Prenatal care utilization and perinatal outcomes among pregnant adolescents in Mexico, 2008-2019.

OBJECTIVE: To describe utilization of prenatal care and outcomes of low birth weight and preterm birth among adolescent births in Mexico. METHODS: We used birth certificate data and included live births to individuals 10-24 years, 2008-2019. Our outcomes were binary measures of adequate prenatal care, low birth weight, and preterm birth. We compared adolescents (10-14 years, 15-16, and 17-19) to those 20-24 years. We included individual-, clinical-, and municipality-level variables, used multivariable logistic regression, and calculated adjusted predicted probabilities. We also tested whether receipt of prenatal care moderated the relationship of age with preterm birth and low birth weight. RESULTS: We included a total of 12 106 710 births to women 10-24 years. The adjusted predicted probability of adequate prenatal care increased with age: 56.07% (95% CI 55.82-56.31%) adjusted probability among adolescents 10-14 years compared with 65.51% (95% CI 65.48%-65.55%) among individuals 20-24 years. Receipt of adequate prenatal care in part mitigated disparities in preterm birth and low birthweight across all age groups: 7.30% (95% CI 7.17%-7.43%) adjusted probability of delivering a preterm infant among those 10-14 years who received adequate prenatal care compared with 9.37% (95% CI 9.20%-9.53%) among those 10-14 years without adequate prenatal care. CONCLUSION: In Mexico, adolescent pregnancies are associated with inadequate prenatal care as well as higher odds of preterm delivery and low birth weight. Youngest adolescents (10-14 years) have the highest probability of adverse outcomes. Adequate prenatal care may help partially mitigate disparities in poor perinatal outcomes.

Implementing Interventions to Address Gender and Power Inequalities in Early Adolescence: Utilizing a Theory of Change to Assess Conditions for Success.

PURPOSE: To create a set of criteria to assess facilitators and barriers to implementation among gender transformative interventions that target very young adolescents (VYAs) across different cultural settings. METHODS: Interventionists and researchers involved in the Global Early Adolescent Study created a Theory of Change (ToC) based on summarizing intervention components from five different gender transformative intervention curricula. Embedded within the ToC is a set of criteria labeled, 'Conditions of Success' which were developed to illustrate that change cannot happen unless interventions are implemented successfully. To test the feasibility of these criteria, implementation data collected across the five interventions in Global Early Adolescent Study were mapped onto the 'Conditions for Success' criteria and used to identify common facilitators and barriers to implementation. RESULTS: Using the 'Conditions for Success' criteria, we found that gender transformative interventions targeting VYAs were most challenged in meeting program delivery and facilitation conditions and needed to build more multisectoral support to shift rigid gender norms. Parents and caregivers also needed to be engaged in the program either as a separate target population or as codesigners and implementers for the interventions. DISCUSSION: The Conditions for Success criteria provide a useful framework for assessing facilitators and barriers to implementation among gender transformative interventions for VYAs. Additional research is underway to examine whether interventions that meet more conditions of success result in greater program impact, which will be used to further refine the overall ToC.

The More You Know, the Less You Stress: Menstrual Health Literacy in Schools Reduces Menstruation-Related Stress and Increases Self-Efficacy for Very Young Adolescent Girls in Mexico.

Improving the menstrual health literacy of girls and boys is a key strategy within a holistic framework of Save the Children's school health and comprehensive sexuality education programming. As menstrual health is an emerging area of study and programming, Save the Children continues to learn and adjust its interventions using program evaluations and rigorous monitoring. This paper will examine program-monitoring data from three cohorts, representing 47 public schools in Mexico City, Puebla, and Mérida, Mexico. The study focuses on female students in 5th and 6th grade who participated in We See Equal, a school-based program centered on gender equality and puberty education, between September 2018 and December 2019. This study used a cross-sectional quantitative cohort approach to document changes in girls' experiences and perceptions around managing menstruation in school. The analysis compares girls' knowledge and experiences before and after participation in We See Equal to understand how knowledge changes over the program and how those changes may contribute to menstruation-related school engagement, stress, and self-efficacy (MENSES) outcomes. Multivariate regression models explored relationships between MENSES outcomes, knowledge and socioeconomic status (SES). Overall, results show that the more knowledge girls acquired, the higher their self-efficacy score and the lower their stress score, however, certain MHH knowledge was more predictive of MENSES outcomes and varied by SES. Among girls from lower SES, we observed significant relationships between knowing what their period was prior to menarche and the three MENSES outcomes. Decreases in menstruation-related stress were driven by items related to the practical knowledge of how to dispose of sanitary pads and reduced feelings of nervousness on days they had their period at school. Increases in self-efficacy were primarily driven by girls' confidence in their ability to track their period from month to month, feelings that they could still do well on an exam if they had their period at school, and security that they could ask a friend to lend them a pad if they needed one. Implications for future menstrual health literacy programming and targeting populations for menstrual health education, as well as priorities for future research will be discussed.

Context, Development, and Digital Media: Implications for Very Young Adolescents in LMICs.

The rapidly expanding universe of information, media, and learning experiences available through digital technology is creating unique opportunities and vulnerabilities for children and adolescents. These issues are particularly salient during the developmental window at the transition from childhood into adolescence. This period of early adolescence is a time of formative social and emotional learning experiences that can shape identity development in both healthy and unhealthy ways. Increasingly, many of these foundational learning experiences are occurring in on-line digital environments. These expanding vulnerabilities and opportunities are being further amplified for young adolescents growing up in low resourced settings around the world. Cultural and contextual factors influence access, use, and appropriation of digital technology. Further, neurobehavioral changes associated with the onset of puberty often coincide with entry into social media and more autonomous use of technology. In low-and-middle-income countries (LMICs), disparities in access, use, and appropriation of digital media can amplify prevailing economic gaps, and compound gender inequalities during early adolescence. In LMICs, adolescents are often the early adopters of mobile technology and social media platforms. While the impact of social media on the well-being, particularly mental health, of young adolescents has been a focus of research in high-income countries (HICs), much less is known about the impacts of social media use on young adolescents in LMICs. In this paper, we review what is known about the interaction between digital media and early adolescent development. We highlight crucial gaps in the evidence in LMICs; and describe some hypotheses and areas for future research to address these compelling issues.

Girl-only clubs' influence on SRH knowledge, HIV risk reduction, and negative SRH outcomes among very young adolescent girls in rural Malawi.

BACKGROUND: Early adolescence is an important period to lay the foundation for positive sexual health development that can overcome sexual and reproductive health (SRH) challenges faced by very young adolescents (VYAs) as they reach puberty and sexual debut. In this study, we explored the following questions: first, what are the experiences of VYA girls on DREAMS' Go Girl club participation? Second, how does club participation influence the VYAs SRH knowledge to reduce their risk for HIV and negative sexual health outcomes? METHODS: This was a qualitative study in which twenty-three in-depth interviews were conducted with VYA girls aged 12-14 years. These girls were enrolled in girl-only clubs in two rural southern districts in Malawi. The clubs were a part of larger comprehensive HIV prevention project called DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe) which provided an evidence-based core package of interventions to VYAs to prevent HIV. Interventions included improved access to key health services, education support, social skills, asset building, and economic strengthening. Narrative inquiry was used to generate first-hand accounts of the girls' experiences with club participation. Thematic analysis was used to generate themes from the transcribed stories. RESULTS: Six main themes were generated: 1) reasons for joining the clubs with desire to learn about SRH as a motivation for joining the clubs.; 2) influence on gender norms and roles whereby participants described a change of gender roles and norms at home; 3) influence on child abuse practices whereby participants reported a decline in child abusive practices at home;4) influence on life skills and social networks whereby participants described learning about networking; 5) support to go back to school whereby out-of-school girls described how economic empowerment of their guardians facilitated their return to school; and 6) influence of clubs on SRH knowledge acquisition and behaviours whereby participants described acquiring knowledge on sexual health issues. CONCLUSION: Girls-only HIV and SRH programs coupled with economic empowerment for their families can be effective in keeping VYA girls in school and improving SRH knowledge and health seeking behavior.

Parent-child sexual and reproductive health communication among very young adolescents in Korogocho informal settlement in Nairobi, Kenya.

BACKGROUND: Parents are an important source of sexual and reproductive health (SRH) information for very young adolescents and are likely to have a significant influence on adolescents' sexual attitudes, values, and risk-related beliefs. This study explored the nature and content of parent-child communication about SRH issues. METHODS: Thirty-two parents and 30 adolescent boys and girls aged between 11 and 13 years participated in narrative interviews in a resource-poor urban setting in Nairobi, Kenya. Interviews were audio-recorded, transcribed, translated into English, and uploaded on Atlas.ti software for coding and analysis. RESULTS: Findings from the study show gender differences in parent-child communication. More girls than boys reported that they had talked with their parents about romantic relationships. Four approaches-no communication, fear-based communication, supportive communication, and involving an external person were used by parents in SRH communication. Parents hostile attitudes towards romantic relationships during adolescence discouraged adolescents from disclosing their relationship status. While communication did occur, it was mainly reactive, one-sided, and authoritarian, often initiated by parents. CONCLUSIONS: Parents need to be empowered with adequate and factual SRH information and effective communication strategies to enhance communication with very young adolescents. There is a need for further research to identify the most effective parent-child communication approaches to improve SRH outcomes among adolescents.

Evaluation of a school based comprehensive sexuality education program among very young adolescents in rural Uganda.

BACKGROUND: Limited research has been conducted on the effectiveness of sexuality education for very young adolescents (VYAs) ages 10-14 years in Sub-Saharan Africa. Furthermore, evaluations of sexuality education programs often report outcomes of risky sexual practices, yet positive aspects of sexuality are hardly studied and rarely reported. This study evaluates the effectiveness of a Comprehensive Sexuality Education (CSE) intervention for VYAs in Uganda, analyzing both positive and negative outcome indicators. METHODS: We conducted a mixed methods study, incorporating a cluster randomized trial (NCT03669913) among pupils in 33 randomly selected primary schools in Mbarara district. This was followed by a qualitative evaluation of the intervention in 4 schools that included 14 in-depth interviews and 3 focus group discussions distributed among pupils, teachers and parents. Quantitative data were analyzed using ordered logistic regression to compare differences in the change from baseline to endline between the intervention and control arms. We conducted bivariate analysis and multiple regression analysis controlling for key covariates, including age, gender, school location (rural vs urban), truancy, and orphanhood. Qualitative data were analyzed by thematic approach using ATLAS TI. RESULTS: Between July 2016 and August 2017, 1096 pupils were recruited. Outcomes were studied among 380 pupils in the intervention arm and 484 pupils in the control arm. The proportion of pupils who ever had sex increased from 9 to 12.1% in intervention compared to 5.2 to 7.4% in the control group between baseline and endline, however the differences between groups were not statistically significant. We found greater improvements in sexual and reproductive health (SRH) knowledge among intervention schools (AOR: 2.18, 95% CI: 1.66-2.86) and no significant differences in self-esteem, body image or gender equitable norms. Qualitative evidence echoes perceived SRH knowledge acquisition, increased their perception of SRH related risks, and intentions to delay sexual intercourse to prevent unwanted pregnancy, HIV and other STIs. CONCLUSION: This study demonstrates that CSE can improve SRH knowledge and behavioral intentions among VYAs in Uganda. These results further emphasize the importance of initiating sexuality education before most adolescents have started engaging in sexual activity, enabling them to make informed decisions in the future. TRIAL REGISTRATION: NCT03669913 , registered retrospectively on September 13th, 2018.

Does it take a village? Fostering gender equity among early adolescents in Nepal.

Background Gender inequity contributes to a range of poor health outcomes. Early adolescence presents a window of opportunity for gender transformative interventions to shift inequitable gender norms, attitudes and behaviors. Objective The objective of this study is to evaluate a set of individual, family and community interventions to increase gender equity among very young adolescents (VYAs) in rural Nepal. Methods Two communities received the individual-level Choices intervention as well the family and community Voices and Promises interventions (CVP). Two comparison communities received only Choices. Samples of 1200 VYAs and 600 parents were interviewed at baseline before implementation and at end line 1 year later. Results In both CVP and Choices only areas most measures of gender norms, attitudes, and behaviors improved, suggesting a positive effect of the individual-level intervention. Increases in norms, attitudes, and behaviors reported by VYAs were generally greater in CVP areas compared to Choices areas, suggesting an added benefit from the family and community interventions. Parent-reported measures did not demonstrate an intervention effect of the family and community interventions. Uneven evaluation results, particularly among parents, may reflect implementation challenges such as the compressed 3-month intervention period due to the 2015 earthquakes and subsequent political unrest. Conclusion Overall findings are encouraging and suggest that adding family and community interventions may improve gender equity.

Understanding the unique experiences, perspectives and sexual and reproductive health needs of very young adolescents: Somali refugees in Ethiopia.

BACKGROUND: Kobe Refugee camp hosts roughly 39,000 refugees displaced from Somalia during the 2011-2012 Horn of Africa Crisis. Sexual and reproductive health, as with the greater issues of health and well-being for adolescents displaced from this crisis remain largely unknown and neglected. In 2013, the Women's Refugee Commission, Johns Hopkins University, and International Medical Corps in Ethiopia, implemented qualitative and quantitative research to explore the factors and risks that impact the health of very young adolescents (VYAs), those 10-14 years of age, in this setting. This paper presents findings from the qualitative effort. METHODS: Focus group discussions (FGD), incorporating community mapping and photo elicitation activities, were conducted with 10-12 and 13-14 year-olds to obtain information about their own perspectives, experiences and values. FGDs were also implemented with 15-16 year-olds and adults, to consider their perspectives on the sexual and reproductive health needs and risks of VYAs. RESULTS: This research identified several factors that were found to influence the health and well-being of VYAs in Kobe refugee camp, including newfound access to education and security, combined with gender divisions and parental communication around early SRH and puberty that remained intact from traditional Somali culture. Girls were found to face an additional risk of child marriage and early pregnancy exacerbated since displacement, which significantly limited their ability to access education and achieve future aspirations. CONCLUSION: Findings from this study could help to inform future programs in Kobe and similar contexts involving long-term displacement from conflict, focusing on the health and development needs of VYAs. Future programs should consider the determinants of positive VYA health and development, including access to education, gender equity, and safety.By better understanding the unique experiences, perspectives and needs of VYAs, practitioners, policy makers and donors can invest in the individual and community assets that reinforce positive behaviors established in early adolescence, in order to achieve long-term SRH impacts.

Sexual and reproductive health needs and risks of very young adolescent refugees and migrants from Myanmar living in Thailand.

BACKGROUND: The very young adolescent (VYA) population age 10-14 years is often neglected in the field of sexual and reproductive health (SRH) research due to the combined sensitivity of the topic and the young age group, resulting in little data about the SRH needs and concerns of VYA. In 2013, the Women's Refugee Commission (WRC), Johns Hopkins University (JHU), Adolescent and Reproductive Health Network (ARHN) and Karen Youth Organization (KYO) implemented qualitative participatory research to explore the SRH needs and risks of VYA. The study was conducted in Mae Sot town and Mae La refugee camp, both in Thailand, with migrant populations and refugees, respectively. METHODS: A total of 22 focus group discussions (FGD) were conducted with 176 participants. FGD were implemented with girls and boys aged 10-16, and adults in both settings. The FGD with 10-14 year olds included community mapping and photo elicitation interviews. These activities gathered information about their own perspectives, experiences and values regarding SRH, as well as SRH risks. The FGD with 15-16 year olds and adults focused on their perspectives regarding the SRH needs and risks of VYA. RESULTS: Fourteen (64%) of FGD were conducted in Mae Sot town, and 8 (36%) were conducted in Mae La refugee camp.Schools, youth centers and religious institutions were identified as key locations for obtaining SRH information. Schools are most promising, but access to schools is unequal between boys and girls. Parents can provide support and education to adolescents if they are supported to do so and if trust and comfort can be built between adolescents and parents around SRH. CONCLUSIONS: To a large degree, the same themes emerged from both locations, in terms of the awareness of body changes and puberty, the centrality of peer influences, and the value of education. These findings call for rigorous study of youth-directed programs and policies that meaningfully involve key influential adults identified by vulnerable young adolescents and utilize the specific places young adolescents, themselves, voice as being critical settings for obtaining information on SRH issues.

Transitions into puberty and access to sexual and reproductive health information in two humanitarian settings: a cross-sectional survey of very young adolescents from Somalia and Myanmar.

BACKGROUND: Very young adolescents (VYA) in humanitarian settings are largely neglected in terms of sexual and reproductive health (SRH). This study describes the characteristics of VYA aged 10-14 years in two humanitarian settings, focusing on transitions into puberty and access to SRH information. METHODS: Data were collected through a cross-sectional survey with Somali VYA residing in the Kobe refugee camp in Ethiopia (N = 406) and VYA from Myanmar residing in the Mae Sot and Phop Phra migrant communities in Thailand (N = 399). The average age was 12 years (about half were girls) in both communities. Participants were recruited using multi-stage cluster-based sampling with probability proportional to size in each site. Descriptive statistics were used to describe the sociodemographic, family, peer, and schooling characteristics and to explore transitions into puberty and access to SRH information. RESULTS: Most VYA in both sites reported living with both parents; nine in ten reported feeling that their parents/guardians care about them, and over half said that their parents/guardians monitor how and with whom they spend their free time. High proportions in both sites were currently enrolled in school (91.4% Somali, 87.0% from Myanmar). Few VYA, particularly those aged 10-12, reported starting puberty, although one in four Somali indicated not knowing whether they did so. Most girls from Myanmar who had started menstruating reported access to menstrual hygiene supplies (water, sanitation, cloths/pads). No Somali girls reported access to all these supplies. While over half of respondents in both sites reported learning about body changes, less than 20% had learnt about pregnancy and the majority (87.4% Somali, 78.6% from Myanmar) indicated a need for more information about body changes. Parents/guardians were the most common source of SRH information in both sites, however VYA indicated that they would like more information from friends, siblings, teachers and health workers. CONCLUSIONS: This study highlights gaps in SRH information necessary for healthy transitions through puberty and supplies for menstrual hygiene in two humanitarian settings. VYA in these settings expressed closeness to their parents/guardians and the majority were in school. Introducing early SRH interventions that involve parents and educational centers may thus yield promising results, providing VYA with the necessary skills for understanding and dealing with their pubertal and sexual development.

Investing in very young adolescents' sexual and reproductive health.

Very young adolescents (VYAs) between the ages of 10 and 14 represent about half of the 1.2 billion adolescents aged 10-19 in the world today. In lower- and middle-income countries, where most unwanted pregnancies, unsafe abortions, maternal deaths and sexually transmitted infections occur, investment in positive youth development to promote sexual and reproductive health (SRH) is increasing. Most interventions, though, focus on older adolescents, overlooking VYAs. Since early adolescence marks a critical transition between childhood and older adolescence and adulthood, setting the stage for future SRH and gendered attitudes and behaviours, targeted investment in VYAs is imperative to lay foundations for healthy future relationships and positive SRH. This article advocates for such investments and identifies roles that policy-makers, donors, programme designers and researchers and evaluators can play to address the disparity.

Sexual behavior, knowledge and information sources of very young adolescents in four sub-Saharan African countries.

Adolescents are a key target group for HIV and pregnancy prevention efforts, yet very little is known about the youngest adolescents: those under age 15. New survey data from 12-14 year olds in Burkina Faso, Ghana, Malawi and Uganda are used to describe their sexual activity, knowledge about HIV, STIs and pregnancy prevention, and sources of sexual and reproductive health information, including sex education in schools. Results show that very young adolescents are already beginning to be sexually active and many believe their close friends are sexually active. They have high levels of awareness but little in-depth knowledge about pregnancy and HIV prevention. Multiple information sources are used and preferred by very young adolescents. Given their needs for HIV, STI and pregnancy prevention information that is specific and practical and considering that the large majority are attending school in most countries in Sub-Saharan Africa, school-based sex education is a particularly promising avenue for reaching adolescents under age 15.