Community group participation:

Effect of HIV/AIDS on labour productivity and the moderating role of literacy rate: A panel study of Africa and its sub-regions

This study examined the effect of human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) on labour productivity in Africa and its sub-regions while controlling for the moderating effect of literacy rate. The study used the system Generalised Method of Moment estimation technique and annual panel data from 2010 to 2020 for 53 African economies. Labour productivity and literacy rate were measured by the ratio of gross domestic product to total employment and gross secondary school enrolment respectively. The results indicate that HIV/AIDS retards labour productivity, and that literacy rate can ease this depressing effect of HIV/AIDS in Africa. The sub-regional differences in Africa obtained in this study revealed that the depressing effect of HIV/AIDS on labour productivity is highest in Southern Africa and lowest in Northern and Central Africa. Interestingly, the study also established that per capita health expenditure, per capita income, gross capital formation, and information and communications technology are important drivers of labour productivity in Africa. The study, therefore, concludes that there is need for governments and other stakeholders to help to increase school enrolment and improve the quality of the content of education curriculum in Africa to increase the awareness of HIV/AIDS, especially as it relates to its channels of transmission like unprofessional blood transfusion, unprotected sexual activity, and genital mutilation, among others.

Different Responses to Social Capital Among Black People and White People: What Racial Differential Item Functioning Reveals for Racial Health Equity

Social capital has been conceptualized as features of social organization, such as networks, and norms that facilitate coordination and cooperation for mutual benefit. Because of long-standing anti-Black structural oppression in the United States, social capital may be associated with health differently for Black people than for other racial/ethnic groups. Our aim was to examine the psychometric properties of social capital indicators, comparing responses from Black and White people to identify whether there is differential item functioning (DIF) in social capital according to race. DIF examines how items are related to a latent construct and whether this relationship differs across groups such as different racial groups. We used data from respondents to the Southeastern Pennsylvania Household Health Survey in 2004, who lived in Philadelphia (n = 2,048), a city with a large Black population. We used item response theory analysis to test for racial DIF. We found DIF across the items, indicating measurement error, which could be related to the way these items were developed (i.e., based on cultural assumptions tested in mainstream White America). Hence, our findings underscore the need to interrogate the assumptions that underly existing social capital items through an equity-based lens, and to take corrective action when developing new items to ensure that they are racially and culturally congruent.

Mapping social capital across Wales (UK) using secondary data and spatial analysis

Social capital, a powerful community resource based on trust, relationships, norms, culture, values, networks and belonging, could shape the acceptance, cooperation, and involvement of citizens towards new policies or interventions. In past, connections of social capital have been studied in relation to human health, wellbeing, social and economic development. More recently, social capital has been studied with respect to human resilience and adaptation to climate change. We argue that social capital could also play a vital role in our efforts to reduce carbon footprint through behaviour change, a shift on shared local renewable energy resources, and adoption of low carbon technologies. In Wales (UK) there is no national scale dataset, reflecting its social capital landscape, that could be used for designing the right policies/interventions in this context, based on an expected level of trust, cooperation, and support within the communities. This paper is an effort to fill this data gap using secondary datasets. Firstly, a literature review is carried out to identify the indicators of social capital (cognitive and participatory). Secondary datasets have then been identified and acquired. Geospatial analysis has been carried out to produce the criterion maps for various indicators of social capital. Finally, Analytical Hierarchy Process is applied to generate a social capital map of Wales combining these indicators together. For validation of the produced data, social capital's known correlations were tested with crime rates, income level and multiple deprivations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43545-023-00639-1.

Exploring the Influence of Social Capital on HIV Prevention with Migrants from the Democratic Republic of Congo (DRC) Living in Durban, South Africa

Background: Research shows a growing attentiveness to the role of social and environmental influences on HIV risk behaviours. Moreover, the understanding of HIV risk behaviours has moved from an earlier consideration of individual risk, to ecological models, with the understanding that behaviours are rooted in the economic, environmental and social structure. Aim: To explore how social capital, specifically on a social bonding level, operates as a risk or protective factor for the spread of HIV among French-speaking migrants from the Democratic Republic of Congo (DRC), living in Durban, South Africa. Methods: A qualitative approach using a case study design was used to conduct the study. Data were collected through focus group discussions and individual in-depth interviews from a purposive sample of French-speaking migrants from DRC, living in Durban, South Africa. Ethical approval to conduct the study was obtained from the University of KwaZulu-Natal's Human and Social Science Research Ethics' Committee. Data were analysed thematically using Creswell's steps of data analysis. Results: This study found that social capital can act as both a protective factor in certain circumstances, and a risk factor in others. Trust, norms, reciprocity and social networks are complex elements in the refugee community and are influenced by a myriad of factors including the past and present stressors that are prevalent within this community. Conclusions: The findings confirm the complexity of issues related to HIV prevention which necessitate policy and practice interventions to mitigate consequences that may result from the higher risks of HIV transmission in this community.

Health Mothers' Groups in Nepal: Barriers, Facilitators, and Recommendations

Background

Nepal's female community health volunteers (FCHVs) each lead a monthly health mothers' group (HMG) to share health-related information and engage communities in the health system. Suaahara II (SII), a US Agency for International Development-funded multisectoral nutrition program, uses social and behavior change interventions to promote HMG participation and uses its health systems interventions to strengthen HMG quality.

Objectives

This study aimed to explore HMG functionality and variation across Nepal, including barriers and facilitators to attending HMG meetings.

Methods

SII's cross-sectional annual survey data from 16 districts (n = 192 FCHVs and 1850 mothers with children <2 y) were used. Descriptive and logistic regression analyses were conducted where the outcome variable was whether mothers were active HMG members or not, with FCHV and maternal characteristics as explanatory variables. Qualitative data were obtained from 3 of 16 survey districts (n = 30 observations, n = 30 in-depth interviews with mothers, and n = 16 focus group discussions with mothers, family members, FCHVs, health workers, and SII staff).

Results

Among FCHVs, 90% reported facilitating HMG meetings, whereas 64% of mothers reported HMG availability, and only 25% reported participating actively in meetings. Household head sex, maternal age, maternal education, maternal self-efficacy, and engagement with an FCHV and SII were associated with whether mothers were active participants in HMG meetings. Qualitative findings highlighted systems-level barriers, including lack of FCHV skills, demotivation, and heavy workload. Mothers noted time as the major constraint and family support, the HMG's savings component, and active FCHVs as facilitators to participation.

Conclusions

Findings suggest that both supply- and demand-side solutions are needed to improve HMG performance and uptake in Nepal. These solutions need to include improving FCHV skills and motivating them to provide high-quality HMG services, as well as encouraging family members to support women so that they have time to participate in the HMGs.

A Solution for Loneliness in Rural Populations: The Effects of Osekkai Conferences during the COVID-19 Pandemic

Social prescribing is an essential solution to the lack of social connection and interaction and provides a key approach to problems faced by communities during the COVID-19 pandemic. One social prescription used in Japan is the Osekkai conference, which has the potential to increase social participation in rural communities. The revitalization of Osekkai can improve social interactions among people involved in the conference, thereby reducing loneliness. This interventional study was conducted with people who participated in the Osekkai conference. The primary outcomes of the degree of loneliness were compared between 2021 and 2022 using the Japanese version of the three-item UCLA Loneliness Scale. The demographic data and process outcomes of participants were measured using a questionnaire. The participants’ roles in the Osekkai conference increased between the two periods. Loneliness scores tended to decrease during the study period (4.25 to 4.05, p = 0.099). In the questionnaire on loneliness, the scores for item 2 decreased significantly during the study period (1.36 to 1.25, p = 0.038). In conclusion, this study shows that the continual provision of Osekkai conferences as a social prescription may reduce the degree of loneliness among participants with improved social participation in rural communities. Future studies should investigate comparative interventions to show the effectiveness of social prescription on loneliness in communities.

Rural Social Participation through Osekkai during the COVID-19 Pandemic

We investigated the effects of enabling Osekkai, the traditional Japanese behavior of creating a helping culture, on social participation among rural people in rebuilding social connections that can be vital during the coronavirus diseases 2019 (COVID-19) pandemic. The subjects of this cross-sectional study were people interested in the Osekkai conference (control group) and those actively involved in Osekkai activities (exposure group). The primary outcome of social participation was measured as the frequency of meeting and the number of friends or acquaintances. The demographic data of the participants and process outcomes were measured using a questionnaire provided to all 287 registered participants. The effective response rate was 64.5% (185 responses). The involvement in Osekkai conferences was statistically associated with a high frequency and number of meetings with friends or acquaintances (p < 0.001 and 0.048, respectively). A health check was significantly associated with the number of friends or acquaintances met in the previous month, while high social support was significantly associated with loneliness. Thus, we confirm that Osekkai contributes to high social participation, although we see no relationship with loneliness. Future studies should investigate this cause-and-effect relationship and promote culturally sensitive activities to improve social and health outcomes in rural Japan.

Gendered economic, social and health effects of the COVID-19 pandemic and mitigation policies in Kenya: evidence from a prospective cohort survey in Nairobi informal settlements

OBJECTIVES

COVID-19 may spread rapidly in densely populated urban informal settlements. Kenya swiftly implemented mitigation policies; we assess the economic, social and health-related harm disproportionately impacting women.

DESIGN

A prospective longitudinal cohort study with repeated mobile phone surveys in April, May and June 2020.

PARTICIPANTS AND SETTING

2009 households across five informal settlements in Nairobi, sampled from two previously interviewed cohorts.

PRIMARY AND SECONDARY OUTCOME MEASURES

Outcomes include food insecurity, risk of household violence and forgoing necessary health services due to the pandemic. Gender-stratified linear probability regression models were constructed to determine the factors associated with these outcomes.

RESULTS

By May, more women than men reported adverse effects of COVID-19 mitigation policies on their lives. Women were 6 percentage points more likely to skip a meal versus men (coefficient: 0.055; 95% CI 0.016 to 0.094), and those who had completely lost their income were 15 percentage points more likely versus those employed (coefficient: 0.154; 95% CI 0.125 to 0.184) to skip a meal. Compared with men, women were 8 percentage points more likely to report increased risk of household violence (coefficient: 0.079; 95% CI 0.028 to 0.130) and 6 percentage points more likely to forgo necessary healthcare (coefficient: 0.056; 95% CI 0.037 to 0.076).

CONCLUSIONS

The pandemic rapidly and disproportionately impacted the lives of women. As Kenya reopens, policymakers must deploy assistance to ensure women in urban informal settlements are able to return to work, and get healthcare and services they need to not lose progress on gender equity made to date.

How social capital helps communities weather the COVID-19 pandemic

Why have the effects of COVID-19 been so unevenly geographically distributed in the United States? This paper investigates the role of social capital as a mediating factor for the spread of the virus. Because social capital is associated with greater trust and relationships within a community, it could endow individuals with a greater concern for others, thereby leading to more hygienic practices and social distancing. Using data for over 2,700 US counties, we investigate how social capital explains the level and growth rate of infections. We find that moving a county from the 25th to the 75th percentile of the distribution of social capital would lead to a 18% and 5.7% decline in the cumulative number of infections and deaths, as well as suggestive evidence of a lower spread of the virus. Our results are robust to many demographic characteristics, controls, and alternative measures of social capital.

Social Capital and Risk of Concurrent Sexual Partners Among African Americans in Jackson, Mississippi

Concurrent sexual partnerships (i.e., relationships that overlap in time) contribute to higher HIV acquisition risk. Social capital, defined as resources and connections available to individuals is hypothesized to reduce sexual HIV risk behavior, including sexual concurrency. Additionally, we do not know whether any association between social capital and sexual concurrency is moderated by gender. Multivariable logistic regression tested the association between social capital and sexual concurrency and effect modification by gender. Among 1445 African Americans presenting for care at an urban STI clinic in Jackson, Mississippi, mean social capital was 2.85 (range 1-5), mean age was 25 (SD = 6), and 62% were women. Sexual concurrency in the current year was lower for women compared to men (45% vs. 55%, χ²(df = 1) = 11.07, p = .001). Higher social capital was associated with lower adjusted odds of sexual concurrency for women compared to men (adjusted Odds Ratio [aOR] = 0.62 (95% CI 0.39-0.97), p = 0.034), controlling for sociodemographic and psychosocial covariates. Interventions that add social capital components may be important for lowering sexual risk among African Americans in Mississippi.

Do Sexual Partners Talk to Each Other About HIV? Exploring Factors Associated with HIV-Related Partner Communication Among Men and Women in Tanzania

Communication between sexual partners is an important component of HIV prevention and occurs within a broader context of socio-culturally defined gender norms and dynamics. We analyzed cross-sectional data from a community-based random sample of men and women living in Kisarawe, Tanzania to understand factors related to partner communication about HIV. Bivariate and multivariate logistic regression analyses, disaggregated by gender, included variables at the individual-, relational-, and community-levels. Individuals who knew their HIV-positive status prior to the study were excluded as the focus was on risk communication, not HIV status disclosure. Of 524 participants, 129 women (43.3%) and 96 men (42.5%) reported HIV-related communication with their most recent sexual partner. For women but not men, individual-level socioeconomic factors-including education, possession of a household radio, and employment-and relational-level factors-including partner age and type-were significantly associated with partner communication. At the community level, being socially engaged was positively correlated with partner communication across genders (aOR = 2.02, 95% CI 1.05-3.89, p = 0.03 for men and aOR = 1.74, 95% CI 1.03-2.95, p = 0.04 for women). For women, having less discriminatory attitudes toward people living with HIV and favorable perceived norms of HIV-related communication were significantly associated with partner communication. For men, agreeing that women should be allowed to work outside the home was significantly correlated with partner communication (aOR = 6.02, 95% CI 2.23-16.24, p < 0.001). Findings suggest a link between gender dynamics and partner communication, with individual and relational factors being associated with communication for women and community-level factors being associated with communication for both genders.

Multilevel Measures of Education and Pathways to Incident Herpes Simplex Virus Type 2 in Adolescent Girls and Young Women in South Africa

PURPOSE

Schooling is associated with a lower risk of Herpes simplex virus type 2 (HSV-2) in adolescent girls and young women, but there is little understanding of the pathways underlying this relationship.

METHODS

We used data from adolescent girls and young women in South Africa enrolled in the HIV Prevention Trials Network 068 study. We tested a structural equation model where individual household and community education measures were associated directly and indirectly with incident HSV-2 through HIV knowledge, future aspirations, age-disparate partnerships, sex in the last 12 months, and condomless sex.

RESULTS

Community, household, and individual measures of schooling were all associated with incident HSV-2 infection through mediated pathways that increased the likelihood of having sex. Low school attendance (<80% of school days) increased the likelihood of having sex through increased age-disparate partnerships and reduced future aspirations. Fewer community years of education increased the likelihood of having sex through increased age-disparate partnerships. Parental education level was indirectly associated with HSV-2 overall, although we could not identify the individual pathways that were responsible for this association.

CONCLUSIONS

Community and individual schooling interventions may reduce the risk of HSV-2 infection by influencing the likelihood of having sex, partner age, and future aspirations.

Participation in community groups increases the likelihood of PrEP awareness: New Orleans NHBS-MSM Cycle, 2014

Background

Gay, bisexual, and other men who have sex with men (GBM) have the highest proportion of incident HIV infection. Pre-exposure prophylaxis (PrEP) use and screening for sexually transmitted infections (STIs) are primary HIV prevention strategies, however, uptake remains low. Social capital, collective resources generated through social connections, are associated with lower HIV risk and infection. We investigated social capital in association with PrEP indicators among GBM.

Methods

Analyses included (N = 376) GBM from the 2014 National HIV Behavioral Surveillance (NHBS) in New Orleans. Multiple regression methods assessed the association between one item within each of eight domains from the Onyx and Bullen Social Capital Scale and: awareness and willingness to use PrEP. Analyses are adjusted for age, race, education, sexual intercourse with women, and health insurance.

Results

Forty percent of GBM were 18–29 years, 52 percent White. Sixty percent were willing to use PrEP. Social capital was above 50 percent across 7 of 8 indicators. Community group participation (vs no participation) was associated with higher likelihoods of PrEP awareness (adjusted Prevalence Ratio [aPR] = 1.41, 95% Confidence Interval [CI] = 1.02, 1.95). None of the seven remaining social capital indicators were significantly associated with any of the PrEP outcomes.

Conclusions

Community groups and organizations could be targeted for interventions to increase uptake of HIV prevention strategies among GBM in New Orleans

Social capital, social movements and global public health: Fighting for health-enabling contexts in marginalised settings

Research linking health and social capital is often cited in relation to global public health policies and programmes that mobilise local community participation in health promotion in marginalised settings. A long-standing criticism of this body of analysis and action is its inadequate attention to the power inequalities that drive poor health, often linked to macro-social forces beyond the reach of local community activism. Supplementing social capital research with attention to more ambitious and wide-ranging forms of health activism tackles this criticism. It puts the reproduction and transformation of health-relevant power inequalities at the heart of social capital research and community mobilisation strategies. We use the South African Treatment Action Campaign as a prototype for expanding understandings of social capital for health promotion. Existing social capital work currently focuses on facilitating community mobilisation to create co-operative bonding and bridging social capital (networks of solidarity within and between marginalised communities respectively), as well as linking social capital (networks uniting marginalised communities and more powerful champions). We call for an expanded focus that takes account of how these co-operative networks may serve as springboards for community involvement in adversarial social movements. In such cases, these networks of solidarity serve as launch pads for various forms of demand and protest where the marginalised and their allies confront power-holders in conflictual struggles over health-relevant social resources. We illustrate this expanded framework with two examples of collective action for mental health: the Movement for Global Mental Health and the UK Mental Health User and Survivor Movement. Both seek to use bonding, bridging and linking networks as the basis for movements to pressurise power-holders to increase access to appropriate psychiatric services, adequate welfare support and social respect and recognition for people living with mental distress.

Social capital and HIV/AIDS in the United States: Knowledge, gaps, and future directions

Purpose

Social capital is a well-established predictor of several behavioral health outcomes. However, we know less about the relationship with prevention, transmission, and treatment of HIV/AIDS outcomes in the United States (US).

Methods

In 2017, we conducted a scoping review of empirical studies investigating the relationships between social capital and HIV/AIDS in the US by searching PubMed, Embase, PsycINFO, Web of Science, and Sociological Abstracts with no restriction on publication date, for articles in English language. Sample search terms included: HIV infections OR HIV OR AIDS OR acquired immunodeficiency syndrome OR human immunodeficiency virus AND social capital OR social control, informal OR social participation OR social cohesion OR generalized trust OR social trust OR collective efficacy OR community mob* OR civic participation.

Results

We identified 1581 unique manuscripts and reviewed 13 based on eligibility criteria. The earliest eligible study was published in 2003. More than half (n=7/13) focused on HIV or AIDS diagnosis, then prescribing ART and/or adherence (n=5/13), then linkage and or engagement in HIV care (n=4/13). Fifty eight percent (58%) documented a protective association between at least one social capital measure and an HIV/AIDS outcome. Seven studies used validated social capital scales, however there was substantial variation in conceptual/operational definitions and measures used. Most studies were based on samples from the Northeast. Three studies directly focused on or stratified analyses among subgroups or key populations. Studies were cross-sectional, so causal inference is unknown.

Conclusion

Our review suggests that social capital may be an important determinant of HIV/AIDS prevention, transmission, and treatment outcomes. We recommend future research assess these associations using qualitative and mixed-methods approaches, longitudinally, examine differences across subgroups and geographic region, include a wider range of social capital constructs, and examine indicators beyond HIV diagnosis, as well as how mechanisms like stigma link social capital to HIV/AIDS.

The impact of social organizations on HIV/AIDS prevention knowledge among migrants in Hefei, China

BACKGROUND

There is a growing recognition of the need to provide HIV/AIDS prevention and care to migrant workers. Social involvement, a type of social capital, is considered a 'critical enabler' of effective HIV/AIDS prevention. Designated participation in formal community groups by the government (e.g., political parties) and informal, voluntary local networks by NGOs (e.g., alumni association, cultural & sports club) play different roles in HIV prevention. The objective of this study is to assess the impact of different types of social organizations on HIV/AIDS prevention knowledge among migrant workers.

METHODS

A cross-sectional study of 758 migrants was conducted in Hefei, Anhui Province, China. Data were collected through a self-reported questionnaire. Logistic regression was used to assess associations between different social organizations and HIV/AIDS prevention.

RESULTS

Migrants who participated in social organizations had a higher awareness of HIV/AIDS knowledge than migrants who do not participate in social organizations. Higher levels of HIV/AIDS knowledge is associated with positive HIV/AIDS behaviors for people who attended political parties (odds ratio [OR] = 3.49, 95% CI: 1.22-9.99). This effect is not significant for alumni association. For both political parties and alumni association members (OR = 0.19, 95% CI: 0.06-0.66, OR = 0.20, 95% CI: 0.08-0.61, respectively), people who exhibited higher levels of HIV/AIDS knowledge had more negative attitudes than those with less knowledge.

CONCLUSION

Social organizations play an important role in improving HIV/AIDS knowledge and behavior in migrants, providing a great opportunity for HIV/AIDS prevention.

Perceptions of social capital and sexual behaviour among youth in South Africa

With about one quarter of new human immunodeficiency virus (HIV) infections occuring in young people, there is an on-going debate regarding the role of social capital on youth sexual behaviour. Some studies have suggested that high levels of family and community social capital may act as protective factors that lessen the likelihood of negative consequences; while others have concluded that social capital may be a risk factor for risky sexual behaviour among youth. Using data from the Third National Communications Survey (2012) conducted in South Africa, we examined the relationship between perceptions of social capital and youth sexual behaviour measured by age at first sex and condom use among 3 399 males and females (aged between 16 and 24 years). We assessed community perceptions of social capital with questions that measured trust, social participation, and support. The Cox proportional hazards regression model was used to predict the risk for early sexual debut. Logistic regression was used to predict the odds of condom use. There was no association between perceptions of social capital and youth sexual behaviour. This work reveals that youth sexual behaviour in South Africa may be influenced by socio-economic characteristics, especially at the individual level.

Community social capital on the timing of sexual debut and teen birth in Nicaragua: a multilevel approach

Background

Community attributes have been gradually recognized as critical determinants shaping sexual behaviors in young population; nevertheless, most of the published studies were conducted in high income countries. The study aims to examine the association between community social capital with the time to sexual onset and to first birth in Central America.

Methods

Building upon the 2011/12 Demographic and Health Survey conducted in Nicaragua, we identified a sample of 2766 community-dwelling female adolescents aged 15 to 19 years. Multilevel survival analyses were performed to estimate the risks linked with three domains of community social capital (i.e., norms, resource and social network).

Results

Higher prevalence of female sexual debut (norms) and higher proportion of secondary school or higher education (resource) in the community are associated with an earlier age of sexual debut by 47 % (p < 0.05) and 16 %, respectively (p < 0.001). Living in a community with a high proportion of females having a child increases the hazard of teen birth (p < 0.001) and resource is negatively associated with teen childbearing (p < 0.05). Residential stability and community religious composition (social network) were not linked with teen-onset sex and birth.

Conclusions

The norm and resource aspects of social capital appeared differentially associated with adolescent sexual and reproductive behaviors. Interventions aiming to tackle unfavorable sexual and reproductive outcomes in young people should be devised and implemented with integration of social process.

"It's Not What You Know but Who You Know": Role of Social Capital in Predicting Risky Injection Drug Use Behavior in a Sample of People who Inject Drugs in Baltimore City

BACKGROUND

Injection drug use is the third highest risk factor for HIV transmission. Injection drug users, marginalized population, continue to be at threat for several health problems, including HIV, Hepatitis B & C and drug overdose. The area of social capital and risk behaviors is understudied. The current study aims to prospectively assess the relationship between social capital and the risk behaviors associated with injection drug use.

METHODS

The sample of the present study is a subset of 130 drug users who reported injection drug use (IDU) at both baseline and first follow-up wave for assessing the relationship between social capital and needle sharing in the city of Baltimore, MD. Factor analysis, structural equation modeling and multivariate logistic regression were conducted to explore these relationships.

RESULTS

A single-factor model fit well with factor loadings ranging from .20 to .95. Social capital is shown to be significantly and inversely associated (p<.05) with 35% decreased odds of the risk of sharing needles with every unit increase in social capital (AOR: 0.65, 95% CI: 0.06, 0.84).

CONCLUSION

The result from this study can be used to inform and fill gaps in the field of harm reduction. The interplay between social support, social participation and norms of trust, reciprocity generated from the index's social network and its relationship with behavior of needle sharing demonstrates that these leverage points should be emphasized in future harm reduction interventions.

Does Social Participation Predict Better Health? A Longitudinal Study in Rural Malawi

Research on the relationship between social capital and individual health often suffers from important limitations. Most research relies on cross-sectional data, which precludes identifying whether participation predicts health and/or vice versa. Some important conceptualizations of social capital, like social participation, have seldom been examined. Little is known about participation and health in sub-Saharan Africa. Furthermore, both physical and mental health have seldom been tested together, and variation by age has rarely been examined. We use longitudinal survey data for 2,328 men and women from the Malawi Longitudinal Study of Families and Health, containing (1) several measures of social participation, (2) measures of physical and mental health, and (3) an age range of 15 to 80+ years. Our results differ by gender and age and for mental and physical health. We find that social participation is associated with better physical health but can predict worse mental health for Malawians.

The effects of household wealth on HIV prevalence in Manicaland, Zimbabwe - a prospective household census and population-based open cohort study

Introduction

Intensified poverty arising from economic decline and crisis may have contributed to reductions in HIV prevalence in Zimbabwe.

Objectives

To assess the impact of the economic decline on household wealth and prevalent HIV infection using data from a population-based open cohort.

Methods

Household wealth was estimated using data from a prospective household census in Manicaland Province (1998 to 2011). Temporal trends in summed asset ownership indices for sellable, non-sellable and all assets combined were compared for households in four socio-economic strata (small towns, agricultural estates, roadside settlements and subsistence farming areas). Multivariate logistic random-effects models were used to measure differences in individual-level associations between prevalent HIV infection and place of residence, absolute wealth group and occupation.

Results

Household mean asset scores remained similar at around 0.37 (on a scale of 0 to 1) up to 2007 but decreased to below 0.35 thereafter. Sellable assets fell substantially from 2004 while non-sellable assets continued increasing until 2008. Small-town households had the highest wealth scores but the gap to other locations decreased over time, especially for sellable assets. Concurrently, adult HIV prevalence fell from 22.3 to 14.3%. HIV prevalence was highest in better-off locations (small towns) but differed little by household wealth or occupation. Initially, HIV prevalence was elevated in women from poorer households and lower in men in professional occupations. However, most recently (2009 to 2011), men and women in the poorest households had lower HIV prevalence and men in professional occupations had similar prevalence to unemployed men.

Conclusions

The economic crisis drove more households into extreme poverty. However, HIV prevalence fell in all socio-economic locations and sub-groups, and there was limited evidence that increased poverty contributed to HIV prevalence decline.

Community Support and Adolescent Girls' Vulnerability to HIV/AIDS: Evidence From Botswana, Malawi, and Mozambique

Girls are vulnerable to HIV in part because the social systems in which they live have failed to support and protect them. The goal of this research was to develop a viable supportive community index and test its association with intermediate variables associated with HIV risk across 16 communities in Botswana, Malawi, and Mozambique. This cross-sectional survey with separate samples randomly drawn in each country (2010) yielded a total sample of 1,418 adolescent girls (aged 11-18). Multilevel, multivariate logistic regression, while controlling for vulnerability, age, religion, and residence, found that an increase in supportive community index is positively associated with the odds of indicating improved community support for girls and with the confidence to refuse unwanted sex with a boyfriend across the three countries, as well as with self-efficacy to insist on condom use in Botswana and Mozambique. Program implementers and decision makers alike can use the supportive community index to identify and measure structural factors associated with girls' vulnerability to HIV/AIDS; this will potentially contribute to judicious decision making regarding resource allocation to enhance community-level, protective factors for adolescent girls.

The rise and fall of HIV prevalence in Zimbabwe: the social, political and economic context

For more than 10 years Zimbabwe has experienced social, political and economic instability, including the near collapse in 2008 of its health system. Paradoxically, this period has also seen a fall in estimated HIV prevalence, from 25.6% in 1996 to 13.7% in 2009. This article examines this development in a socio-political and historical context. We focus on the complex interplay of migration, mortality, individual behaviour change, and economic patterns in shaping the presumed epidemiological waning of HIV prevalence in Zimbabwe and explore the evolution and management of the country's HIV/AIDS response. Our assessment of the role that the Zimbabwean state has played in this development leads to the conclusion that a decline in HIV prevalence has been as much an artefact of dire social, political and economic conditions as the outcome of deliberate interventions. Lastly, we propose the need to contextualise available epidemiological data through qualitative research into the social aspects of HIV and the everyday lives of individuals affected by it.

Scaling up beyond 'pills and skills': preventing parent-to-child HIV/AIDS transmission and the public/private divide in southern India

This paper argues that current HIV/AIDS intervention models in southern India--in particular, those targeting the prevention of parent-to-child transmission (PPTCT)--underutilize the private sector and thereby compromise an efficient integration of HIV/AIDS humanitarian responses into India's health development system. While PPTCT is a critical strategy for curbing the HIV/AIDS epidemic-particularly in countries like India, where prevalence rates among young women are escalating-the cascade of prepartum, intrapartum, and postpartum PPTCT interventions are often difficult for women and spouses to access as a result of socio-cultural, structural and economic obstacles. Recognizing the complex ecologies within which PPTCT interventions must take place, qualitative analysis focussed on current PPTCT gaps in southern India and how healthcare providers and policymakers are moving to scale-up PPTCT by integrating into maternal, child and reproductive health services. Fieldwork highlighted a particularly stark gap in PPTCT delivery-the divide in scale-up efforts between public facilities and the private sector, which provides over 50% of national antenatal services. The private sector often serves as women's first point of healthcare contact, as they will avoid reputably poor-quality public facilities; vulnerable groups (e.g. rural and urban poor, tribal communities) are also seeking out subsidized private care, notably in faith-based facilities. Recognizing the need to revise the current humanitarian and health response, this paper details initial efforts to integrate into private care, with aim to present practitioners' successes, challenges and good practices for use in cross learning and a foundation for future research. This paper's analysis makes recommendations for key PPTCT providers and emphasizes the need to: (a) saturate PPTCT services in the private sector, and (b) strengthen mechanisms for integrating PPTCT across sector (private, public, and civil society) and decentralizing deeper into rural India to access vulnerable women, infants and spouses.

Factors shaping the HIV-competence of two primary schools in rural Zimbabwe

We present multi-method case studies of two Zimbabwean primary schools - one rural and one small-town. The rural school scored higher than the small-town school on measures of child well-being and school attendance by HIV-affected children. The small-town school had superior facilities, more teachers with higher morale, more specialist HIV/AIDS activities, and an explicit religious ethos. The relatively impoverished rural school was located in a more cohesive community with a more critically conscious, dynamic and networking headmaster. The current emphasis on HIV/AIDS-related teacher training and specialist school-based activities should be supplemented with greater attention to impacts of school leadership and the nature of the school-community interface on the HIV-competence of schools.

Evaluating social outcomes of HIV/AIDS interventions: a critical assessment of contemporary indicator frameworks

Introduction

Contemporary HIV-related theory and policy emphasize the importance of addressing the social drivers of HIV risk and vulnerability for a long-term response. Consequently, increasing attention is being given to social and structural interventions, and to social outcomes of HIV interventions. Appropriate indicators for social outcomes are needed in order to institutionalize the commitment to addressing social outcomes. This paper critically assesses the current state of social indicators within international HIV/AIDS monitoring and evaluation frameworks.

Methods

We analyzed the indicator frameworks of six international organizations involved in efforts to improve and synchronize the monitoring and evaluation of the HIV/AIDS response. Our analysis classifies the 328 unique indicators according to what they measure and assesses the degree to which they offer comprehensive measurement across three dimensions: domains of the social context, levels of change and organizational capacity.

Results and discussion

The majority of indicators focus on individual-level (clinical and behavioural) interventions and outcomes, neglecting structural interventions, community interventions and social outcomes (e.g. stigma reduction; community capacity building; policy-maker sensitization). The main tool used to address social aspects of HIV/AIDS is the disaggregation of data by social group. This raises three main limitations. Indicator frameworks do not provide comprehensive coverage of the diverse social drivers of the epidemic, particularly neglecting criminalization, stigma, discrimination and gender norms. There is a dearth of indicators for evaluating the social impacts of HIV interventions. Indicators of organizational capacity focus on capacity to effectively deliver and manage clinical services, neglecting capacity to respond appropriately and sustainably to complex social contexts.

Conclusions

Current indicator frameworks cannot adequately assess the social outcomes of HIV interventions. This limits knowledge about social drivers and inhibits the institutionalization of social approaches within the HIV/AIDS response. We conclude that indicator frameworks should expand to offer a more comprehensive range of social indicators for monitoring and evaluation and to include indicators of organizational capacity to tackle social drivers. While such expansion poses challenges for standardization and coordination, we argue that the complexity of interventions producing social outcomes necessitates capacity for flexibility and local tailoring in monitoring and evaluation.

Newcomers in a hazardous environment: a qualitative inquiry into sex worker vulnerability to HIV in Bali, Indonesia

Background

Women new to sex work and those with a greater degree of mobility have higher risk of HIV infection. Using social capital as a theoretical framework, we argue that better understanding of the interactions of micro-level structural factors can be valuable in reshaping and restructuring health promotion programmes in Bali to be more responsive to the concerns and needs of newcomer and mobile female sex workers (FSWs).

Methods

We conducted interviews with 11 newcomer FSWs (worked < six months), 9 mobile FSWs (experienced but worked at the current brothel < six months), and 14 senior FSWs (experienced and worked at current brothel > six months). The interviews explored women’s experience of sex work including how and why they came to sex work, relationships with other FSWs and their HIV prevention practices.

Results

A thematic framework analysis revealed newcomer FSWs faced multiple levels of vulnerability that contributed to increased HIV risk. First, a lack of knowledge and self-efficacy about HIV prevention practices was related to their younger age and low exposure to sexual education. Second, on entering sex work, they experienced intensely competitive working environments fuelled by economic competition. This competition reduced opportunities for positive social networks and social learning about HIV prevention. Finally, the lack of social networks and social capital between FSWs undermined peer trust and solidarity, both of which are essential to promote consistent condom use. For example, newcomer FSWs did not trust that if they refused to have sex without a condom, their peers would also refuse; this increased their likelihood of accepting unprotected sex, thereby increasing HIV risk.

Conclusions

Public health and social welfare interventions and programmes need to build social networks, social support and solidarity within FSW communities, and provide health education and HIV prevention resources much earlier in women’s sex work careers.

To tell or not to tell: disclosure to children and family amongst Thai women living with HIV/AIDS

HIV disclosure is a complex phenomenon. The choice of disclosure or non-disclosure is a reflection of how each HIV-positive person experiences and deals with HIV/AIDS in their everyday life. In this study, we qualitatively explore the experiences of disclosing HIV status to family members and children among HIV-positive women living in Thailand. Due to fear of stigma and discrimination, the women decided to tell only a few people, usually their significant others including parents and children. Although most women received good support from their family members, some were rejected and discriminated against by their family members. This stems from lack of knowledge about HIV/AIDS among family members. Women found disclosure to their children a difficult decision to make. Only some women told their children about their HIV status. They wished to protect their children from emotional burden. This protection also appeared in their attempts to prepare their children for dealing with HIV/AIDS. Support from family members played a major role in the lives of HIV-positive women. Although disclosure has been promoted as a means of ending stigma and discrimination, our data suggested that disclosure may not be positive for some women. This has implications for health promotion in HIV health care. Healthcare providers need to appreciate the ramifications of promoting disclosure to HIV-positive women who are mothers.

Social cohesion, social participation, and HIV related risk among female sex workers in Swaziland

Social capital is important to disadvantaged groups, such as sex workers, as a means of facilitating internal group-related mutual aid and support as well as access to broader social and material resources. Studies among sex workers have linked higher social capital with protective HIV-related behaviors; however, few studies have examined social capital among sex workers in sub-Saharan Africa. This cross-sectional study examined relationships between two key social capital constructs, social cohesion among sex workers and social participation of sex workers in the larger community, and HIV-related risk in Swaziland using respondent-driven sampling. Relationships between social cohesion, social participation, and HIV-related risk factors were assessed using logistic regression. HIV prevalence among the sample was 70.4% (223/317). Social cohesion was associated with consistent condom use in the past week (adjusted odds ratio [AOR]  = 2.25, 95% confidence interval [CI]: 1.30–3.90) and was associated with fewer reports of social discrimination, including denial of police protection. Social participation was associated with HIV testing (AOR = 2.39, 95% CI: 1.36–4.03) and using condoms with non-paying partners (AOR = 1.99, 95% CI: 1.13–3.51), and was inversely associated with reported verbal or physical harassment as a result of selling sex (AOR = 0.55, 95% CI: 0.33–0.91). Both social capital constructs were significantly associated with collective action, which involved participating in meetings to promote sex worker rights or attending HIV-related meetings/ talks with other sex workers. Social- and structural-level interventions focused on building social cohesion and social participation among sex workers could provide significant protection from HIV infection for female sex workers in Swaziland.

Strengthening the enabling environment for women and girls: what is the evidence in social and structural approaches in the HIV response?

There is growing interest in expanding public health approaches that address social and structural drivers that affect the environment in which behaviour occurs. Half of those living with HIV infection are women. The sociocultural and political environment in which women live can enable or inhibit their ability to protect themselves from acquiring HIV. This paper examines the evidence related to six key social and structural drivers of HIV for women: transforming gender norms; addressing violence against women; transforming legal norms to empower women; promoting women's employment, income and livelihood opportunities; advancing education for girls and reducing stigma and discrimination. The paper reviews the evidence for successful and promising social and structural interventions related to each driver. This analysis contains peer-reviewed published research and study reports with clear and transparent data on the effectiveness of interventions. Structural interventions to address these key social and structural drivers have led to increasing HIV-protective behaviours, creating more gender-equitable relationships and decreasing violence, improving services for women, increasing widows' ability to cope with HIV and reducing behaviour that increases HIV risk, particularly among young people.

Women and HIV in Sub-Saharan Africa

Thirty years since the discovery of HIV, the HIV pandemic in sub-Saharan Africa accounts for more than two thirds of the world's HIV infections. Southern Africa remains the region most severely affected by the epidemic. Women continue to bear the brunt of the epidemic with young women infected almost ten years earlier compared to their male counterparts. Epidemiological evidence suggests unacceptably high HIV prevalence and incidence rates among women. A multitude of factors increase women's vulnerability to HIV acquisition, including, biological, behavioral, socioeconomic, cultural and structural risks. There is no magic bullet and behavior alone is unlikely to change the course of the epidemic. Considerable progress has been made in biomedical, behavioral and structural strategies for HIV prevention with attendant challenges of developing appropriate HIV prevention packages which take into consideration the socioeconomic and cultural context of women in society at large.

Evidence for a contribution of the community response to HIV decline in eastern Zimbabwe?

Membership of indigenous local community groups was protective against HIV for women, but not for men, in eastern Zimbabwe during the period of greatest risk reduction (1999–2004). We use four rounds of data from a population cohort to investigate: (1) the effects of membership of multiple community groups during this period; (2) the effects of group membership in the following five years; and (3) the effects of characteristics of groups hypothesised to determine their effect on HIV risk. HIV incidence from 1998 to 2003 was 1.18% (95% CI: 0.78–1.79%), 0.48% (0.20–1.16%) and 1.13% (0.57–2.27%), in women participating in one, two and three or more community groups at baseline versus 2.19% (1.75–2.75%) in other women. In 2003–2005, 36.5% (versus 43% in 1998–2000) of women were members of community groups, 50% and 56% of which discussed HIV prevention and met with other groups, respectively; the corresponding figures for men were 24% (versus 28% in 1998–2000), 51% and 58%. From 2003 to 2008, prior membership of community groups was no longer protective against HIV for women (1.13% versus 1.29%, aIRR = 1.25;p = 0.23). However, membership of groups that provided social spaces for dialogue about HIV prevention (0.62% versus 1.01%, aIRR = 0.54; p = 0.28) and groups that interacted with other groups (0.65% versus 1.01%, aIRR = 0.51; p = 0.19) showed non-significant protective effects. For women, membership of a group with external sponsorship showed a non-significant increase in HIV risk compared to membership of unsponsored groups (adjusted odds ratio = 1.63, p = 0.48). Between 2003 and 2008, membership of community groups showed a non-significant tendency towards higher HIV risk for men (1.47% versus 0.94%, p = 0.23). Community responses contributed to HIV decline in eastern Zimbabwe. Sensitive engagement and support for local groups (including non-AIDS groups) to encourage dialogue on positive local responses to HIV and to challenge harmful social norms and incorrect information could enhance HIV prevention.

Community-directed educational intervention for malaria elimination in Bhutan: quasi-experimental study in malaria endemic areas of Sarpang district

Background

As per the World Malaria Report 2011, there was a 17% reduction in morbidity and 26% reduction in mortality in 2010, compared to 2000. In Bhutan, there were only 194 malaria cases in 2011 as compared to 5,935 cases in 2000. As the country moves towards an elimination phase, educating the community and empowering them on malaria prevention and control is imperative. Hence, this study was conducted to elucidate the effectiveness of the community-directed educational intervention on malaria prevention and control in malaria-endemic areas of Sarpang district, Bhutan.

Methods

This quasi-experimental study design was conducted using both qualitative and quantitative data collection methods. In-depth interviews and focus group discussions were carried out in addition to household survey using a structured questionnaire conducted before and after the intervention. Intervention was conducted using community action groups, who were provided with training and which then developed action plans for implementation of interventions within their communities.

Results

The study resulted in a significant improvement in knowledge and attitude in intervention as compared to control during the post-intervention survey (p < 0.001). The practice score was higher in the control group both during pre- and post-intervention, however, the mean ( ±sd) score of practice in intervention group increased from 6.84 ± 1.26 in pre-intervention to 8.35 ± 1.14 in post-intervention (p < 0.001), where as it decreased from 9.19 ± 1.78 to 9.10 ± 1.98 in the control group (p = 0. 68). When comparing pre- and post- in the intervention group, there was significant improvement during post-intervention in knowledge, attitude and practice (p < 0.001).

Conclusions

The findings from this study corroborate that community-directed interventions can be utilized as an effective means for improving knowledge, attitude and practice in the malaria-endemic areas of Bhutan. Further studies are needed to see the long-term effect and sustainability of such interventions.

Men's migration, women's personal networks, and responses to HIV/AIDS in Mozambique

This study brings together the literature on social network approaches to social capital and health and on migration and HIV risks to examine how non-migrating wives of labor migrants use their personal networks to cope with perceived risks of HIV infection in rural southern Mozambique. Using data from a 2006 survey of 1,680 women and their dyadic interactions, we compare the composition of personal networks, HIV/AIDS communication, and preventive behavior of women married to migrants and those married to non-migrants. Results show that migrants' wives were more likely than non-migrants' wives to have other migrants' wives as personal network members, to engage in HIV/AIDS communication, and to discuss HIV prevention. However, they were no more likely to talk about HIV/AIDS with migrants' wives than with non-migrants' wives. They were also no more likely to talk about AIDS and its prevention than non-migrants' wives who express worry about HIV infection from their spouses. Finally, we detect that network members' prevention behavior was similar to respondents', although this did not depend on migration. We contextualize these findings within the literature and discuss their policy implications.

Impact of individual-level social capital on quality of life among AIDS patients in China

Background

With growing recognition of the social determinants of health, social capital is an increasingly important construct in international health. However, the application of social capital discourse in response to HIV infection remains preliminary. The aim of this study was to assess the impact of social capital on quality of life (QoL) among adult patients with acquired immune deficiency syndrome (AIDS).

Methods

A convenient sample of 283 patients receiving antiretroviral treatment (ART) was investigated in Anhui province, China. QoL data were collected using the Medical Outcomes Study HIV Survey (MOS-HIV) questionnaire. Social capital was measured using a self-developed questionnaire. Logistic regression models were used to explore associations between social capital and QoL.

Results

The study sample had a mean physical health summary (PHS) score of 50.13±9.90 and a mean mental health summary (MHS) score of 41.64±11.68. Cronbach's α coefficients of the five multi-item scales of social capital ranged from 0.44 to 0.79. When other variables were controlled for, lower individual levels of reciprocity and trust were associated with a greater likelihood of having a poor PHS score (odds ratio [OR] = 2.02) or PHS score (OR = 6.90). Additionally, the factors of social support and social networks and ties were associated positively with MHS score (OR = 2.30, OR = 4.17, respectively).

Conclusions

This is the first report to explore the effects of social capital on QoL of AIDS patients in China. The results indicate that social capital is a promising avenue for developing strategies to improve the QoL of AIDS patients in China, suggesting that the contribution of social capital should be fully exploited, especially with enhancement of QoL through social participation. Social capital development policy may be worthy of consideration.

Exploring the relationship between premarital sex and cigarette/alcohol use among college students in Taiwan: a cohort study

BACKGROUND

Cigarette/alcohol use and premarital sex, and their subsequent consequences on the well-being of college students, are international health promotion issues. However, little is known about the temporal relationship of these risk behaviors among Taiwanese college students.

METHODS

This study utilizes data from the Taiwan Youth Project, a cohort sample of 20-year-olds (N = 2,119) with a 2-year follow-up, to explore the relationship between adolescent cigarette/alcohol use, and subsequent premarital sex. To incorporate the Taiwanese context where the normative value of abstinence until marriage remains strong, multivariate logistic regression models included data on premarital sex attitudes, stressful life events, peer influence, as well as family and individual factors which might influence this relationship.

RESULTS

The sample consists of 49% male and 51% female college students. About 16% of the sample report having had premarital sex by age 20. After excluding sexually active youth, 20% of males and 13% of females report engaging in premarital sex in the 2-year follow-up interview. Multivariate logistic regression analyses reveal adolescent alcohol use is significantly associated with a higher likelihood of engaging in premarital sex for both genders; adolescent smoking is significantly associated with premarital sexual activity among males, but not females. Our results indicate liberal premarital sexual attitudes and stressful personal events are also significantly associated with premarital sexual activity.

CONCLUSIONS

These findings suggest health promotion programs for college students need to take developmental and gender perspectives into account. Future research to incorporate a broader, multi-cultural context into risk reduction materials is recommended.

A cross-sectional description of social capital in an international sample of persons living with HIV/AIDS (PLWH)

Background

Social capital refers to the resources linked to having a strong social network. This concept plays into health outcomes among People Living with HIV/AIDS because, globally, this is a highly marginalized population. Case studies show that modifying social capital can lead to improvements in HIV transmission and management; however, there remains a lack of description or definition of social capital in international settings. The purpose of our paper was to describe the degree of social capital in an international sample of adults living with HIV/AIDS.

Methods

We recruited PLWH at 16 sites from five countries including Canada, China, Namibia, Thailand, and the United States. Participants (n = 1,963) completed a cross-sectional survey and data were collected between August, 2009 and December, 2010. Data analyses included descriptive statistics, factor analysis, and correlational analysis.

Results

Participant's mean age was 45.2 years, most (69%) identified as male, African American/Black (39.9%), and unemployed (69.5%). Total mean social capital was 2.68 points, a higher than average total social capital score. Moderate correlations were observed between self-reported physical (r = 0.25) and psychological condition (r = 0.36), social support (r = 0.31), and total social capital. No relationships between mental health factors, including substance use, and social capital were detected.

Conclusions

This is the first report to describe levels of total social capital in an international sample of PLWH and to describe its relationship to self-reported health in this population.

Social capital and risk and protective behaviors: a global health perspective

Social capital and health research has emerged as a focus of contemporary behavioral epidemiology, while intervention research is seeking more effective measures to increase health protective behaviors and decrease health-risk behaviors. In this review we explored current literature on social capital and health outcomes at the micro-, mesa-, and macro-levels with a particular emphasis on research that incorporates a social capital framework, and adolescent and young adult engagement in risk behaviors. These data indicate that across a broad range of socio-cultural and economic contexts, social capital can affect individuals’ risk for negative health outcomes and their engagement in risk behaviors. Further research is needed which should focus on differentiating and measuring positive and negative social capital within both mainstream and alternative social networks, assessing how social constructions of gender, ethnicity, and race – within specific cultural contexts – mediate the relationship between social capital and risk and/or protective behaviors. This new research should integrate the existing research within historical socioeconomic and political conditions. In addition, social capital scales need to be developed to be both culturally and developmentally appropriate for use with adolescents living in a diversity of settings. Despite the proliferation of social capital research, the concept remains underutilized in both assessment and intervention development for adolescents’ and young adults’ engagement in risk behaviors and their associated short- and long-term poor health outcomes.

Building adherence-competent communities: factors promoting children's adherence to anti-retroviral HIV/AIDS treatment in rural Zimbabwe

Given relatively high levels of adherence to HIV treatment in Africa, we explore factors facilitating children's adherence, despite poverty, social disruption and limited health infrastructure. Using interviews with 25 nurses and 40 guardians in Zimbabwe, we develop our conceptualisation of an ‘adherence competent community’, showing how members of five networks (children, guardians, community members, health workers and NGOs) have taken advantage of the gradual public normalisation of HIV/AIDS and improved drug and service availability to construct new norms of solidarity with HIV and AIDS sufferers, recognition of HIV-infected children's social worth, an ethic of care/assistance and a supporting atmosphere of enablement/empowerment.

Perceived social approval and condom use with casual partners among youth in urban Cameroon

Background

HIV prevention programs targeting youth often emphasize the role of peers, and assume that youths will model their behavior after their peers'. We challenge this view; we argue that adopting a given behavior requires social approval, and that youths do not necessarily turn to peers for such approval. This study analyzes survey data on youths in urban Cameroon to 1) identify which type of persons youths look to for social approval, and 2) establish how important social approval by these persons is for condom use among youths.

Methods

We analyzed data from three survey waves (2000, 2002, and 2003) of a reproductive health survey conducted among urban Cameroonian youth (aged 15-24). Only respondents who reported having at least one casual partner in the past year were retained for the analysis. Bivariate analyses and structural equation modeling were used to examine relationships among perceived social approval, attitudes towards condoms and condom use.

Results

The data show that only 3% of youths named their friends as people whose opinion they valued, while 93% mentioned family members. The perceived approval of condom use by these persons had a significant positive effect on the frequency of condom use among youths. The frequency of condom use was also affected by the respondents' attitudes toward condom use, the range of persons with whom they discussed reproductive health matters, whether they were enrolled in school, socioeconomic status, their self-efficacy, perceived severity of AIDS, risk perception and sexual risk behavior. The perceived social approval of condom use and the respondents' own condom attitudes were correlated.

Conclusions

Our analysis demonstrates that perceived social approval facilitates the adoption of condom use among urban Cameroonian youth. However, youths tend to value the opinions of family members much more than the opinions of their peers. These results suggest that interventions targeting youths should not focus exclusively on peers but should also include other groups, such as parents and community leaders.

Creating social spaces to tackle AIDS-related stigma: reviewing the role of church groups in Sub-Saharan Africa

An expanding body of literature explores the role of African church groups in facilitating or hindering the support of people living with AIDS and challenging or contributing to HIV/AIDS-related stigma. Treating church groups as social spaces in which HIV/AIDS-related stigma may potentially be challenged, we systematically review this literature, identifying five themes that highlight the complex and contradictory role of the church as a potential agent of health-enhancing social change. In many ways the church perpetuates HIV/AIDS-related stigma through (i) moralistic attitudes and (ii) its reinforcement of conservative gender ideologies. However some churches have managed move towards action that makes a more positive contribution to HIV/AIDS management through (iii) promoting various forms of social control for HIV prevention, (iv) contributing to the care and support of the AIDS-affected and (v) providing social spaces for challenging stigmatising ideas and practices. We conclude that church groups, including church leadership, can play a key role in facilitating or hindering the creation of supportive social spaces to challenge stigma. Much work remains to be done in developing deeper understandings of the multi-layered factors that enable some churches, but not others, to respond effectively to HIV/AIDS.

Understanding social capital and HIV risk in rural African American communities

BACKGROUND

African Americans (AA) and rural communities often suffer disproportionately from poorer health. Theory-guided research examining how individual- and community-level factors influence health behaviors and contribute to disparities is needed.

OBJECTIVE

To understand how a social network model that captures the interplay between individual and community factors might inform community-based interventions to reduce HIV risk in rural AA communities.

DESIGN

Qualitative study.

SETTING AND PARTICIPANTS

Eleven focus groups with 38 AA 16-24 year olds, 42 adults over age 25, and 13 formerly incarcerated individuals held in community settings in two rural, predominantly AA counties in North Carolina. Thirty-seven semi-structured interviews with multiethnic key informants.

APPROACH

Semi-structured interviews and focus groups with open-ended questions assessed a) perceptions of multi-level HIV risk determinants from a social network model (individual, interpersonal, social, economic, political and structural) identified through literature review and b) community needs and assets affecting local HIV rates. Qualitative data was analyzed using directive content analysis guided by a social network model.

RESULTS

We identified four themes regarding the interaction between individuals and their communities that mediate HIV risk: interpersonal processes, community structural environment, social disorder, and civic engagement. Communities were characterized as having a high degree of cohesiveness, tension, and HIV-related stigma. The community structural environment-characterized by neighborhood poverty, lack of skilled jobs, segregation, political disenfranchisement and institutional racism-was felt to reduce the availability and accessibility of resources to combat HIV. Adults noted an inability to combat social problems due to social disorder, which fuels HIV risk behaviors. Civic engagement as a means of identifying community concerns and developing solutions is limited by churches' reluctance to address HIV-related issues.

CONCLUSION

To combat HIV-related stigma, physicians should follow recommendations for universal HIV testing. Besides asking about individual health behaviors, physicians should ask about the availability of support and local community resources. Physicians might consider tailoring their treatment recommendations based on available community resources. This strategy may potentially improve patient adherence and clinical outcomes.

Did national HIV prevention programs contribute to HIV decline in Eastern Zimbabwe? Evidence from a prospective community survey

OBJECTIVE

To add to the evidence on the impact of national HIV prevention programs in reducing HIV risk in sub-Saharan African countries.

METHODS

Statistical analysis of prospective data on exposure to HIV prevention programs, relatives with AIDS and unemployment, and sexual behavior change and HIV incidence, in a population cohort of 4047 adults, collected over a period (1998-2003) when HIV prevalence and risk-behavior declined in eastern Zimbabwe.

RESULTS

Exposure to HIV prevention programs and relatives with AIDS-but not unemployment-increased from 1998 to 2003. Men and women exposed to media campaigns and HIV/AIDS meetings had greater knowledge and self-efficacy, attributes that were concomitantly protective against HIV infection. Women attending community HIV/AIDS meetings before recruitment were more likely than other women to adopt lower-risk behavior (96.4% vs. 90.8%; adjusted odds ratio, 3.09; 95% confidence interval [CI], 1.27-7.49) and had lower HIV incidence (0.9% vs. 1.8%; adjusted incidence rate ratio, 0.63; 95% CI, 0.32-1.24) during the intersurvey period. Prior exposure to relatives with AIDS was not associated with differences in behavior change. More newly unemployed men as compared with employed men adopted lower-risk behavior (84.2% vs. 76.0%; adjusted odds ratio, 2.13; 95% CI, 0.98-4.59).

CONCLUSIONS

Community-based HIV/AIDS meetings reduced risk-behavior amongst women who attended them, contributing to HIV decline in eastern Zimbabwe.

"The young ones are the condom generation": condom use amongst out-of-school adolescents in rural southwest Uganda

This article reports on factors influencing condom use among out-of-school adolescents in rural southwest Uganda. Despite an abundance of negative discourses and myths about condoms in the community, these adolescents believe condoms protect them from sexually transmitted infections, HIV, and premarital pregnancies. Girls want partners to use condoms, but most lack the confidence to insist. Girls aged 13 to 14 reported the least difficulty asking for condoms; older girls attributed this to coming-of-age in the era of AIDS when condom use is the norm. Boys under 16 years want to use condoms, but lack confidence in application skills. Boys over 17 years always use condoms with casual partners, but only occasionally for pregnancy prevention with steady partners. Girls need skills training to improve confidence in negotiating condom use. Younger boys require training to improve confidence in skills with condom application. These findings are compared with studies conducted with in-school adolescents in the same study area. Health promotions that provide this skills training and focus on the need to think of the health of future family would be most effective for out-of-school adolescents. This study shows that it is self-confidence, rather than years of schooling, that has the greatest impact on condom use in this cohort.

Social capital and women's reduced vulnerability to HIV infection in rural Zimbabwe

Social capital—especially through its “network” dimension (high levels of participation in local community groups)—is thought to be an important determinant of health in many contexts. We investigate its effect on HIV prevention, using prospective data from a general population cohort in eastern Zimbabwe spanning a period of extensive behavior change (1998–2003). Almost half of the initially uninfected women interviewed were members of at least one community group. In an analysis of 88 communities, individuals with higher levels of community group participation had lower incidence of new HIV infections and more of them had adopted safer behaviors, although these effects were largely accounted for by differences in socio-demographic composition. Individual women in community groups had lower HIV incidence and more extensive behavior change, even after controlling for confounding factors. Community group membership was not associated with lower HIV incidence in men, possibly refecting a propensity among men to participate in groups that allow them to develop and demonstrate their masculine identities—often at the expense of their health. Support for women's community groups could be an effective HIV prevention strategy in countries with large-scale HIV epidemics.

Uncovering tensions and capitalizing on synergies in HIV/AIDS and antiviolence programs

Research frequently points to the need to empower women to effectively combat the twin epidemics of HIV/AIDS and gender-based violence. Simultaneously, there has been increased attention given to working with men in gender equality efforts. The latter approach intervenes on masculinities as part of the fight against HIV/AIDS and violence. No research has considered these 2 lines of work side by side to address several important questions: What are the points of overlap, and the tensions and contradictions between these 2 approaches? What are the limitations and unintended consequences of each? We analyzed these 2 parallel research trends and made suggestions for how to capitalize on the synergies that come from bolstering each position with the strengths of the other.