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Hallfors DD, Iritani BJ, Zhang L, Hartman S, Luseno WK, Mpofu E, Rusakaniko S. 'I thought if I marry the prophet I would not die': The significance of religious affiliation on marriage, HIV testing, and reproductive health practices among young married women in Zimbabwe. SAHARA J 2016; 13:178-187. [PMID: 27762160 PMCID: PMC5642446 DOI: 10.1080/17290376.2016.1245627] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
This study examines the association between religious affiliation and reasons for marriage, perceived church attitudes, and reproductive health-seeking behaviors, including HIV testing, among young women in eastern rural Zimbabwe. The sample comprised women (N = 35) who had married by 2012 while participating in a larger randomized controlled trial (RCT) to test the effects of school support on HIV-related risk. The RCT sample was identified in 2007 as all female sixth graders in 25 rural eastern Zimbabwe primary schools whose parents, one or both, had died (N = 328). In our previous RCT analyses, we found that participants who affiliated with an Apostolic church were more than four times more likely to marry than those from non-Apostolic churches and that control group participants were twice as likely to marry as those in the intervention group. Other studies had found that marriage greatly increased the odds of HIV infection among adolescent women. Given the link between Apostolic affiliation and marriage, we conducted semi-structured interviews to explore type of marriage, reasons for marrying, church affiliation and attitudes, family planning, HIV testing, schooling, and family life. We were interested in differences, as perceived by our sample of young married women congregants, among Apostolic sects and other denominations in their attitudes about marriage and health-seeking behaviors. We were also interested in the influence of church affiliation on intervention participants' decision to marry, since they had comprehensive school support and education is highly valued in Zimbabwe, but costly and often out of financial reach. Interviews were conducted from October 2012 through November 2013; data were analyzed using a general inductive approach. We found that pressure or perceived deception for coitus or marriage was reported only by intervention participants affiliated with Apostolic denominations. Other reasons for marriage were similar between Apostolic and non-Apostolic adherents, as well as intervention and control conditions. All participants believed HIV testing was important, but while all non-Apostolic denominations encouraged HIV testing and clinic/hospital care, there was considerable heterogeneity in attitudes among Apostolics, with ultraconservative denominations most likely to proscribe non-religious health care. We conclude that some, but not all, Apostolic-affiliated women are afforded discretion in their health-seeking behaviors. Since HIV screening and treatment depend on access to clinic/hospital care, continued public health efforts to engage Apostolic leaders is needed, along with monitoring of progress in access and outcomes.
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Affiliation(s)
- Denise Dion Hallfors
- PhD Senior Research Scientist, is affiliated to Pacific Institute for Research and Evaluation, 1516 E. Franklin St., Suite 200, Chapel Hill, NC27514, USA
| | - Bonita J. Iritani
- MS, MA Associate Research Scientist, is affiliated to Pacific Institute for Research and Evaluation, 1516 E. Franklin St., Suite 200, Chapel Hill, NC27514, USA
| | - Lei Zhang
- PhD Associate Research Scientist, is affiliated to Pacific Institute for Research and Evaluation, 1516 E. Franklin St., Suite 200, Chapel Hill, NC27514, USA
| | - Shane Hartman
- BA Research Associate, is affiliated to Pacific Institute for Research and Evaluation, 1516 E. Franklin St., Suite 200, Chapel Hill, NC27514USA
| | - Winnie K. Luseno
- PhD Research Scientist, is affiliated to Pacific Institute for Research and Evaluation, 1516 E. Franklin St., Suite 200, Chapel Hill, NC27514, USA
| | - Elias Mpofu
- PhD, DEd Professor of Rehabilitation Counseling, is affiliated to Department of Rehabilitation Counseling, Faculty of Health Sciences, University of Sydney, Australia
- PhD, DEd Professor of Rehabilitation Counseling, is affiliated to Department of Research and Innovation, Central University of Technology, Bloemfontein, South Africa
| | - Simbarashe Rusakaniko
- PhD Professor and Chairman, is affiliated to Department of Community Medicine, University of Zimbabwe, PO Box A 178, Avondale, Harare, Zimbabwe
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Phillips-Howard PA, Nyothach E, Ter Kuile FO, Omoto J, Wang D, Zeh C, Onyango C, Mason L, Alexander KT, Odhiambo FO, Eleveld A, Mohammed A, van Eijk AM, Edwards RT, Vulule J, Faragher B, Laserson KF. Menstrual cups and sanitary pads to reduce school attrition, and sexually transmitted and reproductive tract infections: a cluster randomised controlled feasibility study in rural Western Kenya. BMJ Open 2016; 6:e013229. [PMID: 27881530 PMCID: PMC5168542 DOI: 10.1136/bmjopen-2016-013229] [Citation(s) in RCA: 77] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES Conduct a feasibility study on the effect of menstrual hygiene on schoolgirls' school and health (reproductive/sexual) outcomes. DESIGN 3-arm single-site open cluster randomised controlled pilot study. SETTING 30 primary schools in rural western Kenya, within a Health and Demographic Surveillance System. PARTICIPANTS Primary schoolgirls 14-16 years, experienced 3 menses, no precluding disability, and resident in the study area. INTERVENTIONS 1 insertable menstrual cup, or monthly sanitary pads, against 'usual practice' control. All participants received puberty education preintervention, and hand wash soap during intervention. Schools received hand wash soap. PRIMARY AND SECONDARY OUTCOME MEASURES Primary: school attrition (drop-out, absence); secondary: sexually transmitted infection (STI) (Trichomonas vaginalis, Chlamydia trachomatis, Neisseria gonorrhoea), reproductive tract infection (RTI) (bacterial vaginosis, Candida albicans); safety: toxic shock syndrome, vaginal Staphylococcus aureus. RESULTS Of 751 girls enrolled 644 were followed-up for a median of 10.9 months. Cups or pads did not reduce school dropout risk (control=8.0%, cups=11.2%, pads=10.2%). Self-reported absence was rarely reported and not assessable. Prevalence of STIs in the end-of-study survey among controls was 7.7% versus 4.2% in the cups arm (adjusted prevalence ratio (aPR) 0.48, 0.24 to 0.96, p=0.039), 4.5% with pads (aPR=0.62; 0.37 to 1.03, p=0.063), and 4.3% with cups and pads pooled (aPR=0.54, 0.34 to 0.87, p=0.012). RTI prevalence was 21.5%, 28.5% and 26.9% among cup, pad and control arms, 71% of which were bacterial vaginosis, with a prevalence of 14.6%, 19.8% and 20.5%, per arm, respectively. Bacterial vaginosis was less prevalent in the cups (12.9%) compared with pads (20.3%, aPR=0.65, 0.44 to 0.97, p=0.034) and control (19.2%, aPR=0.67, 0.43 to 1.04, p=0.075) arm girls enrolled for 9 months or longer. No adverse events were identified. CONCLUSIONS Provision of menstrual cups and sanitary pads for ∼1 school-year was associated with a lower STI risk, and cups with a lower bacterial vaginosis risk, but there was no association with school dropout. A large-scale trial on menstrual cups is warranted. TRIAL REGISTRATION ISRCTN17486946; Results.
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Affiliation(s)
- Penelope A Phillips-Howard
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), UK
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Elizabeth Nyothach
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Feiko O Ter Kuile
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), UK
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Jackton Omoto
- Siaya District Hospital, Ministry of Health, Siaya, Kenya
| | - Duolao Wang
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), UK
| | - Clement Zeh
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
- Centers for Disease Control and Prevention (CDC)-Kenya, Kisumu, Kenya
| | - Clayton Onyango
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
- Centers for Disease Control and Prevention (CDC)-Kenya, Kisumu, Kenya
| | - Linda Mason
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), UK
| | - Kelly T Alexander
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), UK
| | - Frank O Odhiambo
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Alie Eleveld
- Safe Water and AIDS Project (SWAP), Kisumu, Kenya
| | - Aisha Mohammed
- Division of Reproductive Health, Ministry of Public Health and Sanitation, Nairobi, Kenya
| | - Anna M van Eijk
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), UK
| | | | - John Vulule
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
| | - Brian Faragher
- Department of Clinical Sciences, Liverpool School of Tropical Medicine (LSTM), UK
| | - Kayla F Laserson
- Centre for Global Health Research, Kenya Medical Research Institute (KEMRI), Kisumu, Kenya
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Graham H, Tokhi M, Duke T. Scoping review: strategies of providing care for children with chronic health conditions in low- and middle-income countries. Trop Med Int Health 2016; 21:1366-1388. [PMID: 27554327 DOI: 10.1111/tmi.12774] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To identify and review strategies of providing care for children living with chronic health conditions in low- and middle-income countries. METHODS We searched MEDLINE and Cochrane EPOC databases for papers evaluating strategies of providing care for children with chronic health conditions in low- or middle-income countries. Data were systematically extracted using a standardised data charting form, and analysed according to Arksey and O'Malley's 'descriptive analytical method' for scoping reviews. RESULTS Our search identified 71 papers addressing eight chronic conditions; two chronic communicable diseases (HIV and TB) accounted for the majority of papers (n = 37, 52%). Nine (13%) papers reported the use of a package of care provision strategies (mostly related to HIV and/or TB in sub-Saharan Africa). Most papers addressed a narrow aspect of clinical care provision, such as patient education (n = 23) or task-shifting (n = 15). Few papers addressed the strategies for providing care at the community (n = 10, 15%) or policy (n = 6, 9%) level. Low-income countries were under-represented (n = 24, 34%), almost exclusively involving HIV interventions in sub-Saharan Africa (n = 21). Strategies and summary findings are described and components of future models of care proposed. CONCLUSIONS Strategies that have been effective in reducing child mortality globally are unlikely to adequately address the needs of children with chronic health conditions in low- and middle-income settings. Current evidence mostly relates to disease-specific, narrow strategies, and more research is required to develop and evaluate the integrated models of care, which may be effective in improving the outcomes for these children.
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Affiliation(s)
- Hamish Graham
- Centre for International Child Health, Royal Children's Hospital, University of Melbourne, MCRI, Melbourne, VIC, Australia.
| | - Mariam Tokhi
- Victorian Aboriginal Health Service, Melbourne, VIC, Australia
| | - Trevor Duke
- Centre for International Child Health, Royal Children's Hospital, University of Melbourne, MCRI, Melbourne, VIC, Australia
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Pilgrim NA, Ahmed S, Gray RH, Sekasanvu J, Lutalo T, Nalugoda F, Serwadda D, Wawer MJ. Multiple sexual partnerships among female adolescents in rural Uganda: the effects of family structure and school attendance. Int J Adolesc Med Health 2016; 27:319-28. [PMID: 25415632 DOI: 10.1515/ijamh-2014-0032] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Accepted: 08/09/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND A better understanding is needed of the contextual factors that influence HIV risk behaviors among female adolescents in sub-Saharan Africa. The objectives of this study were to assess the influence of family structure on lifetime sexual partners and on the number of sexual partners in the last year among female adolescents in rural Rakai, Uganda. In addition, the study assessed whether the influence of family structure on these outcomes differed by the school attendance status of the adolescents. METHODS The sample consisted of 2337 unmarried adolescent girls, aged 15-19, enrolled in the Rakai Community Cohort Study. The last survey interview within the time period of 2001-2008 available for each girl was used. Analyses were stratified by age (15-17 year olds and 18-19 year olds) and school status. Multinomial logistic and poisson regressions were used. RESULTS Living in a household with a biological father was protective against both outcomes. Family structure was not associated with the outcomes among in-school adolescents but it was significantly associated with the outcomes among out-of-school adolescents. CONCLUSION The findings suggest that understanding the familial context in which female adolescents develop, as well as its interaction with school attendance, is important for HIV prevention efforts. Both research and programmatic initiatives must consider the interplay between the family and school domains when considering ways to reduce HIV acquisition among adolescent women.
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Luseno WK, Zhang L, Iritani BJ, Hartman S, Rusakaniko S, Hallfors DD. Influence of school support on early marriage experiences and health services utilization among young orphaned women in Zimbabwe. Health Care Women Int 2016; 38:283-299. [PMID: 27211856 DOI: 10.1080/07399332.2016.1191494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
School support programs reduce school dropout, early marriage, and early pregnancy for a majority of young orphaned women. We used a mixed-methods approach to examine why these programs are less effective for a significant minority by exploring their influence on marriage and health services utilization. Participants were from a randomized controlled trial testing school support as HIV prevention. Half as many intervention as control participants had been married; married intervention participants had 1 more year of education compared with married control participants. Receiving school support did not appear to improve health-related factors. Pregnancy was among the most common reasons for marriage across both groups. The greatest benefit of school support appears to be in delaying marriage and pregnancy while increasing educational attainment.
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Affiliation(s)
| | - Lei Zhang
- a Pacific Institute for Research and Evaluation , Chapel Hill , North Carolina , USA
| | - Bonita J Iritani
- a Pacific Institute for Research and Evaluation , Chapel Hill , North Carolina , USA
| | - Shane Hartman
- a Pacific Institute for Research and Evaluation , Chapel Hill , North Carolina , USA
| | | | - Denise Dion Hallfors
- a Pacific Institute for Research and Evaluation , Chapel Hill , North Carolina , USA
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Kaljee L, Zhang L, Langhaug L, Munjile K, Tembo S, Menon A, Stanton B, Li X, Malungo J. A randomized-control trial for the teachers’ diploma programme on psychosocial care, support and protection in Zambian government primary schools. PSYCHOL HEALTH MED 2016; 22:381-392. [DOI: 10.1080/13548506.2016.1153682] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Thurman TR, Kidman R, Carton TW, Chiroro P. Psychological and behavioral interventions to reduce HIV risk: evidence from a randomized control trial among orphaned and vulnerable adolescents in South Africa. AIDS Care 2016; 28 Suppl 1:8-15. [PMID: 26886261 PMCID: PMC4828594 DOI: 10.1080/09540121.2016.1146213] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/20/2016] [Indexed: 11/08/2022]
Abstract
Evidence-based approaches are needed to address the high levels of sexual risk behavior and associated HIV infection among orphaned and vulnerable adolescents. This study recruited adolescents from a support program for HIV-affected families and randomly assigned them by cluster to receive one of the following: (1) a structured group-based behavioral health intervention; (2) interpersonal psychotherapy group sessions; (3) both interventions; or (4) no new interventions. With 95% retention, 1014 adolescents were interviewed three times over a 22-month period. Intent-to-treat analyses, applying multivariate difference-in-difference probit regressions, were performed separately for boys and girls to assess intervention impacts on sexual risk behaviors. Exposure to a single intervention did not impact behaviors. Exposure to both interventions was associated with risk-reduction behaviors, but the outcomes varied by gender: boys reported fewer risky sexual partnerships (β = -.48, p = .05) and girls reported more consistent condom (β = 1.37, p = .02). There was no difference in the likelihood of sexual debut for either gender. Providing both psychological and behavioral interventions resulted in long-term changes in sexual behavior that were not present when either intervention was provided in isolation. Multifaceted approaches for reducing sexual risk behaviors among vulnerable adolescents hold significant promise for mitigating the HIV epidemic among this priority population.
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Affiliation(s)
- T. R. Thurman
- Tulane University School of Social Work, Highly Vulnerable Children Research Center, New Orleans, LA, USA
- Tulane International LLC South Africa, Cape Town, South Africa
| | - R. Kidman
- Department of Preventive Medicine, Stony Brook Medicine, Health Sciences Center, Stony Brook, NY, USA
| | - T. W. Carton
- Health Services Research, Louisiana Public Health Institute, New Orleans, LA, USA
| | - P. Chiroro
- Impact Research International, Pretoria, South Africa
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Handa S, Palermo T, Rosenberg M, Pettifor A, Halpern CT, Thirumurthy H. How does a national poverty programme influence sexual debut among Kenyan adolescents? Glob Public Health 2016; 12:617-638. [PMID: 26853950 PMCID: PMC4976080 DOI: 10.1080/17441692.2015.1134617] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Cash transfer programmes have recently emerged as promising interventions for HIV prevention among adolescents in Africa. However, the pathways through which risk reduction occurs are not well understood. We examine data on 1429 adolescents and youth from the Kenya Cash Transfer for Orphans and Vulnerable Children, which has been shown to result in delayed sexual debut among adolescents. We explored three potential mediating pathways: schooling, socioeconomic status and psychosocial status. None of these hypothesised mediators greatly altered the main effect. However, school attendance had a larger protective effect on sexual debut among females but was only increased by the programme among males. This gendered pattern of effects may explain why we did not see a mediating effect of the cash transfer through schooling, despite schooling’s protective effects against early sexual debut. Results also suggest that cash transfer programmes in Africa can contribute to the reduction of HIV related risk behaviours.
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Affiliation(s)
- Sudhanshu Handa
- a Carolina Population Center, University of North Carolina , Chapel Hill , NC , USA.,b Department of Public Policy , University of North Carolina , Chapel Hill , NC , USA.,c UNICEF Office of Research , Florence , Italy
| | - Tia Palermo
- c UNICEF Office of Research , Florence , Italy
| | - Molly Rosenberg
- d Harvard Center for Population and Development Studies , Harvard University , Cambridge , MA , USA
| | - Audrey Pettifor
- a Carolina Population Center, University of North Carolina , Chapel Hill , NC , USA.,e Department of Epidemiology, Gillings School of Global Public Health , University of North Carolina , Chapel Hill , NC , USA
| | - Carolyn Tucker Halpern
- a Carolina Population Center, University of North Carolina , Chapel Hill , NC , USA.,f Department of Maternal & Child Health, Gillings School of Global Public Health , University of North Carolina , Chapel Hill , NC , USA
| | - Harsha Thirumurthy
- a Carolina Population Center, University of North Carolina , Chapel Hill , NC , USA.,g Department of Health Policy & Management, Gillings School of Global Public Health , University of North Carolina , Chapel Hill , NC , USA
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Kerubo E, Laserson KF, Otecko N, Odhiambo C, Mason L, Nyothach E, Oruko KO, Bauman A, Vulule J, Zeh C, Phillips-Howard PA. Prevalence of reproductive tract infections and the predictive value of girls' symptom-based reporting: findings from a cross-sectional survey in rural western Kenya. Sex Transm Infect 2016; 92:251-6. [PMID: 26819339 PMCID: PMC4893088 DOI: 10.1136/sextrans-2015-052371] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2015] [Accepted: 12/30/2015] [Indexed: 11/30/2022] Open
Abstract
Objectives Reproductive tract infections (RTIs), including sexually acquired, among adolescent girls is a public health concern, but few studies have measured prevalence in low-middle-income countries. The objective of this study was to examine prevalence in rural schoolgirls in Kenya against their reported symptoms. Methods In 2013, a survey was conducted in 542 adolescent schoolgirls aged 14–17 years who were enrolled in a menstrual feasibility study. Vaginal self-swabbing was conducted after girls were interviewed face-to-face by trained nurses on symptoms. The prevalence of girls with symptoms and laboratory-confirmed infections, and the sensitivity, specificity, positive and negative predictive values of symptoms compared with laboratory results, were calculated. Results Of 515 girls agreeing to self-swab, 510 answered symptom questions. A quarter (24%) reported one or more symptoms; most commonly vaginal discharge (11%), pain (9%) or itching (4%). Laboratory tests confirmed 28% of girls had one or more RTI. Prevalence rose with age; among girls aged 16–17 years, 33% had infections. Bacterial vaginosis was the most common (18%), followed by Candida albicans (9%), Chlamydia trachomatis (3%), Trichomonas vaginalis (3%) and Neisseria gonorrhoeae (1%). Reported symptoms had a low sensitivity and positive predictive value. Three-quarters of girls with bacterial vaginosis and C. albicans, and 50% with T. vaginalis were asymptomatic. Conclusions There is a high prevalence of adolescent schoolgirls with RTI in rural Kenya. Public efforts are required to identify and treat infections among girls to reduce longer-term sequelae but poor reliability of symptom reporting minimises utility of symptom-based diagnosis in this population. Trial registration number ISRCTN17486946.
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Affiliation(s)
- Emily Kerubo
- Center for Global Health Research, Kenya Medical Research Institute (KEMRI) Kisumu, Kisumu, Kenya
| | - Kayla F Laserson
- Division of Global Health Protection, Center for Global Health, Centers for Disease Control and Prevention (CDC), Atlanta, USA
| | - Newton Otecko
- Center for Global Health Research, Kenya Medical Research Institute (KEMRI) Kisumu, Kisumu, Kenya
| | - Collins Odhiambo
- Center for Global Health Research, Kenya Medical Research Institute (KEMRI) Kisumu, Kisumu, Kenya
| | - Linda Mason
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Elizabeth Nyothach
- Center for Global Health Research, Kenya Medical Research Institute (KEMRI) Kisumu, Kisumu, Kenya
| | - Kelvin O Oruko
- Center for Global Health Research, Kenya Medical Research Institute (KEMRI) Kisumu, Kisumu, Kenya
| | - Ashley Bauman
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - John Vulule
- Center for Global Health Research, Kenya Medical Research Institute (KEMRI) Kisumu, Kisumu, Kenya
| | - Clement Zeh
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Penelope A Phillips-Howard
- Center for Global Health Research, Kenya Medical Research Institute (KEMRI) Kisumu, Kisumu, Kenya Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
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King N, Dewey C, Borish D. Determinants of Primary School Non-Enrollment and Absenteeism: Results from a Retrospective, Convergent Mixed Methods, Cohort Study in Rural Western Kenya. PLoS One 2015; 10:e0138362. [PMID: 26371885 PMCID: PMC4570670 DOI: 10.1371/journal.pone.0138362] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 08/27/2015] [Indexed: 11/18/2022] Open
Abstract
Background Education is a key element in the socioeconomic development required to improve quality of life in Kenya. Despite the introduction of free primary education, primary school enrollment and attendance levels remain low. Drawing on qualitative and quantitative data, this study explores the determinants of non-enrollment and absenteeism in rural western Kenya and potential mitigation strategies to address these issues. Methods The study was conducted in Bwaliro village in rural western Kenya. A random sample of 64 students was obtained by blocking the village primary school’s student population according to grade level, gender, and orphan status. Qualitative and quantitative data were collected through interviews with parents, guardians, and key informants, and focus group discussions with students. Quantitative data were compared using chi-square tests, Student’s T-test, and Poisson regressions. Qualitative data were analyzed using thematic content analysis. Results Malaria, menstruation, and lack of money were among the most notable determinants of primary school dropout and absenteeism, and these factors disproportionately impacted orphans and female students. Potential mitigation strategies suggested by the community included provision of malaria treatment or prevention, reduction in education costs, expansion of the established school-feeding program, and provision of sanitary pads. Conclusion Despite free primary education, numerous factors continue to prevent children in rural western Kenya from attending primary school. The findings suggest that interventions should primarily target orphaned and female students. Prior to implementation, suggested mitigation strategies should be assessed for cost-effectiveness.
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Affiliation(s)
- Nia King
- Department of Population Medicine, Ontario Veterinary College, Guelph, Ontario, Canada
- * E-mail:
| | - Cate Dewey
- Department of Population Medicine, Ontario Veterinary College, Guelph, Ontario, Canada
- Centre for Public Health and Zoonoses, University of Guelph, Guelph, Ontario, Canada
| | - David Borish
- Department of Population Medicine, Ontario Veterinary College, Guelph, Ontario, Canada
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Handa S, Peterman A, Huang C, Halpern C, Pettifor A, Thirumurthy H. Impact of the Kenya Cash Transfer for Orphans and Vulnerable Children on early pregnancy and marriage of adolescent girls. Soc Sci Med 2015; 141:36-45. [PMID: 26246032 PMCID: PMC4659857 DOI: 10.1016/j.socscimed.2015.07.024] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Revised: 07/22/2015] [Accepted: 07/23/2015] [Indexed: 11/25/2022]
Abstract
There is promising evidence that poverty-targeted cash transfer programs can have positive impacts on adolescent transitions to adulthood in resource poor settings, however existing research is typically from small scale programs in diverse geographic and cultural settings. We provide estimates of the impact of a national unconditional cash transfer program, the Kenya Cash Transfer for Orphans and Vulnerable Children, on pregnancy and early marriage among females aged 12 to 24, four years after program initiation. The evaluation was designed as a clustered randomized controlled trial and ran from 2007 to 2011, capitalizing on the existence of a control group, which was delayed entry to the program due to budget constraints. Findings indicate that, among 1549 females included in the study, while the program reduced the likelihood of pregnancy by five percentage points, there was no significant impact on likelihood of early marriage. Program impacts on pregnancy appear to work through increasing the enrollment of young women in school, financial stability of the household and delayed age at first sex. The Kenyan program is similar in design to most other major national cash transfer programs in Eastern and Southern Africa, suggesting a degree of generalizability of the results reported here. Although the objective of the program is primarily poverty alleviation, it appears to have an important impact on facilitating the successful transition of adolescent girls into adulthood.
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Affiliation(s)
- Sudhanshu Handa
- Department of Public Policy, University of North Carolina, Chapel Hill, USA; UNICEF Office of Research Innocenti, Piazza SS. Annunziata 12, 50122 Florence, Italy
| | - Amber Peterman
- UNICEF Office of Research Innocenti, Piazza SS. Annunziata 12, 50122 Florence, Italy.
| | - Carolyn Huang
- Department of Public Policy, University of North Carolina, Chapel Hill, USA
| | - Carolyn Halpern
- Department of Materal and Child Health, UNC Gillings School of Global Public Health, USA
| | - Audrey Pettifor
- Department of Epidemiology, UNC Gillings School of Global Public Health, USA
| | - Harsha Thirumurthy
- Department of Health Policy and Management, UNC Gillings School of Global Public Health, USA
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Braitstein P. Institutional Care of Children in Low- and Middle-Income Settings: Challenging the Conventional Wisdom of Oliver Twist. GLOBAL HEALTH: SCIENCE AND PRACTICE 2015; 3:330-2. [PMID: 26374794 PMCID: PMC4570007 DOI: 10.9745/ghsp-d-15-00228] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Whether institutions or extended families are better suited to care for orphans depends on the specific circumstances. Reported rates of traumatic experiences among orphans and vulnerable children are high in both institutions and extended families; improving the quality of care for such children should be the paramount priority in all settings.
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Affiliation(s)
- Paula Braitstein
- University of Toronto, Dalla Lana School of Public Health, Toronto, ON, Canada
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De Neve JW, Fink G, Subramanian SV, Moyo S, Bor J. Length of secondary schooling and risk of HIV infection in Botswana: evidence from a natural experiment. Lancet Glob Health 2015; 3:e470-e477. [PMID: 26134875 PMCID: PMC4676715 DOI: 10.1016/s2214-109x(15)00087-x] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2014] [Revised: 03/18/2015] [Accepted: 03/27/2015] [Indexed: 12/03/2022]
Abstract
BACKGROUND An estimated 2·1 million individuals are newly infected with HIV every year. Cross-sectional and longitudinal studies have reported conflicting evidence for the association between education and HIV risk, and no randomised trial has identified a causal effect for education on HIV incidence. We aimed to use a policy reform in secondary schooling in Botswana to identify the causal effect of length of schooling on new HIV infection. METHODS Data for HIV biomarkers and demographics were obtained from the nationally representative household 2004 and 2008 Botswana AIDS Impact Surveys (N=7018). In 1996, Botswana reformed the grade structure of secondary school, expanding access to grade ten and increasing educational attainment for affected cohorts. Using exposure to the policy reform as an instrumental variable, we used two-stage least squares to estimate the causal effect of years of schooling on the cumulative probability that an individual contracted HIV up to their age at the time of the survey. We also assessed the cost-effectiveness of secondary schooling as an HIV prevention intervention in comparison to other established interventions. FINDINGS Each additional year of secondary schooling caused by the policy change led to an absolute reduction in the cumulative risk of HIV infection of 8·1 percentage points (p=0·008), relative to a baseline prevalence of 25·5% in the pre-reform 1980 birth cohort. Effects were particularly large in women (11·6 percentage points, p=0·046). Results were robust to a wide array of sensitivity analyses. Secondary school was cost effective as an HIV prevention intervention by standard metrics (cost per HIV infection averted was US$27 753). INTERPRETATION Additional years of secondary schooling had a large protective effect against HIV risk in Botswana, particularly for women. Increasing progression through secondary school could be a cost-effective HIV prevention measure in HIV-endemic settings, in addition to yielding other societal benefits. FUNDING Takemi Program in International Health at the Harvard T.H.Chan School of Public Health, Belgian American Educational Foundation, Fernand Lazard Foundation, Boston University, National Institutes of Health.
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Affiliation(s)
- Jan-Walter De Neve
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Günther Fink
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA; Center for Population and Development Studies, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Sikhulile Moyo
- Botswana-Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Jacob Bor
- Department of Global Health and Center for Global Health and Development, Boston University School of Public Health, Boston, MA, USA.
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Abstract
PURPOSE OF REVIEW Young women in sub-Saharan Africa bear a disproportionate HIV burden. They urgently require new HIV prevention approaches that they can use. This review provides an overview of the use of antiretrovirals for HIV preexposure prophylaxis (PrEP), highlighting some of the challenges with this technology and explores the potential role of mAbs for HIV prevention in women. RECENT FINDINGS Recent findings on the initial steps in viral entry and establishment of a productive local infectious nidus in the vaginal epithelium has provided important clues for HIV prevention in the female genital tract. Topical and oral formulations of antiretroviral drugs have been shown to prevent HIV infection in women with varying levels of success, depending principally on adherence. Further, several new broad and potent mAbs have been isolated over the last 5 years. Nonhuman primate studies demonstrate that broadly neutralizing HIV mAbs can protect rhesus macaques from simian immunodeficiency virus-HIV chimera (SHIV) infection. These findings have created newfound enthusiasm for passive immunization as a potential prevention strategy for women. SUMMARY If potent broadly neutralizing mAbs are effective in preventing HIV infection in women, this outcome could fill an important gap in HIV prevention technologies for young women, especially in Africa.
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Affiliation(s)
- Salim S. Abdool Karim
- CAPRISA - Centre of AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella 4013
- Department of Epidemiology, Columbia University, NY, New York, USA
| | - Quarraisha Abdool Karim
- CAPRISA - Centre of AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella 4013
- Department of Epidemiology, Columbia University, NY, New York, USA
| | - Cheryl Baxter
- CAPRISA - Centre of AIDS Programme of Research in South Africa, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Private Bag X7, Congella 4013
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Luseno W, Zhang L, Rusakaniko S, Cho H, Hallfors D. HIV infection and related risk behaviors: does school support level the playing field between orphans and nonorphans in Zimbabwe? AIDS Care 2015; 27:1191-5. [PMID: 25930236 DOI: 10.1080/09540121.2015.1036726] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Research is limited on whether providing school support to female adolescent orphans mitigates their HIV risk disadvantage compared to other female adolescents. This paper examines 2011 Zimbabwe Demographic and Health Survey (ZDHS) HIV-related biomarker and behavior data for orphaned and nonorphaned rural adolescent females to compare findings from a similar sample participating in a randomized controlled trial (RCT) testing school support as HIV prevention. HIV status, marriage, pregnancy, sexual debut, school dropout, years of schooling, and socioeconomic status were analyzed with the combined data-sets. Bivariate analyses compared variables between RCT comprehensive intervention and delayed partial intervention conditions, and between ZDHS orphan and nonorphan groups. Multivariable analyses included a series of group comparisons as follows: ZDHS orphans vs. ZDHS nonorphans; RCT orphans in each condition vs. ZDHS nonorphans; RCT orphans in each condition vs. ZDHS orphans. Analyses methods accounted for the complex survey sampling design within each data-set. A total of 751 observations were included. All orphan groups had consistently higher odds of HIV infection than ZDHS nonorphans. ZDHS orphans had higher odds of marriage, pregnancy, and sexual debut than ZDHS nonorphans. Comprehensive intervention participants had lower odds of marriage, sexual debut, and school dropout than ZDHS nonorphans. RCT participants in both conditions had lower odds of marriage, sexual debut, and school dropout than ZDHS orphans. The findings indicate that orphans are at a distinct disadvantage to HIV risk compared to nonorphans, and much of this is likely related to vertical transmission. We found no evidence that provision of school fees to orphans will reduce their risk of HIV infection relative to nonorphans but further evidence that such programs may reduce risk behaviors including early sexual debut, child marriage, and school dropout. Further research is needed to determine how these programs can be sustainably scaled-up in resource-limited settings.
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Affiliation(s)
- Winnie Luseno
- a Pacific Institute for Research & Evaluation , Chapel Hill , NC , USA
| | - Lei Zhang
- a Pacific Institute for Research & Evaluation , Chapel Hill , NC , USA
| | | | - Hyunsan Cho
- a Pacific Institute for Research & Evaluation , Chapel Hill , NC , USA
| | - Denise Hallfors
- a Pacific Institute for Research & Evaluation , Chapel Hill , NC , USA
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Beattie TS, Bhattacharjee P, Isac S, Davey C, Javalkar P, Nair S, Thalinja R, Sudhakar G, Collumbien M, Blanchard JF, Watts C, Moses S, Heise L. Supporting adolescent girls to stay in school, reduce child marriage and reduce entry into sex work as HIV risk prevention in north Karnataka, India: protocol for a cluster randomised controlled trial. BMC Public Health 2015; 15:292. [PMID: 25881037 PMCID: PMC4391662 DOI: 10.1186/s12889-015-1623-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 03/09/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Low caste adolescent girls living in rural northern Karnataka are at increased risk of school drop-out, child marriage, and entry into sex-work, which enhances their vulnerability to HIV, early pregnancy and adverse maternal and child health outcomes. This protocol describes the evaluation of Samata, a comprehensive, multi-level intervention designed to address these structural drivers of HIV risk and vulnerability. METHODS/DESIGN The Samata study is a cluster randomised controlled trial that will be conducted in eighty village clusters (40 intervention; 40 control) in Bijapur and Bagalkot districts in northern Karnataka. The intervention seeks to reach low caste girls and their families; adolescent boys; village communities; high school teachers and school governing committees; and local government officials. All low caste (scheduled caste/tribe) adolescent girls attending 7th standard (final year of primary school) will be recruited into the study in two consecutive waves, one year apart. Girls (n = 2100), their families (n = 2100) and school teachers (n = 650) will be interviewed at baseline and at endline. The study is designed to assess the impact of the intervention on four primary outcomes: the proportion of low caste girls who (i) enter into secondary school; (ii) complete secondary school; (iii) marry before age 15; and (iv) engage in sex before age 15. Observers assessing the outcomes will be blinded to group assignment. The primary outcome will be an adjusted, cluster-level intention to treat analysis, comparing outcomes in intervention and control villages at follow-up. We will also conduct survival analyses for the following secondary outcomes: marriage, sexual debut, pregnancy and entry into sex work. Complementary monitoring and evaluation, qualitative and economic research will be used to explore and describe intervention implementation, the pathways through which change occurs, and the cost-effectiveness of the intervention. DISCUSSION This is an innovative trial of a comprehensive intervention to improve the quality of life and reduce HIV vulnerability among marginalised girls in northern Karnataka. The findings will be of interest to programme implementers, policy makers and evaluation researchers working in the development, education, and sexual and reproductive health fields. TRIAL REGISTRATION ClinicalTrials.Gov NCT01996241 . 16th November 2013.
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Affiliation(s)
- Tara S Beattie
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SN, UK.
| | | | - Shajy Isac
- Karnataka Health Promotion Trust, Bangalore, India.
| | - Calum Davey
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SN, UK.
| | | | - Sapna Nair
- Karnataka Health Promotion Trust, Bangalore, India.
| | | | | | - Martine Collumbien
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SN, UK.
| | | | - Charlotte Watts
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SN, UK.
| | | | - Lori Heise
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SN, UK.
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Iritani BJ, Cho H, Rusakaniko S, Mapfumo J, Hartman S, Hallfors DD. Educational Outcomes for Orphan Girls in Rural Zimbabwe: Effects of a School Support Intervention. Health Care Women Int 2015; 37:301-22. [PMID: 25692731 DOI: 10.1080/07399332.2015.1017641] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Educational achievement has important implications for the health and well-being of young women in sub-Saharan Africa. The authors assessed the effects of providing school support on educational outcomes of orphan girls in rural Zimbabwe. Data were from a randomized controlled trial offering the intervention group comprehensive schooling support and controls no treatment initially and then fees only. Results indicated comprehensive support reduced school dropout and absence but did not improve test scores. Providing support to orphan girls is promising for addressing World Health Organization Millennium Development Goals, but further research is needed about contextual factors affecting girls' school participation and learning.
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Affiliation(s)
- Bonita J Iritani
- a Pacific Institute for Research and Evaluation , Chapel Hill , North Carolina , USA
| | - Hyunsan Cho
- a Pacific Institute for Research and Evaluation , Chapel Hill , North Carolina , USA
| | | | - John Mapfumo
- c Faculty of Education, Africa University , Mutare , Zimbabwe
| | - Shane Hartman
- a Pacific Institute for Research and Evaluation , Chapel Hill , North Carolina , USA
| | - Denise Dion Hallfors
- a Pacific Institute for Research and Evaluation , Chapel Hill , North Carolina , USA
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Hallfors DD, Cho H, Rusakaniko S, Mapfumo J, Iritani B, Zhang L, Luseno W, Miller T. The impact of school subsidies on HIV-related outcomes among adolescent female orphans. J Adolesc Health 2015; 56:79-84. [PMID: 25530603 PMCID: PMC4274377 DOI: 10.1016/j.jadohealth.2014.09.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 09/02/2014] [Accepted: 09/02/2014] [Indexed: 11/24/2022]
Abstract
PURPOSE We examine effects of school support as a structural HIV prevention intervention for adolescent female orphans in Zimbabwe after 5 years. METHODS Three hundred twenty-eight orphan adolescent girls were followed in a clustered randomized controlled trial from 2007 to 2010. The experimental group received school fees, uniforms, and school supplies and were assigned a school-based "helper." In 2011-2012, the control group received delayed partial treatment of school fees only. At the final data point in 2012, survey, HIV, and Herpes Simplex Virus Type 2 (HSV-2) biomarker data were collected from approximately 88% of the sample. Bivariate and multivariate analyses were conducted on end point outcomes, controlling for age, religious affiliation, and baseline socioeconomic status. RESULTS The two groups did not differ on HIV or HSV-2 biomarkers. The comprehensive 5-year intervention continued to reduce the likelihood of marriage, improve school retention, improve socioeconomic status (food security), and marginally maintain gains in quality of life, even after providing school fees to the control group. CONCLUSIONS Paying school fees and expenses resulted in significant improvements in life outcomes for orphan adolescent girls. Biological evidence of HIV infection prevention, however, was not observed. Our study adds to the growing body of research on school support as HIV prevention for girls in sub-Saharan Africa, but as yet, no clear picture of effectiveness has emerged.
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Affiliation(s)
| | - Hyunsan Cho
- The Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina
| | | | - John Mapfumo
- Faculty of Education, Africa University, Mutare, Zimbabwe
| | - Bonita Iritani
- The Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina
| | - Lei Zhang
- The Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina
| | - Winnie Luseno
- The Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina
| | - Ted Miller
- The Pacific Institute for Research and Evaluation, Beltsville, Maryland
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Use of HIV and HSV-2 biomarkers in sub-saharan adolescent prevention research: a comparison of two approaches. J Prim Prev 2014; 35:181-91. [PMID: 24682861 PMCID: PMC3996329 DOI: 10.1007/s10935-014-0343-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Self-report of sexual behavior among adolescents is notoriously inconsistent, yet such measures are commonly used as outcomes for human immunodeficiency virus (HIV) prevention intervention trials. There has been a growing interest in the use of HIV and other sexually transmitted disease biomarkers as more valid measures of intervention impact in high HIV prevalence areas, particularly in sub-Saharan Africa. We examine the challenges, benefits, and feasibility of including HIV and herpes simplex virus type 2 (HSV-2) biomarker data, with details about different data collection and disclosure methods from two adolescent prevention trials in Kenya and Zimbabwe. In Kenya, whole blood samples were collected using venipuncture; adult guardians were present during biomarker procedures and test results were disclosed to participants and their guardians. In contrast, in Zimbabwe, samples were collected using finger pricks for dried blood spots (DBS); guardians were not present during biomarker procedures, and results were not disclosed to participants and/or their guardians. In both countries, prevalence in the study samples was low. Although the standard of care for testing for HIV and other sexually transmitted infections includes disclosure in the presence of a guardian for adolescents under age 18, we conclude that more research about the risks and benefits of disclosure to adolescents in the context of a clinical trial is needed. Notably, current serological diagnosis for HSV-2 has a low positive predictive value when prevalence is low, resulting in an unacceptable proportion of false positives and serious concerns about disclosing test results to adolescents within a trial. We also conclude that the DBS approach is more convenient and efficient than venipuncture for field research, although both approaches are feasible. Manufacturer validation studies using DBS for HSV-2, however, are needed for widespread use.
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Dunbar MS, Kang Dufour MS, Lambdin B, Mudekunye-Mahaka I, Nhamo D, Padian NS. The SHAZ! project: results from a pilot randomized trial of a structural intervention to prevent HIV among adolescent women in Zimbabwe. PLoS One 2014; 9:e113621. [PMID: 25415455 PMCID: PMC4240618 DOI: 10.1371/journal.pone.0113621] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 09/27/2014] [Indexed: 11/19/2022] Open
Abstract
UNLABELLED Adolescent females in Zimbabwe are at high risk for HIV acquisition. Shaping the Health of Adolescents in Zimbabwe (SHAZ!) was a randomized controlled trial of a combined intervention package including life-skills and health education, vocational training, micro-grants and social supports compared to life-skills and health education alone. SHAZ! was originally envisioned as a larger effectiveness trial, however, the intervention was scaled back due to contextual and economic conditions in the country at the time. SHAZ! enrolled 315 participants randomly assigned to study arm within blocks of 50 participants (158 intervention and 157 control). The intervention arm participants showed statistically significant differences from the control arm participants for several outcomes during the two years of follow up including; reduced food insecurity [IOR = 0.83 vs. COR = 0.68, p-0.02], and having their own income [IOR = 2.05 vs. COR = 1.67, p = 0.02]. Additionally, within the Intervention arm there was a lower risk of transactional sex [IOR = 0.64, 95% CI (0.50, 0.83)], and a higher likelihood of using a condom with their current partner [IOR = 1.79, 95% CI (1.23, 2.62)] over time compared to baseline. There was also evidence of fewer unintended pregnancies among intervention participants [HR = 0.61, 95% CI (0.37, 1.01)], although this relationship achieved only marginal statistical significance. Several important challenges in this study included the coordination with vocational training programs, the political and economic instability of the area at the time of the study, and the difficulty in creating a true standard of care control arm. Overall the results of the SHAZ! study suggest important potential for HIV prevention intervention packages that include vocational training and micro-grants, and lessons for further economic livelihoods interventions with adolescent females. Further work is needed to refine the intervention model, and test the impact of the intervention at scale on biological outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT02034214.
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Affiliation(s)
- Megan S. Dunbar
- Pangaea Global AIDS Foundation, Oakland, CA, United States of America
| | - Mi-Suk Kang Dufour
- University of California San Francisco, Center for AIDS Prevention Studies, San Francisco, United States of America
| | - Barrot Lambdin
- Pangaea Global AIDS Foundation, Oakland, CA, United States of America
| | | | | | - Nancy S. Padian
- University of California, School of Public Health, Berkeley, United States of America
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Cho H, Luseno W, Halpern C, Zhang L, Mbai I, Milimo B, Hallfors DD. Discordance of HIV and HSV-2 biomarkers and self-reported sexual behaviour among orphan adolescents in Western Kenya. Sex Transm Infect 2014; 91:260-5. [PMID: 25378660 DOI: 10.1136/sextrans-2014-051720] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Accepted: 10/18/2014] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND This paper examines the discordance between biological data of HIV and herpes simplex virus type 2 (HSV-2) infections and self-reported questionnaire responses among orphan adolescents in Western Kenya. METHODS In 2011, 837 orphan adolescents from 26 primary schools were enrolled in an HIV prevention trial. At baseline, blood samples were drawn for HIV and HSV-2 infection biomarker testing, and participants completed an audio computer-assisted self-interviewing survey. RESULTS Comparing biological data with self-reported responses indicated that 70% of HIV-positive (7 out of 10) and 64% of HSV-2-positive (18 out of 28 positive) participants reported never having had sex. Among ever-married adolescents, 65% (57 out of 88) reported never having had sex. Overall, 10% of study participants appeared to have inconsistently reported their sexual behaviour. Logistic regression analyses indicated that lower educational level and exam scores were significant predictors of inconsistent reporting. CONCLUSIONS Our study demonstrates the discordance between infections measured by biomarkers and self-reports of having had sex among orphan adolescents in Kenya. In order to detect programme effects accurately in prevention research, it is necessary to collect both baseline and endline biological data. Furthermore, it is recommended to triangulate multiple data sources about adolescent participants' self-reported information about marriage and pregnancies from school records and parent/guardians to verify the information. Researchers should recognise potential threats to validity in data and design surveys to consider cognitive factors and/or cultural context to obtain more accurate and reliable information from adolescents regarding HIV/sexually transmitted infection risk behaviours. CLINICAL TRAIL REGISTRATION NUMBER NCT01501864.
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Affiliation(s)
- Hyunsan Cho
- The Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina, USA
| | - Winnie Luseno
- The Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina, USA
| | - Carolyn Halpern
- Department of Maternal and Child Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Lei Zhang
- The Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina, USA
| | | | | | - Denise Dion Hallfors
- The Pacific Institute for Research and Evaluation, Chapel Hill, North Carolina, USA
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Remme M, Siapka M, Vassall A, Heise L, Jacobi J, Ahumada C, Gay J, Watts C. The cost and cost-effectiveness of gender-responsive interventions for HIV: a systematic review. J Int AIDS Soc 2014; 17:19228. [PMID: 25373519 PMCID: PMC4221500 DOI: 10.7448/ias.17.1.19228] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 09/16/2014] [Accepted: 09/16/2014] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Harmful gender norms and inequalities, including gender-based violence, are important structural barriers to effective HIV programming. We assess current evidence on what forms of gender-responsive intervention may enhance the effectiveness of basic HIV programmes and be cost-effective. METHODS Effective intervention models were identified from an existing evidence review ("what works for women"). Based on this, we conducted a systematic review of published and grey literature on the costs and cost-effectiveness of each intervention identified. Where possible, we compared incremental costs and effects. RESULTS Our effectiveness search identified 36 publications, reporting on the effectiveness of 22 HIV interventions with a gender focus. Of these, 11 types of interventions had a corresponding/comparable costing or cost-effectiveness study. The findings suggest that couple counselling for the prevention of vertical transmission; gender empowerment, community mobilization, and female condom promotion for female sex workers; expanded female condom distribution for the general population; and post-exposure HIV prophylaxis for rape survivors are cost-effective HIV interventions. Cash transfers for schoolgirls and school support for orphan girls may also be cost-effective in generalized epidemic settings. CONCLUSIONS There has been limited research to assess the cost-effectiveness of interventions that seek to address women's needs and transform harmful gender norms. Our review identified several promising, cost-effective interventions that merit consideration as critical enablers in HIV investment approaches, as well as highlight that broader gender and development interventions can have positive HIV impacts. By no means an exhaustive package, these represent a first set of interventions to be included in the investment framework.
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Affiliation(s)
- Michelle Remme
- Social and Mathematical Epidemiology (SaME) Group, London School of Hygiene and Tropical Medicine, London, UK;
| | - Mariana Siapka
- Social and Mathematical Epidemiology (SaME) Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Anna Vassall
- Social and Mathematical Epidemiology (SaME) Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Lori Heise
- Social and Mathematical Epidemiology (SaME) Group, London School of Hygiene and Tropical Medicine, London, UK
| | - Jantine Jacobi
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Claudia Ahumada
- Joint United Nations Programme on HIV/AIDS (UNAIDS), Geneva, Switzerland
| | - Jill Gay
- Health Policy Project, Futures Group, Washington, DC, USA
| | - Charlotte Watts
- Social and Mathematical Epidemiology (SaME) Group, London School of Hygiene and Tropical Medicine, London, UK
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Mpofu E, Hallfors DD, Mutepfa MM, Dune TM. A Mixed Methods Mapping of Church versus Secular School Messages to Influence Sexual Decision-Making as Perceived by Zimbabwean Orphan Girl Students. JOURNAL OF MIXED METHODS RESEARCH 2014; 8:363-376. [PMID: 25530739 PMCID: PMC4267058 DOI: 10.1177/1558689814539394] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
This study examined the messages perceived by adolescent girls with orphanhood to influence their sexual decision-making. Participants were 125 students (mean age =14.7 years), 54% of whom attended church schools in a rural district of eastern Zimbabwe. We collected and analyzed data using concept mapping, a mixed method approach that enabled the construction of message clusters, with weighting for their relative importance. Messages that clustered under Biblical Teachings and Life Planning ranked highest in salience among students in both church and secular schools. Protecting Family Honor, HIV Prevention, and Social Stigma messages ranked next, respectively. Contrary to study hypotheses, the messages that orphan adolescent girls perceived to influence their sexual decisions did not vary by type of school attended.
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Affiliation(s)
- Elias Mpofu
- Faculty of Health Sciences, University of Sydney, Australia
| | | | | | - Tinashe Moira Dune
- Faculty of Health Sciences, University of Sydney, Australia
- University of New England, Australia
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Ramanath R. Ethical implications of resource-limited evaluations: lessons from an INGO in the eastern Democratic Republic of Congo. EVALUATION AND PROGRAM PLANNING 2014; 46:25-37. [PMID: 24907592 DOI: 10.1016/j.evalprogplan.2014.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Revised: 03/11/2014] [Accepted: 04/23/2014] [Indexed: 06/03/2023]
Abstract
The emphasis on demonstrable program results in international development work has produced countless evaluation guidelines and numerous scholars have championed specific, ethical-based evaluation approaches to guide international nongovernmental organizations (INGOs). Yet few studies have examined the ethical implications of current evaluation practices among INGOs or the resulting effects on INGO-funded programs. This article focuses on one among a growing population of young, U.S.-based INGOs whose evaluation practices reflect limitations of time, methodological expertise and funding. Drawing on existing principles of ethical evaluations, the author explores the circumstances and potential implications of one evaluation performed by an INGO in the eastern Democratic Republic of Congo and concludes that an ethically defensible evaluation exceeds the capacity of this young INGO. Four propositions are forwarded to highlight the tensions between currently accepted evaluation guidelines and INGO realities. Finally, to help under-resourced INGOs minimize the potential ethical implications for their programs, the article recommends that they prioritize their limited resources to: (1) build local capacity and decentralize evaluation tasks and responsibilities; (2) share program agendas and solicit feedback on implementation from evaluands; (3) share field impressions with local and expert stakeholders; and, (4) translate communications into local dialects to facilitate discussion about structuring future programs and their evaluation.
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Affiliation(s)
- Ramya Ramanath
- School of Public Service, DePaul University, 14 E Jackson Blvd., Suite 1606, Chicago, IL 60604, USA.
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Scott J, Hacker M, Averbach S, Modest AM, Cornish S, Spencer D, Murphy M, Parmar P. Influences of sex, age and education on attitudes towards gender inequitable norms and practices in South Sudan. Glob Public Health 2014; 9:773-86. [PMID: 25026024 DOI: 10.1080/17441692.2014.928347] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Prolonged conflict in South Sudan exacerbated gender disparities and inequities. This study assessed differences in attitudes towards gender inequitable norms and practices by sex, age and education to inform programming. Applying community-based participatory research methodology, 680 adult respondents, selected by quota sampling, were interviewed in seven South Sudanese communities from 2009 to 2011. The verbally administered survey assessed attitudes using the Gender Equitable Men scale. Data were stratified by sex, age and education. Of 680 respondents, 352 were female, 326 were male and two did not report their sex. The majority of respondents agreed with gender inequitable household roles, but the majority disagreed with gender inequitable practices (i.e., early marriage, forced marriage and inequitable education of girls). Respondents who reported no education were more likely than those who reported any education to agree with gender inequitable practices (all p < 0.03) except for forced marriage (p = 0.07), and few significant differences were observed when these responses were stratified by sex and by age. The study reveals agreement with gender inequitable norms in the household but an overall disagreement with gender inequitable practices in sampled communities. The findings support that education of both women and men may promote gender equitable norms and practices.
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Affiliation(s)
- Jennifer Scott
- a Department of Obstetrics and Gynecology , Beth Israel Deaconess Medical Center , Boston , MA , USA
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McQueston K, Silverman R, Glassman A. The efficacy of interventions to reduce adolescent childbearing in low- and middle-income countries: a systematic review. Stud Fam Plann 2014; 44:369-88. [PMID: 24323658 DOI: 10.1111/j.1728-4465.2013.00365.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This study reviews the scope and quality of existing literature regarding the interventions to reduce adolescent childbearing in low- and middle-income countries and compiles findings concerning their effectiveness. A total of 737 studies published between 2000 and 2011 were reviewed; 19 were identified as meeting eligibility criteria. Studies were included that: evaluated program effects on adolescents and young people, either as the primary target population or as a subset of a broader target group; evaluated an intervention intended to reduce adolescent fertility or generate improvements on a related outcome; and reported childbearing-related outcomes. Evidence indicates that a variety of interventions may be successful at reducing fertility, including school-based programs, health counseling, and cash transfers. An overview of evaluation efforts to date is provided, and potential best practices are highlighted. Conclusions are that funding for adolescent fertility initiatives should be directed toward programs for which a sound evidence base exists, such as cash transfers or other interventions that encourage school enrollment, and that programs of unknown effectiveness should be conducted in tandem with rigorous evaluation.
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Affiliation(s)
- Kate McQueston
- Program Coordinator of Global Health Policy, Center for Global Development, 1800 Massachusetts Avenue NW, Washington, DC, 20036.
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Cost-effectiveness of school support for orphan girls to prevent HIV infection in Zimbabwe. PREVENTION SCIENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR PREVENTION RESEARCH 2014; 14:503-12. [PMID: 23334923 DOI: 10.1007/s11121-012-0315-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
This cost-effectiveness study analyzes the cost per quality-adjusted life year (QALY) gained in a randomized controlled trial that tested school support as a structural intervention to prevent HIV risk factors among Zimbabwe orphan girl adolescents. The intervention significantly reduced early marriage, increased years of schooling completed, and increased health-related quality of life. By reducing early marriage, the literature suggests the intervention reduced HIV infection. The intervention yielded an estimated US$1,472 in societal benefits and an estimated gain of 0.36 QALYs per orphan supported. It cost an estimated US$6/QALY gained, about 1 % of annual per capita income in Zimbabwe. That is well below the maximum price that the World Health Organization (WHO) Commission on Macroeconomics and Health recommends paying for health gains in low and middle income countries. About half the girls in the intervention condition were boarded when they reached high school. For non-boarders, the intervention's financial benefits exceeded its costs, yielding an estimated net cost savings of $502 per pupil. Without boarding, the intervention would yield net savings even if it were 34 % less effective in replication. Boarding was not cost-effective. It cost an additional $1,234 per girl boarded (over the 3 years of the study, discounted to present value at a 3 % discount rate) but had no effect on any of the outcome measures relative to girls in the treatment group who did not board. For girls who did not board, the average cost of approximately 3 years of school support was US$973.
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Handa S, Halpern CT, Pettifor A, Thirumurthy H. The government of Kenya's cash transfer program reduces the risk of sexual debut among young people age 15-25. PLoS One 2014; 9:e85473. [PMID: 24454875 PMCID: PMC3893206 DOI: 10.1371/journal.pone.0085473] [Citation(s) in RCA: 101] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2013] [Accepted: 11/22/2013] [Indexed: 11/18/2022] Open
Abstract
The aim of this study is to assess whether the Government of Kenya's Cash Transfer for Orphans and Vulnerable Children (Kenya CT-OVC) can reduce the risk of HIV among young people by postponing sexual debut. The program provides an unconditional transfer of US$20 per month directly to the main caregiver in the household. An evaluation of the program was implemented in 2007–2009 in seven districts. Fourteen Locations were randomly assigned to receive the program and fourteen were assigned to a control arm. A sample of households was enrolled in the evaluation in 2007. We revisited these households in 2011 and collected information on sexual activity among individuals between 15–25 years of age. We used logistic regression, adjusted for the respondent's age, sex and relationship to caregiver, the age, sex and schooling of the caregiver and whether or not the household lived in Nairobi at baseline, to compare rates of sexual debut among young people living in program households with those living in control households who had not yet entered the program. Our results, adjusted for these covariates, show that the program reduced the odds of sexual debut by 31 percent. There were no statistically significant effects on secondary outcomes of behavioral risk such as condom use, number of partners and transactional sex. Since the CT-OVC provides cash to the caregiver and not to the child, and there are no explicit conditions associated with receipt, these impacts are indirect, and may have been achieved by keeping young people in school. Our results suggest that large-scale national social cash transfer programs with poverty alleviation objectives may have potential positive spillover benefits in terms of reducing HIV risk among young people in Eastern and Southern Africa.
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Affiliation(s)
- Sudhanshu Handa
- Carolina Population Center and Department of Public Policy, University of North Carolina, Chapel Hill, North Carolina, United States of America
- * E-mail:
| | - Carolyn Tucker Halpern
- Carolina Population Center and Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Audrey Pettifor
- Carolina Population Center and Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
| | - Harsha Thirumurthy
- Carolina Population Center and Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, United States of America
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Marston M, Beguy D, Kabiru C, Cleland J. Predictors of sexual debut among young adolescents in Nairobi's informal settlements. INTERNATIONAL PERSPECTIVES ON SEXUAL AND REPRODUCTIVE HEALTH 2013; 39:22-31. [PMID: 23584465 DOI: 10.1363/3902213] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
CONTEXT There is a need to better understand the various social, psychosocial and behavioral factors associated with sexual activity among young adolescents in various settings in Sub-Saharan Africa. METHODS Data were drawn from Wave 1 (2007-2008) and Wave 2 (2009) of the Transition to Adulthood study, which collected information about key markers of the transition to adulthood and social, demographic and psychosocial characteristics of male and female youth living in two informal settlements in Nairobi, Kenya. Logistic regression analyses were used to examine variables associated with experience of sexual debut by Wave 2 among youth who were aged 12-16 and sexually inexperienced at Wave 1. RESULTS Of the 1,754 youth in the sample, 92 experienced sexual debut between survey waves. For both males and females, sexual debut was positively associated with having permanently dropped out of school (odds ratios, 6.9 and 21.8, respectively), having never attended school (8.6 and 39.4) and having experienced severe family dysfunction (2.8 and 5.7). Lack of parental supervision was a predictor of sexual debut among males only (10.1), whereas low aspiration was a predictor among females only (10.4). Surprisingly, young women, as well as men, who did not have high self-esteem were less likely than those who did to initiate first sex between waves (0.4 and 0.3). CONCLUSIONS Study findings underscore the importance of school attendance, family dysfunction, parental supervision and self-esteem in driving sexual behavior in this age-group. Further studies are warranted to elucidate how these factors can be addressed in prevention programs for young adolescents.
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Affiliation(s)
- Milly Marston
- London School of Hygiene and Tropical Medicine, London.
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81
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Leerlooijer JN, Bos AER, Ruiter RAC, van Reeuwijk MAJ, Rijsdijk LE, Nshakira N, Kok G. Qualitative evaluation of the Teenage Mothers Project in Uganda: a community-based empowerment intervention for unmarried teenage mothers. BMC Public Health 2013; 13:816. [PMID: 24011141 PMCID: PMC3846560 DOI: 10.1186/1471-2458-13-816] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 09/04/2013] [Indexed: 11/30/2022] Open
Abstract
Background A large proportion of unmarried teenage mothers in Uganda face physical, psychological, and social problems after pregnancy and childbirth, such as obstetric complications, lack of education, and stigmatisation in their communities. The Teenage Mothers Project (TMP) in Eastern Uganda empowers unmarried teenage mothers to cope with the consequences of early pregnancy and motherhood. Since 2000, 1036 unmarried teenage mothers, their parents, and community leaders participated in economic and social empowerment interventions. The present study explored the changes resulting from the TMP as well as factors that either enabled or inhibited these changes. Methods Semi-structured interviews (N = 23) were conducted with former teenage mothers , community leaders, and project implementers, and lifeline histories were obtained from former teenage mothers (N = 9). Quantitative monitoring data regarding demographic and social characteristics of teenage mother participants (N = 1036) were analysed. Results The findings suggest that, overall, the TMP seems to have contributed to the well-being of unmarried teenage mothers and to a supportive social environment. It appears that the project contributed to supportive community norms towards teenage mothers’ position and future opportunities, increased agency, improved coping with early motherhood and stigma, continued education, and increased income generation by teenage mothers. The study findings also suggest limited change in disapproving community norms regarding out-of-wedlock sex and pregnancy, late active enrolment of teenage mothers in the project (i.e., ten months after delivery of the child), and differences in the extent to which parents provided support. Conclusions It is concluded that strengths of the community-based TMP seem to be its socio-ecological approach, the participatory planning with community leaders and other stakeholders, counselling of parents and unmarried teenage mothers, and the emphasis on education and income generation. The project can improve by earlier active participation of unmarried pregnant adolescents and increased support for parents.
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Affiliation(s)
- Joanne N Leerlooijer
- Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands.
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82
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Acceptability and feasibility of cash transfers for HIV prevention among adolescent South African women. AIDS Behav 2013; 17:2301-12. [PMID: 23435698 DOI: 10.1007/s10461-013-0433-0] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Women are at increased risk of HIV infection in much of sub-Saharan Africa. Longitudinal and cross-sectional studies have found an association between school attendance and reduced HIV risk. We report feasibility and acceptability results from a pilot of a cash transfer intervention conditional on school attendance paid to young women and their families in rural Mpumalanga, South Africa for the prevention of HIV infection. Twenty-nine young women were randomised to intervention or control and a cash payment based on school attendance made over a 2-month period. Quantitative (survey) and qualitative (focus group and interview) data collection was undertaken with young women, parents, teachers and young men in the same school. Qualitative analysis was conducted in Atlas.ti using a framework approach and basic descriptive analysis in Excel was conducted on the quantitative data. Results indicate it was both feasible and acceptable to introduce such an intervention among this population in rural South Africa. There was good understanding of the process of randomisation and the aims of the study, although some rumours developed in the study community. We address some of the changes necessary to ensure acceptability and feasibility of the main trial.
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83
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Cash transfers for HIV prevention: considering their potential. J Int AIDS Soc 2013; 16:18615. [PMID: 23972159 PMCID: PMC3752431 DOI: 10.7448/ias.16.1.18615] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Revised: 06/19/2013] [Accepted: 07/29/2013] [Indexed: 11/21/2022] Open
Abstract
Introduction Cash payments to vulnerable households and/or individuals have increasingly garnered attention as a means to reduce poverty, improve health and achieve other development-related outcomes. Recent evidence from Malawi and Tanzania suggests that cash transfers can impact HIV-related behaviours and outcomes and, therefore, could serve as an important addition to HIV prevention efforts. Discussion This article reviews the current evidence on cash transfers for HIV prevention and suggests unresolved questions for further research. Gaps include (1) understanding more about the mechanisms and pathways through which cash transfers affect HIV-related outcomes; (2) addressing key operational questions, including the potential feasibility and the costs and benefits of different models of transfers and conditionality; and (3) evaluating and enhancing the wider impacts of cash transfers on health and development. Conclusions Ongoing and future studies should build on current findings to unpack unresolved questions and to collect additional evidence on the multiple impacts of transfers in different settings. Furthermore, in order to address questions on sustainability, cash transfer programmes need to be integrated with other sectors and programmes that address structural factors such as education and programming to promote gender equality and address HIV.
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84
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Kennedy CE, Brahmbhatt H, Likindikoki S, Beckham SW, Mbwambo JK, Kerrigan D. Exploring the potential of a conditional cash transfer intervention to reduce HIV risk among young women in Iringa, Tanzania. AIDS Care 2013; 26:275-81. [PMID: 23926908 DOI: 10.1080/09540121.2013.824539] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Cash transfer programs seek to alter structural determinants of HIV risk such as poverty and gender inequality. We sought to explore the feasibility and potential effectiveness of a cash transfer intervention for young women as part of combination HIV prevention in Iringa, Tanzania. Qualitative, in-depth interviews were conducted with 116 stakeholders and residents from the region, including key informants, service delivery users, and members of key populations. Most respondents felt a cash transfer program would assist young women in Iringa to have more control over sexual decision-making and reduce poverty-driven transactional sex. Respondents were divided on who should receive funds: young women themselves, their parents/guardians, or community leaders. Cash amounts and suggested target groups varied, and several respondents suggested providing microcredit or small business capital instead of cash. Potential concerns included jealousy, dependency, and corruption. However, most respondents felt that some intervention was needed to address underlying poverty driving some sexual risk behavior. A cash transfer program could fill this role, ultimately reducing HIV, sexually transmitted infections, and unintended pregnancies. As increased attention is given to economic and structural interventions for HIV prevention, local input and knowledge should be considered in a program design.
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Affiliation(s)
- Caitlin E Kennedy
- a International Health , Johns Hopkins Bloomberg School of Public Health , Baltimore , MD , USA
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Singh K, Luseno W, Haney E. Gender equality and education: Increasing the uptake of HIV testing among married women in Kenya, Zambia and Zimbabwe. AIDS Care 2013; 25:1452-61. [PMID: 23438082 DOI: 10.1080/09540121.2013.774311] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Gender equality and education are being promoted as strategies to combat the HIV epidemic in Africa, but few studies have looked at the role of gender equality and education in the uptake of a vital service - HIV testing. This study looks at the associations between education (a key input needed for gender equality) and key gender equality measures (financial decision making and attitudes toward violence) with ever tested for HIV and tested for HIV in the past year. The study focused on currently married women ages between15-24 and 25-34 in three countries - Kenya, Zambia, and Zimbabwe. The data came from the Demographic and Health Surveys. Logistic regression was used to study the role of gender equality and education on the HIV testing outcomes after controlling for both social and biological factors. Results indicated that education had a consistent positive relationship with testing for both age groups, and the associations were always significant for young women aged 15-24 years (p<0.01). The belief that gender-based violence is unacceptable was positively associated with testing for women aged 25-34 in all the three countries, although the associations were only significant in Kenya (among women reporting ever being tested: OR 1.58, p<0.00; among women reporting being tested in the past year: OR 1.34, p<0.05) and Zambia (among women reporting ever being tested: OR 1.24, p<0.10; among women reporting being tested in the past year: OR 1.29, p<0.05). High financial decision making was associated with testing for women aged 25-34 in Zimbabwe only (among women reporting ever being tested: OR 1.66, p<0.01). Overall, the findings indicate that the education and the promotion of gender equality are important strategies for increasing uptake of a vital HIV service, and thus are important tools for protecting girls and young women against HIV.
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Affiliation(s)
- Kavita Singh
- a Department of Maternal and Child Health , University of North Carolina at Chapel Hill , Chapel Hill , NC , USA
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Shamu S, Abrahams N, Zarowsky C, Shefer T, Temmerman M. Intimate partner violence during pregnancy in Zimbabwe: a cross-sectional study of prevalence, predictors and associations with HIV. Trop Med Int Health 2013; 18:696-711. [PMID: 23414103 DOI: 10.1111/tmi.12078] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the occurrence, dynamics and predictors of intimate partner violence (IPV) during pregnancy, including links with HIV, in urban Zimbabwe. METHODS A cross-sectional survey of 2042 post-natal women aged 15-49 years was conducted in six public primary healthcare clinics in low-income urban Zimbabwe. An adapted WHO questionnaire was used to measure IPV. Multivariate logistic regression was used to assess factors associated with IPV and severe (six or more episodes) IPV during pregnancy. RESULTS 63.1% of respondents reported physical, emotional and/or sexual IPV during pregnancy: 46.2% reported physical and/or sexual violence, 38.9% sexual violence, 15.9% physical violence and 10% reported severe violence during pregnancy. Physical violence was less common during pregnancy than during the last 12 months before pregnancy (15.9% [95% CI 14.3-17.5] vs. 21.3% [95% confidence interval 19.5-23.1]). Reported rates of emotional (40.3% [95% CI 38.1-42.3] vs. 44.0% [95% CI 41.8-46.1]) and sexual violence (35.6% [95% CI 33.5-37.7] vs. 38.9% [95% CI 36.8-41.0]) were high during and before pregnancy. Associated factors were having a younger male partner, gender inequities, past abuse, problem drinking, partner control of woman's reproductive health and risky sexual practices. HIV status was not associated with either IPV or severe IPV, but reporting a partner with a known HIV status was associated with a lower likelihood of severe abuse. CONCLUSION The rates of IPV during pregnancy in Zimbabwe are among the highest ever reported globally. Primary prevention of violence during childhood through adolescence is urgently needed. Antenatal care may provide an opportunity for secondary prevention but this requires further work. The relationship between IPV and HIV is complex in contexts where both are endemic.
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Affiliation(s)
- Simukai Shamu
- School of Public Health, University of the Western Cape, Cape Town, South Africa.
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Process and outcome evaluation of a community intervention for orphan adolescents in western Kenya. J Community Health 2013; 37:1101-9. [PMID: 22350730 DOI: 10.1007/s10900-012-9548-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
We conducted a 2-year pilot randomized controlled trial (N = 105) in a high HIV-prevalence area in rural western Kenya to test whether providing young orphan adolescents with uniforms, school fees, and community visitors improves school retention and reduces HIV risk factors. The trial was a community intervention, limited to one community. In this paper, we examined intervention implementation and its association with outcomes using longitudinal data. We used both quantitative and qualitative methods to evaluate the community-based model for orphan HIV prevention, with recommendations for future studies. Despite promising effects after 1 year, GEE analyses showed null effects after 2 years. Volunteer community visitors, a key element of the intervention, showed little of the expected effect although qualitative reports documented active assistance to prevent orphans' school absence. For future research, we recommend capturing the transition to high school, a larger sample size, and biomarker data to add strength to the research design. We also recommend a school-based intervention approach to improve implementation and reduce infrastructure costs. Finally, we recommend evaluating nurses as agents for improving school attendance and preventing dropout because of their unique ability to address critical biopsychosocial problems.
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Strathdee SA, Wechsberg WM, Kerrigan DL, Patterson TL. HIV prevention among women in low- and middle-income countries: intervening upon contexts of heightened HIV risk. Annu Rev Public Health 2013; 34:301-16. [PMID: 23297666 DOI: 10.1146/annurev-publhealth-031912-114411] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Women's vulnerability to HIV infection is influenced by contextual factors in the risk environment that operate at multiple levels (i.e., physical, social, economic, policy). We present three case studies that illustrate combination approaches to HIV prevention among women who are at heightened risk for infection, especially sex workers, in low- and middle-income countries (LMICs). Lessons learned from these case studies are consistent with international literature promoting interventions that combine sexual risk reduction, condom promotion, and improved access to sexually transmitted infection (STI) treatment in the context of structural interventions, including policy change and empowerment of sex workers to reduce their vulnerability to HIV/STIs. We suggest avenues for future research and new intervention targets as well as a more nuanced approach to understanding the structural and social vulnerability of women to HIV infection in these settings.
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Affiliation(s)
- Steffanie A Strathdee
- Division of Global Public Health, Department of Medicine, University of California, San Diego, La Jolla, California 92093, USA.
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Trapl ES, Taylor HG, Colabianchi N, Litaker D, Borawski EA. Value of audio-enhanced handheld computers over paper surveys with adolescents. Am J Health Behav 2013; 37:62-9. [PMID: 22943102 DOI: 10.5993/ajhb.37.1.7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the impact of 3 data collection modes on the number of questions answered, data quality, and student preference. METHODS 275 urban seventh-grade students were recruited and randomly assigned to complete a paper survey (SAQ), PDA survey (PDA), or PDA survey with audio (APDA). Students completed a paper debriefing survey. RESULTS APDA respondents completed significantly more questions compared to SAQ and PDA. PDA and APDA had significantly less missing data than did SAQ. No differences were found for student evaluation. CONCLUSIONS Strong benefits may be gained by the use of APDA for adolescent school-based data collection.
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Affiliation(s)
- Erika S Trapl
- Department of Epidemiology and Biostatistics, Prevention Research Center for Healthy Neighborhoods, Case Western Reserve University, Cleveland, OH., USA.
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Abstract
Cash payments to improve health outcomes have been used for many years; however, their use for HIV prevention is new and the impact not yet well understood. We provide a brief background on the rationale behind using cash to improve health outcomes, review current studies completed or underway using cash for prevention of sexual transmission of HIV, and outline some key considerations on the use of cash payments to prevent HIV infections. We searched the literature for studies that implemented cash transfer programs and measured HIV or HIV-related outcomes. We identified 16 studies meeting our criteria; 10 are completed. The majority of studies have been conducted with adolescents in developing countries and payments are focused on addressing structural risk factors such as poverty. Most have seen reductions in sexual behavior and one large trial has documented a difference in HIV prevalence between young women getting cash transfers and those not. Cash transfer programs focused on changing risky sexual behaviors to reduce HIV risk suggest promise. The context in which programs are situated, the purpose of the cash transfer, and the population will all affect the impact of such programs; ongoing RCTs with HIV incidence endpoints will shed more light on the efficacy of cash payments as strategy for HIV prevention.
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91
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Ismayilova L, Ssewamala F, Mooers E, Nabunya P, Sheshadri S. Imagining the future: Community perceptions of a family-based economic empowerment intervention for AIDS-orphaned adolescents in Uganda. CHILDREN AND YOUTH SERVICES REVIEW 2012; 34:2042-2051. [PMID: 23543861 PMCID: PMC3611978 DOI: 10.1016/j.childyouth.2012.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
AIDS-orphaned children and adolescents in sub-Saharan Africa have inadequate access to basic services, including health and education. Using a qualitative approach, the study explores the meaning of education in rural Uganda, obstacles faced by AIDS-orphaned adolescents and their caregivers to access secondary education, and the potential of an economic empowerment intervention SEED in addressing the challenges of accessing educational opportunities for AIDS-orphaned adolescents. The findings come from 29 semi-structured interviews conducted with eleven adolescents study participants, four caregivers and fourteen community leaders involved in the pilot SEED intervention. Study participants and community members indicated that the savings accounts offer a unique opportunity for orphaned adolescents to stay in school and imagine the future with optimism.
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Affiliation(s)
- Leyla Ismayilova
- University of Chicago, School of Social Service Administration, Chicago, IL
| | - Fred Ssewamala
- Columbia University, School of Social Work, New York, NY
| | - Elizabeth Mooers
- Leitner Center for International Law and Justice, Fordham University School of Law, NY, NY
| | - Proscovia Nabunya
- University of Chicago, School of Social Service Administration, Chicago, IL
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92
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Hallfors DD, Cho H, Iritani BJ, Mapfumo J, Mpofu E, Luseno WK, January J. Preventing HIV by providing support for orphan girls to stay in school: does religion matter? ETHNICITY & HEALTH 2012; 18:53-65. [PMID: 22715988 PMCID: PMC3496833 DOI: 10.1080/13557858.2012.694068] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
OBJECTIVE The paper examines the influence of religion on attitudes, behaviors, and HIV infection among rural adolescent women in Zimbabwe. DESIGN We analyzed data from a 2007 to 2010 randomized controlled trial in rural eastern Zimbabwe testing whether school support can prevent HIV risk behaviors and related attitudes among rural adolescent orphan girls; supplementary data from the 2006 Zimbabwe Demographic and Health Survey (ZDHS) were also analyzed. The present study design is largely cross-sectional, using the most recent available survey data from the clinical trial to examine the association between religious affiliation and religiosity on school dropout, marriage, and related attitudes, controlling for intervention condition, age and orphan type. The ZDHS data examined the effect of religious denomination on marriage and HIV status among young rural women, controlling for age. RESULTS Apostolic Church affiliation greatly increased the likelihood of early marriage compared to reference Methodist Church affiliation (odds ratio = 4.5). Greater religiosity independently reduced the likelihood of school dropout, increased gender equity attitudes and disagreement with early sex, and marginally reduced early marriage. Young rural Apostolic women in the ZDHS were nearly four times as likely to marry as teenagers compared to Protestants, and marriage doubled the likelihood of HIV infection. CONCLUSIONS Findings contradict an earlier seminal study that Apostolics are relatively protected from HIV compared to other Christian denominations. Young Apostolic women are at increased risk of HIV infection through early marriage. The Apostolic Church is a large and growing denomination in sub-Saharan Africa and many Apostolic sects discourage medical testing and treatment in favor of faith healing. Since this can increase the risk of undiagnosed HIV infection for young married women and their infants in high prevalence areas, further study is urgently needed to confirm this emerging public health problem, particularly among orphan girls. Although empirical evidence suggests that keeping orphan girls in school can reduce HIV risk factors, further study of the religious context and the implications for prevention are needed.
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Affiliation(s)
- Denise D Hallfors
- Pacific Institute for Research and Evaluation, Chapel Hill, NC, USA.
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Combined structural interventions for gender equality and livelihood security: a critical review of the evidence from southern and eastern Africa and the implications for young people. J Int AIDS Soc 2012; 15 Suppl 1:1-10. [PMID: 22713350 PMCID: PMC3499786 DOI: 10.7448/ias.15.3.17362] [Citation(s) in RCA: 69] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Revised: 03/21/2012] [Accepted: 04/29/2012] [Indexed: 11/08/2022] Open
Abstract
Background Young people in southern and eastern Africa remain disproportionately vulnerable to HIV with gender inequalities and livelihood insecurities being key drivers of this. Behavioural HIV prevention interventions have had weak outcomes and a new generation of structural interventions have emerged seeking to challenge the wider drivers of the HIV epidemic, including gender inequalities and livelihood insecurities. Methods We searched key academic data bases to identify interventions that simultaneously sought to strengthen people's livelihoods and transform gender relationships that had been evaluated in southern and eastern Africa. Our initial search identified 468 articles. We manually reviewed these and identified nine interventions that met our criteria for inclusion. Results We clustered the nine interventions into three groups: microfinance and gender empowerment interventions; supporting greater participation of women and girls in primary and secondary education; and gender empowerment and financial literacy interventions. We summarise the strengths and limitations of these interventions, with a particular focus on what lessons may be learnt for young people (18–24). Conclusions Our review identified three major lessons for structural interventions that sought to transform gender relationships and strengthen livelihoods: 1) interventions have a narrow conceptualisation of livelihoods, 2) there is limited involvement of men and boys in such interventions, 3) studies have typically been done in stable populations. We discuss what this means for future interventions that target young people through these methods.
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Atwood KA, Kennedy SB, Shamblen S, Taylor CH, Quaqua M, Bee EM, Gobeh ME, Woods DV, Dennis B. Reducing sexual risk taking behaviors among adolescents who engage in transactional sex in post-conflict Liberia. VULNERABLE CHILDREN AND YOUTH STUDIES 2012; 7:55-65. [PMID: 23626654 PMCID: PMC3634670 DOI: 10.1080/17450128.2011.647773] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Transactional sex (TS) has been correlated with HIV/STD infection, pregnancy, early marriage, and sexual violence in sub-Saharan Africa (SSA). Few Western-based HIV prevention programs adapted for SSA have examined intervention impacts for this group. This article examines whether an HIV prevention intervention, delivered to sixth-grade students in Liberia (age range 14-17) and found to increase condom use and other mediators for the larger sample, significantly impacted sexual behaviors and mediators for those who engaged in TS. Using an attention-matched, group-randomized controlled design, four matched pairs of elementary schools in Monrovia, Liberia, were randomly assigned to an adapted eight-module HIV prevention or a general health curriculum. Nine-month impacts of the intervention on sexual risk behaviors and mediators for those who engaged in TS, when compared with other study participants, are presented. Twelve percent of our sample of sixth graders (n = 714) ever engaged in TS. The majority of females reported being promised something in exchange for sex (52%), whereas the majority of males (52%) reported being both the giver and recipient of gifts in exchange for sex. Compared with other students, those who engaged in TS reported greater increases in the number of sex partners, reported greater frequency of sexual intercourse, were more likely to try to get pregnant or someone else pregnant, and reported greater reductions in protective sexual attitudes and HIV risk perception at the nine month follow-up, in both the intervention and the control groups. Our intervention, although successful for the general in-school adolescent sample, did not impact risk behaviors or mediators for adolescents who engaged in TS. Future research should explore the complex sexual economy in which TS is embedded and consider adapting HIV prevention interventions to the needs of this high-risk group.
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Affiliation(s)
- Katharine A. Atwood
- Pacific Institute for Research & Evaluation (PIRE), Louisville Center, Louisville, KY, USA
| | - Stephen B. Kennedy
- Pacific Institute for Research & Evaluation (PIRE), Louisville Center, Louisville, KY, USA
- UL-PIRE Africa Center, HIV/STD Prevention Research Center, A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - Steve Shamblen
- Pacific Institute for Research & Evaluation (PIRE), Louisville Center, Louisville, KY, USA
| | - Curtis H. Taylor
- UL-PIRE Africa Center, HIV/STD Prevention Research Center, A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - Monica Quaqua
- UL-PIRE Africa Center, HIV/STD Prevention Research Center, A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - Ernree M. Bee
- UL-PIRE Africa Center, HIV/STD Prevention Research Center, A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - Mawen E. Gobeh
- UL-PIRE Africa Center, HIV/STD Prevention Research Center, A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - Daisajou V. Woods
- UL-PIRE Africa Center, HIV/STD Prevention Research Center, A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
| | - Barclay Dennis
- UL-PIRE Africa Center, HIV/STD Prevention Research Center, A.M. Dogliotti College of Medicine, University of Liberia, Monrovia, Liberia
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Mpofu E, Dune TM, Hallfors DD, Mapfumo J, Mutepfa MM, January J. Apostolic faith church organization contexts for health and wellbeing in women and children. ETHNICITY & HEALTH 2011; 16:551-566. [PMID: 21671203 PMCID: PMC3325018 DOI: 10.1080/13557858.2011.583639] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE The study explored contexts for health and wellbeing for women and children influenced by the structural behavior of an Apostolic faith church organization in Zimbabwe. METHODS Twenty-three purposively selected members of an African indigenous Apostolic church (males = 12; females = 11; age range 22-95 years) were informants to a focus group discussion session. They provided data on the institutional behaviors that were culturally-historically embedded in the organization's activities. Data were analyzed thematically and using cultural-historical activity theory (CHAT) to foreground essential themes. RESULTS The church organization provided social capital to support health and wellbeing in members. However, the culturally embedded practices to minimize decision making by women and child members potentially compromised their health and wellbeing. CONCLUSION The findings suggest that the structural activities of the church for health and wellbeing could also have the paradoxical effect of exposing women and children to health risks from obligatory roles.
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Affiliation(s)
- Elias Mpofu
- Rehabilitation Counselling, Faculty of Health Sciences, University of Sydney, T-428, Cumberland, Lidcombe, NSW 1825, Australia.
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Cho H, Hallfors DD, Mbai II, Itindi J, Milimo BW, Halpern CT, Iritani BJ. Keeping adolescent orphans in school to prevent human immunodeficiency virus infection: evidence from a randomized controlled trial in Kenya. J Adolesc Health 2011; 48:523-6. [PMID: 21501814 PMCID: PMC3079907 DOI: 10.1016/j.jadohealth.2010.08.007] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 08/10/2010] [Accepted: 08/10/2010] [Indexed: 10/18/2022]
Abstract
PURPOSE We report the findings from a pilot study in western Kenya, using an experimental design to test whether comprehensive support used to keep adolescent orphans in school can reduce risk factors associated with infection with human immunodeficiency virus. METHODS Adolescent orphans aged 12-14 years (N = 105) in Nyanza Province were randomized to condition, after stratifying by household, gender, and baseline survey report of sexual behavior. The intervention comprised school fees, uniforms, and a "community visitor" who monitored school attendance and helped to resolve problems that would lead to absence or dropout. Data were analyzed using generalized estimating equations over two time points, controlling for gender and age. RESULTS Compared with the control group, intervention students were less likely to drop out of school, commence sexual intercourse, or report attitudes supporting early sex. School support also increased prosocial bonding and gender equity attitudes. CONCLUSIONS After 1 year of exposure to the intervention, we found evidence suggesting that comprehensive school support can prevent school dropout, delay sexual debut, and reduce risk factors associated with infection with human immunodeficiency virus. Further research, with much larger samples, is needed to better understand factors that mediate the association between educational support and delayed sexual debut, and how gender might moderate these relationships.
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Affiliation(s)
- Hyunsan Cho
- Pacific Institute for Research and Evaluation, 1516 E. Franklin Street, Chapel Hill, NC 27514, USA.
| | | | | | | | | | - Carolyn T. Halpern
- Department of Maternal and Child Health, University of North Carolina, Chapel Hill, NC, USA
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