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

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

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

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

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

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

Adolescents' Sexual Wellbeing in Southwestern Uganda: A Cross-Sectional Assessment of Body Image, Self-Esteem and Gender Equitable Norms.

Measures of sexual wellbeing and positive aspects of sexuality in the World Health Organization definition for sexual health are rarely studied and remain poorly understood, especially among adolescents in Sub-Saharan Africa. The objective of this study was to assess sexual wellbeing in its broad sense-i.e., body image, self-esteem, and gender equitable norms-and associated factors in young adolescents in Uganda. A cross-sectional survey of adolescents ages 10-14 years in schools was carried out between June and July 2016. Among 1096 adolescents analyzed, the median age was 12 (Inter-Quartile Range (IQR): 11, 13) and 58% were female. Self-esteem and body image scores were high with median 24 (IQR: 22, 26, possible range: 7-28) and median 22 (IQR: 19, 24, possible range: 5-25) respectively. Gender equitable norms mean score was 28.1 (SD 5.2: possible range 11-44). We noted high scores for self-esteem and body image but moderate scores on gender equitable norms. Girls had higher scores compared to boys for all outcomes. A higher age and being sexually active were associated with lower scores on gender equitable norms. Gender equitable norms scores decreased with increasing age of adolescents. Comprehensive and timely sexuality education programs focusing on gender differences and norms are recommended.

"Girls Have More Challenges; They Need to Be Locked Up": A Qualitative Study of Gender Norms and the Sexuality of Young Adolescents in Uganda.

Unequal power and gender norms expose adolescent girls to higher risks of HIV, early marriages, pregnancies and coerced sex. In Uganda, almost half of the girls below the age of 18 are already married or pregnant, which poses a danger to the lives of young girls. This study explores the social construction of gender norms from early childhood, and how it influences adolescents' agency. Contrary to the mainstream theory of agency, which focuses on the ability to make informed choices, adolescents' agency appears constrained by context-specific obstacles. This study adopted qualitative research approaches involving 132 participants. Of these, 44 were in-depth interviews and 11 were focus group discussions, parcelled out into separate groups of adolescents (12-14 years), teachers, and parents (n = 88), in Western Uganda. Data were analysed manually using open and axial codes, and conclusions were inductive. Results show that gender norms are established early in life, and have a very substantial impact on the agency of young adolescents. There were stereotypical gender norms depicting boys as sexually active and girls as restrained; girls' movements were restricted; their sexual agency constrained; and prevention of pregnancy was perceived as a girl's responsibility. Programs targeting behavioural change need to begin early in the lives of young children. They should target teachers and parents about the values of gender equality and strengthen the legal system to create an enabling environment to address the health and wellbeing of adolescents.

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

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

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

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

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

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