Background: Antenatal care (ANC) is a service that can reduce the incidence of maternal and neonatal deaths when provided by skilled healthcare workers. Patient satisfaction is an important health system responsiveness goal which has been shown to influence adherence to healthcare interventions. This study aims to assess the determinants of pregnant women’s satisfaction with ANC across Kenya, Tanzania, and Malawi using nationally representative Service Provision Assessment data. Methods: Patient satisfaction was conceptualised mainly based on Donabedian’s theory of healthcare quality with patient characteristics, structure, and process as the major determinants. Bivariate and multivariate analyses were conducted to identify the potential determinants. Results: Findings show that satisfaction was negatively associated with women’s age (AOR: 0.95; 95% CI: 0.92–0.99) and having a secondary (AOR: 0.39; 95% CI: 0.17–0.87) or tertiary education (AOR: 0.41; 95% CI: 0.17–0.99) in Kenya. Women on their first pregnancy were more likely to report satisfaction in Tanzania (AOR: 1.62; 95% CI: 1.00–2.62) while women were less likely to report being satisfied in their second trimester in Malawi (AOR: 0.31; 95% CI: 0.09–0.97). The important structural and process factors for patient satisfaction included: private versus public run facilities in Kenya (AOR: 2.05; 95% CI: 1.22–3.43) and Malawi (AOR: 1.85; 95% CI: 0.99–3.43); level of provider training, that is, specialist versus enrolled nurse in Tanzania (AOR: 0.35; 95% CI: 0.13–0.93) or clinical technician in Malawi (AOR: 0.08; 95% CI: 0.01–0.36); and shorter waiting times across all countries. Conclusion: Findings highlight the importance of professional proficiency and efficient service delivery in determining pregnant women’s satisfaction with ANC. Future studies should incorporate both patient characteristics and institutional factors at health facilities into their conceptualisation of patient satisfaction.

Adolescent girls and young women (AGYW) in South Africa are at a three times higher risk of acquiring HIV than their male counterparts. The HIV prevention cascade is a tool which can be used to measure coverage of HIV prevention services, although there is limited empirical evidence to demonstrate its application in low-resourced settings. The unifying framework is a conceptualisation of the HIV prevention cascade which theorises that both motivation and access are required for an individual to effectively use an HIV prevention method. We applied this framework to data from a random sample of 127,951 beneficiaries of a combination HIV prevention programme for AGYW aged 15–24 in South Africa to measure the steps to, and identify key barriers to, effective use of male condoms and oral pre-exposure prophylaxis (PrEP) among this vulnerable population. Barriers to each step were analysed using univariate and multivariable logistic regression. Among self-reported HIV-negative AGYW who had sex in the past 6 months, effective use of condoms (15.2%), access to PrEP (39.1%) and use of PrEP (3.8%) were low. AGYW were: less likely to be motivated to use condoms if they believed that they had a faithful partner (aOR 0.44, 95% CI 0.22–0.90) or disliked condoms (aOR 0.26, 95% CI 0.11–0.57), less likely to access condoms if the place where AGYW accessed them was far away (aOR 0.25, 95% CI 0.10–0.64), more likely to effectively use condoms if they received counselling on how to use them (aOR 2.24, 95% CI 1.05–4.76), less likely to be motivated to use PrEP if they did not believe PrEP was efficacious (aOR 0.35, 95% CI 0.17–0.72), more likely to be motivated if they felt confident that they could use PrEP, and more likely to have access to PrEP if they had ever been offered PrEP (aOR 2.94, 95% CI 1.19–7.22). This combination HIV prevention programme and similar programmes should focus on risk-reduction counselling interventions for AGYW and their male partners to improve effective use of condoms and ensure easy access to condoms and PrEP by making them available in youth-friendly spaces. Our findings demonstrate that the application of HIV prevention cascades can inform AGYW HIV prevention programming in low-resourced settings.

Despite national declines in HIV prevalence, adolescent girls and young women (AGYW) in South Africa continue to face a disproportionate burden of HIV infection. The syndemic theory provides a framework for understanding how interconnected epidemics such as alcohol use disorders, violence and HIV cluster together and reinforce each other. Using this theory, we aimed to test and explore the relationship between alcohol use and HIV risk and infection amongst AGYW in high HIV-burdened communities in South Africa. Data for this study were drawn from a mixed methods impact evaluation of a combination HIV prevention programme implemented across eight provinces in South Africa. A household survey was conducted among AGYW aged 15─24 years in the 12 intervention sub-districts selected by the Global Fund and 12 matching comparison sub-districts. Dried blood spot specimens were collected to test for HIV; alcohol use and sexual behaviours were reported through a self-completed electronic questionnaire. Generalised linear regression models were used to assess the relationship between alcohol use and HIV risk and infection as well as sexual risk behaviours and hazardous drinking. A subsample of 68 AGYW participated in qualitative in-depth interviews. Interview transcripts were translated into English and analysed using thematic analysis. Of the 5025 survey participants, 10% were living with HIV, and 35% engaged in hazardous drinking. No significant association was found between alcohol use and HIV risk or infection. However, a positive association was found between hazardous drinking and sexual violence (OR=1.51; 95% CI: 1.20─1.90), condomless sex (OR=1.25; 95% CI: 1.07─1.47), and condom counselling (OR=1.32; 95% CI: 1.14─1.53). Qualitative interview participants described how AGYW sought alcohol from older men, knowing that sex would be expected in exchange. This put them in high-risk situations where sexual violence was a concern and negotiating condom use became more challenging. These findings highlight the need for interventions that educate AGYW on the harmful effects of binge drinking and provide safer, healthier alternatives for recreation, particularly in low-resourced communities.

In South Africa, HIV incidence and unintended pregnancy among adolescent girls and young women (AGYW) remain high, driven by a range of shared biological,