Social-structural determinants of HIV vulnerability in marriage : role of gender norms and power relations, masculinity, social norms and relationship quality

About two-thirds of global HIV infections are in sub-Saharan Africa (SSA), with 46% of new cases being in Eastern and Southern Africa. Despite remarkable progress in controlling the epidemic through scaling up antiretroviral treatment and universal health coverage in Tanzania, the HIV prevalence varies significantly across the regions, ranging from 1.5% to 14.8% and remains substantial among married men and women (5.4% and 5.2%) as compared to non-married men and women (1.2% and 3.3%) respectively. It has been argued that understanding the social-structural factors (social-economic, power relations, norms, political and legal context) of HIV beyond individual risk behaviors (condom use, number of multiple sexual partners), could inform the underlying drivers of, and interventions to reduce HIV vulnerability and health inequities in a long-term. This thesis aimed to understand the social-structural determinants of HIV vulnerability among married and cohabiting partners in Tanzania. Guided by the World Health Organization, Commission on the Social Determinants of Health framework, this thesis pursued to provide a more in-depth understanding of how socio-structural factors (social norms, marital status, gender power relations and relationship quality) influence dimensions of HIV vulnerability: a) HIV status b) safer sex communication, and c) extramarital affairs. The study was nested within the community health surveillance cohort entitled “MZIMA” (meaning being healthy), implemented in Ifakara town in south-eastern Tanzania financed by the “Global Fund Round 4”. The overall implementation of this thesis was supported by the Swiss-Tropical and Public Health Institute. In this thesis, a cross sectional sequential explanatory mixed method approach was employed between 2012 and 2015 which combined quantitative and qualitative methods. The quantitative data was part of the MZIMA surveillance cohort study. The qualitative data was primarily collected using in-depth interviews and focus group discussions to explain and explore further the findings of the quantitative study. The main conclusions, contributions, recommendations are provided based on the three levels of investigations and their interaction with the social-structural factors to potentially influence HIV vulnerability in marriage. The table below provides a summary of the study findings. We highlight potential new evidence, and the key contribution that this thesis adds on to the existing literature. Findings in the above table are categorized to highlight the fundamental factors (structural, social-cultural) which within the perspective of the WHO-Social Determinants of Health and the scholars of the drivers of the HIV vulnerability are considered responsible for poor health outcomes including HIV vulnerability. In the context of this thesis, the social-structural and socio-cultural aspects shown in the table above present the potential fundamental drivers of HIV vulnerability among married and cohabiting partners in Ifakara town, Tanzania. The fundamental factors, specifically the ‘structural’ aspects within the social determinants of health, are referred to as “upstream” determinants which present important opportunities for improving health, reducing health disparities and increase protection from unhealthy practices. The socio-cultural aspects are considered as interrelated with the “upstream” factors, which influence health outcomes. The World Health Organization refers to the socio-cultural and structural factors together as the “causes of the causes” since they interact, and may indirectly influence the behavioral risk factors by creating conditions that constrain or facilitate healthy practices. In this thesis behavioral factors that are investigated include safer sex communication among married couples and extramarital affairs. Increased knowledge about the social-structural drivers of behaviors linked to the risk of HIV infection aims at guiding appropriate intervention packages for targeting married and cohabiting couples. The bottom line is that, unlike the biological determinants, the social-structural aspects are amenable for change through structural prevention approaches. It is within this perspective that the interpretation and recommendations provided in this thesis emphasize on the social-structural aspects of HIV vulnerability in marriage. It is worth pointing out that some of the social-structural ingredients identified in this thesis may also influence HIV vulnerability in non-marital individuals, however, the pace of their influence within marriage may be slightly different since married partners may feel protected based on expectations of mutual monogamy. They have limited independence in their decisions regarding healthy choices and practices, since the marriage potentially obligates them to adhere to the opinion of the partner. Hence they are less likely to use HIV prevention methods such as condoms. Chapter 5 of this thesis, from the individual responses data base, investigated the social-structural predictors of HIV status among married and cohabiting partners in Ifakara town (findings are presented in the summary table above). Chapter 6 of this thesis, from the individual responses data base and a qualitative approach, investigated and explored the social-structural aspects that influence extramarital affairs, and the association between extramarital affairs and HIV status among married and cohabiting men and women in Ifakara town (findings are presented in the summary table above). Chapter 7 of this thesis, from a qualitative design, explored how safer sex communication is practiced in marriage and the social-structural factors that influence safer sex communication between polygamous and monogamous partners in Ifakara town (findings are presented in the summary table above). What is potentially new evidence from Ifakara town that this thesis provides? Married women in Ifakara town who engage in extramarital affairs are significantly more likely to be HIV positive than married men despite higher rates of extramarital affairs among men. The social protection groups Village Community Bank (VICOBA) in Ifakara town potentially provide opportunities for men and women to engage in extramarital affairs. Norms of masculinity and low relationship quality may lessen the protective effect of economic opportunities (VICOBA) for married women, and might expose them to sexual risk behaviors (extramarital affairs). Married women may transact money for “quality sex” and care since they may miss these aspects from their marital husbands. Some women in monogamous relations have the agency to initiate safer sex communication to their husbands despite social-structural constraints. In polygamous unions, the husband may choose to divorce women if he fails to satisfy them sexually and economically, increasing their economic vulnerability. In polygamous unions safer sex communication may be considered inappropriate. Only the younger wives may have the legitimacy to communicate about safer sex with the husband. What is the main contribution of this thesis? This thesis links epidemiology (HIV status), public health prevention strategies (safer sex communication and abstinence from extramarital affairs) and social science theories on the underlying social-structural drivers of HIV infections in marriage. The linking provides insights on the pathways in which agency (married partners) interact to influence low relationship quality, women’s economic hardship, gender norms and power-relations, social norms of marriage, marital status (re-marriage, polygamous) and masculinity and later these social-structural aspects influence various levels of social risk behaviors such as extramarital affairs and safer sex communication. Sexuality among women is not homogeneous; some women may actively initiate risk sexual behaviors (extramarital affairs) to meet their sexual satisfaction and others may initiate to meet their economic and social needs. Prevailing gender inequality within marriage based on norms of masculinity may not only sustain married women’s social and economic hardship, but might lower their safer sex negotiation power, expose them to extramarital affairs, and in turn elevate their risk of HIV infection. Norms of masculinity based on religious and social expectations potentially promotes multiple sexual partners among men. Yet, despite the many tangible benefits (power, authority and control over women) that this behavior gives to men, it has negative social and health consequences for both spouses. It destabilizes the peaceful atmosphere and relationship quality in marriage, constrains discussions on safer sex aspects, and often results in both spouses having extramarital partners. Consequently in this thesis, it is not exclusively biological sex that predicted HIV status of married men and women; it was also the socially constructed gender norm (e.g. a woman is not expected to suggest condom use even when she knows that a husband has a disease). This thesis recommends a model which may be adopted to understand HIV vulnerability in marriage. The proposed model is found in section 8.6.1 of the main thesis. The model hypothetically shows how multiple social-cultural, economic and legal aspects as structural aspects interact and intersect to influence HIV vulnerability in marriage. Further research on couples to corroborate these findings is needed as data on the partner’s behavior and HIV status were not available in this study. To conclude, this thesis accentuates that married or cohabiting couples are a window of addressing social-structural drivers of HIV in Tanzania. Addressing HIV vulnerability in marriage requires multiple approaches which are beyond individual interventions, to address the contextual realities of marriages by challenging the harmful social norms, gender norms, power inequality and norms of masculinity that constraints adoption of safer sex communication, engagement and happy life in marriage. Improving quality of relationship and acknowledging married men and women as active agents of HIV prevention could be a social resource to foster safer sex discussions and practices in marriage. Some social-structural aspects of HIV vulnerability in marriage such as social norms, gender power relation and masculinity operate across a wide spectrum of human life and in inter-related ways. This may require changes at policy level: changing the current marriage legal act of 1971 in Tanzania which perpetuates gender discriminatory practices and women’s economic hardship by fostering early marriages for girls (15years), and by legalizing men to marry multiple women. Economic empowerment programs should be tailored to address relationship quality in marriage in order to increase their protection effect against risk sexual behaviors particularly among married women. Social protection policies that discourage wife beating and promote the rights of married men and women to communicate freely about their health and sexual needs requires attention. Health system level: the choice of HIV prevention interventions including health promotion messages should be informed by the context specific evidence on the underlying HIV vulnerability in marriage. Social-structural indicators such as those that relates to gender equality could be incorporated within the HIV multi-sectoral strategic framework in Tanzania to allow implementation, monitoring and evaluation of broader contextual interventions. Couple-based counseling services for HIV prevention could emphasize on social risk aspects of HIV vulnerability: i.e relationship quality, marital status (i.e polygamous), gender power relation, social norms of marriage and norms of masculinity. Emphasize on HIV testing prior to re-marriage may increase opportunity for HIV prevention in marriage. The public health messages may also emphasize on similar aspects. At the community level, influential structures i.e religious leaders, local leaders and political leaders can advocate against the harmful social norms, gender inequality and poor relationship quality in marriage that constrain adoption of safer sex practices in marriage. Pre-wedding ceremonies could be used as venues to emphasize about the significance of relationship quality (fighting against sexual dissatisfaction, extramarital affairs and conflict) and safer sex communication in marriage. Establishing community based marital counseling centers would add value to the HIV prevention efforts targeting married partners. On the family level, childhood socialization should embrace the rights of boys and girls to speak freely about their concerns and equal education opportunity. On the theory part, the WHO-CSDH could be improved by adopting the social determinants that reflect African context buy incorporating the relationship quality, norms of masculinity, marital status and social norms as social determinants of health and health inequity

Social Cognitive Determinants of HIV Voluntary Counselling and Testing Uptake among Married Individuals in Dar es Salaam Tanzania: Theory of Planned Behaviour (TPB)

Cumulative evidence indicates increasing HIV infection among married individuals. Voluntary Counselling and Testing for HIV (HCT) is known to be an effective intervention to induce safer sex behaviour and access to early treatment, care and support among married individuals, which are important for HIV prevention. In this context, knowledge of factors associated with HCT uptake among married individuals is critical in promoting the use of the services. This study therefore intended to identify the social cognitive factors associated with acceptance of HCT among married individuals. In a cross-sectional analytical study face to face questionnaires were administered among 200 randomly selected married individuals in Kinondoni district, Dar es Salaam Tanzania. The questionnaire included self-reported HCT, socio-demographic variables and social cognitive variables (attitude, subjective norms, perceived control and perceived risk). Logistic regression was used to identify the independent association of social cognitive predictors of HCT among married individuals. Nearly half (42%) of the respondents had never had HCT. Of the social cognitive constructs, the strongest predictor of HCT uptake was attitude (OR per additional score point = 1.07, 95% CI 1.04-1.10) followed by perceived behavioural control (OR = 1.04, 95% CI 1.02-1.06). Subjective norm and perceived risk were not associated with HCT uptake. Public health interventions targeting married individuals should be designed to enhance their positive attitude towards HCT and empower them to overcome barriers to the use of the services

Evolving Strategies, Opportunistic Implementation: HIV Risk Reduction in Tanzania in the Context of an Incentive-Based HIV Prevention Intervention.

\ud Behavior change communication (BCC) interventions, while still a necessary component of HIV prevention, have not on their own been shown to be sufficient to stem the tide of the epidemic. The shortcomings of BCC interventions are partly due to barriers arising from structural or economic constraints. Arguments are being made for combination prevention packages that include behavior change, biomedical, and structural interventions to address the complex set of risk factors that may lead to HIV infection. In 2009/2010 we conducted 216 in-depth interviews with a subset of study participants enrolled in the RESPECT study - an HIV prevention trial in Tanzania that used cash awards to incentivize safer sexual behaviors. We analyzed community diaries to understand how the study was perceived in the community. We drew on these data to enhance our understanding of how the intervention influenced strategies for risk reduction. We found that certain situations provide increased leverage for sexual negotiation, and these situations facilitated opportunistic implementation of risk reduction strategies. Opportunities enabled by the RESPECT intervention included leveraging conditional cash awards, but participants also emphasized the importance of exploiting new health status knowledge from regular STI testing. Risk reduction strategies included condom use within partnerships and/or with other partners, and an unexpected emphasis on temporary abstinence. Our results highlight the importance of increasing opportunities for implementing risk reduction strategies. We found that an incentive-based intervention could be effective in part by creating such opportunities, particularly among groups such as women with limited sexual agency. The results provide new evidence that expanding regular testing of STIs is another important mechanism for providing opportunities for negotiating behavior change, beyond the direct benefits of testing. Exploiting the latent demand for STI testing should receive renewed attention as part of innovative new combination interventions for HIV prevention.\u

A qualitative study of discourses on heterosexual anal sexual practice among key, and general populations in Tanzania: implications for HIV prevention.

BACKGROUND: The risk of contracting HIV through heterosexual anal sex (HAS) is significantly higher than from vaginal intercourse. Little has been done to understand the discourses around HAS and terms people use to describe the practice in Tanzania. A better understanding of discourses on HAS would offer useful insights for measurement of the practice as well as designing appropriate interventions to minimise the risks inherent in the practice. METHODS: This study employed qualitative approaches involving 24 focus group discussions and 81 in-depth interviews. The study was conducted in 4 regions of Tanzania, and included samples from the general population and among key population groups (fishermen, truck drivers, sex workers, food and recreational facilities workers). Discourse analysis was conducted with the aid of NVIVO versions 8 and 10 software. RESULTS: Six discourses were delineated in relation to how people talked about HAS. Secrecy versus openness discourse describes the terms used when talking about HAS. "Other" discourse involved participants' perception of HAS as something practiced by others unrelated to them and outside their communities. Acceptability/trendiness discourse: young women described HAS as something trendy and increasingly gaining acceptability in their communities. Materiality discourse: describes HAS as a practice that was more profitable than vaginal sex. Masculinity discourse involved discussions on men proving their manhood by engaging in HAS especially when women initiated the practice. Masculine attitudes were also reflected in how men described the practice using a language that would be considered crude. Public health discourse: describes HAS as riskier for HIV infection than vaginal sex. The reported use of condoms was low due to the perceptions that condoms were unsuitable for anal sex, but also perceptions among some participants that anal sex was safer than vaginal sex. CONCLUSION: Discourses among young women and adult men across the study populations were supportive of HAS. These findings provide useful insights in understanding how different population groups talked about HAS and offer a range of terms that interventions and further research on magnitude of HAS could draw on when addressing health risks of HAS among different study populations

Arts-based approaches to promoting health in sub-Saharan Africa:A scoping review

Introduction: Arts-based approaches to health promotion have been used widely across sub-Saharan Africa (SSA), particularly in public health responses to HIV/AIDS. Such approaches draw on deep-rooted historical traditions of indigenous groups in combination with imported traditions which emerged from colonial engagement. To date, no review has sought to map the locations, health issues, art forms and methods documented by researchers using arts-based approaches in SSA. Methods: Using scoping review methodology, 11 databases spanning biomedicine, arts and humanities and social sciences were searched. Researchers screened search results for papers using predefined criteria. Papers included in the review were read and summarised using a standardised proforma. Descriptive statistics were produced to characterise the location of the studies, art forms used or discussed, and the health issues addressed, and to determine how best to summarise the literature identified. Results: Searches identified a total of 59 794 records, which reduced to 119 after screening. We identified literature representing 30 (62.5%) of the 48 countries in the SSA region. The papers covered 16 health issues. The majority (84.9%) focused on HIV/AIDS-related work, with Ebola (5.0%) and malaria (3.3%) also receiving attention. Most studies used a single art form (79.0%), but a significant number deployed multiple forms (21.0%). Theatre-based approaches were most common (43.7%), followed by music and song (22.6%), visual arts (other) (9.2%), storytelling (7.6%) and film (5.0%). Conclusions: Arts-based approaches have been widely deployed in health promotion in SSA, particularly in response to HIV/AIDS. Historically and as evidenced by this review, arts-based approaches have provided a platform to facilitate enquiry, achieved significant reach and in some instances supported demonstrable health-related change. Challenges relating to content, power relations and evaluation have been reported. Future research should focus on broadening application to other conditions, such as non-communicable diseases, and on addressing challenges raised in research to date

Assessment of Patient Preference in Allocation and Observation of Anti-Tuberculosis Medication in three Districts in Tanzania.

The new tuberculosis (TB) treatment in Tanzania contains rifampicin for six months. Direct observation of drug intake at the health facility for this period is not feasible. Patients and health staff in three districts were interviewed to assess the burden of the current treatment strategy, and opinions on a proposed new strategy where patients are able to choose the place of treatment and the treatment supervisor, and receive treatment as a daily combination tablet. The study included 343 patients in 42 facilities. Daily collection of drugs was perceived as burdensome irrespective of distance needed to travel. Eighty percent of patients viewed medication taken at home or at a closer health facility as an improvement in TB-services. The proposed new treatment strategy was rated favorably by 85% of patients and 75% of health staff. Fifty-three percent of patients would opt for home-based treatment, and 75% would choose a family member or the spouse as treatment supporter. Home-based supervision of TB treatment with fewer drugs is an expressed preference of TB patients in Tanzania. Such a strategy is now being assessed in a pilot study. If effective and feasible, the strategy will contribute to an improved TB control strategy

Understanding the role of the Tanzania national health insurance fund in improving service coverage and quality of care

Health insurance is one of the main financing mechanisms currently being used in low and middle-income countries to improve access to quality services. Tanzania has been running its National Health Insurance Fund (NHIF) since 2001 and has recently undergone significant reforms. However, there is limited attention to the causal mechanisms through which NHIF improves service coverage and quality of care. This paper aims to use a system dynamics (qualitative) approach to understand NHIF causal pathways and feedback loops for improving service coverage and quality of care at the primary healthcare level in Tanzania. We used qualitative interviews with 32 stakeholders from national, regional, district, and health facility levels conducted between May to July 2021. Based on the main findings and themes generated from the interviews, causal mechanisms, and feedback loops were created. The majority of feedback loops in the CLDs were reinforcing cycles for improving service coverage among beneficiaries and the quality of care by providers, with different external factors affecting these two actions. Our main feedback loop shows that the NHIF plays a crucial role in providing additional financial resources to facilities to purchase essential medical commodities to deliver care. However, this cycle is often interrupted by reimbursement delays. Additionally, beneficiaries' perception that lower-level facilities have poorer quality of care has reinforced care seeking at higher-levels. This has decreased lower level facilities' ability to benefit from the insurance and improve their capacity to deliver quality care. Another key finding was that the NHIF funding has resulted in better services for insured populations compared to the uninsured. To increase quality of care, the NHIF may benefit from improving its reimbursement administrative processes, increasing the capacity of lower levels of care to benefit from the insurance and appropriately incentivizing providers for continuity of care

Dog ownership practices and responsibilities for children’s health in terms of rabies control and prevention in rural communities in Tanzania

Interventions tackling zoonoses require an understanding of healthcare patterns related to both human and animal hosts. The control of dog-mediated rabies is a good example. Despite the availability of effective control measures, 59,000 people die of rabies every year worldwide. In Tanzania, children are most at risk, contributing ~40% of deaths. Mass dog vaccination can break the transmission cycle, but reaching the recommended 70% coverage is challenging where vaccination depends on willingness to vaccinate dogs. Awareness campaigns in communities often target children, but do not consider other key individuals in the prevention chain. Understanding factors related to dog ownership and household-level responsibility for dog vaccination and child health is critical to the design of vaccination strategies. We investigated who makes household decisions about dogs and on health care for children in rural Tanzania. In the Kilosa district, in-depth interviews with 10 key informants were conducted to inform analysis of data from a household survey of 799 households and a survey on Knowledge Attitudes and Practices of 417 households. The in-depth interviews were analysed using framework analysis. Descriptive analysis showed responsibilities for household decisions on dogs’ and children’s health. Multivariate analysis determined factors associated with the probability of dogs being owned and the number of dogs owned, as well as factors associated with the responsibility for child health. Dog ownership varied considerably between villages and even households. The number of dogs per household was associated with the size of a household and the presence of livestock. Children are not directly involved in the decision to vaccinate a dog, which is largely made by the father, while responsibility for seeking health care if a child is bitten lies with the mother. These novel results are relevant for the design and implementation of rabies interventions. Specifically, awareness campaigns should focus on decision-makers in households to improve rabies prevention practices and on the understanding of processes critical to the control of zoonoses more broadly