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Prevalence, type, and correlates of trauma exposure among adolescent men and women in Soweto, South Africa: implications for HIV prevention

  • Kalysha Closson1, 2,
  • Janan Janine Dietrich3,
  • Busi Nkala3, 4,
  • Addy Musuku1,
  • Zishan Cui2,
  • Jason Chia2,
  • Glenda Gray3,
  • Nathan J. Lachowsky2, 5,
  • Robert S. Hogg1, 2,
  • Cari L. Miller1 and
  • Angela Kaida1Email author
BMC Public HealthBMC series – open, inclusive and trusted201616:1191

https://doi.org/10.1186/s12889-016-3832-0

Received: 21 May 2016

Accepted: 12 November 2016

Published: 25 November 2016

Abstract

Background

Youth trauma exposure is associated with syndemic HIV risk. We measured lifetime prevalence, type, and correlates of trauma experience by gender among adolescents living in the HIV hyper-endemic setting of Soweto, South Africa.

Methods

Using data from the Botsha Bophelo Adolescent Health Survey (BBAHS), prevalence of “ever” experiencing a traumatic event among adolescents (aged 14–19) was assessed using a modified Traumatic Event Screening Inventory-Child (TESI-C) scale (19 items, study alpha = 0.63). We assessed self-reported number of potentially traumatic events (PTEs) experienced overall and by gender. Gender-stratified multivariable logistic regression models assessed independent correlates of ‘high PTE score’ (≥7 PTEs).

Results

Overall, 767/830 (92%) participants were included (58% adolescent women). Nearly all (99.7%) reported experiencing at least one PTE. Median PTE was 7 [Q1,Q3: 5-9], with no gender differences (p = 0.19). Adolescent men reported more violent PTEs (e.g., “seen an act of violence in the community”) whereas women reported more non-violent HIV/AIDS-related PTEs (e.g., “family member or someone close died of HIV/AIDS”). High PTE score was independently associated with high food insecurity among adolescent men and women (aOR = 2.63, 95%CI = 1.36-5.09; aOR = 2.57, 95%CI = 1.55-4.26, respectively). For men, high PTE score was also associated with older age (aOR = 1.40/year, 95%CI = 1.21-1.63); and recently moving to Soweto (aOR = 2.78, 95%CI = 1.14-6.76). Among women, high PTE score was associated with depression using the CES-D scale (aOR = 2.00, 95%CI = 1.31-3.03,) and inconsistent condom use vs. no sexual experience (aOR = 2.69, 95%CI = 1.66-4.37).

Conclusion

Nearly all adolescents in this study experienced trauma, with gendered differences in PTE types and correlates, but not prevalence. Exposure to PTEs were distributed along social and gendered axes. Among adolescent women, associations with depression and inconsistent condom use suggest pathways for HIV risk. HIV prevention interventions targeting adolescents must address the syndemics of trauma and HIV through the scale-up of gender-transformative, youth-centred, trauma-informed integrated HIV and mental health services.

Keywords

Adolescent Young adult Youth HIV Prevention Trauma Potentially traumatic events Sexual and reproductive health South Africa

Background

South Africa has one of the highest rates of HIV globally, with an adult prevalence of 17.9% [1]. HIV disproportionately affects young people, and young women in particular. Among youth aged 15 to 24 years of age, 13.3% of young women and 3.8% of young men are living with HIV [2]. Addressing the high rate and burden of HIV among South African youth, and adolescent women in particular [3], is a national and global public health priority. While efforts are underway to scale-up access to several biomedical HIV prevention tools, including pre-exposure prophylaxis (PrEP), antiretroviral therapy (ART) for prevention (‘TasP’), medical male circumcision, and female and male condoms [3, 4], demand for these programs will be shaped by the broader developmental, social and structural forces which influence adolescent sexual behaviour [5]. At present, there is a lack of literature on gendered differences in prevalence, types and influence of traumatic experiences and their relationship with adolescent HIV risk.

Experiences of childhood trauma are common among adolescents in South Africa, with estimates of physical and sexual violence in childhood ranging from 1.6–54.2% [6]. Traumatic experiences in childhood and adolescence have serious implications for short and long-term psychological and physical health outcomes, and have been associated with increased incidence of HIV [711]. The pathway from trauma and depression to heightened risk of HIV and other sexually transmitted infections has been described through the negative effects of depression on impulse control, risk perception [12], self-esteem and self-efficacy [13], substance use [14], and socio-structural vulnerability [15], which compromise HIV prevention behaviours [16, 17]. Such pathways are highly gendered, with both the prevalence of depression and associations with increased risk of condomless sex shown to be higher among adolescent women than adolescent men [18].

The disproportionate exposure to potentially traumatic events (PTEs) experienced by people living with HIV (PLHIV), has been referred to as a syndemic (“synergistically interacting epidemics”) [19], yielding a range of poor social, clinical, and public health outcomes, including decreased social functioning, elevated rates of post-traumatic stress disorder (PTSD), increased prevalence of high-risk sexual and drug use behaviours, suboptimal adherence to ART, poor HIV clinical outcomes, increased HIV transmission risk, and higher mortality [7, 9, 10]. Little attention, however, has focused on gendered impacts and the presence of syndemic risks which can have a multiplicative effect on HIV risk [20], including multiple types of PTEs (e.g. physical, sexual, and emotional) [21].

Adolescent men and women are exposed to different types and consequences of trauma, particularly with respect to violent and non-violent forms. Globally, violence against women is a major social justice issue [22, 23], an under-addressed public health priority, and an established risk factor for HIV acquisition and other negative health outcomes [3, 24]. In South Africa, where reports of violence are known to under-estimate the true prevalence [25], 20% of women attending antenatal care reported experiencing sexual violence, among the highest prevalence in the world [22, 26]. Among adolescent men, experiences of perpetrating or witnessing interpersonal violence drive rates of trauma exposure [11, 24, 27]. This is significant as earlier research among South African adolescent men demonstrated an association between witnessing community violence and high sexual HIV risk behaviours such as multiple concurrent sexual partnerships [28].

The effects of experiencing trauma on mental health and coping strategies also differ between adolescent men and women in ways that influence HIV risk pathways. For instance, PTEs experienced by South African women have been shown to increase internalized behaviours such as depression, anxiety and PTSD [23, 29], which synergistically contribute to increased risk for HIV and other sexually transmitted infections (STIs) [26, 30]. However, adolescent men are more likely to respond to PTEs with adverse externalized behaviours that introduce HIV risk, including delinquency, aggression and substance abuse [21]. This distinction in type of PTEs and behavioural responses demands gender-specific analysis, support, and response.

We measured the lifetime prevalence and correlates of PTEs overall, and by gender among adolescent men and women in Soweto, South Africa. This information is critical to inform youth-centred sexual and reproductive health and HIV prevention programming that considers the broader risk environments that youth navigate [31].

Methods

Study setting

We used cross-sectional survey data from adolescents (aged 14–19 years) enrolled in the Botsha Bophelo Adolescent Health Study (BBAHS) in Soweto, South Africa. Soweto is a large township southwest of Johannesburg with a population of approximately 1.3 million predominantly (98.5%) black inhabitants residing in informal and formal settlements [32]. While there are no population-level statistics on HIV prevalence among adolescents in Soweto, a recent study of 11,552 adolescents and young adults (14–25 years) residing in Soweto, reported that 4% of those who accessed HIV testing services at a local youth-centered clinic tested positive for HIV, including 2% of young men 4% of young women [33].

BBAHS was conducted at the Perinatal Health Research Unit (PHRU) and the Kganya Motsha Adolescent Centre (KMAC) in Soweto, South Africa. KMAC was opened in 2008 with a local mandate to address HIV and sexual and reproductive health priorities of adolescents (ages 14–19 years). Earlier pilot studies on adolescent health identified the urgent need for such youth-centred services, and informed the development and implementation of BBAHS [3336].

Study participants

Adolescents aged 14–19 years residing in Soweto were eligible to participate in BBAHS. Participants were recruited from across 41 townships to be representative of adolescents living in formal and informal communities within Soweto. Participant recruitment occurred around local malls, schools, neighbourhood hangouts, through peer-word-of-mouth, and staff outreach. We used a targeted stratified sampling and recruitment approach, based on geographic location, age, and gender. In order to reflect the gendered dimensions of HIV risk in South Africa, we aimed for a sample comprised of 60% young women and 40% young men. The research team approached interested adolescents for participation, and if eligible, were enrolled in the study. A total of 956 interviews were completed between March 2010 and March 2012. This amount of recruitment time was required to meet stratified sampling targets, and to ensure inclusion of youth from more remotely located townships with Soweto and harder-to-reach youth sub-populations. Of 956 completed interviews, n = 126 were excluded as they were determined to be outside of the targeted age criteria or had incomplete data, yielding a final sample of 830 adolescent participants. Additional information about the study procedures of the BBAHS can be found elsewhere [37].

Ethical considerations

Adolescents under 18 years signed an informed assent form and provided a signed informed consent form from a parent or legal guardian. Adolescents aged 18 or 19 signed an informed consent form. Age was verified using birth certificates or other identity documents.

Ethical approval for the study was granted by the ethics committees of the University of the Witwatersrand (Johannesburg, South Africa) and Simon Fraser University (Burnaby, Canada).

Data collection

An interviewer-administered, structured, online questionnaire was delivered to participants (supported by SurveyMonkeyTM software) via iPad or desktop computer. Interviewers received extensive training in good clinical practice guidelines, participant recruitment, administering questionnaires, and participant referral in cases where additional support was required after the study visit. Interviews were conducted in either English or isiZulu at the PHRU, the KMAC, or at a private location selected by the participant. Questionnaires took an average of 60 min to complete, and participants received 50 Rand (approximately 7 USD at the time) as compensation for their time and transportation costs. An international team of experts in adolescent health and HIV, including an adolescent Community Advisory Board (CAB), contributed to the development of the BBAHS questionnaire [37].

Measures

Primary outcome: trauma experience

Assessment of ‘trauma experience’ followed Norris’ [29] comprehensive definition of traumatic events as “any event that produces symptoms of traumatic stress” (23, p. 409). We measured PTEs using a modified version of the Traumatic Events Screening Inventory–Child (TESI-C) [29]. Unlike other trauma scales, the TESI-C scale was developed to be language appropriate for children and youth.

The TESI-C measures the history of trauma by asking about exposure (“yes” vs. “no”) to twenty PTEs including “injuries, hospitalizations, domestic violence, community violence, disasters, accidents, physical abuse and sexual abuse” [38]. Historically, this scale has been used in child and adolescent psychological screening [38]. For our study, the TESI-C items were modified to account for the social context and physical environment of adolescents in Soweto [38]. For example, TESI-C items regarding natural disasters, acts of war or terrorism, kidnapping and animal attacks were omitted. Similar to other South African studies examining the impact of traumatic experiences in adolescents, we added items regarding parents separating, parents arguing, changing schools, parents’ job security, family members with HIV/AIDS, family members dying of HIV/AIDS, discrimination, financial security, personal physical attack were added. The final adapted scale included a total of 19 items (study alpha = 0.63; Table 2). A comparison of items from the original TESI-C scale and the modified version used in this analysis is included in the Additional file 1.

We measured prevalence of experiencing a potentially traumatic event (i.e., a response of “Yes” to one or more of the 19 items included in the modified TESI-C scale) overall and by gender. We also assessed number of reported PTEs and calculated a PTE score (range = 0-19), with higher scores indicating higher PTE experience. Scores greater than the scale median were considered ‘high PTE score’ vs. ‘low PTE score’.

Explanatory factors

Socio-demographic characteristics

We assessed socio-demographic characteristics by gender (adolescent man vs. adolescent woman), age in years (continuous), ethnicity (Zulu, Xhosa, Sotho, Tswana or other), education (high school or greater vs. less than high school), and employment (student vs. unemployed vs. employed [full-time/part-time/self-employed]). Additional determinants of socio-economic status included length of time living in Soweto (<5 years vs. ≥5 years vs. since birth), housing type (brick house or flat owned by family vs. brick house or flat rented by family or other housing type vs. reconstructive development housing [RDP] or shack), food insecurity (low vs. medium vs. high, measured via a 9-item hunger and food security scale [39] [study Cronbach’s α = 0.81]), and receiving a household social grant in the past 12-months (yes vs. no; including disability, age pension, child support or other social grant), and history of incarceration (ever vs. never).

Depression

The 20-point Center for Epidemiologic Studies Depression (CES-D) Scale was utilized to measure probable depression (study Cronbach’s α = 0.81, range = 0-60, with higher scores indicating greater depressive symptoms) [40]. In the general population the American Psychological Association suggests using a cut off of 16 or higher to determine major depressive disorder [41]. We chose a higher cut off of ≥24 as this has been previously described as the best cut-off to determined ‘probable depression’ among adolescents [18, 42].

Sexual behaviour

History of sexual activity was defined by participant report of ever having had intercourse (yes vs. no), current sexual activity was defined as having had sex (vaginal or anal) in the 6 months prior to interview (yes vs. no) and, if yes, whether the participant had more than one sexual partner in the last 6 months (yes vs. no). Consistent condom use was assessed via self-reported lifetime use during anal and/or vaginal sex, as applicable, and frequency (always vs.vs sometimes vs. never) in the 6 months prior to interview (lifetime consistent condom use vs. any inconsistent or no condom use vs. never had sex). History of STI diagnosis and/or symptoms (ever vs. never), history of HIV testing (ever vs. never), and HIV status (HIV-positive vs. HIV-negative vs. unknown HIV status) was assessed via self-report.

Substance use

We assessed self-reported frequency of alcohol use in the 6 months prior to interview (once a month or more vs. less than once a month or never). We also assessed any use of illicit (e.g., heroin, cocaine, ecstasy) or licit drugs used in a manner other than which they are prescribed (e.g., prescription pills, antiretrovials/whoonga), excluding marijuana in the 6 months prior to interview (yes vs. no). Use of marijuana (yes vs. no) was assessed separately, given different patterns of use among youth [43, 44].

Statistical analysis

All analyses were conducted using SAS 9.4, stratified by self-identified gender. Descriptive statistics (median, 1st quartile [Q1] and 3rd quartile [Q3] for continuous variables and n, % for categorical variables) were used to characterize baseline distributions of study variables. Differences in baseline variables and trauma scores by gender were compared using Wilcoxon rank sum test for continuous variables and Pearson χ2 or Fisher’s exact test for categorical variables.

Univariable and multivariable logistic regression were used to identify variables associated with high PTE score, separately for adolescent men and women. Variables of interest with univariable p-values <0.20 were included in multivariable model selections. After testing for collinearity, only the sexual behaviour variable ‘inconsistent condom use (yes vs. no vs. never had sex)’ was considered for inclusion in the final model. For all other variables, model selections were performed using backward selection based on Type III p-values to reach the optimal (minimized) AIC. All statistical tests were considered statistically significant at α < 0.05.

Results

Baseline characteristics

Of 830 participants, 767 answered all 19 TESI-C items and were included in this analysis of whom 442 (58%) were adolescent women and 325 (42%) were adolescent men (Table 1). Median age was 17 years [Q1-Q3: 16-18], 45% were Zulu, 85% were currently enrolled in school, and 6% had ever been incarcerated. A majority had lived in Soweto since birth (77%), lived in brick house/flat owned by the family (71%), reported high food insecurity (52%), and lived in a household which had received a social grant in the last 12 months (57%).
Table 1

Baseline characteristics of participants (aged 14–19 years) overall and by gender (n = 767)

Baseline characteristics

Overall (n = 767)

Adolescent Men (n = 325)

Adolescent Women (n = 442)

p-value

 

n

%

n

%

n

%

 

Socio-demographic characteristics

Age at interview (years, median, Q1,Q3)

17

16,18

17

16,18

18

16,18

0.197

Years lived in Soweto

 < 5 years

71

9.4

27

8.4

44

10.0

0.347

 ≥ 5 years

106

14.0

51

15.9

55

12.5

 

 Since birth

582

76.7

242

75.6

340

77.5

 

 missing

8

 

5

 

3

  

Ethnicity

 Zulu

345

45.0

166

51.1

179

40.5

0.005

 Xhosa

92

12.0

39

12.0

53

12.0

 

 Sotho

124

16.2

40

12.3

84

19.0

 

 Tswana

85

11.1

26

8.0

59

13.4

 

 Other ethnicities

121

15.8

54

16.6

67

15.2

 

Education

 ≥ High school

9

1.2

7

2.2

2

0.5

0.041

 < High school

758

98.8

318

97.9

440

99.6

 

Employment

 Student

649

85.1

264

81.5

385

87.7

0.056

 Unemployed

85

11.1

44

13.6

41

9.3

 

 Employed

29

3.8

16

4.9

13

3.0

 

 Missing

<5

 

<5

 

<5

  

Housing

 Brick house/Flat owned by family

547

71.3

220

67.7

327

74.0

0.160

 Brick house/Flat rented by family/other

18

2.3

9

2.8

9

2.0

 

 RDP house/Shack

202

26.3

96

29.5

106

24.0

 

Food Insecurity

 Low

169

22.0

59

18.2

110

24.9

0.078

 Medium

203

26.5

88

27.1

115

26.0

 

 High

395

51.5

178

54.8

217

49.1

 

Household Social Grant in the last 12 months

 No

325

42.9

141

44.3

184

41.9

0.506

 Yes

432

57.1

177

55.7

255

58.1

 

 missing

10

 

7

 

3

  

Incarceration history

 No

646

93.8

258

91.2

388

95.6

0.019

 Yes

43

6.2

25

8.8

18

4.4

 

 Missing

78

 

42

 

36

  

Sexual behaviour and HIV variables

Ever had sex

 No

338

44.1

116

35.7

222

50.2

<.001

 Yes

429

55.9

209

64.3

220

49.8

 

Sexually Active in the past 6 months (L6M)a

 No

153

36.5

80

39.6

73

33.6

0.205

 Yes

266

63.1

122

60.4

144

66.4

 

 missing

10

 

7

 

3

  

Number of partners (among those reporting sexual activity in L6M)b

 1 partner

168

64.6

51

43.6

117

81.8

<.001

 ≥ 2 partner

92

35.4

66

56.4

26

18.2

 

 Missing

6

      

Condom usea

 Consistent condom use

189

46.3

93

47.2

96

45.5

0.729

 Inconsistent condom use

219

53.7

104

52.8

115

54.5

 

 missing

21

 

12

 

9

  

HIV testing history

 No

414

54.1

187

57.7

227

51.5

0.087

 Yes

351

45.9

137

42.3

214

48.5

 

HIV status (self-report)

 HIV-positive

11

1.4

5

1.5

6

1.4

0.187

 HIV-negative

329

42.9

127

39.1

202

45.7

 

 Unknown/never tested

427

55.7

193

59.4

234

52.9

 

STI or STI symptomologya

 No

332

77.4

173

82.8

159

72.3

<.001

 Yes

97

22.6

36

17.2

61

27.7

 

Substance use and mental health variables

Alcohol use in the last 6 months (L6M)

 No

267

34.99

104

32.1

163

37.1

0.150

 Yes

496

65.01

220

67.9

276

62.9

 

Drug use in L6M (excluding marijuana use)

 No

728

94.9

297

91.4

431

97.5

<.001

 Yes

39

5.1

28

8.6

11

2.5

 

Probable Depression

 No

510

66.5

229

70.5

281

63.6

0.046

 Yes (CES-D score ≥ 24)

257

33.5

96

29.5

161

36.4

 

Note: p-values in bold are significant (<.05)

Abbreviations: CES-D center for epidemiologic studies- depression scale, RDP reconstruction and development programme, STI sexually transmitted infection, HIV human immunodeficiency virus

aAmong those reporting sexual activity ever

bAmong those reporting sexual activity in the last 6 month

Overall, 56% of participants reported having ever had sex, including 64% of adolescent men and 50% of adolescent women (p < 0.001 for gender difference). Of those reporting sexual activity in the six months prior to the interview, 35% reported having more than one sexual partner in the previous 6 months (including 56% of adolescent men and 18% of adolescent women [p < 0.001]). Among those who had ever had sex, 54% reported inconsistent condom use (including 53% of adolescent men and 55% of adolescent women [p = 0.729]) and 23% reported ever having been diagnosed with an STI or experienced STI symptoms (including 17% of adolescent men and 28% of adolescent women [p = 0.009]). Overall, 1.4% reported being HIV-positive (1.5% of adolescent men and 1.4% of women, p = 0.19).

In the six months prior to interview, nearly two-thirds (65%) reported alcohol use and 5% reported using other drugs. One-third (34%) had probable depression, with higher rates among adolescent women than men (36% vs. 30%, p = 0.05).

Experience of potentially traumatic events (PTEs)

Nearly all participants (99.7%) reported experiencing at least 1 PTE. Median number of PTEs experienced was 7 [Q1-Q3: 5-9], with no significant difference by gender (p = 0.19). Overall, 47% of adolescent men and 45% of adolescent women experienced a high PTE score (≥7 events (p = 0.603)).

Table 2 shows the proportion of adolescents who reported experiencing each of the 19 PTE items included in the adapted TESI-C scale by gender. Nearly three-quarters (74%) of adolescent men and women reported experiencing the death of a family member or someone close to them. Over two-thirds (68%) had witnessed a close family member or friend deal with a serious illness or injury. Nearly half reported that their parents were separated or divorced (48%) or that their family struggled with money (46%). In general, adolescent men were more likely to have experienced or perpetuated violent forms of traumatic experiences (e.g. forcing someone to have sex with them [7%], deliberately inflicting harm on another [51%], witnessed an act of violence in the community [76%]). Adolescent women were more likely to experience psychological and emotional experiences of potentially traumatic events (e.g. having a family member have [46%] or die from [41%] HIV/AIDS).
Table 2

Prevalence of potentially trauma event (PTE) experiences among participants (14–19 years) overall and by gender (n = 767)

 

Overall (n = 767)

Adolescent Men (n = 325)

Adolescent Women (n = 442)

p-value

 

n

%

n

%

n

%

 

Experienced at least one PTE

765

99.7

325

100.0

440

99.6

0.511

High trauma score (≥7) (alpha = 0.63)

348

45.4

151

46.5

197

44.6

0.603

Separated from mom (e.g. lived with another relative or in foster care)

253

33.0

118

36.3

135

30.5

0.093

Parents separated

370

48.2

153

47.1

217

49.1

0.581

Parents argued frequently or more than usual

259

33.8

111

34.2

148

33.5

0.846

Changed schools (not because of graduation) or moved to a new home

245

31.9

123

37.9

122

27.6

0.003

Parent/guardian lost job

342

44.6

139

42.8

203

45.9

0.385

Lost home or had no home

65

8.5

38

11.7

27

6.1

0.006

Family member or someone close had HIV/AIDS

287

37.4

85

26.2

202

45.7

<0.001

Family member or someone close died of HIV/AIDS

273

35.6

91

28.0

182

41.2

0.001

Family member or someone close died

569

74.2

243

74.8

326

73.8

0.751

Family member or someone close was very sick or had a bad injury

524

68.3

230

70.8

294

66.5

0.211

Experienced race/ethnicity discrimination

183

23.9

77

23.7

106

24.0

0.926

Family struggled with money

355

46.3

147

45.2

208

47.1

0.616

Seen an act of violence towards someone else (not in family)

538

70.1

248

76.3

290

65.6

0.001

Experienced an act of violence by someone not in your family

316

41.2

147

45.2

169

38.2

0.052

Seen an act of violence in the family

324

42.2

136

41.9

188

42.5

0.849

Experienced an act of violence by someone in your family

240

31.3

107

32.9

133

30.1

0.403

Deliberately inflicted harm on another person

293

38.2

166

51.1

127

28.7

<0.001

Experienced forced Sex

98

12.8

35

10.8

63

14.3

0.153

Experienced forcing someone to have sex

30

3.9

24

7.4

6

1.4

<0.001

Note: p-values in bold are significant (>.05)

Overall, 14% of adolescent women and 11% of adolescent men reported experiencing forced sex (p = 0.153) while 1.4% and 7.4% reported ever forcing someone to have sex with them (p < 0.001).

Correlates of high PTE scores

In unadjusted models among adolescent men (see Table 3), high PTE score was associated with older age, living in Soweto for <5 years, self-reported Tswana ethnicity, high food insecurity, drug use in the past six months, sexual experience, and inconsistent condom use. In the adjusted model (see Table 3), adolescent men with high PTE scores had significantly higher adjusted odds of being older (aOR = 1.40/year, 95%CI = 1.21-1.63); recently moving to Soweto (<5 years) vs. living in Soweto ‘since birth’ (aOR = 2.78, 95%CI = 1.14-6.76); and high vs. low food insecurity (aOR = 2.63 95%CI = 1.36-5.09).
Table 3

Univariate and adjusted analysis of variables associated with high PTE scores among adolescent men (n = 325)

 

Low PTE score

High PTE score

p-value

High PTE score vs. Low PTE score

Variables

n

%

n

%

Wilcoxon/Chisq

OR

95% CI

 

AOR

95% CI

 

Socio-demographic characteristic

Age at interview (per year, median Q1,Q3)

17

15,18

18

16,18

<.001

1.37

1.19

1.59

1.40

1.21

1.63

Years lived in Soweto

 Since birth

133

76.9

109

74.2

0.059

Ref

  

Ref

  

 ≥ 5 years

31

17.9

20

13.6

 

0.79

0.42

1.46

0.75

0.39

1.43

 < 5 years

9

5.2

18

12.2

 

2.44

1.05

5.65

2.78

1.14

6.76

Ethnicity

 Zulu

99

56.9

67

44.4

0.174

Ref

     

 Xhosa

18

10.3

21

13.9

 

1.72

0.85

3.48

Not Selected

  

 Sotho

21

12.1

19

12.6

 

1.34

0.67

2.67

  

 Tswana

10

5.8

16

10.6

 

2.36

1.01

5.52

  

 Other ethnicities

26

14.9

28

18.5

 

1.59

0.86

2.95

  

Employment

 Student

147

85.0

117

77.5

0.193

Ref

     

 Unemployed

20

11.56

24

15.89

 

1.51

0.79

2.86

Not Selected

  

 Employed

6

3.5

10

6.6

 

2.09

0.74

5.93

  

Housing

 Brick house/Flat owned by family

123

70.7

97

64.2

0.414

Ref

     

 Brick house/Flat rented by family/Hostel/Other

5

2.9

4

2.7

 

1.01

0.27

3.88

   

 RDP house/Shack

46

26.44

50

33.11

 

1.38

0.85

2.23

   

Food Insecurity

 Low

39

22.4

20

13.3

0.026

Ref

  

Ref

  

 Medium

51

29.3

37

24.5

 

1.41

0.71

2.81

1.58

0.76

3.29

 High

84

48.3

94

62.3

 

2.18

1.18

4.03

2.63

1.36

5.09

Household Social Grant

 No

81

47.9

60

40.3

0.170

Ref

  

Not Selected

  

 Yes

88

52.1

89

59.7

 

1.37

0.87

2.13

  

Incarceration history

 No

148

92.5

110

89.4

0.367

Ref

     

 Yes

12

7.5

13

10.6

 

1.46

0.64

3.32

   

Sexual behaviour and HIV

HIV testing history

 No

99

57.2

88

58.3

0.848

Ref

     

 Yes

74

42.8

63

41.7

 

0.96

0.62

1.49

   

HIV Result

 Positive

3

1.7

2

1.3

0.940

Ref

     

 Negative

69

39.7

58

38.4

 

1.26

0.20

7.81

   

 Unknown/Never tested

102

58.6

91

60.3

 

1.34

0.22

8.19

   

Sex Ever

 No

77

44.3

39

25.8

0.001

Ref

  

Not includeda

  

 Yes

97

55.8

112

74.2

 

2.28

1.42

3.65

  

Ever STI

 No

85

48.9

88

58.3

0.001

Ref

  

Not includeda

  

 Yes

12

6.9

24

15.9

 

1.93

0.91

4.11

  

 Never had sex

77

44.3

39

25.8

 

0.49

0.30

0.80

  

Sexually Active P6M

 No

41

24.1

39

26.4

0.001

Ref

  

Not Includeda

  

 Yes

52

30.6

70

47.3

 

1.42

0.80

2.49

  

 Never had sex

77

45.3

39

26.4

 

0.53

0.30

0.95

  

Inconsistent condom use

 Never had sex

77

45.8

39

26.9

0.002

Ref

  

Not Selected

  

 No

44

26.2

49

33.8

 

2.20

1.26

3.85

  

 Yes

47

28.0

57

39.3

 

2.39

1.39

4.13

  

More than 1 partner in the L6M

 No

23

13.6

28

19.4

0.016

Ref

  

Not Includeda

  

 Yes

28

16.6

38

26.4

 

1.11

0.53

2.33

  

 Never had sex/Sexually inactive

118

69.8

78

54.2

 

0.54

0.29

1.01

  

Substance use and mental health variables

Alcohol use in L6M

 No

63

36.4

41

27.2

0.075

1.09

0.47

2.52

   

 Yes

110

63.6

110

72.9

 

0.65

0.28

1.51

   

Probable Depression

 No

129

74.1

100

66.2

0.119

Ref

  

Not Selected

  

 Yes (score ≥ 24)

45

25.9

51

33.8

 

1.54

0.96

2.47

  

Drug use ever in L6M (excluding marijuana use)

 No

165

94.8

132

87.4

0.018

Ref

  

Not Selected

  

 Yes

9

5.2

19

12.6

 

2.64

1.16

6.02

  

Note: AORs and p-values in bold are significant (<.05)

Abbreviations: CI confidence intervals, OR odds ratio, AOR adjusted odds ratio, CES-D center for epidemiologic studies- depression scale, RDP reconstruction and development programme, STI, sexually transmitted infection, HIV human immunodeficiency virus

aNot included due to Collinearity

In the unadjusted models among adolescent women (see Table 4), high PTE score was associated with, high food insecurity, incarceration history, received a household social grant in the last year, probable depression, sexual experience and inconsistent condom use. In the adjusted model (see Table 4), adolescent women with high PTE scores had significantly higher adjusted odds of high food insecurity (aOR = 2.57, 95%CI = 1.55-4.26); probable depression (aOR = 2.00, 95%CI = 1.31-3.03); and inconsistent condom use vs. no sexual experience (aOR = 2.69, 95%CI = 1.66-4.37).
Table 4

Univariate and adjusted analysis of variables associated with high PTE scores among adolescent women (n = 442)

 

Low PTE score

High PTE score

p-value

High PTE score vs. Low PTE score

Variables

n

%

n

%

Wilcoxon/Chisq

OR

95% CI

 

AOR

95% CI

Socio-demographic characteristics

Age

17

16,18

18

16,18

0.182

1.10

0.97

1.24

Not Selected

Years lived in Soweto

 < 5 years

22

9.0

22

11.3

0.511

Ref

     

 ≥ 5 years

28

11.5

27

13.9

 

0.96

0.44

2.13

   

 Since birth

194

79.5

146

74.9

 

0.75

0.40

1.41

   

Ethnicity

 Zulu

104

42.5

75

38.1

0.764

Ref

     

 Xhosa

29

11.8

24

12.2

 

1.15

0.62

2.13

   

 Sotho

48

19.6

36

18.3

 

1.04

0.62

1.76

   

 Tswana

29

11.8

30

15.2

 

1.43

0.79

2.59

   

 Other

35

14.3

32

16.2

 

1.27

0.72

2.23

   

Employment

 Student

217

89.7

168

85.3

0.379

Ref

     

 Unemployed

19

7.85

22

11.17

 

1.50

0.78

2.85

   

 Employed

6

2.5

7

3.6

 

1.51

0.50

4.57

   

Housing

 House owned by family

184

75.1

143

72.6

0.577

Ref

     

 House rented by family/Other

6

2.5

3

1.5

 

0.64

0.16

2.62

   

 RDP house/Shack

55

22.45

51

25.89

 

1.19

0.77

1.85

   

Food Insecurity

 Low

77

31.4

33

16.8

<.001

Ref

  

Ref

  

 Medium

71

29.0

44

22.3

 

1.45

0.83

2.52

1.49

0.84

2.65

 High

97

39.6

120

60.9

 

2.89

1.77

4.70

2.57

1.55

4.26

Household ever Received Social Grant

 No

112

46.1

72

36.7

0.048

Ref

  

Not Selected

  

 Yes

131

53.9

124

63.3

 

1.47

1.00

2.16

  

Sexual behaviour and HIV variables

HIV testing history

 No

139

57.0

88

44.7

0.010

Ref

  

Not Selected

  

 Yes

105

43.0

109

55.3

 

1.64

1.12

2.39

  

HIV Result

 Positive

3

1.2

3

1.5

0.131

Ref

     

 Negative

102

41.6

100

50.8

 

0.98

0.19

4.97

   

 Unknown

140

57.1

94

47.7

 

0.67

0.13

3.40

   

Sex Ever

 No

142

58.0

80

40.6

<.001

Ref

  

Not included*

  

 Yes

103

42.0

117

59.4

 

2.02

1.38

2.95

  

STI or STI symptomology

 No

80

32.7

79

40.1

<.001

Ref

     

 Yes

23

9.4

38

19.3

 

1.67

0.91

3.06

   

 Never had sex

142

58.0

80

40.6

 

0.57

0.38

0.86

   

Sexually Active L6M

 No

41

16.9

32

16.3

<.001

Ref

     

 Yes

60

24.7

84

42.9

 

1.79

1.02

3.17

   

 Never had sex

142

58.4

80

40.8

 

0.72

0.42

1.24

   

Inconsistent condom use

 Never had sex

142

59.7

80

41.0

<.001

Ref

  

Ref

  

 No

52

21.9

44

22.6

 

1.50

0.92

2.44

1.59

0.96

2.63

 Yes

44

18.5

71

36.4

 

2.86

1.80

4.56

2.69

1.66

4.37

More than 1 partner in L6M

 No

49

20.2

68

34.9

<.001

Ref

  

Not included*

  

 Yes

11

4.5

15

7.7

 

0.98

0.42

2.32

  

 Never had sex/Sexually inactive

183

75.3

112

57.4

 

0.44

0.29

0.68

  

Substance use and mental health variables

Alcohol Use in the L6M

 No

102

42.0

61

31.1

0.019

Ref

  

Not Selected

  

 Yes

141

58.0

135

68.9

 

1.60

1.08

2.38

   

Probable Depression

 No

176

71.8

105

53.3

<.001

Ref

  

Ref

  

 Yes (score ≥ 24)

69

28.2

92

46.7

 

2.23

1.51

3.32

2.00

1.31

3.03

Incarceration history

 No

226

97.4

162

93.1

0.037

Ref

  

Not Selected

  

 Yes

6

2.6

12

6.9

 

2.79

1.03

7.59

  

Drug use ever in L6M (excluding marijuana use)

 No

239

97.6

192

97.5

0.952

Ref

     

 Yes

6

2.5

5

2.5

 

1.04

0.31

3.45

   

Note: AORs in bold are significant (<.05)

Abbreviations: CI confidence intervals; OR odds ratio, AOR adjusted odds ratio, CES-D center for epidemiologic studies- depression scale, RDP reconstruction and development programme, STI sexually transmitted infection, HIV human immunodeficiency virus

*Not included due to Collinearity

Discussion

Similar to other South African and African studies [8, 45], we found that adolescents in our study experienced high levels of PTEs. Nearly all participants experienced at least one PTE (99.7%) and had experienced on average 7 PTEs at the time of their interview with no differences by gender. A study of U.S adolescents (aged 13–17) found that 61.8% had lifetime PTE experience [46], compared with 99.7% of adolescents within our study. Among both adolescent men and women, increased exposure to PTE was associated with high levels of food insecurity. This finding has implications for sexual and reproductive health (SRH) outcomes and overall well-being for South African adolescent men and women faced with syndemic risks including high levels of community-level violence and sexual victimization [21]. In addition, our findings suggest no difference in the prevalence of PTEs between adolescent men and women, rather differences in the types of traumatic occurrences. Despite no significant differences in PTE prevalence by gender, we pursued a gender stratified analysis to enable examination of differential correlates of experiencing multiple PTEs. These findings highlight a need for future research to explore the differential potential gendered impacts of PTEs experienced among adolescents.

Consistent with previous literature, we found that PTE exposure and the effects are distributed along social and gendered axes. For example, a number of studies globally have found that young women are more likely to experience sexual assault while men are more likely to experience physical assault [29, 31, 45].

Adolescent women

Our results align with previous research indicating that co-occuring multiple PTEs experienced by women influence heightened depression symptomology [8], and compound syndemic risks of HIV transmission through increased HIV risk behaviour such as inconsistent condom use [10, 30]. The synergistic effect of multiple experiences of PTEs and increased HIV acquisition risk may be exacerbated among women living in vulnerable urban environments, such as Soweto, facing economic hardships and high levels of food insecurity [23, 30]. These compounding experiences of structural vulnerability influence economic dependence - placing women in inferior roles in their relationships - in turn increasing experiences of gender-based violence, inability to negotiate condom use, and ultimately HIV transmission risk [3, 23].

Adolescent men

Our results indicate that high-PTE scores were more commonly found among older adolescent men who have recently moved to Soweto, and who face high levels of food insecurity. Experiences of trauma can accumulate over the lifecourse, [47], as such older age was a hypothesized finding for higher number of PTEs among men in our study. The exposure to multiple experiences of PTEs at a young age have been found to perpetuate aggressive behaviour and negative views towards women in adulthood [48, 49]. The development of negative views towards women may perpetuate harmful gender norms and inequitable power dynamics in relationships, which has shown to have significant implications for the HIV epidemic in South Africa [24, 5052]. Furthermore, young men living in South Africa face extremely high rates of interpersonal violence. A study assessing hospital data on injuries within the Mthatha Hospital Complex in South Africa, found that the majority of injuries occurred among men, with 60% of all cases being for acts of interpersonal violence [27]. Despite extremely high levels of PTEs within men participating in our study, we found that this was not significantly associated with increased depression symptomology or inconsistent condom use. Previous research has explored the relationship between high levels of trauma and post-traumatic growth [53]. Resilience to HIV risk among adolescent men living in HIV hyper-endemic nations experiencing concurrent poverty and high-levels of PTEs should be further explored.

Intervention implications

Reducing syndemic risks to traumatic experiences in both adolescent men and women is likely to have a positive impact on HIV transmission through multiple pathways. The scale-up of community and structural level interventions, as well as increased focus on trauma-informed models of care for adolescents in South Africa is critical for addressing the HIV epidemic [21, 54]. For adolescent women, intervention strategies aimed at increasing economic independence, reducing gender-based violence, reducing inequities in relationship power and control, and challenging gender norms, are critical to increase sustained and widespread uptake of HIV prevention options, including male and female condoms and, in more recent years, pre-exposure prophylaxis (PrEP), [48, 5557]. Among adolescent women, high rates of sexual violence and inequities in relationship power [50, 58, 59] intersect to compromise opportunities to negotiate condom use [30, 6062]. Given demonstrated links between trauma, poor mental health, and sexual behaviours, mediated through pathways of gender and power inequity, central to the efforts to reduce HIV incidence among adolescent women is a clear need to scale-up access to youth-centred, trauma-informed, and women-controlled HIV prevention strategies, inclusive of PrEP [4].

Trauma-focused cognitive behavioural therapy (TF-CBT) has been shown to be highly beneficial in reducing sexual health risk. Hien and colleagues [63] implemented a skill-based TF-CBT program focusing on various domains including: personal self-management, coping, communication, boundary setting, HIV risk reduction and reducing unsafe behaviour in general. Women in the trauma-focused intervention were almost half as likely to report unprotected sex compared to women in the control group [63]. Given the high number of PTEs experienced by young people in South Africa, it is imperative to scale-up such trauma-informed mental health services for adolescents [21].

Community-level interventions addressing harmful gender norms, such as Stepping Stones, have been successful at reducing the perpetuation of intimate partner violence, a significant step forward in reducing HIV transmission and experiences of trauma for adolescent women [48]. For both adolescent men and women, interventions aimed at addressing food insecurities may help to mediate the compounding affects of PTEs on HIV transmission within vulnerable urban environments such as Soweto. This relationship merits further examination. Future interventions should consider the importance of resilience and post-traumatic growth within settings where experiences of traumatic events and HIV risk are extremely high [64].

Strengths & limitations

In conducting a gender-stratified analysis of PTE occurrence, we demonstrated the multitude of implications that PTEs have on both SRH programs and HIV intervention — informing a gendered approach to addressing PTE and HIV risk. However, we did not include measurements within our survey to assess PTSD symptomology which is a known outcome of experiencing trauma [8, 10, 21], thus we acknowledge this is a limitation of our study which should be further examined within future South African adolescent health studies. Further, we are unable to assess causation within this cross-sectional study. Additional limitations include recall and social desirability bias due to self-reported measures of sexual behaviour and other sensitive topics. In addition, we used a modified variation of the TESI-C; therefore, caution should be used in comparing these findings with other studies using the original version of the TESI-C and other scales similarly measuring experiences of trauma.

Conclusion

Being an adolescent in Soweto, South Africa poses many challenges: we found a high prevalence of PTEs along with associations highlighting risk for HIV acquisition, particularly for adolescent women. Adolescence is a dynamic and transitional time of the lifecourse, marked by rapid and multiple developmental changes that, through biology and socialization, are distinctly gendered [5, 65, 66]. Enabling and fostering the pathway towards health provides adolescent men and women with a set of meaningful skills and coping mechanisms that they can carry into adulthood [5, 21]. Focusing on preventing multiple co-occurring risks and promoting increased access to mental health services for adolescent men and women facing high exposures to PTEs can begin to address the syndemic of HIV and trauma which pose significant threats to HIV-acquisition, population health and development for South Africa [10].

Abbreviations

AIC: 

Akaike information criterion

AIDS: 

Acquired immune deficiency syndrome

aOR: 

Adjusted odds ratio

ART: 

Antiretroviral therapy

BBAHS: 

Botsha Bophelo adolescent health survey

CES-D: 

Centre for epidemiologic studies depression

HIV: 

Human immunodeficiency virus

KMAC: 

Kganya Motsha Adolescent Centre

PHRU: 

Perinatal HIV research unit

PLHIV: 

People living with HIV/AIDS

PrEP: 

Pre-exposure prophylaxis

PTEs: 

Potentially traumatic events

PTSD: 

Post-traumatic stress disorder

STIs: 

Sexually transmitted infections

TasP: 

Treatment as prevention

TESI-C: 

Traumatic event screening inventory-child (TESI-C)

TF-CBT: 

Trauma-focused cognitive behavioural therapy

Declarations

Acknowledgement

The Botsha Bophelo Adolescent Health Study (BBAHS) Research Team would like to thank our participants and our research team members for all their contributions to this study.

Funding

BBAHS was funded by the Canadian Institutes of Health Research (CIHR), Institute for Human Development, Child and Youth Health (230513). Initial seed funding was provided by Simon Fraser University through a President Research Award to CLM. NJL is supported by a CANFAR/CTN Postdoctoral Fellowship Award. AK received salary support from the Canada Research Chair program in Global Perspectives on HIV and Sexual and Reproductive Health. The PHRU was supported through a grant by the South African Medical Research Council. The authors have no conflict of interest to declare regarding the publication of this manuscript.

Availability of data and materials

For access to the study data, please contact Dr. Cari Miller (Cari.Miller@sfu.ca), Principal Investigator of the Botsha Bophelo Adolescent Health Study.

Authors’ contributions

CLM, JD, BN, GG, RSH and AK designed the study. JD, BN, and GG implemented the study. RSH and CLM had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. JC undertook the data analysis and ZC conducted the statistical analysis. KC, AM and AK interpreted the data and wrote the first draft of the manuscript. All authors read and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

This manuscript does not contain any identifying individual participant data, and thus consent for publication from participants in not applicable for this analysis.

Ethics approval and consent to participate

Ethical approval for the study was granted by the ethics committees of the University of the Witwatersrand (Johannesburg, South Africa) [M090449] and Simon Fraser University (Burnaby, Canada) [#2009 s0196]. Adolescents under 18 years signed an informed assent form and provided a signed informed consent form from a parent or legal guardian. Adolescents aged 18 or 19 signed an informed consent form.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Faculty of Health Sciences, Simon Fraser University (SFU)
(2)
British Columbia Centre for Excellence in HIV/AIDS
(3)
Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand
(4)
Faculty of Humanities, University of the Witwatersrand
(5)
School of Public Health and Social Policy, University of Victoria

References

  1. UNICEF. United Nations Children's Fund. Statistics| South Africa. 2013. http://www.unicef.org/infobycountry/southafrica_statistics.html.
  2. UNAIDS. Global AIDS response progress report 2012: Republic of South Africa. 2012Google Scholar
  3. Dellar RC, Dlamini S, Karim QA. Adolescent girls and young women: key populations for HIV epidemic control. J Int AIDS Soc. 2015;18(2 Suppl 1):19408.PubMedPubMed CentralGoogle Scholar
  4. Venter WD, Cowan F, Black V, Rebe K, Bekker LG. Pre-exposure prophylaxis in Southern Africa: feasible or not? J Int AIDS Soc. 2015;18(4 Suppl 3):19979.PubMedPubMed CentralGoogle Scholar
  5. Bekker LG, Johnson L, Wallace M, Hosek S. Building our youth for the future. J Int AIDS Soc. 2015;18(Suppl 1):20027 http://www.jiasociety.org/index.php/jias/article/view/20027 |http://dx.doi.org/10.7448/IAS.18.2.20027.
  6. Meinck F, Cluver LD, Boyes ME, Mhlongo EL. Risk and protective factors for physical and sexual abuse of children and adolescents in Africa: a review and implications for practice. Trauma Violence Abuse. 2015;16(1):81–107.View ArticlePubMedGoogle Scholar
  7. Pence BW, Shirey K, Whetten K, Agala B, Itemba D, Adams J, Whetten R, Yao J, Shao J. Prevalence of psychological trauma and association with current health and functioning in a sample of HIV-infected and HIV-uninfected Tanzanian adults. PLoS One. 2012;7(5), e36304.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Suliman S, Mkabile SG, Fincham DS, Ahmed R, Stein DJ, Seedat S. Cumulative effect of multiple trauma on symptoms of posttraumatic stress disorder, anxiety, and depression in adolescents. Compr Psychiatry. 2009;50(2):121–7.View ArticlePubMedGoogle Scholar
  9. Whetten K, Shirey K, Pence BW, Yao J, Thielman N, Whetten R, Adams J, Agala B, Ostermann J, O’Donnell K, et al. Trauma history and depression predict incomplete adherence to antiretroviral therapies in a low income country. PLoS One. 2013;8(10), e74771.View ArticlePubMedPubMed CentralGoogle Scholar
  10. Brezing C, Ferrara M, Freudenreich O. The syndemic illness of HIV and trauma: implications for a trauma-informed model of care. Psychosomatics. 2015;56(2):107–18.View ArticlePubMedGoogle Scholar
  11. Neller DJ, Denney RL, Pietz CA, Thmlinson RP. Testing the Trauma Model of Violence. J Fam Viol. 2005;3Google Scholar
  12. Khan MR, Kaufman JS, Pence BW, Gaynes BN, Adimora AA, Weir SS, Miller WC. Depression, Sexually Transmitted Infection, and Sexual Risk Behavior Among Young Adults in the United States. Arch Pediatr Adolesc Med. 2009;163(7):644.View ArticlePubMedPubMed CentralGoogle Scholar
  13. Brawner BM, Gomes MM, Jemmott LS, Deatrick JA, Coleman CL. Clinical depression and HIV risk-related sexual behaviors among African-American adolescent females: unmasking the numbers. AIDS Care. 2012;24(5):618–25.View ArticlePubMedPubMed CentralGoogle Scholar
  14. Shrier LA, Harris SK, Sternberg M, Beardslee WR. Associations of depression, self-esteem, and substance use with sexual risk among adolescents. Prev Med. 2001;33(3):179–89.View ArticlePubMedGoogle Scholar
  15. Hutton HE, Lyketsos CG, Zenilman JM, Thompson RE, Erbelding EJ. Depression and HIV risk behaviors among patients in a sexually transmitted disease clinic. Am J Psychiatry. 2004;161(5):912–4.View ArticlePubMedGoogle Scholar
  16. Gibbs A, Willan S, Sikwyiya Y, Jama Shai N, Washington L. Experiences of childhood trauma increases HIV-risk behaviours in young women and men in urban informal settlements in South Africa. Durban: World AIDS Conference 2016; 2016.Google Scholar
  17. Nduna M, Jewkes RK, Dunkle KL, Shai NP, Colman I. Associations between depressive symptoms, sexual behaviour and relationship characteristics: a prospective cohort study of young women and men in the Eastern Cape, South Africa. J Int AIDS Soc. 2010;13:44.View ArticlePubMedPubMed CentralGoogle Scholar
  18. Barhafumwa B, Dietrich J, Closson K, Samji H, Cescon A, Nkala B, Davis J, Hogg RS, Kaida A, Gray G, et al. High prevalence of depression symptomology among adolescents in Soweto, South Africa assocaited with being female and cofactors relating to HIV transmission. Vulnerable Child Youth Stud. 2016;11(3):263–73.Google Scholar
  19. Millstein B. Introduction to the Syndemics Prevention Network 2002. Accessed 14th Nov 2016. [http://www2.cdc.gov/syndemics/PPT/An%20Introduction%20to%20Syndemics%20(as%20delivered).ppt].
  20. Batchelder AW, Gonzalez JS, Palma A, Schoenbaum E, Lounsbury DW. A Social Ecological Model of Syndemic Risk affecting Women with and At-Risk for HIV in Impoverished Urban Communities. Am J Community Psychol. 2015;56(3–4):229–40.View ArticlePubMedGoogle Scholar
  21. Kaminer D, Hardy A, Heath K, Mosdell J, Bawa U. Gender patterns in the contribution of different types of violence to posttraumatic stress symptoms among South African urban youth. Child Abuse Negl. 2013;37(5):320–30.View ArticlePubMedGoogle Scholar
  22. Abrahams N, Devries K, Watts C, Pallitto C, Petzold M, Shamu S, García-Moreno C. Worldwide prevalence of non-partner sexual violence: a systematic review. Lancet. 2014;383(9929):1648–54.View ArticlePubMedGoogle Scholar
  23. Decker MR, Peitzmeier S, Olumide A, Acharya R, Ojengbede O, Covarrubias L, Gao E, Cheng Y, Delany-Moretlwe S, Brahmbhatt H. Prevalence and Health Impact of Intimate Partner Violence and Non-partner Sexual Violence Among Female Adolescents Aged 15–19 Years in Vulnerable Urban Environments: A Multi-Country Study. J Adolesc Health. 2014;55(6 Suppl):S58–67.View ArticlePubMedGoogle Scholar
  24. Jewkes R, Sikweyiya Y, Morrell R, Dunkle K. Gender inequitable masculinity and sexual entitlement in rape perpetration South Africa: findings of a cross-sectional study. PLoS One. 2011;6(12):e29590.View ArticlePubMedPubMed CentralGoogle Scholar
  25. Jewkes R, Abrahams N. The epidemiology of rape and sexual coercion in South Africa: an overview. Soc Sci Med. 2002;55:1231–44.View ArticlePubMedGoogle Scholar
  26. Dunkle KL, Jewkes RK, Brown HC, Yoshihama M, Gray GE, McIntyre JA, Harlow SD. Prevalence and patterns of gender-based violence and revictimization among women attending antenatal clinics in Soweto, South Africa. Am J Epidemiol. 2004;160(3):230–9.View ArticlePubMedGoogle Scholar
  27. Dhaffala A, Longo-Mbenza B, Kingu JH, Peden M, Kafuko-Bwoye A, Clarke M, Mazwai EL. Demographic profile and epidemiology of injury in Mthatha, South Africa. Afr Health Sci. 2013;13(4):1144–8.View ArticlePubMedPubMed CentralGoogle Scholar
  28. Otwombe KN, Dietrich J, Sikkema KJ, Coetzee J, Hopkins KL, Laher F, Gray GE. Exposure to and experiences of violence among adolescents in lower socio-economic groups in Johannesburg, South Africa. BMC Public Health. 2015;15:450.View ArticlePubMedPubMed CentralGoogle Scholar
  29. Norris FH. Epidemiology of trauma: frequency and impact of different potentially traumatic events on different demographic groups. J Consult Clin Psychol. 1992;60(3):409–18.View ArticlePubMedGoogle Scholar
  30. Pitpitan EV, Kalichman SC, Eaton LA, Cain D, Sikkema KJ, Watt MH, Skinner D, Pieterse D. Co-occurring psychosocial problems and HIV risk among women attending drinking venues in a South African township: a syndemic approach. Ann Behav Med. 2013;45(2):153–62.View ArticlePubMedPubMed CentralGoogle Scholar
  31. Amir M, Sol O. Psychological impact and prevalence of traumatic events in a student sample in Israel: the effect of multiple traumatic events and physical injury. J Trauma Stress. 1999;12(1):139–54.View ArticlePubMedGoogle Scholar
  32. Census 2011- main place “Soweto” [https://www.citypopulation.de/php/southafrica-cityofjohannesburg.php?cid=798026].
  33. Nkala B, Khunwane M, Dietrich J, Otwombe K, Sekoane I, Sonqishe B, Gray G. Kganya Motsha Adolescent Centre: a model for adolescent friendly HIV management and reproductive health for adolescents in Soweto, South Africa. AIDS Care. 2015;27(6):697–702.View ArticlePubMedGoogle Scholar
  34. Dietrich J, Khunwane M, Laher F, de Bruyn G, Sikkema KJ, Gray G. “Group sex” parties and other risk patterns: A qualitative study about the perceptions of sexual behaviors and attitudes of adolescents in Soweto, South Africa. Vulnerable Child Youth Stud. 2011;6(3):244–54.View ArticlePubMedPubMed CentralGoogle Scholar
  35. Dietrich J, Sikkema K, Otwombe KN, Sanchez A, Nkala B, de Bruyn G, Van Der Watt M, Gray GE. Multiple levels of influence in predicting sexual activity and condom use among adolescents in Soweto, Johannesburg, South Africa. J HIV AIDS Soc Serv. 2013;12(3–4):404–23.View ArticlePubMedPubMed CentralGoogle Scholar
  36. Otwombe KN, Sikkema KJ, Dietrich J, de Bruyn G, van der Watt M, Gray GE. Willingness to participate in biomedical HIV prevention studies after the HVTN 503/Phambili trial: a survey conducted among adolescents in Soweto, South Africa. J Acquir Immune Defic Syndr. 2011;58(2):211–8.View ArticlePubMedPubMed CentralGoogle Scholar
  37. Miller CL, Nkala B, Closson K, Chia J, Cui Z, Palmer A, Hogg RS, Gray G, Dietrich J. The Botsha Bophelo Adolescent Health Study (BBAHS): a profile of a South African - Canadian research collaboration. PLoS One. 2016. In PressGoogle Scholar
  38. Gray MJ, Slagle DM. Selecting a Potentially Traumatic Event Screening Measure. J Trauma Pract. 2006;5(2):1–19.View ArticleGoogle Scholar
  39. Kendall A, Olson CM, Edward A, Frongillo J. Validation of the Radimer/Cornell Measures of HUnger and Food Security. J Nutr. 1995;125:2793–801.PubMedGoogle Scholar
  40. Radloff LS. The CES-D scale a self-report depression scale for research in the general population. Appl Psychol Meas. 1977;1(3):385–401.View ArticleGoogle Scholar
  41. Lewinsohn PM, Seeley JR, Roberts RE, Allen NB. Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults. Psychol Aging. 1997;12(2):277–87.View ArticlePubMedGoogle Scholar
  42. Chabrol H, Montovany A, Chouicha K, Duconge E. Study of the CES-D on a sample of 1,953 adolescent students. L’Encéphale. 2002;28(5 Pt 1):429–32.PubMedGoogle Scholar
  43. Bamidele JO, Asekun-Olarinmoye EO, Odu OO, Amusan OA, Egbewale BE. Sociodemographic characteristics and health risk behaviours among students of a tertiary institution in south western Nigeria. Afr J Med Med Sci. 2007;36(2):129–36.PubMedGoogle Scholar
  44. van Heerden MS, Grimsrud AT, Seedat S, Myer L, Williams DR, Stein DJ. Patterns of substance use in South Africa: results from the South African Stress and Health study. S Afr Med J. 2009;99(5 Pt 2):358–66.PubMedPubMed CentralGoogle Scholar
  45. Peltzer K. Predictors of positive health among a sample of South African adolescents. Psychol Rep. 2007;100(3 Pt 2):1186–8.PubMedGoogle Scholar
  46. McLaughlin KA, Koenen KC, Hill ED, Petukhova M, Sampson NA, Zaslavsky AM, Kessler RC. Trauma exposure and posttraumatic stress disorder in a national sample of adolescents. J Am Acad Child Adolesc Psychiatry. 2013;52(8):815–30. e814.View ArticlePubMedPubMed CentralGoogle Scholar
  47. Global Burden of Disease Pediatrics C, Kyu HH, Pinho C, Wagner JA, Brown JC, Bertozzi-Villa A, Charlson FJ, Coffeng LE, Dandona L, Erskine HE, et al. Global and National Burden of Diseases and Injuries Among Children and Adolescents Between 1990 and 2013: Findings From the Global Burden of Disease 2013 Study. JAMA Pediatrics. 2016.Google Scholar
  48. Jewkes R, Nduna M, Levin J, Jama N, Dunkle K, Puren A, Duvvury N. Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial. BMJ. 2008;337:a506.View ArticlePubMedPubMed CentralGoogle Scholar
  49. Hinsberger M, Sommer J, Kaminer D, Holtzhausen L, Weierstall R, Seedat S, Madikane S, Elbert T. Perpetuating the cycle of violence in South African low-income communities: attraction to violence in young men exposed to continuous threat. Eur J psychotraumatol. 2016;7:29099.View ArticlePubMedGoogle Scholar
  50. Jewkes R, Nduna M, Jama-Shai N, Chirwa E, Dunkle K. Understanding the Relationships between Gender Inequitable Behaviours, Childhood Trauma and Socio-Economic Status in Single and Multiple Perpetrator Rape in Rural South Africa: Structural Equation Modelling. PLoS One. 2016;11(5):e0154903.View ArticlePubMedPubMed CentralGoogle Scholar
  51. Jewkes RK, Dunkle K, Nduna M, Shai N. Intimate partner violence, relationship power inequity, and incidence of HIV infection in young women in South Africa: a cohort study. Lancet. 2010;376:41–8.View ArticlePubMedGoogle Scholar
  52. Jewkes R, Morrell R. Gender and sexuality: emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. J Int AIDS Soc. 2010;13:6.PubMedPubMed CentralGoogle Scholar
  53. Sherr L, Nagra N, Kulubya G, Catalan J, Clucas C, Harding R. HIV infection associated post-traumatic stress disorder and post-traumatic growth--a systematic review. Psychol Health Med. 2011;16(5):612–29.View ArticlePubMedGoogle Scholar
  54. Murray LK, Skavenski S, Kane JC, Mayeya J, Dorsey S, Cohen JA, Michalopoulos LT, Imasiku M, Bolton PA. Effectiveness of Trauma-Focused Cognitive Behavioral Therapy Among Trauma-Affected Children in Lusaka, Zambia: A Randomized Clinical Trial. JAMA Pediatr. 2015;169(8):761–9.View ArticlePubMedGoogle Scholar
  55. Pronyk PM, Hargreaves JR, Kim JC, Morison LA, Phetla G, Watts C, Busza J, Porter JDH. Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial. Lancet. 2006;368(9551):1973–83.View ArticlePubMedGoogle Scholar
  56. Harrison A, Colvin CJ, Kuo C, Swartz A, Lurie M. Sustained High HIV Incidence in Young Women in Southern Africa: Social, Behavioral, and Structural Factors and Emerging Intervention Approaches. Curr HIV/AIDS Rep. 2015;12(2):207–15.View ArticlePubMedPubMed CentralGoogle Scholar
  57. Pettifor A, Nguyen NL, Celum C, Cowan FM, Go V, Hightow-Weidman L. Tailored combination prevention packages and PrEP for young key populations. J Int AIDS Soc. 2015;18(2 Suppl 1):19434.PubMedPubMed CentralGoogle Scholar
  58. Jewkes RK, Levin JB, Penn-Kekana LA. Gender inequalities, intimate partner violence and HIV preventive practices: findings of a South African cross-sectional study. Soc Sci Med. 2003;56(1):125–34.View ArticlePubMedGoogle Scholar
  59. Petersen I, Bhana A, McKay M. Sexual violence and youth in South Africa: the need for community-based prevention interventions. Child Abuse Negl. 2005;29(11):1233–48.View ArticlePubMedGoogle Scholar
  60. Schuyler AC, Masvawure TB, Smit JA, Beksinska M, Mabude Z, Ngoloyi C, Mantell JE. Building young women’s knowledge and skills in female condom use: lessons learned from a South African intervention. Health Educ Res. 2016;31(2):260–72.View ArticlePubMedGoogle Scholar
  61. Bhana A, Zimmerman R, Cupp P. Gender role attitudes and sexual risk among adolescents in South Africa. Vulnerable Child Youth Stud. 2008;3:112–9.View ArticleGoogle Scholar
  62. Swan H, O’Connell DJ. The impact of intimate partner violence on women's condom negotiation efficacy. J Interpers Violence. 2012;27(4):775–92.View ArticlePubMedGoogle Scholar
  63. Hien DA, Campbell AN, Killeen T, Hu MC, Hansen C, Jiang H, Hatch-Maillette M, Miele GM, Cohen LR, Gan W, et al. The impact of trauma-focused group therapy upon HIV sexual risk behaviors in the NIDA Clinical Trials Network “Women and trauma” multi-site study. AIDS Behav. 2010;14(2):421–30.View ArticlePubMedGoogle Scholar
  64. van der Walt L, Suliman S, Martin L, Lammers K, Seedat S. Resilience and post-traumatic stress disorder in the acute aftermath of rape: a comparative analysis of adolescents versus adults. J Child Adolesc Mental health. 2014;26(3):239–49.View ArticleGoogle Scholar
  65. Igras SM, Macieira M, Murphy E, Lundgren R. Investing in very young adolescents’ sexual and reproductive health. Glob Public Health. 2014;9(5):555–69.View ArticlePubMedPubMed CentralGoogle Scholar
  66. Johansson EE, Alex L, Christianson M. Gendered discourses of youth sexualities--an exploration of PubMed articles on prevention of sexually transmissible infections. Sex Reprod Healthc. 2014;5(3):81–9.View ArticlePubMedGoogle Scholar

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