Preventing HIV by providing support for orphan girls to stay in school: does religion matter?

Assessment of Consent Comprehension Among Kenyan Adolescents, Young Adults, and Parents: Comparison of Enhanced and Standard Consenting Procedures

PURPOSE

Youth aged 15-19 years and parents of minors aged 15-17 years in sub-Saharan Africa are under-represented in empirical consent research. Thus, knowledge is limited concerning the adequacy of consent procedures and need for strategies to improve consent comprehension among these groups. We assessed comprehension following standard consent procedures and evaluated an enhanced procedure among Kenyan youth and parents.

METHODS

Participants were adolescents aged 15-17 years (n = 273), their parents (n = 196), and young adults aged 18-19 years (n = 196). We used a quasi-experimental cohort design to implement standard and enhanced (single condition: extended discussion, test/feedback) consent procedures. Participants completed a 21-item informed consent comprehension assessment instrument.

RESULTS

After standard consent procedures, mean comprehension scores were 11.36, 13.64, and 13.43 (score range: 0-21) among adolescents, young adults, and parents, respectively. About 6.2% of adolescents, 19.6% of young adults, and 21.4% of parents answered ≥ 80% of the questions correctly. After the enhanced procedures, comprehension scores (15.87 adolescents, 17.81 young adults, and 16.77 parents) and proportions answering ≥ 80% of the questions correctly (44.9% adolescents, 76.8% young adults, and 64.3% parents) increased significantly. Regression analysis indicated statistically significant differences (p < .001) in comprehension scores between the enhanced and standard groups (β = 3.87 adolescents, β = 4.03 young adults, and β = 3.60 parents) after controlling for sociodemographic factors.

DISCUSSION

Enhancing consent procedures with extended discussions, quizzes, and additional explanation where understanding is inadequate is a promising approach for improving comprehension. However, poorer comprehension among adolescents compared to young adults and parents underscores the need for research to identify additional approaches to improve understanding.

Community Space, Community Groups, and Incident HIV Infection Among Adolescent Girls and Young Women in Rural South Africa: A Longitudinal Analysis of HIV Prevention Trials Network 068 Data

BACKGROUND

As adolescent girls and young women (AGYW) transition to adulthood, their interaction with their social context becomes a critical consideration for HIV prevention interventions. Few studies have examined what types of community groups and community spaces might be protective for AGYW HIV acquisition and related sexual behaviors.

METHODS

Data were obtained from HIV Prevention Trials Network 068, a longitudinal study of AGYW (age 13-20 years) in rural South Africa. Survival analyses and generalized estimating equations were used to assess whether community group membership and time spent in community spaces were associated with HIV incidence and sexual behaviors (unprotected sex, transactional sex, and having an older partner).

RESULTS

A total of 2245 AGYW were followed up for up to 4 years. Membership in church groups [adjusted hazard ratio (aHR): 0.75, 95% confidence interval (CI): 0.53 to 0.91] and dance groups (aHR: 0.89, 95% CI: 0.80 to 0.98) and spending time at church (aHR: 0.88, 95% CI: 0.79 to 0.98) were protective for HIV infection. Conversely, spending time at taverns was associated with higher HIV incidence (aHR: 1.27, 95% CI: 1.15 to 1.41). Membership in church groups and spending time at a family member's home and at church were protective for all 3 sexual behaviors. Spending time at a boyfriend's home and taverns was risky for all 3 sexual behaviors.

CONCLUSIONS

The results suggest that community spaces and community groups that include an element of adult supervision are potentially protective, whereas spaces and groups that provide an opportunity for AGYW to interact unsupervised with boyfriends or meet new partners are potentially risky.

Female autonomy and intimate partner violence: findings from the Zimbabwe demographic and health survey, 2015

Intimate partner violence is a persistent social problem in Zimbabwe and has been linked to patriarchal attitudes that promote the superiority of men in marital relationships while denying women agency. Using 2015 Zimbabwe Demographic and Health Survey data, we examined the influence of female autonomy on intimate partner violence. Our analysis was restricted to 2847 women who were in some form of sexual union. Consistent with earlier studies, our results show that more than 40% of the women had experienced some form of intimate partner violence. The most prevalent form of intimate partner violence was emotional violence, followed by physical violence and sexual violence. Low levels of economic autonomy and supportive attitudes towards wife-beating increased the risk of intimate partner violence, while late marriage reduced the risk of all forms of intimate partner violence. Findings provide a basis for interventions that may increase economic control and improve decision making for women, although the association between economic violence and economic decision making requires further research that examines the possibility of reverse causality.

Understanding HIV and associated risk factors among religious groups in Zimbabwe

BACKGROUND

The influence of religion and belief systems is widely recognized as an important factor in understanding of health risk perception and myths in the general fight against the HIV pandemic. This study compares the understanding of HIV risk factors and utilization of some HIV services among religious groups in Zimbabwe.

METHODS

We conducted secondary data statistical analysis to investigate the understanding of HIV and associated risk factors among religious groups in Zimbabwe using 2015-2016 Zimbabwe Demographic and Health Survey (ZDHS) data. We began by investigating associations between understanding of HIV and associated risk factors among religious groups. A multivariate stepwise backward elimination method was carried out to explore factors determining understanding of HIV risk after controlling for confounding factors using the most recent ZDHS data (2015-2016).

RESULTS

The results from the three surveys showed that, in general apostolic sector had low understanding of HIV and associated risk factors compared to other religious groups. Analysis of the 2015-2016 ZDHS data showed that women belonging to the apostolic sector were less likely to know where to get an HIV test odds ratio (OR) and 95% confidence interval, 0.665 (0.503-0.880) and to know that male circumcision reduces HIV transmission OR 0.863 (0.781-0.955). Women from this group had no knowledge that circumcised men can be infected if they do not use condoms OR 0.633 (0.579-0.693), nor that it is possible for a healthy-looking person to have HIV, OR 0.814 (0.719-0.921). They would not buy vegetables from a vendor with HIV OR 0.817 (0.729-0.915) and were less likely to support that HIV positive children should be allowed to attend school with HIV negative children OR 0.804 (0.680-0.950). Similar results were obtained for men in the apostolic sector. These men also did not agree that women were justified to use condoms if the husband has an Sexually Transmitted Infection (STI) OR 0.851 (0.748-0.967).

CONCLUSIONS

Our results suggest that apostolic sector lack adequate knowledge of HIV and associated risk factors than other religious groups. Targeting HIV prevention programmes by religious groups could be an efficient approach for controlling HIV in Zimbabwe.

AIDS-Affected Orphans in Sub-Saharan Africa: A Scoping Review on Outcome Differences in Rural and Urban Environments

Currently, there are more than 11 million AIDS-affected orphans that suffer from various adverse effects, most of whom reside in sub-Saharan Africa. The difference between whether a child resides in a rural or urban environment can have a significant role in a child's education, health status and access to healthcare, and social or family relationships. A scoping review was conducted in order to understand any possible environment-based differences on orphans directly affected by HIV/AIDS in sub-Saharan Africa. There were 233 sources used for this review; however, 164 manuscripts focused more so on a general review of orphans within a rural or urban environment. Thus, after eliminating for various factors, 69 manuscripts were removed, which focused primarily on the social aspect of orphans due to HIV/AIDS. Rural environments provided more family support, while urban environments generally had more resources available to orphans (e.g. school fees). Unfortunately, both rural and urban environments were found to be fairly non-supportive of orphans and their development. This scoping review found, in general, that orphans in both urban and rural environments continue to suffer from the consequential effects of low parental support due to AIDS mortality. These conclusions suggest that specific support to orphans through school and social relationships encourage better development outcomes in sub-Saharan Africa.

Delivering culturally sensitive, sexual health education in western Kenya: a phenomenological case study

While generic programmes have been created to raise sexual health awareness, these cannot always be applied to communities whose cultures and circumstances make them especially vulnerable to infection. Taking a phenomenological approach, this paper examines the circumstances of the Gusii people of Kisii, Kenya, and examines the specific challenges of providing sexual health education to the community as experienced by an ethnic Gusii woman, Joyce Ombasa. Joyce's story reveals that the Gusii living in and around rural villages have several cultural characteristics that make them susceptible to HIV/AIDS and that render community health education problematic, especially if offered by a female educator of the same ethnicity. Women cannot teach men. Discussions of sex and condom use, and viewing the naked bodies of the opposite sex are taboo. Promiscuity is commonplace and there is a reluctance to use condoms and to undergo HIV testing. Female circumcision persists and there is a high rate of sexual violence, incest and intergenerational sexual intercourse. In addition, government policies and legislation threaten to exacerbate some of the sexually risky behaviours. Bringing HIV education and female empowerment to the rural Gusii requires a culturally sensitive approach, discarding sexual abstinence messages in favour of harm minimisation, including the promotion of condom use, regular HIV testing and the rejection of female circumcision and intergenerational sex. Trust needs to be built through tactics such as adopting a complex and fluid outsider identity and replacing formal sex education with training in income generating skills and casual discussions regarding condoms and sexual health.

'I thought if I marry the prophet I would not die': The significance of religious affiliation on marriage, HIV testing, and reproductive health practices among young married women in Zimbabwe

This study examines the association between religious affiliation and reasons for marriage, perceived church attitudes, and reproductive health-seeking behaviors, including HIV testing, among young women in eastern rural Zimbabwe. The sample comprised women (N = 35) who had married by 2012 while participating in a larger randomized controlled trial (RCT) to test the effects of school support on HIV-related risk. The RCT sample was identified in 2007 as all female sixth graders in 25 rural eastern Zimbabwe primary schools whose parents, one or both, had died (N = 328). In our previous RCT analyses, we found that participants who affiliated with an Apostolic church were more than four times more likely to marry than those from non-Apostolic churches and that control group participants were twice as likely to marry as those in the intervention group. Other studies had found that marriage greatly increased the odds of HIV infection among adolescent women. Given the link between Apostolic affiliation and marriage, we conducted semi-structured interviews to explore type of marriage, reasons for marrying, church affiliation and attitudes, family planning, HIV testing, schooling, and family life. We were interested in differences, as perceived by our sample of young married women congregants, among Apostolic sects and other denominations in their attitudes about marriage and health-seeking behaviors. We were also interested in the influence of church affiliation on intervention participants' decision to marry, since they had comprehensive school support and education is highly valued in Zimbabwe, but costly and often out of financial reach. Interviews were conducted from October 2012 through November 2013; data were analyzed using a general inductive approach. We found that pressure or perceived deception for coitus or marriage was reported only by intervention participants affiliated with Apostolic denominations. Other reasons for marriage were similar between Apostolic and non-Apostolic adherents, as well as intervention and control conditions. All participants believed HIV testing was important, but while all non-Apostolic denominations encouraged HIV testing and clinic/hospital care, there was considerable heterogeneity in attitudes among Apostolics, with ultraconservative denominations most likely to proscribe non-religious health care. We conclude that some, but not all, Apostolic-affiliated women are afforded discretion in their health-seeking behaviors. Since HIV screening and treatment depend on access to clinic/hospital care, continued public health efforts to engage Apostolic leaders is needed, along with monitoring of progress in access and outcomes.

Influence of school support on early marriage experiences and health services utilization among young orphaned women in Zimbabwe

School support programs reduce school dropout, early marriage, and early pregnancy for a majority of young orphaned women. We used a mixed-methods approach to examine why these programs are less effective for a significant minority by exploring their influence on marriage and health services utilization. Participants were from a randomized controlled trial testing school support as HIV prevention. Half as many intervention as control participants had been married; married intervention participants had 1 more year of education compared with married control participants. Receiving school support did not appear to improve health-related factors. Pregnancy was among the most common reasons for marriage across both groups. The greatest benefit of school support appears to be in delaying marriage and pregnancy while increasing educational attainment.

Factors Associated with Ever Being HIV-Tested in Zimbabwe: An Extended Analysis of the Zimbabwe Demographic and Health Survey (2010-2011)

INTRODUCTION

Zimbabwe has a high human immunodeficiency virus (HIV) burden. It is therefore important to scale up HIV-testing and counseling (HTC) as a gateway to HIV prevention, treatment and care.

OBJECTIVE

To determine factors associated with being HIV-tested among adult men and women in Zimbabwe.

METHODS

Secondary analysis was done using data from 7,313 women and 6,584 men who completed interviewer-administered questionnaires and provided blood specimens for HIV testing during the Zimbabwe Demographic and Health Survey (ZDHS) 2010-11. Factors associated with ever being HIV-tested were determined using multivariate logistic regression.

RESULTS

HIV-testing was higher among women compared to men (61% versus 39%). HIV-infected respondents were more likely to be tested compared to those who were HIV-negative for both men [adjusted odds ratio (AOR) = 1.53; 95% confidence interval (CI) (1.27-1.84)] and women [AOR = 1.42; 95% CI (1.20-1.69)]. However, only 55% and 74% of these HIV-infected men and women respectively had ever been tested. Among women, visiting antenatal care (ANC) [AOR = 5.48, 95% CI (4.08-7.36)] was the most significant predictor of being tested whilst a novel finding for men was higher odds of testing among those reporting a sexually transmitted infection (STI) in the past 12 months [AOR = 1.86, 95%CI (1.26-2.74)]. Among men, the odds of ever being tested increased with age ≥ 20 years, particularly those 45-49 years [AOR = 4.21; 95% CI (2.74-6.48)] whilst for women testing was highest among those aged 25-29 years [AOR = 2.01; 95% CI (1.63-2.48)]. Other significant factors for both sexes were increasing education level, higher wealth status and currently/formerly being in union.

CONCLUSIONS

There remains a high proportion of undiagnosed HIV-infected persons and hence there is a need for innovative strategies aimed at increasing HIV-testing, particularly for men and in lower-income and lower-educated populations. Promotion of STI services can be an important gateway for testing more men whilst ANC still remains an important option for HIV-testing among pregnant women.

HIV infection and related risk behaviors: does school support level the playing field between orphans and nonorphans in Zimbabwe?

Research is limited on whether providing school support to female adolescent orphans mitigates their HIV risk disadvantage compared to other female adolescents. This paper examines 2011 Zimbabwe Demographic and Health Survey (ZDHS) HIV-related biomarker and behavior data for orphaned and nonorphaned rural adolescent females to compare findings from a similar sample participating in a randomized controlled trial (RCT) testing school support as HIV prevention. HIV status, marriage, pregnancy, sexual debut, school dropout, years of schooling, and socioeconomic status were analyzed with the combined data-sets. Bivariate analyses compared variables between RCT comprehensive intervention and delayed partial intervention conditions, and between ZDHS orphan and nonorphan groups. Multivariable analyses included a series of group comparisons as follows: ZDHS orphans vs. ZDHS nonorphans; RCT orphans in each condition vs. ZDHS nonorphans; RCT orphans in each condition vs. ZDHS orphans. Analyses methods accounted for the complex survey sampling design within each data-set. A total of 751 observations were included. All orphan groups had consistently higher odds of HIV infection than ZDHS nonorphans. ZDHS orphans had higher odds of marriage, pregnancy, and sexual debut than ZDHS nonorphans. Comprehensive intervention participants had lower odds of marriage, sexual debut, and school dropout than ZDHS nonorphans. RCT participants in both conditions had lower odds of marriage, sexual debut, and school dropout than ZDHS orphans. The findings indicate that orphans are at a distinct disadvantage to HIV risk compared to nonorphans, and much of this is likely related to vertical transmission. We found no evidence that provision of school fees to orphans will reduce their risk of HIV infection relative to nonorphans but further evidence that such programs may reduce risk behaviors including early sexual debut, child marriage, and school dropout. Further research is needed to determine how these programs can be sustainably scaled-up in resource-limited settings.

Educational Outcomes for Orphan Girls in Rural Zimbabwe: Effects of a School Support Intervention

Educational achievement has important implications for the health and well-being of young women in sub-Saharan Africa. The authors assessed the effects of providing school support on educational outcomes of orphan girls in rural Zimbabwe. Data were from a randomized controlled trial offering the intervention group comprehensive schooling support and controls no treatment initially and then fees only. Results indicated comprehensive support reduced school dropout and absence but did not improve test scores. Providing support to orphan girls is promising for addressing World Health Organization Millennium Development Goals, but further research is needed about contextual factors affecting girls' school participation and learning.

The impact of school subsidies on HIV-related outcomes among adolescent female orphans

PURPOSE

We examine effects of school support as a structural HIV prevention intervention for adolescent female orphans in Zimbabwe after 5 years.

METHODS

Three hundred twenty-eight orphan adolescent girls were followed in a clustered randomized controlled trial from 2007 to 2010. The experimental group received school fees, uniforms, and school supplies and were assigned a school-based "helper." In 2011-2012, the control group received delayed partial treatment of school fees only. At the final data point in 2012, survey, HIV, and Herpes Simplex Virus Type 2 (HSV-2) biomarker data were collected from approximately 88% of the sample. Bivariate and multivariate analyses were conducted on end point outcomes, controlling for age, religious affiliation, and baseline socioeconomic status.

RESULTS

The two groups did not differ on HIV or HSV-2 biomarkers. The comprehensive 5-year intervention continued to reduce the likelihood of marriage, improve school retention, improve socioeconomic status (food security), and marginally maintain gains in quality of life, even after providing school fees to the control group.

CONCLUSIONS

Paying school fees and expenses resulted in significant improvements in life outcomes for orphan adolescent girls. Biological evidence of HIV infection prevention, however, was not observed. Our study adds to the growing body of research on school support as HIV prevention for girls in sub-Saharan Africa, but as yet, no clear picture of effectiveness has emerged.

A Mixed Methods Mapping of Church versus Secular School Messages to Influence Sexual Decision-Making as Perceived by Zimbabwean Orphan Girl Students

This study examined the messages perceived by adolescent girls with orphanhood to influence their sexual decision-making. Participants were 125 students (mean age =14.7 years), 54% of whom attended church schools in a rural district of eastern Zimbabwe. We collected and analyzed data using concept mapping, a mixed method approach that enabled the construction of message clusters, with weighting for their relative importance. Messages that clustered under Biblical Teachings and Life Planning ranked highest in salience among students in both church and secular schools. Protecting Family Honor, HIV Prevention, and Social Stigma messages ranked next, respectively. Contrary to study hypotheses, the messages that orphan adolescent girls perceived to influence their sexual decisions did not vary by type of school attended.

Is religion the forgotten variable in maternal and child health? Evidence from Zimbabwe

The Apostolic faith, a rapidly growing and increasingly influential force in Zimbabwe, has received attention in the literature due to its potential role in shaping its followers' attitudes and behaviours towards health. Existing literature, however, has only examined small cross-section samples from a few confined survey sites or has failed to adequately control for the many factors that may mediate the effects of religion. This paper examines the effects of the Apostolic faith on the usage of maternal health and child immunization services in Zimbabwe. It is based on a nationally representative sample from the 2009 Multi-Indicator Monitoring Survey and employs the established Andersen model on access to health services. Well controlled multivariate logit regression models derived from these data show that an affiliation with the Apostolic faith is a substantial and significant risk factor in reducing the utilization of both maternal and child health services. Moreover, even when the services were least costly and readily available and when gaps along other social and economic factors were limited, as in the case of Bacillus Calmette-Guérin vaccination and one visit to antenatal care, women and children from Apostolic faith families still fared significantly worse than others in accessing them.

Temporal dynamics of religion as a determinant of HIV infection in East Zimbabwe: a serial cross-sectional analysis

Background

Religion is an important underlying determinant of HIV spread in sub-Saharan Africa. However, little is known about how religion influences changes in HIV prevalence and associated sexual behaviours over time.

Objectives

To compare changes in HIV prevalence between major religious groups in eastern Zimbabwe during a period of substantial HIV risk reduction (1998–2005) and to investigate whether variations observed can be explained by differences in behaviour change.

Methods

We analysed serial cross-sectional data from two rounds of a longitudinal population survey in eastern Zimbabwe. Univariate and multivariate logistic regression models were developed to compare differences in sexual behaviour and HIV prevalence between religious groups and to investigate changes over time controlling for potential confounders.

Results

Christian churches were the most popular religious grouping. Over time, Spiritualist churches increased in popularity and, for men, Traditional religion and no religion became less and more common, respectively. At baseline (1998–2000), HIV prevalence was higher in Traditionalists and in those with no religion than in people in Christian churches (men 26.7% and 23.8% vs. 17.5%, women: 35.4% and 37.5% vs. 24.1%). These effects were explained by differences in socio-demographic characteristics (for Traditional and men with no religion) or sexual behaviour (women with no religion). Spiritualist men (but not women) had lower HIV prevalence than Christians, after adjusting for socio-demographic characteristics (14.4% vs. 17.5%, aOR = 0.8), due to safer behaviour. HIV prevalence had fallen in all religious groups at follow-up (2003–2005). Odds of infection in Christians reduced relative to those in other religious groups for both sexes, effects that were mediated largely by greater reductions in sexual-risk behaviour and, possibly, for women, by patterns of conversion between churches.

Conclusion

Variation in behavioural responses to HIV between the major church groupings has contributed to a change in the religious pattern of infection in eastern Zimbabwe.