Does schooling protect sexual health? The association between three measures of education and STIs among adolescents in Malawi

Meta-analysis of the effectiveness of educational programs about HIV prevention on knowledge, attitude, and behavior among adolescents

The prevalence of human immunodeficiency virus (HIV) among adolescents is on the rise due to a lack of comprehensive knowledge, leading to suboptimal attitudes and behaviors, which emphasizes the critical need for targeted interventions. The aim of this review study was to evaluate the effectiveness of educational interventions for HIV prevention among adolescents by assessing their impact on knowledge, attitude, and behavior. A systematic review of seven databases: PubMed, Science Direct, Cochrane, JSTOR, Embase, Scopus, and EBSCO were identified, and 14 eligible randomized controlled trials published until June 2023 were included. Two independent authors assessed quality appraisal using the Risk of Bias 2.0. Outcomes were measured using the standard mean difference (SMD) with random effects model and a 95% confidence interval. Subgroup analyses and meta-regression were performed to explore heterogeneity. The results showed significant improvements in participants' knowledge (SMD: 1.13, 95%CI: 0.78-1.49), behavior intentions (SMD: 1.22, 95%CI: 0.37-2.07), and attitude (SMD: 0.48, 95%CI: 0.02-0.95) after receiving HIV prevention education programs. Interventions grounded in theoretical principles and incorporating technology, group settings, and audio-visual aids were found to be effective in enhancing knowledge of HIV prevention and promoting behavioral intentions. Peer-led education positively impacted both knowledge and attitude. Moreover, excluding parents from these programs was identified as a crucial factor in improving adolescents' knowledge of HIV prevention. In conclusion, educational programs focused on HIV effectively enhance adolescents' knowledge, attitudes, and behavioral intentions among adolescents. Professionals planning interventions should consider these impactful components in designing comprehensive strategies.

Protective factors for adolescent sexual risk behaviours and experiences linked to HIV infection in South Africa: a three-wave longitudinal analysis of caregiving, education, food security, and social protection

BACKGROUND

Structural interventions are endorsed to enhance biomedical and behavioural HIV prevention programmes for adolescents. Aiming to inform future interventions, we evaluated longitudinal associations between six protective factors that link closely to existing structural HIV prevention interventions, and five sexual risk behaviours for HIV transmission in a cohort of adolescents in South Africa.

METHODS

We used three rounds of data between 2014-2018 on 1046 adolescents living with HIV and 473 age-matched community peers in South Africa's Eastern Cape (Observations = 4402). We estimated sex-specific associations between six time-varying protective factors - number of social grants, education enrolment, days with enough food, caregiver supervision, positive caregiving, and adolescent-caregiver communication; and five HIV risk behaviours - multiple sexual partners, transactional sex, age-disparate sex, condomless sex, and sex on substances. HIV risk behaviours were analysed separately in multivariable random effects within-between logistic regression models that accounted for correlation of repeated observations on the same individual. We calculated prevalence ratios (PR), contrasting adjusted probabilities of HIV risk behaviours at 'No' and 'Yes' for education enrolment, and average and maximum values for the other five protective factors.

RESULTS

The sample mean age was 15.29 (SD: 3.23) years and 58% were girls. Among girls, within-individuals, increases from mean to maximum scores in positive caregiving were associated with lower probability of transactional sex (PR = 0.79; 95%CI = 0.67-0.91); in caregiver supervision were associated with lower probability of transactional sex (PR = 0.75; 95%CI = 0.66-0.84), and age-disparate sex (PR = 0.84; 95%CI = 0.73-0.95); in adolescent-caregiver communication were associated with higher probability of transactional sex (PR = 1.70; 95%CI = 1.08-2.32); and in days with enough food at home were associated with lower probability of multiple sexual partners (PR = 0.89; 95%CI = 0.81-0.97), and transactional sex (PR = 0.82; 95%CI = 0.72-0.92). Change from non-enrolment in education to enrolment was associated with lower probability of age-disparate sex (PR = 0.49; 95%CI = 0.26-0.73). Between-individuals, relative to mean caregiver supervision scores, maximum scores were associated with lower probability of multiple sexual partners (PR = 0.59; 95%CI = 0.46-0.72), condomless sex (PR = 0.80; 95%CI = 0.69-0.91), and sex on substances (PR = 0.42; 95%CI = 0.26-0.59); and relative to non-enrolment, education enrolment was associated with lower probability of condomless sex (PR = 0.59; 95%CI = 0.39-0.78). Among boys, within-individuals, increases from mean to maximum scores in positive caregiving were associated with lower probability of transactional sex (PR = 0.77; 95%CI = 0.59-0.96), and higher probability of condomless sex (PR = 1.26; 95%CI = 1.08-1.43); in caregiver supervision were associated with lower probability of multiple sexual partners (PR = 0.73; 95%CI = 0.64-0.82), transactional sex (PR = 0.63; 95%CI = 0.50-0.76), age-disparate sex (PR = 0.67; 95%CI = 0.49-0.85), and sex on substances (PR = 0.61; 95%CI = 0.45-0.78), and in days with enough food at home were associated with lower probability of transactional sex (PR = 0.91; 95%CI = 0.84-0.98).

CONCLUSION

Effective structural interventions to improve food security and education enrolment among adolescent girls, and positive and supervisory caregiving among adolescent girls and boys are likely to translate into crucial reductions in sexual risk behaviours linked to HIV transmission in this population.

School attendance and sexual and reproductive health outcomes among adolescent girls in Kenya: a cross-sectional analysis

BACKGROUND

Given the high burden of adverse sexual and reproductive health outcomes (SRH) and low levels of school attendance among adolescent girls in Kenya, this study sought to elucidate the association between school attendance and SRH outcomes among adolescent girls in Homa Bay and Narok counties.

METHODS

This study uses baseline quantitative data from the mixed-methods evaluation of the In Their Hands (ITH) program which occurred between September to October 2018 in Homa Bay and Narok counties. In total, 1840 adolescent girls aged 15-19 years participated in the baseline survey, of which 1810 were included in the present analysis. Multivariable logistic regression models were used to assess the association between school attendance (in- versus out-of-school) and ever having sex, condom use during last sex, and ever pregnant, controlling for age, orphan status, income generation, religion, county, relationship status, and correct SRH knowledge.

RESULTS

Across the 1810 participants included in our study, 61.3% were in-school and 38.7% were out-of-school. Compared to adolescent girls who were in-school, those out-of-school were more likely (AOR 5.74 95% CI 3.94, 8.46) to report ever having sex, less likely (AOR: 0.21, 95% CI 0.16, 0.31) to have used a condom during their last sexual intercourse, and more likely (AOR: 6.98, 95% CI 5.04, 9.74) to have ever been pregnant.

CONCLUSIONS

School attendance plays an integral role in adolescent girls' SRH outcomes, and it is imperative that policy actors coordinate with the government and community to develop and implement initiatives that support adolescent girls' school attendance and education.

The development of adolescent agency and implications for reproductive choice among girls in Zambia

Background

A substantial proportion of adolescent girls in Zambia lack the ability to decide their reproductive future. We examined the role of agency in early and unwanted adolescent childbearing.

Methods

Using latent transition analysis, we characterized a multi-dimensional profile of adolescent agency annually over a four-year period. We investigated the influence of early life access to resources and time-varying predictors (school retention, violence, early marriage and unwanted/mistimed pregnancy and childbearing) on agency profile membership as well as transitions in agency status over time.

Results

Four agency profiles were identified, with differences by age cohort (10–14 years vs. 15–19 years). Three profiles identified in both age cohorts were: Low-moderate agency, Self-assured gender conformers, and High agency. Unique to younger girls was the Gender conscious, low belief in abilities status, while among older girls was the Self-assured selective gender conscious status. While younger girls were likely to transition to the highest agency status over time, high agency membership declined among older girls. Early life resources were associated with augmented agency while exposure to negative events, particularly early marriage, were associated with detraction from high agency status. Girls who expressed high self-efficacy but gender-conforming values were most at risk of early marriage and unwanted/mistimed pregnancy while High agency girls were at comparatively low risk.

Conclusions

Results show agency is dynamic but less mutable with increasing age. Early adolescent strategies which address inequitable gender norms and limit early marriage, may guard against losses to agency which contribute to unwanted fertility outcomes.

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Findings support agency as a dynamic, multidimensional construct in adolescence.

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In general, access to resources promoted agency across dimensions.

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Time-varying events, particularly early marriage, detracted from agency status.

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Agency dimensions combined in unique ways with distinct implications for early/unwanted fertility.

Education, Child Marriage, and Work Outcomes Among Young People in Rural Malawi

PURPOSE

School attainment has increased and gender gaps narrowed in many settings without commensurate declines in child marriage and with persistent gender gaps in work. This paper investigates whether child marriage changes young people's ability to translate education into paid work in rural Malawi.

METHODS

Using data from a longitudinal study of adolescents in rural Malawi followed through young adulthood, individual-level fixed-effects regressions that account for time-invariant factors were used to investigate differences in child marriage status on the extent to which grade attainment, reading, and numeracy skills lead to higher participation in paid work and reduce participation in unpaid work. Gender differences in these relationships were explored.

RESULTS

Prevalence of child marriage is high for young women (53% vs. 6% for men), and participation in paid work low (7% vs. 42% for men). Attainment of six grades among young married women and nine grades among young married men was associated with paid work irrespective of child marriage. Reading with comprehension in two languages was associated with paid work for young men married as adults (coefficient = .27, p ≤ .01). Numeracy was associated with paid work among unmarried young women (coefficient = .04, p ≤ .01). Negative associations between grade attainment and unpaid work were found for young women married at ages 16-17 and unmarried, while positive associations were found for young unmarried men.

CONCLUSIONS

The relationship between education and work among young people in Malawi is compromised by related challenges of poor learning and continued high levels of child and young adult marriage.

The relationship between educational attainment and hiv prevalence among pregnant women attending antenatal clinics in six states of India: Sentinel surveillance from 2010 to 2017

Background

The National AIDS Control Programme provides support for HIV prevention services to pregnant women attending antenatal care (ANC) clinics through testing, kit delivery, counseling, and treatment services. The impact of HIV prevention programs in the general population is assessed by monitoring trends and progress made against the HIV epidemic among pregnant women attending ANC clinics during HIV Sentinel Surveillance (HSS).

Objectives

This study explores the association of HIV risk with educational attainment for Indian women across different age groups from four repeated cross-sectional surveillance of antenatal clinics in six states from the southern part of India.

Methods

Data collected from the repeated cross-sectional HSS conducted during the year 2010-2011 (baseline) and 2016-2017 (end line) across six states were used for this analysis. The total sample size was 94,266 at baseline and 99,434 at end line. In the logistic regression analysis, we focused on identifying the association between educational attainment, and HIV prevalence adjusting for period effects across two age groups for women attending ANC clinics.

Results

The analysis showed an inverse association between education and HIV risk across different age groups. The age-segregated and survey period adjusted analysist showed that for older women (≥25 years), the HIV risk in 2010 ranged from 41% lower among 5^th Grade to 80% lower among postgraduates than illiterates. For the <25 year age group, this risk of HIV for pregnant women was 35% to 49% lower.

Conclusions

To ensure an effective national response to control and prevent HIV infection, policymakers in India need to focus on ≥25 years' age group of women attending ANC for designing educational interventions to reduce HIV risk as well as the prevention of mother-to-child transmission of HIV.

Explaining the Education-Health Gradient in Preventing STIs in Andean Peru: Cognitive Executive Functioning, Awareness and Health Knowledge

CONTEXT

Little is known about the pathways mediating the relationship between education and health. It is widely assumed that formal schooling leads to awareness of health risks (e.g., STIs) and, in turn, to adoption of preventive behavior (e.g., condom use); however, evidence supporting this mechanism has been limited.

METHODS

Survey data were collected in 2010 from a sample of 247 adults aged 30-62 living in an isolated Andean district of Peru; these individuals had widely varying exposure to schooling, and their community had recently experienced elevated risks of STIs. Structural equation modeling was used to estimate the degree to which schooling is associated with cognitive resources, STI awareness and sexual health knowledge, and how these jointly are associated with ever-use of condoms.

RESULTS

Thirty-two percent of respondents reported ever-use of condoms. One additional year of schooling was associated with a 2.7-percentage-point increase in the probability of condom use, after adjustment for covariates. The pathway between education and condom use was mediated by cognitive executive functioning (CEF) skills (0.26 standard deviations), STI awareness (0.09) and sexual health knowledge (0.10); CEF skills were associated with condom use both directly and indirectly, through STI awareness and sexual health knowledge, and accounted for two-thirds of the education-condom use gradient.

CONCLUSIONS

The relationship between education and STI prevention may be more complex than is often assumed and is mediated by CEF skills, STI awareness and sexual health knowledge. Studies should examine whether STI prevention interventions are more effective if they enhance cognitive skills used to translate information into protective behaviors.

The Influence of Schooling on the Stability and Mutability of Gender Attitudes: Findings From a Longitudinal Study of Adolescent Girls in Zambia

PURPOSE

Inequitable gender norms are thought to harm lifelong health and well-being. We explore the process of gender attitude change and the role of schooling in shifting or reinforcing gender norms among adolescent girls in Zambia.

METHODS

We used longitudinal data collected from unmarried, vulnerable girls (aged 10-19 years) as part of the Adolescent Girls Empowerment Program. We conducted random effects multinomial logistic regression to determine whether schooling-related factors were associated with shifts in adolescent girls' gender attitudes across three survey rounds and explored whether these relationships varied by age.

RESULTS

Mean gender attitude scores at the aggregate level remained stable over time among rural girls and improved slightly for urban girls. At the individual level, about half the girls had relatively unchanged scores, whereas the other half shifted to higher or lower scores between rounds. Rural and urban girls currently attending school were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable. Educational attainment was not associated with shifts in gender attitudes among rural girls. Urban girls with higher educational attainment were more likely to have relatively stable equitable attitudes than stable, inequitable attitudes, or attitudes that shifted to inequitable or more equitable.

CONCLUSIONS

Patterns of gender attitude stability and change differed more for urban girls than rural girls and varied by age and schooling-related factors. In general, schooling appears to be an institutional lever that holds promise for shifting gender attitudes toward greater equality. Our study highlights the importance of looking longitudinally at the effects of social context and reinforces calls for targeted, context-specific interventions for this age group.