Support for sexual and reproductive health and rights in Sub-Saharan Africa: a new index based on World Values Survey data.

BACKGROUND: Addressing attitudes is central to achieving sexual and reproductive health and rights (SRHR) and Agenda 2030. We aimed to develop a comprehensive index to measure attitudinal support for SRHR, expanding opportunities for global trend analyses and tailored interventions. METHODS: We designed a new module capturing attitudes towards different dimensions of SRHR, collected via the nationally representative World Values Survey in Ethiopia, Kenya, and Zimbabwe during 2020-2021 (n = 3,711). We used exploratory factor analysis of 58 items to identify sub-scales and an overall index. Adjusted regression models were used to evaluate the index according to sociodemographic characteristics, stratified by country and sex. RESULTS: A 23-item, five-factor solution was identified and used to construct sub-indices reflecting support for: (1) sexual and reproductive rights, (2) neighborhood sexual safety, (3) gender-equitable relationships, (4) equitable masculinity norms, and (5) SRHR interventions. These five sub-indices performed well across countries and socioeconomic subgroups and were combined into a comprehensive "SRHR Support Index", standardized on a 1-100 scale (mean = 39.19, SD = 15.27, Cronbach's alpha = 0.80) with higher values indicating more support for SRHR. Mean values were highest in Kenya (45.48, SD = 16.78) followed by Ethiopia (40.2, SD = 13.63), and lowest in Zimbabwe (32.65, SD = 13.77), with no differences by sex. Higher education and being single were associated with more support, except in Ethiopia. Younger age and urban residence correlated with more support among males only. CONCLUSION: The SRHR Support Index has the potential to broaden SRHR attitude research from a comprehensive perspective - addressing the need for a common measure to track progress over time.

Sexual and reproductive health and rights (SRHR) are becoming increasingly polarized worldwide, but researchers have previously not been able to fully measure what people think about SRHR. More research about this topic is needed to address discriminatory norms and advance SRHR for all. In this study, we added new questions to the World Values Survey collected in Ethiopia, Kenya, and Zimbabwe during 2020­2021. We used statistical methods to develop an index capturing to what extent individuals' attitudes were supportive of SRHR. This index, which we call the SRHR Support Index, included 23 survey questions reflecting support for five related dimensions of SRHR. Those dimensions were (1) sexual and reproductive rights, (2) neighborhood sexual safety, (3) gender-equitable relationships, (4) equitable masculinity norms, and (5) SRHR interventions. We found that individuals in Kenya were more supportive of SRHR, followed by Ethiopia and then Zimbabwe. There were no differences in support of SRHR between men and women, but individuals who were single and those with higher education were more supportive of SRHR, except in Ethiopia. Younger men living in urban areas were also more supportive. Our SRHR Support Index enables researchers, policymakers, and others to measure attitudes to SRHR in countries across the world and over time, based on new data from the World Values Survey that are readily available online. If combined with other sources of data, researchers can also investigate how people's support of SRHR is linked to, for example, health and policy.

Impacts of a social and behavior change communication program implemented at scale on infant and young feeding practices in Nigeria: Results of a cluster-randomized evaluation.

BACKGROUND: Infant and young child feeding (IYCF) practices are important for child survival and healthy growth, but IYCF practices remain suboptimal in Nigeria. The objective of this study was to measure the impact of Alive & Thrive's IYCF social and behavior change communication intervention on early initiation of breastfeeding, exclusive breastfeeding, and minimum dietary diversity in Kaduna and Lagos States. METHODS: Local government areas were randomly allocated to intervention or comparison. Cross-sectional surveys of households with children aged 0-23 months were conducted [N = 6,266 baseline (2017), N = 7,320 endline (2020)]. Logistic regression was used to calculate difference-in-differences estimates (DDEs) of impact on IYCF practices and to assess within group changes from baseline to endline. Associations between intervention exposures and IYCF practices were tested in both study groups combined. RESULTS: In Kaduna, a positive differential effect of the intervention was found for exclusive breastfeeding (adjusted DDE 8.9 pp, P<0.099). Increases in both study groups from baseline to endline were observed in Kaduna for early initiation of breastfeeding (intervention 12.2 pp, P = 0.010; comparison 6.4 pp, P = 0.118) and minimum dietary diversity (intervention 20.0 pp, P<0.001; comparison 19.7 pp, P<0.001), which eliminated differential effects. In Lagos, no differential intervention impacts were found on IYCF practices because changes in early initiation of breastfeeding from baseline to endline were small in both study groups and increases in both study groups from baseline to endline were observed for exclusive breastfeeding (intervention 8.9 pp, P = 0.05; comparison 6.6 pp, P<0.001) and minimum dietary diversity (intervention 18.9 pp, P<0.001; comparison 24.3 pp, P<0.001). Odds of all three IYCF practices increased with exposure to facility-based interpersonal communication in both states and with community mobilization or mass media exposure in Kaduna. CONCLUSIONS: This evaluation found weak impacts of the Alive & Thrive intervention on IYCF practices in the difference-in-differences analysis because of suspected intervention spillover to the comparison group. Substantial within group increases in IYCF practices from baseline to endline are likely attributable to the intervention, which was the major IYCF promotion activity in both states. This is supported by the association between intervention exposures and IYCF practices. TRIAL REGISTRATION: The study was registered with clinicaltrials.gov (NCT02975063).

Gender norms and women's empowerment as barriers to facility birth: A population-based cross-sectional study in 26 Nigerian states using the World Values Survey.

BACKGROUND: Central and western Africa struggle with the world's lowest regional proportion of facility birth at 57%. The aim of the current study was to compare beliefs related to maternal health care services, science/technology, gender norms, and empowerment in states with high vs. low proportions of facility birth in Nigeria. METHODS: Face-to-face interviews were performed as part of a nationally representative survey in Nigeria using a new module to measure values and beliefs related to gender and sexual and reproductive health and rights collected as part the 2018 World Values Survey. We compared beliefs related to maternal health care services, science/technology, gender norms, and empowerment between Nigerian states with facility birth proportions > 50% vs. < 25% as presented in the 2018 Nigerian Demographic Health Survey report. Pearson's chi-squared test, the independent t-test, and univariable and multivariable logistic and linear regression were used for analyses. Results were also stratified by gender. RESULTS: Among the 1,273 participants interviewed, 653 resided in states with high and 360 resided in states with low proportions of facility birth. There were no significant differences between the groups in perceived safety of facility birth (96% vs. 94%) and confidence in antenatal care (91% vs 94%). However, in states with low proportions of facility birth, participants had higher confidence in traditional birth attendants (61% vs. 39%, adjusted odds ratio [aOR] 2.1, [1.5-2.8]), men were more often perceived as the ones deciding whether a woman should give birth at a clinic (56% vs. 29%, aOR 2.4 [1.8-3.3]), and participants experienced less freedom over their own lives (56% vs. 72%, aOR 0.56 [0.41-0.76]). Most differences in responses between men and women were not statistically significant. CONCLUSIONS: In order to increase facility births in Nigeria and other similar contexts, transforming gender norms and increasing women's empowerment is key.