'Mum never loved me.' How structural factors influence adolescent sexual and reproductive health through parent–child connectedness: a qualitative study in rural Tanzania

Research in high income countries shows parent–child connectedness to be protective against undesirable sexual and reproductive health (SRH) outcomes among young people. Little has been done to understand the nature of parent–child connectedness, the structural factors that impact on connectedness and parents’ understanding of how connectedness affects their children's sexual behaviour in sub-Saharan Africa and Tanzania in particular. Ethnographic research involved 30 days of observation in 10 households, 9 focus group discussions and 60 in-depth interviews. Thematic analysis was conducted using NVIVO qualitative data analysis software.<p></p> The structural factors with greatest influence on connectedness were economic circumstances, gender, social status, state education, and globalisation. Economic circumstances impacted on parent–child connectedness through parents’ ability to provide for their children's material needs, and the time their occupation allowed for them to spend with their children and monitor their activities. Appropriate parent–child interactions were shaped by gender norms and by social status in the form of respectability, adolescents’ adherence to norms of respect/ obedience shaping their parents’ affection. State education affected parents’ preferences between children but also undermined parental authority, as did broader globalisation. Connectedness was related to SRH in a bi-directional way: lack of connectedness was linked to young people's low self-esteem and risky sexual behaviour while unplanned pregnancies seriously undermined young women's connectedness with their parents. Since material provision was perceived to be a central element of parent–child connectedness, structural factors limiting provision made transactional sex more likely both through direct material pathways and emotional ones. Motives for transactional sex were said to be material needs and to feel loved and cared for.<p></p> An important pathway by which structural factors shape adolescent SRH outcomes is through parent–child connectedness, especially parents’ ability to spend time with their children and provide for their economic needs. Modifying these structural factors should facilitate parent–child connectedness, which may help delay early sexual intercourse, protect young people against unplanned pregnancy through encouraging communication on contraception use and, overall, promote healthy adolescent development

Revisiting the understanding of "transactional sex" in sub-Saharan Africa: A review and synthesis of the literature.

In sub-Saharan Africa, young women ages 15-24 have more than twice the risk of acquiring HIV as their male counterparts. A growing body of epidemiological evidence suggests that the practice of "transactional sex" may contribute to this disparity. Over the last 15 years, the social sciences have contributed significantly to understanding the meaning of and motivations for this practice. The findings from these studies are rich, but varied, rendering lessons difficult to navigate for intervention and further research. We therefore contribute a historically-grounded, comprehensive literature review on the nature and motivations for women's participation in transactional sex in sub-Saharan Africa. Drawing from over 300 studies (through 2014), we distill three prominent paradigms observed in the literature that we review toward presenting a unified conceptualization of the practice. "Sex for basic needs," the first paradigm, positions women as victims in transactional sexual relationships, with implications for interventions that protect girls from exploitation. In contrast, the "sex for improved social status" paradigm positions women as sexual agents who engage in transactional sex toward attaining a middle-class status and lifestyle. Finally, a third paradigm, "sex and material expressions of love," draws attention to the connections between love and money, and the central role of men as providers in relationships. We find important commonalities in the structural factors that shape the three paradigms of transactional sex including gender inequality and processes of economic change. We suggest that there are three continua stretching across these paradigms: deprivation, agency, and instrumentality. This review proposes a definition of transactional sex and discusses implications for research and interventions aiming to reduce young women's risk of HIV through such relationships. We consider the consequences of drawing from too narrow an understanding of the practice, and highlight the benefits of a broader conceptualization

'It is just the way it was in the past before I went to test': a qualitative study to explore responses to HIV prevention counselling in rural Tanzania.

BACKGROUND: Voluntary counselling and testing (VCT) for HIV first evolved in Western settings, with one aim being to promote behaviours which lower the risk of onward transmission or acquisition of HIV. However, although quantitative studies have shown that the impact of VCT on sexual behaviour change has been limited in African settings, there is a lack of qualitative research exploring perceptions of HIV prevention counselling messages, particularly among clients testing HIV-negative. We conducted a qualitative study to explore healthcare worker, community and both HIV-negative and HIV-positive clients' perceptions of HIV prevention counselling messages in rural Tanzania. METHODS: This study was carried out within the context of an ongoing community HIV cohort study in Kisesa, northwest Tanzania. Nine group sessions incorporating participatory learning and action (PLA) activities were conducted in order to gain general community perspectives of HIV testing and counselling (HTC) services. Thirty in-depth interviews (IDIs) with HIV-negative and HIV-positive service users explored individual perceptions of HIV prevention counselling messages, while five IDIs were carried out with nurses or counsellors offering HTC in order to explore provider perspectives. RESULTS: Two key themes revolving around socio-cultural and contextual factors emerged in understanding responses to HIV prevention counselling messages. The first included constraints to client-counsellor interactions, which were impeded as a result of difficulties discussing private sexual behaviours during counselling sessions, a hierarchical relationship between healthcare providers and clients, insufficient levels of training and support for counsellors, and client concerns about confidentiality. The second theme related to imbalanced gender-power dynamics, which constrained the extent to which women felt able to control their HIV-related risk. CONCLUSION: Within the broader social context of a rural African setting, HIV prevention counselling based on a Western model of individual-level agency seems unlikely to make a significant contribution to sexual behaviour change until there is greater recognition by counsellors of the ways in which power dynamics within many relationships influence behaviour change. More culturally relevant counselling strategies and messages and infrastructural improvements such as additional training for counsellors and counselling rooms which ensure privacy and confidentiality, may lead to better outcomes in terms of sexual risk reduction

Transactional sex amongst young people in rural northern Tanzania: an ethnography of young women's motivations and negotiation

BACKGROUND: Material exchange for sex (transactional sex) may be important to sexual relationships and health in certain cultures, yet the motivations for transactional sex, its scale and consequences are still little understood. The aim of this paper is to examine young women's motivations to exchange sex for gifts or money, the way in which they negotiate transactional sex throughout their relationships, and the implications of these negotiations for the HIV epidemic. METHOD: An ethnographic research design was used, with information collected primarily using participant observation and in-depth interviews in a rural community in North Western Tanzania. The qualitative approach was complemented by an innovative assisted self-completion questionnaire. FINDINGS: Transactional sex underlay most non-marital relationships and was not, per se, perceived as immoral. However, women's motivations varied, for instance: escaping intense poverty, seeking beauty products or accumulating business capital. There was also strong pressure from peers to engage in transactional sex, in particular to consume like others and avoid ridicule for inadequate remuneration.Macro-level factors shaping transactional sex (e.g. economic, kinship and normative factors) overwhelmingly benefited men, but at a micro-level there were different dimensions of power, stemming from individual attributes and immediate circumstances, some of which benefited women. Young women actively used their sexuality as an economic resource, often entering into relationships primarily for economic gain. CONCLUSION: Transactional sex is likely to increase the risk of HIV by providing a dynamic for partner change, making more affluent, higher risk men more desirable, and creating further barriers to condom use. Behavioural interventions should directly address how embedded transactional sex is in sexual culture

COVID-19 social distancing measures and informal urban settlements.

To slow down the community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes coronavirus disease 2019 (COVID-19), context-appropriate measures are vital. The first COVID-19 cases in Kenya, Uganda and the United Republic of Tanzania were reported in March 2020. All three countries have introduced measures to slow the spread of the virus, such as encouraging washing and/or sanitizing hands frequently, staying at home, practising physical distancing when outside the home and partial lockdowns. Most of these prevention measures replicate those from high-income countries and implementation in these three countries has not been without added challenges. The blanket transfer of prevention measures to low-income countries is problematic, especially in urban informal settlements in eastern Africa, due to major contextual differences. Here we draw on examples of these three East African countries to illustrate the challenges that individuals and families face in adopting measures such as physical distancing to slow down the spread of SARS-CoV-2

Sexual health of adolescent girls and young women in Central Uganda: exploring perceived coercive aspects of transactional sex.

Adolescent girls and young women (AGYW) in Uganda are at risk of early sexual debut, unwanted pregnancy, violence, and disproportionally high HIV infection rates, driven in part by transactional sex. This paper examines the extent to which AGYW's participation in transactional sex is perceived to be coerced. We conducted 19 focus group discussions and 44 in-depth interviews using semi-structured tools. Interviews were audio recorded, and transcribed verbatim. Data were analysed using a thematic analysis. While AGYW did not necessarily use the language of coercion, their narratives describe a number of coercive aspects in their relationships. First, coercion by force as a result of "de-toothing" a man (whereby they received money or resources but did not wish to provide sex as "obligated" under the implicit "terms" of the relationships). Second, they described the coercive role that receiving resources played in their decision to have sex in the face of men's verbal insistence. Finally, they discussed having sex as a result of coercive economic circumstances including poverty, and because of peer pressure to uphold modern lifestyles. Support for income-generation activities, microfinance and social protection programmes may help reduce AGYW's vulnerability to sexual coercion in transactional sex relationships. Targeting gender norms that contribute to unequal power dynamics and social expectations that obligate AGYW to provide sex in return for resources, critically assessing the meaning of consensual sex, and normative interventions building on parents' efforts to ascertain the source of their daughters' resources may also reduce AGYW's vulnerability to coercion

Measurement and prevalence of sexual harassment in low- and middle-income countries: a systematic review and meta-analysis.

OBJECTIVES: We synthesise evidence on sexual harassment from studies in low-income and middle-income countries (LMICs) to estimate its prevalence and conduct a meta-analysis of the association between sexual harassment and depressive symptoms. METHODS: We searched eight databases. We included peer-reviewed studies published in English from 1990 until April 2020 if they measured sexual harassment prevalence in LMICs, included female or male participants aged 14 and over and conceptualised sexual harassment as an independent or dependant variable. We appraised the quality of evidence, used a narrative syntheses approach to synthesise data and conducted a random effects meta-analysis. RESULTS: From 49 included studies, 38 focused on workplaces and educational institutions and 11 on public places. Many studies used an unclear definition of sexual harassment and did not deploy a validated measurement tool. Studies either used a direct question or a series of behavioural questions to elicit information on acts considered offensive or defined as sexual harassment. Prevalence was higher in educational institutions than in workplaces although there was high heterogeneity in prevalence estimates across studies with no international comparability. This posed a challenge for calculating an overall estimate or measuring a range. Our meta-analysis showed some evidence of an association between sexual harassment and depressive symptoms (OR: 1.75; 95% CI: 1.11 to 2.76; p=0.016) although there were only three studies with a high risk of bias. CONCLUSION: To our knowledge, this is the first systematic review to assess measurement approaches and estimate the prevalence of sexual harassment across settings in LMICs. We also contribute a pooled estimate of the association between sexual harassment and depressive symptoms in LMICs. There is limited definitional clarity, and rigorously designed prevalence studies that use validated measures for sexual harassment in LMICs. Improved measurement will enable us to obtain more accurate prevalence estimates across different settings to design effective interventions and policies

Why Me? Challenges Associated With Recruiting Participants for a Study Focusing on “Wealthy Men”: Reflections From Fieldwork Conducted in Tanzania

It is well-known that conducting research with elite groups presents a range of unique methodological challenges including gaining access to and recruiting a demographic group that is underrepresented if not entirely absent from most research. This issue is particularly pronounced when the research topic is sensitive or potentially politicized and conducted in low-income settings in which large wealth inequalities are apparent. Drawing on recent experiences from fieldwork conducted in Tanzania that aimed to explore attitudes toward HIV testing among wealthy men, we reflect on significant challenges in the recruitment process. These included the framing of the research project, the (often unspoken) politicized subtext of the (sensitive) research, the socioeconomic climate, and the navigation of time requirements. Our experiences suggest that a careful consideration of these methodological issues will help researchers recruit elite participants and ensure that data are collected from appropriate samples

Male and Female Conceptualizations of Sexual Harassment in Tanzania: The Role of Consent, Male Power, and Social Norms.

Sexual harassment is pervasive worldwide, yet there is a lack of clarity on its conceptualization in many settings, especially in low-income countries. Context-specific conceptualization of sexual harassment is vital to develop effective measurement tools, estimate its magnitude, and the design of interventions to address it. We explored how different population groups in Mwanza, Tanzania, understood, conceptualized, and experienced sexual harassment. This study employed a qualitative research design involving 74 in-depth interviews and 13 focus group discussions with participants from educational, workplace, and public settings in Mwanza, Tanzania. Participants were adolescent girls and boys, adult women and men. We explored individual-level perceptions and experiences of sexual harassment, and community norms and expectations around sexual harassment. We analyzed the data using a thematic approach. Participants' perceptions of sexual harassment emphasized the critical role of consent, the expression of male power, and social norms with regard to sexual harassment. Sexual harassment was understood to be a result of men being in positions of power and in charge of material resources, school grades, or employment opportunities. These in turn enabled them to take advantage of girls and women. Social norms around male and female interactions, courtship and seduction, expressions of sexual interest were crucial in delineating what was and what was not considered sexual harassment. Sexual harassment is a fluid concept, and its definition is highly dependent on contextual factors. Consent underpins the conceptualization of sexual harassment and is a fundamental feature in the definition and measurement of sexual harassment in Tanzania. Consent is largely determined by sexual norms around male and female interactions and gendered power. There is a need for consensus in schools, workplaces, and communities about what constitutes sexual harassment in order to measure and address it appropriately

Improving the Measurement of Transactional Sex in Sub-Saharan Africa: A Critical Review.

BACKGROUND: Transactional sex, or informal sexual exchange, is considered to be an important contributing factor to the disproportionately high HIV infection rates experienced by adolescent girls and young women in sub-Saharan Africa. Nonetheless, confusion remains over how best to define and measure this practice, hindering efforts to mitigate the role of transactional sex in the epidemic. We critically review current measures and offer evidence-based recommendations for improvement. SETTING: Although transactional sex is practiced around the world, we focus attention on the definition and measurement of this practice in sub-Saharan Africa, given the role it plays in young women's risk of HIV in this region. METHODS: We relied on both secondary and primary data sources. We draw on a systematic review of literature on transactional sex from sub-Saharan Africa and interview data from both key informants and cognitive interviews (n = 160) with young women (ages 14-24) and men (ages 18-35) in Uganda and Tanzania. RESULTS: We find current measures are inconsistent, conflate transactional sex with sex work, and fail to capture the gendered nature of the practice. We provide an evidence-based definition of transactional sex that guides our measurement recommendations. We then detail the development of improved measures through cognitive interviews. Finally, we offer recommended approaches to improved measurement of transactional sex for women and men in large-scale surveys. CONCLUSIONS: Improved measures are critical for accurate estimation of the prevalence of transactional sex and assessment of the extent to which transactional sex determines HIV risk