Does free schooling affect pathways from adverse childhood experiences via mental health distress to HIV risk among adolescent girls in South Africa: a longitudinal moderated pathway model

Abstract

Introduction Adolescent girls are at high risk of HIV infection in sub‐Saharan Africa. Mental health distress, driven by adverse childhood experiences (ACEs) such as abuse, poverty and family HIV, may be an important driver of HIV risk behaviour among adolescent girls, while education may mitigate these risks. This study aimed to develop an empirically based theoretical model between ACEs, mental health distress and HIV risk behaviour among adolescent girls in South Africa and to investigate the potential moderating effects of free schooling provision. Methods Self‐report questionnaires using validated scales were completed by adolescent girls aged 12 to 17 at baseline in two provinces in South Africa in 2011, with a 99% one‐year follow‐up in 2012 (n = 1498). Sampling included every household in randomly selected census enumeration areas of four deprived health districts. Confirmatory factor analysis was employed to identify measurement models and a structural equation model was developed to test pathways of risk and protection. Results Internalizing and externalizing mental health distress fully mediated the positive relationship between ACEs at baseline and HIV risk behaviour at follow‐up among adolescent girls. Internalizing mental health distress was associated with increased sexual risk at follow‐up via higher externalizing problems. Free schooling provision at baseline and follow‐up eliminated the pathway from internalizing to externalizing mental health distress by moderating the pathway between ACEs and internalizing mental health distress. It also weakened the pathway from externalizing mental health distress to HIV risk behaviour at follow‐up through a direct negative effect on externalizing mental health distress. Conclusions Reducing ACEs and adolescent mental health distress is essential for reducing HIV risk behaviour among girls in South Africa. Free schooling provision may be an important tool for reducing these problems and mitigating negative pathways to HIV risk among vulnerable adolescent girls.

Developing the Concept of Adverse Childhood Experiences: A Global Perspective

“…Researchers referred to these categories as "adverse psychological experiences" (Danese et al, 2009, p. 3). Furthermore, studies in four countries on three different continents, Iraq, South Africa, the Philippines, and Brazil concurred that poverty significantly contributed to ACEs (Al-Shawi & Lafta, 2015;Meinck, Orkin, & Cluver, 2019;Ramiro et al, 2010;Soares et al, 2016Soares et al, ) 2016. In an Iraqi study, poverty, education, personality type, and presence in a war zone were associated with high ACEs (Al-Shawi & Lafta, 2015).…”

Intervening for HIV prevention and mental health: a review of global literature

“…A South African study of HIV risk, adverse childhood experiences (ACEs), adolescent mental health, and free schooling for adolescent girls, found that relationships between ACEs and HIV risk behaviour were mediated by internalizing and externalizing symptoms [62]. Free schooling was associated with fewer externalizing symptoms, suggesting that the mental health-promoting effects of free education confer some protection against HIV risk.…”

“…Cash transfers led to better HIV risk outcomes for boys and girls, but better mental health outcomes for boys [57]. Nevertheless, for vulnerable girls, access to social resources such as free school or cash transfers reduced behaviours directly and indirectly related HIV risk [57,62]. HIV programme implementers must also consider how the social vulnerabilities of adolescents may increase the risk of coercive participation in HIV prevention or may indirectly create barriers to interventions (e.g.…”

A prospective study on adverse childhood experiences and HIV-related risk among adolescents in Malawi

“…It has the added benefit of simplifying data presentation when examining multiple model specifications, and has been used to capture HIV risk in prior studies [e.g. 30,31]. We created composite behavioral risk scores using four binary indicators: no condom use at last sex; early sexual debut (<16 years); three or more lifetime sexual partners; and age-disparate partnerships (>5 years difference).…”