Factors facilitating the use of contraceptive methods among urban adolescents and youth in Guinea: a qualitative study.

BACKGROUND: The use of modern contraceptive methods among adolescents and youth is a public health priority to prevent unintended pregnancies. To our knowledge, no study has ever explored and documented factors promoting contraceptive use among urban adolescents and youth in Guinea. The objective of this study was to explore the factors that promote the use of contraceptive methods at the personal, interpersonal, community, and health system levels among urban adolescents and youth in Guinea. METHODS: We conducted a qualitative research study including twenty-six individual in-depth interviews among adolescents and youth, and 10 group interviews with an additional eighty individuals, for a total of 106 participants. The socio-ecological model was used to orient both data collection and analysis. Data were collected from June to October 2019. Both individual and group interviews were audio-recorded, and transcribed verbatims afterwards. Data was analyzed thematically, using deductive codes. RESULTS: The individual factors favoring contraceptive use among adolescents and youth pertained to perceived benefits of the methods (e.g., discretion, absence of side effects, duration of action, ease of use), knowledge of the family planning service channels, and means to afford the cost of the method. The interpersonal factors were spouse/sexual partner approval, and peer suggestions about contraceptive methods. The community factors included socio-cultural beliefs about the methods, and community expectation not to get pregnant before marriage. The health system factors included access to free contraceptive methods, availability of methods, clinical competence and attitude of the health care provider to advise or administer methods, and proximity of family planning services to users' place of residence. CONCLUSIONS: This qualitative research shows that many adolescents and youth living in Conakry use a variety of contraceptive methods, whether modern, traditional Access to free or affordable methods, discretion of method use, proximity and availability of methods, and suggestions of methods by peers are factors that motivate adolescents and youth to use contraception. In order to optimally facilitate the use of modern contraception among adolescent and young urban Guineans, we recommend that: (1) adolescents and youth have access to public health strategies enabling them to learn about, obtain, and use methods in a way that allows them to remain discreet; (2) the use of modern contraceptive methods be promoted by peers; and (3) health care providers and peers be adequately trained to have accurate and up-to-date knowledge about the different contraceptive methods available, demonstrate clinical skills for teaching and for method placement (if applicable), and show appropriate attitudes toward this population. This knowledge can inform policies and programs to improve the use of effective contraceptive methods by adolescents and youth living in urban Guinea.

BACKGROUND: The use of Family planning (FP) among adolescents and youth is essential to prevent unintended pregnancies. The objective of this study was to understand the personal, interpersonal, community, and health system factors that encourage the use of FP among urban adolescents and youth in Guinea. METHODS: We conducted a qualitative study with adolescents and youth living in Conakry, Guinea. The study took place between June and October 2019. Data were collected through 26 individual in-depth interviews (IDIs), and 10 group interviews (FGDs). Both IDIs and FGDs were recorded and transcribed. Data was analyzed using the "thematic analysis" method. RESULTS: The personal factors favoring the use of FP among adolescents and youth were related to perceived benefits of FP, knowledge of the FP service availability, means to afford the cost of FP. The interpersonal factors included spouse/sexual partner approval and friends' suggestions about FP. The community factors included socio-cultural beliefs about the methods, and community expectations not to get pregnant before marriage. The health system factors pertained to access to free FP, availability of methods, clinical competence and attitude of the health care provider, and proximity of FP services to users' place of residence. CONCLUSIONS: This research shows that many adolescents and youth living in Conakry use a variety of contraceptive methods, whether modern (implant; intrauterine device; injectable; pills; condom; lactational and amenorrhea method), traditional (fixed-day method; abstinence; withdrawal method). In order to optimally facilitate the use of modern contraception among adolescent and young urban Guineans, we recommend that: (1) adolescents and youth have access to public health strategies enabling them to learn about, obtain, and use methods in a way that allows them to remain discreet; (2) the use of modern contraceptive methods be promoted by peers; and (3) health care providers and peers be adequately trained to have accurate and up-to-date knowledge about the different contraceptive methods that exist, demonstrate clinical skills for teaching and for method placement (if applicable), and show appropriate attitudes towards this population. This knowledge can inform FP programs to improve the use of effective contraceptive methods by adolescents and youth in urban Guinea.

Escaping social rejection, gaining total capital: the complex psychological experience of female genital mutilation/cutting (FGM/C) among the Izzi in Southeast Nigeria.

BACKGROUND: While the deleterious effects of FGM/C on physical health are well documented, the psychological experience of this harmful practice is a neglected area of research, which limits global mental health actions. As FGM/C was a traditional practice in some areas of Nigeria, the study aimed to understand the psychological experience of FGM/C in context. METHODS: This qualitative study was completed in urban and rural Izzi communities in Southeast Nigeria where FGM/C was widely practiced. In-depth interviews were completed with 38 women of the same ethnicity using the McGill Illness Narrative Interview (MINI) to explore the collective psychological experience of FGM/C before, during and after the procedure. The MINI was successfully adapted to explore the meaning and experience of FGM/C. We completed thematic content analysis and used the concepts of total capital and habitus by Bourdieu to interpret the data. RESULTS: During the period of adolescence, Izzi young women who had not yet undergone FGM/C reported retrospectively being subjected to intense stigma, humiliation and rejection by their cut peers. Alongside the social benefits from FGM/C the ongoing psychological suffering led many to accept or request to be cut, to end their psychological torture. Virtually all women reported symptoms of severe distress before, during and after the procedure. Some expressed the emotion of relief from knowing their psychological torture would end and that they would gain social acceptance and total capital from being cut. Newly cut young women also expressed that they looked forward to harassing and stigmatizing uncut ones, therein engaging in a complex habitus that underscores their severe trauma as well as their newly acquired enhanced social status. CONCLUSION: FGM/C is profoundly embedded in the local culture, prevention strategies need to involve the whole community to develop preventive pathways in a participatory way that empowers girls and women while preventing the deleterious psychological effects of FGM/C and corresponding stigma. Results suggest the need to provide psychological support for girls and women of practicing Izzi communities of Southeast Nigeria.

Beyond the Sociocultural Rhetoric: Female Genital Mutilation, Cultural Values and the Symbolic Capital (Honor) of Women and Their Family in Conakry, Guinea-A Focused Ethnography Among "Positive Deviants".

Female genital mutilation (FGM) is justified by sociocultural arguments, including that it guarantees girls'/women's appropriate sexual behavior, thus preserving family honor. We explored the perspectives of Guineans who do not practice FGM ("positive deviants"), as well as of Guineans who still practice FGM but who are supportive of abandoning the practice ("reluctant adherents"). We conducted a "focused ethnographic" study in Conakry, Guinea with a sample of 58 people. Individual semi-structured interviews were undertaken to explore the views and experiences of 18 women and 12 men of different generations who abandoned the practice of FGM. Group interviews with an additional 16 women and 12 men (half of whom were "positive deviants" and the other half "reluctant adherents") validated and enriched the data. Participants consider that FGM has deleterious consequences as it: (1) does not prevent girls or married women from being sexually active outside of marriage; (2) may impair couples' sexual satisfaction, and thus lead to divorce, men's infidelity or polygamy; and (3) may reduce women's ability to have multiple children, because of the increased risk of infertility or obstetric complications. In addition, participants reported that many Guineans fear that the promotion of FGM abandonment is a Western plot to eradicate their culture. We conclude that Guineans who practice and do not practice FGM share the same cultural values about the importance of culturally appropriate sexual behavior, being married, and having many children, which are central sources of honor (symbolic capital) to women and their families. They, however, have opposing views on how to achieve these objectives. Based on our participants' perspectives, the harmful consequences of FGM can potentially sabotage these sources of honor. Recommendations for messages aimed at promoting FGM abandonment are discussed.

Beyond will: the empowerment conditions needed to abandon female genital mutilation in Conakry (Guinea), a focused ethnography.

BACKGROUND: Female genital mutilation (FGM) can give rise to immediate and long-term health problems for girls/women. Numerous studies have identified the sociocultural determinants of this tradition, but so far, in a national context where FGM is highly practiced, virtually none have focused on people refusing to have their daughters cut. We therefore aimed to understand the sociocultural dynamics underlying the non-practice of FGM in Guinea, a country which has one of the most prevalent rates of this practice in the world. This research explored the demographic and sociocultural profiles of Guineans who do not practice FGM, as well as their non-practice experience in a context of high FGM prevalence and social pressure. METHODS: We used a "focused ethnography" methodology and conducted semi-structured individual interviews with 30 women and men from different generations (young adults, parents, grandparents) living in Conakry, Guinea. RESULTS: We found that participants 1) do not disclose their non-practicing status in the same way, and 2) have different experiences with social pressure. A typology was created to describe participants as per their various profiles and experiences, which we named as: 1) the "activists", 2) the "discrete", 3) the "courageous", 4) the "strategists". DISCUSSION: Wanting to stop practicing FGM is not enough. The main empowering conditions allowing people to enact their decision not to have their daughters undergo FGM are: benefiting from social support (positive social capital), or being financially independent from the traditional solidarity network (sufficient economic capital). We therefore recommend finding ways to increase women's/families' empowerment to enact their decision not to practice FGM, mainly by: 1) providing them with new sources of social support, and 2) supporting them to gain more financial independence, including through schooling and improved access to better-paid employment. CONCLUSIONS: This study was the first to explore the experience of people who do not practice FGM in a context of high FGM prevalence and social pressure. The results and recommendations of this research can inform strategies for FGM abandonment and therefore contribute to improving or developing intervention strategies that promote the health and well-being of girls and women.

RéSUMé: CONTEXTE: Les mutilations génitales féminines (MGF) peuvent nuire à la santé des filles/femmes. Plusieurs études ont identifié les déterminants socioculturels de cette tradition, or aucune n'a focalisé sur des personnes vivant dans un contexte où les MGF sont hautement pratiquées et qui refusent de faire exciser leurs filles. En Guinée, la prévalence des MGF est très élevée et la pression sociale pour faire exciser les filles est forte. Cette recherche a donc exploré les profils démographiques et socioculturels, et l'expérience de Guinéens qui ne pratiquent pas les MGF. MéTHODES: Nous avons utilisé une méthodologie « d'ethnographie focalisée ¼, et mené des entretiens individuels semi-structurés avec 30 femmes et hommes de différentes générations (jeunes adultes, parents, grands-parents) vivant à Conakry, en Guinée. RéSULTATS: Nous avons constaté que les participants 1) ne divulguent pas tous leur statut de non-pratique, et 2) ont différentes expériences de pression sociale. Nous avons créé une typologie pour les décrire selon leurs différents profils et expériences, et les avons surnommés ainsi: 1) « activistes ¼, 2) « discrets ¼, 3) « courageux ¼, 4) « stratèges ¼. DISCUSSION: Vouloir abandonner la pratique des MGF ne suffit pas. Les principales conditions permettant aux participants de mettre en oeuvre leur décision de ne pas faire exciser leurs filles sont: bénéficier de soutien social (capital social positif), ou être financièrement indépendant du réseau de solidarité traditionnel (capital économique suffisant). Nous recommandons donc de trouver des moyens pour accroître l'autonomisation des femmes/familles pour qu'elles puissent mettre en œuvre leur décision de ne pas faire exciser leurs filles, principalement en les soutenant pour accéder à 1) du soutien social, et 2) l'indépendance financière, y compris par la scolarisation et l'accès à des emplois mieux rémunérés. CONCLUSIONS: Cette étude a été la première à explorer l'expérience de personnes qui ne pratiquent pas les MGF dans un contexte de forte prévalence des MGF et de pression sociale. Les résultats et recommandations de cette recherche peuvent éclairer les stratégies d'abandon des MGF et ainsi contribuer à améliorer ou à développer des stratégies d'intervention qui favorisent la santé et le bien-être des filles/femmes.

Correction to: Au-delà de la volonté: les conditions d'empowerment nécessaires pour abandonner les mutilations génitales féminines à Conakry (Guinée), une ethnographie focalisée.

An amendment to this paper has been published and can be accessed via the original article.

Brief report: A qualitative evidence synthesis of the psychological processes of school-based expressive writing interventions with adolescents.

INTRODUCTION: Expressive writing interventions consist of brief writing sessions on thoughts and emotions and are known to yield positive benefits on adolescents' mental health. However, the psychological mechanisms explaining these effects are not clear. METHOD: This review explored the psychological processes underlying school-based expressive writing interventions with adolescents. A thematic synthesis of qualitative research consisted of identifying, appraising and summarizing the qualitative evidence of eligible studies. RESULTS: Only six of the 510 identified studies met the inclusion criteria of this review. Results provide some validation for cognitive-processing, emotion-regulation, and disinhibition as psychological mechanisms underlying school-based expressive writing with adolescents. CONCLUSIONS: However, these conclusions are still preliminary because of the paucity of the qualitative evidence found, both in quantity and quality. We recommend that more rigorous and in-depth qualitative research be undertaken to: 1) explore adolescents' subjective experience about the expressive writing intervention, using in-depth individual interviews; 2) thoroughly assess the content of students' texts written during the intervention; and 3) document the process of expressive writing interventions through observational methods. The results of such investigations would support the development and implementation of school-based expressive writing-type of interventions adapted to adolescents.

Understanding the motivations of health-care providers in performing female genital mutilation: an integrative review of the literature.

BACKGROUND: Female genital mutilation (FGM) is a traditional harmful practice that can cause severe physical and psychological damages to girls and women. Increasingly, trained health-care providers carry out the practice at the request of families. It is important to understand the motivations of providers in order to reduce the medicalization of FGM. This integrative review identifies, appraises and summarizes qualitative and quantitative literature exploring the factors that are associated with the medicalization of FGM and/or re-infibulation. METHODS: Literature searches were conducted in PubMed, CINAHL and grey literature databases. Hand searches of identified studies were also examined. The "CASP Qualitative Research Checklist" and the "STROBE Statement" were used to assess the methodological quality of the qualitative and quantitative studies respectively. A total of 354 articles were reviewed for inclusion. RESULTS: Fourteen (14) studies, conducted in countries where FGM is largely practiced as well as in countries hosting migrants from these regions, were included. The main findings about the motivations of health-care providers to practice FGM were: (1) the belief that performing FGM would be less harmful for girls or women than the procedure being performed by a traditional practitioner (the so-called "harm reduction" perspective); (2) the belief that the practice was justified for cultural reasons; (3) the financial gains of performing the procedure; (4) responding to requests of the community or feeling pressured by the community to perform FGM. The main reasons given by health-care providers for not performing FGM were that they (1) are concerned about the risks that FGM can cause for girls' and women's health; (2) are preoccupied by the legal sanctions that might result from performing FGM; and (3) consider FGM to be a "bad practice". CONCLUSION: The findings of this review can inform public health program planners, policy makers and researchers to adapt or create strategies to end medicalization of FGM in countries with high prevalence of this practice, as well as in countries hosting immigrants from these regions. Given the methodological limitations in the included studies, it is clear that more robust in-depth qualitative studies are needed, in order to better tackle the complexity of this phenomenon and contribute to eradicating FGM throughout the world.

Acceptability and feasibility of home and hospital follow-up in Burkina Faso and Guinea: A mixed-method study among patients of the COVID-19 Coverage-Africa clinical trial.

Patient experiences and perspectives on trial participation and follow-up may influence their compliance with research procedures or negatively impact their well-being. We aimed to explore the acceptability and feasibility of home-based and hospital-based follow-up modalities among COVID-19 patients enrolled in the ANTICOV ANRS COV33 Coverage-Africa trial in Burkina Faso and Guinea. The trial (2021-2022) evaluated the efficacy of treatments to prevent clinical worsening among COVID-19 patients with mild to moderate symptoms. Patients were either based at home or hospitalized, as per national recommendations, and followed-up through face-to-face visits and phone calls. We conducted a mixed-methods sub-study administering a questionnaire to all consenting participants and individually interviewing purposively selected participants. We performed descriptive analyses of Likert scale questions for the questionnaires and thematic analysis for the interviews. We conducted framework analysis and interpretation. Of the 400 trial patients, 220 completed the questionnaire (n = 182 in Burkina Faso, n = 38 in Guinea) and 24 were interviewed (n = 16 and n = 8, respectively). Participants were mostly followed-up at home in Burkina Faso; all patients from Guinea were first hospitalized, then followed-up at home. Over 90% of participants were satisfied with follow-up. Home follow-up was considered acceptable if (i) participants perceived they were not severely ill, (ii) it was combined with telemedicine, and (iii) the risk of stigma could be avoided. Hospital-based follow-up was viewed as a way to prevent contamination of family members, but could be badly experienced when mandatory and conflicting with family responsibilities and commitments. Phone calls were seen as reassuring and as a way to ensure continuity of care. These overall positive findings support the development of home-based follow-up for mildly ill patients in West-Africa, provided that both emotional and cognitive factors at individual, familial/inter-relational, healthcare and national levels be addressed when planning the implementation of a trial, or developing any public health strategy.

Implementing an outpatient clinical trial on COVID-19 treatment in an emergency epidemic context: a mixed methods study among operational and research stakeholders within the Coverage trial, Bordeaux (France).

BACKGROUND: The emergency set-up and implementation of outpatient clinical trials on epidemic emerging infectious diseases such as COVID-19 raise many issues in terms of research structuration, regulations, and health systems organization. We aimed to describe the experience and points of view of different stakeholders involved in a French home-based outpatient trial on COVID-19 and to identify the early barriers and facilitators to the trial implementation. METHODS: We conducted a mixed-methods study in July 2020. A self-administered questionnaire was emailed to 213 clinical, operational and research stakeholders involved in the Coverage trial; individual semi-directed interviews were conducted among 14 stakeholders. Questionnaire data and written interview notes are presented together by key theme. RESULTS: One hundred fifty six stakeholders responded to the questionnaire. 53.4% did not have prior experience in clinical research. The motivation of most stakeholders to participate in the Coverage trial was to feel useful during the pandemic. 87.9% agreed that the trial had an unusual set-up timeframe, and many regretted a certain lack of regulatory flexibility. Mobile medical teams and specific professional skills were perceived as instrumental for outpatient research. CONCLUSIONS: The implementation of a home-based outpatient clinical trial on COVID-19 was perceived as relevant and innovative although requiring important adaptations of usual professional responsibilities and standard research procedures. Lessons learned from the Coverage trial underline the need for improved networks between hospital and community medicine, and call for a dedicated and reactive outpatient research platform on emerging or threatening infectious diseases.

Perceptions of COVID-19 among communities of Conakry (Guinea): a qualitative study exploring the context of the ANRS COV33 Coverage-Africa therapeutic trial.

OBJECTIVES: To explore communities' perceptions about COVID-19 in the context of the ANRS COV33 Coverage-Africa clinical trial evaluating the efficacy of treatments in preventing clinical worsening of COVID-19. DESIGN: Descriptive qualitative study using semistructured in-depth individual interviews conducted by telephone in French and Soussou between May and September 2021. Data were transcribed, translated in French when applicable and analysed with the thematic analysis method. SETTING: The eight neighbourhoods most affected by COVID-19 in Conakry's urban context, capital of Guinea. PARTICIPANTS: 4 community leaders acting as key informants-providing insights regarding population's opinions-and six community members, who were exposed to an information session conducted as part of Coverage-Africa. RESULTS: According to participants, community members have heterogeneous viewpoints about COVID-19: it exists and is dangerous; it is benign ('bad cold'); or it is fictitious (eg, government conspiracy). The fear of stigmatisation and social isolation of those sick or cured of COVID-19 was largely reported by participants, with illustrations of distressing situations for the victims. To avoid stigma, many patients seem to adopt strategies of discretion (eg, lying/hiding about the disease). Although community attitudes were reported to have evolved since the beginning of the epidemic, stigma remained a pervasive concern for many people. CONCLUSIONS: Community perceptions about COVID-19 in Conakry may be partly explained by the Guinean context of Ebola history and of sociopolitical tensions. Stigmatisation of COVID+ people seems to be aimed at protecting others against contamination. However, social avoidance can greatly affect the morale of stigmatised people, especially in collectivist cultures like Guinea. Further investigating stigma, including its role on seeking COVID-19 screening and treatment services, and its consequences on mental health among affected/exposed people, would contribute to identifying improved prevention and care interventions in preparation for future health threats, and to promoting participation in health research. TRIAL REGISTRATION NUMBER: NCT04920838 (Pre-results stage).