Identifying peer effects using spatial analysis: the role of peers on risky sexual behavior

The effect of a peer's teen pregnancy on sexual behavior

We examine whether a friend or older sibling's teen pregnancy impacts one's own sexual behavior. Employing an event study design and rich retrospective data on sexual activity, we find that those who observe a peer's teen pregnancy change sexual behavior after the pregnancy ends to put themselves at lower risk of their own teen pregnancy; specifically, they are less likely to have unprotected sex and have fewer sexual partners in the year following the end of the teen pregnancy. We find that females are more likely to change their sexual behavior compared to males, and the effects are primarily driven by peer live births, as opposed to other pregnancies. Ultimately, we find a slight decline in the likelihood of one's own teen pregnancy, though estimates are noisy. Our work suggests that education campaigns that provide a realistic portrayal of teen parenthood may be an effective tool for impacting teen behavior.

Reaching Out-of-school Adolescent Girls and Young Women at Risk for HIV Through Their Social Networks

Out-of-school adolescent girls/young women (AGYW) in Africa are at increased risk for HIV and are underserved by HIV prevention interventions. Identifying social networks of out-of-school AGYW may be a strategic approach for reaching them. A sequential mixed methods study design was used. The PLACE (Priorities for Local AIDS Control Efforts) methodology, implemented in one ward of Dar es Salaam, Tanzania, identified 69 networks of AGYW. We randomly selected 28 networks and conducted surveys and network assessments with 80.9% (n = 310) of the members. On average, the networks consisted of 13.7 members, and had a density of 0.65 and a transitivity of 0.80, indicating high cohesion. The networks were mostly female (92%). On average, 67% of network membership were AGYW aged 15-24 years, of whom 70% were out-of-school and 67% were sexually active. Among sexually active AGYW aged 15-24, self-reported HIV seropositivity was 12.2%. We then conducted focus group discussions with 6 purposively selected networks. AGYW described their networks as sources of support and advice. Social norms supported AGYW engaging in transactional sex to alleviate life's hardships; it was the easiest way to earn income without "sweating". AGYW discussed IPV as a common experience, and social norms stigmatized AGYWs' use of condoms. AGYW were largely unaware of pre-exposure prophylaxis. The self-reported HIV prevalence rates of this cohort were higher than national averages, suggesting we tapped into high-risk networks. Social norms promoted transactional and unprotected sex. Social networks are an acceptable channel for HIV prevention intervention delivery to out-of-school AGYW.

Understanding how social norms influence access to and utilization of adolescent sexual and reproductive health services in Northern Nigeria

Background

This study explored the influence of social norms on the access and utilization of sexual and reproductive health services by adolescents. Apart from individual and environmental barriers, social norms influence contraceptive decisions and ultimately sexual and reproductive health outcomes. Social norms that shape group behavior describe acceptable standards of behavior and evoke sanctions when such behavior standards are not adhered to. Sexually active adolescents in Nigeria have a relatively low level of modern contraceptive use being influenced by social norms. Scaling up adolescent reproductive health interventions that integrate normative change for a wider impact of programs remains challenging.

Methods

Using data from 18 communities, 188 married and unmarried adolescents (F52% and M48%) and 69 (F37%; M63%) reference group participants were purposively sampled and participated in a social norms exploration intervention study conducted through focus group discussion and in-depth interviews between October and November 2019. The Advancing Learning and Innovation on Gender Norms (ALIGN) Social Norms Exploration Tool (SNET) was adapted for the data collection into discussion guides and vignettes. Pilot testing of the tools informed review and validation prior to actual data collection.

Findings

Low contraceptive uptake by adolescents was characterized by early and forced marriage in childhood; a prominent practice enshrined in social norms around girl-childchastity, family honor, and disapproval of pre-marital sex and pregnancy out of wedlock.

Conclusion

The understanding of harmful social norms, normative change actors, and potential norm-shifting factors for contraceptive decisions by adolescents is essential for effective adolescent sexual and reproductive health interventions for wider impact and adaptive programming in behavior change interventions for improving the access to and utilization of modern contraceptives by adolescents for improved sexual health outcomes, the attainment of the Family Planning (FP) 2030 commitment and universal health coverage policy.

Relationship, partner factors and stigma are associated with safer conception information, motivation, and behavioral skills among women living with HIV in Botswana

BACKGROUND

A significant proportion (20-59%) of people living with HIV in sub-Saharan Africa desire childbearing, are of reproductive age, and are in sero-different relationships (~50%). Thus it is plausible that some portion of new HIV transmissions are due to attempts to become pregnant. Safer conception (SC) methods that effectively reduce the risk of HIV transmission exist and can be made available in resource-constrained settings. Few studies in the region, and none in Botswana, have quantitatively examined the correlates of information, motivation, and behavioral skills for SC uptake.

METHODS

We surveyed 356 women living with HIV from 6/2018 to 12/2018 at six public-sector health clinics in Gaborone, Botswana. Participants were 18-40 years old, not pregnant, and desired future children or were unsure about their childbearing plans. We examined correlates of SC information, motivation, and behavioral skills using nested linear regression models, adjusting for socio-demographic, interpersonal, and structural variables.

RESULTS

Knowledge of SC methods varied widely. While some SC methods were well known (medical male circumcision by 83%, antiretroviral therapy for viral suppression by 64%), most other methods were known by less than 40% of participants. Our final models reveal that stigma as well as relationship and partner factors affect SC information, motivation, and behavioral skills. Both internalized childbearing stigma (ß=-0.50, 95%CI:-0.17, -0.02) and perceived community childbearing stigma were negatively associated with SC information (ß=-0.09, 95%CI:-0.80, -0.21). Anticipated (ß=-0.06, 95%CI:-0.12, -0.003) and internalized stigma (ß=-0.27, 95%CI:-0.44; -0.10) were associated with decreased SC motivation, while perceived community childbearing stigma was associated with increased SC motivation (ß=0.07, 95%CI:0.02, 0.11). Finally, internalized childbearing stigma was associated with decreased SC behavioral skills (ß=-0.80, 95%CI: -1.12, -0.47) while SC information (ß=0.24, 95%CI:0.12, 0.36), motivation (ß=0.36, 95%CI:0.15, 0.58), and perceived partner willingness to use SC (ß=0.47, 95%CI:0.36, 0.57) were positively associated with behavioral skills CONCLUSIONS: Low SC method-specific information levels are concerning since almost half (47%) of the study participants reported they were in sero-different relationships and desired more children. Findings highlight the importance of addressing HIV stigma and partner dynamics in interventions to improve SC information, motivation, and behavioral skills.

Neighborhoods, networks, and delivery methods

We examine the contribution of information transmission among pregnant women to geographic variation in C-sections in Lombardy, Italy. Defining networks as pregnant women living in the same municipality, we observe that if the incidence of C-sections within the womans network is one standard deviation higher over the 12 months preceding delivery, then her probability of delivering by C-section is 0.007 percentage points (3%) higher. This result is mainly a network effect on Italian women, while it arises from both network and neighborhood effects on foreign women. Both groups respond to additional information, such as the incidence of C-section complications. The selection of pregnant women across hospitals does not uniquely explain our results, which are robust to alternative sample selections and specifications.

Do peer social relationships mediate the harmful effects of a housing mobility experiment on boys' risky behaviors?

PURPOSE

The purpose of this study was to understand why a housing mobility experiment caused harmful effects on adolescent boys' risky behaviors.

METHODS

Moving to Opportunity (MTO) (1994-2010) randomly assigned volunteer families to a treatment group receiving a Section 8 rental voucher or a public housing control group. Our outcome was a global risky behavior index (RBI; measured in 2002, n = 750 boys) measuring the fraction of 10 items the youth engaged in, 6 measuring past 30-day substance use and 4 measuring recent risky sexual behavior. Potential mediators (measured in 2002) included peer social relationships (e.g., peer drug use, peer gang membership).

RESULTS

The voucher treatment main effect on boys' RBI was harmful (B (SE) = 0.05 (0.02), 95% CI 0.01, 0.08), and treatment marginally increased having friends who used drugs compared to controls (B (SE) = 0.67 (0.23), 95% CI 0.22, 1.12). Having friends who used drugs marginally mediated the MTO treatment effect on RBI (indirect effect: B (SE) = 0.02(.01), 95% CI -0.002, 0.04), reducing the total treatment effect by 39%.

CONCLUSIONS

Incorporating additional supports into housing voucher programs may help support teenage boys who experience disruptions to their social networks, to buffer potential adverse consequences of residential mobility.

Social Norms and Adolescents' Sexual Health: An Introduction for Practitioners Working in Low and Mid-income African countries

Donors, practitioners and scholars are increasingly interested in harnessing the potential of social norms theory to improve adolescents' sexual and reproductive health outcomes. However, social norms theory is multifaceted, and its application in field interventions is complex. An introduction to social norms that will be beneficial for those who intend to integrate a social norms perspective in their work to improve adolescents' sexual health in Africa is presented. First three main schools of thought on social norms, looking at the theoretical standpoint of each, are discussed. Next, the difference between two important types of social norms (descriptive and injunctive) is explained and then the concept of a -reference group‖ is examined. The difference between social and gender norms are then considered, highlighting how this difference is motivated by existing yet contrasting approaches to norms (in social psychology and gender theory). In the last section, existing evidence on the role that social norms play in influencing adolescents' sexual and reproductive health are reviewed. Conclusions call for further research and action to understand how norms affecting adolescents' sexual and reproductive health and rights (SRHR) can be changed in sub-Saharan Africa.

Young Men's Social Network Characteristics and Associations with Sexual Partnership Concurrency in Tanzania

Social network influence on young people's sexual behavior is understudied in sub-Saharan Africa. Previous research identified networks of mostly young men in Dar es Salaam who socialize in "camps". This study describes network characteristics within camps and their relationship to young men's concurrent sexual partnerships. We conducted surveys with a nearly complete census of ten camp networks (490 men and 160 women). Surveys included name generators to identify camp-based networks. Fifty seven percent of sexually active men (n = 471) reported past year concurrency, measured using the UNAIDS method. In a multivariable model, men's individual concurrency was associated with being a member of a closer knit camp in which concurrency was the normative behavior. Younger men who had older members in their networks were more likely to engage in concurrency. Respondent concurrency was also associated with inequitable personal gender norms. Our findings suggest strategies for leveraging social networks for HIV prevention among young men.

Evidence of social network influence on multiple HIV risk behaviors and normative beliefs among young Tanzanian men

Research on network-level influences on HIV risk behaviors among young men in sub-Saharan Africa is severely lacking. One significant gap in the literature that may provide direction for future research with this population is understanding the degree to which various HIV risk behaviors and normative beliefs cluster within men's social networks. Such research may help us understand which HIV-related norms and behaviors have the greatest potential to be changed through social influence. Additionally, few network-based studies have described the structure of social networks of young men in sub-Saharan Africa. Understanding the structure of men's peer networks may motivate future research examining the ways in which network structures shape the spread of information, adoption of norms, and diffusion of behaviors. We contribute to filling these gaps by using social network analysis and multilevel modeling to describe a unique dataset of mostly young men (n = 1249 men and 242 women) nested within 59 urban social networks in Dar es Salaam, Tanzania. We examine the means, ranges, and clustering of men's HIV-related normative beliefs and behaviors. Networks in this urban setting varied substantially in both composition and structure and a large proportion of men engaged in risky behaviors including inconsistent condom use, sexual partner concurrency, and intimate partner violence perpetration. We found significant clustering of normative beliefs and risk behaviors within these men's social networks. Specifically, network membership explained between 5.78 and 7.17% of variance in men's normative beliefs and between 1.93 and 15.79% of variance in risk behaviors. Our results suggest that social networks are important socialization sites for young men and may influence the adoption of norms and behaviors. We conclude by calling for more research on men's social networks in Sub-Saharan Africa and map out several areas of future inquiry.