Interventions to improve adolescents' contraceptive behaviors in low- and middle-income countries: a review of the evidence base

Utilisation of Reproductive Health Services among Adolescents in Ghana: Analysis of the 2007 and 2017 Ghana Maternal Health Surveys

Early pubertal development induces early sexual activities among adolescents. In Ghana, despite the high sexual activity among Ghanaian adolescents, sexual and reproductive health (SRH) services are underutilised, primarily due to SRH stigma and a lack of SRH knowledge and information. This study examined the use of SRH services among adolescents aged 15-19 years in Ghana over a ten year period. The study utilised data from the 2007 and 2017 Ghana Maternal Health Surveys (GMHSs). Responses from 2056 and 4909 adolescent females captured in the 2007 and 2017 GMHSs, respectively, were used. The results showed a declining utilisation of SRH services among adolescents from 28.3% in 2007 to 22.5% in 2017. The odds of using family planning among sexually active adolescents increased from 2007 [AOR-0.32, CI-(0.135, 0.77), p < 0.001] to 2017 [AOR-68.62, CI-(36.104, 130.404), p < 0.001]. With increasing age at first sex, adolescents were less likely to use a family planning method in 2007 [AOR-0.94, CI-(0.89,0.99) p < 0.001], but this improved in 2017 [AOR-1.26, CI-(1.220, 1.293), p < 0.001]. Despite this, knowledge of sources for family planning was found to predict its lower utilisation in both 2007 [AOR = 0.15 (95% CI-0.081, 0.283), p < 0.0001] and 2017 [AOR = 0.206 (95% CI-(0.099, 0.426), p < 0.001]. The findings show that even though knowledge of family planning methods predicted low utilisation, knowledge of sources, age at first sex, and educational level positively predicted the utilisation of SRH services from 2007 to 2017. Opportunities for both enhancing the clinical environment and health provider attitudes exist and should be explored for improving SRH outcomes among sexually active adolescents in Ghana.

Does a school-based intervention increase girls' sexual and reproductive health attitudes and intentions? Results from a mixed-methods cluster-randomized trial in Burkina Faso

Adolescent girls in Burkina Faso face unintended pregnancy risk due to a lack of contraceptive use. The (re)solve project was designed to address contraceptive misperceptions and increase girls' perceptions of their pregnancy risk, primarily through a participatory game and a health passport aimed at easing health facility access. The intervention components were implemented for girls in private and public school in grades 4ème and 3ème (grades 9 and 10) in Ouagadougou and Bobo Dioulasso, Burkina Faso. We conducted an impact evaluation using a mixed-methods cluster randomized control trial design to evaluate (re)solve's impact on girls' intentions to use contraception, among other outcomes. Thirty-two schools were randomly allocated intervention or control. The evaluation included quantitative longitudinal surveys at baseline (N = 2,372) and endline (N = 2,072), qualitative in-depth interviews with girls in the intervention group at baseline (N = 41) and endline (N = 48) and with implementation staff (N = 35) and experts (N = 14) at endline. We used generalized estimating equations (GEE) analysis for the main analysis. Girls receiving the intervention had more positive attitudes related to contraception at endline compared to girls at control schools. (re)solve had a positive effect on girls' intention to use contraception (aOR = 1.59, 95% CI 0.97-2.61), though this did not reach statistical significance. The impact was particularly large among girls who had never had sex, girls who attended public schools, and girls in 3ème. Qualitative findings suggest the intervention was well received and positively shifted attitudes and facility-seeking behaviors for many girls, but that myths and misconceptions related to contraceptive use persist in this mostly young, sexually naïve population. That the (re)solve intervention appears to have shifted adolescent girls' attitudes toward using contraception, coupled with positive trends in intention to use contraception, indicates that interventions like (re)solve may 'prime the pump' for behavior change and increasing girls' use of contraception. Trial registration number and date: https://www.isrctn.com/ISRCTN15387847 Registered on June 15th 2021.

Effect and cost-effectiveness of human-centred design-based approaches to increase adolescent uptake of modern contraceptives in Nigeria, Ethiopia and Tanzania: Population-based, quasi-experimental studies

Around half of adolescent pregnancies in low- and middle-income countries are unintended, contributing to millions of unsafe abortions per year. Adolescents 360 (A360), a girl-centred initiative, aimed to increase voluntary uptake of modern contraceptives among adolescents in Nigeria, Ethiopia and Tanzania. We evaluated the effectiveness and cost-effectiveness of A360 in increasing modern contraceptive use in selected geographies. We used before-and-after cross-sectional studies of adolescent girls in four settings. Two Nigerian settings had purposefully selected comparison areas. Baseline and endline household surveys were conducted. The primary study outcome was modern contraceptive prevalence rate (mCPR). Secondary outcomes mapped onto the A360 Theory of Change. Interpretation was aided by a process evaluation along with secular mCPR trends and self-reported A360 exposure data. Incremental design and implementation costs were calculated from implementer systems, site visits, surveys, and interviews. mCPR change was modelled into maternal disability-adjusted life years (DALY) averted to calculate incremental cost-effectiveness ratios. In Oromia, Ethiopia, mCPR increased by 5% points (95% CI 1-10; n = 1,697). In Nigeria, there was no evidence of an effect of A360 on mCPR in Nasarawa (risk ratio: 0·96, 95% CI: 0·76-1·21; n = 5,414) or in Ogun (risk ratio: 1·08, 95% CI: 0·92-1·26; n = 3,230). In Mwanza, Tanzania, mCPR decreased by 9% points (-17 to -0.3; n = 1,973). Incremental cost per DALY averted were $30,855 in Oromia, $111,416 in Nasarawa, $30,114 in Ogun, and $25,579 in Mwanza. Costs per DALY averted were 14-53 times gross domestic product per capita. A360 did not lead to increased adolescent use of modern contraceptives at a population level, except in Oromia, and was not cost-effective. This novel adolescent-centred design approach showed some promise in addressing the reproductive health needs of adolescents, but must be accompanied by efforts to address the contextual drivers of low modern contraceptive use.

Effect of Healthy Transitions intervention in improving family planning uptake among adolescents and young women in Western Nepal: A pre-and post-intervention study

BACKGROUND

Contraceptive use can prevent unintended pregnancies, early childbearing, and abortion-related deaths. Despite these benefits, the use of modern contraceptives remains low among adolescent girls and young women (AGYW) in Nepal. To address this gap, the Healthy Transitions Project was implemented in Karnali Province, Nepal from February 2019 to September 2021. This study aimed at measuring the effect of Healthy Transitions' intervention on improving knowledge and use of modern family planning methods among AGYW in Nepal.

METHODS

We used a pre- and post-intervention study design to assess the effect of Healthy Transitions project. A quantitative survey was conducted at baseline and after the first cohort of AGYW had completed the intervention (1 year later). The baseline survey was conducted in 2019 with a cohort of 786 married and unmarried AGYW aged 15-24 years. An end line survey was conducted in 2020 with 565 AGYW who were interviewed at baseline. Data analysis was done using STATA version 15.1. The exact McNemar significance probability value was used to decide the significance of difference between baseline and endline.

RESULTS

The knowledge and uptake of modern family planning methods have increased in the endline compared to the baseline. AGYW recognised 10 out of the ten modern methods at endline, a significant increase from 7 at baseline (p<0.001). Among AGYW, 99% were aware of sources to obtain family planning methods, compared with 92% at baseline (p< 0.001). The proportion of married AGYW using modern contraceptive methods was significantly higher at the endline 33%, than baseline (26%) (p<0.001).

CONCLUSION

Our results show that multilevel demand and supply-side interventions, targeting adolescents and young women, their families, community, and health system helped to improve knowledge and use of modern family planning methods among AGYW. The study suggests that these intervention approaches can be adopted to improve family planning use among adolescents and young women in other similar settings.

Determinants of awareness, value perception, and societal support for sexual and reproductive health services among in-school adolescents in South-eastern Nigeria

BACKGROUND

Adolescents are vulnerable to sexual and reproductive health (SRH) risks yet, have poor utilisation of SRH services due to personal, social, and demographic influences. This study aimed to compare the experiences of adolescents that had received targeted adolescent SRH interventions and those that did not and evaluated the determinants of awareness, value perception, and societal support for SRH service utilisation among secondary school adolescents in eastern Nigeria.

METHODS

We undertook a cross-sectional study of 515 adolescents in twelve randomly selected public secondary schools, grouped into schools that had received targeted adolescent SRH interventions and those that did not, across six local government areas in Ebonyi State, Nigeria. The intervention comprised training of schools' teachers/counsellors and peer educators and community sensitisation and engagement of community gatekeepers for demand generation. A pre-tested structured questionnaire was administered to the students to assess their experiences with SRH services. Categorical variables were compared using the Chi-square test, and predictors were determined through multivariate logistic regression. The level of statistical significance was determined at p < 0.05 and a 95% confidence limit.

RESULTS

A higher proportion of adolescents in the intervention group, 126(48%), than in the non-intervention group, 35(16.1%), were aware of SRH services available at the health facility (p-value < 0.001). More adolescents in the intervention than the non-intervention group perceived SRH services as valuable- 257(94.7%) Vs 217(87.5%), p-value = 0.004. Parental/community support for SRH service utilisation was reported by more adolescents in the intervention group than in the non-intervention group- 212 (79.7%) Vs 173 (69.7%), p-value = 0.009. The predictors are (i) awareness-intervention group (β = 0.384, CI = 0.290-0.478), urban residence (β=-0.141, CI=-0.240-0.041), older age (β-0.040, CI = 0.003-0.077) (ii) value perception - intervention group (β = 0.197, 0.141-0.253), senior educational class (β = 0.089, CI = 0.019-0.160), work-for-pay (β=-0.079, CI=-0.156-0.002), awareness (β = 0.192, CI = 0.425-0.721) (iii) parental/community support - work-for-pay (β = 0.095, CI = 0.003-0.185).

CONCLUSIONS

Adolescents' awareness, value perception, and societal support for sexual and reproductive health services were influenced by the availability of SRH interventions and socio-economic factors. Relevant authorities should ensure the institutionalisation of sex education in schools and communities, targeting various categories of adolescents, to reduce disparity in the utilisation of sexual and reproductive health services and promote adolescents' health.

Comprehensive sexuality education linked to sexual and reproductive health services reduces early and unintended pregnancies among in-school adolescent girls in Zambia

BACKGROUND

Advancing the health of adolescents, particularly their sexual and reproductive health, including HIV prevention and care, is a development imperative. A critical part for improving their wellbeing and economic development is the social status accorded to adolescent girls and young women (AGYW). However, AGYW in many countries including Zambia, encounter health challenges that stem from gender inequalities, lack of empowerment, inaccurate knowledge on sexuality, and poor access to sexual and reproductive health (SRH) services and information. Addressing the knowledge gaps through comprehensive sexuality education (CSE) and improving access to SRH services and appropriate information, should reduce school attrition from early and unintended pregnancies (EUP) and enhance realization of their full potential.

METHODS

The aim was to reduce EUP and improve SRH outcomes among AGYW in Zambia through provision of CSE linked to receptive SRH services. A 3-Arm randomized control study collected cross-sectional data at baseline, midline and Endline. Schools where CSE was being routinely provided were randomized into a non-intervention arm (arm1), an intervention arm in which information on available SRH services was provided in schools by health workers to complement CSE, (arm 2), and arm 3 in which pupils receiving CSE were also encouraged or supported to access pre-sensitized, receptive SRH services.

RESULTS

Following 3 years of intervention exposure (CSE-Health Facility linkages), findings showed a significant decline of in-school pregnancies amongst AGYW in both intervention arms, with arm two exhibiting a more significant decline, having recorded only 0.74% pregnancies at endline (p < 0.001), as well as arm 3, which recorded 1.34% pregnancies (p < 0.001). No significant decline was recorded in the CSE only control arm. Trends in decline of pregnancies started to show by midline, and persisted at endline (2020), and when difference in differences test was applied, the incident rate ratios (IRR) between the none and exposed arms were equally significant (p < 0.001).

CONCLUSION

Linking provision of CSE with accessible SRH services that are receptive to needs of adolescents and young people reduces EUP, which provides the opportunity for higher retention in school for adolescent girls.

Exposure to family planning messages and teenage pregnancy: results from the 2017 Philippine National Demographic and Health Survey

BACKGROUND

Teenage pregnancy is known to have physical, emotional, and psychosocial effects. Because of these risks, family planning and contraception messages have been disseminated in various forms of media, but their association with teenage pregnancy has not been studied previously in the Philippines. This study aims to examine the association between exposure to various family planning and contraception messages disseminated in various media channels and pregnancy among Filipino women aged 15-19. The study also intended to examine interactions between the different media channels where these family planning and contraception messages are being disseminated on their effect on teenage pregnancy.

METHODS

We used data from the individual recode of the 2017 Philippine National Demographic and Health Survey. We used logistic regression for survey data to  study the association between exposure to family planning and contraception messages and teenage pregnancy.

RESULTS

Out of 5120 respondents, 44% of respondents have accessed information on contraception from the internet, 25% have heard information about contraception through the radio, 55% of respondents have heard about contraception via television, 15% have read about contraception in the newspapers and magazines, and only 6% have received information on contraception via short messaging service (SMS). There were 420 (8.56%) who have ever been pregnant. After adjusting for confounding variables, those who were exposed to family planning/contraceptive messages via the internet (aOR: 0.90; 95% CI: 0.59, 1.35) and newspapers/magazines (aOR: 0.78; 95% CI: 0.44, 1.41) have lower odds of teenage pregnancy, but no strong evidence of their effectiveness. On the other hand, exposure to family planning messages through the radio (aOR: 1.06; 95% CI: 0.71, 1.59), television (aOR: 1.09; 95% CI: 0.72, 1.65), and short messaging service (aOR: 1.29; 95% CI: 0.51, 3.22) marginally increase the risk of teenage pregnancy. We did not find any pairwise interactions between the different exposure variables.

CONCLUSIONS

Our results highlight the need to improve the content and key messages of contraceptive and family planning messages in the Philippines, especially those that are broadcasted online and in print media. There is also a need to increase the reach of these different family planning and contraception messages, especially by utilizing social media and other print and online media platforms commonly used by the youth.

Determinants of the use of contraceptive methods by adolescents in the Democratic Republic of the Congo: results of a cross-sectional survey

Background

Family planning (FP) is an effective strategy to prevent unintended pregnancies of adolescents. We aimed at identifying the socio-demographic factors underlying the low use of contraceptive methods by teenage girls in the Democratic Republic of the Congo (DRC).

Methods

A secondary analysis targeting teenage girls aged 15–19 was carried out on the Performance, Monitoring and Accountability project 2020 (PMA 2020) round 7 data, collected in Kinshasa and Kongo Central provinces. The dependent variable was the “use of contraceptive methods by sexually active teenage girls”, calculated as the proportion of teenagers using modern, traditional or any contraceptive methods. Independent variables were: level of education, age, province, religion, marital status, number of children, knowledge of contraceptive methods and household income. Pearson's chi-square and logistic regression tests helped to measure the relationship between variables at the alpha significance cut point of 0.05.

Results

A total of 943 teenagers were interviewed; of which 22.6, 18.1 and 19.9% ​​used any contraceptive method respectively in Kinshasa, Kongo Central and overall. The use of modern contraceptive methods was estimated at 9.9, 13.4 and 12.0% respectively in Kinshasa, Kongo Central and overall. However, the use of traditional methods estimated at 8.0% overall, was higher in Kinshasa (12.7%) and lower (4.7%) in Kongo Central (p < .001). Some factors such as poor knowledge of contraceptive methods (aOR = 8.868; 95% CI, 2.997–26.240; p < .001); belonging to low-income households (aOR = 1.797; 95% CI, 1.099–2.940; p = .020); and living in Kongo central (aOR = 3.170; 95% CI, 1.974–5.091; p < .001) made teenagers more likely not to use any contraceptive method.

Conclusion

The progress in the use of contraceptive methods by adolescent girls is not yet sufficient in the DRC. Socio-demographic factors, such as living in rural areas, poor knowledge of FP, and low-income are preventing teenagers from using FP methods. These findings highlight the need to fight against such barriers; and to make contraceptive services available, accessible, and affordable for teenagers.

Structural Interventions to Enable Adolescent Contraceptive Use in LMICs: A Mid-Range Theory to Support Intervention Development and Evaluation

Enabling contraceptive use is critical for addressing high adolescent pregnancy rates in low- and middle-income countries (LMICs). Broader or 'upstream' determinants, such as poverty, education, and social norms, can affect the knowledge, attitudes, motivation, and ability to access and use contraception. Structural interventions aim to address these broader determinants, e.g., through poverty alleviation from livelihood training or cash transfers, increasing school participation, or changing social norms. We conducted an evidence synthesis using intervention component analysis, a case-based approach, following a systematic mapping of the evidence base. We identified 17 studies with 29 structural intervention arms, which reported adolescent contraceptive use outcomes compared to a control group or baseline. It was not possible to identify with certainty which interventions were 'likely effective' or 'likely ineffective' due to the high heterogeneity of the methods. We built on an existing framework of family planning use to propose three steps to designing interventions: (1) tailor interventions to adolescents' life stages; (2) assess the baseline situation; and (3) select appropriate activities to match the gaps. These steps will aid developers and evaluators of structural adolescent contraceptive interventions to develop an evidence base that is of use across a wide range of settings and use scenarios.

Translating diagnostics and drug delivery technologies to low-resource settings

Diagnostics and drug delivery technologies engineered for low-resource settings aim to meet their technical design specifications using strategies that are compatible with limited equipment, infrastructure, and operator training. Despite many preclinical successes, very few of these devices have been translated to the clinic. Here, we identify factors that contribute to the clinical success of diagnostics and drug delivery systems for low-resource settings, including the need to engage key stakeholders at an early stage, and provide recommendations for the clinical translation of future medical technologies.

Which Structural Interventions for Adolescent Contraceptive Use Have Been Evaluated in Low- and Middle-Income Countries?

Reducing adolescent childbearing is a global priority, and enabling contraceptive use is one means of achieving this. Upstream factors, e.g., gender inequalities, fertility norms, poverty, empowerment and schooling, can be major factors affecting contraceptive use. We conducted a systematic map to understand which structural adolescent contraception interventions targeting these upstream factors have been evaluated in LMICs. We searched eight academic databases plus relevant websites and a 2016 evidence gap map and screened references based on set inclusion criteria. We screened 6993 references and included 40 unique intervention evaluations, reported in 138 papers. Seventeen evaluations were reported only in grey literature. Poverty reduction/economic empowerment interventions were the most common structural intervention, followed by interventions to increase schooling (e.g., through legislation or cash transfers) and those aiming to change social norms. Half of the evaluations were RCTs. There was variation in the timing of endline outcome data collection and the outcome measures used. A range of structural interventions have been evaluated for their effect on adolescent contraceptive use/pregnancy. These interventions, and their evaluations, are heterogenous in numerous ways. Improved understandings of how structural interventions work, as well as addressing evaluation challenges, are needed to facilitate progress in enabling adolescent contraceptive use in LMICs.

Perspectives of health care professionals’ on delivering mHealth sexual and reproductive health services in rural settings in low-and-middle-income countries: a qualitative systematic review

Background

In low to middle income countries (LMICs) with limited health care providers (HCPs) and health infrastructure, digital technologies are rapidly being adopted to help augment service delivery. In this sphere, sexual and reproductive health (SRH) services are increasingly leveraging mobile health (mHealth) technologies to improve service and information provision in rural areas. This systematic review aimed to identify HCPs perspectives on barriers to, and facilitators of, mobile phone based SRH services and information in rural areas of LMICs from current literature.

Methods

Searches were conducted using the following databases: Medline, Scopus, PsychINFO, CINAHL and Cochrane Library. Based on the inclusion and exclusion criteria, twelve full text qualitative studies published in English between January 2000 and December 2020 were included. The methodological quality of papers was assessed by two authors using the critical skills appraisal programme and synthesized using the narrative thematic analysis approach.

Results

Positive HCPs experiences surrounding the provision of mHealth based SRH services in LMICs included saving consultation time, ability to shift tasks, reduction in travel costs, easy referrals and follow up on clients, convenience in communicating health information confidentially, and the ability to consult groups of clients remotely rather than face-to-face. Barriers to the provision of mHealth reported by HCPs included lack of technological infrastructure, unreliable networks, limited power, the cost of mobile airtime/data and mobile phones and limited technological literacy or skills.

Conclusions

Implementing innovative mHealth based SRH services could bridge a service provision and access gap of SRH information and services in rural areas of LMICs. Despite the advantages of this technology, several challenges associated with delivering mHealth SRH services need to be urgently addressed to enable scale-up and integration of sexual and reproductive mHealth into rural health systems.

Exploring Sexual and Reproductive Health Needs and Associated Barriers of Homeless Young Adults in Urban Ghana: A Qualitative Study

BACKGROUND

Homelessness has become a major global and public health challenge, especially in low- and middle-income countries. This phenomenon predisposes young adults to severe psychosocial and health challenges.

AIM

To explore the sexual and reproductive health needs and behaviours of homeless young adults and challenges in accessing these services.

METHODS

A semi-structured interview guide was used for data collection from in-depth interviews, focus group discussions, and key informant interviews. Data were collected between 01 June and 31 July 2020 from 30 participants using in-depth interviews, two focus group discussions involving 12 participants, and one key informant interview. Thematic analysis was used to analyse transcripts from the interviews.

RESULTS

The findings show that certain behavioural patterns associated with homelessness impact the lives of homeless young adults in their sexual and reproductive health (SRH) choices, beliefs, and perspectives. This group faces several challenges in accessing sexual and reproductive health services (SRHS) such as modern contraceptives and abortion care. The high cost, and undesirable and unfriendly attitude of service providers in health facilities pose as barriers to accessing SRHS by homeless young adults.

CONCLUSION

Sustainable and proactive measures must be put in place to address the identified barriers. Timely delivery of accurate information and educative materials, ensuring affordability, and setting up of accessible and friendly facilities could improve SRHS for this group.

SOCIAL AND PUBLIC POLICY IMPLICATIONS

This study may inform and support policy guideline development to address homelessness and SRH needs of young adults in urban Ghana.

Adolescent pregnancy in Sao Tome and Principe: a cross-sectional hospital-based study

Background

Pregnancy starts early in Sao Tome and Principe (STP) and rates of adolescent pregnancy increased 16% in recent years reaching a 27.3% prevalence. This study aimed to understand the pregnant adolescents’ characteristics and factors associated to early childbearing in STP.

Methods

A cross-sectional hospital-based study was undertaken in Hospital Dr. Ayres de Menezes between 2016 and 2018 with a randomly selected total sample size of 518 mothers. Mothers’ clinical records and interviews were used to collect relevant data. The results among adolescent girls 19 years of age and younger (n=104) were compared to adult mothers (n=414). A subgroup analysis of adolescent pregnant girls was also conducted. Statistically significance was considered at a p-value ≤0.05. Data were analysed using SPSS software.

Results

The study revealed that 20.1% were adolescent mothers. Pregnancy at a very early age (≤15) was experienced by 7.7%. The characteristics founded to be positively associated with adolescent pregnancy were: 1) being single (OR 0.39, 95% CI=0.2–0.6, p≤0.001); 2) having a relationship with the baby´s father for a period of less than one year (OR 0.16, 95% CI=0.09-0.3, p≤0.001); 3) lack of the baby´s father support (OR 0.41, 95% CI=0.2–0.7, p=0.002); 4) not using a contraceptive method (OR 0.33, 95% CI=0.2–0.5, p≤0.001), and 5) inappropriate knowledge concerning the identification of the newborn’s danger signs (OR 15.7, 95% CI= 9–26, p≤0.001). Comparing pregnancy at very early age (≤15) to late (>18 and ≤19) adolescents, main differences were that previous contraceptives were not used at all in girls ≤15 years compared to 9.8% of late childbearing subgroup.

Conclusions

Unfavourable factors linked to adolescent pregnancies were absence of a contraceptive method, getting pregnant in the early first months of one relationship and to be single. Gap age difference between adolescents’ partners, polygamous sexual relationships, previous abortion and having already other living children were also identified. Adolescents also had inappropriate knowledge of the identification of the newborns’ danger signs. Before being sexually active, adolescents critically need sexual and reproductive health information provided by a healthy community and through school programmes on sexual education. Schools should promote girl’s empowerment and awareness and, at the same time, reinforce boy’s role in fatherhood and shared responsibilities. The government should work on the prevention of early sexual initiation, as well as on improving family planning programmes to protect them from pregnancy with special focus for the very early adolescent girls. None of these goals can be achieved if the government doesn’t, simultaneously, improve educational and economic opportunities for girls.

Adolescent pregnancy, public policies, and targeted programs in Latin America and the Caribbean: a systematic review

OBJECTIVE

To present and assess evidence from Latin America and the Caribbean (LAC) on public policies and targeted programs which may have influenced variations in adolescent pregnancy or its proximate determinants, and to identify knowledge gaps that require further research.

METHODS

A systematic review was performed based on the 2015 PRISMA protocol. Five databases were searched for articles published between 2000 and 2019 that refer to at least one country in LAC. The outcomes of interest were adolescent pregnancy or its proximate determinants (sexual behavior, contraceptive use, and/ or abortion). Only studies exploring correlations between the outcomes of interest and public policies or targeted programs were included in the analysis.

RESULTS

Thirty studies spanning 14 countries were selected for analysis. Twenty-three of these (77%) were not included in prior systematic reviews on adolescent pregnancy. Public policies related to conditional cash transfers and compulsory education have the strongest evidence of correlation with adolescent pregnancy prevention. Emerging research points to the potential positive impact of life-skills programs for adolescents. Evidence from public health policies and programs was limited.

CONCLUSIONS

Further research which incorporates an intersectional analysis is needed to better understand which policies and programs could lead to steeper declines in adolescent pregnancy in the region. Evidence on effects of expanded family planning services and secondary school attainment upon adolescent pregnancy are particularly absent.

Contraceptive Conversations among Adolescent Girls and Young Women and Their Partners, Peers, and Older Female Family Members in Lilongwe, Malawi: A QualitativeAnalysis

In sub-Saharan Africa, adolescent girls and young women (AGYW) have high levels of unmet need for contraception, particularly those who are unmarried or nulliparous. Conversations with partners, peers, and family members influence AGYW contraceptive decision-making yet little is known about conversation content and impact or how they vary by relationship status and parity. This paper draws on qualitative data from 60 AGYW (aged 15-24) participating in a sexual and reproductive health study in Malawi to examine contraceptive conversation patterns among participants and their social ties. AGYW's relationship status and parity influenced whether they talked about contraceptives, who they talked to about contraceptives, and the type of contraceptives that were endorsed during conversations. Unmarried and nulliparous AGYW were less likely to discuss contraceptives with all social ties and when conversations occurred, norms and misinformation regarding nonbarrier methods were reinforced, and condoms were largely prescribed. Conversations with intimate partners often provided permission for contraceptive use while conversations with peers and older women in the family provided information on contraceptive methods. Our results highlight the unique roles that social ties play in AGYW contraceptive decision-making and suggest that existing contraceptive conversation patterns might exclude unmarried, nulliparous AGYW from accurate and comprehensive contraceptive information and options.

A scoping review on health education programs for improving Men's engagement with health services in low- and middle- income countries

Objectives

This study aimed to map evidence on health education programs (HEPs) for men engagement in health services in LMICs to guide future research.

Study design

A scoping review was conducted.

Methods

We searched Google Scholar, PubMed, EBSCOhost (CINAHL, MEDLINE, Health Source, Nursing, Academic Edition and Academic Search Complete) and WEB of Science electronic databases for publications from January 2000 to March 2019. We also searched Researchgate, the WHO library, and universities repositories for grey literature such as dissertations, theses, and reports. The search terms included “health,” “education,” “program,” “men”, with Boolean terms, AND and OR, being used to separate the keywords. Articles reporting evidence on HEPs for men aged 15 and older in LMICs and HEPs improving men's engagement in health services in LMICs published in any language between January 2000 to March 2019 were included in this review. We appraised included studies using the 2018 version of the Mixed Methods Appraisal Tool. We used thematic content analysis to extract emerging themes and presented a narrative account of the findings.

Results

Database search retrieved 8905 eligible articles. Of these, only six studies met the inclusion criteria and were included for data extraction. All included studies reported evidence of health education for men engagement in health services. The total number of men reported in the studies was 4372 with an age range of 15–54. Included studies were conducted in Uganda, Kenya, Ghana, and Zimbabwe. Included studies presented evidence on HEPs for men engagement in health services. Two main themes emerged from thematic content analysis of included studies: mode of health delivery (the process of enabling men and boys to become involved in health services as patients/clients) and health benefits to men (to achieve better health outcomes).

Conclusion

Our review revealed limited evidence of HEPs for men engagement in health service. Regardless of mode of health education delivery, notable health benefits to men were reported. We recommend implementation research on HEPs for men engagement in health services to better understand the social, cultural and economic influences in LMICs.

Individual and context correlates of the oral pill and condom use among Brazilian female adolescents

Background

Studies have examined the impact of contextual factors on the use of contraceptives among adolescents and found that many measures of income and social inequality are associated with contraceptive use. However, few have focused on maternal and primary health indicators and its influence on adolescent contraceptive use. This paper assesses whether maternal mortality rates, antenatal care visits, and primary healthcare coverage are associated with pill and condom use among female adolescents in Brazil.

Methods

We used data from the Study of Cardiovascular Risks in Adolescents (ERICA), a national, school-based cross-sectional study conducted in Brazil. A subsample of all female adolescents who had ever had sexual intercourse and were living in one of the 26 State capitals and the Federal District was selected (n = 7415). Multilevel mixed effects logistic regression models were estimated to examine the effect of contextual variables on pill and condom use.

Results

Sixty-five percent of female adolescents reported using pill while 21.9% reported using condom during the last sexual intercourse. Adolescents living in municipalities with low maternal mortality and high antenatal care coverage were significantly more likely to use pill during the last sexual intercourse compared to those from municipalities with high maternal mortality and low antenatal care coverage. Primary healthcare coverage (proportion of the population covered by primary healthcare teams) was not significantly associated with either condom or pill use during the last sexual intercourse.

Conclusion

Our findings suggest that promoting the use of pill among female adolescents may require approaches to strengthen healthcare systems rather than those focused solely on individual attributes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01447-6.

Determinants of accessibility to primary sexual reproductive health care among vulnerable women in Canada: a scoping review protocol

OBJECTIVE

The objective of the review is to describe, synthesize and document the determinants that impact a vulnerable woman's access to primary sexual reproductive health care in Canada.

INTRODUCTION

Canada is committed to advancing sexual reproductive health care initiatives. Although both men and women require sexual reproductive health care, the implications for women are far more significant. While Canadian women do generally experience "good health," issues with sexual reproductive health do exist, particularly for vulnerable women for whom questions about accessibility arise. Therefore, there is a need to understand the true extent of a woman's access to sexual reproductive health in Canada. Findings will be used to inform future implementation research and provide recommendations to key stakeholders.

INCLUSION CRITERIA

Studies on primary access to sexual reproductive health care for vulnerable women (those living in poverty, with risky sexual behaviors, and/or are Indigenous, immigrants or refugees) aged nine to 49 who reside in Canada will be considered. Studies published in French or English from 2008 will be included. Women with a physical and/or mental disability and/or who are part of the lesbian, gay, bisexual, transgender and queer community will be excluded if they do not have one or more of the defining characteristics listed above.

METHODS

Databases to be searched include PubMed, Embase, CINAHL, PsycINFO, Sociological Abstracts and Women's Studies International. Gray literature searches will also be conducted. Following screening, all identified citations will be collated. Titles and abstracts will be screened by independent reviewers. Potentially relevant studies will be retrieved in full and assessed. Data will be extracted by independent reviewers and presented in diagrammatic or tabular form and accompanied by a narrative summary.

The mediating role of partner communication on contraceptive use among adolescent girls and young women participating in a small-group intervention in Malawi: A longitudinal analysis

Though effective reproductive health interventions have been developed for adolescent girls and young women (AGYW) in sub-Saharan Africa, few have explored whether specific components of the interventions are responsible for observed changes in behaviour. Data for this longitudinal mediation analysis come from a quasi-experimental, sexual and reproductive health study conducted among AGYW (age 15-24) in Malawi. We assessed the extent to which the relationship between attending communication-specific small-group sessions and contraceptive use at one-year was mediated by contraceptive communication with partners at six months, using a bootstrapping procedure to estimate indirect effects. Of 358 participants, 44% attended communication-specific small-group sessions, 37% communicated with partners about contraception at six months, and 21% used non-barrier contraception at one-year. Participants who attended communication-specific small-group sessions had increased contraceptive communication with partners at six months (aOR = 1.48, 95% CI: 1.07-2.38) and increased non-barrier contraceptive use at one-year (aOR = 3.53, 95% CI: 1.86-6.69). The relationship between attending communication-specific small-group sessions and non-barrier contraceptive use at one-year was partially mediated by contraceptive communication with partners at six months (indirect effect = 0.04, 95% CI: 0.01-0.07). Our results suggest that contraceptive communication with partners is modifiable through interventions and important for AGYW non-barrier contraceptive uptake.

A systematic review of the evidence on peer education programmes for promoting the sexual and reproductive health of young people in India

In the context of a growing adolescent population globally, it is imperative to understand which interventions will most effectively advance their sexual and reproductive health (SRH). In India and globally, peer education is often utilised as an intervention for promoting the SRH of young people. Globally, the evidence of its effectiveness is mixed. A systematic review of the literature from the Indian context gave insight into the knowledge, attitudinal, and behavioural (KAB) outcomes affected by peer education, as well as the inputs, coverage, content, and context of such interventions. Out of the over 1500 publications initially identified through the database and bibliographic searches, 13 were included in the review; no quality assessment was done, given the dearth of publications matching the inclusion criteria. Analysis of the included publications highlights the multiple ways that peer education is implemented in the Indian context, as part of multi-component programmes and as a stand-alone intervention. The KAB outcomes from these initiatives are mixed, with some multi-component and some stand-alone initiatives affecting statistically significant outcomes and others not-a finding consistent with global literature reviewed for this paper. Despite the mixed results and the limited effects of behaviour relative to knowledge, this paper proposes that peer education has a place in an overall response to improving the SRH of young people. It calls for better research on peer education in India, and for research in relation to the optimal conditions for peer education to succeed in affecting KAB and other outcomes.

Contraceptive use and needs among adolescent women aged 15-19: Regional and global estimates and projections from 1990 to 2030 from a Bayesian hierarchical modelling study

Expanding access to contraception and ensuring that need for family planning is satisfied are essential for achieving universal access to reproductive healthcare services, as called for in the 2030 Agenda for Sustainable Development. To quantify the gaps that remain in meeting needs among adolescents, this study provides a harmonised data set and global estimates and projections of family planning indicators for adolescents aged 15–19 years. We compiled a comprehensive dataset of family-planning indicators among women aged 15–19 from 754 nationally representative surveys. We used a Bayesian hierarchical model with country-specific annual trends to estimate contraceptive prevalence and unmet need for family planning, with 95% uncertainty intervals (UIs), for 185 countries, taking into account changes in proportions married or in a union and differences in sexual activity among unmarried women across countries. Among 300 million women aged 15–19 years in 2019, 29.8 million (95% UI 24.6–41.7) use any contraception, and 15.0 million (95% UI 12.1–29.2) have unmet need for family planning. Population growth and the postponement of marriage influence trends in the absolute number of adolescents using contraception or experiencing unmet need. Large gaps remain in meeting family-planning needs among adolescents. The proportion of the need satisfied by modern methods, Sustainable Development Goals (SDG) indicator 3.7.1, was 59.2% (95% UI 44.8–67.2) globally among adolescents, lower compared to 75.7% (95% UI 73.2%–78.0%) among all women age 15–49 years. It was less than one half of adolescents in need in Western Asia and Northern Africa (38.7%, 95%UI = 20.9–56.5), Central and Southern Asia (43.5%, 95%UI = 36.6–52.3), and sub-Saharan Africa (45.6%, 95%UI = 42.2–49.0). The main limitations of the study are: (i) the uncertainty surrounding estimates for countries with limited or biased data is large; and (ii) underreporting of contraceptive use and needs is likely, especially among unmarried adolescents.

[Adolescents and teachers´ knowledge, attitude and practice towards contraception: results from a qualitative study conducted in the Democratic Republic of the Congo]

Introduction

the purpose of this study was to assess adolescents and teachers´ knowledge, attitude and practices towards family planning (FP).

Methods

in 2018, a qualitative study was conducted among seven teachers and 62 teenagers aged 15-19 years based on the Theory of Reasoned Action published by Fishbein and Ajzen in 2011. Data were collected from six focus group (FG) with adolescents and seven semi-structured interviews of teachers. They were analyzed using Atlas Ti software on the basis of a deductive approach.

Results

periodic abstinence, male condoms and pills were the only contraceptive methods reported. Adolescents and teachers were apprehensive about using artificial contraceptive methods other than irregularly used male condom. Girls prefer natural methods fearing side effects. The majority of adolescents wanted to be informed about FP in school; however, they felt that the content of the Life Education Course (EVIE) was insufficient and that teachers lacked of openness. Peers, brothers, sisters and internet were the main sources of information. Mothers were an important source of information especially for girls, unlike fathers who were generally less appreciated.

Conclusion

knowledge about FP is weak. Misconceptions about contraception lead to the use of ineffective practices to prevent unintended pregnancies. Training programs to improve teachers´ knowledge should be developed and the content of the EVIE course should be formalized and regulated.

Delivery strategies for optimizing uptake of contraceptives among adolescents aged 15-19 years in Nsanje District, Malawi

Background

Despite documented benefits of contraceptives, uptake among young people aged 20–24 years is high compared to adolescents aged 15–19 years in Malawi. As the world’s population of 15–19-year-olds continues to grow the need to meet the increasing demand for contraceptive services and information that address adolescent-specific needs cannot be underestimated. To inform Sexual and Reproductive health services for the youth, we explored strategies for optimizing uptake of contraceptives among this age group.

Methods

An exploratory qualitative cross-sectional study was conducted at Nsanje District Hospital and Nyamadzere Community Day Secondary School guided by Social-Ecological Framework to understand strategies that may optimize the uptake of contraceptives among adolescents aged 15–19. Nsanje district was purposively selected based on the reason that it is the second district in Malawi with the highest rate of adolescent childbearing of girls aged 15–19 years. We conducted a Focus Group Discussion (FGD) with 9 traditional leaders, 11 Key Informant Interviews (KIIs) with health workers, 20 In-depth Interviews (IDIs) with 12 adolescents, 4 teachers, and 4 parents. All data were digitally recorded, transcribed verbatim into English. The data was analyzed and managed using deductive thematic analysis guided by Social-Ecological Framework.

Results

Adolescents suggested accessing contraceptives from local drug stores, pharmacies and hospitals at a health system level and through Youth Centres, clubs, and corners at a Community level. There is a need to ensure a continuous supply of various kinds of contraceptives and the presence of youth-friendly health care workers in the specified areas.

Conclusion

There is no one way of delivering contraceptives to adolescents. Multiple avenues existent at the health facility and community could be leveraged to optimize delivery and uptake of contraceptives in a manner that is not intimidating to an adolescent while involving key stakeholders.

Non-communicable diseases among adolescents: current status, determinants, interventions and policies

BACKGROUND

Addressing non-communicable disease (NCDs) is a global priority in the Sustainable Development Goals, especially for adolescents. However, existing literature on NCD burden, risk factors and determinants, and effective interventions and policies for targeting these diseases in adolescents, is limited. This study develops an evidence-based conceptual framework, and highlights pathways between risk factors and interventions to NCD development during adolescence (ages 10-19 years) and continuing into adulthood. Additionally, the epidemiologic profile of key NCD risk factors and outcomes among adolescents and preventative NCD policies/laws/legislations are examined, and a multivariable analysis is conducted to explore the determinants of NCDs among adolescents and adults.

METHODS

We reviewed literature to develop an adolescent-specific conceptual framework for NCDs. Global data repositories were searched from Jan-July 2018 for data on NCD-related risk factors, outcomes, and policy data for 194 countries from 1990 to 2016. Disability-Adjusted Life Years were used to assess disease burden. A hierarchical modeling approach and ordinary least squares regression was used to explore the basic and underlying causes of NCD burden.

RESULTS

Mental health disorders are the most common NCDs found in adolescents. Adverse behaviours and lifestyle factors, specifically smoking, alcohol and drug use, poor diet and metabolic syndrome, are key risk factors for NCD development in adolescence. Across countries, laws and policies for preventing NCD-related risk factors exist, however those targeting contraceptive use, drug harm reduction, mental health and nutrition are generally limited. Many effective interventions for NCD prevention exist but must be implemented at scale through multisectoral action utilizing diverse delivery mechanisms. Multivariable analyses showed that structural/macro, community and household factors have significant associations with NCD burden among adolescents and adults.

CONCLUSIONS

Multi-sectoral efforts are needed to target NCD risk factors among adolescents to mitigate disease burden and adverse outcomes in adulthood. Findings could guide policy and programming to reduce NCD burden in the sustainable development era.

Individual and contextual factors associated with mistimed and unwanted pregnancies among adolescent girls and young women in selected high fertility countries in sub-Saharan Africa: A multilevel mixed effects analysis

Introduction

Unintended pregnancies are associated with a number of risk factors such as malnutrition, mental illness, unsafe abortion, maternal mortality and horizontal transmission of HIV to children. These risks are predominant among adolescent girls and young women compared to older women. This study examined the individual and contextual factors associated with unintended pregnancy among adolescent girls and young women in selected high fertility countries in sub-Saharan Africa.

Materials and methods

Data for this study was obtained from recent Demographic and Health Surveys carried out between 2010 and 2018 in 10 countries in sub-Sahara Africa. The sample size for this study was made up of 6,791 adolescent girls and young women (aged 15–24), who were pregnant during the surveys and had complete responses on all the variables considered in the study. Unintended pregnancy was the outcome variable in this study. Descriptive and multilevel logistic regression analyses were performed and the fixed effect results of the multilevel logistic regression analysis were reported as adjusted odds ratios at 95% confidence interval.

Results

Unintended pregnancy in the selected countries was 22.4%, with Angola, recording the highest prevalence of 46.6% while Gambia had the lowest prevalence of 10.2%. The likelihood of unintended pregnancy was high among adolescent girls and young women aged 15–19 [aOR = 1.48; 95% CI = 1.26–1.73], those with primary [aOR = 1.99; 95% CI = 1.69–2.33] and secondary/higher [aOR = 2.30; 95% CI = 1.90–2.78] levels of education, single (never married/separated/divorced/widowed) adolescent girls and young women [aOR = 9.23; 95% CI = 7.55–11.28] and those who were cohabiting [aOR = 2.53; 95% CI = 2.16–2.96]. The odds of unintended pregnancy also increased with increasing birth order, with adolescent girls and young women having three or more births more likely to have unintended pregnancies compared to those with one birth [aOR = 1.99; 95% CI = 1.59–2.48]. Adolescent girls and young women who had ever used contraceptives (modern or traditional), had higher odds of unintended pregnancies compared to those who had never used contraceptives [aOR = 1.32; 95% CI = 1.12–1.54]. Finally, adolescent girls and young women who belonged to the rich wealth quintile were more likely to have unintended pregnancy compared to those in the poor wealth quintile [1.28; 95% CI = 1.08–1.51].

Conclusion

The study found that age, marital status, level of education, parity, use of contraceptives and wealth quintile are associated with unintended pregnancy among adolescent girls and young women in high fertility sub-Saharan African countries. These findings call for the need for government and non-governmental organisations in high fertility sub-Saharan African countries to restructure sexual and reproductive health services, taking into consideration these individual and contextual level characteristics of adolescent girls and young women.

Use of the Delphi Method to Enhance Pharmacist Contraceptive Counseling Materials

BACKGROUND

Many states have pharmacist contraceptive prescribing laws with several others in the process of enacting similar legislation. Little continuity or standardization exists across these programs, including development of counseling materials. Although the risk of unplanned pregnancy is greatest among adolescents and young adults, developed materials are not always sensitive to youth.

OBJECTIVE

To use a modified Delphi method to develop standardized youth-friendly counseling tools that are sensitive to pharmacy workflow during pharmacist contraceptive prescribing.

METHODS

A multidisciplinary expert panel of women's health pharmacists, community pharmacists, adolescent medicine pediatricians, obstetrician-gynecologists, and public health advocates was assembled and reviewed materials over 3 iterations. Comments were anonymized, summarized, and addressed with each iteration. A graphic designer assisted with visual representation of panel suggestions. Reviewer feedback was qualitatively analyzed for emergent themes.

RESULTS

The Delphi method produced 5 main themes of feedback integrated into the final materials including attention to work flow, visual appeal, digestible medical information, universal use of materials, and incorporating new evidence-based best practices. Final materials were scored at a Flesch-Kincaid grade of 5.1 for readability.

CONCLUSIONS

The use of the Delphi method allowed for the efficient production of materials that are medically accurate, patient-centered, and reflect multiple disciplinary perspectives. Final materials were more robust and sensitive to the unique needs of youth.

Effects of comprehensive sexuality education on the comprehensive knowledge and attitude to condom use among first-year students in Arba Minch University: a quasi-experimental study

Objective

To assess the effect of comprehensive sexuality education on the comprehensive knowledge and attitude to condom use among first-year students at Arba Minch University.

Results

A total of 832 students participated at a baseline, and 820 students participated at the posttest. This study found that there was a significant effect on changing students’ knowledge and attitude towards a condom. In the education group, the students’ average change of comprehensive condom knowledge score was 0.229 higher than the average score of students’ in the control group (ATE = 0.229, 95% CI 0.132 to 0.328; p < 0.001). The average change of attitude toward condom score of students’ in the education group was 1.834 higher than the average change score of students’ in the control group (ATE = 1.834, 95% CI 1.195 to 2.772; p < 0.001).This study provides further evidence on the effectiveness of comprehensive sexuality education in terms of knowledge and attitude towards a condom. Therefore, the implementation of this education should be strengthened in order the prevent youths from STI/HIV and unintended pregnancies.

Strengthening Social and Behavior Change in Postabortion Care: A Call to Action for Health Professionals

Social and behavior change approaches have shown promise for addressing the demand- and supply-side challenges in postabortion care. As implementers seek to improve the quality of postabortion care, systematically integrating long-standing models and emerging approaches, including behavioral economics, human-centered design, and attribute-based models of behavior change, can promote positive health outcomes.

Designing a guideline for empowering married adolescent girls in reproductive health: a mixed-method study protocol

BACKGROUND

Investing in adolescent's health, especially, the role of girls in community health and future generations is one of the most important strategies of the Millennium Development Goals. In this regard, supplying adolescents' special needs including access to educational, health and counseling services for promoting reproductive health have been emphasized. About 36% of registered marriages in Iran are under the age of 19 though, reproductive health services based on married adolescent girls` needs in social-cultural context were not predicted in national health system. Therefore, this study aim was designing a guideline for empowering married adolescents in reproductive health.

METHODS

This is a sequential exploratory Mixed-method study conducted in three consecutive phases. The first phase, with a qualitative approach, explores needs, barriers and strategies for empowering married adolescent girls in reproductive health. In the second phase, a systematic review will be conducted to identify the recommendation and strategies for empowering married adolescent girls in reproductive health in other countries. Finally, in third phase, data from qualitative study and systematic review are emerged and the most important solutions and recommendations related to the issue are extracted and the final guideline is adapted by the experts.

DISCUSSION

This study is attempting to provide a guideline containing comprehensive recommendations for health system` policy makers and providers in order to empowering adolescent girls in reproductive health.

Reaching Urban Female Adolescents at Key Points of Sexual and Reproductive Health Transitions: Evidence from a Longitudinal Study from Kenya

Urban areas include large numbers of adolescents (ages 15-19) and young adults (ages 20-24) who may have unmet sexual and reproductive health (SRH) needs. Worldwide, adolescents contribute 11% of births, many of which are in low and middle-income countries. This study uses recently collected longitudinal data from urban Kenyan women to examine the association between targeted intervention activities and adolescents' SRH transitions. The focus was on a female adolescent (15-19) sample and their transition to first sex and first pregnancy/birth. Multinomial logistic regression methods were used to examine whether exposure to program activities was associated with delays in transitions. Overall, a high percentage of adolescents were exposed to television activities with family planning messages. About a third were exposed to community events, program posters, or the Shujaaz comic book that included themes related to relationships and positive health outcomes using recognizable characters. Multivariate analyses found that exposure to the Shujaaz comic book was associated with remaining sexually inexperienced and never pregnant at end line. Future programs for urban adolescents should implement interventions that test novel media strategies, like the Shujaaz comic book, that may be more interesting for young people. Innovative strategies are needed to reach female adolescents in urban settings.

Development of an intervention delivered by mobile phone aimed at decreasing unintended pregnancy among young people in three lower middle income countries

BACKGROUND

Unintended pregnancies can result in poorer health outcomes for women, children and families. Young people in low and middle income countries are at particular risk of unintended pregnancies and could benefit from innovative contraceptive interventions. There is growing evidence that interventions delivered by mobile phone can be effective in improving a range of health behaviours. This paper describes the development of a contraceptive behavioural intervention delivered by mobile phone for young people in Tajikistan, Bolivia and Palestine, where unmet need for contraception is high among this group.

METHODS

Guided by Intervention Mapping, the following steps contributed to the development of the interventions: (1) needs assessment; (2) specifying behavioural change to result from the intervention; (3) selecting behaviour change methods to include in the intervention; (4) producing and refining the intervention content.

RESULTS

The results of the needs assessment produced similar interventions across the countries. The interventions consist of short daily messages delivered over 4 months (delivered by text messaging in Palestine and mobile phone application instant messages in Bolivia and Tajikistan). The messages provide information about contraception, target attitudes that are barriers to contraceptive uptake and support young people in feeling that they can influence their reproductive health. The interventions each contain the same ten behaviour change methods, adapted for delivery by mobile phone.

CONCLUSIONS

The development resulted in a well-specified, theory-based intervention, tailored to each country. It is feasible to develop an intervention delivered by mobile phone for young people in resource-limited settings.

Systematic review of strategies to increase access to health services among children over five in low- and middle-income countries

BACKGROUND

The populations of many low- and middle-income countries (LMIC) are young. Despite progress made towards achieving Universal Health Coverage and remarkable health gains, evidence suggests that many children in LMIC are still not accessing needed healthcare services. Delayed or lack of access to health services can lead to a worsening of health and can in turn negatively impact a child's ability to attend school, and future employment opportunities.

METHODS

We conducted a systematic review to assess the effectiveness of interventions aimed at increasing access to health services for children over 5 years in LMIC settings. Four electronic databases were searched in March 2017. Studies were included if they evaluated interventions that aimed to increase: healthcare utilisation, immunisation uptake and compliance with medication/referral. Randomised controlled trials and non-randomised study designs were included in the review. Data extraction included study characteristics, intervention type and measures of access to health services for children above 5 years of age. Study outcomes were classified as positive, negative, mixed or null in terms of their impact on access outcomes.

RESULTS

Ten studies met the criteria for inclusion in the review. Interventions were evaluated in Nicaragua (1), Brazil (1), Turkey (1), India (1), China (1), Uganda (1), Ghana (1), Nigeria (1), South Africa (1) and Swaziland (1). Intervention types included education (2), incentives (1), outreach (1), SMS/phone call reminders (2) and multicomponent interventions (4). All evaluations reported positive findings on measured health access outcomes; however, the quality and strength of evidence were mixed.

CONCLUSION

This review provides evidence of the range of interventions that were used to increase healthcare access for children above 5 years old in LMIC. Nevertheless, further research is needed to examine each of the identified intervention types and the influence of contextual factors, with robust study designs. There is also a need to assess the cost-effectiveness of the interventions to inform decision-makers on which are suitable for scale-up in their particular contexts.

Motherhood increases support for family planning among Kenyan adolescents

OBJECTIVE

Adolescent fertility rates are high in Kenya, and increase the risks of unintended repeat pregnancies and maternal and infant morbidity and mortality. Our objective was to examine knowledge, practices, and influences surrounding contraceptive access and use among Kenyan postpartum adolescents.

STUDY DESIGN

We conducted a mixed methods study (surveys and focus group discussions) with postpartum adolescents and family planning (FP) providers at two maternal and child health clinics in Kenya.

MAIN OUTCOME MEASURES

Four focus group discussions (FGDs) were conducted with postpartum adolescents (stratified by age and site), and two FGDs were conducted with FP providers (stratified by site). Transcripts were analyzed for prevalent themes. The participants also completed individual surveys that were analyzed for contraceptive knowledge.

RESULTS

Adolescent contraceptive decision-making and use were shaped by social norms of adolescent sexual behaviour. Lack of FP knowledge, community misinformation, and insufficient counselling and time with providers all contributed to adolescent concerns about FP. However, as adolescents transitioned to motherhood, they felt more encouraged to use FP and had increased awareness of FP benefits.

CONCLUSION

Both postpartum adolescents and providers felt delivery of FP services could be improved if providers had better training and counselling tools.

Association of Mass Media Communication with Contraceptive Use in Sub-Saharan Africa: A Meta-Analysis of Demographic and Health Surveys

Literature abounds with evidence on the effectiveness of individual mass media interventions on contraceptive use and other health behaviors. There have been, however, very few studies summarizing effect sizes of mass media health communication campaigns in sub-Saharan Africa. In this study, we used meta-analytic techniques to pool data from 47 demographic and health surveys conducted between 2005 and 2015 in 31 sub-Saharan African countries and estimate the prevalence of exposure to family planning-related mass media communication. We also estimated the average effect size of exposure to mass media communication after adjusting for endogeneity. We performed meta-regression to assess the moderating role of selected variables on effect size. On average, 44% of women in sub-Saharan Africa were exposed to family planning-related mass media interventions in the year preceding the survey. Overall, exposure was associated with an effect size equivalent to an odds ratio of 1.93. More recent surveys demonstrated smaller effect sizes than earlier ones, while the effects were larger in lower contraceptive prevalence settings than in higher prevalence ones. The findings have implications for designing communication programs, setting expectations about communication impact, and guiding decisions about sample size estimation for mass media evaluation studies.

Adolescents and Long-Acting Reversible Contraception: Lessons from Mexico

Objectives We describe current use of long acting reversible contraception LARC (tier 1), hormonal (tier 2), barrier and traditional contraceptive methods (tier 3) by adolescent women in Mexico. We test whether knowledge of contraceptive methods is associated with current use of LARC. Methods We used the 1992, 1997, 2006, 2009 and 2014 waves of a nationally representative survey (ENADID). We used information from n = 10,376 (N = 3,635,558) adolescents (15-19 years) who reported ever using any contraceptive method. We used descriptive statistics and logistic regression models to test the association of knowledge of method tiers with use of tier 1 (LARC) versus tier 2, tier 3, and no contraceptive use. Results Over time, LARC use in the overall sample was flat (21 % in 1992, 23 % in 2014; p = 0.130). Among adolescents who have had a pregnancy, LARC use has increased (24 % in 1992 to 37 % in 2014). Among adolescents who did not report a pregnancy, current LARC use has remained low (1 % in 1992 and 2 % in 2014). We found positive association between LARC use and knowledge of tier 1 methods. In the overall sample LARC use is strongly correlated with exposure to marriage compared to use of tier 2 or tier 3 methods. Discussion Among adolescents in Mexico who are currently using modern methods, LARC use is relatively high, but remains primarily tied to having had a pregnancy. Our study highlights the need to expand access to LARC methods outside the post-partum hospital setting.

A never-before opportunity to strengthen investment and action on adolescent contraception, and what we must do to make full use of it

Background

Increasingly, the health and rights of adolescents are being recognized and prioritized on the global agenda. This presents us with a “never-before” opportunity to address adolescent contraception. This is timely, as there are enormous numbers of adolescents who are currently unable to obtain and use contraceptives. From research evidence and programmatic experience, it is clear that we need to do things differently to meet their needs/fulfil their rights.

Main body

In this commentary, we call for action in several key areas to address adolescents’ persistent inability to obtain and use contraceptives. We must move away from one-size-fits-all approaches, from a ‘condoms-only’ mind set, from separate services for adolescents, from ignoring the appeal of pharmacies and shops, and from one-off-training to make health workers adolescent friendly. Our efforts to expand access to quality contraceptive services to adolescents must be combined with efforts to build their desire and ability to use them, and to do so consistently. In order for these changes to be made, action must be taken on several levels. This includes the formulation of sound national policies and strategies, robust programme implementation with monitoring, regular programmatic reviews, and implementation research. Further, high-quality collection, analysis, and dissemination of data must underlie all of our efforts. As we move ahead, we must also recognize and draw lessons from positive examples of large scale and sustained programmes in countries that have led the way in increasing contraceptive use by adolescents.

Conclusion

This unprecedented moment in history gives us a real opportunity to bring about transformational change, particularly when there is so much at stake.

Adolescents Confusion in Receiving Health Services: A Qualitative Study

INTRODUCTION

Providing health services for adolescents requires exploration of hidden factors from the perspective of adolescents, providers, and key individuals. Understanding the process of providing health services from adolescents point of view will help receiving and continuation of services. Although many studies have been conducted in Iran on adolescents health needs, few studies have dealt with provision of these services to adolescents.

AIM

The present study aimed to explain the adolescents and key informants' perception of healthcare provision.

MATERIALS AND METHODS

The present qualitative study was conducted according to grounded theory. Data were collected using deep semi-structured individual interviews and group discussion. Participants were selected through purposive sampling followed by theoretical sampling. Participants in present study were 65 adolescents, nine youths (19-24-year-old), and 19 parents and key people involved in providing health services. Adolescents and their parents were selected from different parts of Tehran. Data collection continued until data saturation, and was analysed using Corbin-Strauss (2008) method.

RESULTS

Issues relating to adolescents perception of the process of providing services included health concerns, society's inappropriate behaviours, and weakness of the health services system in responding to adolescents needs, which as underlying factors contributed to adolescents confusion in receiving services and their proper coping with puberty.

CONCLUSION

Due to lack of education on how to manage puberty by parents, schools, society, and the health system, participating adolescents from Tehran were confused about receiving information and unable to manage puberty problems. Solving this problem requires continuity of services and interaction of family, school and community.

Quality of reproductive healthcare for adolescents: A nationally representative survey of providers in Mexico

OBJECTIVE

Adolescents need sexual and reproductive health services but little is known about quality-of-care in lower- and middle-income countries where most of the world's adolescents reside. Quality-of-care has important implications as lower quality may be linked to higher unplanned pregnancy and sexually transmitted infection rates. This study sought to generate evidence about quality-of-care in public sexual and reproductive health services for adolescents.

METHODS

This cross-sectional study had a complex, probabilistic, stratified sampling design, representative at the national, regional and rural/urban level in Mexico, collecting provider questionnaires at 505 primary care units in 2012. A sexual and reproductive quality-of-healthcare index was defined and multinomial logistic regression was utilized in 2015.

RESULTS

At the national level 13.9% (95%CI: 6.9-26.0) of healthcare units provide low quality, 68.6% (95%CI: 58.4-77.3) medium quality and 17.5% (95%CI: 11.9-25.0) high quality reproductive healthcare services to adolescents. Urban or metropolitan primary care units were at least 10 times more likely to provide high quality care than those in rural areas. Units with a space specifically for counseling adolescents were at least 8 times more likely to provide high quality care. Ministry of Health clinics provided the lowest quality of service, while those from Social Security for the Underserved provided the best.

CONCLUSIONS

The study indicates higher quality sexual and reproductive healthcare services are needed. In Mexico and other middle- to low-income countries where quality-of-care has been shown to be a problem, incorporating adolescent-friendly, gender-equity and rights-based perspectives could contribute to improvement. Setting and disseminating standards for care in guidelines and providing tools such as algorithms could help healthcare personnel provide higher quality care.

Beyond love: a qualitative analysis of factors associated with teenage pregnancy among young women with pregnancy experience in Bolgatanga, Ghana

Globally, an estimated 16 million young women aged 15 to 19 years give birth every year. Most teenage pregnancies are unintended and being pregnant or delivering a baby as a teenager can have serious adverse consequences. Knowledge of the environmental factors and social cognitive determinants influencing young women's failure to protect against unintended pregnancy is necessary to address the high rate of teenage pregnancies. We conducted semi-structured in-depth interviews with 21 young women, who had experience of pregnancy, in Bolgatanga, Ghana. The interview protocol included themes (relationships, sex, pregnancy, family planning) and determinants (knowledge, attitudes, self-efficacy, norms, risk perceptions) derived from empirical studies and theories related to sexuality behaviour. Findings show that young women's motivations for sexual relationships are mostly 'beyond love' and seem to focus on economic factors. The main means of sexual protection seems to be condom use. Other forms of contraception were believed to be linked to infertility. Sexuality remains a largely taboo topic for open discussion and sex education in schools seems limited to abstinence-only messages. The need for more open communication on matters of sexuality with young people and the provision of a more comprehensive sexuality education in school to address teenage pregnancies in Ghana, is discussed.

Targeting factors for change: contraceptive counselling and care of female adolescents

INTRODUCTION

Sexual and reproductive health care should empower and enable all individuals to have a sex life that is as safe and pleasurable as possible. Achievement of this goal for adolescents is often impeded by regional and sociocultural barriers.

OBJECTIVES

To review global barriers to provision of effective counselling and care of adolescents seeking advice on contraception and sexual and reproductive health and identify elements of best practice that can be adapted to meet their needs at regional level.

METHODS

Experts with clinical experience and a scholarly background in the provision of contraceptive services to adolescents participated in a stepwise process of literature review and discussion according to the agreed objectives.

RESULTS

The Global CARE (Contraception: Access, Resources, Education) group identified barriers to the access, availability and acceptance of contraception by adolescents, not only at the political and sociocultural level but also within health care practice. The group collected and summarized successful local strategies and tools suitable for adaptation in other regions. Elements of best practice for providing contraception regardless of setting or regional constraints, including required skills, knowledge, and attitudes, were also proposed.

CONCLUSION

Sharing of evidence-based best practice in delivering contraceptive services, improvements in health care provider education, and sharing of experience between countries will hopefully help to overcome the barriers to appropriate and effective counselling and care of adolescents.