Feasibility and acceptability of peer-delivered interventions using mHealth for PrEP services among adolescent girls and young women in DREAMS program in Botswana.

BACKGROUND: Adolescent girls and young women accounted for 25% of all new HIV infections despite representing only 10% of the population in Sub Saharan Africa. PEPFAR has launched the Determined, Resilient, Empowered, AIDS-free, Mentored, and Safe (DREAMS) initiative, a comprehensive HIV prevention program including PrEP services. Among adolescent girls and young women, PrEP adherence is currently sub-optimal. Tailored strategies for adolescent girls and young women to improve access and use of PrEP delivery are urgently needed to maximise its potential. Recommended interventions include peer-delivered interventions using mobile technology. However, data on the feasibility and acceptability of this approach is limited for SSA. OBJECTIVES: We assessed the feasibility and perceived acceptability of providing mHealth peer-delivered interventions to support PrEP services among adolescent girls and young women in Botswana. METHODS: This cross-sectional study included HIV-negative women aged 18-24 years old seeking health services at DREAMS-supported facilities. Participants completed a survey assessing the feasibility and perceived acceptability of the mHealth peer-delivered interventions, which included the Acceptability of Intervention Measure (AIM). Descriptive analyses were performed. RESULTS: A total of 131 participated in the study. Overall, 89% owned a mobile phone (feasibility). There was no difference in cell phone ownership between participants from rural and urban settings. Among participants, 85% reported interest in participating in a mHealth peer-delivered intervention if it was available to them. Regarding perceived acceptability for mHealthpeer support groups for PrEP, the average score on the AIM was 3.8 out of 5 (SD = 0.8). CONCLUSION: mHealthpeer-delivered interventions appear to be feasible and perceived acceptable among adolescent girls and young women in Botswana. This modality should be incorporated into PEPFAR's programmatic toolkit of implementation strategies to improve PrEP services.

Achieving HIV Epidemic Control and Improving Maternal Healthcare Services with Community-Based HIV Service Delivery in Zambia: Mixed-Methods Assessment of the SMACHT Project.

Novel community-based approaches are needed to achieve and sustain HIV epidemic control in Zambia. Under the Stop Mother and Child HIV Transmission (SMACHT) project, the Community HIV Epidemic Control (CHEC) differentiated service delivery model used community health workers to support HIV testing, ART linkage, viral suppression, and prevention of mother-to-child transmission (MTCT). A multi-methods assessment included programmatic data analysis from April 2015 to September 2020, and qualitative interviews from February to March 2020. CHEC provided HIV testing services to 1,379,387 clients; 46,138 were newly identified as HIV-positive (3.3% yield), with 41,366 (90%) linked to ART. By 2020, 91% (60,694/66,841) of clients on ART were virally suppressed. Qualitatively, healthcare workers and clients benefitted from CHEC, with provision of confidential services, health facility decongestion, and increased HIV care uptake and retention. Community-based models can increase uptake of HIV testing and linkage to care, and help achieve epidemic control and elimination of MTCT.

Assessing risk factors and health impacts across different forms of exchange sex among young women in informal settlements in South Africa: A cross-sectional study.

For women in South Africa, engaging in exchange sex, including transactional sex (TS), or sex work (SW), is associated with several shared poor health outcomes; yet the practices themselves differ in meaningful ways. SW is a form of commodity exchange, while TS is grounded in gendered relationship expectations of male provision and aspects of emotional intimacy. Additionally, exchange sex types could be imagined on a "continuum of instrumentality" from relationships that do not include material support; to those characterized, but not driven by support; to those primarily motivated by material support. We use cross-sectional data from 644 women ages 18-30 enrolled in a trial addressing intimate partner violence in urban KwaZulu-Natal, South Africa to assess whether these conceptualizations may also map onto different types or levels of risk. Using self-reports, we developed four exchange sex relationship categories corresponding to a continuum of instrumentality: no exchange-based relationship; TS with a main partner only; TS with a casual partner; and SW. Using tests of association and adjusted logistic regression models, we compared socio-economic and behavioural risk factors, and health outcomes across reported forms of exchange sex. We find little difference between women who report no exchange sex and those who report TS only with a main partner. By contrast, as compared to women not in exchange sex, women in casual TS and SW were poorer, and significantly more likely to report problematic alcohol use, past drug use, prior non-partner sexual violence, and PTSD; with aOR higher for women in SW for many outcomes. When comparing casual TS to SW, we find women in SW held more gender equitable attitudes and were more likely to report modern contraceptive use. We discuss the implications for distinguishing between TS and SW, and use of the continuum of instrumentality conceptualization for research and programming.

Development of the Gender Roles and Male Provision Expectations Scale.

Existing composite measures assess the extent to which women and men support masculinity ideals concerning the expectation that men should provide for their partners and families. In many contexts across sub-Saharan Africa, the male provider role is taken as given. This core masculinity tenet may be associated with related gender role expectations that result in increasing young women's risk of HIV, especially within the context of transactional sex relationships. Extant literature points to five domains potentially associated with male provider role expectations: male authority, men's sexual decision-making control, women's sexual agency, women's economic dependence, and love. The goal of this study was to develop the Gender Roles and Male Provision Expectations (GRMPE) scale toward understanding whether beliefs attached to male provider role expectations increase HIV risk. We developed the GRMPE across three research phases with young women (ages 15-24) in Central Uganda that (1) used qualitative data to refine domains and develop scale items; (2) cognitively tested the refined items; and (3) pilot tested a 26-item scale across five domains with 108 young women. Using confirmatory factor analyses, we retained 15 items across four factors, corresponding to the domains of male authority, sexual decision-making, women's sexual agency, and love; which we then modeled as indicators in a single second-order factor model. The GRMPE demonstrated initial reliability and validity, and tests of criterion validity found significant associations with known HIV risk behaviors. The GRMPE scale shows promise for better examining the determinants of HIV risk and assessing gender norm change interventions.

A mixed-methods, exploratory, quasi-experimental evaluation of a radio drama intervention to prevent age-disparate transactional sex in Tanzania.

Introduction: Age-disparate transactional sex (ADTS) is associated with HIV, unintended pregnancy, school dropout and violence, yet few interventions have successfully prevented it, and none have set ADTS prevention as their primary outcome. This exploratory evaluation aimed to assess indications of change after exposure to the Learning Initiative on Norms, Exploitation and Abuse (LINEA) intervention, a mass-media, gender-transformative social norms intervention aimed at preventing ADTS in Tanzania. Methods: In a condensed implementation 331 participants were instructed to listen to the LINEA radio drama over seven weeks, and 60 were randomly allocated to household discussion sessions about content. In-depth interviews (n = 81) from girls aged 12-16 years, and women and men caregivers were collected at baseline (September 2021), midline (November) and endline (December 2021). Surveys were conducted (n = 120) at baseline and endline using the Norms and Attitudes on ADTS Scale (NAATSS) and the Gender Roles and Male Provision Expectations (GRMPE) scale. Interviews were thematically analyzed using a framework approach. Age-stratified linear regression models adjusted for baseline scores were used to measure association between the intervention and endline scale scores. Results: Longitudinal data were available from 59 qualitative (73%) and 95 quantitative participants (79%). Qualitative evidence revealed the drama facilitated family conversations about adolescent challenges, allowing caregivers to advise daughters. Some girls gained confidence to refuse men's gifts, learning that accepting them could necessitate sexual reciprocation. Some caregivers felt increased responsibility for supporting girls in the community to avoid ADTS. Blame for ADTS shifted for some from girls to men, suggesting increased understanding of inequitable power dynamics and reductions in victim blaming. Marginal quantitative evidence revealed that highly exposed girls had improved gender equitable beliefs on the GRMPE (ß = -6.26; 95% CI: -12.94, 0.42). Moderately exposed men had increased gender inequitable norms on the NAATSS subscale (ß = 0.42 95% CI: 0.05, 0.79), but there was no effect in highly exposed men. Conclusions: Given the small sample results should be interpreted cautiously. Our initial findings indicate high engagement with the LINEA intervention shows promise in shifting knowledge, behaviors, and attitudes, beliefs and social norms driving ADTS in Shinyanga, Tanzania, supporting a robust impact evaluation.

A qualitative exploration of university student perspectives on mindfulness-based stress reduction exercises via smartphone app in Bangladesh.

PURPOSE: Mental health problems are proliferating, and access to mental health care is difficult due to barriers imposed by the COVID-19 pandemic in low-income countries such as Bangladesh. University students are susceptible to mental health concerns, given their unique stressors (i.e., academic pressure, new social environment). Mindfulness techniques can promote mental health , yet their acceptability has not been examined among Bangladeshi university students. These techniques can be used on a digital app, to decrease barriers to use.Qualitative methods were used to examine the acceptability of mindfulness among university students in Bangladesh. In-depth interviews (n = 12) were conducted to examine student reactions to linguistically (Bangla) and culturally adapted mindfulness exercises. Thematic analysis generated three themes (1) previous experience with mindfulness (2) positive responses to and (3) improvements to mindfulness exercises. RESULTS: The results showed favourable attitudes towards the mindfulness content; students expressed positive psychological and physiological reactions. Students welcomed the concept of using these exercises on an app and felt it could overcomepast barriers to help-seeking. CONCLUSIONS: This evidence suggests the value of exploring the acceptability of an app with mindfulness exercises for mental health promotion through a larger-scale pilot study in university students in Bangladesh.

Confluence of crises: COVID-19, "gassings", blood draws and the continued importance of community engagement in Zambia.

Background: Nationally representative, household-based, health-related surveys are an invaluable source of health information, but face implementation challenges. In sub-Saharan Africa, these challenges are exacerbated when surveys include the collection of biological specimens. In this study, we describe the potential implementation challenges identified during field practice leading up to the 2020 Zambia Population-based HIV Impact Assessment (ZAMPHIA) survey, and explore the role of two crises on community mistrust of, and apprehension to, participate in the survey. Methods: Using focus group methodology to better understand the influence of crises on ZAMPHIA participation, we conducted 12 focus group discussions (FGDs) in five districts across two provinces. FGDs were conducted with three purposively sampled study groups: recognized household heads, community leaders, and young adults aged 18-24 years. We used reflexive thematic analysis to develop themes from across the FGDs. Results: We identified two key themes: the ever-present threat a stranger posed to the community is enhanced by crises, and endorsement of community awareness through sensitization can mitigate outsider challenges in medical research. Conclusion: We argue that these crises emphasized underlying mistrust that can only be addressed with substantial investment in community engagement efforts to build trust and partnership in medical research endeavors. Our findings underline the importance of prioritizing community engagement through substantial investment in varied and extensive approaches to sensitization to facilitate community engagement toward community acceptance of ZAMPHIA and similar studies.

Adolescent Mothers in Eastern and Southern Africa: An Overlooked and Uniquely Vulnerable Subpopulation in the Fight Against HIV.

PURPOSE: Adolescent girls (10-19 years) in Eastern and Southern Africa face a high risk of pregnancy and HIV infection. However, few studies have examined whether the profound developmental, social, and economic changes that accompany adolescent motherhood contribute to HIV risk. This study examines the intersection between adolescent motherhood and HIV infection across 10 Eastern and Southern African countries, where over half of all HIV infections occur among adolescent girls. METHODS: To evaluate whether adolescent motherhood is associated with HIV infection, we used Demographic and Health Survey data on girls (15-19 years) with HIV test results (N = 19,932) from Eswatini, Kenya, Lesotho, Malawi, Mozambique, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe. We examined unweighted bivariate and multivariable associations between adolescent motherhood and HIV using mixed effects logistic regression models that included a country-level random intercept. We examined heterogeneity in the association by testing country-level random slopes using a likelihood ratio test and used intraclass correlation to measure the proportion of total variance explained at the country level. RESULTS: Nearly one fifth of adolescent girls were mothers (range: 9.80%-38.90%), and the HIV prevalence among all adolescent girls was 3.3% (range: 1.03%-10.07%). Relative to nonmothers, adolescent mothers were, on average, older, poorer, and more likely to be married, rural dwellers, and household heads. Adolescent motherhood was positively associated with HIV infection in bivariate and multivariable analyses (odds ratio: 1.87; 95% confidence interval: 1.57-2.23; adjusted odds ratio: 1.53; 95% CI: 1.24-1.89). DISCUSSION: Among adolescents with HIV test results, we observed a robust association between adolescent motherhood and HIV infection across 10 high-burden countries.

Motivations and barriers for clinical mental health help-seeking in Bangladeshi university students: a cross-sectional study.

Background: University and college students are vulnerable to developing depressive symptoms. People in low-income countries are disproportionately impacted by mental health problems, yet few studies examine routes to accessing clinical services. Examining motivation and barriers toward seeking clinical mental health services in university students in Bangladesh is important. Method: Using a cross-sectional survey (n = 350), we assess the relationship between the constructs of autonomy, relatedness, and competency toward using clinical mental health practices (i.e. using professional resources, taking medication) with (1) positive views, (2) perceived need, and (3) use of clinical mental health services among Bangladeshi university students. Results: Results showed that the perceived need for mental health support was the predictor of the largest magnitude (aOR = 4.99, p = 0.005) for using clinical services. Having a positive view of clinical services was predictive of clinical service use (aOR = 2.87, p = 0.033); however, that association became insignificant (p = 0.054) when adjusting for the perceived need for mental health care. Of the SDT constructs, social influences were predictive of perceiving a need for mental health support, and mental health knowledge was predictive (aOR = 1.10, p = 0.001) of having a positive view of clinical mental health care. Conclusion: Our findings show that knowledge of mental health is associated with positive views of mental health services, and that higher levels of stress and the presence of people with mental health problems are associated with the perception of a need for mental health care, which is ultimately responsible for using the services.

Measuring transactional sex in different contexts: How do tools to measure this practice perform in rural South Africa?

Background: Adolescent girls and young women across sub-Saharan Africa are at disproportionate risk of HIV infection compared to their male counterparts. Transactional sex has been identified as an important proximate risk for infection in this population. Definitions and measures of transactional sex vary, necessitating improved measures to better estimate prevalence across settings, over time, and to understand the mechanisms through which transactional sex increases HIV risk. This article describes the results of cognitive interviews in rural KwaZulu-Natal in South Africa to evaluate the performance of an improved measure of transactional sex.Methods: Data were collected between May and June 2017 with sexually active adolescent girls and young women (n = 10) and men (n = 10) drawn from a general population sample. Two questions were tested. Audio-recorded interviews were conducted in isiZulu using a structured tool. Matrices were used to summarise the data across participants which were then compared using constant comparative techniques.Results: Participants captured the instrumental nature of transactional sex relationships clearly and understood that the questions were about relationships that were primarily motivated by benefit. However, despite prior qualitative research in this setting describing transactional sex as widely practised, only one male participant answered either question in the affirmative in this face-to-face interview. This implies a judgement placed on relationships that are deemed as having been motivated mainly by exchange, perhaps compelling people to under-report such relationships.Conclusion: Participants' unwillingness to answer in the affirmative highlights the importance of understanding the research context and the possible social and historical influences which may influence how survey questions are answered. This has implications for measurement development, and highlights the need for measures that can be responsive to contextual differences. Further research is needed for refinements to measurement approaches in this and other settings.

Regional heterogeneity in violence and individual characteristics associated with recent transactional sex among Ugandan girls and young women: A national and regional analysis of data from the Violence Against Children and Youth Survey.

OBJECTIVES: This study assessed associations between recent transactional sex (TS) and potential determinants and variations in patterns across two geographic regions with high HIV burden compared to the rest of Uganda, among adolescent girls and young women (AGYW). METHODS: In 2015, a nationally representative cross-sectional household survey was conducted in Uganda. A stratified multi-stage cluster sample design produced nationally representative estimates and sub-national estimates for AGYW in two high HIV burden regions, DREAMS Central 1 (Bukomansimbi, Ssembabule, and Rakai districts) and DREAMS Central 2 (Mubende, Mityana, Gomba, and Mukono districts), and the rest of Uganda. To identify associations between recent TS (defined as sex in the past 12 months in exchange for material support or help) and risk factors, multivariable logistic regressions were conducted. Interaction terms assessed the associations between violence and recent TS across geographic regions. RESULTS: Nationally, 14.2% of sexually active AGYW engaged in recent TS. Region-specific significant associations emerged between recent TS and marriage, family wealth, friendship, orphanhood, and sexual debut. In DREAMS Central 1 and 2, AGYW who witnessed violence in the home or community, or experienced sexual, physical, or emotional violence had higher odds of recent TS than AGYW who did not experience that form of violence (adjusted odds ratio ranged between 2.10 (95% CI, 1.07, 4.13) and 8.25 (95% CI, 3.40, 20.06)). The magnitude of association between recent TS and types of violence varied by region. CONCLUSIONS: Violence is strongly and consistently associated with recent TS, and patterns in prevalence and risk factors vary across regions in Uganda. Given the high risk of HIV association with recent TS, HIV epidemic control efforts may benefit from focus on comprehensive violence prevention and target persons who engage in TS. Comprehensive HIV prevention programming aimed at keeping AGYW HIV-negative should incorporate prevention of violence and TS as key components to facilitate HIV epidemic control in this vulnerable population.

Sexual risk behaviors, mental health outcomes and attitudes supportive of wife-beating associated with childhood transactional sex among adolescent girls and young women: Findings from the Uganda Violence Against Children Survey.

Compared to young men, Ugandan young women are disproportionately impacted by HIV. Childhood transactional sex may contribute to this disparity. Using data from the 2015 Uganda Violence Against Children Survey, we used logistic regression models to assess the association between childhood transactional sex and negative outcomes. Among 18-24-year-old young women who had sex prior to 18 (n = 982), those who ever engaged in transactional sex had 5.9 times [adjusted odds ratio (AOR); confidence interval (CI): 1.6-22.2] higher odds of having multiple sexual partners in the past year; 5.2 times (AOR; CI: 2.1-12.9) higher odds of infrequent condom use in the past year; 3.0 times (AOR; CI: 1.2-7.9) higher odds of hurting themselves intentionally; and 3.2 times (AOR; CI: 1.3-7.7) higher odds of having attitudes justifying spousal abuse than young women who never engaged in transactional sex. Interventions for transactional sex and HIV in Uganda should consider prioritizing prevention, harm-reduction and continued investment in adolescent girls' and young women's futures.

Economic Inequality and Divergence in Family Formation in sub-Saharan Africa.

Economic inequality has been rising in many sub-Saharan African countries alongside rapid changes to union and family formation. In high-income countries marked by rising inequality, union and family formation practices have diverged across socioeconomic statuses, with intergenerational social and health consequences for the disadvantaged. In this study, we address whether there is also evidence of demographic divergence in low-income settings. Specifically, we model the age at first marriage and first birth by socioeconomic status groups for women born between 1960-1989 using Demographic and Health Survey data from twelve sub-Saharan African countries where economic inequality levels are relatively high or rising. We argue that economic and socio-cultural factors may both serve to increasingly delay marriage and childbearing for the elite as compared to others in the context of rising inequality. We find emerging social stratification in marriage and childbearing, and demonstrate that this demographic divergence is driven by the elites who are increasingly marrying and having children at later ages, with near stagnation in the age at first marriage and birth among the remaining majority. We urge further research at the intersection of socioeconomic and demographic inequality to inform necessary policy levers and curtail negative social and health consequences.

Sexual health of adolescent girls and young women in Central Uganda: exploring perceived coercive aspects of transactional sex.

Adolescent girls and young women (AGYW) in Uganda are at risk of early sexual debut, unwanted pregnancy, violence, and disproportionally high HIV infection rates, driven in part by transactional sex. This paper examines the extent to which AGYW's participation in transactional sex is perceived to be coerced. We conducted 19 focus group discussions and 44 in-depth interviews using semi-structured tools. Interviews were audio recorded, and transcribed verbatim. Data were analysed using a thematic analysis. While AGYW did not necessarily use the language of coercion, their narratives describe a number of coercive aspects in their relationships. First, coercion by force as a result of "de-toothing" a man (whereby they received money or resources but did not wish to provide sex as "obligated" under the implicit "terms" of the relationships). Second, they described the coercive role that receiving resources played in their decision to have sex in the face of men's verbal insistence. Finally, they discussed having sex as a result of coercive economic circumstances including poverty, and because of peer pressure to uphold modern lifestyles. Support for income-generation activities, microfinance and social protection programmes may help reduce AGYW's vulnerability to sexual coercion in transactional sex relationships. Targeting gender norms that contribute to unequal power dynamics and social expectations that obligate AGYW to provide sex in return for resources, critically assessing the meaning of consensual sex, and normative interventions building on parents' efforts to ascertain the source of their daughters' resources may also reduce AGYW's vulnerability to coercion.

Developing Experimental Vignettes to Identify Gender Norms Associated With Transactional Sex for Adolescent Girls and Young Women in Central Uganda.

PURPOSE: Transactional sex or informal sexual exchange relationships increase adolescent girls' and young women's (AGYW) HIV and pregnancy risk in sub-Saharan Africa. These relationships are grounded in the shared expectation that men should provide financial support to their partners. We built a vignette experiment to assess whether gender norms influenced by expectations of provision help to explain how transactional sex increases AGYW's sexual and reproductive health risks. METHODS: We used mixed methods to develop a vignette experiment in Central Uganda with AGYW including 10 focus group discussions, 32 cognitive interviews, and a pilot survey experiment with 108 sexually active unmarried AGYW. Respondents were randomly assigned to one of the two manipulations for three vignettes. The vignettes examined whether the amount a man provided changed perceived social approval of men's authority in relationships, sexual decision-making power, or women having multiple partners. RESULTS: We find that a higher level of male provision is associated with higher levels of perceived community approval for his sexual decision-making power (p < .001) and lower levels of perceived peer approval for AGYW's to seek a second partner (p < .05). We also find that higher levels of male provision are associated with respondent's own approval of male authority and sexual decision-making. CONCLUSION: Our findings suggest that approval of men's sexual decision-making power increases when they provide more and that girls who seek a second partner find higher levels of social approval for this behavior when their primary partner provides less. Vignette experiments may be valuable for identifying social norms that put AGYW's sexual and reproductive health at risk.

Improving the Measurement of Transactional Sex in Sub-Saharan Africa: A Critical Review.

BACKGROUND: Transactional sex, or informal sexual exchange, is considered to be an important contributing factor to the disproportionately high HIV infection rates experienced by adolescent girls and young women in sub-Saharan Africa. Nonetheless, confusion remains over how best to define and measure this practice, hindering efforts to mitigate the role of transactional sex in the epidemic. We critically review current measures and offer evidence-based recommendations for improvement. SETTING: Although transactional sex is practiced around the world, we focus attention on the definition and measurement of this practice in sub-Saharan Africa, given the role it plays in young women's risk of HIV in this region. METHODS: We relied on both secondary and primary data sources. We draw on a systematic review of literature on transactional sex from sub-Saharan Africa and interview data from both key informants and cognitive interviews (n = 160) with young women (ages 14-24) and men (ages 18-35) in Uganda and Tanzania. RESULTS: We find current measures are inconsistent, conflate transactional sex with sex work, and fail to capture the gendered nature of the practice. We provide an evidence-based definition of transactional sex that guides our measurement recommendations. We then detail the development of improved measures through cognitive interviews. Finally, we offer recommended approaches to improved measurement of transactional sex for women and men in large-scale surveys. CONCLUSIONS: Improved measures are critical for accurate estimation of the prevalence of transactional sex and assessment of the extent to which transactional sex determines HIV risk.

Evaluation of a mobile approach to gender-based violence service delivery among Syrian refugees in Lebanon.

As the landscape of humanitarian response shifts from camp-based to urban- and informal-tented settlement-based responses, service providers and policymakers must consider creative modes for delivering health services. Psychosocial support and case management can be life-saving services for refugee women and girls who are at increased risk for physical, sexual and psychological gender-based violence (GBV). However, these services are often unavailable in non-camp refugee settings. We evaluated an innovative mobile service delivery model for GBV response and mitigation implemented by the International Rescue Committee (IRC) in Lebanon. In October 2015, we conducted in-depth interviews with IRC staff (n = 11), Syrian refugee women (n = 40) and adolescent girls (n = 26) to explore whether the mobile services meet the support needs of refugees and uphold international standards for GBV service delivery. Recruitment was conducted via purposive sampling. Data were analysed using deductive and inductive approaches in NVivo. Findings suggest that by providing free, flexible service delivery in women's own communities, the mobile model overcame barriers that limited women's and girls' access to essential services, including transportation, checkpoints, cost and gendered expectations around mobility and domestic responsibilities. Participants described the services as strengthening social networks, reducing feelings of idleness and isolation, and increasing knowledge and self-confidence. Results indicate that the model requires skilled, creative staff who can assess community readiness for activities, quickly build trust and ensure confidentiality in contexts of displacement and disruption. Referring survivors to legal and medical services was challenging in a context with limited access to quality services. The IRC's mobile service delivery model is a promising approach for accessing hard-to-reach refugee populations with critical GBV services.

New Findings on Child Marriage in Sub-Saharan Africa.

Despite increasing global attention and commitments by countries to end the harmful practice of child marriage, each year some 15 million girls marry before the age of 18. The preponderance of the evidence produced historically on child marriage comes from South Asia, where the vast majority of child brides live. Far less attention has been paid to child marriage in sub-Saharan Africa, where prevalence rates remain high. The International Center for Research on Women (ICRW) recently conducted research in Kenya, Senegal, Uganda, and Zambia to contribute to greater understanding of the drivers of child marriage in each of these contexts. Synthesizing findings from 4 diverse countries provides a useful opportunity to identify similarities and differences, as well as understandings that may be applicable to and helpful for preventing child marriage across these and other settings. Across the 4 countries, ICRW's research echoes the existing literature base in affirming that child marriage is rooted in inequitable gender norms that prioritize women's roles as wives, mothers, and household caretakers, resulting in inadequate investments by families in girls' education. These discriminatory norms interact closely with poverty and a lack of employment opportunities for girls and young women to perpetuate marriage as a seemingly viable alternative for girls. We found in the African study sites that sexual relations, unplanned pregnancy, and school dropout often precede child marriage, which differs from much of the existing evidence on child marriage from South Asia. Further, unlike in South Asia, where family members typically determine the spouse a girl will marry, most girls in the Africa study settings have greater autonomy in partner choice selection. In Senegal, increasing educational attainment and labor migration, particularly by young women, has contributed to reduced rates of child marriage for girls. Our findings suggest that improving gender equitable norms and providing more-and more equitable-opportunities for girls, particularly with regard to education and employment, are likely to improve child marriage outcomes. Providing comprehensive sexuality education and youth-friendly reproductive health services can reduce rates of early pregnancy that contribute to child marriage. Finally, identifying ways in which to improve communication between parents and adolescent daughters could go far in ensuring that girls feel valued and that parents feel heard as they make decisions together regarding the lives and opportunities of these adolescent girls.