Effect of a gender-synchronized family planning intervention on inequitable gender norms in a cluster randomized control trial among husbands of married adolescent girls in Dosso, Niger.

Gender inequity is pervasive globally and has severe consequences for health and well-being, particularly for women and girls in Niger. The Reaching Married Adolescents in Niger (RMA) intervention aimed to promote equitable gender norms in order to increase modern contraceptive use and reduce intimate partner violence among married adolescent girls and their husbands in Niger. Using data from a 4-arm factorial cluster randomized control trial of the RMA intervention (2016-2019), the current study assesses effects of the RMA intervention on gender norms among husbands. We used an adjusted hierarchical difference-in-differences linear regression model to assess these effects. The mean score for perceived gender inequitable norms at baseline was 4.1 (n=1,055; range: 0-5). Assignment to the RMA small groups intervention was associated with a 0.62 lower score (95% CI: -1.05, -0.18) relative to controls at follow-up, after adjusting for baseline differences. No significant effects were detected for other intervention arms. As a low-cost, simple, scalable, and transferrable intervention with rigorous evidence of being able to change such gender norms, this community health worker-based small group intervention could be valuable to the field of public health for reducing the negative impact of inequitable gender norms on health and wellbeing in similar settings.

Psychometric Properties and Refinement of the ATT-IPV Scale to Measure Attitudes about Intimate Partner Violence among Married Adolescents and Their Husbands in Niger.

(1) Background: This study sought to assess the appropriateness of a five-item scale to measure attitudes towards IPV (ATT-IPV) among married adolescent girls and their husbands in Niger, a population in which this scale has not yet been tested. (2) Methods: Using data collected from 1100 pairs of married adolescents, aged 13-19 years old, and their husbands across 48 villages in rural Niger, we performed classical test theory reliability and exploratory factor analysis, followed by item response theory (IRT) analyses and testing differential item functioning (DIF) by gender. (3) Results: The ATT-IPV scale was found to be internally consistent (alpha = 0.8) and unidimensional in this population, with all items loading onto one factor. We found differential item functioning of the following item: "In your opinion, is a husband justified in hitting or beating his wife in the following situations: If she burns his food?" by gender, suggesting that in order to have a scale that performs similarly in men and women, that item should be removed. (4) Conclusions: The ATT-IPV scale is useful as a measure of attitudes towards IPV among married adolescents and their husbands in Niger. However, it may need to be updated to reflect additional forms of violence and to eliminate gender-differential responses in order to be a more effective measure.

Effects of the reaching married adolescents program on modern contraceptive use and intimate partner violence: results of a cluster randomized controlled trial among married adolescent girls and their husbands in Dosso, Niger.

BACKGROUND: Niger has the highest rate of adolescent fertility in the world, with early marriage, early childbearing and high gender inequity. This study assesses the impact of Reaching Married Adolescents (RMA), a gender-synchronized social behavioral intervention designed to improve modern contraceptive use and reduce intimate partner violence (IPV) among married adolescent couples in rural Niger. METHODS: We conducted a four-armed cluster-randomized trial in 48 villages across three districts in Dosso region, Niger. Married adolescent girls (ages 13-19) and their husbands were recruited within selected villages. Intervention arms included home visits by gender-matched community health workers (CHWs) (Arm 1), gender-segregated, group discussion sessions (Arm 2), and both approaches (Arm 3). We used multilevel mixed-effects Poisson regression models to assess intervention effects for our primary outcome, current modern contraceptive use, and our secondary outcome, past year IPV. RESULTS: Baseline and 24-month follow-up data were collected April-June 2016 and April-June 2018. At baseline, 1072 adolescent wives were interviewed (88% participation), with 90% retention at follow-up; 1080 husbands were interviewed (88% participation), with 72% retention at follow-up. Adolescent wives had higher likelihood of modern contraceptive use at follow-up relative to controls in Arm 1 (aIRR 3.65, 95% CI 1.41-8.78) and Arm 3 (aIRR 2.99, 95% CI 1.68-5.32); no Arm 2 effects were observed. Relative to those in the control arm, Arm 2 and Arm 3 participants were significantly less likely to report past year IPV (aIRR 0.40, 95% CI 0.18-0.88 for Arm 2; aIRR 0.46, 95% CI 0.21-1.01 for Arm 3). No Arm 1 effects were observed. CONCLUSIONS: The RMA approach blending home visits by CHWs and gender-segregated group discussion sessions is the optimal format for increasing modern contraceptive use and decreasing IPV among married adolescents in Niger. Trial registration This trial is retrospectively registered with ClinicalTrials.gov, Identifier NCT03226730.

Although Niger has both the highest levels of fertility and of child marriage in the world, as well as substantial gender inequity, there have been no high-quality evaluations of public health programs aiming to increase contraceptive use or decrease intimate partner violence. In this study, we conducted a high quality, randomized controlled trial to evaluate whether the Reaching Married Adolescents public health program could increase modern contraceptive use and decrease intimate partner violence among married adolescent girls (13­19 years old) and their husbands in the Dosso region of Niger. The results of this evaluation provide evidence of the value of individual home visits for wives and their husbands in increasing modern contraceptive use, the value of small group discussions in reducing intimate partner violence, and the combined value of receiving both approaches at the same time for both increasing modern contraceptive use and decreasing intimate partner violence. The current study advances the state of evidence regarding contraceptive use and IPV among married adolescents and their husbands in Niger, highlighting the importance of engaging male partners in such public health programs, as well as of using multiple modes of delivery of programs. The success of this intervention in the high-risk context of Niger suggests that other countries in the region may benefit from testing this approach to improve the health and well-being of young wives.

Measuring social norms of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy: an item response modelling of the IPV-ASRA scale.

BACKGROUND: The field of violence prevention research is unequivocal that interventions must target contextual factors, like social norms, to reduce gender-based violence. Limited research, however, on the social norms contributing to intimate partner violence or reproductive coercion exists. One of the driving factors is lack of measurement tools to accurately assess social norms. METHODS: Using an item response modelling approach, this study psychometrically assesses the reliability and validity of a social norms measure of the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy with data from a population-based sample of married adolescent girls (ages 13-18) and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019. RESULTS: A two-dimensional Partial Credit Model for polytomous items was fit, showing evidence of reliability and validity. Higher scores on the "challenging husband authority" dimension were statistically associated with husband perpetration of intimate partner violence. CONCLUSIONS: This brief scale is a short (5 items), practical measure with strong reliability and validity evidence. This scale can help identify populations with high-need for social norms-focused IPV prevention and to help measure the impact of such efforts.

Long-term prevention of gender-based violence, like intimate partner violence and reproductive coercion, requires efforts to change the social environment that facilitates violence against women, yet limited research is available on how to change social environments. One reason is that there are few tools to accurately measure social environments, including social norms, which are the unspoken rules about what behavior is acceptable and what behavior is not. The present research assessed a new social norms measurement tool on the acceptability of intimate partner violence to exert control over wife agency, sexuality, and reproductive autonomy using data from a population-based sample of married adolescents and their husbands in rural Niger (n = 559 husband-wife dyads) collected in 2019. We found that this scale had strong reliability and validity, and that the group of questions about challenging husband authority were related to husband perpetration of intimate partner violence against his wife. This brief scale is a short (5 questions), practical measure with strong reliability and validity evidence that can help identify populations with high-need for social norms-focused prevention and to help measure the impact of such efforts. This evidence strengthens the current set of measurement tools on social norms available to researchers and practitioners.

Long Noncoding RNA Expression Independently Predicts Outcome in Pediatric Acute Myeloid Leukemia.

PURPOSE: Optimized strategies for risk classification are essential to tailor therapy for patients with biologically distinctive disease. Risk classification in pediatric acute myeloid leukemia (pAML) relies on detection of translocations and gene mutations. Long noncoding RNA (lncRNA) transcripts have been shown to associate with and mediate malignant phenotypes in acute myeloid leukemia (AML) but have not been comprehensively evaluated in pAML. METHODS: To identify lncRNA transcripts associated with outcomes, we evaluated the annotated lncRNA landscape by transcript sequencing of 1,298 pediatric and 96 adult AML specimens. Upregulated lncRNAs identified in the pAML training set were used to establish a regularized Cox regression model of event-free survival (EFS), yielding a 37 lncRNA signature (lncScore). Discretized lncScores were correlated with initial and postinduction treatment outcomes using Cox proportional hazards models in validation sets. Predictive model performance was compared with standard stratification methods by concordance analysis. RESULTS: Training set cases with positive lncScores had 5-year EFS and overall survival rates of 26.7% and 42.7%, respectively, compared with 56.9% and 76.3% with negative lncScores (hazard ratio, 2.48 and 3.16; P < .001). Pediatric validation cohorts and an adult AML group yielded comparable results in magnitude and significance. lncScore remained independently prognostic in multivariable models, including key factors used in preinduction and postinduction risk stratification. Subgroup analysis suggested that lncScores provide additional outcome information in heterogeneous subgroups currently classified as indeterminate risk. Concordance analysis showed that lncScore adds to overall classification accuracy with at least comparable predictive performance to current stratification methods that rely on multiple assays. CONCLUSION: Inclusion of the lncScore enhances predictive power of traditional cytogenetic and mutation-defined stratification in pAML with potential, as a single assay, to replace these complex stratification schemes with comparable predictive accuracy.

Preference-Aligned Fertility Management as a Person-Centered Alternative to Contraceptive Use-Focused Measures.

Equating contraceptive use with programmatic success is fundamentally flawed in failing to account for whether individuals desire contraceptive use; this is problematic because nonuse can reflect empowered decision-making and use may reflect an individual's inability to refuse or discontinue a method. A rights-based approach demands respect for individuals' freedom to weigh options and choose how their desire for pregnancy prevention can be accommodated by available methods and within the context of their own personal, social, and material constraints. We offer an alternative construct, preference-aligned fertility management (PFM), that provides a more holistic indicator of whether one's contraceptive needs are met. PFM is more person-centered and informative for programming than status quo measures of unmet need, demand satisfied, and contraceptive use which define a positive outcome in relation to pregnancy risk rather than one's stated preferences. The PFM approach goes beyond other recent proposals for modifying the concept of unmet need by refraining from judgment of legitimate reasons for nonuse of contraception and offers a straightforward way to capture whether people act in line with their preferences. We conclude with discussion of how we plan to measure PFM in the Innovations for Choice and Autonomy (ICAN) study in Nigeria and Uganda.

Sustained impact of community-based interventions on contraceptive use among married adolescent girls in rural Niger: Results from a cluster randomized controlled trial.

OBJECTIVE: To evaluate the sustained impact of community-based family planning (FP) interventions on current modern contraceptive and long-acting reversible contraceptive (LARC) use among married adolescent girls in rural Niger. METHODS: We used a cluster randomized controlled trial design following married adolescent girls and their husbands over 3 years. Villages were randomized to one of four arms: household visits, small group discussions, combined intervention, or control. For 1.5 years, couples were exposed to one intervention activity per month and 1.5 years after implementation ended, we used a multi-level mixed effects logistic regression model to evaluate changes in key FP outcomes. RESULTS: We analyzed survey data from 404 married adolescent girls with data at baseline and endline. Small group discussions (+35.6%; adjusted odds ratio [aOR] 7.94, P < 0.001) and the combined intervention (+17.9%: aOR 4.53, P = 0.005) led to statistically significant increases in the odds of using modern contraceptives at endline compared with the control. The combined intervention (+14.2%; aOR 7.98, P < 0.001) and home visits (+12.6%; aOR 8.09, P < 0.001) led to statistically significant increases in odds of using LARC methods at endline compared with the control. Increase in LARC use was driven by implant use across all intervention groups. CONCLUSION: This study contributes to the empirical evidence base on the sustained impact of community-based interventions on increases in FP use among married adolescent girls in low- and middle-income countries.

Characterizing Nigerien men's social networks and their influence on family planning-related attitudes and behaviors.

This work uses data from a family planning (FP) program evaluation and social network study among men married to adolescent girls (ages 13-19) in Dosso, Niger to explore who influences their FP and through which social mechanisms. We asked men (N = 237) to nominate and describe their perceptions of key social contacts (alters). We sought to interview the most influential alter (N = 157 interviewed alters), asking them about their own FP-related attitudes and behaviors. Men primarily nominated male friends as alters. We found that men participating in the program were more likely to perceive alters to hold attitudes supportive of gender equitable FP decisions (AOR: 4.36, 95% CI: 1.83, 10.35) and FP use (AOR: 4.22, 95% CI: 1.72, 10.35). Alters' attitudes supporting FP were related to those of the men who nominated them (1-unit increase in alters' attitudes score related to a 0.48 unit increase in men's attitudes; 95% CI: 0.32, 0.63). Men who perceived their alters would support gender equitable FP decisions were more likely to have ever used FP methods (AOR: 10.43, 95% CI: 2.50, 43.58) as were those who perceived their alters would support their own FP use (AOR: 12.76, 95% CI: 2.55, 63.81). Men who perceived their alters would support gender equitable FP decisions were more likely to report spousal communication (AOR: 8.71, 95% CI: 3.06, 24.83), as were those who perceived that alters would support their own FP use (AOR: 9.06, 95% CI: 3.01, 27.26). Alters' and men's behaviors (contraceptive use and spousal communication) were not associated. These results demonstrate that perceived approval from network members may be critical to FP-related attitudes and behaviors. However, since FP promotion programs may affect perception and/or composition of social networks, future research should include larger sample sizes and longitudinal data to understand the effect of changing norms on social relationships.

Associations between spousal gender equity and recent unintended pregnancy among married adolescent girls and their husbands in rural Niger.

This study in rural Niger examines if gender equity attitudes of married adolescent girls and their husbands are associated with recent unintended pregnancy (UIP) and ever-use of family planning (FP). Logistic regression models were used to calculate adjusted associations between husbands' and wives' equity (jointly and separately) and the two outcomes. UIP was less likely to be reported by adolescent girls with equitable husbands, controlling for wife's equity (adjusted odds ratio/aOR: 0.57, 95% confidence interval/CI: 0.41-0.80), and was more likely to be reported by equitable wives (aOR: 2.26, CI: 1.59-3.24). In stratified analyses, wife's equity was associated with a nearly three-fold likelihood of UIP in couples with inequitable husbands (aOR: 2.79, CI: 1.58-5.05). Ever having used FP was not associated with husbands' or wives' gender equity. Interventions targeting reproductive health outcomes for married adolescent girls should focus on spousal equity attitudes - improving wives' equity might be ineffective if husbands remain inequitable.

Associations of Age at Marriage With Marital Decision-Making Agency Among Adolescent Wives in Rural Niger.

PURPOSE: Child marriage is associated with multiple adverse health and social outcomes. Although evidence suggests that child marriage is associated with reduced participation in personal and household decisions for women, less is known about the association between age at marriage and decision-making among married adolescent girls. This study assesses associations between adolescents' age at marriage and two dimensions of decision-making (participation and satisfaction) in the high early marriage prevalence settings of Niger. METHODS: Cross-sectional data from a cluster-randomized control trial of a community-level program to increase the use of modern contraceptives among married adolescents in the Dosso region of Niger were analyzed. Multiple logistic regression models were used to determine the association of age at marriage with married girls' participation in and satisfaction with decision-making processes. RESULTS: More than half of married adolescents (N = 796) were married before reaching the age of 15 years. Older age at marriage was associated with adolescents' increased participation in decisions related to economics (adjusted odds ratio: 1.23; 95% confidence interval: 1.05-1.43) and health-care access (adjusted odds ratio: 1.18; 95% confidence interval: 1.01-1.40), but not with greater reported satisfaction with their control over these decisions. CONCLUSIONS: The study suggests that marrying as a very young adolescent places girls in even more disadvantaged positions regarding decision-making. These findings indicate the need to design programs targeted at addressing inequitable gender norms to reduce early child marriage and increase participation in decision-making. Further study of satisfaction with participation in decision-making is recommended, including consideration of whether it is related to gender norms for participation in decisions rather than actual participation.

Social network and social normative characteristics of married female adolescents in Dosso, Niger: Associations with modern contraceptive use.

In this study we analysed the social networks of a sample of married adolescent girls (ages 13-19 years) residing in Dosso, Niger (N = 322); data were collected for evaluation of a family planning (FP) intervention. Participants were asked to name individuals important in their lives (alters) using three name generating questions as part of a larger survey on reproductive health, social norms, and FP. One alter per girl was then recruited to be separately interviewed (N = 250). This provided us with two separate datasets: one with data from each respondent regarding each person that they nominated, and one with the interviewed alters matched with the respondent who nominated them. We found that married adolescent girls who were nulliparous were more likely to have no alters and that those in the intervention had the most alters. Alters of treatment participants were more likely to have used FP. Respondents were more likely to have used FP when their sisters or in-laws had, but there was no correlation with use by friends. Our results provide evidence of diffusion of the FP program to those close to intervention participants. Future research should study these dynamics, crucial to understanding intervention costing, impact, and normative change.

Associations of spousal communication with contraceptive method use among adolescent wives and their husbands in Niger.

OBJECTIVES: This study aims to examine associations between spousal communication about contraception and ever use of modern contraception, overt modern contraceptive use (with husband's knowledge), and covert modern contraceptive use (without husband's knowledge) among adolescent wives and their husbands in Niger. STUDY DESIGN: Cross-sectional data, from the Reaching Married Adolescents Study, were collected from randomly selected adolescent wives (ages 13-19 years) and their husbands from 48 randomly selected villages in rural Niger (N = 1,020 couples). Logistic regression models assessed associations of couples' reports of spousal communication about contraception with wives' reports of contraception (overall, overt, and covert). RESULTS: About one-fourth of adolescent wives and one-fifth of husbands reported spousal communication about contraception. Results showed couples' reports of spousal communication about contraception were positively associated with ever use of modern contraception. Couples' reports of spousal communication about contraception were negatively associated with covert modern contraceptive use compared to overt use. Wives' reports of spousal communication were marginally associated with covert use compared to no use but husbands' reports were not. CONCLUSION: Among a sample of couples in Niger, spousal communication about contraception was positively associated with modern contraceptive use (compared to no use) and negatively with covert use (compared to overt use) but wives' and husbands' reports showed differential associations with covert use compared to no use. Since there is little understanding of couple communication surrounding covert contraceptive use decisions, research should focus on characterizing content and context of couple communication particularly in cases of disagreement over fertility decisions.

Associations of reproductive coercion and intimate partner violence with overt and covert family planning use among married adolescent girls in Niger.

BACKGROUND: In Niger the prevalence of girl child marriage and low female control over family planning (FP) has resulted in the world's highest adolescent fertility. Male control of FP is associated with intimate partner violence (IPV) and reproductive coercion (RC). We assessed associations of IPV and RC with FP use among married adolescent girls (ages 13-19 years) in Dosso, Niger (N = 1072). METHODS: Multivariable, cross-sectional regression models assessed associations between physical IPV, sexual IPV, and RC and any FP use, FP use with husband knowledge (overt use), and FP use without husband knowledge (covert use). FINDINGS: One in four married adolescent girls using FP reported doing so without husband's knowledge. Unadjusted and adjusted models indicated that physical IPV and RC were associated with covert FP use (vs. no use and vs. overt use), but not with overt use vs. no use. Only physical IPV remained significantly associated with covert use in models including all three forms of violence (AOR: 1.94 vs. any use; AOR: 3.63 vs. overt use). INTERPRETATION: Married adolescents experiencing physical IPV or RC were more likely that others to use FP without their husbands' knowledge. No form of GBV affected odds of FP use with husbands' knowledge. Current results suggest caution regarding promoting engagement of men in decisions to use FP in this context, as this may undermine the reproductive autonomy of girls and women who will choose to use FP without the knowledge of their male partners.

Spatial analysis of individual- and village-level sociodemographic characteristics associated with age at marriage among married adolescents in rural Niger.

BACKGROUND: Niger has the highest prevalence of child marriage in the world. While child marriage in Niger is clearly normative in the sense that it is commonly practiced, the social and contextual factors that contribute to it are still unclear. METHODS: Here, we tested the importance of village-level factors as predictors of young age at marriage for a group of married adolescent girls (N = 1031) in the Dosso district of rural Niger, using multi-level and geographic analyses. We aggregated significant individual level factors to determine whether, independent of a girl's own sociodemographic characteristics, the impact of each factor is associated at the village level. Finally, we tested for spatial dependence and heterogeneity in examining whether the village-level associations we find with age at marriage differ geographically. RESULTS: The mean age of marriage for girls in our study was 14.20 years (SD 1.8). Our statistical results are consistent with other literature suggesting that education is associated with delayed marriage, even among adolescent girls. Younger ages at marriage are also associated with a greater age difference between spouses and with a greater likelihood of women being engaged in agricultural work. Consistent with results at the individual level, at the village level we found that the proportion of girls who do agricultural work and the mean age difference between spouses were both predictive of a lower age at marriage for individual girls. Finally, mapping age at marriage at the village level revealed that there is geographical variation in age at marriage, with a cluster of hot spots in the Hausa-dominated eastern area where age at marriage is particularly low and a cluster of cold spots in the Zarma-dominated western areas where age at marriage is relatively high. CONCLUSIONS: Our findings suggest that large-scale approaches to eliminating child marriage in these communities may be less successful if they do not take into consideration geographically and socially determined contextual factors at the village level.

Married very young adolescent girls in Niger at greatest risk of lifetime male partner reproductive coercion and sexual violence.

OBJECTIVE: The purpose of this analysis was to compare and contrast reproductive health (RH), gender equity attitudes, and intimate partner violence (IPV) among married very young adolescent (VYA) girls with married older adolescent girls and young women (AGYW) in rural Niger given limited literature on the topic. METHODS: We conducted an exploratory analysis of baseline data from the Reaching Married Adolescents Trial in Dosso region, Niger. We report counts and percents, by age group (13-14 years (VYA), 15-16 years, 17-19 years), of AGYW's self-efficacy to use family planning (FP), accurate knowledge of FP, current use of modern FP, and unintended last pregnancy (UIP); lifetime reproductive coercion (RC), physical IPV, and sexual IPV; and gender equity attitudes. We also assess whether percents differ between VYA and older groups using Pearson's Chi-Square and Fisher's exact p-values. Results are stratified by parity. Finally, we use logistic regression to consider associations. RESULTS: There were 49 VYA, 248 girls aged 15-16, and 775 AGYW aged 17-19 in our sample (n = 1072). Accurate knowledge of FP, self-efficacy to use FP, current use of modern FP, and UIP increased with age; all percents between VYA and AGYW 17-19 were marginally or statistically significantly different. We also saw VYA report higher lifetime RC and sexual IPV versus older groups, with sexual IPV statistically different between VYA and girls 17-19. Parous VYA reported a significantly higher percent of lifetime RC versus older AGYW. Among 17-19 year-olds, odds of current use of FP were higher among AGYW who reported physical IPV, and odds of UIP were higher among those reporting more gender equitable attitudes, both adjusted for parity. CONCLUSIONS: We observed differences in RH, RC, and sexual IPV among married VYA and older AGYW in rural Niger. VYA should be prioritized in research to confirm and further understand their RH needs.

Protocol for cluster randomized evaluation of reaching married adolescents - a gender-synchronized intervention to increase modern contraceptive use among married adolescent girls and young women and their husbands in Niger.

BACKGROUND: Early marriage and early childbearing are highly prevalent in Niger with 75% of girls married before age 18 years and 42% of girls giving birth between ages 15 and 18 years. In 2012, only 7% of all 15-19-year-old married adolescents (male and female) reported use of a modern contraceptive method with barriers including misinformation, and social norms unsupportive of contraception. To meet the needs of married adolescents and their husbands in Niger, the Reaching Married Adolescents (RMA) program was developed with the goal of improving modern contraceptive method uptake in the Dosso region of Niger. METHODS: Using a four-arm cluster randomized control design, the RMA study seeks to assess whether household visits only (Arm 1), small group discussions only (Arm 2), or a combination of both (Arm 3), as compared to controls (no intervention - Arm 4), improve modern contraceptive method use among married adolescent girls and young women (AGYW), age 13-19 years-old, in three districts of the Dosso region. Intervention conditions were randomly assigned across the three districts, Dosso, Doutchi, and Loga. Within each district, eligible villages were assigned to either that intervention condition or to the control condition (12 intervention and 4 control per district). Across the three intervention conditions, community dialogues regarding modern contraceptive use were also implemented. Data for the study was collected at baseline (April - June 2016), at 24 months post-intervention (April - June 2018), and a final round of data collection will occur at 40 months post-intervention (October - December 2019). DISCUSSION: The RMA intervention is a gender-synchronized and community-based program implemented among married adolescent girls and their husbands in the context of rural Niger. The intervention is designed to provide education about modern contraception and to promote gender equity in order to increase uptake of modern contraceptive methods. Results from this cluster randomized control study will contribute to the knowledge base regarding the utility of male engagement as a strategy within community-level approaches to promote modern contraceptive method use in the high need context of West Africa. TRIAL REGISTRATION: Registered October 2017 - ClinicalTrials.gov NCT03226730.

Bad girl and unmet family planning need among Sub-Saharan African adolescents: the role of sexual and reproductive health stigma.

Adolescent pregnancy contributes to high maternal mortality rates in Sub-Saharan Africa. We explored stigma surrounding adolescent sexual and reproductive health (SRH) and its impact on young Ghanaian women's family planning (FP) outcomes. We conducted in-depth, semi-structured interviews with 63 women ages 15-24 recruited from health facilities and schools in Accra and Kumasi, Ghana. Purposive sampling provided diversity in reproductive/relationship/socioeconomic/religious characteristics. Using both deductive and inductive approaches, our thematic analysis applied principles of grounded theory. Participants described adolescent SRH experiences as cutting across five stigma domains. First, community norms identified non-marital sex and its consequences (pregnancy, childbearing, abortion, sexually transmitted infections) as immoral, disrespectful, and disobedient, resulting in bad girl labeling. Second, enacted stigma entailed gossip, marginalization, and mistreatment from all community members, especially healthcare workers. Third, young sexually active, pregnant, and childbearing women experienced internalized stigma as disgrace, shame and shyness. Fourth, non-disclosure and secret-keeping were used to avoid/reduce stigma. Fifth, stigma resilience was achieved through social support. Collectively, SRH stigma precluded adolescents' use of FP methods and services. Our resulting conceptual model of adolescent SRH stigma can guide health service, public health, and policy efforts to address unmet FP need and de-stigmatize SRH for young women worldwide.

Factors associated with sexual and reproductive health stigma among adolescent girls in Ghana.

OBJECTIVE: Using our previously developed and tested Adolescent Sexual and Reproductive Health (SRH) Stigma Scale, we investigated factors associated with perceived SRH stigma among adolescent girls in Ghana. METHODS: We drew upon data from our survey study of 1,063 females 15-24yrs recruited from community- and clinic-based sites in two Ghanaian cities. Our Adolescent SRH Stigma Scale comprised 20 items and 3 sub-scales (Internalized, Enacted, Lay Attitudes) to measure stigma occurring with sexual activity, contraceptive use, pregnancy, abortion and family planning service use. We assessed relationships between a comprehensive set of demographic, health and social factors and SRH Stigma with multi-level multivariable linear regression models. RESULTS: In unadjusted bivariate analyses, compared to their counterparts, SRH stigma scores were higher among girls who were younger, Accra residents, Muslim, still in/dropped out of secondary school, unemployed, reporting excellent/very good health, not in a relationship, not sexually experienced, never received family planning services, never used contraception, but had been pregnant (all p-values <0.05). In multivariable models, higher SRH stigma scores were associated with history of pregnancy (ß = 1.53, CI = 0.51,2.56) and excellent/very good self-rated health (ß = 0.89, CI = 0.20,1.58), while lower stigma scores were associated with older age (ß = -0.17, 95%CI = -0.24,-0.09), higher educational attainment (ß = -1.22, CI = -1.82,-0.63), and sexual intercourse experience (ß = -1.32, CI = -2.10,-0.55). CONCLUSIONS: Findings provide insight into factors contributing to SRH stigma among this young Ghanaian female sample. Further research disentangling the complex interrelationships between SRH stigma, health, and social context is needed to guide multi-level interventions to address SRH stigma and its causes and consequences for adolescents worldwide.

Multiple levels of social influence on adolescent sexual and reproductive health decision-making and behaviors in Ghana.

Little is known about the multilevel social determinants of adolescent sexual and reproductive health (SRH) that shape the use of family planning (FP) among young women in Africa. We conducted in-depth, semi-structured, qualitative interviews with 63 women aged 15-24 years in Accra and Kumasi, Ghana. We used purposive, stratified sampling to recruit women from community-based sites. Interviews were conducted in English or local languages, recorded, and transcribed verbatim. Grounded theory-guided thematic analysis identified salient themes. Three primary levels of influence emerged as shaping young women's SRH experiences, decision-making, and behaviors. Interpersonal influences (peers, partners, and parents) were both supportive and unsupportive influences on sexual debut, contraceptive (non) use, and pregnancy resolution. Community influences included perceived norms about acceptability/unacceptability of adolescent sexual activity and its consequences (pregnancy, childbearing, abortion). Macro-social influences involved religion and abstinence and teachings about premarital sex, lack of comprehensive sex education, and limited access to confidential, quality SRH care. The willingness and ability of young women in our study to use FP methods and services were affected, often negatively, by factors operating within and across each level. These findings have implications for research, programs, and policies to address social determinants of adolescent SRH.