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HIV Risk Among Displaced Adolescent Girls in Ethiopia: the Role of Gender Attitudes and Self-Esteem

  • Laura Gauer Bermudez
  • Gary Yu
  • Lily Lu
  • Kathryn Falb
  • Jennate Eoomkham
  • Gizman Abdella
  • Lindsay Stark
Article

Abstract

Adolescent girls in sub-Saharan Africa have been deemed one of the most critical populations to address in the campaign for an HIV-free generation. Experiences of intimate partner violence (IPV), harmful gender norms, diminished personal agency, and age-disparate sex have been identified as factors in the increasing rate of new infections among this population. Using baseline data from a cluster-randomized controlled trial in three refugee camps in Benishangul-Gumuz Regional State in Ethiopia, our study quantitatively examined the associations between HIV risk factors, attitudes on gender inequality, IPV acceptability, and self-esteem for female adolescent refugees primarily from Sudan and South Sudan (n = 919). In multivariate models, adjusting for age and education, results showed girls who were more accepting of gender inequitable norms and IPV had greater odds of ever experiencing forced (OR 1.40, CI 1.15–1.70; OR 1.66, CI 1.42–1.94) or transactional sex (OR 1.28, CI 1.05–1.55; OR 1.59, CI 1.37–1.85) compared to girls who demonstrated less approval. Higher self-esteem was associated with increased odds of condom use (OR 1.13, CI 1.02–1.24) as well as decreased odds of adolescent marriage (OR 0.93, CI 0.90–0.95), age-disparate sex (OR 0.90, CI 0.86–0.94), and transactional sex (OR 0.96, CI 0.93–0.99). The findings suggest acceptance of inequitable gender norms (including those that perpetuate violence against women) and low self-esteem to be associated with common HIV risk factors among refugee adolescents living in Ethiopia. Greater attention towards the intersections of gender equality and self-valuation is needed when seeking to understand HIV risk among refugee adolescent girls in sub-Saharan Africa.

Keywords

Refugees Adolescent marriage Age-disparate sex Transactional sex Condom use 

Notes

Acknowledgements

The authors wish to thank the collaborators from Columbia University, IRC Ethiopia, and IRC headquarters. We are also grateful to the adolescent girls who are participating in the COMPASS research study.

Author Contributions

LGB conceptualized the paper topic and drafted the manuscript. GY led data analysis for the paper. LL contributed to drafting of the manuscript. LS is the PI for the COMPASS study, the parent grant on which the results presented here are based. LS, KF (co-I of the study), JE, and GA reviewed and contributed to the draft. All authors approved the final version of the manuscript.

Funding Information

This document is an output from a project funded with UK aid from the UK Department for International Development (DFID) for the benefit of developing countries (grant #40080602). However, the views expressed and information contained in it are not necessarily those of or endorsed by DFID, which can accept no responsibility for such views or information or for any reliance placed on them.

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and it slater amendments or comparable ethical standards.

Informed Consent

Informed consent was obtained from all individual participants included in the study.

References

  1. Agardh, A., Cantor-Graae, E., & Östergren, P. O. (2012). Youth, sexual risk-taking behavior, and mental health: a study of university students in Uganda. International Journal of Behavioral Medicine, 19, 208–216.CrossRefPubMedGoogle Scholar
  2. Anglewicz, P., & Clark, S. (2013). The effect of marriage and HIV risks on condom use acceptability in rural Malawi. Social Science & Medicine, 97, 29–40.CrossRefGoogle Scholar
  3. Bhana, A., Mellins, C. A., Small, L., Nestadt, D. F., Leu, C. S., Petersen, I., & McKay, M. (2016). Resilience in perinatal HIV+ adolescents in South Africa. AIDS Care, 28, 49–59.CrossRefPubMedPubMedCentralGoogle Scholar
  4. Breuer, E., Myer, L., Struthers, H., & Joska, J. A. (2011). HIV/AIDS and mental health research in sub-Saharan Africa: a systematic review. African Journal of AIDS Research, 10, 101–122.CrossRefPubMedGoogle Scholar
  5. Brooks-Gunn, J., & Furstenberg Jr., F. F. (1989). Adolescent sexual behavior. American Psychologist, 44, 249.CrossRefPubMedGoogle Scholar
  6. Casey, S. E. (2015). Evaluations of reproductive health programs in humanitarian settings: a systematic review. Conflict and Health, 9, S1.CrossRefPubMedPubMedCentralGoogle Scholar
  7. Casey, S. E., Chynoweth, S. K., Cornier, N., Gallagher, M. C., & Wheeler, E. E. (2015). Progress and gaps in reproductive health services in three humanitarian settings: mixed-methods case studies. Conflict and Health, 9, S3.CrossRefPubMedPubMedCentralGoogle Scholar
  8. Cluver, L., Boyes, M., Orkin, M., Pantelic, M., Molwena, T., & Sherr, L. (2013). Child-focused state cash transfers and adolescent risk of HIV infection in South Africa: a propensity-score-matched case-control study. The Lancet Global Health, 1, e362–e370.CrossRefPubMedGoogle Scholar
  9. De Walque, D. (2002). How does educational attainment affect the risk of being infected by HIV/AIDS? Evidence from a general population cohort in rural Uganda.Google Scholar
  10. Dellar, R. C., Dlamini, S., & Karim, Q. A. (2015). Adolescent girls and young women: key populations for HIV epidemic control. Journal of the International AIDS Society, 18, 64–70.CrossRefGoogle Scholar
  11. Erulkar, A. (2013). Early marriage, marital relations and intimate partner violence in Ethiopia. International Perspectives on Sexual and Reproductive Health, 6–13.Google Scholar
  12. Falb, K. L., Tanner, S., Ward, L., Erksine, D., Noble, E., Assazenew, A., … & Neiman, A. (2016). Creating opportunities through mentorship, parental involvement, and safe spaces (COMPASS) program: multi-country study protocol to protect girls from violence in humanitarian settings. BMC Public Health, 16, 231.Google Scholar
  13. Global Women’s Institute (GWI), International Rescue Committee, Care International UK, & Forcier Consulting. (2017). No safe place: a lifetime of violence for conflict-affected women and girls in South Sudan. Retrieved 17 January 2018 from https://reliefweb.int/sites/reliefweb.int/files/resources/southsudanlgonline.pdf.
  14. Grabska, K. (2012). Marrying on credit: the burden of bridewealth on refugee youth. Forced Migration Review, 40, 7.Google Scholar
  15. Gupta, G. R., Parkhurst, J. O., Ogden, J. A., Aggleton, P., & Mahal, A. (2008). Structural approaches to HIV prevention. The Lancet, 372, 764–775.CrossRefGoogle Scholar
  16. Hankins, C. A., Friedman, S. R., Zafar, T., & Strathdee, S. A. (2002). Transmission and prevention of HIV and sexually transmitted infections in war settings: implications for current and future armed conflicts. AIDS, 16, 2245–2252.CrossRefPubMedGoogle Scholar
  17. Hargreaves, J. R., Bonell, C. P., Boler, T., Boccia, D., Birdthistle, I., Fletcher, A., & Glynn, J. R. (2008). Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS, 22, 403–414.CrossRefPubMedGoogle Scholar
  18. Jewkes, R., Dunkle, K., Nduna, M., & Shai, N. J. (2012). Transactional sex and HIV incidence in a cohort of young women in the stepping stones trial. Journal of AIDS and Clinical Research, 3.Google Scholar
  19. Kaufman, Z. A., Spencer, T. S., & Ross, D. A. (2013). Effectiveness of sport-based HIV prevention interventions: a systematic review of the evidence. AIDS and Behavior, 17, 987–1001.CrossRefPubMedGoogle Scholar
  20. Kennedy, C. E., Spaulding, A. B., Brickley, D. B., Almers, L., Mirjahangir, J., Packel, L., … & Osborne, K. (2010). Linking sexual and reproductive health and HIV interventions: a systematic review. Journal of the International AIDS Society, 13, 26.Google Scholar
  21. Leclerc-Madlala, S. (2003). Transactional sex and the pursuit of modernity. Social Dynamics, 29, 213–233.CrossRefGoogle Scholar
  22. Leclerc-Madlala, S. (2008). Age-disparate and intergenerational sex in southern Africa: the dynamics of hypervulnerability. AIDS, 22, S17–S25.CrossRefPubMedGoogle Scholar
  23. Maclin, B., Kelly, J., Kabanga, J., & VanRooyen, M. (2015). ‘They have embraced a different behaviour’: transactional sex and family dynamics in eastern Congo’s conflict. Culture, Health & Sexuality, 17, 119–131.CrossRefGoogle Scholar
  24. Mensch, B. S., & Hewett, P. C. (2007). Obtaining more accurate and reliable information from adolescents regarding STI/HIV risk behaviors. New York: The Population Council.Google Scholar
  25. Mills, E. J., Singh, S., Nelson, B. D., & Nachega, J. B. (2006). The impact of conflict on HIV/AIDS in sub-Saharan Africa. International Journal of STD & AIDS, 17, 713–717.CrossRefGoogle Scholar
  26. Mpondo, F., Ruiter, R. A., van den Borne, B., & Reddy, P. S. (2015). Self-determination and gender–power relations as predictors of condom use self-efficacy among South African women. Health Psychology Open, 2, 2055102915598676.CrossRefPubMedPubMedCentralGoogle Scholar
  27. Neal, S., Stone, N., & Ingham, R. (2016). The impact of armed conflict on adolescent transitions: a systematic review of quantitative research on age of sexual debut, first marriage and first birth in young women under the age of 20 years. BMC Public Health, 16, 225.CrossRefPubMedPubMedCentralGoogle Scholar
  28. Organization for Economic Cooperation and Development (OECD). (2016). Social Institutions & Gender Index (SIGI)—Sudan.Google Scholar
  29. Pettifor, A. E., Measham, D. M., Rees, H. V., & Padian, N. S. (2004). Sexual power and HIV risk, South Africa. Emerging Infectious Diseases, 10, 1996.CrossRefPubMedPubMedCentralGoogle Scholar
  30. Puffer, E. S., Meade, C. S., Drabkin, A. S., Broverman, S. A., Ogwang-Odhiambo, R. A., & Sikkema, K. J. (2011). Individual-and family-level psychosocial correlates of HIV risk behavior among youth in rural Kenya. AIDS and Behavior, 15, 1264–1274.CrossRefPubMedPubMedCentralGoogle Scholar
  31. Raj, A., & Boehmer, U. (2013). Girl child marriage and its association with national rates of HIV, maternal health, and infant mortality across 97 countries. Violence Against Women, 19, 536–551.CrossRefPubMedGoogle Scholar
  32. Rosenfield, S., & Mouzon, D. (2013). Gender and mental health. In Handbook of the sociology of mental health (pp. 277–296). Netherlands: Springer.CrossRefGoogle Scholar
  33. Schaefer, R., Gregson, S., Eaton, J. W., Mugurungi, O., Rhead, R., Takaruza, A., & Nyamukapa, C. (2017). Age-disparate relationships and HIV incidence in adolescent girls and young women: evidence from a general-population cohort in Zimbabwe. AIDS.Google Scholar
  34. Schmitt, D. P., & Allik, J. (2005). Simultaneous administration of the Rosenberg Self-Esteem Scale in 53 nations: exploring the universal and culture-specific features of global self-esteem. Journal of Personality and Social Psychology, 89, 623.CrossRefPubMedGoogle Scholar
  35. Scott, J., Averbach, S., Modest, A. M., Hacker, M. R., Cornish, S., Spencer, D., & Parmar, P. (2013). An assessment of gender inequitable norms and gender-based violence in South Sudan: a community-based participatory research approach. Conflict and Health, 7, 4.CrossRefPubMedPubMedCentralGoogle Scholar
  36. Shannon, K., Leiter, K., Phaladze, N., Hlanze, Z., Tsai, A. C., Heisler, M., et al. (2012). Gender inequity norms are associated with increased male-perpetrated rape and sexual risks for HIV infection in Botswana and Swaziland. PLoS One, 7, e28739.CrossRefPubMedPubMedCentralGoogle Scholar
  37. Spiegel, P. B. (2004). HIV/AIDS among conflict-affected and displaced populations: dispelling myths and taking action. Disasters, 28, 322–339.CrossRefPubMedGoogle Scholar
  38. Spiegel, P. B., Bennedsen, A. R., Claass, J., Bruns, L., Patterson, N., Yiweza, D., & Schilperoord, M. (2007). Prevalence of HIV infection in conflict-affected and displaced people in seven sub-Saharan African countries: a systematic review. The Lancet, 369, 2187–2195.CrossRefGoogle Scholar
  39. Steinberg, L. (2008). A social neuroscience perspective on adolescent risk-taking. Developmental Review, 28, 78–106.CrossRefPubMedPubMedCentralGoogle Scholar
  40. Stöckl, H., Kalra, N., Jacobi, J., & Watts, C. (2013). Is early sexual debut a risk factor for HIV infection among women in sub-Saharan Africa? A systematic review. American Journal of Reproductive Immunology, 69, 27–40.CrossRefPubMedGoogle Scholar
  41. Stockman, J. K., Lucea, M. B., & Campbell, J. C. (2013). Forced sexual initiation, sexual intimate partner violence and HIV risk in women: a global review of the literature. AIDS and Behavior, 17, 832–847.CrossRefPubMedPubMedCentralGoogle Scholar
  42. Stoebenau, K., Heise, L., Wamoyi, J., & Bobrova, N. (2016). Revisiting the understanding of “transactional sex” in sub-Saharan Africa: a review and synthesis of the literature. Social Science & Medicine, 168, 186–197.CrossRefGoogle Scholar
  43. Teklu, T., & Davey, G. (2016). Which factors influence North Ethiopian adults’ use of dual protection from unintended pregnancy and HIV/AIDS?. The Ethiopian Journal of Health Development (EJHD), 22.Google Scholar
  44. The Joint United Nations Programme on HIV/AIDS (UNAIDS). (2016). Global AIDS update. Geneva: Switzerland.Google Scholar
  45. Tsai, A. C., & Subramanian, S. V. (2012). Proximate context of gender-unequal norms and women’s HIV risk in sub-Saharan Africa. AIDS (London, England), 26(3), 381.CrossRefGoogle Scholar
  46. United Nations High Commissioner for Refugees (UNHCR). (2016). Refugees and asylum-seekers in Ethiopia.Google Scholar
  47. Wamoyi, J., Stobeanau, K., Bobrova, N., Abramsky, T., & Watts, C. (2016). Transactional sex and risk for HIV infection in sub-Saharan Africa: a systematic review and meta-analysis. Journal of the International AIDS Society, 19.Google Scholar
  48. Wild, L. G., Flisher, A. J., Bhana, A., & Lombard, C. (2004). Associations among adolescent risk behaviours and self-esteem in six domains. Journal of Child Psychology and Psychiatry, 45, 1454–1467.CrossRefPubMedGoogle Scholar
  49. Wingood, G. M., & DiClemente, R. J. (2000). Application of the theory of gender and power to examine HIV-related exposures, risk factors, and effective interventions for women. Health Education & Behavior, 27, 539–565.CrossRefGoogle Scholar
  50. Woolf-King, S. E., & Maisto, S. A. (2011). Alcohol use and high-risk sexual behavior in sub-Saharan Africa: a narrative review. Archives of Sexual Behavior, 40, 17–42.CrossRefPubMedGoogle Scholar
  51. World Health Organization (WHO). (2001). Putting women first: ethical and safety recommendations for research on domestic violence against women. Geneva: WHO.Google Scholar
  52. World Health Organization (WHO). (n.d.). Gender disparities in mental health. Geneva: Switzerland.Google Scholar

Copyright information

© Society for Prevention Research 2018

Authors and Affiliations

  • Laura Gauer Bermudez
    • 1
  • Gary Yu
    • 1
    • 2
    • 3
  • Lily Lu
    • 2
  • Kathryn Falb
    • 4
  • Jennate Eoomkham
    • 5
  • Gizman Abdella
    • 5
  • Lindsay Stark
    • 2
  1. 1.Columbia University School of Social Work New YorkUSA
  2. 2.Department of Population and Family HealthColumbia University Mailman School of Public HealthNew YorkUSA
  3. 3.NYU Rory Meyers College of NursingNew YorkUSA
  4. 4.The International Rescue CommitteeWashingtonUSA
  5. 5.The International Rescue CommitteeAddis AbabaEthiopia

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