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

Im/moral healthcare: HIV and universal health coverage in Indonesia

In 2014, Indonesia reinvigorated its commitment to the provision of a universal health care system by introducing the National Health Insurance Program (Jaminan Kesehatan Nasional, JKN), with the aim of increasing access to health care for all sectors of society. A key question that emerges in the current climate is: how can Indonesia ensure people can access HIV health care? This question is critically important given Indonesia is on the verge of passing a law criminalising all sex outside of marriage. If passed, anyone presenting with HIV will be suspected ipso facto of involvement in criminal activity (e.g. them or their partner having sex outside of marriage and/or using intravenous drugs). In this environment, preventing transmission of HIV from mother to child becomes more difficult. In exploring these issues, we argue that, in a time of populist morality, Indonesia must give significant attention to how universal health coverage can prevent HIV transmission, particularly from mother to child. We offer three key strategies for Indonesia to implement in this regard: removing health care provision from a moral framework; de-idealising the category of woman; and repositioning shame and stigma around HIV.

Axes of alienation: applying an intersectional lens on the social contract during the pandemic response to protect sexual and reproductive rights and health

While economic inequalities have been a key focus of attention through the COVID 19 pandemic, gendered relations of power at every level have undermined health rights of women, girls and gender diverse individuals. Sexual and reproductive health rights (SRHR) have always been sites of power contestations within families, societies, cultures, and politics; these struggles are exacerbated by economic, racial, religious, caste, citizenship status, and other social inequities, especially in times of crisis such as these. Policy responses to the COVID pandemic such as lockdown, quarantine, contact tracing and similar measures are premised on the existence of a social contract between the government and the people and among people, with the health sector playing a key role in preventive and curative care.We propose the use of an intersectional lens to explore the impact of the COVID-19 pandemic on the social contract, drawing on our field experiences from different continents particularly as related to SRHR. Along with documenting the ways in which the pandemic hinders access to services, we note that it is essential to interrogate state-society relations in the context of vulnerable and marginalized groups, in order to understand implications for SRHR. Intersectional analysis takes on greater importance now than in non-pandemic times as the state exercises more police or other powers and deploys myriad ways of 'othering'.We conclude that an intersectional analysis should not limit itself to the cumulative disadvantages and injustices posed by the pandemic for specific social groups, but also examine the historical inequalities, structural drivers, and damaged social contract that underlie state-society relationships. At the same time, the pandemic has questioned the status quo and in doing so it has provided opportunities for disruption; for re-imagining a social contract that reaches across sectors, and builds community resilience and solidarities while upholding human rights and gender justice. This must find place in future organizing and advocacy around SRHR.

Services for women's sexual and reproductive health in India: an analysis of treatment-seeking for symptoms of reproductive tract infections in a nationally representative survey

Background

Women’s health policy in India has had a longstanding focus on maternal health and family planning. Recent policy highlights the importance of expanding women’s access to a broader range of sexual and reproductive health services. However, there has been very limited analysis of national survey data to examine the current status of treatment utilisation, variation across states and progress over time.

Methods

This paper examines women’s treatment patterns for reproductive tract infections in India, based on data collected in the National Family Health Survey, a cross-sectional, nationally representative household survey conducted between 2015-16. The survey covered 699,686 women between the ages 15 and 49, of which 91,818 ever sexually active women responded to questions related to symptoms of reproductive tract infections. We estimate prevalence of reported symptoms and treatment-seeking, describe regional variation and utilise multivariable logistic regression to identify factors associated with women’s treatment-seeking patterns.

Results

Thirty-nine percent of women who reported symptoms of reproductive tract infections sought any advice or treatment. Women’s reported treatment-seeking in India has not changed since the last national survey a decade earlier. Reported symptoms and treatment-seeking varied widely across India, ranging from 64% in Punjab to 8% in Nagaland, with no clear regional pattern that emerged. Seventeen percent of symptomatic women sought services in the public sector, an improvement from 11% in 2005–06. Twenty-two percent utilised the private sector, with wide variation by states. National-level multivariable logistic regression indicated that treatment-seeking was associated with age, higher education, higher household wealth and having been employed in the past year. Women in the 25–35 age group had higher odds (aOR1.27; 95% CI: 1.10,1.50) of seeking treatment compared to both younger (15–19 years) and older (35 years and above) women, along with women with more than eight years of schooling (aOR: 1.23; 95% CI: 1.05,1.44) and from richer wealth quintiles (aOR: 1.53; 95% CI: 1.35,1.83).

Conclusion

Women’s use of services for reproductive tract infections remains a challenge in most parts of India. Our findings highlight the need to address barriers to seeking care and to improve measurement of gynaecological ailments in national surveys.

Migrant Women's Access to Sexual and Reproductive Health Services in Malaysia: A Qualitative Study

Providing sexual and reproductive health (SRH) services to migrant workers is key to fulfilling sustainable developmental goals. This study aims to explore key informants’ views on the provision of SRH services for migrant women in Malaysia, exploring the provision of SRH education, contraception, abortion, antenatal and delivery, as well as the management of gender-based violence. In-depth interviews of 44 stakeholders were conducted from July 2018 to July 2019. Data were thematically analysed. Migrant workers that fall pregnant are unable to work legally and are subject to deportation. Despite this, we found that insufficient SRH information and contraceptive access are provided, as these are seen to encourage promiscuity. Pregnancy, rather than sexually transmitted infection prevention, is a core concern among migrant women, the latter of which is not adequately addressed by private providers. Abortions are often seen as the only option for pregnant migrants. Unsafe abortions occur which are linked to financial constraints and cultural disapproval, despite surgical abortions being legal in Malaysia. Pregnant migrants often delay care-seeking, and this may explain poor obstetric outcomes. Although health facilities for gender-based violence are available, non-citizen women face additional barriers in terms of discrimination and scrutiny by authorities. Migrant women face extremely limited options for SRH services in Malaysia and these should be expanded.

Impact of the COVID-19 pandemic on the sexual behavior of the population. The vision of the east and the west

The COVID-19 pandemic has radically changed the way of life around the World. The state of alarm has forced the population to stay at home, radically changing both interpersonal and partner relationships; work at home, social distancing, the continued presence of children at home, fear of infection and not being able to physically meet with others have changed most people's sexual habits. We conducted a review by exploring the impact of the COVID-19 pandemic on sexual behavior in the population from three different countries: Iran, Italy and Spain from each country's perspective. The impact of the coronavirus will be very important in the sexual life of the people and we will attend in the next months or years, to some changes in the relationships at all the levels. The pandemic will negatively affect sexual behaviors due to multiple contact restrictions. In the future, we will be able to assess these effects in more detail.

Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990-2019

BACKGROUND

Unintended pregnancy and abortion estimates document trends in sexual and reproductive health and autonomy. These estimates inform and motivate investment in global health programmes and policies. Variability in the availability and reliability of data poses challenges for measuring and monitoring trends in unintended pregnancy and abortion. We developed a new statistical model that jointly estimated unintended pregnancy and abortion that aimed to better inform efforts towards global equity in sexual and reproductive health and rights.

METHODS

We developed a model that simultaneously estimated incidence of unintended pregnancy and abortion within a Bayesian framework. Data on pregnancy intentions and abortion were compiled from country-based surveys, official statistics, and published studies found through a literature search, and we obtained data on livebirths from the World Population Prospects. We analysed results by World Bank income groups, Sustainable Development Goal regional groupings, and the legal status of abortion.

FINDINGS

In 2015-19, there were 121·0 million unintended pregnancies annually (80% uncertainty interval [UI] 112·8-131·5), corresponding to a global rate of 64 unintended pregnancies (UI 60-70) per 1000 women aged 15-49 years. 61% (58-63) of unintended pregnancies ended in abortion (totalling 73·3 million abortions annually [66·7-82·0]), corresponding to a global abortion rate of 39 abortions (36-44) per 1000 women aged 15-49 years. Using World Bank income groups, we found an inverse relationship between unintended pregnancy and income, whereas abortion rates varied non-monotonically across groups. In countries where abortion was restricted, the proportion of unintended pregnancies ending in abortion had increased compared with the proportion for 1990-94, and the unintended pregnancy rates were higher than in countries where abortion was broadly legal.

INTERPRETATION

Between 1990-94 and 2015-19, the global unintended pregnancy rate has declined, whereas the proportion of unintended pregnancies ending in abortion has increased. As a result, the global average abortion rate in 2015-19 was roughly equal to the estimates for 1990-94. Our findings suggest that people in high-income countries have better access to sexual and reproductive health care than those in low-income countries. Our findings indicate that individuals seek abortion even in settings where it is restricted. These findings emphasise the importance of ensuring access to the full spectrum of sexual and reproductive health services, including contraception and abortion care, and for additional investment towards equity in health-care services.

FUNDING

UK Aid from the UK Government, Dutch Ministry of Foreign Affairs, UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), and The Bill & Melinda Gates Foundation.

Barriers and facilitators for the sexual and reproductive health and rights of young people in refugee contexts globally: A scoping review

BACKGROUND

The need to address sexual and reproductive health and rights (SRHR) in humanitarian settings is more urgent than ever, especially among young refugees. We conducted a scoping review to identify and synthesise the literature on perceived barriers and facilitators to SRHR among young refugees and interventions created to address their needs.

METHODS

We searched three databases (PubMed, Global Health and POPLINE) for peer-reviewed and grey literature published in English between January 2008 and June 2018 that reported on SRHR barriers, facilitators and interventions for young refugees aged 10 to 24 years. We extracted data using standardised templates and assessed the quality of studies according to study design. Data were charted using qualitative content analysis and organised in line with a socio-ecological framework (individual, social and community, institutional and health system, and structural).

FINDINGS

We screened 1,169 records and included 30 publications (qualitative, quantitative, and mixed methods) across 22 countries; 15 were peer-reviewed articles and 15 were from the grey literature. Twenty-two publications reported on young people in refugee camps or alternatives to camps (e.g. sustainable settlements), and eight referred to young refugees who had been resettled to a third country. We identified 19 sub-categories for barriers and 14 for facilitators at the individual, social and community, institutional and health system, and structural levels. No publications discussed the SRHR challenges faced by young homosexual, bisexual, transgender or queer refugees, or those living with HIV. Nine publications described interventions, which tended to focus on the provision of SRHR services and information, and the training of peers, parents, religious leaders and/or service providers.

CONCLUSIONS

Findings highlight that while young refugees experience similar barriers to SRHR as other young people, many of these barriers are exacerbated by the refugee context. The limited number of publications and evidence on interventions underlines the immediate need to invest in and evaluate SRHR interventions in refugee contexts.

Providing reproductive health services for women who inject drugs: a pilot program

Background

Needle syringe programs (NSPs), a proven harm reduction strategy for people who inject drugs, frequently offer limited healthcare services for their clients. Women who inject drugs face multiple barriers to accessing reproductive health care in traditional settings: personal histories of trauma, judgmental treatment from providers, and competing demands on their time. Our aim was to implement patient-centered reproductive healthcare services at a Seattle NSP.

Methods

We interviewed clients and staff of an NSP in Seattle and staff of other community-based organizations serving women who inject drugs, then used the Consolidated Framework for Implementation Research to code transcripts deductively. Based on our qualitative work, we implemented reproductive health care at the NSP program 1 day per week. We evaluated the implementation by surveying staff and clients and auditing charts over a 9-month period.

Results

Clients and staff (N = 15 for clients, N = 13 for staff) noted a high unmet need for trauma-informed, accessible reproductive health care. We successfully implemented reproductive health care services including short- and long-acting contraception, sexually transmitted disease testing, and cervical cancer screening. Survey data was limited but demonstrated client satisfaction with services.

Conclusions

Integrating reproductive health care into an NSP’s clinical services is feasible and can be a source of low-barrier preventive care for women unable to seek gynecologic care elsewhere.

Illicit financial flows and the provision of child and maternal health services in low- and middle-income countries

BACKGROUND

Illicit financial flows (IFFs) drain domestic resources with harmful social effects, especially in countries which are too poor to mobilise the revenues required to finance the provision of essential public goods and services. In this context, this article empirically examined the association between IFFs and the provision of essential health services in low- and middle-income countries.

METHODS

Firstly, a set of indicators was selected to represent the overall coverage of essential health services at the country level. Next, a linear multivariate regression model was specified and estimated for each indicator using cross-sectional data for 72 countries for the period 2008-2013.

RESULTS

After controlling for other relevant factors, the main result of the regression analysis was that an annual 1 percentage point (p.p.) increase in the ratio of IFFs to total trade was associated with a 0.46 p.p. decrease in the level of family planning coverage, a 0.31 p.p. decrease in the percentage of women receiving antenatal care, and a 0.32 p.p. decrease in the level of child vaccination coverage rates.

CONCLUSIONS

These findings suggest that, for the whole sample of countries considered, at least 3.9 million women and 190,000 children may not receive these basic health care interventions in the future as a consequence of a 1 p.p. increase in the ratio of IFFs to total trade. Moreover, given that family planning, reproductive health, and child immunisation are foundational components of health and long-term development in poor countries, the findings show that IFFs could be undermining the achievement of the 2030 Agenda for Sustainable Development.

Sexual and reproductive health and rights for all in Southeast Asia: more than SDGs aspirations

The Sustainable Development Goals (SDGs) and the proclaimed vision of leaving no one behind are lauded for their transformative potential in redressing inequalities. Yet, too few are interrogations of the root causes and underpinning structures that keep uneven development in place. This paper reflects on this omission in relation to sexual and reproductive health and rights (SRHR) drawing on over three decades of professional experience in advancing SRHR enriched by literature sources. Engaging with the theme of the 9th Asia-Pacific Sexual and Reproductive Health and Rights Conference - Leave NO ONE Behind! Justice in Sexual and Reproductive Health, it asks what it would take to realise the pledge of universal access to SRH services and rights. With a focus on Southeast Asia, the paper offers an account of context-specific drivers of disparity and exclusion that preclude the attainment of comprehensive SRHR for all, and especially for stigmatised and marginalised groups. It then discusses the paradigm shift that needs to occur if the ideals of inclusiveness and equity as promised by the SDGs are to be attained in and through SRHR.

Smartphone-Enhanced Training, QA, Monitoring, and Evaluation of a Platform for Secondary Prevention of Cervical Cancer: Opportunities and Challenges to Implementation in Tanzania

PURPOSE

Until human papillomavirus (HPV)-based cervical screening is more affordable and widely available, visual inspection with acetic acid (VIA) is recommended by the WHO for screening in lower-resource settings. Visual inspection will still be required to assess the cervix for women whose screening is positive for high-risk HPV. However, the quality of VIA can vary widely, and it is difficult to maintain a well-trained cadre of providers. We developed a smartphone-enhanced VIA platform (SEVIA) for real-time secure sharing of cervical images for remote supportive supervision, data monitoring, and evaluation.

METHODS

We assessed programmatic outcomes so that findings could be translated into routine care in the Tanzania National Cervical Cancer Prevention Program. We compared VIA positivity rates (for HIV-positive and HIV-negative women) before and after implementation. We collected demographic, diagnostic, treatment, and loss-to-follow-up data.

RESULTS

From July 2016 to June 2017, 10,545 women were screened using SEVIA at 24 health facilities across 5 regions of Tanzania. In the first 6 months of implementation, screening quality increased significantly from the baseline rate in the prior year, with a well-trained cadre of more than 50 health providers who "graduated" from the supportive-supervision training model. However, losses to follow-up for women referred for further evaluation or to a higher level of care were considerable.

CONCLUSION

The SEVIA platform is a feasible, quality improvement, mobile health intervention that can be integrated into a national cervical screening program. Our model demonstrates potential for scalability. As HPV screening becomes more affordable, the platform can be used for visual assessment of the cervix to determine amenability for same-day ablative therapy and/or as a secondary triage step, if needed.

Young migrant and refugee people's views on unintended pregnancy and abortion in Sydney

Although abortion rates appear to be declining in high-income nations, there is still a need for accessible, safe abortion services. However, limited attention has been paid to understanding the social contexts which shape access to abortion information and services for communities who are less engaged with sexual and reproductive health care more generally. This paper explores the views and experiences of 27 migrant and refugee young people (16-24 years old) living in Sydney, Australia, regarding unintended pregnancy and abortion. Pregnancy outside marriage was described by all participants as a shameful prospect as it revealed pre-marital sexual activity. Even when abortion was described as culturally and/or religiously unacceptable, it was believed many families would find an abortion preferable to continuing an unintended pregnancy outside marriage. However, a pervasive culture of silence regarding sexual and reproductive health may limit access to quality information and support in this area. To better meet the needs of these young people, greater attention must be paid to strengthening youth and community awareness of the availability of contraception including emergency contraception, pregnancy options, and access to abortion information and services.

'One-size doesn't fit all': Understanding healthcare practitioners' perceptions, attitudes and behaviours towards sexual and reproductive health and rights in low resource settings: An exploratory qualitative study

Although progress has been made to improve access to sexual and reproductive health services globally in the past two decades, in many low-income countries, improvements have been slow. Discrimination against vulnerable groups and failure to address health inequities openly and comprehensively play a role in this stagnation. Healthcare practitioners are important actors who, often alone, decide who accesses services and how. This study explores how health care practitioners perceive sexual and reproductive health and rights (SRHR) and how background factors influence them during service delivery. Participants were a purposefully selected sample of health practitioners from five low income countries attending a training in at Lund University, Sweden. Semi-structured interviews and qualitative content analysis were used. Three themes emerged. The first theme, "one-size doesn't fit all' in SRHR" reflects health practitioners' perception of SRHR. Although they perceived rights as fundamental to sexual and reproductive health, exercising of these rights was perceived to be context-specific. The second theme, "aligning a pathway to service delivery", illustrates a reflective balancing act between their personal values and societal norms in service delivery, while the third theme, "health practitioners acting as gatekeepers", describes how this balancing act oscillates between enabling and blocking behaviours. The findings suggest that, even though health care practitioners perceive SRHR as fundamental rights, their preparedness to ensure that these rights were upheld in service delivery is influenced by personal values and society norms. This could lead to actions that enable or block service delivery.

Disruption of a primary health care domestic violence and abuse service in two London boroughs: interrupted time series evaluation

Background

Domestic violence and abuse (DVA) is experienced by about 1/3 of women globally and remains a major health concern worldwide. IRIS (Identification and Referral to Improve Safety of women affected by DVA) is a complex, system-level, training and support programme, designed to improve the primary healthcare response to DVA. Following a successful trial in England, since 2011 IRIS has been implemented in eleven London boroughs. In two boroughs the service was disrupted temporarily. This study evaluates the impact of that service disruption.

Methods

We used anonymised data on daily referrals received by DVA service providers from general practices in two IRIS implementation boroughs that had service disruption for a period of time (six and three months). In line with previous work we refer to these as boroughs B and C. The primary outcome was the number of daily referrals received by the DVA service provider across each borough over 48 months (March 2013–April 2017) in borough B and 42 months (October 2013–April 2017) in borough C. The data were analysed using interrupted-time series, non-linear regression with sensitivity analyses exploring different regression models. Incidence Rate Ratio (IRR), 95% confidence intervals and p-values associated with the disruption were reported for each borough.

Results

A mixed-effects negative binomial regression was the best fit model to the data. In borough B, the disruption, lasted for about six months, reducing the referral rate significantly (p = 0.006) by about 70% (95%CI = (23,87%)). In borough C, the three-month service disruption, also significantly (p = 0.005), reduced the referral rate by about 49% (95% CI = (18,68%)).

Conclusions

Disrupting the IRIS service substantially reduced the rate of referrals to DVA service providers. Our findings are evidence in favour of continuous funding and staffing of IRIS as a system level programme.

Investing in the health of girls and women: a best buy for sustainable development

Human rights, theory, evidence, and common sense all suggest that greater investment in women’s health could be among the “best buys” for broader economic development and societal wellbeing, say Michelle Remme and colleagues

Trends in Frequency of Sexual Activity and Number of Sexual Partners Among Adults Aged 18 to 44 Years in the US, 2000-2018

IMPORTANCE

Sexual relationships are important for well-being and health. Recent trends in sexual activity among US adults are unknown.

OBJECTIVES

To examine trends in reported frequency of sexual activity and number of sexual partners by sex and age and the association between measures of sexual activity and sociodemographic variables.

DESIGN, SETTING, AND PARTICIPANTS

In this survey study, repeat, cross-sectional analyses of participants aged 18 to 44 years from 10 rounds of the General Social Survey (2000-2018), a US nationally representative survey, were performed for men and women separately.

MAIN OUTCOMES AND MEASURES

Sexual frequency in the past year (sexual inactivity, once or twice per year, 1-3 times per month, or weekly or more) and number of sexual partners in the past year (0, 1, 2, or ≥3 partners). The association between measures of sexual activity and sociodemographic variables were assessed using logistic regression.

RESULTS

The study population included 4291 men and 5213 women in the analysis of sexual frequency and 4372 men and 5377 women in the analysis of number of sexual partners (mean [SD] age, 31.4 [7.6] years; survey response rate, 59.5%-71.4%). Between 2000-2002 and 2016-2018, the proportion of 18- to 24-year-old individuals who reported having had no sexual activity in the past year increased among men (18.9% vs 30.9%; age-adjusted odds ratio [aOR] for trend across survey periods, 1.20; 95% CI, 1.04-1.39) but not among women (15.1% vs 19.1%; aOR for trend, 1.03; 95% CI, 0.89-1.18). Smaller absolute increases in sexual inactivity were observed among those aged 25 to 34 years for both men (7.0% vs 14.1%; aOR for trend, 1.23; 95% CI, 1.07-1.42) and women (7.0% vs 12.6%; aOR for trend, 1.17; 95% CI, 1.01-1.35) but not among those aged 35 to 44 years. The increase in sexual inactivity coincided with decreases in the proportion reporting weekly or more sexual frequency (men aged 18-24 years: 51.8% vs. 37.4%; aOR for trend, 0.88 [95% CI, 0.79-0.99]; men aged 25-34 years: 65.3% vs 50.3%; aOR for trend, 0.87 [95% CI, 0.81-0.94]; women aged 25-34 years: 66.4% vs. 54.2%; aOR for trend, 0.90 [95% CI, 0.84-0.96]) or 1 sexual partner (men aged 18-24 years: 44.2% vs. 30.0%; aOR for trend, 0.88 [95% CI, 0.80-0.98]; women aged 25-34 years: 79.6% vs 72.7%; aOR for trend, 0.91 [95% CI, 0.84-0.99]) and occurred mainly among unmarried men (unmarried men aged 18-44 years: 16.2% vs 24.4%; aOR for trend, 1.14 [95% CI, 1.04-1.25]). Among married men and women, weekly or more sexual frequency decreased (men: 71.1 % vs 57.7%; aOR for trend, 0.86 [95% CI, 0.79-0.93]; women: 69.1% vs 60.9%; aOR for trend, 0.92 [95% CI, 0.86-0.99]). Men with lower income (aOR for men with an annual income of ≥$50 000 vs $0-$9999, 0.37 [95% CI, 0.15-0.90]) and with part-time (aOR vs full-time employment, 2.08; 95% CI, 1.48-2.93) and no employment (aOR vs full-time employment, 2.08; 95% CI, 1.48-2.93) were more likely to be sexually inactive, as were men (aOR vs full-time employment, 2.94; 95% CI, 2.06-4.21) and women (aOR vs full-time employment, 2.37; 95% CI, 1.68-3.35) who were students.

CONCLUSIONS AND RELEVANCE

This survey study found that from 2000 to 2018, sexual inactivity increased among US men such that approximately 1 in 3 men aged 18 to 24 years reported no sexual activity in the past year. Sexual inactivity also increased among men and women aged 25 to 34 years. These findings may have implications for public health.

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

BACKGROUND

Reproductive coercion (RC) and intimate partner violence (IPV) are prevalent forms of gender-based violence (GBV) associated with reduced female control over contraceptive use and subsequent unintended pregnancy. Although the World Health Organization has recommended the identification and support of GBV survivors within health services, few clinic-based models have been shown to reduce IPV or RC, particularly in low or middle-income countries (LMICs). To date, clinic-based GBV interventions have not been shown to reduce RC or unintended pregnancy in LMIC settings.

INTERVENTION

ARCHES (Addressing Reproductive Coercion in Health Settings) is a single-session, clinic-based model delivered within routine contraceptive counseling that has been demonstrated to reduce RC in the United States. ARCHES was adapted to the Kenyan context via a participatory process to reduce GBV and unintended pregnancy among women and girls seeking contraceptive services in this setting. Core elements of ARCHES include enhanced contraceptive counseling that addresses RC, opportunity for patient disclosure of RC and IPV (and subsequent warm referral to local services), and provision of a palm-sized educational booklet.

METHODS

A matched-pair cluster control trial is being conducted to assess whether the ARCHES intervention (treatment condition), as compared to standard-of-care contraceptive counseling (control condition), reduces RC and IPV, and improves contraceptive outcomes for woman and girls of reproductive age (15 to 49 years) seeking contraceptive services from community-based clinics in Nairobi, Kenya. All six clinics were assigned to intervention-control pairs based on similarities in patient volume and demographics, physical structure and neighborhood context. Survey data will be collected from patients immediately prior to their clinic visit (baseline, T1), immediately after their clinic visit (exit), and at 3- and 6-months post-visit (T2 and T3, respectively).

DISCUSSION

This study is the first to assess the efficacy of an adaptation of the ARCHES model to reduce GBV and improve reproductive health outside of the U.S., and one of only a small number of controlled trials to assess reductions in GBV associated with a clinic-based program in an LMIC context. Evidence from this trial will inform health system efforts to reduce GBV, and to enhance female contraceptive control and reproductive health in Kenya and globally.

TRIAL REGISTRATION

Registered May 23, 2018 - ClinicalTrials.gov, NCT03534401. Unique Protocol ID: 170084.

"To live until you die could actually include being intimate and having sex": A focus group study on nurses' experiences of their work with sexuality in palliative care

AIMS AND OBJECTIVES

To examine nurses' experiences of working with issues of sexuality in palliative care.

BACKGROUND

Sexuality has value for human lives and relations and is important for one's overall well-being throughout life. Guidelines for palliative care state that sexuality should be addressed. Previous research shows that the inclusion of sexuality in general health care is deficient, and there is a knowledge gap on how sexuality is addressed in palliative care.

METHOD

Within a qualitative design, the empirical material was obtained through three focus group interviews with eleven registered nurses working in palliative care. The interviews were analysed using qualitative content analysis.

RESULT

Nurses experience that sexuality has an indistinct place in their work, "sexuality" is a word difficult to use, and differing views are held on whether it is relevant to address sexuality, and if so, when? Although they have experiences involving patient and partner sexuality, which is viewed as sexuality in transformation during the palliative care process, nurses seldom explicitly address patient or partner sexuality. Despite the lack of knowledge, routines and organisational support, they acknowledge the importance of addressing sexuality in palliative care, as they express that they want to do right.

CONCLUSION

Overall, nurses appear to follow differing cultural, interpersonal and intrapsychic scripts on sexuality rather than knowledge-based guidelines. This underlines the importance of managers who safeguard the adherence to existing palliative care guidelines where sexuality is already included. In this work, it is important to be aware of norms to avoid excluding patients and partners that differ from the nurses themselves as well as from societal norms on sexuality.

RELEVANCE TO CLINICAL PRACTICES

The results can be used as a point of departure when implementing existing or new guidelines to include and address sexuality and sexual health needs in palliative care.

"Give Me Proof": A Covert but Coercive Form of Non-partner Sexual Violence Contributing to Teen Pregnancy in Haiti and Opportunities for Biopsychosocial Intervention

Adolescent girls in low-resource settings account for over 7.3 million births annually (generally unplanned). Unplanned teen pregnancies are increasing in low-resource settings. As part of a funded Round 20 Grand Challenges Exploration project (Healthy Minds for Adolescent Mothers), we investigated unplanned teen pregnancies in Haiti's Cité Soleil shantytown, teens' biopsychosocial challenges, and desirable interventions. Key stakeholders (N = 23): pregnant teens (13-17-year-olds, n = 8; 18-19-year-olds, n = 8) and health providers (18 or older, n = 7), participated by age group and role in focus groups (FGs). ATLAS.ti facilitated the analysis of transcribed FG audio recordings. Ninety-four percent (n = 15) of teens reported "Banm prèv," translated "Give me proof," as a cause of their unplanned pregnancies. Banm prèv describes when teens are propositioned by men who demand proof of their unpretentiousness or virginity. A subtle, covert, locally unchallenged phenomenon that is supported by damaging gender norms, Banm prèv constitutes an illusionary choice between teens' yielding non-consensual control of their bodies and the tacit alternative of gang rape. Banm prèv underscores teens' difficulty discerning consensual from coerced sex. Associated unplanned pregnancies occasion guilt, shame, stigma, depression, anxiety, and trauma in teens. Cité Soleil teens need contextually relevant, community-supported, age-appropriate interventions that challenge existing norms, build on cultural strengths, and include comprehensive sexuality education, including knowledge of reproductive rights. A traditional, contextually familiar, engaging, and humorous story-telling tradition, i.e., krik-krak, packaged in video format, is a useful framework for interventions to reduce depressive symptoms, stress, and anxiety for Cité Soleil teens experiencing unplanned pregnancies.

How gains for SRHR in the UN have remained possible in a changing political climate

As right-wing populist movements make electoral gains around the world, one might expect that resultant policy and legislative reversals against sexual and reproductive health and rights (SRHR) would be mirrored by a similar backlash in United Nations (UN) human rights negotiations. Yet the past five years have seen unprecedented advances for SRHR within the UN Human Rights Council (HRC), treaty bodies, and special procedures. In this article, we provide an overview of SRHR gains and setbacks within the HRC and analyse their broader significance, particularly as socially conservative nation states and non-governmental organisations seek to challenge them. We analyse how states have advanced SRHR in the HRC and examine efforts that states which oppose SRHR have undertaken to limit these advances. In an increasingly hostile political climate, the inter-related legal, technical, and political mechanisms through which human rights are advanced within the UN has helped to mitigate the effects of rapid political reversals. Additionally, the HRC's emphasis on previously agreed language helps dampen significant changes in resolutions on SRHR.

Involvement in maternal care by migrants and ethnic minorities: a narrative review

BACKGROUND

Guidelines for improving the quality of maternal health services emphasise women's involvement in care. However, evidence about migrant and ethnic minorities' preferences for participation in maternal care remains unsystematised. Understanding these populations' experiences with and preferred forms of involvement in care provision is crucial for imbuing policies and guidelines with sensitivity to diversity and for implementing people-centred care. This paper presents a narrative synthesis of empirical studies of involvement in maternal health care by migrants and ethnic minorities based on four key dimensions: information, communication, expression of preferences and decision-making.

METHODS

Studies indexed in PubMed and Scopus published until December 2019 were searched. Original quantitative, qualitative and mixed methods studies written in English and reporting on migrant and ethnic minority involvement in maternal care were included. Backward reference tracking was carried out. Three researchers conducted full-text review of selected publications.

RESULTS

In total, 22 studies met the inclusion criteria. The majority of studies were comparative and addressed only one or two dimensions of involvement, with an emphasis on the information and communication dimensions. Compared to natives, migrants and ethnic minorities were more likely to (1) lack access to adequate information as a result of health care staff's limited time, knowledge and misconceptions about women's needs and preferences; (2) report suboptimal communication with care staff caused by language barriers and inadequate interpreting services; (3) be offered fewer opportunities to express preferences and to have preferences be taken less into account; and (4) be less involved in decisions about their care due to difficulties in understanding information, socio-cultural beliefs and previous experiences with care provision less attuned with playing an active role in decision-making and care staff detracting attitudes.

CONCLUSION

Constraints to adequate and inclusive involvement in maternal care can hinder access to quality care and result in severe negative health outcomes for migrant and ethnic minority women. More research is needed into how to tailor the dimensions of involvement to migrant and ethnic minorities' needs and preferences, followed by provision of the resources necessary for effective implementation (e.g. sufficient time for consultations, optimal interpreter systems, health care staff training).

Emerging infectious diseases and outbreaks: implications for women's reproductive health and rights in resource-poor settings

This century is witnessing dramatic changes in the health needs of the world’s populations. The double burden of infectious and chronic diseases constitutes major causes of morbidity and mortality. Over the last two decades, there has been a rise in infectious diseases, including the severe acute respiratory syndrome virus (SARS), the H1N1 pandemic influenza, the Ebolavirus and the Covid-19 virus. These diseases have rapidly spread across the world and have reminded us of the unprecedented connectivity that defines our modern civilization. Though some countries have made substantial progress toward improving global surveillance for emerging infectious diseases (EIDs), the vast majority of Low-and Middle-income Countries (LMICs) with fragile health systems and various system-related bottlenecks remain vulnerable to outbreaks and, as such, experience dramatic social and economic consequences when they are reported. Lessons learned from past outbreaks suggest that gender inequalities are common across a range of health issues relating to Sexual and Reproductive Health and Rights (SRHR), with women being particularly disadvantaged, partially due to the burden placed on them. Though these countries are striving to improve their health systems and be more inclusive to this vulnerable group, the national/ global outbreaks have burdened the overall system and thus paralyzed normal services dedicated to the delivery of Sexual and Reproductive Health (SRH) services. In this paper, we discuss the global commitments to SRH, the impact of the EIDs on the LMICs, the failure in the delivery of SRH services, and the strategies for successful implementation of recovery plans that must address the specific and differentiated needs of women and girls in resource-poor settings.

Unmet Need for Family Planning and Experience of Unintended Pregnancy Among Female Sex Workers in Urban Cameroon: Results From a National Cross-Sectional Study

Female sex workers (FSWs) in Cameroon have unmet need for effective contraception, and experience of unintended pregnancy and pregnancy termination is common. Reducing barriers to accessing high-quality, voluntary family planning services in FSW-focused community services is a key strategy to promote client-centered care, promote informed choice, reduce unintended pregnancies, and improve quality of life for FSWs.

Background:

Female sex workers (FSWs) in Cameroon commonly have unmet need for contraception posing a high risk of unintended pregnancy. Unintended pregnancy leads to a range of outcomes, and due to legal restrictions, FSWs often seek unsafe abortions. Aside from the high burden of HIV, little is known about the broader sexual and reproductive health of FSWs in Cameroon.

Methods:

From December 2015 to October 2016, we recruited FSWs aged ≥18 years through respondent-driven sampling across 5 Cameroonian cities. Cross-sectional data were collected through a behavioral questionnaire. Modified-robust Poisson regression was used to approximate adjusted prevalence ratios (aPR) for TOP and current use of effective nonbarrier contraception.

Results:

Among 2,255 FSWs (median age 28 years), 57.6% reported history of unintended pregnancy and 40.0% reported prior TOP. In multivariable analysis, TOP history was associated with current nonbarrier contraceptive use (aPR=1.23, 95% confidence interval [CI]=1.07, 1.42); ever using emergency contraception (aPR=1.34, 95% CI=1.17, 1.55); >60 clients in the past month (aPR=1.29, 95% CI= 1.07, 1.54) compared to ≤30; inconsistent condom use with clients (aPR=1.17, 95% CI=1.00, 1.37); ever experiencing physical violence (aPR=1.24, 95% CI=1.09, 1.42); and older age. Most (76.5%) women used male condoms for contraception, but only 33.2% reported consistent condom use with all partners. Overall, 26.4% of women reported currently using a nonbarrier contraceptive method, and 6.2% reported using a long-acting method. Previous TOP (aPR=1.41, 95%CI=1.16, 1.72) and ever using emergency contraception (aPR=2.70, 95% CI=2.23, 3.26) were associated with higher nonbarrier contraceptive use. Recent receipt of HIV information (aPR=0.72, 95% CI=0.59, 0.89) and membership in an FSW community-based organization (aPR=0.73, 95% CI=0.57, 0.92) were associated with lower use nonbarrier contraceptive use.

Conclusions:

Experience of unintended pregnancies and TOP is common among FSWs in Cameroon. Given the low use of nonbarrier contraceptive methods and inconsistent condom use, FSWs are at risk of repeat unintended pregnancies. Improved integration of client-centered, voluntary family planning within community-led HIV services may better support the sexual and reproductive health and human rights of FSWs consistent with the United Nations Declaration of Human Rights.

Individual and community-level impact of infertility-related stigma in Malawi

Infertility, a common experience among women and men worldwide, remains on the margins of public health and medicine in low-resource settings. Previous studies identified associations between individual experiences of infertility and negative outcomes, particularly in contexts where childbearing is imperative, but few have examined broader implications of infertility and infertility-related stigma on communities. To understand the production and impact of infertility-related stigma, this study analyzes 12 focus group discussions (FGDs) conducted with 104 women and men in rural Malawi. FGDs, conducted July-September 2018, were used to elicit the range of community norms around family formation, pregnancy, fertility, and infertility. Data were analyzed through memo-ing during and after data collection and collaborative, thematic coding. We found that stigma manifested within existing systems of gender and power. Aligning with Link and Phelan's stigma framework (2001) there were three primary mechanisms by which infertility-related stigma was produced and reinforced: labeling of a person perceived to be infertile (i.e., establishing 'other'), perpetuating negative stereotypes associated with suspected causes of infertility (e.g., abortion, multiple sexual partners, weak sperm), and consequences of infertility that reinforced stigma (e.g., social ridicule and distancing, divorce). Labels, presumed causes, and consequences of infertility were entrenched within gender and sexuality norms. Women perceived as infertile were unable to follow a normative path to achieving adult status, presumed to be sexually transgressive, and considered "useless." Men's masculinity was questioned. Both women's and men's identities, as well as social positions within relationships and communities, were threatened by perceptions of infertility. Ultimately, the manifestation of infertility-related stigma contributed to an environment wherein the risk of being perceived as infertile was highly consequential and unrelenting. Pervasive stigma, at the community-level, impacts decisions around contraceptive use and timing of childbearing, as women and men not only wanted to avoid infertility, but also the appearance of infertility.

Improving sexual and reproductive health knowledge and practice in Mozambican families with media campaign and volunteer family health champions

Objective

To increase knowledge, attitudes and practice of sexual and reproductive health and family planning and to reduce maternal and neonatal mortality rates in Mozambique.

Design

An implementation research project’s intermediate evaluation, applying two cross-sectional surveys. The surveys were planned for 316 subjects before and after interventions.

Setting

Research performed in Natikiri district of Nampula province in northern Mozambique, targeting a suburban and rural populations in their homes.

Participants

452 people were surveyed (91 before, 361 after), all belonging to the Macua ethnic group.

Interventions

A media campaign (2 weekly radio spots, bimonthly theatre performances) was performed for 8 months (2017 to 2018) and family health champions’ teachings (monthly home visits) performed for 3 months, on sexual and reproductive health and family planning. Outcome measures planned and measured were adolescent’s and adult’s knowledge, attitudes and practice about those. Data were analysed by gender, age group and frequencies, using a CI of 95% (p<0.5 statistically significant).

Results

Radio spots, community theatre and volunteer champions increased population’s knowledge about sexual and reproductive health and led to a more positive attitude toward family planning. Concerning attitude, results show differences between adults’ proportions before and after: (1) did you hear about sexual and reproductive health (p=0.0425); (2) knows project key messages (p<0.001); (3) knows prenatal visits importance (p=0.0301); (4) access to contraceptives was easy (p<0.001). Adolescents showed statistically significant differences before and after: (1) knows project key messages (p<0.001); (2) access to contraceptives was easy (p=0.0361). Family planning practice did not increase in both groups.

Conclusion

A health education intervention, using a media campaign and local volunteers, is useful to promote mother and child health. There is an unmet need for family planning and the use of modern contraception is below desired practice, needing further research about cultural barriers. Communication for behaviour change activities will pursue and impact will be assessed to document family planning practice improvement.

Improving the healthcare response to domestic violence and abuse in UK primary care: interrupted time series evaluation of a system-level training and support programme

BACKGROUND

It is unknown whether interventions known to improve the healthcare response to domestic violence and abuse (DVA)-a global health concern-are effective outside of a trial.

METHODS

An observational interrupted time series study in general practice. All registered women aged 16 and above were eligible for inclusion. In four implementation boroughs' general practices, there was face-to-face, practice-based, clinically relevant DVA training, a prompt in the electronic medical record, reminding clinicians to consider DVA, a simple referral pathway to a named advocate, ensuring direct access for women to specialist services, overseen by a national, health-focused DVA organisation, fostering best practice. The fifth comparator borough had only a session delivered by a local DVA specialist agency at community venues conveying information to clinicians. The primary outcome was the daily number of referrals received by DVA workers per 1000 women registered in a general practice, from 205 general practices, in all five northeast London boroughs. The secondary outcome was recorded new DVA cases in the electronic medical record in two boroughs. Data was analysed using an interrupted time series with a mixed effects Poisson regression model.

RESULTS

In the 144 general practices in the four implementation boroughs, there was a significant increase in referrals received by DVA workers-global incidence rate ratio of 30.24 (95% CI 20.55 to 44.77, p < 0.001). There was no increase in the 61 general practices in the other comparator borough (incidence rate ratio of 0.95, 95% CI 0.13 to 6.84, p = 0.959). New DVA cases recorded significantly increased with an incident rate ratio of 1.27 (95% CI 1.09 to 1.48, p < 0.002) in the implementation borough but not in the comparator borough (incidence rate ratio of 1.05, 95% CI 0.82 to 1.34, p = 0.699).

CONCLUSIONS

Implementing integrated referral routes, training and system-level support, guided by a national health-focused DVA organisation, outside of a trial setting, was effective and sustainable at scale, over four years (2012 to 2017) increasing referrals to DVA workers and new DVA cases recorded in electronic medical records.

Scoping review of pharmacy-based initiatives for preventing unintended pregnancy: protocol

INTRODUCTION

Due to a high global incidence of unintended pregnancy, finding novel ways to increase the accessibility of contraceptive products and information is critical. One proposed strategy is to use the accessibility of community pharmacies and expand the role of pharmacists to deliver these services. This protocol reports the methods of a proposed scoping review of pharmacy-based initiatives for preventing unintended pregnancy. We intend to identify the range of interventions employed by pharmacists worldwide and their outcomes and aim to infer the value of task sharing for reducing certain access and equity barriers to contraception.

METHODS AND ANALYSIS

This protocol was developed with guidance from the Joanna Briggs Institute Methodology for Scoping Reviews. Reporting is compliant with the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) protocols. The scoping review will be reported according to the PRISMA Extension for Scoping Reviews. Seven electronic databases (PubMed, Ovid Medline, Embase, Cochrane Library, Scopus and Cumulative Index to Nursing and Allied Health Literature) were systematically searched for relevant literature published in English from 2000, on 22 August 2019. Two authors will individually screen articles for eligibility in Covidence and data will be charted and reported using a tool developed for the purpose of this review.

ETHICS AND DISSEMINATION

Findings will be disseminated in publications and presentations with relevant stakeholders. Ethical approval is not required as we will be using data from publicly available literature sources. We will map available evidence across the breadth of studies that have been conducted and identify the effectiveness and acceptability of interventions.

"In Africa, There Was No Family Planning. Every Year You Just Give Birth": Family Planning Knowledge, Attitudes, and Practices Among Somali and Congolese Refugee Women After Resettlement to the United States

It is crucial for refugee service providers to understand the family planning knowledge, attitudes, and practices of refugee women following third country resettlement. Using an ethnographic approach rooted in Reproductive Justice, we conducted six focus groups that included 66 resettled Somali and Congolese women in a western United States (US) metropolitan area. We analyzed data using modified grounded theory. Three themes emerged within the family planning domain: (a) concepts of family, (b) fertility management, and (c) unintended pregnancy. We contextualized these themes within existing frameworks for refugee cultural transition under the analytic paradigms of "pronatalism and stable versus evolving family structure" and "active versus passive engagement with family planning." Provision of just and equitable family planning care to resettled refugee women requires understanding cultural relativism, social determinants of health, and how lived experiences influence family planning conceptualization. We suggest a counseling approach and provider practice recommendations based on our study findings.

Placing children and adolescents at the centre of the Sustainable Development Goals will deliver for current and future generations

Child health is taking the back seat in development strategies. In summarising a newly released collaborative report, this paper calls for a novel conceptual model where child health takes centre stage in relation to the 2030 Agenda and the Sustainable Development Goals. It lays out five principles by which renewed effort and focus would yield the most benefit for children and adolescents. These include: re-defining global child health in the post-2015 era by placing children and adolescents at the centre of the Sustainable Development Goals; striving for equity; realising the rights of the child to thrive throughout the life-course; facilitating evidence informed policy-making and implementation; and capitalising on interlinkages within the SDGs to galvanise multisectoral action. These five principles offer models that together have the potential of improving design, return and quality of global child health programs while re-energising the 2030 Agenda and the Sustainable Development Goals.

"I did not know it was a medical condition": Predictors, severity and help seeking behaviors of women with female sexual dysfunction in the Volta region of Ghana

Objectives

The study’s main objective was to describe the prevalence and severity of female sexual dysfunction (FSD) amongst a group of Ghanaian women in the outpatient setting of the predominantly rural Volta region of Ghana. Additionally we determine the predictors of FSD severity and care seeking behaviors of women with the condition.

Study design and setting

This was a cross sectional study conducted in the outpatient setting of the Ho Teaching Hospital in the rural-savannah, agro-ecological zone of Volta Region, Ghana.

Methods and procedures

FSD was assessed using the Female Sexual Function Index (FSFI) questionnaire. FSD was defined with a cutoff of ≤23 so as not to under-estimate the prevalence in this conservative setting. FSFI score >23 was designated “no FSD”. We further categorized women with FSD as having mild (FSFI Total score 18–23), moderate (FSFI Total score <18 to >10) or severe (FSFI Total score ≤10) FSD. Due to sample size restrictions, we combined the moderate and severe FSD groups in our analyses and defined “moderate/severe FSD” as an FSFI Total score < 18. Participants with FSD were further asked to indicate whether or not they sought help for their conditions, the reasons they sought help, and the types of help they sought. We used p<0.05 to determine statistical significance for all analyses and logistic regression models were used to determine crude and age-adjusted effect estimates.

Results

FSD Prevalence: Out of 407 women approached, 300 (83.8%) agreed and consented to participate in the study. The prevalence of FSD was 48.3% (n = 145). Compared to those without FSD, over a third of the FSD women resided in rural settings (37.90% vs 20.60%; p = 0.001) and tended to be multiparous, with a significantly greater proportion having at least three children (31.70% vs 18.10%; p = 0.033).

FSD Severity: Over a quarter of the sample (27.6%, n = 40) met the cut-off for moderate to severe FSD. In age-adjusted models, lubrication disorder was associated with 45 times the odds of moderate/severe FSD (age-adj. OR: 45.38, 95% CI: 8.37, 246.00; p<0.001), pain with 17times the odds (age-adj. OR: 17.18, 95% CI: 4.50, 65.50; p<0.001) and satisfaction almost 5times the odds (age-adj. OR: 4.69, 95% CI: 1.09, 20.2; p = 0.04). Compared to those with 1–3 children, nulliparous women had 3.5 times higher odds of moderate/severe sexual dysfunction as well (age-adj. OR:3.51, 95% CI:1.37,8.98; p = 0.009).

FSD-related Health Seeking Behaviors: Statistically significant predictors of FSD-related care seeking included having FSD of pain disorder (age-adj. OR: 5.91, 95% CI:1.29, 27.15; p = 0.02), having ≥4 children (age-adj. OR: 6.29, 95%CI: 1.53, 25.76; p = 0.01). Of those who sought help, seven in 10 sought formal help from a healthcare provider, with General Practitioners preferred over Gynecologist. About one in 3 (31.3%) who did not seek help indicated that they did not know their sexual dysfunction was a medical condition, over a quarter (28.9%) “thought it was normal” to have FSD, and interestingly, 14.1% did not think a medical provider would be able to provide them with assistance.

Conclusions

Sexual dysfunctions are prevalent yet taboo subjects in many countries, including Ghana. Awareness raising and efforts to feminize the physician workforce are necessary to meet the healthcare needs of vulnerable members of Ghanaian society.

Can sexual health interventions make community-based health systems more responsive to adolescents? A realist informed study in rural Zambia

Introduction

Community-based sexual reproductive interventions are key in attaining universal health coverage for all by 2030, yet adolescents in many countries still lack health services that are responsive to their sexual reproductive health and rights’ needs. As the first step of realist evaluation, this study provides a programme theory that explains how, why and under what circumstances community-based sexual reproductive health interventions can transform (or not) ‘ordinary’ community-based health systems (CBHSs) into systems that are responsive to the sexual reproductive health of adolescents.

Methods

This realist approach adopted a case study design. We nested the study in the full intervention arm of the Research Initiative to Support the Empowerment of Girls trial in Zambia. Sixteen in-depth interviews were conducted with stakeholders involved in the development and/or implementation of the trial. All the interviews were recorded and analysed using NVIVO version 12.0. Thematic analysis was used guided by realist evaluation concepts. The findings were later synthesized using the Intervention−Context−Actors−Mechanism−Outcomes conceptualization tool. Using the retroduction approach, we summarized the findings into two programme theories.

Results

We identified two initial testable programme theories. The first theory presumes that adolescent sexual reproductive health and rights (SRHR) interventions that are supported by contextual factors, such as existing policies and guidelines related to SRHR, socio-cultural norms and CBHS structures are more likely to trigger mechanisms among the different actors that can encourage uptake of the interventions, and thus contribute to making the CBHS responsive to the SRHR needs of adolescents. The second and alternative theory suggests that SRHR interventions, if not supported by contextual factors, are less likely to transform the CBHSs in which they are implemented. At individual level the mechanisms, awareness and knowledge were expected to lead to value clarification’, which was also expected would lead to individuals developing a ‘supportive attitude towards adolescent SRHR. It was anticipated that these individual mechanisms would in turn trigger the collective mechanisms, communication, cohesion, social connection and linkages.

Conclusion

The two alternative programme theories describe how, why and under what circumstances SRHR interventions that target adolescents can transform ‘ordinary’ community-based health systems into systems that are responsive to adolescents.

The Change in Attitudes Towards Abortion in Former West and East Germany After Reunification: A Latent Class Analysis and Implications for Abortion Access

Introduction The legal status of abortion has changed in the regions of former East Germany after reunification due to the adoption of restrictive West German abortion policies. The aim of this study was to evaluate the impact on attitudes towards abortion and the associated health care implications in Western and Eastern Germany.

Materials and Methods Nationally representative data on public support for legally restricting abortion access were taken from the German General Social Survey and included the surveys 1992, 1996, 2000, 2006 and 2012 (N = 14 459). Two indicators of barriers to access to abortion care were calculated for each federal state, based on the number of abortion facilities and the proportion of women seeking abortion outside their state of residency. Data were analysed using latent class analysis.

Results Results suggested that abortion attitudes could be classified into three distinct subgroups: 1) support for abortion access independent of womenʼs reason; 2) support on the basis of maternal or foetal health reasons but not for socio-economic reasons (e.g. financial restrictions); and 3) no support. The size of subgroups in favour of partial or complete restriction on abortion access increased in both regions over the study period and this trend could not be explained by changes in socio-demographic characteristics. Respondents living in a federal state with more barriers to access to abortion care were more likely to hold restrictive abortion attitudes.

Conclusion Negative attitudes towards abortion have increased in Western and Eastern Germany during the two decades following reunification and may harm women by limiting acceptability and accessibility of abortion care. Abortion policies, public discourse and provision of abortion care should be informed by international guidelines protecting womenʼs health and rights.

Women's costs for accessing comprehensive sexual and reproductive health services: findings from an observational study in Johannesburg, South Africa

Background

Evaluating progress towards the Sustainable Development Goal of universal access to sexual and reproductive (SRH) services requires an understanding of the health needs of individuals and what constitutes access to services. We explored women’s costs of accessing SRH services in Johannesburg, South Africa and contextualized costs based on estimates of household income.

Methods

We conducted an observational study of women aged 18–49 at a public HIV treatment site and two public primary health care facilities from June 2015 to August 2016. Interviews assessed women’s SRH needs (for contraception, fertility problems, menstrual problems, menopause symptoms, sexually transmitted infections (STI), experiences of intimate-partner violence (IPV), and cervical and breast cancer screening) and associated costs. We calculated average and total costs (including out-of-pocket spending, lost income, and estimated value of time spent) for women who incurred costs. We also estimated the total and average costs of meeting all SRH needs in a hypothetical “full needs met” year. Finally, we contextualize SRH spending against a measure of catastrophic expenditure (> 10% of household income).

Results

Among the 385 women who participated, 94.8% had at least one SRH need in the prior 12 months; 79.7% incurred costs for accessing care. On average, women spent $28.34 on SRH needs during the prior year. Excluding one HIV-negative woman who spent 112% of her annual income on infertility treatment, HIV-positive women spent more on average annually for SRH care than HIV-negative women. Sixty percent of women reported at least one unmet SRH need. If all participants sought care for all reported needs, their average annual cost would rise to $52.65 per woman. Only two women reported catastrophic expenditure – for managing infertility.

Conclusions

SRH needs are constants throughout women’s lives. Small annual costs can become large costs when considered cumulatively over time. As South Africa and other countries grapple with increasing access to SRH services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to SRH services.

Plain English summary

Literature on women’s financial and economic costs for accessing comprehensive sexual and reproductive health care in low- and middle-income countries is extremely limited, and existing literature often overlooks out-of-pocket costs associated with travel, child care, and time spent accessing services. Using data from a survey of 385 women from a public HIV treatment site and two public primary health care facilities in Johannesburg, we found nearly all women reported at least on sexual and reproductive health need and more than 75% of women incurred costs related to those needs. Furthermore, more than half of women surveyed reported not accessing services for their sexual and reproductive health needs, suggesting a total annual cost of more than $50 USD, on average, to access services for all reported needs. While few women spent more than 10% of their total household income on sexual and reproductive health services in the prior year, needs are constant and costs incur throughout a woman’s life suggesting accessing services to meet these needs might still result in financial burden. As South Africa grapples with increasing access to sexual and reproductive health services under the rubric of universal access, it is important to remember that individuals incur costs despite free care at the point of service. Policies that address geographic proximity and service quality would be important for reducing costs and ensuring full access to services.

Impact of a sex education programme in terms of knowledge, attitudes and sexual behaviour among adolescents in Asturias (Spain)

Sex education in schools is an adolescents' right, and can have health benefits, such as improved knowledge or increased condom use. In Asturias, a secondary school programme called Neither Ogres Nor Princesses educates pupils for four years with trained teaching staff and external workshops. This study examined whether this programme (a) improved adolescents' sexuality knowledge, attitudes and skills, and (b) increased condoms use. A quasi-experimental survey was conducted, with comparison arm, with a pre-test in the first year of secondary school (12- to 13-year-olds), and two post-tests: after the intervention (15- to 16-year-olds) and two years later (17- to 18-year-olds). A questionnaire with socio-demographic, knowledge, attitude, skill and sexual behaviour variables was used. The impact was evaluated with 'difference-indifferences' analyses. There was a greater increase of knowledge in the intervention arm in both post-tests, and an increase in skills in the first post-test. Girls in the intervention arm reported less practices with penetration and greater condom use the first time, this also among boys. However, the impact was limited in time. Interventions that aim to increase sex education in curricula with quality and fidelity are a priority to guarantee children's rights and their health.

The State of Adolescent Sexual and Reproductive Health

In the 25 years since the 1994 International Conference on Population and Development, significant progress has been made in adolescent sexual and reproductive health and rights (ASRHR). Trend analysis of key ASRHR indicators at global, national, and subnational levels indicates that adolescent girls today are more likely to marry later, delay their first sexual experience, and delay their first childbirth, compared with 25 years ago; they are also more likely to use contraceptives. Despite overall progress, however, unequal progress in many ASRHR outcomes is evident both within and between countries, and in some locations, the state of adolescents' lives has worsened. Population growth in countries with some of the worst shortfalls in ASRHR mean that declining rates, of child marriage, for example, coexist with higher absolute numbers of girls affected, compared with 25 years ago. Emerging trends that warrant closer attention include increasing rates of ovarian and breast cancer among adolescent girls and sharp increases in the proportion of adolescents who are overweight or obese, which has long-term health implications.

The Political, Research, Programmatic, and Social Responses to Adolescent Sexual and Reproductive Health and Rights in the 25 Years Since the International Conference on Population and Development

Among the ground-breaking achievements of the International Conference on Population and Development (ICPD) was its call to place adolescent sexual and reproductive health (ASRH) on global health and development agendas. This article reviews progress made in low- and middle-income countries in the 25 years since the ICPD in six areas central to ASRH-adolescent pregnancy, HIV, child marriage, violence against women and girls, female genital mutilation, and menstrual hygiene and health. It also examines the ICPD's contribution to the progress made. The article presents epidemiologic levels and trends; political, research, programmatic and social responses; and factors that helped or hindered progress. To do so, it draws on research evidence and programmatic experience and the expertise and experiences of a wide number of individuals, including youth leaders, in numerous countries and organizations. Overall, looking across the six health topics over a 25-year trajectory, there has been great progress at the global and regional levels in putting adolescent health, and especially adolescent sexual and reproductive health and rights, higher on the agenda, raising investment in this area, building the epidemiologic and evidence-base, and setting norms to guide investment and action. At the national level, too, there has been progress in formulating laws and policies, developing strategies and programs and executing them, and engaging communities and societies in moving the agenda forward. Still, progress has been uneven across issues and geography. Furthermore, it has raced ahead sometimes and has stalled at others. The ICPD's Plan of Action contributed to the progress made in ASRH not just because of its bold call in 1994 but also because it provided a springboard for advocacy, investment, action, and research that remains important to this day.

Forward, Together: A Collaborative Path to Comprehensive Adolescent Sexual and Reproductive Health and Rights in Our Time

The 1994 International Conference on Population and Development established a basis for the advancement of adolescent sexual and reproductive health and rights (ASRHR) that endures today. Twenty-five years later, our vision for the future warrants reflection based on a clear understanding of the opportunities and challenges before us. Inclusion of adolescents on global, regional, and national agendas; increased investment in ASRHR policies and programs; renewed commitments to universal health coverage; increased school enrollment; and advances in technology are all critical opportunities we can and must leverage to catalyze progress for adolescents. At the same time, a range of significant challenges remain, have newly emerged, or can be seen on the horizon, including persistent denial of adolescent sexuality; entrenched gender inequality; resistance to meaningfully engaging adolescents and young people in political and programmatic processes; weak systems, integration, and multisectoral coordination; changes in population dynamics; humanitarian and climate crises; and changes in family and community structures. To achieve as much progress toward our vision for ASRHR as possible, the global ASRHR community must take strategic and specific steps in the next 10 years within five areas for action: (1) mobilize and make full use of political and social support for ASRHR policies and programs; (2) increase and make effective use of external and domestic funding for ASRHR; (3) develop, communicate, apply, and monitor enabling and protective laws and policies for ASRHR; (4) use and improve available ASRHR data and evidence to strengthen advocacy, policies, and programs; and (5) manage the implementation of ASRHR strategies at scale with quality and equity.

A Package of Sexual and Reproductive Health and Rights Interventions-What Does It Mean for Adolescents?

This article analyzes the relevance of the comprehensive definition of sexual and reproductive health and rights (SRHR) to adolescents and identifies adolescent-specific implications for the implementation of an essential package of SRHR interventions. The delivery of a comprehensive approach to SRHR targeting adolescents is underpinned by five principles-equity, quality, accountability, multisectorality, and meaningful engagement. All SRHR interventions included in the package are relevant to adolescents, given the diversity of adolescents' SRHR needs and considering their specific attributes, circumstances, and experiences. Ensuring that this package is available, accessible, and acceptable to adolescents requires an approach that looks at adolescents as being biologically and socially distinct from other age groups and acknowledges that they face some specific barriers when accessing SRHR services. This article provides cross-cutting strategies for the implementation of a comprehensive approach to SRHR for adolescents and specific considerations in delivering each intervention in the package of essential SRHR interventions. To further implement the International Conference on Population and Development Programme of Action, a prerequisite for achieving the Sustainable Development Goals, SRHR interventions must be adolescent responsive, delivered through multiple platforms, leveraging multisectoral collaboration, and strengthening accountability and participation.