Do adolescent girls' education and friendships have independent effects on early pregnancy? Results of a mediation analysis from a longitudinal cohort study in Nairobi, Kenya.

Background: Few studies have examined whether the effect of education on pregnancy and childbearing is due to the academic skills acquired or the social environment that schooling provides. This paper explores whether adolescent girls' learning skills, school enrollment, grade attainment, and friendships affect risk of pregnancy, and whether friendships mediate the relationship between education and pregnancy. Methods: We draw on three waves of longitudinal data on adolescent girls aged 11-15 in Kibera, an informal settlement in Nairobi, Kenya between years 2015-2019. We use fixed effects regression models to estimate effects of girls' learning skills, school attendance, grade attainment, and friendships on their probability of experiencing a pregnancy. We conduct mediation analyses to assess whether friendships mediate the relationship between education and pregnancy. Results: By round one (2015), 0.1 % of girls reported having experienced a pregnancy; by round three (2019), 6.3 %. Even after adjusting for friendships, we find that attending school decreases probability of pregnancy by nine percentage points; an additional year of schooling decreases probability of pregnancy by three percentage points; and a one standard deviation increase in numeracy decreases probability of pregnancy by one percentage point. Having any male friends who do not attend school increases girls' probability of experiencing a pregnancy by four percentage points; this association remains after adjusting for girls' education. However, out-of-school girls are far more likely to report out-of-school male friends. We find no evidence that other types of friendships affect girls' probability of becoming pregnant. Conclusion: We find significant protective effects of school attendance, higher grade attainment and numeracy skills on girls' pregnancy, and that having close friendships with out-of-school males increases girls' probability of pregnancy. We did not find evidence of meaningful mediation, suggesting that the protective effects of school attendance and learning remain regardless of any risk they may face from their friendships.

Gender, power, and violence: A systematic review of measures and their association with male perpetration of IPV.

INTRODUCTION: Harmful gender norms, views on the acceptability of violence against women, and power inequities in relationships have been explored as key drivers of male perpetration of intimate partner violence (IPV). Yet such antecedents have been inconsistently measured in the empirical literature. This systematic review aimed to identify which measures of gender inequitable norms, views, relations and practices are currently being used in the field, and which are most closely tied with male IPV perpetration. METHODS: We searched five electronic databases to identify studies published between 2000 and 2015 that reported the association between such gender inequities and male perpetration of IPV. Identified scales were categorized by content area and level of generality, as well as other attributes, and we compared the consistency of scale performance across each category. RESULTS: Twenty-three studies were identified, employing 64 measures. Scales were categorized into three main thematic areas: views on gender roles/norms, acceptance of violence against women, and gender-related inequities in relationship power and control. We also classified whether the scale was oriented to respondents' own views, or what they believed others do or think. While overall, measures were positively associated with IPV perpetration in 45% of cases, this finding varied by scale type. Measures inclusive of acceptance of violence against women or beliefs about men's sexual entitlement, followed by scales that measured respondents' views on gender roles/norms, were most consistently associated with IPV perpetration. Measures of relationship power showed less consistent associations. We found few scales that measured peer or community norms. CONCLUSION: Validated scales that encompass views on the acceptance of violence against women, and scales inclusive of beliefs about men's sexual entitlement, may be particularly promising for unpacking pathways to IPV perpetration, targeting interventions, and monitoring progress in IPV prevention efforts. A number of gaps in the literature are identified.

A Systematic Review of Adolescent Girl Program Implementation in Low- and Middle-Income Countries: Evidence Gaps and Insights.

Increasing attention to adolescent girls has generated an abundance of programs and a growing body of research on adolescent girls in low- and middle-income countries. Despite this, questions remain about what implementation approaches in program design are most effective, hindering efficient resource allocation, program scale-up, and replication across settings. To address these questions, we conducted a systematic review to identify lessons learned and gaps in the evidence base. We searched four electronic databases to identify studies published between 1990 and 2014 that evaluated health, social, and/or economic development programs targeting adolescent girls in low- and middle-income countries. Seventy-seven (77) studies meeting specified criteria were identified, of which 19 presented results that allowed conclusions relevant to implementation science. Studies examining the following questions were assessed: To what extent, if any, do multicomponent interventions (as opposed to single-component interventions) improve outcomes for girls? What is the added value of involving actors in addition to the girl herself such as parents, guardians, husbands (i.e., multilevel interventions)? What is the threshold proportion of girls who need to participate in a program to bring about normative and behavior changes at the community level? Is a greater level of program exposure associated with greater programmatic benefit for girls? Can supplemental "booster" activities extend the benefits of a program after it ends? We found evidence to support associations between multicomponent (vs. single component) programs, and longer program exposure (vs. less program exposure), with more favorable outcomes for girls, although both conclusions include methodological limitations. Overall, few studies assessed boosters or program saturation, and evidence on multilevel versus single-level programs was inconclusive. Few studies assessed implementation science questions by design, exposing large gaps in the evidence base. We call for future research to explicitly test such implementation science questions to inform more effective use of resources and to improve outcomes for girls.

Women's Perceptions and Misperceptions of Male Circumcision: A Mixed Methods Study in Zambia.

Women's perceptions of male circumcision (MC) have implications for behavioral risk compensation, demand, and the impact of MC programs on women's health. This mixed methods study combines data from the first two rounds of a longitudinal study (n = 934) and in-depth interviews with a subsample of respondents (n = 45) between rounds. Most women correctly reported that MC reduces men's risk of HIV (64% R1, 82% R2). However, 30% of women at R1, and significantly more (41%) at R2, incorrectly believed MC is fully protective for men against HIV. Women also greatly overestimated the protection MC offers against STIs. The proportion of women who believed MC reduces a woman's HIV risk if she has sex with a man who is circumcised increased significantly (50% to 70%). Qualitative data elaborate women's misperception regarding MC. Programs should address women's informational needs and continue to emphasize that condoms remain critical, regardless of male partner's circumcision status.

The case for addressing gender and power in sexuality and HIV education: a comprehensive review of evaluation studies.

CONTEXT: Curriculum-based sexuality and HIV education is a mainstay of interventions to prevent STIs, HIV and unintended pregnancy among young people. Evidence links traditional gender norms, unequal power in sexual relationships and intimate partner violence with negative sexual and reproductive health outcomes. However, little attention has been paid to analyzing whether addressing gender and power in sexuality education curricula is associated with better outcomes. METHODS: To explore whether the inclusion of content on gender and power matters for program efficacy, electronic and hand searches were conducted to identify rigorous sexuality and HIV education evaluations from developed and developing countries published between 1990 and 2012. Intervention and study design characteristics of the included interventions were disaggregated by whether they addressed issues of gender and power. RESULTS: Of the 22 interventions that met the inclusion criteria, 10 addressed gender or power, and 12 did not. The programs that addressed gender or power were five times as likely to be effective as those that did not; fully 80% of them were associated with a significantly lower rate of STIs or unintended pregnancy. In contrast, among the programs that did not address gender or power, only 17% had such an association. CONCLUSIONS: Addressing gender and power should be considered a key characteristic of effective sexuality and HIV education programs.

Female sex workers, male circumcision and HIV: a qualitative study of their understanding, experience, and HIV risk in Zambia.

Several sub-Saharan African countries, including Zambia, have initiated national voluntary medical male circumcision (MC) programs to reduce HIV incidence. In-depth interviews were conducted with twenty female sex workers (FSWs) in Lusaka to examine their understanding of MC and experiences with circumcised clients. Knowledge of MC was derived primarily through informal sources, with very few FSWs reporting exposure to MC educational campaigns. MC was not widely believed to be protective against HIV, however it was viewed by some as protective against STIs. Three FSWs reported having sex with recently circumcised clients, and most reported that men often used their MC status to try to convince FSWs to forego condoms. Findings suggest that FSWs, already at high risk for HIV infection, may face additional pressure toward higher risk behavior as a result of MC. As MC services are expanded, programs should support FSWs' efforts to protect themselves by providing information about what MC can--and cannot--offer for HIV/STI infection prevention.