Material deprivation affects high sexual risk behavior among young people in urban slums, South Africa

Situational context of home-based sexual education in urban slums of Ibadan, Nigeria-evidence from a qualitative study

This study explores the influence of situational context on parent-adolescent communication about sexual and reproductive health (SRH) issues in the urban slums of Ibadan, Nigeria. A qualitative exploratory study was conducted in the Southeast and Northeast LGAs of Ibadan. Eight (8) vignette-based focus group discussions (FGDs) with parents and adolescents of both sexes were conducted in addition to four (4) key informant interviews (KIIs) with community and women's leaders. Interviews were tape-recorded, transcribed, and translated into English. Thematic analysis was adopted using ATLAS Ti 9 software. Findings portray SRH meanings and experiences, intergenerational cultural norms, and expectations for SRH, gender double standards in SRH discussion, streetwise SRH knowledge, and social media exposure as contexts that interfere with parent-adolescent communication on SRH issues. The findings show that despite understanding the need for SRH discussion, parents and adolescents lack effective communication on SRH issues due to the interference of unfiltered streetwise SRH knowledge and social media exposure. Also, SRH conversation between parents and adolescents promotes gender inequalities as different information is passed to adolescent girls and boys. Interventions that take into account situational occurrences must be geared towards enabling parents to give their adolescents early exposure to relevant, context-specific SRH knowledge.

Youth migration and access to health services in a trading centre in southern Uganda: A qualitative exploration

Impeded access to health services is a major factor influencing migrant health. In Uganda, previous research has shown lower utilisation of health services for young rural-urban migrants compared to their non-migrant counterparts. However, access to health services does not start at utilisation, but can be hampered by being able to identify a need for care. Using qualitative methods, we aimed to explore young rural-urban migrants' perceptions of health and patterns of engagement with health services. We analysed, using thematic analysis, a purposive sample of 18 in-depth interviews with 10 young people who had recently migrated within Uganda. Our results are presented through a framework conceptualising access at the intersection between abilities of people and characteristics of services. Participants perceived a need for care mostly through serious crises. Their ability to obtain care was hindered by a lack of resources, as well as the relative social isolation brought by migration. Our study highlights other barriers to accessing care such as the role of social norms and HIV-related stigma in health issues prioritisation, and healthcare workers' attitudes. This knowledge can inform approaches to ensure that community-based services are able to support healthcare access and improved health outcomes for this vulnerable group.

Sexual and reproductive health education and its association with ever use of contraception: a cross-sectional study among women in urban slums, Accra

Background

Sexual and reproductive health education among girls and women has several reproductive health benefits, including improved contraceptive knowledge, contraception use at first intercourse, increased chance of contraceptive use in a lifetime, and effective usage of contraceptives. It is however not clear whether women/girls in urban slums who have had sexual and reproductive health education would likely utilize contraception. This study sets out to test the hypothesis that Accra slum women who have had sex education have higher chances of ever using contraception.

Methods

A cross-sectional survey was conducted among reproductive aged women in two slums (i.e. Agbogbloshie and Old Fadama) in Accra, Ghana. A sample size of 691, made up of respondents who provided responses to the question on ever used contraception, sex education as well as those with complete information on all the other variables of interest was considered in this study. Binary logistic regression models were fitted to examine association between sexual and reproductive health education and ever use of contraception. Crude odds ratios (cOR) and adjusted odds ratios (aOR) at p-value less than 0.05 were used to assess the strength of the association between the outcome and independent variables.

Results

More than half (56.73%) of the women have never received sexual and reproductive health education. Most of the respondents (77.28%) had ever used contraceptives. Women who had no form of sexual and reproductive health education had lower odds of ever using contraception (OR = 0.641, 95% CI 0.443, 0.928) and this persisted after controlling for the effect of demographic factors (AOR = 0.652, 95% CI 0.436, 0.975] compared to those who have ever received any form of sex education. Non-married women as well as women who were exposed to media (newspapers/radio/television) were also more likely to use contraceptives in slums in Accra, Ghana.

Conclusion

The study revealed a relatively low prevalence of sex education among women in urban slums in Accra. However, sex education was found to increase the odds of ever use of contraception. These findings call for intensified sexual and reproductive health education among reproductive aged girls and women in urban slums in Accra using existing informal social networks and local media platforms.

Sexual and reproductive health education among girls and women has several reproductive health benefits, including improved contraceptive knowledge, contraception use at first intercourse, increased chance of contraceptive use in a lifetime, and effective usage of contraceptives. It is however not clear whether women/girls in urban slums who have had some form of sex education would likely utilize contraception more than those who have not. This study sets out to test the hypothesis that Accra slum women who have had sex education have higher chances of ever using contraception. A cross-sectional survey was conducted among reproductive aged women in two slums (i.e. Agbogbloshie and Old Fadama) in Accra, Ghana. A sample size of 691 girls/women aged 15–49 was considered. More than half (56.73%) of the women had never received some form of sex education. Most of the respondents (77.28%) had ever used contraceptives. Women who had no form of sex education had lower odds of ever using contraception and this persisted after controlling for the effect of demographic factors compared to those who have ever received any form of sex education. Non-married women as well as women who were exposed to media (newspapers/radio/television) were also more likely to use contraceptives in slums in Accra, Ghana. In sum, the study revealed that while prevalence of sex education was relatively low among urban slum women, sex education generally increased the chances of ever use of contraception. These findings call for more and targeted sexual and reproductive health education among reproductive aged girls and women in urban slums in Accra using existing informal social networks and local media platforms.

Associations between density and quality of health promotion programmes and built environment features across Jerusalem

BACKGROUND

Health promotion programmes (HPPs) have the potential to influence individual health, depending on their quality and characteristics. Little is known about how they interact with built environment features and neighbourhood demographics in cities with substantial health disparities.

METHODS

Using the European Quality Instrument for Health Promotion (EQUIHP), we assessed the quality of HPPs, operating between 2016 and 2017, among adults aged 18-75 in Jerusalem. Areas were characterized by ethnicity and area socioeconomic level. Health information (body mass index, physical activity level) was obtained from the city profile survey. Geospatial information on the location and length of walking paths and bicycle lanes was obtained. Spearman correlations were used to assess associations among variables.

RESULTS

Ninety-three HPPs operating in 349 locations in Jerusalem were identified. Programmes were unevenly distributed across urban planning areas (UPAs), with the highest density observed in the southwest, areas populated mainly by non-orthodox Jewish residents. However, the best performing HPPs based on EQUIHP score were in the north and east UPAs, inhabited primarily by Arab residents. At a neighbourhood level, characteristics of the built environment positively correlated with higher total EQUIHP scores: the ratio between walking lane length to the neighbourhood's population size (r = 0.413, P < 0.001) and length of bicycle lane per population (r = 0.309, P = 0.5). Median EQUIHP score negatively correlated with the number of programmes per neighbourhood size (m2) (r = -0.327, P = 0.006) and neighbourhood average socioeconomic status (SES; r = -0.266, P = 0.027).

CONCLUSIONS

Our findings suggest that higher quality HPPs were preferentially located in areas of lower SES and served minority populations in Jerusalem.

Resource demands reduce partner discrimination in Himba women

Where autonomy for partner choice is high, partner preferences may be shaped by both social and ecological conditions. In particular, women's access to resources can influence both the type and number of partnerships she engages in. However, most existing data linking resources and partner choice rely on either priming effects or large demographic databases, rather than preferences for specific individuals. Here we leverage a combination of demographic data, food insecurity scores and trait and partner preference ratings to determine whether resource security modulates partner preferences among Himba pastoralists. We find that while food insecurity alone has a weak effect on women's openness to new partners, the interaction of food insecurity and number of dependent children strongly predicts women's openness to potential partners. Further, we show that women who have more dependants have stronger preferences for wealthy and influential men. An alternative hypothesis derived from mating-market dynamics, that female desirability affects female preferences, had no effect. Our data show that women who face greater resource constraints are less discriminating in the number of partners they are open to, and have stronger preferences for resource-related traits. These findings highlight the importance of ecological signals in explaining the plasticity of mate preferences.

Intimate partner violence: A key correlate of women's physical and mental health in informal settlements in Nairobi, Kenya

Globally, one billion people live in informal settlements, and that number is expected to triple by 2050. Studies suggests that health in informal settlements is a serious and growing concern, yet there is a paucity of research focused on health outcomes and the correlates of health in these settlements. Studies cite individual, environmental and social correlates to health in informal settlements, but they often lack empirical evidence. In particular, research suggests that high rates of violence against women (VAW) in informal settlements may be associated with detrimental effects on women's health, but few studies have investigated this link. The purpose of this study was to fill this gap by empirically exploring associations between women's experiences of intimate partner violence (IPV) and their physical and mental health. Data for this study were collected in August 2018 in Mathare Valley Informal Settlement in Nairobi, Kenya. A total of 550 randomly-selected women participated in surveys; however, analyses for this study were run on a subpopulation of the women (n = 361). Multivariate logistic regressions were used to investigate the link between psychological, sexual, and emotional IPV and women's mental and physical health. Results suggest that while some socioeconomic, demographic, and environmental variables were significantly associated with women's mental and physical health outcomes, all types of IPV emerged key correlates in this context. In particular, women's experiences of IPV were associated with lower odds of normal-high physical health component scores (based on SF-36); higher odds of gynecological and reproductive health issues, psychological distress (based on K-10), depression, suicidality, and substance use. Findings from this study suggest that policies and interventions focused on prevention and response to VAW in informal settlements may make critical contributions to improving health for women in these rapidly growing settlements.

"Left behind": why implementing migration-aware responses to HIV for migrant farm workers is a priority for South Africa

Like many other countries, South Africa (SA) has committed to the Sustainable Development Goals that aim to "leave no-one behind", in efforts towards universal health coverage, and meeting the UNAIDS 90-90-90 targets through the implementation of universal test and treat (UTT) interventions. SA is associated with high levels of international and internal migration that, in certain contexts, are known to (1) increase the risk of acquiring HIV and (2) present challenges to HIV treatment access and continuity. Despite this, migration and mobility are not adequately considered in responses to HIV. As SA rolls out UTT programmes and antiretroviral treatment as prevention (TasP) interventions, including pre-exposure prophylaxis (PreP), there is an urgent need to ensure that these are migration-aware and mobility-competent. In SA, a key population that experiences a disproportionate HIV burden is international migrant farm workers living and working on commercial farms along the border with Zimbabwe. In this article, a social determinants of health approach is applied to explore the context within which this population struggles to access positive determinants of health, including the public health care system, and the implications of this for HIV programming. It is argued that, unless policies and programming become migration-aware and mobility-competent, UTT and TasP interventions will struggle to address the high burden of HIV among this population and, as a result, progress towards global health targets will be limited.

Neighbourhood-level deprivation indices and postpartum women's health: results from the Community Child Health Network (CCHN) multi-site study

Background

Area-level socioeconomic characteristics have been shown to be related to health status and mortality however, little is known about the association between residential community characteristics in relation to postpartum women’s health.

Methods

Data from the longitudinal, multi-site Community Child Health Network (CCHN) study were used. Postpartum women (n = 2510), aged 18–40 were recruited from 2008 to 2012 within a month of delivery. Socioeconomic data was used to create deprivation indices. Census data were analysed using principal components analysis (PCA) and logistic regression to assess the association between deprivation indices (DIs) and various health indicators.

Results

PCA resulted in two unique DIs that accounted for 67.5% of the total variance of the combined all-site area deprivation. The first DI was comprised of variables representing a high percentage of Hispanic or Latina, foreign-born individuals, dense households (more than one person per room of residence), with less than a high-school education, and who spent more than 30% of their income on housing costs. The second DI was comprised of a high percentage of African-Americans, single mothers, and high levels of unemployment. In a multivariate logistic regression model, using the quartiles of each DI, women who reside in the geographic area of Q4-Q2 of the second DI, were almost twice as likely to have more than three adverse health conditions compared to those who resided in the least deprived areas. (Q2vs.Q1:OR = 2.09,P = 0.001,Q3vs.Q1:OR = 1.89,P = 0.006,Q4vs.Q1:OR = 1.95,P = 0.004 respectively).

Conclusions

Our results support the utility of examining deprivation indices as predictors of maternal postpartum health.

The changing modes of human immunodeficiency virus transmission and spatial variations among women in a minority prefecture in southwest China: An exploratory study

Liangshan Yi Autonomous Prefecture in Southwest China has a high human immunodeficiency virus (HIV) prevalence rate. This study examined the changing modes of HIV transmission among women with new HIV infections and explored the spatial heterogeneities in the factors associated with heterosexual transmission in this minority region.The data consisting of women with new HIV infections from 2011 to 2014 were collected from multiple sources. New infections were identified by BED capture enzyme immunoassay. The Bayesian hierarchical model was used to estimate the proportion of women with new HIV infections via heterosexual transmission across all townships in the Prefecture. A geographically weighted regression (GWR) model was utilized to investigate spatial variations in the sociodemographic characteristics associated with the changing modes of HIV transmission.An analytical sample of 927 women with new HIV infections was constructed and utilized to investigate the changing mode of HIV transmission. The rate of heterosexual transmission among women with new HIV infections in 2011 was below 20%. However, by 2014 this rate dramatically increased to nearly 80%. Among sociodemographic characteristics, GWR results revealed significant ethnic differences in heterosexual HIV transmission between Yi women and women in other ethnic groups, with Yi women demonstrating a lower risk of infection through heterosexual transmission. However, such ethnic differences were observed only in 30% of the townships in the Prefecture. Moreover, having a primary education decreased the odds of heterosexual transmission, which was observed in about 56% of the townships. Also, being involved in occupations other than agriculture or animal husbandry and being single or married decreased the odds of HIV infection through heterosexual contact among women, which did not significantly vary across the Prefecture.Heterosexual transmission was the predominant mode of HIV transmission among women in the Prefecture, and this transformation was clearly marked by a fast-growing trend and a spatial diffusion pattern. Spatial variations also existed in sociodemographic factors that were associated with the changing modes of HIV transmission.

Persistence of traditional and emergence of new structural drivers and factors for the HIV epidemic in rural Uganda; A qualitative study

BACKGROUND

In Uganda, the HIV epidemic is now mature and generalized. Recently, there have been reports of resurgence in the incidence of HIV after several years of successful control. The causes for this resurgence are not clear but suspected to be driven by structural factors that influence large groups of people rather than individuals. The aim of this study was to describe the structural drivers of the HIV epidemic in high prevalence regions and inform the next generation of interventions.

METHODOLOGY

We conducted a total of 35 focus group discussions in 11 districts in Uganda. Due to their high HIV prevalence, the districts had been selected to implement a donor supported program to scale up HIV prevention, care and treatment. Focus groups consisted of men and women including opinion leaders, civil servants including teachers, police officers, religious, political leaders, shop keepers, local residents and other ordinary persons from all walks of life. The qualitative data were transcribed and analyzed manually. Texts were coded using a coding scheme which was prepared ahead of time but emerging themes and codes were also allowed.

RESULTS

Our data indicated there is persistence of several structural drivers and factors for HIV in rural Uganda. The structural drivers of HIV were divided into three categories: Gender issues, socio-cultural, and economic drivers. The specific drivers included several gender issues, stigma surrounding illness, traditional medical practices, urbanization, alcohol and substance abuse and poverty. New drivers arising from urbanization, easy access to mobile phone, internet and technological advancement have emerged. These drivers are intertwined within an existing culture, lifestyle and the mixture is influenced by modernization.

CONCLUSION

The traditional structural drivers of HIV have persisted since the emergence of the HIV epidemic in Uganda and new ones have emerged. All these drivers may require combined structural interventions that are culturally and locally adapted in order to tackle the resurgence in incidence of HIV in Uganda.

Perspectives of adolescent and young adults on poverty-related stressors: a qualitative study in Ghana, Malawi and Tanzania

OBJECTIVES

To define key stressors experienced and coping behaviours within poor agrarian communities in sub-Saharan Africa.

DESIGN

Descriptive qualitative study incorporating inductive thematic analysis.

PARTICIPANTS

81 participants purposely sampled, stratified by age (adolescents and young adults) and sex SETTING: The study was conducted in villages in Ghana, Malawi, and Tanzania.

RESULTS

Stressors were thematically grouped into those directly related to poverty and the lack of basic necessities (eg, food insecurity), and additional stressors (eg, drought) that worsen poverty-related stress. Impacts on functioning, health and well-being and key coping behaviours, both positive and negative, were identified. The findings together inform a more nuanced view of stress within these contexts.

CONCLUSION

Although participants were asked to provide general reflections about stress in their community, the salience of poverty-related stressors was ubiquitously reflected in respondents' responses. Poverty-related stressors affect development, well-being and gender-based violence. Future research should focus on interventions to alleviate poverty-related stress to achieve the United Nations Sustainable Development Goals.

A Systematised Review of the Health Impact of Urban Informal Settlements and Implications for Upgrading Interventions in South Africa, a Rapidly Urbanising Middle-Income Country

Informal settlements are becoming more entrenched within African cities as the urban population continues to grow. Characterised by poor housing conditions and inadequate services, informal settlements are associated with an increased risk of disease and ill-health. However, little is known about how informal settlement upgrading impacts health over time. A systematised literature review was conducted to explore existing evidence and knowledge gaps on the association between informal settlement characteristics and health and the impact of informal settlement upgrading on health, within South Africa, an upper-middle income African country. Using two databases, Web of Science and PubMed, we identified 46 relevant peer-reviewed articles published since 1998. Findings highlight a growing body of research investigating the ways in which complete physical, mental and social health are influenced by the physical housing structure, the psychosocial home environment and the features of the neighbourhood and community in the context of informal settlements. However, there is a paucity of longitudinal research investigating the temporal impact of informal settlement upgrading or housing improvements on health outcomes of these urban residents. Informal settlements pose health risks particularly to vulnerable populations such as children, the elderly, and people with suppressed immune systems, and are likely to aggravate gender-related inequalities. Due to the complex interaction between health and factors of the built environment, there is a need for further research utilising a systems approach to generate evidence that investigates the interlinked factors that longitudinally influence health in the context of informal settlement upgrading in rapidly growing cities worldwide.

The Socioeconomic and Sexual Health Status of Young People Living in Urban Slum Areas of Kampala, Uganda

Slum dweller youth in Kampala, Uganda, face social economic exclusion and a plethora of health risks, and their needs are poorly understood. The aim of the current study was to analyze their needs and to suggest contextual evidence-based solutions to improve their well-being sustainably. We conducted a qualitative study involving 10 focus group discussions (FGDs; N = 113) and 20 key informant (KII) interviews. Emerging themes and sub-themes were identified, defined, reviewed, and organized and narrated following the structuration theoretical framework, which enabled the examination of the inherent capacity of slum dweller youth to make choices independently and the recurrent rules and resources that influence or limit the choices and opportunities available to them. The findings suggest that the slum dweller youth's ability to reach and fulfil their potential remains constrained by a confluence of individual and societal-level factors. The individual factors were poor quality of and dissatisfaction with life, and poor sexual and reproductive health practices. The societal-level factors were poor sexual and reproductive health services, and an extremely weak labor market. The needs of slum dweller youth in Kampala, Uganda, remain unaddressed, and leaving such a large population economically unproductive and dissatisfied with life is a recipe for political instability and insecurity. Interventions to address their needs need to adopt a whole-community approach in order to engage and empower all parts of the slum community and strengthen community structures that improve livelihoods and harness the opportunities that engender income fortification and socio-civic transformation for the youth.

Effects of Migration on Risky Sexual Behavior and HIV Acquisition in South Africa: A Systematic Review and Meta-analysis, 2000-2017

While human mobility has been implicated in fueling the HIV epidemic in South Africa, the link between migration and HIV has not been systematically reviewed and quantified. We conducted a systematic review of the role of migration in HIV risk acquisition and sexual behaviour based on 29 studies published between 2000 and 2017. Furthermore, we performed a meta-analysis of the association between migration and HIV risk acquisition in four of the studies that used HIV incidence as an outcome measure. The systematic review results show that HIV acquisition and risky sexual behavior were more prevalent among both male and female migrants compared to their non-migrant counterparts. The meta-analysis results demonstrate that migration was significantly associated with increased HIV acquisition risk (aOR = 1.69, 95% CI 1.33-2.14; I² = 35.0%). There is an urgent need for effective combination HIV prevention strategies (comprising biomedical, behavioral and structural interventions) that target migrant populations.

Challenges of quality improvement in the healthcare of South Africa post-apartheid: A critical review

Background

There is overwhelming evidence that the quality of health care in South Africa has been compromised by various challenges that impact negatively on healthcare quality. Improvement in quality care means fewer errors, reduced delays in care delivery, improvement in efficiency, increased market share and lower cost. Decline in quality health care has caused the public to lose trust in the healthcare system in South Africa.

Objectives

The purpose of this study was to identify challenges that are being incurred in practice that compromise quality in the healthcare sector, including strategies employed by government to improve the quality of health delivery.

Method

Literature search included the following computer-assisted databases and bibliographies: Medline (Medical Literature Online), EBSCOhost, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Google, Google Scholar and ScienceDirect. Furthermore, websites were used to source policy documents of organisations such as the National Department of Health in South Africa and the World Health Organization.

Results

Seventy-four articles were selected from 1366 retrieved. These articles quantify problems facing quality care delivery and strategies used to improve the healthcare system in South Africa.

Conclusion

The findings revealed that there were many quality improvement programmes that had been initiated, adapted, modified and then tested but did not produce the required level of quality service delivery as desired. As a result, the Government of South Africa has a challenge to ensure that implementation of National Core Standards will deliver the desired health outcomes, because achieving a lasting quality improvement system in health care seems to be an arduous challenge.

The Association of Material Hardship with Medication Adherence and Perceived Stress Among People Living with HIV in Rural Zambia

The intersection of poverty and HIV/AIDS has exacerbated socioeconomic inequalities in Zambia. For example, the downstream consequences of HIV/AIDS are likely to be severe among the poor. Current research has relied on multidimensional indicators of poverty, which encompass various forms of deprivation, including material. Although comprehensive measures help us understand what constitutes poverty and deprivation, their complexity and scope may hinder the development of appropriate and feasible interventions. These limitations prompted us to examine whether material hardship, a more practicable, modifiable aspect of poverty, is associated with medication adherence and perceived stress among people living with HIV (PLHIV) in Zambia. We used cross-sectional data from 101 PLHIV in Lundazi District, Eastern Province. Data were collected using a questionnaire and hospital records. Material hardship was measured using a five-item scale. Perceived stress was measured using the ten-item perceived stress scale. Adherence was a binary variable measured using a visual analog scale and medication possession ratio (MPR) obtained from pharmacy data. We analyzed the data with multivariable linear and logistic regressions using multiply imputed datasets. Results indicated that greater material hardship was significantly associated with MPR nonadherence (odds ratio = 0.83) and higher levels of perceived mental distress (β = 0.34). Our findings provide one of the first evidence on the association of material hardship with treatment and mental health outcomes among PLHIV. The findings also draw attention to the importance of economic opportunities for PLHIV and their implications for reducing material hardship and improving adherence and mental health status.

Structural Effects on HIV Risk Among Youth: A Multi-level Analysis

We proposed a multilevel model of structural influences on HIV-risky sexual partnerships in a diverse sample of 1793 youth residing in 23 states and the District of Columbia. We examined the influence of concentrated disadvantage, HIV stigma, and sexual and gender minority stigma on engagement in HIV risky sexual partnerships and whether youth's participation in opportunity structures, anticipation of HIV stigma, and perceptions of their community as youth-supportive settings mediated structural effects. After controlling for age, HIV status, and race, we found structural HIV stigma had deleterious indirect effects on youth's participation in HIV-risky sexual partnerships. Concentrated disadvantage and structural sexual and gender minority stigma had direct negative effects on youth's perceptions of their communities as supportive and on their participation in prosocial activity. Support perceptions had direct, protective effects on avoidance of HIV-risky sexual partnerships. Structural stigma undermines youth's belief that their communities invest in their safety and well-being.

South African Adolescents' Neighborhood Perceptions Predict Longitudinal Change in Youth and Family Functioning

This study examined South African early adolescent youth (aged 10 to 14) and their female caregivers (N = 99 dyads) participating in an HIV prevention intervention over a period of eight months. We examined youth perceptions of neighborhood cohesion, safety, and collective monitoring as they related to concurrent and longitudinal associations with youth (externalizing behavior and hope about the future) and family (parent-youth relationship quality, parental involvement, and parental responsiveness to sex communication) functioning while controlling for baseline characteristics. Neighborhood perceptions were significantly associated (p < .05) with short- and longer-term outcomes. Gender differences suggested a greater protective association of perceived neighborhood conditions with changes in functioning for boys versus girls. Unexpected associations were also observed, including short-term associations suggesting a link between better neighborhood quality and poorer family functioning. We account for the culture of this South African community when contextualizing our findings and conclude with recommendations for interventions targeting neighborhood contexts.

Economic Context and HIV Vulnerability in Adolescents and Young Adults Living in Urban Slums in Kenya: A Qualitative Analysis Based on Scarcity Theory

Urban slum adolescents and young adults have disproportionately high rates of HIV compared to rural and non-slum urban youth. Yet, few studies have examined youth's perceptions of the economic drivers of HIV. Informed by traditional and behavioral economics, we applied a scarcity theoretical framework to qualitatively examine how poverty influences sexual risk behaviors among adolescents and young adults. Focus group discussions with one hundred twenty youth in Kenyan's urban slums were transcribed, coded, and analyzed using interpretive phenomenology. Results indicated that slum youth made many sexual decisions considered rational from a traditional economics perspective, such as acquiring more sex when resources were available, maximizing wealth through sex, being price-sensitive to costs of condoms or testing services, and taking more risks when protected from adverse sexual consequences. Youth's engagement in sexual risk behaviors was also motivated by scarcity phenomena explained by behavioral economics, such as compensating for sex lost during scarce periods (risk-seeking), valuing economic gains over HIV risks (tunneling, bandwidth tax), and transacting sex as an investment strategy (internal referencing). When scarcity was alleviated, young women additionally described reducing the number of sex partners to account for non-economic preferences (slack). Prevention strategies should address the traditional and behavioral economics of the HIV epidemic.

The Stepping Stones and Creating Futures intervention to prevent intimate partner violence and HIV-risk behaviours in Durban, South Africa: study protocol for a cluster randomized control trial, and baseline characteristics

BACKGROUND

Preventing intimate partner violence (IPV) remains a global public health challenge. Studies suggest urban informal settlements have particularly high levels of IPV and HIV-prevalence and these settlements are rapidly growing. The current evidence base of effective approaches to preventing IPV recognizes the potential of combining economic strengthening and gender transformative interventions. However, few of these interventions have been done in urban informal settlements, and almost none have included men as direct recipients of these interventions.

METHODS

Stepping Stones and Creating Futures intervention is a participatory gender transformative and livelihoods strengthening intervention. It is being evaluated through a cluster randomized control trial amongst young women and men (18-30) living in urban informal settlements in eThekwini Municipality, South Africa. The evaluation includes a qualitative process evaluation and cost-effectiveness analysis. A comparison of baseline characteristics of participants is also included.

DISCUSSION

This is one of the first large trials to prevent IPV and HIV-vulnerability amongst young women and men in urban informal settlements. Given the mixed methods evaluation, the results of this trial have the ability to develop a stronger understanding of what works to prevent violence against women and the processes of change in interventions.

TRIAL REGISTRATION

NCT03022370 . Registered 13 January 2017, retrospectively registered.

Economic Resources and HIV Preventive Behaviors Among School-Enrolled Young Women in Rural South Africa (HPTN 068)

Individual economic resources may have greater influence on school-enrolled young women's sexual decision-making than household wealth measures. However, few studies have investigated the effects of personal income, employment, and other financial assets on young women's sexual behaviors. Using baseline data from the HIV Prevention Trials Network (HPTN) 068 study, we examined the association of ever having sex and adopting sexually-protective practices with individual-level economic resources among school-enrolled women, aged 13-20 years (n = 2533). Age-adjusted results showed that among all women employment was associated with ever having sex (OR 1.56, 95 % CI 1.28-1.90). Among sexually-experienced women, paid work was associated with changes in partner selection practices (OR 2.38, 95 % CI 1.58-3.58) and periodic sexual abstinence to avoid HIV (OR 1.71, 95 % CI 1.07-2.75). Having money to spend on oneself was associated with reducing the number of sexual partners (OR 1.94, 95 % CI 1.08-3.46), discussing HIV testing (OR 2.15, 95 % CI 1.13-4.06), and discussing condom use (OR 1.99, 95 % CI 1.04-3.80). Having a bank account was associated with condom use (OR 1.49, 95 % CI 1.01-2.19). Economic hardship was positively associated with ever having sex, but not with sexually-protective behaviors. Maximizing women's individual economic resources may complement future prevention initiatives.

Tackling gender inequalities and intimate partner violence in the response to HIV: moving towards effective interventions in Southern and Eastern Africa

Ending intimate partner violence (IPV) and reducing gender inequalities are recognised as critical to "'ending AIDS" by 2030. Amongst women, experiencing IPV has been shown to increase HIV acquisition, reduce women's ability to use HIV prevention strategies and reduce adherence to antiretroviral therapy (ART). In Southern and Eastern Africa there has recently been a significant push to strengthen programming around this through broad funding and programming streams. However, while gender inequality underpins IPV and HIV acquisition, in different contexts a variety of other factors intersect to shape this vulnerability. Using reflections focused on young women living in urban informal settlements and the Stepping Stones and Creating Futures intervention, this paper illustrates the need to understand the specific drivers of HIV and IPV in any given context and the need for interventions to prevent this. Any intervention needs to include three key components: 1) resonate with the lived realities of women they target; 2) tackle multiple factors shaping women's vulnerability to IPV and HIV simultaneously; and 3) consider how best to work with men and boys to achieve improved outcomes for women. Such an approach, it is argued, resonating with the "slow research" movement, will yield better outcomes for interventions, but will also require a fundamental rethinking of how interventions to prevent IPV and HIV amongst women are conceptualised, with a greater emphasis on understanding the ways in which gender resonates in each context and how interventions can operate.

Effects of PREPARE, a Multi-component, School-Based HIV and Intimate Partner Violence (IPV) Prevention Programme on Adolescent Sexual Risk Behaviour and IPV: Cluster Randomised Controlled Trial

Young South Africans, especially women, are at high risk of HIV. We evaluated the effects of PREPARE, a multi-component, school-based HIV prevention intervention to delay sexual debut, increase condom use and decrease intimate partner violence (IPV) among young adolescents. We conducted a cluster RCT among Grade eights in 42 high schools. The intervention comprised education sessions, a school health service and a school sexual violence prevention programme. Participants completed questionnaires at baseline, 6 and 12 months. Regression was undertaken to provide ORs or coefficients adjusted for clustering. Of 6244 sampled adolescents, 55.3 % participated. At 12 months there were no differences between intervention and control arms in sexual risk behaviours. Participants in the intervention arm were less likely to report IPV victimisation (35.1 vs. 40.9 %; OR 0.77, 95 % CI 0.61–0.99; t(40) = 2.14) suggesting the intervention shaped intimate partnerships into safer ones, potentially lowering the risk for HIV.

Previous induced abortion among young women seeking abortion-related care in Kenya: a cross-sectional analysis

Background

Unsafe abortion is a leading cause of death among young women aged 10–24 years in sub-Saharan Africa. Although having multiple induced abortions may exacerbate the risk for poor health outcomes, there has been minimal research on young women in this region who have multiple induced abortions. The objective of this study was therefore to assess the prevalence and correlates of reporting a previous induced abortion among young females aged 12–24 years seeking abortion-related care in Kenya.

Methods

We used data on 1,378 young women aged 12–24 years who presented for abortion-related care in 246 health facilities in a nationwide survey conducted in 2012. Socio-demographic characteristics, reproductive and clinical histories, and physical examination assessment data were collected from women during a one-month data collection period using an abortion case capture form.

Results

Nine percent (n = 98) of young women reported a previous induced abortion prior to the index pregnancy for which they were receiving care. Statistically significant differences by previous history of induced abortion were observed for area of residence, religion and occupation at bivariate level. Urban dwellers and unemployed/other young women were more likely to report a previous induced abortion. A greater proportion of young women reporting a previous induced abortion stated that they were using a contraceptive method at the time of the index pregnancy (47 %) compared with those reporting no previous induced abortion (23 %). Not surprisingly, a greater proportion of young women reporting a previous induced abortion (82 %) reported their index pregnancy as unintended (not wanted at all or mistimed) compared with women reporting no previous induced abortion (64 %).

Conclusions

Our study results show that about one in every ten young women seeking abortion-related care in Kenya reports a previous induced abortion. Comprehensive post-abortion care services targeting young women are needed. In particular, post-abortion care service providers must ensure that young clients receive contraceptive counseling and effective pregnancy prevention methods before discharge from the health care facility to prevent unintended pregnancies that may result in subsequent induced abortions.

Material deprivation and unemployment affect coercive sex among young people in the urban slums of Blantyre, Malawi: A multi-level approach

We explore relations among material deprivation (measured by insufficient housing, food insecurity and poor healthcare access), socio-economic status (employment, income and education) and coercive sex. A binary logistic multi-level model is used in the estimation of data from a survey of 1071 young people aged 18–23 years, undertaken between June and July 2013, in the urban slums of Blantyre, Malawi. For young men, unemployment was associated with coercive sex (odds ratio [OR]=1.77, 95% confidence interval [CI]: 1.09–3.21) while material deprivation (OR=1.34, 95% CI: 0.75–2.39) was not. Young women in materially deprived households were more likely to report coercive sex (OR=1.37, 95% CI: 1.07–2.22) than in non-materially deprived households. Analysis of local indicators of deprivation is critical to inform the development of effective strategies to reduce coercive sex in urban slums in Malawi.

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Local measures were used for an analysis of association between deprivation and coercive sex.

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Unemployment was associated with coercive sex among young men.

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Material deprivation was associated with coercive sex among young women.

The role of material deprivation and consumerism in the decisions to engage in transactional sex among young people in the urban slums of Blantyre, Malawi

Transactional sex has been associated with a high risk of HIV acquisition and unintended pregnancy among young women in urban slums in sub-Saharan Africa. However, few studies have explored the structural drivers of transactional sex from the perspective of both genders in these settings. This paper explores how young men and women understand the factors that lead to transactional sex among their peers, and how deprivation of material resources (housing, food and health care access) and consumerism (a desire for fashionable goods) may instigate transactional sex in the urban slums of Blantyre, Malawi. Data from 5 focus group discussions and 12 in-depth interviews undertaken with a total of 60 young men and women aged 18-23 years old, conducted between December 2012 and May 2013, were analysed using anticipated and grounded codes. Housing and food deprivation influenced decisions to engage in transactional sex for both young men and women. Poor health care access and a desire for fashionable goods (such as the latest hair or clothing styles and cellular phones) influenced the decisions of young women that led to transactional sex. Interventions that engage with deprivations and consumerism are essential to reducing sexual and reproductive health risks in urban slums.

Stepping Stones and Creating Futures intervention: shortened interrupted time series evaluation of a behavioural and structural health promotion and violence prevention intervention for young people in informal settlements in Durban, South Africa

Background

Gender-based violence and HIV are highly prevalent in the harsh environment of informal settlements and reducing violence here is very challenging. The group intervention Stepping Stones has been shown to reduce men’s perpetration of violence in more rural areas, but violence experienced by women in the study was not affected. Economic empowerment interventions with gender training can protect older women from violence, but microloan interventions have proved challenging with young women. We investigated whether combining a broad economic empowerment intervention and Stepping Stones could impact on violence among young men and women. The intervention, Creating Futures, was developed as a new generation of economic empowerment intervention, which enabled livelihood strengthening though helping participants find work or set up a business, and did not give cash or make loans.

Methods

We piloted Stepping Stones with Creating Futures in two informal settlements of Durban with 232 out of school youth, mostly aged 18–30 and evaluated with a shortened interrupted time series of two baseline surveys and at 28 and 58 weeks post-baseline. 94/110 men and 111/122 women completed the last assessment, 85.5% and 90.2% respectively of those enrolled. To determine trend, we built random effects regression models with each individual as the cluster for each variable, and measured the slope of the line across the time points.

Results

Men’s mean earnings in the past month increased by 247% from R411 (~$40) to R1015 (~$102, and women’s by 278% R 174 (~$17) to R 484 (about $48) (trend test, p < 0.0001). There was a significant reduction in women’s experience of the combined measure of physical and/or sexual IPV in the prior three months from 30.3% to 18.9% (p = 0.037). This was not seen for men. However both men and women scored significantly better on gender attitudes and men significantly reduced their controlling practices in their relationship. The prevalence of moderate or severe depression symptomatology among men and suicidal thoughts decreased significantly (p < 0.0001 and p = 0.01).

Conclusions

These findings are very positive for an exploratory study and indicate that the Creating Futures/Stepping Stones intervention has potential for impact in these difficult areas with young men and women. Further evaluation is needed.