom use among sexually active individuals in rural Malawi.

Methods

Three communities sequentially rolled out the program. Effectiveness was evaluated using repeated surveys. At Time 1, no community had offered the intervention. At Time 2, the first community had offered the intervention and two had not (control group). At Time 3, two communities had offered the intervention and one had not (control group). We used two condom use indicators; condom use frequency in the last 2 months (N = 776) and condom use at last sex (N = 880). For each indicator, the sample included all sexually active persons answering that question at one or more time points. Regression analyses were used to model the two condom indicators over time, controlling for demographic factors, UNAIDS HIV knowledge, safer sex self-efficacy and partner communication.

Results

This peer group intervention implemented by trained community volunteers increased both condom use indicators at Times 2 and 3. In the final regression models. Other predictors of greater condom use for at least one condom use indicator included younger age group (13-19), male gender, not married/cohabiting, high involvement in religiously affiliated activities, higher safer sex self-efficacy, and greater partner communication. Although the intervention increased UNAIDS HIV knowledge, knowledge did not predict condom use.

Conclusions

This community engaged implementation study found that an evidence-based peer group program for HIV prevention increased condom use when delivered by trained community volunteers. Leveraging community strengths and human capital resources facilitated implementation of this effective HIV prevention program in rural Malawi. Community ownership and program delivery by trained local volunteers offers an innovative and cost-effective strategy to address ongoing HIV prevention needs without overburdening heathcare systems in sub.

Trial registration

Clinical Trials.gov NCT02765659 Registered May 6, 2016.

Prevalence and determinants of inconsistent condom use among unmarried sexually active youth. a secondary analysis of the 2016-2017 Eswatini HIV incidence measurement survey

INTRODUCTION

In sub-Saharan Africa, youth continue to have a high burden of sexually transmitted infections and unplanned pregnancies that could be reduced through improved condom use. We aimed to investigate inconsistent condom use with the three most recent sexual partners among unmarried sexually active youth in Eswatini.

METHODS

Data were analysed for 1,324 youth from the 2016-2017 Swaziland HIV incidence measurement survey (SHIMS2) using multivariable logistic regression method.

RESULTS

The prevalence of inconsistent condom use among youth was 56.8% in 2017. Higher odds of inconsistent condom use were observed among youth aged 20-24, residents in the Lubombo region, those aged less than 18 years at sexual debut and those who had two or more sexual partners in the last 12 months before the survey. Lower odds of inconsistent condom use were observed among males, and those that knew their partners reported HIV status to be negative.

CONCLUSION

Our findings highlight a notable prevalence of inconsistent condom use among youth in Eswatini. Programs that aim to reduce the incidence of HIV infections and STIs among youth in Eswatini should focus on these factors associated with inconsistent condom use.

Predictors of consistent condom use among young psychoactive substance users in Kampala's informal settlements, Uganda

Introduction

The use of psychoactive substances increases the likelihood of unprotected sexual intercourse with individuals whose health status is not known, and consequently sexually transmitted infections, especially among young people. Despite this risk, there is limited evidence of the predictors of consistent condom use among young psychoactive substance users (YPSUs) in informal settings. This study examined the predictors of condom use among YPSUs in Kampala's informal settlements, Uganda.

Methods

A cross-sectional study was conducted among 768 YPSUs. Respondent-driven sampling was used to recruit respondents. A structured questionnaire was used to collect respondent data on condom use. Data were analysed using Stata version 15.0. Prevalence ratios (PR) were used to determine the predictors of consistent condom use.

Results

Out of the 744 YPSUs, only 37.4% of the respondents reported consistent condom use in the last 30 days. The prevalence of condom use was statistically lower among young people aged 20-24 years (35.4%) compared to those aged 18-19 years (43.7%), and among the married (17.3%) compared to respondents with a "single" marital status (43.0%). Being married (PR 0.42, 95% CI: 0.30-0.59), longer duration between meeting the most recent partner and having initial sexual contact with them (7 months to 1 year: PR 0.56, 95% CI: 0.36-0.88; more than a year: PR 0.36, 95% CI: 0.17-0.75) was negatively associated with consistent condom use. Spending less than 24 h between meeting the most recent partner and having initial sexual contact was positively associated with consistent condom use (PR 1.60, 95% CI: 1.24-2.08).

Conclusion

The prevalence of consistent condom use in the last 30 days among YPSUs was low. Marital status and the duration between meeting the most recent partner and initial sexual contact predicted consistent condom use. There is a need to intensify awareness on the importance of consistent condom use among young people.

"It was protected, except, it wasn't [with] a condom": a mixed-methods study of BBVs/STIs protective practices among International University Students in Sydney, Australia

BACKGROUND

A number of previous sex-related studies among international students in Australia and other Western societies may be limited by conflating students from conservative and non-conservative sexual backgrounds. Such conflation leads to situations where nuances and complexities around sex-related experiences are lost or, at most, tangentially investigated. To address this research problem, this study used a mixed-methods design to examine protective practices against blood-borne viruses and sexually transmissible infections (BBVs/STIs) among Sydney-based East Asian and sub-Saharan African international students.

METHODS

This mixed-methods study generated quantitative data using anonymous online survey (n = 149), and qualitative data through in-depth interviews (n = 20). The main recruitment strategy involved advertising the study through paper and electronic flyers. Quantitative data were analysed using logistic regression, while interviews data were analysed using reflexive thematic analysis.

RESULTS

Self-reported BBVs/STIs protective practices in the last 12 months include abstinence (28.7%), consistent condom use (19.9%), occasional condom use (18.7%), single partner fidelity (25.1%), other strategies (1.8%), and nothing (5.8%). Further, findings from the bivariate analysis showed higher BBVs/STIs prevention knowledge, lower acculturation into Australian sexual culture, greater access to sexual health information, less conservative sexual norms, greater emotional social support and older age were significantly associated with increased protective practices. Variables significant at bivariate level were entered into a logistic regression. The model was statistically significant, (X²(6) = 31.33, p < 0.01) and explained 33.1% of the variance in BBVs/STIs protective practices. However, only acculturation to sexual norms in Australia (OR = 0.883, 95% CI = 0.820-0.952) was found to be independent predictor of BBVs/STIs protective practices. The results of the study based on the quantitative data, indicated condom use (consistent and occasional) was the most reported BBVs/STIs protective behaviour among sexually active participants. Therefore, interviews data was used to explore condom-use motives and practices. The interviews results showed participants primary concern as regards condom use was around pregnancy and not BBVs/STIs. Thus, some participants described safe sex largely as contraception, with BBVs/STIs constituting a secondary concern or no concern at all.

CONCLUSIONS

Based on the results of this study, tailored sexual health interventions for international students; which incorporate strategies for modifying perceived sexual norms in Australia, are advocated. In addition, this study recommends sexual health interventions that promote dual protection of condoms for both contraception and BBVs/STIs.

Getting to zero HIV/AIDS in sub-Saharan Africa: Understanding perceptions of locals using the social determinants of health framework

This study explored a community perception of the facilitators and inhibitors of Getting to Zero (GTZ) in rural Zambia, sub-Saharan Africa. Data were collected in 2017. We use the Social Determinants of Health framework to guide organisation of key themes emerging from semistructured, focus group interviews with community members (N = 52). Data were analysed through an iterative descriptive/thematic approach which allowed for the highlighting of key themes. Emerging themes point to the significance of (a) individual, (b) sociocultural, (c) environmental and (d) economic factors, for example, treatment adherence, gender norms, food security and access to health care as important in GTZ. Implications for policy, practise and scholarship are suggested.

Application of community dialogue approach to prevent adolescent pregnancy, early marriage and school dropout in Zambia: a case study

Background

Adolescent pregnancy carries both health and economic risks for the pregnant girl and resulting baby, and it is common in Zambia. Providing alternative methods of preventing early pregnancy than abstinence is regarded as culturally and religiously unacceptable in most parts of the country. The community dialogue approach is being tested to address norms and beliefs around early pregnancy, marriage and school dropout, and is based on Paulo Freire’s transformative communication approach. The objective of this paper was to understand parents’ perspectives on the application of the community dialogue approach in addressing adolescents’ early pregnancy and school dropout in a cluster randomized controlled trial in rural Zambia.

Methods/design

This was a case study design. We nested the study in the community dialogue intervention arm of the Research Initiative to Support the Empowerment of Girls trial in Zambia. Dialogue meetings were held and economic support was provided for a period of 27 months from September 2016 until November 2018. We held focus group discussions in November 2018 with guardians/parents in six schools in Chibombo District of Central Province. All the discussions were audio recorded and transcribed verbatim. Thematic analysis was used to analyze the data.

Results

The guardians/parents perceived the community dialogue to be a relevant approach for addressing social and cultural norms regarding early pregnancy, marriage and school dropout. It was embraced for its value in initiating individual and collective change. The facilitators’ interactive approach and dialogue in the community meetings coupled with the use of films and role plays with the parents, lead to active participation and open discussions about sexual and reproductive health (SRH) topics during the community dialogue meetings. Group interactions and sharing of experiences helped parents clarify their SRH values and subsequently made them feel able to communicate about SRH issues with their children. However, cultural and religious beliefs among the parents regarding some topics, like the use of condoms and contraceptives, complicated the delivery of reproductive health messages from the parents to their children.

Conclusion

The study indicated that the community dialogue was appreciated by the parents and helped in addressing cultural barriers to discussing SRH issues between generations.

Adolescent pregnancy carries health and economic risks for the pregnant girl and her baby. However, many adolescent girls in Zambia become pregnant and this is partly due to social norms around fertility and marriage. Community dialogue meetings may be useful in order to discuss norms and beliefs around early pregnancy, marriage and school dropout and encourage reflection around cultural practices in the communities. A cluster randomized controlled trial in rural Zambia tested the effects of organizing community dialogue meetings and providing economic support for families with adolescent girls for a period of 27 months, from 2016 to 2018. The objective of this case study was to understand parents’ perspectives on the use of the community dialogue approach.

Focus group discussions were held in November 2018 with guardians/parents in six schools in Chibombo District of Central Province. The guardians/parents perceived the community dialogue to be a relevant approach for addressing social and cultural norms regarding early pregnancy, marriage and school dropout. The facilitators’ interactive approach in the community meetings coupled with the use of films and role plays, lead to active participation and open discussions about sexual and reproductive health topics during the community dialogue meetings. Group interactions and sharing of experiences made the guardians feel able to communicate about sexual and reproductive health issues with their children. However, cultural and religious beliefs among the parents regarding the use of condoms and contraceptives made it difficult for them to touch upon this topic.

OUP accepted manuscript

Background

Sexually transmitted infections (STIs) affect individuals of all ages, but adolescent girls and young women are disproportionately affected. We examined the prevalence and factors associated with self-reported STIs (SR-STIs) among adolescent girls and young women in sub-Saharan Africa (SSA).

Methods

Demographic and Health Survey data of 27 sub-Saharan African countries were used for the study. The sample size comprised 68944 adolescent girls and young women (15–24 y of age). The outcome variable was SR-STIs. Multilevel binary logistic regression analysis was performed to identify factors associated with SR-STIs.

Results

On average, the prevalence of SR-STIs among adolescent girls and young women in SSA was 6.92%. The likelihood of SR-STIs was higher among young women aged 20–24 y (adjusted odds ratio [aOR] 1.36 [confidence interval {CI} 1.27 to 1.46]), those not married (aOR 1.64 [CI 1.51 to 1.79]), those working (aOR 1.20 [CI 1.12 to 1.27]), those whose age at first sex was ≤19 y (aOR 1.99 [CI 1.80 to 2.20]), those with two or more sex partners (aOR 1.56 [CI 1.35 to 1.80]), those who listened to radio (aOR 1.26 [CI 1.17 to 1.35]), those in urban areas (aOR 1.42 [CI 1.30 to 1.51]) and those with a wealth index of rich (aOR 1.28 [CI 1.17 to 1.40]) compared with their counterparts. In contrast, those with a primary (aOR 0.86 [CI 0.78 to 0.94]) or secondary/higher level of education (aOR 0.83 [CI 0.75 to 0.92]) compared with those with no formal education and those who were exposed to television (aOR 0.90 [CI 0.84 to 0.98]) compared with those who were not exposed were less likely to report STIs.

Conclusions

Our findings demonstrate the need for countries in SSA to commit towards reducing the incidence of STIs. Community-based health educational programs are required to intensify the awareness of STIs and their prevention in various sub-Saharan African countries considering the factors that expose adolescent girls and young women to STIs.

Urban Family Planning in Low- and Middle-Income Countries: A Critical Scoping Review

Health agendas for low- and middle-income countries (LMICs) should embrace and afford greater priority to urban family planning to help achieve a number of the global Sustainable Development Goals. The urgency of doing so is heightened by emerging evidence of urban fertility stalls and reversals in some sub-Saharan African contexts as well as the significance of natural increase over migration in driving rapid urban growth. Moreover, there is new evidence from evaluations of large programmatic interventions focused on urban family planning that suggest ways to inform future programmes and policies that are adapted to local contexts. We present the key dimensions and challenges of urban growth in LMICs, offer a critical scoping review of recent research findings on urban family planning and fertility dynamics, and highlight priorities for future research.

Understanding how social norms affect modern contraceptive use

BACKGROUND

An aim of this study is to introduce a practitioner-friendly behavior model. Few theories of health behavior explicitly take the effect of social norms on behavior into account. Generally, theories that do take social norms into account assume that the effect of social norms on behavior operates through motivation. We use the Fogg Behavior Model (FBM), a behavior model that is new to public health, to explore whether social norms are associated with modern contraceptive use among Nigerian women, and whether they affect behavior through motivation or through ability. In other words, do social norms that discourage contraception lower women's motivation to use contraception or do they lower women's ability to use contraception.

METHODS

This study uses data from a cross-sectional household survey of Nigerian women, ages 14-24. The survey collected data on socio-economic and demographic characteristics of women, whether they were sexually experienced, and whether they used contraception. Modern contraceptive use was the outcome of interest for the study. The survey also collected data on social norms around premarital sex and contraceptive use. Multivariate logistic regression was used for the analysis.

RESULTS

After adjusting for a range of socio-economic and demographic variables, we found that social norms that discourage contraception had a statistically significant negative association with contraceptive use (aOR = 0.90, p < 0.001). The analysis found that the negative association between social norms and contraceptive use remained statistically significant after controlling for motivation but did not remain statistically significant after controlling for ability.

CONCLUSION

These findings suggest that social norms may affect contraceptive use in Nigeria through ability rather than motivation. In terms of programmatic implications, these finding suggest that public health interventions may be able to counter the negative effects of social norms that discourage contraceptive use by increasing women's ability to practice contraception.

A spatial analysis of the epidemiology of HIV-infected students in Zhejiang province, China

BACKGROUND

The upsurge in HIV infections among students is a matter of particular concern. However, few studies have explored the epidemiological characteristics including the risky sexual networking of HIV-infected students in Zhejiang province, China.

METHODS

Using the provincial surveillance data of HIV-infected students, we conducted a retrospective epidemiology study to describe the epidemiological characteristics of 628 newly diagnosed cases from 2011 to 2016 and detailed information of 124 cases from 2015 to 2016. Spatial analyses were conducted using ArcGIS software, and statistical analyses were performed using SPSS software.

RESULTS

A total of 628 cases of HIV/AIDS were diagnosed among students in Zhejiang Province, China between 2011 and 2016. The cases showed an overall increasing trend over time, while the proportions of students with HIV disease status, cases diagnosed by HIV voluntary counseling and testing (VCT), and cases of homosexual transmission remained stable over time. Significant spatial heterogeneity in the cases was seen at the county level. Detailed data on 124 HIV-positive individuals collected from the local Center for Disease Control and Prevention (CDC) from 2015 and 2016, showed that the majority of them (85.5%,) engaged in homosexual behavior, and 93.4% had sex with casual partners. These partners included not only social members, but also other students. Online dating applications represented the most common means of seeking and communicating with homosexual partners. The level of awareness regarding the risk of HIV infection, and the amount coverage of face-to-face education towards students were both low.

CONCLUSIONS

HIV infections among students were characterized by increasing trend and spatial clustering in Zhejiang Province between 2011 and 2016, with homosexual sexual activity being the main mode of infection. Interventions are urgently required to prevent HIV infection in this population by increasing awareness of the disease. HIV testing programs and information regarding disease prevention specifically through online dating applications are needed.

Condom Use Errors and Problems in a Sample of Young Colombian Adults

Condom effectiveness can be reduced by a number of problems and errors that take place during use. The purpose of the present study was to translate and adapt the Condom Use Errors and Problems Survey (CUES) into Spanish and to use it for testing the prevalence of these issues in a sample of young Colombian adults. A total of 775 people (414 women and 361 men) between 18 and 26 years of age participated in the study. Participants completed the following questionnaires online: Condom Use Errors and Problems Survey, Sexual Opinion Survey, Sexual Assertiveness Scale, Multidimensional Condom Attitudes Scale, a sociodemographic and sexual history questionnaire, plus two questions concerning condom-associated erectile problems. Results showed significant differences in the prevalence of condom use errors/problems associated with gender, sexual orientation, and whether the participant had a stable sexual partner. The occurrence of problems/errors ranged from 9.4% to 69.5%. Except for certain specific practices, observations were similar to those of studies performed in North America. Results indicate that the present linguistic adaptation of the CUES for its use in Colombian Spanish-speaking populations is an effective instrument to assess problems and errors associated with the use of male condoms.

Associated factors and sex differences in condom non-use among adolescents: Brazilian National School Health Survey (PeNSE)

Background

Condom non-use among sexually active adolescents is a major cause of unintended pregnancy and sexually transmitted infections. In order to promote condom use, it is essential to understand factors associated with condom non-use.

Aim

Our aim was to evaluate sex differences and associated factors of condom non-use based on the nationally representative Brazilian National School Health Survey.

Methods

The study participants were 100,962 adolescents 13–18 years old, 9th graders from both public and private schools throughout Brazil. The following factors were considered as explanatory group variables for the outcome of condom non-use among adolescents: school and health service, sexual behavior, substance use, and self-reported body and health perception. Poisson regression model was performed.

Results

Of the total students, 28% (n = 28,157) had had sexual intercourse at least once. (boys, 37.1%; girls, 19.5%). Of these, 69.2% had used condoms the last time they had intercourse (girls: 68%; boys: 69.9%). The variables associated with condom non-use for both sexes were not having accessed a health service or approached a health professional for health-related care; not having received pregnancy prevention counseling or guidance on AIDS or STI prevention at school; early sexual initiation; no additional contraception method; substance use; feeling alone; not being satisfied with their own body; feeling fat or thin; and poor self-reported health. The number of sexual partners was also associated with condom non-use; however, contrasting behavior was indicated between sexes. A higher number of sexual partners indicated less use of condoms among girls, while for boys, a higher number of sexual partners indicated higher condom use.

Conclusion

High condom non-use appears to be associated with lack of health care access and sexual health education, poor sexual practices, substance use, and poor self-perception, indicating areas for health promotion programs.

Left behind?: male clients of female sex workers in Zambia

Male clients of female sex workers (CFSWs) are a key-affected group within the HIV epidemic. However, few studies have quantified HIV/STI burdens among CFSWs. This study used nationally representative data from the 2013-14 Zambia Demographic and Health Survey to estimate proxies for HIV and STI prevalence among sexually active men aged 15-59 paying for sex recently (past 12 months) [5%, n = 679] or in their lifetime [15%, n = 1,887]. Chi-square tests were calculated to assess differences in prevalence estimates between CFSWs and non-clients. Multivariable logistic regression models were generated to identify sociodemographic factors associated with prevention characteristics. CFSWs had higher odds of reporting HIV infection (recent: aOR 1.413, p < 0.05; lifetime: aOR 1.604, p < 0.001) and past-year STI symptomology (recent: aOR 3.342, p < 0.001; lifetime: aOR 2.266, p < 0.001) than non-clients, irrespective of transactional sex recency. Compared to non-clients, CFSWs were more likely to be <25yo (42% vs. 29%, p < 0.001), have a cohabitating partner (43% vs. 35%, p < 0.001), use condoms at last sex (31% vs. 27%, p < 0.001), and never test for HIV (36% vs. 29%, p < 0.001). When comparing CFSWs to non-clients, marital status was an effect modifier of HIV testing, medical circumcision, and condom use at last sex. Findings suggest high HIV/STI burdens and highlight the urgent need for differentiated HIV prevention programming for CFSWs in Zambia including the provision of PrEP.

Can sexual health interventions make community-based health systems more responsive to adolescents? A realist informed study in rural Zambia

Introduction

Community-based sexual reproductive interventions are key in attaining universal health coverage for all by 2030, yet adolescents in many countries still lack health services that are responsive to their sexual reproductive health and rights’ needs. As the first step of realist evaluation, this study provides a programme theory that explains how, why and under what circumstances community-based sexual reproductive health interventions can transform (or not) ‘ordinary’ community-based health systems (CBHSs) into systems that are responsive to the sexual reproductive health of adolescents.

Methods

This realist approach adopted a case study design. We nested the study in the full intervention arm of the Research Initiative to Support the Empowerment of Girls trial in Zambia. Sixteen in-depth interviews were conducted with stakeholders involved in the development and/or implementation of the trial. All the interviews were recorded and analysed using NVIVO version 12.0. Thematic analysis was used guided by realist evaluation concepts. The findings were later synthesized using the Intervention−Context−Actors−Mechanism−Outcomes conceptualization tool. Using the retroduction approach, we summarized the findings into two programme theories.

Results

We identified two initial testable programme theories. The first theory presumes that adolescent sexual reproductive health and rights (SRHR) interventions that are supported by contextual factors, such as existing policies and guidelines related to SRHR, socio-cultural norms and CBHS structures are more likely to trigger mechanisms among the different actors that can encourage uptake of the interventions, and thus contribute to making the CBHS responsive to the SRHR needs of adolescents. The second and alternative theory suggests that SRHR interventions, if not supported by contextual factors, are less likely to transform the CBHSs in which they are implemented. At individual level the mechanisms, awareness and knowledge were expected to lead to value clarification’, which was also expected would lead to individuals developing a ‘supportive attitude towards adolescent SRHR. It was anticipated that these individual mechanisms would in turn trigger the collective mechanisms, communication, cohesion, social connection and linkages.

Conclusion

The two alternative programme theories describe how, why and under what circumstances SRHR interventions that target adolescents can transform ‘ordinary’ community-based health systems into systems that are responsive to adolescents.

Impact of internal female migration on unmet need for modern contraception in Zambia

Background

Unmet need for contraception, the proportion of women who want to limit or delay childbirth but use no form of contraception, is the core indicator to evaluate the effectiveness of family planning programs. Understanding how migration influences unmet need is important to identify to whom and how to target sexual and reproductive health programs. We assessed how migration status in rural and urban settings is associated with having an unmet need for family planning.

Methods

Data on sexually active, fecund, reproductive-aged (15–49 years) women from the 2013–14 Zambia Demographic and Health Survey were analysed through univariate and multivariate logistic regression models.

Results

Unmet need for modern contraceptive methods was significantly higher among rural to rural migrant women (OR 1.30, 95%CI 1.00–1.70 p < 0.05) and rural non-migrant women (OR 1.41, 95%CI 1.06–1.85 p < 0.01) compared to urban non-migrant women after controlling for age, marital status, parity, religion, education and wealth.

Conclusion

Women residing in, and migrating between, rural areas were significantly more likely to have an unmet need for contraception. Our findings highlight the importance of understanding migration and migrant streams to strengthen family planning programs. In Zambia, a focus on rural-rural migrants, rural non-migrants and the poorest could improve the health of the entire population.

Risky Sexual Behaviors and Associated Factors Among College Students in Lusaka, Zambia

Risky sexual behaviors are important factors driving the HIV/AIDS epidemic. Although Zambia experiences a high HIV prevalence, especially among youth, there is a dearth of information regarding risky sexual behaviors among young adults. Therefore, we investigated the prevalence and associated factors of risky sexual behaviors among college students in Lusaka, Zambia. A cross-sectional study was conducted in February 2017 among 427 college students at the University of Zambia. Participants reported their sexual behaviors, sexual attitudes, and lifestyle using self-administered questionnaires. Multinomial logistic regression models were employed to assess potential determinants of risky sexual behaviors. Among the 205 students who reported ever having sex, 148 (72.2%) engaged in risky sexual behaviors in the last 12 months. Participants who were older (OR 1.30, 95% CI 1.12-1.51), engaged in low physical activity (OR 2.25, 95% CI 1.05-4.84), and reported liberal sexual attitudes (OR 1.88, 95% CI 1.02-3.47) were more likely to engage in any risky sexual behavior, while frequent alcohol use (OR 8.38, 95% CI 4.60-15.27) and suicide attempts (OR 6.42, 95% CI 2.03-20.29) predicted multiple risky sexual behaviors. In conclusion, this study indicates that Zambian college students' risky sexual behaviors are associated with multiple behavioral health risks. Future research should consider using a multiple-behavior change intervention.

Exploring gender and partner communication: Theory of planned behavior predictors for condom use among urban youth in Zambia

OBJECTIVE

To understand how knowledge and perceptions of condoms and partner communication influence use of condoms in a high HIV prevalence setting and gender-specific differences.

METHODS

A cross-sectional study was conducted in Zambia from 2015 to 2016. The survey included questions on demographics, sexual behavior, contraceptive perceptions, and behaviors. We constructed multivariate regression models using the Theory of Planned Behavior to determine associations between knowledge, perceptions, and perceived control with intended, communicated, and reported use of condoms by gender.

RESULTS

The participants were 2388 sexually active urban residents aged 18-24 years. In the sample, 1646 (69%) were female, 841 (35%) married, and 1894 (61%) unemployed. Partner communication was the predictor most associated with use of condoms. Among women, partner communication was associated with over three times higher odds of condom use (odds ratio [OR] 3.51, 95% confidence interval [CI] 2.65-4.65) but being married reduced the odds of condom use by 76% (OR 0.24, 95% CI 0.17-0.33). For men, a network of friends that was supportive of the use of contraception was associated with increased odds of 55% for use of condoms (OR 1.55, 95% CI 1.10-2.18).

CONCLUSION

Public health programs aimed at increasing safer sexual behavior and use of condoms must consider improving gender equity and partner communication, as knowledge of contraceptives and positive perceptions are not enough to ensure their use.

Dual Unsafe Injection and Sexual Behaviors for HIV Infection Among People Who Inject Drugs in Iran

We used two national surveys (2010: N = 1597; 2013: N = 1057) of people who inject drugs (PWID) in past-month to assess the prevalence and population size of PWID with either safe or unsafe injection and sex behaviors, overall and by HIV status. In 2013, only 27.0% (vs. 32.3% in 2010) had safe injection and sex, 24.6% (vs. 23.3% in 2010) had unsafe injection and sex, 26.4% (vs. 26.5% in 2010) had only unsafe injection, and 22.0% (vs. 18.0% in 2010) had unsafe sex only. Among HIV-positive PWID in 2013, only 22.1% (~ 2200 persons) had safe injection and sex, 14.2% (~ 1400 persons) had unsafe injection and sex, 53.1% (~ 5200 persons) had unsafe injection, and 10.6% had unsafe sex (~ 1100 persons). Among HIV-negative PWID in 2013, only 27.5% (~ 22,200 persons) had safe injection and sex, 25.9% (~ 20,900 PWID) had unsafe injection and sex, 23.2% (~ 18,700 persons) had unsafe injection, and 23.3% (~ 18,800 persons) had unsafe sex. HIV-positive and -negative PWID in Iran continue to be at risk of HIV acquisition or transmission which calls for targeted preventions services.

Early Childbearing, School Attainment, and Cognitive Skills: Evidence From Madagascar

Female secondary school attendance has recently increased in sub-Saharan Africa, and so has the risk of becoming pregnant while attending school. We analyze the impact of teenage pregnancy on young women’s human capital using longitudinal data in Madagascar that capture the transition from adolescence to adulthood for a cohort aged 21–24 in 2012, first interviewed in 2004. We find that early childbearing increases the likelihood of dropping out of school and decreases the chances of completing secondary school. This pregnancy-related school dropout also has a detrimental impact on standardized test scores in math and French. We instrument early pregnancy with the young woman’s community-level access and her exposure to condoms since age 15 after controlling for pre-fertility socioeconomic conditions. Our results are robust to different specifications that address potential endogeneity of program placement and instrument validity.