Climate and Gender: Association Between Droughts and Intimate Partner Violence in India.

Extreme climate events are related to women's exposure to different forms of violence. We examined the relationship between droughts and physical, sexual, and emotional intimate partner violence (IPV) in India by using 2 different definitions of drought: precipitation-based drought and socioeconomic drought. We analyzed data from 2 rounds of a nationally representative survey, the National Family Health Survey, where married women were asked about their experiences of IPV in the previous year (2015-2016 and 2019-2021; n = 122,696). Precipitation-based drought was estimated using remote sensing data and geographic information system (GIS) mapping, while socioeconomic drought status was collected from government records. Logistic regression models showed precipitation-based drought to increase the risk of experiencing physical IPV and emotional IPV. Similar findings were observed for socioeconomic drought; women residing in areas classified as drought-impacted by the government were more likely to report physical IPV, sexual IPV, and emotional IPV. These findings support the growing body of evidence regarding the relationship between climate change and women's vulnerability, and highlight the need for gender responsive strategies for disaster management and preparedness.

Evaluating a scalable ARCHES (Addressing Reproductive Coercion in Health Settings) model in government health facilities in Uasin Gishu county, Kenya: study protocol for a cluster-randomized controlled trial.

BACKGROUND: Since 2013, the World Health Organization has recommended that reproductive coercion (RC) and intimate partner violence (IPV) be addressed within reproductive health services and, in 2018, the Lancet Commission on Sexual and Reproductive Health and Rights found that RC and IPV were significant contributors to unmet need for family planning (FP) and unintended pregnancy. In Kenya, the Ministry of Health (MOH) has made reduction of unintended pregnancy and gender-based violence a primary objective. Despite this need and guidance, no clinic-based intervention models outside of the U.S. (apart from the one described here) have demonstrated efficacy to improve FP use and reduce IPV or RC thereby reducing unintended pregnancy. ARCHES (Addressing Reproductive Coercion in Health Settings) is a brief, clinic-based intervention delivered by existing FP providers aiming to: (1) Increase women's ability to use FP without interference, (2) Provide a safe and supportive environment for IPV disclosure and referral to support services, and (3) Improve quality of FP counseling, including addressing RC and IPV. The objective of this study is to generate evidence on scaling integrated FP services (including FP, RC, and IPV) in public sector health facilities in Uasin Gishu county, Kenya via adaptation and implementation of ARCHES in partnership with the Kenya MOH. METHODS: A cluster-randomized controlled trial paired with concurrent implementation science assessments will test effectiveness of the ARCHES model, adapted for scale by the Kenya MOH, in reducing unintended pregnancy. Female FP clients aged 15-49 years at selected sites will complete baseline surveys (immediately prior to receiving care), immediately post-visit exit surveys, and 6-month follow-up surveys. Provider surveys will assess changes in gender-equitable attitudes and self-efficacy to address violence reported by their clients. Costs associated with scaling ARCHES will be tracked and utilized in combination with results of the effectiveness trial to assess costs and cost-effectiveness relative to the standard of care. DISCUSSION: This study will provide evidence of the effectiveness of a facility-based intervention to address RC and IPV within public sector FP services at scale, as adapted and implemented in Uasin Gishu county, Kenya. Trial registration Trial registered on 28 September 2023 with clinicaltrials.gov NCT06059196.

This study will document evidence of the effectiveness of the ARCHES intervention, a brief, clinic-based counselling intervention demonstrated to reduce intimate partner violence and reproductive coercion and promote women's reproductive health, as scaled in government health facilities in Kenya. ARCHES aims to (1) decrease unintended pregnancy, (2) increase family planning uptake and use/continuation, (3) decrease experiences of reproductive coercion and intimate partner violence of women and girls aged 15­49 years seeking family planning services, and to (4) improve quality of care, (5) increase gender equitable attitudes, and (6) increase self-efficacy to provide comprehensive family planning counseling among providers trained in ARCHES.

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.

Migration and Mobility: Correlates of Recent HIV Testing Among Substance Using Female Sex Workers at the Mexico-Guatemala Border.

The goal of this paper is to determine the association between traveling to engage in sex work in another country and recent access to HIV testing among substance-using female sex workers (FSWs) in the Mexico-Guatemala border region. From 2012 to 2015, through modified time-location sampling and peer referral, 255 FSWs were recruited at Mexico's southern border. Participants completed questionnaires on sociodemographics, migration and mobility experiences, work environment factors, and substance use. A conceptual framework, as depicted by a directed acyclic graph (DAG), guided our analysis. Crude and adjusted logistic regression models were used to evaluate the relationships between mobility experiences and HIV testing in the past year. Overall HIV testing was low (41%); after considering relevant covariates (i.e., interaction with health services and organizations, and sex work characteristics) traveling to engage in sex work in another country was found to be positively associated with HIV testing in the past year. Future efforts need to consider voluntary and non-stigmatizing prevention HIV services and focus on reaching out to less mobile women.

RESUMEN: El objetivo de este artículo es determinar la asociación entre viajar a otro país para ejercer el comercio sexual y el acceso a una prueba reciente de VIH, en una población de mujeres trabajadoras sexuales en la frontera de México con Guatemala. Entre el 2012 y 2015, utilizando un muestreo por conveniencia y por referencia de pares, se invitó a 255 mujeres trabajadoras sexuales en la frontera sur de México a participar en este proyecto de investigación. Las participantes completaron una encuesta que comprendió preguntas sociodemográficas así como experiencias de migración y movilidad, características del trabajo sexual, y patrones de uso de sustancia. Utilizamos un marco conceptual que se ilustra en una Gráfica Acíclica Dirigida (DAG) el cual sirvió para guiar nuestro análisis. Realizamos análisis de regresión logística cruda y ajustada para evaluar la asociación entre experiencias de movilidad y haber recibido una prueba de VIH en el último año. En general, el porcentaje de haber recibido una prueba de VIH en el último año fue bajo (41%); después de considerar covariables relevantes; (ej., interacción con organizaciones y servicios de salud, características del trabajo sexual) encontramos que viajar a otro país para ejercer el comercio sexual está asociado con haber recibido una prueba de VIH en el último año. Es importante que, en el futuro, se concentren esfuerzos en servicios de prevención del VIH que sean voluntarios, no estigmatizantes, y que se enfoquen en mujeres trabajadoras sexuales menos móviles.

Economic vulnerability, violence, and sexual risk factors for HIV among female sex workers in Tijuana, Mexico.

Economic vulnerability is often reported to underlie involvement in sex work among female sex workers (FSW), but may also create urgency in women's work, limiting women's negotiating power with clients and in turn, increasing their vulnerability for violence and HIV. This study assessed economic vulnerability in relation to violence and sexual risk behaviors for HIV among a sample of FSW in Tijuana, Mexico. FSW at least 18 years of age were recruited through venue-based sampling for a survey (n = 228) and in-depth interviews (n = 50) to investigate HIV risk factors in this region. Using crude and adjusted logistic regression models, we assessed lack of financial support from others as well as reports of financial hardship separately in relation to experiencing sexual violence (e.g. by clients, police, relationship partners, in the past 6 months), physical violence (past 6 months), STI diagnosis, and inconsistent condom use (past 30 days). Qualitative interviews (n = 50), conducted with a subsample of the survey participants, were also examined for related themes. FSW who reported no financial support were more likely to report sexual violence (OR = 2.1; 95% CI:1.1-4.2). FSW who reported financial hardship were more likely to experience sexual violence (OR = 1.9; 95% CI:1.1-3.6) and physical violence (OR = 1.9; 95% CI:1.1-3.6), as well as to report past 30-day inconsistent condom use (OR = 2.4; 95%CI: 1.3-4.6) and to test positive for an STI (OR = 1.9; 95% CI:1.1-3.4). Qualitative data substantiated these findings. Findings suggest that interventions to improve economic well-being may be useful to prevent the intersecting concerns of violence and HIV among FSW.

Associations of attitudes and social norms with experiences of intimate partner violence among married adolescents and their husbands in rural Niger: a dyadic cross-sectional study.

BACKGROUND: Prior cross-sectional research suggests that both men's and women's attitudes towards intimate partner violence (IPV) are predictive of women's IPV experience, although this can vary greatly by context. In general, women who have experienced IPV are likely to report attitudes accepting of it. Men who perpetrate IPV may also report attitudes accepting of it, although some research has found that there is not always an association. Studies that investigate these dynamics often conflate attitudes with social norms, or use attitudes as a proxy for social norms, given that valid measures on social norms are usually lacking. Here we conduct a secondary data analysis to ask how are men's and women's IPV-related attitudes associated with women's reports of IPV and how are men's and women's perceived social norms associated with women's reports of IPV. METHODS: Dyadic data were collected from a representative sample of married adolescent girls and their husbands in 48 rural villages of the Dosso region of Niger (N = 1010). Assessments included logistic regression analyses of husbands' and wives' reports of individual attitudes towards IPV, and social norms based on husbands' and wives' perceptions of their communities' beliefs related to gender roles and acceptability of IPV. RESULTS: Eight percent of women in this sample reported IPV. We found that, consistent with other research, wives who have reported IPV are more likely to report attitudes in support of IPV, while for husbands whose wives report IPV, that relationship is insignificant. On the other hand, husbands who report that people in their community believe there are times when a woman deserves to be beaten are more likely to have perpetrated IPV, while for wives there is no association between the community norm and IPV reporting. Finally, wives who report that people in their community hold inequitable gender norms in general are more likely to have experienced IPV, while for husbands, community gender norms are not predictive of whether their wives have reported IPV. CONCLUSIONS: Our results are evidence that IPV prevention interventions focused solely on individual attitudes may be insufficient. Targeting and assessment of social norms are likely critical to advancing understanding and prevention of IPV.

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.

Male-female concordance in reported involvement of women in contraceptive decision-making and its association with modern contraceptive use among couples in rural Maharashtra, India.

OBJECTIVE: Women's involvement in contraceptive decision-making increases contraceptive use and reduces unmet need, but study of this has been limited to women's self-reports. Less research is available examining couple concordance and women's involvement in contraceptive decision-making as reported by both men and women. STUDY DESIGN: We carried out a cross-sectional study using data from rural India (N = 961 young married couples). Using multivariable regression we examined the association between concordance or discordance in spousal reports of wife's involvement in contraceptive decision-making and modern contraceptive use, adjusting for demographics, intimate partner violence, and contraceptive use discussion. RESULTS: More than one third (38.3%) of women reported current modern contraceptive use. Report of women's involvement in contraceptive decision-making showed 70.3% of couples agreed that women were involved, jointly or alone (categorized as Concordant 1), 4.2% agreed women were not involved (categorized at Concordant 2), 13.2% had women report involvement but men report women were uninvolved (categorized as Discordant 1), and 12.2% had women report uninvolvement but men report that women were involved (categorized as Discordant 2). Discordant 2 couples had lower odds of modern contraceptive use relative to Concordant 1 couples (adjusted RR = 0.61, 95% CI 0.45-0.83). No other significant differences between Concordant 1 couples and other categories were observed. CONCLUSION: One in four couples indicated discordance on women's involvement in contraceptive decision making, with Discordant 2 category having lower odds of contraceptive use. Couples' concordance in women's involvement in contraceptive decision-making offers a target for family planning research and interventions to better meet their needs. Trial registration ClinicalTrial.gov, NCT03514914. https://clinicaltrials.gov/ct2/show/NCT03514914.

Evidence on women's involvement in decision-making are limited to women's self reports and often not specific to contraceptive decision-making. This study uses couples dyadic data to assess male­female concordance on women's involvement in contraceptive decision-making and contraceptive use outcomes. Couple's concordance on women's involvement in contraceptive decision-making is associated with contraceptive use. There is potential in couple-focused family planning counseling that enhances women's contraceptive decision-making agency to improve women's contraceptive use.

Disrupting gender norms in health systems: making the case for change.

Restrictive gender norms and gender inequalities are replicated and reinforced in health systems, contributing to gender inequalities in health. In this Series paper, we explore how to address all three through recognition and then with disruptive solutions. We used intersectional feminist theory to guide our systematic reviews, qualitative case studies based on lived experiences, and quantitative analyses based on cross-sectional and evaluation research. We found that health systems reinforce patients' traditional gender roles and neglect gender inequalities in health, health system models and clinic-based programmes are rarely gender responsive, and women have less authority as health workers than men and are often devalued and abused. With regard to potential for disruption, we found that gender equality policies are associated with greater representation of female physicians, which in turn is associated with better health outcomes, but that gender parity is insufficient to achieve gender equality. We found that institutional support and respect of nurses improves quality of care, and that women's empowerment collectives can increase health-care access and provider responsiveness. We see promise from social movements in supporting women's reproductive rights and policies. Our findings suggest we must view gender as a fundamental factor that predetermines and shapes health systems and outcomes. Without addressing the role of restrictive gender norms and gender inequalities within and outside health systems, we will not reach our collective ambitions of universal health coverage and the Sustainable Development Goals. We propose action to systematically identify and address restrictive gender norms and gender inequalities in health systems.

Prevalence of and Risk Factors for Intimate Partner Violence in the First 6 Months Following HIV Diagnosis Among a Population-Based Sample in Rural Uganda.

Research in Uganda examining HIV-positive status disclosure and IPV victimization is scarce, and existing findings may not generalize to community-based samples of men and women newly diagnosed with HIV in Uganda. We investigated the prevalence of lifetime IPV, IPV experienced between HIV diagnosis and 6 months following diagnosis (recent IPV), and IPV specifically related to a partner learning one's HIV-positive status among a sample of men and women newly diagnosed with HIV in a population-based study in rural Uganda. We also examined correlates of recent IPV, including HIV-positive status disclosure. The sample included 337 participants followed for 6 months after HIV diagnosis. Lifetime IPV findings showed that over half of the sample reported experiencing emotional IPV (62.81% of men, 70.37% of women), followed by physical IPV (21.49% of men, 26.39% of women) then sexual IPV (7.44% of men, 17.59% of women). For recent IPV, men and women reported similar rates of physical (4.63% and 8.29%, respectively) and emotional (19.44% and 25.91%, respectively) IPV. Women were more likely than men to report recent sexual IPV (8.29% vs. 1.85%); however, this relationship was no longer significant after controlling for other risk factors associated with sexual IPV (AOR = 3.47, 95% CI [0.65, 18.42]). Participants who disclosed their HIV-positive status to their partner had 59% lower odds of reporting emotional IPV (AOR = 0.41, 95% CI [0.21, 0.81]) than participants who did not disclose their HIV-positive status. Younger age, non-polygamous marriage, lower social support, and greater acceptance for violence against women were also significantly associated with experience of recent IPV. Overall, 12.20% of participants who experienced recent IPV reported that the IPV was related to their partner learning their HIV-positive status. Findings highlight the need for IPV screening and intervention integrated into HIV diagnosis, care, and treatment services.

HIV Infection and Risk Heightened Among Female Sex Workers Who Entered the Sex Trade as Adolescents in Guatemala.

A dearth of empirical research exists on female sex workers in Central America who begin selling sex under age 18. Data were collected from adult female sex workers (N = 1216) sampled using census and modified time-location sampling in three urban centers of Guatemala. In adjusted analyses, female sex workers who entered the sex trade under age 16 years were more likely to be HIV positive (AOR = 4.6, 95% CI 1.6, 13.2), have not received HIV education in their first year of sex trade (AOR = 2.8, 95% CI 1.5, 5.5), have experienced violence to force commercial sex (AOR = 4.6, 95% CI 2.2, 9.8) and have not used condoms in their first month (AOR = 2.8, 95% CI 1.3, 6.1) , relative to those who entered as adults. An interaction between age at entry and foreign migration at entry was found for HIV risk. Efforts to prevent adolescent sex trade entry are needed and may also help to reduce HIV rates in Guatemala.

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.

Women's and girls' experiences of reproductive coercion and opportunities for intervention in family planning clinics in Nairobi, Kenya: a qualitative study.

BACKGROUND: Reproductive coercion (RC), which includes contraceptive sabotage and pregnancy coercion, may help explain known associations between intimate partner violence (IPV) and poor reproductive health outcomes, such as unintended pregnancy. In Kenya, where 40% of ever-married women report IPV and 35% of ever-pregnant women report unintended pregnancy, these experiences are pervasive and co-occurring, yet little research exists on RC experiences among women and adolescent girls. This study seeks to qualitatively describe women's and girls' experiences of RC in Nairobi, Kenya and opportunities for clinical intervention. METHODS: Qualitative data were collected as part of the formative research for the adaptation of an evidence-based intervention to address reproductive coercion and IPV in clinical family planning counselling and provision in Nairobi, Kenya in April 2017. Focus group discussions (n = 4, 30 total participants) and in-depth interviews (n = 10) with family planning clients (ages 15-49) were conducted to identify specific forms of reproductive coercion, other partner-specific barriers to successful contraception use, and perceived opportunities for family planning providers to address RC among women and girls seeking family planning services. Additionally, data were collected via semi-structured interviews with family planning providers (n = 8) and clinic managers (n = 3) from family planning clinics. Data were coded according to structural and emergent themes, summarized, and illustrative quotes were identified to demonstrate sub-themes. Kenyan family planning providers and administrators informed interpretation. RESULTS: The results of this study identified specific forms of pregnancy coercion and contraceptive sabotage to be common, and often severe, impeding the use of contraceptives among female family planning clients. This study offers important examples of women's strategies for preventing pregnancy despite experiencing reproductive coercion, as well as opportunities for family planning providers to support clients experiencing reproductive coercion in clinical settings. CONCLUSIONS: Reproductive coercion is a critical barrier to modern contraceptive use in Kenya. Results from this study highlight opportunities for family planning providers to play a critical role in supporting women and girls in their use of contraception when reproductive coercion is present.

Protocol for a matched-pair cluster control trial of ARCHES (Addressing Reproductive Coercion in Health Settings) among women and girls seeking contraceptive services from community-based clinics in Nairobi, Kenya.

BACKGROUND: Reproductive coercion (RC) and intimate partner violence (IPV) are prevalent forms of gender-based violence (GBV) associated with reduced female control over contraceptive use and subsequent unintended pregnancy. Although the World Health Organization has recommended the identification and support of GBV survivors within health services, few clinic-based models have been shown to reduce IPV or RC, particularly in low or middle-income countries (LMICs). To date, clinic-based GBV interventions have not been shown to reduce RC or unintended pregnancy in LMIC settings. INTERVENTION: ARCHES (Addressing Reproductive Coercion in Health Settings) is a single-session, clinic-based model delivered within routine contraceptive counseling that has been demonstrated to reduce RC in the United States. ARCHES was adapted to the Kenyan context via a participatory process to reduce GBV and unintended pregnancy among women and girls seeking contraceptive services in this setting. Core elements of ARCHES include enhanced contraceptive counseling that addresses RC, opportunity for patient disclosure of RC and IPV (and subsequent warm referral to local services), and provision of a palm-sized educational booklet. METHODS: A matched-pair cluster control trial is being conducted to assess whether the ARCHES intervention (treatment condition), as compared to standard-of-care contraceptive counseling (control condition), reduces RC and IPV, and improves contraceptive outcomes for woman and girls of reproductive age (15 to 49 years) seeking contraceptive services from community-based clinics in Nairobi, Kenya. All six clinics were assigned to intervention-control pairs based on similarities in patient volume and demographics, physical structure and neighborhood context. Survey data will be collected from patients immediately prior to their clinic visit (baseline, T1), immediately after their clinic visit (exit), and at 3- and 6-months post-visit (T2 and T3, respectively). DISCUSSION: This study is the first to assess the efficacy of an adaptation of the ARCHES model to reduce GBV and improve reproductive health outside of the U.S., and one of only a small number of controlled trials to assess reductions in GBV associated with a clinic-based program in an LMIC context. Evidence from this trial will inform health system efforts to reduce GBV, and to enhance female contraceptive control and reproductive health in Kenya and globally. TRIAL REGISTRATION: Registered May 23, 2018 - ClinicalTrials.gov, NCT03534401. Unique Protocol ID: 170084.

Family planning counseling and its associations with modern contraceptive use, initiation, and continuation in rural Uttar Pradesh, India.

BACKGROUND: We examine the association between the quality of family planning (FP) counseling received in past 24 months, and current modern contraceptive use, initiation, and continuation, among a sample of women in rural Uttar Pradesh, India. METHODS: This study included data from a longitudinal study with two rounds of representative household survey (2014 and 2016), with currently married women of age 15-49 years; the analysis excluded women who were already using a permanent method of contraceptive during the first round of survey and who reported discontinuation because they wanted to be pregnant (N = 1398). We measured quality of FP counseling using four items on whether women were informed of advantages and disadvantages of different methods, were told of method(s) that are appropriate for them, whether their questions were answered, and whether they perceived the counseling to be helpful. Positive responses to every item was categorized as higher quality counseling, vs lower quality counseling for positive response to less than four items. Outcome variables included modern contraceptive use during the second round of survey, and a variable categorizing women based on their contraceptive use behavior during the two rounds: continued-users, new-users, discontinued-users, and non-users. RESULTS: Around 22% had received any FP counseling; only 4% received higher-quality counseling. Those who received lower-quality FP counseling had 2.42x the odds of reporting current use of any modern contraceptive method (95% CI: 1.56-3.76), and those who received higher quality FP counseling at 4.14x the odds of reporting modern contraceptive use (95% CI: 1.72-9.99), as compared to women reporting no FP counseling. Women receiving higher-quality counseling also had higher likelihood of continued use (ARRR 5.93; 95% CI: 1.97-17.83), as well as new use or initiation (ARRR: 4.2; 95% CI: 1.44-12.35) of modern contraceptives. Receipt of lower-quality counseling also showed statistically significant associations with continued and new use of modern contraceptives, but the effect sizes were smaller than those for higher-quality counseling. CONCLUSIONS: Findings suggest the value of FP counseling. With a patient-centered approach to counseling, continued use of modern contraceptives can be supported among married women of reproductive age. Unfortunately, FP counseling, particularly higher-quality FP counseling remains rare.

Can community health workers increase modern contraceptive use among young married women? A cross-sectional study in rural Niger.

BACKGROUND: The Republic of Niger has the highest rate of early marriage and adolescent fertility in the world. Recent global health initiatives, such as Family Planning 2020, have reinvigorated investments in family planning in low- and middle-income countries (LMICs). As part of this initiative, Niger has implemented ambitious plans to increase contraceptive prevalence through policies designed to increase coverage and access to family planning services. One strategy involves the deployment of volunteer community health workers (relais communautaires) in rural settings to improve access to family planning services, especially among adolescents and youth. The objective of this article is to determine if visits by relais are associated with increased use of modern contraception among young married women in rural Niger. METHODS: Cross-sectional data from a household survey were collected from young married women between the ages of 13 and 19 in three rural districts in the region of Dosso, Niger from May to August 2016. Multivariate logistic regression was conducted to assess the odds of married female youth reporting current use of modern contraceptive methods based on being visited by a relais in the past three months. RESULTS: A total of 956 young married women were included in the final analysis. Among study participants, 9.3% reported a relais visit to discuss health issues in the past three months and 11.4% reported currently using a modern method of contraception. Controlling for socio-demographic variables, the odds of current use of modern contraceptive methods were higher among young married women who were visited by a relais in the last three months compared to those not visited by a relais during this period (AOR = 1.94[95% CI 1.07-3.51]). In this study setting, relais were less likely to visit nulliparous women and women that worked in the past 12 months. CONCLUSION: Young married women visited by relais were more likely to use modern contraceptive methods compared to those not visited by a relais. These results are consistent with similar family planning studies from sub-Saharan Africa and suggest that relais in Niger may be able to provide access to essential family planning services in rural and hard-to-reach areas. Additional efforts to understand the contraceptive barriers faced by nulliparous women and working women should be a key research priority in Niger. TRIAL REGISTRATION: Clinical trial registration number 2016-1430 ; registered on October 7, 2016 (retrospectively registered).

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.

Cyber Sexual Harassment: Prevalence and association with substance use, poor mental health, and STI history among sexually active adolescent girls.

INTRODUCTION: The current study aims to assess the prevalence, perpetrators, and consequences of cyber sexual harassment (CSH) among adolescent females. METHODS: Sexually active adolescent females (N = 159) ages 15-19 were recruited from a health clinic in a low-income, urban area of southeast San Diego County, California to complete a tablet-administered survey that included items on sexual violence and harassment, including CSH. Using logistic regression models, we assessed CSH in relation to substance use, poor mental health outcomes and STI history. RESULTS: Participants were, on average, 17 years of age and half were currently in a relationship. The majority of girls (68%) reported at least one form of CSH, which included receiving unwanted sexual messages/photos (53%), receiving unwanted messages asking them to do something sexual (49%), being pressured to send sexual photos (36%), and having sexual photos shared without permission (6%). Perpetrators included known and unknown males; almost a third (27%) reported perpetration by a relationship partner. In logistic regression models adjusting for race, CSH was associated with: past 30-day alcohol use, drug use (ever), feeling depressed (past 30 days), and feeling anxious (past 30 days) (Odds Ratios ranged: 2.9-7.5). CSH was also associated with past-year suicidal thoughts and STI diagnosis (ever) (p < 0.05, ORs not presented due to small numbers). CONCLUSIONS: Our findings suggest that in some subgroups, CSH appears to be affecting the majority of girls, which is especially concerning given its association with multiple poor health outcomes.

Substance Use among Female Sex Workers in Two US-Mexico Border Cities: Associations with Age of Entry.

BACKGROUND: Research has documented consistent associations between entry into sex work as a minor and sexual HIV risk. However, previous studies have not examined whether substance use and related HIV risk are elevated among those who enter sex work under age 18. METHODS: Quantitative data were collected via time-location sampling of 603 female sex workers (FSWs) ages 18 years and older residing in two Mexico-US border cities. Age of entry into sex work (categorized as 15 years or younger, 16-17 years, or 18 years and older) was assessed as a predictor of substance use (forced and voluntary) within the first month post-entry and recent (past 30 days) substance use with clients. RESULTS: Compared to those who entered as adults, participants who entered sex work at age 15 or younger were significantly more likely to report drug use (AOR = 5.2, CI = 2.9-8.9) and forced drug use within the first 30 days of entry (AOR= 6.0, CI = 1.9-18.9), as well as past month drug use with clients (AOR= 3.4, CI = 1.9-5.8). Similar results were found among participants who entered sex work at age 16-17. CONCLUSIONS: Increased risk of recent substance use with clients indicates continuing elevated risk for those entering sex work at these early ages. Early and forced substance use at entry may underlie the elevated risk of HIV infection consistently observed among this population.