The esoto dance, circumcision practices and negative condom beliefs: A survey assessing HIV risk among the Maasai of Tanzania Public

Siegler, Aaron J. (2012)

Permanent URL: https://etd.library.emory.edu/concern/etds/1n79h509d?locale=fr
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Abstract

This study addresses the intersection of Maasai culture and HIV prevention
opportunities by designing and implementing a survey instrument that was tailored
through interviews, focus groups and cognitive interviewing. This dissertation is
comprised of three studies based on a survey of 370 adults in Siha and Ngorongoro
Districts, Tanzania.
The first study applied the Dynamic Social Systems Model (DSSM) to the esoto
dance. Esoto accounted for over two-thirds of participants' lifetime sexual partners.
Participants reported multifaceted beliefs: a majority viewed the dance as exciting and
essential, yet most men feared social stigma and three-quarters of women experienced
physical punishment for non-attendance. Combining systems and ecological models, the
DSSM was utilized to characterize esoto, revealing feedback loops and indicating
avenues for future interventions.
The second study evaluated acceptability of improved instrument sanitation and
medical male circumcision (MMC) among the traditionally circumcising Maasai.
Traditional circumcision has higher rates of complications than MMC. We found
inadequate instrument sanitation, with 56% circumcised with a shared knife rinsed in
water between initiates and 16% circumcised with a knife not cleaned between initiates.
Contrasting practice, 88% favored use of medical supplies for their sons' circumcisions.
Acceptability of providing MMC to sons was 28%. Given traditional leadership support
for MMC, this rose to 84%. Future interventions to address circumcision safety,
including traditional circumciser training and MMC, are discussed.
The third study evaluated levels of belief in negative condom rumors, developed
the Negative Condom Beliefs Scale (NCBS), and assessed how it predicts willingness to
use condoms. NCBS item agreement ranged from 35-53% for the following rumors
regarding condoms: causing cancer, having holes, containing HIV, having worms and the
worms causing HIV. The NCBS loaded on a single latent factor, had high internal
consistency and indicated convergent validity. In a multivariate model, NCBS score was
the strongest predictor of willingness to use condoms.
By qualitatively tailoring a survey to incorporate cultural elements relevant to the
Maasai, this dissertation has programmatic implications for HIV prevention programs
targeting this group. Moreover, we found that local needs likely generalize to other
populations. Study implications for broader HIV prevention efforts are discussed.

Table of Contents

TABLE OF CONTENTS Introduction__________________________________________________________ 1 Specific Aims___________________________________________________________ 1 Background____________________________________________________________ 3 HIV/AIDS in Tanzania__________________________________________________ 3 The Maasai of Tanzania________________________________________________ 3 HIV/AIDS Among the Maasai____________________________________________ 4

Importance of age-set and age-group among the Maasai_________________________ 5

HIV risk-related behaviors among the Maasai_________________________________ 6

Variable reporting of numbers of sexual partners________________________________________ 6 Polygyny among the Maasai_______________________________________________________ 6 Sexual access to age-mates wives____________________________________________________ 7 Low levels of HIV/AIDS knowledge among the Maasai__________________________________ 7

Limited data indicate low levels of condom use among the Maasai_________________________ 9

Limited validity of self-report sexual data in Tanzania__________________________ 9

Cognitive interviewing__________________________________________________ 10 Significance____________________________________________________________ 11 Preliminary Studies______________________________________________________ 12 Methods_______________________________________________________________ 13 Study methods overview_________________________________________________ 13 Pre-survey procedures__________________________________________________ 13 In-depth interviews_______________________________________________________________ 13 Cognitive interviewing____________________________________________________________ 14 Target population, sample frame and sample size_______________________________________ 15

Sampling methodology and sample size_____________________________________ 15

Measures____________________________________________________________ 16 Demographic, marital variables and HIV knowledge_____________________________________ 16 Condom-related beliefs and environment______________________________________________ 17 Circumcision experiences and beliefs_________________________________________________ 17 Non-spousal partners and esoto-specific items__________________________________________ 18 Violence against women, gender-power and stigma_____________________________________ 19 Analysis_______________________________________________________________ 19 Limitations____________________________________________________________ 20 Citations______________________________________________________________ 21

Applying the Dynamic Social Systems Model to HIV prevention in a rural African context: The Maasai and the esoto dance 27

Abstract_______________________________________________________________ 27 Introduction____________________________________________________________ 28 Background__________________________________________________________ 28

Theoretical Model_____________________________________________________ 28

HIV-related Maasai Customs_____________________________________________ 29

Methods_______________________________________________________________ 31 Overview____________________________________________________________ 31 Measures____________________________________________________________ 32 Demographic____________________________________________________________________ 32 HIV-related_____________________________________________________________________ 32 Sexual partnership_______________________________________________________________ 32

Dependent and independent variables_________________________________________________ 33

Data Analysis_________________________________________________________ 34

Application of theoretical model__________________________________________ 34

Results________________________________________________________________ 35 Demographics________________________________________________________ 35

HIV knowledge and condom use___________________________________________ 36

Premarital sexual partnership and Maasai traditions____________________________ 36

Esoto experience______________________________________________________ 37

Correlates of esoto participation__________________________________________ 38

Dynamic Social Systems Model of the Esoto Dance____________________________ 39

Discussion_____________________________________________________________ 42 Table 1 Demographic variables_____________________________________________ 44

Table 2 Means of lifetime sexual partners in emic Maasai categories_________________ 45

Table 3 Esoto dance atendees' beliefs and sexual experiences regarding

esoto by gender_________________________________________________________ 46

Table 4 Logistic regressions predicting attendance of esoto dance with

Maasai socio-demographic and esoto factors___________________________________ 47

Table 5 Dynamic Social Systems Model of the esoto dance________________________ 48

Citations______________________________________________________________ 49

Acceptability of improved instrument sanitation and medical male circumcision among the traditionally circumcising Maasai of Tanzania_____________________________________________________________________ 53

Abstract_______________________________________________________________ 53 Introduction____________________________________________________________ 54 Methods_______________________________________________________________ 57 Setting______________________________________________________________ 57 Survey Methodology___________________________________________________ 58 Measures____________________________________________________________ 58 Data analysis plan_____________________________________________________ 60 Results________________________________________________________________ 61 Discussion_____________________________________________________________ 63

Table 1 Circumcision instrument sanitation and ritual____________________________ 66

Table 2 Circumcision practices and opinions by gender___________________________ 67

Table 3 Logistic regressions predicting willingness to provide sons

with male medical circumcision_____________________________________________ 68 Citations______________________________________________________________ 69

Condoms "contain worms", "cause cancer" and "cause HIV" in Tanzania: Negative Condom Beliefs Scale development and implications for HIV prevention________________________________________________________ 74

Abstract_______________________________________________________________ 74 Introduction____________________________________________________________ 75 Methods_______________________________________________________________ 78 Study Design_________________________________________________________ 78 Setting and Inclusion Criteria_____________________________________________ 79 Measures____________________________________________________________ 79 Data analysis plan_____________________________________________________ 81 Ethical Considerations__________________________________________________ 82 Results________________________________________________________________ 83 NCBS Item Analyses___________________________________________________ 83

Scale dimensionality, convergent validity and internal consistency________________ 83

Demographics and the NCBS_____________________________________________ 85

Condom use intentions predicted by NCBS___________________________________ 85

Discussion_____________________________________________________________ 86 Overview____________________________________________________________ 86 Limitations__________________________________________________________ 89 Conclusions__________________________________________________________ 90

Table 1 Condom rumor scale ítems: percent agreement, n and

ítem-rest correlation_____________________________________________________ 91

Table 2 Demographic characteristics, mean NCBS values and

association with willingness to use condoms____________________________________ 92

Table 3 Logistic regressions predicting willingness to use condoms___________________ 93

Citations______________________________________________________________ 94 Conclusion _________________________________________________________ 100 Summary of key sub-study findings _________________________________________ 100 Negative condom beliefs scale __________________________________________ 100 Esoto_____________________________________________________________ 100 Circumcision _______________________________________________________ 101 Utility of a mixed-methods approach _______________________________________ 101 Utility of culturally-tailored studies ________________________________________ 103 Study implications for future research _______________________________________ 104

Study implications for future programs among the Maasai _______________________ 105

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