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The impact of community and provider-driven social accountability interventions on contraceptive use: Findings from a cohort study of new users in Ghana and Tanzania
No full textBackground: Although contraceptive use has increased over 15 years, discontinuation rates remain high. Contraceptive use is becoming more important when addressing unmet need for family planning. Social accountability, defined here as collective processes for holding duty bearers to account for their actions, is a rights-based participatory process that supports service provision and person-centred care, as well as, informed decision-making among community members regarding their health. A study implemented in Ghana and Tanzania was designed to understand and evaluate how social accountability and participatory processes influences quality of care and client satisfaction and whether this results in increased contraceptive uptake and use. We report here on the relationship between social accountability and the use of modern contraceptives, i.e., contraceptive method discontinuation, contraceptive method switching, and contraceptive discontinuation. Methods: As part of Community and Provider driven Social Accountability Intervention (CaPSAI) Project, a cohort of women aged 15 to 49 years who were new users of contraception and accessing family planning and contraceptives services at the study facilities across both intervention and control groups were followed-up over a 12-month period to measure changes contraceptive use. Results: In this cohort study over a one-year duration, we did not find a statistically significant difference in Ghana and Tanzania in overall method discontinuation, switching, and contraceptive discontinuation after exposure to a social accountability intervention. In Ghana but not in Tanzania, when stratified by the type of facility (district level vs. health centre), there were significantly less method and contraceptive discontinuation in the district level facility and significantly more method and contraceptive discontinuation in the health centres in the intervention group. In Ghana, the most important reasons reported for stopping a method were fear of side-effects, health concerns and wanting to become pregnant in the control group and fear of side-effects wanting a more effective method and infrequent sex in the intervention group. In Tanzania, the most important reasons reported for stopping a method were fear of side-effects, wanting a more effective method, and method not available in the control group compared to wanting a more effective method, fear of side-effects and health concerns in the intervention group. Conclusions: We did not demonstrate a statistically significant impact of a six-month CaPSAI intervention on contraceptives use among new users in Tanzania and Ghana. However, since social accountability have important impacts beyond contraceptive use it is important consider results of the intermediate outcomes, cases of change, and process evaluation to fully understand the impact of this intervention. Trial registration: The CaPSAI Project has been registered at Australian New Zealand Clinical Trials Registry (ACTRN12619000378123, 11/03/2019)
Exploring COVID-19 vaccine hesitancy and uptake in Nairobi\u27s urban informal settlements: An unsupervised machine learning analysis of a longitudinal prospective cohort study from 2021 to 2022
No full textObjectives: To illustrate the utility of unsupervised machine learning compared with traditional methods of analysis by identifying archetypes within the population that may be more or less likely to get the COVID-19 vaccine. Design: A longitudinal prospective cohort study (n=2009 households) with recurring phone surveys from 2020 to 2022 to assess COVID-19 knowledge, attitudes and practices. Vaccine questions were added in 2021 (n=1117) and 2022 (n=1121) rounds. Setting: Five informal settlements in Nairobi, Kenya. Participants: Individuals from 2009 households included. Outcome Measures and Analysis: Respondents were asked about COVID-19 vaccine acceptance (February 2021) and vaccine uptake (March 2022). Three distinct clusters were estimated using K-Means clustering and analysed against vaccine acceptance and vaccine uptake outcomes using regression forest analysis. Results: Despite higher educational attainment and fewer concerns regarding the pandemic, young adults (cluster 3) were less likely to intend to get the vaccine compared with cluster 1 (41.5% vs 55.3%, respectively; p \u3c 0.01). Despite believing certain COVID-19 myths, older adults with larger households and more fears regarding economic impacts of the pandemic (cluster 1) were more likely to ultimately to get vaccinated than cluster 3 (78% vs 66.4%; p \u3c 0.01), potentially due to employment requirements. Middle-aged women who are married or divorced and reported higher risk of gender-based violence in the home (cluster 2) were more likely than young adults (cluster 3) to report wanting to get the vaccine (50.5% vs 41.5%; p = 0.014) but not more likely to have gotten it (69.3% vs 66.4%; p = 0.41), indicating potential gaps in access and broader need for social support for this group. Conclusions: Findings suggest this methodology can be a useful tool to characterise populations, with utility for improving targeted policy, programmes and behavioural messaging to promote uptake of healthy behaviours and ensure equitable distribution of prevention measures
Guidance document on the use of the Confidante tool to track new or recent cases of female genital mutilation
Get PDFFemale genital mutilation (FGM) is internationally recognised as a violation of human rights that is rooted in social norms including harmful gender norms. In countries where it is prevalent, FGM contributes to bottlenecks that curtail realisation of full potential by girls and women. In settings where FGM is illegal, practising communities may adopt strategies such as cutting girls at very young ages, performing supposedly less severe cuts, or conducting FGM in secret, and thus underreport the occurrence of the practice due to fear of legal consequences. This may hamper tracking and/or measuring the effectiveness and/or impact of interventions and actions to end the practice.
Adopting methods from other related fields used to measure sensitive or hidden behaviours may provide an innovative approach to more accurately capturing new or recent cases of FGM, which are a powerful indicator of ongoing violations of human rights. Such data can support advocacy activities as well as strengthen the evaluation of legal frameworks and health systems approaches to address FGM. To this end, the FGM Data Hub developed and piloted a tool that involved the use of the Confidante Method to document new or recent cases of FGM.
The evidence generated from piloting the tool was shared with a team of experts (Annex 1) in measurement of sensitive or hidden behaviours during a half-day virtual convening to provide feedback on the application of the tool. The evidence and the tool were further reviewed by end-FGM programme implementers from The Girl Generation-Africa-led Movement to End FGM (TGG-ALM) and other partners across Kenya during a three-day workshop held in Nairobi in June 2023. The tool and this accompanying guide were finalised based on feedback obtained from those engagements
Exposure to pornographic content among Indian adolescents and young adults and its associated risks: Evidence from UDAYA survey in Bihar and Uttar Pradesh
No full textAdolescence is period characterized by sexual development, increasing romantic relationships, and the initiation of sexual activity. To enhance the exploration of their sexuality, adolescents may look into sexual resources such as pornography. There has been little research in India to understand how much adolescents are exposed to Internet pornography and what are the associated risk factors. This study examined the level of exposure to pornography among adolescents and the associated factors which determine the exposure to pornography in Uttar Pradesh and Bihar. Understanding the Lives of Adolescents and Young Adults (UDAYA) survey data collected in 2015–2016 was used for this study. The study was based on 3885 adolescent boys and 7766 adolescent girls aged 15–19 years. The mean age for adolescent boys was 16.66 years (SD: 1.3), and for girls it was 16.67 years (SD: 1.3). About 47% of adolescent boys but only 6% of girls were exposed to pornography. The likelihood of exposure to pornography was 1.69 times and 2.27 times more likely among adolescents and girls who had their own personal mobile phones, respectively, compared to those who did not have their own personal mobile phones. The odds of exposure to pornography were significantly higher among adolescent boys who had frequent media exposure than those who had no/rare exposure. Programs on life skills and comprehensive sexuality education need to be prioritize
Is Pakistan’s fertility transition stalling?
No full textThis study examines the question as to whether Pakistan’s fertility transition is stalling. The paper reviews the trajectories of fertility and its various determinants and compares Pakistan’s trends with those of India and Bangladesh. Countries in the South Asia region share features such as cultural similarities (e.g. the low status of women and son preference) and high poverty levels. However, while Bangladesh and India are near replacement fertility today with modern contraceptive prevalence rates well above 50 per cent, Pakistan still has one of the highest fertility and lowest contraceptive prevalence levels in Asia. Our main conclusion is that Pakistan’s fertility transition is close to stalling in mid-transition. The key causes of this stall are a high and unchanging desired family size, stalling demand for contraception and relatively low satisfaction of this demand. These are important obstacles to future decline in fertility
The Radical Power of Education
Get PDFWhen education works, people thrive and societies flourish alongside economies. We have made real progress on primary enrollment on the global scale, with 90% of children enrolling in school. However, completion rates lag far behind—only 77% of children complete lower secondary school and 58% complete upper secondary. Those numbers decline sharply for those living in poverty, for girls, and for Indigenous communities, with 44% of adolescent girls in low- and middle-income countries (LMICs) either dropping out of primary school or never attending at all.
Low educational attainment and illiteracy exclude children from the freedoms that come with learning and also leave vast social and economic potential untapped. People with better education have greater capacity to care for themselves and their families, participate in civic life, and raise their children well. And a single year of education has been estimated to increase individual earnings by 10%, or up to 15% among women in sub-Saharan Africa. Education does more than increase earning potential or productivity—it also improves health, well-being, and quality of life. Women and girls with 12 years of education are less likely to be married as children and less likely to experience domestic or intimate partner violence (IPV) than other women.
In this report, we simulated the multisectoral benefits afforded by 12 years of education in LMICs, based on data from published sources and accounting for uncertainty. These predictive models offer a glimpse into what the future can look like if the global community can rally around the goal of universal primary and secondary education. We estimate that universal secondary education in LMICs could boost annual gross national income (GNI) by $8.1 trillion for young adults aged 15-24 years, reduce the annual number of child marriages by 2 million, and reduce the number of women aged 15-49 who experience any form of IPV by 81.3 million, Universal maternal secondary education could also reduce the annual number of deaths among children under the age of 5 years by 524,834 and the number of stunted under-5 children by 22.5 million. We discuss the socioeconomic, cultural, and systemic barriers to achieving these benefits of education and make recommendations for a path to achieving universal coverage of secondary schooling
Accidental traffickers: Qualitative findings on labour recruitment in Ethiopia
No full textBackground: The growth of labour migration and associated risks of human trafficking and exploitation remain significant global human rights and health challenges. There is increasing policy interest in addressing structural determinants of adverse migration outcomes such as migrants’ use of informal employment recruiters. In Ethiopia, “safe migration” policies have introduced regulations for registered private employment agencies and penalties for anyone else placing migrants into work overseas. Yet migrants continue to use informal facilitators who are often demonised as traffickers without evidence of their motivations, experiences or perceptions. We conducted qualitative interviews with 28 informal facilitators as part of a study into how recruitment practices shape risks for female migrants seeking domestic work in the Middle East and Gulf States. We present the realities of irregular recruitment on the ground, and how these practices are affected by policies that dichotomise recruiters into legal/safe and illegal/unsafe categories. Results: We identified four main themes. First, arranging migration from rural areas differs from in the capital, Addis Ababa, where laws and regulations originate. Outside Addis Ababa, registration was difficult for facilitators to arrange, with little incentive to do so due to its lack of importance to prospective migrants. Second, the ability to circumvent legal requirements was considered an advantage of informal facilitators because it reduced costs and expedited migrants’ departure. Third, facilitators did not work alone but operated in long “chains” of diverse actors. This meant migrants’ safety was not determined by any given individual, but spread across numerous people involved in sending a migrant abroad, some of whom might be registered and others not. And finally, facilitators did not believe they could realistically safeguard migrants once they were outside of Ethiopia and working under different laws and employers. Conclusions: Findings from this study add to a growing body of work demonstrating the diversity of people involved in the migration process, and consequent oversimplification of popular policy solutions. A more effective approach might be to constructively engage informal facilitators and identify ways they could assist with referring migrant workers to registered agencies and safe employment, rather than criminalising their participation
Exploring the role of men in child marriage decision-making in rural Upper Egypt
Get PDFEgypt’s 2021 Family Health Survey indicated that nearly 18% of women aged 20–24 years had married or were engaged before turning 18. This brief explores the perspectives of adolescent girls, their families, and key stakeholders on the role of men in the decision-making process pertaining to child marriage. The study took place in Assiut and Sohag in Upper Egypt selected on the basis of the high prevalence of child marriage. Results confirm that, in line with the patriarchal norms that underlie most marriage decisions in rural Upper Egypt, fathers/male guardians are the primary decision-makers regarding when a girl gets married and to whom. Poverty and fear about the girl’s reputation push fathers to marry off their underage daughters while misconceptions about masculinity along with inequitable gender norms drive men to seek child brides to ensure their subordination. Lack of financial, cognitive, and social capital undermine girls’ negotiating power and push them to accept marriage at an early age. In some instances girls can mobilize support from other family members and stop an early or unwanted marriage from happening. Recommendations are suggested to curb child marriage in rural Upper Egypt
Which intervention synergies maximize AGYW\u27s HIV outcomes? A classification and regression tree analysis of layered HIV prevention programming
No full textIntroduction: Intersecting behavioral, social, and structural factors increase adolescent girls\u27 (AG) and young women\u27s (YW) HIV vulnerability. Yet, understanding of optimal intervention synergies remains limited. We identified intervention combinations that statistically maximized reductions in AGYW\u27s HIV-related risk. Methods: Using data collected in 2018 with Zambian AG (n = 487, aged 15–19 years) and YW (n = 505, aged 20–25 years) after 12–14 months exposure to Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (multisectoral HIV program), we used classification and regression trees to explore relationships between interventions (safe space/social asset building [SAB] and provision of/linkage to youth-friendly health services [YFHS], education social protection [Educ], economic social protection [Econ]) and HIV-related outcomes (HIV testing, consistent condom use, transactional sex, and sexual violence experience from partners and nonpartners). Results: Overall, 59.9% completed SAB and 81.5%, 35.4%, and 29.6% received YHFS, Educ, and Econ, respectively. For AG, HIV testing improved (from 73% to 83%) with exposure to all interventions, condom use improved with Econ (from 33% to 46%), transactional sex reduced with SAB + Educ, and sexual violence from partners and nonpartners reduced with Educ and SAB, respectively. For YW, HIV testing increased with Educ (from 77% to 91%), condom use increased with SAB + YFHS (from 36% to 52%), transactional sex reduced with combinations of all interventions, and sexual violence from partners reduced with YFHS and from nonpartners with SAB + Econ. Conclusions: Tailored interventions might be more effective than uniform combination intervention packages in reducing AGYW\u27s HIV risk. AG benefitted most from SAB and/or Educ while YFHS, Educ, and/or SAB reduced YW\u27s HIV-related risk. Educational and asset-building interventions could have the greatest impact on AGYW\u27s HIV risk
Adapting a community-based intervention to address social determinants of health influencing pre-exposure prophylaxis services for Black adults in Washington, District of Columbia: A study protocol
No full textCommunity-based HIV treatment initiation and continuation helps to address social determinants of health (SDOH) barriers to care and increase antiretroviral therapy (ART) uptake and adherence. Similarly, community-based pre-exposure prophylaxis (cbPrEP) services can help address SDOH barriers such as transportation costs and stigma. However, few studies have examined cbPrEP programming in the Washington, District of Columbia (DC) area where more Blacks are disproportionately affected by HIV and have low PrEP uptake. This study aims to adapt and pilot a community-based ART intervention (cbART) intervention for cbPrEP service delivery for Black adults in the Washington, DC area. The adaptation of the cbART intervention will be informed by the ADAPT-ITT framework and the Consolidated Framework for Implementation Research. For Aim 1, in-depth and key informant interviews will be conducted with PrEP program managers at community-based organizations (N = 10), DC health department representatives (N = 8), PrEP providers (N = 10) and current and potential Black PrEP users (n = 24). The interviews will provide an initial assessment of barriers and facilitators to PrEP services and inform the decisions on how to adapt the cbART intervention for cbPrEP services. In Aim 2, we will train and pilot test the cbPrEP intervention for acceptability, feasibility, and appropriateness with Black adults (n = 60). Enrolled participants will complete a survey at baseline and at 45 days post-enrollment. In-depth interviews will be conducted with a subset (N = 16) of participants, those who did not enroll (N = 10) and providers implementing the cbPrEP intervention (N = 8). Alternative strategies to PrEP service delivery are needed to increase PrEP uptake among those most in need in the DC area. If cbPrEP delivery is found to be acceptable, feasible, and appropriate, it could have a significant impact on DC’s Ending the HIV Epidemic efforts and will inform future efforts to investigate the intervention’s efficacy on PrEP uptake and continuation among Black adults in DC