Barriers to achieving the first 90%: gender norms and HIV testing among men in the Democratic Republic of the Congo.

Gender inequality and gender norms are key social drivers of the HIV epidemic through their influences on sexual relationships, behavior, and risk taking. However, few empirical studies have measured the influence of gender norms on HIV sexual-risk behaviors and HIV testing among men in sub-Saharan Africa. We analyzed cross-sectional, survey data from 399 sexually active men (ages 18-39) in Democratic Republic of the Congo to examine the relationship between the men's support for inequitable gender norms and their HIV-risk behaviors. Logistic regression analyses revealed that moderate and strong levels of support for inequitable gender norms were significantly associated with never having been tested for HIV (AOR = 2.92, p < .05 and AOR = 3.41, p < .01, for moderate and strong support, respectively). Our findings indicate that changing the prevailing gender norms should be prioritized in HIV-prevention efforts that aim to increase counseling and testing for men.

Experiences with the levonorgestrel-releasing intrauterine system in Kenya: qualitative interviews with users and their partners.

OBJECTIVES: The levonorgestrel-releasing intrauterine system (LNG-IUS) is an underused contraceptive method in sub-Saharan Africa. A recent market assessment in Kenya found that if a more affordable version of the method were available it may increase demand and uptake of the method. We therefore aimed to examine attitudes and perceptions around the LNG-IUS and experiences of method use, including exploring attributes such as bleeding changes, contraceptive-related amenorrhoea and perceived non-contraceptive benefits. METHODS: Qualitative interviews were conducted among 29 women who were current or recent users of the LNG-IUS, and among a subset (n = 9) of their husbands/partners. RESULTS: Our findings indicate that women's main reason for choosing the LNG-IUS for contraception was their perception that the method had fewer side effects compared with other contraceptive methods. Women had favourable attitudes towards using the LNG-IUS. Husbands were also very positive about their partner's use of the method. CONCLUSION: Understanding the motivations and experiences of early adopters of the LNG-IUS can help inform the development of demand creation and communication strategies to influence uptake and continuation of the LNG-IUS both in Kenya and perhaps more broadly. Communication efforts that emphasise the positive attributes of the LNG-IUS could help promote wider use of the method, especially if new, more affordable product(s) become available.

Meeting the Reproductive Health Needs of Female Key Populations Affected by HIV in Low- and Middle-Income Countries: A Review of the Evidence.

Female sex workers and other women at high risk of acquiring HIV have the right to sexual and reproductive health, including the right to determine the number and timing of pregnancies. We conducted a literature review to examine the data that exist regarding the family planning and reproductive health needs of female key populations, the underlying determinants of these populations' vulnerability to poor reproductive health outcomes, and the obstacles they face in accessing high-quality reproductive health services. Findings indicate that female key populations experience high rates of unmet need for family planning and safer conception services, unintended pregnancies, sexual violence, and abortion, and that they practice inconsistent condom use. Restrictive policy environments, stigma and discrimination in health care settings, gender inequality, and economic marginalization restrict access to services and undermine the ability to safely achieve reproductive intentions. We offer recommendations for structural, health system, community, and individual-level interventions that can mitigate the effects of these barriers and improve reproductive health outcomes.

INTERACTIVE WORKSHOPS TO PROMOTE GENDER EQUITY AND FAMILY PLANNING IN RURAL COMMUNITIES OF GUATEMALA: RESULTS OF A COMMUNITY RANDOMIZED STUDY.

In Guatemala, especially in rural areas, gender norms contribute to high fertility and closely spaced births by discouraging contraceptive use and constraining women from making decisions regarding the timing of their pregnancies and the size of their families. Community workshops for men, women and couples were conducted in 30 rural communities in Guatemala to test the hypothesis that the promotion of gender equity in the context of reproductive health will contribute to gender-equitable attitudes and strengthen the practice of family planning. Communities were randomly assigned to intervention and control groups. Pre/post surveys were conducted. Odds ratios estimated with mixed effect models to account for community-level randomization and repeated measures per participant were compared. The analyses showed statistically significant effects of the intervention on two of the three outcomes examined: gender attitudes and contraceptive knowledge. Findings regarding contraceptive use were suggestive but not significant. The results suggest that it is possible to influence both inequitable gender norms and reproductive health knowledge and, potentially, behaviours in a short span of time using appropriately designed communications interventions that engage communities in re-thinking the inequitable gender norms that act as barriers to health.

The influence of gender attitudes on contraceptive use in Tanzania: new evidence using husbands' and wives' survey data.

This paper explores the hypothesis that gender attitude scales (which measure the degree of equity in gender attitudes) are associated with contraceptive use. Four hundred male and female respondents (200 couples) were interviewed using a pre-tested, structured questionnaire. Analyses included comparisons of means and prevalence rates on gender equity indicators, other related factors and socio-demographic characteristics; t-tests to compare mean scores on each gender scale for wives and husbands to identify any significant differences; chi-squared tests to compare associations between individual attributes, attitudes and contraceptive use; and multivariate logistic regression to examine associations between each gender scale and contraceptive use. The findings revealed that, on average, wives endorsed more inequitable gender attitudes compared with husbands on all gender attitude scales. For wives, more equitable gender attitudes were positively associated with contraceptive use. For husbands, the role of gender attitudes had no significant association with wives' reported contraceptive use. Family planning programmes that aim to challenge inegalitarian gender norms should not overlook women in their efforts since both men and women often accept and support inequality in a social system and, in some cases, it may be women's gender attitudes that most influence family planning decisions.

Expectant care versus surgical treatment for miscarriage.

BACKGROUND: Miscarriage is a common complication of early pregnancy that can have both medical and psychological consequences such as depression and anxiety. The need for routine surgical evacuation with miscarriage has been questioned because of potential complications such as cervical trauma, uterine perforation, hemorrhage, or infection. OBJECTIVES: To compare the safety and effectiveness of expectant management versus surgical treatment for early pregnancy failure. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (9 February 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4 of 4), PubMed (2005 to 11 January 2012), POPLINE (inception to 11 January 2012), LILACS (2005 to 11 January 2012) and reference lists of retrieved studies. SELECTION CRITERIA: Randomized trials comparing expectant care and surgical treatment (vacuum aspiration or dilation and curettage) for miscarriage were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors assessed trial quality and extracted data. We contacted study authors for additional information. For dichotomous data, we calculated the Mantel-Haenszel risk ratio (RR) with 95% confidence interval (CI). For continuous data, we computed the mean difference (MD) and 95% CI. We entered additional data such as medians into 'Other data' tables. MAIN RESULTS: We included seven trials with 1521 participants in this review. The expectant-care group was more likely to have an incomplete miscarriage by two weeks (RR 3.98; 95% CI 2.94 to 5.38) or by six to eight weeks (RR 2.56; 95% CI 1.15 to 5.69). The need for unplanned surgical treatment was greater for the expectant-care group (RR 7.35; 95% CI 5.04 to 10.72). The mean percentage needing surgical management in the expectant-care group was 28%, while 4% of the surgical-treatment group needed additional surgery. The expectant-care group had more days of bleeding (MD 1.59; 95% CI 0.74 to 2.45). Further, more of the expectant-care group needed transfusion (RR 6.45; 95% CI 1.21 to 34.42). The mean percentage needing blood transfusion was 1.4% for expectant care compared with none for surgical management. Results were mixed for pain. Diagnosis of infection was similar for the two groups (RR 0.63; 95% CI 0.36 to 1.12), as were results for various psychological outcomes. Pregnancy data were limited. Costs were lower for the expectant-care group (MD -499.10; 95% CI -613.04 to -385.16; in UK pounds sterling). AUTHORS' CONCLUSIONS: Expectant management led to a higher risk of incomplete miscarriage, need for unplanned (or additional) surgical emptying of the uterus, bleeding and need for transfusion. Risk of infection and psychological outcomes were similar for both groups. Costs were lower for expectant management. Given the lack of clear superiority of either approach, the woman's preference should be important in decision making. Pharmacological ('medical') management has added choices for women and their clinicians and has been examined in other reviews.

Seeking synergies: understanding the evidence that links menstrual health and sexual and reproductive health and rights.

Global efforts to improve menstrual health and sexual and reproductive health and rights (SRHR) are fundamentally intertwined and share similar goals for improving health and well-being and increasing gender equality. Historically, however, the two fields have operated independently and missed opportunities to build upon their biological and sociocultural linkages. Biological touchpoints connecting the two fields include genital tract infections, menstrual disorders, contraception, and menopause. From a sociocultural perspective, intersections occur in relation to the experience of puberty and menarche, gender norms and equity, education, gender-based violence, and transactional sex. We describe evidence linking menstrual health and SRHR and offer recommendations for integration that could strengthen the impact of both fields.

Boys Mentoring, Gender Norms, and Reproductive Health-Potential for Transformation.

PURPOSE: Understanding and addressing the unique health and development needs of adolescent boys and young men (ABYM) is critical to achieving positive development outcomes for all genders. While major investments have been historically allocated toward adolescent girls and young women, a handful of approaches designed explicitly to reach ABYM have been successful. This review aims to understand the potential impact of mentoring interventions for ABYM on reproductive health (RH) knowledge and practices; social assets and soft skills; levels of gender-based and interpersonal violence; attitudes around gender equality; and substance use and financial vulnerability. METHODS: An electronic search of peer-reviewed and gray literature produced a review of 1,178 articles which yielded a total of 29 articles evaluating the 27 interventions included in the final review. RESULTS: Mentoring approaches demonstrate promise for improving soft skills and social assets among ABYM-two factors that are thought to contribute to positive youth development outcomes-and for reducing violence perpetration. While these findings demonstrate the importance of this approach for ABYM in their own right, evidence regarding impact on gender norm transformation, RH, and substance use is mixed. CONCLUSIONS: Mentoring programs appear to be a promising practice for ABYM; they have demonstrated the potential to improve soft skills and social assets, as well as to impact rates of violence perpetration. More research is needed to better understand why the evidence for impact on gender norm transformation, RH, and substance use is mixed, and how to build upon those programs that demonstrated positive results.

Experiences With the Levonorgestrel Intrauterine System Among Clients, Providers, and Key Opinion Leaders: A Mixed-Methods Study in Nigeria.

BACKGROUND: The levonorgestrel intrauterine system (LNG IUS) is one of the most effective contraceptive methods, and it has noncontraceptive health benefits, including treatment for women with heavy menstrual bleeding. In 2016, Marie Stopes International Organisation Nigeria (MSION) expanded LNG IUS provision through training and support to 9 mobile outreach teams, 105 social franchise clinics, and 20 public-sector providers in 17 states. Information about the LNG IUS was added to awareness-raising materials, and community mobilizers provided information on the LNG IUS alongside other voluntary family planning methods. METHODS: In 2016, Marie Stopes International, MSION, and FHI 360 examined clients' and providers' experiences with the LNG IUS to assess the potential for further scale-up of the method as part of a comprehensive approach to family planning in Nigeria. A mixed-methods approach was used including analysis of routine service data, supplemental data specific to LNG IUS clients, and in-depth interviews with LNG IUS clients, providers, and key opinion leaders. RESULTS: Just under 1,000 LNG IUS were inserted from September 2016 to December 2017 in 16 states in channels supported by MSION, representing 0.4% of all long-acting and reversible contraceptive (LARC) services provided by the participating providers during this time frame. The vast majority (82%) of LARCs provided were implants. A small pool of providers was responsible for providing almost half of the LNG IUS services. Common reasons for women choosing the LNG IUS were reduced menstrual bleeding (61%), long-acting duration (52%), effectiveness (49%), and discreetness (42%). Almost 80% of the users first heard about the method from a provider. Almost all users and providers reported positive experiences with the method, noting the noncontraceptive benefits and fewer side effects compared with other methods. All providers who were interviewed said they would continue offering the LNG IUS. Several key opinion leaders mentioned a total market approach incorporating both public and private sectors would be needed to successfully scale up the LNG IUS. CONCLUSION: Reduced menstrual bleeding and fewer side effects compared with other methods were identified as important attributes of the LNG IUS by clients, providers, and key opinion leaders. Challenges to uptake of the LNG IUS include difficulty with introducing a new method within a busy service delivery infrastructure and limited awareness and demand-generation activities on the LNG IUS specifically. A comprehensive product introduction approach with coordinated demand- and supply-side activities may be required for this method to reach its full potential.

Mentoring Interventions and the Impact of Protective Assets on the Reproductive Health of Adolescent Girls and Young Women.

Adolescent girls and young women (AGYW) are disproportionately affected by HIV and AIDS and other negative reproductive health (RH) outcomes. Emerging evidence suggests that programs to build AGYW's assets can help reduce their vulnerability to poor RH. Mentoring interventions have demonstrated a positive impact on a variety of youth development outcomes, including the protective assets needed to circumvent poor RH outcomes. The purpose of this review was to understand the types of mentoring programs for AGYW that have demonstrated effectiveness in improving protective assets, and/or, RH knowledge, intentions, behaviors, or outcomes themselves. Interventions were identified through an electronic search of the peer-reviewed and the gray literature. Studies were excluded in stages based on reviews of titles, abstracts, and full text. A review of 491 publications yielded a total of 19 articles that were included in the final review. The majority of the publications examined the impact of the one-to-one mentoring model in the United States. However, a good proportion examined the impact of both one-on-one and group-based interventions globally. The few interventions that followed a group-based model demonstrated more promise; evaluations of this model demonstrated a positive impact on RH knowledge and behavior, academic achievement, financial behavior, and social networks, as well as reductions in the experience of violence. Group-based mentoring programs demonstrated the most promise in building AGYW's protective assets and improving their RH outcomes. The most successful interventions consisted of multiple components, including mentoring, that sought to directly improve AGYW's protective assets and met with more frequency over a longer duration. Despite the promising evidence, more research is needed to better understand the relationship between assets and RH; the characteristics of successful mentoring programs; and the influence mentoring alone has on RH outcomes, versus mentoring as part of a larger RH program.