Measuring couple relationship quality in a rural African population: Validation of a Couple Functionality Assessment Tool in Malawi

Development and Empirical Test of the Research-Informed South African Relationship Functioning Assessment (SARFA)

Intimate partners play an important role in chronic diseases. Despite the chronic disease burden increase in sub-Saharan Africa, very few culturally-relevant quantitative measures of intimate relationship functioning are available. We conducted an empirical investigation evaluating the psychometric properties of the South African Relationship Functioning Assessment (SARFA) assessing healthy relationship functioning in N = 150 community members (50% women; M age = 27.2 years) living in the Vulindlela area of KwaZulu-Natal, South Africa. Item development was based on prior qualitative research from two South African communities. All assessments were conducted in isiZulu, participants' primary language. An exploratory factor analysis was conducted on the initial 39-item measure. The best-fitting model consisted of one factor with 22 items. The SARFA's internal consistency was α = .94. Convergent validity was observed via significant positive associations (all rs ≥ .38, p < .001) between the SARFA's total score and measures of trust, emotional intimacy, constructive communication, sexual satisfaction, and relationship control (women only). Divergent validity was observed for women only. Encouraging initial psychometric properties of a culturally-relevant measure of relationship functioning in KwaZulu-Natal may have relevance to other communities and potential to be used in research involving couples and health in chronic disease-burdened communities.

Supportive couple relationships buffer against the harms of HIV stigma on HIV treatment adherence

INTRODUCTION

HIV stigma can impact couple relationships through stress or bring partners closer through shared experiences. Conversely, couple relationships may protect against the harms of stigma, including anticipated stigma on negative health outcomes. Yet few studies have assessed the potential link between HIV stigma, relationship dynamics, and antiretroviral therapy (ART) adherence. Using dyadic data from a cross-sectional study of Malawian couples living with HIV, we tested associations between anticipated stigma and: 1) relationship dynamics (e.g., trust, sexual satisfaction, communication) and partner support; and 2) self-reported ART adherence.

METHODS

Heterosexual couples (211 couples, 422 individuals) with at least one partner on ART were recruited from clinics in Zomba, Malawi. Partners completed separate surveys on anticipated stigma, relationship dynamics, and ART adherence. Linear mixed models evaluated associations between anticipated stigma and relationship dynamics, and whether associations varied by gender. Generalized estimating equation models tested for associations between anticipated stigma and high ART adherence (90-100% vs. < 90%) at the individual level, and whether they were moderated by relationship dynamics at the couple level.

RESULTS

Couples' relationship length averaged 12.5 years, 66.8% were HIV sero-concordant, and 95.6% reported high ART adherence. In multivariable models, sexual satisfaction (β = -0.22, 95%CI = -0.41;-0.03, p = 0.020) and partner social support (β = -0.02, 95%CI = -0.04;-0.01, p < 0.01) were negatively associated with anticipated stigma. Significant interaction effects showed that adherence is moderated in couples with higher partner support and sexual satisfaction such that adherence is lowest when anticipated stigma is high and social support is low, and that adherence is lowest when anticipated stigma is high and sexual satisfaction is low.

CONCLUSIONS

Increased anticipated stigma is most associated with lower ART non-adherence at lower levels of social support and sexual satisfaction. Conversely, supportive and fulfilling relationships may buffer the negative association between stigma and ART adherence. Couples' interventions that focus on improving communication and support systems within couples could reduce the negative impacts of anticipated stigma on couples living with HIV.

Effects of the Waya Intervention on Marital Satisfaction and HIV Risk Behaviors in Western Kenya: A Pre-Post Study Design

Poor marital satisfaction is associated with high-risk sexual behavior and HIV transmission. We tested whether a counselor-led couple education and counseling intervention dubbed Waya (paternal aunt) would improve marital satisfaction and reduce HIV risk behavior among married couples in Kisumu County, western Kenya. In a pre-post design, we enrolled 60 heterosexual married couples at high risk for HIV to undergo five 1-h couple education and counseling sessions over 56 days. We collected self-reported data on marital satisfaction, the number of sex partners, and condom use with extramarital partners at pre- and post-intervention visits. We used Wilcoxon and McNemar tests to examine the association of our intervention with marital relationship satisfaction and reduction in HIV risk sexual behavior. The intervention was associated with marital relationship satisfaction score improvement from a median of 5 (interquartile range [IQR], 4-5) to 6 (IQR, 6-7) among men and 4 (IQR, 3-5) to 6 (IQR, 5-6) among women (p < .01). The intervention was also associated with reducing HIV risk sexual behaviors depicted by a reduction in the number of sex partners in the past one month and an increase in consistent extramarital condom use. The number of sex partners reduced from a median of 2 (IQR, 1-2) to 1 (IQR, 1-2) and consistent extramarital condom use increased from 4% at baseline to 56% among men. Our intervention was associated with improvements in marital relationship satisfaction and reductions in HIV high-risk behaviors necessary for achieving epidemic control in HIV hotspots such as fishing communities in western Kenya.

Factors associated with men's health facility attendance as clients and caregivers in Malawi: a community-representative survey

Introduction

Men have higher rates of morbidity and mortality across nearly all top ten causes of mortality worldwide. Much of this disparity is attributed to men’s lower utilization of routine health services; however, little is known about men’s general healthcare utilization in sub-Saharan Africa.

Methods

We analyze the responses of 1,116 men in a community-representative survey of men drawn from a multi-staged sample of residents of 36 villages in Malawi to identify factors associated with men’s facility attendance in the last 12 months, either for men’s own health (client visit) or to support the health care of someone else (caregiver visit). We conducted single-variable tests of association and multivariable logistic regression with random effects to account for clustering at the village level.

Results

Median age of participants was 34, 74% were married, and 82% attended a health facility in the last year (63% as client, 47% as caregiver). Neither gender norm beliefs nor socioeconomic factors were independently associated with attending a client visit. Only problems with quality of health services (adjusted odds ratio [aOR] 0.294, 95% confidence interval [CI] 0.10—0.823) and good health (aOR 0.668, 95% CI 0.462–0.967) were independently associated with client visit attendance. Stronger beliefs in gender norms were associated with caregiver visits (beliefs about acceptability of violence [aOR = 0.661, 95% CI 0.488–0.896], male sexual dominance [aOR = 0.703, 95% CI 0.505–0.978], and traditional women’s roles [aOR = 0.718, 95% CI 0.533–0.966]). Older age (aOR 0.542, 95% CI 0.401–0.731) and being married (aOR 2.380, 95% CI 1.196–4.737) were also independently associated with caregiver visits.

Conclusion

Quality of services offered at local health facilities and men’s health status were the only variables associated with client facility visits among men, while harmful gender norms, not being married, and being younger were negatively associated with caregiver visits.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-14300-8.

Couple Efficacy and Communal Coping for HIV Prevention Among Kenyan Pregnant Couples

Involving both partners of a couple in HIV prevention can improve maternal and child health outcomes in sub-Saharan Africa. Using data from 96 couples, we explored the actor and partner effects of perceived relationship dynamics on a couple's confidence and ability to reduce HIV risk together. Perceived relationship quality altered perceived confidence and ability to reduce HIV threat. One's own ability to confidently act together with their spouse appeared to be stronger for husbands than wives with respect to relationship commitment. A partner's confidence to communicate with their spouse about HIV risk reduction appeared to be stronger from husbands to wives for relationship satisfaction and trust. Gender differences in perceived relationship quality and effects on communal coping may exist and requires further study for applicability in intervention development in this setting. Efficacious couple-oriented interventions for HIV prevention should incorporate evidence on how partners mutually influence each other's health beliefs and behaviors.

Relationship Dynamics are Associated with Self-Reported Adherence but not an Objective Adherence Measure in Malawi

Couple relationships can be leveraged to improve adherence to antiretroviral therapy (ART), but few studies have identified relationship factors to target in interventions in sub-Saharan Africa. We conducted a cross-sectional study with 211 couples in southern Malawi with at least one partner on ART to test for associations between ART adherence and relationship dynamics (intimacy, trust, relationship satisfaction, unity, commitment, and partner support). We measured ART adherence through subjective measures (patient and partner reports) and an objective measure (ART drug levels in hair) and hypothesized that more positive relationship dynamics (e.g., higher intimacy) would be associated with better adherence. Multi-level logistic and linear regression models were used to evaluate study hypotheses, controlling for the clustering of individuals within couples. High levels of adherence were found by all three measures. Unity, satisfaction, and partner support were associated with higher patient and partner reports of adherence, and additional relationship dynamics (intimacy, trust) were associated with higher partner reported adherence. No associations were found between relationship dynamics and drug levels in hair, although drug levels were high overall. Future studies should perform longitudinal assessments of relationship dynamics and objective metrics of adherence, and examine these associations in populations with lower adherence levels such as young women or individuals starting ART.

The impact of a maternal mental health intervention on intimate partner violence in Northern Ghana and the mediating roles of social support and couple communication: secondary analysis of a cluster randomized controlled trial

BACKGROUNDS

Diverse intervention efforts are implemented to address intimate partner violence (IPV) against women. Via a syndemics theory lens and emerging empirical evidence, mental health interventions demonstrate promise to partially ameliorate IPV. However, the mechanisms of change underlying many IPV interventions are not well understood. These gaps impede our efforts to strengthen or integrate effective components into the current mental health resources, especially in low- and middle-income countries (LMICs). This study aims to examine the impact of a maternal mental health intervention called Integrated Mothers and Babies Course & Early Childhood Development (iMBC/ECD) on IPV and whether social support and/or couple communication mediates the intervention effects among women in rural, Northern Ghana.

METHODS

The current study is a secondary data analysis of a cluster randomized controlled trial. IPV was measured at baseline and 8 months post-intervention (~ 19 months post-baseline). At baseline, 84.8% of the women enrolled in the study (n = 374) reported some type of IPV in the past 12 months. Logistic regression models and multiple mediation analyses were used to address the study aims.

RESULTS

iMBC/ECD did not reduce IPV in the intervention group compared to the control group. Social support and couple communication did not mediate the intervention effects on IPV as indicated by the indirect effects of the multiple mediation models. However, increase in social support reduced women's odds of experiencing emotional violence by 7%, odds ratio (OR) = 0.93, p = 0.007; b = - 0.07, 95% confidence interval (CI) = (- 0.13, - 0.02), and improvement in couple communication demonstrated promise in reducing women's odds of experiencing controlling behaviors by 7%, OR = 0.93, p = 0.07; b = - 0.07, CI = (- 0.14, 0.005), though the improvements were not due to the intervention.

CONCLUSION

This maternal mental health intervention did not reduce IPV; however, the findings extend our knowledge about the impact of such interventions on IPV and the potential mechanisms of change via social support and couple communication. Future research evaluating the impact of mental health interventions on IPV and mechanisms of change is essential for the development of effective interventions. Future programs addressing IPV in LMICs should consider risk factors beyond relationship level (e.g. poverty and gender inequity).

TRIAL REGISTRATION

ClinicalTrials.gov # NCT03665246 , Registered on August 20th, 2018.

Development and Validation of the Couple Sexual Satisfaction Scale for HIV and Sexual Health Research

Sexual satisfaction is an important dimension of relationship quality with implications for sexual and reproductive health (SRH), and HIV prevention, care, and treatment. We developed and validated the Couple Sexual Satisfaction Scale (CSSS) with heterosexual couples in sub-Saharan Africa. Using data from qualitative interviews with 94 partnered women and men in Swaziland and Malawi, we generated a 22-item scale and administered it to 211 couples with at least one partner living with HIV in Malawi. We performed an exploratory factor analysis (EFA) to identify and confirmatory factor analysis (CFA) to test the factor structure. To assess validity, we tested for associations between the CSSS and relationship quality, consistent condom use, and intimate partner violence (IPV) using generalized estimating equations. The EFA yielded two factors, general sexual satisfaction (13-item CSSS-Gen subscale, e.g., "I am satisfied with the sweetness of sex in our relationship") and HIV-specific sexual satisfaction (4-item CSSS-HIV subscale, e.g., "My appetite for sex has gone down due to HIV"), accounting for 78% of the shared variance. The CFA supported the two-factor solution: χ²(118) = 203.60; CFI = 0.909; SRMR = 0.057; RMSEA = 0.058. Participants with higher CSSS-Gen scores reported higher coital frequency and relationship quality (intimacy, trust, unity, equality, relationship satisfaction, commitment, partner social support), and less consistent condom use, physical IPV, and emotional IPV. Participants with higher CSSS-HIV scores reported higher coital frequency and relationship quality (trust, partner support), and less consistent condom use, and sexual IPV. The CSSS demonstrated good psychometric properties and provides new opportunities to study sexual reproductive health and HIV-related health behaviors among couples in sub-Saharan Africa.

Enhancing LPG Adoption in Ghana (ELAG): A Trial Testing Policy-Relevant Interventions to Increase Sustained Use of Clean Fuels

Rural Ghanaians rely on solid biomass fuels for their cooking. National efforts to promote the Sustainable Development Goals include the Rural Liquefied Petroleum Gas Promotion Program (RLP), which freely distributes LPG stoves, but evaluations have demonstrated low sustained use among recipients. Our study objective was to assess if cheap and scalable add-on interventions could increase sustained use of LPG stoves under the RLP scheme. We replicated RLP conditions among participants in 27 communities in Kintampo, Ghana, but cluster-randomized them to four add-on interventions: a behavioral intervention, fuel delivery service, combined intervention, or control. We reported on the final 6 months of a 12-month follow-up for participants (n = 778). Results demonstrated increased use for each intervention, but magnitudes were small. The direct delivery intervention induced the largest increase: 280 min over 6 months (p < 0.001), ∼1.5 min per day. Self-reported refills (a secondary outcome), support increased use for the dual intervention arm (IRR = 2.2, p = 0.026). Past literature demonstrates that recipients of clean cookstoves rarely achieve sustained use of the technologies. While these results are statistically significant, we interpret them as null given the implied persistent reliance on solid fuels. Future research should investigate if fuel subsidies would increase sustained use since current LPG promotion activities do not.

Prevalence and correlates of maternal early stimulation behaviors during pregnancy in northern Ghana: a cross-sectional survey

BACKGROUND

Per UNICEF's Nurturing Care Framework, early childhood development (ECD) begins during pregnancy and many lower-resource settings need data to inform their programs for optimal child development. The maternal-fetal relationship can be partly examined via a series of bonding activities called early stimulation behaviors (ESB). This study describes early stimulation behaviors and the associated correlates among pregnant women in Ghana.

METHODS

This cross-sectional study used data from a cluster-randomized trial in two districts of Northern Ghana. A total of 374 pregnant women were enrolled at baseline and administered a pre-intervention survey. Communication-related early stimulation behaviors was the primary outcome which was evaluated using three maternal-fetal bonding activities; did the woman self-report touching and/or talking, singing, and/or talking about family to her belly. A generalized estimating equation modified Poisson model was used for the bivariate and multivariable analysis.

RESULTS

About half of the participants reported performing communication-related ESB during pregnancy frequently or sometimes. Bivariate analysis revealed that negative life experiences including higher rates of emotional, physical and sexual intimate partner violence (IPV) and having moderate to severe depressive symptoms were associated with women performing early stimulation behaviors more often. In the multivariable model, physical intimate partner violence remained significantly associated with early stimulation behaviors.

CONCLUSION

Research on early stimulation behaviors is still in a nascent phase. It is unclear why our results revealed an association between intimate partner violence and early stimulation behaviors; this could reflect a coping mechanism for the expectant mother. Further research is needed to better understand this association and explore potential long-term impacts of early stimulation behaviors during pregnancy on child development.

TRIAL REGISTRATION

Clinical Trials # NCT03665246 , August 29, 2018.

Re-conceptualising gender and power relations for sexual and reproductive health: contrasting narratives of tradition, unity, and rights

Sexual and reproductive health interventions in sub-Saharan Africa will be most effective if grounded in emic (insider) perspectives of gender and power in intimate relationships. We conducted eight focus group discussions with 62 young adults in Malawi to explore conceptions of gender and power relations and areas of tension between different perspectives. We framed our enquiry according to the three social structures of the Theory of Gender and Power: the sexual division of labour, the sexual division of power, and social norms and affective attachments around femininity and masculinity. Young adults drew on interrelated and competing narratives to describe the state of gender relations, which we named tradition, unity, and rights. Participants used tradition narratives most frequently to describe patriarchal gender roles, norms and ideals. Some participants challenged this predominant discourse using unity and rights narratives. Unity narratives illustrated how love and couple reciprocity were essential sources of 'power with' as opposed to 'power over'. Rights narratives were more contested than other narratives, with some participants acknowledging that women's rights were important to the family's survival and others viewing women's rights as problematic for gender relations. Gender-responsive interventions should consider the tensions and intersections between multiple narratives on gender and power, including unity as a gender-equitable form of power.

Individual and Relationship Predictors of Couple-Level Sexual Concurrency in Heterosexual South African Couples

One of the major goals of couple-based HIV prevention programs in sub-Saharan Africa is to reduce outside sex partners, known as sexual concurrency. This cross-sectional study examined sexual concurrency at the couple-level and differentiated couples based on whether neither, one, or both partners engaged in sexual concurrency over the past 6 months. Individual predictors (alcohol use and lifetime history of physical or sexual trauma) and relationship predictors (mistrust, relationship inequity, relationship satisfaction, and sexual satisfaction) were used as predictors of couple-level sexual concurrency. A quantitative investigation using path analysis was carried out with data collected from 286 South African heterosexual couples. Results showed that alcohol use for both sexes, relationship dissatisfaction for women, and mistrust among women were predictive of different types of sexual concurrency. Findings suggest that consideration of the experiences and behavior of both partners may be useful in understanding different reasons for engagement in sexual concurrency.

Impact of social capital, harassment of women and girls, and water and sanitation access on premature birth and low infant birth weight in India

BACKGROUND

Globally, preterm birth (PTB) and low infant birth weight (LBW) are leading causes of maternal and child morbidity and mortality. Inadequate water and sanitation access (WASH) are risk factors for PTB and LBW in low-income countries. Physical stress from carrying water and psychosocial stress from addressing sanitation needs in the open may be mechanisms underlying these associations. If so, then living in a community with strong social capital should be able to buffer the adverse effects of WASH on birth outcomes. The objective of this study is to assess the relationships between WASH access and social conditions (including harassment and social capital) on PTB and LBW outcomes among Indian women, and to test whether social conditions modified the association between WASH and birth outcomes.

METHODS AND FINDINGS

This cohort study examined the effect of pre-birth WASH and social conditions on self-reported PTB status and LBW status for 7,926 women who gave birth between 2004/2005 and 2011/2012 Waves of the India Human Development Survey. PTB and LBW occurred in 14.9% and 15.5% of women, respectively. After adjusting for maternal biological and socioeconomic conditions, PTB was associated with sharing a building/compound latrine (Odds Ratio (OR) = 1.55; 95% Confidence Interval (CI) = 1.01, 2.38) versus private latrine access, but suggested an effect in the opposite direction for sharing a community/public latrine (OR = 0.67; CI = 0.45, 1.01). Open defecation, type of drinking water source, minutes per day spent fetching water, and one-way time to a drinking water source were not associated with PTB. LBW was associated with spending more than two hours per day fetching water compared to less than two hours (OR = 1.33; CI = 1.05, 1.70) and suggested an association with open defecation (OR = 1.22; CI = 1.00, 1.48), but was not associated with other types of sanitation, type of drinking water source, or time to a drinking water source. Harassment of women and girls in the community was associated with both PTB (OR = 1.33; CI = 1.09, 1.62) and LBW (OR = 1.26; CI = 1.03, 1.54). The data also showed a possible association of local crime with LBW (OR = 1.30; CI = 1.00, 1.68). Statistically significant (p<0.05) evidence of effect modification was only found for collective efficacy on the association between type of sanitation access and PTB. In addition, stratified analyses identified differences in effect size for walking time to the primary drinking water source and PTB by crime, sanitation access and PTB by harassment, and total hours per day fetching water and LBW by collective efficacy. Limitations of this observational study include risk of bias, inability to confirm causality, reliance on self-reported outcomes, and limited sub-group sample sizes for testing effect modification.

CONCLUSIONS

The relationship between adverse birth outcomes and sanitation access, domestic water fetching, crime, and gender-based harassment suggests physical and psychosocial stress are possible mechanisms by which WASH access affects PTB and LBW among Indian women. Interventions that reduce domestic responsibilities related to water and sanitation and change social norms related to gender-based harassment may reduce rates of PTB and LBW in India.