Aims To identify the relationships among social determinants, public policies, behaviors, and adolescent pregnancy and child marriage – in the context of a declining HIV epidemic in the Rakai region of rural Uganda. Social determinants may influence key adolescent social transitions such as leaving school, marriage, and childbearing.
Methods Data on young women 15-19 years from 17 surveys (1994-2018) in a population-based, open cohort of households in 28 communities followed continuously since 1994. Social determinants included school enrollment, a household assets measure of socioeconomic status (SES), and orphanhood (death of one or both parents). A previously validated measure (the Pregnancy Risk Index or PRI) was used to estimate young women’s risk of becoming pregnant - based on their sexual activity, nonuse of contraception or use of specific contraception methods, and method-specific contraceptive failure rates. The PRI was compared with current pregnancy, based on self-report and urine testing. Child marriage was measured as ever-married before age 18. Statistical evidence for change over time was assessed using regression analyses with robust variance estimation. The sample included 15,606 women-rounds of observation.
Results School enrollment rose from 26% in 1994 to 61% in 2018 (p<0.001), coinciding with a national policy of universal primary education instituted in 1997 and considerable increases in household SES. Rates of orphanhood declined from 52% in 2004 to 23% to 2018 (p<0.001), corresponding to availability in antiretroviral therapy from 2004. Child marriage among women 15-19 years declined from 33% to 4% (p<0.001). Current pregnancy declined by 65%; a parallel 58% decline in the average PRI score reflects a decline in sexual experience (67% to 40%) and increases in current contraception use (29% to 42%, all trends p<0.001). Adjusted for age and survey rounds, school enrollees compared to non-enrollees reported less sexual experience (43% vs. 79%, p<0.001), greater use of condoms (55% v 20%, p<0.001) and greater use of any contraceptive method (61% v 39%, p<0.001).
Conclusions Adolescent pregnancy and child marriage declined from 1994 to 2018 as enrollment in school and socioeconomic status increased and HIV-related orphanhood declined. Social determinants can have an enormous influence on adolescent health and social transitions.
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