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Okyere J, Yeboa NK, Nikoi C, Owusu-Amoako M, Ferka L, Nurzhynska A, Amo-Adjei J. Adolescent sexual and reproductive health needs and utilisation of health services in the Bono East Region, Ghana. Reprod Health 2024; 21:87. [PMID: 38886821 PMCID: PMC11184831 DOI: 10.1186/s12978-024-01822-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 05/31/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Adolescents in Ghana are vulnerable to unequal power relations at the personal, community and structural levels which in turn limits their opportunities in access to critical sexual and reproductive health information and services. There is therefore high unmet need for sexual and reproductive health (SRH) information and services and the Bono East region typifies this situation, recording some of the poorest SRHR outcomes among adolescents. We, therefore, aimed to investigate the SRH needs (unmet), behaviors and utilization of SRH services among adolescents in the Bono East region. METHODS Using a maximum variation sampling approach, this qualitative study conducted in-depth interviews and focused group discussions with adolescent boys and girls, parents, community leaders, and healthcare providers. RESULTS Our findings are presented under two broad categories: major SRHR concerns of adolescents, and perspectives about that influences adolescents' utilization of SRHR services. Under the major SRHR need of adolescents, the following themes emerged: information and services on pregnancy prevention, menstrual hygiene management, availability of comprehensive abortion care services, and attitudes towards adolescent pregnancy. The perspectives about the factors that influence adolescent children were discussed at multiple levels: individual/personal. interpersonal and community/societal. At the individual level, limited understanding of adolescence/puberty, desire of adolescents to belong and misperceptions about contraceptives. At the interpersonal level, issues relating to technical capacity needs of service providers, disrespect exhibited by service providers, and parental failure were identified as influential factors. Then at the community/societal level, we identified structural constraints and compromised social safety concerns in accessing contraceptives and services. CONCLUSION In conclusion, the findings from this study offer valuable insights into the complex landscape of adolescent sexual and reproductive health in the Bono East region. The implications for policy and practice are manifold, ranging from comprehensive education to addressing menstrual hygiene, involving parents, training healthcare providers, and promoting respectful care.
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Affiliation(s)
- Joshua Okyere
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
- School of Nursing and Midwifery, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Naomi Kyeremaa Yeboa
- Department of Maternal and Child Health, School of Nursing and Midwifery, University of Cape Coast, Cape Coast, Ghana
| | - Charity Nikoi
- UNICEF Ghana Office, Social and Behaviour Change Communication Unit, Accra, Ghana
| | | | - Listowel Ferka
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana
| | - Anastasia Nurzhynska
- UNICEF Kenya Office, Social and Behaviour Change Communication Unit, Nairobi, Kenya
| | - Joshua Amo-Adjei
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana.
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Nkrumah J, Abuosi AA, Baku AAA, Yarney L, Abekah-Nkrumah G, Tettey CR. Adolescent sexual and reproductive health literacy needs: a sub-national level assessment in Ghana. Health Promot Int 2024; 39:daae065. [PMID: 38902982 DOI: 10.1093/heapro/daae065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2024] Open
Abstract
This study assessed young adolescents' access and literacy challenges to sexual and reproductive health information and knowledge gaps in the Effutu Municipality in the Central Region of Ghana. We used a narrative design and a focus group discussion method to glean data from 52 in-school adolescents, aged 11-15. Focus group discussions were conducted using a discussion guide and data were processed using QDA Miner (version 6.0). We analyzed data thematically using an iterative process of data validation, coding and recording. The participants had poor knowledge of the concepts of sexual and reproductive health and its essential domains. Abstinence was the predominant sexual and reproductive health goal of the participants. Yet, many males admitted to having sexual partners. There was difficult linguistic and physical access to structured and safe information. Personal hygiene, signs of sexual maturation and abstinence were the predominant contents available to young adolescents. A revision of adolescent health policies and strategies to embrace actions for improving unrestricted access to easy-to-read educational materials and adolescent health literacy is essential. Creating adolescent corners and introducing peer education in schools within Effutu and other municipalities in the Central Region will be useful.
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Affiliation(s)
- Jacqueline Nkrumah
- Department of Health Administration and Education, University of Education, Winneba, P. O. Box 25, Winneba Commercial Street, Winneba, Central Region, 233, Ghana
| | - Aaron A Abuosi
- Department of Health Services Management, University of Ghana Business School, P. O. Box 78, Volta Hall Road, Accra-Legon, Greater Accra Region, 233, Ghana
| | - Anita Asiwome Adzo Baku
- Department of Health Services Management, University of Ghana Business School, P. O. Box 78, Volta Hall Road, Accra-Legon, Greater Accra Region, 233, Ghana
| | - Lily Yarney
- Department of Health Services Management, University of Ghana Business School, P. O. Box 78, Volta Hall Road, Accra-Legon, Greater Accra Region, 233, Ghana
| | - Gordon Abekah-Nkrumah
- Department of Health Services Management, University of Ghana Business School, P. O. Box 78, Volta Hall Road, Accra-Legon, Greater Accra Region, 233, Ghana
| | - Cecil Randolph Tettey
- University of Education, Winneba, Health Service Directorate, P. O. Box 25, Winneba Commercial Street, Winneba, Central Region, 233, Ghana
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Hartmann M, Nyblade L, Otticha S, Marton T, Agot K, Roberts ST. The development of a conceptual framework on PrEP stigma among adolescent girls and young women in sub-Saharan Africa. J Int AIDS Soc 2024; 27:e26213. [PMID: 38379129 PMCID: PMC10879468 DOI: 10.1002/jia2.26213] [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: 06/01/2023] [Accepted: 01/17/2024] [Indexed: 02/22/2024] Open
Abstract
INTRODUCTION Stigma is a well-known barrier to HIV testing and treatment and is an emerging barrier to pre-exposure prophylaxis (PrEP) use. To guide future research, measurement and interventions, we developed a conceptual framework for PrEP stigma among adolescent girls and young women (AGYW) in sub-Saharan Africa, a priority population for PrEP. METHODS A literature review, expert consultations and focus group discussions (FGDs) were conducted to adapt the Health Stigma and Discrimination Framework, describing the stigmatization process nested within the socio-ecological framework. We reviewed all articles on PrEP stigma and on HIV, contraceptive or sexuality stigma among AGYW from 2009 to 2019. Expert consultations were conducted with 10 stigma or PrEP researchers and two Kenyan youth advisory boards to revise the framework. Finally, FGDs were conducted with AGYW PrEP users (4 FGDs; n = 20) and key influencers (14 FGDs; n = 72) in Kenya with the help of a Youth Research Team who aided in FGD conduct and results interpretation. Results from each phase were reviewed and the framework was updated to incorporate new and divergent findings. This was validated against an updated literature search from 2020 to 2023. RESULTS The conceptual framework identifies potential drivers, facilitators and manifestations of PrEP stigma, its outcomes and health impacts, and relevant intersecting stigmas. The main findings include: (1) PrEP stigma is driven by HIV, gender and sexuality stigmas, and low PrEP community awareness. (2) Stigma is facilitated by factors at multiple levels: policy (e.g. targeting of PrEP to high-risk populations), health systems (e.g. youth-friendly service availability), community (e.g. social capital) and individual (e.g. empowerment). (3) Similar to other stigmas, manifestations include labelling, violence and shame. (4) PrEP stigma results in decreased access to and acceptability of PrEP, limited social support and community resistance, which can impact mental health and decrease PrEP uptake and adherence. (5) Stigma may engender resilience by motivating AGYW to think of PrEP as an exercise in personal agency. CONCLUSIONS Our PrEP stigma conceptual framework highlights potential intervention targets at multiple levels in the stigmatization process. Its adoption would enable researchers to develop standardized measures and compare stigma across timepoints and populations as well as design and evaluate interventions.
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Affiliation(s)
- Miriam Hartmann
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
- Department of Global Public HealthKarolinska InstitutetStockholmSweden
| | - Laura Nyblade
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
| | | | - Tozoe Marton
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
| | - Kawango Agot
- Impact Research Development OrganizationKisumuKenya
| | - Sarah T. Roberts
- Women's Global Health ImperativeRTI InternationalBerkeleyCaliforniaUSA
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Truong HHM, Heylen E, Kadede K, Amboka S, Otieno B, Odhiambo H, Odeny D, Hewa M, Opiyo M, Opondo F, Ogolla D, Guzé MA, Miller LE, Bukusi EA, Cohen CR. Brief Report: HIV Pre-Exposure Prophylaxis Awareness and Use Among Adolescents in Kenya. J Acquir Immune Defic Syndr 2024; 95:133-137. [PMID: 37988676 PMCID: PMC10872474 DOI: 10.1097/qai.0000000000003338] [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: 05/18/2023] [Accepted: 07/24/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND HIV pre-exposure prophylaxis (PrEP) is an effective prevention tool; however, use among adolescents is thought to be low. To determine the unmet need and opportunity to expand use, we assessed awareness, prior use, and willingness to take PrEP among Kenyan adolescents. METHODS The Maneno Yetu study recruited a community-based sample of adolescents aged 15-19 years (N = 3061) in Kisumu for a survey using respondent-driven sampling. RESULTS Overall, 50% of adolescents had heard of PrEP and 2% had used PrEP. Girls were more likely than boys to have heard of PrEP (53.4% vs. 45.1%; P < 0.001) and used PrEP (3.6% vs. 0.3%; P < 0.001). Among participants, 14% engaged in transactional sex and 21% experienced forced sexual contact. PrEP use was higher among adolescents who engaged in transactional sex (4.8% vs. 0.6%; P < 0.001) and experienced forced sexual contact (2.7% vs. 0.7%; P < 0.001) compared with those who did not. Among adolescents with no prior use, 53% were willing to consider using PrEP, although girls were less willing than boys (49.7% vs. 55.9%; P = 0.001). CONCLUSIONS PrEP is an important prevention tool, especially for adolescents whose circumstances potentially expose them to HIV-positive or unknown status sexual partners, yet remains underused, particularly in resource-limited settings. Although many expressed willingness to use PrEP, low awareness and use highlight the need to expand HIV prevention education and services tailored for adolescents. Our finding that boys were more willing to use PrEP suggests campaigns should also be designed to reach male youth to narrow the gender gap and expand uptake in the adolescent population.
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Agblevor EA, Darko NA, Acquah PA, Addom S, Mirzoev T, Agyepong IA. "We have nice policies but…": implementation gaps in the Ghana adolescent health service policy and strategy (2016-2020). Front Public Health 2023; 11:1198150. [PMID: 38148876 PMCID: PMC10749951 DOI: 10.3389/fpubh.2023.1198150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 11/20/2023] [Indexed: 12/28/2023] Open
Abstract
Introduction Although policies for adolescent health exist in Ghana, their implementation is challenging. Availability of services for adolescent sexual and reproductive health and adolescent mental health remains less than desired, with adolescent mental health being particularly neglected despite being an important contributor to poor health outcomes. This study presents an analysis of gaps in the implementation of the Ghana Adolescent Health Service Policy and Strategy (2016-2020), including how and why the context influenced the observed implementation gaps. Methods Data for this study is drawn from 17 in-depth interviews with purposefully identified key stakeholders in adolescent mental, sexual, and reproductive health across the national and subnational levels; four focus group discussions (FGDs) with district health management teams; and 11 FGDs with adolescents in and out of schools in four selected districts in the Greater Accra region. Data were analyzed using both inductive and deductive approaches. The deductive analysis drew on Leichter's conceptualization of context as structural, cultural, situational, and environmental factors. Results Of the 23 planned strategies and programs for implementing the policy, 13 (57%) were partially implemented, 6 (26%) were not implemented at all, and only 4 (17%) were fully implemented. Multiple contextual factors constrained the policy implementation and contributed to the majority of strategies not being implemented or partially implemented. These factors included a lack of financial resources for implementation at all levels of the health system and the related high dependence on external funding for policy implementation. Service delivery for adolescent mental health, and adolescent sexual and reproductive health, appeared to be disconnected from the delivery of other health services, which resulted in weak or low cohesion with other interventions within the health system. Discussion Bottom-up approaches that engage closely with adolescent perspectives and consider structural and cultural contexts are essential for effective policy implementation. It is also important to apply systemic and multi-sectoral approaches that avoid fragmentation and synergistically integrate policy interventions.
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Affiliation(s)
- Emelia Afi Agblevor
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
| | | | - Priscilla Ama Acquah
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Selasie Addom
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
| | - Tolib Mirzoev
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Irene Akua Agyepong
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana
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Maurya C, Muhammad T, Thakkar S. Examining the relationship between risky sexual behavior and suicidal thoughts among unmarried adolescents in India. Sci Rep 2023; 13:7733. [PMID: 37173519 PMCID: PMC10182050 DOI: 10.1038/s41598-023-34975-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 05/10/2023] [Indexed: 05/15/2023] Open
Abstract
Addressing the problem of suicidal thoughts in adolescents requires understanding the associated risk factors. Multiple studies have shown that risky sexual behavior affected the adolescents' psychological health that leads to their suicidal thoughts, behaviors and attempts. This study aimed to identify the association between various risky sexual behaviours and suicidal thoughts among unmarried adolescents in India. We used data collected from 4221 unmarried adolescent boys and 5987 unmarried adolescent girls aged 10-19 years, from the two rounds of the Understanding the Lives of Adolescents and Young Adults (UDAYA) survey. Descriptive analysis was done to observe changes in the selected variables from wave-1 to wave-2. Random effect regression analysis was used to estimate the association of suicidal thoughts among unmarried adolescents with their risky sexual behaviours. The percentage of adolescent boys having suicidal thoughts increased from 1.35% in wave 1 to 2.19% in wave 2. Among adolescent girls, the percentage increased from 2.92% in wave 1 to 5.05% in wave 2. A proportion of 3.26% adolescent boys had more than one sexual partner during wave 1 whereas in wave 2, it rose to 8.71%, while in case of adolescent girls, the estimates only increased from 0.26% at wave 1 to 0.78% at wave 2. Nearly 4.55% boys and 1.37% girls had early sexual debut. Almost five percentage boys were sexually active at wave 1 whereas in wave 2, it rose to 13.56%, while among adolescent girls, the estimates decreased from 1.54% at wave 1 to 1.51% at wave 2. Contraceptive use increased over time among both adolescent boy and girls. Also, a large proportion of adolescent boys reported watching pornography (27.08% at waive 1 and 49.39% at wave 2) compared to adolescent girls (4.46% at wave 1 and 13.10% at wave 2). Adolescents who had more than one sexual partner [Coef: 0.04; p < 0.001], exposed to early sexual debut [Coef; 0.019; p < 0.01], sexually active [Coef: 0.058; p < 0.001] and reported watching pornography [Coef: 0.017; p < 0.001] were more likely to have suicidal thoughts. Adolescent boys and girls with risky sexual behaviors are likely to be at a higher risk of suicidal ideation, and thus, they should be treated with special care and attention by local healthcare practitioners.
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Affiliation(s)
- Chanda Maurya
- Department of Survey Research and Data Analytics, International Institute for Population Sciences, Mumbai, India
| | - T Muhammad
- Department of Family and Generations, International Institute for Population Sciences, Mumbai, India.
| | - Shriya Thakkar
- Department of Sociology, Louisiana State University, 26, Stubbs Hall, Baton Rouge, LA, 70803, USA
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Stoner MCD, Kelly NK, Gomez-Olive FX, Kahn K, Wagner D, Bhushan NL, Aiello AE, Pettifor AE. Relationships Between Stress-Responsive Biomarkers, ART Adherence, and Viral Suppression Among Adolescent Girls and Young Women Living With HIV in South Africa: An HPTN 068 Analysis. J Acquir Immune Defic Syndr 2023; 92:349-358. [PMID: 36729676 PMCID: PMC10006401 DOI: 10.1097/qai.0000000000003149] [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] [Indexed: 02/03/2023]
Abstract
BACKGROUND Adolescent girls and young women (AGYW) living with HIV who have higher stress levels may be at risk of stress-related biological alterations, which could influence HIV progression and adherence to antiretroviral therapy (ART). SETTING We aimed to estimate associations among stress-responsive biomarkers, ART adherence, and viral suppression in AGYW living with HIV in South Africa. We also hypothesized that psychosocial stressors [eg, depression, food insecurity, low socioeconomic status (SES), and HSV-2] would be associated with higher biomarker levels. METHODS We used 2018/2019 data from the HIV Prevention Trials Network 068 cohort to assess associations between stress-responsive biomarkers and viral suppression (<1000 copies/mL) and ART adherence measured using dried blood spot cards. Stress-responsive biomarkers included C-reactive protein, herpes simplex virus type 1, and cytomegalovirus infection and reactivation. Associations were estimated using unadjusted log-binomial or ordinal logistic regression models. RESULTS In 166 AGYW living with HIV, there was no association between stress-responsive biomarkers and viral suppression or ART adherence. However, increased C-reactive protein levels were associated with higher HSV-2 infection [odds ratio (OR) 1.98; 95% confidence interval (CI) 1.11, 3.52], being a government grant recipient (OR 3.21; 95% CI: 1.30, 7.92), lower food insecurity (OR 0.34; 95% CI: 0.13, 0.90), and increased body mass index (OR 1.07; 95% CI: 1.01, 1.14). CONCLUSIONS High prevalence of psychosocial stressors and persistent herpesviruses in AGYW living with HIV has the potential to lead to poorer health outcomes. More research is needed to untangle relationships between economic stability, chronic disease, and chronic stress.
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Affiliation(s)
- Marie C D Stoner
- Women's Global Health Imperative, RTI International, Berkeley, CA
| | - Nicole K Kelly
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
| | - F Xavier Gomez-Olive
- 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
| | - 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
| | - Danielle Wagner
- Women's Global Health Imperative, RTI International, Berkeley, CA
| | - Nivedita L Bhushan
- Center for Communication Science, RTI International, Research Triangle Park, NC
| | - Allison E Aiello
- Department of Epidemiology, Robert N Butler Columbia Aging Center, Mailman School of Public Health, Columbia University, USA
| | - Audrey E Pettifor
- Department of Epidemiology, University of North Carolina, Chapel Hill, NC
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Konlan KD, Dangah MM. Students’ experiences of sexual harassment; a descriptive cross-sectional study in a college of education, Ghana. Heliyon 2023; 9:e14764. [PMID: 37064438 PMCID: PMC10102191 DOI: 10.1016/j.heliyon.2023.e14764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 03/09/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Introduction Sexual harassment is a component of gender-based discrimination that indicates unequal power relations and affects students' psychological and physical well-being and academic achievement. This study assessed students' experiences of sexual harassment at the Offinso College of Education. Methods This cross-sectional descriptive study incorporated a whole population sampling of second and third-year female students to respond to a pre-tested questionnaire uploaded on Google Forms. The data were vetted for appropriateness, cleaned in Microsoft Excel, and transferred to IBM Statistical Package for Social Sciences for analysis into descriptive statistics and chi-square tests of associations. Results The study indicated that women (66%) had previously had sex before admission into college and perceived that they were at risk of sexual harassment (43.0%). It was statistically significant that the student's level of education was associated with the experience of being sexually harassed (χ2 = 10.950, p-value <0.00) and the perception that sexual harassment was a problem among students (χ2 = 13.376, p-value <0.01). The nature of the female students' marital relationships was statistically significant (χ2 = 11.209, p-value<0.02) to the perception of sexual harassment as a problem in the college. Conclusion Female students must have adequate education on the sexual harassment policy of the institution and measures put in place to identify and provide appropriate sanctions to issues of sexual harassment at the college education level.
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Free C, Palmer MJ, Potter K, McCarthy OL, Jerome L, Berendes S, Gubijev A, Knight M, Jamal Z, Dhaliwal F, Carpenter JR, Morris TP, Edwards P, French R, Macgregor L, Turner KME, Baraitser P, Hickson FCI, Wellings K, Roberts I, Bailey JV, Hart G, Michie S, Clayton T, Devries K. Behavioural intervention to reduce sexually transmitted infections in people aged 16–24 years in the UK: the safetxt RCT. PUBLIC HEALTH RESEARCH 2023. [DOI: 10.3310/dane8826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Background
The prevalence of genital chlamydia and gonorrhoea is higher in the 16–24 years age group than those in other age group. With users, we developed the theory-based safetxt intervention to reduce sexually transmitted infections.
Objectives
To establish the effect of the safetxt intervention on the incidence of chlamydia/gonorrhoea infection at 1 year.
Design
A parallel-group, individual-level, randomised superiority trial in which care providers and outcome assessors were blinded to allocation.
Setting
Recruitment was from 92 UK sexual health clinics.
Participants
Inclusion criteria were a positive chlamydia or gonorrhoea test result, diagnosis of non-specific urethritis or treatment started for chlamydia/gonorrhoea/non-specific urethritis in the last 2 weeks; owning a personal mobile phone; and being aged 16–24 years.
Allocation
Remote computer-based randomisation with an automated link to the messaging system delivering intervention or control group messages.
Intervention
The safetxt intervention was designed to reduce sexually transmitted infection by increasing partner notification, condom use and sexually transmitted infection testing before sex with new partners. It employed educational, enabling and incentivising content delivered by 42–79 text messages over 1 year, tailored according to type of infection, gender and sexuality.
Comparator
A monthly message regarding trial participation.
Main outcomes
The primary outcome was the incidence of chlamydia and gonorrhoea infection at 12 months, assessed using nucleic acid amplification tests. Secondary outcomes at 1 and 12 months included self-reported partner notification, condom use and sexually transmitted infection testing prior to sex with new partner(s).
Results
Between 1 April 2016 and 23 November 2018, we assessed 20,476 people for eligibility and consented and randomised 6248 participants, allocating 3123 to the safetxt intervention and 3125 to the control. Primary outcome data were available for 4675 (74.8%) participants. The incidence of chlamydia/gonorrhoea infection was 22.2% (693/3123) in the intervention group and 20.3% (633/3125) in the control group (odds ratio 1.13, 95% confidence interval 0.98 to 1.31). There was no evidence of heterogeneity in any of the prespecified subgroups. Partner notification was 85.6% in the intervention group and 84.0% in the control group (odds ratio 1.14, 95% confidence interval 0.99 to 1.33). At 12 months, condom use at last sex was 33.8% in the intervention group and 31.2% in the control group (odds ratio 1.14, 95% confidence interval 1.01 to 1.28) and condom use at first sex with most recent new partner was 54.4% in the intervention group and 48.7% in the control group (odds ratio 1.27, 95% confidence interval 1.11 to 1.45). Testing before sex with a new partner was 39.5% in the intervention group and 40.9% in the control group (odds ratio 0.95, 95% confidence interval 0.82 to 1.10). Having two or more partners since joining the trial was 56.9% in the intervention group and 54.8% in the control group (odds ratio 1.11, 95% confidence interval 1.00 to 1.24) and having sex with someone new since joining the trial was 69.7% in the intervention group and 67.4% in the control group (odds ratio 1.13, 95% confidence interval 1.00 to 1.28). There were no differences in safety outcomes. Additional sensitivity and per-protocol analyses showed similar results.
Limitations
Our understanding of the mechanism of action for the unanticipated effects is limited.
Conclusions
The safetxt intervention did not reduce chlamydia and gonorrhoea infections, with slightly more infections in the intervention group. The intervention increased condom use but also increased the number of partners and new partners. Randomised controlled trials are essential for evaluating health communication interventions, which can have unanticipated effects.
Future work
Randomised controlled trials evaluating novel interventions in this complex area are needed.
Trial registration
This trial is registered as ISRCTN64390461.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 11, No. 1. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Caroline Free
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Melissa J Palmer
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Kimberley Potter
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Ona L McCarthy
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Lauren Jerome
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Sima Berendes
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Anasztazia Gubijev
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Megan Knight
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Zahra Jamal
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Farandeep Dhaliwal
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - James R Carpenter
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Tim P Morris
- Medical Research Council Clinical Trials Unit, London, UK
| | - Phil Edwards
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Rebecca French
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Louis Macgregor
- Bristol Veterinary School, University of Bristol, Bristol, UK
| | - Katy ME Turner
- Bristol Veterinary School, University of Bristol, Bristol, UK
| | | | - Ford CI Hickson
- Sigma Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Kaye Wellings
- Department of Social and Environmental Health Research, London School of Hygiene & Tropical Medicine, London, UK
| | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Julia V Bailey
- eHealth Unit, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Graham Hart
- Department of Infection and Population Health, University College London, London, UK
| | - Susan Michie
- Centre for Outcomes Research and Effectiveness, University College London, London, UK
| | - Tim Clayton
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Karen Devries
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
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Azie RAE, Bagrmwin L, Setordzi M, Ndanu TA, Aniteye P. Parents’ attitude towards sexual and reproductive health communication: The case of Wa West district of the Upper West Region, Ghana. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2023. [DOI: 10.1016/j.ijans.2023.100551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023] Open
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11
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Free C, Palmer MJ, McCarthy OL, Jerome L, Berendes S, Knight M, Carpenter JR, Morris TP, Jamal Z, Dhaliwal F, French RS, Hickson FCI, Gubijev A, Wellings K, Baraitser P, Roberts I, Bailey JV, Clayton T, Devries K, Edwards P, Hart G, Michie S, Macgregor L, Turner KME, Potter K. Effectiveness of a behavioural intervention delivered by text messages (safetxt) on sexually transmitted reinfections in people aged 16-24 years: randomised controlled trial. BMJ 2022; 378:e070351. [PMID: 36170988 PMCID: PMC9516322 DOI: 10.1136/bmj-2022-070351] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To quantify the effects of a series of text messages (safetxt) delivered in the community on incidence of chlamydia and gonorrhoea reinfection at one year in people aged 16-24 years. DESIGN Parallel group randomised controlled trial. SETTING 92 sexual health clinics in the United Kingdom. PARTICIPANTS People aged 16-24 years with a diagnosis of, or treatment for, chlamydia, gonorrhoea, or non-specific urethritis in the past two weeks who owned a mobile phone. INTERVENTIONS 3123 participants assigned to the safetxt intervention received a series of text messages to improve sex behaviours: four texts daily for days 1-3, one or two daily for days 4-28, two or three weekly for month 2, and 2-5 monthly for months 3-12. 3125 control participants received a monthly text message for one year asking for any change to postal or email address. It was hypothesised that safetxt would reduce the risk of chlamydia and gonorrhoea reinfection at one year by improving three key safer sex behaviours: partner notification at one month, condom use, and sexually transmitted infection testing before unprotected sex with a new partner. Care providers and outcome assessors were blind to allocation. MAIN OUTCOME MEASURES The primary outcome was the cumulative incidence of chlamydia or gonorrhoea reinfection at one year, assessed by nucleic acid amplification tests. Safety outcomes were self-reported road traffic incidents and partner violence. All analyses were by intention to treat. RESULTS 6248 of 20 476 people assessed for eligibility between 1 April 2016 and 23 November 2018 were randomised. Primary outcome data were available for 4675/6248 (74.8%). At one year, the cumulative incidence of chlamydia or gonorrhoea reinfection was 22.2% (693/3123) in the safetxt arm versus 20.3% (633/3125) in the control arm (odds ratio 1.13, 95% confidence interval 0.98 to 1.31). The number needed to harm was 64 (95% confidence interval number needed to benefit 334 to ∞ to number needed to harm 24) The risk of road traffic incidents and partner violence was similar between the groups. CONCLUSIONS The safetxt intervention did not reduce chlamydia and gonorrhoea reinfections at one year in people aged 16-24 years. More reinfections occurred in the safetxt group. The results highlight the need for rigorous evaluation of health communication interventions. TRIAL REGISTRATION ISRCTN registry ISRCTN64390461.
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Affiliation(s)
- Caroline Free
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa J Palmer
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Ona L McCarthy
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Lauren Jerome
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Sima Berendes
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Megan Knight
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - James R Carpenter
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Zahra Jamal
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Farandeep Dhaliwal
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Rebecca S French
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Anasztazia Gubijev
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Kaye Wellings
- Department of Public Health, Environments and Society, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Ian Roberts
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Julia V Bailey
- eHealth Unit, Research Department of Primary care and Population Health, University College London, London, UK
| | - Tim Clayton
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Karen Devries
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Phil Edwards
- Clinical Trials Unit, Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Graham Hart
- Department of Infection and Population Health, University College London, London, UK
| | - Susan Michie
- Centre for Outcomes Research and Effectiveness, University College London, London, UK
| | - Louis Macgregor
- Bristol Veterinary School, University of Bristol, Bristol, UK
| | - Katy M E Turner
- Bristol Veterinary School, University of Bristol, Bristol, UK
| | - Kimberley Potter
- Clinical Trials Unit, Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
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Mprah WK, Opoku MP, Duorinaah J, Nketsia W. Level of satisfaction and sexual and reproductive health needs of deaf persons in Ghana: a sequential explanatory mixed method study. BMC Health Serv Res 2022; 22:1152. [PMID: 36096825 PMCID: PMC9469610 DOI: 10.1186/s12913-022-08515-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 08/31/2022] [Indexed: 11/21/2022] Open
Abstract
Background The intersection between deafness and culture in sub-Saharan African contexts such as Ghana has culminated in restricted access to sexual and reproductive health (SRH) services. While some attention has been given to the barriers faced by deaf persons in accessing SRH services, discussion of their needs and satisfaction with SRH services is at an embryonic stage. This lends support to the use of sequential mixed-method study design to assess the level of satisfaction and SRH needs of deaf persons. Methods This study was guided by explanatory sequential mixed-method study design. Thus, a two-phase data collection approach was adopted. In Phase I, a 32-item questionnaire with 16 items each for satisfaction regarding SRH services and SRH needs, was used for data collection from 288 deaf persons recruited from 3 of the 16 regions in Ghana. The data were subjected to the following computations: means, t-tests, analysis of variance, correlations, and multiple regression. In Phase II, a semi-structured interview guide was used to collect data from 60 participants who were drawn from the earlier pool. The interviews were subjected to thematic analysis. Results The results showed of correlation and multiple analyses showed a small relationship and significant contribution of needs in the variance of satisfaction. Also, there was a convergence between both the qualitative and quantitative data as participants confirmed the lack of consideration given to the needs of deaf persons regarding SRH service provisions. Conclusion Deaf persons who took part in this study were unsatisfied with SRH services due to barriers such as sign language interpreters and inaccessible information. Consequently, they expressed the need for preferred mode of communication and expedition of awareness creation on SRH. The study findings warrant the need for policymakers to inculcate the needs of deaf person in SRH services to improve access and thus, enhance satisfaction. For instance, recommendations such as the training of health professionals in the use of sign language could be considered in future SRH policy and other implications, are discussed.
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Negri M, de Souza E, Torloni MR, Ribeiro MC, Araujo E, Guazzelli CAF. Sexual function in Brazilian female adolescents and young adults: a cross-sectional study. Rev Assoc Med Bras (1992) 2022; 68:1210-1215. [PMID: 36228252 PMCID: PMC9575009 DOI: 10.1590/1806-9282.20220232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/23/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The aim of this study was to investigate and compare the sexual function of Brazilian adolescents and young women who were using popular contraceptive methods. METHODS This cross-sectional study took place in 2012-2014 in a free family planning clinic of a tertiary teaching hospital in Brazil. Participants were female adolescents (10-19 years) and young adults (20-24 years) who were using barrier (condom) or hormonal contraceptive methods. The Female Sexual Function Index questionnaire was used to assess the sexual function in the last 4 weeks. RESULTS A total of 199 women (128 adolescents and 71 young adults) were included. There were no significant differences in the mean total Female Sexual Function Index scores of adolescents and young adults (26.6±5.7 versus 27.6±6.2, respectively, p=0.264). Compared to young adults, adolescents had significantly lower mean scores for orgasm (3.9±1.5 versus 4.4±1.4, p=0.020) and dyspareunia (4.4±1.6 versus 5.2±1.5, p=0.001; lower scores indicate more dyspareunia). There were no significant differences in the proportion of adolescents versus adults classified as being at risk for sexual dysfunction (38.3 versus 42.3%, p=0.651) or at risk of low desire (18.0 versus 21.1%, p=0.579). CONCLUSION Nearly 40% of Brazilian female adolescents and young adults are at risk for sexual dysfunctional symptoms and 19% have low desire, without significant differences between the two age groups.
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Affiliation(s)
- Mariana Negri
- Universidade Federal de São Paulo, Paulista School of Medicine, Department of Obstetrics – São Paulo (SP), Brazil
| | - Eduardo de Souza
- Universidade Federal de São Paulo, Paulista School of Medicine, Department of Obstetrics – São Paulo (SP), Brazil
| | - Maria Regina Torloni
- Universidade Federal de São Paulo, Paulista School of Medicine, Department of Internal Medicine – São Paulo (SP), Brazil
| | - Meireluci Costa Ribeiro
- Centro Universitário Salesiano de São Paulo, Postgraduate Program in Sex Therapy – São Paulo (SP), Brazil
| | - Edward Araujo
- Universidade Federal de São Paulo, Paulista School of Medicine, Department of Obstetrics – São Paulo (SP), Brazil
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Polat F, Şenol DK. Examining the correlation between sexual and reproductive health stigmatization level and gender perception: a case of a university in Turkey - a descriptive cross-sectional study. SAO PAULO MED J 2022; 141:146-153. [PMID: 36102465 PMCID: PMC10005470 DOI: 10.1590/1516-3180.2022.0278.03062022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 06/03/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Stigmatization, which emerges depending on the sexual behavior of young individuals, leads to negative health and social outcomes, such as shame, social marginalization, violence, and mental health morbidity. OBJECTIVE This study aimed to examine the correlation between the level of sexual and reproductive health stigma and gender perception in female university students. DESIGN AND SETTING This descriptive cross-sectional study was conducted at the Faculty of Health Sciences of a university in Turkey. METHODS The data of this study were collected from digital media between July and October 2020 from a study population of 385 students. The data were collected using the Personal Information Form, including the socio-demographic characteristics of students, the Sexual and Reproductive Health Stigmatization Scale in Young Women and the Perception of Gender Scale. Descriptive statistics, independent samples t-test, analysis of variance, and Pearson's correlation test were used to assess the data. RESULTS It was determined that there was a negative correlation between the Sexual and Reproductive Health Stigmatization Scale in Young Women and the Perception of Gender Scale (r = -0.173, P = 0.001). CONCLUSION It was determined that as the gender perception in the young women who participated in the study increased, the sexual and reproductive health stigmatization level decreased. The sexual and reproductive health stigmatization levels of the participants were at an above average level, and gender perception was at a medium level.
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Affiliation(s)
- Filiz Polat
- PhD. Assistant Professor, Department of Midwifery, Faculty of Health
Sciences, Osmaniye Korkut Ata University, Osmaniye, Turkey
| | - Derya Kaya Şenol
- PhD. Assistant Professor, Department of Midwifery, Faculty of
Health Sciences, Osmaniye Korkut Ata University, Osmaniye, Turkey
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Harrington EK, Casmir E, Kithao P, Kinuthia J, John-Stewart G, Drake AL, Unger JA, Ngure K. "Spoiled" girls: Understanding social influences on adolescent contraceptive decision-making in Kenya. PLoS One 2021; 16:e0255954. [PMID: 34383836 PMCID: PMC8360567 DOI: 10.1371/journal.pone.0255954] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 07/27/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Despite significant public health emphasis on unintended pregnancy prevention among adolescent girls and young women in Sub-Saharan Africa, there is a gap in understanding how adolescents' own reproductive priorities and the social influences on their decision-making align and compete. We examined the social context of contraceptive decision-making among Kenyan female adolescents. METHODS Using community-based sampling, we conducted 40 in-depth interviews and 6 focus group discussions among sexually-active or partnered adolescent girls and young women aged 15-19 in the Nyanza region of Kenya. We analyzed the data in Dedoose using an inductive, grounded theory approach, and developed a conceptual model from the data illustrating social influences on adolescent contraceptive decision-making. RESULTS Participants viewed adolescent pregnancy as unacceptable, and described severe social, financial, and health consequences of unintended pregnancy, including abortion under unsafe conditions. Yet, their contraceptive behaviors often did not reflect their desire to delay pregnancy. Contraceptive decision-making was influenced by multiple social factors, centering on the intersecting stigmas of adolescent female sexuality, pregnancy, and contraceptive use, as well as unequal power in sexual relationships. To prioritize pregnancy prevention, adolescents must navigate conflicting social norms and power dynamics, and put their perceived future fertility at risk. CONCLUSIONS Contraceptive decision-making among Kenyan female adolescents is strongly influenced by opposing social norms within families, communities, and sexual relationships, which compel them to risk stigma whether they use a contraceptive method or become pregnant as adolescents. These findings put into perspective adolescents' seemingly incongruent pregnancy preferences and contraceptive behaviors. Interventions to address adolescent unintended pregnancy should focus on supporting adolescent decision-making agency, addressing fertility-related contraceptive concerns, and promoting innovative contraceptive access points rather than increasing contraceptive prevalence.
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Affiliation(s)
- Elizabeth K. Harrington
- Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington, United States of America
| | - Edinah Casmir
- Kenya Medical Research Institute, Center for Clinical Research, Thika, Kenya
| | - Peninah Kithao
- Department of Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
| | - John Kinuthia
- Department of Research & Programs, Kenyatta National Hospital, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Medicine, University of Washington, Seattle, Washington, United States of America
- Department of Epidemiology, University of Washington, Seattle, Washington, United States of America
- Department of Pediatrics, University of Washington, Seattle, Washington, United States of America
| | - Alison L. Drake
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Jennifer A. Unger
- Department of Obstetrics & Gynecology, University of Washington, Seattle, Washington, United States of America
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Kenneth Ngure
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
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Why women do not use contraceptives: Exploring the role of male out-migration. PLoS One 2021; 16:e0249177. [PMID: 33784370 PMCID: PMC8009410 DOI: 10.1371/journal.pone.0249177] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 03/12/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction Contextual understanding of reasons for non-use of contraceptives is key to devising family planning (FP) strategies. This study aimed to understand the reasons for non-use of contraceptives among women in the context of male out-migration. Methods Focus Group Discussions (FGDs) were conducted in two high male out-migration districts in Bihar, namely Nawada and Gopalganj. Twenty-five FGDs were conducted with currently married women with migrant husbands, currently married men and Accredited Social Health Activists (ASHAs) during April-June 2019. Data were analysed by using a thematic approach through Atlas.ti-6.2. Results The reasons for contraceptive non-use in areas with high male out-migration were complex, as this included barriers to contraceptive use unique to high-migration areas and reasons commonly found in other rural settings. Non-use of contraceptives among women with migrant husbands was mostly driven by lack of contraceptive preparedness before husband’s arrival, inability to procure contraceptives due to inaccessibility to health facilities and stigma to procure when husband was away. Other migration environment related factors included low ASHA outreach, myths and side effects of contraceptives, community fertility norms and poor spousal communications around FP. Conclusion The reasons for non-use of contraceptives are multifaceted, complex and interlinked. Exploration of these reasons in migration context suggest that FP programs in migration affected areas need to address a range of barriers to contraceptive use at multiple levels.
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Loll D, Fleming PJ, Stephenson R, King EJ, Morhe E, Manu A, Hall KS. Factors associated with reproductive autonomy in Ghana. CULTURE, HEALTH & SEXUALITY 2021; 23:349-366. [PMID: 32301400 DOI: 10.1080/13691058.2019.1710567] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 12/27/2019] [Indexed: 06/11/2023]
Abstract
Reproductive autonomy is essential for women to achieve reproductive rights and freedom. However, the factors associated with reproductive autonomy in various contexts have not been explored. The aim of this analysis was to understand the socio-demographic, reproductive history and social context variables associated with two validated reproductive autonomy sub-scales among 516 young Ghanaian women age 15 to 24. We used multiple linear regression modelling to test associations between covariates of interest and the communication sub-scale and decision-making sub-scale. Covariates included age, educational attainment, ethnic group, employment, religion, religious attendance, relationship type, previous pregnancy, previous abortion, social support for adolescent sexual and reproductive health, and social stigma towards adolescent sexual and reproductive health. Results from final models demonstrated that factors associated with the communication scale included education (p = 0.008), ethnic group (p = 0.039), and social support for adolescent sexual and reproductive health (B = 0.12, p = 0.003). Factors associated with the decision-making scale included ethnic group (p = 0.002), religion (p = 0.003), religious attendance (p = 0.043), and previous pregnancy (p = 0.008). Communication reproductive autonomy and decision-making reproductive autonomy were associated with different factors, providing insight into potential intervention approaches and points. Social support for adolescent sexual and reproductive health was associated with increases in young women's abilities to communicate with their partners about sexual and reproductive health issues including sex, contraceptive use and fertility.
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Affiliation(s)
- Dana Loll
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Paul J Fleming
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Rob Stephenson
- Department of Systems, Population, and Leadership, School of Nursing, Center for Sexuality and Health Disparities, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth J King
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Emmanuel Morhe
- Komfo Anokye Teaching Hospital, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | - Adom Manu
- Department of Population, Family, and Reproductive Health, School of Public Health, University of Ghana, Accra, Ghana
| | - Kelli Stidham Hall
- Department of Behavioral Sciences and Health Education, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Roberts ST, Edwards P, Mulenga D, Chelwa N, Nyblade L, Brander C, Musheke M, Mbizvo M, Subramanian S. Family Support for Adolescent Girls and Young Women Living With HIV in Zambia: Benefits, Challenges, and Recommendations for Intervention Development. J Assoc Nurses AIDS Care 2021; 32:160-173. [PMID: 33332869 PMCID: PMC7914154 DOI: 10.1097/jnc.0000000000000225] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Lack of family involvement is barrier to antiretroviral therapy adherence among adolescent girls and young women (AGYW). This study assessed family support for AGYW's engagement along the HIV care continuum to inform the design of a family-focused intervention in Lusaka, Zambia. We conducted 16 in-depth interviews and four focus group discussions with 40 AGYW living with HIV. Three strategies were identified to strengthen family support. First, emotional and instrumental support are highly valued by AGYW and should be further developed or reinforced. Second, AGYW wanted more informational support and open discussion of HIV from family, and an intervention should aim to enhance these types of support. Third, existing appraisal support reinforced anticipated stigma among AGYW and discouraged disclosure, yet participants wished for more interactions with peers living with HIV. Appraisal support should therefore be reframed to help AGYW decide to whom they should disclose and how to do so safely.
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Affiliation(s)
- Sarah T Roberts
- Sarah T. Roberts, PhD, MPH, is a Research Epidemiologist, Women's Global Health Imperative, RTI International, Berkeley, California, USA. Patrick Edwards, MSc, is an Economist, Health Care Financing and Payment Program, RTI International, Research Triangle Park, North Carolina, USA. Drosin Mulenga, BSW, is a Program Officer, Population Council, Lusaka, Zambia. Nachela Chelwa, MPH, is a Monitoring, Evaluation and Implementation Research Manager, Population Council, Lusaka, Zambia. Laura Nyblade, PhD, is an RTI Fellow and Senior Technical Advisor on Stigma and Discrimination, Global Health Division, RTI International, Washington, District of Columbia, USA. Caila Brander, MSc, is a Health Researcher and Global Health Corp Fellow, Population Council, Lusaka, Zambia. Maurice Musheke, PhD, is a Social and Operations Research Manager, Population Council, Lusaka, Zambia. Michael Mbizvo, PhD, is a Senior Associate & Zambia Country Director, Population Council, Lusaka, Zambia. Sujha Subramanian, PhD, is a Senior Fellow, Public Health Research Division, RTI International, Waltham, Massachusetts, USA
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Tripathi N. Does family life education influence attitudes towards sexual and reproductive health matters among unmarried young women in India? PLoS One 2021; 16:e0245883. [PMID: 33493186 PMCID: PMC7833152 DOI: 10.1371/journal.pone.0245883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/11/2021] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Inadequate efforts towards meeting the sexual and reproductive health needs of adolescents and young people, who disproportionately share the burden of unwanted pregnancies, poor maternal and child health outcomes, risks of RTI/STI and HIV/AIDS, increase the risk of losing much of the progress made towards the Millennium Development Goals over the last decade, particularly in the context of low-and-middle-income countries like India. DATA AND METHODS Using the nationally representative data on 160551 unmarried young women aged 15-24 years from the District Level Reproductive and Child Health Survey (DLHS: 2007-2008) in India, this research evaluated the demographic and socioeconomic differentials in the access to family life/sex education (FLE) among youth in India. Using the adjusted multiple logistic regression models, the association between access to family life/sex education and attitudes towards a range of sexual and reproductive health matters among young unmarried Indian women were investigated. RESULTS Less than half of the unmarried young women had received some form of FLE (48 percent) in India. However, there were substantial demographic and socioeconomic variations in their access to FLE, as relatively less educated women from the poorest wealth quintiles, religious and social minorities (Muslims, Scheduled Castes/Scheduled Tribes) were significantly less likely to receive FLE as compared to other women. Importantly, the likelihood of holding favourable/positive attitudes towards reproductive processes, knowledge and discussion of contraceptive methods, precise awareness about the transmission pathways of RTIs/STIs and HIV/AIDS was significantly higher among those women in India who had access to FLE. CONCLUSION The present research underscores the protective role of family life education towards improving the sexual and reproductive life experiences of young people. It further underscores the vital need to implement a comprehensive and culturally appropriate programme of family life education in order to meet the sexual and reproductive health demands of the adolescents and young people in India.
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Affiliation(s)
- Niharika Tripathi
- ICMR-National Institute of Medical Statistics (NIMS), Ansari Nagar, New Delhi
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Stangl AL, Sebany M, Kapungu C, Jessee C, Ricker CL, Chard E. Is HIV index testing and partner notification safe for adolescent girls and young women in low- and middle-income countries? J Int AIDS Soc 2020; 23 Suppl 5:e25562. [PMID: 32869478 PMCID: PMC7459168 DOI: 10.1002/jia2.25562] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/22/2020] [Accepted: 06/05/2020] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION While HIV index testing and partner notification (PN) services have the potential to reach adolescent girls and young women (AGYW) aged 15 to 24 and their sexual partners in need of HIV testing services, the potential social harms have not yet been studied. This commentary highlights the risks of this approach, including intimate partner violence (IPV), stigma and discrimination, and outlines an urgent research agenda to fully understand the potential harms of PN for AGYW, calling for the development of mitigation strategies. DISCUSSION A substantial evidence base exists demonstrating the feasibility, acceptability and effectiveness of index testing and partner notification for adults aged 18 years and older in low- and middle-income countries (LMICs), particularly for men, and for adults who are married/cohabiting and referring a current sexual partner. AGYW who are most vulnerable to HIV infection in LMICs do not reflect these demographics. Instead, they are often in age-disparate partnerships, have limited negotiating power within relationships, experience high rates of violence and face economic challenges that necessitate transactional sex. PN services may be particularly difficult for adolescent girls under 18 who face restrictions on their decision making and are at increased risk of rape. Adolescent girls may also face coercion to notify partners due to unequal power dynamics in the provider-adolescent client relationship, as well as judgemental attitudes towards adolescent sexual activity among providers. CONCLUSIONS As index testing and PN with AGYW is already being rolled out in some LMICs, research is urgently needed to assess its feasibility and acceptability. Implementation science studies should assess the availability, accessibility, acceptability and quality of HIV PN services for AGYW. Qualitative studies and routine monitoring with age-disaggregated data are critical to capture potential social harms, PN preferences and support needs for AGYW aged 15 to 17, 18 to 20 and 21 to 24. To mitigate potential harms, PN methods should prioritize confidentiality and avoidance of adverse outcomes. Healthcare providers should be trained to conduct routine enquiry for IPV and provide first-line support. Support services for AGYW living with HIV and survivors of violence should be implemented alongside HIV PN.
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Affiliation(s)
- Anne L Stangl
- International Center for Research on WomenWashingtonDCUSA
- Hera SolutionsBaltimoreMDUSA
| | - Meroji Sebany
- International Center for Research on WomenWashingtonDCUSA
| | | | - Cassandra Jessee
- International Center for Research on WomenWashingtonDCUSA
- Making Cents InternationalWashingtonDCUSA
| | - Chelsea L Ricker
- International Center for Research on WomenWashingtonDCUSA
- Independent ConsultantWashingtonDCUSA
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Rehnström Loi U, Otieno B, Oguttu M, Gemzell-Danielsson K, Klingberg-Allvin M, Faxelid E, Makenzius M. Abortion and contraceptive use stigma: a cross-sectional study of attitudes and beliefs in secondary school students in western Kenya. Sex Reprod Health Matters 2020; 27:1652028. [PMID: 31533554 PMCID: PMC7887988 DOI: 10.1080/26410397.2019.1652028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Social stigma related to women's reproductive decision-making negatively impacts the health of women. However, little is known about stigmatising attitudes and beliefs surrounding abortion and contraceptive use among adolescents. The aim of this study was to measure stigmatising attitudes and beliefs regarding abortion and contraceptive use among secondary school students in western Kenya. A self-reported classroom questionnaire-survey was administered in February 2017 to students at two suburban secondary schools in western Kenya. Two scales were used to measure the stigma surrounding abortion and contraceptive use - the Adolescent Stigmatizing Attitudes, Beliefs and Actions (ASABA) scale and the Contraceptive Use Stigma (CUS) scale. 1,369 students were eligible for the study; 1,207 (females = 618, males = 582) aged 13-21 years were included in the analysis. Descriptive statistics, Pearson's χ2 test, and the t-test were used to analyse the data. Binary logistic regression analysis was used to calculate odds ratios (OR) and 95% confidence intervals (CI). The students reported stigma associated with abortion (53.2%), and contraceptive use (54.4%). A larger proportion of male students reported abortion stigma (57.7%) and contraceptive use stigma (58.5%), compared to female students (49.0%, p = .003 and 50.6%, p = .007, respectively). Higher scores were displayed by younger rather than older age groups. No associations were identified between sexual debut and abortion stigma (p = .899) or contraceptive use stigma (p = .823). Abortion and contraceptive use are stigmatised by students in Kenya. The results can be used to combat abortion stigma and to increase contraceptive use among adolescents in Kenya.
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Affiliation(s)
- Ulrika Rehnström Loi
- PhD Student, Department of Women's and Children's Health, Karolinska Institutet , Stockholm , Sweden
| | - Beatrice Otieno
- Project Officer, Kisumu Medical Education Trust (KMET) , Kisumu , Kenya
| | - Monica Oguttu
- Executive Director, Kisumu Medical Education Trust (KMET), Kisumu, Kenya; College of Health Sciences, School of Nursing Sciences, University of Nairobi , Nairobi , Kenya
| | - Kristina Gemzell-Danielsson
- Professor, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; Karolinska University Hospital , Solna , Sweden
| | - Marie Klingberg-Allvin
- Professor, Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden; School of Education, Health and Social Studies, Dalarna University , Falun , Sweden
| | - Elisabeth Faxelid
- Professor, Department of Public Health Sciences, Global Health, Karolinska Institutet , Stockholm , Sweden
| | - Marlene Makenzius
- PhD, Department of Public Health Sciences, Global Health, Karolinska Institutet , Stockholm , Sweden
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Ameh S, D’Ambruoso L, Gómez-Olivé FX, Kahn K, Tollman SM, Klipstein-Grobusch K. Paradox of HIV stigma in an integrated chronic disease care in rural South Africa: Viewpoints of service users and providers. PLoS One 2020; 15:e0236270. [PMID: 32735616 PMCID: PMC7394420 DOI: 10.1371/journal.pone.0236270] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 07/02/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND An integrated chronic disease management (ICDM) model was introduced by the National Department of Health in South Africa to tackle the dual burden of HIV/AIDS and non-communicable diseases. One of the aims of the ICDM model is to reduce HIV-related stigma. This paper describes the viewpoints of service users and providers on HIV stigma in an ICDM model in rural South Africa. MATERIALS AND METHODS A content analysis of HIV stigmatisation in seven primary health care (PHC) facilities and their catchment communities was conducted in 2013 in the rural Agincourt sub-district, South Africa. Eight Focus Group Discussions were used to obtain data from 61 purposively selected participants who were 18 years and above. Seven In-Depth Interviews were conducted with the nurses-in-charge of the facilities. The transcripts were inductively analysed using MAXQDA 2018 qualitative software. RESULTS The emerging themes were HIV stigma, HIV testing and reproductive health-related concerns. Both service providers and users perceived implementation of the ICDM model may have led to reduced HIV stigma in the facilities. On the other hand, service users and providers thought HIV stigma increased in the communities because community members thought that home-based carers visited the homes of People living with HIV. Service users thought that routine HIV testing, intended for pregnant women, was linked with unwanted pregnancies among adolescents who wanted to use contraceptives but refused to take an HIV test as a precondition for receiving contraceptives. CONCLUSIONS Although the ICDM model was perceived to have contributed to reducing HIV stigma in the health facilities, it was linked with stigma in the communities. This has implications for practice in the community component of the ICDM model in the study setting and elsewhere in South Africa.
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Affiliation(s)
- Soter Ameh
- Department of Community Medicine, Faculty of Medicine, University of Calabar, Calabar, Cross River State, Nigeria
- Medical Research Council/Wits University 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 Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Lucia D’Ambruoso
- Institute of Applied Health Sciences and Centre for Sustainable International Development, University of Aberdeen, Aberdeen, United Kingdom
| | - Francesc Xavier Gómez-Olivé
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Accra, Ghana
| | - Kathleen Kahn
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Accra, Ghana
- Umea Centre for Global Health Research, Epidemiology and Global Health, Umea University, Umea, Sweden
| | - Stephen M. Tollman
- Medical Research Council/Wits University Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- The International Network for the Demographic Evaluation of Populations and Their Health in Developing Countries (INDEPTH) Accra, Accra, Ghana
- Umea Centre for Global Health Research, Epidemiology and Global Health, Umea University, Umea, Sweden
| | - Kerstin Klipstein-Grobusch
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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23
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Challenges, Coping Strategies, and Social Support among Breast Cancer Patients in Ghana. ADVANCES IN PUBLIC HEALTH 2020. [DOI: 10.1155/2020/4817932] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Background. Despite the high incidence and mortality rate of breast cancer (BC) in Ghana, little attention has been given to the issue of how adult women cope with having BC. The aim of this study was to explore the challenges, coping strategies, and support systems among women diagnosed with BC in Ghana. Methods. A descriptive cross-sectional study was conducted from February to August 2017 at the Komfo Anokye Teaching Hospital (KATH), Ghana. A systematic random sampling technique was used to select 202 women with a confirmed diagnosis of BC. Coping strategies of women with BC were assessed using the Brief-COPE. The associations between sociodemographic characteristics, social network/support, and coping strategies were assessed using linear regression models. Results. The most and least adopted active coping strategies were religious coping and humors, respectively. Self-distraction and substance use were the most and least adopted avoidant coping strategies, respectively. Spouses and children offered the most support to women with BC; having support from 5 or more sources was associated with higher mean active coping (beta [β] 1.14; 95% CI 0.66 to 1.62) and avoidant coping (β 1.46; 95% CI 0.98 to 1.94), as compared with having <2 sources of social support. Conclusion. This study demonstrates that women diagnosed with BC in Ghana adopt varied coping strategies to deal with these challenges. The forms of coping strategies adopted by women diagnosed with BC are influenced by the extent of social support received. Psychosocial counseling and support should be an integral part of BC management. Exploring and including social networks could play an important role in the management of BC in Ghana.
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Li Z, Patton G, Sabet F, Zhou Z, Subramanian SV, Lu C. Contraceptive Use in Adolescent Girls and Adult Women in Low- and Middle-Income Countries. JAMA Netw Open 2020; 3:e1921437. [PMID: 32074290 DOI: 10.1001/jamanetworkopen.2019.21437] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Preventing unwanted pregnancy through adequate use of contraceptives among adolescent girls is essential for improving maternal and child health and social well-being. OBJECTIVE To estimate the levels and trends of contraceptive use in adolescent girls (age 15-19 years) compared with adult women (age 20-34 years). DESIGN, SETTING, AND PARTICIPANTS This survey study used data from 261 Demographic and Health Surveys or Multiple Cluster Indicator Surveys conducted in 103 low- and middle-income countries between 2000 and 2017. Modern contraceptive use in 90 countries and unmet need for family planning in 73 countries for adolescent girls and adult women were assessed at country and aggregate levels. Data analyses for this study were conducted between March 2019 and December 2019. MAIN OUTCOMES AND MEASURES Modern contraceptive use and unmet need for family planning, estimated between adolescent girls and adult women for absolute inequality and relative inequality (defined as the ratio in service use between adult women and adolescent girls). Inequalities by wealth and place of residence in each age group were also assessed. RESULTS A total of 832 673 adolescent girls and 2 156 268 adult women were included in the analysis. Adolescent girls were significantly less likely to use modern contraceptives (31.6% [95% CI, 30.3% to 32.8%] vs 43.5% [95% CI, 42.4% to 44.7%]; absolute inequality, 11.9 percentage points [PPs] [95% CI, 11.7 to 12.1 PPs]; relative inequality, 1.38 PPs [95% CI, 1.36 to 1.40 PPs]) and more likely to have an unmet need for family planning (50.8% [95% CI, 49.0% to 52.5%] vs 36.4% [95% CI, 34.9% to 35.8%]; absolute inequality, -14.4 PPs [95% CI, -15.8 to -15.0 PPs]; relative inequality, 0.72 PPs [95% CI, 0.69 to 0.75 PPs]). Contraceptive use generally improved over time (aggregate-level use of contraceptives increased from 17.8% [95% CI, 16.6% to 19.0%] in 2000-2006 to 27.2% [95% CI, 26.6% to 27.8%] in 2013-2017 for adolescents and from 30.9% [95% CI, 29.8% to 32.0%] in 2000-2006 to 40.3% [95% CI, 39.8% to 40.8%] in 2013-2017 for adult women), but inequalities between adolescents and adult women persisted. Aggregate-level prevalence of unmet need for family planning decreased only among adult women (from 45.8% [95% CI, 44.9% to 46.7%] in 2000-2006 to 38.0% [95% CI, 37.3% to 38.7%] in 2013-2017). For adolescents, the prevalence remained at approximately 52% over time. The inequality between the 2 age groups therefore significantly increased from 7.5 PPs (95% CI, 6.5 to 8.4 PPs) in 2000 to 2006 to 14.0 PPs (95% CI, 13.4 to 14.6 PPs) in 2013 to 2017. An increasing gap between adolescent girls and adult women was found in 18 countries for modern contraceptive use and in 20 countries for unmet need for family planning. In India, for example, both age groups had increased percentage of unmet need for family planning over time, from 16.2% (95% CI, 15.9% to 16.6%) in 2006 to 29.8% (95% CI, 29.6% to 30.1%) in 2015 for adult women and from 23.9% (95% CI, 23.0% to 24.9%) to 64.5% (95% CI, 63.3% to 65.7%) among adolescents. Thus, inequality increased from 7.7 PPs (95% CI, 7.2 to 8.2 PPs) in 2006 to 34.7 PPs (95% CI, 34.2 to 35.1 PPs) in 2015. CONCLUSIONS AND RELEVANCE Despite a growing focus on contraception in the past decade with initiatives such as Family Planning 2020, adolescent girls continue to lag behind adult women in contraceptive use. There is a pressing need to develop age-appropriate strategies for increasing access and maintaining contraceptive use in sexually active adolescent girls.
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Affiliation(s)
- Zhihui Li
- Department of Global Health and Population, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - George Patton
- University of Melbourne, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Farnaz Sabet
- University of Melbourne, Parkville, Victoria, Australia
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Zhiying Zhou
- Xi'an Jiaotong University School of Public Policy and Administration, Xi'an, Shaanxi, China
| | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Chunling Lu
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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