Internalizing problems, externalizing problems, and prosocial behavior - three dimensions of the strengths and difficulties questionnaire (SDQ): A study among South African adolescents.

This study aimed to examine the factor structure of the Strengths and Difficulties Questionnaire Self-Report version (SDQ-S), its psychometric properties and measurement invariance by gender and language spoken at home, among secondary school students in Western Cape, South Africa. A sample of 3,542 adolescents in Grade 8 (Mean age = 13.7 years) completed the SDQ-S in a three-language questionnaire (Afrikaans, English and isiXhosa). The data were collected from 42 secondary schools in Cape Town, South Africa. Confirmatory factor analyses with the WLSMV estimator with adjustment for cluster effects (schools) were applied. The SDQ-S was originally developed to cover five domains: four "difficulty" domains (hyperactivity/inattention, emotional, conduct, and peer) and one "strengths" domain (prosocial behavior). When the five factors were tested on the data for the current study, poor fit was obtained. After excluding four items, a three-factor solution with no cross-loadings and no correlated error terms obtained acceptable fit. The results are consistent with previous studies. Strong measurement invariance across genders and language spoken at home was confirmed. In studies of community samples, the use of the SDQ-S scale as an instrument with a three-factor dimension (internalizing, externalizing and prosocial) may be more appropriate than using the original five-factor model.

Effects of a School-Based Intervention on Frequency and Quality of Adolescent-Parent/Caregiver Sexuality Communication: Results from a Randomized-Controlled Trial in Uganda.

In a cluster-randomized trial conducted in 22 government secondary schools in Uganda, effects of a school-based intervention aimed at improving aspects of parent/caregiver-adolescent communication on sexuality were examined. The intervention comprised classroom-based education sessions, take home assignments for students to discuss with parents/caregivers and parenting workshops. Baseline and post intervention questionnaires were completed by students and by parents/caregivers. Effect estimates were significant for both students and parents/caregivers on sexuality communication frequency and quality, and for positive and negative attitudes towards sex-related communication, all in the desired direction with effect sizes ranging from 0.17 to 0.38. Effects on four sum scores related to general parenting proved significant only for parents'/caregivers' legitimacy with regard to rule setting (parents'/caregivers' reports only). These results suggest that in Uganda, using schools as gateways, parent/caregiver-adolescent communication can be improved through modification of existing school curricula, training teachers in learner-centred approaches and through mobilization and training of parents/caregivers.

Effect of the PREPARE intervention on sexual initiation and condom use among adolescents aged 12-14: a cluster randomised controlled trial in Dar es Salaam, Tanzania.

BACKGROUND: Unsafe sexual practices continue to put adolescents at risk for a number of negative health outcomes in Tanzania. While there are some effective theory-based intervention packages with positive impact on important mediators of sexual behaviours, a context specific and tested intervention is urgently needed in Tanzania. PURPOSE: To develop and evaluate an intervention that will have a significant effect in reducing sexual initiation and promoting condom use among adolescents aged 12-14 in Dar es Salaam, Tanzania. DESIGN: A school-based Cluster Randomised Controlled Trial was conducted during 2011-2014 in Kinondoni Municipality. METHODS: A total of 38 public primary schools were randomly selected, of which half were assigned to the intervention and half to the control group based on their size and geographic location. Participants were interviewed using a self-administered questionnaire at baseline before the PREPARE intervention and then, 6 and 12 months following intervention. The primary outcomes were self-reported sex initiation and condom use during the past 6 months. Data analysis was done using Generalized Estimating Equation (GEE) modelling controlling for repeated measures and clustering of students within schools. RESULTS: A total of 5091 students were recruited at baseline, and interviewed again at 6 (n = 4783) and 12 months (n = 4370). Mean age of participants at baseline was 12.4 years. Baseline sociodemographic, psychometric and behavioural characteristics did not significantly differ between the two study arms. The GEE analysis indicated that the intervention had a significant effect on sexual initiation in both sexes after controlling for clustering and correlated repeated measures. A significantly higher level of action planning to use condoms was reported among female adolescent in the intervention arm than those in the control arm (p = 0.042). An effect on condom use behaviour was observed among male adolescent (p = 0.004), but not among female (p = 0.463). CONCLUSIONS: The PREPARE intervention had an effect in delaying self-reported sexual initiation among adolescents aged 12-14 in Dar es Salaam Tanzania. The intervention positively influenced action planning to use condoms for both sexes and increased actual condom use among male adolescents only. Future interventions addressing adolescent sexual and reproductive health should focus on impacting mediators of behaviour change. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12613000900718 , registered on 13 August, 2013.

Effects of PREPARE, a Multi-component, School-Based HIV and Intimate Partner Violence (IPV) Prevention Programme on Adolescent Sexual Risk Behaviour and IPV: Cluster Randomised Controlled Trial.

Young South Africans, especially women, are at high risk of HIV. We evaluated the effects of PREPARE, a multi-component, school-based HIV prevention intervention to delay sexual debut, increase condom use and decrease intimate partner violence (IPV) among young adolescents. We conducted a cluster RCT among Grade eights in 42 high schools. The intervention comprised education sessions, a school health service and a school sexual violence prevention programme. Participants completed questionnaires at baseline, 6 and 12 months. Regression was undertaken to provide ORs or coefficients adjusted for clustering. Of 6244 sampled adolescents, 55.3 % participated. At 12 months there were no differences between intervention and control arms in sexual risk behaviours. Participants in the intervention arm were less likely to report IPV victimisation (35.1 vs. 40.9 %; OR 0.77, 95 % CI 0.61-0.99; t(40) = 2.14) suggesting the intervention shaped intimate partnerships into safer ones, potentially lowering the risk for HIV.

Social Cognition Variables and Victimization as Predictors of Sexual Debut Among Adolescents in South Africa and Tanzania: A Multi-group SEM Analysis.

Early sexual debut is common in South Africa and Tanzania, with potentially negative reproductive health outcomes. The role of violence as a predictor of sexual debut was studied, in a context of predictors borrowed from social cognition models. Data were taken from cluster-randomized trials of school-based HIV prevention interventions in three sites in South Africa and Tanzania. Analyses consisted of descriptive statistics and multi-group structural equation modelling. The basic model functioned fairly well for Cape Town, but less well for Mankweng and Dar es Salaam (low R(2) values). Attitudes were the strongest predictor of intention. Adding socio-demographic variables to the model did not reduce the associations much and neither did subsequent inclusion of violence. Sexual debut was strongly associated with victimization; adding violence also substantially increased R(2) for sexual debut. Besides social cognition factors, intimate partner violence should be addressed in future research on reproductive health interventions for adolescents.

Adolescents' Communication with Parents, Other Adult Family Members and Teachers on Sexuality: Effects of School-Based Interventions in South Africa and Tanzania.

Cluster-randomized controlled trials were carried out to examine effects on sexual practices of school-based interventions among adolescents in three sites in sub-Saharan Africa. In this publication, effects on communication about sexuality with significant adults (including parents) and such communication as a mediator of other outcomes were examined. Belonging to the intervention group was significantly associated with fewer reported sexual debuts in Dar es Salaam only (OR 0.648). Effects on communication with adults about sexuality issues were stronger for Dar es Salaam than for the other sites. In Dar, increase in communication with adults proved to partially mediate associations between intervention and a number of social cognition outcomes. The hypothesized mediational effect of communication on sexual debut was not confirmed. Promoting intergenerational communication on sexuality issues is associated with several positive outcomes and therefore important. Future research should search for mediating factors influencing behavior beyond those examined in the present study.

Promoting sexual and reproductive health among adolescents in southern and eastern Africa (PREPARE): project design and conceptual framework.

BACKGROUND: Young people in sub-Saharan Africa are affected by the HIV pandemic to a greater extent than young people elsewhere and effective HIV-preventive intervention programmes are urgently needed. The present article presents the rationale behind an EU-funded research project (PREPARE) examining effects of community-based (school delivered) interventions conducted in four sites in sub-Saharan Africa. One intervention focuses on changing beliefs and cognitions related to sexual practices (Mankweng, Limpopo, South Africa). Another promotes improved parent-offspring communication on sexuality (Kampala, Uganda). Two further interventions are more comprehensive aiming to promote healthy sexual practices. One of these (Western Cape, South Africa) also aims to reduce intimate partner violence while the other (Dar es Salaam, Tanzania) utilises school-based peer education. METHODS/DESIGN: A modified Intervention Mapping approach is used to develop all programmes. Cluster randomised controlled trials of programmes delivered to school students aged 12-14 will be conducted in each study site. Schools will be randomly allocated (after matching or stratification) to intervention and delayed intervention arms. Baseline surveys at each site are followed by interventions and then by one (Kampala and Limpopo) or two (Western Cape and Dar es Salaam) post-intervention data collections. Questionnaires include questions common for all sites and are partly based on a set of social cognition models previously applied to the study of HIV-preventive behaviours. Data from all sites will be merged in order to compare prevalence and associations across sites on core variables. Power is set to .80 or higher and significance level to .05 or lower in order to detect intervention effects. Intraclass correlations will be estimated from previous surveys carried out at each site. DISCUSSION: We expect PREPARE interventions to have an impact on hypothesized determinants of risky sexual behaviour and in Western Cape and Dar es Salaam to change sexual practices. Results from PREPARE will (i) identify modifiable cognitions and social processes related to risky sexual behaviour and (ii) identify promising intervention approaches among young adolescents in sub-Saharan cultures and contexts. TRIAL REGISTRATIONS: Controlled Trials ISRCTN56270821 (Cape Town); Controlled Trials ISRCTN10386599 (Limpopo); Clinical Trials NCT01772628 (Kampala); Australian New Zealand Clinical Trials Registry ACTRN12613000900718 (Dar es Salaam).

Condom use and sexuality communication with adults: a study among high school students in South Africa and Tanzania.

BACKGROUND: Fostering adolescents' communication on sexuality issues with their parents and other significant adults is often assumed to be an important component of intervention programmes aimed at promoting healthy adolescent sexual practices. However, there are few studies describing the relationship between such communication and sexual practices, particularly in sub-Saharan Africa. This study examined the relationships between adolescents' communication with significant adults and their condom use in three sites in this region. METHODS: Data stem from a multi-site randomized controlled trial of a school-based HIV prevention intervention implemented in Cape Town and Mankweng, South Africa and Dar es Salaam, Tanzania. Only data from comparison schools were used. The design is therefore a prospective panel study with three waves of data collections. Data were collected in 2004 from 6,251 participants in 40 schools. Associations between adolescents' communication with adults about sexuality issues and their use of condoms were analysed cross-sectionally using analysis of variance, as well as prospectively using multiple ordinal logistic regression analysis. RESULTS: Cross-sectional analyses showed that consistent condom users had significantly higher mean scores on communication (across topics and communication partners) than both occasional users and never-users, who had the lowest scores. After controlling for condom use at the first data collection occasion in each model as well as for possible confounders, communication scores significantly predicted consistent condom use prospectively in all three ordinal logistic regression models (Model R(2) = .23 to .31). CONCLUSION: The findings are consistent with the assertion that communication on sexuality issues between adolescents and significant adults results in safer sexual practices, as reflected by condom use, among in-school adolescents. The associations between communication variables and condom use might have been stronger if we had measured additional aspects of communication such as whether or not it was initiated by the adolescents themselves, the quality of advice provided by adults, and if it took place in a context of positive adult-adolescent interaction. Studies with experimental designs are needed in order to provide stronger evidence of causality.

Associations between attitudes toward violence and intimate partner violence in South Africa and Tanzania.

Attitude change approaches are common in the prevention of intimate partner violence (IPV) among adolescents. This study examined associations between perpetration or victimization and attitudes toward IPV with data from a longitudinal randomized controlled trial (RCT) of an HIV prevention intervention among school students in three sites in South Africa and Tanzania. Data analyses were confined to students from the control group only, and to those with experience with romantic relationships. Boys and those more involved with violence reported more violence-supportive attitudes. For Cape Town (and to some extent Mankweng), the results of prospective prediction are consistent with the notion of a bidirectional attitudes-behavior interrelationship. For Dar es Salaam attitudes predicted behavior prospectively; however, prediction in the opposite direction was not confirmed. These results indicate that attitude change strategies may be useful complementary to structural approaches also in global South settings, although their effectiveness may vary.

An HIV/AIDS knowledge scale for adolescents: item response theory analyses based on data from a study in South Africa and Tanzania.

A 14-item human immunodeficiency virus/acquired immunodeficiency syndrome knowledge scale was used among school students in 80 schools in 3 sites in Sub-Saharan Africa (Cape Town and Mankweng, South Africa, and Dar es Salaam, Tanzania). For each item, an incorrect or don't know response was coded as 0 and correct response as 1. Exploratory factor analyses based on polychoric correlations showed two separate factors for all sites. Two-parameter item response theory (IRT) analysis (bifactorial multiple indicators multiple causes confirmatory factor analysis models) consistently showed a general first factor and a second 'method' factor. One single global latent variable seemed to sufficiently well capture most of the systematic variation in knowledge. Some items did not discriminate well between levels of the underlying knowledge latent variable and information values were highest for low levels of knowledge. The scale might be improved by adding items, in particular items that are more difficult to answer. Some differential item functioning effects related to site and socioeconomic status were identified. Scores on the latent knowledge variable were particularly low among females in Dar es Salaam and Mankweng, and were negatively associated with socioeconomic status. This study illustrates advantages of using IRT analysis instead of more conventional approaches to examining psychometric properties of knowledge scales.

Predictors of early first sexual intercourse among adolescents in Cape Town, South Africa.

Early coital debut is a risk factor for HIV. In this paper we investigate the predictors of young adolescents' transition to first intercourse using a social cognition theoretical framework. The analyses reported here were based on a longitudinal study of 2,360 students in the schools allocated to the control arm of a cluster-randomized controlled trial to investigate the effect of a school-based HIV prevention programme among Grade 8 students in Cape Town. Structural equation modelling was performed with Mplus version 3.11. Of the 1440 students who were virgins at baseline, 1,144 remained virgins 15 months later and 296 (20.6%) reported having had their first sexual intercourse. Transition to first sexual intercourse was more likely among males than females, among older students and among students with a lower socio-economic status. Transition to first sexual intercourse was significantly associated with intentions to have sexual intercourse, poor self-efficacy to negotiate delayed sex and intimate partner violence. The model predicted 35% of the variance in intentions and 16% of the variance in transition. These findings indicate some of the factors that influence young adolescent's transition to first intercourse and that need to be addressed when designing effective interventions.

Parental education as an indicator of socioeconomic status: improving quality of data by requiring consistency across measurement occasions.

AIMS: Adolescents' reports of parents' education are sometimes used as indicators of socioeconomic status in surveys of health behaviour. The quality of such measurements is questionable. We hypothesized that consistent reporting of parents' education across measurement occasions in prospective panel studies indicates a higher quality of data than single or inconsistent reports. METHODS: A multi-site, prospective panel study (three measurement occasions) was carried out among adolescents in Cape Town and Mankweng (South Africa), and Dar es Salaam (Tanzania). Analyses were based on data from students participating at baseline and with a valid code for school number (n = 15,684). RESULTS: For Cape Town and Dar es Salaam students, the associations between parents' education and an alternative indicator of socioeconomic status (both measured at baseline) increased with increasing consistency of reports about parents' education across measurement occasions. For Cape Town, the associations of father's education with a range of behavioural and social cognition variables were significantly stronger among ;;consistent'' than among other students. The pattern was the same for mother's education, but with fewer significant interaction effects. CONCLUSIONS: Requiring consistency of reports across data-collection occasions may, under the right combination of circumstances, make a difference. Insignificant and "close to zero'' associations may turn out to be at least moderately strong and statistically significant. When applying indicators of socioeconomic status, such as parents' highest level of completed education, it is most advantageous to use data from prospective panel studies, and to check for consistency of answers across measurement occasions.

Dating violence among school students in Tanzania and South Africa: prevalence and socio-demographic variations.

AIMS: Widespread adolescent dating violence (DV) in Sub-Saharan Africa calls for immediate action, particularly since it is linked to the spread of HIV/AIDS. This article presents prevalence and demographic correlates of DV among school students in Cape Town and Mankweng (South Africa) and Dar es Salaam (Tanzania). METHODS: Data were derived from the baseline data collection of a multi-site randomized controlled trial of an HIV prevention intervention among young adolescents. The results were confined to students who reported previously or currently being in a relationship (n = 6,979). Multiple logistic regression analysis with demographic predictors was employed, controlled for cluster effect. RESULTS: Within our sample 10.2%-37.8% had been victims, 3.1%-21.8% had been perpetrators, and 8.6%-42.8% had been both (percentages dependent on site and gender). Before controlling for other factors, religion was a protective factor against violence in Cape Town. After controlling for other factors, a higher age and lower socioeconomic status were associated with belonging to any of the three groups of violence. Being male in all sites was associated with perpetration; being female with victimization (except in Cape Town where the converse finding was obtained). Higher parental education in Cape Town was protective against all types of violence. Ethnicity and living with biological parents were not associated with violence. CONCLUSIONS: DV is prevalent and widespread in the study sites. Violence control policies and interventions should target young adolescents. Since there was not one clearly defined subgroup identified as being at high risk, such programmes should not be limited to high risk groups only.