Older Sexual Partners and Adolescent Females' Mental Health

Exploring the relationship between established HIV risk factors and depressive symptoms amongst young women without HIV in two sites in South Africa

PURPOSE

Adolescent girls are at high risk for depression and human immunodeficiency virus (HIV) acquisition. Poor mental health can increase vulnerability to risky sexual behaviours. Therefore, this study aims to determine the prevalence of depressive symptomology and explore the convergence of HIV risk factors with depressive symptoms amongst cis-gender adolescent girls and young women (AGYW) in rural KwaZulu-Natal (KZN) and peri-urban Western Cape (WC) communities in South Africa.

METHODS

Cross-sectional survey data from two sites in South Africa was used - the rural Vulindlela community in KZN and the peri-urban Philippi East community in the WC. Study inclusion criteria included being sexually active with at least one male partner, and not planning to relocate in the next 12 months. The PHQ-9 scale was used to determine depressive symptomology, a socio-behavioural questionnaire was used to determine sexual behaviours, odds ratios and confidence intervals derived from logistic regression models were used to explore the associations between depressive symptomology and socio-behavioural factors associated with HIV acquisition.

RESULTS

The cohort consisted of 274 adolescent girls, 38.6% from the WC site and 61.4% from the KZN site. Overall, 15.7% (43/274) of AGYW reported depressive symptoms. Participants from the peri-urban WC site were more likely to experience depressive symptoms (OR 8.34; 95% CI 3.80-18.30) compared to those living in the rural KZN site. Depressive symptoms were less likely to occur in adolescent girls between the ages of 14 to 17 as compared to those between the ages of 18 and 19 (OR 0.44; 95% CI 0.22-0.90). Socio-behavioural HIV risk factors associated with depressive symptoms include: age disparate relationships (OR 2.98; 95% CI 1.52-5.84), high (four or more) numbers of lifetime partners (OR 8.15; 95% CI 3.60-18.45) and engaging in sex under the influence of alcohol (OR 2.58; 95% CI 1.32-5.04). Multivariate analysis showed that participants from the WC site (AOR 5.25; 95% CI 1.95-14.17) had higher odds of experiencing depressive symptoms while participants with four or more lifetime partners (AOR 3.46; 95% CI 1.24-9.60) were at higher odds of experiencing depressive symptoms.

CONCLUSION

In this cross-sectional study, depressive symptomology is associated with certain HIV risk behaviours. Longitudinal studies are required to test the causal relationship between depression and HIV acquisition and to better understand the geospatial differences observed.

Experiences of intimate partner violence (IPV) among females with same-sex partners in South Africa: what is the role of age-disparity?

BACKGROUND

South African women have been exposed to epidemic proportions of intimate partner violence (IPV) amongst heterosexual relationships but not much is known about same-sex partnerships. Sexual minorities are excluded from research but are subject to intimate partner violence as much as heteronormative persons. The purpose of this study is to determine the association between age-disparity and IPV outcomes among females with same-sex partners in South Africa.

METHODS

A cross-sectional study of the nationally representative South African National HIV Prevalence, Incidence, Behaviour and Communication Survey (SABSSM 2017) is used. A weighted sample of 63,567 female respondents identified as having a same-sex partner are analysed. IPV is measured as ever been physically and/ or sexually abused. Any experience of IPV is included in the dependent variable of this study. Descriptive and inferential statistics are used to estimate the relationship between demographic, socioeconomic, age-disparity and IPV.

RESULTS

Almost 16% of females in same-sex relationships experienced IPV and about 22% from younger partners. In female same-sex partnerships, partner age-disparity (OR: 1.30, CI: 1.18 - 1.51), type of place of residence (OR: 2.27, CI: 1.79 - 3.79), highest level of education (OR: 1.07, CI: 0.97 - 1.17), marital status (OR: 1.60, CI: 1.37 - 1.88), and race (OR: 1.47, CI: 1.41 - 1.54) are associated with an increased likelihood of violence.

CONCLUSION

IPV programs that are specifically targeted for non-heteronormative orientations are needed. These programs should promote health equity and safety for non-confirmative sexual identities in the country.

Dating and friendships in adolescence: Variation across same-sex and other-sex romantic partners

This research examined associations between dating and number of friends for rural adolescents with same-sex and other-sex dating partners using longitudinal sociometric data (N = 2826; 55% female, 87% White, mean age = 14 at baseline). In multilevel models assessing within-person change, boys gained female friends when they were in same-sex romantic relationships, compared to when they were single. In contrast, girls in same-sex relationships lost female friends and gained male friends. Adolescents in other-sex romantic relationships gained same-sex friends compared to when they were single. Results advance understanding of adolescent social and sexual development, suggesting that sexual minority adolescents find allies when dating but may struggle to maintain same-sex friendships.

"It gives you a road map of what to do to solve your problems": acceptability of a combination HIV prevention intervention among adolescent girls in Uganda

BACKGROUND

The HIV burden remains a critical public health concern and adolescent girls are at significantly higher risk compared to the general adult population. Similar to other sub-Saharan African countries, Uganda reports high HIV prevalence among adolescent girls and young women. Yet, both evidence-based HIV prevention interventions and their acceptability among adolescent girls have not been widely studied. In this study, we examined the acceptability of the Suubi4Her intervention, an evidence-based combination intervention aimed at reducing HIV risk among adolescent girls in Uganda.

METHODS

We conducted semi-structured in-depth interviews with 25 adolescent girls upon intervention completion to explore their experiences with the Suubi4Her intervention that was tested in a clinical trial in Uganda (2017-2023). Specifically, we explored their decision-making process for participating in the intervention, experiences with program attendance, and their feedback on specific intervention characteristics. Informed by the Theoretical Framework of Acceptability, the data were analyzed using thematic analysis.

RESULTS

The main motivation for participation was access to health-related information, including information on STIs, HIV, and pregnancy as well as information on banking, saving, and income-generating activities. Though many participants did not have any initial concerns, mistrust of programs, initial paperwork, caregiver's ability to commit time, concerns about ability to save, and HIV/STI and pregnancy testing were raised by some participants. Facilitators to session attendance included motivation to learn information, caregiver commitment, reminder calls, and incentives received for participation. The main challenges included household responsibilities and obligations, difficulty raising transport money, and weather challenges. Adolescent girls appreciated the group format and found the location and times of the sessions convenient. They also found the content relevant to their needs and noted positive changes in their families.

CONCLUSIONS

The results showed high intervention acceptability among adolescent girls. These findings have important programmatic and policy implications in Uganda, especially given the higher HIV prevalence among adolescent girls in the country.

TRIAL REGISTRATION

NCT03307226 (Registered: 10/11/17).

Marital status, immigration, and reproductive health among adolescent mothers in Canada, 1990-2018: A population-based, observational study

Immigrants to Canada increasingly come from regions where child marriage (<18 years) is prevalent. We described the prevalence, demographic characteristics, and reproductive health correlates of marriage among births to Canadian-born and foreign-born adolescent mothers. Using Canadian birth registrations from 1990 to 2018, marriage prevalence, parental birth region, and parental age gap were examined by maternal birthplace (Canada and 12 world regions) among births to mothers <18 years. Adjusted odds ratios (AORs) of preterm birth (PTB), small for gestational age (SGA), and repeat birth were estimated for the joint associations of adolescent maternal age group (<18-year, 18-19-year, and 20-24-year), marriage, and nativity status (n = 1,904,200). Depending on maternal birthplace, marital births represented 2.6% to 81.8% of births to mothers <18 years. Marriage among mothers giving birth at <18 years was associated with higher proportions of parents from the same birthplace and larger parental age gaps. AORs of PTB tended to increase with lower maternal age. AORs of SGA were generally higher among births to foreign-born mothers. Marriage was associated with lower AORs of PTB and SGA among births to Canadian-born mothers and PTB among births to foreign-born mothers in the older adolescent age groups, but no association existed in the <18-year group. Marriage was positively associated with repeat birth in all adolescent age groups, with stronger associations in the <18-year group. The reproductive health correlates of marriage are similar between births to Canadian-born and foreign-born mothers <18 years but some differ between births to mothers <18 years and those to older adolescent mothers.

Adolescents' Frequency of Alcohol Use and Problems from Alcohol Abuse: Integrating Dating Partners with Parent and Peer Influences

Despite the centrality of dating relationships for teens, it is unclear whether the influence of romantic partners' alcohol use on adolescents' under-age drinking is distinct from the influence of peers and parents. To address this gap, this study used longitudinal data from a population-based sample of 825 adolescents (49% male, 51% female), ages 12 to 19. Adolescents completed a survey using laptops for privacy, and a parent completed a survey separately. Ordinary least squares and logistic regression models assessed alcohol use frequency and alcohol problems and included dating partners' drinking, adolescents' prior drinking, peers' drinking, parents' substance use, parental monitoring, and sociodemographic background characteristics. Alcohol use frequency and alcohol problems were influenced by dating partners' alcohol use and dating partners' influence was stronger on older adolescents and male adolescents. The study results are useful for public health messaging and prevention efforts by demonstrating the influence of parents, peers, and dating partners on teens' alcohol use.

Lover, Mentor, or Exploiter: Retrospective Perspectives of the Older Person Following Sexual Relationships with Adults During Adolescence

Sexual relationships between an adolescent and an older person are considered controversial and in many countries are conceptualized under the legal definition of statutory relationship/rape. Despite the consensus regarding their potential negative implications, little is known about how adolescents perceive and construct them. To address this lacuna, the current exploratory study examined how individuals who have experienced sexual relationships with an adult while growing up perceived the older person and the meaning they ascribed to the age gap (M age gap, 7.78 years; range, 2-18 years). A qualitative thematic methodology was incorporated in analyzing in-depth semi-structured interviews with 28 individuals (M age, 29.89 years) who had experienced sexual relationships with an (at least 2 years) older person during adolescence (M age, 14.78 years). Participants described five different perceptions of the older persons: romantic partner; sexual partner; authority figure; complex/unstable figure; and exploiter. Subsequent analysis, focusing on the role participants assigned to age when describing these different images of older persons, shed additional light on their subjective perceptions; namely, for each image, age had a particular meaning. This paper may contribute to the understanding of individuals' experiences of sexual relationships with an older person by emphasizing the complexity of such relationships, as reflected in the participants' construction of the older person's image, potentially providing important information that can inform best practice for professionals working with this population. Findings highlight the need to address diversity and ambiguity rather than the uniform dichotomy that characterizes the legal framing of automatically constructing these relationships as statutory. Further implications for research, policy, and practice are discussed.

Suubi4Her: a study protocol to examine the impact and cost associated with a combination intervention to prevent HIV risk behavior and improve mental health functioning among adolescent girls in Uganda

BACKGROUND

Asset-based economic empowerment interventions, which take an integrated approach to building human, social, and economic capital, have shown promise in their ability to reduce HIV risk for young people, including adolescent girls, in sub-Saharan Africa. Similarly, community and family strengthening interventions have proven beneficial in addressing mental health and behavioral challenges of adolescents transitioning to adulthood. Yet, few programs aimed at addressing sexual risk have applied combination interventions to address economic stability and mental health within the traditional framework of health education and HIV counseling/testing. This paper describes a study protocol for a 5-year, NIMH-funded, cluster randomized-controlled trial to evaluate a combination intervention aimed at reducing HIV risk among adolescent girls in Uganda. The intervention, titled Suubi4Her, combines savings-led economic empowerment through youth development accounts (YDA) with an innovative family strengthening component delivered via Multiple Family Groups (MFG).

METHODS

Suubi4Her will be evaluated via a three-arm cluster randomized-controlled trial design (YDA only, YDA + MFG, Usual Care) in 42 secondary schools in the Central region of Uganda, targeting a total of 1260 girls (ages 15-17 at enrollment). Assessments will occur at baseline, 12, 24, and 36 months. This study addresses two primary outcomes: 1) change in HIV risk behavior and 2) change in mental health functioning. Secondary exploratory outcomes include HIV and STI incidence, pregnancy, educational attainment, financial savings behavior, gender attitudes, and self-esteem. For potential scale-up, cost effectiveness analysis will be employed to compare the relative costs and outcomes associated with each study arm.

CONCLUSIONS

Suubi4Her will be one of the first prospective studies to examine the impact and cost of a combination intervention integrating economic and social components to reduce known HIV risk factors and improve mental health functioning among adolescent girls, while concurrently exploring mental health as a mediator in HIV risk reduction. The findings will illuminate the pathways that connect economic needs, mental health, family support, and HIV risk. If successful, the results will promote holistic HIV prevention strategies to reduce risk among adolescent girls in Uganda and potentially the broader sub-Saharan Africa region.

TRIAL REGISTRATION

Clinical Trials NCT03307226 (Registered: 10/11/17).