Do adolescent girls' education and friendships have independent effects on early pregnancy? Results of a mediation analysis from a longitudinal cohort study in Nairobi, Kenya.

Background: Few studies have examined whether the effect of education on pregnancy and childbearing is due to the academic skills acquired or the social environment that schooling provides. This paper explores whether adolescent girls' learning skills, school enrollment, grade attainment, and friendships affect risk of pregnancy, and whether friendships mediate the relationship between education and pregnancy. Methods: We draw on three waves of longitudinal data on adolescent girls aged 11-15 in Kibera, an informal settlement in Nairobi, Kenya between years 2015-2019. We use fixed effects regression models to estimate effects of girls' learning skills, school attendance, grade attainment, and friendships on their probability of experiencing a pregnancy. We conduct mediation analyses to assess whether friendships mediate the relationship between education and pregnancy. Results: By round one (2015), 0.1 % of girls reported having experienced a pregnancy; by round three (2019), 6.3 %. Even after adjusting for friendships, we find that attending school decreases probability of pregnancy by nine percentage points; an additional year of schooling decreases probability of pregnancy by three percentage points; and a one standard deviation increase in numeracy decreases probability of pregnancy by one percentage point. Having any male friends who do not attend school increases girls' probability of experiencing a pregnancy by four percentage points; this association remains after adjusting for girls' education. However, out-of-school girls are far more likely to report out-of-school male friends. We find no evidence that other types of friendships affect girls' probability of becoming pregnant. Conclusion: We find significant protective effects of school attendance, higher grade attainment and numeracy skills on girls' pregnancy, and that having close friendships with out-of-school males increases girls' probability of pregnancy. We did not find evidence of meaningful mediation, suggesting that the protective effects of school attendance and learning remain regardless of any risk they may face from their friendships.

The gendered effects of the COVID-19 pandemic on adolescent literacy and schooling outcomes in India.

The COVID-19 pandemic disrupted education delivery around the world, with school closures affecting over 1.6 billion students worldwide. In India, schools were closed for over 18 months, affecting 248 million students. This study estimates the effect of the pandemic on adolescent literacy and schooling outcomes in India. We used data from the National Family Health Survey. (NFHS-5) which covered 636,699 households across all districts of India from June 2019 to April 2021. We considered 15-17 year old adolescents who were surveyed after March 2020 as the post-COVID group while those surveyed earlier were included in the pre-COVID group. We used propensity score matching and inverse propensity score weighted regression methods to account for differences in socioeconomic characteristics between the two groups. Rates of literacy (ability to read a complete sentence) were 1.5-1.6% lower among post-COVID girls as compared with similar pre-COVID girls. Among post-COVID girls in the lowest wealth quintile, rates of literacy were 3.1-3.8% lower than similar pre-COVID girls. There was no loss in literacy among post-COVID girls in the highest wealth quintile. COVID-induced loss in literacy among girls was twice in rural areas as compared to urban areas, and substantially higher among socioeconomically disadvantaged caste groups as compared with privileged caste groups. Post-COVID girls also had 0.08-0.1 lower years of schooling completed than similar pre-COVID girls but there was no difference in out-of-school rates. In a smaller subsample of 15-17 year old boys, the post-COVID group had 2% lower out-of-school rates and there was no difference in literacy or years of schooling completed as compared with matched pre-COVID boys. While markers of vulnerability such as residence, caste, and poverty further amplified the risk of learning. loss for girls, they did not have the same effect on boys.

Understanding the effects of universal test and treat on longitudinal HIV care outcomes among South African youth: a retrospective cohort study.

INTRODUCTION: Little is known about the effects of universal test and treat (UTT) policies on HIV care outcomes among youth living with HIV (YLHIV). Moreover, there is a paucity of information regarding when YLHIV are most susceptible to disengagement from care under the newest treatment guidelines. The longitudinal HIV care continuum is an underutilized tool that can provide a holistic understanding of population-level HIV care trajectories and be used to compare treatment outcomes across groups. We aimed to explore effects of the UTT policy on longitudinal outcomes among South African YLHIV and identify temporally precise opportunities for re-engaging this priority population in the UTT era. METHODS: Using medical record data, we conducted a retrospective cohort study among youth aged 18-24 diagnosed with HIV from August 2015-December 2018 in nine health care facilities in South Africa. We used Fine and Gray sub-distribution proportional hazards models to characterize longitudinal care continuum outcomes in the population overall and stratified by treatment era of diagnosis. We estimated the proportion of individuals in each stage of the continuum over time and the restricted mean time spent in each stage in the first year following diagnosis. Sub-group estimates were compared using differences. RESULTS: A total of 420 YLHIV were included. By day 365 following diagnosis, just 23% of individuals had no 90-or-more-day lapse in care and were virally suppressed. Those diagnosed in the UTT era spent less time as ART-naïve (mean difference=-19.3 days; 95% CI: -27.7, -10.9) and more time virally suppressed (mean difference = 17.7; 95% CI: 1.0, 34.4) compared to those diagnosed pre-UTT. Most individuals who were diagnosed in the UTT era and experienced a 90-or-more-day lapse in care disengaged between diagnosis and linkage to care or ART initiation and viral suppression. CONCLUSIONS: Implementation of UTT yielded modest improvements in time spent on ART and virally suppressed among South African YLHIV- however, meeting UNAIDS' 95-95-95 targets remains a challenge. Retention in care and re-engagement interventions that can be implemented between diagnosis and linkage to care and between ART initiation and viral suppression (e.g., longitudinal counseling) may be particularly important to improving care outcomes among South African YLHIV in the UTT era.

Prevention and Treatment of Chemotherapy-Induced Alopecia: What Is Available and What Is Coming?

Millions of new cancer patients receive chemotherapy each year. In addition to killing cancer cells, chemotherapy is likely to damage rapidly proliferating healthy cells, including the hair follicle keratinocytes. Chemotherapy causes substantial thinning or loss of hair, termed chemotherapy-induced alopecia (CIA), in approximately 65% of patients. CIA is often ranked as one of the most distressing adverse effects of chemotherapy, but interventional options have been limited. To date, only scalp cooling has been cleared by the US Food and Drug Administration (FDA) to prevent CIA. However, several factors, including the high costs not always covered by insurance, preclude its broader use. Here we review the current options for CIA prevention and treatment and discuss new approaches being tested. CIA interventions include scalp cooling systems (both non-portable and portable) and topical agents to prevent hair loss, versus topical and oral minoxidil, photobiomodulation therapy (PBMT), and platelet-rich plasma (PRP) injections, among others, to stimulate hair regrowth after hair loss. Evidence-based studies are needed to develop and validate methods to prevent hair loss and/or accelerate hair regrowth in cancer patients receiving chemotherapy, which could significantly improve cancer patients' quality of life and may help improve compliance and consequently the outcome of cancer treatment.

Growth failure among children of adolescent mothers at ages 0-5 and 6-12 years in India.

Adolescent motherhood has been linked with poor health outcomes at birth for children, including high neonatal mortality, low birthweight, and small-for-gestational-age rates. However, longer-term growth outcomes in the children of adolescent mothers in low-resource settings remain inadequately studied. We used longitudinal data from the India Human Development Surveys, 2004-2005 and 2011-2012 (n = 12,182) and employed regression and propensity score matching analysis to compare the following growth indicators of children born to adolescent mothers (ages 19 years or below) with those born to older mothers. Growth indicators included height and weight during ages 0-5 years and 6-12 years and change in height and weight between the two periods. In regression-based estimates, children born to adolescent mothers were 0.01 m shorter and weighed 0.2 kg less than children of older mothers at ages 0-5 years. At ages 6-12 years, those born to adolescent mothers were 0.02 m shorter and weighed 0.97 kg less. The height difference between the two groups increased by 0.01 m and the weight difference grew by 0.77 kg over time. Height and weight difference between the two groups worsened among boys over time, while for girls, only the weight gap worsened. The results were similar when using propensity score matching methods. Public policies for reducing child marriage, combined with targeted health, nutrition, and well-being programs for adolescent mothers, are essential for both preventing adolescent childbearing and reducing its impact on growth failure among children in India.

A community mobilisation intervention to improve engagement in HIV testing, linkage to care, and retention in care in South Africa: a cluster-randomised controlled trial.

BACKGROUND: Community mobilisation, engaging communities in a process to collectively enact change, could improve HIV testing and care engagement. In South Africa, current rates fall below those needed for epidemic control. We assessed whether community mobilisation increased HIV testing, linkage to care, and retention in care over time in intervention relative to control communities. METHODS: We conducted a cluster-randomised controlled trial in villages in the Agincourt sub-district of the rural Mpumalanga Province in South Africa. 15 villages were randomly assigned to either a community mobilisation intervention engaging residents to address social barriers to HIV testing and treatment (intervention arm) or to a control arm using balanced randomisation. Villages were eligible if they had been fully enumerated in 2014, had not been included in previous mobilisation activities, and included over 500 permanent adult residents aged 18-49 years. Primary outcomes included quarterly rates of HIV testing, linkage to care, and retention in care documented from health facility records among residents of the intervention and control communities over the 3-year study period. Intention-to-treat analyses employed generalised estimating equations stratified by sex. This trial is registered with ClinicalTrials.gov, NCT02197793. FINDINGS: Between Aug 1, 2015, and July 31, 2018, residents in eight intervention communities (n=20 544 residents) and seven control communities (n=17 848) contributed data; 92 residents contributed to both arms. Among men, HIV testing increased quarterly by 12·1% (relative change [RC] 1·121, 95% CI 1·099 to 1·143, p<0·0001) in the intervention communities and 9·5% (1·095, 1·075 to 1·114, p=0·011) in the control communities; although increases in testing were greater in the intervention villages, differences did not reach significance (exponentiated interaction coefficient 1·024, 95% CI 0·997 to 1·052, p=0·078). Among women, HIV testing increased quarterly by 10·6% (RC 1·106, 95% CI 1·097 to 1·114, p<0·0001) in the intervention communities and 9·3% (1·093, 1·084 to 1·102, p=0·053) in the control communities; increases were greater in intervention communities (exponentiated interaction coefficient 1·012, 95% CI 1·001 to 1·023, p=0·043). Quarterly linkage increased significantly among women in the intervention communities (RC 1·013, 95% CI 1·002 to 1·023, p=0·018) only. Quarterly linkage fell among men in both arms, but decreased significantly among men in the control communities (0·977, 0·954 to 1·002, p=0·043). Quarterly retention fell among women in both arms; however, reductions were tempered among women in the intervention communities (exponentiated interaction coefficient 1·003, 95% CI <1·000 to 1·006, p=0·062). Retention fell significantly among men in both arms with difference in rates of decline. INTERPRETATION: Community mobilisation was associated with modest improvements in select trial outcomes. The sum of these incremental, quarterly improvements achieved by addressing social barriers to HIV care engagement can impact epidemic control. However, achieving optimal impacts will probably require integrated efforts addressing both social barriers through community mobilisation and provision of improved service delivery. FUNDING: US National Institutes of Health, National Institute of Mental Health, and United States President's Emergency Plan for AIDS Relief through Right to Care and Project SOAR.

PROTOCOL: Causal mechanisms linking education with fertility, HIV, and child mortality: A systematic review.

In this review, we will investigate the pathways linking education and health to understand why education appears to improve health in some settings or among certain populations, and not in others, as well as to inform recommendations about how best to target investments in education to maximize the benefits to health. We will seek to answer the following key research questions, focusing specifically on the mechanisms that affect fertility, HIV, and infant and child mortality. If feasible, these answers will include meta-analyses of comparable education and mediator outcomes: (1) Do changes in education affect the primary theorized mediators (e.g., knowledge, attitudes, resources, and agency; health behaviors and harmful practices) of the relationship between education and fertility, HIV and child mortality? (2) How does the relationship between these mediators and education vary across different aspects of education (e.g., grade attainment vs. literacy/numeracy vs. attendance)?

Policies and interventions to remove gender-related barriers to girls' school participation and learning in low- and middle-income countries: A systematic review of the evidence.

Background: Gender disparities in education continue to undermine girls' opportunities, despite enormous strides in recent years to improve primary enrolment and attainment for girls in low- and middle-income countries (LMICs). At the regional, country and subnational levels gender gaps remain, with girls in many settings less likely to complete primary school, less likely to complete secondary, and often less likely to be literate than boys. The academic and policy literatures on the topic of gender-related barriers to girls' education are both extensive. However, there remain gaps in knowledge regarding which interventions are most likely to work in contexts with different combinations of barriers. Objectives: This systematic review identified and assessed the strength of the evidence of interventions and exposures addressing gender-related barriers to schooling for girls in LMICs. Search Methods: The AEA RCT Registry, Africa Bibliography, African Education Research Database, African Journals Online, DEC USAID, Dissertation Abstracts, EconLit, ELDIS, Evidence Hub, Global Index Medicus, IDEAS-Repec, Intl Clinical Trials Registry, NBER, OpenGrey, Open Knowledge Repository, POPLINE, PsychINFO, PubMed, Research for Development Outputs, ScienceDirect, Sociological Abstracts, Web of Science, as well as relevant organization websites were searched electronically in March and April of 2019. Further searches were conducted through review of bibliographies as well as through inquiries to authors of included studies, relevant researchers and relevant organizations, and completed in March 2020. Selection Criteria: We included randomized controlled trials as well as quasi-experimental studies that used quantitative models that attempted to control for endogeneity. Manuscripts could be either published, peer-reviewed articles or grey literature such as working papers, reports and dissertations. Studies must have been published on or after 2000, employed an intervention or exposure that attempted to address a gender-related barrier to schooling, analyzed the effects of the intervention/exposure on at least one of our primary outcomes of interest, and utilized data from LMICs to be included. Data Collection and Analysis: A team of reviewers was grouped into pairs to independently screen articles for relevance, extract data and assess risk of bias for each included study. A third reviewer assisted in resolving any disputes. Risk of bias was assessed either through the RoB 2 tool for experimental studies or the ROBINS-I tool for quasi-experimental studies. Due to the heterogeneity of study characteristics and reported outcome measures between studies, we applied the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach adapted for situations where a meta-analysis is not possible to synthesize the research. Results: Interventions rated as effective exist for three gender-related barriers: inability to afford tuition and fees, lack of adequate food, and insufficient academic support. Promising interventions exist for three gender-related barriers: inadequate school access, inability to afford school materials, and lack of water and sanitation. More research is needed for the remaining 12 gender-related barriers: lack of support for girls' education, child marriage and adolescent pregnancy, lack of information on returns to education/alternative roles for women, school-related gender-based violence (SRGBV), lack of safe spaces and social connections, inadequate sports programs for girls, inadequate health and childcare services, inadequate life skills, inadequate menstrual hygiene management (MHM), poor policy/legal environment, lack of teaching materials and supplies, and gender-insensitive school environment. We find substantial gaps in the evidence. Several gender-related barriers to girls' schooling are under-examined. For nine of these barriers we found fewer than 10 relevant evaluations, and for five of the barriers-child marriage and adolescent pregnancy, SRGBV, inadequate sports programs for girls, inadequate health and childcare services, and inadequate MHM-we found fewer than five relevant evaluations; thus, more research is needed to understand the most effective interventions to address many of those barriers. Also, nearly half of programs evaluated in the included studies were multi-component, and most evaluations were not designed to tease out the effects of individual components. As a result, even when interventions were effective overall, it is often difficult to identify how much, if any, of the impact is attributable to a given program component. The combination of components varies between studies, with few comparable interventions, further limiting our ability to identify packages of interventions that work well. Finally, the context-specific nature of these barriers-whether a barrier exists in a setting and how it manifests and operates-means that a program that is effective in one setting may not be effective in another. Authors' Conclusions: While some effective and promising approaches exist to address gender-related barriers to education for girls, evidence gaps exist on more than half of our hypothesized gender-related barriers to education, including lack of support for girls' education, SRGBV, lack of safe spaces and social connections, inadequate life skills, and inadequate MHM, among others. In some cases, despite numerous studies examining interventions addressing a specific barrier, studies either did not disaggregate results by sex, or they were not designed to isolate the effects of each intervention component. Differences in context and in implementation, such as the number of program components, curricula content, and duration of interventions, also make it difficult to compare interventions to one another. Finally, few studies looked at pathways between interventions and education outcomes, so the reasons for differences in outcomes largely remain unclear.

Shifting gender norms to improve HIV service uptake: Qualitative findings from a large-scale community mobilization intervention in rural South Africa.

BACKGROUND: Interventions to improve HIV service uptake are increasingly addressing inequitable and restrictive gender norms. Yet comparatively little is known about which gender norms are most salient for HIV testing and treatment and how changing these specific norms translates into HIV service uptake. To explore these questions, we implemented a qualitative study during a community mobilization trial targeting social barriers to HIV service uptake in South Africa. METHODS: We conducted 55 in-depth interviews in 2018, during the final months of a three-year intervention in rural Mpumalanga province. Participants included 25 intervention community members (48% women) and 30 intervention staff/community-opinion-leaders (70% women). Data were analyzed using an inductive-deductive approach. RESULTS: We identified three avenues for gender norms change which, when coupled with other strategies, were described to support HIV service uptake: (1) Challenging norms around male toughness/avoidance of help-seeking, combined with information on the health and preventive benefits of early antiretroviral therapy (ART), eased men's fears of a positive diagnosis and facilitated HIV service uptake. (2) Challenging norms about men's expected control over women, combined with communication and conflict resolution skill-building, encouraged couple support around HIV service uptake. (3) Challenging norms around women being solely responsible for the family's health, combined with information about sero-discordance and why both members of the couple should be tested, encouraged men to test for HIV rather than relying on their partner's results. Facility-level barriers such as long wait times continued to prevent some men from accessing care. CONCLUSIONS: Despite continued facility-level barriers, we found that promoting critical reflection around several specific gender norms, coupled with information (e.g., benefits of ART) and skill-building (e.g., communication), were perceived to support men's and women's engagement in HIV services. There is a need to identify and tailor programming around specific gender norms that hinder HIV service uptake.

What shapes gender attitudes among adolescent girls and boys? Evidence from the UDAYA Longitudinal Study in India.

INTRODUCTION: The role of gender norms in shaping education and work opportunities, distribution of power and resources, and health and wellbeing is well recognised. However, rigorous studies in low- and middle-income countries on when and how norms change over time and what factors shape adolescents' and young adult's gender attitudes are limited. This paper explores the factors that determine adolescents' gender attitudes, as well as patterns in gender attitude shifts over time among younger and older adolescent boys and girls in India. DATA AND METHODS: Data presented in this paper were drawn from a unique longitudinal study of adolescents aged 10-19 (Understanding the lives of adolescent and young adults-UDAYA study) in the states of Bihar and Uttar Pradesh in India, conducted during 2015-2016 (wave 1) and 2018-2019 (wave 2). The analysis presented in this paper drew on data from 4,428 boys and 7,607 girls who were aged 10-19 and unmarried at wave 1 and interviewed at both rounds of the survey. We used univariate and bivariate analyses to examine changes in adolescents' gender role attitudes over time and the association between explanatory variables and gender role attitudes. We also used linear fixed effects regression models to identify factors that shape adolescents' gender role attitudes. RESULTS: Gender role attitudes became more egalitarian over time among boys and girls, except among the older cohort of boys in our study. Among both younger and older cohorts, girls/young women held more egalitarian views than boys/young men and this pattern held over time for both cohorts. Factors that influenced gender role attitudes differed for younger and older adolescents, particularly among boys. While some predictors differed for boys and girls, there were substantial similarities as well. Gender attitudes were affected by factors at the individual, family, peer, and societal levels, as well as by community engagement. CONCLUSIONS: Our findings show that it is possible to shift gender attitudes toward greater equity and, in so doing, contribute to improved health and rights.

Associations Between Key Psychosocial Stressors and Viral Suppression and Retention in Care Among Youth with HIV in Rural South Africa.

Despite improvements in access to antiretroviral treatment over the past decade, sub-optimal HIV care outcomes persist among youth with HIV (YWH) in rural South Africa. Psychosocial stressors could impede improved HIV treatment outcomes within this population. We linked self-reported psychosocial health and demographic data from a cross-sectional survey conducted among YWH aged 12-24 in rural South Africa to individual medical record data, including facility visit history and viral load measurements. Poisson regression with robust standard errors was used to estimate the associations between five psychosocial stressors- heightened depressive symptoms (Center for Epidemiological Studies-Depression scale scores ≥ 16), lower social support (Medical Outcomes Social Support Scale scores ≤ 38), lower resilience (Conner-Davidson Resilience Scale scores ≤ 73), lower self-esteem (Rosenberg Self-Esteem Scale scores ≤ 21), and higher perceived stress (Sheldon Cohen Perceived Stress Scale scores ≥ 10)- and viral non-suppression (viral load ≥ 400 copies/mL) and loss to care (no documented clinic visits within the 90 days prior to survey), separately. A total of 359 YWH were included in this analysis. The median age of study participants was 21 (interquartile range: 16-23), and most were female (70.2%), single (82.4%), and attending school (54.7%). Over a quarter of participants (28.1%) had heightened depressive symptoms. Just 16.2% of all participants (n = 58) were lost to care at the time of survey, while 32.4% (n = 73) of the 225 participants with viral load data were non-suppressed. The prevalence of non-suppression in individuals with lower self-esteem was 1.71 (95% confidence interval: 1.12, 2.61) times the prevalence of non-suppression in those with higher self-esteem after adjustment. No meaningful association was observed between heightened depressive symptoms, lower social support, lower resilience, and higher perceived stress and viral non-suppression or loss to care in adjusted analyses. Retention in care and viral suppression among YWH in rural South Africa are below global targets. Interventions aimed at improving viral suppression among YWH should incorporate modules to improve participant's self-esteem as low self-esteem is associated with viral non-suppression in this setting. Future studies should longitudinally explore the joint effects of co-occurring psychosocial stressors on HIV care outcomes in YWH and assess meaningful differences in these effects by age, gender, and route of transmission.

Examining the relationship between physical and sexual violence and psychosocial health in young people living with HIV in rural South Africa.

INTRODUCTION: Experiences of violence during youth contravene young people's rights and increase the risk of depression and poor human immunodeficiency virus (HIV) care outcomes among youth living with HIV (YLWH). Intervention targets for mitigating the negative psychosocial effects of violence are needed, particularly in areas like rural South Africa where violence remains pervasive and mental healthcare is limited. This study aims to quantify the associations between physical and sexual violence and depressive symptoms in YLWH in rural South Africa and explore the modification of these associations by key measures of psychosocial well-being. METHODS: We conducted a cross-sectional survey among 362 YLWH ages 12 to 24 in rural South Africa to ascertain participants' history of physical and sexual violence, current depressive symptoms (Center for Epidemiological Studies-Depression Scale) and levels of social support (Medical Outcomes Social Support Scale), resilience (Conner-Davidson Resilience Scale) and self-esteem (Rosenberg Self-Esteem Scale). Log-binomial regression was used to estimate the association between history of physical or sexual violence and clinically meaningful depressive symptoms (scores  ≥ 16). Effect measure modification by high versus low resilience, social support and self-esteem was assessed using likelihood ratio tests (α = 0.20). RESULTS: A total of 334 individuals with a median age of 21 (interquartile range: 16 to 23) were included in this analysis. Most participants were female (71.3%), single (81.4%) and attending school (53.0%). Ninety-four participants (28.1%) reported a history of physical or sexual violence and 92 individuals (27.5%) had clinically meaningful depressive symptoms. Meaningful depressive symptoms were significantly higher among participants with a history of physical or sexual violence as compared to those with no history of violence (adjusted prevalence ratio: 2.01; 95% CI: 1.43, 2.83). However, this association was significantly modified by social support (p = 0.04) and self-esteem (p = 0.02). CONCLUSIONS: In this setting, the prevalence of meaningful depressive symptoms was significantly higher among YLWH with a history of physical or sexual violence as compared to those without a history of violence. However, higher levels of self-esteem or social support appeared to mitigate this association. Programmes to improve self-esteem and social support for youth have the potential to minimize depressive symptoms in YLWH who have experienced physical or sexual violence.

Gaining traction: Promising shifts in gender norms and intimate partner violence in the context of a community-based HIV prevention trial in South Africa.

BACKGROUND: HIV and violence prevention programs increasingly seek to transform gender norms among participants, yet how to do so at the community level, and subsequent pathways to behavior change, remain poorly understood. We assessed shifts in endorsement of equitable gender norms, and intimate partner violence (IPV), during the three-year community-based trial of Tsima, an HIV 'treatment as prevention' intervention in rural South Africa. METHODS: Cross-sectional household surveys were conducted with men and women ages 18-49 years, in 8 intervention and 7 control communities, at 2014-baseline (n = 1,149) and 2018-endline (n = 1,189). Endorsement of equitable gender norms was measured by the GEM Scale. Intent-to-treat analyses assessed intervention effects and change over time. Qualitative research with 59 community members and 38 staff examined the change process. RESULTS: Nearly two-thirds of men and half of women in intervention communities had heard of the intervention/seen the logo; half of these had attended a two-day workshop. Regression analyses showed a 15% improvement in GEM Scale score over time, irrespective of the intervention, among men (p<0.001) and women (p<0.001). Younger women (ages 18-29) had a decreased odds of reporting IPV in intervention vs. control communities (aOR 0.53; p<0.05). Qualitative data suggest that gender norms shifts may be linked to increased media access (via satellite TV/smartphones) and consequent exposure to serial dramas modeling equitable relationships and negatively portraying violence. Tsima's couple communication/conflict resolution skills-building activities, eagerly received by intervention participants, appear to have further supported IPV reductions. CONCLUSIONS: There was a population-level shift towards greater endorsement of equitable gender norms between 2014-2018, potentially linked with rapid escalation in media access. There was also an intervention effect on reported IPV among young women, likely owing to improved couple communication. Societal-level gender norm shifts may create enabling environments for interventions to find new traction for violence and HIV-related behavior change.

Addressing Intimate Partner Violence and Power in Intimate Relationships in HIV Testing Services in Nairobi, Kenya.

Intimate partner violence (IPV) undermines women's uptake of HIV services and violates their human rights. In a two-arm randomized controlled trial we evaluated a short intervention that went a step beyond IPV screening to discuss violence and power with women receiving HIV testing services during antenatal care (ANC). The intervention included training and support for HIV counselors, a take-home card for clients, and an on-site IPV counselor. One third (35%) of women (N = 688) reported experiencing IPV in the past year; 6% were living with HIV. Among women experiencing IPV, program participants were more likely to disclose violence to their counselor than women receiving standard care (32% vs. 7%, p < 0.001). At second ANC visit, intervention group women were significantly more likely to report that talking with their counselor made a positive difference (aOR 2.9; 95% CI 1.8, 4.4; p < 0.001) and felt more confident in how they deserved to be treated (aOR 2.7; 95% CI 1.7, 4.4; p < 0.001). Exploratory analyses of intent to use ARVs to prevent mother-to-child transmission and actions to address violence were also encouraging.

The Influence of Schooling on the Stability and Mutability of Gender Attitudes: Findings From a Longitudinal Study of Adolescent Girls in Zambia.

PURPOSE: Inequitable gender norms are thought to harm lifelong health and well-being. We explore the process of gender attitude change and the role of schooling in shifting or reinforcing gender norms among adolescent girls in Zambia. METHODS: We used longitudinal data collected from unmarried, vulnerable girls (aged 10-19 years) as part of the Adolescent Girls Empowerment Program. We conducted random effects multinomial logistic regression to determine whether schooling-related factors were associated with shifts in adolescent girls' gender attitudes across three survey rounds and explored whether these relationships varied by age. RESULTS: Mean gender attitude scores at the aggregate level remained stable over time among rural girls and improved slightly for urban girls. At the individual level, about half the girls had relatively unchanged scores, whereas the other half shifted to higher or lower scores between rounds. Rural and urban girls currently attending school were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable. Educational attainment was not associated with shifts in gender attitudes among rural girls. Urban girls with higher educational attainment were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable or more equitable. CONCLUSIONS: Patterns of gender attitude stability and change differed more for urban girls than rural girls and varied by age and schooling-related factors. In general, schooling appears to be an institutional lever that holds promise for shifting gender attitudes toward greater equality. Our study highlights the importance of looking longitudinally at the effects of social context and reinforces calls for targeted, context-specific interventions for this age group.

Gender norms and health: insights from global survey data.

Despite global commitments to achieving gender equality and improving health and wellbeing for all, quantitative data and methods to precisely estimate the effect of gender norms on health inequities are underdeveloped. Nonetheless, existing global, national, and subnational data provide some key opportunities for testing associations between gender norms and health. Using innovative approaches to analysing proxies for gender norms, we generated evidence that gender norms impact the health of women and men across life stages, health sectors, and world regions. Six case studies showed that: (1) gender norms are complex and can intersect with other social factors to impact health over the life course; (2) early gender-normative influences by parents and peers can have multiple and differing health consequences for girls and boys; (3) non-conformity with, and transgression of, gender norms can be harmful to health, particularly when they trigger negative sanctions; and (4) the impact of gender norms on health can be context-specific, demanding care when designing effective gender-transformative health policies and programmes. Limitations of survey-based data are described that resulted in missed opportunities for investigating certain populations and domains. Recommendations for optimising and advancing research on the health impacts of gender norms are made.

Gender, power, and violence: A systematic review of measures and their association with male perpetration of IPV.

INTRODUCTION: Harmful gender norms, views on the acceptability of violence against women, and power inequities in relationships have been explored as key drivers of male perpetration of intimate partner violence (IPV). Yet such antecedents have been inconsistently measured in the empirical literature. This systematic review aimed to identify which measures of gender inequitable norms, views, relations and practices are currently being used in the field, and which are most closely tied with male IPV perpetration. METHODS: We searched five electronic databases to identify studies published between 2000 and 2015 that reported the association between such gender inequities and male perpetration of IPV. Identified scales were categorized by content area and level of generality, as well as other attributes, and we compared the consistency of scale performance across each category. RESULTS: Twenty-three studies were identified, employing 64 measures. Scales were categorized into three main thematic areas: views on gender roles/norms, acceptance of violence against women, and gender-related inequities in relationship power and control. We also classified whether the scale was oriented to respondents' own views, or what they believed others do or think. While overall, measures were positively associated with IPV perpetration in 45% of cases, this finding varied by scale type. Measures inclusive of acceptance of violence against women or beliefs about men's sexual entitlement, followed by scales that measured respondents' views on gender roles/norms, were most consistently associated with IPV perpetration. Measures of relationship power showed less consistent associations. We found few scales that measured peer or community norms. CONCLUSION: Validated scales that encompass views on the acceptance of violence against women, and scales inclusive of beliefs about men's sexual entitlement, may be particularly promising for unpacking pathways to IPV perpetration, targeting interventions, and monitoring progress in IPV prevention efforts. A number of gaps in the literature are identified.

A Systematic Review of Adolescent Girl Program Implementation in Low- and Middle-Income Countries: Evidence Gaps and Insights.

Increasing attention to adolescent girls has generated an abundance of programs and a growing body of research on adolescent girls in low- and middle-income countries. Despite this, questions remain about what implementation approaches in program design are most effective, hindering efficient resource allocation, program scale-up, and replication across settings. To address these questions, we conducted a systematic review to identify lessons learned and gaps in the evidence base. We searched four electronic databases to identify studies published between 1990 and 2014 that evaluated health, social, and/or economic development programs targeting adolescent girls in low- and middle-income countries. Seventy-seven (77) studies meeting specified criteria were identified, of which 19 presented results that allowed conclusions relevant to implementation science. Studies examining the following questions were assessed: To what extent, if any, do multicomponent interventions (as opposed to single-component interventions) improve outcomes for girls? What is the added value of involving actors in addition to the girl herself such as parents, guardians, husbands (i.e., multilevel interventions)? What is the threshold proportion of girls who need to participate in a program to bring about normative and behavior changes at the community level? Is a greater level of program exposure associated with greater programmatic benefit for girls? Can supplemental "booster" activities extend the benefits of a program after it ends? We found evidence to support associations between multicomponent (vs. single component) programs, and longer program exposure (vs. less program exposure), with more favorable outcomes for girls, although both conclusions include methodological limitations. Overall, few studies assessed boosters or program saturation, and evidence on multilevel versus single-level programs was inconclusive. Few studies assessed implementation science questions by design, exposing large gaps in the evidence base. We call for future research to explicitly test such implementation science questions to inform more effective use of resources and to improve outcomes for girls.

Experiences in implementation and publication of operations research interventions: gaps and a way forward.

INTRODUCTION: According to UNAIDS, the world currently has an adequate collection of proven HIV prevention, treatment and diagnostic tools, which, if scaled up, can lay the foundation for ending the AIDS epidemic. HIV operations research (OR) tests and promotes the use of interventions that can increase the demand for and supply of these tools. However, current publications of OR mainly focus on outcomes, leaving gaps in reporting of intervention characteristics, which are essential to address for the utilization of OR findings. This has prompted WHO and other international public health agencies to issue reporting requirements for OR studies. The objective of this commentary is to review experiences in HIV OR intervention design, implementation, process data collection and publication in order to identify gaps, contribute to the body of knowledge and propose a way forward to improve the focus on "implementation" in implementation research. DISCUSSION: Interventions in OR, like ordinary service delivery programmes, are subject to the programme cycle, which continually uses insights from implementation and the local context to modify service delivery modalities. Given that some of these modifications in the intervention may influence study outcomes, the documentation of process data becomes vital in OR. However, a key challenge is that study resources tend to be skewed towards documentation and the reporting of study outcomes to the detriment of process data, even though process data is vital for understanding factors influencing the outcomes. CONCLUSIONS: Interventions in OR should be viewed using the lens of programme evaluation, which includes formative assessment (to determine concept and design), followed by process evaluation (to monitor inputs and outputs) and effectiveness evaluation (to assess outcomes and effectiveness). Study resources should be equitably used between process evaluation and outcome measurement to facilitate inclusion of data about fidelity and dose in publications in order to enable explanation of the relationship between dosing and study outcomes for purposes of scaling up and further refinement through research.