Accelerate progress-sexual and reproductive health and rights for all: report of the Guttmacher-Lancet Commission

Awareness and access to mass media sources of information about modern family planning methods among women with disabilities in Nigeria: An analysis of 2018 demographic and health survey

BACKGROUND

Family planning is the foundation of sexual and reproductive health, and necessary for achieving the Sustainable Development Goals. Yet, the needs of women with disabilities and their access to these services have been neglected for decades, especially in Low and Middle-income Countries. To improve utilization of these services among women with disabilities, they have to be aware and informed about the services. This study was conducted to examine awareness and mass media sources of information on family planning between women with and without disabilities.

METHODS

This study used data from the 2018 Nigeria Demographic and Health Surveys (NDHS). Our analytic sample included 26,585 women between 15 and 49 years of age who answered the disability module. We compared demographics and socioeconomic characteristics of women with and without disabilities using the chi-square test for categorical variables. In addition, we conducted logistic regressions to estimate the unadjusted and adjusted odds ratio (with 95% confidence intervals) for level of awareness and mass media sources of information on modern contraceptive methods, using women without a disability as the reference group.

RESULTS

Finding showed that women with disabilities have poor awareness about family planning compared to women without disabilities even after adjusting for all covariates (AOR = 0.42, 95% CI: 0.23-0.76, P < 0.05). We also found that women with disabilities are less likely to receive information about family planning from any of the available mass media channels even after adjusting for covariates (AOR = 0.46, 95% CI: 0.22-0.98, P < 0.05).

CONCLUSIONS

The study revealed that women with disabilities Nigeria have poor awareness about modern family planning methods compared to non-disabled women. They are also less likely to receive information about modern family planning methods compared to non-disabled women. To effectively reach women with disabilities, information barriers must be eliminated, coupled with increased opportunities to access family planning information. Donors, government, and other relevant stakeholders should consider funding inclusive campaigns and explore other mechanisms for disseminating family planning information to women with disabilities.

Ask me, listen to me, treat me well and I shall tell: a qualitative study of Swedish youths' experiences of systematic assessment of sexual health and risk-taking (SEXIT)

Sexual ill health among young people, in terms of sexually transmitted infections (STIs), unintended pregnancy, transactional sex and sexual violence, is a global public health concern. To that end, the SEXual health Identification Tool (SEXIT) was developed. The purpose of this study was to explore the visitors' experiences of a youth clinic visit when SEXIT was used. A purposively selected sample of 20 participants (16-24 years of age) was recruited from three Swedish youth clinics using SEXIT. Participants were interviewed individually in March and April 2016, and data were analysed using inductive qualitative content analysis. The analysis resulted in four main categories describing the participants' experiences of using SEXIT: "Issues of concern" includes descriptions of the items in SEXIT as important; "Enabling disclosure" describes how SEXIT serves as an invitation to talk and facilitates disclosure of negative experiences; "Road to change" captures experiences of the conversation with the healthcare professional; and "Managing power imbalance" describes experiences regarding the response and attitudes of the healthcare professional as well as the participants' fears of being judged. The categories are connected by the overarching theme "Ask me, listen to me, treat me well and I shall tell". This study contributes knowledge on young people's experiences of a tool-supported dialogue on sexual health and risk-taking initiated by the healthcare professional. Structured questions in a written format, as a basis for dialogue, are appreciated and experienced as a functioning way of addressing sexual ill health and risk-taking at Swedish youth clinics.

Identifying sexual risk-taking and ill health in the meeting with young people-experiences of using an assessment tool

BACKGROUND

Identifying young people exposed to sexual risk-taking or violence is fundamental, when seeking to strengthen their health. However, young people seldom share sexual health concerns or experiences of violence with healthcare professionals (HCPs). Studies evaluating how use of a risk assessment tool influences the dialogue about sexual health and violence are sparse.

AIMS

The aim of this study was to explore HCPs' experiences of using the SEXual health Identification Tool (SEXIT) in encounters with young people at Swedish youth clinics.

METHOD

Three focus group interviews were conducted with 21 HCPs from nine youth clinics, where SEXIT had been introduced. Data were analysed using thematic content analysis.

RESULTS

Three themes were identified. The theme, Facilitates dialogue about sexuality and vulnerability, describes how the questionnaire pertaining to SEXIT helped to normalise and help both HCPs and young people to take part in the dialogue about sensitive issues. Need for a trustful encounter presents HCPs' ethical concerns regarding how the questionnaire affects the integrity of young people and trust-making. Sensitive topics entail challenges describes HCPs' challenges when dealing with sensitive issues. Additionally, it describes needs for knowledge and collaboration when targeting vulnerable young people.

CONCLUSIONS

The HCPs stated that using SEXIT developed their ability to address sensitive issues and helped both them and young people to take part in the dialogue about sexuality and exposure to violence. SEXIT involves experiences of ethical concerns regarding integrity and trust-making. It also entails challenges in having dialogues about sensitive issues, how to deal with risk assessment outcomes and in improvements regarding inter-professional collaborations.

Are sexual and reproductive health and rights taught in medical school? Results from a global survey

Our aim was to investigate the inclusion of sexual and reproductive health and rights (SRHR) topics in medical curricula and the perceived need for, feasibility of, and barriers to teaching SRHR. We distributed a survey with questions on SRHR content, and factors regulating SRHR content, to medical universities worldwide using chain referral. Associations between high SRHR content and independent variables were analyzed using unconditional linear regression or χ² test. Text data were analyzed by thematic analysis. We collected data from 219 respondents, 143 universities and 54 countries. Clinical SRHR topics such as safe pregnancy and childbirth (95.7%) and contraceptive methods (97.2%) were more frequently reported as taught compared with complex SRHR topics such as sexual violence (63.8%), unsafe abortion (65.7%), and the vulnerability of LGBTQIA persons (23.2%). High SRHR content was associated with high-income level (P = 0.003) and low abortion restriction (P = 0.042) but varied within settings. Most respondents described teaching SRHR as essential to the health of society. Complexity was cited as a barrier, as were cultural taboos, lack of stakeholder recognition, and dependency on fees and ranking.

Factors associated with access to sexual and reproductive health services among women with disabilities in Nepal

Aim

The aim of the study is to investigate the relationships between social determinants and disability status and access and use of sexual and reproductive health services among women with disabilities in Nepal.

Materials ad methods

This study used data on women with disability from the Multiple Indicator Cluster Survey (MICS) of 2019, in which 13,320 women and 290 women with disabilities were included for the analysis. We used bivariate analysis to compare the social determinants with disability status and multivariate logistic regression to determine the association between social determinants and access and use of sexual and reproductive health services among women with disabilities.

Findings

The findings showed, in comparison with non-disabled women, women with disabilities had low education, low economic status, low media exposure and low access to sexual and reproductive health. On provincial level, those from Madesh [AOR = 0.22 (95%CI:0.06, 0.76)] and Lumbini [AOR = 0.24 (95%CI:0.06,0.88)] had lower attitude to violence. The usage of family planning (FP) methods among women with disabilities in Karnali [AOR = 3.57 (95% CI: 1.42-13.22)] and Sudurpashchim [AOR = 1.05 (95% CI: 1.01-1.071)] was higher than those in Province 1. Women with disabilities with secondary education were more than nine times [AOR = 9.28(95%CI:2.67,32,26)] and primary education had more than three times [AOR = 3.59 (95%CI:1.07, 12.02)] of knowledge on HIV/AIDS compared to those of no education. The odds of being tested for HIV/AIDS among women with disabilities with secondary education was more than eight times [AOR = 8.8 (95% CI:2.23-34.6)] than those of no education.

Conclusion

This study provides noteworthy findings that women with disabilities have poor socioeconomic status, high-risk behavior, and low access to sexual and reproductive health services in Nepal. This study highlights the significance of actions needed to address sexual and reproductive health services in Nepal that unfairly impact women with disabilities.

Unmet need for contraception and its associated factors among adolescent and young women in Guinea: A multilevel analysis of the 2018 Demographic and Health Surveys

Despite the recent repositioning efforts to increase the use of modern contraceptives, the prevalence of unmet need for contraception remains high among adolescent and young women in Guinea. This study analyzed the individual and contextual factors associated with the unmet need for contraception among adolescent and young women in 2018 in Guinea. We conducted a secondary analysis of the 2018 Demographic and Health Survey data. Multilevel mixed-effects logistic regression models were used to assess the association between individual and contextual characteristics and unmet need for contraception among adolescents and young women. Adjusted odds ratios (AORs) with their 95% confidence intervals (CIs) were calculated, with statistical significance set at p &lt; 0.05. The prevalence of total unmet need for contraception was 22.6% (95% CI, 18.1–27.8). Being an adolescent aged 15–19 years (AOR = 1.44; 95% CI, 1.01–2.05), unmarried (AOR = 5.19; 95% CI, 3.51–7.67), having one or two children (AOR = 3.04; 95% CI, 2.18–4.25), or more than two children (AOR = 4.79; 95% CI, 3.00–7.62) were individual factors associated with the unmet need for contraception. As for community factors, only living in Labé (AOR = 2.54; 95% CI, 1.24–5.18) or Mamou (AOR = 1.73; 95% CI, 1.21–2.48) was significantly associated with the unmet need for contraception. In conclusion, both individual and community characteristics were significantly associated with the unmet need for contraception. This highlights the need to focus and strengthen communication and counseling strategies targeting adolescents and young women and aiming to increase the uptake of family planning in Guinea.

Infertility prevalence and the methods of estimation from 1990 to 2021: a systematic review and meta-analysis

STUDY QUESTION

What is the contemporary prevalence of infertility in world populations and how do they differ by methodological and study characteristics?

SUMMARY ANSWER

Pooled estimates of lifetime and period prevalence of 12-month infertility were 17.5% and 12.6%, respectively, but this varied by study population and methodological approach.

WHAT IS KNOWN ALREADY

Infertility affects millions of individuals worldwide. Accurate measures of its magnitude are needed to effectively address and manage the condition. There are distinct challenges and variation in how infertility is defined and measured, limiting comparability of estimates across studies. Further research is needed to understand whether and how differences in methodological approaches and study characteristics account for heterogeneity in estimates.

STUDY DESIGN SIZE DURATION

We conducted a systematic review and meta-analysis. Six electronic databases, websites of relevant organizations, and conference proceedings were systematically searched. Searches were limited to those published between 1 January 1990 and 11 March 2021, with no language restrictions.

PARTICIPANTS/MATERIALS SETTING METHODS

Descriptive and random-effects meta-analysis models were used to examine range of estimates and generate estimates of pooled lifetime and period prevalence of 12-month infertility, respectively, among representative populations. Meta-regression using restricted maximum likelihood was applied to account for definitional and study characteristics and to obtain adjusted estimates. Risk of bias was assessed with a validated tool.

MAIN RESULTS AND THE ROLE OF CHANCE

The search yielded 12 241 unique records of which 133 studies met the criteria for the systematic review. There were 65 and 69 studies that provided data for lifetime and period prevalence of 12-month infertility, respectively. Five methodological approaches were identified: prospective time-to-pregnancy (TTP) design, current duration design, retrospective TTP design, self-reported infertility measure and constructed infertility measure. Ranges for lifetime (3.3-39.7%) and period estimates (1.6-34.0%) were similar and wide even after accounting for methodological and study characteristics. Pooled estimates of lifetime and period prevalence were 17.5% (95% CI: 15.0, 20.3, n = 37 studies, I ² = 99.5%) and 12.6% (95% CI: 10.7, 14.6, n = 43 studies, I ² = 99.8%), respectively, with some variation in magnitude by region and methodological approach, but with most CIs overlapping.

LIMITATIONS REASONS FOR CAUTION

Pooled estimates generated from meta-analysis were derived from 12-month infertility prevalence estimates that were heterogeneous across different domains, even after adjusting for definitional and study characteristics. The number of studies was small for certain strata from which pooled estimates were derived (e.g. there were only two studies for lifetime prevalence in Africa).

WIDER IMPLICATIONS OF THE FINDINGS

While findings show a high prevalence of infertility globally and regionally, it also reveals variation in measures to ascertain and compare infertility prevalence. More systematic and comprehensive collection of data using a consistent definition is needed to improve infertility prevalence estimates at global, regional and country-levels.

STUDY FUNDING/COMPETING INTERESTS

This work was supported by the World Health Organization. The authors have no conflicts of interest.

REGISTRATION NUMBER

PROSPERO CRD42020211704.

Facility readiness to remove subdermal contraceptive implants in 6 sub-Saharan African countries

OBJECTIVE

This study aimed to estimate the proportion of health facilities without the capability to remove contraceptive implants and those that have the capability to insert them and to understand facility-level barriers to implant removal across 6 countries in sub-Saharan Africa.

STUDY DESIGN

Using facility data from the Performance Monitoring for Action in Burkina Faso, the Democratic Republic of Congo, Ethiopia, Kenya, Nigeria, and Uganda from 2020, we examined the extent to which implant-providing facilities (1) lacked necessary supplies to remove implants, (2) did not have a provider trained to remove implants onsite, (3) could not remove deeply placed implants onsite, and (4) reported any of the above barriers to implant removal. We calculated the proportion of facilities that report each barrier, stratifying by facility type.

RESULTS

Between 31% and 58% of implant-providing facilities reported at least 1 barrier to implant removal in each country (6 sub-Saharan African countries). Lack of trained providers was the least common barrier to implant removal (0%-17% of facilities), whereas lack of supplies (17%-44% of facilities) and the inability to remove a deeply placed implant (16%-42%) represented more common obstacles to removal. Blades and forceps were commonly missing supplies across all 6 countries. Barriers to implant removal were less commonly reported at hospitals than at lower-level facilities in all countries except Burkina Faso.

CONCLUSION

This multicountry analysis showed that facility-level barriers to contraceptive implant removal are widespread among facilities that offer implant insertion. By preventing users from being able to discontinue their implants on request, these barriers pose a threat to contraceptive autonomy and reproductive health.

Development and psychometric assessment of the sexual-reproductive health profile of women with type-1 diabetes mellitus

Background

To improve the sexual-reproductive health (SRH) of women with type-1 diabetes mellitus (T1DM), plans should be formulated on the basis of the existing situation. The situation can be examined by a valid tool conforming to the specific domains of SRH in the target group. The present study seeks to develop and assess the psychometric properties of the SRH Profile of Women with T1DM.

Method

Based on the extracted concepts of SRH Profile of Women with T1DM in a previously conducted study, a tool was designed using the following steps: The selection of the conceptual model, explaining the objectives, designing the roadmap and development of the tool. In the psychometric assessment phase, the content, face and construct validity (convergent validity and principal component analysis) were assessed with the participation of 365 married women of reproductive age with T1DM. The reliability of the tool was determined by the internal consistency method (Cronbach’s alpha) and its stability using the test-retest method (Intraclass Correlation Coefficients).

Results

The SRH Profile of Women with T1DM was formed with 53 items in two sections. Twenty-six items were about safe motherhood and reproductive system; 27 items were about the three components of concerns about the reproductive system health and function, sexual health and function, and violence related to T1DM. The three components in the second section explained 49.44% of the total variance. Cronbach’s alpha was 0.872 and the total intra-cluster correlation coefficient was 0.946.

Conclusion

SRH Profile of Women with T1DM is a valid, reliable, and specific tool for assessing sexual-reproductive health in women with type-1 diabetes mellitus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14400-5.

Impact of the COVID-19 pandemic on access to and utilisation of services for sexual and reproductive health: a scoping review

Introduction

The COVID-19 pandemic has negatively impacted health systems globally and widened preexisting disparities. We conducted a scoping review on the impact of the COVID-19 pandemic on women and girls’ access to and utilisation of sexual and reproductive health (SRH) services for contraception, abortion, gender-based and intimate partner violence (GBV/IPV) and sexually transmitted infections (STIs).

Methods

We systematically searched peer reviewed literature and quantitative reports, published between December 2019 and July 2021, focused on women and girls’ (15–49 years old) access to and utilisation of selected SRH services during the COVID-19 pandemic. Included studies were grouped based on setting, SRH service area, study design, population and reported impact. Qualitative data were coded, organised thematically and grouped by major findings.

Results

We included 83 of 3067 identified studies and found that access to contraception, in-person safe abortion services, in-person services for GBV/IPV and STI/HIV testing, prevention and treatment decreased. The geographical distribution of this body of research was uneven and significantly less representative of countries where COVID-19 restrictions were very strict. Access was limited by demand and supply side barriers including transportation disruptions, financial hardships, limited resources and legal restrictions. Few studies focused on marginalised groups with distinct SRH needs.

Conclusion

Reports indicated negative impacts on access to and utilisation of SRH services globally, especially for marginalised populations during the pandemic. Our findings call for strengthening of health systems preparedness and resilience to safeguard global access to essential SRH services in ongoing and future emergencies.

Social desirability and under-reporting of smokeless tobacco use among reproductive age women: Evidence from National Family Health Survey

Introduction

This study hypothesises that the presence of a third person during the interaction between the survey investigator and the woman respondent leads to underreporting of smokeless tobacco (SLT) use by Indian women, including pregnant and breastfeeding women.

Methods

Cross-sectional data from the National Family Health Survey conducted in 2015-16 was analysed for SLT use among women aged 15-49. Multivariate logistic regression examined the odds of SLT use reporting by women respondents in the presence of their husbands and other male or female adults.

Results

SLT use reporting by women significantly varied by the presence of someone during the interview. The analysis shows that the odds of reporting SLT use among women who were neither pregnant nor lactating was 20.6% lower when they were interviewed in the presence of their husbands than when they were interviewed alone. Similarly, compared to those interviewed alone, the odds of women reporting SLT use was 16.5% lower among pregnant and breastfeeding women interviewed in the presence of any adult female. The odds of women under-reporting SLT use were higher in Central and Western India.

Conclusions

This study argues that the current survey estimates misconstrue the authentic prevalence of tobacco use among women in India, including pregnant and lactating women. Due to social desirability or the presence of a third person during the survey interview, those respondents who do not report their tobacco use status are also more likely to forego essential support for successful tobacco cessation. Survey methodology must be strengthened to avert the presence of a third person during the interview to ensure better reporting and population health estimates.

Prevalence of induced abortion among Chinese women aged 18-49 years: Findings from three cross-sectional studies

There are few latest researches about induced abortion in China. We aimed to evaluate the prevalence of induced abortion and the related factors, thereby helping make targeted policies and measures to promote women's health. Three comparable cross-sectional surveys among Chinese women aged 18-49 years were performed in 2016, 2017, and 2021. A total of 14,573 eligible respondents were included in the study. 16.70% (95%CI 16.10%-17.31%) of respondents self-reported having experienced induced abortion, while 6.88% (95%CI 6.46%-7.29%) self-reported repeat induced abortion. Age range of 25-49 years (aOR 2.27-6.31, all P<0.05), living in western (aOR 1.72, 95%CI 1.50-1.98) and central (aOR 1.36, 95%CI 1.21-1.52) regions, having children (aOR 2.85, 95%CI 2.35-3.46) were associated with higher prevalence of induced abortion. Moreover, age range of 25-49 years, living in western and central regions, having children were also related to higher prevalence of repeat induced abortion (aOR 1.67-11.52, all P<0.05). Conversely, educational level of college or higher, household annual income over 80,000 Chinese yuan were associated with lower prevalence of induced abortion and repeat induced abortion (aOR 0.52-0.80, all P<0.05). Induced abortion remains noticeable in China. Sustained efforts are required to reduce unintentional pregnancy, improve reproductive health and post-abortion care services, and promote women's health.

Facilitating an encounter with a new sexuality discourse: the role of civic communicators in building sexual health literacy among newly arrived migrants

Language and different sexual health discourses constitute barriers to the uptake of information on sexual and reproductive health and rights among migrants. Challenges remain with regards to the design and implementation of culturally appropriate programmes and interventions. This study explored the role of civic communicators in increasing access to sexual health information among migrants resettling in Sweden. Twenty in-depth interviews were conducted and analysed using qualitative content analysis. Findings illustrate the potential role of civic communicators in identifying sexual health needs, deconstructing misinformation and providing a space for reflective dialogue. Training in adult pedagogy, leadership, cultural competence and subject knowledge, and allocating sufficient time to cover themes that are culturally different, sensitive and politicised, are essential for good quality implementation and promoting rights-based sexual health.

Telemedicine as an alternative way to access abortion in Italy and characteristics of requests during the COVID-19 pandemic

INTRODUCTION

Induced abortion is legal in Italy but with restrictions. The online abortion provider Women on Web (WoW) serves as an alternative way to access abortion. The COVID-19 pandemic has affected sexual and reproductive health worldwide. Italy was one of the first countries hit by the pandemic and imposed strict lockdown measures. We aimed to understand why women requested WoW abortion in Italy and how this was affected by the pandemic.

METHODS

We conducted an observational study analysing requests made to WoW before and during the pandemic. We analysed 778 requests for medical abortion from Italy between 1 March 2019 to 30 November 2020 and compared the characteristics of requests submitted before and during the pandemic. We also performed subgroup analysis on teenagers and COVID-19-specific requests.

RESULTS

There was an increase in requests during the COVID-19 pandemic compared with the previous year (12% in the first 9 months). The most common reasons for requesting a telemedicine abortion through WoW were privacy-related (40.9%); however, this shifted to COVID-19-specific (50.3%) reasons during the pandemic. Requests from teenagers (n=61) were more frequently made at later gestational stages (p=0.003), had a higher prevalence of rape (p=0.003) as the cause of unwanted pregnancies, and exhibited less access to healthcare services compared with adult women.

CONCLUSIONS

There was an increase in total demand for self-managed abortion during the pandemic and reasons for requesting an abortion changed, shifting from privacy-related to COVID-19-specific reasons. This study also highlighted the uniquely vulnerable situation of teenagers with unwanted pregnancies seeking self-managed abortion.

Public policy on the prevention of subsequent adolescent pregnancy: what type of policy prevails?

This study aims to conduct a search of public-policy instruments seeking explicit references to subsequent adolescent pregnancy, as well as to discern what kinds of actions have been proposed as part of the international and national agendas to facilitate subsequent adolescent pregnancy prevention and care. During June 2021, we used an integrative review to search and to analyze national and international public policy instruments along with other documents related to subsequent adolescent pregnancy. We observed, for each, the presence of statements on subsequent adolescent pregnancy. The research team was then divided into triads to discuss and to classify each reference under one of the following categories: (a) a symbolic statement, that is, an intention not implying a specific action but rather presenting a vision for the future; (b) a substantive-material statement concerning an action intended to solve a problem; and (c) a procedural-material statement indicating specific actions, processes, budgets, and actors. We analyzed a total of 135 public-policy documents: 102 in Mexico and 33 internationally. Only four national and six international documents contained either symbolic or substantive-material references to the subject of interest and only one specified a procedural-material statement. The prevention and care of subsequent adolescent pregnancy are addressed only secondarily on the public agendas. Only a minimal number of actions comprise specific and standardized measures to prevent subsequent adolescent pregnancy according to the different actors involved. Designing a greater number of procedural-material policies will help to reduce morbidity and mortality in the mother-child binomial and promote a comprehensive development of this population.

Sexual Modesty in Sexual Expression and Experience: A Scoping Review, 2000 - 2021

Sexual modesty is the social, cultural, interpersonal, and psychological systems - defined by the tenets of Script Theory - that regulate individuals' sexual expression and experience at the social, legal, and interpersonal boundaries of acceptable/not-acceptable, private/public, and personal/social. Almost all aspects of sexual expression and experience are touched by the pervasive modesty standards for sexual communication, sexual display, sexual relations, and sexual behaviors. Sexual modesty influences an array of sexual and reproductive health outcomes. Many aspects of sexual modesty are enforced by legal as well as social, cultural, and religious proscriptions, including social shaming and ostracism as well as corporal and capital punishments. The purpose of this paper is to summarize a diverse literature related to sexual modesty from the years 2000 to 2021 in order to clarify its role in sexual health and sexual wellbeing and to identify directions for new research.

Factors influencing the integration of comprehensive sexuality education into educational systems in low- and middle-income countries: a systematic review

BACKGROUND

Comprehensive sexuality education (CSE) plays a critical role in promoting youth and adolescent's sexual and reproductive health and wellbeing. However, little is known about the enablers and barriers affecting the integration of CSE into educational programmes. The aim of this review is to explore positive and negative factors influencing the integration of CSE into national curricula and educational systems in low- and middle-income countries.

METHODS

We conducted a systematic literature review (January 2010 to August 2022). The results accord with the Preferred Reporting Items for Systematic Reviews and Meta-analysis standards for systematic reviews. Data were retrieved from the PubMed, Cochrane, Google Scholar, and Web of Hinari databases. The search yielded 442 publications, of which 34 met the inclusion criteria for full-text screening. The review is guided by an established conceptual framework that incorporates the integration of health innovations into health systems. Data were analysed using a thematic synthesis approach.

RESULTS

The magnitude of the problem is evidenced by sexual and reproductive health challenges such as high teenage pregnancies, early marriages, and sexually transmitted infections. Awareness of these challenges can facilitate the development of interventions and the implementation and integration of CSE. Reported aspects of the interventions include core CSE content, delivery methods, training materials and resources, and various teacher-training factors. Reasons for adoption include perceived benefits of CSE, experiences and characteristics of both teachers and learners, and religious, social and cultural factors. Broad system characteristics include strengthening links between schools and health facilities, school and community-based collaboration, coordination of CSE implementation, and the monitoring and evaluation of CSE. Ultimately, the availability of resources, national policies and laws, international agendas, and political commitment will impact upon the extent and level of integration.

CONCLUSION

Social, economic, cultural, political, legal, and financial contextual factors influence the implementation and integration of CSE into national curricula and educational systems. Stakeholder collaboration and involvement in the design and appropriateness of interventions is critical.

Teenagers' and young adults' sexual behaviour and its associations with exposure to violence, among visitors at a Youth Centre in Sweden

OBJECTIVES

This study aimed to investigate differences between teenagers and young adults in sexual behaviours and exposure to emotional, physical and/or sexual violence, and the associations between sexual behaviours and exposure to violence, among youths who visit a Youth Centre in Sweden.

METHODS

A cross-sectional web survey was used among sexually experienced teenagers, aged 15-19, and young adults 20-24 years, wherein a total of 452 participated. Descriptive and bivariate analyses were used in the study.

RESULTS

A majority had unprotected sex during the last year, namely 55.4 % of teenagers and 58.3 % of young adults. A higher proportion of teenagers reported having early sex debut, before 15 years age, compared with young adults (p = .003). A higher proportion of young adults reported having experienced a sexually transmitted infection (p = <.001). Nearly half of the teenagers (44.9 %) and the young adults (44.6 %) stated having been exposed to emotional, physical and/or sexual violence during their lifetime. Associations were found between all types of exposure to violence and having unprotected sex, using alcohol or drugs together with sex, and having had three or more different sex partners during last year.

CONCLUSIONS

Regardless of age, there was a high proportion of youths, visiting a Youth Centre, having unprotected sex and who experienced exposure to violence. As these experiences may negatively affect youths' future sexual and reproductive health, healthcare professionals should identify youths in need or with early-in-life needs.

Quality of care in abortion in the era of technological and medical advancements and self-care

Background

Discussions around quality of abortion care have been focused mainly on service-delivery aspects inside healthcare facilities. More recently, with availability of medical abortion (MA), increase in its self-use, and emergence of other delivery platforms such as telemedicine, the responsibility of quality care has broadened to actors outside of facilities.

Body of text

This commentary discusses the meaning of quality of abortion care with the paradigm shift brought by medical and technological advancement in abortions, and raises questions on the role of the state in ensuring quality in abortion management—especially in settings where abortion is decriminalized, but also in countries where abortion is permitted under certain circumstances. It consolidates the experience gained thus far in the provision of safe abortion services and also serves as a forward-thinking tool to keep pace with the uptake of newer health technologies (e.g., availability of medical abortion drugs), service delivery platforms (e.g., telemedicine, online pharmacies), and abortion care providers (e.g., community based pharmacists).

Conclusions

This commentary provides context and rationale, and identifies areas for action that different stakeholders, including health advocates, policymakers, program managers, and women themselves, can adopt to fit into an alternative regime of abortion care.

Level of satisfaction and sexual and reproductive health needs of deaf persons in Ghana: a sequential explanatory mixed method study

Background

The intersection between deafness and culture in sub-Saharan African contexts such as Ghana has culminated in restricted access to sexual and reproductive health (SRH) services. While some attention has been given to the barriers faced by deaf persons in accessing SRH services, discussion of their needs and satisfaction with SRH services is at an embryonic stage. This lends support to the use of sequential mixed-method study design to assess the level of satisfaction and SRH needs of deaf persons.

Methods

This study was guided by explanatory sequential mixed-method study design. Thus, a two-phase data collection approach was adopted. In Phase I, a 32-item questionnaire with 16 items each for satisfaction regarding SRH services and SRH needs, was used for data collection from 288 deaf persons recruited from 3 of the 16 regions in Ghana. The data were subjected to the following computations: means, t-tests, analysis of variance, correlations, and multiple regression. In Phase II, a semi-structured interview guide was used to collect data from 60 participants who were drawn from the earlier pool. The interviews were subjected to thematic analysis.

Results

The results showed of correlation and multiple analyses showed a small relationship and significant contribution of needs in the variance of satisfaction. Also, there was a convergence between both the qualitative and quantitative data as participants confirmed the lack of consideration given to the needs of deaf persons regarding SRH service provisions.

Conclusion

Deaf persons who took part in this study were unsatisfied with SRH services due to barriers such as sign language interpreters and inaccessible information. Consequently, they expressed the need for preferred mode of communication and expedition of awareness creation on SRH. The study findings warrant the need for policymakers to inculcate the needs of deaf person in SRH services to improve access and thus, enhance satisfaction. For instance, recommendations such as the training of health professionals in the use of sign language could be considered in future SRH policy and other implications, are discussed.

Migrants in Swedish sexual and reproductive health and rights related policies: a critical discourse analysis

BACKGROUND

Previous research has shown that migrants in Sweden are disadvantaged in terms of sexual and reproductive health and rights (SRHR). SRHR policies might play a crucial role in shaping migrants' SRHR outcomes. The purpose of the study was to critically examine: a) how migrants were represented in the discourses embedded within Swedish SRHR-related policies, and b) how migrants' SRHR-related issues were framed and addressed within these discourses.

METHODS

Critical discourse analysis (CDA) was used to analyze a total of 54 policy documents. Following Jäger's approach to CDA, discourse strands and entanglements between different discourse strands were examined.

RESULTS

Our findings consisted of three discourse strands: 1) "Emphasizing vulnerability", 2) "Constructing otherness", and 3) "Prioritizing the structural level or the individual level?". Migrants' representation in Swedish SRHR-related policies is often associated with the concept of vulnerability, a concept that can hold negative connotations such as reinforcing social control, stigma, and disempowerment. Alongside the discourse of vulnerability, the discourse of otherness appears when framing migrants' SRHR in relation to what is defined as honor-related violence and oppression. Furthermore, migrant SRHR issues are occasionally conceptualized as structural issues, as suggested by the human rights-based approach embraced by Swedish SRHR-related policies. Relevant structural factors, namely migration laws and regulations, are omitted when addressing, for example, human trafficking and HIV/AIDS.

CONCLUSIONS

We conclude that the dominant discourses favor depictions of migrants as vulnerable and as the Other. Moreover, despite the prevailing human rights-based discourse, structural factors are not always considered when framing and addressing migrants' SRHR issues. This paper calls for a critical analysis of the concept of vulnerability in relation to migrants' SRHR. It also highlights the importance of avoiding othering and paying attention to the structural factors when addressing migrants' SRHR.

Males' Awareness of Female and Male Contraception Methods, Information, Outreach, and Acquisition Locations in Abidjan, Côte d'Ivoire, Nairobi, Kenya, and Lagos, Nigeria

PURPOSE

The aim of this study is to describe modern female and male method awareness, information sources, outreach exposures, and acquisition source awareness among young men aged 15-24 by sexual behavior status in sub-Saharan Africa.

METHODS

Cross-sectional surveys were conducted with unmarried, young men aged 15-24 recruited via respondent-driven sampling in Abidjan, Côte d'Ivoire (n = 1,028), Nairobi, Kenya (n = 691), and Lagos, Nigeria (n = 706). Descriptive statistics characterized contraception awareness of male and female methods and information sources, outreach exposures, acquisition source awareness, and preferred contraception source. Multivariate regressions characterized factors associated with awareness of each method.

RESULTS

Majority of respondents were aged 15-20 (59%), sexually active (65%), and had secondary or more education (89%). Awareness was low for all methods (short-acting reversible contraception, 47%; emergency contraception, 35%; long-acting reversible contraception, 32%; withdrawal, 18%), except condoms (85%). Respondents reported low levels of contraception information sources, recent outreach exposures, and acquisition location awareness that varied by sexual behavior (higher among sexually active than nonsexually active respondents). Multivariate analyses demonstrated common factors associated across awareness of all methods included information sources (teacher, friend, Internet, social media for all respondents; pharmacist for sexually active respondents) and acquisition locations (private healthcare, pharmacy, market/store for all respondents; public healthcare, mobile clinic, faith-based organizations for sexually active respondents). Sexually active respondents' rank order for preferred contraception source was doctors/nurses followed by teachers, friends, mothers, and fathers; and for nonsexually active respondents' rank order was teachers followed by friends, mothers, doctors/nurses, and health centers.

DISCUSSION

Findings have implications for increasing young men's method awareness, specific sources, and settings to target contraceptive outreach.

Socioeconomic Factors and Patterns of Intimate Partner Violence among Ever-Married Women in Uganda: Pathways and Actions for Multicomponent Violence Prevention Strategies

Intimate partner violence (IPV) is a severe public health problem in sub-Saharan Africa (SSA) with harmful effects on the physical, psychological, and socioeconomic wellbeing of survivors and their families. In SSA, IPV is associated with mental health disorders, high-risk behaviors, and HIV vulnerability, especially among women. In Uganda, poor socioeconomic status increases women's vulnerability to IPV. Yet there is limited evidence on the association between socioeconomic factors and IPV severity in Uganda. Our study used population-based data to (a) establish different patterns describing the severity of IPV experiences, (b) explore associations between socioeconomic factors and severity of IPV experiences among Ugandan ever-married women, and (c) examine direct and indirect pathways from socioeconomic factors to severity of IPV experiences. Data were drawn from the 2016 Uganda Demographic and Health Survey's sample of 7,536 ever-married women aged 15-49 years. A latent class analysis examined distinct patterns of IPV severity among this sample, yielding a four-class solution: low violence (n = 5,059; 67.1%); high physical violence, low sexual violence (n = 1,501; 19.9%); high sexual violence, moderate physical violence (n = 535; 7.1%); and high sexual and severe physical violence (n = 441; 5.9%). Using the low violence group as the reference category, we conducted a multinomial logistic regression that found significant associations between secondary education (aOR 2.35, 95% CI: [1.06, 5.24]), poorest on the wealth index (aOR 2.00, 95% CI: [1.13, 3.54]), and severe IPV experiences. Decision-making (aOR 0.81, 95% CI: [0.68, 0.96]) played a protective role against membership in the high sexual and physical violence class compared to the reference category. Using path analysis, we found that labor force participation partially mediated the path from wealth index and education to IPV severity. Findings indicate the need for interventions that aim to keep girls in school and target schools, communities, and media platforms to address gender norms, economic vulnerability, and comprehensive screening for multiple forms of violence.

Are LARC Users Less Likely to Use Condoms? An Analysis of U.S. Women Initiating LARC in 2008-2018

INTRODUCTION

Public health professionals have raised concern that increased use of long-acting reversible contraceptives (LARC) could raise women's risk for sexually transmitted infections (STIs), because LARC's superior pregnancy protection may decrease women's motivation to use a barrier method for supplemental pregnancy prevention. This study uses population-based data to examine whether condom use is lower, particularly among young women who are at increased STI risk, after initiating LARC versus moderately effective methods.

METHODS

With the 2011-2019 data files of the National Survey of Family Growth, we examine the percent of sexually active months with condom use in the year after LARC or moderately effective method initiation for a nationally representative sample of 2,018 women aged 15-44 years. Multinomial logistic models regressed condom use on method type and age group, as well as their interaction, while adjusting for key confounders.

RESULTS

The unadjusted likelihood of any condom use is substantially lower among women who initiated LARC versus moderately effective methods (12% vs. 37%), and this difference is greater among younger versus older women. After accounting for differences in women's reproductive and sociodemographic profiles, however, a statistically significant difference in condom use by method initiated remains only for those aged 20-34 years.

CONCLUSIONS

Crude estimates suggest that condom use is lower after initiating LARC versus moderately effective methods, especially among young women. After accounting for the confounding effects of LARC users' distinct profiles-particularly in terms of parity and teenage childbearing-the difference is decreased overall and no longer significant for adolescent women. Overall results indicate a need for new STI prevention strategies and policies that emphasize the importance of dual prevention for LARC users at risk of STIs.

Competing health risks associated with the COVID-19 pandemic and early response: A scoping review

BACKGROUND

COVID-19 has rapidly emerged as a global public health threat with infections recorded in nearly every country. Responses to COVID-19 have varied in intensity and breadth, but generally have included domestic and international travel limitations, closure of non-essential businesses, and repurposing of health services. While these interventions have focused on testing, treatment, and mitigation of COVID-19, there have been reports of interruptions to diagnostic, prevention, and treatment services for other public health threats.

OBJECTIVES

We conducted a scoping review to characterize the early impact of COVID-19 on HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

METHODS

A scoping literature review was completed using searches of PubMed and preprint servers (medRxiv/bioRxiv) from November 1st, 2019 to October 31st, 2020, using Medical Subject Headings (MeSH) terms related to SARS-CoV-2 or COVID-19 and HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition. Empiric studies reporting original data collection or mathematical models were included, and available data synthesized by region. Studies were excluded if they were not written in English.

RESULTS

A total of 1604 published papers and 205 preprints were retrieved in the search. Overall, 8.0% (129/1604) of published studies and 10.2% (21/205) of preprints met the inclusion criteria and were included in this review: 7.3% (68/931) on HIV, 7.1% (24/339) on tuberculosis, 11.6% (26/224) on malaria, 7.8% (19/183) on sexual and reproductive health, and 9.8% (13/132) on malnutrition. Thematic results were similar across competing health risks, with substantial indirect effects of the COVID-19 pandemic and response on diagnostic, prevention, and treatment services for HIV, tuberculosis, malaria, sexual and reproductive health, and malnutrition.

DISCUSSION

COVID-19 emerged in the context of existing public health threats that result in millions of deaths every year. Thus, effectively responding to COVID-19 while minimizing the negative impacts of COVID-19 necessitates innovation and integration of existing programs that are often siloed across health systems. Inequities have been a consistent driver of existing health threats; COVID-19 has worsened disparities, reinforcing the need for programs that address structural risks. The data reviewed here suggest that effective strengthening of health systems should include investment and planning focused on ensuring the continuity of care for both rapidly emergent and existing public health threats.

Addressing sexual and reproductive health and rights with men in prisons: co-production and feasibility testing of a relationship, sexuality and future fatherhood education programme

PURPOSE

Young incarcerated male offenders are at risk of poorer sexual health, adolescent parenthood and lack opportunities for formative relationship and sexuality education (RSE) as well as positive male role models. The purpose of this paper is to report the process of co-production and feasibility testing of a novel, gender-transformative RSE programme with young male offenders to encourage positive healthy relationships, gender equality, and future positive fatherhood.

DESIGN/METHODOLOGY/APPROACH

Using a rights-based participatory approach, the authors co-produced an RSE programme with young offenders and service providers at two UK prison sites using a sequential research design of: needs analysis, co-production and a feasibility pilot. Core components of the programme are grounded in evidence-based RSE, gender-transformative and behaviour change theory.

FINDINGS

A needs analysis highlighted the men's interest in RSE along with the appeal of film drama and peer-group-based activities. In the co-production stage, scripts were developed with the young men to generate tailored film dramas and associated activities. This co-production led to "If I Were a Dad", an eight-week programme comprising short films and activities addressing masculinities, relationships, sexual health and future fatherhood. A feasibility pilot of the programme demonstrated acceptability and feasibility of delivery in two prison sites. The programme warrants further implementation and evaluation studies.

ORIGINALITY/VALUE

The contribution of this paper is the generation of an evidence-based, user-informed, gender-transformative programme designed to promote SRHR of young male offenders to foster positive sexual and reproductive health and well-being in their own lives and that of their partners and (future) children.

Contraception knowledge and uptake among in-school adolescents in three South African townships: Baseline findings from the Girls Achieve Power (GAP Year) Trial

Background: South African adolescents experience barriers to sexual and reproductive health (SRH) knowledge and uptake. This study provides insight into contraceptive and other SRH service knowledge, perceptions, and uptake among adolescents in high HIV prevalence settings. Methods: A baseline cross sectional survey was conducted among 3432 grade 8s enrolled into the Girls Achieve Power (GAP Year) trial from 26 public high schools across three South African townships (Soweto, Thembisa and Khayelitsha) (2017 - 2018). An interviewer-led survey collected information on SRH knowledge and perceptions; an audio computer-assisted self-interviewing technique gathered SRH service uptake. Descriptive analysis indicates frequency distribution of socio-demographics and knowledge, uptake and perceptions of SRH services. Chi-square test tested for associations between age and sex and selected variables that measure SRH knowledge and uptake. Results: In total, 2383 learners, completed both survey components. Of these, 63.1% (n=1504) were female and 81.4% (n=1938) aged 12-14. Almost a fifth (18.3%, n=436) had ever had sex and less than 1% had accessed SRH services in the last year. Of the 157 females who had ever had sex, 50.9% had ever used contraception. Of those who had sex in the last three months, 59.0% reported using a contraceptive method. Condom use was inconsistent: almost all females said they had not used or could not remember if a condom was used at last sex. Conclusion: This paper contributes to the evidence strengthening learner SRH education, including the national Integrated School Health Programme. Key themes include the need for age-appropriate, differentiated comprehensive sexuality education (CSE) for the range of ages found in the same grade in South African schools. Education on different contraceptive methods, informed decision-making, and emergency contraception is key. School-based interventions should embrace integrated HIV, STI, and pregnancy prevention messages. Closer links with health services need to be constantly fostered and reinforced.

Self-experienced sexual and reproductive health in young women with Attention Deficit Hyperactivity Disorder: A qualitative interview study

Background

Sexual risk behaviors and struggles in romantic relationships result in higher risk of unplanned pregnancy, sexually transmitted diseases, sexual victimization and lower satisfaction in relationships for young women with Attention Deficit Hyperactivity Disorder (ADHD). There is a need to better understand sexual behaviors and the consequences of relational difficulties to help health professionals promote sexual and reproductive health. To deepen knowledge in this area, this study aimed to identify and describe self-experienced sexual and reproductive health in young women with ADHD.

Methods

A qualitative design was used. Data was collected with individual and focus group interviews with 15 young women, aged 15–29, with an ADHD diagnosis, and analyzed with thematic analysis.

Results

Data analysis identified the themes Acceptance of being different and Feeling sexually secure. The women reveal feelings of being different from others without ADHD as they break norms of sexual behavior, struggle with romantic relationships, and have difficulties concentrating during sex. There is a need to be understood and accepted, to not feel judged, and to manage romantic relationships. Self-knowledge helps them to recognize needs for support and to develop strategies that can improve sexual satisfaction. Feeling sexually secure illustrates the women’s need to feel comfortable with their own sexuality and in control in the sexual situation. Low self-esteem and a negative self-image, described as a consequence of living with ADHD, can compromise communication in sexual situations and increase fear of being rejected. Further, misjudging sexual partners and situations can contribute to sexual victimization.

Conclusions

This study provides knowledge of how ADHD affects emotions and sexual behaviors in young women. The results highlight the need for understanding and acceptance by peers and partners. It accentuates the value of involving the partner in counselling and the importance of self-knowledge. Feeling insecure in sexual relationships further implies the importance of early diagnosis to prevent secondary outcomes of ADHD, and the need for sexual victimization screening in professional settings.

The Liberal Social Values of Swedish Healthcare Providers in Women’s Healthcare: Implications for Clinical Encounters in a Diversified Sexual and Reproductive Healthcare

Objectives: Women’s healthcare is a potential source of cross-cultural conflicts. Diverging values between healthcare providers and patients challenges the provision of culturally sensitive care and meeting migrant women’s needs. The aim is to investigate healthcare providers’ values in relation to sexual and reproductive rights, gender equality, migration and religion in Swedish sexual and reproductive healthcare.

Methods: A national cross-sectional study was carried out. The questionnaire was distributed through a non-probability sample to midwives or other nurses, gynaecologists and obstetricians, and hospital social workers (n = 1,041). Through descriptive statistics, we mapped their values, comparing healthcare provider data to external representative population survey data.

Results: Healthcare providers in sexual and reproductive healthcare displayed homogeneous liberal social values, being permissive towards sexual and reproductive rights and restrictive against gender-based violence. They were for gender equality, expressed low anti-immigrant sentiments, and had even more liberal values than the Swedish population and a demographically comparative sub-population.

Conclusion: Individuals with very liberal values are selected to work in Swedish sexual and reproductive healthcare. Healthcare providers need self-reflexivity to avoid conflicts in clinical encounters in a diversified society.

Attitudes Toward the Copper IUD in Sweden: A Survey Study

Background

While the efficacy and safety of the contraceptive copper intrauterine device (IUD) have been affirmed, alongside its importance for the prevention of unintended pregnancies, some studies have pointed to negative attitudes toward the device. In recent years, social media communication about it has included claims about systemic side effects, unsubstantiated by medical authorities. Research from the Swedish context is sparse. This study investigates attitudes toward the copper IUD and any correlations between negative attitudes toward or experiences of the device, and (1) sociodemographic characteristics, (2) the evaluation of the reliability of different sources of information, and (3) trust in healthcare and other societal institutions.

Methods

A survey was distributed online to adult women in Sweden (n = 2,000). Aside from descriptive statistics, associations between negative attitudes toward or experiences of the copper IUD and sociodemographic and other variables were calculated using logistic regressions and expressed as odds ratios (ORs) with 95% confidence intervals (95% CIs). Open survey responses (n = 650) were analyzed thematically.

Results

While many reported positive attitudes toward and experiences of the IUD, 34.7% of all respondents reported negative attitudes and 45.4% of users reported negative experiences. Negative attitudes were strongly correlated with negative experiences. Negative attitudes and experiences were associated with low income, but no conclusive associations were identified with other socioeconomic variables. Negative attitudes and experiences were associated with lower levels of confidence in and satisfaction with healthcare, as well as lower self-assessed access and ability to assess the origin and reliability of information about the IUD. In open responses, negative comments were prevalent and included references to both common and unestablished perceived side-effects. Respondents pointed to problematic aspects of information and knowledge about the copper IUD and called for improved healthcare communication and updated research.

Conclusion

Healthcare provider communication about the copper IUD should promote reproductive autonomy and trust by providing clear information about potential side effects and being open to discuss women's experiences and concerns. Further research on copper IUD dissatisfaction and ways in which health professionals do and may best respond to it is needed.

Analysing intersecting social resources in young people's ability to suggest safer sex - results from a national population-based survey in Sweden

Background

Safer sex is one of the most crucial areas in sexual and reproductive health and rights (SRHR). Drawing on the theory of health promotion where social life generates resources for health our hypothesis is that having control over one’s life situation, affects the ability for safer sex and thereby sexual health. The aim is to explore the association between having control over one’s life and the ability to suggest safer sex among young people aged 16–29, and how this plays out in relation to membership of six constructed social groups based on: gender, transgender experience, sexual identity, economy, being foreign-born, and social welfare recipiency followed by an in-depth analysis of the intersection of gender and sexual identity.

Methods

The data set comprises cross-sectional survey responses from a stratified random sample of 7755 in the total Swedish population of young people. The SRHR-focused questionnaire was developed within the HIV-monitoring program at the Public Health Agency of Sweden. Data collection was conducted by Statistics Sweden between April 15 and June 8 in 2015. The survey had a response rate of 26%, which was in line with the study design. Statistical analysis was used to explore the self-reported outcome variable ability for safer sex and the exposure variable control over one’s life. The methods used comprise multivariate logistic regression and an intersecting multivariate regression exploring 12 intersecting social positions by gender and sexual identity.

Results

The results show that young people’s control over their lives is associated with their ability for safer sex. Due to this, control over one’s life can be seen as a resource for safer sex. The associations in the 12 intersecting social positions showed complex patterns.

Conclusions

The intersections of resources show the complexity and that gender cannot account for all differences in the resources for young people’s ability to suggest safer sex. Implications for policy and practitioners involve both addressing and strengthening the sexual rights of young people from sexual minorities and tailoring interventions in a way that takes the intersections between gender and sexual identity into consideration.

Policy Implementation Challenges and Barriers to Access Sexual and Reproductive Health Services Faced By People With Disabilities: An Intersectional Analysis of Policy Actors' Perspectives in Post-Conflict Northern Uganda

BACKGROUND

Emerging from a 20-year armed conflict, Uganda adopted several laws and policies to protect the rights of people with disabilities, including their sexual and reproductive health (SRH) rights. However, the SRH rights of people with disabilities continue to be infringed in Uganda. We explored policy actors' perceptions of existing pro-disability legislation and policy implementation, their perceptions of potential barriers experienced by people with disabilities in accessing and using SRH services in post-conflict Northern Uganda, and their recommendations on how to redress these inequities.

METHODS

Through an intersectionality-informed approach, we conducted and thematically analysed 13 in-depth semi-structured interviews with macro level policy actors (national policy-makers and international and national organisations); seven focus groups (FGs) at meso level with 68 health service providers and representatives of disabled people's organisations (DPOs); and a two-day participatory workshop on disability-sensitive health service provision for 34 healthcare providers.

RESULTS

We identified four main themes: (1) legislation and policy implementation was fraught with numerous technical and financial challenges, coupled with lack of prioritisation of disability issues; (2) people with disabilities experienced multiple physical, attitudinal, communication, and structural barriers to access and use SRH services; (3) the conflict was perceived to have persisting impacts on the access to services; and (4) policy actors recommended concrete solutions to reduce health inequities faced by people with disabilities.

CONCLUSION

This study provides substantial evidence of the multilayered disadvantages people with disabilities face when using SRH services and the difficulty of implementing disability-focused policy in Uganda. Informed by an intersectionality approach, policy actors were able to identify concrete solutions and recommendations beyond the identification of problems. These recommendations can be acted upon in a practical road map to remove different types of barriers in the access to SRH services by people with disabilities, irrespective of their geographic location in Uganda.

Intimate Partner Abuse Among Rohingya Women and Its Relationship With Their Abilities to Reject Husbands' Advances to Unwanted Sex

Currently, around a million Rohingya refugees live in Cox's Bazar, Bangladesh. Displacement from homelands and restrictions on movement in the refugee camps may exacerbate intimate partner abuse (IPA) against refugee women and their abilities to reject husbands' advances to unwanted sex. This study examines Rohingya refugee women's attitudes toward and experience of intimate partner abuse (IPA) and their impact on the abilities to reject husbands' advances to unwanted sex. A survey was conducted among Rohingya refugee women in Cox's Bazar, Bangladesh. Women's attitudes toward IPA, and experience of IPA were the exposure variables. Women's abilities to say "no" to husbands' advances to unwanted sexual intercourse was the outcome variable. Multivariable logistic regression models were used to examine the relationships. Participants' median age was 22 years (range: 13-41). Most women perceived hitting/beatings by their husbands in certain situations as justifiable, 72% had experienced such abuse and 56.5% had to engage in unwanted sexual intercourse with their husbands. Women with increasing leniency towards hitting/beatings and those who had experienced such abuse were less likely to be able to say "no" to husbands' advances to unwanted sexual intercourse. Rohingya women's attitudes toward and experience of IPA are associated with their abilities to say "no" to husbands' advances to unwanted sex. Intervention is needed to denormalize the current practice of IPA, create awareness against IPA, and ensure formal education for girls.

Investigating the association between infertility and psychological distress using Australian Longitudinal Study on Women's Health (ALSWH)

Infertility affects millions of people globally. Although an estimated 1 in 6 couples in Australia are unable to conceive without medical intervention, little is known about the mental health impacts of infertility. This study investigated how infertility impacts the mental health of women. The study used nationally representative Australian Longitudinal Study on Women's Health (ALSWH) data. We analysed data from survey periods 2-8 conducted every three years between 2000 and 2018 for 6582 women born in 1973-78. We used a Generalised Equation Modelling (GEE) method to investigate the association of primary, secondary and resolved fertility status and psychological distress over time. Multiple measures were used to measure psychological distress: the (1) the mental health index subscale of the 36-item short form survey (SF-36), (2) the Center for Epidemiological Studies Depression Scale (CESD-10), (3) the Goldberg Anxiety and Depression Scale (GADanx) anxiety subscale; and a (4) composite psychological distress variable. About a third (30%) of women reported infertility at any of the survey rounds; a steady increase over 18 years from 1.7% at round 2 to 19.3% at round 8. Half of the women reporting primary or secondary infertility reported psychological distress, with the odds of having psychological distress was higher in women reporting primary (odds ratio (OR) 1.24, 95% confidence interval (CI) 1.06-1.45), secondary (OR 1.27, 95% CI 1.10-1.46) or resolved infertility (OR 1.15, 95% CI 1.05-1.26) compared to women reporting normal fertility status. Women with partners, underweight or higher BMI, smoking, and high-risk alcohol use had higher odds of psychological distress, whereas women in paid work had significantly lower odds of psychological distress (p < 0.001). Diabetes, high blood pressure, asthma, and other chronic physical illness were independently associated with higher odds of psychological distress. Infertility has a significant impact on mental health even after it is resolved. Frequent mental health assessment and a holistic approach to address the lifestyle factors should be undertaken during the treatment of infertility.

Leveling up evidence syntheses: filling conceptual gaps of the role of midwifery in health systems through a network analysis

OBJECTIVE

In the research note, our main objective is to explore the value of combining an evidence synthesis with a network analysis. The discussion is based on a critical interpretive synthesis, which combines systematic review methodology with qualitive inquiry, and 'research concept' network analysis focused on understanding the roles of midwives in health systems. The interpretative analytic approach of a critical interpretive synthesis has a high explanatory value by allowing for the review of a diverse body of literature and is well-suited to delving into areas that are not well understood, such as midwifery.

RESULTS

Network analyses use graphs to represent relationships between concepts and brought to light important additional insights into the literature that were not present in the evidence synthesis alone. Given the lack of theoretical development in the area of midwifery in health systems, the critical interpretive synthesis allowed for the generation of concepts used to inform a theoretical framework, while the novel application of an exploratory network analysis deepened understanding of conceptual areas of saturation within the field, as well as identifying critical gaps in the literature.

Designing illustrative social media stories to promote adolescent peer support and healthy sexual behaviors

Objective

Adolescent females in the United States continue to have unmet sexual and reproductive healthcare needs. Research shows that interventions incorporating peer support can augment perceived self-efficacy and reinforce healthy behaviors. Yet, few user-centered digital sexual health interventions incorporate peer support, and aim to change perceptions of peer norms and model social skills. The objective of this study was to design and demonstrate the receptivity of adolescent females to illustrated digital social media stories that promote healthy sexual behaviors and peer social support.

Methods

We conducted a three-phase study approved by our Institutional Review Board. In Phase 1, we presented sexually active adolescent female emergency department patients aged 14-19 with eight sexual health scenarios via a survey study. Participants wrote three text messages addressed to the protagonist of each scenario which motivated and encouraged her to consider the use of contraceptives. Messages were scored based on the construct of peer support (emotional, tangible, informational, and belonging). In Phase 2, we worked with a professional artist and screenwriter to design digital sexual health comics using the gathered messages. In Phase 3, we gathered feedback on the comics from adolescent female emergency department patients.

Results

Females (n  =  22) provided 352 messages. Using top rated messages, we designed five digital visualizations in a running story called Mari tells it like it is. Each story incorporated 5-12 peer-authored quotes. We inserted the final images into Instagram®. Additional females (n  =  39) found the images "relatable," "super-realistic," and "educational."

Conclusion

Collecting peer-authored texts from our local adolescent community led to the creation of well-received sexual health visualizations. This novel method of design incorporated adolescent voices to promote peer support and healthy behaviors.

Sexual and reproductive health and rights of "last mile" adolescents: a scoping review

Globally, significant progress has been made in the realm of adolescent sexual and reproductive health. We conceptualised "last mile" adolescents as having two or more of the following factors of identity: refugee, Indigenous, 2SLGBTQIA+, out of school, rurally or remotely located, slum dwelling, incarcerated or previously incarcerated, HIV/AIDS infected, and living with a disability. We conducted a scoping review with an aim to synthesise evidence and identify research gaps in the literature pertaining to the sexual and reproductive health and rights (SRHR) of last mile adolescents. We conducted searches in three databases (Embase, Global Health, and Medline). Fifty-four publications met our inclusion criteria. Our results revealed that the state of evidence on the SRHR of last mile adolescents is poor. Very few studies used qualitative and mixed-method inquiry. The number of studies carried out in North America, Europe, and Oceania were limited. We found insufficient disaggregated data with respect to SRHR-related knowledge, behaviour, and access to services. Adopting an intersectional lens is critical to uncover the multiplicative effects of last mile adolescents' factors of identity on their SRHR. National data systems should be strengthened to enable the collection of quality disaggregated data which can play a vital role in identifying SRHR inequities affecting last mile adolescents. Research priorities should be realigned to generate data globally on the SRHR of last mile adolescents whose lives are marked by intersecting vulnerabilities.

Being dragged into adulthood? Young people's agency concerning sex, relationships and marriage in Malawi, Mozambique and Zambia

This study aimed to explore how young people exercise agency in rural Malawi, Mozambique and Zambia in relation to sex, relationships and marriage, to inform local programmes aiming to prevent teenage pregnancy and child marriage. In each country, focus group discussions with young people and parents, in-depth interviews with young people and a variety of other participants, and a household survey with young people (15-24 years) were conducted. We found that (child) marriage was often a response to teenage pregnancy, which was highly prevalent in all study areas. Young people's aspirations to enter adulthood were influenced by their life circumstances. Initiation ceremonies symbolised the transition to adulthood and gave social endorsement to young people to start engaging in (often unprotected) sexual activity. Given the uncertain socio-economic context, resource constraints led families to marry off their daughters; or girls themselves to marry early to relieve the burden on their families, but also to get pregnant as a 'next step' towards adulthood. Transactional sex was common. These intersecting cultural, social and economic contextual factors constrained young women's agency, more as compared to young men. However, young women did manoeuvre within contextual constraints to exercise a degree of agency.

Perceptions of family planning among some Somali men living in Sweden: A phenomenographic study

OBJECTIVE

A growing body of research in Sweden has focused on migration and reproductive health, particularly on women's perspectives, including family planning and contraception. However, knowledge is limited on how immigrant men perceive family planning. The topic is important because women's use of family planning has been shown to be influenced by their partners and community. Therefore, this study aims to explore perceptions of family planning among Somali men living in Sweden.

METHODS

A qualitative phenomenographic approach was used. Four focus group discussions were conducted with 41 men aged 28-59 years. Data were analysed using phenomenographic analysis.

FINDINGS

The following four categories were identified in the analysis: 1) a happier and more sustainable family; 2) ideal family size versus cultural commitment; 3) fears of using modern family planning methods; and 4) a need to be included in family planning. The findings illuminated the complexities of perceptions of family planning. Although Somali men understood the benefits of family planning, they seemed to prefer a large family. However, due to their new social context in Sweden, they had also changed their views on having as large a family as in their home country.

CONCLUSION

Our findings suggest that Somali men living in Sweden want to be involved in family planning counselling, which may increase women's use of contraception. However, healthcare providers must ensure that the woman desires her partner's involvement and be culturally sensitive about couples' needs.

Why do young people engage in dating relationships during early adolescence? An inter-generational qualitative analysis from Blantyre, Malawi

Engagement in dating relationships plays an important role in the health trajectories of young people, particularly during the early adolescent period between ages 10-14. Yet little is known about such relationships among youth in low resource contexts. This study sought to contribute to the literature on this topic by exploring reasons why school-going young people aged 12-14 years engage in dating relationships in Blantyre, Malawi. A thematic analysis was used to code and analyse in-depth interview data from 23 young people and 19 caregivers. Against the backdrop of growing sexual desires and feelings of attraction, participants stressed harassment from boys and coercion from older men, peer pressure, social status attainment, financial deprivation and encouragement during initiation ceremonies as reasons for engaging in dating relationships. Girls were found to be subject to multiple power dynamics-including gender power relations, as well as power dynamics within same-gender peer groups-that influenced their sex and relationship involvement. These findings carry implications for the design and timing of sexual and reproductive health youth programmes in Sub-Saharan Africa and emphasise the need for multi-level interventions to address the multiple influences in young people's dating lives.

Prevalence of intimate partner violence against infertile women in low-income and middle-income countries: a systematic review and meta-analysis

Background

Infertility and intimate partner violence (IPV) are of serious concern globally, yet the prevalence of IPV against infertile women has not been quantified at the regional or global level. We aimed to estimate the prevalence of IPV against infertile women and its variation in low-income and middle-income countries (LMICs).

Methods

We did a systematic literature search of 11 databases for articles published between database inception and Sept 30, 2021, and performed meta-analyses to estimate the pooled prevalence and 95% CI of IPV against infertile women in LMICs. We used subgroup analyses and meta-regressions to explore variation in the prevalence by study period (2010 and before vs after 2010), study region (Africa, west Asia, south Asia, and east Asia), type of infertility (primary or secondary), risk of bias (high, moderate, or low), sample size (continuous variable), and measuring tools (the modified Abuse Assessment Screen, the WHO Violence Against Women instrument, or the revised Conflict Tactics Scales). This study is registered with PROSPERO, CRD42021248448.

Findings

Of 2661 references identified (2637 via database searches and 24 via secondary searches), 120 full-text articles were reviewed, and we identified 30 relevant studies conducted in nine LMICs between 2000 and 2019. 25 studies met the inclusion criteria for meta-analysis, with a total sample size of 7164 participants. The 12-month prevalence of IPV among infertile women was 36·0% (95% CI 20·4–55·2), compared with a lifetime prevalence of 47·2% (31·7–63·3). The most common type of IPV was psychological violence, with a prevalence of 24·6% (11·3–45·6) over 12 months and 51·5% (38·8–64·0) over a lifetime (slightly higher than the pooled overall rate due to different data sources), respectively; followed by physical violence (11·9% [5·2–25·1] and 20·2% [12·1–31·7]); sexual violence (8·7% [2·6–25·0] and 11·5% [6·1–20·7]); and economic coercion (2·6% [0·4–13·7] and 9·8% [5·7–16·5]). Significant variations of lifetime prevalence estimates were presented by study period (R²=39·46%), region (R²=50·95%), and measuring tools (R²=54·27%).

Interpretation

A high prevalence of IPV against infertile women is evident despite heterogeneity across studies. IPV screening, counselling, and structural interventions should be tailored to address this urgent issue at multiple levels of society.

Funding

China Medical Board and WHO.

Sexual satisfaction and its associations with patient-reported outcomes in a cohort of women living with human immunodeficiency virus in Sweden

Background: Sexual satisfaction is an important dimension of health-related quality of life that needs to be addressed. Various factors may influence sexual satisfaction in women living with HIV (WLHIV); however, research in this area is limited. The aim of this study was to investigate patients' self-reported sexual satisfaction and its associations with patient-reported outcomes in WLHIV in Sweden. Methods: Data was retrieved from the InfCareHIV registry for the years 2011-2016. The registry includes a self-reported validated 9-item health questionnaire to assess patient-reported outcomes, side effects and adherence. In total, 1292 WLHIV aged ≥18 years were included, corresponding to 42.8% of the female Swedish InfCareHIV cohort 2011-2016. A total of 2444 questionnaires were included in the study. The patient-reported outcomes used were satisfaction with physical health and psychological health, sexual satisfaction, and experiencing side effects from HIV-medication. Associations were tested in univariable and multivariable models. Results: The study shows that there was a significant association between sexual satisfaction and satisfaction with psychological health (p ≤ 0.0001). There was a lower probability of reporting sexual satisfaction in women who were of an older age when they received an HIV-diagnosis (p = 0.033), who had lived for more years with HIV (p = 0.0004), or who had experienced side effects (p = 0.028). Conclusions: This national register-based study identified that sexual satisfaction in WLHIV is associated with psychological health and with having experienced side-effects. Patient-reported outcomes can provide valuable information so that the care of WLHIV covers all aspects of health and supports sexual satisfaction, which is an important part of quality of life.

Effects of the COVID-19 Pandemic on LGBTQ+'s Sexual Behaviors in Turkey: "Everything about Sex Had Become A Black Box"

The COVID-19 pandemic has forced changes in the behavior patterns of many population groups due to restrictive measures all over the world. In this study, qualitative research method based on a phenomenological approach was used to determine the changes in the sexual behavior of a group of LGBTQ+ people living in Turkey. The COVID-19 pandemic has culminated in changes in the sexual life of LGBTQ+s. It has been determined that feelings such as the need of emotional support, loneliness, devaluation and helplessness were experienced, and quarantine and curfew restrictions were effective on sexuality and sexual behaviors. In addition, it has been determined that LGBTQ+s have changed in the standards of determining partners during the pandemic process. The use of sex toys has increased, the sensitivity toward self-care and hygiene rules has increased, the tendency to have sexual fantasies has changed, the sexual behavior of people in their social environment has changed, and the disruptions in health services have posed negative effects. It is recommended to carry out studies focusing on the sexual behavior of LGBTQ+s and to develop counseling services regarding the sexual behaviors of LGBTQ+s and the situations that occur in their sexual lives.

Knowledge, uptake and patterns of contraception use among in-school adolescents in three South African townships: Baseline findings from the Girls Achieve Power (GAP Year) Trial

Background: South African adolescents experience barriers to sexual and reproductive health (SRH) knowledge and uptake. This study provides insight into contraceptive and other SRH service knowledge, perceptions, and uptake among adolescents in high HIV prevalence settings. Methods: A baseline cross sectional survey was conducted among 3432 grade 8’s enrolled into the Girls Achieve Power (GAP Year) trial from 26 public high schools across three South African townships (Soweto, Thembisa and Khayelitsha) (2017 - 2018). An interviewer-led survey collected information on SRH knowledge and perceptions; an audio computer-assisted self-interviewing technique gathered SRH service uptake. Descriptive analysis indicates frequency distribution of socio-demographics and knowledge, uptake and perceptions of SRH services. Chi-square test tested for associations between age and sex and selected variables that measure SRH knowledge and uptake. Results: In total, 2383 learners, completed both survey components. Of these, 63.1% (n=1504) were female and 81.4% (n=1938) aged 12-14. Almost a fifth (18.3%, n=436) had ever had sex and less than 1% had accessed SRH services in the last year. Of the 157 females who had ever had sex, 50.9% had ever used contraception. Of those who had sex in the last three months, 59.0% reported using a contraceptive method. Condom use was inconsistent: almost all females said they had not used or could not remember if a condom was used at last sex. Conclusion: This paper contributes to the evidence strengthening learner SRH education, including the national Integrated School Health Programme. Key themes include the need for age-appropriate, differentiated comprehensive sexuality education (CSE) for the range of ages found in the same grade in South African schools. Education on different contraceptive methods, informed decision-making, and emergency contraception is key. School-based interventions should embrace integrated HIV, STI, and pregnancy prevention messages. Closer links with health services need to be constantly fostered and reinforced.

[Worldwide contraception]

The latest statistics concerning contraceptive use in the world have been published in 2019 by the United Nations. Among the 1.9 billion of women of reproductive age (15-49 years), 1.1 billion have a need for family planning. Among them, 190 millions are not using any contraception, although they wanted to avoid a pregnancy. There is a significant discrepancy among continents concerning the percentage of contraceptive use and the distribution of the different types of contraception. Female sterilization is the most widespread method of contraception since it represents 24% of all contraception methods used. Male condoms is used by 21% of couples. Thus, progress is still needed to disseminate effective, well tolerated and potentially reversible methods of contraception. Education of females, couples, medical and paramedical staff is one of the priority targets to improve contraception throughout the world.

Framing and the formation of global health priorities

Health issues vary in the amount of attention and resources they receive from global health organisations and national governments. How issues are framed could shape differences in levels of priority. We reviewed scholarship on global health policy making to examine the role of framing in shaping global health priorities. The review provides evidence of the influence of three framing processes-securitisation, moralisation, and technification. Securitisation refers to an issue's framing as an existential threat, moralisation as an ethical imperative, and technification as a wise investment that science can solve. These framing processes concern more than how issues are portrayed publicly. They are socio-political processes, characterised by contestation among actors in civil society, government, international organisations, foundations, and research institutions. These actors deploy various forms of power to advance particular frames as a means of securing attention and resources for the issues that concern them. The ascription of an issue as a security concern, an ethical imperative, or a wise investment is historically contingent: it is not inevitable that any given issue will be framed in one or more of these ways. A health issue's inherent characteristics-such as the lethality of a pathogen that causes it-also shape these ascriptions, but do not fully determine them. Although commonly facing resistance, global health elites often determine which frames prevail, raising questions about the legitimacy of priority-setting processes. We draw on the review to offer ideas on how to make these processes fairer than they are at present, including a call for democratic representation even as necessary space is preserved for elite expertise.