"I will find the best method that will work for me": navigating contraceptive journeys amongst South African adolescent girls and young women.

BACKGROUND: Given that South Africa has one of the highest rates of pregnancy amongst adolescent girls and young women (AGYW) globally, the provision of contraceptives to this group has been a key focus in recent years. Pregnancy prevention involves an on-going continuum of decision-making around contraceptive method choice, uptake, use, experience, continuation, and discontinuation. METHODS: This paper presents analysis of data from a cross-sectional survey with 2376 AGYW, as well as qualitative in-depth interviews (IDIs) with 54 AGYW, inclusive of contraceptive journey narratives. We examine the preferences, valued characteristics, choices, beliefs, understandings and experiences of choosing and using contraceptives amongst AGYW in two South African communities characterised by high rates of pregnancy. RESULTS: These findings shed light on the preferences towards, beliefs about, and experiences of choosing, using and discontinuing contraceptive methods amongst this population, with survey data suggesting that the most popular methods were the injection, followed by the implant, and then the oral pill. Findings illustrate the complexity and dynamic nature of contraceptive decision-making and the varied embodied and lived experiences of contraceptive use, and how these are impacted by contraception service provision. CONCLUSIONS: Our findings show that contraception experiences of each individual are cumulative, and comprise a continuum of method initiation, use, discontinuation, method switching and on-going circular decision-making influenced by multiple social, structural, contextual and interpersonal factors, combined with shifting preferences, values and needs. To maximise the use of contraceptives amongst South African AGYW, it is necessary to provide responsive contraception service provision to reflect the changing contexts and preferences of users, in order to ensure that pregnancy prevention needs are catered for throughout their reproductive life course.

Adolescent girls and young women's (AGYW) access to and use of contraception services in Cape Town: perspectives from AGYW and health care providers.

BACKGROUND: Access and use of contraception services by adolescent girls and young women (AGYW) remains suboptimal, exposing AGYW to early and often unexpected pregnancy. Unexpected pregnancies are a public health concern, associated with poor neonatal and maternal health outcomes, as well as school dropout, which may result in economic hardships. This study aimed to explore (a) AGYW perceptions and experiences of receiving contraception services from health care providers and (b) health care providers' perceptions and experiences of providing contraception services to AGYW. METHODS: Data were collected through semi-structured individual interviews with AGYW aged 15-24 years old and health care providers working in eight health care facilities around the Cape Town metropolitan area, in South Africa's Western Cape Province. Thematic analysis was used to analyse the data. RESULTS: AGYW and health care providers voiced varying, and often contrasting, perceptions of some of the barriers that hinder AGYW's access to contraception services. AGYW indicated that provider-imposed rules about when to access contraceptive services hindered access, while health care providers felt that these rules were necessary for coordinating their work. In addition, AGYW highlighted health care providers' hostile attitudes towards them as an important factor discouraging access. On the contrary, health care providers did not think that their attitudes hampered AGYW's access to and use of contraception services, instead they emphasised that challenges at the health system level were a major issue, which they feel they have little control over. Such challenges made health care providers' work unpleasant and frustrating, impacting on their work approach and how they receive and offer services to AGYW. CONCLUSION: The expectation of negative attitudes from health care providers continues to be at the centre of AGYW discouragement towards accessing contraception services. System challenges are among some of the key drivers of health care provider's hostile attitudes, posing challenges to the efficient provision of services. In order to improve AGYW's access to and use of contraception services, and subsequently achieve the country's SDGs, conscious efforts need to be directed towards improving the workload and working conditions of health care providers.

Applying the HIV Prevention Cascade to an Evaluation of a Large-Scale Combination HIV Prevention Programme for Adolescent Girls and Young Women in South Africa.

Adolescent girls and young women (AGYW) in South Africa are at a three times higher risk of acquiring HIV than their male counterparts. The HIV prevention cascade is a tool which can be used to measure coverage of HIV prevention services, although there is limited empirical evidence to demonstrate its application in low-resourced settings. The unifying framework is a conceptualisation of the HIV prevention cascade which theorises that both motivation and access are required for an individual to effectively use an HIV prevention method. We applied this framework to data from a random sample of 127,951 beneficiaries of a combination HIV prevention programme for AGYW aged 15-24 in South Africa to measure the steps to, and identify key barriers to, effective use of male condoms and oral pre-exposure prophylaxis (PrEP) among this vulnerable population. Barriers to each step were analysed using univariate and multivariable logistic regression. Among self-reported HIV-negative AGYW who had sex in the past 6 months, effective use of condoms (15.2%), access to PrEP (39.1%) and use of PrEP (3.8%) were low. AGYW were: less likely to be motivated to use condoms if they believed that they had a faithful partner (aOR 0.44, 95% CI 0.22-0.90) or disliked condoms (aOR 0.26, 95% CI 0.11-0.57), less likely to access condoms if the place where AGYW accessed them was far away (aOR 0.25, 95% CI 0.10-0.64), more likely to effectively use condoms if they received counselling on how to use them (aOR 2.24, 95% CI 1.05-4.76), less likely to be motivated to use PrEP if they did not believe PrEP was efficacious (aOR 0.35, 95% CI 0.17-0.72), more likely to be motivated if they felt confident that they could use PrEP, and more likely to have access to PrEP if they had ever been offered PrEP (aOR 2.94, 95% CI 1.19-7.22). This combination HIV prevention programme and similar programmes should focus on risk-reduction counselling interventions for AGYW and their male partners to improve effective use of condoms and ensure easy access to condoms and PrEP by making them available in youth-friendly spaces. Our findings demonstrate that the application of HIV prevention cascades can inform AGYW HIV prevention programming in low-resourced settings.

Using prevention cascades to investigate coverage of contraception services among young women enrolled in a large-scale combination HIV prevention program in South Africa.

OBJECTIVES: We investigated the coverage of contraception services (excluding condoms) to prevent unintended pregnancy among young women and girls aged 15 to 24 years who were beneficiaries of one of the two largest combination HIV and pregnancy prevention program in South Africa. STUDY DESIGN: We invited 2160 randomly sampled beneficiaries who were living in six of the 12 program districts across six provinces to participate in a telephone survey. We created pregnancy prevention coverage cascades and conducted univariate and multivariable analyses to identify key barriers and facilitators associated with each step of the cascade. RESULTS: We achieved a response rate of 23.8%, resulting in 515 respondents, of whom 303 had sex in the 6 months before the survey. Of this subsample, 80.4% had access to contraception services, 60.6% had access and motivation to use contraceptives, and 21.9% had access to, motivation to use, and effectively used contraceptives. Distance to travel to services and not ever being offered contraceptives by health workers were access barriers, while low pregnancy risk perception was a barrier to motivation. CONCLUSIONS: Most respondents had access to and were motivated to use contraceptives other than condoms but were not effectively using them. Having been offered contraceptives facilitated better access, while distance to the services was a barrier, suggesting the importance of improving supply-side interventions, such as increasing the number and accessibility of spaces where Sexual and Reproductive Health (SRH) services are offered. We recommend longitudinal behavioral counseling for young people, especially adolescents, as well as risk reduction and information-tailored interventions. IMPLICATIONS: Pregnancy prevention cascades are a promising tool to monitor progress toward universal access to contraception services and to identify barriers that need to be addressed to achieve the effective use of contraceptives.

Factors Associated with COVID-19 Vaccine Uptake among Schoolgoing Adolescent Girls and Young Women in South Africa.

(1) Background: By October 2022, vaccination rates with at least one dose of a COVID-19 vaccine were low among adolescent girls aged 12-17 (38%) and young women aged 18-34 (45%) in South Africa. This study aimed to measure and identify barriers to and facilitators of motivation to take up, access to, and uptake of COVID-19 vaccines among schoolgoing adolescent girls and young women in two districts in South Africa. (2) Methods: Using the theory of the HIV prevention cascade, we conceptualised the relationship between motivation, access, and uptake of COVID-19 vaccines, and associated barriers. Potential barriers and facilitators were identified using bivariate and multivariable Poisson regression. (3) Results: Among all 2375 participants, access was high (69%), but motivation (49%) and vaccination with at least one COVID-19 vaccine (45%) were lower. Fear of injections was a barrier to vaccine uptake (aRR 0.85 95% CI 0.82-0.88), while being tested for COVID-19 (aRR 2.10 95% CI 1.85-2.38) and believing that the COVID-19 vaccine was safe (aRR 1.31 95% CI 1.18-1.44) and would prevent you from getting very sick (aRR 1.11 95% CI 1.04-1.19) were facilitators. (4) Conclusions: The controversy about the value of vaccinating adolescents and the delay in vaccine rollout for adolescents and young adults may have contributed to fears about the safety and efficacy of COVID-19 vaccines, as well as a lack of motivation to get vaccinated.

"These Girls Have a Chance to be the Future Generation of HIV Negative": Experiences of Implementing a PrEP Programme for Adolescent Girls and Young Women in South Africa.

Daily oral pre-exposure prophylaxis (PrEP) is highly efficacious for HIV prevention. Adolescent girls and young women (AGYW) have been prioritised for PrEP delivery in South Africa. A combination HIV prevention intervention providing integrated biomedical, behavioural and structural interventions for AGYW aged 15-24 in twelve districts in South Africa characterised by high HIV prevalence, was implemented 2019-2022. We conducted qualitative interviews to explore PrEP implementation experiences with 38 individuals involved in the implementation of the combination HIV prevention programme, including programme managers and project coordinators, health care providers / nurses, social workers, counsellors, peer group trainers and outreach workers. Narratives included various challenges associated with PrEP uptake, adherence and acceptability experienced by implementers. Barriers to PrEP acceptability included AGYW fears of side effects and preference for injectable versus daily oral PrEP; resistance towards PrEP from AGYW, communities and parents due to a lack of accurate information; PrEP stigma linked to associations with antiretrovirals and assumptions of promiscuity; and issues pertaining to parental consent. Additionally, implementers faced logistical challenges related to procurement, stockouts, and supply of PrEP. Findings highlighted the critical role of parental and community acceptability of PrEP for successful implementation. Overall, PrEP was perceived by implementers as a valuable HIV prevention tool. In order to ensure the accessibility of PrEP for AGYW in South Africa, efforts to reduce stigma and foster social support for PrEP use, campaigns to raise awareness, ensure positive framing of PrEP, and build community acceptability of PrEP, are needed.

"Men Rule this is the Normal Thing. We Normalise it and it's Wrong": Gendered Power in Decision-Making Around Sex and Condom Use in Heterosexual Relationships Amongst Adolescents and Young People in South Africa.

We examined power and decision-making in heterosexual relationships amongst South African adolescents and young people. A survey conducted with 515 adolescent girls and young women (AGYW) included items from the Sexual Relationship Power Scale (SRPS) adapted for South African women. Qualitative interviews with fifty AGYW aged between 15 and 24, and nine males aged 18 years and above, explored decision-making in heterosexual relationships, particularly relating to timing of sex and condom use. Theories of gendered power, sexual relationship power and sexual scripting were used in interpreting the data. Findings showed that the power AGYW have in sexual relationships determines their ability to use condoms, and that males generally control condom use and timing of sex. Both survey and interview data suggest that male control over female partners' behaviour also extends beyond the sexual domain. Although while male power is pervasive and enduring, it is simultaneously contested and negotiated. Despite some young people believing that gendered power in decision-making should be equal, it is not always possible for AGYW to enact agency in the dyadic context of heterosexual relationships. Whilst adolescents and young people in South Africa move away from traditional cultural gendered expectations, relationship power inequity and hegemonic masculinities continue to legitimise men's power over women, constraining the sexual agency of adolescent girls and young women and discouraging them from taking control of their own sexual interests and sexual health.

Identifying the determinants of patient satisfaction in the context of antenatal care in Kenya, Tanzania, and Malawi using service provision assessment data.

BACKGROUND: Antenatal care (ANC) is a service that can reduce the incidence of maternal and neonatal deaths when provided by skilled healthcare workers. Patient satisfaction is an important health system responsiveness goal which has been shown to influence adherence to healthcare interventions. This study aims to assess the determinants of pregnant women's satisfaction with ANC across Kenya, Tanzania, and Malawi using nationally representative Service Provision Assessment data. METHODS: Patient satisfaction was conceptualised mainly based on Donabedian's theory of healthcare quality with patient characteristics, structure, and process as the major determinants. Bivariate and multivariate analyses were conducted to identify the potential determinants. RESULTS: Findings show that satisfaction was negatively associated with women's age (AOR: 0.95; 95% CI: 0.92-0.99) and having a secondary (AOR: 0.39; 95% CI: 0.17-0.87) or tertiary education (AOR: 0.41; 95% CI: 0.17-0.99) in Kenya. Women on their first pregnancy were more likely to report satisfaction in Tanzania (AOR: 1.62; 95% CI: 1.00-2.62) while women were less likely to report being satisfied in their second trimester in Malawi (AOR: 0.31; 95% CI: 0.09-0.97). The important structural and process factors for patient satisfaction included: private versus public run facilities in Kenya (AOR: 2.05; 95% CI: 1.22-3.43) and Malawi (AOR: 1.85; 95% CI: 0.99-3.43); level of provider training, that is, specialist versus enrolled nurse in Tanzania (AOR: 0.35; 95% CI: 0.13-0.93) or clinical technician in Malawi (AOR: 0.08; 95% CI: 0.01-0.36); and shorter waiting times across all countries. CONCLUSION: Findings highlight the importance of professional proficiency and efficient service delivery in determining pregnant women's satisfaction with ANC. Future studies should incorporate both patient characteristics and institutional factors at health facilities into their conceptualisation of patient satisfaction.

Safe spaces for beneficiaries of a combination HIV prevention intervention for adolescent girls and young women in South Africa: access, feasibility, and acceptability.

BACKGROUND: Safe Spaces are a feature of combination HIV prevention interventions for adolescent girls and young women (AGYW) in South Africa. We investigated whether AGYW at risk for adverse sexual and reproductive health (SRH) outcomes accessed Safe Spaces that were part of an intervention, as well as their feasibility and acceptability. METHODS: In December 2020 to February 2021, as part of a process evaluation of a combination HIV prevention intervention, we randomly sampled 2160 AGYW intervention beneficiaries aged 15-24 years from 6 of the 12 intervention districts. We invited them to participate in a phone survey, with questions about their vulnerability to adverse SRH outcomes, and participation in intervention components including Safe Spaces. We examined factors associated with use of Safe Spaces using bivariate analyses and Pearson's chi squared tests. We also conducted in-depth interviews with 50 AGYW beneficiaries, 27 intervention implementers, 4 health workers, 7 social workers, and 12 community stakeholders, to explore perceptions and experiences of the intervention. Thematic analysis of the qualitative data was performed. RESULTS: At least 30 Safe Spaces were established across 6 districts. Five hundred fifteen of two thousand one hundred sixty sampled AGYW participated in the survey of whom 22.6% visited a Safe Space, accessing HIV testing (52.2%), mobile health services (21.2%) and counselling for distress (24.8%) while there. Beneficiaries of lower socioeconomic status (SES) were less likely to have visited a Safe Space, compared with those of higher SES (13.6% versus 25.3%; p < 0.01). Implementers described political, structural and financial challenges in identifying and setting up Safe Spaces that were safe, accessible and adequately-resourced, and challenges with AGYW not utilising them as expected. AGYW shared positive views of Safe Spaces, describing benefits such as access to computers and the internet, support with homework and job and education applications, and a space in which to connect with peers. CONCLUSION: AGYW are attracted to Safe Spaces by educational and employment promoting interventions and recreational activities, and many will take up the offer of SRH services while there. The poorest AGYW are more likely to be excluded, therefore, an understanding of the obstacles to, and enablers of their inclusion should inform Safe Space intervention design.

Intersections between COVID-19 and socio-economic mental health stressors in the lives of South African adolescent girls and young women.

BACKGROUND: In contexts where poverty and mental health stressors already interact to negatively impact the most vulnerable populations, COVID-19 is likely to have worsened these impacts. Before the COVID-19 pandemic, adolescent girls and young women (AGYW) in South Africa already faced intersecting mental health stressors and vulnerabilities. It is critical to understand how additional challenges brought on by COVID-19 have intersected with existing vulnerabilities and mental health risks AGYW faced, particularly given the intersections between psychological distress and increased risk behaviours that impact sexual and reproductive health. We aimed to examine socio-economic and mental health impacts of COVID-19 on South African AGYW in order to understand how additional challenges brought on by COVID-19 have intersected with existing challenges, compounding AGYW vulnerabilities. METHODS: Using qualitative and quantitative methods, framed by the syndemic theory, we examined the intersections between mental health and the COVID-19 epidemic amongst AGYW in six districts of South Africa characterised by high rates of HIV, teenage pregnancy and socio-economic hardship. Between November 2020 and March 2021 we conducted a cross-sectional telephone survey with 515 AGYW, and in-depth interviews with 50 AGYW, aged 15 to 24 years. RESULTS: Our findings reveal how COVID-19 restrictions led to increased experiences of stress and anxiety. Poor mental health was compounded by strained family relationships, increased fear of domestic violence, household unemployment, economic stress and food insecurity. Respondents described feelings of boredom, frustration, isolation, loneliness, fear and hopelessness. However, despite the multitude of challenges, some AGYW articulated emotional resilience, describing ways in which they coped and retained hope. CONCLUSION: Various psycho-social risk factors already disproportionally affect the mental health of AGYW in these communities; the COVID-19 pandemic intersects with these pre-existing social and environmental factors. Understanding strategies AGYW have used to positively cope with the uncertainty of COVID-19 amongst an array of pre-existing mental health stressors, is key in informing efforts to respond to their needs. Multisectoral interventions are needed to address the drivers of poor mental health among AGYW, and bolster healthy coping mechanisms; interventions seeking to mitigate the mental health impacts on this vulnerable population need to be responsive to the unpredictable pandemic environment.