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Nabunya P, Byansi W, Muwanga J, Bahar OS, Namuwonge F, Ssentumbwe V, Ssewamala FM. Family Factors and Gender Norms as Protective Factors Against Sexual Risk-Taking Behaviors Among Adolescent Girls in Southern Uganda. GLOBAL SOCIAL WELFARE : RESEARCH, POLICY & PRACTICE 2024; 11:111-121. [PMID: 38859819 PMCID: PMC11164544 DOI: 10.1007/s40609-022-00237-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/05/2022] [Indexed: 06/11/2024]
Abstract
Adolescent girls and young women are at a higher risk for HIV infection stemming from barriers to accessing comprehensive sexual health education, unequal cultural, social, and economic statuses, limited access to education and health care services, and gender-based violence. This makes adolescent girls susceptible to high-risk sexual behaviors. This study examines the protective role of family, social support factors and gender norms against sexual risk-taking behaviors among secondary school adolescent girls in Uganda. Baseline data from the National Institute of Mental Health-funded Suubi4Her study were analyzed. A total of 1260 girls aged 14-17 years and enrolled in the first or second year of secondary school were recruited across 47 secondary schools. Hierarchical linear regression models were conducted to determine the role of family, social support factors and gender norms on sexual risk-taking behaviors. Results indicate that traditional gender norms, family care and relationships, and social support were all associated with lower levels of sexual risk-taking intentions-a proxy for engaging in sexual risk behaviors. Findings point to the need to develop family level support interventions to equip adolescent girls with adequate sexual health-related knowledge and skills to facilitate safer sexual practices and reduce high-risk sexual-taking behaviors, as they develop and transition into young adulthood.
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Affiliation(s)
- Proscovia Nabunya
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis, Brown School, 1 Brookings Drive, St. Louis, MO 63130, USA
| | - William Byansi
- Boston College School of Social Work, 140 Commonwealth Avenue, Chestnut Hill, MA 02467, USA
| | - Joelynn Muwanga
- Department of Health and Human Services, New Hampshire, Division of Public Health, Littleton, USA
| | - Ozge Sensoy Bahar
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis, Brown School, 1 Brookings Drive, St. Louis, MO 63130, USA
| | - Flavia Namuwonge
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis, Brown School, 1 Brookings Drive, St. Louis, MO 63130, USA
| | - Vicent Ssentumbwe
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis, Brown School, 1 Brookings Drive, St. Louis, MO 63130, USA
| | - Fred M. Ssewamala
- International Center for Child Health and Development (ICHAD), Washington University in St. Louis, Brown School, 1 Brookings Drive, St. Louis, MO 63130, USA
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Denison JA, Willis K, DeLong SM, Sievwright KM, Agwu AL, Arrington-Sanders R, Kaufman MR, Prabhu S, Williams AM, Fields EL, Alexander KA, Lee L, Yang C. Advancing Adolescent and Young Adult HIV Prevention and Care and Treatment Through Use of Multi-level Theories and Frameworks: A Scoping Review and Adapted HIV Ecological Framework. AIDS Behav 2024; 28:1694-1707. [PMID: 38351279 PMCID: PMC11069483 DOI: 10.1007/s10461-023-04255-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2023] [Indexed: 05/05/2024]
Abstract
While multi-level theories and frameworks have become a cornerstone in broader efforts to address HIV inequities, little is known regarding their application in adolescent and young adult (AYA) HIV research. To address this gap, we conducted a scoping review to assess the use and application of multi-level theories and frameworks in AYA HIV prevention and care and treatment empirical research. We systematically searched five databases for articles published between 2010 and May 2020, screened abstracts, and reviewed eligible full-text articles for inclusion. Of the 5890 citations identified, 1706 underwent full-text review and 88 met the inclusion criteria: 70 focused on HIV prevention, with only 14 on care and treatment, 2 on both HIV prevention and care and treatment, and 2 on HIV-affected AYA. Most authors described the theory-based multi-level framework as informing their data analysis, with only 12 describing it as informing/guiding an intervention. More than seventy different multi-level theories were described, with 38% utilizing socio-ecological models or the eco-developmental theory. Findings were used to inform the adaptation of an AYA World Health Organization multi-level framework specifically to guide AYA HIV research.
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Affiliation(s)
- Julie A Denison
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street. Room E5546, Baltimore, MD, 21205, USA.
| | - Kalai Willis
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Stephanie M DeLong
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kirsty M Sievwright
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street. Room E5546, Baltimore, MD, 21205, USA
- HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute and Columbia University, New York, US
| | - Allison L Agwu
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Michelle R Kaufman
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Sandeep Prabhu
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street. Room E5546, Baltimore, MD, 21205, USA
| | - Ashlie M Williams
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe Street. Room E5546, Baltimore, MD, 21205, USA
| | - Errol L Fields
- Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Lana Lee
- Adult Clinical Branch, Office of HIV/AIDS, United States Agency for International Development, Washington, DC, USA
| | - Cui Yang
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Agathis NT, Annor FB, Xu L, Swedo E, Chiang L, Coomer R, Hegle J, Patel P, Forster N, O’Malley G, Ensminger AL, Kamuingona R, Andjamba H, Nshimyimana B, Manyando M, Massetti GM. Strong Father-Child Relationships and Other Positive Childhood Experiences, Adverse Childhood Experiences, and Sexual Risk Factors for HIV among Young Adults Aged 19-24 Years, Namibia, 2019: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6376. [PMID: 37510608 PMCID: PMC10378761 DOI: 10.3390/ijerph20146376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/07/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023]
Abstract
Using cross-sectional data from the 2019 Namibia Violence Against Children and Youth Survey and sex-stratified multivariable models, we assessed the associations between four different positive childhood experiences (PCEs) and having ≥3 adverse childhood experiences (ACEs), including ≥3 ACE-PCE interaction terms, and seven sexual risk factors for HIV acquisition among young adults aged 19-24 years. One PCE, having a strong father-child relationship, was inversely associated with two risk factors among women (lifetime transactional sex (OR, 0.4; 95% CI, 0.2-0.7) and recent age-disparate sexual relationships (OR, 0.3; 95% CI, 0.2-0.5)), and significantly interacted with having ≥3 ACEs for three risk factors among women (not knowing a partner's HIV status, infrequently using condoms, and ever having an STI) and one among men (having multiple sexual partners in the past year). The other PCEs were significantly associated with ≤1 HIV risk factor and had no significant interaction terms. Strong father-child relationships may reduce HIV acquisition risk and mitigate the effect of childhood adversity on HIV risk among young adults in Namibia.
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Affiliation(s)
- Nickolas T. Agathis
- Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Francis B. Annor
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Likang Xu
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Elizabeth Swedo
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Laura Chiang
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
| | - Rachel Coomer
- Division of Global HIV and TB, Global Health Center, Centers for Disease Control and Prevention, Private Bag, Windhoek 12029, Namibia
| | - Jennifer Hegle
- Division of Global HIV and TB, Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Pragna Patel
- Division of Global HIV and TB, Global Health Center, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Norbert Forster
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA 98195, USA
| | - Gabrielle O’Malley
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA 98195, USA
| | - Alison L. Ensminger
- International Training and Education Center for Health, Department of Global Health, University of Washington, Seattle, WA 98195, USA
| | - Rahimisa Kamuingona
- Ministry of Gender Equality, Poverty Eradication, and Social Welfare, Private Bag, Windhoek 13359, Namibia
| | - Helena Andjamba
- Ministry of Gender Equality, Poverty Eradication, and Social Welfare, Private Bag, Windhoek 13359, Namibia
| | - Brigitte Nshimyimana
- Ministry of Gender Equality, Poverty Eradication, and Social Welfare, Private Bag, Windhoek 13359, Namibia
| | - Molisa Manyando
- US Agency for International Development, Washington, DC 20004, USA
| | - Greta M. Massetti
- Division of Violence Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA
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Parental Education and Left Lateral Orbitofrontal Cortical Activity during N-Back Task: An fMRI Study of American Adolescents. Brain Sci 2021; 11:brainsci11030401. [PMID: 33809905 PMCID: PMC8004246 DOI: 10.3390/brainsci11030401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 03/19/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction. The Orbitofrontal Cortex (OFC) is a cortical structure that has implications in cognition, memory, reward anticipation, outcome evaluation, decision making, and learning. As such, OFC activity correlates with these cognitive brain abilities. Despite research suggesting race and socioeconomic status (SES) indicators such as parental education may be associated with OFC activity, limited knowledge exists on multiplicative effects of race and parental education on OFC activity and associated cognitive ability. Purpose. Using functional brain imaging data from the Adolescent Brain Cognitive Development (ABCD) study, we tested the multiplicative effects of race and parental education on left lateral OFC activity during an N-Back task. In our study, we used a sociological rather than biological theory that conceptualizes race and SES as proxies of access to the opportunity structure and exposure to social adversities rather than innate and non-modifiable brain differences. We explored racial variation in the effect of parental educational attainment, a primary indicator of SES, on left lateral OFC activity during an N-Back task between Black and White 9–10 years old adolescents. Methods. The ABCD study is a national, landmark, multi-center brain imaging investigation of American adolescents. The total sample was 4290 9–10 years old Black or White adolescents. The independent variables were SES indicators, namely family income, parental education, and neighborhood income. The primary outcome was the average beta weight for N-Back (2 back versus 0 back contrast) in ASEG ROI left OFC activity, measured by functional Magnetic Resonance Imaging (fMRI) during an N-Back task. Ethnicity, age, sex, subjective SES, and family structure were the study covariates. For data analysis, we used linear regression models. Results. In White but not Black adolescents, parental education was associated with higher left lateral OFC activity during the N-Back task. In the pooled sample, we found a significant interaction between race and parental education on the outcome, suggesting that high parental education is associated with a larger increase in left OFC activity of White than Black adolescents. Conclusions. For American adolescents, race and SES jointly influence left lateral OFC activity correlated with cognition, memory, decision making, and learning. Given the central role of left lateral OFC activity in learning and memory, our finding calls for additional research on contextual factors that reduce the gain of SES for Black adolescents. Cognitive inequalities are not merely due to the additive effects of race and SES but also its multiplicative effects.
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Ali MM, Merdad L, Bellizzi S. Socioeconomic variations in risky sexual behavior among adolescents in 14 sub-Saharan Africa countries who report ever having had sex. Int J Equity Health 2021; 20:11. [PMID: 33407497 PMCID: PMC7789383 DOI: 10.1186/s12939-020-01352-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/09/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Equity is a guiding principle of the Global Strategy for Women, Children and Adolescents' Health (2016-2030) aimed at improving adolescent health and responding more effectively to adolescents' needs. We investigated the socioeconomic differentials in having multiple sexual partners and condom use among unmarried adolescents who reported ever having had sex aged 15-19 years in 14 sub-Saharan countries. METHODS Using the most recent publicly available Demographic and Health Surveys conducted between 2011 and 2018, we calculated survey- and sex-specific proportions of two or more partners and condomless sex, both overall and by selected socioeconomic characteristics and we fitted logistic regression models to estimate the survey- and sex-specific adjusted odds ratios. The pooled adjusted odds ratios were estimated using multilevel logistic regression. RESULTS In most countries, higher percentages of male adolescents than female adolescents reported having more than one partner in the last 12 months. Conversely, a lower percentage of young male reported having condomless sex when compared to young female: from 19.8% in Gabon to 84.5% in Sierra Leone among male adolescents and from 32.6% in Gabon to 93.2% in Sierra Leone among female adolescents. In the multilevel analyses, condomless sex was associated with place of residence, wealth and schooling for both female and male adolescents, while among male adolescents multiple partnerships was significantly associated with place of residence. CONCLUSION Our findings on disparities in condomless sex associated with socioeconomic characteristics might reflect constraint choice and decision making. Results also suggest the need for educational programming and services and better access to barrier methods.
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Affiliation(s)
- Mohamed M Ali
- UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), World Health Organization, 20 Avenue Appia, 1211, Geneva, Switzerland.
| | - Leena Merdad
- Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Saverio Bellizzi
- Partnership for Maternal, Newborn and Child Health, Geneva, Switzerland
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Rizkianti A, Maisya IB, Kusumawardani N, Linhart C, Pardosi JF. Sexual Intercourse and Its Correlates Among School-aged Adolescents in Indonesia: Analysis of the 2015 Global School-based Health Survey. J Prev Med Public Health 2020; 53:323-331. [PMID: 33070504 PMCID: PMC7569018 DOI: 10.3961/jpmph.20.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 06/11/2020] [Indexed: 11/24/2022] Open
Abstract
Objectives This study aimed to determine the prevalence and correlates of sexual intercourse among junior secondary and high school students in Indonesia from the 2015 Global School-based Health Survey (GSHS). Methods The survey was conducted among 11 110 students from 75 schools in Indonesia using a self-administered questionnaire. Univariate and multivariate analyses were conducted to explore associations between sexual intercourse and socio-demographic variables, substance use, mental distress, and protective factors. Results Overall, 5.3% of students reported having ever had sex (6.9% of boys and 3.8% of girls). Of students who engaged in sexual intercourse, 72.7% of boys and 90.3% of girls had an early sexual debut (before reaching the age of 15) and around 60% had multiple sex partners. Sexual intercourse was associated with gender, school grade, smoking, alcohol consumption, drug use, suicidal ideation, truancy, peer support, and parental supervision. Conclusions These findings indicate a pressing need to develop more comprehensive sexual health education in the national curriculum. An effective strategy should also address other risky behaviours.
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Affiliation(s)
- Anissa Rizkianti
- Centre for Research and Development of Public Health Efforts, National Institute of Health Research and Development (NIHRD), Jakarta, Indonesia
| | - Iram Barida Maisya
- Centre for Research and Development of Public Health Efforts, National Institute of Health Research and Development (NIHRD), Jakarta, Indonesia
| | - Nunik Kusumawardani
- Centre for Research and Development of Public Health Efforts, National Institute of Health Research and Development (NIHRD), Jakarta, Indonesia
| | - Christine Linhart
- School of Public Health and Community Medicine, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Jerico Franciscus Pardosi
- Centre for Research and Development of Public Health Efforts, National Institute of Health Research and Development (NIHRD), Jakarta, Indonesia.,School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
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Nalukwago J, Alaii J, Borne BVD, Bukuluki PM, Crutzen R. Application of Core Processes for Understanding Multiple Concurrent Sexual Partnerships Among Adolescents in Uganda. Front Public Health 2018; 6:371. [PMID: 30622938 PMCID: PMC6308184 DOI: 10.3389/fpubh.2018.00371] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/04/2018] [Indexed: 12/29/2022] Open
Abstract
Introduction: Adolescents in Uganda, as in other sub-Saharan countries, engage in sex with multiple concurrent partners, thus placing them at risk for HIV and unplanned pregnancies, but it is not clear why. This study explored why adolescents in Uganda engage in multiple concurrent sexual partnerships (MCSP). Methods: This study used a Core Processes methodology. We used the processes of brainstorming, and identification of evidence and theoretical support, in various phases/steps of intervention planning, to provide possible explanations for adolescent MCSP. Results: Adolescents were found to have limited knowledge of the risks associated with MCSP and perceived a low risk for HIV. Peer influence to engage in MCSP exacerbated the problem among adolescents. Poor communication with sexual partners and parents and societal indifference to multiple sexual partnerships increased permissive attitudes toward infidelity. The unclear adolescent sexual and reproductive health policies hampered access to services, and transactional sexual relationships with older (polygamous) sexual partners increased the HIV risk. Adolescents were found to be more concerned about unplanned pregnancies than HIV risk. Discussion: From the empirical evidence, adolescent health programs in Uganda should incorporate comprehensive sexual health education on HIV and teenage pregnancy risk-reduction strategies. Programs should strengthen parental and community support through enhanced collaborative training on communication with and for adolescents. Forming strategic partnerships with various stakeholders for concerted efforts to address the MCSP problem among adolescents is critical.
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Affiliation(s)
- Judith Nalukwago
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
- Family Health International 360 (Uganda), Kampala, Uganda
- Department of Social Work and Social Administration, Makerere University, Kampala, Uganda
| | - Jane Alaii
- Context Factor Solutions, Nairobi, Kenya
| | - Bart Van Den Borne
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
| | - Paul Mukisa Bukuluki
- Department of Social Work and Social Administration, Makerere University, Kampala, Uganda
| | - Rik Crutzen
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, Netherlands
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Ziraba A, Orindi B, Muuo S, Floyd S, Birdthistle IJ, Mumah J, Osindo J, Njoroge P, Kabiru CW. Understanding HIV risks among adolescent girls and young women in informal settlements of Nairobi, Kenya: Lessons for DREAMS. PLoS One 2018; 13:e0197479. [PMID: 29851988 PMCID: PMC5978990 DOI: 10.1371/journal.pone.0197479] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 05/02/2018] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION High incidence of HIV infection among adolescent girls and young women (AGYW) has been attributed to the numerous and often layered vulnerabilities that they encounter including violence against women, unfavourable power relations that are worsened by age-disparate sexual relations, and limited access to sexual and reproductive health information and services. For AGYW living in urban informal settlements (slums), these vulnerabilities are compounded by pervasive poverty, fragmented social networks, and limited access to social services including health and education. In this paper, we assess sexual risk behaviours and their correlates among AGYW in two slum settlements in Nairobi, Kenya, prior to the implementation of interventions under the Determined Resilient Empowered AIDS-free Mentored and Safe (DREAMS) Partnership. METHODS We drew on secondary data from the Transition to Adulthood study, the most recent representative study on adolescent sexual behaviour in the two settlements. The study was nested within the Nairobi Urban Health and Demographic Surveillance System (NUHDSS). Data were collected in 2009 from 1,390 AGYW aged 12-23 years. We estimated the proportions of AGYW reporting ever tested for HIV, condom use, multiple sexual partners and age-disparate sex by socio-demographic characteristics. "High risk" sexual behaviour was defined as a composite of these four variables and age at first sex. Multivariable regression analyses were performed to identify factors associated with risk behaviours. RESULTS Fifty-one percent of AGYW reported that they had ever tested for HIV and received results of their last test, with the proportion rising steeply by age (from 15% to 84% among those <15 years and 20-23 years, respectively). Of 578 AGYW who were sexually active in the 12 months preceding the survey, 26% reported using a condom at last sex, 4% had more than one sexual partner, and 26% had sex with men who were at least 5 years older or younger. All girls aged below 15 years who had sex (n = 9) had not used condoms at last sex. The likelihood of engaging in "high risk" sexual risk behaviour was higher among older AGYW (19-23 years), those in marital unions, of Luo ethnicity, out of school, living alone or with a friend (versus parents), living with spouse (versus parents), and those whose friends engaged in risky/anti-social behaviours. In contrast, Muslim faith, co-residence with both parents, and belonging to an organised social group were associated with lower odds of risky sexual behaviours. CONCLUSION Our study findings suggest that multifaceted approaches addressing the educational and social mediators of AGYW's vulnerability and that also reach the people with whom AGYW live and interact, are needed to reduce the rapid onset of sexual risk during the adolescent years. There is a particular need to reach the youngest adolescent girls in poor urban settings, among whom condom use and awareness of HIV status is rare.
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Affiliation(s)
- Abdhalah Ziraba
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
| | - Benedict Orindi
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
- Katholieke Universiteit Leuven, Kapucijnenvoer 35, Leuven, Belgium
| | - Sheru Muuo
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
| | - Sian Floyd
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Isolde J. Birdthistle
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joyce Mumah
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
| | - Jane Osindo
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
| | - Pauline Njoroge
- African Population and Health Research Center, Manga Close, Nairobi, Kenya
| | - Caroline W. Kabiru
- School of Public Health, University of Witwatersrand, Parktown, South Africa
- Population Council, Nairobi, Kenya
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