Reproductive Autonomy and Sexual and Reproductive Health Outcomes among Young Women in Ghana

Background: Women’s empowerment is a powerful outcome of, as well as a pathway through which to improve, sexual and reproductive health (SRH) and wellbeing. Prior research suggests associations between women’s empowerment and SRH outcomes. However, there is variability in how researchers measure empowerment and proxies are frequently used. This dissertation will examine the construct of reproductive autonomy (RA), a specific domain of empowerment defined as “having the power to decide about and control matters associated with contraceptive use, pregnancy, and childbearing” (Upadhyay, Dworkin, et al. 2014). RA has not yet been studied in a Sub-Saharan African context nor among young women. This dissertation examines the following three relationships in a sample of young Ghanaian women: 1) demographic, reproductive and social factors associated with RA; 2) associations between RA and modern contraceptive use; and 3) associations between RA and pregnancy decision-making, an understudied SRH outcome reflecting who had the most say in the outcome of the last pregnancy. Methods: The RA items and original research questions here were prospectively embedded into a larger parent study focused on stigma toward SRH among adolescents. This study sampled 1,080 young Ghanaian women ages 15 to 24 from facility and community-based sites in Accra and Kumasi, Ghana. Decision-making RA and communication RA measures were created as summative scales using items adapted from the validated scale and ranged from 3 (low RA) to 12 (high RA). In Paper 1, I tested associations between each RA sub-scale and sociodemographic, reproductive history, and social context variables of interest using bivariate statistics (student’s t-tests and ANOVA, where appropriate) and multivariable linear regression models. For Paper 2, I used bivariate statistics (chi-square and t-tests) and multivariable logistic regression models to examine the associations between the RA sub-scales and modern contraceptive use at last sex. For Paper 3, I used bivariate statistics (chi-square and ANOVA) and multinomial regression models to examine associations between the RA sub-scales and pregnancy decision-making (who made the decision about the outcome of the last pregnancy). Results: Regarding Paper 1, I found that a different set of factors were significantly associated with decision-making RA as compared to communication RA. Ethnic group, religion, frequency of religious attendance, and previous pregnancy were significantly associated with decision-making RA, while educational attainment, ethnic group, and social approval for adolescent SRH were associated with communication RA (p-values < 0.05). In Paper two, I found that after adjusting for socio-demographic factors of interest, decision-making RA was associated with modern contraceptive use at last sex among young Ghanaian women (Adjusted Odds Ratio [aOR]: 1.12; 95% CI: 1.01-1.24); communication RA was not significantly associated (aOR: 1.03; 95% CI: 0.88-1.19). In paper three, I found that higher levels of decision-making RA were associated with a decreased relative risk of a woman’s partner having the most say about the pregnancy decision as compared to her having the most say (Adjusted Relative Risk Ratio: 0.79; 95% CI: 0.66-0.93). Conclusions: The results of this dissertation demonstrate that RA may be an important construct to consider when addressing SRH among young Ghanaian women. Additional research should continue to explore the importance of social context for more robust conceptualization and measurement of RA. Public health interventions may benefit from incorporating gender transformative approaches to increase RA among young women, thereby improving SRH outcomes including modern contraceptive use and pregnancy decision-making.PHDHealth Behavior & Health EducationUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttps://deepblue.lib.umich.edu/bitstream/2027.42/149987/1/dloll_1.pd

“When I sleep under the net, nothing bothers me; I sleep well and I’m happy”: Senegal’s culture of net use and how inconveniences to net use do not translate to net abandonment

Abstract Background Despite recent advances in the fight against the disease, malaria remains a serious threat to the health and well-being of populations in endemic countries. The use of long-lasting insecticidal nets (LLIN) reduces contact between the vector and humans, thereby reducing transmission of the disease. LLINs have become an essential component of malaria control programmes worldwide. Methods The Culture of Net Use study used qualitative and quantitative methods in a longitudinal and iterative design over two phases, in order to capture changes in net use over a year and a half period and covering both dry and rainy seasons. Data were collected from a total of 56 households in eight regions to understand variations due to geographical, cultural, and universal coverage differences. At the time of the data collection, the universal coverage campaign had been completed in six of the eight regions (Dakar and Thies excluded). Results Perceived barriers to use were primarily related to the characteristics of the net itself, include shape, insecticide, and a variety of minority responses, such as perceived lack of mosquito density and being unaccustomed to using nets. Insecticide-related complaints found that insecticide did not present a significant barrier to use, but was cited as a nuisance. Feelings of suffocation continued to be the most commonly cited nuisance. Respondents who favoured the use of insecticide on nets appeared to be more aware of the health and malaria prevention benefits of the insecticide than those who perceived it negatively. Conclusion Despite prior evidence that barriers such as heat, shape, insecticide and perceived mosquito density contribute to non-use of LLINs in other countries, this study has shown that these factors are considered more as nuisances and that they do not consistently prevent the use of nets among respondents in Senegal. Of those who cited inconveniences with their nets, few were moved to stop using a net. Respondents from this study overcame these barriers and continue to value the importance of nets.http://deepblue.lib.umich.edu/bitstream/2027.42/109445/1/12936_2014_Article_3396.pd

Decision-making on intra-household allocation of bed nets in Uganda: do households prioritize the most vulnerable members?

Abstract Background Access to insecticide-treated bed nets has increased substantially in recent years, but ownership and use remain well below 100% in many malaria endemic areas. Understanding decision-making around net allocation in households with too few nets is essential to ensuring protection of the most vulnerable. This study explores household net allocation preferences and practices across four districts in Uganda. Methods Data collection consisted of eight focus group discussions, twelve in-depth interviews, and a structured questionnaire to inventory 107 sleeping spaces in 28 households. Results In focus group discussions and in-depth interviews, participants almost unanimously stated that pregnant women, infants, and young children should be prioritized when allocating nets. However, sleeping space surveys reveal that heads of household sometimes receive priority over children less than five years of age when households have too few nets to cover all members. Conclusions When asked directly, most net owners highlight the importance of allocating nets to the most biologically vulnerable household members. This is consistent with malaria behaviour change and health education messages. In actual allocation, however, factors other than biological vulnerability may influence who does and does not receive a net.http://deepblue.lib.umich.edu/bitstream/2027.42/109479/1/12936_2014_Article_3219.pd

User-determined end of net life in Senegal: a qualitative assessment of decision-making related to the retirement of expired nets

Abstract Background Procurement and distribution of long-lasting insecticidal nets (LLINs) in the African region has decreased from 145 million in 2010 to 66 million nets in 2012. As resources for LLIN distribution appear to stagnate, it is important to understand the users’ perception of the life span of a net and at what point and why they stop using it. In order to get the most value out of distributed nets and to ensure that they are used for as long as possible, programmes must communicate to users about how to assess useful net life and how to extend it. Methods Data were collected from 114 respondents who participated in 56 in-depth interviews (IDIs) and eight focus group discussions (FGDs) in August 2012 in eight regions in Senegal. Households were eligible for the study if they owned at least one net and had an available household member over the age of 18. Data were coded by a team of four coders in ATLAS.ti using a primarily deductive approach. Results Respondents reported assessing useful net life using the following criteria: the age of net, the number and size of holes and the presence of mosquitoes in the net at night. If they had the means to do so, many respondents preferred the acquisition of a new net rather than the continued use of a very torn net. However, respondents would preferentially use newer nets, saving older, but useable nets for the future or sharing them with family or friends. Participants reported observing alternative uses of nets, primarily for nets that were considered expired. Conclusions The results indicate that decisions regarding the end of net life vary among community members in Senegal, but are primarily related to net integrity. Additional research is needed into user-determined end of net life as well as care and repair behaviours, which could extend useful net life. The results from this study and from future research on this topic should be used to understand current behaviours and develop communication programmes to prolong the useful life of nets.http://deepblue.lib.umich.edu/bitstream/2027.42/112729/1/12936_2013_Article_2942.pd

Bad girl and unmet family planning need among Sub-Saharan African adolescents: the role of sexual and reproductive health stigma

Adolescent pregnancy contributes to high maternal mortality rates in Sub-Saharan Africa. We explored stigma surrounding adolescent sexual and reproductive health (SRH) and its impact on young Ghanaian women’s family planning (FP) outcomes. We conducted in-depth, semi-structured interviews with 63 women ages 15-24 recruited from health facilities and schools in Accra and Kumasi, Ghana. Purposive sampling provided diversity in reproductive/relationship/socioeconomic/religious characteristics. Using both deductive and inductive approaches, our thematic analysis applied principles of grounded theory. Participants described adolescent SRH experiences as cutting across five stigma domains. First, community norms identified non-marital sex and its consequences (pregnancy, childbearing, abortion, sexually transmitted infections) as immoral, disrespectful, and disobedient, resulting in bad girl labeling. Second, enacted stigma entailed gossip, marginalization, and mistreatment from all community members, especially healthcare workers. Third, young sexually active, pregnant, and childbearing women experienced internalized stigma as disgrace, shame and shyness. Fourth, non-disclosure and secret-keeping were used to avoid/reduce stigma. Fifth, stigma resilience was achieved through social support. Collectively, SRH stigma precluded adolescents’ use of FP methods and services. Our resulting conceptual model of adolescent SRH stigma can guide health service, public health, and policy efforts to address unmet FP need and de-stigmatize SRH for young women worldwide

“People will say that I am proud”: a qualitative study of barriers to bed net use away from home in four Ugandan districts

Abstract Background Despite increased access and ownership, barriers to insecticide-treated bed net (ITN) use persist. While barriers within the home have been well documented, the challenges to net use when sleeping away from home remain relatively unexplored. This study examines common situations in which people sleep away from home and the barriers to ITN use in those situations. Methods To explore these issues, a group of researchers conducted 28 in-depth interviews and four focus groups amongst adults from net-owning households in four Ugandan districts. Results In addition to sleeping outside during hot season, participants identified social events, livelihood activities, and times of difficulty as circumstances in which large numbers of people sleep away from home. Associated challenges to ITN use included social barriers such as fear of appearing proud, logistical barriers such as not having a place to hang a net, and resource limitations such as not having an extra net with which to travel. Social disapproval emerged as an important barrier to ITN use in public settings. Conclusions Unique barriers to ITN use exist when people spend the night away from home. It is essential to identify and address these barriers in order to reduce malaria exposure in such situations. For events like funerals or religious “crusades” where large numbers of people sleep away from home, alternative approaches, such as spatial repellents may be more appropriate than ITNs. Additional research is required to identify the acceptability and feasibility of alternative prevention strategies in situations where ITNs are unlikely to be effective.http://deepblue.lib.umich.edu/bitstream/2027.42/109543/1/12936_2013_Article_3146.pd

“You need to take care of it like you take care of your soul”: perceptions and behaviours related to mosquito net damage, care, and repair in Senegal

Abstract Background Net care and repair behaviours are essential for prolonging the durability of long-lasting insecticidal nets. Increased net durability has implications for protection against malaria as well as cost savings from less frequent net distributions. This study investigated behaviours and motivations for net care and repair behaviours in Senegal with the aim of informing social and behaviour change communication (SBCC) programmes, using the Health Belief Model as a framework. Methods Data were collected from 114 participants in eight regions of Senegal. Participants were eligible for the study if they were at least 18 years old and if their household owned at least one net. These respondents included 56 in-depth interview respondents and eight focus groups with 58 participants. In addition, the qualitative data were supplemented with observational questionnaire data from a total of 556 sleeping spaces. Of these spaces, 394 had an associated net. Results Reported net care and repair behaviours and motivations varied substantially within this sample. Children and improper handling were seen as major sources of net damage and respondents often tried to prevent damage by storing nets when not in use. Washing was seen as an additional method of care, but practices for washing varied and may have been damaging to nets in some cases. Participants mentioned a sense of pride of having a net in good condition and the uncertainty around when they could expect another net distribution as motivations for net care. Net repair appeared to be a less common behaviour and was limited by the perspective that net degradation was inevitable and that repairs themselves could weaken nets. Conclusion These findings can be understood using the Health Belief Model framework of perceived severity, perceived susceptibility, perceived barriers, perceived benefits, self-efficacy, and cues to action. This model can guide SBCC messages surrounding net care and repair to promote practices associated with net longevity. Such messages should promote the benefits of intact nets and provide tools for overcoming barriers to care and repair.http://deepblue.lib.umich.edu/bitstream/2027.42/109489/1/12936_2014_Article_3355.pd

Reproductive autonomy and pregnancy decision-making among young Ghanaian women

Decision-making regarding the outcome of a pregnancy may include participation of the woman herself, her sexual partner, parents, family, and/or community. This paper examines who had the most say in the outcome of young Ghanaian women’s last pregnancy and whether this correlated with her level of reproductive autonomy (RA). We analysed cross-sectional data from 380 previously pregnant young women in urban Ghana. We measured communication and decision-making RA using modified scales ranging from 3 (low RA) to 12 (high RA). We tested unadjusted associations between the RA sub-scales and who made the pregnancy decision (self, partner, both together, or someone else) and used multinomial regression models to understand these associations when controlling for sociodemographic, reproductive history, and social context variables. In final models, a one-point increase in decision-making RA was associated with an adjusted relative risk ratio of 0.79 (95% CI: 0.66–0.93; p = 0.006) of partner having the most say as compared to the woman having the most say. The communication RA scale was not associated. Programmes that increase RA may be effective in increasing women’s rights to execute decisions about reproductive health and outcomes. Future research should explore this notion and the role of pregnancy disclosure in this relationship

Evaluating a youth-designed sexual and reproductive health mass and social media campaign in Côte d’Ivoire: triangulation of three independent evaluations

AbstractMerci Mon Héros (MMH) is a youth-designed multi-media campaign seeking to improve sexual and reproductive health and family planning (SRH/FP) outcomes among youth living in nine francophone countries. A mixed methods approach was implemented to assess the MMH campaign progress and impact in Côte d’Ivoire. Three data sources were triangulated to evaluate the campaign: social media listening (October 2019–January 2021); a quantitative cross-sectional monitoring survey (September 2020) with 412 youth (aged 16–24) and 597 adults (aged 25–49); and a qualitative study using a Most Significant Change approach (March 2021), including a total of 24 focus group discussions with youth (aged 15–24) and adults (aged 25+) exposed to the MMH campaign. Data from all three studies were analysed independently and then brought together through a triangulation workshop where the study team compared findings to achieve convergence in evaluation results. Social listening results showed topic-specific online conversations related to MMH campaign spiked significantly during the two-week period after topic-specific campaign posts (p < .05), suggesting potential campaign impact. Survey results showed both adults and youth were more likely to have spoken with someone about FP in the past five months if exposed to the campaign (p < 0.01). Qualitative findings support the campaign’s effect on shifting attitudes and behavioural uptake of intergenerational communication among adults and youth. This evaluation shows evidence of MMH’s strong potential for impact in encouraging communication and the need to focus efforts on strategies to strengthen supportive adults’ communication competencies and redefine what it means to act in support of SRH/FP for youth