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Table of Contents Social-Structural Determinants of HIV vulnerability in Marriage: Role of gender norms and power relations, masculinity, social norms and relationship quality A study from the Ifakara town, Tanzania Inauguraldissertation zur Erlangung der Würden eines Doktors der Philosophie vorgelegt der Philosophisch-Naturwissenschaftlichen Fakultät der Universität Basel von Sally Mmanyi Mtenga aus Tansania Basel, 2016 Originaldokument gespeichert auf dem Dokumentenserver der Universität Basel edoc.unibas.ch Genehmigt von der Philosophisch-Naturwissenschaflichen Fakultät auf Antrag von Prof. Dr. Marcel Tanner (Fakultätsverantwortlicher), Dr. Constanze Pfeiffer (Dissertationsleiterin) und Prof. Jacob Malungo (Korreferent). Basel, den 20.9. 2016 Prof. Dr. Jörg Schibler Dekan Dedication To the memory of my lovely, adorable late mother Josephine Mgonja To my lovely father Dr. Allyson Mmanyi To my precious husband Joseph Mtenga and our lovely children (Gabriel and Gideon) Tables of contents Table of contents List of Tables…………………………………………………………………………………………...VI List of Figures….………………………………………………………………………………..…..…VII List of Publications………………………………………………………………..………………….VIII Summary …………………………………………………………………….......…………………..…IX Acknowledgements ……………………………………………………………………………….....XV List of abbreviations………………………………………………….……………………….……..XIX 1. Introduction ........................................................................................................................ 1 1.1. The burden of HIV in adults and among married partners in SSA.................................. 1 1.2. The burden of HIV among adults including married partners in Tanzania ...................... 2 1.3. Factors associated with HIV vulnerability among adults focusing on marriage .............. 4 1.4. Global strategies to address HIV in adults and among married partners ....................... 5 1.5. Strategies to address HIV vulnerability in Tanzania ....................................................... 6 1.6. The typology of marriage in Tanzania ........................................................................... 9 2. Conceptual framework ..................................................................................................... 11 2.1 The WHO Commission on the Social Determinants of Health (WHO-CSDHs) framework .............................................................................................................................. 11 2.2 Levels of study investigation within the WHO-SDHs approach .................................... 14 2.3 Social structures .......................................................................................................... 15 2.4 Social norms as the structural determinants of health ................................................. 16 2.5 Gender power relation as a social determinant of health ............................................. 17 2.6 Relationship quality as a social determinant of health ................................................. 17 3. Aims and Objectives ........................................................................................................ 19 4. Study setting and methods ............................................................................................. 20 4.1. Study area ................................................................................................................... 20 4.2. Methods ...................................................................................................................... 22 4.3. Data entry and analysis ............................................................................................... 27 Ethics ..................................................................................................................................... 28 5. Prevalence and social drivers of HIV among married and cohabitating heterosexual adults in south-eastern Tanzania: analysis of adult health community cohort data .......... 29 5.1. Abstract ....................................................................................................................... 30 5.2. Background ................................................................................................................. 31 5.3. Methods ...................................................................................................................... 32 5.4. Results ........................................................................................................................ 36 Tables of contents 5.5. Discussion ................................................................................................................... 40 5.6. Conclusion .................................................................................................................. 43 6. Gender differences in exposure to HIV infection through extramarital affairs, and the contextual determinants of extramarital affairs among adults in a rural community- Tanzania: A mixed methods study ......................................................................................... 45 6.1. Abstract ....................................................................................................................... 46 6.2. Introduction ................................................................................................................. 48 6.3. Methods ...................................................................................................................... 51 6.4. Results ........................................................................................................................ 56 6.5. Discussion ................................................................................................................... 68 6.6. Conclusion .................................................................................................................. 72 Limitation ............................................................................................................................... 73 7. “It is not expected for married couples”: A qualitative study on challenges to safer sex communication among polygamous and monogamous partners in southeastern Tanzania ................................................................................................................................... 75 7.1 Abstract ....................................................................................................................... 76 7.2 Introduction ................................................................................................................. 77 7.3 Methods ...................................................................................................................... 80 7.4 Results ........................................................................................................................ 84 7.5 Discussion ................................................................................................................... 89 7.6 Conclusion .................................................................................................................. 92 8.0. Overall discussion and conclusion ............................................................................. 94 8.1. Gender norms, gender power relations and women’s economic hardship as structural determinants of HIV vulnerability in marriage ......................................................................... 95 8.2. Norms of Masculinity, social expectations and social norms as structural determinants of HIV vulnerability in marriage .............................................................................................. 97 8.3. Relationship quality and marital status (polygamous, remarriage) as social determinants of HIV vulnerability ........................................................................................... 98 8.4. Strengths and limitations of methods and design ........... Error! Bookmark not defined. 8.5. Implication for policy, theory and practice .................................................................. 102 8.6. Novel contributions of the thesis ................................................................................ 107 8.6.1 Proposed modelef for understanding HIV vulnerability in marriage..................... 107 8.7. Overall conclusion ..................................................................................................... 109 9 References ...................................................................................................................... 112 List of tables List of tables Table 5-1: Frequency distribution of currently married men and women in Ifakara, Tanzania .... 36 Table 5-2: Bivariate analysis of HIV status by each of the independent variables among currently married men and women in Ifakara, Tanzania (cross-tabulations) (n = 3,737) ........................... 38 Table 5-3: Multivariate logistic regression of correlates of HIV positive status among currently married men and women in Ifakara, Tanzania (n=3,737) ........................................................... 40 Table 6-1: Profile of respondents for extra marital affair assessment in Ifakara, ........................ 56 Table 6-2: The Logistic regression results of the association between extramarital affair and HIV status of men and women in Ifakara town, Tanzania (2015) ...................................................... 57 Table 6-3: Percentages distribution of extramarital affair practices by characteristics
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