Towards Harmonized Adolescent Health Measurement: Assessing Alignment Between Current Recommendations and the Global Action for Measurement of Adolescent Health-Recommended Indicators.

PURPOSE: This study identified alignment of indicators across different initiatives and data collection instruments as a foundation for future harmonization of adolescent health measurement. METHODS: Using the Global Action for Measurement of Adolescent health (GAMA) recommended indicators as the basis for comparison, we conducted a desk review of 14 global-level initiatives, such as the Sustainable Development Goals and the Global Strategy for Women's, Children's and Adolescents' Health, and five multicountry survey programs, such as the Multiple Indicator Cluster Surveys and the Global school-based Student Health Survey. We identified initiative and survey indicators similar to a GAMA indicator, deconstructed indicators into standard elements to facilitate comparison, and assessed alignment to the corresponding GAMA indicator across each of the elements. RESULTS: A total of 144 initiative indicators and 90 survey indicators were identified. Twenty-four initiative indicators (17%) and 14 survey indicators (16%) matched the corresponding GAMA indicators across all elements. Population of interest was the most commonly discrepant element; whereas GAMA indicators mostly refer to ages 10-19, many survey and initiative indicators encompass only part of this age range, for example, 15-19-year-olds as a subset of adults ages 15-49 years. An additional 53 initiative indicators (39%) and 44 survey indicators (49%) matched on all elements except the population of interest. DISCUSSION: The current adolescent measurement landscape is inconsistent, with differing recommendations on what and how to measure. Findings from this study support efforts to promote indicator alignment and harmonization across adolescent health measurement stakeholders at the global, regional, and country levels.

Indicators to Measure Adolescent Health at the Country, Regional, and Global Levels: Results of a Five-Year Selection Process by the Global Action for the Measurement of Adolescent Health.

PURPOSE: To improve adolescent health measurement, the Global Action for the Measurement of Adolescent health (GAMA) Advisory Group was formed in 2018 and published a draft list of 52 indicators across six adolescent health domains in 2022. We describe the process and results of selecting the adolescent health indicators recommended by GAMA (hereafter, "GAMA-recommended indicators"). METHODS: Each indicator in the draft list was assessed using the following inputs: (1) availability of data and stakeholders' perceptions on their relevance, acceptability, and feasibility across selected countries; (2) alignment with current measurement recommendations and practices; and (3) data in global databases. Topic-specific working groups comprised of GAMA experts and representatives of United Nations partner agencies reviewed results and provided preliminary recommendations, which were appraised by all GAMA members and finalized. RESULTS: There are 47 GAMA-recommended indicators (36 core and 11 additional) for adolescent health measurement across six domains: policies, programs, and laws (4 indicators); systems performance and interventions (4); health determinants (7); health behaviors and risks (20); subjective well-being (2); and health outcomes and conditions (10). DISCUSSION: These indicators are the result of a robust and structured five-year process to identify a priority set of indicators with relevance to adolescent health globally. This inclusive and participatory approach incorporated inputs from a broad range of stakeholders, including adolescents and young people themselves. The GAMA-recommended indicators are now ready to be used to measure adolescent health at the country, regional, and global levels.

Exploring a Preliminary Set of Indicators to Measure Adolescent Health: Results From a 12-Country Feasibility Study.

PURPOSE: To explore data availability, perceived relevance, acceptability and feasibility of implementing 52 draft indicators for adolescent health measurement in different countries globally. METHODS: A mixed-methods, sequential explanatory study was conducted in 12 countries. An online spreadsheet was used to assess data availability and a stakeholder survey to assess perceived relevance, acceptability, and feasibility of implementing each draft indicator proposed by the Global Action for Measurement of Adolescent health (GAMA). The assessments were discussed in virtual meetings with all countries and in deep dives with three countries. Findings were synthesized using descriptive statistics and qualitative thematic analysis. RESULTS: Data availability varied across the 52 draft GAMA indicators and across countries. Nine countries reported measuring over half of the indicators. Most indicators were rated relevant by stakeholders, while some were considered less acceptable and feasible. The ten lowest-ranking indicators were related to mental health, sexual health and substance use; the highest-ranking indicators centered on broader adolescent health issues, like use of health services. Indicators with higher data availability and alignment with national priorities were generally considered most relevant, acceptable and feasible. Barriers to measurement included legal, ethical and sensitivity issues, challenges with multi-sectoral coordination and data systems flexibility. DISCUSSION: Most of the draft GAMA indicators were deemed relevant and feasible, but contextual priorities and perceived acceptability influenced their implementation in countries. To increase their use for a more comprehensive understanding of adolescent health, better multi-sectoral coordination and tailored capacity building to accommodate the diverse data systems in countries will be required.

Challenges and Opportunities to Advance Adolescent Health Measurement in Armenia: Alignment Between Global Priority Indicators and National Policies, and Feasibility of Collecting Sexual, Reproductive, and Mental Health Indicators.

PURPOSE: To assess alignment of the Global Action for Measurement of Adolescent health (GAMA) draft adolescent health indicators with national policies and explore challenges and opportunities for collecting data on adolescent sexual, reproductive, and mental health in Armenia. METHODS: We reviewed Armenia's national laws, decrees, policies, strategies, and programs for content related to the draft indicators. We conducted three focus group discussions with government and nongovernmental stakeholders and youth representatives on the feasibility of collecting the draft indicators, and analyzed the discussion segments related to sexual, reproductive, and mental health indicators. RESULTS: The policy review included 22 documents. Armenia's national laws, policies, strategies, orders, and decrees mention a range of tracking and monitoring activities in adolescent health, and many draft GAMA indicators are already incorporated into national statistics and are collected in ongoing surveys. However, policies and strategies often lack specificity around how to measure and report indicators. Sexual, reproductive, and mental health indicators were particularly sensitive to collect due to Armenian cultural norms and expectations, especially for younger adolescents under the age of 15 years. DISCUSSION: Guidance should be developed to facilitate the formulation of relevant policies with well-defined indicators and complete tracking and reporting information. Data collection should be further harmonized within the overall health information flow to avoid data overlap. While sensitization work and interviewer training can help address some issues around collecting data on sexual, reproductive, and mental health, it may be necessary to adapt certain indicators to be culturally acceptable in Armenia, such as by limiting the age range to above 15 years for highly sensitive indicators.

An arterial access system for targeted chemotherapy delivery and arterial-arterial extracorporeal recirculation for 'end stage' peripheral vascular disease.

BACKGROUND: Vascular access via a single arterial catheter for targeted chemotherapy delivery has difficulties with concentration, dilution, drug retention, plasma binding, and lack of control of the tumour microcirculation. An implantable arterial access system to accommodate multi-catheter access was developed address these problems. The system was also adapted for isolated arterial-to-arterial extracorporeal suprasystolic perfusion for end stage peripheral vascular disease. The arterial-to-arterial logistics were compared with standard venovenous and arteriovenous fistulae access employed in haemodialysis. METHODS: Targeted chemotherapy delivery was addressed in a pilot study of vascular liver isolation. Ten patients with secondary colorectal cancer, were treated with multiple infusions employing up to five individually steered catheters. The arterial-to-arterial extracorporeal access system was also used to treat end stage peripheral vascular disease in 20 patients where amputation was the only option. The trial was named Hypertensive Extracorporeal Limb Perfusion (HELP). RESULTS: Multiple day only infusions produced a partial response or stable disease in six out of the ten patients in an 'end stage' setting. The mean survival was 11.2 months. Of the twenty patients facing amputation 40% had avoided amputation at follow-up 22 months and 20% had delay of 4 months. CONCLUSION: The access system allows repeatable steerable multi-catheter arterial access for chemotherapy delivery to address difficulties of concentration, dilution, plasma binding and microvascular control. The access system supports multiple repeatable suprasystolic extracorporeal arterial to arterial access. It is cardiac independent generating flows of greater than 1 L/min with zero flow in between treatments. The device logistics compares favourably with arteriovenous and venovenous access systems.

Contraceptive and abortion practices of young Ghanaian women aged 15-24: evidence from a nationally representative survey.

BACKGROUND: Young Ghanaian women experience high rates of unmet need for contraception and unintended pregnancy, and face unique barriers to accessing sexual and reproductive health services. This study provides a comprehensive national analysis of young women's contraceptive and abortion practices and needs. METHODS: In 2018, we conducted a nationally representative survey of women aged 15-49, including 1039 women aged 15-24. We used descriptive statistics, multivariable logistic and multinomial regression to compare young versus older (25-49 year-old) women's preferred contraceptive attributes, reasons for discontinuing contraception, quality of counseling, use of Primolut N-tablet, method choice correlates, and friends' and partners' influence. We also examined youth's self-reported abortion incidence, abortion methods, post-abortion care, and barriers to safe abortion. RESULTS: Among Ghanaian 15-24 year-olds who had ever had sex, one-third (32%) were using contraception. Compared to older women, they had higher desires to avoid pregnancy, lower ever use of contraception, more intermittent sexual activity, and were more likely to report pregnancies as unintended and to have recently ended a pregnancy. Young contraceptors most commonly used condoms (22%), injectables (21%), withdrawal (20%) or implants (20%); and were more likely than older women to use condoms, withdrawal, emergency contraception, and N-tablet. They valued methods for effectiveness (70%), no risk of harming health (31%) nor future fertility (26%), ease of use (20%), and no effect on menstruation (19%). Infrequent sex accounted for over half of youth contraceptive discontinuation. Relative to older women, young women's social networks were more influential on contraceptive use. The annual self-reported abortion rate among young women was 30 per thousand. Over half of young women used abortion methods obtained from non-formal providers. Among the third of young women who experienced abortion complications, 40% did not access treatment. CONCLUSIONS: Young people's intermittent sexual activity, desire for methods that do not harm their health, access barriers and provider bias, likely contribute to their greater use of coital-dependent methods. Providers should be equipped to provide confidential, non-discriminatory counseling addressing concerns about infertility, side effects and alternative methods. Use of social networks can be leveraged to educate around issues like safe abortion and correct use of N-tablet.

Young Ghanaian women can experience difficulties accessing sexual and reproductive health services, and many are not using contraception despite wanting to avoid pregnancy. To better understand their needs, we describe their preferences and behaviors around contraception and abortion. We surveyed a nationally representative sample of women aged 15­49, and compared young (15­24) versus older (25­49) women's contraceptive preferences, reasons for stopping contraception, quality of counseling, friends' and partners' influence on contraceptive use, and use of abortion. One-third of 15­24 year-olds who ever had sex were using contraception. Compared to older women, young women's pregnancies were more likely to be unintended and to end in abortion. Young women most commonly used condoms, injectables, withdrawal or implants; and were more likely than older women to use condoms, withdrawal, emergency contraception, and Primolut N-tablet. They preferred methods that were effective, did not harm their health or future fertility, were easy to use, and did not disrupt their menstrual cycle. Over half of young women who stopped contraception did so because they were not having sex regularly. Friends had more influence on contraceptive use among young women than older women. Each year on average, there were 30 abortions per 1000 young women. Over half of young women who had abortions used methods from non-formal providers, and 40% of those who had complications did not get treated. Providers should be equipped to provide confidential, non-discriminatory counseling about contraceptive side effects and options. Social networks can be used to educate women about safe abortion.

Hormonal contraceptive use in Ghana: The role of method attributes and side effects in method choice and continuation.

OBJECTIVE: To understand the barriers and facilitators of hormonal contraceptive use among Ghanaian women, in order to help improve contraceptive counseling and reduce the high rates of unintended pregnancy. STUDY DESIGN: We conducted a nationally representative community-based survey of 4143 women aged 15-49 in 2018, and used descriptive statistics and logistic regression to examine correlates of current hormonal method use, preferred method attributes and their association with method choice, and the role of side effects in hormonal method discontinuation. RESULTS: Hormonal method use (vs. contraceptive non-use) was associated with younger age, higher parity and education, but not with union status, wealth or residence. Preferences for key method attributes were associated with choosing particular methods. Most valued attributes were effectiveness at preventing pregnancy, and low risks of harming health and future fertility. These last 2 concerns are echoed in the second most common reason for discontinuation (health concerns). While menstrual changes were a common concern, leading some respondents to discontinue hormonal contraceptives, many were willing to endure these effects. In contrast, having experienced long-term health issues as a perceived result of hormonal method use more than halved the odds of current use. Contraceptive counseling on menstrual changes, other side effects, and impacts on future fertility had not been universally provided. CONCLUSIONS: Ghanaian women value hormonal methods for their effectiveness against pregnancy. However, concerns about side effects (particularly bleeding changes), future fertility impairment, and long-term health issues led some women to discontinue hormonal methods. Counseling on these issues was reportedly inadequate. IMPLICATIONS: Identifying barriers to, and facilitators of, hormonal contraceptive use, as well as method attributes important to Ghanaian women, can help to better tailor contraceptive counseling to individual needs, in order to ensure that all women can access the method that suits them best, and decide whether and how to manage side effects, switch methods or discontinue.

Prevalence and Correlates of Perceived Infertility in Ghana.

Perceived infertility is an understudied phenomenon in low- and middle-income countries, where biomedical infertility can have severe consequences, particularly for women. We conducted a nationally representative survey of Ghanaian women, estimated the prevalence of and reasons for perceived infertility, and assessed factors associated with higher levels of perceived infertility using a partial proportional odds model. Among 4,070 women, 13 percent believed they were "very likely" to have difficulty getting pregnant when they wanted to, 21 percent believed this was "somewhat likely," and 66 percent believed this was "not at all likely." Reasons for perceived infertility varied by whether the respondent was currently seeking pregnancy. In multivariable analysis, several factors were associated with higher levels of perceived infertility, while unexpectedly, women who reported ever using contraception were less likely to report perceived infertility. Acknowledging the need to address infertility globally and understanding the role of perceived infertility are important components in supporting people's ability to decide whether and when to have children.

Estimating the incidence of abortion: using the Abortion Incidence Complications Methodology in Ghana, 2017.

Introduction: Induced abortion is legally permitted in Ghana under specific conditions, but access to services that meet guidelines approved by government is limited. As part of a larger project comparing five methodologies to estimate abortion incidence, we implemented an indirect estimation approach: the Abortion Incidence Complications Methodology (AICM), to understand the incidence of abortion in Ghana in 2017. Methods: We drew a nationally representative, two-stage, stratified sample of health facilities. We used information from 539 responding facilities to estimate treated complications stemming from illegal induced abortions, and to estimate the number of legal abortions provided. We used information from 146 knowledgeable informants to generate zonal multipliers representing the inverse of the proportion of illegal induced abortions treated for complications in facilities in Ghana's three ecological zones. We applied multipliers to estimates of treated complications from illegal abortions, and added legal abortions to obtain an annual estimate of all induced abortions. Results: The AICM approach suggests that approximately 200 000 abortions occurred in Ghana in 2017, corresponding to a national abortion rate of 26.8 (95% CI 21.7 to 31.9) per 1000 women 15-49. Abortion rates were lowest in the Northern zone (18.6) and highest in the Middle zone (30.4). Of all abortions, 71% were illegal. Conclusion: Despite Ghana's relatively liberal abortion law and efforts to expand access to safe abortion services, illegal induced abortion appears common. A concurrently published paper compares the AICM-derived estimates presented in this paper to those from other methodological approaches.

Novel approaches to estimating abortion incidence.

BACKGROUND: In countries where abortion is legally restricted or clandestine, estimates of abortion incidence are needed in order to bring attention to the reality of this practice. Innovations in methods for estimating stigmatized behaviors, coupled with changes in the conditions under which women obtain abortions, prompt us to review new approaches to estimating abortion incidence and propose innovations in this field. METHODS: We discuss five approaches for yielding accurate estimates in countries with restrictive abortion laws. These include two prevailing approaches in the field (direct questioning of women about their abortions and the Abortion Incidence Complications Method (AICM)), one that has begun to be in use in recent years (the List Experiment) and two that are newly proposed by the authors (the Confidante Approach and a modification of the AICM). We discuss assumptions, strengths and weaknesses of each approach. Finally, we suggest strategies for assessing the validity of the findings in the absence of a gold standard. RESULTS: Though direct questioning has consistently been shown to miss many abortions, reporting can potentially be improved by normalizing or reframing the experience of abortion. The AICM has had the advantage of not relying on women's reports about their abortions; however as self-induced abortion becomes more common, this strength becomes a weakness. The modified AICM, which uses women's abortion reports to estimate the proportion of abortions that lead to treated complications, improves our chances of capturing self-induced abortions. The List Experiment preserves the woman's anonymity (not just her confidentiality), but it can be cognitively challenging and the potential to make subgroup estimates is extremely limited. The Confidante Approach entails asking survey respondents about abortions among women who confide in them, rather than their own abortions. An adjustment factor can be applied to estimate the incidence of confidantes' abortions that are unknown to respondents. This approach relies on the assumption that women know and will report whether their confidantes had an abortion. In the absence of a gold standard measure of abortion incidence, four strategies can be employed to compare and assess these approaches: (a) comparing the level of underreporting across methods susceptible to underreporting but not to overreporting, (2) validating components of abortion estimates against an objective measure, (3) testing whether these strategies accurately estimate other sensitive behaviors for which a gold standard exists, and 4) sensitivity analyses. Ultimately, it might be appropriate to employ more than one methodology when measuring abortion incidence.

Challenges to implementing national comprehensive sexuality education curricula in low- and middle-income countries: Case studies of Ghana, Kenya, Peru and Guatemala.

School-based comprehensive sexuality education (CSE) can help adolescents achieve their full potential and realize their sexual and reproductive health and rights. This is particularly pressing in low- and middle-income countries (LMICs), where high rates of unintended pregnancy and STIs among adolescents can limit countries' ability to capitalize on the demographic dividend. While many LMICs have developed CSE curricula, their full implementation is often hindered by challenges around program planning and roll-out at the national and local level. A better understanding of these barriers, and similarities and differences across countries, can help devise strategies to improve implementation; yet few studies have examined these barriers. This paper analyzes the challenges to the implementation of national CSE curricula in four LMICs: Ghana, Kenya, Peru and Guatemala. It presents qualitative findings from in-depth interviews with central and local government officials, civil society representatives, and community level stakeholders ranging from religious leaders to youth representatives. Qualitative findings are complemented by quantitative results from surveys of principals, teachers who teach CSE topics, and students aged 15-17 in a representative sample of 60-80 secondary schools distributed across three regions in each country, for a total of around 3000 students per country. Challenges encountered were strikingly similar across countries. Program planning-related challenges included insufficient and piecemeal funding for CSE; lack of coordination of the various efforts by central and local government, NGOs and development partners; and inadequate systems for monitoring and evaluating teachers and students on CSE. Curriculum implementation-related challenges included inadequate weight given to CSE when integrated into other subjects, insufficient adaptation of the curriculum to local contexts, and limited stakeholder participation in curriculum development. While challenges were similar across countries, the strategies used to overcome them were different, and offer useful lessons to improve implementation for these and other low- and middle-income countries facing similar challenges.

Postpartum Contraception in Northern Tanzania: Patterns of Use, Relationship to Antenatal Intentions, and Impact of Antenatal Counseling.

In Tanzania, unmet need for contraception is high, particularly in the postpartum period. Contraceptive counseling during routine antenatal HIV testing could reach 97 percent of pregnant women with much-needed information, but requires an understanding of postpartum contraceptive use and its relationship to antenatal intentions. We conducted a baseline survey of reproductive behavior among 5,284 antenatal clients in Northern Tanzania, followed by an intervention offering contraceptive counseling to half the respondents. A follow-up survey at 6-15 months postpartum examined patterns and determinants of postpartum contraceptive use, assessed their correspondence with antenatal intentions, and evaluated the impact of the intervention. Despite high loss to follow-up, our findings indicate that condoms and hormonal methods had particular and distinct roles in the postpartum period, based on understandings of postpartum fertility. Antenatal intentions were poor predictors of postpartum reproductive behavior. Antenatal counseling had an effect on postpartum contraceptive intentions, but not on use. Different antenatal/contraceptive service integration models should be tested to determine how and when antenatal counseling can be most effective.

Incidence of Induced Abortion and Post-Abortion Care in Tanzania.

BACKGROUND: Tanzania has one of the highest maternal mortality ratios in the world, and unsafe abortion is one of its leading causes. Yet little is known about its incidence. OBJECTIVES: To provide the first ever estimates of the incidence of unsafe abortion in Tanzania, at the national level and for each of the 8 geopolitical zones (7 in Mainland plus Zanzibar). METHODS: A nationally representative survey of health facilities was conducted to determine the number of induced abortion complications treated in facilities. A survey of experts on abortion was conducted to estimate the likelihood of women experiencing complications and obtaining treatment. These surveys were complemented with population and fertility data to obtain abortion numbers, rates and ratios, using the Abortion Incidence Complications Methodology. RESULTS: In Tanzania, women obtained just over 405,000 induced abortions in 2013, for a national rate of 36 abortions per 1,000 women age 15-49 and a ratio of 21 abortions per 100 live births. For each woman treated in a facility for induced abortion complications, 6 times as many women had an abortion but did not receive care. Abortion rates vary widely by zone, from 10.7 in Zanzibar to 50.7 in the Lake zone. CONCLUSIONS: The abortion rate is similar to that of other countries in the region. Variations by zone are explained mainly by differences in fertility and contraceptive prevalence. Measures to reduce the incidence of unsafe abortion and associated maternal mortality include expanding access to post-abortion care and contraceptive services to prevent unintended pregnancies.

Estimates of the incidence of induced abortion and consequences of unsafe abortion in Senegal.

CONTEXT: Abortion is highly restricted by law in Senegal. Although women seek care for abortion complications, no national estimate of abortion incidence exists. METHODS: Data on postabortion care and abortion in Senegal were collected in 2013 using surveys of a nationally representative sample of 168 health facilities that provide postabortion care and of 110 professionals knowledgeable about abortion service provision. Indirect estimation techniques were applied to the data to estimate the incidence of induced abortion in the country. Abortion rates and ratios were calculated for the nation and separately for the Dakar region and the rest of the country. The distribution of pregnancies by planning status and by outcome was estimated. RESULTS: In 2012, an estimated 51,500 induced abortions were performed in Senegal, and 16,700 (32%) resulted in complications that were treated at health facilities. The estimated abortion rate was 17 per 1,000 women aged 15-44 and the abortion ratio was 10 per 100 live births. The rate was higher in Dakar (21 per 1,000) than in the rest of the country (16 per 1,000). Poor women were far more likely to experience abortion complications, and less likely to receive treatment for complications, than nonpoor women. About 31% of pregnancies were unintended, and 24% of unintended pregnancies (8% of all pregnancies) ended in abortion. CONCLUSIONS: Unsafe abortion exacts a heavy toll on women in Senegal. Reducing the barriers to effective contraceptive use and ensuring access to postabortion care without the risk of legal consequences may reduce the incidence of and complications from unsafe abortion.

Bucking social norms: examining anomalous fertility aspirations in the face of HIV in Lusaka, Zambia.

In settings of high fertility and high HIV prevalence, individuals are making fertility decisions while simultaneously trying to avoid or manage HIV. We sought to increase our understanding of how individuals dually manage HIV risk while attempting to achieve their fertility goals as part of the project entitled HIV Status and Achieving Fertility Desires conducted in Zambia in 2011. Using multivariate regression to predict fertility patterns based on socio-demographic characteristics for respondents from facility-based and community-based surveys, we employed Anomalous Case Analysis (ACA) whereby in-depth interview respondents were selected from the groups of outliers amongst the survey respondents who reported lower or higher fertility preferences than predicted as well as those who adhered to predicted patterns, and lived in Lusaka (n=45). All of the facility-based respondents were HIV-positive. We utilize the Theory of Conjunctural Action (TCA) to categorize domains of influence on individuals' preferences and behavior. Both community-based and facility-based right-tail respondents (outliers whose fertility intentions indicated that they wanted a/nother child when we predicted that they did not) expressed comparatively less control over their fertility and gave more weight to pressures from others to continue childbearing. Partner communication about fertility desires was greater among left-tail respondents (outliers whose fertility intentions indicated that they did not want a/nother child when we predicted that they did). HIV-positive right-tail respondents were more likely to see anti-retroviral therapies (ARTs) which prevent mother to child transmission of HIV as highly effective, mitigating inhibitions to further childbearing. Drug interactions between ARTs and contraceptives were identified as a limitation to HIV-positive individuals' contraceptive options on both sides of the distribution. Factors that should be taken into account in the future to understand fertility behavior in high HIV-prevalent settings include couples' communication around fertility and perception of the efficacy of ARTs.