State your health outcome of interest. (It could be the one you used for week #2 or another one.) Pick two key behaviors that are important factors leading to your health outcome. Explain the importance of these behaviors either for etiology, prevention, or intervention. (If none of the behaviors in the readings are important for your health outcome, suggest another behavior that is.)
Brief background (for context)
The overall objective of my dissertation work is to determine the perceived impact and mediating pathways of a household level multisectoral agricultural and finance intervention on adolescent sexual, behavioral and psychological outcomes. My central hypothesis is that improvements in household food security and wealth will contribute to increased uptake of HIV prevention and reproductive health (RH) services, reduced sexual risk-taking, lower prevalence of STIs, pregnancy and HIV and improve psychosocial functioning among adolescents and young women (AGYW). I plan to enroll approximately 150 HIV-affected AGYW who reside in compounds of participants enrolled into the multisectoral agricultural and finance intervention study (Shamba Maisha) (1:1 ratio, intervention and control arms). The participants (i.e. their caregivers are HIV-infected, the AGYW are not)
My health outcome of interest is
- Incidence of HSV-2, HIV and unwanted pregnancy among HIV-affected AGYW aged 15-24 in southwestern Kenya
- AGYW mental health status
Two key behaviors that are important factors leading to these are
- Sexual risk-taking behavior e.g. unprotected sex, multiple sexual partnerships, transactional sex and early sexual debut
- Parental caregiving practice- measured by Intrahousehold functioning (i am particularly passionate about this- as an African from Kenya- we don't don't talk about this enough)
Explain the importance of these behaviors either for etiology, prevention, or intervention
1. Sexual risk taking behavior: Inconsistent condom use with a nonprimary partner, sex exchange (transactional sex), intergenerational sexual relationships, early sexual debut, and lack of control in sexual relationships e.g. are all associated with increased risk of getting HSV-2, HIV and unwanted pregnancy.
2. Parental caregiving practice and intrahousehold functioning: When economic pressure (due to lack of financial and material resources) is high, parents are at an increased risk for emotional distress, which in turn, leads to disrupted family relationships, marital conflict and negative caregiving practices.1 These negative caregiving practices include insufficient or inconsistent surveillance (monitoring), lack of control over the child’s behavior (boundary setting), lack of warmth and support, and displays of aggression or hostility by parents. A study in Kenya found that orphans (includes HIV-affected) reported less supervision by adults at home, and perceived that they were less loved at home than non-orphans.2 These harsh parenting practices contribute to poor youth emotional well-being and elevated health risk behaviors1 including high-risk sexual behavior.
Describe how you would study the role of one of the behaviors described in question #1 and your health outcome of interest. Incorporate a social factor (e.g. race/ethnicity, social exclusion, stress) in the study approach.
I plan to nest my study within an existing cluster randomized trial of Shamba Maisha. I will enroll an equal number of adolescents and their caregivers from both intervention and control arms across all clusters. In our previous formative work, we demonstrated that an increase in household food security was associated with less intra-couple fighting and arguments. I am therefore interested in intrahousehold functioning believing that if the intervention works – it will result in less parenting stress and improved parental caregiving practices and intrahousehold functioning and be associated with better sexual reproductive and mental health outcomes for the AGYW
Approach:
Parental caregiving practice: I will conduct quantitative and qualitative interviews with caregiver- AGYW dyads in both control and intervention and tease out differences and similarities. I will measure both parental and AGYW perspectives on parental caregiving practice and intra-household functioning as below. Because I am going to start midway – the interviews will have to be cross-sectional in nature. In my head - my perfect design would have been to do baseline and end line for both groups and do a difference in difference analysis. I will use the following measures (disclaimer- still a works in progress...)
AGYW perspective:
- Change in the family relationship from baseline will be measured using the Family Relationship Scale (FRS),3 and the Inventory of ParentPeer Attachment (IPPA). The FRS consists of the cohesion, expressiveness, and conflict subscales and measures the AGYW perception of the quality of her family relationship functioning. On the other hand, the IPPA assesses AGYW’ perceptions of the positive and negative affective/cognitive dimension of relationships with parents and close friends; particularly how well these figures serve as sources of psychological security.
- Change in family communication as regards sexual matters from baseline will be measured through the Parent-Adolescent Communication Scale (PACS)4. The PACS scale assesses AGYW’ self-reported frequency of communicating about sexually related topics with their parents. Specifically, AGYW will be asked whether, in the past 6 months, they and their parent(s) talked about: (1) sex, (2) how to use condoms, (3) protection against STDs, (4) protection against the AIDS virus, and (5) protection against becoming pregnant
Parental perspective
- Family processes/ intra-household functioning will be assessed using the Parent Child Relationship Inventory (PCRI).5 PCRI is a self-report instrument for caregivers acting in a parental role. I will use three subscales: (1) involvement (i.e., spending time with and showing interest in the AGYW), (2) quality of communication (i.e., parent empathy and conversation across situations), and (3) autonomy (i.e., the extent to which the caregiver promotes AGYW independence).
Change in parenting monitoring from baseline will be measured through the Alabama Parenting Questionnaire nine-item short form (APQ-9), which is an often used assessment of parenting in research and applied settings. It uses parent and youth ratings for three scales: Positive Parenting, Inconsistent Discipline, and Poor Supervision6.The APQ-9 has been widely used as a reliable measurement of parent behavior in parts of South Africa.7
- Parenting stress: I will measure caregiver stress using the Parenting Stress Index (36 items)8. This scale has been used widely throughout the world including East and Southern African populations.9 The scale measures items related to parental distress, difficult child, and caregiver-child dysfunctional relationships.
3. If key health behaviors (e.g. smoking, exercise, nutritious diet) are strongly influenced by neighborhood, income, and/or education, do we need to continue to study how these behaviors influence health outcomes?
Yes, we still need to continue to study how these behaviors influence health outcomes because similar to what we learned last week about the interaction of genetics and environment, I believe these behaviors interact/intersect with these SES factors such as neighborhood either synergistically or in negative vicious cycles to worsen each other. Studying the behavior and SES interactions, allows us to know when to intervene. I think about teenage pregnancy. Impoverished girls from poor households are more likely to engage in high-risk sexual behaviours and get unwanted pregnancies in their teens which further compounds their poverty status and puts their own lives at risk as they are less likely to attend ANC, deliver in hospital, have higher rates of maternal mortality and infant mortality, have higher rates of depression and their children if girls are even more likely to have teenage pregnancies and if boys to get involved with alcoholism and drug use and violence. Here we see both behavioral and SES factors being passed on almost as if they were genes. From Arreola et al.behaviours, we learn that behaviors formed earlier own in life are carried on into adult life. Its almost like a primer for poor behaviour in later life even when the SES factors like neighborhood, income/wealth are no longer pertinent. Within the HIV field, we do know that having the first sex without a condom has been shown to influence subsequent sexual encounters to be condomless as well. Understanding this behavior at this trend – allows us to emphasize safer sex using condoms at an early age since we know that it will impact future sexual encounters regardless of the SES.
I am now beginning to really get the concept of why we need to have a life course approach in our research. It wasnt clear at the beginning but the readings are opening my mind.
Thank you
1. Conger RD, Conger KJ, Martin MJ. Socioeconomic Status, Family Processes, and Individual Development. Journal of marriage and the family. 2010;72(3):685-704.
2. Juma M, Askew, I., Ferguson, A., & Population Council. Situation analysis of the sexual and reproductive health and HIV risks and prevention needs of older orphaned and vulnerable children in Nyanza Province, Kenya. Nairobi, Kenya: Population Council.;2007.
3. Fok CCT, Allen J, Henry D, Team PA. The Brief Family Relationship Scale: A Brief Measure of the Relationship Dimension in Family Functioning. Assessment. February 1, 2014 2014;21(1):67-72.
4. Sales JM, Milhausen RR, Wingood GM, DiClemente RJ, Salazar LF, Crosby RA. Validation of a Parent-Adolescent Communication Scale for Use in STD/HIV Prevention Interventions. Health Education & Behavior. June 1, 2008 2008;35(3):332-345.
5. Gerard AB. Parent-child relationship inventory (PCRI) : manual. Los Angeles, Calif.: Western Psychological Services; 1994.
6. Gross TJ, Fleming CB, Mason WA, Haggerty KP. Alabama Parenting Questionnaire-9: Longitudinal Measurement Invariance Across Parents and Youth During the Transition to High School. Assessment. Dec 15 2015.
7. Lachman J, Cluver L, Boyes M, Kuo C, Casale M. Positive parenting for positive parents: HIV/AIDS, poverty, caregiver depression, child behavior and parenting in South Africa. AIDS care. 08/12 2014;26(3):304-313.
8. Abidin RR. The Determinants of Parenting Behavior. Journal of Clinical Child Psychology. 1992/12/01 1992;21(4):407-412.
9. Oburu PO, Palmerus K. Stress related factors among primary and part-time caregiving grandmothers of Kenyan grandchildren. International journal of aging & human development. 2005;60(4):273-282.