Adolescent experiences of HIV and sexual health communication with parents and caregivers in Soweto, South Africa

'A difficult conversation': community stakeholders' and key informants' perceptions of the barriers to talking about sex and HIV with adolescents and young people in KwaZulu-Natal, South Africa

Adolescence and young adulthood are important periods of transition and therefore for action and intervention to ensure future sexual and reproductive health (SRH). Caregiver-adolescent communication about sex and sexuality is a protective factor for SRH, but there are often barriers to this. Adults' perspectives are limited within the literature but important as they should lead this process. This paper uses exploratory qualitative data from in-depth interviews with 40 purposively sampled community stakeholders and key informants to explore their insights into the perceived, experienced or expected challenges adults' experience when having these conversations within a high HIV prevalence, South African context. Findings suggest that respondents recognised the value of communication and were generally willing to try it. However, they identified barriers such as fear, discomfort and limited knowledge and perceived capacity to do so. They show that in high prevalence contexts adults grapple with their own personal risks, behaviours and fears that may affect their ability to have these conversations. This demonstrates the need to equip caregivers with the confidence and ability to communicate about sex and HIV, alongside managing their own complex risks and situations to overcome barriers. It is also necessary to shift the negative framing of adolescents and sex.

'I can't go to her when I have a problem': sexuality communication between South African adolescent girls and young women and their mothers

Parent–adolescent sexuality communication, the process in which parents and their adolescent children discuss sexuality and sexual and reproductive health, is a key component for adolescents’ protective behaviours. Open communication with parents, particularly mothers, enables informed sexual and reproductive health (SRH) decision-making amongst adolescent girls and young women (AGYW). As part of a qualitative study evaluating a South African combination HIV prevention intervention for AGYW, we explored perspectives on SRH communication among AGYW and mothers of AGYW, and the effects of the intervention on sexuality communication as perceived by AGYW, mothers of AGYW, intervention facilitators and implementers, and community leaders. In-depth interviews and focus group discussions were conducted with 185 AGYW aged 15–24 years who had participated in the intervention, seven mothers of AGYW intervention recipients, 14 intervention facilitators, six community leaders, and 12 intervention implementers. Key themes that emerged in analysis were (1) Barriers to Sexuality communication, (2) Implications of Gaps in Sexuality Communication, and (3) Addressing Barriers to Sexuality communication. Barriers to sexuality communication included inability or unwillingness to discuss sex, a generation gap, proscriptive socio-cultural guidelines, and mothers’ discomfort, lack of knowledge and self-efficacy, and fear of encouraging promiscuity. AGYW described making poorly-informed SRH decisions alone, expressing a desire for more open communication with and support from parents/mothers. Framed within the social cognitive theory, these findings can help to guide efforts to address barriers around parent–adolescent sexuality communication, inform interventions aimed at targeting SRH issues amongst AGYW, such as unintended pregnancy and HIV, and support meaningful engagement of parents in supporting AGYW in navigating pathways to achieving their SRH goals.

A qualitative investigation of facilitators and barriers to DREAMS uptake among adolescents with grandparent caregivers in rural KwaZulu-Natal, South Africa

Adolescents with grandparent caregivers have experienced challenges including the death of one or both parents due to HIV in sub-Saharan Africa. They may be left out of existing HIV prevention interventions targeting parents and children. We investigated the facilitators and barriers to DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe) programme uptake among adolescents with grandparent caregivers across different levels of the socio-ecological model in rural South Africa. Data were collected in three phases (October 2017 to September 2018). Adolescents (13-19 years old) and their grandparent caregivers (≥50 years old) (n = 12) contributed to repeat in-depth interviews to share their perceptions and experiences regarding adolescents' participation in DREAMS. Data were triangulated using key informant interviews with DREAMS intervention facilitators (n = 2) to give insights into their experiences of delivering DREAMS interventions. Written informed consent or child assent was obtained from all individuals before participation. All data were collected in isiZulu and audio-recorded, transcribed verbatim and translated into English. Thematic and dyadic analysis approaches were conducted guided by the socio-ecological model. Participation in DREAMS was most effective when DREAMS messaging reinforced existing norms around sex and sexuality and when the interventions improved care relationships between the adolescents and their older caregivers. DREAMS was less acceptable when it deviated from the norms, raised SRH information that conflicts with abstinence and virginity, and when youth empowerment was perceived as a potential threat to intergenerational power dynamics. While DREAMS was able to engage these complex families, there were failures, about factors uniquely critical to these families, such as in engaging children and carers with disabilities and failure to include adolescent boys in some interventions. There is a need to adapt HIV prevention interventions to tackle care relationships specific to adolescent-grandparent caregiver communication.

The Role of Families in Adolescent and Young Adults' PrEP Use

While pre-exposure prophylaxis (PrEP) is a key HIV prevention tool for adolescents and young adults (AYAs), its initiation and sustained use is shaped by AYAs' unique social contexts, including family. We explored the role of families in AYAs' PrEP use through qualitative in-depth interview (IDI) data from iPrevent, an end-user study designed to identify factors that could optimize PrEP adherence among South African youth (18-24 years old). These data were collected using a semi structured guide and were analysed using an inductive approach. Several themes describing family influence on AYAs' PrEP use emerged including family support; family attitude towards PrEP; and the family's ability to obviate PrEP disclosure challenges. In addition, dimensions of family closeness, categorized as 'close', 'in-between' and 'loose-knit,' appeared important in contextualizing family influence on AYAs' PrEP use. We found that family remains a proximal and fundamental social system in which AYA are socialized and greater family engagement could aid PrEP implementation in this priority population.

Project Last Mile and the development of the Girl Champ brand in eSwatini: engaging the private sector to promote uptake of health services among adolescent girls and young women

In eSwatini and across sub-Saharan Africa, adolescent girls and young women (AGYW) are at significantly higher risk of HIV infection and poorer sexual and reproductive health (SRH) than their male counterparts. AGYW demonstrate low demand for SRH services, further contributing to poor outcomes. Strategic marketing approaches, including those used by multinational corporations, have potential to support demand creation for SRH services among AGYW, but there is limited empirical evidence on the direct application of private-sector strategic marketing approaches in this context. Therefore, we examined how Project Last Mile worked with eSwatini's Ministry of Heath to translate strategic marketing approaches from the Coca-Cola system to attract AGYW to SRH services. We present qualitative market research using the ZMET® methodology with 12 young Swazi women (ages 15-24), which informed development of a highly branded communication strategy consistent with other successful gain-framing approaches. Qualitative in-depth interviews with 19 stakeholders revealed receptivity to the market research findings, and highlighted local ownership over the strategic marketing process and brand. These results can inform similar efforts to translate strategic marketing to support demand generation in pursuit of public health goals to reduce HIV risk and improve SRH.

Mental health outcomes of a pilot 2-arm randomized controlled trial of a HIV-prevention program for South African adolescent girls and young women and their female caregivers

Background

South African adolescent girls and young women (AGYW) report significant mental distress and sexual and reproductive health concerns. Mental health problems and trauma symptoms are consistently associated with sexual and reproductive health behavior. Despite their intersection, few interventions address them simultaneously or engage female caregivers (FC) as collaborators. This study presents findings from a pilot test of an empirically supported culturally adapted family-based HIV-prevention program, Informed Motivated Aware and Responsible Adolescents and Adults- South Africa (IMARA-SA), on AGYW anxiety, depression, and trauma.

Methods

Sixty 15–19-year-old AGYW (mean age = 17.1 years) and their FC from outside Cape Town were randomized to IMARA-SA or a health promotion control program. AGYW reported their anxiety using the GAD-7, depression using the PHQ-9, and trauma using the PC-PTSD-5 at baseline and follow-up (6–10 months post). Both interventions were delivered by Xhosa-speaking Black South African women in groups over 2 days for approximately 10 h. We examined intervention effects using zero-inflated negative binomial regression for anxiety, multinomial logistic regression for depression, and logistic regression for trauma.

Results

At baseline, groups did not differ in demographic characteristics but AGYW randomized to IMARA-SA had higher depression scores than controls (p = 0.04) and a greater proportion screened positive for PTSD (p = .07). Controlling for baseline mental health scores, AGYW who received IMARA-SA compared to controls had significantly fewer anxiety symptoms at follow-up (adjusted incidence rate ratio for count model = 0.54, 95% CI = 0.29–0.99, p = 0.05), were less likely to report at least one depressive symptom relative to no symptoms (relative risk ratio = 0.22, 95% CI = 0.05, 0.95, p = 0.04), and were less likely to report symptoms of PTSD relative to no symptoms, but this difference was not statistically significant.

Conclusions

Mental health is implicated in risky sexual behavior, and reducing emotional distress can mitigate exposure to poor sexual and reproductive health outcomes. This pilot study yielded promising findings for the mental health impact of IMARA-SA, justifying replication in a larger randomized trial.

Trial registration

ClinicalTrials.gov Number NCT04758390, accepted 17/02/2021.

An individually randomized controlled trial of a mother-daughter HIV/STI prevention program for adolescent girls and young women in South Africa: IMARA-SA study protocol

BACKGROUND

South Africa has the world's largest HIV epidemic, but South African adolescent girls and young women (AGYW) acquire HIV at twice the rate of and seroconvert on average 5-7 years earlier than their male peers. Female caregivers (FC) are an untapped resource for HIV/STI prevention in South Africa and offer a novel opportunity to strengthen AGYW prevention efforts. This study will evaluate the effectiveness and cost-effectiveness of an evidence-based mother-daughter HIV/STI prevention program tested in the United States and adapted for South Africa, Informed Motivated Aware and Responsible Adolescents and Adults (IMARA), to decrease STI incident infections and increase HIV testing and counseling (HTC) and PrEP uptake in AGYW.

METHODS

This is a 2-arm individually randomized controlled trial comparing IMARA to a family-based control program matched in time and intensity with 525 15-19-year-old Black South African AGYW and their FC-dyads in Cape Town's informal communities. AGYW will complete baseline, 6-, and 12-month assessments. Following randomization, AGYW-FC dyads will participate in a 2-day group workshop (total 10 h) that includes joint and separate mother and daughter activities. Primary outcomes are AGYW STI incidence, HTC uptake, and PrEP uptake at 6 months. Secondary outcomes are AGYW STI incidence, HTC uptake, and PrEP uptake at 12 months, sexual behavior (e.g., condom use, number of partners), HIV incidence, and ART/PrEP adherence and intervention cost-effectiveness. AGYW who test positive for a STI will receive free treatment at the study site. HIV positive participants will be referred to ART clinics.

DISCUSSION

Primary prevention remains the most viable strategy to stem new STI and HIV transmissions. HIV and STI disparities go beyond individual level factors, and prevention packages that include supportive relationships (e.g., FC) may produce greater reductions in HIV-risk, improve HTC and PrEP uptake, and increase linkage, retention, and adherence to care. Reducing new HIV and STI infections among South African AGYW is global public health priority.

TRIAL REGISTRATION

ClinicalTrials.gov Number NCT04758390 , accepted 02/16/2021.

"Knowledge I seek because culture doesn't work anymore … It doesn't work, death comes": the experiences of third-generation female caregivers (gogos) in South Africa discussing sex, sexuality and HIV and AIDS with children in their care

Background

Sexual reproductive health communication between parents and children has been shown to promote safer sexual choices. In many South African households, third-generation female caregivers, often grandmothers or other older females, locally known as gogos, are primary caregivers of children due to parents being deceased or absent. Subsequently, the responsibility of talking about sex and related issues has shifted to these gogos. This study explored the experiences of gogos living in Alexandra, Johannesburg on talking about sex, sexuality and HIV and AIDS with children aged 10–18 years that are in their care.

Methods

Ten primary caregivers were purposively selected. Data were collected through in-depth individual interviews. Thematic analysis was performed and inductive codes and themes identified.

Results

All gogos selected found it difficult to discuss sex, sexuality and HIV and AIDS due to culture and traditional values impacting on personal experiences as well as generation and gender barriers. Perceived low self-efficacy due to low levels of knowledge and limited skills in speaking about sex, sexuality and HIV and AIDS also contributed to low levels of sexual reproductive health communication.

Conclusions

This study highlights the need for interventions that focus on improving gogos’ knowledge about sexual reproductive health in addition to providing them with the skills to talk about sex, sexuality and HIV and AIDS with children in their care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10494-5.

Exploring perceptions of low risk behaviour and drivers to test for HIV among South African youth

Human Immunodeficiency Virus (HIV) prevalence among South African youth is high, yet HIV testing remains suboptimal. We explored how perceptions of HIV risk and behaviours informed decisions to test for HIV. This study was conducted from April 2018 to March 2019 in Ekurhuleni district, Gauteng Province with males and females aged between 15–24 years. Twenty-five youth with unknown HIV status participated in in-depth interviews (IDIs); while four focus group discussions (FGDs) were conducted with those that previously tested for HIV. Probes used in the guides included types of incentives that youth would value when testing for HIV or receiving treatment; barriers and motivators to HIV testing; enablers and challenges to using cellphone technology and preferences on type of social media that could be used to create awareness about HIV testing services. IDIs and FGDs were audio-recorded, transcribed, and translated. QSR NVIVO 10 was used for the analysis. The majority of the youth perceived that their risk of HIV infection was low due to factors such as being young, lacking physical signs of HIV, being sexually inactive and parents not being HIV positive. However, youth identified high risk behaviours such as unprotected sex, multiple sexual partners, excessive drinking of alcohol, being victims of sexual abuse, road accidents and violent behaviour as increasing their vulnerability to HIV. Most youth highlighted cues to action that would motivate them to test for HIV such as support of parents, receiving incentives, improved confidentiality during HIV testing and receiving information about HIV via social media (Facebook, Twitter and Whatsapp). Despite perceptions of low risk to HIV, youth remain vulnerable to HIV. Disseminating HIV information via digital platforms; giving youth options to choose between testing locations that they consider to be private; providing incentives and equipping parents/guardians to encourage youth to test could optimise HIV testing.

Parent-child sexual and reproductive health communication among very young adolescents in Korogocho informal settlement in Nairobi, Kenya

Background

Parents are an important source of sexual and reproductive health (SRH) information for very young adolescents and are likely to have a significant influence on adolescents’ sexual attitudes, values, and risk-related beliefs. This study explored the nature and content of parent-child communication about SRH issues.

Methods

Thirty-two parents and 30 adolescent boys and girls aged between 11 and 13 years participated in narrative interviews in a resource-poor urban setting in Nairobi, Kenya. Interviews were audio-recorded, transcribed, translated into English, and uploaded on Atlas.ti software for coding and analysis.

Results

Findings from the study show gender differences in parent-child communication. More girls than boys reported that they had talked with their parents about romantic relationships. Four approaches—no communication, fear-based communication, supportive communication, and involving an external person were used by parents in SRH communication. Parents hostile attitudes towards romantic relationships during adolescence discouraged adolescents from disclosing their relationship status. While communication did occur, it was mainly reactive, one-sided, and authoritarian, often initiated by parents.

Conclusions

Parents need to be empowered with adequate and factual SRH information and effective communication strategies to enhance communication with very young adolescents. There is a need for further research to identify the most effective parent-child communication approaches to improve SRH outcomes among adolescents.

Obstacles to intergenerational communication in caregivers' narratives regarding young people's sexual and reproductive health and lifestyle in rural South Africa

BACKGROUND

Statistics from South Africa show the world's highest HIV prevalence with an estimated seven million people living with the virus. Several studies have pointed to communication about sexuality between parents/caregivers and children as a protective factor. However, communication between generations has been described as problematic, especially due to discomfort in discussing sexual matters. The aim of this study was to explore how caregivers in a poor, rural part of South Africa talked about young people in general, their sexuality, and their lifestyle practices. A particular interest was directed towards central discourses in the caregivers' narratives and how these discourses were of importance for the caregivers to function as conversation partners for young people.

METHODS

In this qualitative study convenience sampling was used to select and invite participants. Information was collected from nine one-on-one interviews conducted with caregivers from rural areas within South Africa. The interview guide included nine main questions and optional probing questions. Each interview took place in an uninterrupted setting of choice associated with the caregivers' home environment. The interviews were transcribed and analyzed using discourse analysis.

RESULTS

Interview narratives were characterized by three central discourses - demoralized youths in a changing society, prevailing risks and modernity and a generation gap. The youths were discursively constructed as a problematic group relating to specific prevailing risks such as early pregnancies, modern technologies, STI/HIV and contraceptives. The interview narratives illustrated that caregivers tried to impose their views of a respectable lifestyle in young people. At the same time caregivers expressed a morality of despair mirroring a generation gap which counteracted their ability to communicate with their children and grandchildren.

CONCLUSIONS

The findings add to the body of earlier research illustrating that rural South African caregivers and their children/grandchildren hold different moral standards. The interview material reflected a 'clash' between generations relating to their differing perceptions of a desirable lifestyle. To overcome the generational gap, we recommend further research about how a well-founded national and community collaboration linked to school-based programs can support family participation in order to empower adults in their communication with young people.

Sources of social support and sexual behaviour advice for young adults in rural South Africa

Introduction

While young people in sub-Saharan Africa (SSA) are at greatest risk of HIV acquisition, uptake of HIV prevention interventions among them has been limited. Interventions delivered through social connections have changed behaviour in many settings, but not to date in SSA. There is little systematic evidence on whom young SSA adults turn to for advice. We therefore conducted an exploratory cross-sectional study from whom young rural South Africans received support and sexual behaviour-specific advice.

Methods

We asked 119 18–34  year olds in rural KwaZulu-Natal about the important people in their lives who provided emotional, informational, financial, physical, social or other support. We also asked whether they had discussed sex or HIV prevention with each contact named. We used descriptive statistics and logistic regression to analyse support and advice provision patterns.

Results

Respondents named 394 important contacts, each providing a mean of 1.7 types of support. Most contacts were relatives, same-gender friends or romantic partners. Relatives provided most informational, financial and physical support; friends and partners more social support and sexual advice. Respondents reported discussing sexual matters with 60% of contacts. Sources of support changed with age, from friends and parents, towards siblings and partners.

Discussion

Sexual health interventions for young adults in rural South Africa may be able to harness friend and same-generation kin social ties through which sex is already discussed, and parental ties through which other forms of support are transmitted. The gender-segregated nature of social connections may require separate interventions for men and women.

What Messages are Adolescent Voluntary Medical Male Circumcision (VMMC) Clients Getting and How? Findings From an Observational Study in Tanzania

Uncircumcised adolescent males in sub-Saharan Africa are an important group to reach with voluntary medical male circumcision (VMMC) services due to high HIV burden occurring among this age group. Appropriateness of the content and delivery of sexual health and HIV prevention messages to adolescent VMMC clients has not been extensively described. A study was conducted in Tanzania to examine quality, delivery and content of messages provided to adolescent (aged 15-19) and adult (aged 20+) VMMC clients (n = 320). Results show that counseling of mixed age groups during group education lacked selected key messages, compared to more age-homogeneous groups. Additionally, adolescents received more comprehensive information in individual counseling compared to group education. We recommend that health care providers are provided with skills and job aides to assist them to segment VMMC clients by age; provide age-appropriate messages; and increase use of individual counseling as a means to communicate with adolescent clients.