Process evaluation of a parent-child communication intervention for adolescent sexual and reproductive health in Uganda.

BACKGROUND: Previous initiatives concerning adolescent sexual and reproductive health (SRH) education in Low-or-Middle Income Countries (LMICs) have been limited by cultural norms and misinformation perpetuated within families. Responding to the paucity of research on the implementation of SRH interventions in LMICs and limited knowledge regarding their mechanisms, this study undertakes a process evaluation of a parent-focused intervention to promote parent-adolescent communication about SRH in Uganda. METHODS: This paper explores the implementation, contextual factors and mechanisms of impact of the intervention, using the Medical Research Council (MRC) guidelines for process evaluations. Implementation was evaluated through indicators of dose, fidelity and adaptations, acceptability and feasibility. The contextual factors and mechanisms of impact were evaluated to refine the intervention's causal assumptions. Data was collected during April - October 2021 in South-Western Uganda using a mixed-methods approach, including document analysis, intervention observations, interviews, focus group discussions and most significant change stories. RESULTS: The acceptability of the intervention was related to its community engagement, the strong rapport with delivery agents, and individual characteristics of participants. Five contextual factors influencing implementation were highlighted; (i) cultural norms, (ii) perceptions about youth SRH, (iii) poverty, (iv) Covid-19 pandemic, and (v) prior research projects in the community. When considering the intervention's mechanisms of impact, four causal pathways were identified; (i) Awareness of SRH needs helped parents overcome stigma, (ii) Parenting skills training improved SRH communication, (iii) Group learning stimulated shared parenting, and (iv) Group learning improved co-parenting. CONCLUSION: The paper presented three key learnings and corresponding recommendations for future research. Firstly, implementation success was credited to meaningful community engagement which improved acceptability and uptake. Secondly, the complex influences of contextual factors highlighted the need for contextual analysis in research studies to inform intervention design. Finally, this evaluation recognised the interplay between mechanisms of impact and suggested further research consider such combined impacts when designing intervention content.

Beyond individualisation: towards a more contextualised understanding of women's social egg freezing experiences.

Recently, Petersen provided in this journal a critical discussion of individualisation arguments in the context of social egg freezing. This argument underlines the idea that it is morally problematic to use individual technological solutions to solve societal challenges that women face. So far, however, there is a lack of empirical data to contextualise his central normative claim that individualisation arguments are implausible. This article discusses an empirical study that supports a contextualised reading of the normative work of Petersen. Based on a qualitative interview study, we found that most women could make sense of this argument but addressed other concerns that are overlooked in the premises of moral individualisation arguments, for instance, the influence of relationship formation on the demand of egg freezing. Furthermore, women did not experience social egg freezing as morally problematic. Nonetheless, the interviewees pointed to a need of more societal solutions and even actively advocated for efforts to increase accessibility such as a partial reimbursement and better quality of information. The implications of these findings for empirical bioethics are discussed. While more research is needed, we argue that, in order to better address individualisation arguments and related ethical concerns, we need to contextualise normative evaluations within women's moral reasoning.

Level and comfort of caregiver-young adolescent communication on sexual and reproductive health: a cross-sectional survey in south-western Uganda.

BACKGROUND: Communication on sexual and reproductive health (SRH) between caregivers and their young adolescent children plays a significant role in shaping attitudes and behaviours that are critical to laying the foundations for positive and safe SRH behaviours in later adolescence. Nevertheless, this communication is often limited, particularly in countries where adolescent sexuality is taboo. This study assessed the topics discussed ('level') and the comfort of caregivers with communicating with young adolescents on SRH, and their correlates.  METHODS: A cross-sectional survey was conducted among 218 caregivers of young adolescents (10-14 years) in Mbarara district of south-western Uganda in January and February 2020. Participants were selected through consecutive sampling. A structured, pre-tested questionnaire administered by interviewers was used for data collection. The surveys were computer-assisted using Kobo Collect software. Data was exported to STATA 14 for analysis. Level of SRH communication was measured based on 10 SRH communication topics, while comfort was based on 9 SRH discussion topics. Bivariate and multivariate linear regression analyses were conducted to determine correlates of level of, and comfort with, SRH communication P-value < 0.05 was considered for statistical significance. RESULTS: The mean number of topics that caregivers discussed was 3.9 (SD = 2.7) out of the 10 SRH topics explored. None of the respondents discussed all the topics; 2% reported ever discussing nine topics with their young adolescent, while 3.5% reported never discussing any of the topics. General health and bodily hygiene (89.9%) and HIV/AIDS and other sexually transmitted infections (STIs) (77.5%) were the most commonly discussed, while night emissions in boys (4.3%) and condoms (8.3%) were least discussed. The majority of caregivers (62%) reported a high level of comfort with discussing SRH. The mean comfort score was 21.9 (SD = 3.8). In general, the level of SRH communication increased with an increase in comfort with SRH communication ß = 0.22 (0.04); 95% CI = (0.15, 0.30). The level of comfort with SRH communication decreased with an increase in the number of YAs in a household ß = -0.92 (0.38); 95%CI = (-1.66,-0.18). CONCLUSION: Overall, the level of SRH communication is low and varies according to the number of SRH topics. Caregivers' comfort with SRH communication with YAs was a significant correlate of SRH communication. This justifies the need for interventions that aim to improve caregivers' comfort with communicating with young adolescents about SRH.

'I feel that injustice is being done to me': a qualitative study of women's viewpoints on the (lack of) reimbursement for social egg freezing.

BACKGROUND: During the last decade, the possibility for women to cryopreserve oocytes in anticipation of age-related fertility loss, also referred to as social egg freezing, has become an established practice at fertility clinics around the globe. In Europe, there is extensive variation in the costs for this procedure, with the common denominator that there are almost no funding arrangements or reimbursement policies. This is the first qualitative study that specifically explores viewpoints on the (lack of) reimbursement for women who had considered to uptake at least one social egg freezing cycle in Belgium. METHODS: To understand the moral considerations of these women, drawing from twenty-one interviews, this paper integrates elements of a symbiotic empirical ethics approach and thematic analysis. RESULTS: We identify four themes: (1) being confronted with unclear information; (2) financial costs as ongoing concern; (3) necessity of coverage; (4) extent of reimbursement. In the first theme, we found that some women were concerned about the lack of clear information about the cost of social egg freezing. In the second theme, we report moral sentiments of injustice and discrimination which some women attributed to their struggles and needs not being recognised. The third theme illustrates diverse views on reimbursement, ranging from viewing social egg freezing as an elective treatment not appropriate for reimbursement to preferences for greater public responsibility and wider access. Finally, we describe the participants' varying proposals for partial reimbursement and the idea that it should not be made available for free. CONCLUSIONS: This research adds important empirical insights to the bioethics debate on social egg freezing, in particular by presenting (potential) users' views on the lack of reimbursement. While there is much more to say about the ethical and political complexities of the reimbursement of this procedure, our study highlighted the voices of (potential) users and showed that at least some of them would welcome the coverage of SEF through the public healthcare insurance.

Poverty, gender and reproductive justice. A qualitative study among adolescent girls in Western Uganda.

Low socio-economic status has been consistently identified as a primary risk factor for sexual and reproductive health violations affecting young women. This study shows how poverty interacts with gender power relations to impact upon adolescent girls' sexual and reproductive lives in Western Uganda. Qualitative research with 147 participants was undertaken. This comprised 59 in-depth interviews and 11 focus group discussions with groups of 12-14 year-old young women, teachers and parents. Data were analysed manually using open and axial coding, and conclusions were generated inductively. Findings reveal that young women are restricted in exercising their sexual and reproductive rights not only by poverty and unequal gender relations, but also by corruption and poor service provision. In contrast to interventions using liberal rights-based approaches, we advocate the use of a 'marketplace of options' since access to sexual and reproductive health services is very limited for poor girls and not evenly distributed. Moreover, while poverty and unequal gender relations render girls vulnerable to sexual coercion and violence, the criminal justice system is often weak, leaving victims powerless. Investment in appropriate resources and inclusive and affordable access to justice is essential to advance young women's sexual and reproductive health.

Evaluation of a school based comprehensive sexuality education program among very young adolescents in rural Uganda.

BACKGROUND: Limited research has been conducted on the effectiveness of sexuality education for very young adolescents (VYAs) ages 10-14 years in Sub-Saharan Africa. Furthermore, evaluations of sexuality education programs often report outcomes of risky sexual practices, yet positive aspects of sexuality are hardly studied and rarely reported. This study evaluates the effectiveness of a Comprehensive Sexuality Education (CSE) intervention for VYAs in Uganda, analyzing both positive and negative outcome indicators. METHODS: We conducted a mixed methods study, incorporating a cluster randomized trial (NCT03669913) among pupils in 33 randomly selected primary schools in Mbarara district. This was followed by a qualitative evaluation of the intervention in 4 schools that included 14 in-depth interviews and 3 focus group discussions distributed among pupils, teachers and parents. Quantitative data were analyzed using ordered logistic regression to compare differences in the change from baseline to endline between the intervention and control arms. We conducted bivariate analysis and multiple regression analysis controlling for key covariates, including age, gender, school location (rural vs urban), truancy, and orphanhood. Qualitative data were analyzed by thematic approach using ATLAS TI. RESULTS: Between July 2016 and August 2017, 1096 pupils were recruited. Outcomes were studied among 380 pupils in the intervention arm and 484 pupils in the control arm. The proportion of pupils who ever had sex increased from 9 to 12.1% in intervention compared to 5.2 to 7.4% in the control group between baseline and endline, however the differences between groups were not statistically significant. We found greater improvements in sexual and reproductive health (SRH) knowledge among intervention schools (AOR: 2.18, 95% CI: 1.66-2.86) and no significant differences in self-esteem, body image or gender equitable norms. Qualitative evidence echoes perceived SRH knowledge acquisition, increased their perception of SRH related risks, and intentions to delay sexual intercourse to prevent unwanted pregnancy, HIV and other STIs. CONCLUSION: This study demonstrates that CSE can improve SRH knowledge and behavioral intentions among VYAs in Uganda. These results further emphasize the importance of initiating sexuality education before most adolescents have started engaging in sexual activity, enabling them to make informed decisions in the future. TRIAL REGISTRATION: NCT03669913 , registered retrospectively on September 13th, 2018.

Women with infertility complying with and resisting polygyny: an explorative qualitative study in urban Gambia.

BACKGROUND: In many low-and middle-income countries women with infertility are often in polygynous marriages. From a human and women's rights perspective, the practice of polygyny is commonly understood as harmful. Studies indicate that polygyny aggravates negative life circumstances of women with infertility with respect to their health and social well-being. The purpose of this qualitative study is to explore how women with infertility experience polygyny and to understand their decision-making regarding these marriages. METHODS: An explorative qualitative study was conducted among women with infertility in the urban communities of the West Coast region of The Gambia using in-depth interviews (30). Data analysis involved an emergent and partially inductive thematic framework and was carried out using NVivo 11. RESULTS: With the exception of some women with infertility who described positive experiences within polygynous marriages, most women emphasised conflicts that exist within polygynous households and reported financial and emotional difficulties. Thematic analysis identified several strategies of women with infertility to cope with and resist polygynous marriages, including overcoming childlessness, addressing conflict, spending time outside the compound, looking for social support, kanyaleng kafoolu, living separately and initiating divorce. Moreover, the experiences and decision-making power of women with infertility when it comes to polygynous marriages was found to be closely related to their socio-demographic background. CONCLUSION: This work highlights how women with infertility in polygynous marriages are in a precarious situation in urban Gambia. Women utilize a mix of compliance, coping and resistance strategies to navigate the challenges of polygynous marriages in a structurally constraining context.

Perceptions and decision-making with regard to pregnancy among HIV positive women in rural Maputo Province, Mozambique - a qualitative study.

BACKGROUND: In preventing the transfer of HIV to their children, the Ministry of Health in Mozambique recommends all couples follow medical advice prior to a pregnancy. However, little is known about how such women experience pregnancy, nor the values they adhere to when making childbearing decisions. This qualitative study explores perceptions and decision-making processes regarding pregnancy among HIV positive women in rural Maputo Province. METHODS: In-depth interviews and five focus group discussions with fifty-nine women who had recently become mothers were carried out. In addition, six semi-structured interviews were held with maternity and child health nurses. The ethnographic methods employed here were guided by Bourdieu's practice theory. RESULTS: The study indicated that women often perceived pregnancy as a test of fertility and identity. It was not only viewed as a rite of passage from childhood to womanhood, but also as a duty for married women to have children. Most women did not follow recommended medical advice prior to gestation. This was primarily due to perceptions that decision-making about pregnancy was regarded as a private issue not requiring consultation with a healthcare provider. Additionally, stigmatisation of women living with HIV, lack of knowledge about the need to consult a healthcare provider prior to pregnancy, and unintended pregnancy due to inadequate use of contraceptive were crucial factors. CONCLUSION: Women's experiences and decisions regarding pregnancy are more influenced by social and cultural norms than medical advice. Therefore, education concerning sexual and reproductive health in relation to HIV/AIDS and childbearing is recommended. In particular, we recommend maternal and child healthcare nurses need to be sensitive to women's perceptions and the cultural context of maternity when providing information about sexual and reproductive health.

'I am always crying on the inside': a qualitative study on the implications of infertility on women's lives in urban Gambia.

BACKGROUND: There is an increasing awareness that infertility in Sub-Saharan Africa constitutes a severe social and public health problem. Few of the existing studies on infertility explicitly take into account the differences between women. However, how women experience infertility is formed by their various social positions. This research explores the implications of infertility on women's lives in urban Gambia and aims to provide an in-depth understanding of how this relates to gender and cultural norms as well as different social positions. METHODS: Qualitative data were collected through interviews (33), group discussions (13), participatory observations (14) and informal conversations (31). Purposive and snowball sampling techniques were used to identify participants. The data was analysed thematically using NVivo 11. RESULTS: Results showed that there was strong social pressure on urban women in The Gambia to procreate. Unable to conform to their gender role, women with infertility were confronted with financial problems, social stigma, as well as emotional and physical violence in their marriage. All women expressed feelings of trauma, stress and sadness. The intersectional approach used in this study highlighted how different positions influenced women's experiences of infertility. Urban women with a high socio-economic status had a more powerful position within their marriages and the broader community, due to their financial position, professional career and, sometimes, their educational background. In contrast, women from a lower socio-economic background were more likely to be harshly confronted with the social stigma of infertility. CONCLUSION: The lives of most women with infertility in The Gambia are characterized by social suffering resulting from gender and pro-natal norms, cultural beliefs and moral concerns, cultural practices and limited access to health care. An intersectional approach is an effective tool to inform public health and social policy since it highlights how, in specific situations, certain groups are more vulnerable than others.

Sexual health of very young adolescents in South Western Uganda: a cross-sectional assessment of sexual knowledge and behavior.

BACKGROUND: In most Sub-Saharan African countries, little is known about young adolescents' sexual and reproductive health (SRH). Though some efforts have been made to understand and improve SRH of older adolescents, very young adolescents (VYAs) are often overlooked, and little is known about their sexual knowledge and behaviors. The goal of this study was to describe SRH knowledge, information-seeking, and sexual behavior of VYAs in Uganda. METHODS: A cross-sectional survey was administered in 33 primary schools in June and July of 2016. Trained interviewers administered surveys to adolescents ages 10-14 regarding SRH knowledge, information-seeking, sexual behavior, and relevant covariates. Continuous variables were summarized as means (SD) or medians (IQR) whereas categorical variables were summarized as proportions (percentages). RESULTS: A total of 1096 adolescents were included in this analysis, 81.8% of which were from rural areas, with a median age of 12. Regarding sexually transmitted infections (STIs) knowledge; 95% knew HIV while 37% knew other STIs apart from HIV. Although 47% knew at least one way in which HIV is acquired only 8% knew at least four ways. Regarding contraceptive knowledge, 56% mentioned at least one modern method of preventing pregnancy (condoms, pills, intrauterine devices, implants, or injections). The majority (85%) of VYAs reported accessing SRH information in the media with 35% reporting accessing media with sexual content while 10% vs 22% consulted their father or mother respectively and 31% a school source. At least 7.6% of VYAs had ever had sexual intercourse, 90% of which were not using any protection. CONCLUSION: Comprehensive SRH knowledge was low among VYAs in this study. Media remains an important source of information for SRH for this age group though it may be misused as some adolescents reported accessing sexual content that may be inappropriate. A large proportion of sexually active VYAs reported sexual risky behaviors. This study highlights the need for an accurate and more comprehensive SRH education approach for VYAs in Uganda at an opportune age before the majority engage in sexual behavior.

"If I have only two children and they die who will take care of me?" -a qualitative study exploring knowledge, attitudes and practices about family planning among Mozambican female and male adults.

BACKGROUND: By focusing upon family planning counselling services, the Mozambican government has significantly enhanced the general health of female and male clients. However, little is known about the experiences of family planning by female and male adults. This article focuses on knowledge, attitudes and practices regarding contraceptive methods and fertility intentions. METHODS: An in-depth qualitative study of female and male clients was conducted in two settings in Maputo province - Ndlavela and Boane. A total of sixteen in-depth interviews, four informal conversations, and observations were equally divided between both study sites. The analysis followed a constructionist approach. Three steps were considered in the analysis: examining commonalities, differences and relationships. RESULTS: Although there was a high level of family planning knowledge, there were discrepancies in clients' everyday practices. Male and female clients are confronted with a variety of expectations concerning fertility intentions and family size, and are under pressure in numerous ways. Social pressures include traditional expectations and meanings connected to having children, as well as religious factors. Short interaction time between clients and health workers is a problem. Additionally, imposed contraceptive methods, and typically brief conversations about birth control between couples only adds to the burden. Because family planning is largely viewed as a woman's concern, most clients have never attended counselling sessions with their partners. Attitudes towards responsibility for contraceptive use and risk-taking are strongly gendered. CONCLUSIONS: Female and male clients have differing expectations about contraceptive use and fertility intentions. They participate differently in family planning programs leading to their inconsistent and ambivalent practices as well as vague perceptions of risk-taking. Therefore, policymakers must address the reasons behind ambivalence and inconsistency regarding contraceptives and family planning.

Changing practices and shifting meanings of female genital cutting among the Maasai of Arusha and Manyara regions of Tanzania.

Using mixed methods that combined participant observation and semi-structured in-depth interviews, this study looked at changing practices and shifting meanings of female genital cutting among the Maasai people in Tanzania. The findings suggest that an increasing social pressure to abandon female genital cutting has inspired the hiding of the practice, causing the actual cutting to become detached from its traditional ceremonial connotations. This detaching of cutting from ceremony has created a shift in meanings: the ceremony still carries the meaning of passage into adulthood, while the cutting seems to function as a way of inscribing Maasai identity into the body. The detaching of genital cutting from ceremony offers those willing to continue the practice the opportunity to do so without being prosecuted, and those unwilling to undergo or perform the practice the opportunity to evade it by faking the cutting without being socially sanctioned for it. Findings also suggest changing attitudes towards the practice among the younger generation as the result of education. Maasai culture and the practice of female genital cutting are not static but actively challenged and reinterpreted from within the community, with formally schooled and women taking up leading roles in reshaping gender norms.

"It is challenging oh, nobody likes it!": a qualitative study exploring Mozambican adolescents and young adults' experiences with contraception.

BACKGROUND: By focusing upon formal sex education programmes, the Mozambican government has significantly enhanced the general health of adolescents and young adults. However, when it comes to contraception, little is known about how adolescents and young adults actually behave. METHODS: Based upon a qualitative study in two settings in Maputo province - Ndlavela and Boane - this paper explores the knowledge and practices of contraception among adolescents and young adults. A total of four focus group discussions, 16 in-depth interviews, four informal conversations, and observations were equally divided between both study sites. RESULTS: Discrepancies between what adolescents and young adults know and what they do quickly became evident. Ambivalent and contradictory practices concerning contraceptive use was the result. As well, young people had numerous interpretations of risk-taking when not using contraceptives. These inconsistencies are influenced by social and medical barriers such as restricted dialogue on sexuality among adolescents and young adults and their parents and peers. Additionally, ideas about indigenous contraceptives, notions of masculinity and femininity, misconceptions and fear of the side effects of contraceptives, make people of all ages wary of modern birth control. Other barriers include imposed contraceptive choice - meaning no choice, overly technical medical language used at clinics and the absence of healthcare workers more attuned to the needs of adolescents and young adults. CONCLUSIONS: Adolescents and young adults have numerous - often erroneous - opinions about contraception, leading to inconsistent use as well as vague perceptions of risk-taking. Moreover, social norms and cultural gender roles often contradict and hinder risk-avoiding behaviour. Therefore, in order to improve young people's health, policymakers must address the reasons behind this ambivalence and inconsistency.

Couple based family planning education: changes in male involvement and contraceptive use among married couples in Jimma Zone, Ethiopia.

BACKGROUND: Family planning contributes substantially in achieving the Millennium Development Goals. Recently, male involvement has gained considerable attention in family planning programs but the implementation thereof remains a challenge. In that context, our study aimed at measuring the effect of a six-month-long family planning education program on male involvement in family planning, as well as on couples' contraceptive practice. METHODS: We conducted a quasi-experimental research among 811 married couples in Jimma Zone, southwest Ethiopia. Our study consisted of an intervention and a control group for comparative purpose; and surveyed before and after the implementation of the intervention. The intervention consisted of family planning education, given to both men and women at the household level in the intervention arm, in addition to monthly community gatherings. During the intervention period, households in the control group were not subject to particular activities but had access to routine health care services. RESULTS: We obtained follow-up data from 760 out of 786 (96.7%) couples who were originally enrolled in the survey. Findings were compared within and between groups before and after intervention surveys. At the baseline, contraceptive use in both control and intervention households were similar. After the intervention, we observed among men in the intervention arm a significantly higher level of willingness to be actively involved in family planning compared to the men in the control arm (p < 0.001). In addition, the difference between spouses that discussed family planning issues was less reported within the control group, both in the case of men and women ((p = 0.031) and (p < 0.001)) respectively. In general, a significant, positive difference in male involvement was observed. Concerning contraceptive use, there was change observed among the intervention group who were not using contraception at baseline. CONCLUSIONS: This study showed that family planning educational intervention, which includes both spouses and promotes spousal communication, might be useful to foster contraceptive practice among couples. The results also offer practical information on the benefits of male involvement in family planning as a best means to increase contraceptive use. Thus, providing opportunities to reinforce family planning education may strengthen the existing family planning service delivery system.

Spousal discordance on fertility preference and its effect on contraceptive practice among married couples in Jimma zone, Ethiopia.

OBJECTIVES: To assess spousal agreement levels regarding fertility preference and spousal communication, and to look at how it affects contraceptive use by couples. METHODS: We conducted a cross-sectional study to collect quantitative data from March to May 2010 in Jimma zone, Ethiopia, using a multistage sampling design covering six districts. In each of the 811 couples included in the survey, both spouses were interviewed. Concordance between the husband and wife was assessed using different statistics and tests including concordance rates, ANOVA, Cohen's Κ and McNemar's test for paired samples. Multivariate analysis was computed to ascertain factors associated with contraceptive use. RESULTS: Over half of the couples wanted more children and 27.8% of the spouses differed about the desire for more children. In terms of sex preference, there was a 48.7% discord in couples who wanted to have more children. At large, spousal concordance on the importance of family planning was positive. However, it was the husband's favourable attitude towards family planning that determined a couple's use of contraception. Overall, contraceptive prevalence was 42.9%. Among the groups with the highest level of contraceptive users, were couples where the husband does not want any more children. Spousal communication about the decision to use contraception showed a positive association with a couple's contraceptive prevalence. CONCLUSIONS: Family planning programs aiming to increase contraceptive uptake could benefit from findings on spousal agreement regarding fertility desire, because the characteristics of each spouse influences the couple's fertility level. Disparities between husband and wife about the desire for more children sustain the need for male consideration while analysing the unmet need for contraception. Moreover, men play a significant role in the decision making concerning contraceptive use. Accordingly, involving men in family planning programs could increase a couple's contraceptive practice in the future.

Trends and Challenges in Comprehensive Sex Education (CSE) Research in Sub-Saharan Africa: a Narrative Review.

Purpose of the Review: Adolescent sexual and reproductive health remains a major public health challenge in Sub-Saharan Africa (SSA). Comprehensive sex education (CSE) has been hailed as a key strategy to inform young people about sexual health and wellbeing and prevent negative health outcomes. This paper presents an overview of the trends and challenges around sex education in SSA and puts forth key recommendations for future research and policy initiatives. Recent Findings: This review employed a narrative approach to synthesize evidence on the implementation of comprehensive sex education in SSA. The literature review elicited four key themes: (i) comprehensiveness of CSE curricula, (ii) gender norms in CSE, (iii) prominence of 'fear' narratives in CSE implementation, and (iv) CSE delivery methods. Additionally, the authors propose a fifth theme-'Future-proofing CSE programs', based on their learnings from implementing sex education interventions during the COVID-19 pandemic. These five themes are presented through a narrative description of current research accompanied by reflections from the authors on the implementation of a parent-focused sex education program in Uganda. Summary: Based on the insights from the literature review and the authors' reflections, three recommendations are put forward to guide the design of further CSE initiatives: (i) stakeholder engagement in determining CSE priorities and strategies, (ii) diverse delivery pathways for CSE programs, and (iii) active engagement of both boys and girls to challenge gender norms in CSE.

Narratives of most significant change to explore experiences of caregivers in a caregiver-young adolescent sexual and reproductive health communication intervention in rural south-western Uganda.

BACKGROUND: This paper presents findings from a qualitative effectiveness evaluation of an intervention aimed at improving caregiver-young adolescent sexual and reproductive health (SRH) communication including training modules for caregivers on parent-child SRH communication. METHODS: Data was collected (October 2021-November 2021) using a narrative interviewing technique with thirty caregivers (8 males and 22 females), who received the parent-child communication intervention in Mbarara district, south-western Uganda. We explored caregivers' experiences with the intervention based on four domains of change: caregiver-young adolescent communication on SRH issues, knowledge and attitudes towards adolescent SRH, parenting skills, and personal life and family. Thematic analysis was used to code and analyse the data, with attention to gender differences. RESULTS: Findings highlight positive parenting as a key attribute of SRH communication, along with a transformation of knowledge and attitudes towards the SRH of young adolescents leading to an overall improvement in SRH communication. However, communication is still limited to comfortable topics. CONCLUSION: Our findings indicate improved caregiver-adolescent SRH communication practices following a community intervention. Programming for adolescent health on broader sexuality topics, comfortability and attitude change among caregivers could promote behaviour change on a long term. Future studies may focus on the long term impacts of interventions of this nature and test interventions aimed at addressing comfortability with discussingSRH issues.

Sex-based differences in end-of-life decision making in Flanders, Belgium.

BACKGROUND: Sex-related differences in end-of-life decisions (EOLD) are underresearched and unexplored. OBJECTIVES: To investigate whether there are (1) differences in demographic and/or clinical characteristics between male and female decedents; (2) differences between men and women in the prevalence of EOLD with a possible or certain life-shortening effect; (3) differences in EOL decision making between men and women. METHODS: In 2007, we performed a postmortem survey in Flanders, Belgium among physicians certifying a large representative sample (n=6927) of death certificates. Response rate was 58.4%. RESULTS: Of patients with nonsudden death, women more often die in a care home than men (31.4% vs. 18.2%) who more often die at home (24.1% vs. 17.9%). Men tend to die more often from cancer than women (45.4% vs. 32.1%). Decisions to withhold or withdraw potentially life-prolonging treatment are more often made in women (28.0% vs. 22.8%, P=0.003); euthanasia and pain and symptoms treatment [alleviation of pain and symptoms (APS)] occur more often in men (3.6% vs. 2.1% euthanasia, P=0.023; 41.8% vs. 36.9% APS, P=0.012). These differences disappear after controlling for confounders. Bivariate associations were found between sex and EOL decision making. Some of them remained after controlling for confounders. CONCLUSIONS: It is not the patient's sex in itself that determines the likelihood of an EOLD, but the different clinical profiles of men and women at the end of life. Although sex is not a determining factor in the prevalence of EOLD, it influences the decision-making process, indicating that there may be a difference in the way that male and female patients participate in EOL decision making.

Gendered Experiences of Parent-Child Communication on Sexual and Reproductive Health Issues: A Qualitative Study Employing Community-Based Participatory Methods among Primary Caregivers and Community Stakeholders in Rural South-Western Uganda.

Open and positive parent-child communication about sexual and reproductive health (SRH) is known to reduce negative SRH outcomes for young people. However, socio-cultural influences can inhibit meaningful SRH communication. Restrictive gender norms threaten the SRH of adolescents, as they make adolescent boys more likely to engage in risky sexual behavior and make girls more vulnerable to negative SRH outcomes. This study intended to critically understand the impact of gender norms and expectations on parent-child SRH communication in rural south-western Uganda. METHODS: The study adopted a community-based participatory approach using community stakeholder engagement meetings (n = 2), in-depth interviews (n = 12), and three focus group discussions with parents (n = 18). The study considered biological parents, step-parents, grandparents, uncles and aunties, as long as they were primary caregivers of adolescents aged 10-14. RESULTS: Participants elaborated on the socio-cultural aspects that shaped their experiences of parent-child SRH communication such as cultural gender norms, religion, and media influences. They also referred to socio-economic challenges, lack of knowledge, and the role of peers and schools. CONCLUSIONS: There is need for community-based interventions to improve parent-child SRH communication to address the deeply rooted cultural and gender contexts in rural south-western Uganda.

The fertile grounds of reproductive activism in The Gambia: A qualitative study of local key stakeholders' understandings and heterogeneous actions related to infertility.

INTRODUCTION: While several studies have focussed on the experiences of women living with infertility, there is a paucity of information related to understandings, representations and actions of key stakeholders (i.e. organisations and individual actors involved in activities or professional care surrounding infertility) when it comes to infertility in Sub-Saharan Africa. This ethnographic study conducted in The Gambia, West Africa, focuses on how key stakeholders in the country understand infertility, and on their activities to improve the lives of people with infertility. METHODOLOGY: This ethnographic study draws on primary and secondary data for thematic analysis. Primary qualitative data were collected using in-depth interviews, observations, informal conversations and group discussion with various stakeholders (i.e. health care providers and representatives of non-governmental, governmental and international organisations). Sources of secondary data included government and non-governmental reports and media outputs. RESULTS: Results illustrated that most key stakeholders had a good understanding of the cultural frameworks and social realities of women living with infertility, with less focus on, or awareness of, men's experiences of infertility. We distinguished three different positions of these actors and organisations, first, the infertility supporters, i.e. those who despite political challenges and a lack of funding, initiated activities to raise awareness about the problems people with infertility are facing and aim to increase access to infertility services. The second are moderate supporters, i.e. those who recognise the problems infertility poses and whose organisations target some of the perceived causes of infertility (i.e. lack of health education and harmful cultural practices). A third group of neutral or moderate opponents consist mainly of formal health care providers who do not consider infertility a current priority, given many competing demands in the resource-constrained healthcare system. CONCLUSION: While international donors still largely neglect the emotional and social implications of infertility in Sub-Saharan African countries, some local stakeholders are working to bring services closer to people with infertility. The efforts of these local stakeholders require support and integration, and should include engaging with different groups for widespread sensitisation to reduce stigma and promote attendance to health centres for reproductive health challenges.