What can the global movement to end child marriage learn from the implementation of other multi-sectoral initiatives?

If the Sustainable Development Goal (SDG) target 5.3 to end child marriage by 2030 is to be met, the annual rate of reduction in the prevalence of child marriage must increase from 1.9% to 23%. Over 30 countries have developed, or are developing, national policies/programmes towards this goal. However, many are struggling to operationalise these policies/programmes, particularly at subnational levels. Thus, Girls Not Brides and the WHO commissioned a review of lessons learnt from national and subnational implementation of multi-sectoral policies/programmes targeting other issues that could be applied to the global movement to end child marriage. This review identified a number of pragmatic lessons learnt. At the national level, countries should identify and engage committed and skilled leadership, build a shared understanding of the target issue and how to address it, and delineate and clarify the roles and responsibilities of relevant stakeholders. At the subnational level, countries should establish coordination mechanisms, build awareness and capacity of staff, use subnational evidence to contextualise and tailor interventions, develop coordinated budgets and cost-sharing mechanisms, and integrate monitoring and evaluation systems. These lessons are remarkably consistent, despite coming from different target issues and contexts. The commonality of these findings reveals that various stakeholders are repeatedly and consistently failing to ensure that these fundamental requirements are in place. It is vital that the global movement to end child marriage learns from and uses these lessons if it is to meet its SDG target

Research priorities for improving menstrual health across the life-course in low- and middle-income countries

Background: Research on menstrual health is required to understand menstrual needs and generate solutions to improve health, wellbeing, and productivity. The identification of research priorities will help inform where to invest efforts and resources. Objectives: To identify research priorities for menstrual health across the life-course, in consultation with a range of stakeholder groups from a variety of geographic regions, and to identify if menstrual health research priorities varied by expertise. Methods: A modified version of the Child Health and Nutrition Research Initiative approach was utilized to reach consensus on a set of research priorities. Multisector stakeholders with menstrual health expertise, identified through networks and the literature, were invited to submit research questions through an online survey. Responses were consolidated and individuals were invited to rank these questions based on novelty, potential for intervention, and importance/impact. Research priority scores were calculated and evaluated by participants’ characteristics. Results: Eighty-two participants proposed 1135 research questions, which were consolidated into 94 unique research questions. Mean number of questions did not differ between low- and middle-income (LMIC, N=30) and high-income county participants (HIC, N=52), but significantly more questions were raised by participants with expertise in mental health and WASH. Sixty-six participants then ranked these questions. The top ten-ranked research questions included four on ‘understanding the problem’, four on ‘designing and implementing interventions’, one on ‘integrating and scaling up’, and one on ‘measurement’. Indicators for the measurement of adequate menstrual health over time was ranked the highest priority by all stakeholders. Top ten ranked research questions differed between academics and non-academics, and between participants from HICs and LMICs, reflecting differences in needs and knowledge gaps. Conclusions: A list of ranked research priorities was generated through a consultative process with stakeholders across LMICs and HICs which can inform where to invest efforts and resources

The state of adolescent menstrual health in low- and middle-income countries and suggestions for future action and research

In recognition of the opportunity created by the increasing attention to menstrual health at global, regional, and national levels, the World Health Organization’s Department of Sexual and Reproductive Health and Research and the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction convened a global research collaborative meeting on menstrual health in adolescents in August 2018. Experts considered nine domains of menstrual health (awareness and understanding; stigma, norms, and socio-cultural practices; menstrual products; water and sanitation; disposal; empathy and support; clinical care; integration with other programmes; and financing) and answered the following five questions: (1) What is the current situation? (2) What are the factors contributing to this situation? (3) What should the status of this domain of adolescent menstrual health be in 10 years? (4) What actions are needed to achieve these goals? (5) What research is needed to achieve these goals? This commentary summarizes the consensus reached in relation to these questions during the expert consultation. In doing so, it describes the state of adolescent menstrual health in low- and middle-income countries and sets out suggestions for action and research that could contribute to meeting the holistic menstrual health needs of adolescent girls and others who menstruate worldwide

The political, research, programmatic, and social responses to adolescent sexual and reproductive health and rights in the 25 years since the International Conference on Population and Development

Among the ground-breaking achievements of the International Conference on Population and Development (ICPD) was its call to place adolescent sexual and reproductive health (ASRH) on global health and development agendas. This article reviews progressmade in low- and middle-income countries in the 25 years since the ICPD in six areas central to ASRH-adolescent pregnancy, HIV, child marriage, violence against women and girls, female genital mutilation, and menstrual hygiene and health. It also examines the ICPD's contribution to the progress made. The article presents epidemiologic levels and trends; political, research, programmatic and social responses; and factors that helped or hindered progress. To do so, it draws on research evidence and programmatic experience and the expertise and experiences of a wide number of individuals, including youth leaders, in numerous countries and organizations. Overall, looking across the six health topics over a 25-year trajectory, there has been great progress at the global and regional levels in putting adolescent health, and especially adolescent sexual and reproductive health and rights, higher on the agenda, raising investment in this area, building the epidemiologic and evidence-base, and setting norms to guide investment and action. At the national level, too, there has been progress in formulating laws and policies, developing strategies and programs and executing them, and engaging communities and societies in moving the agenda forward. Still, progress has been uneven across issues and geography. Furthermore, it has raced ahead sometimes and has stalled at others. The ICPD's Plan of Action contributed to the progress made in ASRH not just because of its bold call in 1994 but also because it provided a springboard for advocacy, investment, action, and research that remains important to this day. (C) 2019 Published by Elsevier Inc. on behalf of Society for Adolescent Health and Medicine

Postpartum contraception initiation, discontinuation, and method switch in Western Kenya

Thesis (Master's)--University of Washington, 2017-06Objective: The objective of this study is to prospectively measure contraceptive use throughout the postpartum period among Kenyan women and characterize trends in postpartum contraceptive initiation, discontinuation, and method switch. Design: Prospective cohort study Methods: We conducted an analysis of postpartum contraceptive use among a cohort of women enrolled in a study aimed to measure maternal HIV acquisition during and after pregnancy in western Kenya. Women were enrolled in the parent study during antenatal care (ANC) and were eligible for this analysis if they remained HIV-seronegative throughout pregnancy and through 9 months postpartum and had at least one postpartum study visit. At study visits (scheduled at 2, 6, 10, 14 weeks; 6 and 9 months postpartum), women completed questionnaires to assess maternal health, sexual behavior, and contraceptive use (postpartum only). Contraceptive use was categorized as modern contraception (all methods of contraception excluding natural methods), highly effective contraception (all modern contraceptive methods excluding barrier methods), and long acting reversible contraception (LARC; intrauterine devices (IUD) and implants). Generalized linear models and Cox proportional hazards regression models were used to identify cofactors associated with contraceptive use during the postpartum period and time to contraceptive initiation and discontinuation, respectively. Results: Overall, 1257 postpartum women were included in the analysis. Median age was 22 years, 78% were married, median relationship duration was 4 years, and 68% of women were multiparous. Overall, 739 women (59%) used modern contraception, 623 (50%) used highly effective contraception, and 116 (9%) used LARC during the postpartum period. Injectable contraceptives, condoms, and OCPs were the most common methods used (45%, 22%, and 21% of contraceptive users, respectively). Among 739 women who initiated contraception, 8% discontinued use and 16% switched to a different method in the postpartum period. During 6095 person-months of follow-up, the incidence of initiation of modern contraception was 11.7/100 person-months (95% confidence interval [CI]: 10.9-12.6). Women who had resumed sexual activity, higher education, and a history of interpersonal violence were more likely to use contraception; women who had experienced pregnancy loss were less likely to use modern contraception postpartum compared to women with live births in the most recent pregnancy (HR, 95% CI). The modern contraceptive discontinuation rate was 0.63 per 100 person-months (95% CI 0.49-0.81) and discontinuation was associated with being employed and cessation of breastfeeding. Conclusion: While uptake of modern contraceptives was high among postpartum Kenyan women, discontinuation rates and method switching were common. Further research is needed to understand reasons for method discontinuation, to guide improved counseling messages

The revised international technical guidance on sexuality education - a powerful tool at an important crossroads for sexuality education

Abstract In January 2018, UNESCO, together with UNAIDS, UNFPA, UNICEF, UN Women, and the WHO, completed the substantial technical and political process of updating the International Technical Guidance on Sexuality Education, thereby unifying a UN position on rationale, evidence, and guidance on designing and delivering comprehensive sexuality education (CSE). The revised Guidance builds on the original Guidance, with improvements and updates based on new evidence and good practice documented from across the globe. User-surveys and structured consultations with representatives from a wide range of fields and interest-groups informed and guided the revision process. The revised Guidance presents one, commonly agreed definition of CSE; enhances and expands its key concepts, topics and learning objectives; places a strengthened focus on gender and human rights; provides guidance on building support and planning the implementation of CSE programmes; and reflects the contribution of CSE to the realization of multiple Sustainable Development Goals (SDGs). With its unified voice, progressive position, and attention to key implementation challenges, the revised Guidance is a responsive, timely, and critically needed tool to advance towards a tipping point for the large-scale application of quality CSE

38.8 million additional modern contraceptive users: this, in fact, is “a never-before opportunity to strengthen investment and action on adolescent contraception”

Abstract Background We thank Bijlmakers et al. for their interest in our article, “A never-before opportunity to strengthen investment and action on adolescent contraception, and what we must do to make full use of it”, and are grateful for the opportunity to respond to their four key assertions. Response First, we fully agree that sexual rights are controversial, which we discussed in depth in our original article. However, we reaffirm that there is global consensus on adolescent contraception as evidenced in part by recent data emerging from FP2020 on 38.8 million additional modern contraceptive users, the Global Goods and commitments emanating from the 2017 FP2020 summit, and their translated actions at the country level. Additionally, we clarify WHO’s working definitions of sex, sexual health, and sexuality, and introduce WHO’s newly released Operational Framework on Sexual Health and its Linkages to Reproductive Health. We welcome and agree with Bijlmakers et al.’s second point, which elaborates on the barrier of restrictive laws and policies. To address this barrier, we describe examples of resources that can help programmes understand the political/social context that drives these laws and policies at national and subnational levels, and identify programmatic gaps and best practices to address them within specific political/social contexts. We also welcome and agree with Bijlmakers et al.’s third point, which reiterates that discomfort around adolescent sexuality is a major barrier for sexuality education. In response, we point to four relevant reviews of CSE policies and their implementation, our original article’s description of three programmes that have successfully addressed inadequate teacher skills, and our ongoing work on documenting strategies to build an enabling environment for CSE and deal with resistance. Lastly, we wholeheartedly agree that the harmful policies noted by Bijlmakers et al. are damaging to international efforts to improve adolescent SRH and rights. We argue, though, that these policies alone will not undermine efforts by countless other stakeholders around the world who are working in defence and promotion of adolescents’ SRH and rights. Conclusion Despite the many valid obstacles noted by Bijlmakers et al., we truly believe that this is “a never-before opportunity to strengthen investment and action on adolescent contraception”

Improving health worker motivation and performance to deliver adolescent sexual and reproductive health services in the Democratic Republic of Congo: study design of implementation research to assess the feasibility, acceptability, and effectiveness of a package of interventions

During its last funding cycle from 2018–2020, the Global Fund in collaboration with the Ministry of Health, World Health Organization, and implementing partners Cordaid and Santé Rural (SANRU), implemented a multi-sectoral, contextualized approach to improve the sexual and reproductive health of adolescent girls and young women in two regions in the Democratic Republic of the Congo, which included community-based, school-based and health facility-based actions. This implementation research focuses on the health-facility component. The objective of this research is to evaluate the feasibility, acceptability, and effectiveness of a package of interventions to improve health workers’ knowledge, skills, and attitudes in providing sexual and reproductive health services to adolescents, whilst concomitantly creating an enabling work environment for building health workers’ motivation. The package includes a combination of job descriptions, training and refresher training, desk reference tools, and collaborative learning. The package did not focus on improving amenities, providing or repairing equipment, or providing medicines and supplies. The underlying theoretical framework informing the project and the implementation research draws from Social Network Theory, Diffusion of Innovations and Normalization Process Theory. Qualitative and quantitative process and outcome data from in-depth interviews and focus group discussions with health workers and health managers, field notes, monitoring reports, costing sheets, and health worker surveys, adolescent mystery client assessments, and exit interviews with adolescents will be collected as part of a time-series study. The findings from this implementation research will be utilized to inform future adaptations and/or scale-up of the package of interventions to improve health worker motivation and performance in the Democratic Republic of the Congo and elsewhere. The findings will also contribute to advancing the use of theoretical approaches within the field of implementation research

Menstrual health: a definition for policy, practice, and research

The term menstrual health has seen increased use across advocacy, programming, policy, and research, but has lacked a consistent, self-contained definition. As a rapidly growing field of research and practice a comprehensive definition is needed to (1) ensure menstrual health is prioritised as a unified objective in global health, development, national policy, and funding frameworks, (2) elucidate the breadth of menstrual health, even where different needs may be prioritised in different sectors, and (3) facilitate a shared vocabulary through which stakeholders can communicate across silos to share learning. To achieve these aims, we present a definition of menstrual health developed by the Terminology Action Group of the Global Menstrual Collective. We describe the definition development process, drawing on existing research and terminology, related definitions of health, and consultation with a broad set of stakeholders. Further, we provide elaboration, based on current evidence, to support interpretation of the definition