Country is a nominal measure that was measured in 2006 (POFO Round 1) as part of the study design. The three countries, out of the six POFO study settings, that were included in this dissertation are: Ethiopia; Kenya; and Tanzania. This variable is dummy coded.
Gender was recorded by the interviewer as male or female, based on observation, at POFO baseline in 2006 (POFO Round 1) and, for the purposes of this dissertation, was a binary variable for male and female OSY. Gender was included as a covariate as it was identified in the literature review as being predictive of HIV testing among youth in SSA, with female youth more likely to report HIV testing than male youth. It may, therefore, explain some of the variance in HIV testing in and of itself.
Age (in months) was initially established in 2006 (POFO screening and baseline) through self-reported questionnaires with primary caregivers. Current age (in years) was calculated at each round of data collection using the baseline age and the interview date. Age in years is a continuous variable measured in 2014 (POFO Round 10). It was included because, as noted in Chapter 2, testing had been shown to vary between older and younger groups of individuals, with older individuals more likely to test than those who are younger. Age was included because it, too, may explain some of the variance in HIV testing.
Orphan status is a nominal variable reflecting whether an OSY was a maternal, paternal, double or separated orphan. As noted in Chapter 2, this variable is often included in studies
pertaining to orphans as it provides additional context to the circumstances of their orphanhood. For these analyses, orphan status was considered a time-fixed variable that was measured at POFO baseline in 2006 (POFO Round 1).
Educational attainment is an ordinal variable that was designed to provide a meaningful assessment of the educational attainment of POFO participants. Participants were asked at each round of data collection if they were currently in school and, if so, what grade they were in. The participant’s grade-for-age was then calculated using the participant’s age, their grade, and an established country-specific standard or target grade for each age. This measure has been used in previous analyses with this dataset and is treated such that individuals are either “on target” for their grade, or above or below the target grade-for-age in each country.157 For this dissertation, educational attainment was measured in 2014 (POFO Round 10). This variable is included as it was identified in the literature review that youth with higher levels of educational attainment are more likely to report HIV testing than those with lower levels. Similar to gender and age, educational attainment was also included because it might explain some of the variance in HIV testing.
Recent use of a Western health facility was a self-reported dichotomous (yes/no) variable assessed asking participants: “Have you been to any of the following health care providers during the past 6 months due to a health problem?” Options included: the hospital; health center,
dispensary/pharmacy; community health worker; maternal and child health clinic; mobile/outreach clinic; or private physician. This information was asked in 2014 at POFO Round 10.
HIV knowledge is measured using the orphan self-reported instrument conducted in 2014 (POFO Wave 10). The instrument was a slightly adapted version of the validated HIV KQ 18 scale; HIV KQ 18 is particularly suited for assessing knowledge with low literacy and among low income individuals.158 Responses are typically summed or averaged with higher scores representing greater HIV knowledge. Of the 18 dichotomous (yes/no) items included in the original validated scale, 12 were included in the POFO questionnaire. This was based on thorough pre-testing of the items within each country. For this dissertation, items were averaged to reflect the proportion of items an
individual correctly answered. As noted in Chapter 2, greater HIV knowledge has been associated with HIV testing among youth in SSA.
HIV risk perception was a self-reported measure that was asked of OSY in 2014 (POFO Round 10). It is a single item that asked “How high do you think your own risk is for getting HIV?” Ordinal response options were: 1) no risk at all; 2) very little risk; 3) some risk; 4) quite a bit of risk; 5) a great deal of risk. However, the response distribution did not support an ordinal analysis. As such, this item was dichotomized (no risk/some or more risk). As noted in Chapter 2, HIV risk perception is positively associated with HIV testing among youth in SSA and may, therefore, explain some of the variance in HIV testing in the proposed study.
HIV stigmatizing attitudes were assessed through self-report in 2014 (POFO Round 10) using 16 separate dichotomous items that were developed specifically for POFO (see Appendix B).
Although not previously validated, these items were developed by the POFO study team based on formative work conducted about stigmatizing attitudes towards orphanhood, and were subsequently adapted by the team to also include attitudes towards individuals living with HIV. The POFO study team amended their IRB approval to add these items at POFO Round 10, which was the only round in which they were administered. As detailed below in the statistical analysis section, I applied the
HIV Stigma Framework159 to identify items theoretically aligned with HIV testing; this process reduced the number of items to 9. I then conducted confirmatory factor analysis using WLSMV (weighted least squares with adjustments for the mean and variance) estimator to determine whether a one-factor solution reasonably represented the data structure of the 9-items. I then average the items, with averages reflecting the proportion of stigmatizing items with which the participant agreed. According to the literature review, HIV stigmatizing attitudes have been found to be negatively associated with HIV testing in SSA.
Food insecurity was a relative measure of economic well-being. This was a self-reported variable assessed in 2014 (POFO Round 10) when interviewers asked participants how frequently, in the past six months, they had gone without eating while hungry. Ordinal response options included: never; once; a few times a month; a few times a week; every day. However, the distribution
suggested this variable should be dichotomized (yes/no) to reflect whether someone had experienced food insecurity more than once in the past six-months. This variable is included as empirical literature indicates youth with higher levels of economic well-being are more likely to report testing for HIV.
HIV risk behavior was assessed in 2014 (POFO Wave 10) by summing four dichotomous (yes/no) items: 1) past-year unprotected sex; 2) past-year sex while drinking alcohol or on drugs; 3) past-year transactional sex; 4) past-year multiple (more than 1) sex partners. The final variable reflects whether a participant mentioned engaging in past-year sexual HIV risk behavior. As noted in Chapter 2, previous studies have shown that being sexually experienced and having multiple sexual partners are positively associated with HIV testing among youth in SSA.
Ever tested for HIV was a self-reported measure assessing, in 2014 (POFO Round 10) whether an OSY has ever tested for HIV. It was included in the model as a control for previous HIV testing.