A Systematic Review of Sexual and Reproductive Health Knowledge, Experiences and Access to Services among Refugee, Migrant and Displaced Girls and Young Women in Africa

Adolescent girls and young women are an overlooked group within conflict- or disaster-affected populations, and their sexual and reproductive health (SRH) needs are often neglected. Existing evidence shows that forced migration and human mobility make girls and women more vulnerable to poor SRH outcomes such as high risk sexual behaviors, lack of contraception use, STIs and HIV/AIDS. We performed a systematic literature review to explore knowledge, experiences and access to SRH services in this population group across the African continent. Two databases (PubMed and Web of Science) were searched and from 896 identified publications, 15 peer-reviewed articles published in English met the inclusion criteria for this review. These consisted of eight applied qualitative, five quantitative and two mixed-method study designs. The quality of the studies was evaluated by the mixed-methods appraisal tool (MMAT) using scores in percentages (0-100%). Available evidence indicates that knowledge of young women and girls regarding contraceptive methods, STIs and HIV/AIDS are limited. This population group often experiences gender-based and sexual violence and abuse. The access and availability of SRH services are often limited due to distances, costs and stigma. This review demonstrates that there is still a dearth of peer-reviewed literature on SRH related aspects among refugee, migrant and displaced girls and young women in Africa. The data disaggregation by sex and age should be emphasized for future research in this field

Evaluation of a school based comprehensive sexuality education program among very young adolescents in rural Uganda

Background: Limited research has been conducted on the effectiveness of sexuality education for very young adolescents (VYAs) ages 10-14 years in Sub-Saharan Africa. Furthermore, evaluations of sexuality education programs often report outcomes of risky sexual practices, yet positive aspects of sexuality are hardly studied and rarely reported. This study evaluates the effectiveness of a Comprehensive Sexuality Education (CSE) intervention for VYAs in Uganda, analyzing both positive and negative outcome indicators. Methods: We conducted a mixed methods study, incorporating a cluster randomized trial (NCT03669913) among pupils in 33 randomly selected primary schools in Mbarara district. This was followed by a qualitative evaluation of the intervention in 4 schools that included 14 in-depth interviews and 3 focus group discussions distributed among pupils, teachers and parents. Quantitative data were analyzed using ordered logistic regression to compare differences in the change from baseline to endline between the intervention and control arms. We conducted bivariate analysis and multiple regression analysis controlling for key covariates, including age, gender, school location (rural vs urban), truancy, and orphanhood. Qualitative data were analyzed by thematic approach using ATLAS TI. Results: Between July 2016 and August 2017, 1096 pupils were recruited. Outcomes were studied among 380 pupils in the intervention arm and 484 pupils in the control arm. The proportion of pupils who ever had sex increased from 9 to 12.1% in intervention compared to 5.2 to 7.4% in the control group between baseline and endline, however the differences between groups were not statistically significant. We found greater improvements in sexual and reproductive health (SRH) knowledge among intervention schools (AOR: 2.18, 95% CI: 1.66-2.86) and no significant differences in self-esteem, body image or gender equitable norms. Qualitative evidence echoes perceived SRH knowledge acquisition, increased their perception of SRH related risks, and intentions to delay sexual intercourse to prevent unwanted pregnancy, HIV and other STIs. Conclusion: This study demonstrates that CSE can improve SRH knowledge and behavioral intentions among VYAs in Uganda. These results further emphasize the importance of initiating sexuality education before most adolescents have started engaging in sexual activity, enabling them to make informed decisions in the future

Induced abortion : a cross-sectional study on knowledge of and attitudes toward the new abortion law in Maputo and Quelimane cities, Mozambique

Background Maternal mortality, of which 6.7% is attributable to abortion complications, remains high in Mozambique. The objective of this paper is to assess the level of induced abortion at the community, as well as to assess awareness of and attitudes towards the new abortion law among women of reproductive age in suburban areas of Maputo and Quelimane cities. Methods A cross-sectional household survey among women aged 15-49 years in Maputo and Quelimane cities was conducted using a multi-stage clustered sampling design. Data on sociodemographic characteristics, maternal outcomes, contraceptive use, knowledge and attitudes towards the new abortion law were collected. Bivariate and multiple logistic regression analysis using the complex samples procedure in SPSS were applied. Results A total of 1657 women (827 Maputo and 830 Quelimane) were interviewed between August 2016 and February 2017. The mean age was 27 years; 45.7% were married and 75.5% had ever been pregnant. 9.2% of the women reported having had an induced abortion, of which 20.0% (17) had unsafe abortion. Of the respondents, 28.8% knew the new legal status of abortion. 17% thought that the legalization of abortion was beneficial to women's health. Having ever been pregnant, being unmarried, student, Muslim, as well as residing in Maputo were associated with higher odds of having knowledge of the new abortion law. Conclusion Reports of abortion appear to be low compared to other studies from Sub-Saharan African countries. Furthermore, respondents demonstrated limited knowledge of the abortion law. Social factors such as education status, religion, residence in a large city as well as pregnancy history were associated with having knowledge of the abortion law. Only a small percentage of women perceived abortion as beneficial to women's health. There is a need for widespread sensitization about the new law and its benefits

Redesigning Delivery: Boosting Adoption of Coffee Management Practices in Uganda. The climate smart investment pathway approach and the farmer segmentation tool

Coffee is an important crop for the Ugandan economy, as it earns the country US$415 million in foreign export revenues and supports 1.7 million smallholder farmers (UCDA, 2016). Nevertheless, coffee yields have stagnated for over a decade, despite concerted efforts to improve productivity. Climate change is increasing the pressure on the sector, and the effects are already being felt. Climate smart agricultural (CSA) practices are being promoted as a means to help farmers cope with climate change. The CSA training package focuses on planning good agricultural practices in a way that the changing climate is taken into consideration. The training package for coffee consists of a large number of practices (soil and water conservation, tree management, quality of coffee, among others), and is currently provided all in one go as a complete package. This approach is cumbersome and not aligned to pertinent needs of coffee farmers, as coffee is a perennial crop and needs continuous care throughout the year. To address the need for better targeting of practices, this Info Note presents two complementary approaches: the climate smart investment pathways (CSIPs) and farmer segmentation. The CSIPs break down the full training package of CSA practices into more manageable subsets of practices. These smaller packages are aimed at being more aligned with the structural (resource endowments) and functional (entrepreneurship) characteristics of different types of farmers. CSIPs build up a sequential and incremental approach to implementing the practices. The farmer segmentation tool differentiates the coffee farmers into different groups, based on their assets and entrepreneurial characteristics. These segmentations will help advise the relevant stakeholders that support farmers on how to best engage with and train farmers in the most relevant practices (based on the CSIP) by taking their capacity and willingness to implement the practices into consideration. This Info Note will first go through the development process of the CSIPs, based on the results from a study on Robusta coffee systems in Luweero and Nakasongola. Then it will move onto the process and results of the farmer segmentation work done in the Greater Luweero region (which encompasses Luweero and Nakasongola). The implications of this work will be discussed and recommendations will be made for further work and use of these methods

Sexual health of very young adolescents in South Western Uganda : a cross-sectional assessment of sexual knowledge and behavior

Background: In most Sub-Saharan African countries, little is known about young adolescents' sexual and reproductive health (SRH). Though some efforts have been made to understand and improve SRH of older adolescents, very young adolescents (VYAs) are often overlooked, and little is known about their sexual knowledge and behaviors. The goal of this study was to describe SRH knowledge, information-seeking, and sexual behavior of VYAs in Uganda. Methods: A cross-sectional survey was administered in 33 primary schools in June and July of 2016. Trained interviewers administered surveys to adolescents ages 10-14 regarding SRH knowledge, information-seeking, sexual behavior, and relevant covariates. Continuous variables were summarized as means (SD) or medians (IQR) whereas categorical variables were summarized as proportions (percentages). Results: A total of 1096 adolescents were included in this analysis, 81.8% of which were from rural areas, with a median age of 12. Regarding sexually transmitted infections (STIs) knowledge; 95% knew HIV while 37% knew other STIs apart from HIV. Although 47% knew at least one way in which HIV is acquired only 8% knew at least four ways. Regarding contraceptive knowledge, 56% mentioned at least one modern method of preventing pregnancy (condoms, pills, intrauterine devices, implants, or injections). The majority (85%) of VYAs reported accessing SRH information in the media with 35% reporting accessing media with sexual content while 10% vs 22% consulted their father or mother respectively and 31% a school source. At least 7.6% of VYAs had ever had sexual intercourse, 90% of which were not using any protection. Conclusion: Comprehensive SRH knowledge was low among VYAs in this study. Media remains an important source of information for SRH for this age group though it may be misused as some adolescents reported accessing sexual content that may be inappropriate. A large proportion of sexually active VYAs reported sexual risky behaviors. This study highlights the need for an accurate and more comprehensive SRH education approach for VYAs in Uganda at an opportune age before the majority engage in sexual behavior

Adolescents' sexual wellbeing in Southwestern Uganda : a cross-sectional assessment of body image, self-esteem and gender equitable norms

Measures of sexual wellbeing and positive aspects of sexuality in the World Health Organization definition for sexual health are rarely studied and remain poorly understood, especially among adolescents in Sub-Saharan Africa. The objective of this study was to assess sexual wellbeing in its broad sense-i.e., body image, self-esteem, and gender equitable norms-and associated factors in young adolescents in Uganda. A cross-sectional survey of adolescents ages 10-14 years in schools was carried out between June and July 2016. Among 1096 adolescents analyzed, the median age was 12 (Inter-Quartile Range (IQR): 11, 13) and 58% were female. Self-esteem and body image scores were high with median 24 (IQR: 22, 26, possible range: 7-28) and median 22 (IQR: 19, 24, possible range: 5-25) respectively. Gender equitable norms mean score was 28.1 (SD 5.2: possible range 11-44). We noted high scores for self-esteem and body image but moderate scores on gender equitable norms. Girls had higher scores compared to boys for all outcomes. A higher age and being sexually active were associated with lower scores on gender equitable norms. Gender equitable norms scores decreased with increasing age of adolescents. Comprehensive and timely sexuality education programs focusing on gender differences and norms are recommended

'Girls have more challenges; they need to be locked up' : a qualitative study of gender norms and the sexuality of young adolescents in Uganda

Unequal power and gender norms expose adolescent girls to higher risks of HIV, early marriages, pregnancies and coerced sex. In Uganda, almost half of the girls below the age of 18 are already married or pregnant, which poses a danger to the lives of young girls. This study explores the social construction of gender norms from early childhood, and how it influences adolescents' agency. Contrary to the mainstream theory of agency, which focuses on the ability to make informed choices, adolescents' agency appears constrained by context-specific obstacles. This study adopted qualitative research approaches involving 132 participants. Of these, 44 were in-depth interviews and 11 were focus group discussions, parcelled out into separate groups of adolescents (12-14 years), teachers, and parents (n = 88), in Western Uganda. Data were analysed manually using open and axial codes, and conclusions were inductive. Results show that gender norms are established early in life, and have a very substantial impact on the agency of young adolescents. There were stereotypical gender norms depicting boys as sexually active and girls as restrained; girls' movements were restricted; their sexual agency constrained; and prevention of pregnancy was perceived as a girl's responsibility. Programs targeting behavioural change need to begin early in the lives of young children. They should target teachers and parents about the values of gender equality and strengthen the legal system to create an enabling environment to address the health and wellbeing of adolescents

Exploring the experiences of healthcare professionals in South Africa and Uganda around communicating with children about life-threatening conditions: a workshop-based qualitative study to inform the adaptation of communication frameworks for use in these settings

OBJECTIVES: This study aimed to explore how published communication frameworks could be amended to ensure applicability and cultural appropriateness for professionals to support family-centred conversations by investigating’ healthcare professionals’ (1) experiences of providing support to families when a caregiver or a dependent child (<18 years old) has a life-threatening condition, (2) perceived challenges for caregivers and healthcare professionals in communicating with children about illness, (3) perceptions of how clinicians could be equipped to facilitate conversations between caregivers and children about an adult or the child’s own life-threatening condition and (4) suggestions for amendments to previously published guidelines to ensure cultural relevance in South Africa and Uganda. DESIGN: A qualitative study involving two 2-day workshops with embedded focus group discussions, break out rooms and consensus discussions. SETTING: Health and social care and third sector organisations in South Africa and Uganda. PARTICIPANTS: Thirty-two professionals providing care to families affected by life-threatening conditions in South Africa or Uganda who were aged 18 years or older and able to converse in English. RESULTS: Participants identified obstacles to having conversations with caregivers about children and to telling children about serious illness during consultations. These included patients’ beliefs about illness, medicine and death, language barriers between families and the healthcare team, and emotional and practical challenges for professionals in having these conversations. Culturally appropriate adaptations were made to previously published communication frameworks for professionals to support family-centred conversations. CONCLUSIONS: Culturally sensitive communication frameworks could help healthcare professionals to talk with families about what children need to know when they or a caregiver have a serious illness. More broadly, effective communication could be facilitated by promoting healthcare professionals’ and communities’ understanding of the benefits of telling children about illness within the family. Together these strategies may mitigate the psychological impact of global disease on children and their families

Intimate Partner Violence During COVID-19 Restrictions: A Study of 30 Countries From the I-SHARE Consortium.

Intimate partner violence (IPV) causes substantial physical and psychological trauma. Restrictions introduced in response to the COVID-19 pandemic, including lockdowns and movement restrictions, may exacerbate IPV risk and reduce access to IPV support services. This cross-sectional study examines IPV during COVID-19 restrictions in 30 countries from the International Sexual HeAlth and REproductive Health (I-SHARE) study conducted from July 20th, 2020, to February, 15th, 2021. IPV was a primary outcome measure adapted from a World Health Organization multicountry survey. Mixed-effects modeling was used to determine IPV correlates among participants stratified by cohabitation status. The sample included 23,067 participants from 30 countries. A total of 1,070/15,336 (7.0%) participants stated that they experienced IPV during COVID-19 restrictions. A total of 1,486/15,336 (9.2%) participants stated that they had experienced either physical or sexual partner violence before the restrictions, which then decreased to 1,070 (7.0%) after the restrictions. In general, identifying as a sexual minority and experiencing greater economic vulnerability were associated with higher odds of experiencing IPV during COVID-19 restrictions, which were accentuated among participants who were living with their partners. Greater stringency of COVID-19 restrictions and living in urban or semi-urban areas were associated with lower odds of experiencing IPV in some settings. The I-SHARE data suggest a substantial burden of IPV during COVID-19 restrictions. However, the restrictions were correlated with reduced IPV in some settings. There is a need for investing in specific support systems for survivors of IPV during the implementation of restrictions designed to contain infectious disease outbreaks