Needs and unmet needs for support services for recently pregnant intimate partner violence survivors in Ethiopia during the COVID-19 pandemic.

BACKGROUND: Globally, 2-14% of women experience intimate partner violence (IPV) during pregnancy. Timely response to IPV is critical to mitigate related adverse health outcomes. Barriers to accessing limited IPV support services are pervasive in low- and middle-income countries (LMICs), such as Ethiopia; key barriers include mistrust, stigmatization, and self-blame, and discourage women from disclosing their experiences. Infection control measures for COVID-19 have the potential to further disrupt access to IPV services. METHODS: In-depth qualitative interviews were undertaken from October-November 2020 with 24 women who experienced IPV during recent pregnancy to understand the needs and unmet needs of IPV survivors in Ethiopia amid the COVID-19 pandemic. Trained qualitative interviewers used a structured note-taking tool to allow probing of experiences, while permitting rapid analysis for timely results. Inductive thematic analysis identified emergent themes, which were organized into matrices for synthesis. RESULTS: Qualitative themes center around knowledge of IPV services; experiences of women in seeking services; challenges in accessing services; the impact of COVID-19 on resource access; and persistent unmet needs of IPV survivors. Notably, few women discussed the violence they experienced as unique to pregnancy, with most referring to IPV over an extended period, both prior to and during COVID-19 restrictions. The majority of IPV survivors in our study heavily relied on their informal network of family and friends for protection and assistance in resolving the violence. Though formal IPV services remained open throughout the pandemic, restrictions resulted in the perception that services were not available, and this perception discouraged survivors from seeking help. Survivors further identified lack of integrated and tailored services as enduring unmet needs. CONCLUSIONS: Results reveal a persistent low awareness and utilization of formal IPV support and urge future policy efforts to address unmet needs through expansion of services by reducing socio-cultural barriers. COVID-19 impacted access to both formal and informal support systems, highlighting needs for adaptable, remote service delivery and upstream violence prevention. Public health interventions must strengthen linkages between formal and informal resources to fill the unmet needs of IPV survivors in receiving medical, psychosocial, and legal support in their home communities.

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.

Partner involvement in abortion trajectories and subsequent abortion safety in Nigeria and Côte d'Ivoire.

BACKGROUND: Unsafe abortions contribute to maternal mortality and morbidity worldwide, with disproportionate impacts in lower-income countries. Identifying factors associated with an elevated risk of experiencing an abortion under the most unsafe conditions is an important component of addressing this burden. The partner's role in obtaining a safe or unsafe abortion is not well understood. This study provides a quantitative assessment of the relationship between partner involvement and subsequent abortion safety. METHODS: The data are drawn from the PMA2020 female surveys and abortion follow-up surveys, fielded in Nigeria and Côte d'Ivoire between 2018 and 2020. The sample includes 1144 women in Nigeria and 347 women in Côte d'Ivoire who reported having ever experienced an abortion. We assess partner involvement in discussing the abortion decision and/or in selecting the method or source and evaluate the relationship between partner involvement and most unsafe abortion (using non-recommended methods from a non-clinical source) versus safe or less safe abortion, adjusting for sociodemographic characteristics. RESULTS: We find a strong association between experiencing any partner involvement and decreased odds of experiencing a most unsafe abortion (Nigeria: aOR = 0.34, 95% CI 0.26-0.45; Côte d'Ivoire: aOR = 0.27, 95% CI 0.16-0.47). Analyzing the two types of partner involvement separately, we find that partner involvement in the decision is associated with lower odds of most unsafe abortion in both countries (Nigeria: aOR = 0.48, 95% CI 0.39-0.72; Côte d'Ivoire: aOR = 0.34, 95% CI 0.19-0.60); partner involvement in selecting the method and/or source was only significantly associated with lower odds of most unsafe abortion in Nigeria (Nigeria: aOR = 0.53, 95% CI 0.39-0.72; Côte d'Ivoire: aOR = 0.65, 95% CI 0.32-1.32). CONCLUSION: In Nigeria and in Côte d'Ivoire, respondents whose partners were involved in their abortion trajectory experienced safer abortions than those whose partners were not involved. These findings suggest the potential importance of including men in education on safe abortion care and persistent need to make safe abortion accessible to all, regardless of partner support.

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.

A scoping review on women's sexual health in the postpartum period: opportunities for research and practice within low-and middle-income countries.

BACKGROUND: Women's sexual health is generally defined and explored solely in relation to reproductive capacity, and often omits elements of sexual function and/or dysfunction. Concerted focus is given to women's health during pregnancy; however, women's sexual health is largely neglected after childbirth. This scoping review explored how the sexual health of postpartum women has been defined, measured, and researched in low- and middle-income countries (LMICs). METHODS: Articles eligible for review were those that investigated women's sexual health during the first 12 months postpartum and were conducted among women aged 15-49 in LMICs. Eligibility was further restricted to studies that were published within the last 20 years (2001-2021). The initial PubMed search identified 812 articles, but upon further eligibility review, 97 remained. At this time, the decision was made to focus this review only on articles addressing sexual function and/or dysfunction, which yielded 46 articles. Key article characteristics were described and analyzed by outcome. RESULTS: Of the final included articles, five studies focused on positive sexual health, 13 on negative sexual health, and the remaining 28 on both positive and negative sexual health or without specified directionality. The most common outcome examined was resumption of sex after childbirth. Most studies occurred within sub-Saharan Africa (n = 27), with geographic spread throughout the Middle East (n = 10), Asia (n = 5), North Africa (n = 3), and cross-geography (n = 1); notably, all five studies on positive sexual health were conducted in Iran. Negative sexual health outcomes included vaginismus, dyspareunia, episiotomy, perineal tears, prolapse, infection, obstetric fistula, female genital cutting, postnatal pain, uterine prolapse, coercion to resume sex, sexual violence, and loss of sexual desire/arousal. Most studies were quantitative, though eight qualitative studies elucidated the difficulties women endured in receiving information specific to sexual health and hesitance in seeking help for sexual morbidities in the postpartum period. CONCLUSIONS: Overall, the evidence base surrounding women's sexual health in the postpartum period within LMICs remains limited, with most studies focusing solely on the timing of resumption of sex. Integration of sexual health counseling into postnatal care and nonjudgmental service provision can help women navigate these bodily changes and ultimately improve their sexual health.

Family Planning Beliefs and Their Association with Contraceptive Use Dynamics: Results from a Longitudinal Study in Uganda.

Norms and beliefs toward contraception, both positive and negative, motivate contraceptive use; however, they have seldom been explored longitudinally in low- and middle-income countries, limiting our understanding of their influence on contraceptive dynamics. We used PMA2020 Uganda national longitudinal data of reproductive aged women in 2018 (baseline) and 2019 (follow-up) to explore discontinuation and switching among modern contraceptive users at baseline (n = 688) and contraceptive use at follow-up among nonusers at baseline (n = 1,377). Multivariable simple and multinomial logistic regressions assessed the association of individual and community-level contraceptive beliefs with contraceptive uptake, discontinuation and switching. One-quarter of nonusers at baseline were using contraception at follow-up, while 37 percent of users at baseline had discontinued and 28 percent had switched methods at follow-up. The odds of contraceptive uptake were lower among women who strongly agreed that contraception impacted future fertility or caused conflict within a couple, relative to those who strongly disagreed (adjusted odds ratio (aOR): 0.7 and aOR: 0.6, respectively), but higher among women who strongly agreed that contraception preserved beauty (aOR: 1.6). Women who strongly agreed that it was acceptable to use contraception before having children were less likely to discontinue their method than those who strongly disagreed (adjusted relative risk ratio (aRRR): 0.5), though living in a community where more women agreed with this statement was associated with higher discontinuation (aRRR: 6.0). Family planning programs that promote positive beliefs toward family planning could improve contraceptive uptake and continuation. More research is needed to understand how contraceptive beliefs shape contraceptive decisions across the life course.

Association between experience of specific side-effects and contraceptive switching and discontinuation in Uganda: results from a longitudinal study.

BACKGROUND: There is substantial evidence that contraceptive side-effects are a major deterrent to consistent use of contraception but few studies in low- or middle-income countries explore the role of specific side-effects on contraceptive use dynamics. This study used population-based, longitudinal data to explore the effect of specific side-effects on contraceptive continuation, discontinuation, and switching in Uganda. METHODS: Data for this study come from two rounds of survey data collection in Uganda: PMA2020's sixth cross-sectional survey and a follow-up survey conducted 1 year later. The main outcomes of interest were discontinuation and switching among users of hormonal contraceptive methods (implants, injectables and oral pill) and the IUD at baseline (n = 560). Multivariable logistic regressions assessed the association of experiencing specific side-effects (more bleeding, less bleeding, irregular bleeding, increased dryness/reduced libido, and physical discomfort) with discontinuation and switching 1 year later, adjusting for socio-demographic characteristics, type of method, and length of use. We also examined the differential effects of side-effects between discontinuation and switching risks. RESULTS: About 23% of hormonal and IUD contraceptive users reported experiencing side-effects at baseline survey. Overall, discontinuation and switching were higher among injectables and pill users, compared to IUD and implants users. Reporting more bleeding or less bleeding increased the odds of discontinuation and switching by 2.74 (95% CI 1.00-7.51) and 1.86 (1.04-3.34), respectively. There was no significant difference in discontinuation and switching by side-effects. CONCLUSIONS: Greater attention should be paid to understanding the unique contributions of side-effects to contraceptive behavior using population-based data. While about a quarter of women reported experiencing side effects, those who experienced bleeding specific side effects were at higher risk of contraceptive discontinuation and switching. Providing greater individualized care that includes information and counseling about common side-effects, how they may impact daily life, and how tolerable these effects may be is necessary.

Research has shown that experiencing side-effects is related to stopping use of contraception, even when women wish to avoid pregnancy. Most research, however, does not differentiate between distinct side-effects, such as increased bleeding or changes to sexual experience, and instead combined all into "side-effects or health concerns". We used data from 560 women in Uganda, who were interviewed twice, 1 year apart, to see if women who reported different side-effects at the first interview were more likely to stop using contraception or switch to a different contraceptive method than women who did not report experiencing side-effects. We found that increased or decreased menstrual bleeding was associated with a higher odds of contraceptive discontinuation and switching, Contraceptive discontinuation or switching was not different by women's reporting of vaginal dryness/reduced libido or physical discomfort, such as cramping. It is important to understand what side-effects are likely to motivate stopping or switching contraception so that education and counseling can inform women of side-effects they may experience, help them choose the best method based on what side-effects they deem important, and if necessary, aid in switching contraceptive methods.

A sexual and reproductive empowerment framework to explore volitional sex in sub-Saharan Africa.

Volitional sex is central to the sexual health and well-being of women and girls globally. To date, few studies have examined women's empowerment and its application to sexual health outcomes, including volitional sex. The aim of this study was to explore the relevance of a sexual and reproductive empowerment framework to volitional sex across four geographically and culturally diverse contexts in sub-Saharan Africa. Qualitative data were collected between July and August 2017 in four sites: Ethiopia, Nigeria (Anambra and Kano states) and Uganda. A total of 352 women aged 15-49 and 88 men aged 18 and older were interviewed through 120 in-depth interviews and 38 focus group discussions (n = 440 total participants). Results describe the substantial barriers restraining women's sexual choices, particularly norms that stigmatise women's requests for sex, even within marriage. Results further highlight women's internal sexual motivations, particularly related to the enjoyment of sex and the role of sex in strengthening partner relationships. Future empowerment research and measurement should focus not only on sexual constraints, but also integrate internal motivations, in order to fully understand the factors that shape women's sexual health outcomes.

Reproductive Coercion among Intimate Partner Violence Survivors in Nairobi.

Reproductive coercion (RC), or partner interference in reproductive decisions, limits women's autonomy. Little is known about RC behaviors and measurement in low- and middle-income countries (LMICs). In this mixed-methods study, we examined the transferability of the US-developed RC Scale to the Kenyan context. Through community-based sampling, recent intimate partner violence (IPV) survivors were recruited from Nairobi's informal settlements. We conducted quantitative analyses (n = 327) to assess the transferability of RC measures via exploratory factor analysis and used descriptive statistics to examine prevalence and continuous metrics. We conducted in-depth interviews (IDIs; n = 30) to contextualize results. Psychometric analyses indicated a two-factor solution comprising pregnancy coercion and condom manipulation (alpha = 0.86). Eighty-two percent of IPV survivors reported experiencing RC (pregnancy coercion = 76.6 percent; condom manipulation = 59.5 percent). IDIs highlighted women's multiple, severe RC experiences; experiences described in IDIs were largely consistent with quantitative findings. We found the RC Scale was transferable to this LMIC context, where IPV survivors face prevalent, severe RC and would benefit from linkage to woman-centered support services.

"You better use the safer one leave this one": the role of health providers in women's pursuit of their preferred family planning methods.

BACKGROUND: Universal access to quality sexual and reproductive health (SRH) services is pivotal to ensuring gender equality. In high-income countries, patient-provider interactions have been shown to shape women's decisions about contraception, with poor exchanges decreasing method uptake and satisfaction. While significant progress has been made to increase women's access to SRH services, in low- and middle-income countries, little is known about the quality of family planning patient-provider interactions. The primary objective of this analysis was to explore the role of health care providers in women's family planning decision-making in Ethiopia. METHODS: From July to August 2017, 10 focus group discussions (n = 80) and 30 in-depth interviews were conducted with women aged 15-49 and men aged 18+ recruited via purposive sampling from urban and rural sites in Ethiopia. Semi-structured interview guides explored women's and girls' empowerment in SRH surrounding sex, childbearing, and contraception. All interviews were conducted in Amharic, audio-recorded, and transcribed verbatim into English. Inductive thematic analysis was used to analyze data. Eleven codes specific to provider services for family planning were reviewed and matrixes creates for synthesis. RESULTS: Three primary themes emerged: the role of providers in women's awareness of and demand for family planning services; selection and uptake of contraceptive methods; and discontinuation and switching of contraceptive methods. Results indicate that health extension workers were central to women's awareness of family planning, and health providers' endorsements were instrumental in decisions to adopt methods. The majority of respondents described positive interactions with providers and appreciated thorough counseling when considering using or switching methods. Some women, however, described health providers directing them toward long-acting methods by communicating inaccurate information or emphasizing disadvantages of short-acting methods. A few women described provider reluctance or resistance to switching methods, especially from implants. CONCLUSIONS: Women shared many narratives about the central roles health providers played in their awareness and decision-making for family planning. Those narratives also included provider bias against women's preferred methods. Further research and program assessments are needed to ascertain the extent to which these biases hinder women's decision-making autonomy in using contraception.

Covert use of contraception in three sub-Saharan African countries: a qualitative exploration of motivations and challenges.

BACKGROUND: The balance between increasing men's participation in family planning and rights-based initiatives favoring women's empowerment is highlighted with the issue of covert use of contraception. While covert use has been documented in low- and middle-income countries as a way for women to obtain contraception in light of partner opposition, little is known about women's decision-making processes, actions, and potential consequences of discreet contraceptive use. We aimed to understand women's choices to use contraception covertly and the challenges they faced in concealing their use across three sub-Saharan African countries. METHODS: Women aged 15-49 and their male partners were purposively sampled from urban and rural sites in Ethiopia, Northern and Southern Nigeria, and Uganda for 120 in-depth interviews and 38 focus group discussions. Semi-structured interviews explored women's and girls' empowerment surrounding sex, childbearing, and contraception. Interviews were conducted in local languages, audio-recorded, and transcribed verbatim into English. Inductive thematic analysis was used to analyze data; covert use codes were reviewed and matrices were created based on themes and sub-themes. RESULTS: Findings comprised three thematic areas: the practice of covert contraceptive use and reasons for using covertly; challenges for women who use contraception covertly; and consequences of disclosure or being discovered. While some women initiated using contraception covertly due to tensions within relationships or to keep peace within the home due to known partner opposition, others did not consider family planning to be a male responsibility. Though covert use was commonly discussed, it was also socially sanctioned, and portrayed as an act of female disobedience that questioned the social order of patriarchy. Further challenges of using covertly included lack of financial and social support, and suspicions surrounding delayed fertility and contraceptive-related side effects. Repercussions comprised increased suspicion, threats, or violence, though some women reported improved couple communication with disclosure. CONCLUSIONS: Results indicate that while covert use of contraception is common, continued covert use is challenging, especially when side effects manifest. Covert use may further suggest women taking independent action, symbolizing some level of empowerment. Results underscore the importance of disentangling unique reasons for covert use and the severity of repercussions of disclosure.

Adapting the myPlan safety app to respond to intimate partner violence for women in low and middle income country settings: app tailoring and randomized controlled trial protocol.

BACKGROUND: Intimate partner violence (IPV) is a leading threat to women's health and safety globally. Women in abusive relationships make critical decisions about safety and harm reduction while weighing multiple competing priorities, such as safety of children, housing and employment. In many low- and middle-income countries (LMIC), IPV prevention and response services are limited and women lack access to safety planning resources. In high-resource settings, an interactive safety decision aid app (myPlan) has been found valuable in reducing decisional conflict and empowering women to take action in accordance with their safety priorities. This paper describes 1) the community-participatory formative process used to adapt the myPlan app content, interface, and implementation for the Kenya context, and 2) the randomized clinical trial study protocol for efficacy evaluation of myPlan Kenya. METHODS: A community-participatory formative process engaged service providers and stakeholders, as well as IPV survivors for adaptation, followed by an in-depth pilot and final refinements. A randomized clinical trial design will then be used to determine efficacy of the myPlan Kenya app compared to standard care among women reporting IPV or fear of partner and living in an urban settlement. myPlan Kenya app provides and solicits information on a) relationship health; b) safety priorities; and c) severity of relationship violence. Based on the woman's inputs, the evidence-based algorithm developed for myPlan Kenya generates a tailored safety plan. Outcome measures are assessed at baseline, immediate post-intervention, and 3-month post-baseline. Difference-in-differences analysis compares primary (e.g. safety preparedness, safety behavior, IPV), and secondary outcomes (e.g. resilience, mental health, service utilization, self-blame) across timepoints by group. DISCUSSION: Formative phase revealed high feasibility and acceptability of a technology-based intervention for safety planning in this LMIC setting. This phase generated essential refinements to myPlan Kenya app readability, content and implementation, including increased visualization of messaging, and implementation via community health volunteers (CHVs). The resulting trial will be the first to evaluate efficacy of a community-partnered technology-based IPV intervention in a LMIC. Our adaptation process and trial results will inform researchers and interventionists to integrate multiple data sources to adapt IPV intervention content and interface in settings where technology-based interventions for IPV are novel and literacy is limited. TRIAL REGISTRATION: Pan African Clinical Trial Registry approval received 25 April 2018 (PACTR201804003321122); retrospectively registered.

Sexual violence among adolescent girls and young women in Malawi: a cluster-randomized controlled implementation trial of empowerment self-defense training.

BACKGROUND: Globally, sexual violence is prevalent, particularly for adolescent women. This cluster-randomized controlled implementation trial examines empowerment self-defense (ESD) for sexual assault risk reduction among school-age women in Malawi. METHODS: The unit of randomization and analysis was the school (n = 141). Intervention participants received a 12-h intervention over 6 weeks, with refreshers. Primary outcomes were past-year prevalence and incident rate of sexual violence. Secondary outcomes included confidence, self-defense knowledge, and, for those victimized, violence disclosure. Interaction effects on outcomes were evaluated with Poisson models with school-correlated robust variance estimates for risk ratios and incident rate ratios (baseline n = 6644, follow-up n = 4278). RESULTS: Past-year sexual assault prevalence was reduced among intervention students (risk ratio [RR] 0.68, 95% CI 0.56, 0.82), but not control students (interaction effect p < 0.001). Significant increases in self-defense knowledge were observed solely among intervention students (RR 3.33, 95% CI 2.76, 4.02; interaction effect p < 0.001). Significant changes in sexual violence prevalence and knowledge were observed for both primary and secondary students. Favorable reductions were also observed in sexual violence incident rate among students overall (interaction effect p = 0.01). CONCLUSIONS: This intervention reduced sexual violence victimization in both primary and secondary school settings. Results support the effectiveness of ESD to address sexual violence, and approach the elimination of violence against women and girls set forth with Sustainable Development Goal #5. Implementation within the education system can enable sustainability and reach. TRIAL REGISTRATION: Pan African Clinical Trials Registry PACTR201702002028911 . Registered 09 February 2017. Retrospectively registered.

Association between circulating levels of sex steroid hormones and Barrett's esophagus in men: a case-control analysis.

BACKGROUND & AIMS: Esophageal adenocarcinoma is believed to result from the progression of gastroesophageal reflux disease to erosive esophagitis and re-epithelialization of the esophagus with a columnar cell population termed Barrett's esophagus (BE). Men develop BE and esophageal adenocarcinoma more frequently than women, yet little is known about the mechanisms of this difference. We assessed whether sex steroid hormones were associated with BE in a male population. METHODS: We analyzed data from the Barrett's Esophagus Early Detection Case Control Study, based at the Walter Reed National Military Medical Center. Blood samples were collected from 174 men with BE and 213 men without BE (controls, based on endoscopic analysis); 13 sex steroid hormones were measured by mass spectrometry and sex hormone binding globulin was measured by enzyme-linked immunosorbent assay. We also calculated free estradiol, free testosterone, and free dihydrotestosterone (DHT). We used multivariable logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) adjusted for age, race, smoking status, alcohol consumption, body mass index, heartburn, regurgitation, and gastroesophageal symptom score (excluding heartburn and regurgitation). RESULTS: Levels of free testosterone and free DHT were associated positively with BE risk; patients in the highest quartile for these hormones were most likely to have BE (free testosterone: OR, 5.36; 95% CI, 2.21-13.03; P = .0002; free DHT: OR, 4.25; 95% CI, 1.87-9.66; P = .001). Level of estrone sulfate was associated inversely with BE risk (P for trend = .02). No other hormone was associated with BE risk. Relationships were not modified by age or BMI. CONCLUSIONS: In an analysis of men, levels of free testosterone and free DHT were significantly associated with BE.

Breast cancer in Sub-Saharan Africa: opportunities for prevention.

Although breast cancer is a growing health problem in sub-Saharan Africa, reasons for its increased occurrence remain unclear. We reviewed the published literature to determine the magnitude of the increase in breast cancer, associated risk factors (including for breast cancer subtypes), and ways to reduce incidence and mortality. Some of the increased breast cancer occurrence likely reflects that women are living longer and adopting lifestyles that favor higher incidence rates. However, a greater proportion of breast cancers occur among premenopausal women as compared to elsewhere, which may reflect unique risk factors. Breast cancers diagnosed among African women reportedly include a disproportionate number of poor prognosis tumors, including hormone receptor negative, triple negative, and core basal phenotype tumors. However, it is unclear how lack of standardized methods for tissue collection, fixation, and classification contribute to these rates. Given appropriate classifications, it will be of interest to compare rates with other populations and to identify risk factors that relate to specific tumor subtypes. This includes not only risk factors that have been recognized in other populations but also some that may play unique roles among African women, such as genetic factors, microbiomata, xenoestrogens, hair relaxers, and skin lighteners. With limited opportunities for effective treatment, a focus is needed on identifying etiologic factors that may be amenable to intervention. It will also be essential to understand reasons why women delay seeking care after the onset of symptoms and for there to be educational campaigns about the importance of early detection.

Family planning service disruptions in the first two years of the COVID-19 pandemic: Evidence from health facilities in seven low- and middle-income countries.

Many speculated that COVID-19 would severely restrict the delivery of essential health services, including family planning (FP), but evidence of this impact is limited, partly due to data limitations. We use cross-sectional data collected from regional and national samples of health facilities (n = 2,610) offering FP across seven low- and middle-income countries (LMICs) between 2019 and 2021, with longitudinal data from four geographies, to examine reported disruptions to the FP service environment during COVID-19, assess how these disruptions varied according to health system characteristics, and evaluate how disruptions evolved throughout the first two years of the pandemic, relative to a pre-pandemic period. Findings show significant variation in the impact of COVID-19 on facility-based FP services across LMICs, with the largest disruptions to services occurring in Rajasthan, India, where COVID-19 cases were highest among geographies sampled, while in most sub-Saharan African settings there were limited disruptions impacting FP service availability, method provision, and contraceptive supplies. Facility-reported disruptions to care were not reflected in observed changes to the number of FP clients or types of stockouts experienced in the first two years of the pandemic. Public and higher-level facilities were generally less likely to experience COVID-19-related disruptions to FP services, suggesting policy mitigation measures-particularly those implemented among government-operated health facilities-may have been critical to ensuring sustained delivery of reproductive healthcare during the pandemic.

Risk for Severe Intimate Partner Violence in Nairobi's Informal Settlements: Tailoring the Danger Assessment to Kenya.

INTRODUCTION: Understanding the risk for severe intimate partner violence (IPV) can help women and providers assess danger. The validated, widely used Danger Assessment (DA) developed for this purpose has not been tested in a low- and middle-income country (LMIC). We tailored the DA to Nairobi, Kenya, and prospectively evaluated baseline danger against severe IPV at 3-month follow-up. METHODS: We used data from the myPlan Kenya trial conducted in 3 informal settlements in Nairobi, Kenya, from 2017 to 2018. DA items were refined through formative and pilot phases, yielding minor wording modifications. Quantitative analyses prospectively evaluated baseline DA against severe IPV at 3-month follow-up to understand the predictive effect of the (1) original 20-item DA, (2) 16-item Kenya-DA (highest relative risk ratios [RRR] with severe IPV), and (3) 16-item Kenya-DA weighted (weighting based on strength of RRRs). Diagnostic criteria, including C-statistics, sensitivity, specificity, receiver operating characteristic curve, and area under the curve, were examined; logistic regressions quantified the odds of each metric predicting severe IPV at follow-up. RESULTS: The original 20-item DA produced the highest specificity (75.41%) and lowest sensitivity (57.14%), resulting in the overall lowest C-statistic. Compared to the 16-item Kenya-DA, the Kenya-DA weighted produced slightly higher sensitivity (66.67% vs. 64.29%) and specificity (77.05% vs. 72.13%), resulting in the highest C-statistic (0.78 vs. 0.75). All versions successfully predicted severe IPV at 3-month follow-up (original DA: odds ratio [OR]=1.26, 95% confidence interval [CI]=1.12, 1.41, P<.001; Kenya-DA: OR=1.33, 95% CI=1.16, 1.53, P<.001; Kenya-DA weighted: OR=1.19, 95% CI=1.10, 1.28, P<.001). Several factors identified as homicide risk factors in other settings were not prospectively associated with severe IPV. CONCLUSION: Within a high-danger LMIC context, all 3 DA configurations performed well diagnostically. We recommend the 16-item Kenya-DA given the value for simplicity and field implementation, whereas the Kenya-DA weighted can add accuracy for research purposes.

A qualitative exploration of reproductive coercion experiences and perceptions in four geo-culturally diverse sub-Saharan African settings.

Reproductive coercion (RC) is any intentional behavior that interferes with another's reproductive decision-making or pregnancy outcome. This study aims to qualitatively examine RC experiences and perceptions among women and men in Ethiopia, Nigeria (Kano and Anambra States), and Uganda. This is a secondary analysis utilizing qualitative data from the Women's and Girls' Empowerment in Sexual and Reproductive Health study. Across sites, focus group discussions (38 groups; n=320 participants) and in-depth interviews (n=120) were conducted, recorded, and transcribed. Transcripts were loaded into Atlas.ti, and quotes describing experiences of reproductive control or abuse were coded as "reproductive coercion." RC quotes were input into a matrix for thematic analysis. Emergent RC themes included indirect reproductive pressures, direct family planning interference, concurrent experiences of violence, and responses to RC. Indirect reproductive pressures included tactics to both promote and prevent pregnancy, while direct interference centered on pregnancy promotion. Women who were not compliant with their partners' reproductive demands were often subjected to violence from multiple actors (i.e., parents, in-laws, community members) in addition to their partners. Despite concurrent forms of violence, women across sites resisted RC by using contraceptives covertly, choosing to abort, or leaving their abusive partnerships. Women and men across sites indicated that men were highly influential in fertility. RC behaviors were a mechanism of control over desired reproductive outcomes, which were often rooted in perceptions of childbearing as social status. Findings indicate a need for more nuanced community interventions targeting social norms, as well as improved RC screening and response within health services.

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.