Sexual behavior among emerging adults in Africa: a systematic review and meta-analysis.

BACKGROUND: Estimates on sexual behavior (SB) among emerging adults (EmA) is varied in literature, which presents a challenge when designing targeted interventions. We aimed to summarize literature on prevalence and risk factors of SB among EmA in Africa. METHODS: A search for studies published in PubMed, Embase and Psych Info by March 2023 was done. Studies involving EmA (18-25 years), conducted in Africa and reporting one or more of seven SB were reviewed. Pooled prevalence estimates were summarized using forest plots. Heterogeneity in SB was explored. Risk factors were synthesized using a modified socio-ecological model. RESULTS: Overall, 143 studies were analyzed. Non-condom use had the highest pooled prevalence (47% [95% CI: 42-51]), followed by study-defined SB (37% [95% CI: 25-50]) and concurrency (37% [95% CI: 21-54]), multiple sex partners (31% [95% CI: 25-37]), younger age at sexual debut (26% [95% CI: 20-32]), age disparate relationships (24% [95% CI: 17-32]) and transactional sex (19% [95% CI: 13-26]). Heterogeneity was partially explained by sex, with female participants having higher pooled prevalence estimates compared to their male counterparts. In four of the seven outcomes, alcohol/drug use was the most common risk factor. CONCLUSIONS: SB was common among EmA and differentially higher in emerging female adults. Non-condom use had the highest pooled prevalence, which may contribute to the transmission of HIV and other sexually transmitted infections (STIs). Interventions targeting emerging female adults and alcohol/drug use may reduce SB, which may in-turn mitigate transmission of HIV and other STIs among EmA in Africa.

Effects of COVID-19 measures on access to HIV/STI testing and condoms among adults in Sweden: a cross-sectional online survey.

AIMS: To investigate the self-reported impact of COVID-19 measures on access to testing for HIV and other sexually transmitted infections (STIs) and condoms and factors associated with reduced access among adults in Sweden. METHODS: Cross-sectional data were collected in late 2020 through a web panel with adults (18-49 years) in Sweden as part of the International Sexual Health And REproductive health survey (I-SHARE) (N=1307). The primary outcome was self-reported access to HIV/STI testing and condoms during COVID-19 measures. Logistic regression was used to assess adjusted odds ratios of experiencing reduced access to HIV/STI testing and condoms in relation to sociodemographic characteristics, changes in sexual behaviours and COVID-19-related factors. RESULTS: Of the 1138 sexually active respondents, 17% wanted an HIV/STI test, and of those over half (57%) reported reduced access during the COVID-19 measures in 2020. Compared with cis-women, transgender or non-binary respondents were more likely to experience lower access to testing. Among those who usually used condoms (n=568), 23% reported hampered condom access due to COVID-19 restrictions. Reduced condom access was associated with identifying as non-cis gender and a cis-man compared with cis-woman, non-heterosexual orientation, being foreign-born and financially worried. CONCLUSIONS: Findings indicate that access to HIV/STI testing and condoms among sexually active adults of reproductive age in Sweden was disrupted during the COVID-19 pandemic in 2020 with varied impact depending on sexual orientation, gender identity or socioeconomic situation. This signals the importance of ensuring equitable access to sexual and reproductive health services and commodities in future crises response.

Process evaluation of a parent-child communication intervention for adolescent sexual and reproductive health in Uganda.

BACKGROUND: Previous initiatives concerning adolescent sexual and reproductive health (SRH) education in Low-or-Middle Income Countries (LMICs) have been limited by cultural norms and misinformation perpetuated within families. Responding to the paucity of research on the implementation of SRH interventions in LMICs and limited knowledge regarding their mechanisms, this study undertakes a process evaluation of a parent-focused intervention to promote parent-adolescent communication about SRH in Uganda. METHODS: This paper explores the implementation, contextual factors and mechanisms of impact of the intervention, using the Medical Research Council (MRC) guidelines for process evaluations. Implementation was evaluated through indicators of dose, fidelity and adaptations, acceptability and feasibility. The contextual factors and mechanisms of impact were evaluated to refine the intervention's causal assumptions. Data was collected during April - October 2021 in South-Western Uganda using a mixed-methods approach, including document analysis, intervention observations, interviews, focus group discussions and most significant change stories. RESULTS: The acceptability of the intervention was related to its community engagement, the strong rapport with delivery agents, and individual characteristics of participants. Five contextual factors influencing implementation were highlighted; (i) cultural norms, (ii) perceptions about youth SRH, (iii) poverty, (iv) Covid-19 pandemic, and (v) prior research projects in the community. When considering the intervention's mechanisms of impact, four causal pathways were identified; (i) Awareness of SRH needs helped parents overcome stigma, (ii) Parenting skills training improved SRH communication, (iii) Group learning stimulated shared parenting, and (iv) Group learning improved co-parenting. CONCLUSION: The paper presented three key learnings and corresponding recommendations for future research. Firstly, implementation success was credited to meaningful community engagement which improved acceptability and uptake. Secondly, the complex influences of contextual factors highlighted the need for contextual analysis in research studies to inform intervention design. Finally, this evaluation recognised the interplay between mechanisms of impact and suggested further research consider such combined impacts when designing intervention content.

How can civil society organizations contribute to the scale-up of comprehensive sexuality education? Presentation of a scaling framework illustrated with examples from Indonesia.

Comprehensive sexuality education (CSE) can substantially contribute to the health and well-being of young people. Yet, most CSE interventions remain limited to the small piloting or research phase and scale-up is often an afterthought at the end of a project. Because of the specificities of CSE, including it being a controversial topic in many contexts and a topic on the fringe between health, education and youth, a specific scaling approach to CSE is needed. The commentary presents a practical framework to support civil society organisations (CSOs), to address barriers to scaling up CSE in their contexts. The utilization and relevance of the framework is demonstrated in this article, by featuring examples from the scale up process of CSE in Indonesia. The framework identifies key principles for scaling up, including: taking a scaling mindset from the start, government ownership and political commitment for scale-up, and identifying the added value of CSOs. The framework starts with a self-assessment by the CSO and then follows four phases: making the case, engaging in dialogue, establishing building blocks and implementation and scale-up. Each of these phases are illustrated with examples from Indonesia.This framework is a call to action with practical guidelines to support CSOs to take on this role, because with the right scaling strategies, the largest generation of young people ever alive can become healthy, empowered and productive adults.

The International Sexual Health And REproductive Health during COVID-19 (I-SHARE) Study: A Multicountry Analysis of Adults from 30 Countries Prior to and During the Initial Coronavirus Disease 2019 Wave.

BACKGROUND: There is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of coronavirus disease 2019 (COVID-19). To address this gap, our team organized a multicountry, cross-sectional online survey as part of a global consortium. METHODS: Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service use, and we compared 3 months prior to and during policy measures to mitigate COVID-19. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence. RESULTS: Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%), and 640 (14.1%) reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063 of 15 144, 7.0%) compared to before COVID-19 measures (1469 of 15 887, 9.3%). COVID-19 measures impeded access to condoms (933 of 10 790, 8.7%), contraceptives (610 of 8175, 7.5%), and human immunodeficiency virus/sexually transmitted infection (HIV/STI) testing (750 of 1965, 30.7%). Pooled estimates from meta-analysis indicate that during COVID-19 measures, 32.3% (95% confidence interval [CI], 23.9%-42.1%) of people needing HIV/STI testing had hindered access, 4.4% (95% CI, 3.4%-5.4%) experienced partner violence, and 5.8% (95% CI, 5.4%-8.2%) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy. CONCLUSIONS: Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

How did COVID-19 measures impact sexual behaviour and access to HIV/STI services in Panama? Results from a national cross-sectional online survey.

OBJECTIVE: To describe reported changes in sexual behaviours, including virtual sex (sexting and cybersex), and access to HIV/STI testing and care during COVID-19 measures in Panama. METHODS: We conducted an online cross-sectional survey from 8 August to 12 September 2020 among adults (≥18 years) residing in Panama. Participants were recruited through social media. Questions included demographics, access to HIV/STI testing and HIV care, and sexual behaviours 3 months before COVID-19 social distancing measures and during social distancing measures (COVID-19 measures). Logistic regression was used to identify associations between variables and behavioural changes. RESULTS: We recruited 960 participants; 526 (54.8%) identified as cis-women, 366 (38.1%) cis-men and 68 (7.1%) non-binary or another gender. The median age was 28 years (IQR: 23-37 years), and 531 of 957 (55.5%) were of mixed ethnicity (mixed Indigenous/European/Afro-descendant ancestry). Before COVID-19 measures, virtual sex was reported by 38.5% (181 of 470) of cis-women, 58.4% (184 of 315) cis-men and 45.0% (27 of 60) non-binary participants. During COVID-19 measures, virtual sex increased among 17.2% of cis-women, 24.7% cis-men and 8.9% non-binary participants. During COVID-19 measures, 230 of 800 (28.8%) participants reported decreased casual sex compared with pre-COVID-19 measures. Compared with pre-COVID-19 measures, decreased casual sex was reported more frequently during COVID-19 measures by cis-men compared with cis-women (39.2% vs 22.9%, urban/rural adjusted OR (AOR)=2.17, 95% CI 1.57 to 3.01), and by Afro-descendant compared with participants of mixed ethnicity (40.0% vs 29.8%, AOR=1.78, 95% CI 1.07 to 2.94). Compared with no change in virtual sex (16.8%), increased virtual sex (38.5%, AOR=1.78, 95% CI 1.10 to 2.88) and decreased virtual sex (86.7%, AOR=16.53, 95% CI 7.74 to 35.27) were associated with decreased casual sex encounters. During COVID-19 measures, HIV/STI testing could not be obtained by 58.0% (58 of 100) of the participants who needed a test, and interrupted HIV care was reported by 53.3% (8 of 15) of participants living with HIV. CONCLUSIONS: COVID-19 measures in Panama were associated with a decrease in casual sex among cis-men and Afro-descendant people, while access to HIV/STI testing and care was seriously disrupted.

Trends and determinants of adolescent pregnancy: Results from Kenya demographic health surveys 2003-2014.

BACKGROUND: Adolescent pregnancy increases the risk of disability and death due to unsafe abortion, prolonged labour and delivery, and complications after birth. Availability of accurate data is important to guide decision-making related to adolescent sexual reproductive health (ASRH). This study analyses the trends in prevalence and factors associated with adolescent pregnancy in Kenya using data from three national Demographic Health Surveys (2003, 2008/2009, 2014). METHODS: Our analysis focused on a subsample of data collected from women aged 20 to 24 years. A trend analysis was performed to establish a change in the rate of adolescent pregnancy in 2003, 2008/2009, and 2014 survey data points. Binary Logistic regression and pooled regression analysis were used to explore factors associated with adolescent pregnancy. RESULTS: The percentage of women aged 20 to 24 years who reported their first pregnancy between ages 15 and 19 years was 42% in 2003 and 42.2% in 2009 but declined to 38.9% in 2014. Using regression analyses, we established that education status, marital status, religion and wealth quintile were associated with adolescent pregnancy. Trend analysis shows that there was an overall decreasing trend in adolescent pregnancy between 2003 and 2014. CONCLUSION: Although Kenya has made strides in reducing the prevalence of adolescent pregnancy in the last decade, much more needs to be done to further reduce the burden, which remains high. DEFINITION: Adolescents: Although WHO defines the adolescence period as being 10-19 years, this paper focuses on the late adolescent period, 15-19 years, here in referred to as adolescents.

Sexual satisfaction and sexual behaviors during the COVID-19 pandemic: results from the International Sexual Health And REproductive (I-SHARE) health survey in Luxembourg.

AIM: To identify the impact of COVID-19 measures on sexual behaviors and sexual satisfaction in Luxembourg residents. METHODS: We conducted a cross-sectional online survey of adults (> 18 years of age) residing in Luxembourg, while COVID-19 restrictions were in place. The survey was available from January 15 to February 12, 2021 in four languages (French, German, English and Portuguese). Survey questions focused on masturbation, cuddling, condom use, sex frequency, sexting, cybersex, watching porn, and sexual satisfaction. RESULTS: 557 volunteers completed the survey (35.5% men, 64.3% women). Sexual satisfaction and sexual problems variables were assessed on 4-point Likert scales (0 = not at all/never to 3 = very/often). Sexual problems increased during the COVID-19 measures while sexual satisfaction decreased compared to before the introduction of COVID-19 restrictions (assessed retrospectively). Factors associated with increased odds of sexual satisfaction included having a steady relationship before COVID-19 restrictions, engaging in sexting, reporting good mental health and not altering alcohol intake. CONCLUSIONS: The context of the COVID-19 pandemic and the measures implemented in Luxembourg affected sexual behaviors and sexual satisfaction. Sexual and reproductive health care centers and health professionals in general should take these results into consideration when providing care. Recommendations on the importance of sexual health for general wellbeing and behaviors associated with sexual satisfaction should be offered and possibilities to experience sexuality while reducing contamination risks be discussed.

Level and comfort of caregiver-young adolescent communication on sexual and reproductive health: a cross-sectional survey in south-western Uganda.

BACKGROUND: Communication on sexual and reproductive health (SRH) between caregivers and their young adolescent children plays a significant role in shaping attitudes and behaviours that are critical to laying the foundations for positive and safe SRH behaviours in later adolescence. Nevertheless, this communication is often limited, particularly in countries where adolescent sexuality is taboo. This study assessed the topics discussed ('level') and the comfort of caregivers with communicating with young adolescents on SRH, and their correlates.  METHODS: A cross-sectional survey was conducted among 218 caregivers of young adolescents (10-14 years) in Mbarara district of south-western Uganda in January and February 2020. Participants were selected through consecutive sampling. A structured, pre-tested questionnaire administered by interviewers was used for data collection. The surveys were computer-assisted using Kobo Collect software. Data was exported to STATA 14 for analysis. Level of SRH communication was measured based on 10 SRH communication topics, while comfort was based on 9 SRH discussion topics. Bivariate and multivariate linear regression analyses were conducted to determine correlates of level of, and comfort with, SRH communication P-value < 0.05 was considered for statistical significance. RESULTS: The mean number of topics that caregivers discussed was 3.9 (SD = 2.7) out of the 10 SRH topics explored. None of the respondents discussed all the topics; 2% reported ever discussing nine topics with their young adolescent, while 3.5% reported never discussing any of the topics. General health and bodily hygiene (89.9%) and HIV/AIDS and other sexually transmitted infections (STIs) (77.5%) were the most commonly discussed, while night emissions in boys (4.3%) and condoms (8.3%) were least discussed. The majority of caregivers (62%) reported a high level of comfort with discussing SRH. The mean comfort score was 21.9 (SD = 3.8). In general, the level of SRH communication increased with an increase in comfort with SRH communication ß = 0.22 (0.04); 95% CI = (0.15, 0.30). The level of comfort with SRH communication decreased with an increase in the number of YAs in a household ß = -0.92 (0.38); 95%CI = (-1.66,-0.18). CONCLUSION: Overall, the level of SRH communication is low and varies according to the number of SRH topics. Caregivers' comfort with SRH communication with YAs was a significant correlate of SRH communication. This justifies the need for interventions that aim to improve caregivers' comfort with communicating with young adolescents about SRH.

A comparative human rights analysis of laws and policies for adolescent contraception in Uganda and Kenya.

BACKGROUND: Improving access to adolescent contraception information and services is essential to reduce unplanned adolescent pregnancies and maternal mortality in Uganda and Kenya, and attain the SDGs on health and gender equality. This research studies to what degree national laws and policies for adolescent contraception in Uganda and Kenya are consistent with WHO standards and human rights law. METHODS: This is a comparative content analysis of law and policy documents in force between 2010 and 2018 governing adolescent (age 10-19 years) contraception. Between and within country differences were analysed using WHO's guidelines "Ensuring human rights in the provision of contraceptive information and services". RESULTS: Of the 93 laws and policies screened, 26 documents were included (13 policies in Uganda, 13 policies in Kenya). Ugandan policies include a median of 1 WHO recommendation for adolescent contraception per policy (range 0-4) that most frequently concerns contraception accessibility. Ugandan policies have 6/9 WHO recommendations (14/24 sub-recommendations) and miss entirely WHO's recommendations for adolescent contraception availability, quality, and accountability. On the other hand, most Kenyan policies consistently address multiple WHO recommendations (median 2 recommendations/policy, range 0-6), most frequently for contraception availability and accessibility for adolescents. Kenyan policies cover 8/9 WHO recommendations (16/24 sub-recommendations) except for accountability. CONCLUSIONS: The current policy landscapes for adolescent contraception in Uganda and Kenya include important references to human rights and evidence-based practice (in WHO's recommendations); however, there is still room for improvement. Aligning national laws and policies with WHO's recommendations on contraceptive information and services for adolescents may support interventions to improve health outcomes, provided these frameworks are effectively implemented.

The unmet need for contraception among adolescents is high in Uganda and Kenya, and has many negative consequences, including unwanted pregnancy, exposure to unsafe abortion, and maternal morbidity and mortality. National laws and policies play an important role in determining adolescents' access to contraception. For example, national laws and policies can shape the government programs that provide (or withhold) contraception, and the social norms influencing adolescents' access to contraception. Therefore, this research compares national laws and policies that determine access to contraception services and information for adolescents in Uganda and Kenya with WHO's recommendations for access to contraception.This is an analysis of the content of Ugandan and Kenyan laws and policies in force between 2010 and 2018. The content of these documents was analyzed using WHO's nine recommendations for how contraception information and services should be provided: non-discrimination, availability, accessibility, acceptability, quality, informed decision-making, confidentiality, participation, accountability.Ninety-three documents were screened and 26 documents were included in the analysis: 13 policies from Uganda and 13 policies from Kenya. On average, Ugandan policies include one WHO recommendation for adolescent contraception per policy and Kenyan policies include two WHO recommendations. This recommendation most frequently mentioned in all policies is the accessibility of contraception (for example, for adolescents living remotely, integrated in adolescent HIV or pre-/post-natal care, etc.). Together, all Ugandan policies mentioned 6/9 WHO recommendations whereas all Kenyan policies cover 8/9 WHO recommendations.In conclusion, Ugandan and Kenyan policies are consistent with many of WHO's recommendations for access to contraception, however, there is still room for improvement.

Which factors contribute to sexual well-being? A comparative study among 17 to 20 year old boys and girls in Belgium and Ecuador.

Despite recognition that sexual well-being is an important part of adolescent sexual and reproductive health, a clear description of adolescent sexual well-being does not yet exist. Through six in-depth interviews and four focus group discussions with 56 young people in two distinct contexts (Belgium and Ecuador), we used the social-ecological framework to identify factors influencing adolescent sexual well-being. According to respondents, the main factors that influence adolescent sexual well-being are not only situated at the individual (having knowledge and skills and being physically, sexually and mental mature and healthy) and interpersonal levels (positive attraction towards others and communication about sexuality), but at a broader societal level, including social acceptance of sex, gender and sexual diversity and its (legal) translation into comprehensive sexuality education and the ready availability of contraceptives. Our results go well beyond two existing definitions of (adolescent) sexual well-being to contribute to understanding and measurement from the perspective of young people themselves, adding substantively to ongoing discussion about the definition of the concept.

International Sexual Health And REproductive health (I-SHARE) survey during COVID-19: study protocol for online national surveys and global comparative analyses.

BACKGROUND: COVID-19 may have a profound impact on sexual health, reproductive health and social life across the world. Shelter in place regulations that have extended across the globe may influence condomless sex, exacerbate intimate partner violence and reduce access to essential reproductive health services. Population representative research is challenging during shelter in place, leaving major gaps in our understanding of sexual and reproductive health during COVID-19. This International Sexual Health And ReproductivE health (I-SHARE) study protocol manuscript describes a common plan for online national surveys and global comparative analyses. METHODS: The purpose of this cross-sectional study is to better understand sexual and reproductive health in selected countries during the COVID-19 pandemic and facilitate multinational comparisons. Participants will be recruited through an online survey link disseminated through local, regional and national networks. In each country, a lead organisation will be responsible for organising ethical review, translation and survey administration. The consortium network provides support for national studies, coordination and multinational comparison. We will use multilevel modelling to determine the relationship between COVID-19 and condomless sex, intimate partner violence, access to reproductive health services, HIV testing and other key items. This study protocol defines primary outcomes, prespecified subanalyses and analysis plans. CONCLUSION: The I-SHARE study examines sexual and reproductive health at the national and global level during the COVID-19 pandemic. We will use multilevel modelling to investigate country-level variables associated with outcomes of interest. This will provide a foundation for subsequent online multicountry comparison using more robust sampling methodologies.

Induced abortion: a cross-sectional study on knowledge of and attitudes toward the new abortion law in Maputo and Quelimane cities, Mozambique.

BACKGROUND: Maternal mortality, of which 6.7% is attributable to abortion complications, remains high in Mozambique. The objective of this paper is to assess the level of induced abortion at the community, as well as to assess awareness of and attitudes towards the new abortion law among women of reproductive age in suburban areas of Maputo and Quelimane cities. METHODS: A cross-sectional household survey among women aged 15-49 years in Maputo and Quelimane cities was conducted using a multi-stage clustered sampling design. Data on sociodemographic characteristics, maternal outcomes, contraceptive use, knowledge and attitudes towards the new abortion law were collected. Bivariate and multiple logistic regression analysis using the complex samples procedure in SPSS were applied. RESULTS: A total of 1657 women (827 Maputo and 830 Quelimane) were interviewed between August 2016 and February 2017. The mean age was 27 years; 45.7% were married and 75.5% had ever been pregnant. 9.2% of the women reported having had an induced abortion, of which 20.0% (17) had unsafe abortion. Of the respondents, 28.8% knew the new legal status of abortion. 17% thought that the legalization of abortion was beneficial to women's health. Having ever been pregnant, being unmarried, student, Muslim, as well as residing in Maputo were associated with higher odds of having knowledge of the new abortion law. CONCLUSION: Reports of abortion appear to be low compared to other studies from Sub-Saharan African countries. Furthermore, respondents demonstrated limited knowledge of the abortion law. Social factors such as education status, religion, residence in a large city as well as pregnancy history were associated with having knowledge of the abortion law. Only a small percentage of women perceived abortion as beneficial to women's health. There is a need for widespread sensitization about the new law and its benefits.

Components of antenatal care received by women in fishing communities on Lake Victoria, Uganda; a cross sectional survey.

BACKGROUND: Uganda has one of the highest maternal deaths at a ratio of 336 per 100,000 live births. As Uganda strives to achieve sustainable development goals, appropriate antenatal care is key to reduction of maternal mortality. We explored women's reported receipt of seven of the Uganda guidelines components of antenatal care, and associated factors in hard to reach Lake Victoria island fishing communities of Kalangala district. METHODS: A cross sectional survey among 486 consenting women aged 15-49 years, who were pregnant at any time in the past 6 months was conducted in 6 island fishing communities of Kalangala district, Uganda, during January-May 2018. Interviewer administered questionnaires, were used to collect data on socio-demographics and receipt of seven of the Uganda guidelines components of antenatal care. Regression modeling was used to determine factors associated with receipt of all seven components. RESULTS: Over three fifths (65.0%) had at least one ANC visit during current or most recent pregnancy. Fewer than a quarter of women who reported attending care at least four times received all seven ANC components [(23.6%), P < 0.05]. Women who reported receipt of ANC from the mainland were twice as likely to have received all seven components as those who received care from islands (aOR = 1.8; 95% CI:0.9-3.7). Receipt of care from a doctor was associated with thrice likelihood of receiving all components relative to ANC by a midwife or nurse (aOR = 3.2; 95% CI:1.1-9.1). CONCLUSIONS: We observed that the delivery of antenatal care components per Ugandan guidelines is poor in these communities. Cost effective endeavors to improve components of antenatal care received by women are urgently needed. Task shifting some components of ANC to community health workers may improve care in these island communities. TRIAL REGISTRATION: PACTR201903906459874 (Retrospectively registered).

Poverty, gender and reproductive justice. A qualitative study among adolescent girls in Western Uganda.

Low socio-economic status has been consistently identified as a primary risk factor for sexual and reproductive health violations affecting young women. This study shows how poverty interacts with gender power relations to impact upon adolescent girls' sexual and reproductive lives in Western Uganda. Qualitative research with 147 participants was undertaken. This comprised 59 in-depth interviews and 11 focus group discussions with groups of 12-14 year-old young women, teachers and parents. Data were analysed manually using open and axial coding, and conclusions were generated inductively. Findings reveal that young women are restricted in exercising their sexual and reproductive rights not only by poverty and unequal gender relations, but also by corruption and poor service provision. In contrast to interventions using liberal rights-based approaches, we advocate the use of a 'marketplace of options' since access to sexual and reproductive health services is very limited for poor girls and not evenly distributed. Moreover, while poverty and unequal gender relations render girls vulnerable to sexual coercion and violence, the criminal justice system is often weak, leaving victims powerless. Investment in appropriate resources and inclusive and affordable access to justice is essential to advance young women's sexual and reproductive health.

Evaluation of a school based comprehensive sexuality education program among very young adolescents in rural Uganda.

BACKGROUND: Limited research has been conducted on the effectiveness of sexuality education for very young adolescents (VYAs) ages 10-14 years in Sub-Saharan Africa. Furthermore, evaluations of sexuality education programs often report outcomes of risky sexual practices, yet positive aspects of sexuality are hardly studied and rarely reported. This study evaluates the effectiveness of a Comprehensive Sexuality Education (CSE) intervention for VYAs in Uganda, analyzing both positive and negative outcome indicators. METHODS: We conducted a mixed methods study, incorporating a cluster randomized trial (NCT03669913) among pupils in 33 randomly selected primary schools in Mbarara district. This was followed by a qualitative evaluation of the intervention in 4 schools that included 14 in-depth interviews and 3 focus group discussions distributed among pupils, teachers and parents. Quantitative data were analyzed using ordered logistic regression to compare differences in the change from baseline to endline between the intervention and control arms. We conducted bivariate analysis and multiple regression analysis controlling for key covariates, including age, gender, school location (rural vs urban), truancy, and orphanhood. Qualitative data were analyzed by thematic approach using ATLAS TI. RESULTS: Between July 2016 and August 2017, 1096 pupils were recruited. Outcomes were studied among 380 pupils in the intervention arm and 484 pupils in the control arm. The proportion of pupils who ever had sex increased from 9 to 12.1% in intervention compared to 5.2 to 7.4% in the control group between baseline and endline, however the differences between groups were not statistically significant. We found greater improvements in sexual and reproductive health (SRH) knowledge among intervention schools (AOR: 2.18, 95% CI: 1.66-2.86) and no significant differences in self-esteem, body image or gender equitable norms. Qualitative evidence echoes perceived SRH knowledge acquisition, increased their perception of SRH related risks, and intentions to delay sexual intercourse to prevent unwanted pregnancy, HIV and other STIs. CONCLUSION: This study demonstrates that CSE can improve SRH knowledge and behavioral intentions among VYAs in Uganda. These results further emphasize the importance of initiating sexuality education before most adolescents have started engaging in sexual activity, enabling them to make informed decisions in the future. TRIAL REGISTRATION: NCT03669913 , registered retrospectively on September 13th, 2018.

Adult and young women communication on sexuality: a pilot intervention in Maputo-Mozambique.

BACKGROUND: Communication on sexuality within the family has been considered a determinant factor for the sexual behaviour of young women, contributing to delaying sexual initiation. Taking into account that young women are increasingly exposed to sexualized messages, they need clear, trustful and open communication on sexuality more than ever. However, in Mozambique, communication about sexuality is hampered by strict social norms. This paper evaluates the case of an intervention aimed at reducing the generational barrier for talking about sexuality and to contribute to better communication within the family context. METHODS: The intervention consisted of three weekly one-hour coached sessions in which female adults and young interacted about sexuality. Realist evaluation was used as a framework to assess context, mechanisms, and outcomes of the intervention. Interviews were conducted among 13 participants of the sessions. RESULT: The interaction sessions were positively appreciated by the participants and contributed to change norms and attitudes towards communication on sexuality within families. Recognition of similarities and awareness of differences were key in the mechanisms leading to these outcomes. This was reinforced by the use of visual materials and the atmosphere of respect and freedom of speech that characterized the interactions. Limiting factors were related to the long-standing taboo on sexuality and existing misconceptions on sexuality education and talks about sex. CONCLUSION: By elucidating mechanisms and contextual factors our study adds knowledge on strategies to improve transgenerational communication about sexuality.

Evaluating the effectiveness of a combined approach to improve utilization of adolescent sexual reproductive health services in Kenya: a quasi-experimental design study protocol.

BACKGROUND: Access to and utilization of adolescent sexual and reproductive health (ASRH) services remains poor. ASRH services in Kenya are primarily offered in health facilities and include counselling, information, and services on family planning, sexually transmitted infections, and HIV and basic life skills. The Ministry of Education also provides age-appropriate sexual and reproductive health information in schools. This paper presents a study protocol that will evaluate the effectiveness of a combined approach toward improving utilization of ASRH services. METHODS: This will be a quasi-experimental study utilizing qualitative and quantitative methods. During the formative phase, data will be collected through focus group discussions, in-depth interviews, and key informant interviews to explore the barriers and facilitators of provision and utilization of ASRH services. A quantitative design will be used to obtain baseline and endline data through household surveys and client exit interviews. Following the formative and baseline household and client exit assessments, an intervention focusing on provision of ASRH service package targeting boys and girls will be implemented for 18 months. The package will include contextualized ASRH services, including counselling and age-appropriate, comprehensive sexual education for behavior change with an aim to increase utilization of ASRH services. An analysis of the primary outcome (utilization of ASRH services) will be undertaken to establish the difference in difference between the control and intervention arm, before the intervention (using the baseline survey data) and after the intervention (using the endline survey data). DISCUSSION: Adolescents have now been included in the World Health Organization's Global strategy for women's, children's and adolescents' health (2016-2030), acknowledging the unique health challenges facing young people and their pivotal role as drivers of change in the post-2015 era. This study will generate evidence on whether a combined school, facility, and community approach works toward improving utilization of ASRH services. The information generated from the study will be beneficial for programming as it will identify underlying reasons for low utilization of ASRH services. Results will help to shape ASRH programs and reduce teenage pregnancy within Kenya and other similar low middle-income countries. TRIAL REGISTRATION: The study is registered at http://www.pactr.org/ , registration number PACTR201906738029948.

Evaluation of the ELIMIKA Pilot Project: Improving ART Adherence among HIV Positive Youth Using an eHealth Intervention in Mombasa, Kenya.

Adolescents and young people are arguably the most dynamic and challenging group among populations living with HIV. The adherence to anti-retroviral treatment (ART) is often low among HIV-positive youth, thus creative and context specific interventions are necessary. We aimed at evaluating the usability and effectiveness of the pilot digital peer support platform - ELIMIKA, implemented in Mombasa, Kenya. We applied a pre-post-test design. Data collection consisted of two parts: pre- and post-online knowledge and behavior questionnaires, and a mid-term usability survey. From 90 recruited participants, 81 completed the pre- and post-questionnaires. Overall, the participants were satisfied with the main features of the web platform and stated that they would use it again (95%). However, there was not a significant change in knowledge and behavior, but adherence intentions after 3 months intervention period have improved. This study provides valuable information on feasibility, evaluation and challenges of eHealth intervention in Kenya that supports further research in this area.