Social networks, perceptions of risk, and changing attitudes towards HIV/AIDS: new evidence from a longitudinal study using fixed-effects analysis

Public Stigma and Personal Networks: Confronting the Limitations of Unidimensional Measures of Social Contact

One of the most promising directions for reducing mental illness stigma lies in Allport's contact theory, which suggests that intergroup interactions reduce stigma. Here, we argue that stigmatizing attitudes are driven by the nature, magnitude, and valence of community-based ties to people with mental illness (PMI), not simply their presence. Using the 2018 General Social Survey (N = 1,113), we compare network-based measures of contact to traditional survey indicators. We find that knowing someone with mental illness, or even number of people known, explains little about desire for social distance, perceptions of dangerousness, or endorsement of treatment coercion. However, having stronger relationships with more PMI, having more friends and family (but not more peripheral ties) with mental illness, and knowing people in treatment are associated with less stigma endorsement. In contrast, we find that exposure to PMI who are perceived as dangerous is associated with greater levels of stigma.

You Know What I Know: Interviewer Knowledge Effects in Subjective Expectation Elicitation

Directly eliciting individuals' subjective beliefs via surveys is increasingly popular in social science research, but doing so via face-to-face surveys has an important downside: the interviewer's knowledge of the topic may spill over onto the respondent's recorded beliefs. Using a randomized experiment that used interviewers to implement an information treatment, we show that reported beliefs are significantly shifted by interviewer knowledge. Trained interviewers primed respondents to use the exact numbers used in the training, nudging them away from higher answers; recorded responses decreased by about 0.3 standard deviations of the initial belief distribution. Furthermore, respondents with stronger prior beliefs were less affected by interviewer knowledge. We suggest corrections for this issue from the perspectives of interviewer recruitment, survey design, and experiment setup.

The multidimensional vulnerability of people with disability to HIV infection: Results from the handiSSR study in Bujumbura, Burundi

BACKGROUND

In resource-limited contexts, available data indicate that people with disability are disproportionally affected by the HIV epidemic. While disability resulting from chronic HIV infection has received some attention, few epidemiologic studies have examined the vulnerability of people with disability to HIV acquisition. The aims of the study were as follows: to estimate and compare HIV prevalence among people with and without disability living in Bujumbura, Burundi; to examine how the interaction among disability, gender and socioeconomic environment shapes vulnerability to HIV; and to identify potential pathways to higher HIV risk.

METHODS

In this cross-sectional population-based study, 623 persons with disability (302 with disability onset ≤10 years ["early disability"]) and 609 persons without disability matched for age, sex and location were randomly selected to be tested for HIV and to participate in an interview about their life history, their social environment and their knowledge of sexual health.

FINDINGS

A total of 68% of men and 75% of women with disability were affected by multidimensional poverty compared to 54% and 46% of their peers without disability (p<0.0001). Higher HIV prevalence was observed among women with disability (12.1% [8.2-16]) than among those without (3.8% [1.7-6], ORa 3.8, p<0.0001), while it was similar among men with disability and those without (p = 0·8). Women with disability were also at higher risk of sexual violence than were those without (ORa 2.7, p<0.0001). The vulnerability of women with early disability to HIV was higher among those who were socially isolated (HIV prevalence in this group: 19% [12-27]). In addition, education level and sexual violence mediated 53% of the association between early disability and HIV (p = 0.001).

INTERPRETATION

This study highlights how the intersection of disability, gender and social environment shapes vulnerability to HIV. It also shows that the vulnerability to HIV of women who grew up with a disability is mediated by sexual violence.

FUNDING

This research was funded by the Netherlands Organization for Scientific Research (Grant W08.560.005) and the Initiative HIV-TB-Malaria (new name of the organisation).

Smoking behavior prevalence in one's personal social network and peer's popularity: A population-based study of middle-aged adults in Japan

Although previous social network studies have consistently shown the social influence of peers' smoking on one's (ego's) smoking, few studies have examined how the influence differs according to peers' structural positions in the network. Investigations are also lacking on whether vulnerability to the influence varies by ego's socioeconomic position. Thus, the present study aimed to examine how the association between peers' smoking and ego's smoking differs by peers' popularity in ego's personal network and ego's educational attainment. We used data from the third-wave Japanese Study on Stratification, Health, Income, and Neighborhood (J-SHINE) conducted in 2017, which targeted middle-aged (32-58-year-old) residents in four municipalities within Japanese metropolitan areas. Information on four close peers' characteristics and behaviors and their mutual relationships was collected by the name generator and name interpreter methods. Data on 1989 respondents and 7956 peers were evaluated. Peers' eigenvector centrality was used as their popularity index in ego's personal network. We set ego's smoking as an outcome, regressed on each peer's smoking, each peer's popularity, and ego's educational attainment adjusting for ego's age, sex, working status, marital status, spouse's/partner's smoking status, as well as similarity in socioeconomic backgrounds between peer and ego, using a logistic regression model with robust standard errors. We then added a three-way interaction term for these three explanatory variables to the model. Results showed that peer's smoking status was related to ego's smoking even more strongly when the peer was popular but only in the case of ego with lower educational attainment. The results suggested that the disparity in smoking behavior across socioeconomic positions may be partly explained by susceptibility to social influence from one's personal network among the socioeconomically vulnerable. This study proposes a plausible method for pinpointing the peer influencer in one's personal social network to close the socioeconomic gap in smoking.

The Effect of Social Networks and Social Constructions on HIV Risk Perceptions

Roughly 1 in 7 people living with HIV in the United States is unaware of their sero-status, signaling that individuals may be underestimating their risk for HIV. Few studies have examined the effect of socio-structural and socio-cognitive factors on HIV risk perceptions. This analysis identifies individual, interpersonal and network influences on HIV risk perceptions among high-risk heterosexuals. Data come from the Colorado Springs study, a CDC-funded project focused on HIV transmission among high-risk heterosexuals. Using social network data, analyses were first conducted at the individual-level using a partial proportional odds regression to identify predictors of self-perceived HIV risk. Next, multivariate binary logistic regression using GEE was used to examine  predictors of perceptions of network member's  HIV risk. Interpersonal characteristics such as perceptions of network member's HIV risk, racial homophily, and engagement in multiplexity (co-occurrence of drug-use, needle sharing and sex within relationships) were significantly associated with respondents' self-perceived HIV risk. Factors associated with perceptions of network member's HIV risk include self-perceived HIV risk, emotional closeness within relationships, and density of drug ties. Analyses found HIV risk perception is the product of not only individual-level factors, but also interpersonal and social network processes. We also found a reciprocal relationship between individuals' perceptions of their own risk and the risk of their associates/network members. Findings highlight the need for understanding risk perception as a function of interpersonal relationships, social constructions, including socio-cognitive processes.

Development, implementation and dissemination: Couples and Parent-Child Communication Workshops in Zambia

Over a million people are living with HIV in Zambia, representing ∼13% of the country's population. To increase HIV prevention communication, a community-based communication training program, the Parent-Child and Couples Communication Workshop, was developed from pilot data and culturally tailored for dissemination in Zambia. Workshop trainees (N = 195) were 18 years of age or more and community educators and counselors in the Copperbelt and Southern Provinces of Zambia, e.g., peer educators, lay counselors, teachers, nurses, mentors and program officers, workshops (N = 16) were conducted. Satisfaction with the workshops, readiness to conduct a workshop and implementation were assessed. Overall, readiness to conduct workshops following training and satisfaction with the workshop was similarly high across Provinces. Following the initial training, more than half of workshop trainees conducted workshops in their own communities. Zambian community members were receptive to learning techniques to disseminate communication strategies that could prevent HIV transmission. The use of culturally appropriate strategies and a training of trainers approach for communication and prevention may have enhanced workshop dissemination in Zambian communities. Future research should explore the use of culturally congruent HIV prevention initiatives in the Zambian context.

Nomads' perceptions of quality, accessibility, and affordability of health services as determinants of using skilled birth attendants in Gossi, Mali

AIM

More than half of all maternal deaths worldwide occur in sub-Saharan Africa (SSA). For nomadic pastoralists (30 to 60 million) in SSA, the risk of maternal death is very high because of the low proportion of assisted deliveries in the areas where they live. The objective of this research was to understand the determinants of using skilled birth attendants in relation to the perceptions of quality, geographic accessibility, and financial affordability of health services by nomadic women.

METHODS

We used a qualitative research design, inspired by ethnography. Research was conducted in the commune of Gossi (Mali), where 90% of the population is nomadic. The study population consisted of 26 nomadic women living in their camps. Saturation and diversification guided sampling. Semi-structured individual interviews and non-participant observation enabled concomitant data collection. Thematic content analysis was performed using QDA Miner software.

RESULTS

Our results show that only 10 women used assisted childbirth for their last delivery. These women thought that health workers were competent and well trained, and they liked the fact that these workers were recruited locally. Similarly, these 10 women deemed the health workers' attitude acceptable and appreciated their availability. In contrast, the majority of participants (16 women) were prevented or discouraged from using skill birth attendants. Some of them did not use them because they were afraid of being undressed, of giving birth on a table, and especially of male staff. They also said that they did not have access to information about health services. In addition, respondents considered health services very difficult to access due to distances, unavailable means of transportation, and costs perceived as being expensive.

CONCLUSION

Our results identify several determinants of the use or non-use of skilled birth attendants by nomadic women in relation to the context and way of life. In addition, our findings call for future research to better understand these determinants and to deepen, refine, and test emerging strategies that seem potentially hopeful with respect to facilitating the use of skilled birth attendance in SSA.

Friendships Among Young South African Women, Sexual Behaviours and Connections to Sexual Partners (HPTN 068)

Friends could be influential on young women's sexual health via influences on sexual behaviours and as connections to sexual partners, but are understudied in sub-Saharan Africa. We cross-sectionally surveyed 2326 13-20 year-old young women eligible for grades 8-11 in rural South Africa about their sexual behaviour and up to three sexual partners. Participants each described five specific but unidentified friends and the relationships between them in an 'egocentric' network analysis design. We used logistic regression to investigate associations between friendship characteristics and participants' reports of ever having had sex (n = 2326) and recent condom use (n = 457). We used linear regression with random effects by participant to investigate friendship characteristics and age differences with sexual partners (n = 633 participants, 1051 partners). We found that it was common for friends to introduce young women to those who later became sexual partners, and having older friends was associated with having older sexual partners, (increase of 0.37 years per friend at least 1 year older, 95% CI 0.21-0.52, adjusted). Young women were more likely to report ever having had sex when more friends were perceived to be sexually active (adjusted OR 1.85, 95% CI 1.72-2.01 per friend) and when they discussed sex, condoms and HIV with friends. Perception of friends' condom use was not associated with participants' reported condom use. While this study is preliminary and unique in this population and further research should be conducted, social connections between friends and sexual partners and perceptions of friend sexual behaviours could be considered in the design of sexual health interventions for young women in South Africa.

Reaching marginalized young women for HIV prevention in Botswana: a pilot social network analysis

Almost one-fifth of Botswana's population is infected with HIV. The Inter-Ministerial National Structural Intervention Trial is a trial to test the impact on HIV rates of a structural intervention that refocuses government structural support programs in favor of young women. Ensuring that the intervention reaches all vulnerable young women in any given community is a challenge. Door-to-door recruitment was inefficient in previous work, so we explored innovative ways to reach this population. We sought to understand the support networks of marginalized young women, and to test the possibility of using social networks to support universal recruitment in this population. Ego-centric and sociometric analyses were used to describe the support networks of marginalized young women. Marginalized young women go to other women and relatives for support, and they communicate face to face rather than using social media. Network maps show how young women were connected to each other. Lessons from the pilot include a better understanding of how to use social networks as a recruitment method, such as the time required and the types of community members that can help. Social networks could help reach other hard-to-reach populations.

Sociocultural determinants of nomadic women's utilization of assisted childbirth in Gossi, Mali: a qualitative study

BACKGROUND

In sub-Saharan Africa (SSA), nomads account for 30 to 60 million people. Their mobility, due to a constant search for pastures and water points, makes health services less accessible to them. Few nomadic women use assisted delivery, which increases the risk of maternal mortality. The reasons behind this limited use have been poorly documented. The objective of this study was to understand the sociocultural determinants of assisted childbirth by nomadic women.

METHODS

We conducted a qualitative research in the health area of Gossi (Mali), mainly populated by nomads. Data were collected through a literature review, 26 semi-structured interviews, a non-participant observation, and a logbook. Nomadic women who gave birth in the past three months were included in the study, whether they used assisted delivery or not. A thematic content analysis was performed with QDA Miner software.

RESULTS

The study identified a complex combination of determinants resulting in the use or non-use of assisted childbirth by the nomads of Gossi. Several participants recognized the value of assisted delivery but gave birth at home. They identified sociocultural determinants related to their representations and bodily experiences; the risks and emotions (fear, stress, anxiety) associated with pregnancy; the onset of labor and delivery; and their weak autonomy in terms of movement, decision-making, and economic agency. Nomadic women are not free in their movements, and in order to seek care, they require the permission and support of a man (husband, brother, or father). Furthermore, the participants are housewives, and men control family resources and make decisions regarding all financial matters. Assisted delivery is often only considered when there are complications.

CONCLUSION

This research has made it possible to understand the sociocultural determinants of the use of assisted childbirth among nomadic women, which should be taken into account when organizing health services for these populations.

Social network correlates of risky sexual behavior among adolescents in Bahir Dar and Mecha Districts, North West Ethiopia: an institution-based study

Background

Behaviors established during adolescence such as risky sexual behaviors have negative effects on future health and well-being. Extant literature indicated that individual attributes such as peer pressure and substance use have impacts on healthy development of young peoples’ sexual behavior. The patterns of relationships (social network structure) and the social network content (members’ norm regarding sexual practice) established by adolescents’ network on adolescents’ risky sexual behaviors are not well investigated.

Methods

This cross-sectional study assessed the roles of social networks on sexual behavior of high school adolescents in Bahir Dar and Mecha district, North West Ethiopia. Data were collected from 806 high school adolescents using a pretested anonymously self administered questionnaire. Hierarchical logistic regression model was used for analysis.

Results

The results indicated that more than 13% had risky sexual behavior. Taking social networks into account improved the explanation of risky sexual behavior over individual attributes. Adolescents embedded within increasing sexual practice approving norm (AOR 1.61; 95%CI: 1.04 – 2.50), increasing network tie strength (AOR 1.12; 95% CI: 1.06 – 1.19), and homogeneous networks (AOR 1.58; 95% CI: .98 – 2.55) were more likely to had risky sexual behavior. Engaging within increasing number of sexuality discussion networks was found protective of risky sexual behavior (AOR .84; 95% CI: .72 – .97).

Conclusion

Social networks better predict adolescent’s risky sexual behavior than individual attributes. The findings indicated the circumstances or contexts that social networks exert risks or protective effects on adolescents’ sexual behavior. Programs designed to reduce school adolescents’ sexual risk behavior should consider their patterns of social relationships.

Women's social networks and use of facility delivery services for uncomplicated births in North West Ethiopia: a community-based case-control study

BACKGROUND

High maternal mortality has remained an unmet public health challenge in the developing world. Maternal mortality in Ethiopia is among the highest in the world. Since most maternal deaths occur during labor, delivery, and the immediate postpartum period, facility delivery with skilled birth attendants is recommended to reduce maternal mortality. Nonetheless, the majority of women in Ethiopia give birth at home. Individual attributes and availability and accessibility of services deter service utilization. The role of social networks that may facilitate or constrain service use is not well studied.

METHODS

Community-based case-control study was conducted between February and March 2014 in Jabi Tehinan District, North West Ethiopia. Retrospective data were collected from 134 women who had uncomplicated births at health facilities and 140 women who had uncomplicated births at home within a year preceding the survey. Interviews were held with eight women who had uncomplicated births at health facilities and 11 who had uncomplicated births at home. The quantitative data were entered and analyzed using SPSS for Windows versions 16.0 and hierarchical logistic regression model was used for analysis. The qualitative data were transcribed verbatim and data were used to substantiate the quantitative data.

RESULTS

The results indicated that social network variables were significantly associated with the use of health facilities for delivery. Taking social networks into account improved the explanation of facility use for delivery services over women's individual attributes. Women embedded within homogeneous network members (Adjusted OR 2.53; 95% CI: 1.26-5.06) and embedded within high SBA endorsement networks (Adjusted OR 7.97; 95% CI: 4.07-12.16) were more likely to deliver at health facilities than their counterparts. Women living in urban areas (Adjusted OR 3.32; 95% CI: 1.37-8.05) and had better knowledge of obstetric complications (Adjusted OR 3.01; 95% CI: 1.46-6.18) were more likely to deliver at health facilities.

CONCLUSION

Social networks facilitate SBA utilization by serving as a reference for the behavior to deliver at health facilities. These findings inform health professionals and other stakeholders regarding the importance of considering women's social networks in designing intervention to increase the proportion of women who deliver at health facilities.

Why rely on friends instead of family? The role of exchanges and civic engagement in a rural sub-Saharan African context

Social science research has shown there is a nearly universal norm of seeking assistance from family members in times of need. However, when do individuals prefer to rely on friends, rather than family members, when they need support? This question has not been carefully addressed. To fill this gap in the literature we examine why rural Malawians - who typically have strong bonds with kin - might prefer to rely on friends instead of family if a crisis were to occur. Using the 2008 and 2010 waves of the Malawi Longitudinal Study of Families and Health (MLSFH), we consider how financial and non-financial exchanges with kin, and civic engagement, are associated with the composition of individuals' support networks. We find the decision to request a friend's help during a crisis is consistently associated with participation in civic-oriented activities, expanding our understanding of the determinants of different risk-pooling strategies.

Promotion of couples' voluntary HIV counseling and testing: a comparison of influence networks in Rwanda and Zambia

BACKGROUND

Many African adults do not know that partners in steady or cohabiting relationships can have different HIV test results. Despite WHO recommendations for couples' voluntary counseling and testing (CVCT), fewer than 10 % of couples have been jointly tested and counseled. We examine the roles and interactions of influential network leaders (INLs) and influential network agents (INAs) in promoting CVCT in Kigali, Rwanda and Lusaka, Zambia.

METHODS

INLs were identified in the faith-based, non-governmental, private, and health sectors. Each INL recruited and mentored several INAs who promoted CVCT. INLs and INAs were interviewed about demographic characteristics, promotional efforts, and working relationships. We also surveyed CVCT clients about sources of CVCT information.

RESULTS

In Zambia, 53 INAs and 31 INLs were surveyed. In Rwanda, 33 INAs and 27 INLs were surveyed. Most (75 %-90 %) INAs believed that INL support was necessary for their promotional work. Zambian INLs reported being more engaged with their INAs than Rwandan INLs, with 58 % of Zambian INLs reporting that they gave a lot of support to their INAs versus 39 % in Rwanda. INAs in both Rwanda and Zambia reported promoting CVCT via group forums (77 %-97 %) and speaking to a community leader about CVCT (79 %-88 %) in the past month. More Rwandan INAs and INLs reported previous joint or individual HIV testing compared with their Zambian counterparts, of which more than half had not been tested. In Zambia and Rwanda, 1271 and 3895 CVCT clients were surveyed, respectively. Hearing about CVCT from INAs during one-on-one promotions was the most frequent source of information reported by clients in Zambia (71 %). In contrast, Rwandan couples who tested were more likely to have heard about CVCT from a previously tested couple (59 %).

CONCLUSIONS

CVCT has long been endorsed for HIV prevention but few couples have been reached. Influential social networks can successfully promote evidence-based HIV prevention in Africa. Support from more senior INLs and group presentations leveraged INAs' one-on-one promotions. The INL/INA model was effective in promoting couples to seek joint HIV testing and counseling and may have broader application to other sub-Saharan African countries to sustainably increase CVCT uptake.

HIV Risk Perceptions, the Transition to Marriage, and Divorce in Southern Malawi

Little is known about whether the timing of marriage is used as a strategy to avoid HIV infection among young people in sub-Saharan Africa. Analyzing five rounds of longitudinal data from the Malawi Schooling and Adolescent Survey, we do not find support for the hypothesis that young women's perceived chances of future HIV infection are associated with the transition to marriage, but we do find evidence that young married women who see themselves as at risk of future infection have a greater likelihood of divorcing than do women who perceive no chance of future infection. We also use individual-level fixed-effects regressions to examine how the transition to marriage affects respondents' expectations of future HIV infection. Respondents are consistently more likely to perceive any chance of future HIV infection in the years following marriage than in the years preceding it. Our findings suggest that young women revise their risk perceptions based on their marital experiences and that divorce may serve as a protective strategy for young married women concerned about their chance of future HIV infection.

Persistent misconceptions about HIV transmission among males and females in Malawi

Background

The prevalence of HIV in Malawi is one of the highest in sub-Saharan Africa, and misconceptions about its mode of transmission are considered a major contributor to the continued spread of the virus.

Methods

Using the 2010 Malawi Demographic and Health Survey, the current study explored factors associated with misconceptions about HIV transmission among males and females.

Results

We found that higher levels of ABC prevention knowledge were associated with lower likelihood of endorsing misconceptions among females and males (OR = 0.85, p < 0.001; OR = 0.85, p < 0.001, respectively). Compared to those in the Northern region, both females and males in the Central (OR = 0.54, p < 0.001; OR = 0.53, p < 0.001, respectively) and Southern regions (OR = 0.49, p < 0.001; OR = 0.43, p < 0.001, respectively) were less likely to endorse misconceptions about HIV transmission. Moreover, marital status and ethnicity were significant predictors of HIV transmission misconceptions among females but not among males. Also, household wealth quintiles, education, religion, and urban–rural residence were significantly associated with endorsing misconceptions about HIV transmission.

Conclusion

Based on our findings, we recommend that education on HIV transmission in Malawi should integrate cultural and ethnic considerations of HIV/AIDS.

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

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

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

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

The Spouse's Level of Education and Individuals' Dietary Behaviors in China

BACKGROUND

There has been a growing interest in understanding relationships between educational attainment of an individual and his or her spouse's health. However, the issue has not been extensively studied, particularly in East Asian nations.

PURPOSE

We investigated the relation between individuals' specific dietary behaviors and their spouses' educational attainment in China.

METHOD

A total of 2071 individuals were surveyed in the 2012 Zhuzhou Healthy City Project, in China. Multivariate logistic regressions were used to model two specific individual dietary behaviors (i.e., oil intake and salt intake) as a function of own and their spouses' educational attainment. The models were also constructed by gender.

RESULTS

Spouses' education was positively associated both with individuals' oil intake and salt intake after adjusting for the demographic characteristics, socioeconomic status, and health knowledge. Also, females (i.e., wives) were more likely to benefit from her spouse's education in terms of healthy dietary behaviors. When his or her spouse's level of education were greater, an individual was more likely to meet the dietary guidelines of salt and oil intakes. This Chinese study supports the male dominance hypothesis (i.e., males are more influential on female's health behavior) and the highest status dominance hypothesis (i.e., individuals with higher socioeconomic status are more influential on those with lower status). In terms of the social cognitive theory, married couples exchange health knowledge and share health behaviors.

CONCLUSION

Spouses' educational attainment and health knowledge should be incorporated into the design of health promotion programs targeting married couples in China. Finally, additional theoretical explanations and implications are evaluated in this article.

The effect of peers on HIV infection expectations among Malawian adolescents: Using an instrumental variables/school fixed effect approach

Malawian adolescents overestimate their HIV infection risk. Understanding why they do so is important since such overestimation is likely to be linked to later-life outcomes. This study focuses on the influence peers have on HIV infection expectations. I use novel school-based survey data collected in Malawi between October 2011 and March 2012 (n = 7910), which has more reliable measures of peers' HIV infection expectations than other studies. I employ a combined instrumental variables/fixed effects methodology designed to addresses several methodological challenges in estimating peer effects, including self-selection of friends, the issue of unobserved environmental confounders, and the bi-directionality of peer effects. Several tests are conducted in order to assess the robustness of the specifications. Results suggest that a one-percentage-point increase in the mean probabilistic expectation of HIV infection among peers increases an adolescent's own subjective expectation of infection by an average of 0.65 percentage points. This paper shows that peer influence is greater for males than for females. Results also suggest that the peer effects on HIV infection expectations are only statistically significant among those lacking more complete knowledge of HIV/AIDS.

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.

Cross-cultural and site-based influences on demographic, well-being, and social network predictors of risk perception in hazard and disaster settings in Ecuador and Mexico: predictors of risk perception in hazard and disaster settings in Ecuador and Mexico

Although virtually all comparative research about risk perception focuses on which hazards are of concern to people in different culture groups, much can be gained by focusing on predictors of levels of risk perception in various countries and places. In this case, we examine standard and novel predictors of risk perception in seven sites among communities affected by a flood in Mexico (one site) and volcanic eruptions in Mexico (one site) and Ecuador (five sites). We conducted more than 450 interviews with questions about how people feel at the time (after the disaster) regarding what happened in the past, their current concerns, and their expectations for the future. We explore how aspects of the context in which people live have an effect on how strongly people perceive natural hazards in relationship with demographic, well-being, and social network factors. Generally, our research indicates that levels of risk perception for past, present, and future aspects of a specific hazard are similar across these two countries and seven sites. However, these contexts produced different predictors of risk perception-in other words, there was little overlap between sites in the variables that predicted the past, present, or future aspects of risk perception in each site. Generally, current stress was related to perception of past danger of an event in the Mexican sites, but not in Ecuador; network variables were mainly important for perception of past danger (rather than future or present danger), although specific network correlates varied from site to site across the countries.

Promotion of couples' voluntary HIV counselling and testing in Lusaka, Zambia by influence network leaders and agents

OBJECTIVES

Hypothesising that couples' voluntary counselling and testing (CVCT) promotions can increase CVCT uptake, this study identified predictors of successful CVCT promotion in Lusaka, Zambia.

DESIGN

Cohort study.

SETTING

Lusaka, Zambia.

PARTICIPANTS

68 influential network leaders (INLs) identified 320 agents (INAs) who delivered 29 119 CVCT invitations to heterosexual couples.

INTERVENTION

The CVCT promotional model used INLs who identified INAs, who in turn conducted community-based promotion and distribution of CVCT invitations in two neighbourhoods over 18 months, with a mobile unit in one neighbourhood crossing over to the other mid-way through.

PRIMARY OUTCOME

The primary outcome of interest was couple testing (yes/no) after receipt of a CVCT invitation. INA, couple and invitation characteristics predictive of couples' testing were evaluated accounting for two-level clustering.

RESULTS

INAs delivered invitations resulting in 1727 couples testing (6% success rate). In multivariate analyses, INA characteristics significantly predictive of CVCT uptake included promoting in community-based (adjusted OR (aOR)=1.3; 95% CI 1.0 to 1.8) or health (aOR=1.5; 95% CI 1.2 to 2.0) networks versus private networks; being employed in the sales/service industry (aOR=1.5; 95% CI 1.0 to 2.1) versus unskilled manual labour; owning a home (aOR=0.7; 95% CI 0.6 to 0.9) versus not; and having tested for HIV with a partner (aOR=1.4; 95% CI 1.1 to 1.7) or alone (aOR=1.3; 95% CI 1.0 to 1.6) versus never having tested. Cohabiting couples were more likely to test (aOR=1.4; 95% CI 1.2 to 1.6) than non-cohabiting couples. Context characteristics predictive of CVCT uptake included inviting couples (aOR=1.2; 95% CI 1.0 to 1.4) versus individuals; the woman (aOR=1.6; 95% CI 1.2 to 2.2) or couple (aOR=1.4; 95% CI 1.0 to 1.8) initiating contact versus the INA; the couple being socially acquainted with the INA (aOR=1.6; 95% CI 1.4 to 1.9) versus having just met; home invitation delivery (aOR=1.3; 95% CI 1.1 to 1.5) versus elsewhere; and easy invitation delivery (aOR=1.8; 95% CI 1.4 to 2.2) versus difficult as reported by the INA.

CONCLUSIONS

This study demonstrated the ability of influential people to promote CVCT and identified agent, couple and context-level factors associated with CVCT uptake in Lusaka, Zambia. We encourage the development of CVCT promotions in other sub-Saharan African countries to support sustained CVCT dissemination.

Spousal communication about HIV prevention in Kenya

High HIV rates among cohabiting couples in many African countries have led to greater programmatic emphasis on spousal communication in HIV prevention. This study examines how demographic and socioeconomic characteristics of cohabiting adults influence their dyadic communication about HIV. A central focus of this research is on how the position of women relative to their male partners influences spousal communication about HIV prevention. The authors analyze gaps in spousal age and education and females' participation in household decision making as key factors influencing spousal communication about HIV, while controlling for sexual behaviors of both partners as well as other individual and contextual factors. Data were obtained from the 2003 Kenya Demographic and Health Survey for 1,388 cohabiting couples. Information regarding spousal communication was self-reported, assessing whether both, either, or neither partner ever discussed HIV prevention with the other. Analyses showed higher levels of education for the female partner and participation in household decision making are positively associated with spousal communication about HIV prevention. With females' education and other factors controlled, couples with more educated male partners were more likely to have discussed HIV prevention than couples in which both partners have the same level of education. Spousal communication was also positively associated with household wealth status and exposure to the mass media, but couples in which male partners reported having nonspousal sex in the past year were less likely to have discussed HIV prevention with their spouses. Findings suggest HIV prevention programs should promote female empowerment and encourage male participation in sexual health discussion.

How to do (or not to do) ... a social network analysis in health systems research

The main challenges in international health are to scale up effective health interventions in low- and middle-income countries in order to reach a higher proportion of the population. This can be achieved through better insight into how health systems are structured. Social network analysis can provide an appropriate and innovative paradigm for the health systems researcher, allow new analyses of the structure of health systems, and facilitate understanding of the role of stakeholders within a health system. The social network analysis methodology adapted to health systems research and described in detail by the authors comprises three main stages: (i) describing the set of actors and members of the network; (ii) characterizing the relationships between actors; and (iii) analysing the structure of the systems. Evidence generated through social network analysis could help policy makers to understand how health systems react over time and to better adjust health programmes and innovations to the capacities of health systems in low- and middle-income countries to achieve universal coverage.

Nonresponse in repeat population-based voluntary counseling and testing for HIV in rural Malawi

Despite the increasing number of population-based surveys in sub-Saharan Africa that provide testing and counselingfor HIV over the past decade, understanding the nature ofnonresponse in these surveys, especially panel HIV surveys, is still limited. This article uses longitudinal HIV data collected from rural Malawi in 2004 and 2006 to examine nonresponse in repeat population-based testing. It shows that nonresponse in repeat testing led to significant bias in the estimates of HIV prevalence and to inconsistent conclusions about the predictors of HIV status. In contrast, previous cross-sectional analyses found that nonresponse does not significantly bias the estimates of HIV prevalence. The difference in conclusions from cross-sectional and longitudinal analyses of nonresponse can be attributed to two factors. the different definitions of what constitutes nonresponse in both contexts, and the risk profiles of the missed populations. In particular, although refusal and temporary absence are the major sources ofnonresponse in the cross-sectional contexts, attrition attributable to mortality and out-migration are additional sources of nonresponse in repeat testing. Evidence shows that out-migrants have higher HIV prevalence than nonmigrants, which could account for significant bias in the estimates ofprevalence among participants in both tests observed in this study.

Socioeconomic effects of HIV/AIDS and farmers' involvement in risky behaviour in southern Nigeria

This article analyses farmers' perceptions on the socioeconomic effects of HIV/AIDS and factors associated with their involvement in risky behaviour in southern part of Nigeria. The data were collected in 2004 from 515 farmers in five randomly selected states in southern Nigeria. The results show that most of the affected farmers spend reduced hours in daily work, as well as having a reduced income and reduced participation in community development due to HIV/AIDS. Logistic regression reveals that age and education significantly reduce the probability of being involved in behaviour conducive to HIV/AIDS infection, which is increased by not believing in the existence of HIV/AIDS, ignorance about HIV/AIDS methods of prevention, lack of warning about HIV/AIDS, reports of HIV/AIDS in the village, the distance to the public health centre and the lack of a health centre. These findings, while unsurprising, emphasise the importance of HIV/AIDS as a socioeconomic issue.

A qualitative study on commercial sex behaviors among male clients in Sichuan Province, China

Males who seek commercial sex have been identified as an important "bridging population" in the transmission of HIV. There is little information on the HIV-related risk perceptions and behaviors among commercial sex male clients (CSMCs) in China. This study reports qualitative findings from six focus groups and 41 in-depth interviews with CSMCs in Sichuan Province, China. Commercial sex visits were described as a group activity and associated with patterns of social-network specific interactions and norms. Primary motivations for visiting female sex workers included peer pressure, stress reduction, and fulfilling a need for an intimate and emotional support. Male clients' decisions about condom use were influenced by their perceived norms of condom use, susceptibility of HIV infection, and the condom policy and availability in the establishments. Implications of these findings for further research and interventions are discussed.

The Malawi Religion Project: Data collection and selected analyses

Scholars have recently become increasingly interested in the role religion plays in the responses to the HIV/AIDS epidemic in sub-Saharan Africa. Here, we present the Malawi Religion Project (MRP), which provides data to examine the relationship between religion and HIV/AIDS through surveys and in-depth interviews with denominational leaders, congregational leaders, and congregation members in three districts of rural Malawi. In the paper, we outline existing perspectives on the religion-HIV/AIDS link, describe the MRP's design, implementation, and subsequent data; provide initial evidence for a series of general research hypotheses; and describe how these data can be used both to extend explorations of these relationships further and as a model for gathering similar data in other contexts. In particular we highlight the unique possibilities this project provides for analyses that link MRP data to the Malawi Diffusion and Ideational Change Project. These linked data produce a multi-level data set covering individuals, congregations and their communities, allowing empirical research on religion, HIV/AIDS risk, related behaviors, attitudes, and norms.

Estimating HIV prevalence and risk behaviors among high-risk heterosexual men with multiple sex partners: use of respondent-driven sampling

OBJECTIVES

To collect HIV data from high-risk men who have multiple, younger, female sex partners in a periurban township in South Africa.

DESIGN

Unlinked anonymous cross-sectional survey using respondent-driven sampling.

METHODS

Survey conducted among men aged 18 years or older who reported having had sex with more than 1 female partner in the previous 3 months (one of whom was either 3 or more years younger than the participant or below the age of 24) and lived in the area of recruitment.

RESULTS

The median age of the 421 recruited men was 28 years (range: 18-62 years). They reported a median of 6 sexual partners (range: 2-39) during the past 3 months, and 51% (confidence interval: 45.0 to 59.6) reported inconsistent condom use with their casual partners. During the 3 months before the survey, 98% of men reported having concurrent sexual relationships. HIV prevalence was 12.3% (confidence interval: 8.3% to 16.9%). Being older than 24 years and not using a condom during the last sexual intercourse with a 1-time sexual partner were significantly associated with HIV infection.

CONCLUSIONS

This group of heterosexual urban men practice high levels of risky sexual behavior and are an important group that require more targeted HIV surveillance and prevention interventions.

What the better half is thinking: A comparison of men's and women's responses and agreement between spouses regarding reported sexual and reproductive behaviors in Rwanda

Objective

To compare responses to a sexual behavioral survey of spouses in cohabiting heterosexual relationships in Kigali, Rwanda.

Design

Cross-sectional survey.

Methods

Husbands and wives in 779 cohabiting couples were interviewed separately with parallel questionnaires. Participants were recruited from a three-year old cohort of 1458 antenatal clinic attendees enrolled in a prospective study in 1988. Analyses compared responses at the gender- and couple-level for agreement and disagreement.

Results

Couples were in disagreement more than agreement. Women reported occasionally refusing sex, suggesting condom use, and believing married men were unfaithful. Men reported being in a faithful relationship, greater condom use, and being understanding when wives refused sex. Agreement included relationship characteristics, safety of condoms, and whether condoms had ever been used in the relationship. Disagreement included the preferred timing of next pregnancy, desire for more children, and whether a birth control method was currently used and type of method.

Conclusions

Rwandan husbands and wives differed in sexual behavior and reproductive-related topics. Couple-level reporting provides the most reliable measure for relationship aspects as couples’ agreement cannot be assumed among cohabiting partnerships. Furthermore, HIV prevention programs for couples should incorporate communication skills to encourage couple agreement of HIV-related issues.

Marriage behavior response to prime-age adult mortality: evidence from Malawi

This article examines the effect of AIDS-related mortality of the prime-age adult population on marriage behavior among women in Malawi. A rise in prime-age adult mortality increases risks associated with the search for a marriage partner in the marriage market. A possible behavioral change in the marriage market in response to an increase in prime-age adult mortality is to marry earlier to avoid exposure to HIV/AIDS risks. We test this hypothesis by using micro data from Malawi, where prime-age adult mortality has drastically increased. In the analysis, we estimate the probability of prime-age adult mortality that sample women have observed during their adolescent period by utilizing retrospective information on deaths of their siblings. Empirical analysis shows that excess prime-age adult mortality in the local marriage market lowers the marriage age for females and shortens the interval between the first sex and first marriage.

Overestimating HIV infection: The construction and accuracy of subjective probabilities of HIV infection in rural Malawi

In the absence of HIV testing, how do rural Malawians assess their HIV status? In this paper, we use a unique dataset that includes respondents' HIV status as well as their subjective likelihood of HIV infection. These data show that many rural Malawians overestimate their likelihood of current HIV infection. The discrepancy between actual and perceived status raises an important question: Why are so many wrong? We begin by identifying determinants of self-assessed HIV status, and then compare these assessments with HIV biomarker results. Finally, we ask what characteristics of individuals are associated with errors in self-assessments.

Association between knowing someone who died of AIDS and behavior change among South African youth

In South Africa, the rising AIDS related mortality has increased the publicity of the HIV/AIDS epidemic and may have an impact on behavior change. We examined the association between knowing someone who has died of AIDS and self-reported behavior change, condom use at last intercourse, number of partners in the prior 12 months, and attitudes towards HIV, among South African youth aged 15-24. We found that over 40% of youth reported knowing someone who died of AIDS, most commonly a neighbor. Using multivariable logistic regression, we found that high school-educated youth who knew someone who died of AIDS were significantly more likely to report having changed their behavior as a result of HIV (OR 2.01, 95% CI: 1.32;3.06). We found no association between knowing someone who died of AIDS and other HIV prevention-related behaviors. While youth tended to have increased odds of perceiving HIV to be serious, they did not consistently perceive their risk of contracting HIV to be higher when they knew someone who died of AIDS. Our results suggest that part of the key to impacting behavior change in youth may lie in better understanding what factors increase youth's perceived risk of contracting HIV which will help us better target our interventions. If youth are impacted by personal knowledge of an AIDS death, to the point that they change their behaviors, we must continue to encourage discourse about HIV/AIDS with the hope that persons dying from AIDS will feel more comfortable disclosing their diagnosis to youth they know and others.

Iranian epidemiological training programs for AIDS prevention in Mazandaran Province

The aim of this study to report data is derived from an investigation of the knowledge, attitudes, beliefs and practices of AIDS prevention among the large the descendant of the Iranian prisoners. Using a multistage area sampling method, a random sample of individuals aged 18-65 years in southern coastwise of the Caspian Sea from February to December 2006. To select a representative sample of the prisoners' population within 5 different prisons in Mazandaran Province had the same probability to be sampled. Prisoners who agreed to participate were given a four-page self-administered questionnaire. 760 (88%) of the 2000 eligible participants completed the questionnaire. The mean age of respondents was 30.05 +/- 8.1 years ranging from 18 to 59, 1686 (95.8%) were male and mostly married 1054 (59.9%) and had received secondary education or above 1178 (66.9%). Most respondents (1690, 96%) had household income levels low or average and 716 (40.7%) were out of work. The findings indicated that the respondents had average to fairly good knowledge about AIDS. The correct answers ranged from 11.9% to about 85.9%. Also the results showed that the majority of the respondents were strongly agree or agree with the statement that people with AIDS should have social right to study or work (1378, 78.3%) or with the statement that AIDS is public health problem (1522, 86.5%). The majority of the respondents (1538, 83.4%) said that the mass media including radio, television and newspapers were the main source of their information about HIV/AIDS. Such findings suggest that prevention programs should be encourage and these might have the potential role to limit the emergence of Iran's HIV/AIDS epidemic especially in prison's this of country.

Drug use in the social networks of heroin and cocaine users before and after drug cessation

The present study examined social control processes in drug cessation among adults. Social control theory posits that the association between drug use and the drug use of a person's social network results from an individual seeking out similar peers. The data included 629 individuals who reported past-year heroin or cocaine use at baseline and had follow-up data in a community study in Baltimore, MD. Negative binomial regression modeling indicated that the reduction in social network drug use was significantly greater for quitters than those who did not quit. Compared to non-quitters at baseline, the incidence rate ratio (IRR) of the number of drug-using network members was 0.86 for quitters at baseline, 0.71 for non-quitters at follow-up, and 0.28 for quitters at follow-up (all p<0.05). These findings support social control theory in adult drug use cessation. Future research should extend the length of follow-up and assess bidirectional influences.

Social support and response to AIDS and severe acute respiratory syndrome

Negative public reactions to emerging infectious diseases can adversely affect population health. We assessed whether social support was associated with knowledge of, worry about, and attitudes towards AIDS and severe acute respiratory syndrome. Our findings suggest that social support may be central to our understanding of public responses to emerging infectious diseases.

Promotion of couples' voluntary counselling and testing for HIV through influential networks in two African capital cities

BACKGROUND

Most new HIV infections in Africa are acquired from cohabiting heterosexual partners. Couples' Voluntary Counselling and Testing (CVCT) is an effective prevention strategy for this group. We present our experience with a community-based program for the promotion of CVCT in Kigali, Rwanda and Lusaka, Zambia.

METHODS

Influence Network Agents (INAs) from the health, religious, non-governmental, and private sectors were trained to invite couples for CVCT. Predictors of successful promotion were identified using a multi-level hierarchical analysis.

RESULTS

In 4 months, 9,900 invitations were distributed by 61 INAs, with 1,411 (14.3%) couples requesting CVCT. INAs in Rwanda distributed fewer invitations (2,680 vs. 7,220) and had higher response rates (26.9% vs. 9.6%), than INAs in Zambia. Context of the invitation event, including a discreet location such as the INA's home (OR 3.3-3.4), delivery of the invitation to both partners in the couple (OR 1.6-1.7) or to someone known to the INA (OR 1.7-1.8), and use of public endorsement (OR 1.7-1.8) were stronger predictors of success than INA or couple-level characteristics.

CONCLUSION

Predictors of successful CVCT promotion included strategies that can be easily implemented in Africa. As new resources become available for Africans with HIV, CVCT should be broadly implemented as a point of entry for prevention, care and support.

A broader perspective on education and mortality: are we influenced by other people's education?

The objective of this study was to find out whether the educational achievements of family members and people in the municipality have an impact on a person's mortality, net of the well-known strong influence of his or her own education. Using register data, discrete-time hazard models for all-cause mortality in 1980-2003 were estimated for all Norwegian men and women born between 1950 and 1973 (i.e. age 30-53). There were 23,692 deaths during the 19.1 million person-years of follow-up. The education of a former or current spouse had the clearest beneficial effect, although own education was more important. Mortality was also negatively associated with the education of the oldest sibling and to a lesser extent with that of the sibling-in-law and father-in-law. The average education in the municipality was not generally related to mortality, but a beneficial effect was seen among men with college education. In contrast to this, parents' education affected mortality adversely, especially among women. The data did not allow causal pathways to be identified, but possible mechanisms were discussed. For example, it was argued that others' education may affect mortality favourably through transmission of knowledge, imitation of behaviour, economic support, and the quality of health services. In some societies, childhood health might also be an issue. On the other hand, having better-educated family members or living in a community with many better-educated people, who typically also have higher incomes, may trigger psychosocial stress. However, one should be careful to interpret the observed relationships as reflecting purely causal effects. Various unobserved factors may influence the person's choice of spouse and place of residence as well as mortality, and having parents with higher (lower) education may signal that the person has had special problems (resources) during childhood or adolescence, which also may have implications for later health.

HIV infection does not disproportionately affect the poorer in sub-Saharan Africa

BACKGROUND

Wealthier populations do better than poorer ones on most measures of health status, including nutrition, morbidity and mortality, and healthcare utilization.

OBJECTIVES

This study examines the association between household wealth status and HIV serostatus to identify what characteristics and behaviours are associated with HIV infection, and the role of confounding factors such as place of residence and other risk factors.

METHODS

Data are from eight national surveys in sub-Saharan Africa (Kenya, Ghana, Burkina Faso, Cameroon, Tanzania, Lesotho, Malawi, and Uganda) conducted during 2003-2005. Dried blood spot samples were collected and tested for HIV, following internationally accepted ethical standards and laboratory procedures. The association between household wealth (measured by an index based on household ownership of durable assets and other amenities) and HIV serostatus is examined using both descriptive and multivariate statistical methods.

RESULTS

In all eight countries, adults in the wealthiest quintiles have a higher prevalence of HIV than those in the poorer quintiles. Prevalence increases monotonically with wealth in most cases. Similarly for cohabiting couples, the likelihood that one or both partners is HIV infected increases with wealth. The positive association between wealth and HIV prevalence is only partly explained by an association of wealth with other underlying factors, such as place of residence and education, and by differences in sexual behaviour, such as multiple sex partners, condom use, and male circumcision.

CONCLUSION

In sub-Saharan Africa, HIV prevalence does not exhibit the same pattern of association with poverty as most other diseases. HIV programmes should also focus on the wealthier segments of the population.

Social networks and HIV/AIDs risk perceptions

Understanding the determinants of individuals' perceptions of their risk of becoming infected with HIV and their perceptions of acceptable strategies of prevention is an essential step toward curtailing the spread of this disease. We focus in this article on learning and decision-making about AIDS in the context of high uncertainty about the disease and appropriate behavioral responses. We argue that social interactions are important for both. Using longitudinal survey data from rural Kenya and Malawi, we test this hypothesis. We investigate whether social interactions--and especially the extent to which social network partners perceive themselves to be at risk--exert causal influences on respondents' risk perceptions and on one approach to prevention, spousal communication about the threat of AIDS to the couple and their children. The study explicitly allows for the possibility that important characteristics, such as unobserved preferences or community characteristics, determine not only the outcomes of interest but also the size and composition of networks. The most important empirical result is that social networks have significant and substantial effects on risk perceptions and the adoption of new behaviors even after we control for unobserved factors.