Personal beliefs and social norms regarding the sexual exploitation of girls in age-disparate transactional sexual relationships in Brazil: a mixed-methods study.

BACKGROUND: In the global debate around transactional sex little attention has concentrated on Brazil, despite ranking fourth globally in absolute number of girls married or co-habiting by the age of 15 years, and evidence showing that these unions often begin as age-disparate transactional sex (ADTS). This article contributes to filling this gap by exploring the personal beliefs and social norms related to ADTS in urban (favela) communities of Rio de Janeiro, Brazil between adult men (> 18 years) and girls and adolescents (G/A) (< 18 years) with a minimum 5-year age disparity. The primary objective of this study was to identify the social norms that promote and prevent ADTS, and the dynamics between individual beliefs and social norms, to provide contextualized recommendations to prevent ADTS in this setting. METHODS: An exploratory, sequential, mixed-methods design was used, starting with a qualitative phase that included semi-structured, in-depth interviews and focus groups, and a subsequent quantitative phase comprising of a community survey. The items for the quantitative questionnaires were developed based on the qualitative results. RESULTS: Mixed methods results indicate that in these communities ADTS is normalised and not considered exploitative. We identified three themes related to the reasons ADTS occurs: girls' responsibility, male desires and benefits of ADTS. Men's role in ADTS was largely minimised because of a general acceptance of a notion of masculinity characterised by hypersexuality and lack of impulse control. Individual beliefs, however, did not tend to align with these social norms. CONCLUSIONS: In this study, personal beliefs and social norms often did not align, suggesting that initiatives working to change personal or attitudes regarding ADTS may not lead to meaningful change in ADTS behaviours, and social norms interventions may be more effective. Our findings reinforce the need to develop programs tailored to local understandings of ADTS, targeting not only girls but also a wide range of actors. Interventions could also consider the structural factors acting in local and global contexts that promote or prevent ADTS.

This article explores the personal beliefs and social norms related to the exchange of sexual favours or relationships for material favours, gifts and/or support in some form, between adult men (> 18 years) and girls and adolescents (< 18 years) with a minimum 5-year age difference. We used interviews, focus groups and questionnaires to understand the factors that promote and prevent these sexual relationships between men and girls. Motivators for these relationships were often related to girls' responsibilities, male desires and the benefits of these relationships. Men's responsibility for their participation in these relationships with girls were often minimised due to a general acceptance of men as overly sexual and lacking impulse control. In this study, personal beliefs and social norms were often not aligned, suggesting that interventions focused on changing personal beliefs or attitudes about these sexual relationships may not be enough to change social norms. The findings highlight the need to develop solutions that consider a wider range of actors, instead of interventions focused only on girls. The study findings also support the need to further investigate how communities and shared expectations can influence sexual relationships in exchange for goods between adult men and girls and adolescents.

Measuring social norms and attitudes about age-disparate transactional sex: Psychometric testing of the NAATSS.

Background: Transactional sex between girls under 18 years-old and adult men at least ten years older, known as age-disparate transactional sex (ADTS), is an established risk factor for HIV, STI and early pregnancy among girls and women. Social norms or beliefs about what others expect from you and what others do can sustain behaviours such as ADTS even when individuals may be personally against them. In order to evaluate interventions to change social norms, validated instruments for measuring change in personal beliefs and social norms regarding ADTS are needed. Methods: Items for the Norms and Attitudes on Age-Disparate Transactional Sex Scale (NAATSS) were generated based on qualitative interviews and expert panel review. The reliability and validity of the NAATSS was tested in a representative sample (N = 431) from Brazilian favelas. Factor analysis assessed construct validity, Cronbach's alpha assessed reliability, and t-tests and analysis of variances tested hypothesized differences between gender, age, and previous experience with ADTS in both the social norms and personal beliefs domains. Findings: Factor analysis revealed three factors in each domain. The factors were labelled "Attributions to Girls' Behaviour" which has 5 items, "Men's Motivations" with 5 items, and "Girls' Readiness to have Sex" with 3 items. The subscales evidenced acceptable reliability with Cronbach's alphas ranging from 0.72 to 0.83 for the social norms subscales and 0.59 to 0.82 for the personal beliefs subscales. Interpretation: The items were developed based on qualitative research and expert rankings and the resulting Norms and Attitudes on ADTS Scale exhibits strong psychometric properties. Each of the three subscales within the two domains illustrate good factor structure, acceptable internal consistency reliability, and are supported by the significance of the hypothesized group differences. Funding: This work was supported by the OAK Foundation [grant number OCAY-16-188].

Community perceptions of transactional sex with children and adolescent girls, a qualitative study in favelas of Rio de Janeiro.

The sexual exploitation of children and adolescents is a frequently underestimated health problem which includes transactional sex (TS), or the practice of sexual activity based on an expected return of benefits, favours and/or support in some form. This qualitative study focuses on age-disparate transactional sex (ATS) in urban favela communities of Rio de Janeiro between adult men (over 18) and girls and adolescents (G/A) (under 18), involving a minimum 5-year age disparity. We have employed social norms theory as a framework to identify the prevailing social norms contributing to or protecting children and adolescents from these relationships. Data collection utilised semi-structured interviews (n = 30) and ten focus groups with a total of 130 men/boys and women/girls selected through purposive sampling and varying in age from 15 to 65. Overall the findings identify factors, especially the essentialisation of gender, which promote the acceptability of ATS. When ATS surpassed the acceptability threshold, social norms discouraged direct interference. Concluding remarks point to possible strategies for reducing the occurrence of ATS. These must include girls, boys, women and men with community involvement in the deconstruction of social norms involving gender, age and economic consumption.

Assessing the Influence of Water Management and Rainfall Seasonality on Water Quality and Intestinal Parasitism in Rural Northeastern Brazil.

INTRODUCTION: The drought in the Brazilian semiarid region has affected the quality of water. This study assessed the relationships between enteric parasitoses, water management, and water quality, correlating them with pluviometric seasonality. METHODS: Cross-sectional surveys were carried out in four rural communities at the beginning of the dry season (n=151), at the end of the dry season (n=184), and in the rainy season (n=199), in order to collect sociodemographic data, human fecal samples, and samples of the water used for human consumption for physicochemical and microbiological analyses. In 2015, water filters were provided to 30 households under study. RESULTS: There was an increasing trend in detection rates of commensal protozoa and the Entamoeba histolytica/Entamoeba dispar complex at the beginning of the rainy season, with detection rates of 6% in 2014 and 21.6% in 2016. Giardia intestinalis and Ascaris lumbricoides presented distinct temporal distributions, which peaked in 2015: 20.1% and 30%, respectively. The proportion of inhabitants drinking inadequate water was 55% at the beginning of the dry season and 28.8% at the end of the dry season, reaching 70.9% at the beginning of the rainy season. The presence of filters reduced this proportion among those who received the hollow ceramic candle filter. CONCLUSIONS: Data suggest that the strategies to increase water supply in the Brazilian semiarid region can be ameliorated in order to improve the quality of drinking water.

The Brazilian Family Health Strategy and the management of intestinal parasitic infections.

AimThis study analyzed the management of intestinal parasitic infections in the Family Health Strategy covering Brazilian urban slums. BACKGROUND: The Family Health Strategy is the preferred strategy for providing public, community-based primary health care in the Brazilian Unified Health System (SUS). Through this strategy, Family Health teams are responsible for the health of residents of a defined territory, including health promotion, health education and control of neglected tropical diseases such as intestinal parasitic infections. METHODS: Knowledge, attitudes and practices surveys were applied with Family Health team members (n=58) and patients (n=571) of an agglomeration of Brazilian urban slums in Rio de Janeiro.FindingsThe management of intestinal parasitic infections and health promotion were limited. Health education was not considered an essential aspect of team members' work and did not include environmental or social determinants of health. Community health workers and urban slum residents presented similar knowledge, attitudes and practices regarding intestinal parasitic infections. CONCLUSIONS: Multiple, competing demands promote prioritization of the aspects of care where curative, biomedical activities predominate over prevention and an integral approach to health. However, the complex processes involving the cycle of poverty and disease go beyond the biomedical, limiting the potential for health in urban slums. Implications include a need to better prepare health professionals for primary health care services through reflection on local concerns and the social determinants of health, highlighting the importance of territorialized care and permanent education.

Evaluation matrix for health promotion programs in socially vulnerable territories. / Matriz de avaliação de programas de promoção da saúde em territórios de vulnerabilidade social.

Health promotion has a set of strategies for advancing health and reducing inequalities. However, evaluating the effectiveness of health promotion programs has been a challenge. This paper shows the development and application of the Evaluation Matrix, constructed with qualitative-quantitative and multidimensional indicators supported by public policies targeting socially vulnerable territories. This is a cross-sectional study with the implementation of a health promotion program in order to develop an Evaluation Matrix to be applied in two distinct socio-environmentally vulnerable areas. The Evaluation Matrix proved to be easily applicable and enabled the detection of strengths and weaknesses of health promotion programs applied in different territories. The participation of managers, teams, population and multiple sectors of society was decisive for the success of the program. Furthermore, community health workers stood out as essential stakeholders due to their linkages with the population. Contributions include a tool and methodology for evaluating health promotion programs to be applied in different territories and modified according to the territory.

A promoção da saúde possui um conjunto de estratégias para trazer saúde e reduzir desigualdades. No entanto, tem sido um desafio avaliar a efetividade de programas de promoção de saúde. Este artigo apresenta o desenvolvimento e a aplicação de Matriz de Avaliação, construída por meio de indicadores quali-quantitativos e multidimensionais, que estão apoiados nas políticas públicas voltadas para territórios com vulnerabilidade social. Estudo transversal, com realização de programa de promoção da saúde e a finalidade de desenvolver uma Matriz de Avaliação, com possibilidade de aplicação em duas áreas de distinta vulnerabilidade socioambiental. A Matriz de Avaliação demonstrou ser de fácil aplicação e permitiu detectar os pontos fortes e fracos dos programas de promoção da saúde aplicados em diferentes territórios. Verificou-se que a adesão dos gestores, das equipes, da população e dos diversos setores da sociedade foram decisivos para o sucesso do programa. Adicionalmente, os agentes de saúde se destacaram como atores essenciais devido ao seu vínculo com a população. As contribuições incluem instrumento e metodologia para avaliar os programas de promoção da saúde, que podem ser aplicados em realidades distintas e modificados de acordo com o território.

Matriz de avaliação de programas de promoção da saúde em territórios de vulnerabilidade social / Evaluation matrix for health promotion programs in socially vulnerable territories

Resumo A promoção da saúde possui um conjunto de estratégias para trazer saúde e reduzir desigualdades. No entanto, tem sido um desafio avaliar a efetividade de programas de promoção de saúde. Este artigo apresenta o desenvolvimento e a aplicação de Matriz de Avaliação, construída por meio de indicadores quali-quantitativos e multidimensionais, que estão apoiados nas políticas públicas voltadas para territórios com vulnerabilidade social. Estudo transversal, com realização de programa de promoção da saúde e a finalidade de desenvolver uma Matriz de Avaliação, com possibilidade de aplicação em duas áreas de distinta vulnerabilidade socioambiental. A Matriz de Avaliação demonstrou ser de fácil aplicação e permitiu detectar os pontos fortes e fracos dos programas de promoção da saúde aplicados em diferentes territórios. Verificou-se que a adesão dos gestores, das equipes, da população e dos diversos setores da sociedade foram decisivos para o sucesso do programa. Adicionalmente, os agentes de saúde se destacaram como atores essenciais devido ao seu vínculo com a população. As contribuições incluem instrumento e metodologia para avaliar os programas de promoção da saúde, que podem ser aplicados em realidades distintas e modificados de acordo com o território.

Abstract Health promotion has a set of strategies for advancing health and reducing inequalities. However, evaluating the effectiveness of health promotion programs has been a challenge. This paper shows the development and application of the Evaluation Matrix, constructed with qualitative-quantitative and multidimensional indicators supported by public policies targeting socially vulnerable territories. This is a cross-sectional study with the implementation of a health promotion program in order to develop an Evaluation Matrix to be applied in two distinct socio-environmentally vulnerable areas. The Evaluation Matrix proved to be easily applicable and enabled the detection of strengths and weaknesses of health promotion programs applied in different territories. The participation of managers, teams, population and multiple sectors of society was decisive for the success of the program. Furthermore, community health workers stood out as essential stakeholders due to their linkages with the population. Contributions include a tool and methodology for evaluating health promotion programs to be applied in different territories and modified according to the territory.

Socioenvironmental conditions and intestinal parasitic infections in Brazilian urban slums: a cross-sectional study.

METHODS: A cross-sectional study covering an agglomeration of urban slums was conducted between 2015 and 2016 using participants observation, a socioeconomic survey, and the spontaneous sedimentation method with three slides per sample to analyze fresh stool specimens ( n =595) searching for intestinal parasites. RESULTS: Endolimax nana ( n =95, 16.0%) and Entamoeba coli ( n =65, 10.9%) were the most frequently identified agents, followed by Giardia intestinalis ( n =24, 4.0%) and Ascaris lumbricoides ( n =11, 1.8%). Coinfections caused by E. nana and E. histolytica/dispar and by Entamoeba coli/A. lumbricoides were significant. The use of piped water as drinking water, the presence of A. lumbricoides , and contamination with coliform bacteria and Escherichia coli were more common in major area (MA) 1. Children (0-19 years) had a greater chance of living in poverty (OR 3.36; 95% CI: 2.50- 4.52; p <0.001) which was pervasive. The predominance of protozoa parasites suggests that a one-size-fits-all approach focusing on preventive chemotherapy for soil-transmitted helminths is not appropriate for all communities in developing countries. It is important that both residents and health professionals consider the socioenvironmental conditions of urban slums when assessing intestinal parasitic infections for disease control and health promotion initiatives.

Intestinal parasitic infections in a lowincome urban community: prevalence and knowledge, attitudes and practices of inhabitants of Parque Oswaldo Cruz, Rio de Janeiro, Brazil

Intestinal parasitic infections (IPIs) are present in Brazil from upper-to low-income communities, with varying infection estimates; however, they affect those living in urban and rural poverty more severely, without adequate access to consistently safe drinking water, sanitation, waste disposal, medical access and education. Estimates show the need for establishing infection prevalence and socioeconomic features, along with population knowledge, attitudes and practices (KAP) regarding IPIs. The purpose of this study is to assess the prevalence and KAP regarding IPIs of residents of an urban low-income community (Parque Oswaldo Cruz/Amorim) of the Complexo de Manguinhos, Rio de Janeiro, Brazil. The Lutz sedimentation technique was used for parasite detection (n=1,121) and, to obtain data on community KAP regarding IPIs, a KAP survey, adapted from Mello et al. was applied (n=505). An overall prevalence of 20.7% was detected with protozoa composing 92.9% (n=235) of the positive samples. Questionnaires revealed generally correct knowledge but with several inconsistencies, unawareness of the association between the etiological agent and the disease, and uncertainty regarding own knowledge of the subject. The population understood the importance of prevention and was willing to utilize prevention strategies despite being unsure of how to prevent infection. Further studies are required to investigate best practices for improving health equity, community health empowerment and IPIs prevention in Rio de Janeiro, Brazil.