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Comprehensive sexuality education (CSE) seeks to improve young people's knowledge, attitudes and practices in relation to sexual and reproductive health, sexual and social relationships, and dignity and rights. In Ethiopia, young people with disabilities and young women involved in sex work are particularly vulnerable to sexual violence and poor sexual health, yet face stigma and accessibility challenges that continue to exclude them from information, support and services. Because they are often out of school, these groups are also often excluded from programmes that are largely delivered in school settings. This paper explores the challenges faced by these groups of young people in accessing inclusive and age-appropriate sexual and reproductive health knowledge and services in the Ethiopian context and the implications for delivering CSE. The research included literature review, mapping analysis and interviews with young people from those two groups and with service providers and programme implementers. Our findings indicate that young people with disabilities and young women involved in sex work face myriad barriers to accessing information and services that support positive and healthy sexuality, relationships and rights. However, changes over the past decade to national and regional governance structures and a political environment in which CSE has become increasingly contested have generated siloed approaches to the provision of sexual and reproductive health information and services, and poor linkages to complementary services including violence prevention and social protection. It is vital that efforts to implement comprehensive sexuality education are informed by these challenges in the wider policy environment. [ABSTRACT FROM AUTHOR]

This paper presents the findings of a research study in Thane District, Maharashtra, India, on access to sexual and reproductive health and rights (SRHR) for women and girls of Nomadic and Denotified Tribes (NT-DNT). NT-DNT communities face stigma and violence due to their historically criminalised status and nomadic lifestyle. Their precarious legal, social, and economic status has a negative impact on women's SRHR. Existing literature on this subject is sparse, and studies by researchers from within the community, which could bring about organic and community-led change, are almost non-existent. This study, carried out by a woman from a Nomadic Tribe, presents an insider's perspective on the experiences of and factors underlying the violation of the SRHR of girls and women of NT-DNT communities. The study used a human rights-based participatory methodology with qualitative methods including three focus group discussions with 21 women and 10 in-depth interviews with women and key informants from NT-DNT communities. The findings describe the gender, community, and health system barriers which hinder women's and girls' access to SRHR. Issues such as language barriers between the women and medical fraternity, criminalisation by the police, and extreme deprivation – more intense than faced by the general poor – are unique to women of these communities. The NT-DNT communities face extreme deprivation of basic resources such as identity documents, shelter, sanitation, education support, workplace safety, and transportation, which further deny women their sexual and reproductive rights. The paper aims to amplify these women's voices to advocate for better SRHR services for women and girls of NT-DNT communities. [ABSTRACT FROM AUTHOR]

High levels of adolescent pregnancy and child marriage rates in low- and middle-income countries is an issue of concern to many stakeholders, including in Zambia where almost one-third of women give birth before age 18. The aim of this paper is to explore and analyse social norms concerning adolescents' sexual behaviour within the context of an intervention trial in rural communities in southern Zambia. It is based on a qualitative study applying individual interviews, focus group discussions and participatory research methods. We apply the distinction between injunctive and descriptive norms to demonstrate that adolescent girls are caught between conflicting norms. Injunctive norms express that premarital sex, contraceptive use, and discussions about sex between adults and youths are socially condemned. At the same time poor girls are reported to feel pressure towards having sexual relations for the economic benefits such relations can bring, and this practice is considered so common that it amounts to a descriptive norm. Norms and structural conditions combine to create a disabling and disempowering environment for adolescent sexual and reproductive health, which limits girls' agency and exposes them to unwanted pregnancies. [ABSTRACT FROM AUTHOR]

Background: Persons with disabilities comprise more than one billion people in the world, yet they are one of the most discriminated groups and face significant health disparities. Particularly in developing countries, which contain 80% of the entire population with disabilities, these individuals experience major barriers in accessing sexual and reproductive health (SRH) services. Education is an important factor that greatly affects individuals' SRH service utilization. Hence, we sought to investigate the relationship between education and SRH service utilization for persons with disabilities in Bangladesh. Methods: Using an explanatory sequential mixed-methods design, a total of 5000 persons with disabilities were surveyed for the quantitative component and 15 mini-ethnographic case studies were conducted with persons with disabilities for the qualitative component. Chi-squared tests and logistic regression analyses were performed on the survey data, while the qualitative interviews were coded and their SRH themes synthesized accordingly. Results: Our quantitative findings show that education statistically significantly increases persons with disabilities' SRH service utilization of antenatal care, delivery care, postnatal care, and family planning (P < 0.05). Interestingly, for persons with disabilities, primary education shows increased adjusted odds of family planning use but is likely not enough to increase antenatal care, delivery care, or postnatal care use; secondary or post-secondary education may be required to improve utilization of these latter services. Qualitative findings support the association between higher education levels and greater SRH service use. Persons with disabilities of lower educational attainment held misinformation and distrust in SRH services and experienced mistreatment by SRH healthcare providers, discouraging them from seeking future SRH services. Conclusions: We report that higher formal education level is associated with greater SRH service use for persons with disabilities in Bangladesh. Formally educating persons with disabilities expands their SRH knowledge and familiarity with SRH services, as well as leads to more economic opportunities so they can afford SRH services. Increasing formal education levels for persons with disabilities, paired with integrating comprehensive sexuality education (CSE) in their schools, will likely help close the gap in SRH health disparities for this vulnerable population. Plain Language Summary: Out of more than one billion persons with disabilities in the world, 80% of them live in developing countries. Persons with disabilities commonly face discrimination and health disparities, particularly experiencing major barriers in accessing sexual and reproductive health (SRH) services. Education is a key factor that often leads to social and economic empowerment, which positively contributes towards individuals' SRH service utilization. In this paper, we examined the relationship between education and SRH service utilization for persons with disabilities in Bangladesh. We surveyed persons with disabilities across all of Bangladesh on their utilization of SRH services and conducted mini-ethnographic case studies with selected participants to more deeply understand their SRH issues and SRH service utilization. Our survey findings show that education significantly increases persons with disabilities' SRH service utilization of antenatal care, delivery care, postnatal care, and family planning in Bangladesh. Interestingly, for persons with disabilities, primary education may only be able to increase family planning use while secondary or post-secondary education may be required to increase antenatal care, delivery care, and postnatal care use. Our qualitative findings support the association between higher education levels and greater SRH service use. Persons with disabilities of higher education prioritized obtaining formal SRH services from qualified health care providers, even when financially constrained, while lower educated participants tended to be misinformed and distrustful of formal SRH services. We recommend helping persons with disabilities attain higher formal education levels and including comprehensive sexuality education (CSE) in their schools, as it likely will reduce SRH health disparities for this vulnerable group. [ABSTRACT FROM AUTHOR]

Background: Adolescent pregnancy carries both health and economic risks for the pregnant girl and resulting baby, and it is common in Zambia. Providing alternative methods of preventing early pregnancy than abstinence is regarded as culturally and religiously unacceptable in most parts of the country. The community dialogue approach is being tested to address norms and beliefs around early pregnancy, marriage and school dropout, and is based on Paulo Freire's transformative communication approach. The objective of this paper was to understand parents' perspectives on the application of the community dialogue approach in addressing adolescents' early pregnancy and school dropout in a cluster randomized controlled trial in rural Zambia. Methods/design: This was a case study design. We nested the study in the community dialogue intervention arm of the Research Initiative to Support the Empowerment of Girls trial in Zambia. Dialogue meetings were held and economic support was provided for a period of 27 months from September 2016 until November 2018. We held focus group discussions in November 2018 with guardians/parents in six schools in Chibombo District of Central Province. All the discussions were audio recorded and transcribed verbatim. Thematic analysis was used to analyze the data. Results: The guardians/parents perceived the community dialogue to be a relevant approach for addressing social and cultural norms regarding early pregnancy, marriage and school dropout. It was embraced for its value in initiating individual and collective change. The facilitators' interactive approach and dialogue in the community meetings coupled with the use of films and role plays with the parents, lead to active participation and open discussions about sexual and reproductive health (SRH) topics during the community dialogue meetings. Group interactions and sharing of experiences helped parents clarify their SRH values and subsequently made them feel able to communicate about SRH issues with their children. However, cultural and religious beliefs among the parents regarding some topics, like the use of condoms and contraceptives, complicated the delivery of reproductive health messages from the parents to their children. Conclusion: The study indicated that the community dialogue was appreciated by the parents and helped in addressing cultural barriers to discussing SRH issues between generations. Plain language summary: Adolescent pregnancy carries health and economic risks for the pregnant girl and her baby. However, many adolescent girls in Zambia become pregnant and this is partly due to social norms around fertility and marriage. Community dialogue meetings may be useful in order to discuss norms and beliefs around early pregnancy, marriage and school dropout and encourage reflection around cultural practices in the communities. A cluster randomized controlled trial in rural Zambia tested the effects of organizing community dialogue meetings and providing economic support for families with adolescent girls for a period of 27 months, from 2016 to 2018. The objective of this case study was to understand parents' perspectives on the use of the community dialogue approach. Focus group discussions were held in November 2018 with guardians/parents in six schools in Chibombo District of Central Province. The guardians/parents perceived the community dialogue to be a relevant approach for addressing social and cultural norms regarding early pregnancy, marriage and school dropout. The facilitators' interactive approach in the community meetings coupled with the use of films and role plays, lead to active participation and open discussions about sexual and reproductive health topics during the community dialogue meetings. Group interactions and sharing of experiences made the guardians feel able to communicate about sexual and reproductive health issues with their children. However, cultural and religious beliefs among the parents regarding the use of condoms and contraceptives made it difficult for them to touch upon this topic. [ABSTRACT FROM AUTHOR]

Internally displaced women are underserved by health schemes and policies, even as they may face greater risk of violence and unplanned pregnancies, among other burdens. There are an estimated 450,000 internally displaced persons in India, but they are not formally recognised as a group. Displacement has been a common feature in India's northeast region. This paper examines reproductive and maternal health (RMH) care-seeking among Bru displaced women in India. The study employed qualitative methodology: four focus group discussions (FGDs) were held with 49 displaced Bru women aged 18–45 between June and July 2018; three follow-up interviews with FGD participants and five in-depth interviews with community health workers (Accredited Social Health Activists – ASHAs) in camps for Bru displaced people in the Indian state of Tripura. All interviewees gave written or verbal informed consent; discussions were conducted in the local dialect, recorded, and transcribed. Data were indexed deductively from a dataset coded using grounded approaches. Most women were unaware of many of the RMH services provided by health facilities; very few accessed such care. ASHAs had helped increase institutional deliveries over the years. Women were aware of temporary contraceptive methods as well as medical abortion, but lacked awareness of the full range of contraceptive options. Challenges in accessing RMH services included distance of facilities from camps, and multiple costs (for transport, medicines, and informal payments to facility staff). The study highlighted a need for comprehensive intervention to improve RMH knowledge, attitudes, and practices among displaced women and to reduce access barriers. [ABSTRACT FROM AUTHOR]

In this paper, we present the results of a qualitative study by a non-profit organisation implementing a community-based urban adolescent development programme. The study highlights the sexual and reproductive health and rights (SRHR) situation of marginalised young women in a developed state of India. Our findings, based on in-depth interviews with young women and frontline health providers, show that structural factors, such as economic and social stratifiers, gender norms and cultural beliefs, result in further marginalisation of young women. In turn, marginalisation adversely affects the realisation of SRHR through discriminatory practices around menstruation and lack of control in matters related to sexuality, contraception, pregnancy and safe abortion. Rights to the highest standards of sexual and reproductive health (SRH) care are compromised. Health system factors like providers' attitudes and knowledge, commodity supplies, and indifference to ensuring delivery of contraceptives and other services often result in unplanned pregnancies and affect the quality of young women's SRH care. Whatever information and support adolescents and young women get is from local community-based organisations. We conclude that structural determinants and violations of fundamental rights to education, equal opportunities and participation constitute a significant barrier to the enjoyment of SRHR by the marginalised young women in the study. Unless these are addressed, government policies and programmes to promote young people's SRHR will not benefit young women from disadvantaged communities. Partnership and complementarity between government programmes, adolescents and health rights civil society organisations are recommended to promote rights-based, equitable adolescent and youth-friendly services to this vulnerable population. [ABSTRACT FROM AUTHOR]

Introduction. Recent experiences from global outbreaks have highlighted the severe disruptions in sexual and reproductive health services that expose women and girls to preventable health risks. Yet, to date, there is no review studying the possible impact of outbreaks on sexual and reproductive health (SRH). Methodology. Studies reporting outbreaks impacting sexual and reproductive health and pregnancy outcomes were identified using MEDLINE, Embase, and ISI-WoS. Reported impacts were reviewed at systems, community, and legislative levels. Results. The initial run listed 4423 studies; the 37 studies that met all inclusion criteria were mainly from Latin America and Africa. Studies on outbreaks of diseases like Zika and Ebola have documented declines in facility-based deliveries, contraceptive use, and antenatal and institutional care due to burdened healthcare system. Service usage was also impacted by a lack of trust in the healthcare system and system shocks, including workforce capacity and availability. At the community level, poverty and lack of awareness were critical contributors to poor access to SRH services. Assessing the target population's knowledge, attitude, beliefs, and behavior and using health literacy principles for communication were fundamental for designing service delivery. Online resources for SRH services were an acceptable medium of information among young adults. In outbreak situations, SRH and pregnancy outcomes were improved by implementing laboratory surveillance, free-of-cost contraceptive services, improved screening through professional training, and quality of care. In addition, mobile health clinics were reported to be effective in remote areas. Knowledge Contribution. In outbreaks, the interventions are categorized into preoutbreak, during, and postoutbreak periods. The proposed steps can help to improve and do course correction in emergencies. Though conducted before the COVID-19 crisis, the authors believe that lessons can be drawn from the paper to understand and mitigate the impact of the pandemic on sexual and reproductive health services. [ABSTRACT FROM AUTHOR]

Background: The adolescent (ages 15-19) and young adult (ages 20-24) years are a crucial time as many sexual and reproductive health (SRH) transitions take place in these years. The study of youth SRH transitions in sub-Saharan Africa is limited due to a paucity of longitudinal data needed to examine the timing and circumstances of these transitions.Methods: This paper uses recently collected longitudinal data from select urban areas in Kenya and Nigeria that include a large youth sample at baseline (2010/2011) and endline (2014). We control for unobserved heterogeneity in our modelling approach to correct for selectivity issues that are often ignored in similar types of analyses.Results: We demonstrate that the transition patterns (i.e., sexual initiation, first marriage, and first pregnancy/birth) differ within and across the urban areas and countries studied. Urban Kenyan youth have more premarital sex and pregnancy than youth from the Nigerian cities. Further analyses demonstrate that more educated and wealthier youth transition later than their less educated and poorer counterparts.Conclusions: The findings from this study can be used to inform programs seeking to serve young people based on their varying reproductive health needs in different contexts over the adolescent and young adult years. [ABSTRACT FROM AUTHOR]

Objectives The maternal and child health (MCH) community, partnering with women and their families, has the potential to play a critical role in advancing a new multi-sector social movement focused on creating a women's reproductive and economic justice agenda. Since the turn of the twenty-first century, the MCH field has been planting seeds for change. The time has come for this work to bear fruit as many states are facing stagnant or slow progress in reducing infant mortality, increasing maternal death rates, and growing health inequities. Methods This paper synthesizes three current, interrelated approaches to addressing MCH challenges-life course theory, preconception health, and social justice/reproductive equity. Conclusion Based on these core constructs, the authors offer four directions for advancing efforts to improve MCH outcomes. The first is to ensure access to quality health care for all. The second is to facilitate change through critical conversations about challenging issues such as poverty, racism, sexism, and immigration; the relevance of evidence-based practice in disenfranchised communities; and how we might be perpetuating inequities in our institutions. The third is to develop collaborative spaces in which leaders across diverse sectors can see their roles in creating equitable neighborhood conditions that ensure optimal reproductive choices and outcomes for women and their families. Last, the authors suggest that leaders engage the MCH workforce and its consumers in dialogue and action about local and national policies that address the social determinants of health and how these policies influence reproductive and early childhood outcomes. [ABSTRACT FROM AUTHOR]

Background: In many contexts, women with disability have less access to sexual and reproductive health information, screening, prevention, and care services than women without disability. Women with disability are also known to be more likely to experience physical and sexual violence than women without disability. In the Philippines, health service providers often have little awareness of the sexual and reproductive experiences of women with disability and limited capacity to provide services in response to their needs. Very limited data are available to inform development of disability-inclusive sexual and reproductive health, and violence prevention and response, services in the country. This paper presents the protocol for W-DARE (Women with Disability taking Action on REproductive and sexual health), a three-year program of participatory action research that aims to improve the sexual and reproductive health of women with disability in the Philippines.Design: W-DARE is a disability-inclusive program that will use mixed methods to 1) increase understanding of factors influencing the sexual and reproductive health of women with disability, and 2) develop, implement and evaluate local interventions to increase supply of and demand for services. W-DARE will generate data on the prevalence of disability in two districts; the wellbeing and community participation of people with and without disability, and identify barriers to community; and describe the sexual and reproductive health needs and experiences, and service-related experiences of women with disability. These data will inform the development and evaluation of interventions aiming to improve access to sexual and reproductive health services, and violence prevention and response services, for women with disability. Local women with disabilities, their representative organisations, and SRH service providers will be involved as members of the research team across all stages of the research.Discussion: This three-year study will provide evidence about factors undermining the sexual and reproductive health of women with disability in a lower-middle income country, and provide new insights about what may be effective in increasing access to services in settings of limited resources. Findings will be relevant across Asia and the Pacific. Analysis of the program will also provide evidence about disability-inclusion in participatory action research approaches. [ABSTRACT FROM AUTHOR]