Adaptation of the sexual and reproductive empowerment scale for adolescents and young adults in Kenya

Empowerment as an Outcome and a Process: Longitudinal Validation of a Reproductive Empowerment Scale in Plateau State, Nigeria

Measurement of reproductive empowerment (RE) is necessary to understand and address barriers to RE and to evaluate the impact of policies and practices that increase RE as a pathway to improving reproductive health. This study validated an existing RE scale, developed in 2016 for sub-Saharan African (SSA) contexts, using longitudinal survey data from a cohort of women in Plateau State, Nigeria. Psychometric properties were assessed through confirmatory factor analysis, and invariance tests evaluated the scale's consistency across baseline and endline. Longitudinal logistic regression models examined whether changes in RE levels predicted family planning outcomes. The results demonstrate the final RE scale is a valid and predictive tool, comprising 24 items across five subscales that measure empowerment at individual, immediate relational, and distant relational levels. The RE scale also predicts the use of family planning and intention to use modern contraception in the future. This is one of the few RE scales designed specifically for SSA contexts and the only one known to be validated longitudinally. The RE scale provides a robust framework for measuring RE across levels and over time and can be used in SSA contexts to measure RE as a dynamic process and as an outcome.

Exploring Adolescents' Contraceptive Preferences and Trade-Offs: Findings From a Discrete Choice Experiment in Kenya

A focus on contraceptive preferences is essential to the provision of person-centered care. Adolescent girls and young women (AGYW) in the WHO African Region experience disparities in contraceptive access and use and reproductive health outcomes. Despite increasing recognition of AGYW needs as unique, their preferences are understudied, limiting strategies to improve contraceptive care access and quality among marginalized youth populations. We designed and conducted a discrete choice experiment among five hundred 15-20-year-old AGYW in Kisumu, Kenya, to examine the relative importance of trade-offs between contraceptive methods and service delivery attributes. Participants answered eight choice sets including three alternatives: two hypothetical contraceptive options characterized by seven attributes (effectiveness, bleeding pattern, duration of use, privacy, access location, counseling source, and cost) and a "no method" opt-out. We used random-parameters logit models to estimate preference weights and trade-offs among alternatives. The bleeding pattern was the most important determinant of stated choice, with a strong preference for unchanged or irregular bleeding over heavier bleeding or amenorrhea. Participants preferred the lowest chance of method failure as well as the longest duration of use (one year) over daily use or use during/after sex. Parous AGYW were more likely to prefer the longest duration of use. The ability to keep method use completely private was also an influential choice, particularly among 15-17-year-olds. AGYW traded effectiveness and increased cost for preferred bleeding patterns and privacy. The opt-out "no method" alternative was chosen only 2.7 percent of the time, indicating a strong preference for pregnancy prevention. Our findings highlight key insights for enhancing the person-centeredness of contraceptive care for AGYW: Kenyan AGYW place a high value on preferred menstrual bleeding patterns, high method effectiveness, longer duration of use, and the ability to keep method use private. Preference data can inform programs, including contraceptive decision-support interventions, to improve AGYW access to quality preference-sensitive contraceptive services.

How migration shapes modern contraceptive use among urban young women: Evidence from six African countries

BACKGROUND

Internal migration is an important part of the transition to adulthood for many young people in sub-Saharan Africa. This study examines how migration, in relation to marriage and parenthood, impacts modern contraceptive use and health facility visits amongst young urban women.

METHODS

We draw on Performance Monitoring for Action (PMA) surveys conducted in Burkina Faso, Côte d'Ivoire, Democratic Republic of Congo, Kenya, Nigeria, and Uganda (2019-2022). Our analysis is unique in being able to adjust for whether women wanted to get pregnant soon. Our sample includes women ages 15-24 years currently residing in urban areas (n = 6,225). We conducted logistic regression models clustered by village level identifier to explore the sequence of life events and the timing of migration in relation to current modern contraceptive use and recent health facility visit, a proxy for engagement with formal health services.

RESULTS

The timing of migration matters more than the sequence of these life events. Young urban women who experienced both migration and a birth, regardless of the order, had increased contraceptive use and recent health facility visit, compared to women who had only experienced one event or neither. Young women who migrated in the past year had 24% lower odds of using a modern method (Odds Ratio = 0.76; 95% confidence interval 0.63, 0.91), adjusting for demographic factors and adjusting for fertility preference (Wanting to get pregnant soon). Having had a birth was highly significant for health facility visit and among women who had had a birth, those who migrated in the last year had lower odds of a recent visit (OR = 0.68, 95% CI 0.41, 0.89). Results suggest an initially disruptive effect of migration.

DISCUSSION

Our results suggest young women who recently migrated to urban areas may need additional support in accessing contraception and formal health services for themselves or their children.

Enhancing HIV pre-exposure prophylaxis outcomes among Kenyan adolescent girls and young women with a novel pharmacy-based PrEP delivery platform: protocol for a cluster-randomized controlled trial

BACKGROUND

In Kenya, 65% of sexually active unmarried women use modern contraceptives, a population at increased risk of HIV acquisition compared to other populations. Anchoring HIV prevention services, including pre-exposure prophylaxis (PrEP), to trusted contraceptive delivery settings offers opportunities to efficiently reach this important population. In Kenya, almost half (40%) of women accessing contraception services do so outside traditional healthcare facilities, such as retail pharmacies. Thus, integrating PrEP services into retail pharmacies may increase options for reaching adolescent girls and young women (AGYW) who could benefit from PrEP. Efforts are underway to define care pathways for pharmacy-delivered PrEP services in Kenya, including unsupported and supported models with nurse navigators.

METHODS

The AGYW Pharmacy PrEP study is an unblinded 2-arm cluster-randomized controlled trial in Kisumu, Kenya. The objective is to determine the effect that unsupported versus supported pharmacy-delivered PrEP services has on PrEP initiation, persistence, and adherence among AGYW seeking contraception. Twenty retail pharmacies offering pharmacy provider-led PrEP delivery will be randomized 1:1 to either receive or not receive a nurse navigator to support PrEP delivery. Eligible AGYW (n = 1900 total, n = 950/arm) will be ≥ 15 years old, purchasing a method of contraception at the pharmacy. Trained pharmacy provider will offer eligible AGYW either daily oral PrEP or the monthly DPV vaginal ring. The primary trial outcomes are PrEP initiation (use of PrEP at 1 month), persistence (use of PrEP at 10 months), and adherence (quantified by levels of TFV or DPV in hair samples). Additionally, several secondary (STI incidence, PrEP method selection, predictors of PrEP adherence) and exploratory outcomes (HIV incidence, quality of care, contraceptive method mix) will be explored.

DISCUSSION

We hypothesize pharmacy-delivered PrEP services supported with nurse navigator, versus delivered by pharmacy providers alone, will improve PrEP outcomes among AGYW seeking contraception. Our results will help policy makers better understand how to potentially implement this novel differentiated service model for PrEP and prime pharmacies for the delivery of new PrEP agents in the pipeline (e.g., long-acting injectables and multi-purpose technologies). The study was initiated on May 13, 2023, and is expected to be completed by February 2025.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT05467306), with registration on July 20, 2022.

Confirmatory Factor Analysis and Validation of the Sexual and Reproductive Empowerment Scale for Adolescents and Young Adults in Kenya

Understanding the levels of power that adolescent girls and young women exercise in their sexual and reproductive lives is imperative to inform interventions to help them meet their goals. We implemented an adapted version of the Sexual and Reproductive Health Empowerment (SRE) Scale for Adolescents and Young Adults among 500 adolescent girls and young women aged 15-20 in Kisumu, Kenya. We used confirmatory factor analysis (CFA) to assess factor structure, and logistic regression to examine construct validity through the relationship between empowerment scores and ability to mitigate risk of undesired pregnancy through consistent contraceptive use. Participants had a mean age of 17.5, and most were students (61 percent), were currently partnered (94 percent), and reported having sex in the past 3 months (70 percent). The final, 26-item CFA model had acceptable fit. All subscales had Cronbach's alpha scores >0.7, and all items had rotated factor loadings >0.5, indicating good internal consistency and robust factor-variable associations. The total SRE-Kenya (SRE-K) score was associated with increased odds of the consistent method used in the past three months (adjusted odds ratio: 1.98, 95 percent CI: 1.29-3.10). The SRE-K scale is a newly adapted and valid measure of sexual and reproductive empowerment specific to adolescent girls and young women in an East African setting.

Priorities for contraceptive method and service delivery attributes among adolescent girls and young women in Kenya: a qualitative study

Introduction

Despite increasing global commitment to meeting the family planning needs of adolescent girls and young women (AGYW), there is limited research on how they prioritize contraceptive method and service delivery characteristics. In this qualitative study, we examine the specific elements that drive the contraceptive choices of Kenyan AGYW, and apply our findings to the development of attributes and levels for a discrete choice experiment (DCE).

Methods

Our four-stage approach included data collection, data reduction, removing inappropriate attributes, and optimizing wording. Between June-October 2021, we conducted in-depth interviews with 30 sexually-active 15-24 year-old AGYW in Kisumu county, Kenya who were non-pregnant and desired to delay pregnancy. Interviews focused on priorities for contraceptive attributes, how AGYW make trade-offs between among these attributes, and the influences of preferences on contraceptive choice. Translated transcripts were qualitatively coded and analyzed with a constant comparative approach to identify key concepts. We developed and iteratively revised a list of attributes and levels, and pre-tested draft DCE choice tasks using cognitive interviews with an additional 15 AGYW to optimize comprehension and relevance.

Results

In-depth interview participants' median age was 18, 70% were current students, and 93% had a primary sexual partner. AGYW named a variety of priorities and preferences related to choosing and accessing contraceptive methods, which we distilled into six key themes: side effects; effectiveness; user control; privacy; source of services; and cost. Bleeding pattern was top of mind for participants; amenorrhea was generally considered an intolerable side effect. Many participants felt more strongly about privacy than effectiveness, though some prioritized duration of use and minimizing chance of pregnancy above other contraceptive characteristics. Most AGYW preferred a clinic setting for access, as they desired contraceptive counseling from a provider, but pharmacies were considered preferable for reasons of privacy. We selected, refined, and pre-tested 7 DCE attributes, each with 2-4 levels.

Conclusions

Identifying AGYW preferences for contraceptive method and service delivery characteristics is essential to developing innovative strategies to meet their unique SRH needs. DCE methods may provide valuable quantitative perspectives to guide and tailor contraceptive counseling and service delivery interventions for AGYW who want to use contraception.