Increased reproductive tract infections among secondary school girls during the COVID-19 pandemic: associations with pandemic-related stress, mental health, and domestic safety

Abstract

Background: Kenya, like many countries, shuttered schools during COVID-19, with subsequent increases in poor mental health, sexual activity, and pregnancy.

Aim: We sought to understand how the COVID-19 pandemic may mediate the risk of reproductive tract infections.

Methods: We analyzed data from a cohort of 436 secondary schoolgirls in western Kenya. Baseline and 6-, 12-, and 18-month study visits occurred from April 2018 to December 2019 (pre-COVID-19), and 30-, 36-, and 48-month study visits occurred from September 2020 to July 2022 (COVID-19 period). Participants self-completed a survey for sociodemographics and sexual activity and provided self-collected vaginal swabs for bacterial vaginosis (BV) testing, with sexually transmitted infection (STI) testing at annual visits. We hypothesized that greater COVID-19-related stress would mediate risk via mental health, feeling safe inside the home, and sexual exposure, given the pandemic mitigation-related impacts of school closures on these factors. COVID-19-related stress was measured with a standardized scale and dichotomized at the highest quartile. Mixed effects modeling quantified how BV and STI changed over time. Longitudinal mediation analysis quantified how the relationship between COVID-19 stress and increased BV was mediated.

Outcomes: Analysis outcomes were BV and STI.

Results: BV and STI prevalence increased from 12.1% and 10.7% pre-COVID-19 to 24.5% and 18.1% during COVID-19, respectively. This equated to 26% (95% CI, 1.00-1.59) and 36% (95% CI, 0.98-1.88) higher relative prevalence of BV and STIs in the COVID-19 vs pre-COVID-19 periods, adjusted for numerous sociodemographic and behavioral factors. Higher COVID-19-related stress was associated with elevated depressive symptoms and feeling less safe inside the home, which were each associated with a greater likelihood of having a boyfriend. In mediation analyses, the direct effect of COVID-19-related stress on BV was small and nonsignificant, indicating that the increased BV was due to the constellation of factors that were affected during the COVID-19 pandemic.

Clinical translation: These results highlight factors to help maintain reproductive health for adolescent girls in future crises, such as anticipating and mitigating mental health impacts, domestic safety concerns, and maintaining sexual health services.

Strengths and limitations: Impacts of the COVID-19 pandemic on drivers of reproductive tract health among those who did not attend school or who live in different settings may differ.

Conclusions: In this cohort of adolescent girls, BV and STIs increased following COVID-19-related school closures, and risk was mediated by depressive symptoms and feeling less safe in the home, which led to a higher likelihood of sexual exposures.

Keywords: COVID-19; Kenya; adolescent girls and young women; bacterial vaginosis; cohort; mediation; reproductive tract infections; sexually transmitted infections.

Figure 1

Conceptual model shows the hypothesized linkages between COVID-19–related stress and bacterial vaginosis (BV). The hypothesized relationship between elevated COVID-19–related stress and BV (direct effect, a0) is depicted with pathways being mediated through level 1 mediators (a1–elevated depressive symptoms [PHQ-9 ≥5] and a2–feeling less safe inside the home vs before the COVID-19 pandemic) and level 2 mediator a3–having a boyfriend. We hypothesized that socioeconomic status confounded the association between elevated COVID-19–related stress and increased depressive symptoms and feeling less safe inside the home. We also hypothesized that transactional sex confounded the association between elevated COVID-19–related stress and BV. Assigned intervention status (menstrual cup arm or control arm) and participant age were also controlled for and are not depicted in the figure. PHQ-9, 9-item Personal Health Questionnaire.

Figure 2

Prevalence of BV and STIs over time before and during COVID-19. The y-axis shows the prevalence of BV and STIs over study visits (x-axis). The pre–COVID-19 and COVID-19 periods are indicated with the dates underneath the x-axis with darker intensity of shading in the visits occurring during the COVID-19 period. BV, bacterial vaginosis; STI, sexually transmitted infection.