I am interested in Understanding the impact of gender inequality and food and livelihood insecurity on sexual reproductive health, HIV outcomes and psychosocial functioning among young persons in western Kenya.
Question #1
Among structural factors, I am interested in gender and income. Both gender inequalities and income have been identified as the fundamental drivers of HIV.
Gender can be described as a social structure that men and women are highly invested in and reproduce in their everyday interactions1. "Gender prescribes certain behaviors for men and women and also structures access to resources; typically men benefit compared to women, but not all men benefit to the same degree and some women may also gain from these relationships" 1,2. Gender norms are related to early marriage, sexual coercion, intimate partner violence, homophobic bullying, girls' agency, school safety and even sex trafficking. The HIV epidemic in my country Kenya demonstrates this gender inequality. Young women (15 to 24 years) are 2.5 to 4.5 times more likely to be infected with HIV than young men3-5
Income (livelihood security): I acknowledge the Braveman paper. It highlights that while the US looks at income, the UK looks at the occupation and all with a different meaning. In my context, I want to look at income from a broader perspective of livelihood security. Livelihood security embodies three attributes: 1) the possession of human capabilities (e.g. education, skills, health, and psychological orientation); 2) access to tangible and intangible assets (social, natural, and economic capital); and 3) the existence of economic activities. Young people in Africa are disproportionately unemployed and not receiving any financial income from work 6. This is due factors such as climate change, urbanization and migration, and a changing economy that is moving towards less labor-intensive processes 7-12.
For women, their lack of economic resources undermines their ability to negotiate condom use with male partners13,14 and keeps them in abusive relationships 15 or involved in transactional sex to secure social and economic 13,16,17. On the flip side, as men’s livelihood strategies collapse, particularly their wage labor, men struggle to achieve social demonstrations of their masculinity 13,17. Livelihood insecure men may try to assert further control over women, through violence 18, or through seeking additional sexual partners as a way of ‘‘securing’’ their masculinity 13. Men who are unemployed or poorly paid, often lack hope for the future and engage in behaviors that yield short-term rewards such as drinking and casual sex, both of which put them at risk of poor SRH outcomes including HIV and STDs19,20.
Intermediary factors
Food insecurity. Studies have found food insecurity to be associated with higher sexual risk-taking behaviors,21-23 such as inconsistent condom use, transactional sex, intergenerational sex, multiple concurrent sexual partners, and forced sex; which are strong determinants of HIV acquisition.23-29 21-23,30_ENREF_4 Food insecurity also impedes health care-seeking behaviors for reproductive health; A study in Nepal showed that AGYW living in severe food insecure households had lower odds of using a modern method of family planning and poor health care-seeking behaviors for reproductive health.22 Together, these studies suggest that food insecurity may potentiate the acquisition and transmission of HIV and STIs (including HSV-2)
Question #2
Social economic characteristics of neighbourhoods: My work is based in western Kenya, which has the highest HIV prevalence and also ranks top in numerous other disease morbidity and mortality indicators. To understand the dynamics of this – one has to understand 3 things: 1) The colonial history; this region was administered from Kampala Uganda and as such the systems are dissimilar to the rest of Kenya and at independence, there were no established systems to ensure trickle down resources to the area; 2) the political history: this area with the exception of years 2008-2012, has always been in the opposition party to the ruling party. The ruling party forms the government and by default controls resource distribution. By always voting against the ruling party, this area has not been prioritized for development and as such is characterized by extremely high levels of poverty, food insecurity, poor infrastructure and few health facilities. 3) A non-responsive Health sector policy: as part of the colonial legacy- this area had only one main hospital, which could train medical doctors. The health sector document required that doctors be retained within the administrative provinces in which they were trained. With only one training facility- over the years, western Kenya has had one of the lowest numbers of qualified medical doctors. Within this relatively adverse “neighbourhood” one can begin to understand why in this region 65% of the population lives below the poverty line,31,32 the prevalence of Critical Food Poverty (pCFP) is 28%, which exceeds the national average33 and sadly it also hosts the largest proportion of adolescents affected by HIV in Kenya at 19%.34
Life course: Adolescents, especially those residing in households affected by HIV are at an increased risk of growing up in poverty owing to the loss of at least one family provider and usually the deteriorating health of the second member.35 Such circumstances not only deprive the family of resources as the result of lost earnings but also often lead to families devoting scarce household economic resources to the care of ill family members.36 Over the time, these adolescents, exposed at an earlier age to poverty and parental ill health are at higher risk of STIs. Several studies have found higher rates of emotional and behavioral problems, including poor school functioning, depression and anxiety, and higher sexual risk among uninfected adolescents living with HIV-infected parents as compared with adolescents with uninfected parents 37-43.