The Importance of the Individual in PrEP Uptake: Multilevel Correlates of PrEP Uptake Among Adolescent Girls and Young Women in Tshwane, South Africa.

Adolescent girls and young women (AGYW) account for 25% of new HIV infections in South Africa. Pre-exposure prophylaxis (PrEP) is approved by the South African Government, but the factors that promote PrEP uptake among AGYW are not well understood. This study examines multilevel factors associated with PrEP uptake among AGYW in six clinic catchment areas in Tshwane (Pretoria), South Africa. After consent/assent, PrEP-eligible AGYW (n = 448) completed a questionnaire assessing factors at the individual, network/interpersonal, and community levels and were prescribed PrEP in study clinics, if interested. A multivariable model, adjusting for clustering, assessed factors associated with PrEP uptake over a 9-month period. At the individual level, multiple partners in the past 3 months (OR = 0.47), perceived risk of HIV (OR = 0.71), and PrEP-related shame (OR = 0.63) were correlated with lower odds of PrEP uptake (ps ≤ 0.05). The findings highlight modifiable factors that should be addressed to support PrEP uptake efforts.

Qualitative assessment of providers' experiences with a segmentation counseling tool for family planning in Niger.

INTRODUCTION: This study examines experiences with a family planning segmentation counseling tool that is used during the provision of family planning services. Based on answers to a series of questions, women are segmented into one of five categories of family planning users and counseled based on their identified segment. This study aimed to qualitatively assess provider perspectives on implementation of the tool. METHODS: Semi-structured in-depth interviews took place in the Dosso region of Niger among 16 family planning providers who had been trained in segmentation and were currently using the segmentation tool. The facilities chosen for interviews were part of a larger mixed methods study assessing the impact of using the segmentation approach. Interview questions focused on training, supervision, how segmentation occurs at the health facility, how segmentation changes provider-client interactions, and any difficulties faced with implementation. Interviews were translated and transcribed into French and data were coded and thematically analyzed. RESULTS: All providers in the study reported positive outcomes associated with segmentation. While providers acknowledged that the segmentation approach added time to the clinic visit, they did see the benefit of this extra time in providing more meaningful interactions between clients and providers, leaving clients with a deeper understanding of family planning and of the different methods available. The implementation of the tool did not change other aspects of service delivery, except that a segmentation sheet was required to be filled in and kept in each patient's file. Difficulties reported included translating the segmentation tool questions into local languages, training enough health care providers and avoiding stock outs of the segmentation sheets. CONCLUSION: The segmentation process is of benefit to family planning clients in Niger and the scale-up of the strategy could bring higher quality services to women. If this approach is brought to scale the implementation challenges uncovered need to be addressed, especially adequate training. Further research is needed to determine if segmentation leads to changes in family planning use outcomes.

This is a study about what nurses and other health care staff in Niger think about a segmentation counseling tool that is used during family planning services. Segmentation means that during counseling each woman is asked a series of questions and, depending on her answers, she is segmented into one of five 'client type' categories and counseled based on that 'client type' or segment. Face-to-face interviews with health care staff took place in the Dosso region of Niger among 16 staff who were using the tool with their patients. The facilities chosen for interviews were part of a larger study assessing how well segmentation was working. Staff were asked about training, supervision, how segmentation occurs at the facility, how segmentation changes how they interact with patients, and any difficulties faced with implementation. All the interviews were then analyzed. All providers in the study had positive things to say about segmentation, including the benefit of spending extra time with each client. This extra time results in more meaningful interactions between clients and providers, leaving clients with a deeper understanding of family planning and of the different methods available. Difficulties reported included translating the segmentation tool questions into local languages, training enough health care providers and avoiding stock outs of the segmentation sheets. The segmentation process is of benefit to family planning clients in Niger and can contribute to higher quality family planning services for women. The challenges that were found need to be addressed, especially adequate training.

Community perspectives on family planning service quality among users and non-users: a qualitative study from two cities in Burkina Faso.

BACKGROUND: Most studies that focus on quality of family planning (FP) services collect data from facilities. These studies miss the perspectives of quality from women who do not visit a facility and for whom perceived quality may be a barrier to service utilization. METHODS: This qualitative study from two cities in Burkina Faso examines perceived quality of FP services from women who were recruited at the community level to avoid potential biases based on recruiting women at facilities. Twenty focus group discussions were undertaken with varying groups of women of different ages (15-19; 20-24; 25+), marital statuses (unmarried; married), and current modern contraceptive use experiences (current non-users; current users). All focus group discussions were undertaken in the local language and transcribed and translated into French for coding and analysis. RESULTS: Women discuss FP service quality in a variety of locations, depending on their age group. Perspectives on service quality for younger women are often informed by others' experiences whereas for the older women, they are formed by their own and others' experiences. Two important aspects of service delivery emerge from the discussions including interactions with providers and selected system-level aspects of service provision. Important components of provider interactions relate to (a) the initial reception from the provider, (b) the quality of counseling received, (c) stigma and bias from providers, and d) privacy and confidentiality. At the health system level, discussions revolved around (a) wait time; (b) stockouts of methods; (c) costs of services/methods; (d) the expectation for tests as part of service provision; and (e) difficulties with method removal. CONCLUSIONS: To increase contraceptive use among women, it is crucial to address the components of service quality they identify as related to higher quality services. This means supporting providers to offer services in a more friendly and respectful manner. In addition, it is important to ensure that full information is provided to clients on what to expect during a visit to avoid false expectations that lead to poor perceived quality. These types of client-focused activities can improve perceptions of service quality and ideally support use of FP to meet women's needs.

"So let me give you money, you give me what I want": decision-making priorities around contraceptive method and source choice among young women in Kenya.

BACKGROUND: Many factors influence young women's choice of contraceptive methods and where to source them, yet less is known about whether one of these choices (method or source) is prioritized and the relationship between these choices. This study qualitatively explored decision-making around contraceptive method and source choice among young women in Kenya. METHODS: In August-September 2019, 30 in-depth interviews were conducted with women ages 18-24 who had used two or more contraceptive methods and resided in three counties: Nairobi, Mombasa or Migori. Participants were recruited from public and private health facilities and pharmacies. Interview guides captured information about decision-making processes for each contraceptive method the respondent had ever used. Responses were audio-recorded, transcribed, translated into English, coded, and analyzed thematically. RESULTS: The majority of respondents knew which method they wanted to use prior to seeking it from a source. This was true for all types of methods that women ever used. Of the small number of respondents who selected their source first, most were in the post-partum period or experiencing side effects and sought counseling at a source before choosing a method. CONCLUSIONS: This study highlights the importance of providing young women with high quality counseling that provides full information about contraceptive options and addresses that young women's needs vary along the reproductive health continuum of care. This will ensure that young women have information to inform future contraceptive decision-making prior to seeking care.

Does Provider Bias Affect Choice of a Facility for Family Planning Services by Women in Urban Senegal?

Few studies to date have determined the effect of provider bias based on age, parity, and marital status on women's method and facility choice. Using data from women using modern methods in six cities of Senegal and a facility survey that included a facility audit and provider interviews, we undertake conditional logit analyses to determine whether women's choice of a family planning facility is associated with provider bias at the facility, controlling for other facility characteristics (e.g., size, sector, and number of methods available). We find that women bypass facilities where there is greater provider bias to attain their current family planning method. Women also bypass facilities of lower quality. This is the first study to demonstrate the effects of provider bias on women's contraceptive seeking behaviors and suggests the importance of training providers to reduce age and parity bias that affect access to a full range of methods and facilities for all women.

Stigma in the health clinic and implications for PrEP access and use by adolescent girls and young women: conflicting perspectives in South Africa.

BACKGROUND: Globally, an urgent need exists to expand access to HIV prevention among adolescent girls and young women (AGYW), but the need is particularly acute in sub-Saharan Africa. Oral pre-exposure prophylaxis (PrEP) offers an effective HIV prevention method. In many countries, however, accessing PrEP necessitates that AGYW visit their local health clinic, where they may face access challenges. Some countries have implemented youth-friendly services to reduce certain challenges in local health clinics, but barriers to access persist, including clinic stigma. However, evidence of clinic stigma toward AGYW, particularly with respect to PrEP service delivery, is still limited. This mixed methods study explores stigma toward AGYW seeking clinic services, in particular PrEP, from the perspective of both clinic staff (clinical and nonclinical) and AGYW who seek services at clinic sites in Tshwane province, South Africa. METHODS: Six focus group discussions were conducted with AGYW (43 total participants) and four with clinic staff (42 total participants) and triangulated with survey data with AGYW (n = 449) and clinic staff (n = 130). Thematic analysis was applied to the qualitative data and descriptive statistics were conducted with the survey data. RESULTS: Four common themes emerged across the qualitative and quantitative data and with both AGYW and clinic staff, although with varying degrees of resonance between these two groups. These themes included (1) clinic manifestations of stigma toward AGYW, (2) concerns about providing PrEP services for AGYW, (3) healthcare providers' identity as mothers, and (4) privacy and breaches of confidentiality. An additional theme identified mainly in the AGYW data pertained to stigma and access to healthcare. CONCLUSION: Evidence is needed to inform strategies for addressing clinic stigma toward AGYW, with the goal of removing barriers to PrEP services for this group. While awareness has increased and progress has been achieved around the provision of comprehensive, youth-friendly sexual and reproductive health services, these programs need to be adapted for the specific concerns of young people seeking PrEP services. Our findings point to the four key areas noted above where programs seeking to address stigma toward AGYW in clinics can tailor their programming.

The association of quality contraceptive counseling measures with postabortion contraceptive method acceptance and choice: results from client exit interviews across eight countries.

The availability of a variety of modern contraceptive methods is necessary but insufficient to provide a high-quality contraceptive service to postabortion clients. Women, especially young women, must be empowered to make informed choices about which methods they receive, including whether to use contraception following an abortion service. In this study, we conducted 2,488 client exit interviews with abortion clients after their induced abortion service or postabortion care visit in Ipas-supported health facilities in eight countries: Argentina, Bolivia, Ethiopia, Kenya, Mexico, Nepal, Nigeria, and Uganda. We evaluated the quality of postabortion contraceptive counseling across two domains of contraceptive counseling: information exchange and interpersonal communication. We measured the association between these quality elements and two outcomes: 1) client-perceived choice of contraceptive method and 2) whether or not the client received a modern contraceptive method. We examined these relationships while adjusting for sociodemographic and confounding variables, such as the client feeling pressure from the provider to accept a particular method. Finally, we determined whether associations identified differ by age group: under 25 and 25+. Information exchange and interpersonal communication both emerged as important counseling domains for ensuring that clients felt they had the ability to choose a contraceptive method. The domain of information exchange was associated with having received a contraceptive method for all abortion clients, including young abortion clients under 25. Nearly 14% of clients interviewed reported pressure from the provider to accept a particular contraceptive method; and pressure from the provider was significantly associated with a client's perception of not having a choice in selecting and receiving a contraceptive method during her visit to the facility. Improving interpersonal communication, strengthening contraceptive information exchange, and ensuring clients are not pressured by a provider to accept a contraceptive method, must all be prioritized in postabortion contraceptive counseling in health facilities to ensure postabortion contraceptive services are woman-centered and rights-based for abortion clients.

Perceptions of peer contraceptive use and its influence on contraceptive method use and choice among young women and men in Kenya: a quantitative cross-sectional study.

BACKGROUND: Prior research has established that an individual's social environment may influence his or her reproductive behaviors, yet less is known about peer influence on contraceptive use among young people (ages 15-24). In Kenya, the site of this study, 15% of adolescents ages 15-19 have begun childbearing and 45% of sexually active young women report current use of a modern contraceptive method. This highlights the need to better understand what factors influence young people to use contraception. The objective of this study is to explore the relationship between the perception of peers' use of contraceptives and contraceptive use and method choice among young men and women in Kenya. METHODS: This study utilizes a nationally representative sample of women and men aged 15-24 years from the 2018 and 2019 cross sectional Shujaaz State of the Kenyan Youth annual surveys. Among the sample of sexually experienced young people (59%), multivariable multinomial logistic regression was used to explore the association between the perception of peers' use of contraceptives and the respondent's contraceptive method choice: non-user, condom use or use of any other modern method. Results are presented separately for young men and young women. RESULTS: Our results show that sexually experienced young men and women who perceive that their peers are using contraceptives are more likely to report current use of condoms compared to being a nonuser (RRR = 2.12, p < 0.001, RRR = 2.59, p < 0.001, respectively); they are also more likely to use condoms than another modern method of contraception (RRR = 2.13, p = 0.034, RRR = 1.71, p = 0.014, respectively). Young women are more likely to use another modern method (not including condoms) than be a nonuser when they perceive that their peers' use contraceptives (RRR = 1.51, p = 0.020). CONCLUSIONS: The results of this study highlight the important role of peer influence on young people's contraceptive choices. These findings can be used to develop programs that encourage behavior change communication activities in Kenya that focus on normalizing use of a full range of contraceptive methods among peer groups of sexually experienced young people.

In Kenya, about 15% of women age 15­19 have already had a birth and approximately one third of these women did not want to have a child at that time. Yet about 45% of sexually active women ages 15­24 report that they currently use family planning (FP). Among young people, friends and peers are an important influence on behaviors.This study focused on a representative sample from Kenya of female and male youth (ages 15­24) who ever had sex. Men and women were asked questions about use of FP, if they think their peers use FP and about characteristics such as age and education.The results showed that young women and men who believed their peers use FP were more likely to use FP themselves. Also, young men and women who believed that peers use FP were more likely to use condoms than not use any FP and more likely to use condoms than to use another modern method of FP. Young women who thought their peers use were more likely to use another modern method (not including condoms) than to be a nonuser of FP.Programs targeting young people should include information on a range of FP methods and aim to include groups of peers and encourage open discussion.

Associations of Father and Adult Male Presence with First Pregnancy and HIV Infection: Longitudinal Evidence from Adolescent Girls and Young Women in Rural South Africa (HPTN 068).

This study, a secondary analysis of the HPTN 068 randomized control trial, aimed to quantify the association of father and male presence with HIV incidence and first pregnancy among 2533 school-going adolescent girls and young women (AGYW) in rural South Africa participating in the trial between March 2011 and April 2017. Participants' ages ranged from 13-20 years at study enrollment and 17-25 at the post-intervention visit. HIV and pregnancy incidence rates were calculated for each level of the exposure variables using Poisson regression, adjusted for age using restricted quadratic spline variables, and, in the case of pregnancy, also adjusted for whether the household received a social grant. Our study found that AGYW whose fathers were deceased and adult males were absent from the household were most at risk for incidence of first pregnancy and HIV (pregnancy: aIRR = 1.30, Wald 95% CI 1.05, 1.61, Wald chi-square p = 0.016; HIV: aIRR = 1.27, Wald 95% CI 0.84, 1.91, Wald chi-square p = 0.263) as compared to AGYW whose biological fathers resided with them. For AGYW whose fathers were deceased, having other adult males present as household members seemed to attenuate the incidence (pregnancy: aIRR = 0.92, Wald 95% CI 0.74, 1.15, Wald chi-square p = 0.462; HIV: aIRR = 0.90, Wald 95% CI 0.58, 1.39, Wald chi-square p = 0.623) such that it was similar, and therefore not statistically significantly different, to AGYW whose fathers were present in the household.

The association of empowerment measures with maternal, child and family planning outcomes in Plateau State Nigeria by urban-rural residence.

BACKGROUND: Nigeria is experiencing a high level of urbanization and urban poverty. Within Nigeria maternal and child health and family planning outcomes may differ by residence (capital city, urban/non-capital city and rural) as well as by measures of women's empowerment and wealth. This paper presents a detailed analysis of maternal and child health and family planning outcomes in Plateau State, Nigeria. METHODS: Data came from the 2017 Nigerian Urban Reproductive Health Initiative Sustainability Study. Multivariable logistic regression was used to study the associations between the key independent variables of residence, women's empowerment and wealth with having a skilled birth attendant at childbirth and childhood preventative visits. The women's empowerment variables included perceptions about household decision-making, financial decision-making, views on wife beating and having a prohibition, defined as a restriction on specific activities imposed by a woman's husband. Multinomial regression was used to study the association of the same factors with the family planning outcome which had three categories - no use, traditional method use and modern method use. Regressions were also run separately for urban and rural populations. RESULTS: Women in the capital city of Jos were significantly more likely to have a skilled birth attendant at childbirth, take a child to a preventative visit and use family planning than women in rural areas of Plateau State. Three of the four measures of empowerment (household decision-making, financial decision-making and having a prohibition) were significantly associated with the family planning outcome, while having a prohibition was negatively associated with having a skilled birth attendant at childbirth. In rural areas, women involved in financial decisions were significantly less likely to use a modern method compared to a traditional method. Wealth was a significant factor for all outcomes. DISCUSSION: State-level analyses can provide valuable information to inform programs and policies at a local level. Efforts to improve use of maternal and child health and family planning services in Plateau state, Nigeria, should consider women's empowerment, residence and poverty. Community education on the effectiveness of modern versus traditional methods and potential side effects of specific modern methods, may help women make informed decisions about contraception.

Facility-level characteristics associated with family planning and child immunization services integration in urban areas of Nigeria: a longitudinal analysis.

BACKGROUND: Unmet need for postpartum contraception is high. Integration of family planning with routine child immunization services may help to satisfy unmet need. However, evidence about the determinants and effects of integration has been inconsistent, and more evidence is required to ascertain whether and how to invest in integration. In this study, facility-level family planning and immunization integration index scores are used to: (1) determine whether integration changes over time and (2) identify whether facility-level characteristics, including exposure to the Nigerian Urban Reproductive Health Initiative (NURHI), are associated with integration across facilities in six urban areas of Nigeria. METHODS: This study utilizes health facility data collected at baseline (n = 400) and endline (n = 385) for the NURHI impact evaluation. Difference-in-differences models estimate the associations between facility-level characteristics, including exposure to NURHI, and Provider and Facility Integration Index scores. The two outcome measures, Provider and Facility Integration Index scores, reflect attributes that support integrated service delivery. These indexes, which range from 0 (low) to 10 (high), were constructed using principal component analysis. Scores were calculated for each facility. Independent variables are (1) time period, (2) whether the facility received the NURHI intervention, and (3) additional facility-level characteristics. RESULTS: Within intervention facilities, mean Provider Integration Index scores were 6.46 at baseline and 6.79 at endline; mean Facility Integration Index scores were 7.16 (baseline) and 7.36 (endline). Within non-intervention facilities, mean Provider Integration Index scores were 5.01 at baseline and 6.25 at endline; mean Facility Integration Index scores were 5.83 (baseline) and 6.12 (endline). Provider Integration Index scores increased significantly (p = 0.00) among non-intervention facilities. Facility Integration Index scores did not increase significantly in either group. Results identify facility-level characteristics associated with higher levels of integration, including smaller family planning client load, family planning training among providers, and public facility ownership. Exposure to NURHI was not associated with integration index scores. CONCLUSION: Programs aiming to increase integration of family planning and immunization services should monitor and provide targeted support for the implementation of a well-defined integration strategy that considers the influence of facility characteristics and concurrent initiatives.

Assessment of segmentation and targeted counseling on family planning quality of care and client satisfaction: a facility-based survey of clients in Niger.

BACKGROUND: Niger demonstrates high fertility and low contraceptive use that are typical in much of the West and Central African region. The government of Niger has committed to increasing modern contraceptive use as part of its health strategy. Designing and testing strategies to improve quality of care and satisfaction of family planning clients is important for addressing low contraceptive use in contexts like Niger. METHODS: This study uses recently collected client exit interview data from 2720 clients surveyed in the Dosso region of Niger to examine whether implementation of segmentation-based counseling leads to improved quality of services and client satisfaction. We compare three scenarios: a) facilities where segmentation counseling was implemented since 2017; b) facilities where segmentation counseling began in late 2019; and c) facilities without segmentation counseling. Bivariate and multivariate analyses are undertaken to determine if there are differences in quality of services and client satisfaction between the facility groups and between clients that were segmented and those who were not segmented in the first two scenarios. RESULTS: Results demonstrate that clients in facilities with segmentation generally received better quality services than clients in facilities without segmentation. Clients in facilities implementing segmentation longer reported higher quality services than the recent segmentation facilities. Clients who were segmented compared to those who were not segmented also reported better quality services. New clients reported higher quality services than returning clients and among new clients, those who were segmented also reported higher quality services. No differences were found in client satisfaction between facility scenarios or between segmented and non-segmented clients. CONCLUSIONS: These findings demonstrate that segmentation or another targeted counseling strategy could be useful to the government of Niger to improve the quality of services offered. As part of the scale up process, the government needs to consider strategies that ensure that all new clients are segmented and design an approach that is sustainable and does not risk failing should there be stock-out of segmentation sheets or loss of counseling cards. This type of targeted counseling could improve the quality of services offered and ideally lead to increased contraceptive use in Niger.

Return to pregnancy after contraceptive discontinuation to become pregnant: a pooled analysis of West and East African populations.

BACKGROUND: The fear of infertility or delayed return to fertility is a common barrier to contraceptive use in sub-Saharan Africa, particularly among young or nulliparous women. Global evidence on return to pregnancy after method discontinuation suggests these fears may be misplaced; yet the topic has not been widely studied in sub-Saharan Africa nor by age and parity group. METHODS: Reproductive calendar data from recent Demographic and Health Surveys of 15 sub-Saharan African countries were used to analyze time-to-pregnancy following discontinuation of a contraceptive method with the reason to become pregnant. The probability of pregnancy at 12 months was estimated using single-decrement life tables run by type of method discontinued, age and parity. Results are presented by region: francophone West Africa, anglophone West Africa and East Africa. RESULTS: The 12-month probability of pregnancy after discontinuation of contraception to become pregnant was 73.0% in francophone West Africa, 78.8% in anglophone West Africa, and 82.0% in East Africa. Our results showed significant regional differences in return to pregnancy by 12 months, with probabilities in francophone West Africa being significantly lower than in anglophone West Africa or East Africa. A lower return to pregnancy by 12 months was seen among women ages 35-49 years and was lowest after discontinuation of a hormonal method for all age groups. Differences by parity group were only evident after discontinuation of hormonal methods in francophone West Africa. CONCLUSIONS: Sustainable gains in increasing contraceptive uptake, especially among youth, may be difficult to achieve without information and counseling that address concerns about infertility and potential delays in return to pregnancy following use of hormonal methods.

The fear of infertility or delayed return to fertility is a common barrier to contraceptive use in sub-Saharan Africa, particularly among young or childless women. Global evidence on the time it takes to become pregnant after the discontinuation of a contraceptive method suggests these fears may be misplaced; yet the topic has not been widely studied in sub-Saharan Africa. Data from recent Demographic and Health Surveys of 15 sub-Saharan African countries were used to analyze the time it takes to become pregnant after discontinuation of a contraceptive method with the reason to become pregnant. The probability of becoming pregnant by 12 months was estimated using a life table approach. Results were compared by type of method discontinued, age and whether women had any children, in three regions of sub-Saharan Africa. Our findings show that the 12-month probability of pregnancy after discontinuation of contraception to become pregnant was 73.0% in francophone West Africa, 78.8% in anglophone West Africa, and 82.0% in East Africa. A lower return to pregnancy by 12 months was seen among women ages 35­49 years and was lowest after discontinuation of a hormonal method for all age groups. Differences by whether women had any children were only evident after discontinuation of hormonal methods in francophone West Africa. The findings indicate that sustainable gains in increasing contraceptive uptake, especially among youth, may be difficult to achieve without information and counseling that address concerns about infertility and potential delays in return to pregnancy following use of hormonal methods.

Development of integration indexes to determine the extent of family planning and child immunization services integration in health facilities in urban areas of Nigeria.

BACKGROUND: Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities. METHODS: This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high). RESULTS: Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high. CONCLUSION: Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.

Communication, social norms, and contraceptive use among adolescent girls and young women in Lilongwe, Malawi.

In Malawi, 50% of adolescent girls and young women (AGYW) have had a first child by age 19 and 45% report their pregnancies as unintended or mistimed. Yet, uptake of contraception remains low. Understanding how interactions with social ties impact AGYW contraceptive use might explain low uptake beyond individual and environmental factors. Data are from Girl-Power, a study among sexually active AGYW, aged 15-24, in Malawi. We used logistic regression models to examine whether contraceptive communication and social norms (descriptive and injunctive) were associated with contraceptive use (non-barrier methods and condoms) and how associations differed across social ties (older women in the family, peers, and partners). The sample included 942 participants: 28% reported using non-barrier methods and 66% reported using condoms. Contraceptive communication with older women in the family (aOR: 1.48, 95% CI: 0.99, 2.20), peers (aOR: 3.12, 95% CI: 1.96, 4.96), and partners (aOR 5.15, 95% CI: 3.13, 8.48) was associated with non-barrier method use. Descriptive norms were associated with non-barrier methods among peers (aOR 2.57, 95% CI: 1.63, 4.96) but not among older women in the family (aOR: 1.22, 95% CI 0.80, 1.88). There were no associations among contraceptive communication, social norms, and condom use across older women in the family, peers, and partners. The findings highlight the need to consider the influence of social ties in the design of future family planning interventions and suggest that interventions that encourage interpersonal communication about contraception and target peer-based descriptive norms have the potential to impact uptake of non-barrier methods.

The Examination of Diffusion Effects on Modern Contraceptive Use in Nigeria.

This study uses data gathered for an evaluation of a Bill & Melinda Gates Foundation-funded initiative designed to increase modern contraceptive use in select urban areas of Nigeria. When the initiative was conceived, the hope was that any positive momentum in the cities would diffuse to surrounding areas. Using a variety of statistical methods, we study three aspects of diffusion and their effects on modern contraceptive use: spread through mass communications, social learning, and social influence. Using a dynamic causal model, we find strong evidence of social multiplier effects through social learning. The results for social influence and spread through mass communications are promising, but we are unable to identify definitive causal impacts.

Impact evaluation of scripted lesson plans for HIV-related content in a life orientation curriculum: results from two provinces in South Africa.

BACKGROUND: Young people under age 25 years are a key population at risk of unintended pregnancies, HIV and other sexually transmitted infections. School-based programming, focusing on youth under 17 years is strategic given that many in this age group are in school or are required to be in school and spend a considerable amount of their time at school. Prior evaluations of school-based HIV prevention programs for young people often employed weak study designs or lacked biomarkers (e.g., HIV or STI testing) to inform outcomes. METHODS: This study used longitudinal data collected in 2016 from a cohort of grade-8 girls from Mpumalanga and KwaZulu-Natal Provinces in South Africa. We followed them for 2 years to examine the impact of the South African Department of Basic Education's revised scripted lesson plans for the HIV and sexual content of a "life orientation" curriculum on knowledge, attitudes, condom use behaviors, pregnancy incidence, and genital herpes incidence. Schools were randomized to intervention and control arms. Multivariable analyses were undertaken using hazard modeling for incidence-based outcomes (genital herpes and pregnancy) and generalized linear latent and mixed modeling for outcomes measured at each time period (knowledge, attitudes, and condom use). RESULTS: At end line, 105 schools were included from the two provinces (44 from Mpumalanga and 61 from KwaZulu-Natal). Fifty-five were intervention and fifty were control schools. A total of 2802 girls were surveyed at both time periods (1477 intervention and 1325 control). At baseline, participating girls were about 13.6 years; by end line, they were about 2 years older. Longitudinal data demonstrated few differences between intervention and control groups on knowledge, attitudes, condom use, genital herpes, and pregnancy experience. Monitoring data demonstrated that the program was not implemented as intended. Our results demonstrated 7% incidence of genital herpes in the two-year follow-up period indicating sexual risk-taking among our cohort. CONCLUSIONS: We did not find significant effects of the revised life orientation curriculum on key outcomes; however, this may reflect poor implementation. Future HIV prevention programs for young people need to be implemented with fidelity to ensure they meet the crucial needs of the next generation. TRIAL REGISTRATION: This study has been registered at ClinicalTrials.gov . The trial registration number is: NCT04205721 . The trial was retrospectively registered on December 18, 2019.

The PrEPARE Pretoria Project: protocol for a cluster-randomized factorial-design trial to prevent HIV with PrEP among adolescent girls and young women in Tshwane, South Africa.

BACKGROUND: Despite increased prevention efforts, HIV remains the leading cause of death among adolescent girls and young women in South Africa. Although research indicates important determinants of HIV acquisition at the individual and interpersonal levels, structural-level stigma and discrimination continue to be critical barriers to reaching and retaining this key population for HIV prevention and sexual and reproductive health services. Innovative and multilevel interventions are needed that can address the intersectional structural and gender issues that young women face, including stigma, alcohol and drug use, gender-based violence, and other risk factors when seeking health services. Oral pre-exposure prophylaxis (PrEP) taken daily has been found to be an effective biomedical HIV prevention tool. Testing a comprehensive gender-focused biobehavioral HIV prevention intervention that is inclusive of social ecological determinants, such as stigma and discrimination reduction in clinics, is critical for reducing HIV among adolescent girls and young women. METHODS: This project involves both a Community Collaborative Board and a Youth Advisory Board in helping to adapt the Young Women's Health CoOp intervention and the Health Policy Project (HPP) Stigma and Discrimination (S&D) reduction training curriculum to the setting and population. This study uses a two-by-two factorial design with stratified randomization of 12 clinics, each with distinct catchment areas. The Young Women's Health CoOp addresses substance use, sexual risk, violence prevention and sexual negotiation, condom demonstration, and problem solving with the following additions: knowledge of PrEP, the importance of PrEP adherence, and sexual and reproductive health. Adolescent girls and young women will be assessed with behavioral and biological measures at baseline, 3-, 6- and 9-month follow-up. The S&D reduction training is provided for all staff in the clinics randomized to this condition. Clinic staff will be surveyed at baseline, 4- and 8-month follow-up. We will recruit 900 AGYW from communities in the 12 clinic catchment areas. DISCUSSION: The study findings, if efficacious across the outcomes, will be incorporated into the gender-focused HIV prevention intervention toolkit and disseminated to inform multilevel prevention approaches. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT04048551 (Recruiting). Registered: August 7, 2019 (Retrospectively registered).

Influences of health facility type for delivery and experience of cesarean section on maternal and newborn postnatal care between birth and facility discharge in Malawi.

BACKGROUND: A number of studies in the past have looked at determinants of postnatal care. However, many of them do not distinguish between postnatal care (PNC) before discharge and after discharge for women delivering at health facilities. Conceptually and practically, factors associated with PNC before discharge and after discharge should be different. This study examines key factors for maternal and newborn PNC before discharge. METHODS: Data from the 2015-16 Malawi Demographic and Health Survey were used for the study. Three categorical endogenous variables examined in the study were whether or not mothers received a postnatal check between birth and facility discharge, whether or not newborns received a postnatal check between birth and facility discharge and whether or not women delivered by cesarean section. Delivery by cesarean section was considered as a mediator in the model. The main predictor of interest was type of health facility where women delivered. Other exogenous variables included were women's age at most recent birth, number of antenatal visits, women's education, household wealth, parity, newborn size, region of the country and residence. Simultaneous equation modeling was used to examine the associations of interest. RESULTS: 47% of the mothers and 68% of the newborns had PNC before facility discharge. The total and direct effects of delivering in private hospitals on maternal and newborn PNC before facility discharge were significantly higher than the effects of delivering in government hospitals. The total effects of delivering in government health centers or health posts on maternal and newborn PNC before facility discharge were significantly lower than the effects of delivering in government hospitals. Delivering by cesarean section compared to delivering vaginally was positively associated with maternal and newborn PNC before facility discharge. CONCLUSION: It is important that all women and newborns receive PNC before they are discharged from the facility regardless of whether or not they had a complication. The same standard of quality PNC should be provided equitably across all types and affiliations of health facilities.

Longitudinal examination of changing fertility intentions and behaviors over a four-year period in urban Senegal.

BACKGROUND: Fertility intentions and contraceptive use are often used to demonstrate gaps in programs and policies to meet the contraceptive needs of women and couples. Prior work demonstrated that fertility intentions are fluid and change over a woman's (or couple's) life course with changing marital status, childbearing, and education/employment opportunities. This study uses longitudinal data to better examine the fluidity of women's fertility intentions and disentangle the complex interrelationships between fertility and contraceptive use. METHODS: Using survey data from three time points and three urban sites in Senegal, this study examines how women's fertility intentions and contraceptive use in an earlier period affect pregnancy experience and the intentionality of experienced pregnancies among a sample of 1050 women who were in union at all three time points. We apply correlated random effect longitudinal regression methods to predict a subsequent birth by fertility intentions and modern contraceptive use at an earlier period addressing endogeneity concerns of earlier analyses that only include two time periods. RESULTS: Descriptive results demonstrate some change in fertility desires over time such that 6-8% of women who reported their pregnancy as intended (i.e., wanted to get pregnant at time of pregnancy) reported earlier that they did not want any(more) children. Multivariate analyses demonstrate that women who want to delay or avoid a pregnancy and are using modern contraception are the least likely to get pregnant. Among women who became pregnant, the only factor differentiating whether the pregnancy is reported as intended or unintended (mistimed or unwanted) was prior fertility intention. Women who wanted to delay a pregnancy previously were more likely to report the pregnancy as unintended compared to women who wanted to get pregnant soon. CONCLUSIONS: These results suggest some post-hoc rationalization among women who are getting pregnant. Women who say they do not want to get pregnant may be choosing not to use a contraceptive method in this urban Senegal context of high fertility. Programs seeking to reach these women need to consider their complex situations including their fertility intentions, family planning use, and the community norms within which they are reporting these intentions and behaviors.