Empowerment, Stigma, and Structural Factors and their Influences on Sexual and Reproductive Health Care of Young Women

Adolescent girls and young women (AGYW) in East and southern Africa face parallel epidemics of HIV incidence and unintended pregnancy. AGYW in Kenya, specifically, confront unique challenges to sexual and reproductive health access, quality, and wellbeing. To understand the social and structural barriers that impede optimal reproductive health outcomes, it is crucial to understand the experiences of stigma, empowerment, and health system structural factors and how they affect sexual and reproductive health care among AGYW in Kenya. First, we describe HIV pre-exposure prophylaxis (PrEP) metrics among AGYW (ages 15-30) in post-abortion care (PAC) clinics in an implementation-science study delivering PrEP in 14 PAC clinics (n=6788 women), and evaluate associations between structural factors and facility-level PrEP offers and uptake to identify the prominent gaps where health systems can improve. Among a subset of AGYW in PAC settings that were enrolled into research (N=401), we quantitatively measure PrEP and abortion stigma and assess the effects of stigma on PrEP use and family planning (FP). Lastly, we evaluate the factor structure and internal consistency of an adapted scale to measure sexual and reproductive health empowerment among AGYW (ages 15-20) utilizing data from a cross-sectional cohort in Kenya (n=500), and assess the relationship between empowerment scores and ability to prevent undesired pregnancy to gauge construct validity. We demonstrated that several health systems factors, including PrEP and HIV testing commodities supplies, type of clinic (private vs. public), and proportion of PAC providers that are trained in delivering PrEP, are significantly associated with both PrEP offers and uptake at the facility level. Among 401 AGYW initiating PrEP through their PAC provider, 120 (29.9%) initiated highly effective FP. We found a high burden of abortion stigma among AGYW, and the higher scores in the subdomain of isolation were significantly associated with greater likelihood of initiating a highly effective FP product, while the higher scores in the subdomain of community condemnation were significantly associated with reduction in the likelihood of initiating a highly effective FP product after an abortion. Among 114 (28.4%) AGYW returning for their month 1 follow-up visit, 95 (78.5%) women reported continuing PrEP and 60 (50.0%) were adherent to PrEP, as detected via urine assay. In this subset, higher levels of PrEP stigma were significantly associated with greater likelihood of PrEP adherence, and there was no statistical association with self-reported PrEP continuation. Lastly, the 26-item adapted sexual and reproductive health empowerment scale had acceptable fit, as all subscales had Cronbach’s alpha scores >0.7, and all items had rotated factor loadings >0.5, indicating good internal consistency and robust factor-variable associations. Total empowerment score was significantly associated with an increased odds of consistent method use (no episodes of sex when method was not used) in past 3 months. Together, the results presented in this dissertation provide insights into the design of effective reproductive health programs that address the unique structural and psychosocial challenges faced by young women in Kenya, namely investing in health systems to stabilize the environment for delivering PrEP, integrating stigma-informed methods to counsel young women to choose optimal FP and PrEP decisions, and utilizing an adapted measure of empowerment to tailor research efforts and measure success. This work contributes to efforts for centering the needs and improving experiences of young women’s in sexual and reproductive health care.