Individual, partner, and community variables associated with method-specific contraceptive beliefs in urban and rural Kenya.

OBJECTIVES: Global unmet need for contraception remains high. Contraceptive health-related beliefs are a barrier to contraceptive use but are poorly understood. This study examined quantitative differences in two health-related beliefs between pills, injectables, and implants. STUDY DESIGN: We used cross-sectional baseline data collected between August and December 2016 from Nairobi (urban) and Homa Bay (rural) Kenya among women aged 15 to 39 years (N = 5081). Dichotomous outcome variables were constructed for two health-related beliefs (infertility and serious health problems) for the three methods. Using a socioecological framework, possible risk factors at individual, relationship, and community levels were identified a priori. We used logistic regression to identify factors associated with method-specific beliefs. RESULTS: Roughly a quarter of participants believed the methods caused serious health problems, while a smaller overall proportion believed the methods caused infertility. Risk factors patterned similarly across methods but differed between beliefs. In adjusted models, perceived partner approval of a method was associated with lower odds of believing it caused infertility or serious health problems. Unsatisfactory or mixed social network experiences predicted serious health problems but not infertility beliefs. Current use was associated with lower odds of believing all three methods caused serious health problems, but only implant users were more likely to believe they caused infertility. Past use was associated with higher odds of serious health problems but not infertility beliefs. CONCLUSIONS: Across three methods, negative community and perceived partner attitudes toward specific contraceptive methods were associated with higher individual-level odds of contraceptive health beliefs in Kenya. IMPLICATIONS: Efforts to support women who want to use contraception should focus on providing information on contraceptive health and fertility concerns, ideally targeting partners and women of all ages in addition to potential contraceptive users. It is reasonable to address these concerns broadly across commonly used contraceptive methods.

Prevalence of adolescent mental disorders in Kenya, Indonesia, and Viet Nam measured by the National Adolescent Mental Health Surveys (NAMHS): a multi-national cross-sectional study.

BACKGROUND: Mental disorders are the leading global cause of health burden among adolescents. However, prevalence data for mental disorders among adolescents in low-income and middle-income countries are scarce with often limited generalisability. This study aimed to generate nationally representative prevalence estimates for mental disorders in adolescents in Kenya, Indonesia, and Viet Nam. METHODS: As part of the National Adolescent Mental Health Surveys (NAMHS), a multinational cross-sectional study, nationally representative household surveys were conducted in Kenya, Indonesia, and Viet Nam between March and December, 2021. Adolescents aged 10-17 years and their primary caregiver were interviewed from households selected randomly according to sampling frames specifically designed to elicit nationally representative results. Six mental disorders (social phobia, generalised anxiety disorder, major depressive disorder, post-traumatic stress disorder, conduct disorder, and attention-deficit hyperactivity disorder) were assessed with the Diagnostic Interview Schedule for Children, Version 5. Suicidal behaviours and self-harm in the past 12 months were also assessed. Prevalence in the past 12 months and past 4 weeks was calculated for each mental disorder and collectively for any mental disorder (ie, of the six mental disorders assessed). Prevalence of suicidal behaviours (ie, ideation, planning, and attempt) and self-harm in the past 12 months was calculated, along with adjusted odds ratios (aORs) to show the association with prevalence of any mental disorder in the past 12 months. Inverse probability weighting was applied to generate national estimates with corresponding 95% CIs. FINDINGS: Final samples consisted of 5155 households (ie, adolescent and primary caregiver pairs) from Kenya, 5664 households from Indonesia, and 5996 households from Viet Nam. In Kenya, 2416 (46·9%) adolescents were male and 2739 (53·1%) were female; in Indonesia, 2803 (49·5%) adolescents were male and 2861 (50·5%) were female; and in Viet Nam, 3151 (52·5%) were male and 2845 (47·4%) were female. Prevalence of any mental disorder in the past 12 months was 12·1% (95% CI 10·9-13·5) in Kenya, 5·5% (4·3-6·9) in Indonesia, and 3·3% (2·7-4·1) in Viet Nam. Prevalence in the past 4 weeks was 9·4% (8·3-10·6) in Kenya, 4·4% (3·4-5·6) in Indonesia, and 2·7% (2·2-3·3) in Viet Nam. The prevalence of suicidal behaviours in the past 12 months was low in all three countries, with suicide ideation ranging from 1·4% in Indonesia (1·0-2·0) and Viet Nam (1·0-1·9) to 4·6% (3·9-5·3) in Kenya, suicide planning ranging from 0·4% in Indonesia (0·3-0·8) and Viet Nam (0·2-0·6) to 2·4% (1·9-2·9) in Kenya, and suicide attempts ranging from 0·2% in Indonesia (0·1-0·4) and Viet Nam (0·1-0·3) to 1·0% (0·7-1·4) in Kenya. The prevalence of self-harm in the past 12 months was also low in all three countries, ranging from 0·9% (0·6-1·3) in Indonesia to 1·2% (0·9-1·7) in Kenya. However, the prevalence of suicidal behaviours and self-harm in the past 12 months was significantly higher among those with any mental disorder in the past 12 months than those without (eg, aORs for suicidal ideation ranged from 7·1 [3·1-15·9] in Indonesia to 14·7 [7·5-28·6] in Viet Nam). INTERPRETATION: NAMHS provides the first national adolescent mental disorders prevalence estimates for Kenya, Indonesia, and Viet Nam. These data can inform mental health and broader health policies in low-income and middle-income countries. FUNDING: The University of Queensland in America (TUQIA) through support from Pivotal Ventures, a Melinda French Gates company.

Exploring Barriers to Accessing Adolescents Sexual and Reproductive Health Services in South Ethiopia Regional State: A Phenomenological Study Using Levesque's Framework.

Introduction: Evidence suggests that adolescents face multiple barriers to accessing Sexual and Reproductive Health (SRH) services. However, there remains a notable gap in the literature regarding the nuanced interplay between supply-side and demand-side barriers. Therefore, this study aimed to examine barriers to accessing SRH services in the Gamo Zone of South Ethiopia Regional State. Methods: A descriptive phenomenology study was conducted from September 04 to October 15, 2023. A total of seven Focus Group Discussions (FGDs), four with girls and three with boys, with a total of 75 adolescents, and ten Key informant interviews (KIIs)with healthcare providers participated in the study. A semi-structured interview guide was used to explore their lived experiences. All interviews and discussions were audio-recorded. To analyze and manage data framework analysis approach was applied using ATLAS Ti version 7 software. Results: The major barriers preventing adolescents from accessing SRH services are related to the interplay between supply and demand-side barriers across all five domains of the Levesque framework. Despite the high need for access to health care, lack of SRH literacy, lack of outreach activities, and integration of SRH information in health facilities often hampered adolescents' healthcare need. Additionally, fear of stigma from family and community, social norms, and lack of discussion of SRH issues hindered their ability to seek health care. Shortage of supplies and healthcare providers' behaviors further hindering adolescents' ability to access health care services. Furthermore, the limited involvement of adolescents in decision-making and the lack of effective coordination further complicate the appropriateness of services for adolescents. Conclusion: The finding of this study reveals that adolescents face multifaceted barriers. Therefore, there is a need for high-impact complex interventions, program and policy that address both supply and demand side barriers needs to give due intention to improve access to SRH services for adolescents.

Socio-Ecological Analysis of Barriers to Access and Utilization of Adolescent Sexual and Reproductive Health Services in Sub-Saharan Africa: A Qualitative Systematic Review.

Background: In sub-Saharan African countries (SSA), despite the efforts to enable adolescents to access sexual and reproductive health (SRH) services, there are limited systematic review studies that comprehensively synthesize barriers to accessing services using a social-ecological model. Therefore, this review was conducted to fill this gap. Methods: This study protocol was registered in the PROSPERO database (CRD42022259095). We followed PRISMA guideline to conduct this review. PubMed, Google Scholar, Embase and African Journal Online databases were used. Two authors individually screened articles. Only qualitative articles published in the English in last 10 years were included in this review. Results: From the total of 4890 studies, 23 qualitative studies fulfilled the eligibility criteria. Those studies were from 11 SSA countries. This review finding revealed that inadequate information about the services, the incorrect perception about services, low self-esteem, fear of being noticed by family members, and financial constraints are barriers at the intrapersonal level. Unsupportive families and lack of open communication between adolescent-parent about sexuality issues were interpersonal barriers to access. Lack of provider competency, provider attitude, an unsupportive environment, physical inaccessibility of services, and shortage of medicine, and supplies were identified as institutional-level barriers. Moreover, community-level barriers like community stigma, social, religious, and gender norms within the society were identified as the main barriers to accessing services for adolescents. Conclusion: This review finding reveals that the main barriers to access SRH services for adolescents living in SSA are misperception about services, low self-esteem to access services, financial constraints, unsupportive families, community stigma and social norms, unsupportive environments in health facilities, healthcare provider behavior, poor competency, being judgmental attitude, and breaking privacy and confidentiality. This study finding calls for new approach like a multi-pronged that works with service providers, with community, with families, and with adolescent to improve SRH services utilization of adolescent.

Women's beliefs about methods and contraceptive discontinuation: Results from a prospective study from Nairobi and Homa Bay counties in Kenya.

Background: Rates of contraceptive discontinuation are high in many low and middle countries contributing to unmet need for contraception and other adverse reproductive health outcomes. Few studies have investigated how women's beliefs about methods and strength of fertility preferences affect discontinuation rates. This study examines this question using primary data collected in Nairobi and Homa Bay counties in Kenya. Methods: We used data from two rounds of a longitudinal study of married women ages 15-39 years (2,812 and 2,424 women from Nairobi and Homa Bay respectively at round 1). Information on fertility preferences, past and current contraceptive behavior, and method-related beliefs about six modern contraceptive methods were collected, along with a monthly calendar of contraceptive use between the two interviews. The analysis focused on discontinuation of the two most commonly used methods in both sites, injectables and implants. We carry out competing risk survival analysis to identify which method related beliefs predict discontinuation among women using at the first round. Results: The percentages of episodes discontinued in the 12 months between the two rounds was 36%, with a higher rate of discontinuation in Homa Bay (43%) than in the Nairobi slums (32%) and higher for injectables than implants. Method related concerns and side effects were the major self-reported reasons for discontinuation in both sites. The competing risk survival analysis showed that the probability of method related discontinuation of implants and injectables was significantly lower among respondents who believed that the methods do not cause serious health problems (SHR = 0.78, 95% CI: 0.62-0.98), do not interfere with regular menses (SHR = 0.76, 95% CI: 0.61-0.95) and do not cause unpleasant side effects (SHR = 0.72, 95% CI 0.56-0.89). By contrast, there were no net effects of three method related beliefs that are commonly cited as obstacles to contraceptive use in African societies: safety for long-term use, ability to have children after stopping the method, and the approval of the husband. Conclusion: This study is unique in its examination of the effect of method-specific beliefs on subsequent discontinuation for a method-related reason, using a longitudinal design. The single most important result is that concerns about serious health problems, which are largely unjustified and only moderately associated with beliefs about side effects, are a significant influence on discontinuation. The negative results for other beliefs show that the determinants of discontinuation differ from the determinants of method adoption and method choice.

Sexual and reproductive health service utilization among adolescent girls in Kenya: A cross-sectional analysis.

We examined the association between adolescents' sexual and reproductive health (SRH) service utilization in the past 12 months and structural, health facility, community, interpersonal, and individual level factors in Kenya. This cross-sectional analysis used baseline data collected in Homa Bay and Narok counties as part of the In Their Hands intervention evaluation from September to October 2018. In total, 1840 adolescent girls aged 15 to 19 years were recruited to complete a baseline survey. We used unadjusted and adjusted logistic regression to model factors associated with SRH utilization across the social-ecological framework levels. Overall, 36% of participants reported visiting a health facility for SRH services in the past 12 months. At the structural level being out-of-school (AOR: 2.12 95% CI: 1.60-2.82) and not needing to get permission to go (AOR: 1.37 95%CI: 1.04-1.82) were associated with SRH service utilization. At the interpersonal level, participants who reported being able to ask adults for help when they needed it were more likely to report using SRH services in the past 12 months (AOR: 1.98, 95% CI: 1.09-3.78). At the individual level, having knowledge about where to obtain family planning (AOR = 2.48 95% CI: 1.74-3.57) and receiving information on SRH services in the past year (AOR: 1.44 95% CI:1.15-1.80) were associated with SRH service utilization. Our findings demonstrate the need for interventions, policies, and practices to be implemented across structural, health facility, community, interpersonal, and individual levels to comprehensively support adolescent girls to access and use SRH services.

Measuring the Prevalence of Mental Disorders in Adolescents in Kenya, Indonesia, and Vietnam: Study Protocol for the National Adolescent Mental Health Surveys.

PURPOSE: In low- and middle-income countries, there are limited data on mental disorders among adolescents. To address this gap, the National Adolescent Mental Health Surveys (NAMHS) will provide nationally representative prevalence data of mental disorders among adolescents in Kenya, Indonesia, and Vietnam. This paper details the NAMHS study protocol. METHODS: In each country, a multistage stratified cluster sampling design will be used. Participants will be eligible pairs of adolescents aged 10-17 years and their primary caregiver. Adolescents will be assessed for social phobia, generalized anxiety disorder, major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and post-traumatic stress disorder using the Diagnostic Interview Schedule for Children, version 5. Demographics, risk and protective factors, and service use information will also be collected. In the parallel clinical calibration study, diagnoses of major depressive disorder, social phobia, and generalized anxiety disorder made using the Diagnostic Interview Schedule for Children, version 5 will be calibrated against a diagnostic assessment by in-country clinicians in a separate sample. RESULTS: Data collection for the national survey and clinical calibration study will commence in 2021, with dissemination of findings and methodology due to occur in 2022. CONCLUSIONS: Accurately quantifying the prevalence of mental disorders in adolescents is essential for service planning. NAMHS will address this lack of prevalence data, both within the NAMHS countries and within their respective regions, while establishing a gold-standard methodology for data collection on adolescent mental health in low- and middle-income countries. More broadly, NAMHS will encourage capacity building within each country by establishing linkages between researcher, clinician, government, and other networks.

Exposure to violence, adverse life events and the mental health of adolescent girls in Nairobi slums.

INTRODUCTION: Mental health problems rank among the leading causes of disability among young people globally. Young people growing up in urban slums are exposed to adverse childhood experiences, violence, and other adversities. There is limited research on how exposure to violence and adverse life events influence adolescents' mental health in urban poor settings. This study examines the associations between exposure to violence, adverse life events and self-reported depression in the slums of Nairobi. METHODS: This study draws on data collected from 2106 adolescent girls aged 12-19 years who were interviewed in the third wave of the Adolescent Girls Initiative Kenya (AGI-K). Mental health was measured using the Patient Health Questionnaire (PHQ 9). Frequency distributions, bivariate chi-squared analysis and multi-variate regression models were computed to identify factors that are independently associated with depression. RESULTS: About 13.3% of girls had symptoms of depression based on PHQ 9, 22% reported physical or sexual violence in the past year and about 47% of girls reported exposure to adverse life events in the family in the past year. After adjusting for the effects of socio-demographic factors, exposure to physical violence (AOR = 2.926, 95% CI 2.175-3.936), sexual violence (AOR = 2.519, 95% CI 1.637-3.875), perception of neighborhood safety (AOR = 1.533, 95% CI 1.159-2.028) and experience of adverse life events (AOR = 1.326, 95% CI 1.002-1.753) were significantly associated with self-reported depression. The presence of social support moderated the relationship between violence and mental health by reducing the strength of the association between violence and mental health in this setting. CONCLUSION: Given the magnitude of violence victimisation, adverse life events and depressive symptoms, there is a need to design interventions that reduce exposure to violence and provide psychosocial support to adolescents exposed to adverse events in urban slums in Nairobi.

Impacts of multisectoral cash plus programs after four years in an urban informal settlement: Adolescent Girls Initiative-Kenya (AGI-K) randomized trial.

BACKGROUND: The vast majority of adolescent births occur in low- and middle-income countries and are associated with negative outcomes for both the mother and her child. A multitude of risk factors may explain why few programs have been successful in delaying childbearing and suggest that multisectoral interventions may be necessary. This study examines the longer-term impact of a two-year (2015-17) multisectoral program on early sexual debut and fertility in an urban informal settlement in Kenya. METHODS: The study used a randomized trial design, longitudinally following 2,075 girls 11-14 years old in 2015 until 2019. The interventions included community dialogues on unequal gender norms and their consequences (violence prevention), a conditional cash transfer (education), health and life skills training (health), and financial literacy training and savings activities (wealth). Girls were randomized to one of four study arms: 1) violence prevention only (V-only); 2) V-only and education (VE); 3) VE and health (VEH); or 4) all four interventions (VEHW). We used ANCOVA to estimate intent-to-treat (ITT) impacts of each study arm and of pooled study arms VE, VEH, and VEHW relative to the V-only arm, on primary outcomes of fertility and herpes simplex virus-2 (HSV-2) infection, and secondary outcomes of education, health knowledge, and wealth creation. Post-hoc analysis was carried out on older girls who were 13-14-years-old at baseline. In 2018, in the VEHW arm, in-depth qualitative evaluation were carried out with adolescent girls, their parents, school staff, mentors, community conversation facilitators, and community gatekeepers. The trial is registered at ISRCTN: ISRCTN77455458. RESULTS: At endline in the V-only study arm, 21.0 percent of girls reported having had sex, 7.7 percent having ever been pregnant and 6.6 percent having ever given birth, with higher rates for the older subsample at 32.5 percent, 11.8 percent, and 10.1 percent, respectively. In the full sample, ever having given birth was reduced by 2.3 percentage points (pp) in the VE and VEHW study arms, significant at 10 percent. For the older subsample there were larger and significant reductions in the percent ever having had sex (8.2 pp), HSV-2 prevalence (7.5 pp) and HSV-2 incidence (5.6 pp) in the VE arm. Two years after the end of the interventions, girls continued to have increased schooling, sexual and reproductive health knowledge, and improved financial savings behaviors. Qualitatively, respondents reported that girls were likely to have sex as a result of child sexual exploitation, peer pressure or influence from the media, as well as for sexual adventure and as a mark of maturity. CONCLUSION: This study demonstrates that multisectoral cash plus interventions targeting the community and household level, combined with interventions in the education, health, and wealth-creation sectors that directly target individual girls in early adolescence, generate protective factors against early pregnancy during adolescence. Such interventions, therefore, potentially have beneficial impacts on the longer-term health and economic outcomes of girls residing in impoverished settings. CLINICAL TRIAL REGISTRATION: ISRCTN registry: ISRCTN77455458; https://doi.org/10.1186/ISRCTN77455458.

Exploring Providers' Perception Towards Provision of Sexual and Reproductive Health Services for Unmarried Adolescents in Gamo Zone, Southern Ethiopia: A Phenomenological Study.

BACKGROUND: Healthcare providers play a critical role in the provision of sexual and reproductive health services for adolescents. In Ethiopia, due to different reasons, including healthcare providers associated reasons, most unmarried adolescents are not accessing the services. However, little is known about healthcare providers' perception towards the provision of SRH services for unmarried adolescents. This study aimed to explore healthcare provider perception towards the provision of SRH services to unmarried adolescents in Gamo zone, Southern Ethiopia. METHODS: A qualitative phenomenological research design was used in May 2021. Fifteen healthcare providers (HCPs) working in adolescent and youth sexual and reproductive health centers were involved in this study. A purposive sampling technique was used to select healthcare providers assuming they are "information-rich" regarding the phenomenon of interest. Inclusion of the study participants was continued until data saturation is reached. To analyze the data, we used inductive thematic analysis, method, and main themes, which captured the diverse views and feelings of the participants. To maintain the trustworthiness of the data, we used dependability, transferability, conformability, and credibility. RESULTS: In this study, individual-level attributes such as healthcare provider's personal belief, attitude, and motivation; community-level influences like socio-cultural norms, religious reasons, and lack of parental support; and health system setbacks like shortage of essential medical supplies and lack of training are identified as major obstacles in the provision of sexual and reproductive health services for unmarried adolescents. CONCLUSION: Provision of sexual and reproductive health services for unmarried adolescents is constrained by the interplay of factors acting at an individual level, community level, and health system level. The Ministry of Health (MOH), program planners and policymakers are recommended to give due attention to fulfill the necessary inputs, improving healthcare provider's attitude and skill and engagement of religious and community leaders to create a safe and supportive environment for providing sexual and reproductive health services to unmarried adolescents.

The Potential of Self-Managed Abortion to Expand Abortion Access in Humanitarian Contexts.

Refugees and displaced people face uniquely challenging barriers to abortion access, including the collapse of health systems, statelessness, and a lack of prioritization of sexual and reproductive health services by humanitarian agencies. This article summarizes the evidence around abortion access in humanitarian contexts, and highlights the opportunities for interventions that could increase knowledge and support around self-managed abortion. We explore how lessons learned from other contexts can be applied to the development of effective interventions to reduce abortion-related morbidity and mortality, and may improve access to information about safe methods of abortion, including self-management, in humanitarian settings. We conclude by laying out a forward-thinking research agenda that addresses gaps in our knowledge around abortion access and experiences in humanitarian contexts.

Impacts of two-year multisectoral cash plus programs on young adolescent girls' education, health and economic outcomes: Adolescent Girls Initiative-Kenya (AGI-K) randomized trial.

BACKGROUND: Early adolescence is a critical window for intervention when it is possible to lay a foundation for a safe transition to adulthood, before negative outcomes occur. The Adolescent Girls Initiative-Kenya randomized trial tested the effects of combinations of interventions for young adolescent girls in two sites - the Kibera informal settlement in Nairobi and rural Wajir County in the Northeastern region. METHODS: The interventions included community dialogues on the role and value of girls (violence prevention), a conditional cash transfer (education), weekly group meetings for girls with health and life skills training (health), and training and incentives for financial literacy and savings activities (wealth creation). Participants were randomized to one of four study arms: 1) violence prevention only, 2) violence prevention and education, 3) violence prevention, education and health or 4) violence prevention, education, health and wealth creation. An intent-to-treat (ITT) analysis was conducted using longitudinal data to estimate the impact of each combination of interventions and various sensitivity analyses conducted addressing potential attrition bias and multiple hypothesis testing concerns. RESULTS: In Kibera, the education conditional cash transfer had small effects on grade attainment but larger impacts on completion of primary school and the transition to secondary school in the most comprehensive arm; the health intervention improved sexual and reproductive health knowledge and condom self-efficacy; and the wealth intervention improved financial literacy and savings behavior. In Wajir, the education conditional cash transfer increased school enrollment and grade attainment, and the wealth intervention improved savings behavior. CONCLUSIONS: The results indicate that when trying to improve a range of outcomes related to adolescent wellbeing for young girls, a multisectoral intervention with components addressing household economic constraints is a promising approach. TRIAL REGISTRATION: Trial Registry: ISRCTN, ISRCTN77455458 . Registered 24/12/2015 - Retrospectively registered.

Method-specific beliefs and subsequent contraceptive method choice: Results from a longitudinal study in urban and rural Kenya.

INTRODUCTION: Evidence from sub-Saharan Africa, including Kenya, shows that negative beliefs about contraceptive methods are associated with non-use. However, little is known about the relationship between contraceptive beliefs and subsequent method choice. METHODOLOGY: We used data from a two-year longitudinal survey of married women aged 15-39 years at enrollment from one urban site (Nairobi) and one rural site (Homa Bay) in Kenya. Analysis entails descriptive statistics and estimation of a conditional logit analysis to examine associations between method-specific beliefs and choice of injectables, implants or pills among women who were not using any method or were pregnant at baseline (round 1) but adopted these methods at 12-month follow-up (Nairobi, n = 221; Homa Bay n = 197). RESULTS: Beliefs about pills, injectables and implants among non-users were generally negative. With the partial exception of the pill in Nairobi, the majority thought that each method was likely to cause serious health problems, unpleasant side effects, menstrual disruption, and would be unsafe for long-term use. In both sites, satisfied past use of a method and the perception that a method is easy to use had a major influence on method choice. Concerns about menstrual disruption and safety for long-term use were unimportant in both sites. There were some marked differences between the two sites. Beliefs about long-term fertility impairment and perceived husband approval had strong influences on choice of injectables, implants or pills in the urban site but not in the rural site. CONCLUSION: The relative importance of beliefs, some erroneous, in predisposing women to choose one method over another appears to be conditioned by the social context. There is need for family planning counseling programmes to pay attention to erroneous beliefs and misconceptions about contraceptives.

Intimate partner violence against adolescents and young women in sub-Saharan Africa: who is most vulnerable?

BACKGROUND: Intimate partner violence (IPV) is a global public health and human rights issue that affects millions of women and girls. While disaggregated national statistics are crucial to assess inequalities, little evidence exists on inequalities in exposure to violence against adolescents and young women (AYW). The aim of this study was to determine inequalities in physical or sexual IPV against AYW and beliefs about gender based violence (GBV) in sub-Saharan Africa (SSA). METHODS: We used data from the most recent Demographic and Health Surveys (DHS) conducted in 27 countries in SSA. Only data from surveys conducted after 2010 were included. Our analysis focused on married or cohabiting AYW aged 15-24 years and compared inequalities in physical or sexual IPV by place of residence, education and wealth. We also examined IPV variations by AYW's beliefs about GBV and the association of country characteristics such as gender inequality with IPV prevalence. RESULTS: The proportion of AYW reporting IPV in the year before the survey ranged from 6.5% in Comoros to 43.3% in Gabon, with a median of 25.2%. Overall, reported IPV levels were higher in countries in the Central Africa region than other sub-regions. Although the prevalence of IPV varied by place of residence, education and wealth, there was no clear pattern of inequalities. In many countries with high prevalence of IPV, a higher proportion of AYW from rural areas, with lower education and from the poorest wealth quintile reported IPV. In almost all countries, a greater proportion of AYW who approved wife beating for any reason reported IPV compared to their counterparts who disapproved wife beating. Reporting of IPV was weakly correlated with the Gender Inequality Index and other societal level variables but was moderately positively correlated with adult alcohol consumption (r = 0.48) and negative attitudes towards GBV (r = 0.38). CONCLUSION: IPV is pervasive among AYW, with substantial variation across and within countries reflecting the role of contextual and structural factors in shaping the vulnerability to IPV. The lack of consistent patterns of inequalities by the stratifiers within countries shows that IPV against women and girls cuts across socio-economic boundaries suggesting the need for comprehensive and multi-sectoral approaches to preventing and responding to IPV.

HIV trends and disparities by gender and urban-rural residence among adolescents in sub-Saharan Africa.

BACKGROUND: In sub-Saharan Africa HIV transmission is a major challenge in adolescents, especially among girls and those living in urban settings. Major international efforts have aimed at reducing sexual transmission of HIV. This analysis aims to assess the trends in HIV prevalence by gender in adolescents, as well as urban-rural disparities. METHODS: HIV prevalence data at ages 15-19 years were obtained for 31 countries with a national survey since 2010 and for 23 countries with one survey circa 2005 and a recent survey circa 2015. Country medians and average annual rates of changes were used to summarize the trends for two subregions in sub-Saharan Africa, Eastern and Southern Africa and West and Central Africa, which largely correspond with higher and lower HIV prevalence countries. Data on HIV incidence at ages 15-24 and prevalence at 5-9 and 10-14 years were reviewed from 11 recent national surveys. Trends in urban-rural disparities in HIV prevalence and selected indicators of sexual and HIV testing behaviours were assessed for females and males 15-24 years, using the same surveys. RESULTS: HIV prevalence among girls 15-19 years declined in eastern and Southern Africa from 5.7 to 2.6% during 2005-2015 (country median), corresponding with an average annual rate of reduction of 6.5% per year. Among boys, the median HIV prevalence declined from 2.1 to 1.2%. Changes were also observed in West and Central Africa where median HIV prevalence among girls decreased from 0.7 to 0.4% (average annual rate of reduction 5.9%), but not for boys (0.3%). Girl-boy differences at 10-14 years were small with a country median HIV of 1.0% and 1.3%, respectively. Urban females and males 15-24 had at least 1.5 times higher HIV prevalence than their rural counterparts in both subregions, and since the urban-rural declines were similar, the gaps persisted during 2005-2015. CONCLUSIONS: HIV prevalence among adolescents declined in almost all countries during the last decade, in both urban and rural settings. The urban-rural gap persisted and HIV transmission to girls, but not boys, is still a major challenge in Eastern and Southern African countries.

"Those are things for married people" exploring parents'/adults' and adolescents' perspectives on contraceptives in Narok and Homa Bay Counties, Kenya.

BACKGROUND: Contraceptive use among adolescent girls is low in many sub-Saharan African countries including Kenya. Attitude and perspectives about contraception of community members including adolescent girls themselves may be likely to limit contraceptive use among adolescent girls. This study was conducted to explore and compare adults'/parents' and adolescent girls' narratives and perspectives about contraception in Narok and Homa Bay counties, Kenya. METHODS: Qualitative data from 45 in-depth-interviews conducted with purposively selected consenting adolescent girls aged 15-19 was used. Additionally, twelve focus group discussions were held with 86 consenting adults conveniently recruited from the two counties. All discussions were conducted in the local language and audio recorded following consent of the study participants. Female moderators were engaged throughout the study making it appropriate for the study to solicit feedback from the targeted respondents. RESULTS: Findings highlighted adults' perceptions on adolescents' sexuality and the presence of stringent conceptions about the side-effects of contraception in the study communities. Some participants underscored the need for open contraceptive talk between parents and their adolescent girls. Four main themes emerged from the discussions; (i) Perceptions about adolescents' sexuality and risk prevention, (ii) Conceptions about contraception among nulligravida adolescents: fear of infertility, malformation and sexual libertinism, (iii) Post-pregnancy contraceptive considerations and (iv) Thinking differently: divergent views regarding contraceptives and parent/adolescent discussion. CONCLUSIONS: Our findings suggest the need for increased attention towards adolescents and their caregivers particularly in demystifying contraceptive misconceptions. Programmatic responses and models which include the provision of comprehensive sexuality education and increased access to and utilization of SRH information, products and services through a well-informed approach need to be well executed. Programmatic efforts like SRH community education should further seek to enhance the capacity of parents to discuss sexuality with their adolescents.

"I was tricked": understanding reasons for unintended pregnancy among sexually active adolescent girls.

BACKGROUND: While the Kenya government is mobilizing high-level strategies to end adolescent pregnancy by 2030, a clear understanding of drivers of early unintended pregnancy in the country is a necessary precursor. In this study, we determine the prevalence, associated factors, and reasons for unintended pregnancy among sexually active adolescent girls (aged 15-19 in two Kenya counties with the highest rate of teenage pregnancy. METHODS: We used the "In Their Hands" (ITH) program's baseline evaluation data. The study adopted a mixed-methods design with 1110 sexually active adolescent girls in the quantitative component and 19 girls who were either pregnant or nursing a child in the qualitative. We used adjusted and unadjusted logistic regression to model factors associated with unintended pregnancy among respondents. We used a thematic analysis of qualitative data to examine girls' reasons for having unintended pregnancy. RESULTS: Overall, 42% of respondents have had an unintended pregnancy; however, higher proportions were observed among girls who were 19 years (49.4%), double orphans (53.6%), never used contraceptive (49.9%), out-of-school (53.8%), and married (55.6%). After adjusting for relevant covariates, the odds of unintended pregnancy were higher among girls who resided in rural areas (AOR 1.64, 95% CI 1.22-2.20), had primary or no formal education (AOR 1.50 95% CI 1.11-2.02), and had never used contraceptive (AOR 1.69 95% CI 1.25-2.29) compared with their counterparts. Current school attendance was associated with a 66% reduction in the probability of having an unintended pregnancy. Participants of the qualitative study stated that the desire to maintain a relationship, poor contraceptive knowledge, misinformation about contraceptive side effects, and lack of trusted mentors were the main reasons for their unintended pregnancies. CONCLUSION: A massive burden of unintended pregnancy exists among sexually active adolescent girls in the study setting. Adolescent boys and girls need better access to sexuality education and contraceptives in the study setting to reduce early unintended pregnancy.

RéSUMé: CONTEXTE: Alors que le gouvernement kenyan déploie des stratégies de haut niveau pour mettre fin aux grossesses chez les adolescentes d'ici 2030, il est nécessaire de bien cerner les facteurs qui favorisent les grossesses précoces non planifiées dans le pays. Dans cette étude, nous déterminons la prévalence, les facteurs associés et les causes des grossesses non planifiées chez les adolescentes sexuellement actives (âgées de 15 à 19 ans) dans deux comtés du Kenya où le taux de grossesse adolescente est le plus élevé. MéTHODOLOGIE: Nous avons utilisé les données d'évaluation de base du programme « In Their Hands ¼ (ITH). L'étude a adopté une approche mixte comprenant 1110 adolescentes sexuellement actives dans la composante quantitative et 19 adolescentes enceintes ou allaitantes dans la composante qualitative. Nous avons utilisé une régression logistique ajustée et non ajustée pour modéliser les facteurs associés à une grossesse non planifiée chez les répondantes. Pour ce qui est des données qualitatives, nous avons procédé à une analyse thématique afin d'examiner les facteurs expliquant les grossesses non planifiées chez les filles. RéSULTATS: Globalement, 42 % des répondantes ont vécu une grossesse non planifiée ; toutefois, des proportions plus élevées ont été observées chez les filles âgées de 19 ans (49,4 %), celles doublement orphelines (53,6 %), celles qui n'ont jamais utilisé de moyens contraceptifs (49,9 %), celles non scolarisées (53,8 %) et chez celles qui étaient mariées (55,6 %). Après ajustement des covariables pertinentes, les probabilités de grossesse non planifiée étaient plus élevées chez les filles qui résidaient dans des zones rurales (AOR:1,64, IC 95%:1,22-2,20), avaient un niveau d'éducation primaire ou aucune éducation formelle (AOR:1,50 IC 95%:1,11-2,02), et n'avaient jamais utilisé de contraceptifs (AOR:1,69 IC 95%-1,25-2,29) par rapport à leurs congénères. La fréquentation scolaire actuelle était associée à une réduction de 66 % de la probabilité d'être confrontée à une grossesse non planifiée. Les participantes à l'étude qualitative ont déclaré que le désir d'entretenir une relation, une mauvaise connaissance des contraceptifs, de fausses informations sur les effets secondaires des contraceptifs et le manque de mentors de confiance étaient les principales raisons de leurs grossesses non planifiées. CONCLUSION: Un lourd fardeau lié aux grossesses non désirées existe parmi les adolescentes sexuellement actives de la zone étudiée. Les adolescents, garçons et filles, doivent avoir un meilleur accès à l'éducation sexuelle et aux contraceptifs dans la zone étudiée afin de réduire les grossesses non planifiées précoces.

An examination of the characteristics and contraceptive acceptance of post-abortion clients in Ethiopia.

This national study examined the socio-demographic, health facility, and provider characteristics associated with the use of postabortion contraception in Ethiopia in 2014. We used data from a Prospective Morbidity Survey (PMS) conducted in Ethiopia in 2014 to measure abortion incidence and morbidity nationally. Data were collected on the presentation, care and treatment of 5,604 women who sought abortion services in 365 health facilities over 30 days. Descriptive and multivariate logistic regression analysis were used to examine postabortion contraceptive uptake. Nearly 75% of abortion clients received postabortion contraception. The majority received short-acting methods, around one-third chose a long-acting or permanent method. Most women sought abortion services at public health centers (61.8%) and were cared for by midlevel providers (82.5%). Multivariate regression results showed that women who sought services during the first trimester (odds ratio/OR = 1.44; 95% confidence interval/CI 1.06, 1.95), for induced abortions (OR = 3.55; 95% CI 2.52, 4.99), from public sector facilities, and those served by midlevel providers, had greater odds of receiving postabortion contraception. We conclude that providing strong contraceptive services postabortion in government facilities, including long-acting methods in the method mix, and providing this care by midlevel providers could further reduce unmet need for contraception and repeat abortions.

Nature of, and responses to key sexual and reproductive health challenges for adolescents in urban slums in sub-Saharan Africa: a scoping review.

BACKGROUND: Addressing adolescents' sexual and reproductive health and rights (SRHR) requires an understanding of the socio-cultural and spatial settings within which they live. One setting of particular importance is the informal settlements or 'slums' that are gradually dominating the urban space. We undertook a scoping review and synthesis of existing evidence on adolescent SRHR in slums in sub-Saharan Africa (SSA) focusing on the characteristics and nature of existing evidence. METHODS: The scoping review was conducted based on Arksey and O'Malley framework and in accordance with the guidance on scoping reviews from the Joanna Briggs Institute (JBI) and using PRISMA reporting guidelines for scoping reviews. A comprehensive search was undertaken in PubMed, POPLINE, African Journals Online (AJOL), Bioline International and Google Scholar. The search was confined to studies published in peer reviewed journals and reports published online between January 2000 and May 2019. Studies were included in the review if they addressed SRHR issues among adolescents living in urban slums in SSA. RESULTS: The review included a total of 54 studies. The majority (79.5%) of studies were quantitative. The bulk of studies (85.2%) were observational studies with only eight intervention studies. While half (27) of the studies focused exclusively on adolescents (10-19 years), 12 studies combined adolescents with other young people (10-24 years). The studies were skewed towards sexual behavior (44%) and HIV/AIDS (43%) with very few studies focusing on other SRHR issues such as contraception, abortion, gender-based violence and sexually transmitted infections (STIs) other than HIV. Most of the studies highlighted the significantly higher risks for poor SRHR outcomes among adolescents in slums as compared to their peers in other settlements. CONCLUSION: Young people growing up in slums face tremendous challenges in relation to their SRHR needs resulting in poor outcomes such as early and unintended pregnancy, STIs, and sexual violence. The results of this review point to several potential target areas for programming, policy, and research aimed at improved adolescent SRHR in slums in SSA.

Pregnancy and early motherhood among adolescents in five East African countries: a multi-level analysis of risk and protective factors.

BACKGROUND: Adolescent pregnancy remains a major challenge in both developed and developing countries. Early and unintended pregnancies among adolescents are associated with several adverse health, educational, social and economic outcomes. The aim of this study was to identify the contextual factors that influence adolescent pregnancy and early motherhood in five East African countries. METHODS: We use DHS data from five East African countries to examine trends and risk factors associated with adolescent pregnancy. DHS surveys collect detailed information on individual and household characteristics, sexual behavior, contraception, and related reproductive behaviors. Our analysis focuses on a weighted subsample of adolescent's age 15-19 years (Kenya, 5820; Tanzania, 2904; Uganda, 4263; Malawi, 5263; Zambia, 3675). Multilevel logistic regression analysis was used to identify the net effects of individual, household and community level contextual variables on adolescent pregnancy after adjusting for potential confounders. RESULTS: Adolescent pregnancy and early motherhood is common in the five countries, ranging from 18% among adolescents in Kenya (2014) to 29% in Malawi (2016) and Zambia (2014). Although all five countries experienced a decline in adolescent pregnancy since 1990, the declines have been largely inconsistent. More than half of the adolescent's most recent pregnancies and or births in these countries were unintended. The regression analysis found that educational attainment, age at first sex, household wealth, family structure and exposure to media were significantly associated with adolescent pregnancy in at least one of the five countries after adjusting for socio-demographic factors. CONCLUSION: The study highlights the importance of considering multi-sectoral approaches to addressing adolescent pregnancy. Broader development programs that have positive impacts on girls educational and employment opportunities may potentially influence their agency and decision-making around if and when to have children. Likewise, policies and programs that promote access to and uptake of adolescent sexual and reproductive health services are required to reduce barriers to the use of adolescent Sexual and Reproductive Health (SRH) services.