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Prevalence, type, and correlates of trauma exposure among adolescent men and women in Soweto, South Africa:… Closson, Kalysha; Dietrich, Janan J; Nkala, Busi; Musuku, Addy; Cui, Zishan; Chia, Jason; Gray, Glenda; Lachowsky, Nathan J; Hogg, Robert S; Miller, Cari L; Kaida, Angela Nov 25, 2016

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RESEARCH ARTICLE Open AccessPrevalence, type, and correlates of traumaexposure among adolescent men andwomen in Soweto, South Africa:implications for HIV preventionKalysha 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 Kaida1*AbstractBackground: Youth trauma exposure is associated with syndemic HIV risk. We measured lifetime prevalence, type, andcorrelates 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 atraumatic 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 assessedindependent correlates of ‘high PTE score’ (≥7 PTEs).Results: Overall, 767/830 (92%) participants were included (58% adolescent women). Nearly all (99.7%) reportedexperiencing at least one PTE. Median PTE was 7 [Q1,Q3: 5-9], with no gender differences (p = 0.19). Adolescent menreported 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 wasindependently 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 PTEscore was associated with depression using the CES-D scale (aOR = 2.00, 95%CI = 1.31-3.03,) and inconsistent condomuse 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 andcorrelates, but not prevalence. Exposure to PTEs were distributed along social and gendered axes. Among adolescentwomen, associations with depression and inconsistent condom use suggest pathways for HIV risk. HIV preventioninterventions 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 andreproductive health, South Africa* Correspondence: Kangela@sfu.ca1Faculty of Health Sciences, Simon Fraser University (SFU), Blusson Hall Rm10522, 8888 University Drive, Burnaby BC V5A 1S6, CanadaFull list of author information is available at the end of the article© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe 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.Closson et al. BMC Public Health  (2016) 16:1191 DOI 10.1186/s12889-016-3832-0BackgroundSouth Africa has one of the highest rates of HIV globally,with an adult prevalence of 17.9% [1]. HIV disproportion-ately affects young people, and young women in particu-lar. Among youth aged 15 to 24 years of age, 13.3% ofyoung women and 3.8% of young men are living with HIV[2]. Addressing the high rate and burden of HIV amongSouth African youth, and adolescent women in particular[3], is a national and global public health priority. Whileefforts are underway to scale-up access to several biomed-ical HIV prevention tools, including pre-exposure prophy-laxis (PrEP), antiretroviral therapy (ART) for prevention(‘TasP’), medical male circumcision, and female and malecondoms [3, 4], demand for these programs will be shapedby the broader developmental, social and structural forceswhich influence adolescent sexual behaviour [5]. Atpresent, there is a lack of literature on gendered differ-ences in prevalence, types and influence of traumatic ex-periences and their relationship with adolescent HIV risk.Experiences of childhood trauma are common amongadolescents in South Africa, with estimates of physicaland sexual violence in childhood ranging from 1.6–54.2% [6]. Traumatic experiences in childhood andadolescence have serious implications for short andlong-term psychological and physical health outcomes,and have been associated with increased incidence ofHIV [7–11]. The pathway from trauma and depressionto heightened risk of HIV and other sexually transmittedinfections has been described through the negative ef-fects of depression on impulse control, risk perception[12], self-esteem and self-efficacy [13], substance use[14], and socio-structural vulnerability [15], which com-promise HIV prevention behaviours [16, 17]. Such path-ways are highly gendered, with both the prevalence ofdepression and associations with increased risk of con-domless sex shown to be higher among adolescentwomen than adolescent men [18].The disproportionate exposure to potentially traumaticevents (PTEs) experienced by people living with HIV(PLHIV), has been referred to as a syndemic (“synergis-tically interacting epidemics”) [19], yielding a range ofpoor social, clinical, and public health outcomes, includ-ing decreased social functioning, elevated rates of post-traumatic stress disorder (PTSD), increased prevalenceof high-risk sexual and drug use behaviours, suboptimaladherence to ART, poor HIV clinical outcomes,increased HIV transmission risk, and higher mortality[7, 9, 10]. Little attention, however, has focused on gen-dered impacts and the presence of syndemic risks whichcan have a multiplicative effect on HIV risk [20], includ-ing multiple types of PTEs (e.g. physical, sexual, andemotional) [21].Adolescent men and women are exposed to differenttypes and consequences of trauma, particularly withrespect to violent and non-violent forms. Globally, vio-lence against women is a major social justice issue[22, 23], an under-addressed public health priority, andan established risk factor for HIV acquisition andother negative health outcomes [3, 24]. In SouthAfrica, where reports of violence are known to under-estimate the true prevalence [25], 20% of women at-tending antenatal care reported experiencing sexualviolence, among the highest prevalence in the world[22, 26]. Among adolescent men, experiences of per-petrating or witnessing interpersonal violence driverates of trauma exposure [11, 24, 27]. This is signifi-cant as earlier research among South African adoles-cent men demonstrated an association betweenwitnessing community violence and high sexual HIVrisk behaviours such as multiple concurrent sexualpartnerships [28].The effects of experiencing trauma on mental healthand coping strategies also differ between adolescent menand women in ways that influence HIV risk pathways.For instance, PTEs experienced by South African womenhave been shown to increase internalized behaviourssuch as depression, anxiety and PTSD [23, 29], whichsynergistically contribute to increased risk for HIV andother sexually transmitted infections (STIs) [26, 30].However, adolescent men are more likely to respond toPTEs with adverse externalized behaviours that intro-duce HIV risk, including delinquency, aggression andsubstance abuse [21]. This distinction in type of PTEsand behavioural responses demands gender-specific ana-lysis, support, and response.We measured the lifetime prevalence and correlatesof PTEs overall, and by gender among adolescentmen and women in Soweto, South Africa. This infor-mation is critical to inform youth-centred sexual andreproductive health and HIV prevention programmingthat considers the broader risk environments thatyouth navigate [31].MethodsStudy settingWe used cross-sectional survey data from adolescents(aged 14–19 years) enrolled in the Botsha Bophelo Ado-lescent Health Study (BBAHS) in Soweto, South Africa.Soweto is a large township southwest of Johannesburgwith a population of approximately 1.3 million predomin-antly (98.5%) black inhabitants residing in informal andformal settlements [32]. While there are no population-level statistics on HIV prevalence among adolescents inSoweto, a recent study of 11,552 adolescents and youngadults (14–25 years) residing in Soweto, reported that 4%of those who accessed HIV testing services at a localyouth-centered clinic tested positive for HIV, including 2%of young men 4% of young women [33].Closson et al. BMC Public Health  (2016) 16:1191 Page 2 of 15BBAHS was conducted at the Perinatal Health Re-search Unit (PHRU) and the Kganya Motsha AdolescentCentre (KMAC) in Soweto, South Africa. KMAC wasopened in 2008 with a local mandate to address HIV andsexual and reproductive health priorities of adolescents(ages 14–19 years). Earlier pilot studies on adolescenthealth identified the urgent need for such youth-centredservices, and informed the development and implementa-tion of BBAHS [33–36].Study participantsAdolescents aged 14–19 years residing in Soweto wereeligible to participate in BBAHS. Participants were re-cruited from across 41 townships to be representative ofadolescents living in formal and informal communitieswithin Soweto. Participant recruitment occurred aroundlocal malls, schools, neighbourhood hangouts, throughpeer-word-of-mouth, and staff outreach. We used a tar-geted stratified sampling and recruitment approach,based on geographic location, age, and gender. In orderto reflect the gendered dimensions of HIV risk in SouthAfrica, we aimed for a sample comprised of 60% youngwomen and 40% young men. The research teamapproached interested adolescents for participation, andif eligible, were enrolled in the study. A total of 956 in-terviews were completed between March 2010 andMarch 2012. This amount of recruitment time was re-quired to meet stratified sampling targets, and to ensureinclusion of youth from more remotely located town-ships with Soweto and harder-to-reach youth sub-populations. Of 956 completed interviews, n = 126 wereexcluded as they were determined to be outside of thetargeted age criteria or had incomplete data, yielding afinal sample of 830 adolescent participants. Additionalinformation about the study procedures of the BBAHScan be found elsewhere [37].Ethical considerationsAdolescents under 18 years signed an informed assentform and provided a signed informed consent form froma parent or legal guardian. Adolescents aged 18 or 19signed an informed consent form. Age was verified usingbirth certificates or other identity documents.Ethical approval for the study was granted by the ethicscommittees of the University of the Witwatersrand(Johannesburg, South Africa) and Simon Fraser University(Burnaby, Canada).Data collectionAn interviewer-administered, structured, online ques-tionnaire was delivered to participants (supported bySurveyMonkeyTM software) via iPad or desktop com-puter. Interviewers received extensive training in goodclinical practice guidelines, participant recruitment,administering questionnaires, and participant referral incases where additional support was required after thestudy visit. Interviews were conducted in either Englishor isiZulu at the PHRU, the KMAC, or at a private loca-tion selected by the participant. Questionnaires took anaverage of 60 min to complete, and participants received50 Rand (approximately 7 USD at the time) as compen-sation for their time and transportation costs. An inter-national team of experts in adolescent health and HIV,including an adolescent Community Advisory Board(CAB), contributed to the development of the BBAHSquestionnaire [37].MeasuresPrimary outcome: trauma experienceAssessment of ‘trauma experience’ followed Norris’ [29]comprehensive definition of traumatic events as “anyevent that produces symptoms of traumatic stress” (23, p.409). We measured PTEs using a modified version ofthe Traumatic Events Screening Inventory–Child (TESI-C) [29]. Unlike other trauma scales, the TESI-C scalewas developed to be language appropriate for childrenand youth.The TESI-C measures the history of trauma by ask-ing about exposure (“yes” vs. “no”) to twenty PTEsincluding “injuries, hospitalizations, domestic vio-lence, community violence, disasters, accidents, phys-ical abuse and sexual abuse” [38]. Historically, thisscale has been used in child and adolescent psycho-logical screening [38]. For our study, the TESI-Citems were modified to account for the social contextand physical environment of adolescents in Soweto[38]. For example, TESI-C items regarding natural di-sasters, acts of war or terrorism, kidnapping and ani-mal attacks were omitted. Similar to other SouthAfrican studies examining the impact of traumaticexperiences in adolescents, we added items regardingparents 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 wereadded. The final adapted scale included a total of 19items (study alpha = 0.63; Table 2). A comparison ofitems from the original TESI-C scale and the modi-fied version used in this analysis is included in theAdditional file 1.We measured prevalence of experiencing a potentiallytraumatic event (i.e., a response of “Yes” to one or moreof the 19 items included in the modified TESI-C scale)overall and by gender. We also assessed number of re-ported 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’.Closson et al. BMC Public Health  (2016) 16:1191 Page 3 of 15Explanatory factorsSocio-demographic characteristics We assessed socio-demographic characteristics by gender (adolescent manvs. adolescent woman), age in years (continuous), ethni-city (Zulu, Xhosa, Sotho, Tswana or other), education(high school or greater vs. less than high school), andemployment (student vs. unemployed vs. employed [full-time/part-time/self-employed]). Additional determinantsof socio-economic status included length of time livingin Soweto (<5 years vs. ≥5 years vs. since birth), housingtype (brick house or flat owned by family vs. brick houseor flat rented by family or other housing type vs. recon-structive development housing [RDP] or shack), food in-security (low vs. medium vs. high, measured via a 9-itemhunger and food security scale [39] [study Cronbach’s α= 0.81]), and receiving a household social grant in thepast 12-months (yes vs. no; including disability, age pen-sion, child support or other social grant), and history ofincarceration (ever vs. never).Depression The 20-point Center for EpidemiologicStudies Depression (CES-D) Scale was utilized to meas-ure probable depression (study Cronbach’s α = 0.81,range = 0-60, with higher scores indicating greater de-pressive symptoms) [40]. In the general population theAmerican Psychological Association suggests using a cutoff of 16 or higher to determine major depressive dis-order [41]. We chose a higher cut off of ≥24 as this hasbeen previously described as the best cut-off to deter-mined ‘probable depression’ among adolescents [18, 42].Sexual behaviour History of sexual activity was definedby participant report of ever having had intercourse (yesvs. no), current sexual activity was defined as having hadsex (vaginal or anal) in the 6 months prior to interview(yes vs. no) and, if yes, whether the participant had morethan one sexual partner in the last 6 months (yes vs. no).Consistent condom use was assessed via self-reportedlifetime use during anal and/or vaginal sex, as applicable,and frequency (always vs.vs sometimes vs. never) in the6 months prior to interview (lifetime consistent condomuse vs. any inconsistent or no condom use vs. never hadsex). History of STI diagnosis and/or symptoms (ever vs.never), history of HIV testing (ever vs. never), and HIVstatus (HIV-positive vs. HIV-negative vs. unknown HIVstatus) was assessed via self-report.Substance use We assessed self-reported frequency ofalcohol use in the 6 months prior to interview (once amonth or more vs. less than once a month or never). Wealso assessed any use of illicit (e.g., heroin, cocaine, ec-stasy) or licit drugs used in a manner other than whichthey are prescribed (e.g., prescription pills, antiretrovials/whoonga), excluding marijuana in the 6 months prior tointerview (yes vs. no). Use of marijuana (yes vs. no) wasassessed separately, given different patterns of use amongyouth [43, 44].Statistical analysisAll analyses were conducted using SAS 9.4, stratified byself-identified gender. Descriptive statistics (median, 1stquartile [Q1] and 3rd quartile [Q3] for continuous vari-ables and n, % for categorical variables) were used tocharacterize baseline distributions of study variables. Dif-ferences in baseline variables and trauma scores by gen-der were compared using Wilcoxon rank sum test forcontinuous variables and Pearson χ2 or Fisher’s exact testfor categorical variables.Univariable and multivariable logistic regression wereused to identify variables associated with high PTE score,separately for adolescent men and women. Variables ofinterest with univariable p-values <0.20 were included inmultivariable model selections. After testing for collinear-ity, only the sexual behaviour variable ‘inconsistent con-dom use (yes vs. no vs. never had sex)’ was considered forinclusion in the final model. For all other variables, modelselections were performed using backward selection basedon Type III p-values to reach the optimal (minimized)AIC. All statistical tests were considered statistically sig-nificant at α < 0.05.ResultsBaseline characteristicsOf 830 participants, 767 answered all 19 TESI-Citems and were included in this analysis of whom 442(58%) were adolescent women and 325 (42%) wereadolescent men (Table 1). Median age was 17 years[Q1-Q3: 16-18], 45% were Zulu, 85% were currentlyenrolled in school, and 6% had ever been incarcer-ated. 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 livedin a household which had received a social grant inthe last 12 months (57%).Overall, 56% of participants reported having everhad sex, including 64% of adolescent men and 50% ofadolescent women (p < 0.001 for gender difference).Of those reporting sexual activity in the six monthsprior to the interview, 35% reported having morethan one sexual partner in the previous 6 months (in-cluding 56% of adolescent men and 18% of adolescentwomen [p < 0.001]). Among those who had ever hadsex, 54% reported inconsistent condom use (including53% of adolescent men and 55% of adolescent women[p = 0.729]) and 23% reported ever having beenClosson et al. BMC Public Health  (2016) 16:1191 Page 4 of 15Table 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-valuen % n % n %Socio-demographic characteristicsAge at interview (years, median, Q1,Q3) 17 16,18 17 16,18 18 16,18 0.197Years 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 12.5Since birth 582 76.7 242 75.6 340 77.5missing 8 5 3EthnicityZulu 345 45.0 166 51.1 179 40.5 0.005Xhosa 92 12.0 39 12.0 53 12.0Sotho 124 16.2 40 12.3 84 19.0Tswana 85 11.1 26 8.0 59 13.4Other ethnicities 121 15.8 54 16.6 67 15.2Education≥ High school 9 1.2 7 2.2 2 0.5 0.041< High school 758 98.8 318 97.9 440 99.6EmploymentStudent 649 85.1 264 81.5 385 87.7 0.056Unemployed 85 11.1 44 13.6 41 9.3Employed 29 3.8 16 4.9 13 3.0Missing <5 <5 <5HousingBrick house/Flat owned by family 547 71.3 220 67.7 327 74.0 0.160Brick house/Flat rented by family/other 18 2.3 9 2.8 9 2.0RDP house/Shack 202 26.3 96 29.5 106 24.0Food InsecurityLow 169 22.0 59 18.2 110 24.9 0.078Medium 203 26.5 88 27.1 115 26.0High 395 51.5 178 54.8 217 49.1Household Social Grant in the last 12 monthsNo 325 42.9 141 44.3 184 41.9 0.506Yes 432 57.1 177 55.7 255 58.1missing 10 7 3Incarceration historyNo 646 93.8 258 91.2 388 95.6 0.019Yes 43 6.2 25 8.8 18 4.4Missing 78 42 36Sexual behaviour and HIV variablesEver had sexNo 338 44.1 116 35.7 222 50.2 <.001Yes 429 55.9 209 64.3 220 49.8Closson et al. BMC Public Health  (2016) 16:1191 Page 5 of 15diagnosed with an STI or experienced STI symptoms(including 17% of adolescent men and 28% of adoles-cent women [p = 0.009]). Overall, 1.4% reported be-ing HIV-positive (1.5% of adolescent men and 1.4% ofwomen, p = 0.19).In the six months prior to interview, nearly two-thirds (65%) reported alcohol use and 5% reportedusing other drugs. One-third (34%) had probable de-pression, with higher rates among adolescent womenthan men (36% vs. 30%, p = 0.05).Experience of potentially traumatic events (PTEs)Nearly all participants (99.7%) reported experiencingat least 1 PTE. Median number of PTEs experiencedwas 7 [Q1-Q3: 5-9], with no significant difference bygender (p = 0.19). Overall, 47% of adolescent menand 45% of adolescent women experienced a highPTE score (≥7 events (p = 0.603)).Table 2 shows the proportion of adolescents who re-ported experiencing each of the 19 PTE items includedin the adapted TESI-C scale by gender. Nearly three-Table 1 Baseline characteristics of participants (aged 14–19 years) overall and by gender (n = 767) (Continued)Sexually Active in the past 6 months (L6M)aNo 153 36.5 80 39.6 73 33.6 0.205Yes 266 63.1 122 60.4 144 66.4missing 10 7 3Number of partners (among those reporting sexual activity in L6M)b1 partner 168 64.6 51 43.6 117 81.8 <.001≥ 2 partner 92 35.4 66 56.4 26 18.2Missing 6Condom useaConsistent condom use 189 46.3 93 47.2 96 45.5 0.729Inconsistent condom use 219 53.7 104 52.8 115 54.5missing 21 12 9HIV testing historyNo 414 54.1 187 57.7 227 51.5 0.087Yes 351 45.9 137 42.3 214 48.5HIV status (self-report)HIV-positive 11 1.4 5 1.5 6 1.4 0.187HIV-negative 329 42.9 127 39.1 202 45.7Unknown/never tested 427 55.7 193 59.4 234 52.9STI or STI symptomologyaNo 332 77.4 173 82.8 159 72.3 <.001Yes 97 22.6 36 17.2 61 27.7Substance use and mental health variablesAlcohol use in the last 6 months (L6M)No 267 34.99 104 32.1 163 37.1 0.150Yes 496 65.01 220 67.9 276 62.9Drug use in L6M (excluding marijuana use)No 728 94.9 297 91.4 431 97.5 <.001Yes 39 5.1 28 8.6 11 2.5Probable DepressionNo 510 66.5 229 70.5 281 63.6 0.046Yes (CES-D score ≥ 24) 257 33.5 96 29.5 161 36.4Note: 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, HIVhuman immunodeficiency virusaAmong those reporting sexual activity everbAmong those reporting sexual activity in the last 6 monthClosson et al. BMC Public Health  (2016) 16:1191 Page 6 of 15quarters (74%) of adolescent men and women reportedexperiencing the death of a family member or someoneclose to them. Over two-thirds (68%) had witnessed aclose family member or friend deal with a serious illnessor injury. Nearly half reported that their parents wereseparated or divorced (48%) or that their family strug-gled with money (46%). In general, adolescent men weremore likely to have experienced or perpetuated violentforms of traumatic experiences (e.g. forcing someone tohave sex with them [7%], deliberately inflicting harm onanother [51%], witnessed an act of violence in the com-munity [76%]). Adolescent women were more likely toexperience psychological and emotional experiences ofpotentially traumatic events (e.g. having a family mem-ber have [46%] or die from [41%] HIV/AIDS).Overall, 14% of adolescent women and 11% of adoles-cent men reported experiencing forced sex (p = 0.153)while 1.4% and 7.4% reported ever forcing someone tohave sex with them (p < 0.001).Correlates of high PTE scoresIn unadjusted models among adolescent men (seeTable 3), high PTE score was associated with older age,living in Soweto for <5 years, self-reported Tswana eth-nicity, high food insecurity, drug use in the past sixmonths, sexual experience, and inconsistent condomuse. In the adjusted model (see Table 3), adolescent menwith high PTE scores had significantly higher adjustedodds of being older (aOR = 1.40/year, 95%CI = 1.21-1.63); recently moving to Soweto (<5 years) vs. living inSoweto ‘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).In the unadjusted models among adolescent women(see Table 4), high PTE score was associated with, highfood insecurity, incarceration history, received a house-hold social grant in the last year, probable depression,sexual experience and inconsistent condom use. In theadjusted model (see Table 4), adolescent women withhigh PTE scores had significantly higher adjusted oddsof 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 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-valuen % n % n %Experienced at least one PTE 765 99.7 325 100.0 440 99.6 0.511High trauma score (≥7) (alpha = 0.63) 348 45.4 151 46.5 197 44.6 0.603Separated from mom (e.g. lived with another relative or in foster care) 253 33.0 118 36.3 135 30.5 0.093Parents separated 370 48.2 153 47.1 217 49.1 0.581Parents argued frequently or more than usual 259 33.8 111 34.2 148 33.5 0.846Changed schools (not because of graduation) or moved to a new home 245 31.9 123 37.9 122 27.6 0.003Parent/guardian lost job 342 44.6 139 42.8 203 45.9 0.385Lost home or had no home 65 8.5 38 11.7 27 6.1 0.006Family member or someone close had HIV/AIDS 287 37.4 85 26.2 202 45.7 <0.001Family member or someone close died of HIV/AIDS 273 35.6 91 28.0 182 41.2 0.001Family member or someone close died 569 74.2 243 74.8 326 73.8 0.751Family member or someone close was very sick or had a bad injury 524 68.3 230 70.8 294 66.5 0.211Experienced race/ethnicity discrimination 183 23.9 77 23.7 106 24.0 0.926Family struggled with money 355 46.3 147 45.2 208 47.1 0.616Seen an act of violence towards someone else (not in family) 538 70.1 248 76.3 290 65.6 0.001Experienced an act of violence by someone not in your family 316 41.2 147 45.2 169 38.2 0.052Seen an act of violence in the family 324 42.2 136 41.9 188 42.5 0.849Experienced an act of violence by someone in your family 240 31.3 107 32.9 133 30.1 0.403Deliberately inflicted harm on another person 293 38.2 166 51.1 127 28.7 <0.001Experienced forced Sex 98 12.8 35 10.8 63 14.3 0.153Experienced forcing someone to have sex 30 3.9 24 7.4 6 1.4 <0.001Note: p-values in bold are significant (>.05)Closson et al. BMC Public Health  (2016) 16:1191 Page 7 of 15Table 3 Univariate and adjusted analysis of variables associated with high PTE scores among adolescent men (n = 325)Low PTEscoreHigh PTEscorep-value High PTE score vs. Low PTE scoreVariables n % n % Wilcoxon/Chisq OR 95% CI AOR 95% CISocio-demographic characteristicAge at interview (per year, median Q1,Q3) 17 15,18 18 16,18 <.001 1.37 1.19 1.59 1.40 1.21 1.63Years lived in SowetoSince 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 6.76EthnicityZulu 99 56.9 67 44.4 0.174 RefXhosa 18 10.3 21 13.9 1.72 0.85 3.48 Not SelectedSotho 21 12.1 19 12.6 1.34 0.67 2.67Tswana 10 5.8 16 10.6 2.36 1.01 5.52Other ethnicities 26 14.9 28 18.5 1.59 0.86 2.95EmploymentStudent 147 85.0 117 77.5 0.193 RefUnemployed 20 11.56 24 15.89 1.51 0.79 2.86 Not SelectedEmployed 6 3.5 10 6.6 2.09 0.74 5.93HousingBrick house/Flat owned by family 123 70.7 97 64.2 0.414 RefBrick house/Flat rented by family/Hostel/Other 5 2.9 4 2.7 1.01 0.27 3.88RDP house/Shack 46 26.44 50 33.11 1.38 0.85 2.23Food InsecurityLow 39 22.4 20 13.3 0.026 Ref RefMedium 51 29.3 37 24.5 1.41 0.71 2.81 1.58 0.76 3.29High 84 48.3 94 62.3 2.18 1.18 4.03 2.63 1.36 5.09Household Social GrantNo 81 47.9 60 40.3 0.170 Ref Not SelectedYes 88 52.1 89 59.7 1.37 0.87 2.13Incarceration historyNo 148 92.5 110 89.4 0.367 RefYes 12 7.5 13 10.6 1.46 0.64 3.32Sexual behaviour and HIVHIV testing historyNo 99 57.2 88 58.3 0.848 RefYes 74 42.8 63 41.7 0.96 0.62 1.49HIV ResultPositive 3 1.7 2 1.3 0.940 RefNegative 69 39.7 58 38.4 1.26 0.20 7.81Unknown/Never tested 102 58.6 91 60.3 1.34 0.22 8.19Sex EverNo 77 44.3 39 25.8 0.001 Ref Not includedaYes 97 55.8 112 74.2 2.28 1.42 3.65Closson et al. BMC Public Health  (2016) 16:1191 Page 8 of 15DiscussionSimilar to other South African and African studies[8, 45], we found that adolescents in our study experi-enced high levels of PTEs. Nearly all participants experi-enced at least one PTE (99.7%) and had experienced onaverage 7 PTEs at the time of their interview with nodifferences by gender. A study of U.S adolescents (aged13–17) found that 61.8% had lifetime PTE experience[46], compared with 99.7% of adolescents within ourstudy. Among both adolescent men and women, in-creased exposure to PTE was associated with high levelsof food insecurity. This finding has implications for sex-ual and reproductive health (SRH) outcomes and overallwell-being for South African adolescent men and womenfaced with syndemic risks including high levels ofcommunity-level violence and sexual victimization [21].In addition, our findings suggest no difference in theprevalence of PTEs between adolescent men andwomen, rather differences in the types of traumatic oc-currences. Despite no significant differences in PTEprevalence by gender, we pursued a gender stratifiedanalysis to enable examination of differential correlates ofexperiencing multiple PTEs. These findings highlight aneed for future research to explore the differential poten-tial gendered impacts of PTEs experienced amongadolescents.Consistent with previous literature, we found that PTEexposure and the effects are distributed along social andgendered axes. For example, a number of studies glo-bally have found that young women are more likely toexperience sexual assault while men are more likely toexperience physical assault [29, 31, 45].Table 3 Univariate and adjusted analysis of variables associated with high PTE scores among adolescent men (n = 325) (Continued)Ever STINo 85 48.9 88 58.3 0.001 Ref Not includedaYes 12 6.9 24 15.9 1.93 0.91 4.11Never had sex 77 44.3 39 25.8 0.49 0.30 0.80Sexually Active P6MNo 41 24.1 39 26.4 0.001 Ref Not IncludedaYes 52 30.6 70 47.3 1.42 0.80 2.49Never had sex 77 45.3 39 26.4 0.53 0.30 0.95Inconsistent condom useNever had sex 77 45.8 39 26.9 0.002 Ref Not SelectedNo 44 26.2 49 33.8 2.20 1.26 3.85Yes 47 28.0 57 39.3 2.39 1.39 4.13More than 1 partner in the L6MNo 23 13.6 28 19.4 0.016 Ref Not IncludedaYes 28 16.6 38 26.4 1.11 0.53 2.33Never had sex/Sexually inactive 118 69.8 78 54.2 0.54 0.29 1.01Substance use and mental health variablesAlcohol use in L6MNo 63 36.4 41 27.2 0.075 1.09 0.47 2.52Yes 110 63.6 110 72.9 0.65 0.28 1.51Probable DepressionNo 129 74.1 100 66.2 0.119 Ref Not SelectedYes (score ≥ 24) 45 25.9 51 33.8 1.54 0.96 2.47Drug use ever in L6M (excluding marijuana use)No 165 94.8 132 87.4 0.018 Ref Not SelectedYes 9 5.2 19 12.6 2.64 1.16 6.02Note: 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 anddevelopment programme, STI, sexually transmitted infection, HIV human immunodeficiency virusaNot included due to CollinearityClosson et al. BMC Public Health  (2016) 16:1191 Page 9 of 15Table 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 scoreVariables n % n % Wilcoxon/Chisq OR 95% CI AOR 95% CISocio-demographic characteristicsAge 17 16,18 18 16,18 0.182 1.10 0.97 1.24 Not SelectedYears 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 2.13Since birth 194 79.5 146 74.9 0.75 0.40 1.41EthnicityZulu 104 42.5 75 38.1 0.764 RefXhosa 29 11.8 24 12.2 1.15 0.62 2.13Sotho 48 19.6 36 18.3 1.04 0.62 1.76Tswana 29 11.8 30 15.2 1.43 0.79 2.59Other 35 14.3 32 16.2 1.27 0.72 2.23EmploymentStudent 217 89.7 168 85.3 0.379 RefUnemployed 19 7.85 22 11.17 1.50 0.78 2.85Employed 6 2.5 7 3.6 1.51 0.50 4.57HousingHouse owned by family 184 75.1 143 72.6 0.577 RefHouse rented by family/Other 6 2.5 3 1.5 0.64 0.16 2.62RDP house/Shack 55 22.45 51 25.89 1.19 0.77 1.85Food InsecurityLow 77 31.4 33 16.8 <.001 Ref RefMedium 71 29.0 44 22.3 1.45 0.83 2.52 1.49 0.84 2.65High 97 39.6 120 60.9 2.89 1.77 4.70 2.57 1.55 4.26Household ever Received Social GrantNo 112 46.1 72 36.7 0.048 Ref Not SelectedYes 131 53.9 124 63.3 1.47 1.00 2.16Sexual behaviour and HIV variablesHIV testing historyNo 139 57.0 88 44.7 0.010 Ref Not SelectedYes 105 43.0 109 55.3 1.64 1.12 2.39HIV ResultPositive 3 1.2 3 1.5 0.131 RefNegative 102 41.6 100 50.8 0.98 0.19 4.97Unknown 140 57.1 94 47.7 0.67 0.13 3.40Sex EverNo 142 58.0 80 40.6 <.001 Ref Not included*Yes 103 42.0 117 59.4 2.02 1.38 2.95STI or STI symptomologyNo 80 32.7 79 40.1 <.001 RefYes 23 9.4 38 19.3 1.67 0.91 3.06Never had sex 142 58.0 80 40.6 0.57 0.38 0.86Closson et al. BMC Public Health  (2016) 16:1191 Page 10 of 15Adolescent womenOur results align with previous research indicating thatco-occuring multiple PTEs experienced by women influ-ence heightened depression symptomology [8], and com-pound syndemic risks of HIV transmission throughincreased HIV risk behaviour such as inconsistent con-dom use [10, 30]. The synergistic effect of multiple expe-riences of PTEs and increased HIV acquisition risk maybe exacerbated among women living in vulnerable urbanenvironments, such as Soweto, facing economic hard-ships and high levels of food insecurity [23, 30]. Thesecompounding experiences of structural vulnerability in-fluence economic dependence - placing women in infer-ior roles in their relationships - in turn increasingexperiences of gender-based violence, inability to negoti-ate condom use, and ultimately HIV transmission risk[3, 23].Adolescent menOur results indicate that high-PTE scores were morecommonly found among older adolescent men who haverecently moved to Soweto, and who face high levels offood insecurity. Experiences of trauma can accumulateover the lifecourse, [47], as such older age was a hypothe-sized finding for higher number of PTEs among men inour study. The exposure to multiple experiences of PTEsat a young age have been found to perpetuate aggressivebehaviour and negative views towards women in adult-hood [48, 49]. The development of negative views towardswomen may perpetuate harmful gender norms and in-equitable power dynamics in relationships, which hasshown to have significant implications for the HIV epi-demic in South Africa [24, 50–52]. Furthermore, youngmen living in South Africa face extremely high rates ofinterpersonal violence. A study assessing hospital data onTable 4 Univariate and adjusted analysis of variables associated with high PTE scores among adolescent women (n = 442)(Continued)Sexually Active L6MNo 41 16.9 32 16.3 <.001 RefYes 60 24.7 84 42.9 1.79 1.02 3.17Never had sex 142 58.4 80 40.8 0.72 0.42 1.24Inconsistent condom useNever had sex 142 59.7 80 41.0 <.001 Ref RefNo 52 21.9 44 22.6 1.50 0.92 2.44 1.59 0.96 2.63Yes 44 18.5 71 36.4 2.86 1.80 4.56 2.69 1.66 4.37More than 1 partner in L6MNo 49 20.2 68 34.9 <.001 Ref Not included*Yes 11 4.5 15 7.7 0.98 0.42 2.32Never had sex/Sexually inactive 183 75.3 112 57.4 0.44 0.29 0.68Substance use and mental health variablesAlcohol Use in the L6MNo 102 42.0 61 31.1 0.019 Ref Not SelectedYes 141 58.0 135 68.9 1.60 1.08 2.38Probable DepressionNo 176 71.8 105 53.3 <.001 Ref RefYes (score ≥ 24) 69 28.2 92 46.7 2.23 1.51 3.32 2.00 1.31 3.03Incarceration historyNo 226 97.4 162 93.1 0.037 Ref Not SelectedYes 6 2.6 12 6.9 2.79 1.03 7.59Drug use ever in L6M (excluding marijuana use)No 239 97.6 192 97.5 0.952 RefYes 6 2.5 5 2.5 1.04 0.31 3.45Note: 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 anddevelopment programme, STI sexually transmitted infection, HIV human immunodeficiency virus*Not included due to CollinearityClosson et al. BMC Public Health  (2016) 16:1191 Page 11 of 15injuries within the Mthatha Hospital Complex in SouthAfrica, found that the majority of injuries occurred amongmen, with 60% of all cases being for acts of interpersonalviolence [27]. Despite extremely high levels of PTEs withinmen participating in our study, we found that this was notsignificantly associated with increased depression sympto-mology or inconsistent condom use. Previous researchhas explored the relationship between high levels oftrauma and post-traumatic growth [53]. Resilience to HIVrisk among adolescent men living in HIV hyper-endemicnations experiencing concurrent poverty and high-levelsof PTEs should be further explored.Intervention implicationsReducing syndemic risks to traumatic experiences in bothadolescent men and women is likely to have a positive im-pact on HIV transmission through multiple pathways. Thescale-up of community and structural level interventions,as well as increased focus on trauma-informed models ofcare for adolescents in South Africa is critical for address-ing the HIV epidemic [21, 54]. For adolescent women,intervention strategies aimed at increasing economic inde-pendence, reducing gender-based violence, reducing in-equities in relationship power and control, andchallenging gender norms, are critical to increase sus-tained and widespread uptake of HIV prevention options,including male and female condoms and, in more recentyears, pre-exposure prophylaxis (PrEP), [48, 55–57].Among adolescent women, high rates of sexual violenceand inequities in relationship power [50, 58, 59] intersectto compromise opportunities to negotiate condom use[30, 60–62]. Given demonstrated links between trauma,poor mental health, and sexual behaviours, mediatedthrough pathways of gender and power inequity, centralto the efforts to reduce HIV incidence among adolescentwomen is a clear need to scale-up access to youth-centred, trauma-informed, and women-controlled HIVprevention strategies, inclusive of PrEP [4].Trauma-focused cognitive behavioural therapy (TF-CBT) has been shown to be highly beneficial in reducingsexual health risk. Hien and colleagues [63] implementeda skill-based TF-CBT program focusing on various do-mains including: personal self-management, coping,communication, boundary setting, HIV risk reductionand reducing unsafe behaviour in general. Women inthe trauma-focused intervention were almost half aslikely to report unprotected sex compared to women inthe control group [63]. Given the high number of PTEsexperienced by young people in South Africa, it is im-perative to scale-up such trauma-informed mental healthservices for adolescents [21].Community-level interventions addressing harmfulgender norms, such as Stepping Stones, have beensuccessful at reducing the perpetuation of intimatepartner violence, a significant step forward in redu-cing HIV transmission and experiences of trauma foradolescent women [48]. For both adolescent men andwomen, interventions aimed at addressing food inse-curities may help to mediate the compounding affectsof PTEs on HIV transmission within vulnerable urbanenvironments such as Soweto. This relationshipmerits further examination. Future interventionsshould consider the importance of resilience andpost-traumatic growth within settings where experi-ences of traumatic events and HIV risk are extremelyhigh [64].Strengths & limitationsIn conducting a gender-stratified analysis of PTE occur-rence, we demonstrated the multitude of implicationsthat PTEs have on both SRH programs and HIV inter-vention — informing a gendered approach to address-ing PTE and HIV risk. However, we did not includemeasurements within our survey to assess PTSD symp-tomology which is a known outcome of experiencingtrauma [8, 10, 21], thus we acknowledge this is a limita-tion of our study which should be further examinedwithin future South African adolescent health studies.Further, we are unable to assess causation within thiscross-sectional study. Additional limitations include re-call and social desirability bias due to self-reportedmeasures 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 thesefindings with other studies using the original version ofthe TESI-C and other scales similarly measuring experi-ences of trauma.ConclusionBeing an adolescent in Soweto, South Africa posesmany challenges: we found a high prevalence of PTEsalong with associations highlighting risk for HIV ac-quisition, particularly for adolescent women. Adolescenceis a dynamic and transitional time of the lifecourse, markedby rapid and multiple developmental changes that, throughbiology and socialization, are distinctly gendered [5, 65, 66].Enabling and fostering the pathway towards healthprovides adolescent men and women with a set ofmeaningful skills and coping mechanisms that theycan carry into adulthood [5, 21]. Focusing on prevent-ing multiple co-occurring risks and promoting increasedaccess to mental health services for adolescent men andwomen facing high exposures to PTEs can begin to ad-dress the syndemic of HIV and trauma which pose signifi-cant threats to HIV-acquisition, population health anddevelopment for South Africa [10].Closson et al. BMC Public Health  (2016) 16:1191 Page 12 of 15Additional fileAdditional file 1: Comparison of potentially traumatic event itemsassessed within the Botsha Bophelo Adolescent Health Survey andTESI-C items. (DOCX 101 kb)AbbreviationsAIC: Akaike information criterion; AIDS: Acquired immune deficiencysyndrome; aOR: Adjusted odds ratio; ART: Antiretroviral therapy;BBAHS: Botsha Bophelo adolescent health survey; CES-D: Centre forepidemiologic 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 therapyAcknowledgementThe Botsha Bophelo Adolescent Health Study (BBAHS) Research Team wouldlike to thank our participants and our research team members for all theircontributions to this study.FundingBBAHS was funded by the Canadian Institutes of Health Research (CIHR),Institute for Human Development, Child and Youth Health (230513). Initialseed funding was provided by Simon Fraser University through a PresidentResearch Award to CLM. NJL is supported by a CANFAR/CTN PostdoctoralFellowship Award. AK received salary support from the Canada ResearchChair program in Global Perspectives on HIV and Sexual and ReproductiveHealth. The PHRU was supported through a grant by the South AfricanMedical Research Council. The authors have no conflict of interest to declareregarding the publication of this manuscript.Availability of data and materialsFor access to the study data, please contact Dr. Cari Miller (Cari.Miller@sfu.ca),Principal Investigator of the Botsha Bophelo Adolescent Health Study.Authors’ contributionsCLM, JD, BN, GG, RSH and AK designed the study. JD, BN, and GGimplemented the study. RSH and CLM had full access to the data in thestudy and take responsibility for the integrity of the data and the accuracy ofthe data analysis. JC undertook the data analysis and ZC conducted thestatistical analysis. KC, AM and AK interpreted the data and wrote the firstdraft of the manuscript. All authors read and approved the final manuscript.Competing interestsThe authors declare that they have no competing interests.Consent for publicationThis manuscript does not contain any identifying individual participantdata, and thus consent for publication from participants in notapplicable for this analysis.Ethics approval and consent to participateEthical approval for the study was granted by the ethics committees of theUniversity of the Witwatersrand (Johannesburg, South Africa) [M090449] andSimon Fraser University (Burnaby, Canada) [#2009 s0196]. Adolescents under18 years signed an informed assent form and provided a signed informedconsent form from a parent or legal guardian. 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