Prevalence of and risk factors for iron deficiency among pregnant women with moderate or severe anaemia in Nigeria: a cross-sectional study.

BACKGROUND: Anaemia during pregnancy causes adverse outcomes to the woman and the foetus, including anaemic heart failure, prematurity, and intrauterine growth restriction. Iron deficiency anaemia (IDA) is the leading cause of anaemia and oral iron supplementation during pregnancy is widely recommended. However, little focus is directed to dietary intake. This study estimates the contribution of IDA among pregnant women and examines its risk factors (including dietary) in those with moderate or severe IDA in Lagos and Kano states, Nigeria. METHODS: In this cross-sectional study, 11,582 women were screened for anaemia at 20-32 weeks gestation. The 872 who had moderate or severe anaemia (haemoglobin concentration < 10 g/dL) were included in this study. Iron deficiency was defined as serum ferritin level < 30 ng/mL. We described the sociodemographic and obstetric characteristics of the sample and their self-report of consumption of common food items. We conducted bivariate and multivariable logistic regression analysis to identify risk factors associated with IDA. RESULTS: Iron deficiency was observed among 41% (95%CI: 38 - 45) of women with moderate or severe anaemia and the prevalence increased with gestational age. The odds for IDA reduces from aOR: 0.36 (95%CI: 0.13 - 0.98) among pregnant women who consume green leafy vegetables every 2-3 weeks, to 0.26 (95%CI: 0.09 - 0.73) among daily consumers, compared to those who do not eat it. Daily consumption of edible kaolin clay was associated with increased odds of having IDA compared to non-consumption, aOR 9.13 (95%CI: 3.27 - 25.48). Consumption of soybeans three to four times a week was associated with higher odds of IDA compared to non-consumption, aOR: 1.78 (95%CI: 1.12 - 2.82). CONCLUSION: About 4 in 10 women with moderate or severe anaemia during pregnancy had IDA. Our study provides evidence for the protective effect of green leafy vegetables against IDA while self-reported consumption of edible kaolin clay and soybeans appeared to increase the odds of having IDA during pregnancy. Health education on diet during pregnancy needs to be strengthened since this could potentially increase awareness and change behaviours that could reduce IDA among pregnant women with moderate or severe anaemia in Nigeria and other countries.

Effects of COVID-19 measures on access to HIV/STI testing and condoms among adults in Sweden: a cross-sectional online survey.

AIMS: To investigate the self-reported impact of COVID-19 measures on access to testing for HIV and other sexually transmitted infections (STIs) and condoms and factors associated with reduced access among adults in Sweden. METHODS: Cross-sectional data were collected in late 2020 through a web panel with adults (18-49 years) in Sweden as part of the International Sexual Health And REproductive health survey (I-SHARE) (N=1307). The primary outcome was self-reported access to HIV/STI testing and condoms during COVID-19 measures. Logistic regression was used to assess adjusted odds ratios of experiencing reduced access to HIV/STI testing and condoms in relation to sociodemographic characteristics, changes in sexual behaviours and COVID-19-related factors. RESULTS: Of the 1138 sexually active respondents, 17% wanted an HIV/STI test, and of those over half (57%) reported reduced access during the COVID-19 measures in 2020. Compared with cis-women, transgender or non-binary respondents were more likely to experience lower access to testing. Among those who usually used condoms (n=568), 23% reported hampered condom access due to COVID-19 restrictions. Reduced condom access was associated with identifying as non-cis gender and a cis-man compared with cis-woman, non-heterosexual orientation, being foreign-born and financially worried. CONCLUSIONS: Findings indicate that access to HIV/STI testing and condoms among sexually active adults of reproductive age in Sweden was disrupted during the COVID-19 pandemic in 2020 with varied impact depending on sexual orientation, gender identity or socioeconomic situation. This signals the importance of ensuring equitable access to sexual and reproductive health services and commodities in future crises response.

Implementing digital sexual and reproductive health care services in youth clinics: a qualitative study on perceived barriers and facilitators among midwives in Stockholm, Sweden.

BACKGROUND: Digital health care services have the potential to improve access to sexual and reproductive health care for youth but require substantial implementation efforts to translate into individual and public health gains. Health care providers are influential both regarding implementation and utilization of the services, and hence, their perceptions of digital health care services and the implementation process are essential to identify and address. The aim of this study was to explore midwives' perception of digital sexual and reproductive health care services for youth, and to identify perceived barriers and facilitators of the implementation of digital health care provision in youth clinics. METHODS: We performed semi-structured interviews with midwives (n = 16) working at youth clinics providing both on-site and digital sexual and reproductive health care services to youth in Stockholm, Sweden. Interview data were analyzed using a content analysis approach guided by the Consolidated Framework for Implementation Research (CFIR). RESULTS: Midwives acknowledged that the implementation of digital health care improved the overall access and timeliness of the services at youth clinics. The ability to accommodate the needs of youth regarding their preferred meeting environment (digital or on-site) and easy access to follow-up consultations were identified as benefits of digital health care. Challenges to provide digital health care included communication barriers, privacy and confidentiality concerns, time constraints, inability to offer digital appointments for social counselling, and midwives' preference for in person consultations. Experiencing organizational support during the implementation was appreciated but varied between the respondents. CONCLUSION: Digital sexual and reproductive health care services could increase access and are valuable complements to on-site services in youth clinics. Sufficient training for midwives and organizational support are crucial to ensure high quality health care. Privacy and safety concerns for the youth might aggravate implementation of digital health care. Future research could focus on equitable access and youth' perceptions of digital health care services for sexual and reproductive health.

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

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

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

Can extended health communication improve newly settled refugees' health literacy? A quasi-experimental study from Sweden.

Structural and contextual factors such as limited work and housing opportunities negatively affect the health and well-being of newly settled refugee migrants in receiving high-income countries. Health promotion initiatives aiming at strengthening health and integration have been tried out within the Swedish Introduction program for refugee migrants. However, longitudinal evaluations of these interventions are rare. The aim of the current study was to compare the effectiveness of a regular and an extended civic orientation course with added health communication and examine whether the latter would improve self-rated health and psychological well-being, health literacy and social capital among newly settled refugee migrants in Sweden. Pre- and post-assessment questionnaires were collected from the intervention group receiving the extended course (n = 143) and a control group receiving the regular course (n = 173). Linear mixed models and chi-square analyses showed a significant increase with a small effect size (0.21) in health literacy in the intervention group. However, there were no significant changes in emotional and practical support, general self-rated health or psychological well-being. The findings indicate that added health communication provided embedded in the civic orientation course can increase health literacy. However, further longitudinal studies are needed to confirm the sustainability of the observed effect and examine whether these short-term improvements in health literacy translate to long-term advances in health and integration.

IMplementing best practice post-partum contraceptive services through a quality imPROVEment initiative for and with immigrant women in Sweden (IMPROVE it): a protocol for a cluster randomised control trial with a process evaluation.

BACKGROUND: Immigrant women's challenges in realizing sexual and reproductive health and rights (SRHR) are exacerbated by the lack of knowledge regarding how to tailor post-partum contraceptive services to their needs. Therefore, the overall aim of the IMPROVE-it project is to promote equity in SRHR through improvement of contraceptive services with and for immigrant women, and, thus, to strengthen women's possibility to choose and initiate effective contraceptive methods post-partum. METHODS: This Quality Improvement Collaborative (QIC) on contraceptive services and use will combine a cluster randomized controlled trial (cRCT) with a process evaluation. The cRCT will be conducted at 28 maternal health clinics (MHCs) in Sweden, that are the clusters and unit of randomization, and include women attending regular post-partum visits within 16 weeks post birth. Utilizing the Breakthrough Series Collaborative model, the study's intervention strategies include learning sessions, action periods, and workshops informed by joint learning, co-design, and evidence-based practices. The primary outcome, women's choice of an effective contraceptive method within 16 weeks after giving birth, will be measured using the Swedish Pregnancy Register (SPR). Secondary outcomes regarding women's experiences of contraceptive counselling, use and satisfaction of chosen contraceptive method will be evaluated using questionnaires completed by participating women at enrolment, 6 and 12 months post enrolment. The outcomes including readiness, motivation, competence and confidence will be measured through project documentation and questionnaires. The project's primary outcome involving women's choice of contraceptive method will be estimated by using a logistic regression analysis. A multivariate analysis will be performed to control for age, sociodemographic characteristics, and reproductive history. The process evaluation will be conducted using recordings from learning sessions, questionnaires aimed at participating midwives, intervention checklists and project documents. DISCUSSION: The intervention's co-design activities will meaningfully include immigrants in implementation research and allow midwives to have a direct, immediate impact on improving patient care. This study will also provide evidence as to what extent, how and why the QIC was effective in post-partum contraceptive services. TRIAL REGISTRATION: NCT05521646, August 30, 2022.

COVID-19 vaccine hesitancy among first-generation immigrants living in Sweden.

BACKGROUND: In many countries, immigrants face higher risks of contracting and dying from COVID-19 compared with the native-born population. Moreover, their COVID-19 vaccination uptake tends to be lower. This study aimed to investigate COVID-19 vaccine hesitancy in relation to sociodemographic characteristics, COVID-19-related exposures and social values, norms and perceptions among first-generation immigrants in Sweden. Vaccine hesitancy is an important public health issue to ensure protection against vaccine-preventable mortality and morbidity. METHODS: Nation-wide representative data were collected by the Migrant World Values Survey. Descriptive and multinomial multivariate analyses were performed to analyze vaccine hesitancy among 2612 men and women aged ≥16 years. RESULTS: One-quarter of the respondents expressed some degree of vaccine hesitancy; 5% said they would definitely not vaccinate, 7% probably not, 4% did not know and 7% did not want to answer. Young age, arriving to Sweden during the large migration wave in 2015, Eastern European origin, female gender, lower education and low trust in authorities, and less perceived benefits of vaccination were all significant determinants of vaccine hesitancy. CONCLUSIONS: The results underscore the importance of trust in healthcare providers and government authorities. Additionally, the importance of providing adequate and targeted information about vaccination to groups who face the largest barriers to care, enabling informed decision-making about the benefits and risks of vaccination in relation to health risks. Given these health risks, it is crucial that government agencies and the health sector address the multiple social dimensions that shape the low vaccine uptake and, in turn, health equity.

What factors influence a Quality Improvement Collaborative in improving contraceptive services for foreign-born women? A qualitative study in Sweden.

BACKGROUND: Improved contraceptive services could reduce the unmet need for contraception and unintended pregnancies globally. This is especially true among foreign-born women in high-income countries, as the health outcomes related to unmet need of contraception disproportionally affect this group. A widely used quality improvement approach to improve health care services is Quality Improvement Collaborative (QIC). However, evidence on to what extent, how and why it is effective and what factors influence a QIC in different healthcare contexts is limited. The purpose of this study was to analyse what factors have influenced a successful QIC intervention that is aimed to improve contraceptive service in postpartum care, mainly targeting foreign-born women in Sweden. METHODS: A qualitative, deductive design was used, guided by the Consolidated Framework for Implementation Research (CFIR). The study triangulated secondary data from four learning seminars as part of the QIC, with primary interview data with four QIC-facilitators. The QIC involved midwives at three maternal health clinics in Stockholm County, Sweden, 2018-2019. RESULTS: Factors from all five CFIR domains were identified, however, the majority of factors that influenced the QIC were found inside the QIC-setting, in three domains: intervention characteristics, inner setting and process. Outside factors and those related to individuals were less influential. A favourable learning climate, emphasizing co-creation and mutual learning, facilitated reflections among the participating midwives. The application of the QIC was facilitated by adaptability, trialability, and a motivated and skilled project team. Our study further suggests that the QIC was complex because it required a high level of engagement from the midwives and facilitators. Additionally, it was challenging due to unclear roles and objectives in the initial phases. CONCLUSIONS: The application of the CFIR framework identified crucial factors influencing the success of a QIC in contraceptive services in a high-income setting. These factors highlight the importance of establishing a learning climate characterised by co-creation and mutual learning among the participating midwives as well as the facilitators. Furthermore, to invest in planning and formation of the project group during the QIC initiation; and to ensure adaptability and trialability of the improvement activities.

Developing contraceptive services for immigrant women postpartum - a case study of a quality improvement collaborative in Sweden.

BACKGROUND: Immigrant women use less effective contraceptive methods and have a higher risk of unintended pregnancies. Maternal health care services offer a central opportunity to strengthen contraceptive services, especially among immigrants. This study aimed to evaluate a Quality Improvement Collaborative QIC. Its objective was to improve contraceptive services for immigrant women postpartum, through health care professionals' (HCPs) counselling and a more effective choice of contraceptive methods. METHODS: The pilot study was designed as an organisational case study including both qualitative and quantitative data collection and analysis. Midwives at three maternal health clinics (MHCs) in Stockholm, Sweden participated in a QIC during 2018-2019. In addition, two recently pregnant women and a couple contributed user feedback. Data on women's choice of contraceptive method at the postpartum visit were registered in the Swedish Pregnancy Register over 1 year. RESULTS: The participating midwives decided that increasing the proportion of immigrant women choosing a more effective contraceptive method postpartum would be the goal of the QIC. Evidence-based changes in contraceptive services, supported by user feedback, were tested in clinical practice during three action periods. During the QIC, the proportion of women choosing a more effective contraceptive method postpartum increased at an early stage of the QIC. Among immigrant women, the choice of a more effective contraception increased from 30 to 47% during the study period. Midwives reported that their counselling skills had developed due to participation in the QIC, and they found using a register beneficial for evaluating women's choice of contraceptive methods. CONCLUSIONS: The QIC, supported by a register and user feedback, helped midwives to improve their contraceptive services during the pregnancy and postpartum periods. Immigrant women's choice of a more effective contraceptive method postpartum increased during the QIC. This implies that a QIC could increase the choice of a more effective contraception of postpartum contraception among immigrants.

"This course is like a compass to us" - a qualitative study on newly settled migrants' perceptions of civic and health orientation in Sweden.

BACKGROUND: Migrants face structural, socio-political barriers in their resettlement processes that negatively affect their health. Migration also adversely impacts resources such as social capital and health literacy that are of importance for health and integration into society. Hence, there is a need for health promotion in the early post-migration phase. In Sweden, newly settled refugee migrants who have received a residence permit are offered an Introduction programme including a civic orientation course. The program is intended to facilitate access to the labour market and promote integration. The aim of the study was to explore participants' perceptions and experiences of a civic orientation course with added health communication. METHODS: We performed six focus group discussions: two in Arabic, two in Farsi and two in Somali. The discussions were facilitated by native speaking moderators. Participants were 32 men and women recruited from civic orientation classes in the county of Stockholm. We used an interview guide with semi-structured questions. The data were analysed using a method for content analysis for focus group discussions. RESULTS: Three main categories were identified: (1) 'The course gives valuable information but needs adjustments', which includes that the civic and health orientation is needed earlier, during the asylum phase, and that planning and course content need adjustments. (2) 'The health communication inspired participants to focus on their health', which includes that the health communication was useful and inspired uptake of healthier habits. (3) 'Participation in the course promoted independence and self-confidence', which includes that the course gave insights into society and values in Sweden, and promoted independence and new social contacts. CONCLUSION: This study adds knowledge about the users' perspectives on the potential of civic orientation to promote the health and integration of newly settled migrants, describing ways in which civic orientation with added health communication promoted health and empowerment. However, the content and delivery of the course need adjustment to better fit the migrants' life situations and varying pre-existing knowledge.

Understanding the needs and use of sexual and reproductive health services among Thai women: a descriptive cross-sectional study in Sweden.

Background Immigrants are at increased risk of HIV infection in Europe and at risk of delayed diagnosis. In Sweden, Thailand belongs to one of the three most common countries of origin among immigrants diagnosed with HIV. This study investigated the need and use of sexual and reproductive health (SRH) services among Thai women residing in Sweden. Use of contraceptives and HIV testing in Thailand was also investigated to understand if this influences utilisation of SRH services in Sweden. METHODS: A cross-sectional study using postal questionnaire to all Thai-born women (age 23-60) in Stockholm, residing in Sweden since 2014. The response rate was 52.3% (n= 266). Bivariate and multivariate logistic regression analyses were used. RESULTS: The majority reported a significant need for information related to SRH services. Most of the women using contraception (70%) bought their contraceptives in Thailand. In total, 60% of the women had been HIV-tested at some point in their lives; the majority were tested in Thailand. Women who had been HIV-tested in Thailand were more likely to also have been tested in Sweden. Significant differences in contraception use, participation in contraceptive counselling and having had an HIV test were found between groups of younger and older women. CONCLUSIONS: Our findings imply that age is an important factor to understand women's need and use of SRH services in Sweden versus Thailand. Furthermore, women's lack of knowledge and reported need for SRH information needs to be considered when making policies and strategies to increase access to SRH services.

Opportunities for linking research to policy: lessons learned from implementation research in sexual and reproductive health within the ANSER network.

BACKGROUND: The uptake of findings from sexual and reproductive health and rights research into policy-making remains a complex and non-linear process. Different models of research utilisation and guidelines to maximise this in policy-making exist, however, challenges still remain for researchers to improve uptake of their research findings and for policy-makers to use research evidence in their work. METHODS: A participatory workshop with researchers was organised in November 2017 by the Academic Network for Sexual and Reproductive Health and Rights Policy (ANSER) to address this gap. ANSER is a consortium of experienced researchers, some of whom have policy-making experience, working on sexual and reproductive health and rights issues across 16 countries and 5 continents. The experiential learning cycle was used to guide the workshop discussions based on case studies and to encourage participants to focus on key lessons learned. Workshop findings were thematically analysed using specific stages from Hanney et al.'s (Health Res Policy Syst 1:2, 2003) framework on the place of policy-making in the stages of assessment of research utilisation and outcomes. RESULTS: The workshop identified key strategies for translating research into policy, including joint agenda-setting between researchers and policy-makers, as well as building trust and partnerships with different stakeholders. These were linked to stages within Hanney et al.'s framework as opportunities for engaging with policy-makers to ensure uptake of research findings. CONCLUSION: The engagement of stakeholders during the research development and implementation phases, especially at strategic moments, has a positive impact on uptake of research findings. The strategies and stages described in this paper can be applied to improve utilisation of research findings into policy development and implementation globally.

Unintended Consequences of Gender Equality Promotion in Swedish Multicultural Contraceptive Counseling: A Discourse Analysis.

In this article, we explore how reproductive health care providers in Sweden, a country often described as one of the most gender-equal countries in the world, incorporate gender equality ideals in multicultural contraceptive counseling. In the tension between gender equality promotion on one hand and respect for cultural diversity and individualized care on the other, we will demonstrate that values of gender equality were often given priority. This is not necessarily undesirable. Nevertheless, our proposal is that the gender equality ideology may inhibit providers' ability to think differently about issues at stake in contraceptive counseling, which may negatively influence women's possibilities to obtain adequate support. At the end of the article, we suggest how health care providers' reflexivity might be used as a working tool for increased awareness about the taken-for-granted cultural norms that exist in their clinical milieu.

Associations between the COVID-19 pandemic and women's fertility intentions: a multi-country, cross-sectional (I-SHARE) study.

INTRODUCTION: The COVID-19 pandemic, together with the subsequent social distancing measures, could lead to shifts in family and fertility planning. This study aimed to explore the associations between the COVID-19 pandemic and changes in fertility intentions among an international sample of reproductive-aged women. METHODS: A multi-country, cross-sectional study based on data from 10 672 women aged 18-49 years who participated in the International Sexual Health And REproductive Health (I-SHARE) study, which organised an international online survey between July 2020 and February 2021. Factors associated with changes in fertility intentions were explored using multinomial probit regression models. Cluster-robust standard errors were used to calculate model parameters. RESULTS: Of 10 672 included reproductive-aged women, 14.4% reported changing their fertility intentions due to the pandemic, with 10.2% postponement and 4.2% acceleration. Women who had ever been isolated/quarantined were more likely to postpone their fertility intentions (adjusted odds ratio (AOR)=1.41; 95% CI 1.18 to 1.69) compared with those who had not; women who lived with a steady partner were more likely to want children sooner (AOR=1.57; 95% CI 1.10 to 2.23) compared with those who did not; and those who reported a higher frequency of getting angry, feeling frustrated, or worrying about their finances were more likely to postpone their fertility intentions. The main findings were robust in the sensitivity analyses. CONCLUSIONS: Most women who changed fertility intentions because of the pandemic have postponed intentions to expand their families. The pandemic-induced exposures were associated with these postponements.

Two decades of research capacity strengthening and reciprocal learning on sexual and reproductive health in East Africa - a point of (no) return.

As the world is facing challenges such as pandemics, climate change, conflicts, and changing political landscapes, the need to secure access to safe and high-quality abortion care is more urgent than ever. On 27th of June 2023, the Swedish government decided to cut funding resources available for developmental research, which has played a fundamental role in the advancement of sexual and reproductive health and rights (SRHR) globally, including abortion care. Withdrawal of this funding not only threatens the fulfilment of the United Nations sustainable development goals (SDGS) - target 3.7 on ensuring universal access to SRHR and target 5 on gender equality - but also jeopardises two decades of research capacity strengthening. In this article, we describe how the partnerships that we have built over the course of two decades have amounted to numerous publications, doctoral graduates, and important advancements within the field of SRHR in East Africa and beyond.

Main findings: The two-decade long collaboration between Sweden and East Africa, funded by the Swedish government, has resulted in important partnerships, research findings, and advancements within sexual and reproductive health and rights in East Africa.Added knowledge: The Swedish government is now cutting funding for development research, which jeopardises the progress made so far.Global health impact for policy and action: Governments need to prioritise women's sexual and reproductive health and rights.

Adherence to Modern Contraceptives Among Female Refugee Adolescents in Northern Uganda: A Prospective Single Cohort Study.

Background: Contraceptive adherence is the current and consistent use of a contraceptive method as prescribed by a health worker or family planning provider so as to prevent pregnancy. Globally, adherence is lowest among adolescents. This has greatly contributed to the high burden of adolescent pregnancies. Adherence and reasons for discontinuation among refugee adolescents are poorly understood. The aim of this study was to determine the rates and predictors of adherence to modern contraceptives among female refugee adolescents in northern Uganda. Methods: This was a prospective single cohort study, nested into a randomised controlled trial (RCT) assessing the effect of peer counselling on acceptance of modern contraceptives. The RCT was conducted among female refugee adolescents in Palabek refugee settlement, northern Uganda. The study involved 272 new starters of modern contraceptives who were followed up for six months from May 2019 to January 2020. The outcome was measured at one, three, and six months after receiving a contraceptive method, and the predictors of adherence were determined using Generalised Estimating Equations (GEE). Data were analysed using STATA version 14.0. Results: Adherence rates were low and reduced over time. By the end of the six months, only 44% of the participants were using a contraceptive method. Participants using long-acting reversible contraceptives (LARC) were more likely to adhere compared to those who were using short-acting reversible contraceptives (SARC) (OR: 3.37, 95% CI: 1.914-5.937, p<0.001). Conclusion: Adherence to modern contraceptives was low, leaving adolescents at risk of unintended pregnancies. Participants using LARC were more likely to adhere than those using SARC. Interventions addressing fear of side effects and partner prohibition should be studied and implemented to enable adherence to modern contraceptives.

"Who is Anders Tegnell?" Unanswered questions hamper COVID-19 vaccine uptake: A qualitative study among ethnic minorities in Sweden.

BACKGROUND: Despite high COVID-19 vaccination coverage in many European countries, vaccination uptake has been lower among ethnic minorities, including in Sweden. This is in spite of the increased risk of contracting the virus and targeted efforts to vaccinate among first and second generation migrants. The aim of this study was to understand this dilemma by investigating ethnic minorities' perceptions and their experience of accessing the COVID-19 vaccine. METHODS: This is a qualitative study drawing on 18 semi-structured interviews with health volunteers working in ethnic minority communities and with participants from the two largest ethnic minorities in Sweden (Syria and Somalia). Deductive qualitative analysis was completed using the 3C model by WHO (Complacency, Confidence and Convenience). RESULTS: Complacency does not appear to be a barrier to intention to vaccinate. Participants are well aware of COVID-19 risk and the benefits of the vaccine. However, confidence in vaccine poses a barrier to uptake and there are a lot of questions and concerns about vaccine side effects, efficacy and related rumors. Confidence in health providers, particularly doctors is high but there was a sense of conflicting information. Accessing individually tailored health information and health providers is not convenient and a major reason for delaying vaccination or not vaccinating at all. Trust in peers, schools and faith-leaders is high and constitute pathways for effective health information sharing. CONCLUSION: Ethnic minorities in Sweden are willing to get vaccinated against COVID-19. However, to increase vaccination uptake, access to individually tailored and face to face health information to answer questions about vaccine safety, efficacy, conflicting information and rumors is urgently required.

Prevalence and predictors of use of long-term and short-acting reversible contraceptives among women of reproductive age in Wakiso and Hoima districts, Uganda: A cross-sectional study.

Modern contraceptive use has increased globally, but unmet needs persist in low- and middle-income countries. This study in Uganda aimed to examine the prevalence and factors influencing the use of short-acting reversible contraceptives (SARC) like pills and long-term methods such as intrauterine devices. Limited evidence exists on the use of SARC and long-term methods in Uganda. Data from the Africa Medical and Behavioural Sciences Organization (AMBSO) Population Health Surveillance (APHS) in Hoima and Wakiso districts were analysed. Among the 1642 women aged 15-49 years, the prevalence of modern contraceptive use was 30% for SARC, and 18% for long-term method. Women with formal education were three times more likely to use long-term methods than those without formal education, relative risk ratios (RRR), 3.1-3.4, (95%CI 1.2-8.2). Joint decision-making for contraceptive use increased SARC usage, RRR 1.4 (95%CI 1.1-1.8). Urbanization played a role, with women in more urbanized Wakiso district less likely to use any modern contraception, RRR 0.6-0.7 (95%CI 0.5-0.9) compared to those living in the less urbanized Hoima. About half of the women in the study used modern contraceptives and the use of SARC was almost twice that of long-term methods. Increased access to contraception education for all women of reproductive age could significantly improve the use of long-term methods which offer more reliable protection against unintended pregnancies. The findings shed light on the need to strengthen both general and sexuality education to girls and women and to tailor contraception access for all in need, for mobile semi-urban as well as rural women. Well-informed strategies that engage young men and male partners in informed decision-making for contraceptive use could enhance progress.

Intimate Partner Violence During COVID-19 Restrictions: A Study of 30 Countries From the I-SHARE Consortium.

Intimate partner violence (IPV) causes substantial physical and psychological trauma. Restrictions introduced in response to the COVID-19 pandemic, including lockdowns and movement restrictions, may exacerbate IPV risk and reduce access to IPV support services. This cross-sectional study examines IPV during COVID-19 restrictions in 30 countries from the International Sexual HeAlth and REproductive Health (I-SHARE) study conducted from July 20th, 2020, to February, 15th, 2021. IPV was a primary outcome measure adapted from a World Health Organization multicountry survey. Mixed-effects modeling was used to determine IPV correlates among participants stratified by cohabitation status. The sample included 23,067 participants from 30 countries. A total of 1,070/15,336 (7.0%) participants stated that they experienced IPV during COVID-19 restrictions. A total of 1,486/15,336 (9.2%) participants stated that they had experienced either physical or sexual partner violence before the restrictions, which then decreased to 1,070 (7.0%) after the restrictions. In general, identifying as a sexual minority and experiencing greater economic vulnerability were associated with higher odds of experiencing IPV during COVID-19 restrictions, which were accentuated among participants who were living with their partners. Greater stringency of COVID-19 restrictions and living in urban or semi-urban areas were associated with lower odds of experiencing IPV in some settings. The I-SHARE data suggest a substantial burden of IPV during COVID-19 restrictions. However, the restrictions were correlated with reduced IPV in some settings. There is a need for investing in specific support systems for survivors of IPV during the implementation of restrictions designed to contain infectious disease outbreaks.

Antenatal care services in rural Uganda: missed opportunities for good-quality care.

Experience from countries that have achieved low maternal mortality suggests that access to good-quality maternity services is critical to improve maternal health. In this article we appraise the quality of antenatal care (ANC) services in a rural district of Uganda. We used a mixed methods approach, relying on a combination of semistructured interviews with both clients and providers, structured observations of provider-patient interactions, and infrastructure assessment of selected health facilities. We found several bottlenecks in health service delivery, including ineffective organization of educational sessions; selective omission of certain services; lack of explanation of important clinical and laboratory procedures; failure to link the performed procedures with preventive information; and occasional lack of respect for clients. The policy implications of these findings are discussed in relation to the need to (a) ensure an adequate supply of medical equipment and drugs, (b) enhance health workers' compliance with ANC guidelines, and (c) combine medical procedures with educational messages.