Transactional sex among adolescent girls and young women enrolled in a cash plus intervention in rural Tanzania: a mixed-methods study

Qualitative evaluation of an edutainment intervention to prevent age-disparate transactional sex in Tanzania: Changes in educational aspirations and gender equitable attitudes towards work

Age-disparate transactional sex is a major contributor to the disproportionate rates of HIV experienced by adolescent girls in sub-Saharan Africa, and a key driver of unintended adolescent pregnancy. This paper comprises one element of the impact evaluation of the Learning Initiative on Norms, Exploitation and Abuse (LINEA) radio drama intervention to prevent age-disparate transactional sex. It provides new insights into the radio drama's influence on distal drivers of age-disparate transactional sex identified in formative research: girls' own educational aspirations, and gendered attitudes towards work. The intervention, which targeted adolescent girls and their caregivers in the Shinyanga Region of Tanzania, uses an edutainment approach to prevent transactional sex between girls aged 12-16 years and men at least 5-10 years older. We distributed the 39-episode radio drama on USB flash drives to 331 households and conducted longitudinal in-depth interviews with 59 participants. We conducted a thematic analysis of endline (December 2021) transcripts from 23 girls, 18 women caregivers, and 18 men caregivers of girls (n = 59), and midline (November 2021) transcripts from a sub-sample of these participants: 16 girls, 16 women and 13 men (n = 45). Findings suggest the radio drama created an enabling environment for preventing age-disparate transactional sex by increasing girls' motivation to focus on their studies and remain in school. There was also strong evidence of increased gender-equitable attitudes about work among girls and women and men caregivers. These supported women joining the workforce in positions traditionally reserved for men and challenging the male provider role. Our findings suggest that the LINEA radio drama can supplement interventions that address structural drivers of age-disparate transactional sex. The radio drama may also have impacts beyond preventing age-disparate transactional sex, such as reducing girls' HIV morbidity and mortality, and challenging attitudes that promote sexual and gender-based violence to foster more gender-equitable communities across Tanzania.

Systematic review of cash plus or bundled interventions targeting adolescents in Africa to reduce HIV risk

BACKGROUND

HIV remains a leading cause of death for adolescents and young people aged 10-24 years. HIV prevention requires multisectoral approaches that target adolescents and young people, addressing HIV risk pathways (e.g., transactional sex, gender-based violence, and school attendance) through bundled interventions that combine economic strengthening, health capabilities, and gender equality education. However, best practices are unknown because evidence on multisectoral programming targeted to adolescents and combining these components has not been systematically reviewed.

METHODS

We conducted a systematic review to summarize the evidence on bundled interventions combining health and economic strengthening components for adolescents and young people and their effects on HIV/STI incidence and risk factors. We included studies from Africa published between 2005 and 2023, combining at least one economic strengthening and one health component, directed toward adolescents and young people aged 10-24 years. Included studies measured programmatic impacts on primary outcomes: HIV and STI incidence/prevalence; and mediators as secondary outcomes: sexual behaviours, sexual and reproductive health, school attendance, health-seeking behaviours, and violence. We conducted key word searches in PubMed, EMBASE, and Web of Science, imported titles/abstracts from the initial search, and reviewed them using the inclusion criteria. Full texts of selected articles were reviewed and information was extracted for analysis. Findings from the full texts identified were summarized.

RESULTS

We reviewed 58 studies, including 43 quantitative studies and 15 qualitative studies, evaluating 26 unique interventions. A majority of studies reviewed were conducted in Eastern and Southern Africa. Interventions reviewed showed a greater number of significant results in improving economic outcomes; mental health and psychosocial outcomes; sexual and reproductive health knowledge and services utilization; and HIV prevention knowledge and testing. They showed fewer significant results in improving outcomes related to HIV incidence/prevalence; sexual risk behaviours; gender-based violence; gender attitudes; education; STI incidence, prevalence and testing; and sexual debut.

CONCLUSIONS

Our review demonstrated the potential for bundled, multisectoral interventions for preventing HIV and facilitating safe transitions to adulthood. Findings have implications for designing HIV sensitive programmes on a larger scale, including how interventions may need to address multiple strata of the social ecological model to achieve success in the prevention of HIV and related pathways.

The influence of gender-equitable attitudes on sexual behaviour among unmarried adolescents in rural Tanzania: a longitudinal study

PLAIN LANGUAGE STATEMENT

Gender norms that centre men and disadvantage women create gender inequality, which can lead to risky sexual behaviour. This study examined how both community and individual attitudes toward gender norms influenced risky sexual behaviour in adolescents, and whether that influence was different between males and females. We found that higher gender-equitable attitudes were linked to increased odds of HIV testing in the last 12 months, and decreased odds of engaging in a sexual relationship with a much older partner. Individual high gender-equitable attitudes among girls were also linked to higher odds of them using condoms and contraceptives. Gender-equitable attitudes did not seem to influence early sexual debut, engagement in transactional sex, having multiple sexual partners at the same time, or the number of sexual partners a participant had in the last 12 months. Based on these findings, programming designed to increase gender-equitable attitudes might be helpful in increasing HIV testing and condom and contraceptive use, but it needs to involve the entire community, not just individual boys and girls.

Experiences of Exploitation and Associations With Economic Abuse in Adolescent Dating Relationships: Findings From a U.S. Cross-Sectional Survey

Adolescent relationship abuse (ARA) (i.e. physical, sexual, psychological, or economic abuse in the context of romantic relationships) is associated with adverse health outcomes, including anxiety, depression, suicidality, unintended pregnancy, and substance misuse. A related phenomenon, reproductive coercion involves interference with the reproductive decision making of a partner with the intention of promoting pregnancy or controlling outcomes of a pregnancy. Reproductive coercion is associated with unintended pregnancy, partner violence, and sexually transmitted infections. Little is known about the intersection between economic ARA, sexual exploitation, and reproductive coercion. This paper explores the intersections between reproductive coercion, transactional sex, and economic abuse victimization in adolescent dating relationships. In an online survey, 1,752 adolescents (ages 13-17) were asked about economic adolescent relationship abuse (educational, employment and financial interference), transactional sex, reproductive coercion, and contraceptive access within their relationships. We assessed associations with chi-square tests and logistic regression analysis. Youth who experienced economic ARA (70%, 1,232) reported financial dependence on their partner, contraceptive access, and reproductive coercion (74-83%; p-values<0.001) more often than their counterparts without economic ARA. Adolescents experiencing economic abuse were more likely to report transactional sex (aOR = 2.76, CI [2.12, 3.60], p < .001), depending on a partner to pay for contraception or birth control (aOR = 2.20, CI [1.71, 2.84], p < .001), and reproductive coercion (aOR = 3.20, CI [2.37, 4.32], p < .001). Youth-serving providers and agencies should be aware of intersections between economic ARA, transactional sex, financial dependence, and reproductive coercion, particularly for adolescents with health-related social needs.