Maternal usage of varying levels of dietary folate affects the postnatal development of cerebellar folia and cortical layer volumes.

OBJECTIVE: The cerebellum has a long, protracted developmental period; therefore, it is more sensitive to intrauterine and postnatal insults like nutritional deficiencies. Folate is an essential nutrient in fetal and postnatal brain development, and its supplementation during pregnancy is widely recommended. This study aimed to describe the effects of maternal folate intake on postnatal cerebellum development. METHODS: Twelve adult female Rattus norwegicus (6-8 weeks old) rats were randomly assigned to one of four groups and given one of four premixed diets: a standard diet (2 mg/kg), a folate-deficient (folate 0 mg/kg), folate-supplemented (8 mg/kg), or folate supra-supplemented (40 mg/kg). The rats began consuming their specific diets 14 days before mating and were maintained on them throughout pregnancy and lactation. Five pups from each group were sacrificed, and their brains processed for light microscopic examination on postnatal days 1, 7, 21, and 35. The data gathered included the morphology of the cerebellar folia and an estimate of the volume of the cerebellar cortical layer using the Cavalieri method. RESULTS: Folia of the folate-supplemented and supra-supplemented groups were thicker and showed extensive branching with sub-lobule formation. The folate-deficient diet group's folia were smaller, had more inter-folial spaces, or fused. When compared to the folate-deficient group, the volumes of the cerebellum and individual cerebellar cortical layers were significantly larger in the folate-supplemented and supra-supplemented groups (p<0.05). CONCLUSION: Folate supplementation during pregnancy and lactation improves the degree and complexity of the cerebellar folia and the volumes of individual cerebellar cortical layers.

Pattern and determinants of contraceptive use among the muslim women in Wajir and Lamu counties in Kenya: a cross-sectional study.

BACKGROUND: Improving access to family planning (FP) is associated with positive health benefits that includes averting nearly a third of all maternal deaths and 10% of childhood deaths. Kenya has made great strides in improving access to family planning services. However, amid this considerable progress, regional variation has been noted which begs the need for a clearer understanding of the the patterns and determinants that drive these inconsistencies. METHODS: We conducted a cross-sectional study that involved 663 Muslim women of reproductive age (15-49 years) from Wajir and Lamu counties in Kenya between March and October 2018.The objective of this study was to understand patterns and determinants of contraceptive use in two predominantly Muslim settings of Lamu and Wajir counties that have varying contraceptive uptake. Eligible women were interviewed using a semi-structured questionnaire containing socio-demographic information and history of family planning use. Simple and multiple logistic regression were used to identify determinants of family planning use. The results were presented as Crude Odds Ratio (COR) and Adjusted Odds Ratio (AOR) ratios at 95% confidence interval. A p-value of 0.05 was considered statistically significant. RESULTS: Of the 663 Muslim women of reproductive age consenting to participate in the study, 51.5%, n = 342 and 48.5%, n = 321 were from Lamu and Wajir County, respectively. The prevalence of women currently using contraceptive was 18.6% (n = 123). In Lamu, the prevalence was 32.8%, while in Wajir, it was 3.4%. The determinants of current contraceptive use in Lamu include; marital status, age at marriage, employment status, discussion with a partner on FP, acceptability of FP in culture, and willingness to obtain information on FP. While in Wajir, determinants of current contraceptive use were education, and the belief that family planning is allowed in Islam. CONCLUSIONS: Our study found moderately high use of contraceptives among Muslim women of reproductive age in Lamu county and very low contraceptive use among women in Wajir. Given the role of men in decision making, it is critical to design male involvement strategy particularly in Wajir where the male influence is very prominent. It is critical for the government to invest in women and girls' education to enhance their ability to make informed decisions; particularly in Wajir where FP uptake is low with low education attainment. Further, our findings highlight the need for culturally appropriate messages and involvement of religious leaders to demystify the myths and misconception around family planning and Islam particularly in Wajir.

Validation and Predictive Utility of a Person-Centered Quality of Contraceptive Counseling (QCC-10) Scale in Sub-Saharan Africa: A Multicountry Study of Family Planning Clients and a New Indicator for Measuring High-Quality, Rights-Based Care.

The lack of validated, cross-cultural measures for examining quality of contraceptive counseling compromises progress toward improved services. We tested the validity and reliability of the 10-item Quality of Contraceptive Counseling scale (QCC-10) and its association with continued protection from unintended pregnancy and person-centered outcomes using longitudinal data from women aged 15-49 in Burkina Faso, Kenya, and Nigeria. Psychometric analysis showed moderate-to-strong reliability (alphas: 0.73-0.91) and high convergent validity with greatest service satisfaction. At follow-up, QCC-10 scores were not associated with continued pregnancy protection but were linked to contraceptive informational needs being met among Burkinabe and Kenyan women; the reverse was true in Kano. Higher QCC-10 scores were also associated with care-seeking among Kenyan women experiencing side effects. The QCC-10 is a validated scale for assessing quality of contraceptive counseling across diverse contexts. Future work is needed to improve understanding of how the QCC-10 relates to person-centered measures of reproductive health.

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.

Formative assessment to identify perceived benefits and barriers of HIV oral self-testing among female sex workers, service providers, outreach workers, and peer educators to inform scale-up in Kenya.

In Kenya, HIV prevalence estimates among female sex workers (FSWs) are almost five times higher than among women in the general population. However, only 68% of infected FSWs are aware of their HIV-positive status. We aimed to identify perceived benefits, opportunities, and barriers of HIV self-testing (HIVST) in improving testing coverage among FSWs. Twenty focus group discussions were conducted with 77 service providers, 42 peer educators (PEs) and outreach workers, and 37 FSWs attending drop-in centers (DiCEs) in four regions of Kenya. An additional 8 FSWs with HIV-negative or unknown status-completed in-depth interviews. Data were analyzed thematically. Acceptability of HIVST was high, with cited benefits including confidentiality, convenience, and ease of use. Barriers included absence of counseling, potential for inaccurate results, fear of partner reaction, possible misuse, and fear that HIVST could lead to further stigmatization. PEs and DiCEs were the preferred models for distributing HIVST kits. FSWs wanted kits made available free or at a nominal cost (100 Kenya Shillings or ∼USD 1). Linkage to confirmatory testing, the efficiency of distributing HIVST kits using peers and DiCEs, and the types and content of effective HIVST messaging require further research.

Trends and determinants of adolescent pregnancy: Results from Kenya demographic health surveys 2003-2014.

BACKGROUND: Adolescent pregnancy increases the risk of disability and death due to unsafe abortion, prolonged labour and delivery, and complications after birth. Availability of accurate data is important to guide decision-making related to adolescent sexual reproductive health (ASRH). This study analyses the trends in prevalence and factors associated with adolescent pregnancy in Kenya using data from three national Demographic Health Surveys (2003, 2008/2009, 2014). METHODS: Our analysis focused on a subsample of data collected from women aged 20 to 24 years. A trend analysis was performed to establish a change in the rate of adolescent pregnancy in 2003, 2008/2009, and 2014 survey data points. Binary Logistic regression and pooled regression analysis were used to explore factors associated with adolescent pregnancy. RESULTS: The percentage of women aged 20 to 24 years who reported their first pregnancy between ages 15 and 19 years was 42% in 2003 and 42.2% in 2009 but declined to 38.9% in 2014. Using regression analyses, we established that education status, marital status, religion and wealth quintile were associated with adolescent pregnancy. Trend analysis shows that there was an overall decreasing trend in adolescent pregnancy between 2003 and 2014. CONCLUSION: Although Kenya has made strides in reducing the prevalence of adolescent pregnancy in the last decade, much more needs to be done to further reduce the burden, which remains high. DEFINITION: Adolescents: Although WHO defines the adolescence period as being 10-19 years, this paper focuses on the late adolescent period, 15-19 years, here in referred to as adolescents.

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.

Increased condom use among key populations using oral PrEP in Kenya: results from large scale programmatic surveillance.

BACKGROUND: Female sex workers (FSW) and men having sex with men (MSM) in Kenya have high rates of HIV infection. Following a 2015 WHO recommendation, Kenya initiated national scale-up of pre-exposure prophylaxis (PrEP) for all persons at high-risk. Concerns have been raised about PrEP users' potential changes in sexual behaviors such adopting condomless sex and multiple partners as a result of perceived reduction in HIV risk, a phenomenon known as risk compensation. Increased condomless sex may lead to unintended pregnancies and sexually transmitted infections and has been described in research contexts but not in the programmatic setting. This study looks at changes in condom use among FSW and MSM on PrEP through a national a scale-up program. METHODS: Routine program data collected between February 2017 and December 2019 were used to assess changes in condom use during the first three months of PrEP in 80 health facilities supported by a scale-up project, Jilinde. The primary outcome was self-reported condom use. Analyses were conducted separately for FSW and for MSM. Log-Binomial Regression with Generalized Estimating Equations was used to compare the incidence proportion ("risk") of consistent condom use at the month 1, and month 3 visits relative to the initiation visit. RESULTS: At initiation, 69% of FSW and 65% of MSM reported consistent condom use. At month 3, this rose to 87% for FSW and 91% for MSM. MSM were 24% more likely to report consistent condom use at month 1 (Relative Risk [RR], 1.24, 95% Confidence Interval [CI], 1.18-1.30) and 40% more likely at month 3 (RR, 1.40, 95% CI, 1.33-1.47) compared to at initiation. FSW were 15% more likely to report consistent condom use at the month one visit (RR, 1.15, 95% CI, 1.13-1.17) and 27% more likely to report condom use on the month 3 visit (RR 1.27, 95% CI, 1.24-1.29). CONCLUSION: Condom use increased substantially among both FSW and MSM. This may be because oral PrEP was provided as part of a combination prevention strategy that included counseling and condoms but could also be due to the low retention rates among those who initiated.

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.

Solidarity, support and competition among communities of female and male sex workers in Mombasa, Kenya.

Female and male sex workers are at elevated risk for HIV infection, psychological distress and other adverse health outcomes. It is therefore important to understand how sex workers' social relationships with one another might inform psychosocial support services for this population. We conducted semi-structured interviews to examine the formation and nature of social networks of 25 female and 25 male sex workers recruited from bars and clubs in Mombasa, Kenya. Relationships between and among female and male participants were often formed based on a mutual understanding of the challenging nature of sex work. Both groups described their relationships in terms of friendship and brotherhood/sisterhood and highlighted the following benefits of sex worker social networks: economic benefits, access to information about HIV/STIs and protection, and support against violence from clients and law enforcement agents. Social networks were often threatened by competition for clients and hence could result in conflict. However, sex workers explained that their sense of solidarity and reliance on one another for health, protection and economic well-being helped minimise conflict. The social networks of sex workers could therefore be used to leverage or optimise access to HIV prevention and care.

Does the Belief That Contraceptive Use Causes Infertility Actually Affect Use? Findings from a Social Network Study in Kenya.

The belief that contraceptive use causes infertility has been documented across sub-Saharan Africa, but its quantitative association with actual contraceptive use has not been examined. We collected and analyzed sociocentric network data covering 74 percent of the population in two villages in rural Kenya. We asked respondents to nominate people from their village (their network), and then we matched their network (alters) to the individual participant (ego) to understand how their beliefs and behaviors differ. We asked about contraceptive use and level of agreement with a statement about contraceptive use causing infertility. We calculated the average nominated network contraceptive use score and the average nominated network belief score. Holding the individual belief that contraceptive use causes infertility was associated with lower odds of using contraceptive (AOR = 0.82, p = < 0.01); however, when one's own nominated network connections held this belief, the odds of using contraceptive were even lower (AOR = 0.75, p <0.01). Our findings show that this belief is associated with lower odds of contraceptive use and highlights the role that other people in one's network play in reinforcing it. Sexual and reproductive health programs should address this misperception at the individual and social network level.

Is Client Reporting on Contraceptive Use Always Accurate? Measuring Consistency and Change with a Multicountry Study.

The consistency of self-reported contraceptive use over short periods of time is important for understanding measurement reliability. We assess the consistency of and change in contraceptive use using longitudinal data from 9,390 urban female clients interviewed in DR Congo, India, Kenya, Niger, Nigeria, and Burkina Faso. Clients were interviewed in-person at a health facility and four to six months later by phone. We compared reports of contraceptive use at baseline with recall of baseline contraceptive use at follow-up. Agreement between these measures ranged from 59.1 percent in DR Congo to 84.4 percent in India. Change in both contraceptive method type (sterilization, long-acting, short-acting, nonuse) and use status (user, nonuser, discontinuer, adopter, switcher) was assessed comparing baseline to follow-up reports and retrospective versus current reports within the follow-up survey. More change in use was observed with panel reporting than within the cross section. The percent agreement between the two scenarios of change ranged from 64.8 percent in DR Congo to 84.5 percent in India, with cross-site variation. Consistently reported change in use status was highest for nonusers, followed by users, discontinuers, adopters, and switchers. Inconsistency in self-reported contraceptive use, even over four to six months, was nontrivial, indicating that studying measurement reliability of contraceptive use remains important.

Association between utilization and quality of antenatal care with stillbirths in four tertiary hospitals in a low-income urban setting.

INTRODUCTION: About 2.6 million stillbirths per year occur globally with 98% occurring in low- and middle-income countries including Kenya, where an estimated 35 000 stillbirths occur annually. Most studies have focused on the direct causes of stillbirth. The aim of this study was to determine the association between antenatal care utilization and quality with stillbirth in a Kenyan set up. This information is key when planning strategies to reduce the stillbirth burden. MATERIAL AND METHODS: This was a case-control study in four urban tertiary hospitals carried out between August 2018 and April 2019. A total of 214 women with stillbirths (cases) and 428 with livebirths (controls) between 28 and 42 weeks were enrolled. Information was obtained through interviews and data abstracted from medical records. Antenatal care utilization was assessed by the proportions of women not attending antenatal care; booking first antenatal care visit in first trimester and not making the requisite four antenatal care visits. Quality of antenatal care was assessed using individual surrogate indicators (antenatal profile testing, weight/blood pressure/urinalysis testing in each antenatal visit, utilization of early obstetric ultrasound, completeness of antenatal records) and a codified indicator made up of seven parameters (attending antenatal care, booking first antenatal care in the first trimester, making four or more antenatal visits, having all antenatal profile tests, having a complete antenatal record, having blood pressure and weight measured at all visits). The association between antenatal care utilization and quality with stillbirth was assessed using univariate and multivariate analysis using logistic regression. Statistical significance was defined as a two-tailed P value ≤ .05. RESULTS: Women with stillbirth were likely to have a parity ≥4 (19.6% vs 12.6%, P = .02), have an obstetric complication (36% vs 8.6%, P = .001) and have a medical disorder (5.6% vs 1.6%, P = .01). The odds of a stillbirth were four times higher among those who did not attend antenatal care ( odds ratio [OR] 4.1, 95% confidence interval [CI] 1.6-10, P < .003). Compared with four antenatal care visits, those who had one or two visits had higher odds of a stillbirth: OR 2.96 (95% CI 1.4-6.1), P = .003, and OR 2.9 (95% CI 1.7-5), P = .003, respectively. As per the individual surrogate indicators, the likelihood of a stillbirth was lower in women who received good quality antenatal care: Hemoglobin testing (OR 0.6, 95% CI 0.4-0.8, P = .03), blood group test (OR 0.4, 95% CI 0.2-0.6, P < .001), HIV test (OR 0.3, 95% CI 0.2-0.5, P = .001), venereal disease research laboratory test (OR 0.2, 95% CI 0.1-0.4, P = .001), weight measurement (OR 0.7, 95% CI 0.5-1.0, P = .047). As per the composite indicator, the quality of antenatal care was poor across the board and there was no association between this surrogate indicator and stillbirth. CONCLUSIONS: Lack of antenatal care, attending fewer than four antenatal visits and poor quality antenatal care as measured by surrogate indicators were significantly associated with stillbirth. In addition, women with low education level, obstetric complications, multiparity and medical complications had a significantly higher likelihood of stillbirth. Improving the utilization of four or more antenatal visits and the quality of antenatal care can reduce the risk of stillbirth.

Early detection of cervical cancer in western Kenya: determinants of healthcare providers performing a gynaecological examination for abnormal vaginal discharge or bleeding.

BACKGROUND: In western Kenya, women often present with late-stage cervical cancer despite prior contact with the health care system. The aim of this study was to predict primary health care providers' behaviour in examining women who present with abnormal discharge or bleeding. METHODS: This was a cross-sectional survey using the theory of planned behaviour (TPB). A sample of primary health care practitioners in western Kenya completed a 59-item questionnaire. Structural equation modelling was used to identify the determinants of providers' intention to perform a gynaecological examination. Bivariate analysis was conducted to investigate the relationship between the external variables and intention. RESULTS: Direct measures of subjective norms (DMSN), direct measures of perceived behavioural control (DMPBC), and indirect measures of attitude predicted the intention to examine patients. Negative attitudes toward examining women had a suppressor effect on the prediction of health workers' intentions. However, the predictors of intention with the highest coefficients were the external variables being a nurse (ß = 0.32) as opposed to a clinical officer and workload of attending less than 50 patients per day (ß = 0.56). In bivariate analysis with intention to perform a gynaecological examination, there was no evidence that working experience, being female, having a lower workload, or being a private practitioner were associated with a higher intention to conduct vaginal examinations. Clinical officers and nurses were equally likely to examine women. CONCLUSIONS: The TPB is a suitable theoretical basis to predict the intention to perform a gynaecological examination. Overall, the model predicted 47% of the variation in health care providers' intention to examine women who present with recurrent vaginal bleeding or discharge. Direct subjective norms (health provider's conformity with what their colleagues do or expect them to do), PBC (providers need to feel competent and confident in performing examinations in women), and negative attitudes toward conducting vaginal examination accounted for the most variance. External variables in this study also contributed to the overall variance. As the model in this study could not explain 53% of the variance, investigating other external variables that influence the intention to examine women should be undertaken.

"I Couldn't Afford to Resist": Condom Negotiations Between Male Sex Workers and Male Clients in Mombasa, Kenya.

Male sex workers in Kenya face a disproportionate burden of HIV and often engage in condomless sex with their commercial partners, yet little is known about how condom negotiations between male sex workers and clients take place. We conducted semi-structured interviews with 25 male sex workers and 11 male clients of male sex workers in Mombasa, Kenya, to examine barriers and facilitators to condom use and how condom use negotiation takes place in these interactions. Participants reported positive attitudes toward condom use and perceived condom use to be a health-promoting behavior. Barriers to condom use included extra-payment for condomless sex, low perceived HIV/STI risk with some sexual partners, perceived reduced pleasure associated with using condoms, alcohol use, and violence against male sex workers by clients. Future interventions should address individual- and structural-level barriers to condom use to promote effective condom use negotiation between male sex workers and male clients.

Reconceptualizing Measurement of Emergency Contraceptive Use: Comparison of Approaches to Estimate the Use of Emergency Contraception.

Estimated use of emergency contraception (EC) remains low, and one reason is measurement challenges. The study aims to compare EC use estimates using five approaches. Data come from Performance Monitoring and Accountability 2020 surveys from 10 countries, representative sample surveys of women aged 15 to 49 years. We explore EC use employing the five definitions and calculate absolute differences between a reference definition (percentage of women currently using EC as the most effective method) and each of the subsequent four, including the most inclusive (percentage of women having used EC in the past year). Across the 17 geographies, estimated use varies greatly by definition and EC use employing the most inclusive definition is statistically significantly higher than the reference estimate. Impact of using various definitions is most pronounced among unmarried sexually active women. The conventional definition of EC use likely underestimates the magnitude of EC use, which has unique programmatic implications.

Prevalence and patterns of gender-based violence across adolescent girls and young women in Mombasa, Kenya.

BACKGROUND: We sought to estimate the prevalence and describe heterogeneity in experiences of gender-based violence (GBV) across subgroups of adolescent girls and young women (AGYW). METHODS: We used data from a cross-sectional bio-behavioural survey among 1299 AGYW aged 14-24 in Mombasa, Kenya in 2015. Respondents were recruited from hotspots associated with sex work, and self-selected into one of three subgroups: young women engaged in casual sex (YCS), young women engaged in transactional sex (YTS), and young women engaged in sex work (YSW). We compared overall and across subgroups: prevalence of lifetime and recent (within previous year) self-reported experience of physical, sexual, and police violence; patterns and perpetrators of first and most recent episode of physical and sexual violence; and factors associated with physical and sexual violence. RESULTS: The prevalences of lifetime and recent physical violence were 18.0 and 10.7% respectively. Lifetime and recent sexual violence respectively were reported by 20.5 and 9.8% of respondents. Prevalence of lifetime and recent experience of police violence were 34.7 and 25.8% respectively. All forms of violence were most frequently reported by YSW, followed by YTS and then YCS. 62%/81% of respondents reported having sex during the first episode of physical/sexual violence, and 48%/62% of those sex acts at first episode of physical/sexual violence were condomless. In the most recent episode of violence when sex took place levels of condom use remained low at 53-61%. The main perpetrators of violence were intimate partners for YCS, and both intimate partners and regular non-client partners for YTS. For YSW, first-time and regular paying clients were the main perpetrators of physical and sexual violence. Alcohol use, ever being pregnant and regular source of income were associated with physical and sexual violence though it differed by subgroup and type of violence. CONCLUSIONS: AGYW in these settings experience high vulnerability to physical, sexual and police violence. However, AGYW are not a homogeneous group, and there are heterogeneities in prevalence and predictors of violence between subgroups of AGYW that need to be understood to design effective programmes to address violence.

Exploring contraception myths and misconceptions among young men and women in Kwale County, Kenya.

BACKGROUND: Myths and misconceptions around modern contraceptives have been associated with low contraceptive uptake in sub-Saharan Africa and Kenya in particular. Addressing persistent contraceptive knowledge gaps can make a significant contribution towards improved contraceptive uptake among young women. This qualitative study therefore sought to explore and understand young people's knowledge of modern contraception and to identify their key concerns regarding these methods. METHODS: We used focus group discussions (FGD) with vignette and writing activities to explore key myths and misconceptions around the use of contraceptives. Six FGDs (three for young men and three for young women) were conducted with a total of 28 young women and 30 young men from Kwale County, Kenya. We included 10 discussants aged 18-24 per FGD, one FGD had 8 participants. Predefined codes reflecting the discussion guides and emerging issues in the FGDs were used to develop the thematic coding framework. Our analysis followed a pattern of association on the key preset themes focusing on myths and misconceptions around contraceptive use. RESULTS: Results are presented under four key themes: awareness of contraception, myths and misconceptions around contraception, males' contraceptive narratives and young people's preferred sources of contraceptives. Both men and women participants reported basic awareness of contraceptives. A mixture of biological and social misconceptions were discussed and included perceptions that modern contraception: jeopardized future fertility, could result in problems conceiving or birth defects, made women promiscuous, was 'un-African', and would deny couples their sexual freedom. Compared to female respondents in the study, young men appeared to be strong believers of the perceived socio-cultural effects of contraceptives. On preferred sources of contraceptives, respondents reported on two main sources, pharmacies and public hospitals, however, they could not agree on which one was suitable for them. CONCLUSIONS: This study revealed the presence of a mixture of biological and social myths and misconceptions around contraception, with young men also strongly adhering to these misconceptions. The low level of contraceptive knowledge, particularly on contraceptive fears as revealed by the study demonstrate critical gaps in sexual and reproductive health (SRH) knowledge among young people. Improved SRH literacy to address contraceptives' fears through appropriate and gender specific interventions to reach out to young men and women with factual SRH information may therefore contribute to increased uptake of SRH services including modern contraceptive methods.

Low program access despite high burden of sexual, structural, and reproductive health vulnerabilities among young women who sell sex in Mombasa, Kenya.

BACKGROUND: Across Sub-Saharan Africa, young women who sell sex (YSW) face institutional barriers in accessing sexual health and HIV prevention programs designed for female sex workers. In 2018, Kenya developed a national framework to guide service provision for YSW aged 14-24 years. To help inform the implementation of the framework, we estimated the burden of vulnerabilities related to the Sustainable Development Goals (SDGs related to health and gender equality) and program contact among YSW. METHODS: We used data from Transitions, a 2015 bio-behavioural cross-sectional survey of 408 YSW aged 14-24 years in Mombasa, Kenya. We estimated the prevalence of sexual (inconsistent condom use), structural (financial, violence), and reproductive health vulnerabilities; and characterized engagement with local HIV programs tailored to sex workers. We then compared the prevalence of vulnerabilities by age group (14-18 years, N = 117; 19-24 years, N = 291) and by program contact (ever contacted by local program for sex workers). RESULTS: 47.3% reported inconsistent condom use with any partner in the previous week (no difference by age-group, p = 1.00). Structural vulnerabilities were common and did not vary by age: 83.6% did not have a regular source of income; 29.9 and 29.2% had experienced physical and sexual violence, respectively. 26.5% reported at least one pregnancy before age 18, and 18.5% used a non-reliable form of contraception with little variability by age. 25.7% were aware of at least one program, and only 13.7% of YSW had ever been contacted by a program (8.5% of those aged 14-18 years; and 15.8% of those aged 19-24 years, p = 0.06). Sexual, structural, and reproductive health vulnerabilities did not vary by program contact. CONCLUSIONS: SDG-related vulnerabilities begin early in the lives of YSW who are not currently reached by programs designed for female sex workers.

Religious, socio-cultural norms and gender stereotypes influence uptake and utilization of maternal health services among the Digo community in Kwale, Kenya: a qualitative study.

BACKGROUND: Maternal health outcomes in resource-limited settings are typically influenced by supply-side factors affecting the provision of quality health services. The extent to which demand-side factors contribute to this influence is unclear. We aimed to explore how individual and community-wide factors influenced uptake and utilization of maternal health services among the Digo community residing in Kwale County of coastal Kenya. METHODS: Between March and December 2015, we conducted 5 focus group discussions (FGDs) and 15 in-depth interviews (IDIs) with members of the Digo community predominant in Kwale county, Kenya. Respondents were sampled purposively and included female (pregnant and postpartum) as well as male adult community members. A thematic content analytic approach was used. RESULTS: There were a total of 47 FGD respondents, including 15 (32%) females with a median (interquartile, IQR) age of 38 (27-55) years and 6 (3-8) children. Majority (40%) reported attaining secondary-level education. All IDI respondents were female with a median (IQR) age of 27 (24-35) years and 4 (2-5) children. Majority (80%) had attained primary-level education. We found that religious and socio-cultural norms as well as gender stereotypes were important influences on the uptake and utilization of maternal health services, including facility-based delivery and contraception. Key amongst this was the unspoken deference to the counsel of a prominent matriarchal figure in the decision-making process. CONCLUSIONS: Among the Digo community of coastal Kenya, a unique social-cultural context comprising of a religious and gendered value belief system influences women's reproductive health and rights. These findings highlight the important role of demand-side factors in influencing maternal health outcomes. In addition to addressing supply-side factors, programs in such settings should aim to address factors that leverage inherent social capital to drive demand for maternal health services ensuring that they are not only effective, but also responsive to the local context.