Are Contraceptive Method Preferences Stable? Measuring Change in the Preferred Method among Kenyan Women.

Contraceptive preferences are important for reproductive outcomes, such as contraceptive continuation and pregnancy. Current approaches to measuring reproductive preferences in population surveys are limited to exploring only fertility preferences and implicitly assume that contracepting people are using a method they want. We know that people change their fertility preferences over the life course as a response to life events, but there is no information about changes in contraceptive preferences, given the limited evidence about the measurement and distribution of contraceptive preferences. In this study, we examined the extent of change in women's contraceptive preferences over one year and identified characteristics associated with this change in Kenya using three rounds of nationally representative longitudinal data. Over one year, 18 percent of contraceptive users and 46 percent of contraceptive nonusers reported changes in their preferred contraceptive. Experiencing a pregnancy or birth and changes in marital status were associated with changes in contraceptive preferences for users and nonusers. We found that contraceptive preferences are dynamic, suggesting that family planning programs should ensure people's access to various methods to respond to women's changing circumstances and preferences.

Trends in Adolescent Sexual and Reproductive Health Outcomes Before and Into the COVID-19 Pandemic in Burkina Faso and Kenya: Evidence From Panel Data.

PURPOSE: Many predicted that COVID-19 would have a substantial impact on the sexual and reproductive health (SRH) trajectories of adolescents in sub-Saharan Africa. The lack of longitudinal data with information collected before and into the pandemic has limited investigation into this topic. METHODS: We performed a secondary analysis using nationally representative longitudinal data from Kenya and Burkina Faso, collected at three time points (pre-COVID-19 in late 2019, and during COVID-19 in 2020 and 2021), to determine the extent to which SRH outcomes and behaviors, including pregnancy, contraceptive use, partnership status, and sexual activity, changed during the pandemic among adolescent women. RESULTS: Among adolescents aged 15-19 years (Kenya n = 1,893, Burkina Faso n = 1,422), there was a reduction in both partnership and pregnancy in 2021 as compared to pre-COVID 2019. Contraception use significantly increased between 2019 and 2021 in Kenya only (adjusted odds ratio [aOR]: 1.42, 95% confidence interval [CI] 1.03-1.97). COVID-19-related household income loss was associated with a decline in sexual activity among unmarried Kenyan girls (aOR: 0.47, 95% CI 0.25-0.87) and lower odds of pregnancy in Burkina Faso (aOR: 0.13, 95% CI 0.02-0.91). We did not find a relationship between COVID-19 measures and initiation of partnership or marriage in either setting. DISCUSSION: Contrary to expectations, our results suggest that COVID-19 did not have a consistent or sustaining impact on adolescent SRH and behaviors in Burkina Faso and Kenya. Further research is needed to assess the longer-term implications of the pandemic on adolescent social and health outcomes.

Trends in and Correlates of Short-Acting Contraceptive Stock-Outs: Multicountry Analysis of Performance Monitoring for Action Agile Platform Data.

Understanding trends in contraceptive stock-outs, as well as their structural and demand-side correlates, is critical for policymakers and program managers to identify strategies to further anticipate, reduce, and prevent stock-outs. We analyzed trends as well as supply- and demand-side correlates of short-acting contraceptive method stock-outs by using data from multiple rounds of Performance Monitoring for Action Agile surveys. These data longitudinally measured contraceptive availability over 2 years (between November 2017 and January 2020) across 2,134 public and private service delivery points (SDPs) from urban areas of 5 countries (Burkina Faso, Democratic Republic of the Congo [DRC], India, Kenya, and Nigeria). For each country, we analyzed the trends and used multilevel mixed-effect logistic regression to model the odds of short-acting contraceptive stock-outs, adjusting for key structural and demand-side factors of the SDPs. Stock-outs in short-acting contraceptive methods were common in health facilities and varied markedly, ranging from as low as 2.9% (95% confidence interval [CI]=1.7%, 5.1%) in India to 51.0% (95% CIs=46.8%, 56.0%) in Kenya. During the observation period, stock-out rates decreased by 28% in the SDP samples in India (aOR=0.72, P<.001) and 8% in Nigeria (aOR=0.92, P<.001) but increased by 15% in DRC (aOR=1.15; P=036) and 5% in Kenya (aOR=1.05, P=003) with each round of data collection. Correlates of stock-out rates included the facility managerial authority (private versus public), whether the facility was rated high quality, whether the facility was at an advanced tier, and whether there was high demand for short-acting contraceptives. In conclusion, stock-outs of short-acting contraceptives are still common in many settings. Measuring and monitoring contraceptive stock-outs is crucial for identifying and addressing issues related to the availability and supply of short-acting contraceptives.

Differential discontinuation by covert use status in Kenya.

Objectives: Qualitative research suggests that covert users may be more likely to discontinue contraception due to the logistics of discretion and fear of disclosure. This study sought to quantify whether covert users are more likely to discontinue contraception than overt users. Study design: We used a national longitudinal survey from Kenya conducted from November 2019/February 2020 to November 2020/April 2021 to test whether the time to discontinuation between covert and overt users still in need of contraception differed using survival analyses over a period of 5 years since method initiation. Results: Multivariate Cox regression results showed there was an interaction with time and covert use on the risk of discontinuation; for every additional month of use, there was an increased risk of discontinuation of covert users compared to overt users (3% increased hazard, p = 0.02). At 1 and 2 years, there were no differences in the hazard of discontinuation (adjusted hazard ratio [aHR]1 year 0.95, 95% CI 0.54-1.65 and aHR2 years 1.37, 95% CI 0.85-2.21), yet at 3, 4, and 5 years, the hazard of discontinuation was higher for covert compared to overt users (aHR3 years 1.99, 95% 1.11-3.56; aHR4 years 2.89, 95% CI 2.0-6.40; aHR5 years 4.18, 95% CI 1.45-12.0). Conclusions: These results suggest efforts are needed to support covert users in managing their contraceptive use and for improving contraceptive counseling surrounding covert use. Our findings shed light on the increasing challenge covert users face after approximately the first 2 years of use; covert users require additional follow-up in both research and care provision. Implications: Covert users are at a higher risk of discontinuation of contraception while still trying to avoid pregnancy, particularly after the first 2 years of use. Family planning providers and programs must protect access to and maintain the privacy of reproductive services to this population, focusing on follow-up care provision and counseling.

Assessing trends and reasons for unsuccessful implant discontinuation in Burkina Faso and Kenya between 2016 and 2020: a cross-sectional study.

OBJECTIVES: Contraceptive implant use has grown considerably in the last decade, particularly among women in Burkina Faso and Kenya, where implant use is among the highest globally. We aim to quantify the proportion of current implant users who have unsuccessfully attempted implant removal in Burkina Faso and Kenya and document reasons for and location of unsuccessful removal. METHODS: We use nationally representative data collected between 2016 and 2020 from a cross-section of women of reproductive age in Burkina Faso and Kenya to estimate the prevalence of implant use, proportion of current implant users who unsuccessfully attempted removal and proportion of all removal attempts that have been unsuccessful. We describe reasons for and barriers to removal, including the type of facility where successful and unsuccessful attempts occurred. FINDINGS: The total number of participants ranged from 3221 (2017) to 6590 (2020) in Burkina Faso and from 5864 (2017) to 9469 (2019) in Kenya. Over a 4 year period, the percentage of current implant users reporting an unsuccessful implant discontinuation declined from 9% (95% CI: 7% to 12%) to 2% (95% CI: 1% to 3%) in Kenya and from 7% (95% CI: 4% to 14%) to 3% (95% CI: 2% to 6%) in Burkina Faso. Common barriers to removal included being counselled against removal by the provider or told to return a different day. CONCLUSION: Unsuccessful implant discontinuation has decreased in recent years. Despite progress, substantial numbers of women desire having their contraceptive implant removed but are unable to do so. Greater attention to health systems barriers preventing implant removal is imperative to protect reproductive autonomy and ensure women can achieve their reproductive goals.

Fertility and contraceptive dynamics amidst COVID-19: who is at greatest risk for unintended pregnancy among a cohort of adolescents and young adults in Nairobi, Kenya?

OBJECTIVES: Among youth in Nairobi, we (1) characterised fertility and contraceptive use dynamics by gender; (2) estimated pregnancy prevalence over the pandemic; and (3) assessed factors associated with unintended pandemic pregnancy for young women. DESIGN: Longitudinal analyses use cohort data collected at three timepoints prior to and during the COVID-19 pandemic: June to August 2019 (pre-pandemic), August to October 2020 (12-month follow-up) and April to May 2021 (18-month follow-up). SETTING: Nairobi, Kenya. PARTICIPANTS: At initial cohort recruitment, eligible youth were aged 15-24 years, unmarried and residing in Nairobi for at least 1 year. Within-timepoint analyses were restricted to participants with survey data per round; trend and prospective analyses were restricted to those with complete data at all three timepoints (n=586 young men, n=589 young women). PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes comprised fertility and contraceptive use for both genders, and pregnancy for young women. Unintended pandemic pregnancy (assessed at 18-month follow-up) was defined as a current or past 6-month pregnancy with intent to delay pregnancy for more than 1 year at 2020 survey. RESULTS: While fertility intentions remained stable, contraceptive dynamics varied by gender-young men both adopted and discontinued coital-dependent methods, whereas young women adopted coital-dependent or short-acting methods at 12-month follow-up (2020). Current pregnancy was highest at 2020 (4.8%), and approximately 2% at 2019 and 2021. Unintended pandemic pregnancy prevalence was 6.1%, with increased odds for young women recently married (adjusted OR (aOR)=3.79; 95% confidence interval (CI) 1.83-7.86); recent contraceptive use was protective against unintended pandemic pregnancy (aOR=0.23; 95% CI 0.11-0.47). CONCLUSIONS: Current pregnancy in Nairobi was highest at the height of the COVID-19 pandemic (2020), and subsided to pre-pandemic levels by 2021 data collection; however, requires further monitoring. New marriages posed considerable risk for unintended pandemic pregnancy. Contraceptive use remains a crucial preventive strategy to averting unintended pregnancy, particularly for married young women.

Intersection of reproductive coercion and intimate partner violence: cross-sectional influences on women's contraceptive use in Burkina Faso, Côte d'Ivoire and Kenya.

OBJECTIVES: Among nationally representative cross-sections of women in need of contraception from Burkina Faso, Côte d'Ivoire and Kenya, we aimed to: (1) examine the intersection of past-year physical/sexual intimate partner violence (IPV), emotional IPV and reproductive coercion (RC) and (2) assess the impact of physical/sexual IPV, emotional IPV and RC on women's contraceptive use outcomes, including current contraceptive use, method type and covert use. DESIGN: The present analysis uses cross-sectional female data collected in Burkina Faso (December 2020-March 2021), Côte d'Ivoire (October-November 2021) and Kenya (November-December 2020). SETTINGS: Burkina Faso, Côte d'Ivoire and Kenya PARTICIPANTS: Analytical samples were restricted to partnered women with contraceptive need who completed a violence module (Burkina Faso n=1863; Côte d'Ivoire n=1105; Kenya n=3390). PRIMARY AND SECONDARY OUTCOME MEASURES: The exposures of interest-past-year emotional IPV, physical/sexual IPV and RC-were assessed using abridged versions of the Revised Conflict and Tactics Scale-2 and Reproductive Coercion Scale, respectively. Outcomes of interest included current contraceptive use, contraceptive method type (female controlled vs male compliant), and covert contraceptive use, and used standard assessments. RESULTS: Across sites, 6.4% (Côte d'Ivoire) to 7.8% (Kenya) of women in need of contraception experienced RC; approximately one-third to one-half of women experiencing RC reported no other violence forms (31.7% in Burkina Faso to 45.8% in Côte d'Ivoire), whereas physical/sexual IPV largely occurred with emotional IPV. In multivariable models, RC was consistently associated with covert use (Burkina Faso: aOR 2.84 (95% CI 1.21 to 6.64); Côte d'Ivoire: aOR 4.45 (95% CI 1.76 to 11.25); Kenya: aOR 5.77 (95% CI 3.51 to 9.46)). Some IPV in some settings was also associated with covert use (emotional IPV, Burkina Faso: aOR 2.99 (95% CI 1.56 to 5.74); physical/sexual, Kenya: aOR 2.35 (95% CI 1.33 to 4.17)). CONCLUSIONS: Across settings, covert use is a critical strategy for women experiencing RC. Country policies must recognise RC as a unique form of violence with profound implications for women's reproductive health.

Disruptions to youth contraceptive use during COVID-19: Mixed-methods results from Nairobi, Kenya.

Ensuring access to sexual and reproductive health (SRH) services for adolescents is a global priority, given the detrimental health and economic impact of unintended pregnancies. To examine whether and how COVID-19 affected access to SRH services, we use mixed-methods data from young men and women in Nairobi, Kenya to identify those at greatest risk of contraceptive disruptions during COVID-19 restrictions. Analyses utilize cross-sectional data collected from August to October 2020 from an existing cohort of youth aged 16-26. Unadjusted and adjusted logistic regression examined sociodemographic, contraceptive, and COVID-19-related correlates of contraceptive disruption among users of contraception. Qualitative data were collected concurrently via focus group discussions (n = 64, 8 groups) and in-depth interviews (n = 20), with matrices synthesizing emergent challenges to obtaining contraception by gender. Among those using contraception, both young men (40.4%) and young women (34.6%) faced difficulties obtaining contraception during COVID-19. Among young men, difficulty was observed particularly for those unable to meet their basic needs (aOR = 1.60; p = 0.05). Among young women, risk centered around those with multiple partners (aOR = 1.91; p = 0.01), or who procured their method from a hospital (aOR = 1.71; p = 0.04) or clinic (aOR = 2.14; p = 0.03). Qualitative data highlight economic barriers to obtaining contraceptives, namely job loss and limited supply of free methods previously available. Universal access to a variety of contraceptive methods during global health emergencies, including long-acting reversible methods, is an essential priority to help youth avert unintended pregnancies and withstand periods of disruptions to services. Non-judgmental, youth-friendly services must remain accessible throughout the pandemic into the post-COVID-19 period.

Prevalence and correlates of reproductive coercion across ten sites: commonalities and divergence.

BACKGROUND: Reproductive coercion (RC) is a type of abuse where a partner asserts control over a woman's reproductive health trajectories. Recent research emphasizes that RC experiences may differ within and across low- and middle-income countries (LMICs), as compared to higher income contexts, given social pressures surrounding childbearing. To date, nationally representative surveys have lacked comprehensive measures for RC, leading to gaps in understanding its prevalence and risk factors. Across eight LMICs (10 sites), we aimed to (1) validate the RC Scale; (2) calculate prevalence of RC and specific behaviors; and (3) assess correlates of RC. METHODS: This analysis leverages cross-sectional Performance Monitoring for Action (PMA) data collected from November 2020 to May 2022. Analyses were limited to women in need of contraception (Burkina Faso n = 2767; Côte d'Ivoire n = 1561; Kongo Central, Democratic Republic of Congo (DRC) n = 830; Kinshasa, DRC n = 846; Kenya n = 4588; Kano, Nigeria n = 535; Lagos, Nigeria n = 612; Niger n = 1525; Rajasthan, India n = 3017; Uganda n = 2020). Past-year RC was assessed via five items adapted from the original RC Scale and previously tested in LMICs. Confirmatory factor analysis examined fit statistics by site. Per-item and overall prevalence were calculated. Site-specific bivariate and multivariable logistic regression examined RC correlates across the socioecological framework. RESULTS: Confirmatory factor analysis confirmed goodness of fit across all sites, with moderate internal consistency (alpha range: 0.66 Cote d'Ivoire-0.89 Kinshasa, DRC/Lagos, Nigeria). Past-year reported prevalence of RC was highest in Kongo Central, DRC (20.3%) and lowest in Niger (3.1%). Prevalence of individual items varied substantially by geography. Polygyny was the most common RC risk factor across six sites (adjusted odds ratio (aOR) range: 1.59-10.76). Increased partner education levels were protective in Kenya and Kano, Nigeria (aOR range: 0.23-0.67). Other assessed correlates differed by site. CONCLUSIONS: Understanding RC prevalence and behaviors is central to providing woman-centered reproductive care. RC was most strongly correlated with factors at the partner dyad level; future research is needed to unpack the relative contributions of relationship power dynamics versus cultural norms surrounding childbearing. Family planning services must recognize and respond to women's immediate needs to ensure RC does not alter reproductive trajectories, including vulnerability to unintended pregnancy.

Reproductive coercion (RC) is a type of abuse where a partner asserts control over a woman's reproductive health trajectories. While RC was conceptualized in the United States, recent research highlights that it may be prominent in other geographies, including sub-Saharan Africa. Existing national surveillance programs, including the Demographic and Health Surveys, have included a single item on RC beginning in 2018. Given the phased approach to Demographic and Health Survey roll-out, no studies have examined this single item across diverse contexts. Further, this single item may miss the range of abusive experiences women face when seeking to manage their fertility. Using annual national cross-sections in 10 diverse contexts (eight countries), we sought to: (1) validate a comprehensive RC measure; (2) calculate prevalence of RC and specific behaviors; (3) understand risk factors for RC across contexts. We found that the comprehensive RC measure performed well across sites. Prevalence of past-year RC was highest in the Kongo Central region of the Democratic Republic of Congo (20.3%) and lowest in Niger (3.1%). Polygynous marriage was associated with increased risk of RC across six sites, whereas increased partner education levels were protective against RC in two sites. Understanding the prevalence of RC within a given context and range of specific abusive behaviors, as well as risk profiles, can help alert local service providers to women's needs. A thorough understanding of commonalities and divergence of RC experiences and drivers across sites can help inform prevention and response programming to address RC and its health effects.

Impact of COVID-19 on the mental health of adolescents and youth in Nairobi, Kenya.

Objective: To report on the mental health status of adolescents and youth in relation to the COVID-19 pandemic in Nairobi County, Kenya. Methodology: This was a mixed-methods study with cross-sectional quantitative and qualitative components conducted in Nairobi County, Kenya from August to September 2020. The quantitative survey involved phone interviews of n = 1,217 adolescents and youth. Qualitative components included virtual focus group discussions (FGDs) with adolescents and youth (n = 64 unmarried youths aged 16-25 years, across 8 FGDs) and youth-serving stakeholders (n = 34, across 4 FGDs), key informant interviews (n = 12 higher-level stakeholders from Ministries of Health, Gender, and Education), and in-depth interviews with youth (n = 20) so as to examine the COVID-19 impact on mental health. Results: Among the participants, 26.6% of young men and 30.0% of young women reported probable depressive symptoms, of whom 37.7% of young men and 38.9% of young women reported little interest or pleasure in doing various activities. Hopelessness and feeling down nearly every day was additionally reported by 10.7% of young women and 6.3% of young men. Further, about 8.8% of young men and 7.6% of young women reported they could not get the emotional help and support they may need from people in their life. Multivariable regression results showed an association between depressive symptoms and reduced working hours due to COVID-19 and increased intimate partner violence. Additionally, the results show that respondents with higher emotional help and support were less likely to report depressive symptoms. Qualitative results confirm the quantitative findings and exemplify the negative behavior arising from the impact of adherence to COVID-19 prevention measures. Conclusion: Mental health issues were common among adolescents and youth and may have been augmented by isolation and economic hardships brought about by COVID-19 restrictions. There is a need for concerted efforts to support adolescents and young people to meet their mental health needs, while considering the unique variations by gender. There is need to urgently strengthen the mental health system in Kenya, including via integrating psychosocial support services in communities, schools, and healthcare services, to ensure adolescents and young persons are not left behind.

Sexual harassment before and during the COVID-19 pandemic among adolescent girls and young women (AGYW) in Nairobi, Kenya: a cross-sectional study.

OBJECTIVES: Sexual harassment among adolescent girls and young women (AGYW) is a prevalent and understudied form of gender-based violence (GBV) with negative impacts on health and well-being. The COVID-19 pandemic raised global concern about GBV within homes; less is known about how it affected GBV in public spaces. METHODS: Present analyses use cross-sectional data from a cohort of adolescents and young adults residing in Nairobi, Kenya, restricted to female participants. Data were collected August-October 2020 via phone after implementation of COVID-19 restrictions. Prevalence of past-year sexual harassment and harassment relative to COVID-19 restrictions were calculated for overall sample, and by individual, household, and pandemic-related factors. Multivariate negative binomial regression models examine correlates of (1) past-year sexual harassment and (2) increases in sexual harassment relative to COVID-19 restrictions. RESULTS: Overall, 18.1% of AGYW experienced past-year sexual harassment at the 2020 survey. Among this group, 14.6% experienced sexual harassment pre-COVID-19 only, 18.8% after only and 66.6% at both time points. Among the latter group, 34.9% reported more occurrences following COVID-19 restrictions, 20.5% reported less occurrences and 44.7% reported no change in occurrence. Overall, 42.0% of AGYW experienced an increase in sexual harassment while 58.0% experienced no increase since COVID-19. In adjusted models, past-year sexual harassment was associated with higher educational attainment (adjusted risk ratio, aRR 2.11; 95% CI 1.27 to 3.52) and inability to meet basic financial needs (aRR 1.67; 95% CI 1.05 to 2.66). Increased sexual harassment since COVID-19 was associated with having full control to leave the home (aRR 1.69; 95% CI 1.00 to 2.90). CONCLUSIONS: Sexual harassment among AGYW in Nairobi, Kenya was prevalent before and during COVID-19 restrictions. Safety in public spaces remains a highly gendered issue that impacts women's safety and ability to participate in public life. Prevention and support services to address sexual harassment remain an important element in ensuring safe, sustainable public spaces.

Violence against women from partners and other household members during COVID-19 in Burkina Faso and Kenya.

BACKGROUND: Global evidence indicates increases in gender-based violence (GBV) during the COVID-19 pandemic following mitigation measures, such as stay at home orders. Indirect effects of the pandemic, including income loss, strained social support, and closed or inaccessible violence response services, may further exacerbate GBV and undermine help-seeking. In Kenya and Burkina Faso, as in many settings, GBV was prevalent prior to the COVID-19 pandemic. Studies specific to COVID-impact on GBV in Kenya indicate mixed results and there remains a lack of evidence from Burkina Faso. Our study takes a comprehensive lens by addressing both intimate partner violence (IPV) and non-partner household abuse through the COVID-19 pandemic in two priority settings. METHODS: Annual, national cross-sections of women ages 15-49 completed survey data collection in November-December 2020 and December 2020-March 2021; the GBV module was limited to one woman per household [Kenya n = 6715; Burkina n = 4065]. Descriptive statistics, Venn diagrams, and logistic and multinomial regression characterized prevalence of IPV and other household abuse, frequency relative to the COVID-19 pandemic, help-seeking behaviors, and predictors of IPV and household abuse across the socioecological framework. RESULTS: In both settings, past-year IPV prevalence exceeded non-partner household abuse (Kenya: 23.5%IPV, 11.0%household; Burkina Faso: 25.7%IPV, 16.2%household). Over half of those affected in each setting did not seek help; those that did turned first to family. Among those with past-year experiences, increased frequency since COVID-19 was noted for IPV (16.0%Burkina Faso; 33.6%Kenya) and household violence (14.3%Burkina Faso; 26.2%Kenya). Both context-specific (i.e., financial autonomy in Burkina Faso) and universal (i.e., COVID-related income loss) risk factors emerged. CONCLUSION: Past-year IPV and household violence against women in Kenya and Burkina Faso were prevalent, and in some cases, intensified during the COVID-19 pandemic. Across settings, help-seeking from formal services was notably low, likely reflecting shame, blame, and stigmatization identified as barriers in pre-COVID literature. Both primary prevention and survivor-centered support services, including those related to economic empowerment, should be integrated within COVID-recovery efforts, and extended into the post-pandemic period to fully meet women's safety needs.

Product-access challenges to menstrual health throughout the COVID-19 pandemic among a cohort of adolescent girls and young women in Nairobi, Kenya.

Background: Access to menstrual hygiene products enables positive health for adolescent girls and young women (AGYW). Among AGYW in Nairobi, Kenya, this prospective mixed-methods study characterised menstrual health product-access challenges at two time points during the COVID-19 pandemic; assessed trajectories over the pandemic; and examined factors associated with product-access trajectories. Methods: Data were collected from an AGYW cohort in August-October 2020 and March-June 2021 (n=591). The prevalence of menstrual health product-access challenges was calculated per timepoint, with trajectories characterizing product-access challenges over time. Logistic regression models examined associations with any product-access challenge throughout the pandemic; multinomial and logistic regressions further assessed factors associated with trajectories. Qualitative data contextualize results. Findings: In 2020, 52·0% of AGYW experienced a menstrual health product-access challenge; approximately six months later, this proportion dropped to 30·3%. Product-access challenges during the pandemic were heightened for AGYW with secondary or lower education (aOR=2·40; p<0·001), living with parents (aOR=1·86; p=0·05), not the prime earner (aOR=2·27; p=0·05); and unable to meet their basic needs (aOR=2·25; p<0·001). Between timepoints, 38·0% experienced no product-access challenge and 31·7% resolved, however, 10·2% acquired a challenge and 20·1% experienced sustained challenges. Acquired product-access challenges, compared to no challenges, were concentrated among those living with parents (aOR=3·21; p=0·05); multinomial models further elucidated nuances. Qualitative data indicate deprioritization of menstrual health within household budgets as a contributor. Interpretation: Menstrual health product-access challenges are prevalent among AGYW during the pandemic; barriers were primarily financial. Results may reflect endemic product-access gaps amplified by COVID-specific constraints. Ensuring access to menstrual products is essential to ensure AGYW's health needs. Funding: This work was supported, in whole, by the Bill & Melinda Gates Foundation [010481].

Implementation of respondent driven sampling in Nairobi, Kenya, for tracking key family planning indicators among adolescents and youth: lessons learnt.

OBJECTIVE: Adolescents and youth constitute a significant proportion of the population in developing nations. Conventional survey methods risk missing adolescents/youth because their family planning/contraception (FP/C) behavior is hidden. Respondent-driven sampling (RDS), a modified chain-referral recruitment sampling approach, was used to reach unmarried adolescents/youth aged 15-24 in Nairobi, Kenya to measure key FP/C indicators. Seeds were selected and issued with three coupons which they used to invite their peers, male or female, to participate in the study. Referred participants were also given coupons to invite others till sample size was achieved. We report on key implementation parameters following standard RDS reporting recommendations. RESULTS: A total of 1674 coupons were issued to generate a sample size of 1354. Coupon return rate was 82.7%. Study participants self-administered most survey questions and missing data was low. Differential enrolment by gender was seen with 56.0% of females recruiting females while 44.0% of males recruited males. In about two months, it was possible to reach the desired sample size using RDS methodology. Implementation challenges included presentation of expired coupons, recruitment of ineligible participants and difficulty recruiting seeds and recruits from affluent neighborhoods. Challenges were consistent with RDS implementation in other settings and populations. RDS can complement standard surveillance/survey approaches, particularly for mobile populations like adolescents/youth.

Gendered time use during COVID-19 among adolescents and young adults in Nairobi, Kenya.

Background: Gender disparities in time use contribute to poor outcomes in women. Large-scale disruptions can affect time use. The objectives of this study were to characterize time use across the pandemic by gender and to assess how gender associates with 2021-time use, overall and by 2020 economic dependency status. Methods: A prospective cohort of youth in Nairobi, Kenya, completed phone-based surveys in August-October 2020 and April-May 2021. Time use was characterized at both time points and 1,777 participants with complete time use data at both time points were included in the analysis. 2021-time use was regressed on gender and stratified by 2020 economic dependency status. Findings: At both time points, significant gender differences in time use found young men with more time on paid work and less time on domestic work [1·6 h; 95% CI: 1·1, 2·2] and [-1·9 h; 95% CI: -1·1, -1·5], respectively; 2021. In adjusted models, the gender differential in unpaid domestic work were significant overall and at all levels of economic dependency (dependent, semi-dependent, independent). The gender differential in paid work was evident among semi-dependent and independent. Interpretation: Young women spent less time on paid work and more time on domestic duties than male counterparts, consistently across a six-month period during the pandemic, suggesting gendered time poverty. Resulting gendered gaps in earnings can contribute to women's longer-term economic vulnerability. Funding: This work was supported by the Bill & Melinda Gates Foundation [010481].

Males' Awareness of Female and Male Contraception Methods, Information, Outreach, and Acquisition Locations in Abidjan, Côte d'Ivoire, Nairobi, Kenya, and Lagos, Nigeria.

PURPOSE: The aim of this study is to describe modern female and male method awareness, information sources, outreach exposures, and acquisition source awareness among young men aged 15-24 by sexual behavior status in sub-Saharan Africa. METHODS: Cross-sectional surveys were conducted with unmarried, young men aged 15-24 recruited via respondent-driven sampling in Abidjan, Côte d'Ivoire (n = 1,028), Nairobi, Kenya (n = 691), and Lagos, Nigeria (n = 706). Descriptive statistics characterized contraception awareness of male and female methods and information sources, outreach exposures, acquisition source awareness, and preferred contraception source. Multivariate regressions characterized factors associated with awareness of each method. RESULTS: Majority of respondents were aged 15-20 (59%), sexually active (65%), and had secondary or more education (89%). Awareness was low for all methods (short-acting reversible contraception, 47%; emergency contraception, 35%; long-acting reversible contraception, 32%; withdrawal, 18%), except condoms (85%). Respondents reported low levels of contraception information sources, recent outreach exposures, and acquisition location awareness that varied by sexual behavior (higher among sexually active than nonsexually active respondents). Multivariate analyses demonstrated common factors associated across awareness of all methods included information sources (teacher, friend, Internet, social media for all respondents; pharmacist for sexually active respondents) and acquisition locations (private healthcare, pharmacy, market/store for all respondents; public healthcare, mobile clinic, faith-based organizations for sexually active respondents). Sexually active respondents' rank order for preferred contraception source was doctors/nurses followed by teachers, friends, mothers, and fathers; and for nonsexually active respondents' rank order was teachers followed by friends, mothers, doctors/nurses, and health centers. DISCUSSION: Findings have implications for increasing young men's method awareness, specific sources, and settings to target contraceptive outreach.

Missed opportunities for family planning counselling among postpartum women in eleven counties in Kenya.

BACKGROUND: Mothers may access medical facilities for their babies and miss opportunities to access family planning (FP) services. This study was undertaken to describe missed opportunities for FP among women within the extended (0-11 months) postpartum period from counties participating in Performance Monitoring and Accountability 2020 (PMA2020) surveys. DESIGN AND SETTING: This study analysed cross-sectional household survey data from 11 counties in Kenya between 2014 and 2018. PMA2020 uses questions extracted from the Demographic and Health survey (DHS) and DHS definitions were used. Multivariable logistic regression was used for inferential statistics with p-value of < 0.05 considered to be significant. PARTICIPANTS: Women aged 15-49 years from the households visited. PRIMARY OUTCOME MEASURE: Missed opportunity for family planning/contraceptives (FP/C) counselling. RESULTS: Of the 34,832 women aged 15-49 years interviewed, 10.9% (3803) and 10.8% (3746) were in the period 0-11 months and 12-23 months postpartum respectively, of whom, 38.8 and 39.6% respectively had their previous pregnancy unintended. Overall, 50.4% of women 0-23 months postpartum had missed opportunities for FP/C counselling. Among women who had contact with health care at the facility, 39.2% of women 0-11 months and 44.7% of women 12-23 months had missed opportunities for FP/C counselling. Less than half of the women 0-11 months postpartum (46.5%) and 64.5% of women 12 - 23 months postpartum were using highly efficacious methods. About 27 and 18% of the women 0-11 months and 12 - 23 months postpartum respectively had unmet need for FP/C. Multivariable analysis showed that being low parity and being from the low wealth quintile significantly increased the odds of missed opportunities for FP/C counselling among women in the extended postpartum period, p < 0.05. CONCLUSIONS: A large proportion of women have missed opportunities for FP/C counselling within 2 years postpartum. Programs should address these missed opportunities.

Gender-based violence during COVID-19 among adolescent girls and young women in Nairobi, Kenya: a mixed-methods prospective study over 18 months.

INTRODUCTION: Adolescent girls and young women (AGYW) disproportionately experience gender-based violence (GBV), which can increase during emergencies like the COVID-19 pandemic. METHODS: A cohort of youth ages 15-24 in Nairobi, Kenya was surveyed at three time points over an 18-month period prior to and during the COVID-19 pandemic: June-August 2019 (prepandemic), August-October 2020 (12-month follow-up) and May 2021 (18-month follow-up). We characterise (1) prevalence, relative timing and help-seeking for leading forms of GBV, (2) GBV trajectories over 18 months and (3) associations of individual, dyad and COVID-related factors on GBV trajectories among AGYW (n=612) in Nairobi, Kenya. Virtual focus group discussions (n=12) and interviews (n=40) contextualise quantitative results. RESULTS: Intimate partner violence (IPV) prevalence hovered at 17% across time points (ever at pre-pandemic; past 12 months at 12-month follow-up (2020); past 6 months at 18-month follow-up (2021)); non-partner sexual violence (SV) was 3% at 12-month and 18-month follow-up. Overall, 27.6% of AGYW experienced IPV during the pandemic. IPV during the pandemic was associated with work as the primary pre-COVID activity, low social support and partner age difference >4 years. Among AGYW partnered at all three time points, 66.2% stayed IPV-free (no IPV), 9.2% saw IPV resolve by 18-month follow-up, while 11.1% had IPV start and 13.6% experienced intermittent IPV. Help-seeking for IPV and SV in 2020 (11.1% and 4.6%, respectively) increased to 21.7% and 15.1%, respectively, by 2021. Qualitative results speak to impacts of curfews, and pandemic-related financial stress in prompting conflict and threatening traditional gender roles, and underlying conditions that enable IPV. CONCLUSION: The persistence of IPV against AGYW in Nairobi prior to and during the COVID-19 pandemic reflects endemic conditions and pandemic-specific stressors. Youth, including unmarried youth, remain a priority population for GBV prevention and survivor-centred response.

Busting contraception myths and misconceptions among youth in Kwale County, Kenya: results of a digital health randomised control trial.

OBJECTIVES: The objective of this randomised controlled trial in Kenya was to assess the effect of delivering sexual and reproductive health (SRH) information via text message to young people on their ability to reject contraception-related myths and misconceptions. DESIGN AND SETTING: A three-arm, unblinded randomised controlled trial with a ratio of 1:1:1 in Kwale County, Kenya. PARTICIPANTS AND INTERVENTIONS: A total of 740 youth aged 18-24 years were randomised. Intervention arm participants could access informational SRH text messages on-demand. Contact arm participants received once weekly texts instructing them to study on an SRH topic on their own. Control arm participants received standard care. The intervention period was 7 weeks. PRIMARY OUTCOME: We assessed change myths believed at baseline and endline using an index of 10 contraception-related myths. We assessed change across arms using difference of difference analysis. RESULTS: Across arms, <5% of participants did not have any formal education, <10% were living alone, about 50% were single and >80% had never given birth. Between baseline and endline, there was a statistically significant drop in the average absolute number of myths and misconceptions believed by intervention arm (11.1%, 95% CI 17.1% to 5.2%), contact arm (14.4%, 95% CI 20.5% to 8.4%) and control arm (11.3%, 95% CI 17.4% to 5.2%) participants. However, we observed no statistically significant difference in the magnitude of change across arms. CONCLUSIONS: We are unable to conclusively state that the text message intervention was better than text message 'contact' or no intervention at all. Digital health likely has potential for improving SRH-related outcomes when used as part of multifaceted interventions. Additional studies with physical and geographical separation of different arms is warranted. TRIAL REGISTRATION NUMBER: ISRCTN85156148.