'Relationships on campus are situationships': A grounded theory study of sexual relationships at a Ugandan university.

Understanding the complexities of sexual relationships is essential to understand the risky sexual behaviours among young people in Ugandan universities. Nine focus group discussions conducted with 31 males and 33 female students in 2014 utilising the grounded theory approach explored the role of sexual relationships in their lives. 'Relationships in campus are situationships' emerged as the core category and referred to the variety of sexual interactions within relationships among young people in a Ugandan university. The study findings indicated that sexual interactions often follow a sexual script that undergoes transitions to negotiate various situations. The sexual scripts in these situationships were strongly influenced by local socio-cultural norms and global aspirations among young people. Students often discussed these sexual scripts within a wider discourse on transactional sexual relationships. The motivations for transactional sexual relationships ranged from 'fulfilling aspirations' of various kinds on the one hand to 'being forced into trading sex' to overcome socio-economic vulnerabilities. Sexual relationships were facilitated by the perception of a university as a sexualized space in which one may enjoy a period of emerging adulthood characterized by exploration in relationships, access to alcohol and prolonged delay in assuming the traditional adult roles of marriage and family. The sexual scripts at the cultural level were grounded in traditional gender roles although at the same time, were under transition during university life with the growing influence of globalization and consumerism in the Ugandan society. Young men and young women must be engaged to critically challenge the implicit assumptions about sexual interactions within various situations that may put them at risk for poor sexual health outcomes.

Prevalence of child maltreatment in India and its association with gender, urbanisation and policy: a rapid review and meta-analysis protocol.

INTRODUCTION: India is home to 20% of the world's children and yet, little is known on the magnitude and trends of child maltreatment nationwide. The aims of this review are to provide a prevalence of child maltreatment in India with considerations for any effects of gender; urbanisation (eg, urban vs rural) and legislation (Protection of Children from Sexual Offences (POCSO) Act 2012). METHODS AND ANALYSIS: A rapid review will be undertaken of all quantitative peer-reviewed studies on child maltreatment in India between 2005 and 2020. Four electronic databases will be systematically searched: PubMed, EMBASE, Cochrane and PsychInfo. The primary outcomes will include all aspects of child maltreatment: physical abuse, sexual abuse, emotional abuse, emotional neglect and physical neglect. Study participants will be between 0 and 18 years and will have reported maltreatment experiences using validated, reliable tools such as the Adverse Childhood Experiences Questionnaire as well as child self-reports and clinician reports. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and the methodological appraisal of the studies will be assessed by the Newcastle-Ottawa Quality assessment scale. A narrative synthesis will be conducted for all included studies. Also, if sufficient data are available, a meta-analysis will be conducted. Effect sizes will be determined from random-effects models stratified by gender, urbanisation and the pre-2012 and post-2012 POCSO Act cut-off. I2 statistics will be used to assess heterogeneity and identify their potential sources and τ2 statistics will indicate any between-study variance. ETHICS AND DISSEMINATION: As this is a rapid review, minimal ethical risks are expected. The protocol and level 1 self-audit checklist were submitted and approved by the Usher Research Ethics Group panel in the Usher Institute (School of Medicine and Veterinary Sciences) at the University of Edinburgh (Reference B126255). Findings from this review will be disseminated widely through peer-reviewed publications and in various media, for example, conferences, congresses or symposia. PROSPERO REGISTRATION NUMBER: CRD42019150403.

Measuring quality of family planning counselling and its effects on uptake of contraceptives in public health facilities in Uttar Pradesh, India: A cross-sectional analysis.

BACKGROUND: Quality of care in family planning traditionally focuses on promoting awareness of the broad array of contraceptive options rather than on the quality of interpersonal communication offered by family planning (FP) providers. There is a growing emphasis on person-centered contraceptive counselling, care that is respectful and focuses on meeting the reproductive needs of a couple, rather than fertility regulation. Despite the increasing global focus on person-centered care, little is known about the quality of FP care provided in low- and middle- income countries like India. This study involves the development and psychometric testing of a Quality of Family Planning Counselling (QFPC) measure, and assessment of its associations with contraceptives selected by clients subsequently. METHODS: We analyzed cross-sectional survey data from N = 237 women following their FP counselling in 120 public health facilities (District Hospitals and Community Health Centers) sampled across the state of Uttar Pradesh in India. The study captured QFPC, contraceptives selected by clients post-counselling, as well as client and provider characteristics. Based on formative research and using Principal Component Analysis, we developed a 13-item measure of quality of FP counselling. We used adjusted regression models to assess the association between QFPC and contraceptive selected post-counselling. RESULTS: The QFPC measure demonstrated good internal reliability (Cronbach alpha = 0.80) as well as criterion validity, as indicated by client reports of high QFPC being significantly more likely for clients with trained versus untrained counsellors. We found that each point increase in QFPC, including increasing quality of counselling, is associated with higher odds of clients selecting an intrauterine device (IUD) (aRR:1.03; 95% CI:1.01-1.05) and sterilization (aRR:1.06; 95% CI:1.03-1.08), compared to no method selected. CONCLUSIONS: High-quality FP counselling is associated with clients subsequently selecting more effective contraceptives, including IUD and sterilization, in India. High-quality counselling is also more likely among FP-trained providers, highlighting the need for focused training and monitoring of quality care. TRIAL REGISTRATION: CTRI/2015/09/006219. Registered 28 September 2015.

Desire to delay the first childbirth among young, married women in India: a cross-sectional study based on national survey data.

BACKGROUND: Young women in India continue to face diverse challenges that threaten their health and wellbeing. The reproductive health and rights of newly married women, who are often expected to begin childbearing soon after marriage, are often neglected. The present study aims to understand some of the factors associated with the desire to delay the first childbirth in young, married women in India. METHODS: The study utilised the data from the most recent National Family Health Survey 2015-16 in India. Our study sample was restricted to married women who were 15-24 years of age and who had never been pregnant at the time of the survey. Chi-squared tests, independent t-tests and multivariable logistic regression analyses were performed to measure associations between multiple independent factors and the reported preferred waiting time for the first childbirth. RESULTS: Among never pregnant, married women aged 15-24, 21.49% reported a preferred waiting time for their first childbirth of 2 years or more. Belonging to an other backward class, or OBC, (ORadjusted 1.55, 95%CI 1.14-2.10), having completed higher education (ORadjusted 2.04, 95%CI 1.11-3.76), marrying after the age of 18 (ORadjusted 1.57, 95%CI 1.10-2.24), a husband's higher education level (ORadjusted 2.42, 95%CI 1.27-4.64), a younger husband (ORadjusted 0.75, 95%CI 0.66-0.84) and non-exposure to physical violence (ORadjusted 1.84, 95%CI 1.09-3.11) were significantly associated with a longer preferred waiting time for the first childbirth. CONCLUSION: Intimate partner violence and partner characteristics play a role in the childbearing intentions of young women after marriage. Delaying the first childbirth could improve women's educational and economic opportunities, their health, and the health of their future and properly planned children. To achieve this, it is crucial to promote and respect women's right to decide who and when to marry, when to have children, and to promote relationships free of gender-based violence.

Family planning counseling and its associations with modern contraceptive use, initiation, and continuation in rural Uttar Pradesh, India.

BACKGROUND: We examine the association between the quality of family planning (FP) counseling received in past 24 months, and current modern contraceptive use, initiation, and continuation, among a sample of women in rural Uttar Pradesh, India. METHODS: This study included data from a longitudinal study with two rounds of representative household survey (2014 and 2016), with currently married women of age 15-49 years; the analysis excluded women who were already using a permanent method of contraceptive during the first round of survey and who reported discontinuation because they wanted to be pregnant (N = 1398). We measured quality of FP counseling using four items on whether women were informed of advantages and disadvantages of different methods, were told of method(s) that are appropriate for them, whether their questions were answered, and whether they perceived the counseling to be helpful. Positive responses to every item was categorized as higher quality counseling, vs lower quality counseling for positive response to less than four items. Outcome variables included modern contraceptive use during the second round of survey, and a variable categorizing women based on their contraceptive use behavior during the two rounds: continued-users, new-users, discontinued-users, and non-users. RESULTS: Around 22% had received any FP counseling; only 4% received higher-quality counseling. Those who received lower-quality FP counseling had 2.42x the odds of reporting current use of any modern contraceptive method (95% CI: 1.56-3.76), and those who received higher quality FP counseling at 4.14x the odds of reporting modern contraceptive use (95% CI: 1.72-9.99), as compared to women reporting no FP counseling. Women receiving higher-quality counseling also had higher likelihood of continued use (ARRR 5.93; 95% CI: 1.97-17.83), as well as new use or initiation (ARRR: 4.2; 95% CI: 1.44-12.35) of modern contraceptives. Receipt of lower-quality counseling also showed statistically significant associations with continued and new use of modern contraceptives, but the effect sizes were smaller than those for higher-quality counseling. CONCLUSIONS: Findings suggest the value of FP counseling. With a patient-centered approach to counseling, continued use of modern contraceptives can be supported among married women of reproductive age. Unfortunately, FP counseling, particularly higher-quality FP counseling remains rare.

Child sexual abuse in India: A systematic review.

OBJECTIVE: Child Sexual Abuse (CSA) is a pressing human right issue and public health concern. We conducted a systematic review of quantitative and qualitative studies published in the past decade on CSA in India to examine the distribution of the prevalence estimates for both genders, to improve understanding of the determinants and consequences of CSA and identify gaps in the current state of research. METHODS: For this systematic review, we searched electronic literature databases (PubMed, POPLINE, and PsycINFO) for articles published in English on Child Sexual Abuse in India between January 1, 2006 and January 1, 2016 using 55 search terms. Data were extracted from published articles only. FINDINGS: Fifty-one studies met inclusion criteria for the review. The review indicates that prevalence rates of CSA is high among both boys and girls in India. Due to heterogeneity of study designs and lack of standardised assessments, reported prevalence estimates varied greatly among both genders in different studies. There is a need to conduct representative studies using a validated instrument to obtain valid epidemiological estimates. Commercial sex workers, men who have sex with men, and women with psychiatric disorders were at higher risks for sexual abuse during childhood. In addition, the synthesis of qualitative data across studies included in the review suggests that exposure and perpetration of CSA is a multifaceted phenomenon grounded in the interplay between individual, family, community, and societal factors. The review indicates poor physical, behavioural, social, and mental health outcomes of CSA in India. We conclude with a research agenda calling for quantitative and qualitative studies to explore the determinants and perpetration of child sexual abuse in India from an ecological lens. This research agenda may be necessary to inform the development of a culturally tailored primary prevention and treatment strategy for CSA victims in India.

Ethical and definitional considerations in research on child sexual violence in India.

BACKGROUND: While critically important, child sexual violence (CSV) research poses numerous ethical and safety challenges. Recently, the studies dedicated to understanding and addressing CSV in India have been on the rise, but no published ethical guidelines to direct such research currently exist. To help inform ethical and safety recommendations for the design, conduct, and reporting of future CSV research in India and similar settings, we systematically reviewed the ethics and safety practices reported in recent Indian CSV literature. METHODS: A multi-tiered approach was used to understand current ethical practices and gaps: 1) systematic review of Indian CSV studies published over the past decade, 2) examination of existing guidelines on related topics to develop an ethical framework, 3) development of an ethics checklist based on the recommendations from the surveyed guidelines, and 4) application of the checklist to each of the reviewed studies. RESULT: Our search yielded 51 eligible studies. From each, data from 6 major thematic areas was extracted: informed consent, confidentiality, selection, training, and protection of study team members, validity of CSV measurement methods, measures to minimize participant harm, and participant compensation. Several gaps were noted: only two-thirds reported approval by ethics committees, obtaining informed consent, and assured participants of confidentiality. Only 25% (13/51) reported assessing ongoing CSV risk and providing necessary support services, none noted whether ongoing CSV was reported to authorities (required by Indian law), and none reported safeguards to protect staff from the effects of conducting CSV research. Further, 43% (22/51) limited surveillance of CSV to one form of abuse and/or used a "loaded term," increasing the potential for underreporting. CONCLUSIONS: Through enhancing understanding of current ethical practices and gaps in CSV research in India, this systematic review informs reporting protocols and future guidelines for CSV research in India and other similar settings.

Under-five mortality and maternal HIV status in Tanzania: analysis of trends between 2003 and 2012 using AIDS Indicator Survey data.

BACKGROUND: Mortality among children under five remains a significant health challenge across sub-Saharan Africa. HIV/AIDS is one of the leading contributors to the relatively slow decline in under-five mortality in this region. In Tanzania, HIV prevalence among under-five children is high and 90% of all infections are due to mother-to-child transmission. OBJECTIVES: The study aimed to examine the association between maternal HIV-positive status and under-five mortality in Tanzania. It also aimed to estimate the proportions and trends of under-five mortality attributable to maternal HIV/AIDS in Tanzania between 2003 and 2012. DESIGN: Binomial logistic regression was used to analyze cross-sectional survey data from the Tanzania AIDS Indicator Surveys to examine the association between maternal HIV positivity and under-five mortality between 2003 and 2012. RESULTS: After controlling for confounders, the adjusted odds ratios were 1.5 (95% CI 1.1-1.9) in 2003-2004, 4.6 (95% CI 2.7-7.8) in 2007-2008, and 2.4 (95% CI 1.2-4.6) in 2011-2012. The maternal HIV-attributable mortality risk percent of under-five children was 3.7 percent in 2003-2004, 11.3 percent in 2007-2008 and 5.6% in 2011-2012. CONCLUSION: Maternal HIV positivity is associated with under-five mortality in Tanzania, making maternal HIV serostatus a relevant determinant of whether a child will survive up to five years of age or not. The impact of maternal HIV/AIDS attributable mortality risk has a significant contribution to the overall under-five mortality in Tanzania. The continued monitoring of HIV and mortality trends is important for policy development and design of interventions.

Transactional sex and HIV risks - evidence from a cross-sectional national survey among young people in Uganda.

BACKGROUND: Transactional sex is associated with the HIV epidemic among young people in Uganda. Few quantitative studies based on nationally representative survey data explored the relationship between sexual behaviors, HIV infection, and transactional sex. OBJECTIVE: This study aimed to determine the associations between risky sexual behaviors, participation in transactional sex, and HIV sero-status among men and women aged 15-24 in Uganda. DESIGN: The study uses data from the Uganda AIDS Indicator Survey, a cross-sectional national HIV serological study conducted in 2011. We analyzed data on 1,516 men and 2,824 women aged 15-24 who had been sexually active in the 12 months preceding the survey. Private, face-to-face interviews were also conducted to record the sociodemographics, sexual history, and experiences of sexual coercion. Logistic regression analysis was performed to measure associations between sexual behaviors and transactional sex, and associations between HIV sero-status and transactional sex. RESULTS: Among young people who had been sexually active in the 12 months prior to the survey, 5.2% of young men reported paying for sex while 3.7% of young women reported receiving gifts, favors, or money for sex. Lower educational attainment (ORadjusted 3.25, CI 1.10-9.60) and experience of sexual coercion (ORadjusted 2.83, CI 1.07-7.47) were significantly associated with paying for sex among men. Multiple concurrent sexual relationships were significantly associated with paying for sex among young men (ORadjusted 5.60, CI 2.08-14.95) and receiving something for sex among young women (ORadjusted 8.04, CI 2.55-25.37). Paying for sex among young men and having three to five lifetime sexual partners among young women were associated with increased odds of testing positive for HIV. CONCLUSIONS: Transactional sex is associated with sexual coercion and HIV risk behaviors such as multiple concurrent sexual partnerships among young people in Uganda. In addition, transactional sex appears to place young men at increased risk for HIV in Uganda. Both sexes appear equally vulnerable to risks associated with transactional sex, and therefore should be targeted in intervention programs. In addition, strengthening universal education policy and improving school retention programs may be beneficial in reducing risky sexual behaviors and transactional sex.

Giving or receiving something for sex: a cross-sectional study of transactional sex among Ugandan university students.

OBJECTIVE: This study sought to determine the prevalence of transactional sex among university students in Uganda and to assess the possible relationship between transactional sex and sexual coercion, physical violence, mental health, and alcohol use. METHODS: In 2010, 1954 undergraduate students at a Ugandan university responded to a self-administered questionnaire that assessed mental health, substance use, physical violence and sexual behaviors including sexual coercion and transactional sex. The prevalence of transactional sex was assessed and logistic regression analysis was performed to measure the associations between various risk factors and reporting transactional sex. RESULTS: Approximately 25% of the study sample reported having taken part in transactional sex, with more women reporting having accepted money, gifts or some compensation for sex, while more men reporting having paid, given a gift or otherwise compensated for sex. Sexual coercion in men and women was significantly associated with having accepted money, gifts or some compensation for sex. Men who were victims of physical violence in the last 12 months had higher probability of having accepted money, gifts or some compensation for sex than other men. Women who were victims of sexual coercion reported greater likelihood of having paid, given a gift or otherwise compensated for sex. Respondents who had been victims of physical violence in last 12 months, engaged in heavy episodic drinking and had poor mental health status were more likely to have paid, given a gift or otherwise compensated for sex. CONCLUSIONS: University students in Uganda are at high risk of transactional sex. Young men and women may be equally vulnerable to the risks and consequences of transactional sex and should be included in program initiatives to prevent transactional sex. The role of sexual coercion, physical violence, mental health, and alcohol use should be considered when designing interventions for countering transactional sex.

Patterns of alcohol consumption and risky sexual behavior: a cross-sectional study among Ugandan university students.

BACKGROUND: As reflected in elevated rates of sexually transmitted infections, there is a high prevalence of risky sexual behavior among Ugandan university students. It has been assumed that alcohol contributes to risky sexual behavior. However, perhaps owing to methodological issues, this relationship has found only mixed support in empirical research. The present study analyzes the association between alcohol use and risky sexual behavior at the global, situational, and event level among Uganda university students with sexual experience. METHODS: A cross-sectional survey was carried out in 2010 among 1954 students at Mbarara University of Science and Technology, Uganda, using a self-administered questionnaire. Alcohol use was measured as consumption over the previous 12 months, during situations related to sexual activity and on the most recent occasion of sexual intercourse. Risky sexual behavior was defined as having two or more sexual partners in the previous 12 months or inconsistent condom use with new partners. Bivariate and multivariate logistic regression was performed to analyze the association between alcohol use and risky sexual behavior separately for males and females. RESULTS: Even after adjusting for confounders, the odds ratio (OR) of having two or more sexual partners in the past year indicated a statistically significant association with alcohol use on all levels (global, situational, and event) for both males and females. The ORs of inconsistent condom use with a new partner were significant for males who often consumed alcohol in relation to sexual activity--even after adjusting for potential confounders (OR, 1.75; confidence interval, 1.01-3.08). The risk of inconsistent condom use with a new partner was twice as high for females who often consumed alcohol in relation to sexual activity, although this association was not statistically significant. CONCLUSIONS: The study supports previous research that alcohol consumption is associated with having multiple sexual partners. Inconsistent condom use was associated with the situational use of alcohol in relation to sexual activity and was similar for both genders. Interventions to reduce alcohol-related risky sexual behavior should target both male and female drinkers, particularly subgroups of students, who often consume alcohol in relation to sexual activity.