Good School Toolkit-Secondary Schools to prevent violence against students: protocol for a pilot cluster randomised controlled trial.

INTRODUCTION: No whole-school interventions which seek to reduce physical, sexual and emotional violence from peers, intimate partners and teachers have been trialled with adolescents. Here, we report a protocol for a pilot trial of the Good School Toolkit-Secondary Schools intervention, to be tested in Ugandan secondary schools. Our main objectives are to (1) refine the intervention, (2) to understand feasibility of delivery of the intervention and (3) to explore design parameters for a subsequent phase III trial. METHODS AND ANALYSIS: We will conduct a pilot cluster randomised controlled trial, with two arms and parallel assignment. Eight schools will be randomly selected from a stratified list of all eligible schools in Kampala and Wakiso Districts. We will conduct a baseline survey and endline survey 18 months after the baseline, with 960 adolescents and 200 teachers. Qualitative data and mixed methods process data collection will be conducted throughout the intervention. Proportion of staff and students reporting acceptability, understanding and implementing with fidelity will be tabulated at endline for intervention schools. Proportions of schools consenting to participation, randomisation and proportions of schools and individual participants completing the baseline and endline surveys will be described in a Consolidated Standards of Reporting Trials diagram. ETHICS AND DISSEMINATION: The ethical requirements of our project are complex. Full approvals have been received from the Mildmay Ethics Committee (0407-2019), the Uganda National Council for Science and Technology (SS 6020) and the London School of Hygiene & Tropical Medicine (16212). Results of this study will be published in peer-reviewed academic journals, and shared with public bodies, policy makers, study participants and the general public in Uganda. TRIAL REGISTRATION NUMBER: PACTR202009826515511.

Adapting a complex violence prevention intervention: a case study of the Good School Toolkit in Uganda.

BACKGROUND: Adaptation is a key strategy to extend the reach of evidence-based interventions to prevent violence in new populations, but there is a dearth of practical case examples. The Good School Toolkit was developed by Ugandan NGO Raising Voices for use in primary schools (GST-P). We describe our systematic approach to adapting the GST-P for use in secondary schools in Uganda, and reflect on the utility of the process as well as limitations of existing adaptation frameworks. METHODS: We adapted the GST-P in four phases, which included: I) clarifying the logic model and core intervention components using a streamlined process; II) conducting formative research (cross-sectional survey, focus groups, etc.) to understand the new population; III) selecting and preparing new intervention components and modifying existing intervention components; and IV) pretesting new intervention components with teachers and students in Uganda. RESULTS: We identified core components using a logic model. Formative research showed results largely in line with our apriori hypotheses. Teacher violence remained highly prevalent in secondary versus primary schools (> 65% of secondary students reported past year exposure), while peer violence significantly increased (secondary = 52% vs. primary girls = 40%, P < 0.001; secondary = 54% vs. primary boys = 44%, P = 0.009) in secondary versus primary schools. Significantly more secondary girls (51%) than secondary boys (45%) reported past year dating/intimate partner violence (P = 0.03). Inequitable, gendered educational practices emerged as a salient theme, perceived to heighten female students' vulnerability to violence. In light of these findings, we made several adjustments to the adapted intervention. We strengthened existing teacher and peer violence intervention components. We also developed, pretested and revised new program components to prevent dating violence and promote 'gender fairness in schools'. Finally, original activities were modified to support engagement with school administration and promote increased student agency in secondary schools. CONCLUSIONS: Based on our experience, it was difficult to apply mechanistic models to clarify the intervention logic of the GST-P, a complex multicomponent intervention, and simpler methods may be sufficient. Our team had high levels of contextual knowledge before the adaptation, and formative research to understand the new target population provided only limited additional insight. In similar situations, a simplified approach to mapping the core intervention components, qualitative research to understand the new target population, and pre-testing of new intervention components may be the most informative elements of systematic adaptation processes.

Understanding the social and physical menstrual health environment of secondary schools in Uganda: A qualitative methods study.

Adolescent girls face social, psychological, and physical problems managing menstruation in schools in low-resource settings. This study aimed to evaluate the social and physical menstrual health environment of secondary schools in Wakiso and Kalungu districts, Uganda, in preparation for a subsequent menstrual health intervention trial to improve education, health and wellbeing. We conducted a qualitative rapid assessment in 75 secondary schools in Uganda. This involved conducting in-depth interviews with 150 head/senior teachers and 274 students, 26 Focus Group Discussions with students, and 13 transect walks to observe school Water, Sanitation and Hygiene (WASH) facilities between May and October 2021. Due to COVID-19 related school closures, face-to-face research activities were halted and in-depth interviews were conducted over phone and replaced focus group discussions. We employed a thematic framework analysis approach using the social-ecological model (which focuses on the complex interplay between individual, interpersonal, institutional, and societal factors) to generate themes and key concepts. Participants described the social and physical menstrual health environment of secondary schools at the individual level (knowledge gaps on menstruation before menarche, negative norms and beliefs about menstrual health); interpersonal level (limited psycho-social support, myths and misconceptions about the disposal of sanitary materials and pain relief, menstrual hygiene management (MHM) support from school nurses, peers and senior teachers); institutional level (non-implementation of Government circulars on MHM, lack of school-level guidelines policies and programs on MHM and poor WASH facilities, i.e. lack of soap, safe water and unclean toilets); and societal level (MHM programmes provided by civil society groups, health workers, and students' school associations). The findings showed individual, societal and institutional burdens related to menstrual experiences. Multi-level evidence-based interventions aimed at improving the social and physical environment for menstrual health among school-going girls are needed.

Preferences for accessing sexual health services among middle-aged and older adults in the UK: a study protocol for a discrete choice experiment using mixed methods.

INTRODUCTION: Sexual health is essential for general health and well-being. Sexual health services for middle-aged and older adults are not prioritised and optimising available services for this population is often overlooked. Not much is known about preferences for accessing sexual health services among middle-aged and older people or level of satisfaction with current services. The aim of this study is to explore preferences for seeking sexual health services among middle-aged and older adults in the UK. This study will use discrete choice experiments (DCEs) including initial qualitative interviews followed by the survey, which have been used as a tool to explore preferences in various health service delivery. METHODS AND ANALYSIS: The project will be carried out in two phases. First, we will conduct in-depth semi-structured interviews with 20-30 adults (aged 45+), including disabled people, and those from sexual minority groups resident in the UK. Interviews will explore indications, preferences and factors related to accessing sexual health services. Themes and subthemes emerging from the analysis of the interviews will then be used to design the choice sets and attribute level for the DCEs. For the second phase, for the DCEs, we will design choice sets composed of sexual health service delivery scenarios. The software Ngene will be used to develop the experimental design matrix for the DCE. We will use descriptive statistics to summarise the key sociodemographic characteristics of the study population. Multinomial logit, latent class and mixed logit models will be explored to assess sexual health service preferences and preference heterogeneity. ETHICS AND DISSEMINATION: Ethical approval for both parts of this study was granted by the Research and Ethics Committee at the London School of Hygiene & Tropical Medicine. Findings from this study will be disseminated widely to relevant stakeholders via scheduled meetings, webinars, presentations and journal publications.

Increasing disclosure of school-related gender-based violence: lessons from a systematic review of data collection methods and existing survey research.

BACKGROUND: School-related gender-based violence (SRGBV) includes sexual, physical or psychological violence occurring in and around schools often perpetrated by teachers or peers. In this review, we focus on studies comparing how data collection methodologies affect children's disclosures of SRGBV. METHODS: We conducted a systematic review, searching nine databases for studies from high, middle and low-income countries using search terms related to violence, disclosure and data collection methodology. Records were initially screened by abstract and then full-texts were retrieved and data from eligible reports extracted. In this paper, we draw on results from this larger systematic review highlighting studies conducted with children which either collected data in schools or asked about violence in schools. We also describe methods compared and results of studies that were not conducted in schools, but that included children and young people. Finally, we describe how multi-country nationally representative surveys conducted in at least one low and middle-income country measure children's experiences of SRGBV. RESULTS: We screened 28,780 records, of which fourteen are included in this article. Only four studies compared data collection methodologies in schools or about violence in schools. These showed a 0 to more than 500-percent variation in the prevalence of violence measured using different data collection methodologies. An additional ten studies which were not conducted in schools, examined disclosure of violence in children and young people that was not specifically school-related. We assessed five multi-country national surveys that measured SRGBV. This limited evidence suggests that methods allowing increased anonymity (e.g. audio computer assisted self-interview, online surveys) may result in higher disclosure of violence, including SRGBV, than face-to-face interviewing. No studies included reported on safety, experiences of young people, or the costs of different methods. Multi-country national surveys used self-completion methods if completed in schools or face-to-face interviewing if completed in households, to measure SRGBV. CONCLUSION: Evidence on the impact of data collection method on SRGBV disclosure is limited, however current prevalence of SRGBV in international surveys used to monitor SDG progress may be underestimated due to data collection methods used. Further research on SRGBV should aim to test the effects of data collection methodology on the disclosure of violence. Efforts to improve the measurement of SRGBV is central to understanding the epidemiology, monitoring changes, and developing school and community-based programs as well as policies to prevent and respond to SRGBV.

Sexual and reproductive health in Britain during the first year of the COVID-19 pandemic: cross-sectional population survey (Natsal-COVID-Wave 2) and national surveillance data.

OBJECTIVES: To assess sexual behaviour, and sexual and reproductive health (SRH) outcomes, after 1 year of the COVID-19 pandemic in Britain. METHODS: 6658 participants aged 18-59 and resident in Britain completed a cross-sectional web-panel survey (Natsal-COVID-Wave 2, March-April 2021), 1 year after the first lockdown. Natsal-COVID-2 follows the Natsal-COVID-Wave 1 survey (July-August 2020) which captured impacts in the initial months. Quota-based sampling and weighting resulted in a quasi-representative population sample. Data were contextualised with reference to the most recent probability sample population data (Natsal-3; collected 2010-12; 15 162 participants aged 16-74) and national surveillance data on recorded sexually transmitted infection (STI) testing, conceptions, and abortions in England/Wales (2010-2020). The main outcomes were: sexual behaviour; SRH service use; pregnancy, abortion and fertility management; sexual dissatisfaction, distress and difficulties. RESULTS: In the year from the first lockdown, over two-thirds of participants reported one or more sexual partners (women 71.8%; men 69.9%), while fewer than 20.0% reported a new partner (women 10.4%; men 16.8%). Median occasions of sex per month was two. Compared with 2010-12 (Natsal-3), we found less sexual risk behaviour (lower reporting of multiple partners, new partners, and new condomless partners), including among younger participants and those reporting same-sex behaviour. One in 10 women reported a pregnancy; pregnancies were fewer than in 2010-12 and less likely to be scored as unplanned. 19.3% of women and 22.8% of men were distressed or worried about their sex life, significantly more than in 2010-12. Compared with surveillance trends from 2010 to 2019, we found lower than expected use of STI-related services and HIV testing, lower levels of chlamydia testing, and fewer conceptions and abortions. CONCLUSIONS: Our findings are consistent with significant changes in sexual behaviour, SRH, and service uptake in the year following the first lockdown in Britain. These data are foundational to SRH recovery and policy planning.

Sexual behaviours and sexual health among middle-aged and older adults in Britain.

OBJECTIVES: Population-representative studies of the sexual health of middle-aged and older adults are lacking in ageing societies. This study aimed to identify latent patterns of sexual behaviours and health of people aged 45-74 years. METHODS: We conducted a latent class analysis of the National Attitudes and Sexual Lifestyles Survey (Natsal-3), a nationally representative survey conducted in Britain in 2011. RESULTS: Of the 5260 respondents aged 45-74 years, 48.86% of men and 44.91% of women belonged to the Content Caseys class who reported good sexual health. The Infrequent Indigos (30.94% of men, 44.38% of women) were characterised by a lack of sexual activity, reported some dissatisfaction, and were more likely to have a disability. The Low-Functioning Lees (11.65% of men, 8.41% of women) reported some more disability and had issues with sexual functioning and higher levels of distress. The Multiple-Partnered Morgans (8.62% of men, 2.30% of women) were characterised by a greater number of sexual partners and several risk behaviours. CONCLUSIONS: The use of these four classes can aid in improved targeting of tailored sexual health services to improve sexual function, sexual satisfaction, reduce distress and risky behaviours among middle-aged and older adults. These services should be inclusive of the disabled community.

Initial Impacts of COVID-19 on Sex Life and Relationship Quality in Steady Relationships in Britain: Findings from a Large, Quasi-representative Survey (Natsal-COVID).

Intimate relationships are ubiquitous and exert a strong influence on health. Widespread disruption to them may impact wellbeing at a population level. We investigated the extent to which the first COVID-19 lockdown (March 2020) affected steady relationships in Britain. In total, 6,654 participants aged 18-59 years completed a web-panel survey (July-August 2020). Quasi-representativeness was achieved via quota sampling and weighting. We explored changes in sex life and relationship quality among participants in steady relationships (n = 4,271) by age, gender, and cohabitation status, and examined factors associated with deterioration to a lower-quality relationship. A total of 64.2% of participants were in a steady relationship (of whom 88.9% were cohabiting). A total of 22.1% perceived no change in their sex-life quality, and 59.5% no change in their relationship quality. Among those perceiving change, sex-life quality was more commonly reported to decrease and relationship quality to improve. There was significant variation by age; less often by gender or cohabitation. Overall, 10.6% reported sexual difficulties that started/worsened during lockdown. In total, 6.9% reported deterioration to a "lower quality" relationship, more commonly those: aged 18-24 and aged 35-44; not living with partner (women only); and reporting depression/anxiety and decrease in sex-life quality. In conclusion, intimate relationship quality is yet another way in which COVID-19 has led to divergence in experience.

How did the COVID-19 pandemic affect access to condoms, chlamydia and HIV testing, and cervical cancer screening at a population level in Britain? (Natsal-COVID).

OBJECTIVES: To investigate how differential access to key interventions to reduce STIs, HIV and their sequelae changed during the COVID-19 pandemic. METHODS: British participants (18-59 years) completed a cross-sectional web survey 1 year (March-April 2021) after the initial lockdown in Britain. Quota-based sampling and weighting resulted in a quasi-representative population sample. We compared Natsal-COVID data with Natsal-3, a household-based probability sample cross-sectional survey (16-74 years) conducted in 2010-2012. Reported unmet need for condoms because of the pandemic and uptake of chlamydia testing/HIV testing/cervical cancer screening were analysed among sexually experienced participants (18-44 years) (n=3869, Natsal-COVID; n=8551, Natsal-3). ORs adjusted for age and other potential confounders describe associations with demographic and behavioural factors. RESULTS: In 2021, 6.9% of women and 16.2% of men reported unmet need for condoms because of the pandemic. This was more likely among participants: aged 18-24 years, of black or black British ethnicity, and reporting same-sex sex (past 5 years) or one or more new relationships (past year). Chlamydia and HIV testing were more commonly reported by younger participants, those reporting condomless sex with new sexual partners and men reporting same-sex partners; a very similar distribution to 10 years previously (Natsal-3). However, there were differences during the pandemic, including stronger associations with chlamydia testing for men reporting same-sex partners; with HIV testing for women reporting new sexual partners and with cervical screening among smokers. CONCLUSIONS: Our study suggests differential access to key primary and secondary STI/HIV prevention interventions continued during the first year of the COVID-19 pandemic. However, there was not strong evidence that differential access has changed during the pandemic when compared with 2010-2012. While the pandemic might not have exacerbated inequalities in access to primary and secondary prevention, it is clear that large inequalities persisted, typically among those at greatest STI/HIV risk.

The Epidemiology of Young People's Work and Experiences of Violence in Nine Countries: Evidence from the Violence against Children Surveys.

Globally, 497 million young people (15-24 years) are in the labour force. The current research on work and violence indicates reciprocal links across the life course. This study draws on data from 35,723 young people aged 13-24 years in the Violence Against Children Surveys (VACS) in nine countries to describe the epidemiology of work in order to explore associations between (1) current work and violence and (2) childhood violence and work in a hazardous site in young adulthood. The prevalence of past-year work among 13-24-year-olds was highest in Malawi: 82.4% among young men and 79.7% among young women. In most countries, young women were more likely to be working in family or domestic dwellings (range: 23.5-60.6%) compared to men (range: 8.0-39.0%), while men were more likely to be working on a farm. Work in a hazardous site was higher among young men compared to women in every country. Among children aged 13-17 years, we found significant positive associations between past-year work and violence among girls in three countries (aORs between 2.14 and 3.07) and boys in five countries (aORs 1.52 to 3.06). Among young people aged 18-24 years, we found significant positive associations among young women in five countries (aORs 1.46 to 2.61) and among young men in one country (aOR 2.62). Associations between childhood violence and past-year work in a hazardous site among 18-24-year-olds were significant in one country among girls and in three countries among boys. Continued efforts are needed to prevent hazardous work, improve work environments, and integrate violence prevention efforts into workplaces.

Remote methods for research on violence against women and children: lessons and challenges from research during the COVID-19 pandemic.

Collecting data to understand violence against women and children during and after the COVID-19 pandemic is essential to inform violence prevention and response efforts. Although researchers across fields have pivoted to remote rather than in-person data collection, remote research on violence against women, children and young people poses particular challenges. As a group of violence researchers, we reflect on our experiences across eight studies in six countries that we redesigned to include remote data collection methods. We found the following areas were crucial in fulfilling our commitments to participants, researchers, violence prevention and research ethics: (1) designing remote data collection in the context of strong research partnerships; (2) adapting data collection approaches; (3) developing additional safeguarding processes in the context of remote data collection during the pandemic; and (4) providing remote support for researchers. We discuss lessons learnt in each of these areas and across the research design and implementation process, and summarise key considerations for other researchers considering remote data collection on violence.

Workplace Violence Against Adolescents, Uganda, 2014-2019.

Objectives. To describe the prevalence of and risk factors for workplace violence among Ugandan adolescents. Methods. The analysis focused on adolescents recruited at primary schools who participated in the endline survey of a trial in 2014 (at ages 11-14 years) and were followed up in 2018-2019 (at ages 17-19 years). The analysis was restricted to those engaged in past-year paid work (n = 1406). We estimated the prevalence of past-year workplace violence and used mixed-effects multivariable logistic regression to explore associations with characteristics measured in early adolescence, current life circumstances, and work-related factors. Methods. The analysis focused on adolescents recruited at primary schools who participated in a 2014 survey and were followed up in 2018-2019. The analysis was restricted to those engaged in past-year paid work (n = 1406). We estimated the prevalence of past-year workplace violence and used mixed-effects multivariable logistic regression to explore associations with characteristics measured in early adolescence, current life circumstances, and work-related factors. Results. Overall, 40% (95% confidence interval [CI] = 37%, 43%) of adolescents in paid work experienced past-year workplace violence; odds were doubled among female domestic workers (vs retail/trade workers; adjusted odds ratio [AOR] = 2.07; 95% CI = 1.28, 3.35). Experiences measured in early adolescence, including eating less than 3 meals the previous day, experiencing severe physical violence (male adolescents: AOR = 1.48; 95% CI = 1.11, 1.98; female adolescents: AOR = 1.69; 95% CI = 1.13, 2.53) and bullying, and having poor mental health (male adolescents: AOR = 2.32 95% CI = 1.37, 3.92; female adolescents: AOR = 2.27; 95% CI = 1.05, 4.89), were associated with increased odds of workplace violence. Current life circumstances (fewer household assets, more moves, functional difficulties, poorer mental health) were also associated with workplace violence. Conclusions. Interventions are needed to address the high prevalence of workplace violence across all sectors, with female domestic workers particularly vulnerable. Early prevention of violence and poor mental health may be promising. (Am J Public Health. 2022;112(11):1651-1661. https://doi.org/10.2105/AJPH.2022.306983).

Menstrual health interventions, schooling, and mental health problems among Ugandan students (MENISCUS): study protocol for a school-based cluster-randomised trial.

BACKGROUND: Menstrual health is an increasingly recognised public health issue, defined as complete physical, mental, and social well-being in relation to the menstrual cycle. The MENISCUS trial aims to assess whether a multi-component intervention addressing physical and emotional aspects of menstrual health improves educational attainment, mental health problems, menstrual management, self-efficacy, and quality of life among girls in secondary school in Uganda. METHODS: The study is a parallel-arm cluster-randomised controlled trial with 60 schools (clusters) in Wakiso and Kalungu districts, with a mixed-methods process evaluation to assess intervention fidelity and acceptability and economic and policy analyses. The schools will be randomised 1:1 to immediate intervention or to optimised usual care with delayed intervention delivery. The intervention includes creation of a Menstrual Health Action Group at schools and NGO-led training of trainers on puberty education, development of a drama skit, delivery of a menstrual health kit including reusable pads and menstrual cups, access to pain management strategies including analgesics, and basic improvements to school water, sanitation, and hygiene facilities. Baseline data will be collected from secondary 2 students in 2022 (median age ~15.5 years), with endline after 1 year of intervention delivery (~3600 females and a random sample of ~900 males). The primary outcomes assessed in girls are (i) examination performance based on the Mathematics, English, and Biology curriculum taught during the intervention delivery (independently assessed by the Uganda National Examinations Board) and (ii) mental health problems using the Total Difficulties Scale of the Strengths and Difficulties 25-item questionnaire. Secondary outcomes are menstrual knowledge and attitudes in girls and boys and, in girls only, menstrual practices, self-efficacy in managing menstruation, quality of life and happiness, prevalence of urogenital infections, school and class attendance using a self-completed menstrual daily diary, and confidence in maths and science. DISCUSSION: The trial is innovative in evaluating a multi-component school-based menstrual health intervention addressing both physical and emotional aspects of menstrual health and using a "training of trainers" model designed to be sustainable within schools. If found to be cost-effective and acceptable, the intervention will have the potential for national and regional scale-up. TRIAL REGISTRATION: ISRCTN 45461276 . Registered on 16 September 2021.

Paper: violence, abuse and exploitation among trafficked women and girls: a mixed-methods study in Nigeria and Uganda.

BACKGROUND: Africa is the global region where modern-slavery is most prevalent, especially among women and girls. Despite the severe health consequences of human trafficking, evidence on the risks and experiences of trafficked adolescents and young women is scarce for the region. This paper addresses this gap by exploring the intersections between violence, migration and exploitation among girls and young women identified as trafficking survivors in Nigeria and Uganda. METHODS: We conducted secondary analysis of the largest routine dataset on human trafficking survivors. We used descriptive statistics to report the experiences of female survivors younger than 25 years-old from Nigeria and Uganda. We also conducted 16 semi-structured interviews with adolescents identified as trafficked in both countries. We used thematic analysis to explore participants' perceptions and experiences before, during and after the trafficking situation. RESULTS: Young female survivors of human trafficking in Nigeria and Uganda are exposed to a range of experiences of violence before migration, during transit and at destination. The qualitative data revealed that children and adolescents migrated to escape family poverty, violence and neglect. They had very low levels of education and most had their studies interrupted before migrating. Family members and close social contacts were the most common intermediaries for their migration. During transit, sexual violence and hunger were common, especially among Nigerians. Participants in both the quantitative and qualitative studies reported high levels of violence, deception, coercion, withheld wages and poor working conditions at destination. The adolescents interviewed in the qualitative study reported severe mental suffering, including suicide attempts. Only one reported the prosecution of perpetrators. CONCLUSIONS: Our findings suggest that interventions to prevent or mitigate the negative impact of adverse childhood experiences can contribute to preventing the trafficking of adolescents in Nigeria and Uganda. These interventions include social protection mechanisms, universal access to education, social service referrals and education of parents and carers. Importantly, effective prevention also needs to address the systemic conditions that makes trafficking of female adolescents invisible, profitable and inconsequential for perpetrators.

Intimate physical contact between people from different households during the COVID-19 pandemic: a mixed-methods study from a large, quasi-representative survey (Natsal-COVID).

OBJECTIVES: Physical distancing as a non-pharmaceutical intervention aims to reduce interactions between people to prevent SARS-CoV-2 transmission. Intimate physical contact outside the household (IPCOH) may expand transmission networks by connecting households. We aimed to explore whether intimacy needs impacted adherence to physical distancing following lockdown in Britain in March 2020. METHODS: The Natsal-COVID web-panel survey (July-August 2020) used quota-sampling and weighting to achieve a quasi-representative population sample. We estimate reporting of IPCOH with a romantic/sexual partner in the 4 weeks prior to interview, describe the type of contact, identify demographic and behavioural factors associated with IPCOH and present age-adjusted ORs (aORs). Qualitative interviews (n=18) were conducted to understand the context, reasons and decision making around IPCOH. RESULTS: Of 6654 participants aged 18-59 years, 9.9% (95% CI 9.1% to 10.6%) reported IPCOH. IPCOH was highest in those aged 18-24 (17.7%), identifying as gay or lesbian (19.5%), and in steady non-cohabiting relationships (56.3%). IPCOH was associated with reporting risk behaviours (eg, condomless sex, higher alcohol consumption). IPCOH was less likely among those reporting bad/very bad health (aOR 0.54; 95% CI 0.32 to 0.93) but more likely among those with COVID-19 symptoms and/or diagnosis (aOR 1.34; 95% CI 1.10 to 1.65). Two-thirds (64.4%) of IPCOH was reported as being within a support bubble. Qualitative interviews found that people reporting IPCOH deliberated over, and made efforts to mitigate, the risks. CONCLUSIONS: Given 90% of people did not report IPCOH, this contact may not be a large additional contributor to SARS-CoV-2 transmission, although heterogeneity exists within the population. Public health messages need to recognise how single people and partners living apart balance sexual intimacy and relationship needs with adherence to control measures.

Initial impacts of the COVID-19 pandemic on sexual and reproductive health service use and unmet need in Britain: findings from a quasi-representative survey (Natsal-COVID).

BACKGROUND: The COVID-19 pandemic has affected sexual and reproductive health (SRH) service use and unmet need, but the impact is unknown. We aimed to determine the proportion of participants reporting sexual risk behaviours, SRH service use and unmet need, and to assess remote sexually transmitted infection (STI) testing service use after the first national lockdown in Britain. METHODS: We used data from the National Surveys of Sexual Attitudes and Lifestyles (Natsal)-COVID cross-sectional, quasi-representative web survey (Natsal-COVID Wave 1). Adults aged 18-59 years who resided in England, Scotland, or Wales completed the survey between July 29 and Aug 10, 2020, which included questions about the approximate 4-month period after announcement of the initial lockdown in Britain (March 23, 2020). Quota-based sampling and weighting were used to achieve a quasi-representative population sample. Participants aged 45-59 years were excluded from services analysis due to low rates of SRH service use. Among individuals aged 18-44 years, we estimated reported SRH service use and inability to access, and calculated age-adjusted odds ratios (aORs) among sexually experienced individuals (those reporting any sexual partner in their lifetime) and sexually active individuals (those reporting any sexual partner in the past year). Unweighted denominators and weighted estimates are presented hereafter. FINDINGS: 6654 individuals had complete interviews and were included in the analysis. Among 3758 participants aged 18-44 years, 82·0% reported being sexually experienced, and 73·7% reported being sexually active. 20·8% of sexually experienced participants aged 18-44 years reported using SRH services in the 4-month period. Overall, 9·7% of 3108 participants (9·5% of men; 9·9% of women) reported being unable to use a service they needed, although of the participants who reported trying but not being able to use a SRH service at least once, 76·4% of participants also reported an instance of successful use. 5·9% of 1221 sexually active men and 3·6% of 1560 sexually active women reported use of STI-related services and 14·8% of 1728 sexually experienced women reported use of contraceptive services, with SRH service use highest among individuals aged 18-24 years. Sexually active participants reporting condomless sex with new partners since lockdown were much more likely to report using STI-related services than those who did not report condomless sex (aOR 23·8 [95% CI 11·6-48·9]) for men, 10·5 [3·9-28·2] for women) and, among men, were also more likely to have an unsuccessful attempt at STI-service use (aOR 13·3 [5·3-32·9]). Among 106 individuals who reported using STI testing services, 64·4% accessed services remotely (telephone, video, or online). Among 2581 women aged 25-59 years, 2·4% reported cervical screening compared with an estimated 6% in a comparable 4-month period before the pandemic. INTERPRETATION: Many people accessed SRH care during the initial lockdown; however, young people and those reporting sexual risk behaviours reported difficulties in accessing services and thus such services might need to address a backlog of need. FUNDING: Wellcome Trust, The Economic and Social Research Council, The National Institute for Health Research, Medical Research Council/Chief Scientist Office and Public Health Sciences Unit, and UCL Coronavirus Response Fund.

Methodology of Natsal-COVID Wave 2: A large, quasi-representative, longitudinal survey measuring the impact of COVID-19 on sexual and reproductive health in Britain.

Background: The National Surveys of Sexual Attitudes and Lifestyles COVID study (Natsal-COVID) was designed to understand the impact of COVID-19 on Britain's sexual and reproductive health (SRH). Natsal-COVID Wave 1 survey and qualitative follow-up interviews were conducted in 2020. The Wave 2 survey was designed to capture one-year prevalence estimates for key SRH outcomes and measure changes over the first year of the pandemic. We describe the Wave 2 survey methodology and assess the sample representativeness. Methods: Natsal-COVID Wave 2 was conducted March-April 2021; approximately one year after the start of Britain's first national lockdown. Data were collected using an online web-panel survey administered by Ipsos. The sample comprised a longitudinal sample of Wave 1 participants who had agreed to re-contact plus a sample of participants residing in Britain, aged 18-59, including a boost sample comprising people aged 18-29. Questions covered reproductive health, relationships, sexual behaviour and SRH service use. Quotas and weighting were used to achieve a quasi-representative sample of the British population. Comparisons were made with recent national probability surveys, Natsal-3 (2010-12) and Natsal-COVID Wave 1 to understand bias. Results: A total of 6,658 individuals completed the survey. In terms of gender, age, ethnicity, and rurality, the weighted Natsal-COVID Wave 2 sample was like the general population. Participants were less likely to be married or to report being in good health than the general population. The longitudinal sample (n=2,098) were broadly like participants who only took part in Wave 1 but were older. Among the sexually active, longitudinal participants were less likely to report multiple sexual partners or a new sexual partner in the past year compared to those who only took part in Wave 1. Conclusions: Natsal-COVID collected longitudinal, quasi-representative population data to enable evaluation of the population-level impact of COVID-19 on SRH and to inform policy.

Impacts of COVID-19 on sexual behaviour in Britain: findings from a large, quasi-representative survey (Natsal-COVID).

OBJECTIVES: Physical restrictions imposed to combat COVID-19 dramatically altered sexual lifestyles but the specific impacts on sexual behaviour are still emerging. We investigated physical and virtual sexual activities, sexual frequency and satisfaction in the 4 months following lockdown in Britain in March 2020 and compared with pre-lockdown. METHODS: Weighted analyses of web panel survey data collected July/August 2020 from a quota-based sample of 6654 people aged 18-59 years in Britain. Multivariable regression took account of participants' opportunity for partnered sex, gender and age, to examine their independent associations with perceived changes in sexual frequency and satisfaction. RESULTS: Most participants (86.7%) reported some form of sex following lockdown with physical activities more commonly reported than virtual activities (83.7% vs 52.6%). Altogether, 63.2% reported sex with someone ('partnered sex') since lockdown, three-quarters of whom were in steady cohabiting relationships. With decreasing relationship formality, partnered sex was less frequently reported, while masturbation, sex toy use and virtual activities were more frequently reported. Around half of all participants perceived no change in partnered sex frequency compared with the 3 months pre-lockdown, but this was only one-third among those not cohabiting, who were more likely to report increases in non-partnered activities than those cohabiting. Two-thirds of participants perceived no change in sexual satisfaction; declines were more common among those not cohabiting. Relationship informality and younger age were independently associated with perceiving change, often declines, in sexual frequency and satisfaction. CONCLUSIONS: Our quasi-representative study of the British population found a substantial minority reported significant shifts in sexual repertoires, frequency and satisfaction following the introduction of COVID-19 restrictions. However, these negative changes were perceived by some more than others; predominantly those not cohabiting and the young. As these groups are most likely to experience adverse sexual health, it is important to monitor behaviour as restrictions ease to understand the longer term consequences, including for health services.

Menstrual characteristics, menstrual anxiety and school attendance among adolescents in Uganda: a longitudinal study.

BACKGROUND: Qualitative data show negative impacts of menstruation on health and education in many settings, but there are few longitudinal quantitative studies of the impact of menstruation. We analyse associations with menstrual anxiety and school attendance in a study of Ugandan secondary school students. METHODS: Data were from a longitudinal pilot study of a menstrual health intervention (MENISCUS), conducted in two secondary schools in Entebbe sub-district, Uganda. Self-completed menstrual-related data, including menstrual anxiety, were collected from 232 participants pre- and post-intervention. A sub-cohort of 100 randomly-selected post-menarcheal girls were asked to self-complete daily diaries during 10 months of follow-up, with data on menstrual flow, pain, and school attendance. We used multivariable logistic regression to estimate associations with menstrual anxiety among all girls at baseline, and random-effects logistic regression to estimate associations of menstrual characteristics with school non-attendance for 3 months pre-intervention in the sub-cohort, adjusting for within-girl clustering. RESULTS: Overall, 130/222 (58.6%) of menstruating girls reported being anxious about their next period. Menstrual anxiety was higher in those not living with their mother (adjusted odds ratio (OR) = 1.91; 95% confidence interval (CI) 1.01-3.60), believing menstrual myths (aOR = 1.83; 0.95-3.50 for not agreeing that it is healthy for a girl to run, dance or cycle during her period; aOR = 1.97; 1.04-3.73 for agreeing that when a girl has her period she is unclean), lower menstrual confidence (aOR = 2.49; 1.33-4.65 for avoiding physical activity during her period; aOR = 1.68; 0.89-3.17 for not feeling comfortable to talk to other girls about her period; aOR = 2.89; 1.28-6.54 for agreeing that boys/girls tease them about their periods; and aOR = 2.27; 1.21-4.27 for worrying about being teased during her period). Those with lower knowledge about menstruation were less likely to report anxiety (aOR = 0.44; 0.23-0.84). During the pre-intervention period of the sub-cohort, school non-attendance was associated with menstrual pain, with 21.7% of girls missing school on days when they reported pain vs. 8.3% on days when no pain was reported (aOR = 3.82; 1.66-8.77). CONCLUSIONS: Menstruation causes substantial anxiety in Ugandan schoolgirls, and menstrual pain is associated with missing school on period-days. Menstrual health interventions should address socio-cultural aspects of menstruation to reduce anxiety, and provide education on pain management strategies to support school attendance.