Publications by authors named "Ilene S Speizer"

123 Publications

Men's social networks, social norms, & family planning in Benin.

Glob Public Health 2021 May 25:1-15. Epub 2021 May 25.

The Institute of Reproductive Health at Georgetown University, Washington D. C., United States.

To address low family planning (FP) use and high unmet need in West Africa, attention has been paid to addressing FP-related social networks and norms. Most work focuses on women. This analysis assesses men's FP-related social networks and norms and their relation to FP use in Benin using data from baseline surveys from the Tékponon Jikuagou intervention. We descriptively analysed men's egocentric FP-related social networks and norms at the village level. Multivariable logistic regression analyses ( = 885) examined the relationship between FP-related social networks, norms, and men's current and future FP use. Twenty-three percent of men reported current modern contraception use and 47% reported intended future use. Most had few network members. While most believed it was acceptable to discuss FP, few talked with peers about FP and most did not discuss FP with their partner(s). In multivariable analyses, neither networks nor norms were significantly related to men's FP use. Men's networks being small and men rarely discussing FP indicate an opportunity for village-based approaches to engage men in FP discussions and spark FP dialogue within couples, between men, and within villages. Future work should further explore the relationship between men's social networks, norms, and FP use.
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http://dx.doi.org/10.1080/17441692.2021.1933125DOI Listing
May 2021

A vignette-based approach to understanding social norms around family planning in three Nigerian cities.

Glob Public Health 2021 May 25:1-13. Epub 2021 May 25.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Understanding the mechanisms through which social norms shape contraceptive use can help prevent unintended pregnancies in low-income countries. The Nigerian Urban Reproductive Health Initiative (NURHI) aimed to increase contraceptive uptake through advocacy, service delivery, and demand generation. Using data from focus group discussions, we examined whether social norms around family planning (FP), and specifically use of modern contraception (MC), varied among women and girls of reproductive age exposed to varying levels of the programme in three Nigerian cities. Injunctive social norms were generally unfavourable of unmarried adolescent girls' use of MC, though participants often shared exceptions for certain types of adolescents whose use of MC would be acceptable. There was greater acceptability for MC use by women who wanted to space or limit pregnancies. Participants reported that norms around FP and MC use have become more accepting in their communities over time. Normative differences between cities were identified. Participants' perceptions of religious leaders' support for FP use may have contributed to positively influencing social norms.
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http://dx.doi.org/10.1080/17441692.2021.1928261DOI Listing
May 2021

The mediating role of partner communication on contraceptive use among adolescent girls and young women participating in a small-group intervention in Malawi: A longitudinal analysis.

Glob Public Health 2021 May 12:1-14. Epub 2021 May 12.

University of North Carolina Project, Lilongwe, Malawi.

Though effective reproductive health interventions have been developed for adolescent girls and young women (AGYW) in sub-Saharan Africa, few have explored whether specific components of the interventions are responsible for observed changes in behaviour. Data for this longitudinal mediation analysis come from a quasi-experimental, sexual and reproductive health study conducted among AGYW (age 15-24) in Malawi. We assessed the extent to which the relationship between attending communication-specific small-group sessions and contraceptive use at one-year was mediated by contraceptive communication with partners at six months, using a bootstrapping procedure to estimate indirect effects. Of 358 participants, 44% attended communication-specific small-group sessions, 37% communicated with partners about contraception at six months, and 21% used non-barrier contraception at one-year. Participants who attended communication-specific small-group sessions had increased contraceptive communication with partners at six months (aOR = 1.48, 95% CI: 1.07-2.38) and increased non-barrier contraceptive use at one-year (aOR = 3.53, 95% CI: 1.86-6.69). The relationship between attending communication-specific small-group sessions and non-barrier contraceptive use at one-year was partially mediated by contraceptive communication with partners at six months (indirect effect = 0.04, 95% CI: 0.01-0.07). Our results suggest that contraceptive communication with partners is modifiable through interventions and important for AGYW non-barrier contraceptive uptake.
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http://dx.doi.org/10.1080/17441692.2021.1924823DOI Listing
May 2021

Communication, social norms, and contraceptive use among adolescent girls and young women in Lilongwe, Malawi.

Women Health 2021 May-Jun;61(5):440-451. Epub 2021 May 4.

University of North Carolina Project, Lilongwe, Malawi.

In Malawi, 50% of adolescent girls and young women (AGYW) have had a first child by age 19 and 45% report their pregnancies as unintended or mistimed. Yet, uptake of contraception remains low. Understanding how interactions with social ties impact AGYW contraceptive use might explain low uptake beyond individual and environmental factors. Data are from Girl-Power, a study among sexually active AGYW, aged 15-24, in Malawi. We used logistic regression models to examine whether contraceptive communication and social norms (descriptive and injunctive) were associated with contraceptive use (non-barrier methods and condoms) and how associations differed across social ties (older women in the family, peers, and partners). The sample included 942 participants: 28% reported using non-barrier methods and 66% reported using condoms. Contraceptive communication with older women in the family (aOR: 1.48, 95% CI: 0.99, 2.20), peers (aOR: 3.12, 95% CI: 1.96, 4.96), and partners (aOR 5.15, 95% CI: 3.13, 8.48) was associated with non-barrier method use. Descriptive norms were associated with non-barrier methods among peers (aOR 2.57, 95% CI: 1.63, 4.96) but not among older women in the family (aOR: 1.22, 95% CI 0.80, 1.88). There were no associations among contraceptive communication, social norms, and condom use across older women in the family, peers, and partners. The findings highlight the need to consider the influence of social ties in the design of future family planning interventions and suggest that interventions that encourage interpersonal communication about contraception and target peer-based descriptive norms have the potential to impact uptake of non-barrier methods.
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http://dx.doi.org/10.1080/03630242.2021.1917479DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8182971PMC
May 2021

Her, his, and their fertility desires and contraceptive behaviours: A focus on young couples in six countries.

Glob Public Health 2021 May 3:1-17. Epub 2021 May 3.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Most studies examining contraceptive use among women focus on their own fertility desires and family planning attitudes and do not incorporate the desires and attitudes of their partner. Using Demographic and Health Survey data from young couples (wife is aged 15-24) from six countries, we use descriptive and multivariate analyses to examine the association between couple-level fertility desires and current contraceptive use and women's future intention to use contraception. Results demonstrate that young couples want to have children immediately or may want to delay having children for two or more years; very few do not want (more) children. Discordant fertility desires were found in all countries. Compared to couples where both partners want a child soon, young couples that want to delay childbearing or where the husband wants a child, and the wife wants to delay or avoid childbearing are significantly more likely to use contraception. Similar results are found for women's intention to use contraception. When discordant fertility desires are associated with the outcomes, the young wife's fertility desire matters more than her husband's. Among young couples, promoting communication and positive social norms for delaying a first or second birth can lead to positive health outcomes for mothers and babies.
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http://dx.doi.org/10.1080/17441692.2021.1922732DOI Listing
May 2021

The association of empowerment measures with maternal, child and family planning outcomes in Plateau State Nigeria by urban-rural residence.

BMC Pregnancy Childbirth 2021 Feb 27;21(1):170. Epub 2021 Feb 27.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Nigeria is experiencing a high level of urbanization and urban poverty. Within Nigeria maternal and child health and family planning outcomes may differ by residence (capital city, urban/non-capital city and rural) as well as by measures of women's empowerment and wealth. This paper presents a detailed analysis of maternal and child health and family planning outcomes in Plateau State, Nigeria.

Methods: Data came from the 2017 Nigerian Urban Reproductive Health Initiative Sustainability Study. Multivariable logistic regression was used to study the associations between the key independent variables of residence, women's empowerment and wealth with having a skilled birth attendant at childbirth and childhood preventative visits. The women's empowerment variables included perceptions about household decision-making, financial decision-making, views on wife beating and having a prohibition, defined as a restriction on specific activities imposed by a woman's husband. Multinomial regression was used to study the association of the same factors with the family planning outcome which had three categories - no use, traditional method use and modern method use. Regressions were also run separately for urban and rural populations.

Results: Women in the capital city of Jos were significantly more likely to have a skilled birth attendant at childbirth, take a child to a preventative visit and use family planning than women in rural areas of Plateau State. Three of the four measures of empowerment (household decision-making, financial decision-making and having a prohibition) were significantly associated with the family planning outcome, while having a prohibition was negatively associated with having a skilled birth attendant at childbirth. In rural areas, women involved in financial decisions were significantly less likely to use a modern method compared to a traditional method. Wealth was a significant factor for all outcomes.

Discussion: State-level analyses can provide valuable information to inform programs and policies at a local level. Efforts to improve use of maternal and child health and family planning services in Plateau state, Nigeria, should consider women's empowerment, residence and poverty. Community education on the effectiveness of modern versus traditional methods and potential side effects of specific modern methods, may help women make informed decisions about contraception.
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http://dx.doi.org/10.1186/s12884-021-03659-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7916291PMC
February 2021

Development of integration indexes to determine the extent of family planning and child immunization services integration in health facilities in urban areas of Nigeria.

Reprod Health 2021 Feb 23;18(1):47. Epub 2021 Feb 23.

University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: Integrating family planning into child immunization services may address unmet need for contraception by offering family planning information and services to postpartum women during routine child immunization visits. However, policies and programs promoting integration are often based on insubstantial or conflicting evidence about its effects on service delivery and health outcomes. While integration models vary, many studies measure integration as binary (a facility is integrated or not) rather than a multidimensional and varying continuum. It is thus challenging to ascertain the determinants and effects of integrated service delivery. This study creates Facility and Provider Integration Indexes, which measure capacity to support integrated family planning and child immunization services and applies them to analyze the extent of integration across 400 health facilities.

Methods: This study utilizes cross-sectional health facility (N = 400; 58% hospitals, 42% primary healthcare centers) and healthcare provider (N = 1479) survey data that were collected in six urban areas of Nigeria for the impact evaluation of the Nigerian Urban Reproductive Health Initiative. Principal Component Analysis was used to develop Provider and Facility Integration Indexes that estimate the extent of integration in these health facilities. The Provider Integration Index measures provider skills and practices that support integrated service delivery while the Facility Integration Index measures facility norms that support integrated service delivery. Index scores range from zero (low) to ten (high).

Results: Mean Provider Integration Index score is 5.42 (SD 3.10), and mean Facility Integration Index score is 6.22 (SD 2.72). Twenty-three percent of facilities were classified as having low Provider Integration scores, 32% as medium, and 45% as high. Fourteen percent of facilities were classified as having low Facility Integration scores, 38% as medium, and 48% as high.

Conclusion: Many facilities in our sample have achieved high levels of integration, while many others have not. Results suggest that using more nuanced measures of integration may (a) more accurately reflect true variation in integration within and across health facilities, (b) enable more precise measurement of the determinants or effects of integration, and (c) provide more tailored, actionable information about how best to improve integration. Overall, results reinforce the importance of utilizing more nuanced measures of facility-level integration.
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http://dx.doi.org/10.1186/s12978-021-01105-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903768PMC
February 2021

Influences on contraceptive method choice among adolescent women across urban centers in Nigeria: a qualitative study.

Contracept Reprod Med 2021 Feb 16;6(1). Epub 2021 Feb 16.

Carolina Population Center, University of North Carolina-Chapel Hill, Chapel Hill, USA.

Background: Despite calls to increase contraceptive use among adolescents and youth, large gaps still exist, creating an unmet need for family planning. Past research has focused on barriers to seeking a method. There is less understanding of the types of methods young women want and who and what influences these decisions. This study examines what method characteristics young Nigerian women prioritize when choosing a method to inform future family planning programming.

Methods: In 2018, eight focus group discussions (FGD) were conducted in the Nigerian cities of Ilorin and Jos with 83 young women ages 15-24. Participants were identified by community contacts and separated into groups by religion and marital status. The discussion guide utilized a vignette structure to understand the participants' perceptions on contraceptive behavior and attitudes and misconceptions surrounding different types of methods. The FGDs were undertaken and analyzed by collaborative teams from the University of Ibadan and the University of North Carolina-Chapel Hill. A thematic analysis of the transcripts was performed using Atlas.ti, including two rounds of coding, and multiple reviews by the research team.

Results: The method characteristics associated with young women's contraceptive decisions include: side effects, reliability, length of coverage, privacy, cost, and accessibility. Side effects, reliability, and privacy were described as negatively linked to short-acting methods whereas easy accessibility and low cost were positive characteristics of these methods. Long-acting methods were generally viewed as positive. Participants' focus on side effects commonly resulted from concerns about the impact on future fertility. The characteristics prioritized by individuals change throughout their adolescence and as their marital status changes. Providers, peers, parents, and partners were all found to have an influence over method choice in different ways. The role of these influencers also changes over the adolescent years.

Conclusion: This study demonstrates that programs should prioritize expanding method choice to increase the number of available options to ensure all young women can access a method that fits their desired method characteristics. Programming should ensure that medically accurate information is widely distributed to harness providers, peers, parents and partners as a resource for information about specific methods.
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http://dx.doi.org/10.1186/s40834-020-00146-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7888078PMC
February 2021

Women's Perspectives on Contraceptive-Induced Amenorrhea in Burkina Faso and Uganda.

Int Perspect Sex Reprod Health 2020 12 31;46:247-262. Epub 2020 Dec 31.

Scientist, Health Services Research Division, FHI 360, Durham, NC, USA.

Context: Women's concerns about contraceptive-induced menstrual changes can lead to method discontinuation and nonuse, contributing to unmet need for contraception. Research on women's perceptions of amenorrhea related to longer acting methods and in low-income countries is limited.

Methods: Data were from nationally representative household surveys and focus group discussions with women of reproductive age conducted in Burkina Faso and Uganda in 2016-2017. Bivariate cross-tabulations and multivariate logistic regression analyses were used to examine sociodemographic and reproductive characteristics associated with women's attitudes about contraceptive-induced amenorrhea (n=2,673 for Burkina Faso and 2,281 for Uganda); menstrual health determinants were also examined for Burkina Faso. Qualitative data from focus group discussions were analyzed to understand reasons behind women's attitudes and how they influence contraceptive decision making.

Results: Sixty-five percent of women in Burkina Faso and 40% in Uganda reported they would choose a method that caused amenorrhea during use. In Burkina Faso, the predicted probability of accepting amenorrhea was higher for women aged 15-19 (compared with older women), living in rural areas, married and cohabiting (compared with never married), currently using a contraceptive method (compared with never users) and from Mossi households (compared with Gourmantché); menstrual health practices were not associated with amenorrhea acceptability. In Uganda, the least wealthy women had the highest predicted probability of accepting amenorrhea (51%). Qualitative analysis revealed a variety of reasons for women's attitudes about amenorrhea and differences by country, but the relationship between these attitudes and contraceptive decision making was similar across countries.

Conclusions: Addressing misconceptions about contraception and menstruation may result in more informed method decision making.
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http://dx.doi.org/10.1363/46e1520DOI Listing
December 2020

Associations of Father and Adult Male Presence with First Pregnancy and HIV Infection: Longitudinal Evidence from Adolescent Girls and Young Women in Rural South Africa (HPTN  068).

AIDS Behav 2021 Jul 8;25(7):2177-2194. Epub 2021 Jan 8.

Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Drive, 2101 McGavran-Greenberg Hall, Chapel Hill, NC, 27599-7435, USA.

This study, a secondary analysis of the HPTN 068 randomized control trial, aimed to quantify the association of father and male presence with HIV incidence and first pregnancy among 2533 school-going adolescent girls and young women (AGYW) in rural South Africa participating in the trial between March 2011 and April 2017. Participants' ages ranged from 13-20 years at study enrollment and 17-25 at the post-intervention visit. HIV and pregnancy incidence rates were calculated for each level of the exposure variables using Poisson regression, adjusted for age using restricted quadratic spline variables, and, in the case of pregnancy, also adjusted for whether the household received a social grant. Our study found that AGYW whose fathers were deceased and adult males were absent from the household were most at risk for incidence of first pregnancy and HIV (pregnancy: aIRR = 1.30, Wald 95% CI 1.05, 1.61, Wald chi-square p = 0.016; HIV: aIRR = 1.27, Wald 95% CI 0.84, 1.91, Wald chi-square p = 0.263) as compared to AGYW whose biological fathers resided with them. For AGYW whose fathers were deceased, having other adult males present as household members seemed to attenuate the incidence (pregnancy: aIRR = 0.92, Wald 95% CI 0.74, 1.15, Wald chi-square p = 0.462; HIV: aIRR = 0.90, Wald 95% CI 0.58, 1.39, Wald chi-square p = 0.623) such that it was similar, and therefore not statistically significantly different, to AGYW whose fathers were present in the household.
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http://dx.doi.org/10.1007/s10461-020-03147-yDOI Listing
July 2021

Government stakeholders' perspectives on the family planning environment in three Nigerian cities: qualitative findings from the Nigerian Urban Reproductive Health Initiative (NURHI) Sustainability Study.

Glob Health Action 2020 12;13(1):1847821

Carolina Population Center, The University of North Carolina at Chapel Hill , Chapel Hill, NC, USA.

: The Nigerian government has made numerous commitments to expanding access to family planning services for its population yet has faced many challenges in implementing these commitments. Foreign donors provide support for expanding access to family planning in key populations. : This study examines the family planning environment after donor funding has ended, including how government stakeholders perceive family planning services and their role in providing them post donor funding. : The NURHI Sustainability Study used qualitative data to evaluate the sustainability of the Nigerian Urban Reproductive Health Initiative (NURHI), which focused on increasing the use of modern contraceptive methods, particularly among the urban poor. This study presents results from in-depth interviews with 16 key government stakeholders, selected using purposive sampling methods, in three cities: Ilorin (where NURHI Phase 1 programming discontinued in 2015), Kaduna (where programming continued under NURHI Phase 2), and Jos (a comparison city). A thematic analysis was employed to identify key themes related to government stakeholders' perspectives on the family planning environment and sustainability of NURHI programming. : Respondents from all three cities highlighted local political leaders' positive perceptions about family planning. All respondents were open to continued foreign donor support for family planning services while respondents in Kaduna and Jos emphasized the need for governments to lead efforts among all family planning actors. Stakeholders highlighted the benefits of a dedicated and implemented family planning budget line and encouraged continued state financial support. Respondents in Kaduna and Ilorin praised the positive influence of NURHI programming while those from Ilorin reflected on the need for future programs to gradually close-out their efforts to support sustainability. : As donors look to transition to government ownership of family planning efforts, it is important for family planning programs to understand and incorporate government stakeholders' perspectives into their sustainability planning efforts.
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http://dx.doi.org/10.1080/16549716.2020.1847821DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717862PMC
December 2020

HIV-Related Knowledge, Attitudes, and Behaviors among Grade 10 Girls and Boys in Mpumalanga and KwaZulu-Natal: Cross-Sectional Results.

Open AIDS J 2020 18;14:75-83. Epub 2020 Sep 18.

SADC Research Centre, Cape Town, South Africa.

Background: Young people in KwaZulu-Natal and Mpumalanga South Africa are at high risk of HIV and other sexually transmitted infections. Programs are needed to reach these young people and change their knowledge, attitudes, and behaviors.

Objective: The objective of this study is to use cross-sectional data from grade 10 female and male learners in randomly assigned intervention and control schools to examine knowledge, attitudes, and sexual behaviors.

Methods: Participants were in grade 10 in the 2018 school year and were attending schools randomly assigned to the intervention and control arms for implementation of the Department of Basic Education's adapted life orientation curriculum that included scripted lesson plans. The study took place in two high HIV prevalence provinces in South Africa. Participants completed self-administered tablet-based surveys and female participants provided a dried blood spot for HIV testing.

Results: Results demonstrate that two-fifths to one-half of male learners reported being sexually experienced and a quarter (KwaZulu-Natal) to a third (Mpumalanga) of the female learners reported the same. A greater percentage of learners in Mpumalanga reported consistent condom use than learners in KwaZulu-Natal. HIV prevalence among female grade 10 learners in both provinces was about 6-7%. No notable differences are observed between intervention and control school learners on the knowledge, attitudes, and behavior outcomes.

Conclusion: The findings demonstrate the importance of developing HIV prevention programs for young people in high HIV prevalence provinces since these young people remain at high risk for HIV and other negative outcomes.

Trial Registration: This study has been registered at ClinicalTrials.gov. The trial registration number is: NCT04205721. The trial was retrospectively registered on December 18, 2019.
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http://dx.doi.org/10.2174/1874613602014010075DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7758912PMC
September 2020

Influences on seeking a contraceptive method among adolescent women in three cities in Nigeria.

Reprod Health 2020 Oct 28;17(1):167. Epub 2020 Oct 28.

Institute of Child Health, University of Ibadan, College of Medicine, Ibadan, Nigeria.

Background: Despite international support for increasing access to contraceptives among adolescents, gaps in use still exist worldwide. Past research has identified barriers to use across all levels of the socioecological model including restrictive policies, a lack of youth friendly services, and knowledge gaps. This study was conducted to further identify influences on contraceptive use among adolescent girls in Nigeria in hopes of guiding future policies and programs.

Methods: In 2018, 12 focus group discussions (FGD) were conducted in three cities in Nigeria with young women ages 15-24 with the objective of determining what and who influence adolescents' contraceptive seeking behaviors. A vignette structure was used to identify perceptions on injunctive and descriptive community norms that influence adolescent contraceptive behaviors. The FGDs were conducted by members of the University of Ibadan Centre for Population and Reproductive Health (CPRH) and analyzed by a researcher at the University of North Carolina-Chapel Hill's Carolina Population Center using a thematic analysis approach.

Results: Participants identified community level resistance to sex and contraceptive use among unmarried adolescents though also acknowledged that these adolescent behaviors are still occurring despite established norms. Concerns about side effects and the preservation of fertility were frequently attached to contraceptive use and pointed to as a reason for community resistance to contraceptive use among this population. Participants saw peers, parents and partners as influencers on a girl's decision to seek a method, though each were believed to play a different role in that decision.

Conclusion: The findings show that that despite barriers created by established injunctive norms, young women with a supportive social network can access contraceptive methods despite these barriers. By harnessing the influence of peers, partners and parents, the Nigerian family planning efforts can strive to improve the health and well-being of young people.
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http://dx.doi.org/10.1186/s12978-020-01019-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7594415PMC
October 2020

Impact evaluation of scripted lesson plans for HIV-related content in a life orientation curriculum: results from two provinces in South Africa.

BMC Public Health 2020 Oct 14;20(1):1542. Epub 2020 Oct 14.

SADC Research Centre, Cape Town, South Africa, USA.

Background: Young people under age 25 years are a key population at risk of unintended pregnancies, HIV and other sexually transmitted infections. School-based programming, focusing on youth under 17 years is strategic given that many in this age group are in school or are required to be in school and spend a considerable amount of their time at school. Prior evaluations of school-based HIV prevention programs for young people often employed weak study designs or lacked biomarkers (e.g., HIV or STI testing) to inform outcomes.

Methods: This study used longitudinal data collected in 2016 from a cohort of grade-8 girls from Mpumalanga and KwaZulu-Natal Provinces in South Africa. We followed them for 2 years to examine the impact of the South African Department of Basic Education's revised scripted lesson plans for the HIV and sexual content of a "life orientation" curriculum on knowledge, attitudes, condom use behaviors, pregnancy incidence, and genital herpes incidence. Schools were randomized to intervention and control arms. Multivariable analyses were undertaken using hazard modeling for incidence-based outcomes (genital herpes and pregnancy) and generalized linear latent and mixed modeling for outcomes measured at each time period (knowledge, attitudes, and condom use).

Results: At end line, 105 schools were included from the two provinces (44 from Mpumalanga and 61 from KwaZulu-Natal). Fifty-five were intervention and fifty were control schools. A total of 2802 girls were surveyed at both time periods (1477 intervention and 1325 control). At baseline, participating girls were about 13.6 years; by end line, they were about 2 years older. Longitudinal data demonstrated few differences between intervention and control groups on knowledge, attitudes, condom use, genital herpes, and pregnancy experience. Monitoring data demonstrated that the program was not implemented as intended. Our results demonstrated 7% incidence of genital herpes in the two-year follow-up period indicating sexual risk-taking among our cohort.

Conclusions: We did not find significant effects of the revised life orientation curriculum on key outcomes; however, this may reflect poor implementation. Future HIV prevention programs for young people need to be implemented with fidelity to ensure they meet the crucial needs of the next generation.

Trial Registration: This study has been registered at ClinicalTrials.gov . The trial registration number is: NCT04205721 . The trial was retrospectively registered on December 18, 2019.
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http://dx.doi.org/10.1186/s12889-020-09640-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7556937PMC
October 2020

The PrEPARE Pretoria Project: protocol for a cluster-randomized factorial-design trial to prevent HIV with PrEP among adolescent girls and young women in Tshwane, South Africa.

BMC Public Health 2020 Sep 15;20(1):1403. Epub 2020 Sep 15.

Setshaba Research Centre, 2088 Block H, Soshanguve, 0152, South Africa.

Background: Despite increased prevention efforts, HIV remains the leading cause of death among adolescent girls and young women in South Africa. Although research indicates important determinants of HIV acquisition at the individual and interpersonal levels, structural-level stigma and discrimination continue to be critical barriers to reaching and retaining this key population for HIV prevention and sexual and reproductive health services. Innovative and multilevel interventions are needed that can address the intersectional structural and gender issues that young women face, including stigma, alcohol and drug use, gender-based violence, and other risk factors when seeking health services. Oral pre-exposure prophylaxis (PrEP) taken daily has been found to be an effective biomedical HIV prevention tool. Testing a comprehensive gender-focused biobehavioral HIV prevention intervention that is inclusive of social ecological determinants, such as stigma and discrimination reduction in clinics, is critical for reducing HIV among adolescent girls and young women.

Methods: This project involves both a Community Collaborative Board and a Youth Advisory Board in helping to adapt the Young Women's Health CoOp intervention and the Health Policy Project (HPP) Stigma and Discrimination (S&D) reduction training curriculum to the setting and population. This study uses a two-by-two factorial design with stratified randomization of 12 clinics, each with distinct catchment areas. The Young Women's Health CoOp addresses substance use, sexual risk, violence prevention and sexual negotiation, condom demonstration, and problem solving with the following additions: knowledge of PrEP, the importance of PrEP adherence, and sexual and reproductive health. Adolescent girls and young women will be assessed with behavioral and biological measures at baseline, 3-, 6- and 9-month follow-up. The S&D reduction training is provided for all staff in the clinics randomized to this condition. Clinic staff will be surveyed at baseline, 4- and 8-month follow-up. We will recruit 900 AGYW from communities in the 12 clinic catchment areas.

Discussion: The study findings, if efficacious across the outcomes, will be incorporated into the gender-focused HIV prevention intervention toolkit and disseminated to inform multilevel prevention approaches.

Trial Registration: ClinicalTrials.gov. Identifier: NCT04048551 (Recruiting). Registered: August 7, 2019 (Retrospectively registered).
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http://dx.doi.org/10.1186/s12889-020-09458-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7490774PMC
September 2020

The Examination of Diffusion Effects on Modern Contraceptive Use in Nigeria.

Demography 2020 06;57(3):873-898

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599-3305, USA.

This study uses data gathered for an evaluation of a Bill & Melinda Gates Foundation-funded initiative designed to increase modern contraceptive use in select urban areas of Nigeria. When the initiative was conceived, the hope was that any positive momentum in the cities would diffuse to surrounding areas. Using a variety of statistical methods, we study three aspects of diffusion and their effects on modern contraceptive use: spread through mass communications, social learning, and social influence. Using a dynamic causal model, we find strong evidence of social multiplier effects through social learning. The results for social influence and spread through mass communications are promising, but we are unable to identify definitive causal impacts.
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http://dx.doi.org/10.1007/s13524-020-00884-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329794PMC
June 2020

Longitudinal examination of changing fertility intentions and behaviors over a four-year period in urban Senegal.

Reprod Health 2020 Mar 17;17(1):38. Epub 2020 Mar 17.

Carolina Population Center, University of North Carolina at Chapel Hill, 123 W. Franklin St, Chapel Hill, NC, 27516, USA.

Background: Fertility intentions and contraceptive use are often used to demonstrate gaps in programs and policies to meet the contraceptive needs of women and couples. Prior work demonstrated that fertility intentions are fluid and change over a woman's (or couple's) life course with changing marital status, childbearing, and education/employment opportunities. This study uses longitudinal data to better examine the fluidity of women's fertility intentions and disentangle the complex interrelationships between fertility and contraceptive use.

Methods: Using survey data from three time points and three urban sites in Senegal, this study examines how women's fertility intentions and contraceptive use in an earlier period affect pregnancy experience and the intentionality of experienced pregnancies among a sample of 1050 women who were in union at all three time points. We apply correlated random effect longitudinal regression methods to predict a subsequent birth by fertility intentions and modern contraceptive use at an earlier period addressing endogeneity concerns of earlier analyses that only include two time periods.

Results: Descriptive results demonstrate some change in fertility desires over time such that 6-8% of women who reported their pregnancy as intended (i.e., wanted to get pregnant at time of pregnancy) reported earlier that they did not want any(more) children. Multivariate analyses demonstrate that women who want to delay or avoid a pregnancy and are using modern contraception are the least likely to get pregnant. Among women who became pregnant, the only factor differentiating whether the pregnancy is reported as intended or unintended (mistimed or unwanted) was prior fertility intention. Women who wanted to delay a pregnancy previously were more likely to report the pregnancy as unintended compared to women who wanted to get pregnant soon.

Conclusions: These results suggest some post-hoc rationalization among women who are getting pregnant. Women who say they do not want to get pregnant may be choosing not to use a contraceptive method in this urban Senegal context of high fertility. Programs seeking to reach these women need to consider their complex situations including their fertility intentions, family planning use, and the community norms within which they are reporting these intentions and behaviors.
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http://dx.doi.org/10.1186/s12978-020-0893-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7077111PMC
March 2020

Measurement Error in Discrete Health Facility Choice Models: an Example from Urban Senegal.

J Appl Econ (Chichester Engl) 2019 Nov-Dec;34(7):1102-1120. Epub 2019 Sep 4.

Gillings School of Global Public Health, Department of Maternal and Child Health and Carolina Population Center, University of North Carolina at Chapel Hill.

We use individual-level health facility choice data from urban Senegal to estimate consumer preferences for facility characteristics related to maternal health services. We find that consumers consider a large number of quality related facility characteristics, as well as travel costs, when making their health facility choice. In contrast to the typical assumption in the literature, our findings indicate that individuals frequently bypass the facility nearest their home. In light of this, we show that the mismeasured data used commonly in the literature produces biased preference estimates; most notably, the literature likely overestimates consumer distaste for travel.
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http://dx.doi.org/10.1002/jae.2739DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7062358PMC
September 2019

Measures of family planning service quality associated with contraceptive discontinuation: an analysis of Measurement, Learning & Evaluation (MLE) project data from urban Kenya.

Gates Open Res 2019 29;3:1453. Epub 2020 Jan 29.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27516, USA.

Several measures to assess family planning service quality (FPQ) exist, yet there is limited evidence on their association with contraceptive discontinuation. Using data from the Measurement, Learning & Evaluation (MLE) Project, this study investigates the association between FPQ and discontinuation-while-in-need without switching in five cities in Kenya. Two measures of FPQ are examined - the Method Information Index (MII) and a comprehensive service delivery point (SDP) assessment rooted in the Bruce Framework for FPQ. Three models were constructed: two to assess MII reported in household interviews (as an ordinal and binary variable) among 1,033 FP users, and one for facility-level quality domains among 938 FP users who could be linked to a facility type included in the SDP assessment. Cox proportional hazards ratios were estimated where the event of interest was discontinuation-while-in-need without switching. Facility-level FPQ domains were identified using exploratory factor analysis (EFA) using SDP assessment data from 124 facilities. A woman's likelihood of discontinuation-while-in-need was approximately halved whether she was informed of one aspect of MII (HR: 0.45, p < 0.05), or all three (HR: 0.51, p < 0.01) versus receiving no information, when MII was assessed as an ordinal variable. Six facility-level quality domains were identified in EFA. Higher scores in information exchange, privacy, autonomy & dignity and technical competence were associated with a reduced risk of discontinuation-while-in-need (p < 0.05). The MII has potential as an actionable metric for FPQ monitoring at the health facility level. Furthermore, family planning facilities and programs should emphasize information provision and client-centered approaches to care alongside technical competence in the provision of FP care.
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http://dx.doi.org/10.12688/gatesopenres.12974.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7042708PMC
January 2020

Influences of health facility type for delivery and experience of cesarean section on maternal and newborn postnatal care between birth and facility discharge in Malawi.

BMC Health Serv Res 2020 Feb 24;20(1):139. Epub 2020 Feb 24.

UNC Project - Malawi, Lilongwe, Malawi.

Background: A number of studies in the past have looked at determinants of postnatal care. However, many of them do not distinguish between postnatal care (PNC) before discharge and after discharge for women delivering at health facilities. Conceptually and practically, factors associated with PNC before discharge and after discharge should be different. This study examines key factors for maternal and newborn PNC before discharge.

Methods: Data from the 2015-16 Malawi Demographic and Health Survey were used for the study. Three categorical endogenous variables examined in the study were whether or not mothers received a postnatal check between birth and facility discharge, whether or not newborns received a postnatal check between birth and facility discharge and whether or not women delivered by cesarean section. Delivery by cesarean section was considered as a mediator in the model. The main predictor of interest was type of health facility where women delivered. Other exogenous variables included were women's age at most recent birth, number of antenatal visits, women's education, household wealth, parity, newborn size, region of the country and residence. Simultaneous equation modeling was used to examine the associations of interest.

Results: 47% of the mothers and 68% of the newborns had PNC before facility discharge. The total and direct effects of delivering in private hospitals on maternal and newborn PNC before facility discharge were significantly higher than the effects of delivering in government hospitals. The total effects of delivering in government health centers or health posts on maternal and newborn PNC before facility discharge were significantly lower than the effects of delivering in government hospitals. Delivering by cesarean section compared to delivering vaginally was positively associated with maternal and newborn PNC before facility discharge.

Conclusion: It is important that all women and newborns receive PNC before they are discharged from the facility regardless of whether or not they had a complication. The same standard of quality PNC should be provided equitably across all types and affiliations of health facilities.
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http://dx.doi.org/10.1186/s12913-020-4958-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7041203PMC
February 2020

Access to family planning for youth: perspectives of young family planning leaders from 40 countries.

Gates Open Res 2019 25;3:1513. Epub 2019 Jul 25.

Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA.

: With growing populations of young people, low and middle-income countries have renewed focus on reaching both unmarried and married youth with family planning (FP) services. Young people themselves bring an important perspective to guide future programmatic directions. : In October 2018, 207 youth leaders in FP from around the world completed an online survey prior to their participation at the International Conference on Family Planning (ICFP). These youth leaders provided their perspectives on the most important influencers for youth FP use, how easy or hard it is for youth to obtain FP, preferred sources of FP methods for youth, and perceptions of commonly used terms in FP programming. We examined differences in perceptions of unmarried and married youth's access to and use of FP using bivariate analyses. : Respondents reported that peers/friends were the most important influencer on use of FP among unmarried youth (80.2%), while spouse/partner was the most important for married youth (80.4%). Oral contraceptive pills, injectable contraception, and contraceptive implants were perceived as significantly harder for unmarried youth to access. Privacy, confidentiality, and anonymity were all important factors for the locations to access FP for unmarried youth, while married youth were more influenced by cost. None of the commonly used terms for FP were perceived positively by a majority of respondents, with the exception of 'birth spacing' by African respondents (51.0%). : These findings indicate that the preferences and needs of unmarried youth are different than married youth, but that all young people face barriers accessing FP. Unmarried youth seeking family planning are more influenced by peers and friends and continue to face difficulty accessing methods compared to married youth. These findings indicate the importance of including youth perspectives in development of youth-focused family planning programs.
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http://dx.doi.org/10.12688/gatesopenres.13045.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6978846PMC
July 2019

Availability of health facilities and utilization of maternal and newborn postnatal care in rural Malawi.

BMC Pregnancy Childbirth 2019 Dec 17;19(1):503. Epub 2019 Dec 17.

Department of International Health (Health Systems Program), Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.

Background: This study explored the role of health facility availability as it relates to maternal and newborn PNC use in rural Malawi.

Methods: Malawi Demographic and Health Survey (MDHS) 2015-16 data, MDHS 2015-16 household cluster GPS data, Malawi Service Provision Assessment (MSPA) 2013-14 data and MSPA 2013-14 facility GPS data were used. Household clusters were spatially linked with facilities using buffers. Descriptive analyses were performed and generalized estimating equations (GEE) were used to determine the effects of having different types of facilities at varying distances from household clusters on receipt of maternal and newborn PNC in rural Malawi.

Results: In rural Malawi, around 96% of women had facilities providing PNC within 10 km of where they live. Among women who have clinic-level facilities within 5 km of where they live, around 25% had clinic-level facilities that provide PNC. For rural women who gave birth in the past 5 years preceding the survey, only about 3% received maternal PNC within 24 h and about 16% received maternal PNC within the first week. As for newborn PNC, 3% of newborns had PNC within 24 h and about 26% had newborn PNC within the first week. PNC mostly took place at facilities (94% for women and 95% for newborns). For women who delivered at home, having a health center providing PNC within 5 km was positively associated with maternal and newborn PNC. For women who delivered at facilities, having a health center providing PNC within 5 km was positively associated with maternal PNC and having a health center providing PNC between 5 km and 10 km was positively associated with both maternal and newborn PNC. Regardless of the place of delivery and distance band, having a clinic-level facility providing PNC did not have significant positive effects on maternal and newborn PNC.

Conclusions: Providers should be trained to perform quality PNC at all facilities. It would also be important to address concerns related to health workers. Lastly, it would be key to increase community awareness about the importance of seeking timely PNC and about the utility of lower-level facilities for receiving preventative PNC.
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http://dx.doi.org/10.1186/s12884-019-2534-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6918704PMC
December 2019

Access to public transportation and health facilities offering long-acting reversible contraceptives among residents of formal and informal settlements in two cities in Kenya.

Reprod Health 2019 Nov 8;16(1):161. Epub 2019 Nov 8.

Carolina Population Center, University of North Carolina (UNC), Chapel Hill, USA.

Background: Despite improved health facility access relative to rural areas, distance and transportation remain barriers in some urban areas. Using household and facility data linked to residential and transportation geographic information we describe availability of health facilities offering long-acting reversible contraceptive (LARC) methods and measure access via matatus (privately owned mid-size vehicles providing public transport) in urban Kenya.

Methods: Study data were collected by the Measurement, Learning and Evaluation (MLE) Project. Location information for clusters (2010) representative of city-level population were used to identify formal and informal settlement residents. We measured straight-line distances between clusters and facilities that participated in facility audits (2014) and offered LARCs. In Kisumu, we created a geographic database of matatu routes using Google Earth. In Nairobi, matatu route data were publicly available via the Digital Matatus Project. We measured straight-line distance between clusters and matatu stops on 'direct' routes (matatu routes with stop(s) ≤1 km from health facility offering LARCs). Facility and matatu access were compared by settlement status using descriptive statistics. We then used client exit interview data from a subset of facilities in Nairobi (N = 56) and Kisumu (N = 37) Kenya (2014) to examine the frequency of matatu use for facility visits.

Results: There were 141 (Informal = 71; Formal = 70) study clusters in Nairoibi and 73 (Informal = 37; Formal = 36) in Kisumu. On average, residential clusters in both cities were located ≤1 km from a facility offering LARCs and ≤ 1 km from approximately three or more matatu stops on direct routes regardless of settlement status. Client exit interview data in Nairobi (N = 1602) and Kisumu (N = 1158) suggest that about 25% of women use matatus to visit health facilities. On average, women who utilized matatus travelled 30 min to the facility, with 5% travelling more than 1 hour. Matatu use increased with greater household wealth.

Conclusions: Overall, formal and informal settlement clusters were within walking distance of a facility offering LARCs, and multiple matatu stops were accessible to get to further away facilities. This level of access will be beneficial as efforts to increase LARC use expand, but the role of wealth and transportation costs on access should be considered, especially among urban poor.
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http://dx.doi.org/10.1186/s12978-019-0828-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6839122PMC
November 2019

On the sustainability of a family planning program in Nigeria when funding ends.

PLoS One 2019 26;14(9):e0222790. Epub 2019 Sep 26.

Data Research and Mapping Corporation, Abuja, Nigeria.

Few studies have examined the sustainability of family planning program outcomes in the post-program period. This article presents the results of a natural experiment where the Nigerian Urban Reproductive Health Initiative Phase I programming ended in early 2015 and Phase II activities continued in a subset of cities. Using data collected in 2015 and 2017, we compare contraceptive ideation and modern family planning use in two cities: Ilorin where program activities concluded in 2015 and Kaduna where program activities continued. The results demonstrate that exposure to program activities decreased in Ilorin but for those individuals reporting continuing exposure, the effect size of exposure on modern family planning use remained the same and was not significantly different from Kaduna. Modern family planning use continued to increase in both cites but at a lower rate than during Phase I. The results are useful for designing family planning programs that sustain beyond the life of the program.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0222790PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6762171PMC
April 2020

The impact of India's accredited social health activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study.

Hum Resour Health 2019 08 19;17(1):68. Epub 2019 Aug 19.

Carolina Population Center, University of North Carolina, Chapel Hill, NC, USA.

Background: In 2006, the Government of India launched the accredited social health activist (ASHA) program, with the goal to connect marginalized communities to the health care system. We assessed the effect of the ASHA program on the utilization of maternity services.

Methods: We used data from Indian Human Development Surveys done in 2004-2005 and in 2011-2012 to assess demographic and socioeconomic factors associated with the receipt of ASHA services, and used difference-in-difference analysis with cluster-level fixed effects to assess the effect of the program on the utilization of at least one antenatal care (ANC) visit, four or more ANC visits, skilled birth attendance (SBA), and giving birth at a health facility.

Results: Substantial variations in the receipt of ASHA services were reported with 66% of women in northeastern states, 30% in high-focus states, and 16% of women in other states. In areas where active ASHA activity was reported, the poorest women, and women belonging to scheduled castes and other backward castes, had the highest odds of receiving ASHA services. Exposure to ASHA services was associated with a 17% (95% CI 11.8-22.1) increase in ANC-1, 5% increase in four or more ANC visits (95% CI - 1.6-11.1), 26% increase in SBA (95% CI 20-31.1), and 28% increase (95% CI 22.4-32.8) in facility births.

Conclusions: Our results suggest that the ASHA program is successfully connecting marginalized communities to maternity health services. Given the potential of the ASHA in impacting service utilization, we emphasize the need to strengthen strategies to recruit, train, incentivize, and retain ASHAs.
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http://dx.doi.org/10.1186/s12960-019-0402-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6701148PMC
August 2019

Assessing the sustainability of the Nigerian urban reproductive health initiative facility-level programming: longitudinal analysis of service quality.

BMC Health Serv Res 2019 Aug 9;19(1):559. Epub 2019 Aug 9.

Department of Economics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.

Background: To date, there is little information on the sustainability of family planning (FP) service quality after completion of a donor-funded program. This paper examines the sustainability of the Nigerian Urban Reproductive Health Initiative (NURHI) program on quality of FP services in two cities: Ilorin, where the program ended in March 2015 and Kaduna where the program continued.

Methods: Data come from three time periods: 2011, before program implementation; 2014, near Phase 1 completion; and 2017, two-years post Phase 1. In 2011, we undertook a facility audit and provider surveys in all public sector facilities in each city as well as all private facilities mentioned as the source for FP or maternal, newborn, and child health services in a 2010 women's household survey. In 2014 and 2017, we returned to the same facilities to undertake the facility audit and provider surveys. Quality is measured from principal component analyses of 30 items from the facility audit and provider surveys. Service use outcomes are measured as the ratio of FP clients (total and new) to the number of reproductive health staff members. Multivariate random effect models are estimated to examine changes in the outcomes over time, between NURHI and non-NURHI facilities and by city.

Results: We demonstrate that NURHI facilities had better quality and higher service use than non-NURHI facilities. Further, while quality of services was higher in Ilorin in 2011, by 2014 and three years later (2017), the quality was better in Kaduna where the program continued. In addition, while no difference was found in service utilization between Ilorin and Kaduna in 2014, by 2017, Kaduna had significantly more new FP users than Ilorin.

Conclusions: In Ilorin, quality of services did not continue its strong upward trend after the program ended. Programs need to consider long-term strategies that support continuation of program components post program implementation. This may include ensuring continued training of providers and addressing equipment and commodity stock-outs through system changes rather than specific facility-level changes. The findings from this study can be used to inform future programs seeking to improve quality of FP services in a sustainable manner.
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http://dx.doi.org/10.1186/s12913-019-4388-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6688378PMC
August 2019

Exploring the associations between physical and sexual gender-based violence and HIV among women who use substances in South Africa: the role of agency and alcohol.

AIDS Care 2019 11 2;31(11):1369-1375. Epub 2019 Apr 2.

Substance Use, Gender, and Applied Research Program, RTI International , Research Triangle Park , NC , USA.

South Africa has the highest prevalence of HIV among women, the highest prevalence of gender-based violence (GBV), and the highest rates of per capita alcohol consumption in the world. The nuanced associations between GBV, alcohol misuse, and HIV must be explored and protective factors identified. This study examines the associations between physical and sexual GBV and HIV infection and explores how alcohol misuse and sexual agency may mediate the GBV-HIV association. Participants were 361 Black African women (Mean age=28.39, SD = 7.92) who reported using alcohol and/or drugs weekly in the past 3 months, engaging in condomless sex, and having a boyfriend. Women were recruited from disadvantaged communities in Pretoria, South Africa. Individuals who met the eligibility criteria and enrolled in the study consented and completed a computer-assisted personal interview assessing GBV, alcohol misuse, and sexual agency and underwent HIV testing (i.e., blood test). The indirect effect of physical assault on HIV status at enrollment through alcohol misuse was significant (log odds = 0.23, SE = 0.12, 95% CI [0.0151, 0.4998]). HIV prevention efforts focusing on reducing alcohol misuse may be more effective, which might reduce the HIV burden among this group of vulnerable South African women.
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http://dx.doi.org/10.1080/09540121.2019.1595512DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733636PMC
November 2019

Evaluation of a maternity waiting home and community education program in two districts of Malawi.

BMC Pregnancy Childbirth 2018 Nov 23;18(1):457. Epub 2018 Nov 23.

UNC Project-Malawi, c/o Kamuzu Central Hospital, 100 Mzimba Road, Private Bag, A-104, Lilongwe, Malawi.

Background: The implementation of Maternity Waiting Homes (MWHs) is a strategy to bring vulnerable women close to a health facility towards the end of their pregnancies. To date, while MWHs are a popular strategy, there is limited evidence on the role that MWHs play in reaching women most in need. This paper contributes to this topic by examining whether two program-supported MWHs in Malawi are reaching women in need and if there are changes in women reached over time.

Methods: Two rounds of exit interviews (2015 and 2017) were conducted with women within 3 months of delivery and included both MWH users and non-MWH users. These exit interviews included questions on sociodemographic factors, obstetric risk factors and use of health services. Bivariate statistics were used to compare MWH users and non-MWH users at baseline and endline and over time. Multivariable logistic regression was used to determine what factors were associated with MWH use, and Poisson regression was used to study factors associated with HIV knowledge. Descriptive data from discharge surveys were used to examine satisfaction with the MWH structure and environment over time.

Results: Primiparous women were more likely to use a MWH compared to women of parity 2 (p < 0.05). Women who were told they were at risk of a complication were more likely to use a MWH compared to those who were not told they were at risk (p < 0.05). There were also significant findings for wealth and time to a facility, with poorer women and those who lived further from a facility being more likely to use a MWH. Attendance at a community event was associated with greater knowledge of HIV (p < 0.05).

Conclusions: MWHs have a role to play in efforts to improve maternal health and reduce maternal mortality. Education provided within the MWHs and through community outreach can improve knowledge of important health topics. Malawi and other low and middle income countries must ensure that health facilities affiliated with the MWHs offer high quality services.
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http://dx.doi.org/10.1186/s12884-018-2084-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6251123PMC
November 2018

Gender norms and modern contraceptive use in urban Nigeria: a multilevel longitudinal study.

BMC Womens Health 2018 10 29;18(1):178. Epub 2018 Oct 29.

Innovations for Maternal, Newborn & Child Health, Concern Worldwide USA, New York, USA.

Background: Evidence suggests that gender equality positively influences family planning. However, the evidence from urban Africa is sparse. This study aimed to examine the association between changes in gender norms and modern contraceptive use over time among women in urban Nigeria.

Methods: Data were collected in 2010/2011 from 16,118 women aged 15-49 living in six cities in Nigeria (Abuja, Benin, Ibadan, Ilorin, Kaduna, and Zaria) and again in 2014 from 10,672 of the same women (34% attrition rate). The analytical sample included 9933 women living in 480 neighborhoods. A four-category outcome variable measured their change in modern contraceptive use within the study period. The exposure variables measured the changes in the level of gender-equitable attitudes towards: a) wife beating; b) household decision-making; c) couples' family planning decisions; and d) family planning self-efficacy. Multilevel multinomial logistic regression models estimated the associations between the exposure variables at the individual and neighborhood levels and modern contraceptive use controlling for the women's age, education, marital status, religion, parity, household wealth, and city of residence.

Results: The proportion of women who reported current use of modern contraceptive methods increased from 21 to 32% during the four-year study period. At both surveys, 58% of the women did not report using modern contraceptives while 11% reported using modern contraceptives; 21% did not use in 2010/2011 but started using by 2014 while 10% used in 2010/2011 but discontinued use by 2014. A positive change in the gender-equitable attitudes towards household decision-making, couples' family planning decisions, and family planning self-efficacy at the individual and neighborhood levels were associated with increased relative probability of modern contraceptive use (adoption and continued use) and decreased relative probability of modern contraceptive discontinuation by 2014. No such associations were found between the individual and neighborhood attitudes towards wife beating and modern contraceptive use. Accounting for the individual and neighborhood gender-equitable attitudes and controlling for the women's demographic characteristics accounted for 55-61% of the variation between neighborhoods in the change in modern contraceptive use during the study period.

Conclusion: Interventions that promote gender equality have the potential to increase modern contraceptive use in Nigerian cities.
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http://dx.doi.org/10.1186/s12905-018-0664-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6206649PMC
October 2018

Association of men's exposure to family planning programming and reported discussion with partner and family planning use: The case of urban Senegal.

PLoS One 2018 25;13(9):e0204049. Epub 2018 Sep 25.

Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America.

Background: Family planning programs increasingly aim to encourage men to be involved in women's reproductive health decision-making as well as support men to be active agents of change for their own and the couple's reproductive health needs. This study contributes to this area of work by examining men's exposure to family planning (FP) program activities in urban Senegal and determining whether exposure is associated with reported FP use and discussion of family planning with female partners.

Methods: This study uses data from two cross-sectional surveys of men in four urban sites of Senegal (Dakar, Pikine, Guédiawaye, Mbao). In 2011 and 2015, men ages 15-59 in a random sample of households from study clusters were approached and asked to participate in a survey about their fertility and family planning experiences. These data were used to determine the association between exposure to the Initiative Sénégalaise de Santé Urbaine (in English: Senegal Urban Reproductive Health Initiative) family planning program interventions with men's reported modern family planning use and their reported discussion of FP with their partners. Since data come from the same study clusters at each time period, fixed effects methods at the cluster level allowed us to control for possible program targeting by geographic area.

Results: Multivariate models demonstrate that religious leaders speaking favorably about family planning, seeing FP messages on the television, hearing FP messages on the radio, and exposure to community outreach activities with a FP focus (e.g., house to house and community religious dialogues) are associated with reported modern family planning use and discussion of family planning with partners among men in the four urban sites of Senegal.

Conclusions: This study demonstrates that it is possible to reach men with FP program activities in urban Senegal and that these activities are positively associated with reported FP behaviors.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0204049PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6155530PMC
March 2019