'You are looked upon as a luxury tool': Young Tanzanian women's perception of community norms supporting partner violence during transactional sex (kudanga).

This paper explores the definition of, and perceived community attitudes, toward kudanga, a Swahili street term for a type of transactional sex practised in Dar es Salaam, Tanzania. Rooted in economic and gender disparity, transactional sex increases adolescent girls' and young women's vulnerability to HIV and gender-based violence. We sought to understand perceived community attitudes about kudanga, and how the internalisation of norms surrounding gender-based violence relate to the experiences of young women who practise kudanga. Using qualitative data from focus group discussions with 37 young women, we found that community perceptions of kudanga were largely negative, and those who engaged in it were looked down upon and despised. Violence and lack of sexual agency were normalised when doing kudanga. However, young women understood kudanga to often be their best option to obtain economic stability and felt strongly that those who practised kudanga should not be stigmatised. Our research provides further evidence that transactional sex exists on a continuum and highlights the importance of reducing community stigma surrounding transactional sex as a means of decreasing risk of HIV and gender-based violence for young women. To our knowledge, this article is the first to explore kudanga.

Economic vulnerabilities, mental health, and coping strategies among Tanzanian youth during COVID-19.

BACKGROUND: The COVID-19 pandemic has exacerbated struggles for youth living in poor households. Youth in rural Tanzania are particularly vulnerable given widespread poverty, lack of formal sector employment opportunities, and health risks. We examine influences of the pandemic on economic insecurity and mental health and explore the coping strategies employed by youth and their households. METHODS: We conducted mixed-method data collection with youth (N = 760 quantitative and N = 44 qualitative interviews) and households (n = 542) via mobile phone among a sub-set of a cohort from an on-going longitudinal sample in two rural regions in Tanzania. In addition to phone interviews, we collected data bi-weekly via SMS messaging. We present mixed-methods, descriptive analysis of the outcomes and longitudinally compare quantitative outcomes pre- and post-COVID-19, within the same individuals. RESULTS: Adverse economic impacts were most salient, and to cope, youth engaged in more labor and domestic chores. Compared to prior the COVID-19 pandemic, youth reported spending more time caring for elderly or sick household members and gathering firewood or nuts. CONCLUSIONS: These findings underscore the potential opportunity to promote policies and programs which address risks youth face. Recommended measures include expansion and adaptation of social protection policies, strengthened food and nutrition surveillance and referral systems, and scaling up community-based mental health programming.

Climate distress, climate-sensitive risk factors, and mental health among Tanzanian youth: a cross-sectional study.

BACKGROUND: Climate change threatens youth mental health through multiple mechanisms, yet empirical studies typically focus on single pathways. We explored feelings of distress over climate change among Tanzanian youth, considering associations with climate change awareness and climate-sensitive risk factors, and assessed how these factors relate to mental health. METHODS: Tanzanian youth (aged 18-23 years) from a cluster randomised controlled trial in Mbeya and Iringa regions of Tanzania were interviewed between Jan 25, and March 3, 2021, and included in this cross-sectional study. A threshold of at least 10 on the ten-item Centre for Epidemiological Studies Depression Scale was used to classify symptom severity indicative of depression. Regardless of climate change awareness, respondents were asked about their feelings of distress on climate change using inclusive language (changing weather patterns or changing seasons). We estimated rate differences in climate change distress (slight or moderate or extreme vs none) by youth characteristics, extent of climate awareness, and climate-sensitive livelihoods (eg, agriculture, tending livestock) and climate-sensitive living conditions (eg, food or water insecurity), using generalised linear models. We compared depression prevalence by extent of climate change distress and climate-sensitive living conditions. FINDINGS: Among 2053 youth (1123 [55%] were male and 930 [45%] were female) included in this analysis, 946 (46%) had reported any distress about climate change. Distress was higher among female, more educated, more religious, older youth, and those working in extreme temperatures. Adjusting for climate awareness-a factor strongly associated with climate distress-helped to explain some of these associations. Depression was 23 percentage points (95% CI 17-28) higher among youth who had severe water insecurity than those who did not. Similarly, youth who had severe food insecurity had 23 percentage points higher depression (95% CI 17-28) compared with those who did not. Those reporting climate change distress also had worse mental health-extremely distressed youth had 18 percentage points (95% CI 6-30) higher depression than those reporting none. INTERPRETATION: Living in conditions worsened by climate change and feeling distressed over climate change have mental health implications among young people from low-resource settings, indicating that climate change can impact youth mental health through multiple pathways. FUNDING: Erasmus Trustfonds, Centre for Global Health Inequalities Research, UK's Foreign, Commonwealth, and Development Office, Oak Foundation, UNICEF, UK's Department of International Development, the Swedish Development Cooperation Agency, Irish Aid.

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

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

Reaching Out-of-school Adolescent Girls and Young Women at Risk for HIV Through Their Social Networks.

Out-of-school adolescent girls/young women (AGYW) in Africa are at increased risk for HIV and are underserved by HIV prevention interventions. Identifying social networks of out-of-school AGYW may be a strategic approach for reaching them. A sequential mixed methods study design was used. The PLACE (Priorities for Local AIDS Control Efforts) methodology, implemented in one ward of Dar es Salaam, Tanzania, identified 69 networks of AGYW. We randomly selected 28 networks and conducted surveys and network assessments with 80.9% (n = 310) of the members. On average, the networks consisted of 13.7 members, and had a density of 0.65 and a transitivity of 0.80, indicating high cohesion. The networks were mostly female (92%). On average, 67% of network membership were AGYW aged 15-24 years, of whom 70% were out-of-school and 67% were sexually active. Among sexually active AGYW aged 15-24, self-reported HIV seropositivity was 12.2%. We then conducted focus group discussions with 6 purposively selected networks. AGYW described their networks as sources of support and advice. Social norms supported AGYW engaging in transactional sex to alleviate life's hardships; it was the easiest way to earn income without "sweating". AGYW discussed IPV as a common experience, and social norms stigmatized AGYWs' use of condoms. AGYW were largely unaware of pre-exposure prophylaxis. The self-reported HIV prevalence rates of this cohort were higher than national averages, suggesting we tapped into high-risk networks. Social norms promoted transactional and unprotected sex. Social networks are an acceptable channel for HIV prevention intervention delivery to out-of-school AGYW.

Development and implementation of a process evaluation for intervention quality improvement of a community-based behavioral HIV intervention trial in Tanzania.

Aim: Process evaluations for social and behavioral interventions are increasingly important as interventions become more complex and multi-faceted. Conducting process evaluations in low-resource international settings can be challenging. Process evaluations in low-resource international settings can help inform and improve quality of ongoing intervention implementation. We conducted a process evaluation of a cluster-randomized controlled trial to assess the efficacy of a microfinance and health leadership program on sexually transmitted infections and intimate partner violence perpetration among young men in Tanzania. Subject and Methods: Our trial included 1,491 participants and the intervention lasted two years. We collected process data on microfinance loan uptake and repayment, and health leaders' health conversations with peers to monitor intervention reach and dose received. We developed a database system that allowed offline data collection and synced to a central database when internet was accessible. Research staff in the U.S. accessed data from the central database to analyze and create regular implementation reports. Results: Process graphical reports facilitated identification of implementation challenges and enabled us to resolve issues before they worsened. For example, from a group with low microfinance loan repayment we learned area participants perceived the loan to be a grant, and then we clarified the misinformation with participants. Conclusions: The process evaluation helped inform ongoing intervention implementation, including approaches to improve reach and uptake of interventions. Field staff time was protected by systemizing the sharing of data processing and analyses across the global team.

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

INTRODUCTION: Transactional sex or material exchange for sex is associated with HIV infection among adolescent girls and young women in sub-Saharan Africa. The motivations for engaging in transactional sex vary from the fulfilment of basic needs, to enhancing social status or for romantic reasons with the expectation that men should provide. Transactional sex is also associated with HIV risk behaviours, such as multiple sexual partners and other determinants of HIV risk, including partner violence and abuse, alcohol consumption and inconsistent condom use. METHODS: We use data from a mixed-method, cluster randomised controlled trial of the Ujana Salama cash "plus" intervention in rural Tanzania. The data are from the first and third rounds of data collection (2017-2019). The impact evaluation consisted of a parallel mixed-methods design where the quantitative and qualitative data collection occurred simultaneously, and integration of the findings was done during the discussion. We first examine contextual factors associated with transactional sex using multivariable logistic regression models and then estimate whether the "plus" intervention reduced transactional sex among adolescent girls and young women using analysis of covariance. We used thematic content analysis for analysing qualitative transcripts. RESULTS: The prevalence of transactional sex among unmarried adolescent girls and young women at round 3 was 26%. Findings show that increasing age is a risk factor for transactional sex (OR = 1.80; 95% CI: [1.50, 2.17]), staying in school was negatively associated with engagement in transactional sex (OR = 0.24; 95% CI: [0.14, 0.40]). The cash plus intervention showed no impacts on reducing transactional sex (ß = 0.003, p = 0.905). CONCLUSIONS: The mechanisms of impact for a cash plus intervention on transactional sex are complex; economic insecurity is an important driver of transactional sex and HIV infection, but psychosocial factors and gendered social norms need consideration in intervention development. Our findings suggest that combination prevention interventions to address the structural drivers of HIV infection should focus on efforts to increase school enrolment and completion.

Effects of Adolescent-Focused Integrated Social Protection on Depression: A Pragmatic Cluster-Randomized Controlled Trial of Tanzania's Cash Plus Intervention.

We assessed the impacts of Tanzania's adolescent-focused Cash Plus intervention on depression. In this pragmatic cluster-randomized controlled trial, 130 villages were randomly allocated to an intervention or control arm (1:1). Youth aged 14-19 years living in households receiving governmental cash transfers were invited to participate. The intervention included an intensive period (a 12-session course) and an aftercare period (9 months of mentoring, productive grants, and strengthened health services). We examined intervention impacts on a depressive symptoms scale (10-item Center for Epidemiologic Studies Depression Scale score (range, 0-30)) and rates of depressive symptomatology (score ≥10 points on the scale), recorded at study baseline (April-June 2017), midline (May-July 2018), and endline (June-August 2019). Using intention-to-treat methodology, we employed logistic and generalized linear models to estimate effects for binary and continuous outcomes, respectively. Quantile regression was used to estimate effects across the scale. From 2,458 baseline participants, 941 intervention and 992 control adolescents were reinterviewed at both follow-ups. At endline, the intervention reduced the odds of depressive symptomatology (adjusted odds ratio = 0.67, 95% confidence interval: 0.52, 0.86), with an undetectable mean scale difference (risk difference = -0.36, 95% confidence interval: -0.84, 0.11). Quantile regression results demonstrated an intervention effect along the upper distribution of the scale. Integration of multisectoral initiatives within existing social protection systems shows potential to improve mental health among youth in low-resource settings.

Intimate partner violence perpetration and sexual risk behaviour: Identifying shared determinants among young men in Tanzania.

In this study we examined factors that predict involvement in different patterns of sexual risk behavior and IPV perpetration among young men in Tanzania (n = 979), with a focus on identifying factors that distinguish men who engage in both behaviours from those who do not. Risk factors were drawn from three domains thought to be upstream drivers of both IPV and sexual risk: poverty, adverse childhood experiences, and inequitable gender norms. A three-step latent class analysis was used to assess whether and how factors from each domain distinguished subgroups of men whose behaviour patterns were characterised as comorbid (involvement in IPV and sexual risk behaviour), IPV-only, sexual risk only, and normative (low risk). Consistent with expectations, greater food insecurity, adverse childhood experiences, and inequitable gender norms related to violence and sexual behaviour predicted increased risk of membership in the comorbid group compared to other sub-groups. Findings support the promise of integrated prevention programmes targeting the common causes of IPV perpetration and sexual risk behaviour.

The Intersection of Intimate Partner Violence Perpetration and Sexual Risk Behavior Among Young Men in Tanzania: A Latent Class Analysis of Patterns and Outcomes.

Few studies of intimate partner violence (IPV) perpetration and sexual risk behavior among men have examined how multiple dimensions of these behaviors intersect in ways that may uniquely elevate health risks. The current study used latent class analysis to: (1) identify distinct patterns of IPV and sexual risk behavior in a sample of Tanzanian men (n = 985) and (2) examine associations between identified patterns and health outcomes. Four classes were identified: normative (64% of the sample), IPV only (14%), sexual risk only (13%), and comorbid IPV/sexual risk (5%). Compared to men in the normative subgroup, men in the comorbid group had significantly higher odds of STI infection, higher perceived HIV risk, and greater odds of substance use. Findings provide evidence that engaging in IPV and multiple sexual partnerships (i.e., a comorbid pattern) denotes elevated health risks across a range of indicators, suggesting the importance of targeted treatment and prevention efforts for men in this subgroup.

RESUMEN: Pocos estudios sobre la violencia infligida por la pareja (IPV) y las conductas sexuales de riesgo entre los hombres han examinado como las múltiples dimensiones de estas conductas pueden combinarse para elevar los riesgos de estas conductas para la salud. El estudio actual utilizó el análisis de clases latentes para: (1) identificar patrones (o clases) distintos de IPV y conductas sexuales de riesgo en una muestra de hombres de Tanzania (n = 985) y (2) examinar asociaciones entre los patrones identificados y indicadores de salud. Se identificaron cuatro clases: normativa (64% de la muestra), IPV solo (14%), riesgo sexual solo (13%) y riesgo sexual / IPV comórbido (5%). En comparación con los hombres del subgrupo normativo, los hombres del grupo comórbido tenían probabilidades significativamente más altas de infección de transmisión sexual, mayor riesgo percibido de VIH, y mayores probabilidades de consumo de sustancias (alcohol y marijuana). Los hallazgos proporcionan evidencia de que ser perpetrador de violencia en pareja y tener múltiples parejas sexuales (un patrón comórbido) es asociado con múltiples riesgos para la salud, lo que sugiere la importancia del tratamiento dirigido y los esfuerzos de prevención para los hombres en este subgrupo.

"Mtoto Wa Nyoka Ni Nyoka," The Child of a Snake is a Snake: A Narrative Analysis of Adverse Childhood Experiences and Perpetration of Interpersonal Violence Among Men in Dar es Salaam, Tanzania.

Childhood exposure to adversity, including abuse and neglect, is consistently found to be a predictor of intimate partner violence (IPV) and peer violence (PV) perpetration in adulthood. The purpose of this study is to qualitatively examine factors that may facilitate or impede the use of violence among those who have been exposed to adversity early in life. We are particularly interested in protective experiences or environments for these participants. The qualitative data were analyzed through thematic coding and narrative analysis of participant life histories.We found three salient themes: (a) parental acceptance and early attachment is protective for coping with stress with intimate partners in adulthood; (b) certain key life turning points can provide a protective context against violent behavior in adulthood; and (c) poverty in adulthood compromises one's ability to cope with stress and anger in adulthood.Our findings contextualize the different factors that may affect the behavior of perpetration of interpersonal violence among high-risk men in Dar es Salaam who have been exposed to adversity in childhood. These findings provide important information on the risk and protective factors for interpersonal violence spanning from childhood to adulthood. This study highlights the importance of child development interventions in this situation, both for the primary prevention of child adversity and for promoting resilience and mitigating the effects of childhood adversity that put men at risk for perpetration of interpersonal violence in adulthood.

Effects of Government-Implemented Cash Plus Model on Violence Experiences and Perpetration Among Adolescents in Tanzania, 2018‒2019.

Objectives. To examine the impacts of a government-implemented cash plus program on violence experiences and perpetration among Tanzanian adolescents. Methods. We used data from a cluster randomized controlled trial (n = 130 communities) conducted in the Mbeya and Iringa regions of Tanzania to isolate impacts of the "plus" components of the cash plus intervention. The panel sample comprised 904 adolescents aged 14 to 19 years living in households receiving a government cash transfer. We estimated intent-to-treat impacts on violence experiences, violence perpetration, and pathways of impact. Results. The plus intervention reduced female participants' experiences of sexual violence by 5 percentage points and male participants' perpetration of physical violence by 6 percentage points. There were no intervention impacts on emotional violence, physical violence, or help seeking. Examining pathways, we found positive impacts on self-esteem and participation in livestock tending and, among female participants, a positive impact on sexual debut delays and a negative effect on school attendance. Conclusions. By addressing poverty and multidimensional vulnerability, integrated social protection can reduce violence. Public Health Implications. There is high potential for scale-up and sustainability, and this program reaches some of the most vulnerable and marginalized adolescents. (Am J Public Health. 2021;111(12):2227-2238. https://doi.org/10.2105/AJPH.2021.306509).

Exploring multilevel social determinants of depressive symptoms for Tanzanian adolescents: evidence from a cross-sectional study.

BACKGROUND: Depression has substantial and enduring impacts for adolescents, particularly those living in poverty. Yet, evidence on its determinants in low-income countries remains scarce. We examined the social determinants of depressive symptoms for Tanzanian adolescents. METHODS: We used cross-sectional data for 2458 adolescents (aged 14-19), to describe associations with depressive symptoms within and across five domains-demographic, economic, neighbourhood, environmental and social-cultural-using linear mixed models. We estimated depressive symptoms using the 10-item Centre for Epidemiological Studies Depression Scale, which ranges from 0 to 30 and increases with additional symptoms. RESULTS: Factors associated with depressive symptoms in the fully adjusted models included experiencing five or more household economic shocks (ß=2.40; 95% CI 1.48 to 3.32), experiencing droughts/floods (ß=0.76; 95% CI 0.36 to 1.17), being in a relationship (ß=1.82; 95% CI 1.30 to 2.33), and having moderate (ß=1.26; 95% CI 0.80 to 1.71) or low (ß=2.27; 95% CI 1.81 to 2.74) social support. Exclusive schooling was protective compared with being engaged in both school and paid work (ß=1.07; 95% CI 0.05 to 2.61) and not engaged in either (ß=0.73; 95% CI 0.24 to 1.22). Household size and relationship status were more important factors for girls, while employment status, and extreme precipitation were more important for boys. CONCLUSION: Mental health is associated with determinants from multiple domains. Results suggest that environmental shocks related to climate change contribute to poor mental health in adolescents, highlighting an important area for intervention and research.

Social and structural determinants of youth alcohol use in Tanzania: The role of gender, social vulnerability and stigma.

Adolescent alcohol use remains an under-addressed population health issue across Africa. Although the literature explores the intersection of alcohol use and vulnerability to HIV and AIDS, there is limited evidence on the gendered uptake and use of alcohol among adolescents. Capturing adolescents' voiced experiences about the societal influences shaping their alcohol usage is essential for identifying contextually relevant interventions to reduce their vulnerability to alcohol and related risky behaviours, such as unsafe sex. We conducted qualitative research in urban Tanzania, including key informant interviews, systematic mapping of alcohol availability, in-depth interviews with adolescents in and out of school and adults, and participatory methodologies with adolescents ages 15-19. The findings described here were drawn from the participatory methodologies (n = 177); and in-depth interviews with adolescents (n = 24) and adults (n = 24). Three key themes emerged: (1) boys' increased social vulnerability to alcohol consumption; (2) the ways in which stigma shapes girls' alcohol usage; and (3) how gendered perceptions of alcohol use reinforce societal inequalities. There exists an urgent need to address the social and gendered vulnerabilities of youth in Africa to the uptake and use of alcohol, and identify interventions that reshape notions of masculinity increasing boy's vulnerability to use.

Adolescent dating violence prevention programmes: a global systematic review of evaluation studies.

Adolescent dating violence negatively affects millions of young people worldwide. Through a global systematic review, we synthesised evidence from rigorous studies of prevention programmes for adolescent dating violence. Our aims were to: (1) describe the breadth of research in this area and evidence of programme effects, and (2) identify gaps in the evidence base. We included experimental and controlled quasi-experimental programme evaluations, published before Jan 1, 2020, that assessed effects on victimisation or perpetration, or both, in adolescent dating violence and in which at least half of the study population was 10-19 years old. Study design, programme elements, and outcomes were compared between evaluations implemented in high-income countries (HICs) and low-income and middle-income countries (LMICs). 52 evaluations met inclusion criteria, of which 20 (38%) were implemented in LMICs. Evaluations in HICs were more likely to assess effects on adolescent dating violence victimisation and perpetration, rather than just victimisation, than those in LMICs, and they were also more likely to include boys and girls, as opposed to just a single sex. Overall, 26 (50%) of the 52 evaluations reported a significant preventive effect on at least one outcome for adolescent dating violence, of which nine were implemented in LMICs. Across LMICs and HICs, findings suggest research is needed to shed light on how adolescent dating violence prevention programmes work and to identify whether programme effects generalise across different settings, outcomes, and subgroups. TRANSLATIONS: For the Chinese, French and Spanish translations of the abstract see Supplementary Materials section.

Examining determinants of gender attitudes: evidence among Tanzanian adolescents.

BACKGROUND: The shaping of gender beliefs and attitudes in early adolescence affects the way young people internalize and self-enforce prevalent notions of masculinity and femininity, with lifelong consequences for sexual and reproductive health. This cross-sectional study examines determinants of gender attitudes among some of the poorest and most vulnerable adolescents in Tanzania using an ecological model. METHODS: Data come from baseline interviews with 2458 males and females aged 14-19 years conducted as part of a larger impact evaluation. Structural equation models are used to examine how factors at the community-, household-, and individual-levels influence gender attitudes in the four domains measured by the Gender Equitable Men (GEM) Scale (i.e. violence, sexual relationships, reproductive health and disease prevention, and domestic chores and daily life). RESULTS: A structural equation model of the four latent domains of the GEM scale regressed on individual, social-interactional and structural level characteristics indicated that secondary school attendance was associated with more equitable gender attitudes, while females held less equitable attitudes than males in the sample. Having had sexual intercourse was associated with more gender equitable attitudes among females, but the reverse was true among males. CONCLUSIONS: Addressing gender inequity requires understanding gender socialisation at the socio-interactional level. As females had more inequitable gender attitudes than males in the study, a special emphasis on highlighting the rights of women to girls should be considered. This study will inform future analysis of programme impacts on gender attitudes and sexual and reproductive health.

Correlates of Anxiety and Depression among Young Men Living in Dar es Salaam, Tanzania.

Depression and anxiety are important sources of morbidity globally, but we have little knowledge of risk groups and risk factors for both classes of disorders in Tanzania and other low-resource settings. We aimed to identify socio-demographic markers and risk and protective factors associated with symptoms of anxiety and depression among 1249 young men belonging to social groups known as "camps" in Dar es Salaam. Anxiety and depression were measured using the HSCL-25. Men living apart from family reported greater symptoms of anxiety and depression than men living with family, and employment was associated with a greater likelihood of clinically significant symptoms of both anxiety and depression. Childhood experience of violence was strongly associated with both anxiety and depression. Social support was associated with lower levels of anxiety and depression, and with a lower likelihood of clinically significant levels of anxiety and depression in this population. Youth not living with family and the working poor may be important populations for future investigation. Interventions targeting survivors of childhood violence and social support-based interventions should be tested to address the burden of anxiety and depression in this setting.

Results from a cluster-randomized trial to evaluate a microfinance and peer health leadership intervention to prevent HIV and intimate partner violence among social networks of Tanzanian men.

Despite calls to engage men in HIV and intimate partner violence (IPV) prevention efforts, effective approaches to reach and engage men in low-resource, high-HIV prevalence settings are limited. We identified and engaged social networks of mostly young men in a study designed to evaluate the efficacy of a combined microfinance and peer health leadership intervention to prevent HIV and IPV. We conducted a cluster-randomized trial among 60 social networks locally referred to as "camps" within Dar es Salaam, Tanzania. Camps were randomly assigned (1:1) to a microfinance and peer health leadership intervention or a control condition that received a brief delayed intervention after the study's conclusion. Allocation was not masked to participants or researchers. Behavioral assessments were conducted at baseline and 30-months post-intervention launch, with biological samples drawn at 30-months to test for sexually-transmitted infections (STIs). Primary outcomes included prevalence of STIs and past-year IPV perpetration. Secondary outcomes included STI sexual risk behaviors and past-year HIV testing. Proximal intervention targets included inequitable gender norm attitudes and hope. A modified Poisson regression approach was used to estimate intention-to-treat intervention effects on outcomes assessed at the 30-month follow-up. We enrolled 1,258 men within 60 camps. Of these men, 1,029 (81.8%) completed the 30-month follow-up. There were no differences by condition in STI prevalence, IPV perpetration, or sexual risk behaviors at the 30-month follow-up. Intervention participants reported greater levels of past-year HIV testing, controlling for baseline testing (aRR 1.13 95% CI 1.005-1.28). They also reported significantly lower levels of inequitable gender norm attitudes (adjusted effect -0.11, 95% CI -0.21-0.003). We successfully engaged and retained social networks of men in this multilevel intervention study. While we did not see an effect on the primary outcomes, our intervention successfully improved HIV testing and reduced inequitable gender norm attitudes.

Patterns of adverse childhood experiences and subsequent risk of interpersonal violence perpetration among men in Dar es Salaam, Tanzania.

BACKGROUND: Adverse childhood experiences (ACEs), including abuse and neglect, are consistently found to be predictors of perpetration of intimate partner violence (IPV) and peer violence (PV) in adulthood. Children are often exposed to patterns of ongoing and/or multiple-type polyvictimization throughout the life course. OBJECTIVES: To identify and characterize patterns of ACEs among men in Dar es Salaam, Tanzania and to examine the relationship between these patterns and perpetration of intimate partner violence (IPV) and peer violence (PV) in adulthood. METHODS: We used latent class analysis to identify respondents with similar patterns of ACEs. The analysis was conducted with a sample of 987 men. RESULTS: We uncovered five distinct classes of men with specific patterns of ACEs. One consisted of nonvictims and four included various forms of polyvictimization. Men in the polyvictimization classes that included non-violent family dysfunction had significantly higher odds of perpetrating psychological IPV compared to the other three classes (AORs 2.33 and 3.04 compared to nonvictims). Men in the polyvictimization classes that included any sexual violence and/or non-violent family dysfunction had significantly higher odds of perpetrating PV compared to the other two classes (AORs 3.54, 6.10, and 7.42 compared to nonvictims). CONCLUSIONS: These findings suggest that distinct patterns of exposure to ACEs among this population are differentially related to perpetration of IPV and PV in adulthood. These findings highlight the importance of child development interventions in low-and middle-income countries, both for the primary prevention of child adversity and for mitigation of the cognitive and emotional effects of ACEs.

Engaging Young Men as Community Health Leaders in an STI and Intimate Partner Violence Prevention Trial in Dar es Salaam, Tanzania.

BACKGROUND: This article presents lessons learned from a microfinance and health intervention for young men designed to prevent sexually transmitted infections (STI) and intimate partner violence (IPV) in Dar es Salaam, Tanzania. We describe the different strategies we used to identify and train young men to become change agents within their social networks. DESCRIPTION: A cluster-randomized trial with 60 camps was undertaken in the Kinondoni District of Dar es Salaam. A total of 170 members from 30 intervention camps were trained in March 2014 as popular opinion leaders (POLs), whom we call Camp Health Leaders (CHLs). We describe the process of nominating, training, and retaining CHLs. We also describe our monitoring process, which included the collection of weekly diaries assessing topics discussed, number of peers engaged in conversations, reactions of peers, and challenges faced. LESSONS LEARNED: POLs within naturally existing social networks can be engaged in STI and IPV prevention initiatives. Continuous efforts in retention, such as holding community advisory board (CAB) meetings, developing prevention slogans and t-shirts, and offering small grants to POL teams for intervention activities, were important to keeping POLs engaged in the intervention. Further, booster-training sessions were critical to maintain the message of the project and ensure that the challenges POLs face with implementing the programs were addressed in a timely manner. CONCLUSION: Recruiting POLs in a Tanzanian urban setting and engaging them in STI and IPV reduction through social networks is possible. Training POLs in health information and interpersonal communication is important. Utilizing booster sessions and a variety of retention strategies for POLs in programs that aim to reduce IPV and STI infections among young men is essential to maintain the health leaders' engagement in the intervention as well as intervention fidelity.