Timing of orphanhood, early sexual debut, and early marriage in four sub-Saharan African countries

Risk and Protective Factors of Commercial Sexual Exploitation of Children and Adolescents in sub-Saharan Africa: A Systematic Review

Commercial sexual exploitation of children (CSEC) has emerged as a critical child protection and public health concern in recent years. While the phenomenon is prevalent globally, its impact is compounded in sub-Saharan Africa owing to the cultural and socioeconomic challenges that leave many households in the region vulnerable. The present study synthesized existing evidence using the socioecological model as a guiding framework to assess the risk and protective factors associated with CSEC in sub-Saharan Africa. A protocol for the study was published in PROSPERO (CRD42022331832) with pre-specified inclusion and exclusion criteria. Studies were screened and extracted from eight databases: PsycINFO, Scopus, Web of Science, PROQUEST (Social Science Premium), PubMed, CINAHL, EMBASE, and MEDLINE via Ovid. After an initial screening of 4,377 papers, seven studies were found eligible for the final review. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guide for reporting systematic reviews. Included studies were appraised and rated using the Cambridge Quality Checklist and GRADE. Findings revealed risk factors, including adverse childhood experience and victimization, females aged 16 years and older, school dropouts, technology influence, child and parental alcohol use, and separation from caregivers. On the other hand, protective factors such as the number of female adolescents in a household, frequent health screening in schools, children being in school, and high parental monitoring were found to be associated with a lower risk of CSEC. Based on these findings, we recommend that interventions in sub-Saharan Africa adopt a holistic approach that addresses identified risk factors while harnessing protective factors to combat CSEC effectively.

What's driving girls' adolescent marriage decline in Rakai, Uganda? The interplay between adolescent pregnancies and social determinants, 1999 - 2018

Few studies have sought to untangle the influence of social determinants and pregnancy on adolescent marriage declines. Using longitudinal data from 15- to 17-year-old girls in the Rakai Community Cohort Survey, we assessed how education, socio-economic status, orphanhood and pregnancy contributed to trends in adolescent marriage. We examined descriptive trends and logistic regressions of the associations between social determinants and adolescent marriage, and conducted causal mediation analysis to assess the extent that pregnancy mediated the effect of education on marriage. Between 1999-2018, adolescent marriages and pregnancies dropped substantially (24%-6% and 28%-8%). Girls' secondary schooling was strongly associated with lower marriage risk (aOR marriage=0.09; 95%CI=0.07-0.12), accounting for time. Lower pregnancy rates partially explained the effect of secondary schooling on lower adolescent marriage (aOR indirect effect=0.55; 95%CI=0.421-0.721). Findings affirm the importance of education in preventing adolescent marriages but call attention to the role of pregnancies in influencing adolescent marriages.

Orphanhood vulnerabilities for violence and HIV by education, sex, and orphan type among 18-24-year-old youth: findings from the 2018 Lesotho violence against children and youth survey

HIV and violence among orphans are key measures of vulnerability in low-resource settings. Although Lesotho has the second highest HIV adult prevalence rate (21.1%) in the world, and the prevalence of orphanhood (44.2%) and violence exposure (67.0%) is high, little research exist on orphanhood vulnerabilities for violence and HIV in Lesotho. Using data from 4,408 youth (18-24 years old) from Lesotho's 2018 Violence Against Children and Youth survey, a nationally representative cross-sectional household survey, the study examined associations among orphan status, violence, and HIV and assessed how associations differed by education, sex, and orphan type, using logistic regression. Orphans had higher odds of violence (aOR, 1.21; 95% CI, 1.01-1.46) and HIV (aOR, 1.69; 95% CI, 1.24-2.29). Having primary education or less (aOR, 1.43; 95% CI, 1.02-2.02), male sex (aOR, 1.74; 95% CI, 1.27-2.36), and being a paternal orphan (aOR, 1.43; 95% CI, 1.14-1.80) were significant interaction terms for violence. Orphans who completed primary school or less (aOR, 1.61; 95% CI, 1.09-2.39), female (aOR, 3.08; 95% CI, 2.14-4.42) and double orphans (aOR, 2.54; 95% CI, 1.56-4.13) had higher odds of HIV. These relationships highlight the importance of comprehensive strategies to support education and family strengthening for orphans as core violence and HIV prevention efforts.

Early Sexual Debut and Its Associated Factors Among Young Women Aged 15-24 in Mali: A Multilevel Analysis

Early sexual debut is associated with increased risk of several sexual and reproductive health problems, including unwanted pregnancies and sexually transmitted infections. Hence, determining factors that promote early sexual initiation is significant to guide policy and inform interventions aimed to promote the health of young people through to adulthood. This study examined the prevalence of early sexual debut and its associated factors among young women in Mali. Using cross-sectional nationally representative data from the 2018 Mali Demographic and Health Survey, a total of 4063 young women aged 15-24 were included in the study. Multilevel binary logistic regression analysis was done to determine the factors associated with early sexual debut. The results were presented using adjusted odds ratios (aOR) and 95% confidence intervals (CIs). The prevalence of early sexual debut in Mali was 17.8% (95% CI; 16-19.7%). Young women who attended higher school had lower odds of early sexual debut (aOR = 0.10, 95% CI; 0.01-0.82) compared to young women who had no formal education. Young women from richest households had lower odds of early sexual debut compared to those from the poorest households (aOR = 0.48, 95% CI; 0.27-0.82). Young women from households with large family size also had lower odds of experiencing early sexual debut compared to those in small family size (aOR = 0.81, 95% CI; 0.66-0.99). Furthermore, the odds of early sexual debut were lower among young women in Koulikoro (aOR = 0.59, 95% CI; 0.39-0.90), Sikasso (aOR = 0.35, 95% CI; 0.21-0.56), Segou (aOR = 0.40, 95% CI; 0.25-0.64), and Mopti (aOR = 0.44, 95% CI; 0.23-0.82) regions compared to young women in Kayes region. Higher odds of early sexual debut were found among currently employed compared to not currently employed young women (aOR = 1.74, 95% CI; 1.42-2.12) and currently married compared to not currently married young women (aOR = 4.64, 95% CI; 3.64-5.92). Young women from the Peulh ethnic groups compared to those from the Bambara ethnic groups were at a higher odds of early sexual debut (aOR = 1.43, 95% CI; 1.03-1.99). The findings suggest the need for interventions aimed at addressing early sexual debut among young women. These can include emphasizing the promotion and importance of female education, addressing the cultural practices that promote negative sexual norms/practices such as child marriages, and ensuring social change through efforts such as creating employment or economic opportunities for families.

Sexual knowledge, risk behavior, and access to reproductive health services among orphaned adolescents in Southwest Nigeria: implications for institutionalized care

Introduction

An orphan has been defined as a child under 18 years of age who has lost one or both parents to any cause. It has been reported that for every 10 Nigerian children, 1 is likely to be an orphan. Adolescents are faced with a serious challenge in meeting their reproductive health need, which oftentimes becomes overwhelming especially when they are orphaned.

Objectives

We compared institutionalized and non-institutionalized orphaned adolescents for their knowledge of sexuality, risky sexual practice, and access to reproductive health services.

Methods

The study adopted a cross-sectional descriptive study design conducted via structured, pretested, and interviewer-administered questionnaires among 205 orphaned adolescents (140 institutionalized and 65 non-institutionalized). Data were analyzed using the Statistical Product and Service Solution (SPSS version 25.0) and summarized using frequency, mean and percentages, and inferential statistics. All analyses were done at a 95% confidence interval and at a p < 0.05 level of significance.

Results

The knowledge levels of a majority of non-institutionalized respondents (73.8%) were good when compared with those in institutions (56.4%) (χ² = 5.713, p = 0.017). Institutionalized orphans displayed better sexual behavior (80.7%) than non-institutionalized respondents (64.6%) (χ² = 6.239, p = 0.011). Access to reproductive health services was found to be slightly higher among institutionalized respondents (66.4%) than among their non-institutionalized counterparts (64.6%).

Conclusion

Institutionalized and non-institutionalized orphans differed in terms of their knowledge of sexuality, sexual behavior, and risky practices, including access to reproductive health services. This study demonstrated the effectiveness of institutionalized care of orphans toward improved access to reproductive health services and good sexual practices. In the light of this, the government and relevant stakeholders should advocate the need for providing better sexuality education and understanding, make sure that access barriers for orphans are removed and orphans utilize the facilities for reproductive health that are available, and also make sure that adolescent health policies are implemented effectively.

"Our parents kiss in front of us": Reasons for early sexual debut among in-school youth in the Manzini Region in Eswatini

BACKGROUND

Early sexual debut (i.e., sex before the age of 15 years), especially if it is unprotected, may increase the risk of acquiring HIV, sexually transmitted infections, and unwanted pregnancies. We investigated the reasons for early sexual debut among in-school youth in Eswatini, a setting with high HIV incidence among youth.

METHODS

This was a qualitative, exploratory-descriptive study whereby data were collected from 81 sexually active in-school youth through seven focus group discussions (FGDs) in four purposively selected public high schools (two urban and two rural) in the Manzini region, Eswatini. In each school, except one, two FGDs (one for boys and one for girls) were conducted. Qualitative data were coded and analyzed thematically in Dedoose version 8.2.14.

RESULTS

Nearly 40% of the participants reported having initiated sexual activity before 18 years. Six major themes emerged from the data: i) Intrapersonal factors (feeling mature, religiosity, nutritional or dietary patterns); ii) Parenting and household factors (living arrangement, lack of sexuality education, working parents, negative role-modeling from adults); iii) Peer and partner pressure (pressure from friends, threats from sexual partners, intergenerational sexual partnerships and transactional sex, testing sexual prowess, desire to fit in); iv) Contextual factors (neighborhood, location); v) Mass media (cell phone ownership, social media, and television shows or movies); and vi) Cultural factors (attending traditional ceremonies, loss of cultural norms, values, and traditions, and dress code).

CONCLUSION AND RECOMMENDATIONS

The poor monitoring and negative role-modeling by elders highlight the importance of involving parents or guardians as key stakeholders when designing interventions targeting risky sexual behavior among youth. The multifaceted nature of the cited reasons for early sexual debut calls for interventions aimed at curbing risky sexual behavior to be culturally sensitive and responsive to the themes identified in this study.

Assessing the social patterning and magnitude of inequalities in sexual violence among young women in Uganda: Findings from 2016 demographic and health survey

Sexual violence (SV) is a significant global public health problem. To develop effectively targeted interventions to prevent SV and allocate resources equitably requires identifying the most vulnerable groups and the magnitude of these social inequities. However, these data are currently lacking. Using the Uganda Demographic and Health Survey, we examined SV among all young women and ever-married young women. We conducted univariate and bivariate analyses to characterise the prevalence and social patterning of SV, and then utilised the World Health Organization Health Equity Assessment Toolkit (HEAT) to assess the magnitude of social inequities in SV. At the national level, 5.5% among all young women and 20.5% of ever-married young women had experienced SV. For all young women, the largest inequities in SV were based on sub-national region of residence. Among the ever-married young women, we found profound education, wealth and place-based inequities in SV, which favoured young women with higher education, in wealthier households, and within central regions of Uganda. Our findings suggest a need for regionally targeted multi-sectoral interventions that take into consideration that multiple intersecting social dimensions such as education, poverty and the safe built environment, to address young women's risk for SV.

Global, regional, and national minimum estimates of children affected by COVID-19-associated orphanhood and caregiver death, by age and family circumstance up to Oct 31, 2021: an updated modelling study

BACKGROUND

In the 6 months following our estimates from March 1, 2020, to April 30, 2021, the proliferation of new coronavirus variants, updated mortality data, and disparities in vaccine access increased the amount of children experiencing COVID-19-associated orphanhood. To inform responses, we aimed to model the increases in numbers of children affected by COVID-19-associated orphanhood and caregiver death, as well as the cumulative orphanhood age-group distribution and circumstance (maternal or paternal orphanhood).

METHODS

We used updated excess mortality and fertility data to model increases in minimum estimates of COVID-19-associated orphanhood and caregiver deaths from our original study period of March 1, 2020-April 30, 2021, to include the new period of May 1-Oct 31, 2021, for 21 countries. Orphanhood was defined as the death of one or both parents; primary caregiver loss included parental death or the death of one or both custodial grandparents; and secondary caregiver loss included co-residing grandparents or kin. We used logistic regression and further incorporated a fixed effect for western European countries into our previous model to avoid over-predicting caregiver loss in that region. For the entire 20-month period, we grouped children by age (0-4 years, 5-9 years, and 10-17 years) and maternal or paternal orphanhood, using fertility contributions, and we modelled global and regional extrapolations of numbers of orphans. 95% credible intervals (CrIs) are given for all estimates.

FINDINGS

The number of children affected by COVID-19-associated orphanhood and caregiver death is estimated to have increased by 90·0% (95% CrI 89·7-90·4) from April 30 to Oct 31, 2021, from 2 737 300 (95% CrI 1 976 100-2 987 000) to 5 200 300 (3 619 400-5 731 400). Between March 1, 2020, and Oct 31, 2021, 491 300 (95% CrI 485 100-497 900) children aged 0-4 years, 736 800 (726 900-746 500) children aged 5-9 years, and 2 146 700 (2 120 900-2 174 200) children aged 10-17 years are estimated to have experienced COVID-19-associated orphanhood. Globally, 76·5% (95% CrI 76·3-76·7) of children were paternal orphans, whereas 23·5% (23·3-23·7) were maternal orphans. In each age group and region, the prevalence of paternal orphanhood exceeded that of maternal orphanhood.

INTERPRETATION

Our findings show that numbers of children affected by COVID-19-associated orphanhood and caregiver death almost doubled in 6 months compared with the amount after the first 14 months of the pandemic. Over the entire 20-month period, 5·0 million COVID-19 deaths meant that 5·2 million children lost a parent or caregiver. Our data on children's ages and circumstances should support pandemic response planning for children globally.

FUNDING

UK Research and Innovation (Global Challenges Research Fund, Engineering and Physical Sciences Research Council, and Medical Research Council), Oak Foundation, UK National Institute for Health Research, US National Institutes of Health, and Imperial College London.

Parental care status and sexual risk behavior in five nationally-representative surveys of sub-Saharan African nations

Background

About 10% of children worldwide do not live with either of their biological parents, and although some of these children are orphans, many have living parents. While research shows that orphaned children in Sub-Saharan Africa tend to engage in more sexual risk behaviors than their peers, possibly due to decreased parental oversight and support, it is unclear if these effects also apply to children separated from their living parents. Exploring the question of whether living without parents, regardless of whether they are deceased, is linked to greater sexual risk-taking, this study is the first, to our knowledge, to examine correlates of parental care status in a multi-country, nationally-representative analysis.

Methods

This study was a secondary analysis of the Centers for Disease Control and Prevention’s Violence Against Children Surveys from Kenya, Malawi, Tanzania, Nigeria, and Zambia. We conducted logistic regressions on N = 6770 surveys of youth aged 13 to 17 years to determine if living with their biological parents predicted the odds of engaging in risky sexual behavior, controlling for demographic factors including orphanhood. Post-hoc regressions examined specific risk behaviors.

Results

Compared to those living with both parents, youth not living with either parent had heightened odds of engaging in any sexual risk behavior, even when controlling for orphanhood (OR = 2.56, 95% CI: [1.96, 3.33]). Non-parental care predicted heightened odds of non-condom use (OR = 3.35, 95% CI: [2.38, 4.72]), early sexual debut (OR = 1.80, 95% CI: [1.31, 2.46]), and more sexual partners (β = .60, p < .001).

Conclusions

This study extends prior research linking orphanhood and sexual risk behavior, lending credence to the idea that it is not parental death, but rather parental absence, that leads to sexual risk in youth. Public health programming in Sub-Saharan Africa should consider targeting not only “orphaned youth,” but all children separated from their parents.

HIV combination prevention and declining orphanhood among adolescents, Rakai, Uganda, 2001-18: an observational community cohort study

BACKGROUND

Orphanhood increased markedly in the 1980s and 1990s in sub-Saharan Africa because of HIV-related mortality. Little is known about the contribution of HIV interventions, such as antiretroviral therapy (ART) and male medical circumcision, to more recent trends in orphanhood. In this study, we examined trends over time in maternal-only, paternal-only, and double orphanhood among adolescents before and after ART and male medical circumcision became widely available in the Rakai region of south-central Uganda. We sought to understand the association between adolescent orphanhood and HIV combination prevention (community-level ART use and prevalence of male medical circumcision). We hypothesised that increasing combination prevention, including greater use of ART and higher prevalence of male medical circumcision, would be associated with a lower probability of orphanhood.

METHODS

We examined the prevalence of orphanhood among adolescents aged 15-19 years, before and after roll-out of ART in mid-2004 and male medical circumcision in 2007, using data from 28 continuously followed communities within the Rakai Community Cohort Study. We used multinomial logistic regression with clustered SEs to estimate adjusted relative risk ratios (RRs) for maternal-only, paternal-only, and double orphanhood compared with non-orphanhood over 11 survey rounds between 2001 and 2018. Controlling for community HIV prevalence, household socioeconomic status, and adolescent age, we examined the association between community prevalence of ART use among people living with HIV and prevalence of male circumcision, including traditional circumcision. The primary outcome was orphanhood among adolescents aged 15-19 years.

FINDINGS

Orphanhood declined from 52% (920 of 1768 participants) in 2001-02 to 23% (592 of 2609 participants) by 2016-18 (p<0·0001), while double orphanhood declined from 20% (346 of 1768 participants) to 3% (86 of 2609 participants) (p<0·0001). Community prevalence of ART use among people living with HIV increased from 11% (105 of 945 participants) in 2005-06 to 78% (1163 of 1485 participants) in 2016-18. Male circumcision rates rose from 19% (147 of 790 participants) in 2005-06 to 65% (3535 of 5433 participants) in 2016-18. In the multinomial logistic regression model, a 10% increase in community prevalence of ART use was associated with a decrease in maternal orphanhood (adjusted relative RR 0·90, 95% CI 0·85-0·95) and double orphanhood (0·80, 0·75-0·85). In the post-ART era, a 10% increase in the community prevalence of male circumcision was associated with a decrease in paternal orphanhood (2005-18, adjusted relative RR 0·92, 0·87-0·97) and double orphanhood (0·91, 0·85-0·98).

INTERPRETATION

Widespread availability and uptake of HIV combination prevention was associated with marked reductions in orphanhood among adolescents. Reductions in orphanhood promise improved health and social outcomes for young people.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institute of Allergy and Infectious Diseases, the National Institute of Mental Health, and the Division of Intramural Research of the National Institute for Allergy and Infectious Diseases.

Projecting the Impact of the COVID-19 Pandemic on Child Marriage

PURPOSE

The study projects the potential impact of COVID-19 on child marriage in the five countries in which the burden of child marriage is the largest: Bangladesh, Brazil, Ethiopia, India, and Nigeria.

METHODS

The projected impact of the pandemic on child marriage is based on a Markov model. A review of empirical and theoretical literature informed construction and parameter estimates of five pathways through which we expect an elevated marriage hazard: death of a parent, interruption of education, pregnancy risk, household income shocks, and reduced access to programs and services. Models are produced for an unmitigated scenario and a mitigated scenario in which effective interventions are applied to reduce the impact.

RESULTS

The total number of excess child marriages in these five countries could range from 3.5 million to 4.9 million in the unmitigated scenario and from 1.8 million to 2.7 million in the mitigated scenario. The elevated risk compared with the baseline projection would continue until 2035.

CONCLUSIONS

These projections represent the impact in five countries that account for 50% of child marriages globally, implying that if similar patterns hold, we might expect the number of excess child marriages due to the pandemic to reach 7 million to 10 million globally. These estimates are necessarily subject to high levels of uncertainty because of limited evidence on the impacts in relation to child marriage and for parameter estimates. It will likely take years to understand the full impact of the pandemic. Despite these limitations, the potential for harm is unquestionably large.

The Intersection of Alcohol Use, Gender Based Violence and HIV: Empirical Findings among Disadvantaged Service-Seeking Youth in Kampala, Uganda

The SAVA syndemic is frequently used to describe the co-occurrence of HIV, gender-based violence (GBV), and substance use. In this study we determine the extent to which the typologies of the SAVA syndemic can be described and utilized for intervention strategies among youth living in the slums of Kampala, Uganda. We analyzed the “Kampala Youth Survey 2014,” a cross-sectional survey conducted in the spring of 2014, consisting of a convenience sample (N = 1134) of urban youth (12–18 years of age). Descriptive statistics were computed for hypothesized risk factors and demographic variables among the 8 typologies of GBV, HIV, and alcohol use. Multinomial logistic regression was conducted to determine statistically significant correlates with each typology. The overall prevalence of GBV was 31.7%, whereas the overall prevalence of alcohol use in the past 12 months was 31.2%. HIV-Positive youth comprised 10.5% of the total sample. Females comprised the majority of the typology with no SAVA components compared to males (55% vs. 45%, respectively), as well as the SAVA syndemic typology (GBV + HIV + ALC +) (58% vs. 42%, respectively). Engaging in commercial sex work (36%), witnessing parental abuse (61%), and depression/suicidality (81%) were all highly prevalent among youth in the SAVA syndemic typology (GBV, HIV, and alcohol use). Sex work and observing parental abuse were associated with the SAVA syndemic typology in the multivariable model. In our study, alcohol rarely coexisted without GBV among the typologies. Therefore, prevention efforts including structural interventions may be particularly warranted in vulnerable populations to address alcohol use, which may directly or indirectly impact GBV and HIV.

Child marriage among Somali refugees in Ethiopia: a cross sectional survey of adolescent girls and adult women

BACKGROUND

Despite child marriage receiving increased attention over the past two decades, research on child marriage in humanitarian settings remains scarce. This study sought to quantify child marriage among Somali adolescent girls residing in Kobe refugee camp in Ethiopia and to identify its correlates and consequences.

METHODS

A cross-sectional survey was conducted using multi-stage cluster-based sampling with probability proportional to size. We randomly sampled households that have at least one female aged 15-49 and at least one adolescent female aged 10-19. In addition to calculating the proportion of girls married under age 18, we used survival methods - namely Kaplan Meier graphs and Cox proportional hazard models - to identify risk factors associated with child marriage in this context. We also used descriptive statistics to describe marital age preferences among female adults and presented measures of important sexual and reproductive health indicators among married adolescent girls.

RESULTS

A total of 603 adult women were surveyed and a household roster was created with information on 3319 household members, of whom 522 were adolescent girls aged 15-19. Of those, 14% were currently married (95% Confidence Interval [CI] 0.11-0.18), and 11% were ever married under age 18 (95% CI 8-15%). Several variables were found to be significantly associated with hazard of child marriage including schooling, sex and employment status of head of household, as well as number of girls under age 18 in the childhood home.. Adult women tended to incorrectly identify minimum legal age at marriage and preferred low marital age for boys and girls - particularly in households of child brides. Among married adolescent girls, contraceptive use was very low (11%; 95% CI 4.94-22.40), and early childbearing was common (60%; 95% CI 45.56-72.89).

CONCLUSIONS

This research contributes to the evidence base on child marriage in humanitarian settings. Insights generated from this study have the potential to inform programs and interventions aiming to prevent and mitigate the impacts of this harmful practice.

20 Years of the Evidence Base on What Works to Prevent Child Marriage: A Systematic Review

PURPOSE

This review assesses evaluations published from 2000 to 2019 to shed light on what approaches work, especially at scale and sustainably, to prevent child marriage in low- and middle-income countries.

METHODS

We conducted a search of electronic databases and gray literature and evaluated the methodological quality and risk of bias of included studies.

RESULTS

A total of 30 studies met the inclusion criteria. Interventions that support girls' schooling through cash or in-kind transfers show the clearest pattern of success in preventing child marriage, with 8 of 10 medium-high quality studies showing positive results. Although limited in number, five studies on favorable job markets and targeted life skills and livelihoods training show consistent positive results. Comparatively, asset or cash transfers conditional on delaying marriage show success only among two of four evaluations, and the three studies on unconditional cash transfers for poverty mitigation show no effect. Findings also show a low success rate for multicomponent interventions with positive results in only one of eight medium-high quality studies. Further, single component interventions were much more likely to be at scale and sustainable than multicomponent interventions.

CONCLUSIONS

These results indicate that enhancement of girls' own human capital and opportunities is the most compelling pathway to delaying marriage. In contrast, low rates of success, scale-up, and sustainability of multicomponent programs requires reconsideration of this approach.

Sexual and reproductive rights violations at sexual debut of male and female adolescents in Ghana

OBJECTIVE

To examine the social and ethical challenges in enforcing sexual and reproductive rights of male and female adolescents abused at sexual debut in Ghana.

METHODOLOGY

This was a secondary analysis of cross-sectional survey data on 278 sexually experienced male and female teenagers from 12 communities selected by cluster random sampling in the Ejisu-Juben district. We extracted relevant data from a 2009 academic thesis project involving 481 respondents. We assessed differences between sexual debut experiences of males and females using Pearson's chi-square and ANOVA tests. P-values ≤0.05 were considered significant.

RESULTS

Mean ages at sexual debut for males and females were 16.05 ± 1.8 and 15.98 ± 1.47 years respectively (P=0.719). Adolescents of both sexes experienced defilement and forced sexual debut; similar proportions had early sexual debut. Females who had early sexual debut were more likely than their older counterparts to have low educational attainment and induced abortion.

CONCLUSIONS

Many male and female adolescents experience sexual and reproductive rights breaches at sexual debut. Prevailing circumstances hinder optimization of sexual and reproductive rights of juveniles in Ghana. We recommend making clear provisions for young persons in the law on sexual offences in the criminal code to facilitate development of interventions to improve access to justice for offenders and victims.

Divorce, living arrangements, and material well-being during the transition to adulthood in rural Malawi

In this paper, we use longitudinal data to investigate how parental death and divorce influence young women's own experience of divorce in Malawi, a setting where women marry relatively early and unions are fragile. We find that maternal death and parental divorce are positively associated with divorce for young women but, after controlling for socio-demographic and marital characteristics, only the association with maternal death remains statistically significant. Maternal and paternal death are both strongly associated with women's post-divorce living arrangements, which in turn affects their material well-being. This finding suggests that divorcing at a young age shapes the subsequent life chances of women; although some women return to their parental home and may have the opportunity to reset the transition to adulthood, other women begin their 20s as head of their own household and with considerable material disadvantage.

Estimating abortion incidence among adolescents and differences in postabortion care by age: a cross-sectional study of postabortion care patients in Uganda

Objectives:

To provide the first estimate of adolescents’ abortion incidence in Uganda and to assess differences in the abortion experiences and morbidities of adolescent and nonadolescent postabortion care (PAC) patients.

Study design:

We used the age-specific Abortion Incidence Complications Method, drawing from three surveys conducted in Uganda in 2013: a nationally representative Health Facilities Survey (n=418), a Health Professionals Survey (n=147) and a Prospective Morbidity Survey of PAC patients (n=2169). Multivariable logistic and Cox proportional hazard models were used to compare adolescent and nonadolescent PAC patients on dimensions including pregnancy intention, gestational age, abortion safety, delays to care, severity of complications and receipt of postabortion family planning. We included an interaction term between adolescents and marital status to assess heterogeneity among adolescents.

Results:

Adolescent women have the lowest abortion rate among women less than 35 years of age (28.4 abortions per 1000 women 15–19) but the highest rate among recently sexually active women (76.1 abortions per 1000 women 15–19). We do not find that adolescents face greater disadvantages in their abortion care experiences as compared to older women. However, unmarried PAC patients, both adolescent and nonadolescent, have higher odds of experiencing severe complications than nonadolescent married women.

Conclusions:

The high abortion rate among sexually active adolescents highlights the critical need to improve adolescent family planning in Uganda. Interventions to prevent unintended pregnancy and to reduce unsafe abortion may be particularly important for unmarried adolescents. Rather than treating adolescents as a homogenous group, we need to understand how marriage and other social factors shape reproductive health outcomes.

Implications:

This paper provides the first estimate of the adolescent abortion rate in Uganda. Studies of adolescent abortion and reproductive health must account for sexual activity and marital status. Further, interventions to address unintended pregnancy and unsafe abortion among unmarried women of all ages in Africa should be a priority.

RELATIONSHIP BETWEEN ORPHANHOOD STATUS, LIVING ARRANGEMENTS AND SEXUAL DEBUT: EVIDENCE FROM FEMALES IN MIDDLE ADOLESCENCE IN SOUTHERN AFRICA

This study examined the relationship between orphanhood status, living arrangements and sexual debut. The study is important in the context of southern Africa, where a substantial number of children live apart from their parents because the parent is dead or living elsewhere, and where female adolescents face disproportionate sexual and reproductive health risks. Data for female adolescents were taken from Demographic and Health Surveys conducted in seven southern African countries. Unadjusted and adjusted hazard ratios of sexual debut were estimated using Cox Proportional Hazard models. The results from multivariate analyses showed that non-co-residence with biological parents was significantly associated with higher risk of sexual debut in five of the seven countries. Using pooled data, the results showed that father absence was associated with higher risk of sexual debut - whether the father was deceased or living elsewhere. Interventions to delay sexual debut among female adolescents should seek to promote father-adolescent co-residence and improve access to education.

Why Are Orphaned Adolescents More Likely to Be HIV Positive? Distinguishing Between Maternal and Sexual HIV Transmission Using 17 Nationally Representative Data Sets in Africa

PURPOSE

Why do orphans have higher rates of HIV infection than nonorphaned peers? Research consistently assumes that orphans acquire HIV primarily through sexual behavior, but infections may instead be due to maternal transmission. Although these two pathways have very different implications for HIV programs and policies, their relative contribution has not been previously examined. In this research, we compare the contribution of maternal and sexual transmission to HIV infection among orphans in Africa.

METHODS

We use Demographic and Health Survey data for 21,463 women and 18,359 men from 17 countries. We propose a conceptual framework linking orphanhood to HIV, and use mediation analysis and structural equation modeling to compare the potential contribution of maternal transmission (measured through direct pathways from orphanhood to HIV) and sexual transmission (measured through reports of risky sexual behavior) to orphan HIV infection.

RESULTS

Our results suggest that maternal transmission is the predominant pathway of HIV infection among orphaned adolescents: there is strong evidence for a direct pathway from maternal (odds ratio [OR]: 2.45; 95% confidence interval [CI]: 1.72-3.51 for females and OR: 2.45; 95% CI: 1.53-3.90 for males) and double orphanhood (OR: 2.69; 95% CI: 1.97-3.66 and OR: 2.53; 95% CI: 1.68-3.82, respectively) to HIV; greater excess HIV risk in maternal versus paternal orphans. The contribution of sexual behavior is largely not significant. We do not observe correspondingly high orphan disparities in other sexually transmitted diseases.

CONCLUSIONS

Maternal transmission is a more likely explanation than sexual transmission for heightened HIV infection among orphans. These results suggest that programs designed to address HIV infection among adolescents should focus on reducing maternal transmission and on identifying and testing undiagnosed HIV among orphans.

Maternal union instability and childhood mortality risk in the Global South, 2010-14

Efforts to improve child survival in lower-income countries typically focus on fundamental factors such as economic resources and infrastructure provision, even though research from post-industrial countries confirms that family instability has important health consequences. We tested the association between maternal union instability and children's mortality risk in Africa, Latin America and the Caribbean, and Asia using children's actual experience of mortality (discrete-time probit hazard models) as well as their experience of untreated morbidity (probit regression). Children of divorced/separated mothers experience compromised survival chances, but children of mothers who have never been in a union generally do not. Among children of partnered women, those whose mothers have experienced prior union transitions have a higher mortality risk. Targeting children of mothers who have experienced union instability-regardless of current union status-may augment ongoing efforts to reduce childhood mortality, especially in Africa and Latin America where union transitions are common.

Psychosocial health concerns among service-seeking orphans in the slums of Kampala

Orphans have many unmet needs. The purpose of the current study is to briefly examine the psychosocial correlates linked to being an orphan among service-seeking youth in the slums of Kampala in order to provide guidance for service provision for youth. The current analysis is based on a cross-sectional survey conducted in 2011 which consisted of a convenience sample of youth living in the slums (ages 14-24) attending a drop-in center, Uganda Youth Development Link (UYDEL). Bivariate and multivariable analyses were used to determine psychosocial correlates with being an orphan. Among the youth participants (n=444), 23.65% (n=105) reported both of their parents died, 37.39% (n=166) reported one parent died, and the remaining 38.96% (n=173) reported both of their parents are living. In the multivariable model, reporting both parents dead was significantly associated with being a female (AOR: 2.79, 95% CI: 1.27, 6.12) and parental abuse (AOR: 0.14; 95% CI: 0.07, 0.27). A large percentage of youth living in the slums of Kampala are orphans. This study presents important findings that inform interventions and policies that can be targeted toward the dire needs of youth living in the streets and slums of Kampala.

Father's Migration and Leaving the Parental Home in Rural Mozambique

Migration is an increasingly common demographic phenomenon and has important implications for the well-being of family members left behind. Although extensive research has examined the impact of parental labor migration on school-age children, less is known about its effect on adolescents. In this study, the authors used longitudinal survey data collected in rural Mozambique (N = 515) to assess the association between father's migration and adolescent children's leaving the parental home, an important component of the transition to adulthood. The results showed that father's migration delays home-leaving for adolescent girls and that these effects are not mediated by school enrollment. The results for boys were inconclusive. The authors also found that remittances and longer durations of paternal migration were negatively associated with the transition out of the home. On the basis of the findings, they argue that father's migration delays girls' marriage.

Influence of school support on early marriage experiences and health services utilization among young orphaned women in Zimbabwe

School support programs reduce school dropout, early marriage, and early pregnancy for a majority of young orphaned women. We used a mixed-methods approach to examine why these programs are less effective for a significant minority by exploring their influence on marriage and health services utilization. Participants were from a randomized controlled trial testing school support as HIV prevention. Half as many intervention as control participants had been married; married intervention participants had 1 more year of education compared with married control participants. Receiving school support did not appear to improve health-related factors. Pregnancy was among the most common reasons for marriage across both groups. The greatest benefit of school support appears to be in delaying marriage and pregnancy while increasing educational attainment.

Are adolescent orphans more likely to be HIV-positive? A pooled data analyses across 19 countries in sub-Saharan Africa

BACKGROUND

Despite extensive resources and numerous programmes directed towards orphans in sub-Saharan Africa, evidence of their disadvantage is surprisingly limited. While initial research suggests that orphans are at greater risk of being HIV-positive, the evidence is limited in geographic scope.

METHODS

To rigorously test disparities in HIV prevalence related to orphanhood and parental HIV status in sub-Saharan Africa, we used Demographic and Health Survey data from 19 countries in sub-Saharan Africa. We conducted pooled multilevel logistic regression on adolescents aged 15-17 years with HIV test results (N=22 837 girls and 20 452 boys).

RESULTS

Regardless of their gender, orphans who lost their mother, lost both parents or had an HIV-infected mother were two to three times more likely to test positive for HIV infection (ORs 1.87-3.17). The loss of a father was also associated with HIV infection risk for females, but of slightly lower magnitude (OR 1.63).

CONCLUSIONS

To better inform interventions, future research is needed to quantify the relative contribution of perinatally-acquired and sexually-acquired infections, and to investigate the specific mechanisms that may account for disparities in the latter. In the meantime, programmes serving HIV-infect adults as well as those serving orphaned and vulnerable children should invest in family-based HIV testing in order to identify adolescents in need of treatment.

Fertility among orphans in rural Malawi: challenging common assumptions about risk and mechanisms

CONTEXT

Although a substantial literature suggests that orphans suffer disadvantage relative to nonorphaned peers, the nature of this disadvantage and the mechanisms driving it are poorly understood. Some evidence suggests that orphans experience elevated fertility, perhaps because structural disadvantage leads them to engage in sexual risk-taking. An alternative explanation is that orphans intentionally become pregnant to achieve a sense of normality, acceptance and love.

METHODS

Data from the 2006 wave of the Malawi Longitudinal Study of Families and Health on 1,033 young adults aged 15-25 were used to examine the relationship of maternal and paternal orphanhood with sexual risk indicators and desired and actual fertility. Regression analyses were used to adjust for covariates, including social and demographic characteristics and elapsed time since parental death.

RESULTS

Twenty-six percent of respondents had lost their father and 15% their mother. Orphanhood was not associated with sexual risk-taking. However, respondents whose mother had died in the past five years desired more children than did those whose mother was still alive (risk differences, 0.52 among women and 0.97 among men). Actual fertility was elevated among women whose father had died more than five years earlier (0.31) and among men whose mother had died in the past five years (1.06) or more than five years earlier (0.47).

CONCLUSION

The elevations in desired and actual fertility among orphans are consistent with the hypothesis that orphans intentionally become pregnant. Strategies that address personal desires for parenthood may need to be part of prevention programs aimed at orphaned youth.