Sexual Self-Efficacy and Gender: A Review of Condom Use and Sexual Negotiation Among Young Men and Women in Sub-Saharan Africa

The Effect of Stigma on Family Planning and HIV Pre-exposure Prophylaxis Decisions of Young Women Accessing Post-Abortion Care in Kenya

Adolescent girls and young women (AGYW) in Eastern and Southern Africa face parallel epidemics of unintended pregnancy and HIV. Their sexual health decisions are often dominated by intersecting stigmas. In an implementation science project integrating delivery of daily, oral pre-exposure prophylaxis (PrEP) for HIV prevention into 14 post-abortion care (PAC) clinics in Kenya, we enrolled a subset of PrEP initiating AGYW (aged 15 to 30 years) into a research cohort. Utilizing log binomial models, we estimated the effect of PrEP stigma on PrEP continuation (measured via self-report and urine assay for tenofovir) and abortion stigma on contraceptive initiation. Between April 2022 and February 2023, 401 AGYW were enrolled after initiating PrEP through their PAC provider, of which 120 (29.9%) initiated highly-effective contraception. Overall, abortion and PrEP stigmas were high in this cohort. Abortion stigma was more prevalent among those that were adolescents, unmarried, and reported social harm. Among 114 AGYW returning for the month 1 follow-up visit, 83.5% reported continuing PrEP and 52.5% had tenofovir detected. In this subset, higher levels of PrEP stigma were significantly associated with greater likelihood of PrEP adherence, but not PrEP continuation. For abortion stigma, greater scores in the subdomain of isolation were significantly associated with greater likelihood of initiating a highly-effective contraception, while greater scores in the subdomain of community condemnation were significantly associated with reduced likelihood of initiating a highly-effective contraception. Given the burden of stigma documented by our work, PAC settings are a pivotal space to integrate stigma-informed counseling and to empower young women to optimize contraceptive and PrEP decisions.

The mediation effects of sexual self-efficacy in the relationship between psychosocial wellbeing and depressive symptoms among female migrant workers in Vietnam

BACKGROUND

Depression is a common mental disorder that significantly contributes to the global burden of disease. Studies have consistently reported that migrant workers experience higher levels of depressive symptoms, especially women.

AIMS

This study aimed to examine the mediation role of sexual self-efficacy on the relationship between psychological wellbeing, and depressive symptoms among young female migrant workers in Vietnam's industrial zones.

METHODS

A cross-sectional study was conducted among 1061 female migrant workers aged 18 to 29 from January to November 2020 in Hanoi, Vietnam. Anonymous interview questionnaires were used to collect data on demographic characteristics, psychosocial wellbeing (PWB), sexual self-efficacy, and depressive symptoms. Mediation analysis was conducted to explore the mediation effect of sexual self-efficacy on the relationship between PWB and depressive symptoms.

RESULTS

Nearly 8% of the female migrant workers reported experiencing depressive symptoms. The final mediation model showed that the effect of overall psychological wellbeing on depressive symptoms was partially mediated by sexual self-efficacy. Specifically, 4.1% of the effect of overall PWB on depressive symptoms was mediated through sexual self-efficacy. In the PWB subdimension analyses, sexual self-efficacy mediated 14.3% of the effect of personal growth, 8.8% of the effect of purpose in life, 8.0% of the effect of autonomy, and 7.8% of the effect of environmental mastery on depressive symptoms, respectively.

CONCLUSION

The study findings demonstrate that sexual self-efficacy plays an important role in the relationship between psychosocial wellbeing and depressive symptoms among female migrant workers in industrial zones in Vietnam. Improving psychosocial wellbeing and promoting sexual health including sexual self-efficacy should be prioritized when addressing depressive symptoms and mental health concerns among industrial zone female migrant workers in Vietnam, which may also be applicable in other low- and middle-income countries with similar socio-cultural settings.

Construction and validation of a scale of sexual self-concept for the elderly Chilean population

BACKGROUND

Sexual self-concept has a central role in the life of the elderly population. Indeed, their sexual self-concept has significant and positive relationships with their satisfaction with life, pleasure, and willingness to interact with others. However, social-cultural prejudice means that the elderly are considered asexual individuals, harming their sexual self-concept. This prejudice is prominent in Chile, where the elderly do not have access to clear information about their sexuality. However, research on the Chilean elderly population is still in its infancy and requires more attention. Hence, this research aims to construct and validate a scale of sexual self-concept for the elderly Chilean population to cover this identified gap in the literature.

METHODS

Sixty items were integrated into the first version of the scale. Ten external judges were asked to assess the content validity. Twenty-eight items were maintained. Subsequently, an instrumental and cross-sectional design was implemented with a non-probabilistic sampling (N = 188). Items were refined with corrected homogeneity indices and conditional estimates of Cronbach's alpha and Omega coefficient.

RESULTS

A final scale of nine items equally distributed in three dimensions was obtained: Sexual self-efficacy (ω = 0.867), Sexual assertiveness (ω = 0.764), and Sexual self-esteem (ω = 0.803). The confirmatory factor analysis reflects that the theoretical model has an adequate fit (CFI = .989; TLI = .984; RMSEA = .086).

CONCLUSIONS

The data analyses confirmed that the scale has adequate psychometric properties. This scale can be used for multidimensional measurements of sexual self-concept in the elderly in Chile. Further research can confirm its psychometric properties in different settings within the Spanish language population.

A syndemic of inequitable gender norms and intersecting stigmas on condom self-efficacy and practices among displaced youth living in urban slums in Uganda: a community-based cross-sectional study

BACKGROUND

Adverse socio-cultural factors compromise the implementation of HIV prevention strategies among displaced youth. While condoms are an affordable and effective HIV prevention strategy for youth, stigma and inequitable gender norms may constrain condom self-efficacy (i.e., knowledge, intentions, and relationship dynamics that facilitate condom negotiation) and use. Further, knowledge of contextually appropriate HIV prevention approaches are constrained by limited understanding of the socio-cultural conditions that affect condom self-efficacy and use among displaced youth. Guided by syndemics theory, we examine independent and joint effects of adverse socio-cultural factors associated with condom self-efficacy and use among displaced youth living in urban slums in Kampala, Uganda.

METHODS

We conducted a community-based cross-sectional survey of displaced youth aged 16-24 years living in five slums in Kampala. We used multivariable logistic regression and multivariate linear regression to assess independent and two-way interactions among adverse socio-cultural factors (adolescent sexual and reproductive health-related stigma [A-SRH stigma], perceived HIV-related stigma, and beliefs in harmful inequitable gender norms) on condom self-efficacy and recent consistent condom use. We calculated the prevalence and co-occurrence of adverse socio-cultural factors; conducted regression analyses to create unique profiles of adverse socio-cultural factors; and then assessed joint effects of adverse socio-cultural factors on condom self-efficacy and practices.

RESULTS

Among participants (mean age: 19.59 years; SD: 2.59; women: n = 333, men: n = 112), 62.5% were sexually active. Of these, only 53.3% reported recent consistent condom use. Overall, 42.73% of participants reported two co-occurring adverse socio-cultural factors, and 16.63% reported three co-occurring exposures. We found a joint effect of beliefs in harmful inequitable gender norms with high A-SRH stigma (β = - 0.20; p < 0.05) and high A-SRH stigma with high perceived HIV stigma (β = - 0.31; p < 0.001) on reduced condom self-efficacy. We found a multiplicative interaction between high A-SRH stigma with high perceived HIV stigma (aOR = 0.52; 95% CI 0.28, 0.96) on recent consistent condom use. Additionally, we found that condom self-efficacy (aOR = 1.01; 95% CI 1.05, 1.16) and safer sexual communication (aOR = 2.12; 95% CI 1.54, 2.91) acted as protective factors on inconsistent condom use.

CONCLUSIONS

Displaced youth living in urban slums exhibited low consistent condom use. Intersecting stigmas were associated with lower condom self-efficacy-a protective factor linked with increased consistent condom use. Findings highlight the importance of gender transformative and intersectional stigma reduction approaches to increase sexual agency and safer sex practices among Kampala's slum-dwelling displaced youth.

Factors Associated with Consistent Condom Use Among Women Engaged in Sex Work: Lessons From the Kyaterekera Study in Southwestern Uganda

We examined the factors associated with consistent condom use among women engaged in sex work in the Southern parts of Uganda. We used baseline data from a longitudinal study involving WESW from 19 hotspots in Southern Uganda. We conducted hierarchical models to determine the individual, economic, behavioral, and health-related factors associated with consistent condom use. We found that, alcohol use (b=-0.48, 95% CI=-0.77, -0.19), accepting money for condomless sex (b=-0.33, 95% CI=-0.38, -0.28), multiple customers (b=-0.01, 95% CI=-0.01, -0.005), being married (b = 0.50, 95% CI = 0.01, 0.99), owning more assets (b = 0.08, 95% CI = 0.05, 0.13), having another income earner in the household (b = 0.55, 95% CI = 0.27, 0.83), condom use self-efficacy (b = 0.11, 95% CI = 0.03, 0.19), condom use communication (b = 0.06, 95% CI = 0.001, 0.12), and being knowledgeable about HIV/STIs transmission (b = 0.08, 95% CI = 0.01, 0.15) were associated with consistent condom use. Additionally, 29% of the women were consistent condom users. Hence, there is need to implement interventions that promote consistent condom use among WESW.

Women's empowerment, maternal depression, and stress: Evidence from rural Burkina Faso

Objective

Though there is a wide array of evidence that women's empowerment is associated with more positive health and nutritional outcomes for women and children, evidence around the relationship with mental health or subjective well-being remains relatively limited. The objective of this paper is to explore this relationship in longitudinal data from rural Burkina Faso.

Methods

We analyze the association between empowerment measured using the project-level Women's Empowerment in Agriculture Index (pro-WEAI), and two additional outcomes of interest: stress (measured using the SRQ-20) and maternal depression (measured using the Edinburgh scale for post-partum depression). The analysis employs both cross-sectional specifications and panel specifications conditional on individual fixed effects.

Results

We find evidence of substantial negative correlations between the empowerment score and maternal stress and depression measured using both continuous and binary variables. This relationship seems to be particularly driven by self-efficacy and respect among household members, where higher scores have negative associations with depression and stress that are both large in magnitude and precisely estimated.

Conclusion

Enhanced mental health may be another channel for a positive effect of empowerment on women's welfare.

Exploring Self-efficacy for Condom Use in Spanish People: A Trend Analyses by Gender from 2004 to 2020

Self-efficacy seems to be one of the most important resources for the different stages underlying condom use and STI prevention. For this reason, this study evaluates trends in self-efficacy by gender, from 2004 to 2008, 2013 and 2020 in Spain. Throughout these years, 6,698 people ranging from 17 to 40 years old, participated filling the Brief scale of condom use self-efficacy. According to our findings, despite the slight improvement in the recent years, self-efficacy still maintains a risky profile for safe sex, especially among the youngest people. Moreover, most of the traditional gender differences continue over the years with women reporting lower scores for condom purchase and men for putting them. However, these differences are not relevant in other dimensions such as using condoms despite drug consumption where women reveal worse results over the years. Therefore, our findings reaffirm the need of intensifying gendered preventive efforts aimed at Spanish people and, particularly, among the youngest.

“Men Rule… this is the Normal Thing. We Normalise it and it’s Wrong”: Gendered Power in Decision-Making Around Sex and Condom Use in Heterosexual Relationships Amongst Adolescents and Young People in South Africa

We examined power and decision-making in heterosexual relationships amongst South African adolescents and young people. A survey conducted with 515 adolescent girls and young women (AGYW) included items from the Sexual Relationship Power Scale (SRPS) adapted for South African women. Qualitative interviews with fifty AGYW aged between 15 and 24, and nine males aged 18 years and above, explored decision-making in heterosexual relationships, particularly relating to timing of sex and condom use. Theories of gendered power, sexual relationship power and sexual scripting were used in interpreting the data. Findings showed that the power AGYW have in sexual relationships determines their ability to use condoms, and that males generally control condom use and timing of sex. Both survey and interview data suggest that male control over female partners’ behaviour also extends beyond the sexual domain. Although while male power is pervasive and enduring, it is simultaneously contested and negotiated. Despite some young people believing that gendered power in decision-making should be equal, it is not always possible for AGYW to enact agency in the dyadic context of heterosexual relationships. Whilst adolescents and young people in South Africa move away from traditional cultural gendered expectations, relationship power inequity and hegemonic masculinities continue to legitimise men’s power over women, constraining the sexual agency of adolescent girls and young women and discouraging them from taking control of their own sexual interests and sexual health.

Internalized homophobia and sexual risk behavior in men who have sex with men: The mediational role of sexual self-concept

Men who have sex with men (MSM) are one of the populations most likely to be infected with human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) worldwide. Sexual risk behaviors (SRB) are the main route of HIV transmission. Among the factors associated with SRB, internalized homophobia (rejection of one’s sexuality) is a risk factor unique for MSM. However, how this factor influences SRB is not clear. Therefore, the present study attempts to clarify the mechanism of action of the relationship between internalized homophobia on SRB based on the mediating effects of sexual self-concept. A study was conducted with 124 MSM living in Chile over 18 years of age (M = 24.4 and SD = 4.19). Through path analysis, it was observed that internalized homophobia has slight inverse effects on SRBs (multiple sexual partners and sexual activity under the influence of alcohol or drugs) when the sexual self-efficacy dimension acts as a mediating variable. These findings suggest that developing sexually transmitted infections (STIs) and HIV/AIDS prevention campaigns focused on MSM must highlight the development of a healthy sexual self-concept and address self-stigma.

Differences in Sexual Behavior and Partner Notification for Sexually Transmitted Infections Between the Out of School Youth and University Students in a Peri-Urban District in South Africa-A Cross-Sectional Survey

The increase in sexually transmitted infections (STIs) in young people is a public health concern. Among those in university and out of school, different contextual factors contribute to their risky sexual behavior and increased susceptibility to STIs and HIV. There are limited comparative studies examining risky sexual behavior and partner notification (PN) between these two groups, particularly in South Africa. We investigated sexual behaviors, self-reported STI diagnosis, health seeking behavior, and preferred PN methods of university students and out of school youth. A descriptive cross-sectional survey was used using convenient sampling to select 917 students across five health sciences universities and through periodic sampling 699 out of school youth were selected from two main local shopping centers in South Africa. Descriptive statistics, bivariate and multivariable logistic analysis were performed using Stata IC version 14. More university students (71.7%) than out of school youth were in casual relationships (28.3%), with half of out of school youth being in steady relations (50.2%). Moreover, university students (65.7%) used a condom in the past 6 months compared to their counterparts (34.3%). Of the 124 youth who were diagnosed with STI in the past 12 months, majority (n = 106, 85%) were out of school youth. The probability of notifying a partner about a STI infection was 82% among university students compared to their counterparts (p = >0.05). The odds of notifying a partner was 1.79 times more for those having multiple sexual partners than those who had only one partner. Both groups preferred a face-to-face STI disclosure with partner; however, more university students (67%) preferred SMS notification than PN referral slips as compared to out of school youth (42%). Both the university students and the out of school youth engaged in risky sexual behaviors. Both groups preferred face-to-face and clinic SMS partner notifications, even though university students were in the majority. There is a need for developing health promotion scripts on disclosing STIs to sexual partners to empower the majority of the youth who prefer face-to-face PN over the prescribed methods.

Past, present, and future dimensions of socioeconomic status and sexual self-efficacy of young women during the transition into adulthood

Socioeconomic disadvantages can undermine a person's ability to control their sexual lives (sexual self-efficacy) during the transition to adulthood. Most scholarship focuses on proximate circumstances, specifically how sexual self-efficacy is a result of current socioeconomic status. Yet, this sexual agency is embedded within much longer behavioral and psychological trajectories shaped by socioeconomic contexts. Therefore, I identify a novel explanation for sexual self-efficacy by connecting it to past, present, and anticipatory future conceptualizations of young adults' socioeconomic circumstances. Drawing from 2.5 years of quarterly data from the Relationship Dynamics and Social Life Study, I found significant associations between more advantaged past, present, and anticipatory future socioeconomic circumstances and greater sexual self-efficacy during the transition to adulthood. Stage-specific dimensions of socioeconomic status (SES) followed two life course patterns (pathways and accumulation). In addition, prospective SES was found to be a more powerful predictor than childhood and current SES. As such, I encourage researchers to conceptualize socioeconomic status in life course terms to illuminate the underlying causes and consequences of varying young adulthoods.

Pilot implementation of a user-driven, web-based application designed to improve sexual health knowledge and communication among young Zambians: a mixed method study (Preprint)

Background

Digital health interventions show promise in improving the uptake of HIV services among adolescents and young people aged 15 to 24 years in sub-Saharan Africa.

Objective

This study aimed to pilot-test a theory-based, empirically grounded web-based application designed to increase condom-related knowledge, sexual and reproductive health (SRH) communication, and healthier choices among young Zambians.

Methods

We conducted a pre-post quasi-experimental evaluation of the user-driven Be in the Know Zambia (BITKZ) web application using web-based surveys and in-depth interviews (IDIs) on the phone. We enrolled participants using social media advertisements. Our final analysis set comprised 46.04% (749/1627) of participants in the intervention group (which received the BITKZ link) and 53.96% (878/1627) of participants in the comparison group (no intervention). We collected survey data at study enrollment (baseline) and 5 weeks after the first enrollment in each group. Approximately 85% (637/749) of BITKZ users completed a user survey, of whom 9.3% (59/637) participated in IDIs. We calculated the time interfacing with BITKZ using the application log files. We conducted descriptive analyses to describe baseline characteristics and the user experience. At the endline, we assessed association using a t test and adjusted logistic regression for binary outcomes and ordinal regression for ordered outcomes, conditioning on age, sex, marital status, and employment status. We used adjusted average treatment effects (aATE) to assess the effects of BITKZ intervention. We conducted rapid matrix analyses of IDI transcripts in Microsoft Excel, sorting the data by theme, gender, and experience rating.

Results

Users rated BITKZ highly (excellent: 352/609, 57.8%; good: 218/609, 35.8%). At the endline, the intervention group had a higher level of knowledge related to condoms (adjusted odds ratio [aOR]: 1.35, 95% CI 1.06-1.69) and on wearing condoms correctly (aOR: 1.23, 95% CI 1.02-1.49). Those who had full-time employment had increased odds of knowing how to wear condoms correctly (aOR: 1.67, 95% CI 1.06-2.63) compared with those who reported being unemployed, as did men when compared with women (aOR: 1.92, 95% CI 1.59-2.31). Those in the intervention group were more likely to score higher for intention to test for sexually transmitted infections (STIs; aATE 0.21; P=.01) and HIV (aATE 0.32; P=.05), as well as for resisting peer pressure (aATE 2.64; P=.02). IDIs corroborated increased knowledge on correct condom use among men and female condoms among women, awareness of STIs and testing, and resistance to peer pressure. Interviewees provided examples of more open SRH communication with partners and peers and of considering, adopting, and influencing others to adopt healthier behaviors.

Conclusions

Despite the high baseline awareness of SRH among Zambian adolescents and young people with internet access, BITKZ provided modest gains in condom-related knowledge, resistance to peer pressure, and intention to test for STIs and HIV.

Mapping evidence on predictors of adverse sexual and reproductive health outcomes among young women in South Africa: A scoping review

Background

Globally, most young women have an unmet need for sexual and reproductive health (SRH), which remains a public health concern. Identifying the predictors can help reduce this challenge.

Aim

This scoping review maps evidence on predictors of adverse sexual and reproductive health outcomes among young women in South Africa.

Method

Askey and O’Malley’s framework guided this review. We searched five databases from January 2000 to December 2020 using relevant keywords, Boolean terms and medical subject heading terms. All relevant extracted data were organised into the study themes, and summary of all the findings were reported in a narrative format.

Results

Nine studies met the inclusion criteria out of 1219 studies identified. Four out of the nine studies were national-based studies, while the remaining five studies were conducted in Western Cape (two), Eastern Cape (two) and KwaZulu-Natal (one). Out of the nine studies included, three reported predictors of unintended pregnancy, while six reported predictors of sexually transmitted infections and HIV among young women in South Africa. The most prevailing predictors of adverse sexual and reproductive health outcomes were gender-based violence and alcohol use, while other predictors were lower socio-economic status, place of residence, multiple sexual partnerships, low education and being between the ages of 20–24 years.

Conclusion

We conclude that gender-based violence and alcohol abuse are the most prevailing predictors of adverse sexual and reproductive health outcomes among young women in South Africa.

Personality traits and sexual self-efficacy in diabetic women: The mediating role of marital satisfaction and sexual function

INTRODUCTION

Although the relationship between personality traits and sexual self-efficacy has received theoretical and empirical support, there is little information on how personality affects the sexual self-efficacy of diabetic women. This study aimed to investigate the mediating role of marital satisfaction and sexual function in the relationship between personality traits and sexual self-efficacy in diabetic women.

METHODS

Using a two-stage sampling method, 410 reproductive-aged Iranian women with type 2 diabetes were recruited in this descriptive-analytical study. The participants completed self-administered questionnaires, including the Vaziri Sexual Self-Efficacy Questionnaire, the Female Sexual Function Index, ENRICH Marital Satisfaction Scale, and the Goldberg's Big Five Questionnaire. To analyze the data, structural equation modeling was employed in Amos software version 24.

RESULTS

Results indicated an acceptable fit of the model to the data. Personality trait of openness to experience was associated with sexual self-efficacy directly (β = .02, p = .030) and indirectly through the mediators of marital satisfaction (β = .06, p = .009) and sexual function (β = .18, p = .014). Furthermore, sexual function was associated with sexual self-efficacy directly (β = .50, p = .025) and indirectly through the mediator of marital satisfaction (β = .36, p = .012).

CONCLUSION

Due to the mediating role of marital satisfaction and sexual function, this study has some practical implications for improving the sexual self-efficacy of diabetic women with different personality traits.

Explaining utilization of HIV prevention and testing services among university students in Mozambique: results from a mixed methods study

BACKGROUND

In Mozambique, HIV infection disproportionately affects young adults, particularly women. Despite awareness and knowledge of HIV transmission, many university students have not received HIV testing and continue to engage in high-risk sexual behaviors, including inconsistent condom use. Further understanding of patterns of engagement with HIV prevention and testing is key to reducing HIV transmission in this at-risk population.

METHODS

This study used a sequential mixed methods approach to examine patterns of engagement and perceptions of HIV prevention and testing services among higher education students in Mozambique. Survey data were collected from a representative sample of 501 students from Universidade Eduardo Mondlane (UEM) in Maputo, Mozambique to assess the primary outcomes of 1) HIV testing within the last 12 months; and 2) condom use during last sexual encounter. We employed univariate and multivariate regression models. The survey was followed by qualitative interviews with 70 survey participants which were analyzed using an inductive, content-focused analysis to further explain and contextualize survey findings.

RESULTS

Over 85% of students reported to be sexually active, among these 74% reported condom use during their last sexual encounter, and 64.2% reported an HIV test within the past 12 months. Females were more likely to have had HIV testing in the past 12 months in comparison to their male peers (aOR 1.82, 95% CI 1.11, 2.99), but were half as likely to have used a condom with their last sexual encounter (aOR 0.52, 95% CI 0.33, 0.83), when controlling for other factors. Qualitative data suggests that these discrepancies may be explained by differential perceptions in risk and trust/mistrust, with women being more concerned about infidelity by their male partner(s) and assuming more responsibility for knowing their own serostatus. Women were also subject to negative stereotypes for possessing condoms in comparison to men, which could explain lower propensity for use.

CONCLUSION

Given gendered differences in uptake of condom use and HIV testing, and perceived HIV risk, interventions tailored specifically to male and female students may impact engagement with HIV prevention and testing and empower informed choices about sexual behaviors.

Sexual quality of life and sexual self-efficacy among women during reproductive-menopausal transition stages and postmenopause: a comparative study

Sexual self-efficacy is essential for appropriate and desirable sexual function and sexual quality of life. This study aimed to compare sexual quality of life and sexual self-efficacy among women during reproductive-menopausal transition stages and postmenopause. This was a cross-sectional study of a sample of Iranian women. The sexual quality of life-female (SQOL-F) scale was used to measure sexual quality of life (SQOL) and sexual self-efficacy (SSE) was measured using the sexual self-efficacy questionnaire (SSEQ). Data were compared between the study groups using multiple linear regression. In all 340 women (170 in reproductive-menopausal transition stages and 170 postmenopause) were studied. The mean ages of reproductive-menopausal transition stages and postmenopausal women was 30.8 ± 6.55 and 56.3 ± 3.54 respectively (P < 0.001). Sexual self-efficacy and sexual quality of life were found to be significantly higher in reproductive-menopausal transition stages compared with postmenopause women (P < 0.001 and P = 0.017 respectively). Sexual and relationship satisfaction and sexual repression subscales differed significantly between the two groups (P = 0.001 and P < 0.001 respectively). Higher sexual self-efficacy contributed to higher sexual quality of life (P < 0.0001). Reproductive-menopausal transition stages women appear to enjoy higher levels of sexual self-efficacy and sexual quality of life. Given the importance of sexual quality of life, it is recommended to pay greater attention to sexual self-efficacy among postmenopausal women in order to improve sexual quality of life in this population.

Adolescent condom use in Southern Africa: narrative systematic review and conceptual model of multilevel barriers and facilitators

BACKGROUND

Adolescent HIV and pregnancy rates in Southern Africa are amongst the highest in the world. Despite decades of sexual and reproductive health (SRH) programming targeting adolescents, recent trends suggest there is a continued need for interventions targeting condom use for this age group.

METHODS

This review synthesises evidence from qualitative studies that describe the determinants of condom use among adolescents in Southern Africa. We conducted systematic searches in four databases. Data were extracted, appraised for quality and analysed using a 'best-fit' framework synthesis approach.

RESULTS

We coded deductively findings from 23 original studies using an a priori framework and subsequently conducted thematic analysis. Synthesised findings produced six key themes relating to: 1) pervasive unequal gender norms and restrictive masculinities favouring male sexual decision-making and stigmatising condom use in committed relationships; 2) other social norms reflecting negative constructions of adolescent sexuality and non-traditional family planning; 3) economic and political barriers including poverty and a lack of policy support for condom use; 4) service-level barriers including a lack of youth-friendly SRH services and comprehensive sex education in schools; 5) interpersonal barriers and facilitators including unequal power dynamics in sexual partnerships, peer influences and encouraging condoning condom use, and inadequate communication about SRH from parents/caregivers; and 6) negative attitudes and beliefs about condoms and condom use among adolescents. A conceptual model was generated to describe determinants of condom use, illustrating individual-, interpersonal- and structural-level barriers and facilitating factors.

CONCLUSION

SRH programming targeting barriers and facilitators of condom use at multiple levels is recommended in Southern Africa. We present a multilevel integrated model of barriers and facilitators to guide adolescent SRH decision-making, programme planning and evaluation. Given the existence of multilevel barriers and facilitators, interventions should, likewise, take a multilevel approach that incorporates locally relevant understanding of the individual-, interpersonal- and structural-level barriers and facilitators to condom use among adolescents in the region.

Psychosocial Experiences of Adolescent Girls and Young Women Subsequent to an Abortion in Sub-saharan Africa and Globally: A Systematic Review

Introduction: Unmet need for contraception, unintended pregnancy, and access to safe abortion remain global challenges preventing adolescent girls and young women (AGYW) from achieving optimal reproductive health. Furthermore, AGYW face difficulties navigating sexual autonomy, lack of agency or experience negotiating sexual acts, and challenges accessing sexual health information and services. The aim of this systematic review is to assess the psychosocial outcomes of AGYW who have experienced an abortion with particular focus on sub-Saharan Africa, which bears the global burden of unintended pregnancy and risk of death due to unsafe abortion.

Materials and Methods: The systematic review was registered and used search terms to identify peer-reviewed articles relevant to “post-abortion,” “psychosocial,” “adolescent girls,” and “young women” from PubMed, Embase, PsycInfo, and Cumulative Index to Nursing and Allied Health Literature. Examples of psychosocial experiences include quality of life, stigma, and mental health outcomes. Rayyan software (Qatar, 2020) was used by two reviewers to assess the relevance of each article to psychosocial outcomes of AGYW any time after an abortion or accessing post-abortion services. Analysis was conducted with a focus on data from Africa and comparisons are made to non-African settings.

Results: A total of 2,406 articles were identified and 38 articles fit the criteria. Six selected articles were from Africa, including Ghana, Kenya, Uganda, and Zambia, and the remaining articles were from other regions. Themes around stigma, shame, and abandonment associated with the experience of abortion were prevalent in all regions. Studies of psychosocial outcomes of AGYW in sub-Saharan Africa highlight social isolation as well as learned resilience among young women who abort.

Discussion: Navigating abortion as an AGYW involves managing internalized and perceived stigma, fear of violence, secrecy, and growing resilient in order to overcome the significant barriers that society and culture place on access to an essential service in sexual and reproductive health. Post-abortion psychosocial outcomes highlight the need for support services and investigation of contexts that perpetuate and necessitate unsafe abortion. Empowerment of AGYW may present an important opportunity to build self-agency and positive coping mechanisms to withstand social pressures during stigmatizing circumstances associated with abortion.

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.

"Condoms Are Boring": Navigating Relationship Dynamics, Gendered Power, and Motivations for Condomless Sex Amongst Adolescents and Young People in South Africa

Condoms remain an important method for preventing HIV prevention and unintentional pregnancies, however their use in South Africa is sub-optimal. We analyzed survey data on reported condom use among 3009 sexually active adolescent girls and young women (AGYW) aged 15-24 years, and qualitative data from interviews and focus group discussions with 237 AGYW and 38 male peers. Our findings describe the current condom use landscape among adolescents and young people in South Africa, illustrating relationship dynamics, gendered power and notions of masculinity which influence condom negotiation and use in young heterosexual South Africans' sexual encounters.

The Power of the Shared Experience: MTN-020/ASPIRE Trial Participants' Descriptions of Peer Influence on Acceptability of and Adherence to the Dapivirine Vaginal Ring for HIV Prevention

Women are disproportionately at risk of acquiring HIV in East and Southern Africa, despite global declines in incidence. Female-initiated HIV prevention methods, like the dapivirine vaginal ring, are needed to end the HIV epidemic. In-depth interviews and focus groups retrospectively explored peer influence on acceptability of and adherence to the ring during the ASPIRE trial, a phase III placebo-controlled trial. Results were analyzed using an inductive analytic approach. Study participants (peers) of all ages and adherence groups developed important interpersonal connections and reported being more open and honest with each other than with external peers or study staff. Study peers who knew each other prior to joining appeared to have a stronger influence on each other's adherence than peers who met in the study. External peers provided primarily negative input about the ring and study, which sometimes led to ring removals. Peers' influence on each other's behavior in both prosocial and detrimental manners could have repercussions on adherence to a biomedical intervention, and consequently, individual disease risk and clinical trial outcomes. Future ring demonstration and implementation studies could use peer networks to intentionally influence uptake and adherence to the ring.

Condom use among young women who sell sex in Zimbabwe: a prevention cascade analysis to identify gaps in HIV prevention programming

INTRODUCTION

Adolescent girls and young women (AGYW), including those who sell sex in sub-Saharan Africa, are especially vulnerable to HIV. Reaching them with effective prevention is a programmatic priority. The HIV prevention cascade can be used to track intervention coverage, and identify gaps and opportunities for programme strengthening. The aim of this study was to characterise gaps in condom use and identify reasons underlying these gaps among young women who sell sex (YWSS) in Zimbabwe using data from enrolment into an impact evaluation of the DREAMS programme. DREAMS provided a package of biomedical, social and economic interventions to AGYW aged 10 to 24 with the aim of reducing HIV incidence.

METHODS

In 2017, we recruited YWSS aged 18 to 24 using respondent-driven sampling in six sites across Zimbabwe. We measured knowledge about efficacy of, access to, and effective (consistent) use of condoms with the most recent three sexual partners, separately by whether YWSS self-identified as female sex workers (FSW) or not. Among YWSS without knowledge about efficacy of, not having access to, and not effectively using condoms, we described the potential reasons underlying the gaps in the condom cascade. To identify socio-demographic characteristics associated with effective condom use, we used logistic regression modelling. All analyses were RDS-II weighted and restricted to YWSS testing HIV-negative at enrolment.

RESULTS

We enrolled 2431 YWSS. Among 1842 (76%) YWSS testing HIV-negative, 66% (n = 1221) self-identified as FSW. 89% of HIV-negative YWSS demonstrated knowledge about efficacy of condoms, 80% reported access to condoms and 58% reported using condoms consistently with the three most recent sexual partners. Knowledge about efficacy of and effective use of condoms was similar regardless of whether or not YWSS self-identified as FSW, but YWSS self-identifying as FSW reported better access to condoms compared to those who did not (87% vs 68%; age- and site-adjusted (adjOR) = 2.69; 95% CI: 2.01 to 3.60; p < 0.001). Women who reported experiencing sexual violence in the past year and common mental disorder in the past week were less likely to use condoms consistently (43% vs. 60%; adjOR = 0.49; 95% CI: 0.35 to 0.68; p < 0.001) and (51% vs. 61%; adjOR = 0.76; 95% CI: 0.60 to 0.97; p = 0.029), respectively.

CONCLUSIONS

Despite high knowledge about efficacy of and access to condoms, there remain large gaps in self-reported consistent condom use among YWSS. Addressing the structural determinants of YWSS' inconsistent condom use, including violence, could reduce this gap. YWSS who do not self-identify as FSW have less access to condoms and may require additional programmatic intervention.

No Evidence of Sexual Risk Compensation Following PrEP Initiation Among Heterosexual HIV Serodiscordant Couples in Kenya and Uganda

Recent studies among men who have sex with men suggest that sexual behaviors associated with risk of sexually transmitted infections increase following initiation of pre-exposure prophylaxis (PrEP) for HIV prevention. We used longitudinal data from HIV-uninfected participants (n = 1013) enrolled in an open-label study of PrEP delivered to Ugandan and Kenyan heterosexual HIV serodiscordant couples to understand the association between PrEP initiation and HIV risk-related sexual behaviors among these couples. In the month following PrEP initiation, the mean number of monthly sex acts within couples decreased from 7.9 to 6.9 (mean difference: - 1.1; 95% CI - 1.5, - 0.7) and the proportion of couples having condomless sex decreased from 65% to 32% (percentage point change: - 33%; 95% CI - 37%, - 30%); these behaviors then remained relatively constant over 2 years. We found no evidence of sexual risk compensation following PrEP initiation within African serodiscordant couples. However, roughly a third of couples continued to engage in condomless sex during follow up, emphasizing the importance of continued PrEP use to sustain HIV protection.

Piloting an evidence-based intervention for HIV prevention among street youth in Eldoret, Kenya

OBJECTIVES

This study presents findings from piloting an adapted evidence-based intervention, Stepping Stones and Creating Futures, to change street-connected young people's HIV knowledge, condom-use self-efficacy, and sexual practices.

METHODS

Eighty street-connected young people participated in a pre- and post-test mixed methods design in Eldoret, Kenya. The primary outcome of interest was HIV knowledge. Secondary outcomes included condom-use self-efficacy and sexual practices. Multiple linear regression models for change scores with adjustment for socio-demographic variables were fitted. Qualitative and quantitative findings are presented together, where integration confirms, expands on, or uncovers discordant findings.

RESULTS

Participants had a significant increase in HIV knowledge from pre- to post-intervention. The median HIV knowledge score pre-intervention was 11 (IQR 8-13) and post-intervention 14 (IQR 12-16). Attendance was significantly associated with HIV knowledge change scores. Qualitatively participants reported increased HIV and condom-use knowledge and improved condom-use self-efficacy and health-seeking practices.

CONCLUSIONS

Our findings support the potential for further testing with a rigorous study design to investigate how best to tailor the intervention, particularly by gender, and increase the overall effectiveness of the program.

Sexual negotiation skills and risky behavior on sexual partnerships, HIV knowledge, and risk perception among urban youth of color: A latent class analysis

Adolescents of color in urban communities are at high risk for contracting HIV, unlikely to have access to HIV testing services, or any other form of screening services. Using latent class analysis among a sample of African American/Black (48.1%) and Hispanic/Latina(o) (42%) youth (N = 668; M _age = 16.30; 51% female), this study examined the association cluster group membership, based on sexual negotiation skills and risk behavior, had on HIV knowledge, perception of risk, and the number of sexual partners. Five distinct cluster groups emerged, with significant heterogeneity observed between cluster groups on select dependent variables. A larger proportion of the study participants were in cluster groups that identified higher levels of sexual negotiation skills; however, variation was present based on risk behaviors. Results provide useful recommendations for research on HIV/AIDS and risk behaviors, as well prevention-intervention programing among urban youth of color.

Syndemic Factors Associated with Safer Sex Efficacy Among Northern and Indigenous Adolescents in Arctic Canada

BACKGROUND

Syndemic approaches explore the synergistic relationships between social and health inequities. Such approaches are particularly salient for the Northwest Territories, Canada, that experiences national social (food insecurity, intimate partner violence [IPV]) and health (sexually transmitted infections [STI]) disparities. Safer sex efficacy (SSE) includes knowledge, intention, and relationship dynamics that facilitate safer sex negotiation. We examined factors associated with SSE among NWT adolescents.

METHODS

We conducted a cross-sectional survey with a venue-based sample of adolescents aged 13-17 in 17 NWT communities from 2016 to 2017. Summary statistics and statistical comparisons were conducted, followed by crude and adjusted multivariable regression models to assess factors associated with SSE.

RESULTS

Among participants (n = 610; mean age 14.2 years [SD 1.5]; 49.5% cisgender women, 48.9% cisgender men, 1.6% transgender persons; 73.3% Indigenous), one-quarter (n = 144; 23.6%) reported food insecurity and nearly one-fifth (n = 111; 18.2%) IPV. In adjusted analyses, among young women, food insecurity (β - 1.89[CI - 2.98, - 0.80], p = 0.001) and IPV (β - 1.31[CI - 2.53, - 0.09], p = 0.036) were associated with lower SSE, and currently dating was associated with increased SSE (β 1.17[CI 0.15, 2.19], p = 0.024). Among young men, food insecurity (β - 2.27[CI - 3.39, - 1.15], p = 0.014) was associated with reduced SSE. Among sexually active participants (n = 115), increased SSE was associated with consistent condom use among young women (β 1.40[0.19, 2.61], p = 0.024) and men (β 2.14[0.14, 4.14], p = 0.036).

CONCLUSIONS

Food insecurity and IPV were associated with lower SSE-a protective factor associated with consistent condom use-underscoring the need to address poverty and violence to advance adolescent sexual health in the NWT.