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.

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.

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.

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.

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.

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.

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.

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.

Factors associated with parent-child communication about HIV/AIDS in the United States and Kenya: a cross-cultural comparison.

This study explored parent-child communication about HIV/AIDS among two populations disproportionately affected by HIV. Similar computer-assisted surveys were completed by parents of pre-teens, including 1,115 African American parents of 9-12-year-old children in southeastern US and 403 parents of 10-12-year-old children in Nyanza Province, Kenya. Multivariate analyses identified factors associated with parental report of ever talking to their child about HIV/AIDS. Twenty-nine percent of US parents and 40% in Kenya had never talked to their pre-teen about HIV/AIDS. In both countries, communication was more likely if parents perceived their child to be ready to learn about sex topics, had gotten information to educate their child about sex, and had greater sexual communication responsiveness (skill, comfort, and confidence communicating about sexuality). Programs are needed that help parents assess children's readiness to learn about sexual issues; access accurate information about adolescent sexual risks; and acquire the responsiveness needed to discuss sexual issues, including HIV/AIDS.

Pre-risk HIV-prevention paradigm shift: the feasibility and acceptability of the parents matter! Program in HIV risk communities.

OBJECTIVES: Many youth begin human immunodeficiency virus (HIV) sexual risk behaviors in preadolescence, yet risk-reduction programs are typically implemented in middle or late adolescence, missing an important window for prevention. Parent-based programming may play an important role in reaching youth early with prevention messages. One such program is the Parents Matter! Program (PMP), a five-session theory- and evidence-based intervention for parents of children aged 9 to 12 years. A randomized controlled trial showed PMP to be efficacious in promoting effective parent-child communication about sexuality and sexual risk reduction. We assessed the feasibility and acceptability of PMP when implemented under typical programmatic circumstances in communities at high risk for HIV infection. METHODS: We selected 15 sites (including health departments, local education agencies, community-based organizations, and faith-based organizations) throughout the U.S. and Puerto Rico to participate in delivering PMP. Sites were provided training, program materials, and ongoing technical assistance. We collected multilevel data to assess the feasibility of program implementation and delivery, program relevance, and satisfaction with PMP activities and materials. RESULTS: PMP was successfully implemented and evaluated in 13 of 15 sites; 76% of parents attended at least four of five sessions. Organization-, facilitator-, and parent-level data indicated the feasibility and acceptability of PMP, and overall high satisfaction with PMP activities and materials. CONCLUSION: The results of this project demonstrate that HIV pre-risk prevention programs for parents can be implemented and embraced by a variety of community organizations in HIV at-risk communities. The time to embrace parents as partners in public health HIV-prevention efforts has come.

Barriers and facilitators to maternal communication with preadolescents about age-relevant sexual topics.

The present study examined factors that promote parent-child discussions about sex topics. A sample of 1,066 dyads of African American mothers and their 9-12-year-old children participated completing computer-administered surveys. After controlling for all other covariates, mother's sexual communication responsiveness (i.e., knowledge, comfort, skills, and confidence) was the most consistent predictor of discussions. Mothers with higher responsiveness had significantly increased odds of discussions about abstinence, puberty, and reproduction, based on both mother and child reports. In addition, child's age, pubertal development, readiness to learn about sex, and being female were positively associated with an increase in the odds of discussions in most models. Findings indicate that encouraging parents to talk with their children early may not be sufficient to promote parent-child sex discussions. Parents also need the knowledge, comfort, skills, and confidence to communicate effectively and keep them from avoiding these often difficult and emotional conversations with their children.

Perceived peer norms and sexual intentions among African American preadolescents.

The purpose of the research was to examine whether perceived peer dating and sexual experience norms are related to attitudes toward dating and sexual behavior and to precoital and sexual intentions among African American preadolescents. Participants included 1,046 African American youth aged 9-12 years (M = 10.57 years). Youth completed a baseline survey as part of a larger intervention study. Perceived peer norms regarding dating and sexual experience were positively related to youth attitudes toward dating and sexual behavior. Youth who perceived their peers as not engaging in sexual activity were less likely to have precoital or sexual intentions. The relationships were not moderated by gender of the preadolescent. Findings from this study suggest that addressing peer norms around dating and sexual activity among preadolescent African American youth may be important for prevention efforts aimed at encouraging abstinence and the delay of sexual activity.

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.

Are parental gender role beliefs a predictor of change in sexual communication in a prevention program?

This study examined if pre-intervention maternal gender role beliefs predict change in sexual communication in a sexual risk behavior prevention program designed to increase parent-pre-adolescent communication about sex. A sample of 281 African American fourth and fifth graders and their mothers participated in the five-session program and completed computerized questionnaires at baseline, postintervention, and 6-month follow-up. Based on mother report, more egalitarian maternal gender role beliefs predicted greater increases in parent-pre-adolescent communication about sex at postintervention. Based on pre-adolescent report, similar findings emerged at the 6-month follow-up, but only for boys. The relationship of maternal gender role beliefs to changes in sexual communication was not accounted for by maternal comfort with sexual communication with their pre-adolescents. The implications of maternal gender role beliefs in a prevention program designed to increase communication about sexual topics are considered.

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.

Stages of sexual readiness and six-month stage progression among African American pre-teens.

We examined the range of sexual intentions and behaviors preceding sexual initiation among 211 African-American pre-teens assigned to the control arm of a longitudinal community-based intervention trial. Stage of sexual readiness was assessed using the stage of change construct from the Transtheoretical Model, and patterns of stage movement during a 6-month period were examined. Overall, 90% of participants were in precontemplation at baseline, with the proportion of participants in this stage declining with each year of age. There was substantial stability in stage of sexual readiness during the 6-month period (87% stable). While definitive conclusions regarding exact patterns of movement are not yet possible, stage movement does not appear to be linear for all pre-teens, and there is evidence of both stage progression and regression. We present emerging patterns of stage movement, which suggest potential variation by age, gender, and baseline stage, and discuss potential implications.

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.

Sexual intentions of black preadolescents: associations with risk and adaptive behaviors.

CONTEXT: Adolescent sexual activity in the United states is prevalent and occurring increasingly early, particularly among minority groups. Other risk behaviors (e.g., alcohol consumption) often co-occur with sexual behavior. By examining the association of risk and adaptive behaviors with precursors of sexual behavior--specifically, sexual intentions--it may be possible to identify preadolescents who are at increased risk for early sexual initiation. METHODS: Data from 1,090 black fourth and fifth graders and their parents from the Parents Matter! Program were used in logistic regression analyses to assess covariation between preadolescents' risk and adaptive behaviors, and their intentions to initiate sexual intercourse in the next year. RESULTS: Risk and adaptive behaviors, as reported by both preadolescents and parents, were associated with sexual intentions; the findings were not qualified by youth's gender. Alcohol consumption and having been in trouble with the police were the primary youth-reported risk behaviors associated with the odds of intending to have intercourse (odds ratios, 2.3 and 1.8); the preadolescent's being in trouble at home was the primary parent-reported risk behavior (2.1). In both sets of reports, performing well on schoolwork was associated with reduced odds of intending to engage in sex (0.5 - 0.6). CONCLUSIONS: Risk and adaptive behaviors are markers of sexual intentions among black preadolescents. Prevention programs can use these behaviors to identify black youth who may be at high risk for early sexual initiation.

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.