The impact of the Adolescent Girls Empowerment Program (AGEP) on short and long term social, economic, education and fertility outcomes: a cluster randomized controlled trial in Zambia

Effectiveness of a resilience, gender equity and mental health group intervention for young people living in informal urban communities in North India: a cluster randomized controlled trial

BACKGROUND

Mental health problems are the leading cause of disease burden among young people in India. While evidence shows that youth mental health and resilience can be improved with group interventions in school settings, such an intervention has not been robustly evaluated in informal urban settings.

OBJECTIVE

This study aimed to evaluate whether the Nae Disha 3 group intervention could improve youth resilience, mental health and gender equal attitudes among disadvantaged young people from low-income urban communities in India.

METHODS

This cluster randomised controlled trial used an analytic sample of 476 adolescents and young adults aged 11-25 years from randomised clusters in urban Dehradun, India. The 251 intervention group participants were 112 boys and 139 girls, and the 225 young people in the wait-control group were 101 boys and 124 girls. Five validated tools measuring resilience gender equity and mental health were filled by participants at three different points in time.

RESULTS

Difference in difference (DiD) analysis at T2 showed that scores improved among girls in intervention group, for adjusted model, resilience (DiD = 4.12; 95% CI: 2.14, 6.09) and among boys, for resilience (DiD = 5.82; 95% CI: 1.57, 9.74).

CONCLUSIONS

The Nae Disha 3 intervention among disadvantaged urban youth moderately improved resilience for both young men and women, though it did not significantly impact mental health, self-efficacy, or gender-equal attitudes. We establish potential merit for this approach to youth mental health but recommend further research to examine active ingredients and the ideal duration of such group interventions.

Is adolescent health a priority program? A qualitative study on the stunting prevention program in Gunungkidul, Yogyakarta, Indonesia

OBJECTIVES

In Indonesia, the Weekly Iron Folic Acid (WIFA) supplementation program has been running since 2016 to prevent anemia and stunting in the future. The Healthy Adolescents Stunting Prevention program (Remaja Sehat Cegah Stunting, known as the "RS Centing" program) in Gresik Regency, Indonesia, has been effective in increasing adolescent understanding of stunting prevention. The prevalence of stunting in Gunungkidul Regency remains high and has reached 22.2 %, exceeding the national target of 14 %. This study aims to analyze whether adolescent health is a priority in the stunting prevention program in Gunungkidul Regency.

METHODS

This study uses a qualitative method with a phenomenological approach. Data were collected through in-depth interviews and a focus group discussion (FGDs) with participants selected by purposive sampling. The respondents in this study comprised 10 officials from the PKPR (adolescents health care services), the local health department, and the Satgas stunting (stunting task force).

RESULTS

The results of the study revealed that three main themes emerged from the in-depth interviews and the FGD, namely: (1) Program implementation; (2) barriers to program implementation; and (3) suggestions.

CONCLUSIONS

Program implementation is still constrained by the lack of adequate funding and human resources, as well as weak monitoring, evaluation, and program continuity.

How do gender transformative interventions reduce adolescent pregnancy in low- and middle-income countries: a realist synthesis

Background

Adolescent pregnancy poses a significant health challenge for girls aged 15-19 in low- and middle-income countries. While gender transformative interventions (GTIs) aim to address this issue, a substantial research gap exists concerning the underlying mechanisms contributing to their success. This study employs a realist synthesis approach to systematically investigate how, why, for whom, and in what contexts GTIs effectively reduce adolescent pregnancy.

Methods

A five-step realist review examined literature from four databases and five organisational repositories, including published and grey literature. The review focused on GTIs for adolescents aged 10-19 in low- or middle-income countries. Narrative synthesis and realist analysis were used to develop context-mechanism-outcome configurations.

Results

The review analysed 28 documents covering 14 interventions and proposing eight programme theories across three settings. In the school, creating a supportive environment to foster positive social norms and providing a safe space was emphasised. Comprehensive sexual health education to promote critical thinking, knowledge retention, and goal setting was one of the key strategies. Empowering boys to adopt positive gender norms for behaviour change was also identified. In the health facility, providing a safe, supportive, and confidential environment for accessing services, as well as using digital health apps to empower adolescents in sexual reproductive health, were key. In the community, empowering girls through life skills and economic support and involving community members to foster stronger interpersonal bonds and a gender-positive environment were highlighted. These interventions led to increased contraceptive use, delayed marriage, and reduced adolescent pregnancy.

Conclusion

This realist synthesis proposes eight nuanced programme theories of successful GTIs, providing essential insights for developing, implementing, and improving future programmes. These findings offer a foundation for effective strategies to mitigate adolescent pregnancy in diverse socio-cultural contexts.

Registration

PROSPERO: CRD42023398293.

Adolescent marriage, maternity, and limited access to education in 106 countries: Bayesian analysis of prevalence, trend, and prediction

Effectively addressing issues related to adolescent children being out of school and vulnerable to harmful practices is essential for advancing SDG 3-5. This study aimed to assess the prevalence, trends, and future projections of adolescent child vulnerability. We analyzed data from 386 datasets spanning 106 countries, encompassing 1,292,258 adolescent girls year 1990- 2023. Bayesian methods were employed to estimate prevalence, trends, and future projections. Sub-Saharan Africa and Latin America & the Caribbean showed a high prevalence of child marriage and early childbirth. Overall, these indicators decreased from 1990 to 2023, but recent years have seen increases in some countries. Projections for 2025 to 2030 suggest that changes in rates will occur in some countries, while most are expected to remain stable. The disparities are in underscore ongoing public health challenges. These issues risk derailing progress towards SDG targets of eliminating harmful practices and ensuring universal access to quality education. Addressing these challenges demands coordinated efforts from countries and the global community to implement effective interventions and strategies.

Post-intervention gendered impacts and moderating factors of a government cash plus intervention for adolescents in Tanzania

Introduction

Reducing poverty (including multidimensional poverty) and gender inequality can improve social development outcomes. Studies have sought to understand how poverty reduction and intersectoral programming targeted to adolescents can facilitate safe transitions to adulthood among adolescents. However, most intersectoral interventions for adolescents to date have been implemented by non-governmental actors with limited generalizability and potential for scale-up. In the current study, we examine 22-month post intervention impacts of the "plus components" of a cash plus intervention, Ujana Salama (Swahili for "Safe Youth") targeted to adolescents ages 14-19 years (males and females) in households participating in a government social protection program in Tanzania. The government-implemented cash plus intervention, comprised of livelihoods and life skills training, a productive grant, mentoring, and linkages to adolescent-friendly health services, was implemented over 18 months in 2018 and 2019.

Methods

Using a cluster randomized controlled trial, we estimated post-intervention impacts in 2021 on the following domains: relationships, modern contraception, health seeking and HIV knowledge and risk, psychosocial outcomes and attitude, and violence. We further examined whether contextual factors, including gender norms and quality of health services, moderated these post-intervention impacts.

Results

Few impacts found at earlier rounds were still evident post-intervention. Exceptions include protective impacts on lifetime sexual violence risk among females and increases in sexual and reproductive health services utilization among males. Moreover, newly detected adverse impacts on mental health contrasted with earlier protective impacts.

Conclusion

While external factors such as lengthy delays of cash transfer payments to adolescents' households and the COVID-19 pandemic may have mitigated the potential for sustained impacts of this intervention, findings suggest that future programs may need to provide different combinations of programming, provide support longer-term, or intervene at more levels of the social ecological model to influence many of the outcomes examined and to effect more lasting change.

Prevalence, risk factors and interventions to prevent violence against adolescents and youths in Sub-Saharan Africa: a scoping review

BACKGROUND

Violence is a pervasive human rights issue with public health consequences affecting adolescents and young people. This review aimed to describe the scope of existing research on the prevalence of violence and risk factors as well as intervention programmes targeted at adolescents and youths in Sub-Saharan Africa.

METHOD

An eleven-year search from 2014 to 2024 was conducted for peer-reviewed research articles, irrespective of their quality, on the prevalence of violence and risk factors as well as interventions on the types of violence against adolescents and youths in all SSA countries using PubMed, Google Scholar, Google search, African Index Medicus and direct searches of reference list of pertinent journal articles. Publications in English or translated to English were included. The methodological framework was described by Arksey and O'Malley and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines was used to describe the review.

RESULT

Hundred and three studies were identified across 33 out of the 46 Sub-Saharan African countries with the majority of articles emanating from Ethiopia. The prevalence studies consisted of 71 articles, sexual coercion was reported in 52 articles with a moderate number of studies focusing on physical or corporal punishment (21) and emotional violence (27). Also, the male gender was grossly understudied in the various forms of violence. The primary interventions on violence were categorized using the socio-ecological framework and the least implemented intervention based on peer-reviewed articles was at the policy level. The effectiveness of the interventions was reported in some studies while others noted no significant reduction in violence.

CONCLUSION

The findings show there is a modest volume of peer-reviewed articles on prevalence of violence mostly in the dimension of sexual violence. Also, the interventions that addressed the policy level are limited and scale-up of focus on the level is imperative in SSA.

Gender-transformative HIV and SRHR programme approaches for adolescents and young people: a realist review to inform policy and programmes

INTRODUCTION

Gender inequalities continue to drive new HIV and sexually transmitted infections (STIs) at rates too high to achieve global goals. In high HIV-burden jurisdictions, this is particularly true for adolescent girls and young women at disproportionate risk, while social and systemic barriers also impede the engagement of young men and gender minorities with health services. We sought evidence of approaches to promote sexual and reproductive health (SRH) outcomes by addressing gender transformation and removing structural barriers that broadly limit prospects for adolescents and young people.

METHODS

We conducted a realist review to identify HIV and SRH-focused interventions with gender transformative mechanisms. Eligible interventions sought to achieve HIV/STI prevention, sexual behaviour or pregnancy outcomes among young people by enhancing agency, resources and social norms supportive of gender transformation. We developed a programme theory to guide the data extraction and synthesis and categorised interventions by strategy, recording impacts on health and/or gender-related outcomes.

RESULTS

We identified 33 eligible interventions, representing diverse programme strategies and outcomes. Most interventions used a combination approach, with economic strengthening as the most common central strategy (n=13), followed by community-based mobilisation for norms change (n=7), then school-based educational curricula (n=6). The majority (n=24) achieved 'dual effects', that is, positive effects on both health and gender-related outcomes; 15 with dual effects specific to HIV prevention. Few evaluations measured or found impacts on HIV/STI incidence. 12 reported positive impacts on condom use alongside improved agency or gender norms.

CONCLUSIONS

Youth-focused interventions that address context-specific economic and social determinants of HIV and SRH risk have proliferated recently, with encouraging impacts on both HIV/SRH and gender-related outcomes. This bodes well for empowering strategies to achieve HIV and STI reduction targets among adolescents and young people, and broader SRH goals. However, most interventions prioritise individual rather than structural change; impeding their 'gender transformative' potential.

'You are looked upon as a luxury tool': Young Tanzanian women's perception of community norms supporting partner violence during transactional sex (kudanga)

This paper explores the definition of, and perceived community attitudes, toward kudanga, a Swahili street term for a type of transactional sex practised in Dar es Salaam, Tanzania. Rooted in economic and gender disparity, transactional sex increases adolescent girls' and young women's vulnerability to HIV and gender-based violence. We sought to understand perceived community attitudes about kudanga, and how the internalisation of norms surrounding gender-based violence relate to the experiences of young women who practise kudanga. Using qualitative data from focus group discussions with 37 young women, we found that community perceptions of kudanga were largely negative, and those who engaged in it were looked down upon and despised. Violence and lack of sexual agency were normalised when doing kudanga. However, young women understood kudanga to often be their best option to obtain economic stability and felt strongly that those who practised kudanga should not be stigmatised. Our research provides further evidence that transactional sex exists on a continuum and highlights the importance of reducing community stigma surrounding transactional sex as a means of decreasing risk of HIV and gender-based violence for young women. To our knowledge, this article is the first to explore kudanga.

Gender-Transformative Interventions for Young Adolescents: What Have We Learned and Where Should We Go?

PURPOSE

To identify the key facilitators and barriers to implementing gender-transformative interventions among young adolescents (ages 10-14 years) in low- and middle-income countries and provide recommendations for guiding the next generation of intervention approaches.

METHODS

A scoping review of the literature was first conducted to identify articles that contained the following inclusion criteria: (1) included 10- to 14-year-olds as a target population; (2) addressed gender inequality as a pathway to improved health; (3) implemented in a low- and middle-income country context; and (4) published between 2010 and 2023. Two databases, Scopus and PubMed, were searched as well as the gray literature. Additionally, to collect critical reflections on gender-transformative interventions, two expert meetings and four key informant interviews were conducted.

RESULTS

Among the 59 articles which were retrieved and reviewed, 30 were evaluations of specific gender-transformative interventions and the remaining 29 included literature reviews or critical reflections of gender-transformative interventions. Three key themes emerged from our analysis: (1) tailoring approaches for both boys and girls; (2) incorporating multilevel approaches; and (3) engaging multiple sectors, such as health, education, and sports. In each theme, we highlight the primary challenges as well as promising practices for implementation.

DISCUSSION

Efforts should continue unpacking the characteristics of intervention approaches where positive results are found among boys and girls in both implementation and impact. In terms of both multilevel and multisectoral programming, more evidence is needed to help identify which intervention activities should target which populations at what levels and how much to achieve positive impacts among young adolescents.

Are social protection and food security accelerators for adolescents to achieve the Global AIDS targets?

INTRODUCTION

Without effective, scalable interventions, we will fail to achieve the Global AIDS Targets of zero AIDS-related deaths, zero HIV transmission and zero discrimination. This study examines associations of social protection and food security among adolescents living with HIV (ALHIV), with three Global AIDS Targets aligned outcomes: antiretroviral treatment (ART) adherence and viral suppression, HIV transmission risk behaviour and enacted stigma.

METHODS

We conducted three study visits over 2014-2018 with 1046 ALHIV in South Africa's Eastern Cape province. Standardized surveys provided information on receipt of government-provided cash transfers and past-week food security, alongside self-reported ART adherence, sexual debut and condom use, and enacted HIV-related stigma. Viral load (VL) data was obtained through data extraction from patient files and linkage with National Health Laboratory Service test results (2014-2020). We used a multivariable random-effects regression model to estimate associations between receiving government cash transfers and food security and three outcomes: ART adherence and viral suppression, delayed sexual debut or consistent condom use and no enacted stigma. We tested moderation by sex and age and fitted disaggregated models for each outcome.

RESULTS

Among the 933 ALHIV completing all three study visits, 55% were female, and the mean age was 13.6 years at baseline. Household receipt of a government cash transfer was associated with improvements on all outcomes: ART adherence and viral suppression (aOR 2.03, 95% CI 1.29-3.19), delayed sexual debut or consistent condom use (aOR 1.62, 95% CI 1.16-2.27) and no enacted stigma (aOR 2.33, 95% CI 1.39-3.89). Food security was associated with improvements on all outcomes: ART adherence and viral suppression (aOR 1.73, 95% CI 1.30-2.30), delayed sexual debut or consistent condom use (aOR 1.30, 95% CI 1.03-1.64) and no enacted stigma (aOR 1.91, 95% CI 1.32-2.76). Receiving both cash transfers and food security increased the probability of ART adherence and VL suppression from 36% to 60%; delayed sexual debut or consistent condom use from 67% to 81%; and no enacted stigma from 84% to 96%.

CONCLUSIONS

Government-provided cash transfers and food security, individually and in combination, are associated with improved outcomes for ALHIV aligned with Global AIDS Targets. They may be important, and underutilized, accelerators for achieving these targets.

Use of contraceptives, empowerment and agency of adolescent girls and young women: a systematic review and meta-analysis

INTRODUCTION

The evidence on adolescent empowerment, which involves access to personal and material resources for reproductive autonomy and economic equity, is limited. This systematic review assesses the use of contraceptives in empowering and strengthening the agency and vice versa among adolescents and young women.

METHODS

We ran the searches in six electronic databases: Cochrane Database of Systematic Reviews (CDSR) and the Cochrane Central Register of Controlled Trials (CENTRAL), The Campbell Library, MEDLINE (PubMed), EMBASE, Cumulated Index to Nursing and Allied Health Literature (CINAHL) and Web of Science. The methodological quality of studies was assessed using ROBINS-I and ROB-II tools as appropriate. Meta-analysis was performed using Review Manager 5.4.

RESULTS

Forty studies that assessed the impact of empowerment on contraceptive use were included. Of these, 14 were non-randomised studies for intervention (NRSIs), and the remaining 26 were randomised controlled trials (RCTs). The results from RCTs show a significant effect of the sexual and reproductive health empowerment in increasing ever use of contraception (RR 1.22; 95% CI 1.02, 1.45; n=9; I²=77%; GRADE: Very Low), and insignificant effect on unprotected sex (RR 0.97; 95% CI 0.74, 1.26; n=5; I²=86%; GRADE: Very Low) and adolescent pregnancy (RR 1.07; 95% CI 0.61, 1.87; n=3; I²=36%; GRADE: Very Low). None of the studies assessed impact of contraceptive use on empowerment.

CONCLUSIONS

Empowerment of adolescents and young women certainly improves contraceptive use in the immediate or short-term period. However, more robust studies with low risk of bias, longer-term outcomes, and impact of contraceptive use on empowerment and agency-strengthening are required. To increase contraceptive use uptake, tailored policies and delivery platforms are necessary for youth in low- and middle-income countries.

Intersectionality, gender norms, and young adolescents in context: a review of longitudinal multicountry research programmes to shape future action

Discriminatory gender norms can intersect and interact with other dimensions of discrimination-such as age, race, ethnicity, disability, education status, and sexual orientation-to shape individuals' experiences and impact their health and wellbeing. This interaction is referred to as intersectionality. Although the theory has been in circulation since the late 1980s, only recently has it gained traction in low-income and middle-income settings, and it has yet to fully penetrate global research on adolescence. The social and structural intersectional drivers of adolescent health and wellbeing, particularly during early adolescence (age 10-14 years), are poorly understood. The evidence base for designing effective interventions for this formative period of life is therefore relatively small. In this Review, we examine how gender intersects with other forms of disadvantage in the early stages of adolescence. Analysing data from hybrid observation-intervention longitudinal studies with young adolescents in 16 countries, our aim is to inform the health and wellbeing of girls and boys from a range of social contexts, including in conflict settings. Adolescents' perceptions about gender norms vary by context, depend on individual opinion, and are shaped by socioecological drivers of gender inequalities in health. Shifting those perceptions is therefore challenging. We argue for the importance of applying an intersectionality lens to improve health and wellbeing outcomes for young adolescents and conclude with five practical recommendations for programme design and research.

Integrated Theory-Based Health and Development Interventions for Young People: A Global Scoping Review

BACKGROUND

Most health and developmental issues affecting young people are interrelated. However, few interventions address multiple behavioral domains simultaneously or are based on theories that encompass a holistic perspective of youth development.

AIM

The purpose of this scoping review was to identify and describe the range of theory-based, multibehavioral health interventions aimed at improving two or more of the following behavioral youth outcomes: (1) sexual and reproductive health; (2) education and employment; (3) violence; and (4) substance use.

METHODS

Interventions conducted worldwide and published in English or Spanish between January 2000 and July 2020 were identified using four databases: PubMed, PsycINFO, LILACS, and SciELO.

RESULTS

A total of 11,084 articles were identified, of which 477 were retrieved and assessed for eligibility. Twenty-three articles (evaluating 21 interventions) ultimately met the inclusion criteria. Most interventions were conducted in the United States and addressed two behavioral domains of interest, although seven interventions incorporated three domains, and one incorporated all four. Substance use was the most common domain (16 interventions) but only in the United States/Canada, followed by sexual and reproductive health (14 interventions). All produced significant improvement in at least one outcome or for at least one subgroup of youth. The most common theoretical foundations were positive youth development and social learning theory.

CONCLUSION

Integrated interventions that are theory based and evidence informed can support positive development and empower youth to make healthy decisions. Further efforts are needed to address structural and policy issues that affect young people's developmental opportunities and health outcomes.

Systematic review of cash plus or bundled interventions targeting adolescents in Africa to reduce HIV risk

BACKGROUND

HIV remains a leading cause of death for adolescents and young people aged 10-24 years. HIV prevention requires multisectoral approaches that target adolescents and young people, addressing HIV risk pathways (e.g., transactional sex, gender-based violence, and school attendance) through bundled interventions that combine economic strengthening, health capabilities, and gender equality education. However, best practices are unknown because evidence on multisectoral programming targeted to adolescents and combining these components has not been systematically reviewed.

METHODS

We conducted a systematic review to summarize the evidence on bundled interventions combining health and economic strengthening components for adolescents and young people and their effects on HIV/STI incidence and risk factors. We included studies from Africa published between 2005 and 2023, combining at least one economic strengthening and one health component, directed toward adolescents and young people aged 10-24 years. Included studies measured programmatic impacts on primary outcomes: HIV and STI incidence/prevalence; and mediators as secondary outcomes: sexual behaviours, sexual and reproductive health, school attendance, health-seeking behaviours, and violence. We conducted key word searches in PubMed, EMBASE, and Web of Science, imported titles/abstracts from the initial search, and reviewed them using the inclusion criteria. Full texts of selected articles were reviewed and information was extracted for analysis. Findings from the full texts identified were summarized.

RESULTS

We reviewed 58 studies, including 43 quantitative studies and 15 qualitative studies, evaluating 26 unique interventions. A majority of studies reviewed were conducted in Eastern and Southern Africa. Interventions reviewed showed a greater number of significant results in improving economic outcomes; mental health and psychosocial outcomes; sexual and reproductive health knowledge and services utilization; and HIV prevention knowledge and testing. They showed fewer significant results in improving outcomes related to HIV incidence/prevalence; sexual risk behaviours; gender-based violence; gender attitudes; education; STI incidence, prevalence and testing; and sexual debut.

CONCLUSIONS

Our review demonstrated the potential for bundled, multisectoral interventions for preventing HIV and facilitating safe transitions to adulthood. Findings have implications for designing HIV sensitive programmes on a larger scale, including how interventions may need to address multiple strata of the social ecological model to achieve success in the prevention of HIV and related pathways.

HIV-sensitive social protection for unemployed and out-of-school young women in Botswana: An exploratory study of barriers and solutions

Promotive social protection programs aim to increase income and capabilities and could help address structural drivers of HIV-vulnerability like poverty, lack of education and gender inequality. Unemployed and out-of-school young women bear the brunt of HIV infection in Botswana, but rarely benefit from such economic empowerment programs. Using a qualitative exploratory study design and a participatory research approach, we explored factors affecting perceived program benefit and potential solutions to barriers. Direct stakeholders (n = 146) included 87 unemployed and out-of-school young women and 59 program and technical officers in five intervention districts. Perceived barriers were identified in 20 semi-structured interviews (one intervention district) and 11 fuzzy cognitive maps. Co-constructed improvement recommendations were generated in deliberative dialogues. Analysis relied on Framework and the socioecological model. Overall, participants viewed existing programs in Botswana as ineffective and inadequate to empower vulnerable young women socially or economically. Factors affecting perceived program benefit related to programs, program officers, the young women, and their social and structural environment. Participants perceived barriers at every socioecological level. Young women's lack of life and job skills, unhelpful attitudes, and irresponsible behaviors were personal-level barriers. At an interpersonal level, competing care responsibilities, lack of support from boyfriends and family, and negative peer influence impeded program benefit. Traditional venues for information dissemination, poverty, inequitable gender norms, and lack of coordination were community- and structural-level barriers. Improvement recommendations focused on improved outreach and peer approaches to implement potential solutions. Unemployed and out-of-school young women face multidimensional, interacting barriers that prevent benefit from available promotive social protection programs in Botswana. To become HIV-sensitive, these socioeconomic empowerment programs would need to accommodate or preferentially attract this key population. This requires more generous and comprehensive programs, a more client-centered program delivery, and improved coordination. Such structural changes require a holistic, intersectoral approach to HIV-sensitive social protection.

Lessons Learned From the Implementation of a School-Based Sexual Health Education Program for Adolescent Girls in Cape Town, South Africa

Comprehensive sexual education (CSE) is an important approach for health promotion dissemination in schools, particularly when delivered in participatory ways that are sport based, peer or near-peer led, and include concepts of gender and power dynamics. Sufficient attendance at CSE sessions is critical to ensure content exposure and build potential for impact. This article details implementation lessons from the delivery of an after-school, near-peer-led CSE program called SKILLZ during a cluster randomized controlled trial among 40 secondary schools in Cape Town, South Africa. SKILLZ is an evidence-based program previously implemented in similar contexts. Attendance in this study was suboptimal (less than 50%) despite qualitative indications of high acceptability and extensive efforts to adapt implementation and boost attendance. Qualitative and quantitative data gathered during anonymous surveys, in-depth interviews, and focus group discussions with participants with high and low attendance records, near-peer coaches, and school staff from both cohorts indicated that poor attendance could be attributed to several factors. Program adaptations, such as delivering difficult-to-access health services before participants attended the SKILLZ program rather than after, may have reduced the incentive for young people to attend the program. Practical barriers to attendance were identified, including security concerns, competing priorities, and unfamiliarity with after-school programming culture in this setting. Community engagement and acceptability of sexual education programs for adolescents alone may be insufficient to ensure program uptake and engagement.

Does girls' empowerment predict contraceptive intentions? Evidence from a survey of secondary school girls in Northwest Nigeria

In sub-Saharan Africa, women's empowerment has been linked to contraceptive use, but little is known about whether girls' empowerment affects contraceptive intentions, particularly in more traditional societies where early marriage and childbearing are common. Drawing on a survey of 240 secondary school students in Kebbi State, Northwest Nigeria, in September-November 2018, we examined whether dimensions of girls' empowerment (academic self-mastery, perceived career feasibility, progressive gender norms, and marriage autonomy) and family planning indicators (knowledge, desired family size) were associated with future intentions to use family planning. We found that half of the girls had no intention to use contraception, and only one-fourth intended to use contraception for both delaying/spacing and stopping pregnancies. Multivariate analysis revealed that one dimension of empowerment (perceived career feasibility) and family planning knowledge were significantly associated with intentions. These results suggest that girls perceive contraceptive use as risky, and require contraceptive knowledge and an anticipated career to overcome their trepidation. To increase girls' intentions to use contraceptives, it is vital that they receive comprehensive sexuality education and career counselling.

Can cash transfer interventions increase contraceptive use and reduce adolescent birth and pregnancy in low and middle income countries? A systematic review and meta-analysis

Becoming pregnant and giving birth under the age of 20 is associated with a range of adverse social, socioeconomic and health outcomes for adolescent girls and their children in Low and middle income countries. Cash transfers are an example of a structural intervention that can change the local social and economic environment, and have been linked with positive health and social outcomes across several domains. As part of a wider review of structural adolescent contraception interventions, we conducted a systematic review on the impact of cash transfers on adolescent contraception and fertility. Fifteen studies were included in the review with eleven studies providing evidence for meta-analyses on contraception use, pregnancy and childbearing. The evidence suggests that cash transfer interventions are generally ineffective in raising levels of contraceptive use. However, cash transfer interventions did reduce levels of early pregnancy (OR 0.90, 95% CI 0.81 to 1.00). There was suggestive evidence that conditional, but not unconditional, cash transfers reduce levels of early childbearing. Given that much of the evidence is drawn from interventions providing cash transfers conditional on school attendance, supporting school attendance may enable adolescent girls and young women to make life choices that do not involve early pregnancy.

Effectiveness of conditional cash transfers, subsidized child care and life skills training on adolescent mothers' schooling, sexual and reproductive health, and mental health outcomes in Burkina Faso and Malawi: the PROMOTE Project pilot randomized controlled trial protocol

INTRODUCTION

Girls' and women's health as well as social and economic wellbeing are often negatively impacted by early childbearing. In many parts of Africa, adolescent girls who get pregnant often drop out of school, resulting in widening gender inequalities in schooling and economic participation. Few interventions have focused on education and economic empowerment of adolescent mothers in the region. We aim to conduct a pilot randomized controlled trial in Blantyre (Malawi) and Ouagadougou (Burkina Faso) to examine the acceptability and feasibility of three interventions in improving educational and health outcomes among adolescent mothers and to estimate the effect and cost-effectiveness of the three interventions in facilitating (re)entry into school or vocational training. We will also test the effect of the interventions on their sexual and reproductive health (SRH) and mental health.

INTERVENTIONS

The three interventions we will assess are: a cash transfer conditioned on (re)enrolment into school or vocational training, subsidized childcare, and life skills training offered through adolescent mothers' clubs. The life skills training will cover nurturing childcare, SRH, mental health, and financial literacy. Community health workers will facilitate the clubs. Each intervention will be implemented for 12 months.

METHODS

We will conduct a baseline survey among adolescent mothers aged 10-19 years (N = 270, per site) enrolled following a household listing in select enumeration areas in each site. Adolescent mothers will be interviewed using a structured survey adapted from a previous survey on the lived experiences of pregnant and parenting adolescents in the two sites. Following the baseline survey, adolescent mothers will be individually randomly assigned to one of three study arms: arm one (adolescent mothers' clubs only); arm two (adolescent mothers' clubs + subsidized childcare), and arm three (adolescent mothers' clubs + subsidized childcare + cash transfer). At endline, we will re-administer the structured survey and assess the average treatment effect across the three groups following intent-to-treat (ITT) analysis, comparing school or vocational training attendance during the intervention period. We will also compare baseline and endline measures of SRH and mental health outcomes. Between the baseline and endline survey, we will conduct a process evaluation to examine the acceptability and feasibility of the interventions and to track the implementation of the interventions.

DISCUSSION

Our research will generate evidence that provides insights on interventions that can enable adolescent mothers to continue their education, as well as improve their SRH and mental health. We aim to maximize the translation of the evidence into policy and action through sustained engagement from inception with key stakeholders and decision makers and strategic communication of research findings. Trial registration number AEARCTR-0009115, May 15, 2022.

Intervention Approaches to Address Intimate Partner Violence and HIV: a Scoping Review of Recent Research

PURPOSE OF REVIEW

Intimate partner violence (IPV) remains a critical challenge to HIV prevention and treatment efforts across the globe. We examined recently published (January 9, 2017-January 9, 2023) integrated behavioral interventions designed to address IPV and HIV across the care continuum.

RECENT FINDINGS

Fifteen studies (involving n = 10,947 participants) met the inclusion criteria for this review. Majority (n = 13) of studies focused on IPV and HIV prevention whereas two studies addressed IPV and HIV care engagement among women living with HIV. Ten studies were conducted on the African continent representing 5 countries. Most interventions (n = 11) focused on individual-level outcomes among cisgender women although two involved male partners. About half of the interventions reviewed (n = 8) showed effectiveness on both IPV and HIV outcomes compared to control groups. Integrated HIV/IPV interventions are needed to address the synergistic nature of these epidemics among marginalized populations. Future studies should focus on developing and implementing strength-based interventions among people living with HIV, men, transgender people, and Black women in the USA. Additionally, researchers and program managers should consider addressing structural and internalized stigma as potential behavioral mechanisms for improving health among people simultaneously experiencing or at-risk for HIV and IPV.

Balancing Quality, Intensity and Scalability: Results of a Multi-level Sexual and Reproductive Health Intervention for Very Young Adolescents in Kinshasa

PURPOSE

In addition to the rapid physical and cognitive transformations very young adolescents (VYAs) experience between ages 10-14, gender and social norms internalized during this period have long-term implications as adolescents become sexually active. This age presents critical opportunities for early intervention to promote gender-equitable attitudes and norms for improved adolescent health.

METHODS

In Kinshasa, DRC, Growing Up GREAT! implemented a scalable approach to engage in- and out-of-school VYAs, caregivers, schools, and communities. A quasi-experimental study evaluated the outcomes of sexual and reproductive health (SRH) knowledge, assets and agency, and gender-equitable attitudes and behaviors among VYA participants. Ongoing monitoring and qualitative studies provided insights into implementation challenges and contextual factors.

RESULTS

Results show significant improvement in SRH knowledge and assets such as caregiver connectedness, communication, and body satisfaction among the intervention group. The intervention was also associated with significant improvements in gender-equitable attitudes related to adolescents' household responsibilities and decreased teasing and bullying. Intervention effects on awareness of SRH services, body satisfaction, chore-sharing, and bullying were stronger for out-of-school and younger VYAs, suggesting the intervention's potential to increase positive outcomes among vulnerable adolescents. The intervention did not shift key gender norm perceptions assessed. Implementation research suggests design decisions made to increase the intervention's scalability necessitated reductions in training and program dosing that may have affected results.

DISCUSSION

Results affirm the potential of early intervention to increase SRH knowledge, assets and gender-equitable behaviors. They also highlight the need for more evidence on effective program approaches and segmentation for shifting VYA and SRH norms.

A Systematic Review of Interventions to Reduce Gender-Based Violence Among Women and Girls in Sub-Saharan Africa

Sub-Saharan Africa (SSA) is disproportionately affected by gender-based violence (GBV). We systematically reviewed English language, peer-reviewed, quantitative evaluations of interventions to reduce violence against women and girls (VAWG) in SSA that involved a comparison group and reported GBV incidence, or GBV-related attitudes, norms and symptoms as an outcome. We identified 53 studies published between January 2000 and April 2020 and classified these programmes from an empowerment perspective using the following categories: social, economic, combined social and economic and psychological empowerment interventions. Our review found social empowerment interventions effective for transforming gender attitudes and norms and reducing GBV, and psychological empowerment interventions effective for managing GBV-related symptoms. The evidence for economic empowerment interventions was equivocal. Key elements of successful interventions included participatory group learning, engaging male partners, engaging the community, longer duration and utilising existing platforms. Promising approaches for further research included gender specific programmes, psychological empowerment interventions delivered by lay workers and psychological empowerment interventions focused on GBV reduction.

Prevalence and determinants of adolescent childbearing: comparative analysis of 2017-18 and 2014 Bangladesh Demographic Health Survey

Objectives

Bangladesh has one of the highest adolescent childbearing rates in South Asia, which prevent women from realizing their full potential in life. This study aimed to compare the prevalence and determinants of adolescent childbearing in Bangladesh using data from the 2014 and 2017-18 Bangladesh Demographic and Health Survey (BDHS).

Methods

Nationally representative surveys of respondents were selected using a two-stage sampling process. The study recruited 2,023 and 1,951 ever-married women aged 15-19 from 2014 and 2017-18 BDHS surveys, respectively, from rural and urban settings from all eight geographic divisions of Bangladesh. Univariate and multivariate logistic regression models were fit to determine the factors associated with adolescent childbearing.

Result

The adolescent childbearing prevalence rate was 30.8% in 2014 BDHS and 27.6% in 2017-18 BDHS. Marriage at age 13 years or less also reduced significantly in 2017-18 compared to 2014 (12.7% vs. 17.4%, respectively). Significantly higher odds of adolescent childbearing were found in 2014 among women in the Sylhet Division (adjusted odds ratio (AOR) = 3.0; 95% confidence interval (CI): 1.6-6.1) and the Chittagong Division (AOR = 1.8; 95% CI: 1.8-2.7) compared to the Barisal Region; however, in 2017, there were no significant differences was found across the geographic Divisions. Compared to women in the lowest wealth quintile, women in all other quintiles had lower odds of adolescent childbearing, with the lowest odds found among women in the wealthiest quintile (AOR = 0.3; 95% CI: 0.2-0.6). Women who married at age 14-17 had 60% lower odds of adolescent childbearing compared to the women who married at age 10-13.

Conclusion

Nearly one-third of married adolescents in Bangladesh were pregnant or had at least one child in 2014, and it was reduced only marginally in 2017-18. Marriage at an early age and income inequalities among families were significant predictors of adolescent childbearing in Bangladesh. This study highlighted change in the magnitude and determinants of adolescent childbearing in Bangladesh taken data from two nationally representative surveys conducted 4 years apart.

Impact of DREAMS interventions on experiences of violence among adolescent girls and young women: Findings from population-based cohort studies in Kenya and South Africa

DREAMS aims to reduce HIV incidence among adolescent girls and young women (AGYW) by tackling drivers of HIV risk including gender-based violence. We evaluate the impact of DREAMS on recent experiences of violence perpetuated by men against AGYW. AGYW cohorts were randomly selected from demographic platforms in South Africa (rural KwaZulu-Natal) and Kenya (Nairobi informal settlements and rural Gem sub-county). AGYW aged 13-22 years were enrolled in 2017 (Nairobi, KwaZulu-Natal) or 2018 (Gem), with annual follow-up to 2019. We described proportions of AGYW who self-reported experiences of violence perpetrated by males in the 12 months preceding the interview, overall and by form (physical, sexual, emotional). We investigated associations with DREAMS (invitation to participate during 2017-2018) through multivariable propensity score-adjusted logistic regression and estimated the causal effect of DREAMS on experiences of violence, under counter-factual scenarios in which all versus no AGYW were DREAMS beneficiaries. Among 852, 1018 and 1712 AGYW followed-up in 2019 in Nairobi, Gem and KZN, respectively, proportions reporting any violence in 2019 were higher in Nairobi (29%) than Gem (18%) and KwaZulu-Natal (19%). By sub-type, emotional and physical violence were more frequently reported than sexual violence. We found no evidence of an impact attributable to DREAMS on overall levels of violence, in any setting. Nor was there evidence of impact on sub-types of violence, with one exception: an increase in physical violence in Nairobi if all, versus no, AGYW were DREAMS beneficiaries (16% vs 11%; +5% difference [95% CI: +0.2%, +10.0%]). Experiences of gender-based violence were common among AGYW, especially in urban settings, and DREAMS had no measurable impact on reducing violence within three years of implementation. Violence prevention programming that reaches more men and the broader community, sustained for longer periods, may yield greater gains in violence reduction than AGYW-focused programming. Additionally, more investment in implementation research is needed to bridge trial-based study findings from efficacy to population-level effectiveness.

Systematic scoping review of interventions to prevent and respond to child marriage across Africa: progress, gaps and priorities

OBJECTIVES

Despite the high prevalence of child marriage in Africa, little is known about the current state of the evidence on interventions to prevent and respond to child marriage in the region. The objectives of this systematic scoping review are to describe the breadth of existing evidence on child marriage prevention and response interventions, analyze where these interventions have been implemented, and identify research gaps and priorities for moving forward.

METHODS

The inclusion criteria incorporated publications that: (1) focused on Africa, (2) described interventions to address child marriage, (3) were published 2000-2021 and (4) were published as peer-reviewed articles or reports in English. We searched seven databases (PubMed, PsychINFO, Embase, Cinahl Plus, Popline, Web of Science and Cochrane Library), hand-searched the websites of 15 organisations and used Google Scholar to identify research published in 2021. Two authors independently screened titles and abstracts followed by full-text reviews and data extraction for included studies.

RESULTS

Our analysis of the 132 intervention studies identified highlights important disparities by intervention type, sub-region, and intervention activities, focus populations and impact. The greatest number of intervention studies focused on Eastern Africa. Health and empowerment approaches were most represented, followed by education and laws and policies. Norms or livelihoods approaches were least represented.

CONCLUSION

Our review finds few high-quality impact evaluations, most of which assess cash transfer programmes. There is a need to strengthen evaluative evidence on other intervention approaches including empowerment and norms change interventions, in particular. Given the linguistic and cultural diversity of the continent, more country-specific studies and research published in languages other than English are needed, particularly in high-prevalence Middle African countries.

The Effects of Participation in an Intensive HIV Prevention Trial on Long-Term Socio-Demographic Outcomes Among Young Women in Rural South Africa

BACKGROUND

Research trial participation may influence health outcomes regardless of the intervention assigned, but is often not assessed.

SETTING

We investigated how participation in an HIV prevention trial (the HIV Prevention Trials Network (HPTN) 068 study) affected health outcomes 4 years after the study in adolescent girls and young women in South Africa beyond effects of the tested intervention.

METHODS

We developed an analytical cohort that included the HIV Prevention 068 trial (HPTN 068) trial participants from the Agincourt Health and Demographic Surveillance System and resembled HPTN 068 trial enrollees (aged 13-20 years and in grades 8-11 in 2011) using inverse probability of treatment weights. We estimated risk differences for the association between trial participation and education and early parity (age <20 years) in 2019, after accounting for differences at baseline between the trial participants and nonparticipants.

RESULTS

There were 3442 young women enrolled in grades 8-11 in 2011; 1669 were in the HPTN 068 trial. Trial participants were more likely to have completed secondary school by 2019 (adjusted RD (aRD) 5.0%, 95% confidence interval (CI) 2.2%, 7.9%; 82.3% in trial participants vs. 77.2% in nonparticipants). Trial participants had similar risk of parity before age 20 compared with nontrial participants (aRD 2.3%, 95% CI: -0.8%, 5.5%).

CONCLUSIONS

Trial participation did not seem to influence early parity, but did increase educational attainment. Our results are compatible with an explanation of Hawthorne effects from trial participation on schooling behaviors that were small, but observable even 4 years after the end of the trial.

Effectiveness of interventions to reduce child marriage and teen pregnancy in sub-Saharan Africa: A systematic review of quantitative evidence

Introduction

Child marriage and teen pregnancy have negative health, social and development consequences. Highest rates of child marriage occur in sub-Saharan Africa (SSA) and 40% of women in Western and Central Africa got married before the age of 18. This systematic review was aimed to fill a gap in evidence of effectiveness to reduce teen pregnancy and child marriage in SSA.

Methods

We considered studies conducted in sub-Saharan Africa that reported on the effect of interventions on child marriage and teen pregnancy among adolescent girls for inclusion. We searched major databses and grey literature sources.

Results

We included 30 articles in this review. We categorized the interventions reported in the review into five general categories: (a) Interventions aimed to build educational assets, (b) Interventions aimed to build life skills and health assets, (c) Wealth building interventions, and (d) Community dialogue. Only few interventions were consistently effective across the studies included in the review. The provision of scholarship and systematically implemented community dialogues are consistently effective across settings.

Conclusion

Program designers aiming to empower adolescent girls should address environmental factors, including financial barriers and community norms. Future researchers should consider designing rigorous effectiveness and cost effectiveness studies to ensure sustainability.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022327397.

Mental health and psychosocial interventions integrating sexual and reproductive rights and health, and HIV care and prevention for adolescents and young people (10-24 years) in sub-Saharan Africa: a systematic scoping review

Background

Interventions targeting combined sexual and reproductive health, Human Immunodeficiency Virus (HIV) management and mental health care in sub-Saharan Africa (SSA) are few. There is a need to address common determinants of poor mental, psychosocial and sexual and reproductive health and rights (SRHR) through multimodal and multipronged interventions for adolescents. The main objective of this study was to identify whether and how interventions targeting adolescent SRHR and HIV with a focus on pregnant and parenting adolescents in SSA include mental health components and how these components and their outcomes have been reported in the literature.

Methods

We carried out a two process scoping review approach between 01.04.2021 and 23.08.2022. In the first stage, we searched the PubMed database to identify studies focusing on adolescents and young people aged 10 to 24 from 2001 to 2021. We identified studies focusing on HIV and SRHR that had mental health and psychosocial aspects to the interventions. Our search yielded 7025 studies. Of these 38 were eligible based on our screening criteria that covered interventions, and on further scrutiny, using PracticeWise, an established coding system, we identified select problems and practices to provide a more granular assessment of how interventions developed for this context mapped on to specific problems. At this second stage process, we selected 27 studies for inclusion as actual interventional designs for further systematic scoping of their findings and we used the Joanna Briggs Quality Appraisal checklist to rate these studies. This review was registered within the International Prospective Register of Systematic Reviews (PROSPERO), number CRD42021234627.

Findings

Our first set of findings is that when coding problems and solutions, mental health concerns were the least common category of problems targeted in these SRHR/HIV interventions; nevertheless, psychoeducation and cognitive behavioral strategies such as improved communication, assertiveness training, and informational support were offered widely. Of the 27 interventional studies included in the final review, 17 RCTs, 7 open trials, and 3 mixed designs, represented nine countries of the 46 countries in SSA. Intervention types included peer, community, family, digital, and mixed modality interventions. Eight interventions focused on caregivers and youth. Social or community ecology associated problems (being an orphan, sexual abuse, homelessness, negative cultural norms) were the most common risk factors and were more frequent than medical issues associated with HIV exposure. Our findings highlight the relevance and centrality of social issues related to adolescent mental and physical health along with the need to strengthen multimodal interventions along the lines of problems we have identified in our review.

Interpretation

Combined interventions jointly addressing adolescent SRHR, HIV, and mental health have been relatively understudied, despite evidence that adverse social and community factors are rampant in this population.

Funding

MK was funded by Fogarty International CenterK43 TW010716-05 and lead the initiative.

Hope, agency, and adolescents' sexual and reproductive health: A mini review

Availability of and access to services that promote sexual and reproductive health (SRH) amongst adolescent girls have become a global priority. Yet, while researchers have explored factors that influence the uptake of SRH services in low-and-middle income countries, the roles that "agency" and "hope" play in adolescent SRH is less understood. To study this, this mini review systematically reviewed the literature across three databases, EBSCO-host web, Pubmed and South Africa (SA) epublications, for the period of January 2012 to January 2022. Findings showed that a paucity of studies identified the link between agency, hope and adolescent SRH respectively. Our review included 12 articles and found no studies that focused on hope and its role in adolescent SRH or seeking SRH services. However, the literature revealed the complexities of adolescent SRH agency and autonomy where female adolescents had limited autonomy to make SRH decisions. Limited access to adolescent friendly SRH services was also found to restrict girls' agency to prevent unintended pregnancies or to take up SRH support. Given the paucity of research, empirical studies are needed to further understand the extent to which hope, agency and other subjective factors implicate adolescent SRH in the African context.

"It Gives You a Feeling of Pride when You Touch Her": The Role of Masculinity in Sexual Harassment of Adolescent Schoolgirls in Tanzania

Sexual harassment or the unwanted offensive behaviours that women and girls experience is a pervasive global challenge. Yet, there is limited evidence on the lived experiences of sexual harassment from school-based settings in sub-Saharan Africa. We explore students' perceived experiences, perpetration, and drivers of sexual harassment in schools in Mwanza, Tanzania. This study employed a qualitative research design involving 30 in-depth interviews and seven focus group discussions with 30 male and 40 female secondary school pupils aged 13-19 years. Data was analysed using a thematic approach. The findings show that experiences of sexual harassment among schoolgirls were widespread. Common forms of harassment were verbal and non-verbal gestures of a sexual nature. The desire to prove one's masculinity and peer pressure were key drivers of perpetration among schoolboys. Teachers took advantage of their positions of authority to sexually harass female pupils and employed corporal punishment to those who resisted their advances. Sexual harassment had multiple negative outcomes, including schoolgirls dropping out of school and mental health issues, such as anxiety, stress and poor academic performance. Girls rarely reported sexual harassment for fear of further victimisation and stigma from others. Sexual harassment of girls is common in secondary schools in Mwanza and is mainly driven by peer pressure and the desire to prove one's masculinity. Given its harmful effects, there is a need to implement clear policies to protect girls, support confidential disclosure and reporting and to address toxic masculinity norms among young men.

Community Mobilization is Associated with HIV Testing Behaviors and Their Psychosocial Antecedents Among Zambian Adults: Results from a Population-Based Study

Community mobilization (CM) is a vital yet under-explored avenue for increasing HIV testing in generalized HIV epidemic settings. Using multi-stage cluster sampling, a population-based sample of 3535 Zambian adults (mean age: 28 years, 50% women) were recruited from 14 districts to complete a household survey. Exploratory factor analysis (EFA) was used to re-validate a 23-item, 5-factor CM scale. Multivariable logistic and Poisson regression were then used to identify associations of CM with HIV testing behaviors and their psychosocial antecedents. A 21-item, 3-factor ("Leadership", "Collective Action Capacity", and "Social Cohesion") CM solution emerged from EFA (Cronbach's α 0.88). Among men and in rural settings, higher CM was significantly (p < 0.05) associated with elevated odds of HIV testing and more past-year HIV testing discussion sources, controlling for socio-demographics and sexual behaviors. Results underscore the importance of prioritizing CM to cultivate more favorable environments for HIV testing uptake, especially for men and rural residents.

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

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

Why do young people engage in dating relationships during early adolescence? An inter-generational qualitative analysis from Blantyre, Malawi

Engagement in dating relationships plays an important role in the health trajectories of young people, particularly during the early adolescent period between ages 10-14. Yet little is known about such relationships among youth in low resource contexts. This study sought to contribute to the literature on this topic by exploring reasons why school-going young people aged 12-14 years engage in dating relationships in Blantyre, Malawi. A thematic analysis was used to code and analyse in-depth interview data from 23 young people and 19 caregivers. Against the backdrop of growing sexual desires and feelings of attraction, participants stressed harassment from boys and coercion from older men, peer pressure, social status attainment, financial deprivation and encouragement during initiation ceremonies as reasons for engaging in dating relationships. Girls were found to be subject to multiple power dynamics-including gender power relations, as well as power dynamics within same-gender peer groups-that influenced their sex and relationship involvement. These findings carry implications for the design and timing of sexual and reproductive health youth programmes in Sub-Saharan Africa and emphasise the need for multi-level interventions to address the multiple influences in young people's dating lives.

Comparing Cohabiting Unions and Formal Marriages Among Adolescent Girls in Zambia: The Role of Premarital Fertility and Parental Support

PURPOSE

In developing countries, approximately one in three girls marry before the age of 18; however, early marriage is not a homogenous experience. Cohabitation can be either a precursor or an alternative to marriage, yet studies and programs often conflate marriage types. The purpose of this study is to understand the underlying factors and stability of cohabiting and formal child marriage unions among adolescent girls.

METHODS

This mixed-methods study draws on four rounds of quantitative data collected annually between 2013 and 2016 as part of a longitudinal study among girls 10-19 years old in Zambia. In-depth interviews were conducted in 2017 with 32 girls, divided by formal unions and informal unions, randomly selected from the quantitative sample. Multivariate logistic models were estimated to test key associations and Cox regression models used to estimate the hazard of separation/divorce by a certain age.

RESULTS

Qualitative findings highlighted that informal unions did not typically have approval of the couples' parents and frequently ended in separation. As compared to formal unions, having both families' approval was associated with 69% lower odds of cohabiting (odds ratio = 0.31, p < .001), while forced entry into union due to pregnancy was associated with 61% greater odds of cohabiting (OR = 1.61, p < .05). Being in a cohabiting union was associated with a 43% greater hazard of union dissolution (hazard ratio = 1.43, p < .05).

DISCUSSION

There are key differences between formal marriages and cohabitation among adolescent girls and young women that should be considered when addressing early marriage in research and programs.

Strengthening women's empowerment and gender equality in fragile contexts towards peaceful and inclusive societies: A systematic review and meta-analysis

Background

Across the globe, gender disparities still exist with regard to equitable access to resources, participation in decision-making processes, and gender and sexual-based violence. This is particularly true in fragile and conflict-affected settings, where women and girls are affected by both fragility and conflict in unique ways. While women have been acknowledged as key actors in peace processes and post-conflict reconstruction (e.g., through the United Nations Security Council Resolution 1325 and the Women, Peace and Security Agenda) evidence on the effectiveness of gender-specific and gender-transformative interventions to improve women's empowerment in fragile and conflict-affected states and situations (FCAS) remains understudied.

Objectives

The purpose of this review was to synthesize the body of evidence around gender-specific and gender-transformative interventions aimed at improving women's empowerment in fragile and conflict-affected settings with high levels of gender inequality. We also aimed to identify barriers and facilitators that could affect the effectiveness of these interventions and to provide implications for policy, practice and research designs within the field of transitional aid.

Methods

We searched for and screened over 100,000 experimental and quasi-experimental studies focused on FCAS at the individual and community levels. We used standard methodological procedures outlined by the Campbell Collaboration for the data collection and analysis, including quantitative and qualitative analyses, and completed the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology to assess the certainty around each body of evidence.

Results

We identified 104 impact evaluations (75% randomised controlled trials) assessing the effects of 14 different types of interventions in FCAS. About 28% of included studies were assessed as having a high risk of bias (45% among quasi-experimental designs). Interventions supporting women's empowerment and gender equality in FCAS produced positive effects on the outcomes related to the primary focus of the intervention. There are no significant negative effects of any included interventions. However, we observe smaller effects on behavioural outcomes further along the causal chain of empowerment. Qualitative syntheses indicated that gender norms and practices are potential barriers to intervention effectiveness, while working with local powers and institutions can facilitate the uptake and legitimacy of interventions.

Conclusions

We observe gaps of rigorous evidence in certain regions (notably MENA and Latin America) and in interventions specifically targeting women as actors of peacebuilding. Gender norms and practices are important elements to consider in programme design and implementation to maximise potential benefits: focusing on empowerment only might not be enough in the absence of targeting the restrictive gender norms and practices that may undermine intervention effectiveness. Lastly, programme designers and implementation should consider explicitly targeting specific empowerment outcomes, promoting social capital and exchange, and tailoring the intervention components to the desired empowerment-related outcomes.

Intertwined epidemics: progress, gaps, and opportunities to address intimate partner violence and HIV among key populations of women

The intersection of intimate partner violence and HIV is a public health problem, particularly among key populations of women, including female sex workers, women who use drugs, and transgender women, and adolescent girls and young women (aged 15-24 years). Intimate partner violence results in greater risk of HIV acquisition and creates barriers to HIV prevention, testing, treatment, and care for key populations of women. Socioecological models can be used to explain the unique multilevel mechanisms linking intimate partner violence and HIV. Few interventions, modelling studies, and economic evaluations that concurrently address both intimate partner violence and HIV exist, with no interventions tailored for transgender populations. Most combination interventions target individual-level risk factors, and rarely consider community or structural factors, or evaluate cost-efficacy. Addressing intimate partner violence is crucial to ending the HIV epidemic; this Review highlights the gaps and opportunities for future research to address the intertwined epidemics of intimate partner violence and HIV among key populations of women.

Policies and interventions to remove gender-related barriers to girls' school participation and learning in low- and middle-income countries: A systematic review of the evidence

Background

Gender disparities in education continue to undermine girls' opportunities, despite enormous strides in recent years to improve primary enrolment and attainment for girls in low- and middle-income countries (LMICs). At the regional, country and subnational levels gender gaps remain, with girls in many settings less likely to complete primary school, less likely to complete secondary, and often less likely to be literate than boys. The academic and policy literatures on the topic of gender-related barriers to girls' education are both extensive. However, there remain gaps in knowledge regarding which interventions are most likely to work in contexts with different combinations of barriers.

Objectives

This systematic review identified and assessed the strength of the evidence of interventions and exposures addressing gender-related barriers to schooling for girls in LMICs.

Search Methods

The AEA RCT Registry, Africa Bibliography, African Education Research Database, African Journals Online, DEC USAID, Dissertation Abstracts, EconLit, ELDIS, Evidence Hub, Global Index Medicus, IDEAS-Repec, Intl Clinical Trials Registry, NBER, OpenGrey, Open Knowledge Repository, POPLINE, PsychINFO, PubMed, Research for Development Outputs, ScienceDirect, Sociological Abstracts, Web of Science, as well as relevant organization websites were searched electronically in March and April of 2019. Further searches were conducted through review of bibliographies as well as through inquiries to authors of included studies, relevant researchers and relevant organizations, and completed in March 2020.

Selection Criteria

We included randomized controlled trials as well as quasi-experimental studies that used quantitative models that attempted to control for endogeneity. Manuscripts could be either published, peer-reviewed articles or grey literature such as working papers, reports and dissertations. Studies must have been published on or after 2000, employed an intervention or exposure that attempted to address a gender-related barrier to schooling, analyzed the effects of the intervention/exposure on at least one of our primary outcomes of interest, and utilized data from LMICs to be included.

Data Collection and Analysis

A team of reviewers was grouped into pairs to independently screen articles for relevance, extract data and assess risk of bias for each included study. A third reviewer assisted in resolving any disputes. Risk of bias was assessed either through the RoB 2 tool for experimental studies or the ROBINS-I tool for quasi-experimental studies. Due to the heterogeneity of study characteristics and reported outcome measures between studies, we applied the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach adapted for situations where a meta-analysis is not possible to synthesize the research.

Results

Interventions rated as effective exist for three gender-related barriers: inability to afford tuition and fees, lack of adequate food, and insufficient academic support. Promising interventions exist for three gender-related barriers: inadequate school access, inability to afford school materials, and lack of water and sanitation. More research is needed for the remaining 12 gender-related barriers: lack of support for girls' education, child marriage and adolescent pregnancy, lack of information on returns to education/alternative roles for women, school-related gender-based violence (SRGBV), lack of safe spaces and social connections, inadequate sports programs for girls, inadequate health and childcare services, inadequate life skills, inadequate menstrual hygiene management (MHM), poor policy/legal environment, lack of teaching materials and supplies, and gender-insensitive school environment. We find substantial gaps in the evidence. Several gender-related barriers to girls' schooling are under-examined. For nine of these barriers we found fewer than 10 relevant evaluations, and for five of the barriers-child marriage and adolescent pregnancy, SRGBV, inadequate sports programs for girls, inadequate health and childcare services, and inadequate MHM-we found fewer than five relevant evaluations; thus, more research is needed to understand the most effective interventions to address many of those barriers. Also, nearly half of programs evaluated in the included studies were multi-component, and most evaluations were not designed to tease out the effects of individual components. As a result, even when interventions were effective overall, it is often difficult to identify how much, if any, of the impact is attributable to a given program component. The combination of components varies between studies, with few comparable interventions, further limiting our ability to identify packages of interventions that work well. Finally, the context-specific nature of these barriers-whether a barrier exists in a setting and how it manifests and operates-means that a program that is effective in one setting may not be effective in another.

Authors' Conclusions

While some effective and promising approaches exist to address gender-related barriers to education for girls, evidence gaps exist on more than half of our hypothesized gender-related barriers to education, including lack of support for girls' education, SRGBV, lack of safe spaces and social connections, inadequate life skills, and inadequate MHM, among others. In some cases, despite numerous studies examining interventions addressing a specific barrier, studies either did not disaggregate results by sex, or they were not designed to isolate the effects of each intervention component. Differences in context and in implementation, such as the number of program components, curricula content, and duration of interventions, also make it difficult to compare interventions to one another. Finally, few studies looked at pathways between interventions and education outcomes, so the reasons for differences in outcomes largely remain unclear.

Heterogeneous Impacts of Interventions Aiming to Delay Girls' Marriage and Pregnancy Across Girls' Backgrounds and Social Contexts

PURPOSE

Despite many programs aiming to delay girls' marriage and pregnancy over the last 2 decades, there is no consensus yet concerning the effectiveness of different approaches and the contexts in which they are implemented. We focus on different social contexts within Bangladesh and Zambia and investigate how literacy, poverty, and community characteristics impact the effectiveness of interventions.

METHODS

We utilize data sets from two randomized controlled trials conducted by the Population Council in Bangladesh and Zambia. Within each respective country, we estimate the impacts of the interventions on marriage and pregnancy among adolescent girls using the analysis of covariance estimator by different social contexts based on community-level variables.

RESULTS

In Bangladesh, providing academic skill training had a significant impact on discouraging child marriage in the villages where girls' paid-work participation rate was relatively high, whereas in low paid-work participation villages, providing gender-awareness skill training had an impact. In Zambia, providing empowerment intervention and safe spaces had a significant impact on delaying pregnancy especially for illiterate girls in the communities where premarital sex was relatively common.

CONCLUSIONS

In Bangladesh, where girls' paid-work participation is limited, premarital sex is uncommon, and marriage is subject to collective decision-making; the effectiveness of a program may depend on girls' agency and the availability of acceptable working opportunities. In Zambia where premarital sex is common, pregnancy may precede marriage, and marriage entails the nature of individual decision-making; empowering the most vulnerable girls seems to be more effective in delaying marriage/pregnancy.

Impacts of two-year multisectoral cash plus programs on young adolescent girls' education, health and economic outcomes: Adolescent Girls Initiative-Kenya (AGI-K) randomized trial

Background

Early adolescence is a critical window for intervention when it is possible to lay a foundation for a safe transition to adulthood, before negative outcomes occur. The Adolescent Girls Initiative–Kenya randomized trial tested the effects of combinations of interventions for young adolescent girls in two sites – the Kibera informal settlement in Nairobi and rural Wajir County in the Northeastern region.

Methods

The interventions included community dialogues on the role and value of girls (violence prevention), a conditional cash transfer (education), weekly group meetings for girls with health and life skills training (health), and training and incentives for financial literacy and savings activities (wealth creation). Participants were randomized to one of four study arms: 1) violence prevention only, 2) violence prevention and education, 3) violence prevention, education and health or 4) violence prevention, education, health and wealth creation. An intent-to-treat (ITT) analysis was conducted using longitudinal data to estimate the impact of each combination of interventions and various sensitivity analyses conducted addressing potential attrition bias and multiple hypothesis testing concerns.

Results

In Kibera, the education conditional cash transfer had small effects on grade attainment but larger impacts on completion of primary school and the transition to secondary school in the most comprehensive arm; the health intervention improved sexual and reproductive health knowledge and condom self-efficacy; and the wealth intervention improved financial literacy and savings behavior. In Wajir, the education conditional cash transfer increased school enrollment and grade attainment, and the wealth intervention improved savings behavior.

Conclusions

The results indicate that when trying to improve a range of outcomes related to adolescent wellbeing for young girls, a multisectoral intervention with components addressing household economic constraints is a promising approach.

Trial registration

Trial Registry: ISRCTN, ISRCTN77455458. Registered 24/12/2015 - Retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12224-3.

HIV-sensitive social protection for vulnerable young women in East and Southern Africa: a systematic review

INTRODUCTION

Social protection programmes are considered HIV-sensitive when addressing risk, vulnerability or impact of HIV infection. Socio-economic interventions, like livelihood and employability programmes, address HIV vulnerabilities like poverty and gender inequality. We explored the HIV-sensitivity of socio-economic interventions for unemployed and out-of-school young women aged 15 to 30 years, in East and Southern Africa, a key population for HIV infection.

METHODS

We conducted a systematic review using a narrative synthesis method and the Mixed Methods Appraisal Tool for quality appraisal. Interventions of interest were work skills training, microfinance, and employment support. Outcomes of interest were socio-economic outcomes (income, assets, savings, skills, (self-) employment) and HIV-related outcomes (behavioural and biological). We searched published and grey literature (January 2005 to November 2019; English/French) in MEDLINE, Scopus, Web of Science and websites of relevant international organizations.

RESULTS

We screened 3870 titles and abstracts and 188 full-text papers to retain 18 papers, representing 12 projects. Projects offered different combinations of HIV-sensitive social protection programmes, complemented with mentors, safe space and training (HIV, reproductive health and gender training). All 12 projects offered work skills training to improve life and business skills. Six offered formal (n = 2) or informal (n = 5) livelihood training. Eleven projects offered microfinance, including microgrants (n = 7), microcredit (n = 6) and savings (n = 4). One project offered employment support in the form of apprenticeships. In general, microgrants, savings, business and life skills contributed improved socio-economic and HIV-related outcomes. Most livelihood training contributed positive socio-economic outcomes, but only two projects showed improved HIV-related outcomes. Microcredit contributed little to either outcome. Programmes were effective when (i) sensitive to beneficiaries' age, needs, interests and economic vulnerability; (ii) adapted to local implementation contexts; and (iii) included life skills. Programme delivery through mentorship and safe space increased social capital and may be critical to improve the HIV-sensitivity of socio-economic programmes.

CONCLUSIONS

A wide variety of livelihood and employability programmes were leveraged to achieve improved socio-economic and HIV-related outcomes among unemployed and out-of-school young women. To be HIV-sensitive, programmes should be designed around their interests, needs and vulnerability, adapted to local implementation contexts, and include life skills. Employment support received little attention in this literature.

Who’s got the power? Expressions of empowerment among in-school adolescents enrolled in the Girls Achieve Power (GAP Year) trial in three peri-urban settings of South Africa

Background: Empowerment is when a person gains mastery of their life and environment. This paper describes three central elements of empowerment (agency, resources, and institutional structures) expressed by adolescents, discussing implications for strengthening adolescent sexual reproductive health, HIV, and violence prevention programming. Methods: A cross-sectional survey was conducted (April 2017 – May 2018) as part of the GAP Year trial among grade eight learners (12 – 18 years) from 26 lowest quintile public high schools in Khayelitsha, Soweto and Thembisa townships, South Africa. Data were on empowerment experiences using a knowledge, attitudes, and practices survey. Descriptive and chi-square test statistics were employed, assessing the association between sociodemographic and domains of empowerment. Results: A total of 2383 adolescents in 26 schools completed the baseline survey: 63.1% female, mean age 13.7 years, 96.9% Black African. Agency: Males (4.04 vs 3.94, p=0.008) and those 15 – 18 years (4.10 vs 3.95, p=0.027) expressed stronger decision-making capacity. Females (3.18 vs 2.92, p<0.001) indicated a greater sense of collective action. Females (0.77 vs 0.72, p=0.008), those aged 12 -14 years (0.76 vs 0.71, p=0.027) and those with at least one parent/guardian employed (p=0.014) had stronger leadership confidence. Resources: Those 12-14 years expressed higher self-esteem (2.18 vs 2.08, p=0.017). Males (2.24 vs 1.87, p<0.001) and those who had at least one parent/guardian employed (p=0.047) had a higher perception of freedom from gender-based violence. Males showed greater mobility (2.89 vs 2.66, p=<0.001). Institutional structures: Coloured participants showed more positive norms than their Black counterparts (5.38 vs 2.12, p=0.005). Conclusions: Males expressed greater empowerment around decision-making, gender-based violence and mobility; females expressed greater collective action and leadership. Working across the ecological model, interventions addressing sex differences, targeting adolescents of all ages, and parental unemployment may strengthen expressions of empowerment, especially adolescents’ safety, mobility, aspirations, and future hopes.

Paediatric to adult healthcare transition in resource-limited settings: a narrative review

Background

Ageing into adulthood is challenging at baseline, and doing so with a chronic disease can add increased stress and vulnerability. Worldwide, a substantial care gap exists as children transition from care in a paediatric to adult setting. There is no current consensus on safe and equitable healthcare transition (HCT) for patients with chronic disease in resource-denied settings. Much of the existing literature is specific to HIV care. The objective of this narrative review was to summarise current literature related to adolescent HCT not associated with HIV, in low-income and middle-income countries (LMICs) and other resource-denied settings, in order to inform equitable health policy strategies.

Methods

A literature search was performed using defined search terms in PubMed and Cumulative Index to Nursing and Allied Health Literature databases to identify all peer-reviewed studies published until January 2020, pertaining to paediatric to adult HCT for adolescents and young adults with chronic disease in resource-denied settings. Following deduplication, 1111 studies were screened and reviewed by two independent reviewers, of which 10 studies met the inclusion criteria. Resulting studies were included in thematic analysis and narrative synthesis.

Results

Twelve subthemes emerged, leading to recommendations which support equitable and age-appropriate adolescent care. Recommendations include (1) improvement of community health education and resilience tools for puberty, reproductive health and mental health comorbidities; (2) strengthening of health systems to create individualised adolescent-responsive policy; (3) incorporation of social and financial resources in the healthcare setting; and (4) formalisation of institution-wide procedures to address community-identified barriers to successful transition.

Conclusion

Limitations of existing evidence relate to the paucity of formal policy for paediatric to adult transition in LMICs for patients with childhood-onset conditions, in the absence of a diagnosis of HIV. With a rise in successful treatments for paediatric-onset chronic disease, adolescent health and transition programmes are needed to guide effective health policy and risk reduction for adolescents in resource-denied settings.

Youth engagement in HIV prevention intervention research in sub-Saharan Africa: a scoping review

INTRODUCTION

Youth engagement in HIV research is generally recognized as essential, but often neglected or minimally implemented in practice. Engagement is a process of working collaboratively with diverse groups of people to address common issues. We conducted a scoping review of youth HIV prevention interventions in sub-Saharan Africa to identify and categorize forms and levels of youth engagement across the lifespan of intervention research.

METHODS

We followed Arksey and O'Malley's framework for organizing a scoping review. We searched seven databases for related articles on identified intervention studies through May 28th 2020. Included studies focused on youth (10 to 24 years old) HIV prevention interventions in sub-Saharan Africa. Two reviewers independently examined citations and full manuscripts for inclusion. Data were extracted on study characteristics, location, description of youth engagement and extent of engagement. Youth engagement approaches were categorized based on Hart's ladder as substantial engagement (strong youth decision-making power), moderate engagement (shared decision making with adults), minimal engagement (no youth decision-making power) or no engagement.

RESULTS

We identified 3149 citations and included 112 studies reporting on 74 unique HIV interventions. Twenty-two interventions were in low-income countries, 49 in middle-income countries, and three were in both. Overall, only nine interventions (12%) had substantial or moderate youth engagement, two-thirds (48, 65%) had minimal youth engagement and 17 interventions (23%) had no youth engagement. We also identified specific engagement strategies (e.g. youth-led research, crowdsourcing) that were feasible in multiple settings and resulted in substantial engagement.

CONCLUSIONS

We found limited youth engagement in youth HIV prevention intervention studies in sub-Saharan Africa. However, several activities resulted in substantial youth engagement and could be relevant in many low-and-middle-income-country (LMIC) settings.

Assessment of an adolescent-girl-focused nutritional educational intervention within a girls' empowerment programme: a cluster randomised evaluation in Zambia

OBJECTIVE

Adolescent girls are at risk for both macro- and micronutrient deficiencies affecting growth, maternal and child health. This study assessed the impact of an adolescent-girl-tailored nutritional education curriculum on nutritional outcomes, including knowledge, dietary behaviour, anthropometry and anaemia.

DESIGN

A cluster-randomised evaluation was conducted with two study arms: girls in mentor-led weekly girls' groups receiving sexual and reproductive health and life-skills training assigned to an age-appropriate nutritional curriculum and control girls in the weekly girls' groups without the nutritional education. The primary analysis was intent-to-treat (ITT) generalised least squares regression. Secondary analysis using two-stage, instrumental-variables estimation was also conducted.

SETTING

The intervention and evaluation were conducted in urban and rural areas across four of ten provinces in Zambia.

PARTICIPANTS

In total, 2660 girl adolescents aged 10-19 years were interviewed in 2013 (baseline) and annually through 2017.

RESULTS

ITT results indicate that exposure to the nutritional educational programme did not meaningfully change outcomes for adolescents or their children. Intervention adolescents were no more likely to correctly identify healthy foods (P = 0·51) or proper infant-feeding practices (P = 0·92); were no less likely to be stunted (P = 0·30) or underweight (P = 0·87) and no less likely to be anaemic (P = 0·38). Outcomes for children of intervention participants were not improved, including being breastfed (P = 0·42), stunted (P = 0·21), wasted (P = 0·77) or anaemic (P = 0·51).

CONCLUSIONS

Even a high-quality nutritional educational intervention tailored to adolescents within an empowerment programme does not assure improved nutritional outcomes; adolescent preferences, resource control and household dynamics require consideration in the context of nutritional educational programmes.