Adapting a complex violence prevention intervention: a case study of the Good School Toolkit in Uganda.

BACKGROUND: Adaptation is a key strategy to extend the reach of evidence-based interventions to prevent violence in new populations, but there is a dearth of practical case examples. The Good School Toolkit was developed by Ugandan NGO Raising Voices for use in primary schools (GST-P). We describe our systematic approach to adapting the GST-P for use in secondary schools in Uganda, and reflect on the utility of the process as well as limitations of existing adaptation frameworks. METHODS: We adapted the GST-P in four phases, which included: I) clarifying the logic model and core intervention components using a streamlined process; II) conducting formative research (cross-sectional survey, focus groups, etc.) to understand the new population; III) selecting and preparing new intervention components and modifying existing intervention components; and IV) pretesting new intervention components with teachers and students in Uganda. RESULTS: We identified core components using a logic model. Formative research showed results largely in line with our apriori hypotheses. Teacher violence remained highly prevalent in secondary versus primary schools (> 65% of secondary students reported past year exposure), while peer violence significantly increased (secondary = 52% vs. primary girls = 40%, P < 0.001; secondary = 54% vs. primary boys = 44%, P = 0.009) in secondary versus primary schools. Significantly more secondary girls (51%) than secondary boys (45%) reported past year dating/intimate partner violence (P = 0.03). Inequitable, gendered educational practices emerged as a salient theme, perceived to heighten female students' vulnerability to violence. In light of these findings, we made several adjustments to the adapted intervention. We strengthened existing teacher and peer violence intervention components. We also developed, pretested and revised new program components to prevent dating violence and promote 'gender fairness in schools'. Finally, original activities were modified to support engagement with school administration and promote increased student agency in secondary schools. CONCLUSIONS: Based on our experience, it was difficult to apply mechanistic models to clarify the intervention logic of the GST-P, a complex multicomponent intervention, and simpler methods may be sufficient. Our team had high levels of contextual knowledge before the adaptation, and formative research to understand the new target population provided only limited additional insight. In similar situations, a simplified approach to mapping the core intervention components, qualitative research to understand the new target population, and pre-testing of new intervention components may be the most informative elements of systematic adaptation processes.

Assessing Survey Items on Social Norms Relating to Dating and Relationship Violence and to Gender: Cognitive Interviews with Young People in England.

Widespread among adolescents in England, dating and relationship violence (DRV) is associated with subsequent injuries and serious mental health problems. While DRV prevention interventions often aim to shift harmful social norms, no established measures exist to assess relevant norms and their role in mediating DRV outcomes. We conducted cognitive interviews exploring the understandability and answerability of candidate measures of social norms relating to DRV and gender roles, informing measure refinement. In all, 11 participants aged 13 to 15 from one school in England participated. Cognitive interviews tested two items assessing descriptive norms (beliefs about what behaviors are typical), three assessing injunctive norms (beliefs about what is socially acceptable), and (for comparison) one assessing personal attitudes. Findings were summarized by drawing on interview notes. Summaries and interview notes were subjected to thematic analysis. For some participants, injunctive norms items required further explanation to clarify that items asked about others' views, not their own. Lack of certainty about, and perceived heterogeneity of, behaviors and views among a broad reference group detracted from answerability. Participants were better able to answer items for which they could draw on concrete experiences of observing or discussing relevant behaviors or social sanctions. Data suggest that a narrowed reference group could improve answerability for items assessing salient norms. Findings informed refinements to social norms measures. It is possible to develop social norms measures that are understandable and answerable for adolescents in England. Measures should assess norms that are salient and publicly manifest among a cohesive and influential reference group.

Social Norms About Dating and Relationship Violence and Gender Among Adolescents: Systematic Review of Measures Used in Dating and Relationship Violence Research.

Adolescent dating and relationship violence (DRV) is widespread and associated with increased risk of subsequent poor mental health outcomes and partner violence. Shifting social norms (i.e., descriptive norms of perceived behavior and injunctive norms of acceptable behavior among a reference group of important others) may be important for reducing DRV. However, few DRV studies assess norms, measurement varies, and evidence on measure quality is diffuse. We aimed to map and assess how studies examining DRV measured social norms concerning DRV and gender. We conducted a systematic review of DRV literature reporting on the use and validity of such measures among participants aged 10-18 years. Searches included English peer-reviewed and grey literature identified via nine databases; Google Scholar; organization websites; reference checking; known studies; and expert requests. We identified 24 eligible studies from the Americas (N = 15), Africa (N = 4), and Europe (N = 5) using 40 eligible measures of DRV norms (descriptive: N = 19; injunctive: N = 14) and gender norms (descriptive: N = 1; injunctive: N = 6). No measure was shared across studies. Most measures were significantly associated with DRV outcomes and most had a defined reference group. Other evidence of quality was mixed. DRV norms measures sometimes specified heterosexual relationships but rarely separated norms governing DRV perpetrated by girls and boys. None specified sexual-minority relationships. Gender norms measures tended to focus on violence, but missed broader gendered expectations underpinning DRV. Future research should develop valid, reliable DRV norms and gender norms measures, and assess whether interventions' impact on norms mediates impact on DRV.

Correction: Youth and healthcare workers' perspectives on the feasibility and acceptability of self-testing for HIV, Hepatitis and Syphilis among young people: Qualitative findings from a pilot study in Gaborone, Botswana.

[This corrects the article DOI: 10.1371/journal.pone.0288971.].

Childhood and adolescent factors shaping vulnerability to underage entry into sex work: a quantitative hierarchical analysis of female sex workers in Nairobi, Kenya.

OBJECTIVE: To explore factors associated with early age at entry into sex work, among a cohort of female sex workers (FSWs) in Nairobi, Kenya. BACKGROUND: Younger age at sex work initiation increases the risk of HIV acquisition, condom non-use, violence victimisation and alcohol and/or substance use problems. This study aimed to understand factors in childhood and adolescence that shape the vulnerability to underage sex work initiation. DESIGN: Building on previous qualitative research with this cohort, analysis of behavioural-biological cross-sectional data using hierarchical logistic regression. PARTICIPANTS AND MEASURES: FSWs aged 18-45 years were randomly selected from seven Sex Workers Outreach Programme clinics in Nairobi, and between June and December 2019, completed a baseline behavioural-biological survey. Measurement tools included WHO Adverse Childhood Experiences, Alcohol, Smoking and Substance Involvement Screening Test and questionnaires on sociodemographic information, sexual risk behaviours and gender-based violence. Descriptive statistics and logistic regression were conducted using hierarchical modelling. RESULTS: Of the 1003 FSWs who participated in the baseline survey (response rate 96%), 176 (17.5%) initiated sex work while underage (<18 years). In the multivariable analysis, factors associated with entering sex work while underage included incomplete secondary school education (aOR=2.82; 95% CI=1.69 to 4.73), experiencing homelessness as a child (aOR=2.20; 95% CI=1.39 to 3.48), experiencing childhood physical or sexual violence (aOR=1.85; 95% CI=1.09 to 3.15), young age of sexual debut (≤15 years) (aOR=5.03; 95% CI=1.83 to 13.79) and being childless at time of sex work initiation (aOR=9.80; 95% CI=3.60 to 26.66). CONCLUSIONS: Lower education level and childhood homelessness, combined with sexual violence and sexual risk behaviours in childhood, create pathways to underage initiation into sex work. Interventions designed for girls and young women at these pivotal points in their lives could help prevent underage sex work initiation and their associated health, social and economic consequences.

Evaluating use of mass-media communication intervention 'MTV-Shuga' on increased awareness and demand for HIV and sexual health services by adolescent girls and young women in South Africa: an observational study.

OBJECTIVE: To investigate the effect of exposure to MTV Shuga:Down South' (MTVShuga-DS) during the scale-up of combination HIV-prevention interventions on awareness and uptake of sexual reproductive health (SRH) and HIV-prevention services by adolescent girls and young women (AGYW). DESIGN: One longitudinal and three cross-sectional surveys of representative samples of AGYW. SETTING: AGYW in four South African districts with high HIV prevalence (>10%) (May 2017 and September 2019). PARTICIPANTS: 6311 AGYW aged 12-24. MEASURES: Using logistic regression, we measured the relationship between exposure to MTV Shuga-DS and awareness of pre-exposure prophylaxis (PrEP), condom use at last sex, uptake of HIV-testing or contraception, and incident pregnancy or herpes simplex virus 2 (HSV-2) infection. RESULTS: Within the rural cohort 2184 (85.5%) of eligible sampled individuals were enrolled, of whom 92.6% had at least one follow-up visit; the urban cross-sectional surveys enrolled 4127 (22.6%) of eligible sampled individuals. Self-report of watching at least one MTV Shuga-DS episode was 14.1% (cohort) and 35.8% (cross-section), while storyline recall was 5.5% (cohort) and 6.7% (cross-section). In the cohort, after adjustment (for HIV-prevention intervention-exposure, age, education, socioeconomic status), MTVShuga-DS exposure was associated with increased PrEP awareness (adjusted OR (aOR) 2.06, 95% CI 1.57 to 2.70), contraception uptake (aOR 2.08, 95% CI 1.45 to 2.98) and consistent condom use (aOR 1.84, 95% CI 1.24 to 2.93), but not with HIV testing (aOR 1.02, 95% CI 0.77 to 1.21) or acquiring HSV-2 (aOR 0.92, 95% CI 0.61 to 1.38). In the cross-sections, MTVShuga-DS was associated with greater PrEP awareness (aOR 1.7, 95% CI 1.20 to 2.43), but no other outcome. CONCLUSIONS: Among both urban and rural AGYW in South Africa, MTVShuga-DS exposure was associated with increased PrEP awareness and improved demand for some HIV prevention and SRH technologies but not sexual health outcomes. However, exposure to MTVShuga-DS was low. Given these positive indications, supportive programming may be required to raise exposure and allow future evaluation of edu-drama impact in this setting.

Syndemic of factors that shape the early lives of women who enter into sex work: a qualitative methods study from Nairobi, Kenya.

OBJECTIVE: To explore the structural and social co-factors that shape the early lives of women who enter sex work in Nairobi, Kenya. DESIGN: Thematic analysis of qualitative data collected as part of the Maisha Fiti study among female sex workers (FSWs) in Nairobi. PARTICIPANTS AND MEASURES: FSWs aged 18-45 years were randomly selected from seven Sex Workers Outreach Programme clinics in Nairobi and participated in baseline behavioural-biological surveys. Participants in this qualitative study were randomly selected from the Maisha Fiti study cohort and were interviewed between October 2019 and July 2020. Women described their lives from childhood, covering topics including sex work, violence and financial management. RESULTS: 48 out of 1003 Maisha Fiti participants participated in the in-depth qualitative interviews. FSWs described how physical and sexual violence, poverty and incomplete education in their childhood and adolescence intertwined with early pregnancy, marriage, intimate partner violence and relationship breakdown in their adolescence and early adulthood. The data analysis found clear syndemic relationships between these risk factors, particularly childhood violence, poverty and incomplete education and highlighted pathways leading to financial desperation and caring for dependents, and subsequent entry into sex work. Women perceived sex work as risky and most would prefer alternative work if possible, but it provided them with some financial independence and agency. CONCLUSIONS: This is the first study in Kenya to qualitatively explore the early lives of sex workers from a syndemic perspective. This method identified the pivotal points of (1) leaving school early due to poverty or pregnancy, (2) breakdown of early intimate relationships and (3) women caring for dependents on their own. Complex, multi-component structural interventions before these points could help increase school retention, reduce teenage pregnancy, tackle violence, support young mothers and reduce entry into sex work and the risk that it entails by expanding livelihood options.

Prevalence, Perpetrators, and Factors Associated With Intimate Partner Violence Among Adolescents Living in Urban Slums of Kampala, Uganda.

Intimate partner violence (IPV) poses a public health burden, yet few studies have assessed co-existence of physical, emotional, and sexual IPV among adolescents. We assessed recent IPV victimization and associated factors and described IPV patterns and perpetrators among young people from urban slums in Kampala, Uganda. We conducted a prospective cohort study among 14 to 19-year-old individuals enrolled from March 2019 to March 2020 and followed quarterly for 12 months. We collected data on socio-demographics, sexual behavior, and substance use through interviews. Recent IPV victimization was documented at all visits if a participant reported experiencing physical, emotional, and/or sexual IPV in the past 3 months. Baseline factors associated with recent IPV victimization were determined using multivariable logistic regression. We enrolled 490 adolescents (60.6% female) with median age 18 years (Interquartile range (IQR) 17-18 years), 91.0% had less than secondary level education. Females mainly engaged in sex work (17.5%) and selling fruits/snacks (9.1%) while males commonly earned from sale of metal scrap or plastic waste (28.5%), 41% reported ≥10 life-time sexual partners, 16.1% were high-risk alcohol drinkers and 34.9% used illicit drugs in the past 3 months. Overall, 27.8% reported recent IPV victimization (20.0% females) with emotional IPV being common (17.8%). At baseline, recent IPV victimization was associated with high-risk alcohol consumption (adjusted odds ratio [aOR] 2.57; 95% confidence interval [CI] [1.44, 4.58]), reported paid sex in the past 3 months (aOR 1.82; [1.02, 3.22]) and being separated (aOR 2.47; [1.29, 4.73]). Recent IPV victimization declined from baseline to month 9 and increased at month 12 visits which coincided with the COVID-19 pandemic. IPV victimization is high among young people living in urban slums with emotional IPV being prevalent. IPV interventions are needed and should also address excessive alcohol consumption.

Development of the Gender Roles and Male Provision Expectations Scale.

Existing composite measures assess the extent to which women and men support masculinity ideals concerning the expectation that men should provide for their partners and families. In many contexts across sub-Saharan Africa, the male provider role is taken as given. This core masculinity tenet may be associated with related gender role expectations that result in increasing young women's risk of HIV, especially within the context of transactional sex relationships. Extant literature points to five domains potentially associated with male provider role expectations: male authority, men's sexual decision-making control, women's sexual agency, women's economic dependence, and love. The goal of this study was to develop the Gender Roles and Male Provision Expectations (GRMPE) scale toward understanding whether beliefs attached to male provider role expectations increase HIV risk. We developed the GRMPE across three research phases with young women (ages 15-24) in Central Uganda that (1) used qualitative data to refine domains and develop scale items; (2) cognitively tested the refined items; and (3) pilot tested a 26-item scale across five domains with 108 young women. Using confirmatory factor analyses, we retained 15 items across four factors, corresponding to the domains of male authority, sexual decision-making, women's sexual agency, and love; which we then modeled as indicators in a single second-order factor model. The GRMPE demonstrated initial reliability and validity, and tests of criterion validity found significant associations with known HIV risk behaviors. The GRMPE scale shows promise for better examining the determinants of HIV risk and assessing gender norm change interventions.

A qualitative exploration of the salience of MTV-Shuga, an edutainment programme, and adolescents' engagement with sexual and reproductive health information in rural KwaZulu-Natal, South Africa.

Young people, particularly adolescent girls and young women, represent a growing proportion of those living with HIV. Edutainment programmes have been widely used throughout the world to "educate" and "entertain" audiences and tackle serious social issues in bold and engaging ways. This paper examines the extent to which an edutainment programme, MTV-Shuga, was reported to influence young people's engagement with sexual and reproductive health (SRH) information in rural KwaZulu-Natal, South Africa. In 2019 we conducted eight community-based screenings of MTV-Shuga episodes followed by 25 individual in-depth interviews and 13 focus group discussions with young people aged between 15 and 30. Interviews were audio recorded and transcribed verbatim. Data analysis was thematic and complemented by constant comparison and deviant case analysis techniques. In this rural and poor setting with a high burden of HIV, young people exhibited high levels of awareness of SRH and HIV but had constrained access to services, and limited ability to engage with parents or guardians on SRH matters. MTV Shuga provided an entertaining guide of ways to navigate the risks that they faced in a way that resonated with them. The findings highlight the importance of enabling young people in rural areas to watch MTV Shuga with peers in a safe space in which discussion of the content is facilitated. There is also value in encouraging parents to watch MTV Shuga as a means of enabling discussions between children and adults in their lives about SRH matters.

A qualitative study exploring parent-daughter approaches for communicating about sex and transactional sex in Central Uganda: Implications for comprehensive sexuality education interventions.

INTRODUCTION: Ugandan adolescent girls and young women are disproportionately impacted by human immunodeficiency virus, and this is largely driven by their engagement in transactional sex. Globally, parent-daughter communication about sex is associated with increased contraceptive use and delayed/decreased sexual activity, but research on parent-daughter communication about transactional sex is lacking. This paper elucidates local perspectives on, and experiences of parent-daughter communication about sex and transactional sex, to inform family-level comprehensive sexuality education interventions. METHODS: We conducted a secondary, thematic analysis of 13 focus group discussions (n = 119) and 30 in-depth interviews collected between 2014 and 2015 with adolescent girls and young women aged 14+, and men and women in Kampala and Masaka. RESULTS: We found that parents used three approaches to discuss sex and transactional sex with their daughters: (1) frightening their daughters into avoiding sex; (2) being "strict"; and (3) relying on mothers rather than fathers to "counsel" daughters. Mother-daughter communication about transactional sex was common, but frequently unidirectional. Adolescent girls and young women bringing home gifts sparked conversations about the risks of transactional sex, although less in poorer households. Mothers felt they lacked control over their daughters' sexual behaviors and thus restricted their movements and friendships to try to prevent them from having sex. In contrast to previous research, we found some evidence of mothers encouraging condom use and father-daughter communication about sex. CONCLUSIONS: Family-level comprehensive sexuality education interventions targeting parent-daughter communication about sex could further highlight the role that fathers might play, and emphasize communication about the inequitable power dynamics in transactional sex and condom negotiation skills, while reducing fear surrounding parent-daughter communication.

Language, meaning and measure: Community perspectives and experiences of physical punishments and the transforming child protection and child rights landscapes in Tanzania.

BACKGROUND: Over the last decade Tanzania has become recognized as a regional leader in addressing issues of violence affecting children. Despite global partnerships and national initiatives, physical punishments remain legally sanctioned and broadly socially supported as part of responsible childrearing. OBJECTIVE: This research aimed to gain insights into community perspectives and experiences of physical punishments in children's upbringings and how community derived meaning and measurement of particular acts relate with global rights-based conceptualizations of physical violence against children. PARTICIPANTS AND SETTING: Fourteen months of ethnographic research was conducted primarily in and around a peri-urban community in northwest Tanzania. Interviews with national- and global-level children's rights and safety representatives were conducted in Dar-es-Salaam. Twenty-four, school-going girls and boys (ages 8-12) and 53 adults directly participated in study activities. METHODS: Data collection methods included participant observation, participatory workshops (9), semi-structured interviews (36) and document reviews. Thematic analysis was used to analyze data. RESULTS: Data revealed ongoing debate regarding the use of physical punishments in children's upbringings and their association with violence. Resistance to the global children's rights promoted discourse of complete elimination of physical punishment of children manifested as avoidance, negotiation and rejection. Corporal punishment proved a particularly problematic term. CONCLUSIONS: Child protection and children's rights are dynamic systems, vernacularized based on unique regional histories and ongoing social change. Prioritization of contextualized and dynamic constructions of children's wellbeing and safety can support the development of sustainable protection systems that support the safety and development of children and families in local communities.

Paper: violence, abuse and exploitation among trafficked women and girls: a mixed-methods study in Nigeria and Uganda.

BACKGROUND: Africa is the global region where modern-slavery is most prevalent, especially among women and girls. Despite the severe health consequences of human trafficking, evidence on the risks and experiences of trafficked adolescents and young women is scarce for the region. This paper addresses this gap by exploring the intersections between violence, migration and exploitation among girls and young women identified as trafficking survivors in Nigeria and Uganda. METHODS: We conducted secondary analysis of the largest routine dataset on human trafficking survivors. We used descriptive statistics to report the experiences of female survivors younger than 25 years-old from Nigeria and Uganda. We also conducted 16 semi-structured interviews with adolescents identified as trafficked in both countries. We used thematic analysis to explore participants' perceptions and experiences before, during and after the trafficking situation. RESULTS: Young female survivors of human trafficking in Nigeria and Uganda are exposed to a range of experiences of violence before migration, during transit and at destination. The qualitative data revealed that children and adolescents migrated to escape family poverty, violence and neglect. They had very low levels of education and most had their studies interrupted before migrating. Family members and close social contacts were the most common intermediaries for their migration. During transit, sexual violence and hunger were common, especially among Nigerians. Participants in both the quantitative and qualitative studies reported high levels of violence, deception, coercion, withheld wages and poor working conditions at destination. The adolescents interviewed in the qualitative study reported severe mental suffering, including suicide attempts. Only one reported the prosecution of perpetrators. CONCLUSIONS: Our findings suggest that interventions to prevent or mitigate the negative impact of adverse childhood experiences can contribute to preventing the trafficking of adolescents in Nigeria and Uganda. These interventions include social protection mechanisms, universal access to education, social service referrals and education of parents and carers. Importantly, effective prevention also needs to address the systemic conditions that makes trafficking of female adolescents invisible, profitable and inconsequential for perpetrators.

"We saw that jealousy can also bring violence": A qualitative exploration of the intersections between jealousy, infidelity and intimate partner violence in Rwanda and Uganda.

Efforts to prevent intimate partner violence (IPV) have been informed by emerging research on common triggers of IPV and the importance of engaging with couple dynamics. This paper reports on secondary data analysis from the qualitative evaluations of the SASA! intervention in Uganda, (conducted in 2012 involving 40 community members) and the Indashyikirwa intervention in Rwanda, (conducted between 2014 and 2018 involving 14 couples and 36 other stakeholders). It explores the under-researched linkages between romantic jealousy and IPV, and describes how these interventions mitigated it. A qualitative approach using interviews and focus groups with women and men was used. Overall, jealousy was common in both settings, and led to relationship challenges including breakdown of trust; quarrels about resources; conflict, controlling behaviours, and ultimately, physical and emotional IPV. Jealousy was seen to operate through different gendered pathways. Participants described women to question men about their whereabouts and intentions because of jealousy or the suspicion of infidelity, whereas participants described men to be jealous or suspicious of women socialising with, or attracting the attention of, other men and using violence in response. Through gender transformative strategies, SASA! and Indashyikirwa were described by participants to reduce the contribution of romantic jealousy to conflict and violence by encouraging improved relationship faithfulness and honesty; supporting reduced suspicion through improved relationship trust and communication; and identifying jealousy and suspicion of, or real infidelity, as direct triggers of IPV. While these programmes show promising results, gaps remain including a lack of standardised measures of the multidimensional concept of romantic jealousy. Recognition that programmes should be evaluated for their ability to reduce romantic jealousy when identified as a trigger for IPV in a specific context should also be emphasised. More research is also needed on the forms, gendered pathways, and consequences of romantic jealousy to inform context-specific programming.

'I trap her with a CD, then tomorrow find her with a big old man who bought her a smart phone'. Constructions of masculinities and transactional sex: a qualitative study from North-Western Tanzania.

Men's role in transactional sex is relatively unexplored, limiting initiatives to prevent exploitative transactional sex and its negative health implications for girls and women. We addressed this literature gap by conducting eight focus group discussions and twenty in-depth-interviews with boys and men aged 14 - 49 years in 2015 in Tanzania. We employed a novel combination of theoretical perspectives - gender and masculinities, and social norms - to understand how transactional sex participation contributes to perpetuating gendered hierarchies, and how reference groups influence men's behaviour. Findings signal two gender norms that men display within transactional sex: the expectation of men's provision in sexual relationships, and the expectation that men should exhibit heightened sexuality and sexual prowess. Adherence to these expectations in transactional sex relationships varied between older and younger men and created hierarchies among men and between men and women and girls. We found that approval of transactional sex was contested. Although young men were likely to object to transactional sex, they occupied a structurally weaker position than older men. Findings suggest that interventions should employ gender synchronised and gender transformative approaches and should prioritise the promotion of alternative positive norms over preventing the exchange of gifts or money in relationships.

Adolescent girls' perceived readiness for sex in Central Uganda - liminal transitions and implications for sexual and reproductive health interventions.

Young women in Uganda are at risk of negative sexual and reproductive health outcomes, in part because of sex with older men. Theoretically grounded in the concept of liminality, this paper examines perceived markers of adolescent girls' suitability for sexual activity. In 2014, we conducted 19 focus group discussions and 44 in-depth interviews in two communities in Uganda. Interviews were conducted using a semi-structured tool, audio-recorded and transcribed verbatim. Interviews examined markers of transition between childhood, adolescence and adulthood and how these were seen as relating to girls' perceived readiness for sex. Analysis was thematic. Pre-liminal status was most often accorded to childhood. Sex with a child was strongly condemned. Physical changes during puberty and children's increasing responsibility, autonomy and awakening sexuality reflected a liminal stage during which girls and young women were not necessarily seen as children and were increasingly described as suitable for sex. Being over 18, leaving home, and occupying 'adult' spaces reflected post-liminal status and perceived appropriateness for sexual activity including for girls under the age of 18. Interventions that seek to prevent early sexual debut and sexual activity with older men have the potential to reduce sexual and reproductive health risks.

Measuring transactional sex in different contexts: How do tools to measure this practice perform in rural South Africa?

Background: Adolescent girls and young women across sub-Saharan Africa are at disproportionate risk of HIV infection compared to their male counterparts. Transactional sex has been identified as an important proximate risk for infection in this population. Definitions and measures of transactional sex vary, necessitating improved measures to better estimate prevalence across settings, over time, and to understand the mechanisms through which transactional sex increases HIV risk. This article describes the results of cognitive interviews in rural KwaZulu-Natal in South Africa to evaluate the performance of an improved measure of transactional sex.Methods: Data were collected between May and June 2017 with sexually active adolescent girls and young women (n = 10) and men (n = 10) drawn from a general population sample. Two questions were tested. Audio-recorded interviews were conducted in isiZulu using a structured tool. Matrices were used to summarise the data across participants which were then compared using constant comparative techniques.Results: Participants captured the instrumental nature of transactional sex relationships clearly and understood that the questions were about relationships that were primarily motivated by benefit. However, despite prior qualitative research in this setting describing transactional sex as widely practised, only one male participant answered either question in the affirmative in this face-to-face interview. This implies a judgement placed on relationships that are deemed as having been motivated mainly by exchange, perhaps compelling people to under-report such relationships.Conclusion: Participants' unwillingness to answer in the affirmative highlights the importance of understanding the research context and the possible social and historical influences which may influence how survey questions are answered. This has implications for measurement development, and highlights the need for measures that can be responsive to contextual differences. Further research is needed for refinements to measurement approaches in this and other settings.

Evaluations of Interventions with Child Domestic Workers: A Rapid Systematic Review.

Little is known about interventions to support the education, skills training, and health of female child domestic workers (CDWs). This rapid systematic literature review followed PRISMA guidelines (PROSPERO registration: CRD42019148702) and summarises peer-reviewed and grey literature on health, education, and economic interventions for CDWs and interventions targeting employers. We searched six electronic databases and purposively searched grey literature. We included observational studies, which included an intervention, quasi-experimental, and experimental studies. Two reviewers independently screened articles. Data were extracted on intervention description, inputs, activities, type of evaluation, outcomes, effect size or impact where applicable, limitations, and ethical considerations. All studies were quality appraised. We identified eight papers from five studies. Six papers reported on health-related outcomes, two on education-related outcomes, and three on economic outcomes. No evaluations of employer-related interventions were identified. Only one intervention specifically targeted CDWs. Others included CDWs in their sample but did not disaggregate data for CDWs. Findings suggest that the evaluated interventions had a limited impact on CDW's health, education, and economic outcomes. While it appears feasible to reach CDWs with outreach interventions, further work is needed to improve the consistency of their effectiveness and their ability to improve CDWs' current and future prospects.

Intimate Partner Relationships and Gender Norms in Mali: The Scope of Cash Transfers Targeted to Men to Reduce Intimate Partner Violence.

Mali has implemented the Filets Sociaux (Jigisémèjiri) program that aims to reduce poverty through cash transfers (CTs) to predominantly male heads of household with accompanying measures. This paper reports on a qualitative study of the effects of the program on intimate partner relationships. In-depth interviews were conducted with men and women in monogamous and polygamous households. Findings revealed that the positive aspects of intimate partner relationships were communication and shared values. However, discussions around decision-making revealed male authority with limited influence by women. Physical violence was reported to be caused by tensions and disputes. Whereas sexual violence was contested, some women described sexual force as violence but men and women asserted that compliance in sexual matters by women was expected. Men also asserted control through preventing women from working outside the home. The CTs were managed by the husband, with some involvement of wives in decision-making about the use of CTs. CTs were reported to reduce household poverty and improve wellbeing, especially for men. There were reports of the effects of the program on IPV, especially in the reduction of physical violence, its effects on sexual violence and controlling behaviour were reported to be limited. Since women are not the primary recipients of the CT, there is limited effect on women's agency to challenge male authority and control around sexual and financial matters. CTs may be more effective if targeted to women, alongside skill and knowledge strengthening to utilize cash transfers to assert their rights to equality and prevent violence.

A Mixed-Methods Systematic Review: Infidelity, Romantic Jealousy and Intimate Partner Violence against Women.

Infidelity and romantic jealousy (RJ) are commonly cited relational level drivers of intimate partner violence (IPV) but remain undertheorized and underutilized in IPV research and prevention. This global systematic review aims to characterize the existing research on real or suspected infidelity and RJ in relation to IPV and inform future research and programming. We systematically searched 11 databases for peer-reviewed research, published between April 2009 and 2019, that provided data on the prevalence or a measure of association (quantitative), or pathway (qualitative), between real or suspected infidelity or RJ, and IPV. Fifty-one papers from 28 countries were included and the evidence showed a consistent association between real or suspected infidelity, RJ and IPV. Our findings identify three overarching mechanisms and six pathways between infidelity, RJ and IPV. These provide support for prominent theories in the field related to patriarchal culture, threatened masculinities and femininities and a lack of emotional regulation and conflict resolution skills, but not evolutionary theories. Our findings suggest that researchers should use standardized measurement tools that make the distinction between RJ and suspected, confirmed and accusations of infidelity. Policy and programming should aim to transform traditional gender roles, accounting for infidelity and RJ and improving couple's communication and trust.