Sara De Meyer

A cross-sectional study on attitudes toward gender equality, sexual behavior, positive sexual experiences, and communication about sex among sexually active and non-sexually active adolescents in Bolivia and Ecuador.

Background It is widely agreed upon that gender is a key aspect of sexuality however, questions remain on how gender exactly influences adolescents’ sexual health. Objective The aim of this research was to study correlations between gender equality attitudes and sexual behavior, sexual experiences and communication about sex among sexually active and non-sexually active adolescents in 2 Latin American countries. Design In 2011, a cross-sectional study was carried out among 5,913 adolescents aged 14–18 in 20 secondary schools in Cochabamba (Bolivia) and 6 secondary schools in Cuenca (Ecuador). Models were built using logistic regressions to assess the predictive value of attitudes toward gender equality on adolescents’ sexual behavior, on experiences and on communication. Results The analysis shows that sexually active adolescents who consider gender equality as important report higher current use of contraceptives within the couple. They are more likely to describe their last sexual intercourse as a positive experience and consider it easier to talk with their partner about sexuality than sexually experienced adolescents who are less positively inclined toward gender equality. These correlations remained consistent whether the respondent was a boy or a girl. Non-sexually active adolescents, who consider gender equality to be important, are more likely to think that sexual intercourse is a positive experience. They consider it less necessary to have sexual intercourse to maintain a relationship and find it easier to communicate with their girlfriend or boyfriend than sexually non-active adolescents who consider gender equality to be less important. Comparable results were found for boys and girls. Conclusions Our results suggest that gender equality attitudes have a positive impact on adolescents’ sexual and reproductive health (SRH) and wellbeing. Further research is necessary to better understand the relationship between gender attitudes and specific SRH outcomes such as unwanted teenage pregnancies and sexual pleasure among adolescents worldwide.

Improving adolescent sexual and reproductive health in Latin America: reflections from an International Congress

In February 2014, an international congress on Promoting Adolescent Sexual and Reproductive Health (ASRH) took place in Cuenca, Ecuador. Its objective was to share evidence on effective ASRH intervention projects and programs in Latin America, and to link this evidence to ASRH policy and program development. Over 800 people participated in the three-day event and sixty-six presentations were presented.This paper summarizes the key points of the Congress and of the Community Embedded Reproductive Health Care for Adolescents (CERCA) project. It aims at guiding future ASRH research and policy in Latin America.1. Context matters. Individual behaviors are strongly influenced by the social context in which they occur, through determinants at the individual, relational, family, community and societal levels. Gender norms/attitudes and ease of communication are two key determinants.2. Innovative action. There is limited and patchy evidence of effective approaches to reach adolescents with the health interventions they need at scale. Yet, there exist several promising and innovative examples of providing comprehensive sexuality education through conventional approaches and using new media, improving access to health services, and reaching adolescents as well as families and community members using community-based interventions were presented at the Congress.3. Better measurement. Evaluation designs and indicators chosen to measure the effect and impact of interventions are not always sensitive to subtle and incremental changes. This can create a gap between measured effectiveness and the impact perceived by the targeted populations.Thus, one conclusion is that we need more evidence to better determine the factors impeding progress in ASRH in Latin American, to innovate and respond flexibly to changing social dynamics and cultural practices, and to better measure the impact of existing intervention strategies. Yet, this Congress offered a starting point from which to build a multi-agency and multi-country effort to generate specific evidence on ASRH with the aim of guiding policy and program decision-making. In a region that contains substantial barriers of access to ASRH education and services, and some of the highest adolescent pregnancy rates in the world, the participants agreed that there is no time to lose.ResumenEn febrero de 2014, un congreso internacional sobre la promoción de la Salud Sexual y Reproductiva de los adolescentes (SSRA) tuvo lugar en Cuenca, Ecuador. Su objetivo era compartir evidencia sobre proyectos y programas de intervención eficaz en SSRA en América Latina, y vincular esta evidencia a la política de SSRA y al desarrollo de programas. Más de 800 personas participaron en un evento de tres días con sesenta y seis presentaciones.Este documento resume los puntos clave del congreso y del proyecto CERCA (Cuidado de la Salud sexual y Reproductiva para Adolescentes enmarcada en la comunidad). Su objetivo es orientar la investigación futura y la política de SSRA en América Latina.1. El contexto es importante. Los comportamientos individuales están fuertemente influenciados por el contexto social en el que se producen a través de factores determinantes a nivel individual, relacional, familiar, comunitario y social. Las normas de género, actitudes y facilidad de comunicación son dos factores determinantes.2. Acción innovadora. Hay evidencia limitada e irregular de los enfoques eficaces para llegar a los adolescentes con intervenciones que necesitan llevarse a escala. Sin embargo, existen varios ejemplos que fueron presentados en el congreso y que se ven prometedores e innovadores porque proporcionan una educación integral de la sexualidad a través de los métodos convencionales y el uso de nuevos medios de comunicación, la mejora del acceso a servicios de salud, y uso de intervenciones comunitarias para llegar a los adolescentes, familias y su comunidad.3. Mejor medición. Los diseños de evaluación y los indicadores elegidos para medir el efecto e impacto de las intervenciones no siempre son sensibles a los cambios sutiles y graduales. Esto puede crear una brecha entre la eficacia de medidas y el impacto percibido por las poblaciones beneficiarias.Por lo tanto, una conclusión es que necesitamos más pruebas para determinar mejor los factores que obstaculizan el progreso en la SSRA de América Latina, para innovar y responder con flexibilidad a los cambios en la dinámica social y las prácticas culturales, y para medir mejor el impacto de las estrategias de intervención existentes. No obstante, este congreso proporcionó un punto de partida para construir un esfuerzo común entre las multi-agencias y multi-país que genere evidencia específica sobre SSRA con el objetivo de orientar la toma de decisiones políticas y programas. En una región que aún tiene barreras de acceso a la educación y los servicios de SSRA y se encuentran las tasas de embarazo adolescente más altas del mundo, los participantes coincidieron en que no hay tiempo que perder.

Primary healthcare providers’ views on improving sexual and reproductive healthcare for adolescents in Bolivia, Ecuador, and Nicaragua

Objectives To elicit the views of primary healthcare providers from Bolivia, Ecuador, and Nicaragua on how adolescent sexual and reproductive health (ASRH) care in their communities can be improved. Methods Overall, 126 healthcare providers (46 from Bolivia, 39 from Ecuador, and 41 from Nicaragua) took part in this qualitative study. During a series of moderated discussions, they provided written opinions about the accessibility and appropriateness of ASRH services and suggestions for its improvement. The data were analyzed by employing a content analysis methodology. Results Study participants emphasized managerial issues such as the prioritization of adolescents as a patient group and increased healthcare providers’ awareness about adolescent-friendly approaches. They noted that such an approach needs to be extended beyond primary healthcare centers. Schools, parents, and the community in general should be encouraged to integrate issues related to ASRH in the everyday life of adolescents and become ‘gate-openers’ to ASRH services. To ensure the success of such measures, action at the policy level would be required. For example, decision-makers could call for developing clinical guidelines for this population group and coordinate multisectoral efforts. Conclusions To improve ASRH services within primary healthcare institutions in three Latin American countries, primary healthcare providers call for focusing on improving the youth-friendliness of health settings. To facilitate this, they suggested engaging with key stakeholders, such as parents, schools, and decision-makers at the policy level.

Sexual onset and contraceptive use among adolescents from poor neighbourhoods in Managua, Nicaragua

Abstract Background and objectives The prevalence of teenage pregnancies in Nicaragua is the highest in Latin-America. This study aimed to gain insight into factors which determine the sexual behaviours concerned. Methods From July until August 2011, a door-to-door survey was conducted among adolescents living in randomly selected poor neighbourhoods of Managua. Logistic regression was used to analyse factors related to sexual onset and contraceptive use. Results Data from 2803 adolescents were analysed. Of the 475 and 299 sexually active boys and girls, 43% and 54%, respectively, reported contraceptive use. Sexual onset was positively related to increasing age, male sex, alcohol consumption and not living with the parents. Catholic boys and boys never feeling peer pressure to have sexual intercourse were more likely to report consistent condom use. Having a partner and feeling comfortable talking about sexuality with the partner were associated with hormonal contraception. Conclusions Our data identified associates of adolescents’ sexual behaviour related to personal characteristics (sex and alcohol use), to the interaction with significant others (parents, partners, peers) and to the environment (housing condition, religion). We interpreted those associates within the context of the rapidly changing society and the recently implemented health system reform in Nicaragua. Chinese Abstract 摘要 背景与目的 尼加瓜拉是拉丁美洲青少年妊娠率最高的国家。本研究旨在深入了解其性行为相关因素。 方法 2011年7月至8月，研究者在马那瓜贫困地区随机抽样，通过入户访视对青少年进行调查。统计方法采用Logistic回归，分析与性发生及避孕相关的影响因素。 结果 研究分析了2 803名青少年的数据。在475名与299名有性活动的男孩与女孩中，分别有43%与54%采取了避孕措施。研究表明，性发生与年龄增长、男性性别、酒精摄入及脱离父母独居等因素呈正相关。天主教男孩与从未感受到性交方面同侪压力的男孩会坚持使用避孕套。有性伴侣且可以与性伴侣坦然讨论性话题与避孕药的使用相关。 结论 研究数据表明，青少年性行为与个人特征（性活动及酒精摄入）、其他个体影响（父母、性伴侣、同侪）以及环境因素（住房条件、宗教）相关。我们认为这些相关性发生的背景为尼加拉瓜瞬息万变的社会环境与近期实施的医疗系统体制的改革。

Factorial validation of the Attitudes toward Women Scale for Adolescents (AWSA) in assessing sexual behaviour patterns in Bolivian and Ecuadorian adolescents

Background Adolescents’ health is greatly influenced by social determinants, including gender norms. Although research has shown that there is an association between gender attitudes and adolescents’ sexual behaviour, few studies have assessed this relationship carefully. The Attitudes toward Women Scale for Adolescents (AWSA) is widely used to assess gender attitudes among adolescents; however, to our knowledge it has not been applied in Latin America. Objective To apply AWSA in Latin America for the first time, to perform a factorial validation of this scale and to assess the relationship of gender attitudes and sexual behaviour in Bolivian and Ecuadorian adolescents. Design This cross-sectional study was carried out in 2011 among 14–18 year olds in 20 high schools in Cochabamba (Bolivia) and six in Cuenca (Ecuador) as a part of a larger project. Schools were purposively selected. A Spanish version of the 12-item AWSA was employed for this study. The assessed aspects of adolescent sexual behaviour were: reported sexual intercourse, reported positive experience during last sexual intercourse and reported current use of contraception. The psychometric properties of AWSA were investigated, and both explanatory and confirmatory factorial analyses were performed. Results The number of questionnaires included in the analysis was 3,518 in Bolivia and 2,401 in Ecuador. A factorial analysis of AWSA resulted in three factors: power dimension (PD), equality dimension (ED) and behavioural dimension (BD). ED showed the highest correlates with adolescent sexual behaviour. Higher scores of this dimension were associated with a more positive experience of sexual relationships, a higher current use of modern contraception and greater sexual activity among girls. Conclusions This study revealed a three-factorial structure of AWSA and demonstrated that by employing factors, the sensitivity of AWSA increases as compared to using the scale as a whole to assess sexual behaviour. This could have important implications for future research on gender and the sexual experiences of adolescents.

“Boys Should Have the Courage to Ask a Girl Out”: Gender Norms in Early Adolescent Romantic Relationships

PURPOSE The purpose of the study is to explore how gender norms emerge in romantic relationships among early adolescents (EAs) living in five poor urban areas. METHODS Data were collected as part of the Global Early Adolescent Study. The current research analyzed data from interviews with 30 EAs (aged 11-13 years) living in five poor urban sites: Baltimore, Cuenca, Edinburgh, Ghent, and Nairobi. All interviews were recorded, transcribed, and analyzed in English using Atlas.ti, focusing on how EAs experience and perceive gender norms in romantic relationships. RESULTS Across the five sites, only a few respondents described having been in love, the majority of whom were boys. Findings indicate that stereotypical gender norms about romantic relationships prevail across these cultural settings, depicting boys as romantically/sexually active and dominant, and girls as innocent with less (romantic) agency. In spite of the similarities, Nairobi was unique in that respondents referred to how sexual behavior and violence can occur within EA relationships. In all countries, heterosexuality was perceived to be the norm. Nevertheless, there were examples of EAs accepting homosexuality and expressing supportive attitudes toward equality between the sexes. CONCLUSIONS While EAs across five different cultural settings seem to endorse stereotypical gender norms in romantic relationships, a few stories also illustrate more gender-equal attitudes. As stereotypical gender norms have a demonstrated negative effect on adolescent sexual and reproductive health and well-being, additional research is needed to understand which factors-at the interpersonal and structural level-contribute to the construction of these norms among EAs.

Reorienting adolescent sexual and reproductive health research: reflections from an international conference

On December 4th 2014, the International Centre for Reproductive Health (ICRH) at Ghent University organized an international conference on adolescent sexual and reproductive health (ASRH) and well-being. This viewpoint highlights two key messages of the conference - 1) ASRH promotion is broadening on different levels and 2) this broadening has important implications for research and interventions – that can guide this research field into the next decade. Adolescent sexuality has long been equated with risk and danger. However, throughout the presentations, it became clear that ASRH and related promotion efforts are broadening on different levels: from risk to well-being, from targeted and individual to comprehensive and structural, from knowledge transfer to innovative tools. However, indicators to measure adolescent sexuality that should accompany this broadening trend, are lacking. While public health related indicators (HIV/STIs, pregnancies) and their behavioral proxies (e.g. condom use, number of partners) are well developed and documented, there is a lack of consensus on indicators for the broader construct of adolescent sexuality, including sexual well-being and aspects of positive sexuality. Furthermore, the debate during the conference clearly indicated that experimental designs may not be the only appropriate study design to measure effectiveness of comprehensive, context-specific and long-term ASRH programmes, and that alternatives need to be identified and applied. Presenters at the conference clearly expressed the need to develop validated tools to measure different sub-constructs of adolescent sexuality and environmental factors. There was a plea to combine (quasi-)experimental effectiveness studies with evaluations of the development and implementation of ASRH promotion initiatives.

Lessons learnt from the CERCA Project, a multicomponent intervention to promote adolescent sexual and reproductive health in three Latin America countries: a qualitative post-hoc evaluation.

Highlights • Large projects like CERCA require a preparatory phase and a thorough analysis of the situation at the country level as well as community-specific context information, to which sufficient time and budget should be attributed.• An essential part of community-based intervention and action research is to adapt the monitoring strategy if the interventions are changed and to thoroughly document all activities.• Accepting teenage pregnancies as a complex issue, not only means adapting interventions to this complexity, but also the evaluation design. In the case of the CERCA Project an overall evaluation should have included a component for each activity.• Further, the evaluation rightly addressed the effectiveness of the intervention package but should have extended this to address their acceptability, and factors that helped or hindered their application among all target groups and other stakeholders.• Through the concerted application of a multi-faceted strategy, it is possible to decrease the taboo on adolescent sexuality in a conservative setting.

‘Yeah, I’ve grown; I can’t go out anymore’: differences in perceived risks between girls and boys entering adolescence

Abstract This analysis is based on data from the Global Early Adolescent Study, which aims to understand the factors that predispose young people aged 10–14 years to positive or negative health trajectories. Specifically, interview transcripts from 202 adolescents and 191 parents across six diverse urban sites (Baltimore, Ghent, Nairobi, Ile Ife, Assuit and Shanghai) were analysed to compare the perceived risks associated with entering adolescence and how these risks differed by gender. Findings reveal that in all sites except Ghent, both young people and their parents perceived that girls face greater risks related to their sexual and reproductive health, and because of their sexual development, were perceived to require more protection. In contrast, when boys grow up, they and their parents recognised that their independence broadened, and parents felt that boys were strong enough to protect themselves. This has negative consequences as well, as boys were perceived to be more prone to risks associated with street violence and peer pressure. These differences in perceptions of vulnerability and related mobility are markers of a gender system that separates young women and men’s roles, responsibilities and behaviours in ways that widen gender power imbalance with lifelong social and health consequences for people of both sexes.

Practical lessons for bringing policy-makers on board in sexual and reproductive health research

BackgroundThe need to translate research into policy, i.e. making research findings a driving force in agenda-setting and policy change, is increasingly acknowledged. However, little is known about translation mechanisms in the field of sexual and reproductive health (SRH) outside North American or European contexts. This paper seeks to give an overview of the existing knowledge on this topic as well as to document practical challenges and remedies from the perspectives of researchers involved in four SRH research consortium projects in Latin America, sub-Saharan Africa, China and India.MethodsA literature review and relevant project documents were used to develop an interview guide through which researchers could reflect on their experiences in engaging with policy-makers, and particularly on the obstacles met and the strategies deployed by the four project consortia to circumvent them.ResultsOur findings confirm current recommendations on an early and steady involvement of policy-makers, however they also suggest that local barriers between researchers and policy-making spheres and individuals can represent major hindrances to the realization of translation objectives. Although many of the challenges might be common to different contexts, creating locally-adapted responses is deemed key to overcome them. Researchers’ experiences also indicate that - although inevitable - recognizing and addressing these challenges is a difficult, time- and energy-consuming process for all partners involved. Despite a lack of existing knowledge on translation efforts in SRH research outside North American or European contexts, and more particularly in low and middle-income countries, it is clear that existing pressure on health and policy systems in these settings further complicates them.ConclusionsThis article brings together literature findings and researchers’ own experiences in translating research results into policy and highlights the major challenges research conducted on sexual and reproductive health outside North American or European contexts can meet. Future SRH projects should be particularly attentive to these potential obstacles in order to tailor appropriate and consistent strategies within their existing resources.