Climate-related experiences and harms in the wake of the COVID-19 pandemic: results from a survey of 152,088 Mexican youth.

The dual crises of COVID-19 and climate change are impacting the lives of adolescents and young people as they transition to adulthood in an uncertain world, yet they are often excluded from research and political discourse. We surveyed young people about their needs and experiences, critical to engaging them and designing effective programs and policies to address these intersecting harms. The 2022 round of a national online survey through the Violence Outcomes in COVID-19 Epoch (VoCes) Study surveyed 152,088 Mexican youth (15-24 years). Logistic regressions were implemented to identify characteristics associated with four climate responses (economic, work-related, receiving government support, or social network support). Overall, 8.1% of participants experienced a recent climate hazard, with major impacts including housing damage from floods, and crop/livestock losses from drought. Participants who experienced a climate hazard were more likely to have experienced a pandemic-related harm, suggesting a dual impact. Poor youth were more likely to report economic losses from both the pandemic and a climate event but least likely to receive government support. Economic effects from the pandemic are exacerbating climate-related harms, unequally threatening the poorest youth. Engaging young people in decision-making and supporting the most vulnerable youth is critical for the next generation to thrive.

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.

The Multidimensional, Intersecting Impacts of COVID-19 on Young People's Lives: Evidence From Cross-Sectional Surveys in Mexico, India, and Kenya.

PURPOSE: Studies have documented diverse adverse effects of the COVID-19 pandemic on young people's lives-for instance on mental health, education/employment prospects, and intrafamily violence. We sought to generate much-needed evidence regarding whether, and which, young people are experiencing multiple intersecting effects. METHODS: Data come from cross-sectional surveys with young people ages 15-25 years in Mexico (nationwide, n = 55,692), Kenya (four counties, n = 2,750), and India (two states, n = 3,537), collected from late 2020 to early 2022. We used latent class analysis to identify subgroups based on multiple adverse effects, then examined associations between these subgroups and COVID-19 infections/family deaths, and sociodemographic characteristics. RESULTS: We found prevalent adverse impacts overall and two distinct subgroups in each country-one experiencing higher levels of all impacts, such as on mental health (44%-78% across countries), education/employment (22%-84%), intrafamily violence (22%-49%), and friendships (66%-86%). This subgroup comprised 40% of the sample in Mexico, 25% in Kenya, and 35% in India. In multivariate analyses, this group consistently had greater odds of experiencing COVID-19-related infections and deaths of loved ones. They were more likely socioeconomically disadvantaged, older, urban residents. Associations with other characteristics were country-specific. DISCUSSION: This study provides novel cross-country evidence that a subgroup of young people has experienced intersecting adverse impacts of COVID-19 on their lives. Findings also confirm prior evidence of multiple elevated vulnerabilities in general. Expanded provision of multiple layers of support is required, particularly for the most vulnerable subgroup, as are multi-sectoral policies and interventions to prevent intersectional effects in future times of crisis.

The Urban Environment and Disparities in Sexual and Reproductive Health Outcomes in the Global South: a Scoping Review.

By 2050, the Global South will contain three-quarters of the world's urban inhabitants, yet no standardized categorizations of urban areas exist. This makes it challenging to compare sub-groups within cities. Sexual and reproductive health and rights (SRHR) are a critical component of ensuring that populations are healthy and productive, yet SRHR outcomes within and across urban settings vary significantly. A scoping review of the literature (2010-2022) was conducted to describe the current body of evidence on SRHR in urban settings in the Global South, understand disparities, and highlight promising approaches to improving urban SRHR outcomes. A total of 115 studies were identified, most from Kenya (30 articles; 26%), Nigeria (15; 13%), and India (16; 14%), focusing on family planning (56; 49%) and HIV/STIs (43; 37%). Findings suggest significant variation in access to services, and challenges such as gender inequality, safety, and precarious circumstances in employment and housing. Many of the studies (n = 84; 80%) focus on individual-level risks and do not consider how neighborhood environments, concentrated poverty, and social exclusion shape behaviors and norms related to SRHR. Research gaps in uniformly categorizing urban areas and key aspects of the urban environment make it challenging to understand the heterogeneity of urban environments, populations, and SRHR outcomes and compare across studies. Findings from this review may inform the development of holistic programs and policies targeting structural barriers to SRHR in urban environments to ensure services are inclusive, equitably available and accessible, and direct future research to fill identified gaps.

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 scoping review of survey research with gender minority adolescents and youth in low and middle-income countries.

BACKGROUND: Survey data that categorizes gender identity in binary terms and conflates sex and gender limits knowledge around the experience of gender minority populations, whose gender identity or expression does not align with the sex they were assigned at birth. In this review, we outline the existing survey research on the experience of a gender minority demographic for whom there is particularly limited data: adolescents and youth in low and middle-income countries (LMICs). METHODS: This paper is a scoping review of peer-reviewed articles, published in English, that use survey data to examine the experience of gender minority adolescents and youth in LMICs. We conducted a search on two major databases using key terms related to gender identity, adolescence and youth, and country and region. This search yielded 385 articles. Following a team-conducted review, we retained 33 articles for the final analysis. RESULTS: Our review shows that surveys with adolescents and youth in LMICs are increasingly including questions and taking sampling approaches that allow gender minority populations to be visible in survey data. Surveys that do so are largely focused in upper middle-income countries (n = 24), rather than lower middle-income or low-income countries, with South East Asia a notable sub-region of focus (n = 15). Sexual health, mental health, and violence are key topics of interest. Most of the surveys rely on some form of network-driven sampling focused on sexual and/or gender minorities (n = 22). The studies vary in how they ask about gender identity, both in terms of question formulation and the answer categories that are offered, as well as the extent to which they describe the questions in the article text. CONCLUSIONS: This review reveals a growing body of work that provides important insights into the experiences of gender minority adolescents and youth in LMICs. More studies could integrate these approaches, but it must be done in a way that is thoughtful about cultural and political context. Given the relatively nascent nature of such research, we encourage scholars to continue providing details on methodology, including around participant recruitment and the development of gender identity questions. This information would be valuable for researchers seeking to better include gender minorities and their experiences in survey research, but who might be daunted methodologically.

The impact of natural disasters and epidemics on sexual and reproductive health in low- and middle-income countries: A narrative synthesis.

BACKGROUND: Natural disasters and epidemics can strain already-fragile health systems, diverting resources away from essential sexual and reproductive health (SRH) services, threatening supply chains, and adversely impacting access to health facilities. OBJECTIVE: To describe how natural disasters and epidemics affect multiple dimensions of SRH service delivery and outcomes, and identify potential approaches to facilitate resumption of services. SEARCH STRATEGY: Key words searched in Google Scholar, PubMed, and Scopus. SELECTION CRITERIA: Studies published in English between 2005 and 2020 covering events in low- and middle-income countries. DATA COLLECTION AND ANALYSIS: This review was developed and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) 2009 checklist. The initial electronic database searching yielded 64 345 studies, but after screening 13 studies were included in the final review. MAIN RESULTS: Across contexts, disruptive events worsened the availability of and women's access to SRH services, contributed to decreased utilization of SRH services, and often resulted in lower use of family planning, particularly methods requiring facility-based interaction. CONCLUSION: SRH in disaster response plans must be prioritized, as women often lose access to these essential services at a time when they are at their most vulnerable. Evidence regarding effective interventions and policies is lacking.

The mental health of Asian American adolescents and young adults amid the rise of anti-Asian racism.

Objectives: We describe the perceptions and experiences of anti-Asian racism and violence and depression severity prior to and during the COVID-19 pandemic among a sample of Asian American (AA) adolescents and young adults. Methods: We used data from the Young Asian American Health Survey (YAAHS), an online-recruited sample of AA adolescents (ages 13-17) and young adults (ages 18-29 years) conducted during May 2021 to March 2022. We presented descriptive statistics examining the univariate distribution and bivariate relationships of depression severity, sociodemographic characteristics, and experiences and perceptions of anti-Asian violence. Results: Our sample (n = 176) comprised AA adolescents and young adults from 17 Asian ethnicities. A quarter said that the frequency and/or severity of their personal experiences of anti-Asian harassment had increased since the pandemic started. 76% indicated feeling less safe now than before the pandemic. Two-thirds reported that their depressive symptoms have increased since the pandemic started. Participants who reported feeling less safe now than before the pandemic were more likely to report increased personal experiences with anti-Asian harassment and increased depression severity since the pandemic started than those who reported feeling as safe or safer before the pandemic (p < 0.01 for both). Discussion: Findings illustrate AA adolescent and young adults are experiencing multiple health and social crises stemming from increased anti-Asian racism during the COVID-19 pandemic. We urge policymakers to strengthen data systems that connect racial discrimination and mental health and to institute prevention measures and anti-racist mental health services that are age- and culturally-appropriate for AA adolescent and young adults.

Heterogeneous Impacts of Interventions Aiming to Delay Girls' Marriage and Pregnancy Across Girls' Backgrounds and Social Contexts.

PURPOSE: Despite many programs aiming to delay girls' marriage and pregnancy over the last 2 decades, there is no consensus yet concerning the effectiveness of different approaches and the contexts in which they are implemented. We focus on different social contexts within Bangladesh and Zambia and investigate how literacy, poverty, and community characteristics impact the effectiveness of interventions. METHODS: We utilize data sets from two randomized controlled trials conducted by the Population Council in Bangladesh and Zambia. Within each respective country, we estimate the impacts of the interventions on marriage and pregnancy among adolescent girls using the analysis of covariance estimator by different social contexts based on community-level variables. RESULTS: In Bangladesh, providing academic skill training had a significant impact on discouraging child marriage in the villages where girls' paid-work participation rate was relatively high, whereas in low paid-work participation villages, providing gender-awareness skill training had an impact. In Zambia, providing empowerment intervention and safe spaces had a significant impact on delaying pregnancy especially for illiterate girls in the communities where premarital sex was relatively common. CONCLUSIONS: In Bangladesh, where girls' paid-work participation is limited, premarital sex is uncommon, and marriage is subject to collective decision-making; the effectiveness of a program may depend on girls' agency and the availability of acceptable working opportunities. In Zambia where premarital sex is common, pregnancy may precede marriage, and marriage entails the nature of individual decision-making; empowering the most vulnerable girls seems to be more effective in delaying marriage/pregnancy.

How Has COVID-19-Related Income Loss and Household Stress Affected Adolescent Mental Health in Kenya?

PURPOSE: Adolescent mental health has been under-researched, particularly in Africa. COVID-19-related household economic stress and school closures will likely have adverse effects. We investigate the relationship among adolescent mental health, adult income loss, and household dynamics during the pandemic in Kenya. METHODS: A cross-sectional mobile phone-based survey was conducted with one adult and adolescent (age 10-19 years) pair from a sample of households identified through previous cohort studies in three urban Kenyan counties (Nairobi, Kilifi, Kisumu). Survey questions covered education, physical and mental health, and COVID-19-related impacts on job loss, food insecurity, and healthcare seeking. Logistic regression models were fit to explore relationships among adult income loss, household dynamics, food insecurity, and adult and adolescent depressive symptoms (defined as PHQ-2 score ≤2). RESULTS: A total of 2,224 adult-adolescent pairs (Nairobi, n = 814; Kilifi, n = 914; Kisumu, n = 496) completed the survey. Over a third (36%) of adolescents reported depressive symptoms, highest among older (15-19 years) boys. Adult loss of income was associated with skipping meals, depressive symptoms, household tensions/violence, and forgoing healthcare. Adolescents had 2.5 higher odds of depressive symptoms if COVID-19 was causing them to skip meals (odds ratio 2.5, 95% confidence interval 2.0-3.1), if their adult head of household reported depressive symptoms (odds ratio 2.6, 95% confidence interval 2.1-3.2). CONCLUSIONS: Income loss during the pandemic adversely affects food insecurity, household dynamics, healthcare-seeking behavior, and worsening adolescent depressive symptoms. With schools reopening, adolescent mental health should be formally addressed, potentially through cash transfers, school or community-based psychosocial programming.

Gendered economic, social and health effects of the COVID-19 pandemic and mitigation policies in Kenya: evidence from a prospective cohort survey in Nairobi informal settlements.

OBJECTIVES: COVID-19 may spread rapidly in densely populated urban informal settlements. Kenya swiftly implemented mitigation policies; we assess the economic, social and health-related harm disproportionately impacting women. DESIGN: A prospective longitudinal cohort study with repeated mobile phone surveys in April, May and June 2020. PARTICIPANTS AND SETTING: 2009 households across five informal settlements in Nairobi, sampled from two previously interviewed cohorts. PRIMARY AND SECONDARY OUTCOME MEASURES: Outcomes include food insecurity, risk of household violence and forgoing necessary health services due to the pandemic. Gender-stratified linear probability regression models were constructed to determine the factors associated with these outcomes. RESULTS: By May, more women than men reported adverse effects of COVID-19 mitigation policies on their lives. Women were 6 percentage points more likely to skip a meal versus men (coefficient: 0.055; 95% CI 0.016 to 0.094), and those who had completely lost their income were 15 percentage points more likely versus those employed (coefficient: 0.154; 95% CI 0.125 to 0.184) to skip a meal. Compared with men, women were 8 percentage points more likely to report increased risk of household violence (coefficient: 0.079; 95% CI 0.028 to 0.130) and 6 percentage points more likely to forgo necessary healthcare (coefficient: 0.056; 95% CI 0.037 to 0.076). CONCLUSIONS: The pandemic rapidly and disproportionately impacted the lives of women. As Kenya reopens, policymakers must deploy assistance to ensure women in urban informal settlements are able to return to work, and get healthcare and services they need to not lose progress on gender equity made to date.

Mobility Patterns During COVID-19 Travel Restrictions in Nairobi Urban Informal Settlements: Who Is Leaving Home and Why.

Nairobi's urban slums are ill equipped to prevent spread of the novel coronavirus disease (COVID-19) due to high population density, multigenerational families in poorly ventilated informal housing, and poor sanitation. Physical distancing policies, curfews, and a citywide lockdown were implemented in March and April 2020 resulting in sharp decreases in movement across the city. However, most people cannot afford to stay home completely (e.g., leaving daily to fetch water). If still employed, they may need to travel longer distances for work, potentially exposing them COVID-19 or contributing to its spread. We conducted a household survey across five urban slums to describe factors associated with mobility in the previous 24 h. A total of 1695 adults were interviewed, 63% female. Of these, most reported neighborhood mobility within their informal settlement (54%), 19% stayed home completely, and 27% reported long-distance mobility outside their informal settlement, mainly for work. In adjusted multinomial regression models, women were 58% more likely than men to stay home (relative risk ratio (RRR): 1.58, 95% confidence interval (CI): 1.16, 2.14) and women were 60% less likely than men to report citywide mobility (RRR: 0.40; 95% CI 0.31, 0.52). Individuals in the wealthiest quintile, particularly younger women, were most likely to not leave home at all. Those who reported citywide travel were less likely to have lost employment (RRR: 0.49; 95% CI 0.38, 0.65) and were less likely to avoid public transportation (RRR: 0.30; 95% CI 0.23, 0.39). Employment and job hunting were the main reasons for traveling outside of the slum; less than 20% report other reasons. Our findings suggest that slum residents who retain their employment are traveling larger distances across Nairobi, using public transportation, and are more likely to be male; this travel may put them at higher risk of COVID-19 infection but is necessary to maintain income. Steps to protect workers from COVID-19 both in the workplace and while in transit (including masks, hand sanitizer stations, and reduced capacity on public transportation) are critical as economic insecurity in the city increases due to COVID-19 mitigation measures. Workers must be able to commute and maintain employment to not be driven further into poverty. Additionally, to protect the majority of individuals who are only travelling locally within their settlement, mitigation measures such as making masks and handwashing stations accessible within informal settlements must also be implemented, with special attention to the burden placed on women.

Effectiveness, safety and acceptability of medical abortion at home versus in the clinic: a systematic review and meta-analysis in response to COVID-19.

BACKGROUND: Increased access to home-based medical abortion may offer women a convenient, safe and effective abortion method, reduce burdens on healthcare systems and support social distancing during the COVID-19 pandemic. Home-based medical abortion is defined as any abortion where mifepristone, misoprostol or both medications are taken at home. METHODS: A systematic review and meta-analysis of randomised controlled trials (RCTs) and non-randomised studies (NRSs) were conducted. We searched databases from inception to 10 July 2019 and 14 June 2020. Successful abortion was the main outcome of interest. Eligible studies were RCTs and NRSs studies with a concurrent comparison group comparing home versus clinic-based medical abortion. Risk ratios (RRs) and their 95% CIs were calculated. Estimates were calculated using a random-effects model. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess risk of bias by outcome and to evaluate the overall quality of the evidence. RESULTS: We identified 6277 potentially eligible published studies. Nineteen studies (3 RCTs and 16 NRSs) were included with 11 576 women seeking abortion up to 9 weeks gestation. Neither the RCTs nor the NRS found any difference between home-based and clinic-based administration of medical abortion in having a successful abortion (RR 0.99, 95% CI 0.98 to 1.01, I2=0%; RR 0.99, 95% CI 0.97 to 1.01, I2=52%, respectively). The certainty of the evidence for the 16 NRSs was downgraded from low to very low due to high risk of bias and publication bias. The certainty of the evidence for the three RCTs was downgraded from high to moderate by one level for high risk of bias. CONCLUSION: Home-based medical abortion is effective, safe and acceptable to women. This evidence should be used to expand women's abortion options and ensure access to abortion for women during COVID-19 and beyond. PROSPERO REGISTRATION NUMBER: CRD42020183171.

Gender specific differences in COVID-19 knowledge, behavior and health effects among adolescents and young adults in Uttar Pradesh and Bihar, India.

On March 24, 2020 India implemented a national lockdown to prevent spread of the novel Coronavirus disease (COVID-19) among its 1.3 billion people. As the pandemic may disproportionately impact women and girls, this study examines gender differences in knowledge of COVID-19 symptoms and preventive behaviors, as well as the adverse effects of the lockdown among adolescents and young adults. A mobile phone-based survey was implemented from April 3-22, 2020 in Uttar Pradesh and Bihar among respondents randomly selected from an existing cohort study. Respondents answered questions related to demographics, COVID-19 knowledge, attitudes, and preventive behaviors practiced, and impacts on social, economic and health outcomes. Descriptive analyses and linear probability regression models were performed for all participants and separately for men and women. A total of 1,666 adolescents and young adults (18-24 years old) were surveyed; 70% were women. While most participants had high awareness of disease symptoms and preventive behaviors, there was variation by gender. Compared to men, women were seven percentage points (pp) less likely to know the main symptoms of COVID-19 (coeff = -0.071; 95% confidence interval: -0.122 - -0.021). Among women, there was variation in knowledge by education level, urban residence, and household wealth. Women were 22 pp less likely to practice key preventive behaviors compared to men (coeff = -0.222; 95% CIL -0.263, -0.181). Women were also more likely to report recent depressive symptoms than men (coeff = 0.057; 95% CI: 0.004, 0.109). Our findings underscore that COVID-19 is already disproportionately impacting adolescent girls and young women and that they may require additional targeted, gender-sensitive messaging to foster behavior change. Gender-sensitive information campaigns and provision of health services must be accessible and provide women and girls with needed resources and support during the pandemic to ensure gains in public health and gender equity are not lost.

The Adolescent Data Hub: The Largest Catalog of Open Access Data on Adolescents Living in Low- and Middle-Income Countries.

The Adolescent Data Hub (ADH) is the first and largest data catalog specifically developed to focus on open access data on adolescents in low- and middle-income countries (LMICs). Developed by the Population Council's Girl Innovation, Research, and Learning (GIRL) Center, and launched in August 2018, the ADH has grown to include more than 750 data sources that fit the inclusion criteria of (1) self-reported data from females and/or males between ages 10 and 24 years; (2) one or more rounds of data collected in year 2000 or later; (3) data collected in one or more LMICs; (4) data are publicly available for download and use. A dynamic resource, the ADH is regularly updated to include new datasets that meet these criteria. The ADH facilitates access to available data on adolescents for researchers attempting to answer important questions related to the lives of adolescents and for donors and policymakers eager to identify gaps in existing data to inform their future investments.

Self-administered versus provider-administered medical abortion.

BACKGROUND: The advent of medical abortion has improved access to safe abortion procedures. Medical abortion procedures involve either administering mifepristone followed by misoprostol or a misoprostol-only regimen. The drugs are commonly administered in the presence of clinicians, which is known as provider-administered medical abortion. In self-administered medical abortion, drugs are administered by the woman herself without the supervision of a healthcare provider during at least one stage of the drug protocol. Self-administration of medical abortion has the potential to provide women with control over the abortion process. In settings where there is a shortage of healthcare providers, self-administration may reduce the burden on the health system. However, it remains unclear whether self-administration of medical abortion is effective and safe. It is important to understand whether women can safely and effectively terminate their own pregnancies when having access to accurate and adequate information, high-quality drugs, and facility-based care in case of complications. OBJECTIVES: To compare the effectiveness, safety, and acceptability of self-administered versus provider-administered medical abortion in any setting. SEARCH METHODS: We searched Cochrane Central Register of Controlled Trials, MEDLINE in process and other non-indexed citations, Embase, CINAHL, POPLINE, LILACS, ClinicalTrials.gov, WHO ICTRP, and Google Scholar from inception to 10 July 2019. SELECTION CRITERIA: We included randomized controlled trials (RCTs) and prospective cohort studies with a concurrent comparison group, using study designs that compared medical abortion by self-administered versus provider-administered methods. DATA COLLECTION AND ANALYSIS: Two reviewers independently extracted the data, and we performed a meta-analysis where appropriate using Review Manager 5. Our primary outcome was successful abortion (effectiveness), defined as complete uterine evacuation without the need for surgical intervention. Ongoing pregnancy (the presence of an intact gestational sac) was our secondary outcome measuring success or effectiveness. We assessed statistical heterogeneity with Chi2 tests and I2 statistics using a cut-off point of P < 0.10 to indicate statistical heterogeneity. Quality assessment of the data used the GRADE approach. We used standard methodological procedures expected by Cochrane. MAIN RESULTS: We identified 18 studies (two RCTs and 16 non-randomized studies (NRSs)) comprising 11,043 women undergoing early medical abortion (≤ 9 weeks gestation) in 10 countries. Sixteen studies took place in low-to-middle income resource settings and two studies were in high-resource settings. One NRS study received analgesics from a pharmaceutical company. Five NRSs and one RCT did not report on funding; nine NRSs received all or partial funding from an anonymous donor. Five NRSs and one RCT received funding from government agencies, private foundations, or non-profit bodies. The intervention in the evidence is predominantly from women taking mifepristone in the presence of a healthcare provider, and subsequently taking misoprostol without healthcare provider supervision (e.g. at home). There is no evidence of a difference in rates of successful abortions between self-administered and provider-administered groups: for two RCTs, risk ratio (RR) 0.99, 95% confidence interval (CI) 0.97 to 1.01; 919 participants; moderate certainty of evidence. There is very low certainty of evidence from 16 NRSs: RR 0.99, 95% CI 0.97 to 1.01; 10,124 participants. For the outcome of ongoing pregnancy there may be little or no difference between the two groups: for one RCT: RR 1.69, 95% CI 0.41 to 7.02; 735 participants; low certainty of evidence; and very low certainty evidence for 11 NRSs: RR 1.28, 95% CI 0.65 to 2.49; 6691 participants. We are uncertain whether there are any differences in complications requiring surgical intervention, since we found no RCTs and evidence from three NRSs was of very low certainty: for three NRSs: RR 2.14, 95% CI 0.80 to 5.71; 2452 participants. AUTHORS' CONCLUSIONS: This review shows that self-administering the second stage of early medical abortion procedures is as effective as provider-administered procedures for the outcome of abortion success. There may be no difference for the outcome of ongoing pregnancy, although the evidence for this is uncertain for this outcome. There is very low-certainty evidence for the risk of complications requiring surgical intervention. Data are limited by the scarcity of high-quality research study designs and the presence of risks of bias. This review provides insufficient evidence to determine the safety of self-administration when compared with administering medication in the presence of healthcare provider supervision. Future research should investigate the effectiveness and safety of self-administered medical abortion in the absence of healthcare provider supervision through the entirety of the medical abortion protocol (e.g. during administration of mifepristone or as part of a misoprostol-only regimen) and at later gestational ages (i.e. more than nine weeks). In the absence of any supervision from medical personnel, research is needed to understand how best to inform and support women who choose to self-administer, including when to seek clinical care.

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.

Opportunities and challenges for the introduction of a new female condom among young adults in urban Zambia.

BACKGROUND: Expanding contraceptive method choices for sexually active youth is critical to prevent STIs/HIV and unintended pregnancies. However, preferences and decision making around contraception among young adults are not well understood. A new female condom (FC), the Woman's Condom (WC), features an improved design and is marketed as a premium product at a higher price point. We conducted a qualitative study to examine the underlying knowledge, attitudes, and perceptions around the FC generally, the WC specifically, and to explore the opportunities and challenges of introducing the WC to young adults in urban Zambia. METHODS: Thirty focus group discussions comprised of 245 men and women aged 18-24 years were facilitated by local moderators in Lusaka, Zambia between August and December 2016. Data were analyzed using thematic content analysis using ATLAS.ti (Version 7.5.17). RESULTS: While interest in the newly launched WC was high, few participants recognized it, so discussion was framed around FCs more generally. The decision to use a FC is challenged by misconceptions regarding safety and correct use, cost, and women's limited power over decision making in relationships. Participants also reported low availability of the product. Several opportunities for FC uptake were discussed, including the perception that FCs provide better sensation during intercourse compared with male condoms, and women reported enthusiasm for the opportunity to be the partner responsible for contraception. Some women expressed interest in the WC in order to ensure it was not tampered with by their partner, a practice commonly reported by both genders that reflects high levels of mistrust. CONCLUSIONS: Findings suggest the FC, including the new WC, has potential to increase gender equity by giving women a product they are comfortable buying and being able to control to ensure correct use; however, future programming should address high perceived cost of the WC and women's limited decision making power in relationships. Findings also highlight the need for interventions that include product demonstration and promote the WC as a method that provides better sensation during sex than male condoms. To increase voluntary uptake, the challenges identified here should be incorporated into future social marketing campaigns.

The evaluation of the Woman's Condom marketing approach: What value did peer-led interpersonal communication add to the promotion of a new female condom in urban Lusaka?

During a mass media campaign accompanying the launch of the Maximum Diva Woman's Condom (WC) in Lusaka, Zambia, a cluster-randomized evaluation was implemented to measure the added impact of a peer-led interpersonal communication (IPC) intervention on the awareness and uptake of the new female condom (FC). The WC and mass media campaign were introduced simultaneously in 40 urban wards in April 2016; half of the wards were randomly assigned to the treatment (IPC intervention) with cross-sectional surveys conducted before (n = 2,364) and one year after (n = 2,430) the start of the intervention. A pre-specified intention-to-treat (ITT) analysis measured the impact of randomization to IPC at the community level. In adjusted ITT models, there were no statistically significant differences between intervention and control groups. Due to significant implementation challenges, we also conducted exploratory secondary analyses to estimate effects among those who attended an IPC event (n = 66) using instrumental variable and inverse probability weighting analyses. In addition to increases in FC identification (IPC attendees had higher reported use of any condom, improved perceptions of FC's, and were more likely to have discussed contraceptive use with their partner as compared to non-attendees). The introduction of a new FC product combined with an IPC intervention significantly increased general knowledge and awareness in the community as compared to media alone, but did not lead to detectable community level impacts on other primary outcomes of interest. Observational evidence from our study suggests that IPC attendance is associated with increased use and negotiation. Future studies should explore the intensity and duration of IPC programming necessary to achieve detectable community level impacts on behavior. Trial Registration: AEARCTR-0000899.