Child disciplinary practices, abuse, and neglect: Findings from a formative study in Chitungwiza, Zimbabwe.

BACKGROUND: Zimbabwe has a high prevalence of children who have experienced abuse according to national data. OBJECTIVE: To understand how parents/caregivers and children describe child discipline, abuse, and neglect and what factors influence each, in order to inform the adaptation of a positive parenting/caregiving intervention in Chitungwiza, Zimbabwe. PARTICIPANTS: A total of eight focus groups were conducted, four with parents/caregivers (N = 40) and four with their children ages 10-14 (N = 40), separately, between June-July 2016. SETTING: Chitungwiza, Zimbabwe. METHODS: We used an inductive and deductive analytic approach to analyze focus group transcripts, using MAXQDA 12. RESULTS: There were similar themes across focus groups of children and parents/caregivers. Findings suggest that parents/caregivers and children may be somewhat aware of the differences between discipline and abuse, but they are not completely clear about what the definitions of discipline and abuse are, and where the boundaries between discipline and abuse lie. The use of both non-physical and physical forms of discipline were described in the community, however physical discipline was a reoccurring theme in the focus groups of both parents/caregivers and their children. There were several factors that influenced discipline and/or abuse of children in the community, including the child's gender and theseverity of the child's misbehavior/actions. Parents/caregivers shared that orphan/non-biological children were particularly vulnerable to forms of abuse and neglect committed by parents/caregivers in the community, for example, withholding food and overworking a child. CONCLUSIONS: Understanding the differences between discipline, abuse and neglect, as well as factors that influence occurrences of abuse/neglect and/or severity of abuse/neglect, need to be considered when assessing the vulnerability of children, in order to develop and refine parenting/caregiving interventions for the Zimbabwean context.

Suffering whether You Tell or Don't Tell: Perceived Re-Victimization as a Barrier to Disclosing Child Sexual Abuse in Zimbabwe.

Disclosing child sexual abuse (CSA) is a necessary first step to access the legal, health, and psycho-social services that survivors and their families need. However, disclosure rates are low: of young women who experienced CSA in Zimbabwe, only 9% disclosed the first incident. The purpose of this qualitative study was to explore and describe perceived barriers to disclosing CSA in Zimbabwe. We conducted focus group discussions with children aged 10-14 years (n = 40) and their parents/caregivers aged 20-62 years (n = 40), participating in an intervention trial in Chitungwiza, Zimbabwe. We found that potential retaliation against survivors and their families is a major barrier to disclosing CSA. These retaliatory acts, which we refer to as "re-victimization," arise from stigma or the victim feeling blamed or doubted and manifest through physical violence, emotional violence, and deprivation of family life and education. Our findings suggest that addressing social and cultural norms related to sex and strengthening legal protection for CSA survivors and their families could encourage CSA disclosure and could help end this violence. Our findings also highlight a need to increase children's awareness of their rights and to create safe systems for disclosure of sexual abuse.

Gender Differences in Sexual and Reproductive Health Protective and Risk Factors of Batswana Adolescents: Implications for Parent and Adolescent Interventions.

Adolescents in sub-Saharan Africa and in Botswana in particular continue to bear the brunt of the HIV epidemic. This analysis assessed gender differences among theory-based sexual and reproductive health protective and risk factors in a cross-sectional sample of 228 Batswana adolescents. Incongruence between preferred and actual sources of sexual information and several important gender differences in parent-adolescent relationships, psychosocial influences, and adolescent sexual behaviors were identified. Parents were the fourth most common source of information about sex; yet, over three-quarters of adolescents preferred to have parents teach them about sex. Boys reported more positive relationships with their parents and girls reported more positive attitudes toward transactional sex. Both boys and girls reported similarly low levels of parental monitoring, parental communication, and parental responsiveness, all of which are important protective factors. These findings suggest interventions should address these gender differences and consider offering parallel interventions for adolescents and their parents in Botswana.

Evaluation of the Families Matter! Program in Tanzania: An Intervention to Promote Effective Parent-Child Communication About Sex, Sexuality, and Sexual Risk Reduction.

The Families Matter! Program (FMP) is a curriculum-based intervention designed to give parents and other primary caregivers the knowledge, skills, comfort, and confidence to deliver messages to their 9-12-year-old children about sexuality and practice positive parenting skills. A pre- and post-intervention evaluation study on FMP outcomes was conducted with 658 parent participants and their preadolescent children in two administrative wards in Tanzania in 2014. There was an increase in the proportion of study participants (parent-preadolescent pairs) that had positive attitudes toward sex education. On parent-child communication, the majority of participants (59-87%) reported having had more sexuality discussions. On communication responsiveness about sexual issues, scores improved in the period between surveys, with parents showing more improvements than preadolescents. Our results corroborate evidence from previous FMP evaluations, lending support to the conclusion that FMP is successful in promoting attitude and behavior change among parents and preadolescents in different cultural contexts.

Guiding and supporting adolescents living with HIV in sub-Saharan Africa: The development of a curriculum for family and community members.

Although HIV-related deaths declined globally by 30% between 2005 and 2012, those among adolescents living with HIV (ALHIV) rose by 50%. This discrepancy is primarily due to failure to address the specific needs of ALHIV and resulting poor clinical outcomes related to late diagnosis and poor adherence to antiretroviral therapy. The Families Matter! Program (FMP) is an evidence-based intervention for parents and caregivers of 9-12 year-olds that promotes positive parenting practices and effective parent-child communication about sexuality and sexual risk reduction. It is delivered to groups of participants at the community level through a series of six weekly three-hour sessions. Recognizing family and community members' need for guidance on issues specific to ALHIV, we developed a seventh FMP session to address their needs. Key themes treated in the curriculum for this session include: stigma and mental health, disclosure, ART adherence and self-care, and responsible sexual relationships. In developing the curriculum, we drew on narratives about growing up with HIV contributed by young Africans to a 2013 scriptwriting competition. We describe the data-driven process of developing this curriculum with a view to informing the development of much-needed interventions to serve this vulnerable population.

Formative Work and Community Engagement Approaches for Implementing an HIV Intervention in Botswana Schools.

Providing adolescents with evidence-based sexual risk reduction interventions is critical to addressing the HIV/AIDS epidemic among adolescents in sub-Saharan Africa. Project AIM (Adult Identity Mentoring) is an innovative, evidence-based, youth development intervention that is being evaluated for the first time in Botswana through a 3-year (2015-2017), 50-school cluster randomized controlled trial, including testing for herpes simplex virus type 2 as a sexual activity biomarker. Conducting a trial of this magnitude requires the support and collaboration of government and community stakeholders. All school staff, including teachers, must be well informed about the study; dedicated staff placed at each school can help to improve school and community familiarity with the study, improve the information flow, and relieve some of the burden study activities places on schools.

Involving parents from the start: formative evaluation for a large randomised controlled trial with Botswana Junior Secondary School students.

While HIV prevention research conducted among adolescent populations may encounter parental resistance, the active engagement of parents from inception to trial completion may alleviate opposition. In preparation for implementing a large randomised controlled trial (RCT) examining the efficacy of a behavioural intervention targeting adolescent sexual risk behaviours, a formative evaluation was undertaken to assess parental reactions to the proposed trial. Six focus groups were conducted with parents of adolescents (aged 13-17) from rural, peri-urban and urban junior secondary schools in Botswana. Focus groups explored comprehension and acceptability among parents of the forthcoming trial including HSV-2 testing, the return of results to the adolescent (not the parent), trial information materials and the parental consent process. Parents welcomed the study and understood and accepted its moral and ethical considerations. Their reactions regarding return of HSV-2 results only to adolescents (not the parent) were mixed. Parents understood the consent process and most agreed to consent, while indicating their desire to remain informed and involved throughout the RCT. The focus group discussions (FGDs) provided valuable information and insights that helped strengthen the study. As a result of parents' feedback, counselling procedures were strengthened and direct linkages to local services and care were made. Informational materials were revised to increase clarity, and materials and procedures were developed to encourage and support parental involvement and parent-child dialogue. Ultimately, parental feedback led to a decision by the Government of Botswana to allow parents to access their child's HSV-2 test results.

Responding to Changes in HIV Policy: Updating and Enhancing the Families Matter! Curriculum.

OBJECTIVES: The past decade has seen changes in US HIV policy in sub-Saharan Africa in response to a new Administration and far-reaching technical, scientific and programmatic developments. These include: dramatically increased access to life-saving ART and related services; the roll-out of voluntary medical male circumcision; and growing sensitivity to gender-based violence, including child sexual abuse, and to its role in increasing vulnerability to HIV. The Families Matter! Program (FMP) is an intervention for parents and caregivers of 9-12 year-olds that promotes effective parent-child communication about sexuality and sexual risk reduction. FMP was adapted from a US evidence-based intervention in 2003-4 and is now implemented in eight African countries. In 2012-13, the FMP curriculum was updated and enhanced to respond to new US Government priorities. METHODS: Enhancements to the curriculum drew on the results of Violence Against Children surveys, on a review of existing literature, on feedback from the field on the existing curriculum, and on stories written by young people across Africa for scriptwriting competitions. RESULTS: We updated FMP with scientific content and stronger linkages to services. We also intensified our focus on structural determinants of risk. This contextualisation of sexual risk-taking within structural constraints led us to place greater emphasis on gendered vulnerability and the diverse pressures children face, and to intensify our situation-based pedagogical approach, drawing on the authentic youth-authored narratives. CONCLUSION: We describe these changes as an illustration of and source of insight into much-needed programmatic adaptation in response to evolving HIV policy.

Parents' reactions to testing for herpes simplex virus type 2 as a biomarker of sexual activity in Botswana junior secondary school students.

UNLABELLED: Background Use of sexual activity biomarkers in HIV prevention trials has been widely supported to validate self-reported data. When such trials involve minors, researchers may face challenges in obtaining parental buy-in, especially if return of results procedures uphold the confidentiality and privacy rights of minors and preclude parental access to test results. In preparation for a randomised controlled trial (RCT) with junior secondary school (JSS) students in Botswana, a formative assessment was conducted to assess parents' opinions and concerns about testing for herpes simplex virus type 2 (HSV-2) (biomarker of sexual activity) as part of the RCT. METHODS: Six focus groups were held with parents (n=32) of JSS students from urban, peri-urban and rural communities. Parents were asked their opinions of students being tested for HSV-2 and procedures for blood sample collection and return of results. RESULTS: Overall, parents were supportive of HSV-2 testing, which they thought was a beneficial sexual health resource for adolescents and parents, and a motivation for parent-child communication about HSV-2, sexual activity and sexual abuse. Some parents supported the proposed plan to disclose HSV-2 test results to adolescents only, citing the importance of adolescent privacy and the possibility of HSV-2 positive adolescents being stigmatised by family members. Conversely, opposing parents requested parental access to results. These parents were concerned that adolescents may experience distress following a positive result and withhold this information thereby reducing parents' abilities to provide support. Parents were also concerned about support for victims of sexual abuse. CONCLUSION: Although the present study demonstrates that parents can be accepting of sexual activity biomarker testing of adolescents, more research is needed to identify best approaches for returning test results.

Curriculum Development Around Parenting Strategies to Prevent and Respond to Child Sexual Abuse in Sub-Saharan Africa: A Program Collaboration Between Families Matter! and Global Dialogues.

Despite widespread recognition of child sexual abuse as a serious problem in sub-Saharan Africa, few far-reaching programmatic interventions addressing child sexual abuse in this setting are currently available, and those interventions that do exist tend to focus on response rather than prevention. The Families Matter! Program is an evidence-based intervention for parents and caregivers of 9- to 12-year-olds in sub-Saharan African countries which promotes positive parenting practices and effective parent-child communication about sex-related issues. This article describes the enhancement of a new Families Matter! Program session on child sexual abuse, drawing on authentic narratives contributed by young people to the Global Dialogues from Africa youth scriptwriting competitions. Experiences are shared with a view to informing the development of interventions addressing child sexual abuse in sub-Saharan Africa.

Involving parents from the start: formative evaluation for a large randomised controlled trial with Botswana junior secondary school students

While HIV prevention research conducted among adolescent populations may encounter parental resistance; the active engagement of parents from inception to trial completion may alleviate opposition. In preparation for implementing a large randomised controlled trial (RCT) examining the efficacy of a behavioural intervention targeting adolescent sexual risk behaviours; a formative evaluation was undertaken to assess parental reactions to the proposed trial. Six focus groups were conducted with parents of adolescents (aged 13-17) from rural; peri-urban and urban junior secondary schools in Botswana. Focus groups explored comprehension and acceptability among parents of the forthcoming trial including HSV-2 testing; the return of results to the adolescent (not the parent); trial information materials and the parental consent process. Parents welcomed the study and understood and accepted its moral and ethical considerations. Their reactions regarding return of HSV-2 results only to adolescents (not the parent) were mixed. Parents understood the consent process and most agreed to consent; while indicating their desire to remain informed and involved throughout the RCT. The focus group discussions (FGDs) provided valuable information and insights that helped strengthen the study. As a result of parents' feedback; counselling procedures were strengthened and direct linkages to local services and care were made. Informational materials were revised to increase clarity; and materials and procedures were developed to encourage and support parental involvement and parent-child dialogue. Ultimately; parental feedback led to a decision by the Government of Botswana to allow parents to access their child's HSV-2 test results

Impact of parent-child communication interventions on sex behaviors and cognitive outcomes for black/African-American and Hispanic/Latino youth: a systematic review, 1988-2012.

PURPOSE: We reviewed human immunodeficiency virus (HIV) and sexually transmitted infection (STI)- behavioral interventions implemented with disproportionately affected black/African-American and Hispanic/Latino youth and designed to improve parent-child communications about sex. We compared their effectiveness in improving sex-related behavior or cognitive outcomes. METHODS: A search of electronic databases identified peer-reviewed studies published between 1988 and 2012. Eligible studies were U.S.-based parent-child communication interventions with active parent components, experimental and quasiexperimental designs, measurement of youth sexual health outcomes, and enrollment of ≥ 50% black/African-American or Hispanic/Latino youth. We conducted systematic, primary reviews of eligible papers to abstract data on study characteristics and youth outcomes. RESULTS: Fifteen studies evaluating 14 interventions were eligible. Although youth outcome measures and follow-up times varied, 13 of 15 studies (87%) showed at least one significantly improved youth sexual health outcome compared with controls (p < .05). Common components of effective interventions included joint parent and child session attendance, promotion of parent/family involvement, sexuality education for parents, developmental and/or cultural tailoring, and opportunities for parents to practice new communication skills with their youth. CONCLUSIONS: Parent-child communication interventions that include parents of youth disproportionately affected by HIV/STIs can effectively reduce sexual risk for youth. These interventions may help reduce HIV/STI-related health disparities and improve sexual health outcomes.

A multidimensional framework for the meanings of the sexual double standard and its application for the sexual health of young black women in the U.S.

There has been debate in the literature as to whether a sexual double standard (SDS) currently exists in the United States. Studies vary greatly in how the SDS is operationalized, making it difficult to interpret findings across studies and translate academic literature into applied fields such as public health. To advance academic and applied research, we propose a multidimensional framework for the SDS that can accommodate complex and nuanced meanings, is flexible enough to allow for the dynamic nature of social ideologies, and is grounded in an understanding of social systems of inequality. In this article, we describe three dimensions that define the broad elements of the SDS: (a) polarized (hetero)sexualities, (b) active male and passive female roles, and (c) the power struggle narrative. To illustrate the use of the framework, we contextualize each dimension in terms of the intersection of race and gender for young Black women in the United States. And finally, to apply the framework, we explore the effects the SDS can have on sexual health and suggest some directions for public health interventions. These analyses lay the groundwork for more complex and comprehensive investigations of the SDS and its effects on sexual health.

Strengthening the network of mentored, underrepresented minority scientists and leaders to reduce HIV-related health disparities.

OBJECTIVES: We reviewed data for the Minority HIV/AIDS Research Initiative (MARI), which was established in 2003 to support underrepresented minority scientists performing HIV prevention research in highly affected communities. METHODS: MARI was established at the Centers for Disease Prevention and Control as a program of competitively awarded, mentored grants for early career researchers conducting HIV prevention research in highly affected racial/ethnic and sexual minority communities. We have described progress from 2003 to 2013. RESULTS: To date, MARI has mentored 27 scientist leaders using low-cost strategies to enhance the development of effective HIV prevention interventions. These scientists have (1) developed research programs in disproportionately affected communities of color, (2) produced first-authored peer-reviewed scientific and programmatic products (including articles and community-level interventions), and (3) obtained larger, subsequent funding awards for research and programmatic work related to HIV prevention and health disparities work. CONCLUSIONS: The MARI program demonstrates how to effectively engage minority scientists to conduct HIV prevention research and reduce racial/ethnic investigator disparities and serves as a model for programs to reduce disparities in other public health areas in which communities of color are disproportionately affected.

Families matter! Presexual risk prevention intervention.

Parent-based HIV prevention programming may play an important role in reaching youths early to help establish lifelong patterns of safe and healthy sexual behaviors. Families Matter! is a 5-session, evidence-based behavioral intervention designed for primary caregivers of children aged 9 to 12 years to promote positive parenting and effective parent-child communication about sexuality and sexual risk reduction. The program's 5-step capacity-building model was implemented with local government, community, and faith-based partners in 8 sub-Saharan African countries with good intervention fidelity and high levels of participant retention. Families Matter! may be useful in other resource-constrained settings.

Association between HIV-related risk behaviors and HIV testing among high school students in the United States, 2009.

OBJECTIVE: To identify the human immunodeficiency virus (HIV)-related risk behaviors associated with HIV testing among US high school students who reported ever having sexual intercourse. DESIGN: Secondary analysis of a cross-sectional study. SETTING: The 2009 national Youth Risk Behavior Survey. PARTICIPANTS: A total of 7591 US high school students who reported ever having sexual intercourse. MAIN EXPOSURES: Risk behaviors related to HIV. MAIN OUTCOME MEASURE: Having ever been tested for HIV. RESULTS: Among the 7591 students who reported ever having sexual intercourse, 22.6% had been tested for HIV. Testing for HIV was most likely to be done among students who had ever injected any illegal drug (41.3%; adjusted odds ratio, 1.70; 95% CI, 1.14-2.56), had ever been physically forced to have sexual intercourse (36.2%; adjusted odds ratio, 1.43; 95% CI, 1.19 -1.72), did not use a condom the last time they had sexual intercourse (28.7%; adjusted odds ratio, 1.28; 95% CI, 1.08-1.51), and had sexual intercourse with 4 or more persons during their life (34.7%; adjusted odds ratio, 2.32; 95% CI, 1.98-2.73). CONCLUSIONS: Most sexually active students, even among those who reported high-risk behaviors for HIV, have not been tested for HIV. New strategies for increasing HIV testing among the adolescent population, including encouraging routine voluntary HIV testing among those who are sexually active, are needed.

Enhancing HIV communication between parents and children: efficacy of the Parents Matter! Program.

We examine efficacy of the Parents Matter! Program (PMP), a program to teach African-American parents of preadolescents sexual communication and HIV-prevention skills, through a multicenter, randomized control trial. A total of 1115 parent-child participants were randomized to one of three intervention arms (enhanced, brief, control). Percentages and 95% confidence intervals compare parents' perception of child readiness to learn about sexual issues, communication effectiveness, and dyad concordance from baseline to 12 months postintervention. Wilcoxon rank sum tests compare the changes in scores measuring communication content in HIV/AIDS, abstinence, and condom use. Compared to control, parents in the enhanced arm increased perception of child readiness to learn about sex (16% vs. 29%; p < .001), and a greater proportion of parent-child dyads reported concordant responses on communication topics: HIV/AIDS (15%, 95% CI = 8-21%; p < .001), abstinence (13%, 95% CI = 7-20%; p < .001), condoms (15%, 95% CI = 9-22%; p < .001). Increases in communication scores in HIV/AIDS, abstinence, and condom use were greater in the enhanced arm than control (p < 0.01). We conclude that the enhanced PMP can help parents educate children about HIV and prepare children to avoid sexual risk.

Why take an HIV test? Concerns, benefits, and strategies to promote HIV testing among low-income heterosexual African American young adults.

A qualitative study examined perceptions of HIV testing and strategies to enhance HIV testing among HIV-negative African American heterosexual young adults (ages 18-25 years). Twenty-six focus groups (13 male groups, 13 female groups) were conducted in two low-income communities (urban and rural). All sessions were audio-recorded and transcribed. Data analysis was completed using AnSWR software. Many participants expressed that learning one's HIV status, regardless of the result, was a benefit of taking an HIV test because this was perceived to produce emotional relief. Additional benefits included the avoidance of unknowingly spreading the virus, being offered treatment access if HIV-positive, and taking time to assess and modify risky sexual behaviors if HIV-negative. If diagnosed HIV-positive, HIV testing concerns included the recognition of one's mortality, the experience of social stigma, and concerns about accessing affordable treatment. Recommended promotion strategies included the use of HIV-positive individuals, pop culture icons, and the media to promote HIV testing messages.

Making HIV prevention programming count: identifying predictors of success in a parent-based HIV prevention program for youth.

Predictors of change in the number of sexual topics parents discussed and responsiveness during sex communication with their preadolescent after participating in a five-session sexual risk reduction intervention for parents were examined. Data were from 339 African American parents of preadolescents enrolled in the intervention arm of a randomized-controlled trial of the Parents' Matter! Program (PMP). Four categories of predictors of success were examined: time and resource constraints, personal characteristics, the parent-child relationship, and parent perceptions of child readiness for sex communication. There were only sporadic associations between success and time and resource constraints for either outcome. Parent perception of child readiness for sex communication was positively associated with discussions of sex topics (b = 1.11, confidence interval [CI]: 0.24-1.97) and parental responsiveness (b = .68, CI:0.22-1.15). Although parents face time and resource constraints, most attended at least four sessions, and demographics such as income had limited effects on program success.