‘It’s because I like things… it’s a status and he buys me airtime’: exploring the role of transactional sex in young women’s consumption patterns in rural South Africa (secondary findings from HPTN 068)

‘It’s because I like things… it’s a status and he buys me airtime’: exploring the role... Background: ‘Transactional sex’, defined as a non-marital, non-commercial sexual relationship in which money or material goods are exchanged for sex, is associated with young women’s increased vulnerability to HIV infection. Existing research illustrates that the motivations for transactional sex are complex. The fulfilment of psycho-social needs such as the need to belong to a peer group are important factors underlying young women’s desires to obtain certain consumption items and thus engage in transactional sex. Methods: We use a mixed-methods approach to explore the relationship between transactional sex and consumption patterns among young women in rural Mpumalanga province, South Africa. In the secondary analysis of 693 sexually active young women, we use factor analysis to group the different consumption items and we use multivariable logistic regression to demonstrate the relationship between transactional sex and consumption patterns. The qualitative study uses five focus group discussions and 19 in-depth interviews to explore further young women’s motivations for acquiring different consumption items. Results: The quantitative results show that young women that engage in transactional sex have higher odds of consuming items for entertainment (e.g., movie tickets) than on practical items (e.g., food and groceries). The qualitative findings also revealed that young women’s perceptions of items that were considered a ‘need’ were strongly influenced by peer pressure and a desire for improved status. Further, there was a perception that emerged from the qualitative data that relationships with sugar daddies offered a way to acquire consumer goods associated with a ‘modern lifestyle’, such as items for personal enhancement and entertainment. However, young women seem aware of the risks associated with such relationships. More importantly, they also develop relationship with partners of similar age, albeit with the continued expectation of material exchange, despite engaging in the relationship for love. (Continued on next page) * Correspondence: Meghna.Ranganathan@lshtm.ac.uk Department for Global Health and Development, Faculty of Public Health and Policy, The London School of Hygiene and Tropical Medicine, London, UK Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the 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. Ranganathan et al. Reproductive Health (2018) 15:102 Page 2 of 21 (Continued from previous page) Conclusion: This study shows that young women are willing to take certain risks in order to have a degree of financial independence. Interventions that provide alternative methods of attaining this independence, such as the provision of cash transfers may have potential in preventing them from engaging in transactional relationships. Further, the psycho-social reasons that drive young women’s motivations for consumption items resulting in risky sexual behaviours need to be better understood. Keywords: Adolescent girls, Young women, Transactional sex, Sexual exchange, Consumption patterns, Spending patterns, Aspirations Plain English summary women (hereafter young women) aged 15–24 in sub- Transactional sex is defined as a sexual relationship out- Saharan Africa (SSA) [1–3]. It can place young women side marriage or formal sex work where money or ma- at heightened risk of HIV via multiple mechanisms – in- terial goods are exchanged for sex. It is associated with creasing their number of sexual partners (partner adolescent girls and young women’s (hereafter young switching to obtain more items) [4–6], encouraging con- women) increased susceptibility to HIV infection. current relationships [4–6] or affecting partner choice Research shows that the motivations for transactional [2]. This in turn might bias young women toward older sex are complex. The fulfilment of psycho-social needs partners who have more resources, but are also more such as the need to belong to a peer group are import- likely to be HIV positive [7–9]. Previous literature has ant factors underlying young women’s desires to obtain emphasised three paradigms to describe motivations for certain types of goods and to engage in transactional transactional sex – sex for basic needs, sex for upward sex. This article advances this line of inquiry by using a mobility and status, and sex for material expressions of mixed- method approach with quantitative and qualita- love [10]. Furthermore, there are additional psychosocial tive methods to focus on the relationship between trans- needs in young women, such as the need to belong to actional sex and spending patterns of young women in peer groups that motivate them to acquire certain items rural Mpumalanga, South Africa and to better under- to enhance their appearance. This may encourage them stand young women’s needs and wants. The overall find- to engage in relationships in order to obtain these items. ings revealed that young women’s perception of items In particular, in some instances, young women’s aspira- that were considered a ‘need’ was strongly influenced by tions for a ‘modern lifestyle’, often measured by their peer pressure and that relationships with older men or consumption patterns (also known as spending patterns) ‘sugar daddies’ offered a way to acquire goods associated or possession of key consumer goods can drive their with a “modern lifestyle”, such as items for personal en- pursuit of transactional sex [11, 12]. In settings with high hancement and entertainment. However, young women unemployment and where opportunities to acquire seem aware of the risks associated with such relation- these items are limited, studies suggest that by ob- ships and also develop relationships with partners of serving older sisters and/or friends, young women similar age, primarily for love, but with the continued realise that material goods can be acquired through expectation of material exchange. This study shows that sexual exchange [6, 13, 14]. young women are willing to take certain risks in order This study advances this line of inquiry by examining to be able to have a degree of financial independence. young women’s patterns of consumption, their motiva- Interventions that provide alternative methods of attain- tions to acquire certain items and the relationship ing this independence, such as the provision of cash between transactional sex and consumption patterns. transfers, may have potential in preventing them from Specifically, we explore whether examining young engaging in transactional relationships. Further, the women’s consumption patterns (what they purchased psycho-social reasons that drive young women’s motiva- and received as gifts) could yield insights into the dy- tions for acquiring items needs to be better understood namics of transactional sex among young women in in order to reduce risky sexual behaviour. rural Mpumalanga, South Africa. Background Theoretical underpinnings Transactional sex - defined as a non-marital, non- To understand the motivations behind young women’s commercial sexual relationship where men and women aspirations to acquire specific items, our study draws on exchange sex for material possessions or favours - has theories of belonging and conformity, especially as they been found to be an important contributing factor to apply to adolescents. Erikson [15] describes adolescence HIV vulnerability among adolescent girls and young as a phase in the life cycle when, “young people are Ranganathan et al. Reproductive Health (2018) 15:102 Page 3 of 21 sometimes morbidly, often curiously, preoccupied with consumption patterns using quantitative methods. This what they appear to be, in the eyes of others as com- informed the development of the focus group discussion pared with what they feel they are...”([16], page 128). and in-depth interview topic guides. We then cross- Thus, adolescents seek conformity within their groups verified findings by comparing the findings of each [16], and are influenced by peers with regard to both method, identifying areas where results diverged, con- neutral behaviours, such as clothing choices, and risky verged, or added insights [29]. behaviours, such as smoking, drug use and risky sex [17]. The need for belonging forms an important tenet Quantitative methods of Maslow’s theory (1943) of hierarchy of needs, which Of the total sample of 2533 young women, our sample proposes that the need to belong is preceded in import- for the secondary analysis included only sexually active, ance only by basic biological needs and a desire for school-going young women (n = 693) who reported ever safety [18]. Researchers have since found that belonging having had vaginal and/or anal sex. For this analysis, the affects people’s emotions [19], self-esteem [20] and per- exposure variable was transactional sex and the outcome ceptions of others. Importantly, belonging to certain variable was consumption patterns of young women. peer groups requires conformity with group values; and a willingness to follow one’s peers [21]. Thus, to be ac- cepted, adolescents may be required to conform to Measurement tools group norms [22]. For example, Wamoyi (2010) shows Due to the personal nature of some of the questions in in her ethnographic fieldwork in Tanzania that young the young women’s questionnaire (i.e. details of sexual women’s desire for acquiring ‘nice’ things and their relationships) young women completed computer-based readiness to have sex to acquire them, is predominantly questionnaires which were primarily self-administered shaped by peer expectations and pressure to conform using Audio-Computer Assisted Self-Interviewing (ACASI). [14]. We follow this line of inquiry in a different context Parents/guardians completed interviewer-administered, and among a larger sample of individuals. We draw on structured, computer-based household questionnaires. these theoretical notions to understand young rural Information on household and socio-economic character- South African women’s motivations for engaging in istics (household questionnaire) and socio-demographic transactional sex. background, sexual experiences and partner history (young women’s questionnaire) were included in the tools. Methods Young women filled out questions that were more per- Research study design sonal by themselves. Both the parent/guardian and young This paper is a secondary analysis of baseline survey woman’s interviews were conducted in the language pre- data from the HPTN 068 study: a phase III individually ferred by the participant - in the local language, xiTsonga, randomised conditional cash transfer (CCT) trial in rural or English. The questionnaires were translated into xiT- South Africa. Data collection was conducted from songa by bilingual researchers and checked for linguistic March 2011–December 2012 in the sub-district of appropriateness, comprehension and cultural relevance Agincourt in rural Mpumalanga Province, north-east and then back-translated from xiTsonga into English to South Africa, an area with high levels of unemployment, ensure accuracy and fidelity to meaning. poverty and labour migration [23–25]. The intervention involved individually randomising young women aged 13–20 years to receive a monthly cash transfer condi- Variables tional on school attendance. Study participants were eli- Outcome variable gible for inclusion in the trial if they were females aged The outcome variable is young women’s consumption 13 to 20 years; enrolled in grades 8, 9, 10 or 11 at se- patterns, measured by spending patterns on a given set lected schools in the study site; and had a bank or post of items. The question in this study asks, “Over the past office account to receive the cash transfer. The total month, did you buy for yourself any [item name] coded sample size of the main trial was 2533 young women as binary (yes/no)” and “Over the past month, how much and their parent/guardian (with one young woman per money in South African Rands did you spend on [item household enrolled). A brief summary of the main trial’s name] for yourself”. We used factor analysis to group the study design is described in Appendix 1; the trial’s sam- 12 items: scented soap, skin creams or lotions; cell ple size calculation, sample recruitment and data collec- phone, airtime, ringtones; shoes, clothing and under- tion are described elsewhere [2, 26]. wear; cool drinks, chips, etc.; make-up and cosmetics; For this study, we used a mixed-methods, sequential hairdressing; food/groceries; school uniform or supplies; explanatory design [27, 28]. Specifically, we explored the transport to work and school; beer/alcohol; movies or relationship between transactional sex and young women’s music tickets and birth control and condoms. Ranganathan et al. Reproductive Health (2018) 15:102 Page 4 of 21 Exposure variable individuals with complete data were included in the final The main exposure variable was ‘ever having had trans- models. Please see Appendix 3 for flowchart on final actional sex’ coded as a binary variable (yes/no) for sex sample size. in exchange for money and/or gifts. We asked the young woman about her sexual and relationship history with Analysis her three most recent partners, starting with the most We used exploratory factor analysis to group the 12- recent partner. The four steps carried out to construct item consumption module into sub-groups by examining the transactional sex variable were: how underlying common constructs influence individual responses on certain variables [30]. This helped to deter- 1) Variable ‘transactional sex for money’ coded 1 if mine items that “hung together” in a questionnaire; to participant said yes to “Did you feel like you had to determine the most important features when classifying have sex with [initials] because they gave you money?”; a group of items; and to generate factor scores that rep- 2) Variable ‘transactional sex for gifts’ coded 1 if resent values of the underlying constructs for use in participant said yes to “Did you feel like you had other analyses [31]. Further, descriptive statistics were to have sex with [initials] because they gave you used to summarise socio-demographic and partnership things (such as airtime, cell phone, groceries, clothes or characteristics of the sample and the prevalence and pat- shoes, perfume or lotions, make-up, cool-drinks, sweets terns of transactional sex. Using logistic regression, we or chips, CDs, DVDs or videos, alcohol or drugs, estimated the odds ratios for groups of consumption flowers, other (specify))?”; items associated with transactional sex. Unadjusted 3) Variable ‘transactional sex for money ‘and’ gifts coded models were fitted, as well as models adjusted for poten- 1 if participant had said yes to question (1) “Did you tial confounders. In this and all subsequent models, we feel like you had to have sex with [initials] because accounted for clustering at the school level by using they gave you money?” and question (2) “Did you feel cluster-robust standard errors. like you had to have sex with [initials] because they gave you things?”; Qualitative methods 4) The final variable ‘transactional sex for money’ The qualitative study used a combination of five focus ‘and/or’ gifts coded 1 if participant said yes to groups (n = 25) and 19 in-depth interviews with school- question (1) “Did you feel like you had to have going young women who were participants in the con- sex with [initials] because they gave you money?” or trol arm of the main trial. Due to ethical reasons, we question (2) “Did you feel like you had to have could only include young women aged 18–21 years for sex with [initials] because they gave you things?” the qualitative study. Data collection was from November 2012 until March 2013. For the focus groups, young Effect modifiers and other variables women were selected using the per capita household con- Per capita household consumption (as a measure of sumption variable collected in the main survey as a meas- household living standards) was hypothesised to be a po- ure of socio-economic status. Based on the information tential effect modifier in the relationship between trans- collected, participants were divided into three socioeco- actional sex and consumption patterns. Furthermore, we nomic categories (high, medium and low), for the discus- selected the following variables as confounders in the sions and allocated to groups of the same category. The transactional sex and consumption patterns relationship per capita household consumption was calculated by sum- from our knowledge of the literature and the unadjusted ming all household spending and consumption on food analysis: the age of young women, age of first sex, young and non-food items and by dividing it by the number of women’s employment status, primary caregiver’s educa- household members [32]. A categorical household con- tional level, number of household members, orphan sta- sumption measure was then obtained by dividing this tus and past year young women’s number of sexual measure into deciles (1–10). For this analysis, we re- partners. For details on the construction of each variable, categorised the variable from deciles to three groups for please refer to Appendix 2. total amount spending/consumption per capita: low (ran- ging from $1.3 to $15.4), medium (ranging from $15.5 to Missing data $32.6) and high (above $32.10). Except for the variable number of sexual partners in the We used focus groups to explore topics around young past 12 months (where missing data were ~ 5%), all the women’s relationships and consumption patterns and we exposure variables had less than 3% missing data. This conducted participatory exercises to elicit young includes cases where young women ‘refused to answer’. women’s perceptions of items they consider a “need” The response ‘don’t know’ was also coded as missing, as versus a “want”. Since young women’s peers were in- the percentage of this response code was small. Only volved in the discussion, focus groups were considered Ranganathan et al. Reproductive Health (2018) 15:102 Page 5 of 21 to be effective in stimulating dialogue between respon- the qualitative analysis were then compared with the dents and yielding insight into people’s thought pro- quantitative findings for interpretation. cesses [33]. To complement the focus groups, we conducted 19 one-on-one private interviews with a sub- Results set of young school-going women. Themes that arose in Participant demographics the focus groups, but were sensitive for young women to Table 1 presents descriptive socio-demographic data on discuss in a group setting (e.g., sexual relationships) were the sample (n = 693) of sexually active young women. probed further in the interviews. Ten of the 19 partici- The age range was 13–20 years old (Table 1). Of the pants invited to be interviewed had reported ever being whole sample (n = 2533), around a quarter reported sexually active and had responded positively to the ques- being sexually active (693 young women or 27.4%) of tion on transactional sex. The remaining nine were in- which 78.2% were 16–20 years old. Among sexually ac- vited back to participate in the interviews, after the tive young women, almost 31% were orphans, with one focus group discussion, based on their levels of engage- or both parents deceased and almost 40% reported being ment and responses during the focus groups (we had no worried that their household did not have enough food prior knowledge of their sexual history). This allowed us in the past year. The primary caregiver for most sexually to interview young women who were both sexually ac- active young women (68.1%) was their mother and a tive and potentially not active. quarter of primary caregivers had never attended school. 78.2% of sexually active young women reported cur- rently having a boyfriend and 21.2% had more than two Data collection sexual partners in the past 12 months. 14% (n = 97) of Focus group discussions were conducted at a village sexually active young women reported feeling as though school within the study site over the weekend and were they had to engage in ‘sex for money, gifts or both’ facilitated by a female, xiTsonga speaker and assisted by (transactional sex). The majority of transactional sexual a designated note-taker. Focus groups were recorded relationships were only with the current partner (67%). with participants’ permission and later translated and The majority of items were received from primary part- transcribed into English by the group facilitators. The ners with 60% receiving money, 25% receiving gifts (such in-depth interviews were 1–1.5 h long, audio-recorded as cosmetics or airtime) and 15% receiving both money and conducted in a private location. The recordings and gifts. were transcribed and translated from xiTtsonga to A subset (n = 45) of the sample were invited to partici- English by the interviewer. Each transcript was quality- pate in the focus group discussions based on their socio- checked by a trained third-party researcher to make sure economic status. Half of these participants were from the translation was accurate. Data collection was it- households dependent on subsistence agriculture and erative, with changes made to the topic guide as the state grants. Half of the participants who were depend- focus group discussions and in-depth interviews pro- ant on subsistence agriculture were from female-headed gressed, based on a review of the data and feedback households. Seven of the 19 young women in the in- from the interviewers. depth interviews had small children, and two were preg- nant at the time of the interview. About third of the 19 Analysis young women interviewed worked in informal labour We used thematic content analysis to analyse qualitative outside school hours, such as in domestic work, yard- data [34, 35]. The first author created an initial coding cleaning or hairdressing. Twelve of the 19 young women framework based on the topic guides that was then ad- either had fathers who were working elsewhere (tempor- justed deductively and inductively, through frequent dis- arily migrated), had passed away, or parents who were cussions between the first two authors. A content matrix separated with the young woman living with her mother. was developed to synthesise data and to display emer- More than half the young women in the overall qualita- gent cross-cutting themes. All data from these focus tive sample reported having ever had two or more boy- groups and interviews were coded using Atlas-ti. Five friends, who were mostly young men within their same steps were followed in the analysis of the transcripts: (1) age peers. The average female respondent was ~ 2.5 years data management and familiarisation; (2) identification younger than her most recent male partner. of a coding framework; (3) displaying themes and sub-themes; (4) data reduction; and (5) interpretation Quantitative findings [27, 35]. Integration of the quantitative and qualitative Exploratory factor analysis produced three groups of data occurred in the final discussion; findings that consumption items (groups 1, 2 and 3) with overlap be- emerged from the preliminary quantitative analysis in- tween the groups (see Appendix 4). When constructing formed the qualitative analysis. Thematic findings from the consumption variables for analysis, we took into Ranganathan et al. Reproductive Health (2018) 15:102 Page 6 of 21 Table 1 Selected socio-demographic, partnership characteristics Table 1 Selected socio-demographic, partnership characteristics and sexual behaviours among sexually active young women and sexual behaviours among sexually active young women (aged 13-20y) (n = 693) (aged 13-20y) (n = 693) (Continued) Socio-demographic characteristics Sexually active (column %) Socio-demographic characteristics Sexually active (column %) Age of young woman (n = 693) Transactional sex 13–15 151 (21.8) Transactional sex (n = 693) 16–20 542 (78.2) No 596 (86) Per capita household consumption (n = 693) Yes 97 (14) Low 220 (31.7) Breakdown of percentages by money or gifts or both (n = 97) Medium 279 (40.3) Sex in exchange for money only 58 (59.8) High 194 (28.0) Sex in exchange for gifts only 24 (24.7) Number of household members (n = 693) Sex in exchange for both money and gifts 15 (15.5) Measure of household living standards calculated as low ((ranging from $1.3 2-3members 87 (12.5) to $15.4), medium (ranging from $15.5 to $32.6) and high (above $32.10) as 4-5members 233 (33.6) monthly expenditures Young women worried about having enough food for her and her family in 6-7members 220 (31.7) the last 12 months > =8members 153 (22.1) Among sexually active young women who responded yes to question on transactional sex Type of primary caregiver (n = 692) Mother 471 (68.1) Father 22 (3.2) consideration the results of the factor analysis. However, Brother/sister 65 (9.4) as there was not much variation between groups (i.e. al- Other blood relative 134 (19.4) most all the young women purchased group 1 items and some purchased group 2 and group 3 items), we also Educational level of primary caregiver (n = 692) took into consideration the sample sizes in each group None 176 (25.4) (which were small for groups 2 and 3) and the qualita- Primary 196 (28.3) tive findings when constructing the groupings. Secondary 164 (23.7) Matric or tertiary 128 (18.5) Factor analysis groupings Adult basic education 28 (4.1) Group 1 (n = 630 (91%)) is labelled ‘personal enhancement Orphan status (n = 684) items’ (PEI)) as most of the items are for female self- Parents alive 475 (69.4) improvement and are considered affordable. It consisted of feminine-enhancement items, such as scented soap, One parent dead 168 (24.6) make-up and cosmetics, where expenditures ran up to Both parents dead 41 (6.0) 200 ZAR (~£18) per month, as well as status enhancing Young women’s perceived food insecurity (n = 684) items, such as cell-phone where expenditures extend to No 412 (60.2) up to 600 South African rands (ZAR) (~£50) per month. Yes 272 (39.8) Group 2 (n = 223 (32.2%)) is labelled ‘practical items’ Partnership characteristics and sexual behaviours (PRAI). It consists of items that are considered necessary for survival and educational progress, such as groceries, Currently have a boyfriend (n = 693) school uniforms and transport to school. These items No 151 (21.8) can be more expensive than Group 1 items. Reported Yes 542 (78.2) expenditures varied from 10 to 1000 ZAR (~£0.83–83.3) Sexual partners the past 12 months (n = 660) per month for school uniforms and supplies, 10–500 1 520 (78.8) ZAR s (£0.83–41.7) per month for food and groceries 2 97 (14.7) and 10–800 ZAR (£0.83–66.67) per month for transport to work or school. > 3 43 (6.5) Group 3 (n = 216 (31.2%)) is labelled ‘entertainment Age of first sex (n = 634) and birth control/condoms’ (EBC). It consists of items Before 15 years 127 (20.0) such as movie tickets, beer/alcohol that are considered 15 years and above 507 (80.0) items of entertainment. Furthermore, we have included forms of contraception, such as birth control and con- doms, that are considered indicators of sexual activity. Ranganathan et al. Reproductive Health (2018) 15:102 Page 7 of 21 We grouped these items together using the results of the of items, and our knowledge of the nature of items that factor analysis (see Appendix 4: alcohol, movie tickets implied risky sexual behaviour. The final groups have and birth control/condoms grouped together) and for been illustrated in Fig. 2. sample size considerations (the sample number for We used the category with the largest sample size young women purchasing only birth control/condoms (personal enhancement items only) as the reference was very small (n = 4), hence could not be a separate cat- group for the analysis. Furthermore, as there are a egory). Expenditures varied from 10 to 500 ZAR (£0.83– sizeable number of young women who purchased items 41.7) per month for movies/music tickets, 10–300 ZAR from groups 1 (PEI) and 2 (PRAI), we have created the (£0.83–250 per month) for beer and alcoholic drinks category practical items (with some personal enhance- and 10–200 ZAR (£0.83–16.67) for contraception. Some ment items). Group 3 are young women that are pur- of these items are expensive (such as movie tickets and chasing items for entertainment and birth control/ particular types of expensive condoms that are not pro- condoms. To create the group entertainment and birth vided for free by the government) and some of these control/condoms (EBC) only that is mutually exclusive, items are cheaper (e.g., beer)). we decided to include young women that are included in group 3 (EBC) only and those that intersect with group 1, with group 2 and with groups 1 and 2. The Overlap between groups two consumption variables that were constructed are Figure 1 shows that young women purchased items from ‘practical items (and some personal enhancement more than one group: a few consumed a combination of items)’ and ‘entertainment and birth control/condoms’ groups 1 and 2, and groups 1 and 3; some consumed items with ‘personal enhancement items only’ as the from all three groups. Most young women consumed reference group. group 1 items. If a few young women consumed items from group 2 and 3, they usually had purchased group 1 items too. 310 young women (44.7%) consumed only Transactional sex and consumption of practical items (PRAI) group 1 and only three young women (0.4%) bought and consumption of entertainment and birth control (EBC) group 2 exclusively, as most group 2 consumption is items along with group 1 or group 1 and 3. Only ten young In Table 2, we report results from unadjusted and women (1.44%) reported consuming group 3 items ex- adjusted analyses of the association between young clusively. Most group 3 consumption happened along women’s engagement in transactional sex and her con- with group 1 or groups 1 and 2. sumption of practical items (PRAI) and transactional sex and her consumption of entertainment and birth control/ Mutually exclusive groups condoms (EBC) items. The results show that engaging in In order to then create mutually exclusive groups, we transactional sex is not associated with young women’s used a combination of: results from the factor analysis, consumption of PRAI in either unadjusted or adjusted our observations from the qualitative findings of young analysis (aOR: 1.09; CI95% = 0.57–2.12; p =0.79). women’s needs and wants (described in the next section) Table 2 also shows unadjusted and adjusted associations , our own theoretical knowledge of the monetary value between young women’s engagement in transactional sex No items purchased = 49 (7.1%) Group 1 Scented soap, skin cream, lotions Cell phone, airtime, Group 1 – Group 2 – ringtones personal practical items Shoes, clothing, underwear enhancement Cool drinks, chips,.etc items Make up/cosmetics 310 (44.7%) Hairdressing 3 (0.4%) 115 (16.6%) Group 2 104 (15%) School uniforms, supplies 101 (14.6%) Transport to work, school Food/groceries 1 (0.1%) Group 3 Movies/music Beer/alcohol Birth control/condoms 10 (1.44%) Group 3 – entertainment and birth control Fig. 1 Groupings of items that sexually active young women consume or purchase Ranganathan et al. Reproductive Health (2018) 15:102 Page 8 of 21 Personal enhancement items (PEI) Scented soap, skin cream, lotions Practical items (PRAI ) and some Cell phone, airtime, ringtones Personal enhancement items personal enhancement items (PEI) Shoes, clothing, underwear (PEI) only Cool drinks, chips.etc 310 (44.7%) Make up/cosmetics Hairdressing 118 (17%) Practical items School uniforms, supplies Transport to work, school Food/groceries 216 (31.2%) Entertainment and birth control items Movies/music No items purchased = Entertainment and birth Beer/alcohol control (EBC) and some PEI and 49 (7.1%) No items purchased = 49 (7.1%) Birth control/condoms PRAI Fig. 2 Creation of mutually exclusive groups based on type and value of consumption items among sexually active young women and consumption of EBC items. The unadjusted results Qualitative findings suggest that young women who engage in transactional The perception of “needs” and “wants” sex have almost 1.7 times higher odds of consuming EBC To study the motivations for transactional sex, we items than those who do not engage in transactional sex sought to understand how the perception of ‘needs and (uOR:1.67; CI95% 1.03–2.72; p =0.04). We hypothesised wants’ related to consumption patterns of young that household per capita consumption (a measure of liv- women. ‘Needs’ were defined as items that a person ing standards) might be an effect modifier for the relation- cannot survive without; ‘wants’ were items that a per- ship between transactional sex and consumption of EBC son desires, but can live without. During the focus items. To test this, we conducted a test of interaction. The groups, young women were asked to freely list on a results showed that overall there was almost no interaction whiteboard, items that themselves and their peers were (p = 0.18) between household per capita consumption and either spending money on or what they sought to ac- transactional sex and consumption of EBC. Furthermore, quire. They were then individually asked to categorise after adjusting for confounders, there was evidence to show items by affixing a red (need) or blue (want) sticker that young women who engage in transactional sex have next to the items on the whiteboard. Items were then three times higher odds of consuming items for EBC items grouped into four categories based on their types, value (aOR:3.03; CI95% 1.12–8.23; P = 0.03). and utility: personal enhancement items, practical Table 2 Unadjusted and adjusted relationship between transactional sex and young women’s consumption of practical items (PRAI) and entertainment and birth control (EBC) items (compared to personal enhancement items) among sexually active women who reported some consumption b d #, Outcome: PRAI (n = 398) uOR 95% CI p-value aOR 95% CI p-value No Reference Reference Yes 1.32 0.72–2.44 0.37 1.09 0.57–2.12 0.79 Outcome: EBC (n = 486) No Reference Reference Yes 1.67 1.03-2.72 0.04* 3.03 1.12-8.23 0.03* As separate analysis for each variable. Sample size for each analysis included in each category Please note: These numbers are the sum of the number of young women (that are sexually active) who are buying practical items + the number that are buying personal enhancement items. Records with missing data excluded. Total missing: n = 30 (7%) These are: work for money (n = 8 or 1.2%) missing), orphan status (n =2 or 0.04% missing), type of primary caregiver (n = 1 or 0.02% missing), number of sex partners past 12 months (n =19 or 4% missing) Please note: These numbers are the sum of the number of young women (that are sexually active) who are buying entertainment related and birth control items + the number that are buying personal enhancement items. Records with missing data excluded. Total missing: n = 40 (7.5%) These are: work for money (n = 7 or 1.3%) missing), orphan (n = 9 or 1.7% missing), number of sex partners past 12 months (n =24 or 4.6% missing) uOR, unadjusted odds ratio aOR Adjusted odds ratio Adjusted for all confounders – age, number of household members, being an orphan, type of primary caregiver, currently has a boyfriend, number of sexual partners last 12 months, working for money, per capita consumption P-value estimation through likelihood ratio test (LRT); *P-values in bold are statistically significant at the < 0.05 level Ranganathan et al. Reproductive Health (2018) 15:102 Page 9 of 21 items, expensive items and entertainment items. Table 3 want to protect ourselves from illness, because you lists the results. cannot grow up without doing it, so you need to The results in Table 3 show that ‘needs’ included protect yourself ’). practical items (e.g., clothes, shoes, sanitary pads), ‘Wants’ included some personal enhancement items female personal enhancement items (e.g., lingerie, (e.g., cosmetics, jewellery), entertainment/ leisure (e.g., hair extensions) and certain expensive items (e.g., beer/alcohol, movie tickets), as well as some expensive fancy shoes, expensive clothes). When probed on items, (e.g., expensive phones). Reasons given for want- whether phones or perfume were actual needs, re- ing these items were to be able to identify with certain sponses indicated that they were considered un- role models either within their peer group as illustrated affordable needs; reasons ranged from needing to by this quote: conform (‘because nowadays other people are using Blackberry’), to needing to boosting their status P3: Even if you can bath and wear nice clothes but if (‘perfume is attractive to me because when I smell it you didn’tput make-upaah…you are not really from someone smelling good, like from teachers, then (young woman’s name]. I tell myself that it’sanexpensive perfume, sothat is why it becomes attractive to me’). Some young women P4: It is just because most of the young women nowadays showed efforts to practice safe sexual behaviours by they like fashion, that is why if you don’thavemake-up mentioning birth control and condoms as needs (‘We you will not feel good. Table 3 Needs and Wants categories Groupings Items Need Want Personal Enhancement Items Expensive perfume Need Hair extensions Need Lingerie (fancy underwear (such as Jockey) Need Toiletries (scented soap, skin cream, body lotion, Need powder, roll-on deodorant) Make-up (eyebrow pencil, mascara, false eye Want lashes, eye liner) Cosmetics (Moisturising cream, nail polish (Cutex), skin-brightening cream, lip balm, Want bag, hair control) Salon treatment (hairdressing/hair highlighting, relaxing, dyeing, manicure, waxing) Want Accessories (watches/handbag) Want Jewellery (bracelets, earrings, necklace, gold tooth) Want Body piercings (belly-ring nose-ring, tongue-ring, tattoo) Want Practical Items Clothes Need Ordinary cell phone and airtime Need Shoes Need Female items (underwear, sanitary pads) Need Food, groceries Need School uniforms/supplies Need Transport to school/work Need Birth control/condoms Need Expensive Items Expensive clothes (skinny jeans, hlokoloza (mini skirt), tekkies (trainers), branded clothes Need Fancy shoes (high heels, Carvela (expensive Italian branded shoes) Need Expensive phones (blackberry/camera phone/Nokia/×2) Want Expensive foods (chocolate, yoghurt, grapes, restaurant) Want Entertainment/leisure Beer/alcohol Want Cold drinks and chips, Ultramel (ready-made custard), Lays (potato crisps) Want Movies/music and travelling Want Pocket money Want Ranganathan et al. Reproductive Health (2018) 15:102 Page 10 of 21 Focus group 4, high socio-economic status P3: Even if you can bath and wear nice clothes but if you didn’t put make-up aah…you are not really [role Some items were classified both as a ‘need’ and a model’s name]. ‘want’ based on their perceived value. For example, staple food (e.g., maize) was a need and expensive P4: It is just because most of the young women nowadays food items (e.g., chocolate) were considered wants. they like fashion, that is why if you don’thavemake-up Interestingly, “ordinary clothes and shoes” as well as you will not feel good. “expensive clothes and shoes” were both considered needs. Furthermore, owning expensive clothes were Focus group 4, high socio-economic status represented by many participants as ‘needs’ similar to the need for food. Hence, it is the ‘perception of But possessing certain expensive items enables a need’ rather than an ‘actual need’ that is important, young woman to send a signal to her peer group that as from the perspective of these rural young women, she is a ‘cool, modern woman’, making her the object owning expensive clothes or expensive shoes is of envy among her peers, and in turn enhancing her construed as a necessity in their lives. It therefore ap- self-esteem. pears that young women are motivated by materialis- tic desires, as well as the pressure to conform to peer P: [I want these items] because they are needed and group expectations through adopting symbols of so- that everyone wish they can have it...that if I found phistication and a modern lifestyle. myself having this I will be ‘the’ person among the However, some young women acknowledged the dif- people and when people see me coming from there ferences between expensive and basic items. They recog- they will turn their heads and look at me. nised that coveting unaffordable items did not imply need and that the perception of needs (and wants) is In-depth interview 2, aged 21y relative and based on an individual’s household socio- economic status. However, it appears that many of the perceived needs are also about social standing among peers. For I: I heard someone say that Blackberry is unnecessary. example, wearing nice uniforms are necessary to Can you please tell me why? avoid being teased and humiliated by classmates, more than being ‘real’ barriers to school attendance. P2: Blackberry is too expensive and I’m still a This did not seem to differ between different socio- school child, and parents cannot afford to buy me economic focus groups, as illustrated by the two Blackberry. I will be fine if I can have cell phone quotes below: worth R150 [£9]. The most important thing is to communicate. I: Ok. What happens if you do not have one of the items that you need? P3: It is necessary to have Blackberry, because you will chat for free on Facebook and Blackberry P2: Like school uniform, I won’t go to school without messenger. enough uniform. And when I wear a skirt that is tearing [torn] and then my friends laugh at me. P1: It is not necessary because even if you don’t chat it doesn’t mean that you are not a human being. Focus group 3, low socio-economic status. P3: That is why I said my need is not your need. P1: Like if you go to school you need to wear proper school uniform because the school children will laugh Focus group 4, high socio-economic status at you. P3: Even if you can bathe and wear nice clothes but if The role of peer pressure and socio-economic status you didn’t put make-up aah…you are not really (certain Peer group pressure played an important factor in in- role model in the village). fluencing young women’s perceptions that certain items were ‘needs’ and motivating them to acquire Focus group 4, high socio-economic status such items. This pressure had many components. The first was to identify with certain role models within Status among friends and perceived “ranking” within a their peer group: social order was of importance to young women. Ranganathan et al. Reproductive Health (2018) 15:102 Page 11 of 21 P1: We want to make ourselves beautiful so that Funding consumption patterns people can recognise us. Parents For many young women (n = 18), particularly in the P3: That’s what I was saying if you didn’t put make-up focus groups, parents or primary caregivers paid for people say you’re a traditional girl [I:we laughed], if you items considered needs or ‘practical items’,suchas have put make-up people recognise you that you are transportation to school,aswellasitems of female South African. personal enhancement and hygiene that require regular monthly replenishment, such as roll-on de- P1: Because people from Mozambique they don’t put odorants. Some young women also indicated that make-up, so if you don’t put make-up they will compare parents, on occasion, bought their daughters hair you with them. pieces and earrings. Items that parents did not pay for were mostly entertainment-related, such as movie Focus group 4, high socio-economic status tickets, beer/alcohol or expensive phones or expen- sive creams. Overall, in the in-depth interviews there was not much In particular, young women felt that their parents were variation by socio-economic status in the responses traditionalists, compared to their own ideas of modern around needs and wants, except for in a couple of in- living, as shown by the following quote on the modern- terviews where the young women recognised the con- day use of body creams compared to traditional items straints of their household’s socio-economic situation. that had been used by parents: They acknowledged that despite having desires, the items were unaffordable, but they were hopeful for P3: And our parents say that when they were the future. These have been illustrated by the follow- young they were not using fancy cream that smells ing excerpts: good they were using “Nhlampfura” (Oil of nut or fruit) in older days… [I: they laughed] and why do P: If you use make up it wastes your time, some they have to spend money for us on fancy creams years back at school l could see that something was whereas in older days they were using “Nhlampfura” wrong about me using make up. You find that we and men proposed them even if they don’tsmell are in class at school and people have put their good…. make up; you have finished your make-up and you don’t have money to buy. You will feel like you are Focus group 2, high socio-economic status very poor. So l stopped using make up because it was not good to use make up when you are still a When probed in the focus groups on how young student. women from higher socio-economic households ob- tain items, the general response irrespective of the I: How do they (make-up) make you feel? socio-economic status of the group was that parents from these households have the means to afford P: It made me feel like other children because I can see non-essential items when compared to those from that I’m different to them, but I feel ok about the way l poorer households. Some participants mentioned the am. l believes that one day l will be successful. choices that young women from richer households have in terms of the security of family support and In-depth interview 14, aged 19 years the ability to demand something and have these de- sires met. This, as a result, makes them more P: I don’t care even if I don’t have Cutex (nail polish) confident (when compared to young women from ...but my heart is painful when I go to school and poorer households). didn’t braid my hair and others will laugh at me saying that I’ve aged......Even if they don’t laugh at me P2: And some our situation is different it might they gossip about my hair.....I have an afro hair so I happenthatmyfriendiscoming fromthe richer just braid it without using hair extension.. I feel family and I from poorer family and they will able good (when they gossip) because I told myself that to buy her fancy things and at home they will not whom are they going to gossip about, if they don’t afford to buy me something because they cannot gossip about me. You must accept because people afford it because we don’t get things easily because are gossiping. of not having money. In-depth interview 14, aged 19 years Focus group discussion 2, high socio-economic status Ranganathan et al. Reproductive Health (2018) 15:102 Page 12 of 21 In contrast, parents from poorer households only place young women at risk of contracting diseases. bought items they considered essential, such as food and Young women acknowledged that (other) young clothes. Thus, the budget constraint in low socio- women chase sugar daddies and stated that hard- economic households dictated items considered essential ships at home compel these young women to en- by parents. gage in such sexual relationships. The hope was that sugar daddies would help them afford items P: Like when their mom got a piece [part-time] job that would enhance their appearance. from other households, like to sweep the yard then when she get paid she buy these items like food for P2: Because youth want expensive thing and parents their children and things that they can make them won’t afford it like hair-piece, a parent won’t take you look able [healthy]. to the salon to do your hair, but if you are involved with an old man he can be able to take you to salon Focus group discussion 3, low socio-economic status and do your hair. However, not all poorer families bought their Focus group discussion 2, high socio-economic status. children only essential items. For example, a young woman from a low-income family described P2: Sugar daddies have money and I want their how, in her friend’s family, the use of cosmetics money… [I: we laughed]. So nowadays girls want to was not encouraged, as her parents perceived it to make themselves beautiful, look nice and wear nice be something which would attract untoward atten- clothes. Some other girls when you give them money tion. However, they did encourage cultivation of they go to the shop and buy snacks… [I: we laughed] but an aesthetic sense and provided the young woman look at me I eat well because I have a relationship with with nicer clothes to help her fit in. Young women a sugar daddy. noted that parents were aware of their need to maintain status. But, many of these families were Focus group discussion 5, low socio-economic status. supported by social grants and did not have the financial means to buy ‘items of need’.Thisre- In contrast, during in-depth interviews, young sulted in young women resorting to other ways of women were more reticent in their responses obtaining items, as illustrated by the following when probed about their personal engagement quote: with sugar daddies. This might be because young women in the interviews were asked questions re- P5: Because like when they buy them make-up they lated to their personal situations, compared to the will think she will start to be a prostitute. focus groups, when the discussion was more gen- eral. There was agreement that the desire to be I: Mmm…Ok, so what about those who like it? with a sugar daddy arises from materialistic moti- vations and peer pressure. P3: They want their children to be beautiful and be recognised. P: [I don’t want sugar daddies] because he is too old and on the other hand I abuse my body. ….. Focus group discussion 3, low socio-economic status Some they want clothes and expensive cell phone like ‘Samsung Galaxy’ [expensive smartphone]. You find that they like it and sometimes this is Sugar daddies cause by peer pressure. You find that my friends ‘Sugar daddies’ were mentioned as sources of fund- are having a relationship with a sugar daddy ing for items parents did not provide. When and she had sex with him then he buys her some probed on the definition of a sugar daddy, the re- items or expensive clothes like label clothes or an sponse was: “an older person (>10 years older), expensive cell phone. I like it then I start to more established in his career, more financially involve myself [with a sugar daddy] to get the stable that solicits younger women primarily for items that I need. sex.” During focus groups, the discussion related to sugar daddies was not positive; there was open ac- In-depth interview 10, aged 20y. knowledgement of the associated social stigma as- sociated with sugar daddy relationships and the fact Yet, there was recognition, even in the focus groups that that sexual relationships with sugar daddies that any sexual relationship with a sugar daddy placed Ranganathan et al. Reproductive Health (2018) 15:102 Page 13 of 21 young women at risk of abusive behaviour and of con- I: What would you do if he didn’t buy you things you tracting HIV, as detailed here: want like airtime? P: Sugar daddy is a person who has a family. If P: I will just leave him, why doesn’t he buy me airtime you are in relationship with him is like he is it will mean he buy it for someone else… abusing you because he is older than you and has his wife. In-depth interview 17, aged 20y. In-depth interview 11, aged 19y. P2: Yes it happens. To have a relationship with someone who own a nice car because when I am P1: Like you find that she’s in a relationship with a sitting with my friends I will tell them that I ride sugar daddy and you don’t know his [HIV] status and with a nice car. And then I will influence them he’s just buying her so he can sleep with her and leave not to have relationships with school boys. They her with diseases. have to date those who are working. Focus group discussion 3, low socio-economic status Focus group discussion 1, low socio-economic status. In the focus groups, when probed on motivations Boyfriends foryoung womentobeinrelationships,two-thirds In contrast to sugar daddies, there was a percep- of young women explicitly said that it was for tion that “a boyfriend is a person you love. A sugar money or material goods. The remainder of young daddy is a boyfriend with benefits...like airtime. women in the focus groups were more reticent about In-depth interview 6”, age 21). The perception was money being their main motivation. Privately, in the that receiving money or gifts from a sugar daddy interviews, most young women were likely to back can almost be likened to prostitution, as the ex- away from group consensus to say that it was love pectation of sex with the provision of money or that made them engage in sexual relationships with giftsisovert,whereas receiving giftsormoney men. Nevertheless, even though love featured in from boyfriends of similar age did not have the most young women’s responses, there was a clear, same level of explicit expectation of sexual ex- but implicit understanding that the need for money change. Boyfriends’ provision of financial and ma- and gifts were important in all relationships. It ap- terial support was mentioned extensively by young pearsfromthis datathatthe rulesand normssur- women in both focus groups and interviews as a rounding sex in exchange for money/gifts are reason for becoming involved in relationships. intricate and sometimes ambiguous; gifts and money Some focus group participants openly expressed are important even in relationships characterised by their preference for being with a partner of similar love. Yet, money exchange does have one constant: a age, but commented that the likelihood of these sexual relationship does not exist without the ex- men having a lucrative job was slim, hence were pectation of a male-to-female transfer of money or less able to act as providers. Similarly, as most gifts. But, young women did make the distinction young women were young and inexperienced, they between “being opportunistic” and “feeling provided aspired for a ‘perceived better life’ filled with po- for and looked after”. tential, such as with a man who can provide. Thus, aspirations to “fit into the crowd” drove I: Mmm… the one you had a relationship with, where their desire to engage in relationships. Some did you meet him? young women mentioned that receiving gifts help increase their social acceptance among friends. P: At school. I wanted him to help me. Like when I They did not report feeling obliged to have sex need money to use he was able to help me things like with their boyfriends in exchange for these items hair extensions. When I wanted it he was able to give (“he buys me things that I should have it as a me money to buy it… I was feeling happy about it girl”, In-depth interview 8,aged 20y). [receiving money]. P: [the reasons I am with him] are because I like things… I: Tell me did you feel like you had to have sex with it’sa status.Hebuysme airtime.Icallhimand friends. him to receive money or gifts. And boast on them that I have been bought airtime. I feel good, something like that. P: No. It was the issue of love. Ranganathan et al. Reproductive Health (2018) 15:102 Page 14 of 21 In-depth interview 18, aged 20y. young women aged 15–25 in an urban township of Durban, South Africa. Madlala’s findings showed that Overall, it is important to mention that social the practice of transactional sex is best illustrated by pressure demands that young women speak of rela- a continuum, where rewards or gifts can vary between tionships as being ‘for love’,and whilethisiscer- what are generally perceived to be ‘needs’ and what tainly a key element of their relationships, the are generally understood as ‘wants’. However both are potential for material gain is also a significant com- always represented and expressed as ‘needs’ [36]. Fur- ponent. Few young women felt that they had to ther, our study illustrated that the pursuit of expen- have sex because of receiving gifts, but gift giving sive or personal enhancement items was not just a was still considered an essential component of their mere exercise of consumption, but one that is per- relationships. ceived to be necessary for survival from social exclu- sion or loneliness. As articulated by Stoebenau et al. Discussion (2013) the term “economic vulnerability” initially This is one of the first and only studies to quantita- coined by Kuate-Defo captures relationships that are tively explore the relationship between transactional motivated by “survival” as well as conformity, social sex and consumption patterns in a cohort of young status and pride among peer group members [37]. women in rural South Africa. Our quantitative results Thus, in contrast to Maslow’sframework,where a showed that transactional sex was associated with al- sense of belonging is linked to the development of most a three-fold increased odds of young women self-worth and recognition, one can infer that young consuming items for entertainment (e.g., movie women’s notions of survival extend beyond just bio- tickets), items that are considered indicators of risky logical and physiological needs (food, clothing, shel- sexual behaviours (e.g. alcohol) and items that are in- ter) and that the need for a sense of belonging to dicators of sexual activity (e.g., birth control and con- their peer group, and for self-esteem are perceived to doms), but this did not vary by household socio- be essential to their survival. Hence, the findings sug- economic status. There was, however no evidence of gest that transactional sex linked to subsistence or to an association between transactional sex and young consumerism are not necessarily mutually exclusive. women’s consumption of practical items, such as This aligns with research in South Africa by Adato et food, school uniforms and transportation to school. al. (2016) and in Kenya by Mojola (2014) that demon- Furthermore, our qualitative data offers unique in- strates how issues related to the articulation of gen- sights into young women’s classification of items that dered needs (e.g., deodorants, skin creams) and non- are considered ‘needs’ versus ‘wants’. It is one of the material needs (e.g., peer pressure, social status and first studies that links these qualitative conceptualisa- conformity) shape young women’s decisions to engage tions to young women’s consumption patterns using in transactional sex [38, 39]. the framework of Maslow’s hierarchy of needs to cat- This study also showed that young women aspire egorise and understand young women’sneedsand for a variety of items, but their household economic wants. It suggests that the distinction between ‘need’ situation, along with circumscribed economic oppor- and ‘want’ is ambiguous and that motivations for tunities in the area, imposes spending constraints. In obtaining such items are not driven merely by sur- turn, relationships appeared to fill this funding gap vival or consumerism, but by higher order psycho- for young women’s consumption. This was especially social needs such as the need to belong to a peer the case when parents were not willing or able to group. These results illustrate that Maslow’shierarchy provide an extra allowance to obtain items that are of needs does not apply strictly to young women’s considered ‘non-essential’. This aligned with Allison needs and wants. In situations of considerable pov- Pugh’s (2009) research in the United States demon- erty, unstable household structure, scarce economic strating the commodification of childhood in the opportunities and a rapidly globalising economy, United States and the dilemma facing low income young women in rural South Africa have ‘admitted’ parents when dealing with their children’sgrowing needs (for items that are considered necessary, such materialistic desires [40]. According to Pugh, these as food or clothes) and ‘hidden’ needs (such as for parents had clear spending constraints, hence only expensive clothes, cosmetics) that are their ‘wants’. bought essential items and maybe indulged their chil- Hidden needs appear to play a pivotal role in these dren occasionally, despite being empathetic to their young women’s quest for enhancing their self-esteem children’s needs and wants [40]. As a result, some and status and feeling like they belong to and are young women enter similar age relationships with accepted by their peer group. This aligns with boyfriends or become involved with sugar daddies to Leclerc-Madlala’s (2004) research with unmarried have a steadyconduit throughwhich moneyor gifts Ranganathan et al. Reproductive Health (2018) 15:102 Page 15 of 21 flow. Participants (particularly in the focus groups) From our quantitative results, as transactional sex is frequently mentioned the existence of sugar daddies associated with the consumption of entertainment re- and that (other) young women have relationships with lated items, such as alcohol, an argument could be them either to fulfil basic needs, but more often to made based on the literature that young women who satisfy their consumerist desires. Interestingly, none of engage in the “game” of alcohol-sex exchange may to the participants admitted to personally engaging with some extent use it as a form of entertainment, both sugar daddies when probed in the in-depth interviews. in the procurement of alcohol and related socialisa- There was a negative connotation associated with tion that occurs in these venues [49]. Research by sugar daddies as a person who was ‘abusive’,was sub- Watt et al. in South Africa suggests that alcohol- stantially older and disrespectful towards young serving venues provide a space to foster social iden- women. There was recognition that in a context of tity with peer groups and to deal with boredom that economic deprivation, sugar daddies were a source by comes with circumscribed employment opportunities which young women could access things they might and lack of recreational activities [50, 51]. Other re- not be able to afford otherwise. In addition, in a set- search in similar settings has shown that gender in- ting where awareness of diseases, including HIV in- equalityand povertyprovideacontext in whichthe fection, is high; many young women mentioned that alcohol-sex exchange can become an attractive strat- sugar daddies would put them at risk of disease, egy for young women [52]. along with the social stigma associated with engaging A theme that also emerged from the qualitative with one. As has been shown in the literature, young research is that young women seek boyfriends out womenengaginginsexualrelationships with older of an aspiration for social mobility, economic inde- men are considered to be at much higher risk of HIV pendence or simply a life enhanced by status, in- acquisition compared to a young woman engaging cluding expensive clothes and fancier items. Our with a similar age male peer [41, 42]. Thus, overtly quantitative results complemented this picture by engaging in sexual relations for money or gifts with a showing that engagement in transactional sex does sugar daddy was considered closer to sex work, as not vary by socio-economic status. In fact, rural the negotiation in the exchange was explicit, whereas young South African women are engaging in trans- having a relationship with a similar age boyfriend actional sex to also purchase entertainment items, (even if it is a source for money or gifts) was still nu- which suggests that young women are aspiring for a anced in its meaning and significance. This finding lifestyle, which is not just about dire need, but also indicates that relationships with sugar daddies are not about choice and entertainment. This finding also necessarily rampant as previously suggested [43]and aligns with research from other settings in South that young women were aware of the associated risks. Africa, Zimbabwe and Kenya [53–56]thatalsodis- Further, as shown by other research conducted by this cuss the commodification of young women’scon- study authors using the same sample of young sumption patterns and the role of transactional sex. women [44], similar-age relationships appear to be Further, in the context of post-apartheid South morethenorm, even if therewas atransactional Africa, through the lifting of restrictions of Black component. people’s movements, improved road infrastructure to Related to this, our qualitative results show a far rural areas, the influx of goods from other counties more nuanced relationship between sex, love and the and increased access to visual and print media, pre- provision of gifts. Women want to be the object of viously “remote” rural areas in South Africa have love (and desire) from their similar age male part- gradually opened socially and geographically. These ners, but also expect to receive money or gifts as an macro-level changes have played a role in exposing expression of this desire. This has also been young women to globalised images and availability discussed in multiple studies throughout the sub- of goods [11]. In addition, one could also argue that Saharan African region (South Africa, Malawi, there are different role models for this generation Tanzania) [45–48]thatdemonstrate thedegreeto than there might have been for previous genera- which love and money are tightly intertwined in re- tions. During apartheid, there was not the same ac- lationships. A number of young women rationalise cesstoimagesofsuccessful Blackpeopleasthere their behaviour of coveting material items or gifts are now, which makes it easier for young Black and genuinely believe that they are in the relation- women to identify with role models [11]. Thus, ship for love (that they engage in sex for love). If irrespective of young women’s household socio- they have a boyfriend, they do expect either money economic position, aspirations for items might also or gifts, but in all these cases the implication is love be influenced by access to media and advertise- and not sex for gifts/money [44]. ments, peer groups, globalisation or macroeconomic Ranganathan et al. Reproductive Health (2018) 15:102 Page 16 of 21 changes in the country, television shows and a that in South Africa, condoms are distributed for strong desire to be socially accepted. free by the government Department of Health and dispensed by local authority clinics. [57] Thus, Strengths and limitations young women might not need to engage in transac- This study has a number of strengths and limitations. tional sex in order to obtain condoms. However, The use of laptops and ACASI software for data col- there was a perception among young people that lection allowed for increased privacy in the quantita- government provided free condoms were of lower tive survey. By removing the face-to-face component status and quality [58] resulting in young women of surveys, the social-desirability aspect of responses preferring the fancier, more expensive condoms. The was partially addressed, thereby tackling the potential government has recently embarked on a new cam- issue of over or under-reporting of sensitive ques- paign to provide free condoms in school in order to tions, such as transactional sex. To address the social increase availability, but also re-brand them, so that stigma around the reporting of sexual behaviours, they appeal to young people. This should hopefully one-on-one interviews were conducted in a private increase the uptake of free condoms [58]. setting, such as the participant’s house, and partici- Finally, due to time and monetary constraints, we pants were assured that the research was going to were unable to interview boys or men and get their benefit the community and that interview data would perspectives on young women’s motivations for being be kept anonymous. We found that focus group dis- in relationships. Hunter’s (2010) historical analysis of cussions and in-depth interviews complemented each love and masculinities in rural KwaZulu-Natal [45] other well, as the focus groups permitted free flow of and Bhana and Pattman’s research [46]inatownship information in a group setting. Young women were outside Durban, KwaZulu-Natal discusses provider less hesitant to speak about the sexual behaviours, as roles as an important feature in feelings of masculin- they were explicitly asked to talk generally in the ity in South African men and how it frames their re- focus groups. In fact, they were more open discussing lationships with women. Future research in the same sugar daddies in the focus groups than in the in- studysiteshould explore men’sperspectivestocom- depth interviews. Thus, the larger themes around pare responses and enrich these findings [45, 46]. their motivations to have a sexual relationship were Moreover, the cross-sectional nature of the data better explored privately in the interviews. means that we cannot make any claims about the This analysis is however limited by the sample for causal direction of these relationships, preventing us the qualitative data, which limits our ability to ex- from understanding to what extent consumption mo- trapolate these results to other individuals, including tivates sexual behaviour. For example, young women young women that are under 18-year olds and/or do reporting transactional sex are using money for not attend school. Moreover, eligibility criteria for entertainment-related items; entertainment might be a being part of the main trial (that young women and consequence of the transactional relationship rather their parents/guardians had to have documentation than a reason for it. We have tried to address this to open a bank account), meant that poorer young limitation through qualitative work where questions women who have limited access to basic services during in-depth interviews explore the types of items and social grants could not enrol in the study. It young women consider a need and want and the mo- may be that transactional sex in this subset of dis- tivations for obtaining such items. Recall bias is also advantaged young women is less consumerist- a potential issue, as the variables to measure transac- oriented and more subsistence-driven. Hence the re- tional sex, young women’s consumption patterns and sults need to be interpreted with caution. Further, all the potential confounders are self-reported. Ques- we recognise that birth control and condoms are tion time-frames were chosen to be consistent with separate items and have different meanings in terms other studies (where applicable) and to facilitate recall of their use; birth control methods do not require (e.g., sexual partners over the past 12 months or past negotiation between partners and the choice of their month consumption). use is with the young woman, whereas, condoms re- quire up-front negotiation between partners, result- Conclusion ing in a potential loss of control for young women. This study offers evidence of an association between However, as this was a secondary analysis of survey transactional sex and consumption patterns among data, and both the items were already together, we young women in rural South Africa. It demonstrates are not able to separate them out. Hence, for this that young women who engage in transactional sex analysis, we have considered them together as birth have higher odds of consuming items for entertain- control/condoms. It is also important to mention ment that might also lead to risky sexual behaviours. Ranganathan et al. Reproductive Health (2018) 15:102 Page 17 of 21 Thus, an underlying driver for transactional sex is annual study visits. Study participants were eligible the need to close a gap in the funding of certain for inclusion in the trial if they were females aged 13 consumer-oriented items. However, the qualitative to 20 years; enrolled in grades 8, 9, 10 or 11 at se- findings also suggest that young women seem aware lected schools in the AHDSS study site; and had a of the risks associated with sugar daddy relation- bank or post office account to receive the transfer. ships. Relationships between young women and men The participants were excluded if they were pregnant of similar age appear to be more prevalent than or married at baseline. Both parental/legal guardian sugar daddy relationships. In these relationships, the consent and young woman consent/assent were re- male to female exchange of commodities is common quired to participate. and expected, but not explicitly linked to sexual ac- tivity. The motivations given for the acquisition of specific lifestyle-related items suggests that they were Appendix 2 not related either to subsistence or consumerist de- Construction of effect modifier and confounding variables sires, but to the fulfilment of psycho-social needs for belonging, peer acceptance and self-esteem. This  The age of young women, was recorded as a study shows that young women are willing to take continuous variable from 13 to 20 years and was certain risks in order to be able to have a degree of re-categorised into two groups of 13–15; 16–20 for financial independence. Interventions that provide al- equal sample size in each category. ternative methods of attaining this independence,  The age of first vaginal and/or anal sex was constructed such as the provision of cash transfers, may have po- from the questions “how old were you when you first tential in preventing them from engaging in transac- had vaginal sex? How old were you when you first tional relationships [59]. However, the psycho-social had anal sex?” and re-categorised into two groups - reasons that drive young women’smotivations for < 15 years and 15 years and older. consumption needs within a rural, but globalising  Employment status of the young woman was recorded context needs to be better understood. In particular, as a binary variable and constructed it from the peer-led education programmes have shown to be question “Did you do any work for pay or family capable of providing vulnerable youth with psycho- gain,including paymentinkindsuchas foodor social support, as well as information and decision housing?” making skills [60]. These programmes will also lever-  Educational level of primary caregiver was measured age youth resilience and protective skills within the as a categorical variable with four categories: none, confines of difficult economic and social circum- primary, secondary, matric (year 12) and adult basic stances to allow them to successfully navigate safer education. sexual relationships [61, 62].  Orphan status (defined as either one or both parents deceased), was binary and constructed from the Appendix 1 question, if the mother was alive and if the father HPTN 068 trial baseline sztudy design: was alive. Data collection was conducted from March 2011–  Young women’s number of sexual partners in the December 2012 in the sub-district of Agincourt in past 12 months was recorded from 0 to 15 and was rural Mpumalanga Province, north-east South Africa, categorised into 4 groups: 0, 1, 2, > 3. an area with high levels of poverty, unemployment  Per capita household consumption as a measure of and labour migration [23–25]. The Medical Research living standards was calculated using the module on Council (MRC)/Wits University Rural Public Health food and non-food spending and consumption in and Health Transitions Research Unit runs the the household questionnaire. This was done by Agincourt Health and Socio-Demographic Surveillance summing all household spending and consumption System (AHDSS) in this area and this was the plat- on food and non-food items and by dividing it by form for identifying eligible households and young the number of household members (total spending women [52]. The trial sought to explore whether pro- and consumption per capita) [32]. A categorical viding cash transfers to young women and their household consumption measure was then obtained households - conditional on school attendance - re- by dividing this measure into deciles (1–10). For this duces HIV incidence among young women [26]. The analysis, we re-categorised the variable from deciles intervention involved individually randomising young to three groups for total amount spending/consumption women aged 13 to 20 to receive a monthly cash per capita: low (ranging from $1.3 to 15.4), transfer, conditional on school attendance. Control medium (ranging from $15.5 to 32.6) and high participants received no cash transfer but attended (above $32.10). Ranganathan et al. Reproductive Health (2018) 15:102 Page 18 of 21 Appendix 3 Fig. 3 Flowchart for analysis between transactional sex and consumption patterns Ranganathan et al. Reproductive Health (2018) 15:102 Page 19 of 21 Appendix 4 Fig. 4 Factor loadings for 12 items from consumption module Acknowledgements Chapel Hill Institutional Review Board (IRB) (no reference number), and the The authors would especially like to thank the young women and their Department of Health and Education, Mpumalanga Province, South Africa (no guardians for their participation in this study, the field staff (Rirhandzu, reference number) where the research was conducted. Violet, Nestor and Ellah), as well as the analysts at HPTN 068 and the Agincourt HDSS who spent many months collecting the data and organising Competing interests the study. Without the time and generosity of both participants and field staff, The authors declare that they have no competing interests. this work would not have been possible. For this we are very grateful. Funding Publisher’sNote This research was supported by the STRIVE research programme consortium Springer Nature remains neutral with regard to jurisdictional claims in funded by UKaid from the Department for International Development. published maps and institutional affiliations. However, the views expressed do not necessarily reflect the department’s official policies. Overall support for the HIV Prevention Trials Network (HPTN) Author details was provided by the National Institute of Allergy and Infectious Diseases Department for Global Health and Development, Faculty of Public Health (NIAID), the National Institute of Mental Health (NIMH) and the National and Policy, The London School of Hygiene and Tropical Medicine, London, Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH) UK. Wits Reproductive Health and HIV Institute, University of Witwatersrand, under Award Numbers UM1AI068619 (HPTN Leadership and Operations Johannesburg, South Africa. MRC/Wits Rural Public Health and Health Center), UM1AI068617 (HPTN Statistical and Data Management Center), Transitions Unit (Agincourt), School of Public Health, Faculty of Health and UM1AI068613 (HPTN Laboratory Center). Additional funding was Sciences, University of the Witwatersrand, Johannesburg, South Africa. provided in part by the Division of Intramural Research, NIAID. The School of Health & Society, University of Wollongong, Wollongong, NSW, study was also funded under Award Number 5R01MH087118–02 and Australia. Department of Epidemiology, University of North Carolina at P2C HD050924 to the Carolina Population Center. The content is solely Chapel Hill, Chapel Hill, NC, USA. Carolina Population Center, University of the responsibility of the authors and does not necessarily represent North Carolina, Chapel Hill, NC, USA. Umeå Centre for Global Health the official views of the National Institute of Allergy and Infectious Research, Division of Epidemiology and Global Health, Department of Public Diseases or the National Institutes of Health. Health and Clinical Medicine, Umeå University, Umeå, Sweden. International Network for the Demographic Evaluation of Populations and Their Health Availability of data and materials (INDEPTH) Network, Accra, Ghana. Department of Population, Family and The datasets generated during and/or analysed during the current study are Reproductive Health, Johns Hopkins Bloomberg School of Public Health and not publicly available because they contain participant identification numbers JHU School of Nursing, Baltimore, MD, USA. but are available from the corresponding author on reasonable request. Received: 9 September 2017 Accepted: 10 May 2018 Authors’ contributions Conceived and designed the study: MR AP CW LH CM. Analysed the data: MR, CM, HS, RJS. Wrote the paper. 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A community-based study to examine the effect of a youth HIV prevention intervention on young people aged 15-24 in South Africa: results of the baseline survey. Tropical Med Int Health. 2005;10(10):971–80. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Reproductive Health Springer Journals

‘It’s because I like things… it’s a status and he buys me airtime’: exploring the role of transactional sex in young women’s consumption patterns in rural South Africa (secondary findings from HPTN 068)

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Medicine & Public Health; Reproductive Medicine; Public Health; Maternal and Child Health
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Abstract

Background: ‘Transactional sex’, defined as a non-marital, non-commercial sexual relationship in which money or material goods are exchanged for sex, is associated with young women’s increased vulnerability to HIV infection. Existing research illustrates that the motivations for transactional sex are complex. The fulfilment of psycho-social needs such as the need to belong to a peer group are important factors underlying young women’s desires to obtain certain consumption items and thus engage in transactional sex. Methods: We use a mixed-methods approach to explore the relationship between transactional sex and consumption patterns among young women in rural Mpumalanga province, South Africa. In the secondary analysis of 693 sexually active young women, we use factor analysis to group the different consumption items and we use multivariable logistic regression to demonstrate the relationship between transactional sex and consumption patterns. The qualitative study uses five focus group discussions and 19 in-depth interviews to explore further young women’s motivations for acquiring different consumption items. Results: The quantitative results show that young women that engage in transactional sex have higher odds of consuming items for entertainment (e.g., movie tickets) than on practical items (e.g., food and groceries). The qualitative findings also revealed that young women’s perceptions of items that were considered a ‘need’ were strongly influenced by peer pressure and a desire for improved status. Further, there was a perception that emerged from the qualitative data that relationships with sugar daddies offered a way to acquire consumer goods associated with a ‘modern lifestyle’, such as items for personal enhancement and entertainment. However, young women seem aware of the risks associated with such relationships. More importantly, they also develop relationship with partners of similar age, albeit with the continued expectation of material exchange, despite engaging in the relationship for love. (Continued on next page) * Correspondence: Meghna.Ranganathan@lshtm.ac.uk Department for Global Health and Development, Faculty of Public Health and Policy, The London School of Hygiene and Tropical Medicine, London, UK Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the 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. Ranganathan et al. Reproductive Health (2018) 15:102 Page 2 of 21 (Continued from previous page) Conclusion: This study shows that young women are willing to take certain risks in order to have a degree of financial independence. Interventions that provide alternative methods of attaining this independence, such as the provision of cash transfers may have potential in preventing them from engaging in transactional relationships. Further, the psycho-social reasons that drive young women’s motivations for consumption items resulting in risky sexual behaviours need to be better understood. Keywords: Adolescent girls, Young women, Transactional sex, Sexual exchange, Consumption patterns, Spending patterns, Aspirations Plain English summary women (hereafter young women) aged 15–24 in sub- Transactional sex is defined as a sexual relationship out- Saharan Africa (SSA) [1–3]. It can place young women side marriage or formal sex work where money or ma- at heightened risk of HIV via multiple mechanisms – in- terial goods are exchanged for sex. It is associated with creasing their number of sexual partners (partner adolescent girls and young women’s (hereafter young switching to obtain more items) [4–6], encouraging con- women) increased susceptibility to HIV infection. current relationships [4–6] or affecting partner choice Research shows that the motivations for transactional [2]. This in turn might bias young women toward older sex are complex. The fulfilment of psycho-social needs partners who have more resources, but are also more such as the need to belong to a peer group are import- likely to be HIV positive [7–9]. Previous literature has ant factors underlying young women’s desires to obtain emphasised three paradigms to describe motivations for certain types of goods and to engage in transactional transactional sex – sex for basic needs, sex for upward sex. This article advances this line of inquiry by using a mobility and status, and sex for material expressions of mixed- method approach with quantitative and qualita- love [10]. Furthermore, there are additional psychosocial tive methods to focus on the relationship between trans- needs in young women, such as the need to belong to actional sex and spending patterns of young women in peer groups that motivate them to acquire certain items rural Mpumalanga, South Africa and to better under- to enhance their appearance. This may encourage them stand young women’s needs and wants. The overall find- to engage in relationships in order to obtain these items. ings revealed that young women’s perception of items In particular, in some instances, young women’s aspira- that were considered a ‘need’ was strongly influenced by tions for a ‘modern lifestyle’, often measured by their peer pressure and that relationships with older men or consumption patterns (also known as spending patterns) ‘sugar daddies’ offered a way to acquire goods associated or possession of key consumer goods can drive their with a “modern lifestyle”, such as items for personal en- pursuit of transactional sex [11, 12]. In settings with high hancement and entertainment. However, young women unemployment and where opportunities to acquire seem aware of the risks associated with such relation- these items are limited, studies suggest that by ob- ships and also develop relationships with partners of serving older sisters and/or friends, young women similar age, primarily for love, but with the continued realise that material goods can be acquired through expectation of material exchange. This study shows that sexual exchange [6, 13, 14]. young women are willing to take certain risks in order This study advances this line of inquiry by examining to be able to have a degree of financial independence. young women’s patterns of consumption, their motiva- Interventions that provide alternative methods of attain- tions to acquire certain items and the relationship ing this independence, such as the provision of cash between transactional sex and consumption patterns. transfers, may have potential in preventing them from Specifically, we explore whether examining young engaging in transactional relationships. Further, the women’s consumption patterns (what they purchased psycho-social reasons that drive young women’s motiva- and received as gifts) could yield insights into the dy- tions for acquiring items needs to be better understood namics of transactional sex among young women in in order to reduce risky sexual behaviour. rural Mpumalanga, South Africa. Background Theoretical underpinnings Transactional sex - defined as a non-marital, non- To understand the motivations behind young women’s commercial sexual relationship where men and women aspirations to acquire specific items, our study draws on exchange sex for material possessions or favours - has theories of belonging and conformity, especially as they been found to be an important contributing factor to apply to adolescents. Erikson [15] describes adolescence HIV vulnerability among adolescent girls and young as a phase in the life cycle when, “young people are Ranganathan et al. Reproductive Health (2018) 15:102 Page 3 of 21 sometimes morbidly, often curiously, preoccupied with consumption patterns using quantitative methods. This what they appear to be, in the eyes of others as com- informed the development of the focus group discussion pared with what they feel they are...”([16], page 128). and in-depth interview topic guides. We then cross- Thus, adolescents seek conformity within their groups verified findings by comparing the findings of each [16], and are influenced by peers with regard to both method, identifying areas where results diverged, con- neutral behaviours, such as clothing choices, and risky verged, or added insights [29]. behaviours, such as smoking, drug use and risky sex [17]. The need for belonging forms an important tenet Quantitative methods of Maslow’s theory (1943) of hierarchy of needs, which Of the total sample of 2533 young women, our sample proposes that the need to belong is preceded in import- for the secondary analysis included only sexually active, ance only by basic biological needs and a desire for school-going young women (n = 693) who reported ever safety [18]. Researchers have since found that belonging having had vaginal and/or anal sex. For this analysis, the affects people’s emotions [19], self-esteem [20] and per- exposure variable was transactional sex and the outcome ceptions of others. Importantly, belonging to certain variable was consumption patterns of young women. peer groups requires conformity with group values; and a willingness to follow one’s peers [21]. Thus, to be ac- cepted, adolescents may be required to conform to Measurement tools group norms [22]. For example, Wamoyi (2010) shows Due to the personal nature of some of the questions in in her ethnographic fieldwork in Tanzania that young the young women’s questionnaire (i.e. details of sexual women’s desire for acquiring ‘nice’ things and their relationships) young women completed computer-based readiness to have sex to acquire them, is predominantly questionnaires which were primarily self-administered shaped by peer expectations and pressure to conform using Audio-Computer Assisted Self-Interviewing (ACASI). [14]. We follow this line of inquiry in a different context Parents/guardians completed interviewer-administered, and among a larger sample of individuals. We draw on structured, computer-based household questionnaires. these theoretical notions to understand young rural Information on household and socio-economic character- South African women’s motivations for engaging in istics (household questionnaire) and socio-demographic transactional sex. background, sexual experiences and partner history (young women’s questionnaire) were included in the tools. Methods Young women filled out questions that were more per- Research study design sonal by themselves. Both the parent/guardian and young This paper is a secondary analysis of baseline survey woman’s interviews were conducted in the language pre- data from the HPTN 068 study: a phase III individually ferred by the participant - in the local language, xiTsonga, randomised conditional cash transfer (CCT) trial in rural or English. The questionnaires were translated into xiT- South Africa. Data collection was conducted from songa by bilingual researchers and checked for linguistic March 2011–December 2012 in the sub-district of appropriateness, comprehension and cultural relevance Agincourt in rural Mpumalanga Province, north-east and then back-translated from xiTsonga into English to South Africa, an area with high levels of unemployment, ensure accuracy and fidelity to meaning. poverty and labour migration [23–25]. The intervention involved individually randomising young women aged 13–20 years to receive a monthly cash transfer condi- Variables tional on school attendance. Study participants were eli- Outcome variable gible for inclusion in the trial if they were females aged The outcome variable is young women’s consumption 13 to 20 years; enrolled in grades 8, 9, 10 or 11 at se- patterns, measured by spending patterns on a given set lected schools in the study site; and had a bank or post of items. The question in this study asks, “Over the past office account to receive the cash transfer. The total month, did you buy for yourself any [item name] coded sample size of the main trial was 2533 young women as binary (yes/no)” and “Over the past month, how much and their parent/guardian (with one young woman per money in South African Rands did you spend on [item household enrolled). A brief summary of the main trial’s name] for yourself”. We used factor analysis to group the study design is described in Appendix 1; the trial’s sam- 12 items: scented soap, skin creams or lotions; cell ple size calculation, sample recruitment and data collec- phone, airtime, ringtones; shoes, clothing and under- tion are described elsewhere [2, 26]. wear; cool drinks, chips, etc.; make-up and cosmetics; For this study, we used a mixed-methods, sequential hairdressing; food/groceries; school uniform or supplies; explanatory design [27, 28]. Specifically, we explored the transport to work and school; beer/alcohol; movies or relationship between transactional sex and young women’s music tickets and birth control and condoms. Ranganathan et al. Reproductive Health (2018) 15:102 Page 4 of 21 Exposure variable individuals with complete data were included in the final The main exposure variable was ‘ever having had trans- models. Please see Appendix 3 for flowchart on final actional sex’ coded as a binary variable (yes/no) for sex sample size. in exchange for money and/or gifts. We asked the young woman about her sexual and relationship history with Analysis her three most recent partners, starting with the most We used exploratory factor analysis to group the 12- recent partner. The four steps carried out to construct item consumption module into sub-groups by examining the transactional sex variable were: how underlying common constructs influence individual responses on certain variables [30]. This helped to deter- 1) Variable ‘transactional sex for money’ coded 1 if mine items that “hung together” in a questionnaire; to participant said yes to “Did you feel like you had to determine the most important features when classifying have sex with [initials] because they gave you money?”; a group of items; and to generate factor scores that rep- 2) Variable ‘transactional sex for gifts’ coded 1 if resent values of the underlying constructs for use in participant said yes to “Did you feel like you had other analyses [31]. Further, descriptive statistics were to have sex with [initials] because they gave you used to summarise socio-demographic and partnership things (such as airtime, cell phone, groceries, clothes or characteristics of the sample and the prevalence and pat- shoes, perfume or lotions, make-up, cool-drinks, sweets terns of transactional sex. Using logistic regression, we or chips, CDs, DVDs or videos, alcohol or drugs, estimated the odds ratios for groups of consumption flowers, other (specify))?”; items associated with transactional sex. Unadjusted 3) Variable ‘transactional sex for money ‘and’ gifts coded models were fitted, as well as models adjusted for poten- 1 if participant had said yes to question (1) “Did you tial confounders. In this and all subsequent models, we feel like you had to have sex with [initials] because accounted for clustering at the school level by using they gave you money?” and question (2) “Did you feel cluster-robust standard errors. like you had to have sex with [initials] because they gave you things?”; Qualitative methods 4) The final variable ‘transactional sex for money’ The qualitative study used a combination of five focus ‘and/or’ gifts coded 1 if participant said yes to groups (n = 25) and 19 in-depth interviews with school- question (1) “Did you feel like you had to have going young women who were participants in the con- sex with [initials] because they gave you money?” or trol arm of the main trial. Due to ethical reasons, we question (2) “Did you feel like you had to have could only include young women aged 18–21 years for sex with [initials] because they gave you things?” the qualitative study. Data collection was from November 2012 until March 2013. For the focus groups, young Effect modifiers and other variables women were selected using the per capita household con- Per capita household consumption (as a measure of sumption variable collected in the main survey as a meas- household living standards) was hypothesised to be a po- ure of socio-economic status. Based on the information tential effect modifier in the relationship between trans- collected, participants were divided into three socioeco- actional sex and consumption patterns. Furthermore, we nomic categories (high, medium and low), for the discus- selected the following variables as confounders in the sions and allocated to groups of the same category. The transactional sex and consumption patterns relationship per capita household consumption was calculated by sum- from our knowledge of the literature and the unadjusted ming all household spending and consumption on food analysis: the age of young women, age of first sex, young and non-food items and by dividing it by the number of women’s employment status, primary caregiver’s educa- household members [32]. A categorical household con- tional level, number of household members, orphan sta- sumption measure was then obtained by dividing this tus and past year young women’s number of sexual measure into deciles (1–10). For this analysis, we re- partners. For details on the construction of each variable, categorised the variable from deciles to three groups for please refer to Appendix 2. total amount spending/consumption per capita: low (ran- ging from $1.3 to $15.4), medium (ranging from $15.5 to Missing data $32.6) and high (above $32.10). Except for the variable number of sexual partners in the We used focus groups to explore topics around young past 12 months (where missing data were ~ 5%), all the women’s relationships and consumption patterns and we exposure variables had less than 3% missing data. This conducted participatory exercises to elicit young includes cases where young women ‘refused to answer’. women’s perceptions of items they consider a “need” The response ‘don’t know’ was also coded as missing, as versus a “want”. Since young women’s peers were in- the percentage of this response code was small. Only volved in the discussion, focus groups were considered Ranganathan et al. Reproductive Health (2018) 15:102 Page 5 of 21 to be effective in stimulating dialogue between respon- the qualitative analysis were then compared with the dents and yielding insight into people’s thought pro- quantitative findings for interpretation. cesses [33]. To complement the focus groups, we conducted 19 one-on-one private interviews with a sub- Results set of young school-going women. Themes that arose in Participant demographics the focus groups, but were sensitive for young women to Table 1 presents descriptive socio-demographic data on discuss in a group setting (e.g., sexual relationships) were the sample (n = 693) of sexually active young women. probed further in the interviews. Ten of the 19 partici- The age range was 13–20 years old (Table 1). Of the pants invited to be interviewed had reported ever being whole sample (n = 2533), around a quarter reported sexually active and had responded positively to the ques- being sexually active (693 young women or 27.4%) of tion on transactional sex. The remaining nine were in- which 78.2% were 16–20 years old. Among sexually ac- vited back to participate in the interviews, after the tive young women, almost 31% were orphans, with one focus group discussion, based on their levels of engage- or both parents deceased and almost 40% reported being ment and responses during the focus groups (we had no worried that their household did not have enough food prior knowledge of their sexual history). This allowed us in the past year. The primary caregiver for most sexually to interview young women who were both sexually ac- active young women (68.1%) was their mother and a tive and potentially not active. quarter of primary caregivers had never attended school. 78.2% of sexually active young women reported cur- rently having a boyfriend and 21.2% had more than two Data collection sexual partners in the past 12 months. 14% (n = 97) of Focus group discussions were conducted at a village sexually active young women reported feeling as though school within the study site over the weekend and were they had to engage in ‘sex for money, gifts or both’ facilitated by a female, xiTsonga speaker and assisted by (transactional sex). The majority of transactional sexual a designated note-taker. Focus groups were recorded relationships were only with the current partner (67%). with participants’ permission and later translated and The majority of items were received from primary part- transcribed into English by the group facilitators. The ners with 60% receiving money, 25% receiving gifts (such in-depth interviews were 1–1.5 h long, audio-recorded as cosmetics or airtime) and 15% receiving both money and conducted in a private location. The recordings and gifts. were transcribed and translated from xiTtsonga to A subset (n = 45) of the sample were invited to partici- English by the interviewer. Each transcript was quality- pate in the focus group discussions based on their socio- checked by a trained third-party researcher to make sure economic status. Half of these participants were from the translation was accurate. Data collection was it- households dependent on subsistence agriculture and erative, with changes made to the topic guide as the state grants. Half of the participants who were depend- focus group discussions and in-depth interviews pro- ant on subsistence agriculture were from female-headed gressed, based on a review of the data and feedback households. Seven of the 19 young women in the in- from the interviewers. depth interviews had small children, and two were preg- nant at the time of the interview. About third of the 19 Analysis young women interviewed worked in informal labour We used thematic content analysis to analyse qualitative outside school hours, such as in domestic work, yard- data [34, 35]. The first author created an initial coding cleaning or hairdressing. Twelve of the 19 young women framework based on the topic guides that was then ad- either had fathers who were working elsewhere (tempor- justed deductively and inductively, through frequent dis- arily migrated), had passed away, or parents who were cussions between the first two authors. A content matrix separated with the young woman living with her mother. was developed to synthesise data and to display emer- More than half the young women in the overall qualita- gent cross-cutting themes. All data from these focus tive sample reported having ever had two or more boy- groups and interviews were coded using Atlas-ti. Five friends, who were mostly young men within their same steps were followed in the analysis of the transcripts: (1) age peers. The average female respondent was ~ 2.5 years data management and familiarisation; (2) identification younger than her most recent male partner. of a coding framework; (3) displaying themes and sub-themes; (4) data reduction; and (5) interpretation Quantitative findings [27, 35]. Integration of the quantitative and qualitative Exploratory factor analysis produced three groups of data occurred in the final discussion; findings that consumption items (groups 1, 2 and 3) with overlap be- emerged from the preliminary quantitative analysis in- tween the groups (see Appendix 4). When constructing formed the qualitative analysis. Thematic findings from the consumption variables for analysis, we took into Ranganathan et al. Reproductive Health (2018) 15:102 Page 6 of 21 Table 1 Selected socio-demographic, partnership characteristics Table 1 Selected socio-demographic, partnership characteristics and sexual behaviours among sexually active young women and sexual behaviours among sexually active young women (aged 13-20y) (n = 693) (aged 13-20y) (n = 693) (Continued) Socio-demographic characteristics Sexually active (column %) Socio-demographic characteristics Sexually active (column %) Age of young woman (n = 693) Transactional sex 13–15 151 (21.8) Transactional sex (n = 693) 16–20 542 (78.2) No 596 (86) Per capita household consumption (n = 693) Yes 97 (14) Low 220 (31.7) Breakdown of percentages by money or gifts or both (n = 97) Medium 279 (40.3) Sex in exchange for money only 58 (59.8) High 194 (28.0) Sex in exchange for gifts only 24 (24.7) Number of household members (n = 693) Sex in exchange for both money and gifts 15 (15.5) Measure of household living standards calculated as low ((ranging from $1.3 2-3members 87 (12.5) to $15.4), medium (ranging from $15.5 to $32.6) and high (above $32.10) as 4-5members 233 (33.6) monthly expenditures Young women worried about having enough food for her and her family in 6-7members 220 (31.7) the last 12 months > =8members 153 (22.1) Among sexually active young women who responded yes to question on transactional sex Type of primary caregiver (n = 692) Mother 471 (68.1) Father 22 (3.2) consideration the results of the factor analysis. However, Brother/sister 65 (9.4) as there was not much variation between groups (i.e. al- Other blood relative 134 (19.4) most all the young women purchased group 1 items and some purchased group 2 and group 3 items), we also Educational level of primary caregiver (n = 692) took into consideration the sample sizes in each group None 176 (25.4) (which were small for groups 2 and 3) and the qualita- Primary 196 (28.3) tive findings when constructing the groupings. Secondary 164 (23.7) Matric or tertiary 128 (18.5) Factor analysis groupings Adult basic education 28 (4.1) Group 1 (n = 630 (91%)) is labelled ‘personal enhancement Orphan status (n = 684) items’ (PEI)) as most of the items are for female self- Parents alive 475 (69.4) improvement and are considered affordable. It consisted of feminine-enhancement items, such as scented soap, One parent dead 168 (24.6) make-up and cosmetics, where expenditures ran up to Both parents dead 41 (6.0) 200 ZAR (~£18) per month, as well as status enhancing Young women’s perceived food insecurity (n = 684) items, such as cell-phone where expenditures extend to No 412 (60.2) up to 600 South African rands (ZAR) (~£50) per month. Yes 272 (39.8) Group 2 (n = 223 (32.2%)) is labelled ‘practical items’ Partnership characteristics and sexual behaviours (PRAI). It consists of items that are considered necessary for survival and educational progress, such as groceries, Currently have a boyfriend (n = 693) school uniforms and transport to school. These items No 151 (21.8) can be more expensive than Group 1 items. Reported Yes 542 (78.2) expenditures varied from 10 to 1000 ZAR (~£0.83–83.3) Sexual partners the past 12 months (n = 660) per month for school uniforms and supplies, 10–500 1 520 (78.8) ZAR s (£0.83–41.7) per month for food and groceries 2 97 (14.7) and 10–800 ZAR (£0.83–66.67) per month for transport to work or school. > 3 43 (6.5) Group 3 (n = 216 (31.2%)) is labelled ‘entertainment Age of first sex (n = 634) and birth control/condoms’ (EBC). It consists of items Before 15 years 127 (20.0) such as movie tickets, beer/alcohol that are considered 15 years and above 507 (80.0) items of entertainment. Furthermore, we have included forms of contraception, such as birth control and con- doms, that are considered indicators of sexual activity. Ranganathan et al. Reproductive Health (2018) 15:102 Page 7 of 21 We grouped these items together using the results of the of items, and our knowledge of the nature of items that factor analysis (see Appendix 4: alcohol, movie tickets implied risky sexual behaviour. The final groups have and birth control/condoms grouped together) and for been illustrated in Fig. 2. sample size considerations (the sample number for We used the category with the largest sample size young women purchasing only birth control/condoms (personal enhancement items only) as the reference was very small (n = 4), hence could not be a separate cat- group for the analysis. Furthermore, as there are a egory). Expenditures varied from 10 to 500 ZAR (£0.83– sizeable number of young women who purchased items 41.7) per month for movies/music tickets, 10–300 ZAR from groups 1 (PEI) and 2 (PRAI), we have created the (£0.83–250 per month) for beer and alcoholic drinks category practical items (with some personal enhance- and 10–200 ZAR (£0.83–16.67) for contraception. Some ment items). Group 3 are young women that are pur- of these items are expensive (such as movie tickets and chasing items for entertainment and birth control/ particular types of expensive condoms that are not pro- condoms. To create the group entertainment and birth vided for free by the government) and some of these control/condoms (EBC) only that is mutually exclusive, items are cheaper (e.g., beer)). we decided to include young women that are included in group 3 (EBC) only and those that intersect with group 1, with group 2 and with groups 1 and 2. The Overlap between groups two consumption variables that were constructed are Figure 1 shows that young women purchased items from ‘practical items (and some personal enhancement more than one group: a few consumed a combination of items)’ and ‘entertainment and birth control/condoms’ groups 1 and 2, and groups 1 and 3; some consumed items with ‘personal enhancement items only’ as the from all three groups. Most young women consumed reference group. group 1 items. If a few young women consumed items from group 2 and 3, they usually had purchased group 1 items too. 310 young women (44.7%) consumed only Transactional sex and consumption of practical items (PRAI) group 1 and only three young women (0.4%) bought and consumption of entertainment and birth control (EBC) group 2 exclusively, as most group 2 consumption is items along with group 1 or group 1 and 3. Only ten young In Table 2, we report results from unadjusted and women (1.44%) reported consuming group 3 items ex- adjusted analyses of the association between young clusively. Most group 3 consumption happened along women’s engagement in transactional sex and her con- with group 1 or groups 1 and 2. sumption of practical items (PRAI) and transactional sex and her consumption of entertainment and birth control/ Mutually exclusive groups condoms (EBC) items. The results show that engaging in In order to then create mutually exclusive groups, we transactional sex is not associated with young women’s used a combination of: results from the factor analysis, consumption of PRAI in either unadjusted or adjusted our observations from the qualitative findings of young analysis (aOR: 1.09; CI95% = 0.57–2.12; p =0.79). women’s needs and wants (described in the next section) Table 2 also shows unadjusted and adjusted associations , our own theoretical knowledge of the monetary value between young women’s engagement in transactional sex No items purchased = 49 (7.1%) Group 1 Scented soap, skin cream, lotions Cell phone, airtime, Group 1 – Group 2 – ringtones personal practical items Shoes, clothing, underwear enhancement Cool drinks, chips,.etc items Make up/cosmetics 310 (44.7%) Hairdressing 3 (0.4%) 115 (16.6%) Group 2 104 (15%) School uniforms, supplies 101 (14.6%) Transport to work, school Food/groceries 1 (0.1%) Group 3 Movies/music Beer/alcohol Birth control/condoms 10 (1.44%) Group 3 – entertainment and birth control Fig. 1 Groupings of items that sexually active young women consume or purchase Ranganathan et al. Reproductive Health (2018) 15:102 Page 8 of 21 Personal enhancement items (PEI) Scented soap, skin cream, lotions Practical items (PRAI ) and some Cell phone, airtime, ringtones Personal enhancement items personal enhancement items (PEI) Shoes, clothing, underwear (PEI) only Cool drinks, chips.etc 310 (44.7%) Make up/cosmetics Hairdressing 118 (17%) Practical items School uniforms, supplies Transport to work, school Food/groceries 216 (31.2%) Entertainment and birth control items Movies/music No items purchased = Entertainment and birth Beer/alcohol control (EBC) and some PEI and 49 (7.1%) No items purchased = 49 (7.1%) Birth control/condoms PRAI Fig. 2 Creation of mutually exclusive groups based on type and value of consumption items among sexually active young women and consumption of EBC items. The unadjusted results Qualitative findings suggest that young women who engage in transactional The perception of “needs” and “wants” sex have almost 1.7 times higher odds of consuming EBC To study the motivations for transactional sex, we items than those who do not engage in transactional sex sought to understand how the perception of ‘needs and (uOR:1.67; CI95% 1.03–2.72; p =0.04). We hypothesised wants’ related to consumption patterns of young that household per capita consumption (a measure of liv- women. ‘Needs’ were defined as items that a person ing standards) might be an effect modifier for the relation- cannot survive without; ‘wants’ were items that a per- ship between transactional sex and consumption of EBC son desires, but can live without. During the focus items. To test this, we conducted a test of interaction. The groups, young women were asked to freely list on a results showed that overall there was almost no interaction whiteboard, items that themselves and their peers were (p = 0.18) between household per capita consumption and either spending money on or what they sought to ac- transactional sex and consumption of EBC. Furthermore, quire. They were then individually asked to categorise after adjusting for confounders, there was evidence to show items by affixing a red (need) or blue (want) sticker that young women who engage in transactional sex have next to the items on the whiteboard. Items were then three times higher odds of consuming items for EBC items grouped into four categories based on their types, value (aOR:3.03; CI95% 1.12–8.23; P = 0.03). and utility: personal enhancement items, practical Table 2 Unadjusted and adjusted relationship between transactional sex and young women’s consumption of practical items (PRAI) and entertainment and birth control (EBC) items (compared to personal enhancement items) among sexually active women who reported some consumption b d #, Outcome: PRAI (n = 398) uOR 95% CI p-value aOR 95% CI p-value No Reference Reference Yes 1.32 0.72–2.44 0.37 1.09 0.57–2.12 0.79 Outcome: EBC (n = 486) No Reference Reference Yes 1.67 1.03-2.72 0.04* 3.03 1.12-8.23 0.03* As separate analysis for each variable. Sample size for each analysis included in each category Please note: These numbers are the sum of the number of young women (that are sexually active) who are buying practical items + the number that are buying personal enhancement items. Records with missing data excluded. Total missing: n = 30 (7%) These are: work for money (n = 8 or 1.2%) missing), orphan status (n =2 or 0.04% missing), type of primary caregiver (n = 1 or 0.02% missing), number of sex partners past 12 months (n =19 or 4% missing) Please note: These numbers are the sum of the number of young women (that are sexually active) who are buying entertainment related and birth control items + the number that are buying personal enhancement items. Records with missing data excluded. Total missing: n = 40 (7.5%) These are: work for money (n = 7 or 1.3%) missing), orphan (n = 9 or 1.7% missing), number of sex partners past 12 months (n =24 or 4.6% missing) uOR, unadjusted odds ratio aOR Adjusted odds ratio Adjusted for all confounders – age, number of household members, being an orphan, type of primary caregiver, currently has a boyfriend, number of sexual partners last 12 months, working for money, per capita consumption P-value estimation through likelihood ratio test (LRT); *P-values in bold are statistically significant at the < 0.05 level Ranganathan et al. Reproductive Health (2018) 15:102 Page 9 of 21 items, expensive items and entertainment items. Table 3 want to protect ourselves from illness, because you lists the results. cannot grow up without doing it, so you need to The results in Table 3 show that ‘needs’ included protect yourself ’). practical items (e.g., clothes, shoes, sanitary pads), ‘Wants’ included some personal enhancement items female personal enhancement items (e.g., lingerie, (e.g., cosmetics, jewellery), entertainment/ leisure (e.g., hair extensions) and certain expensive items (e.g., beer/alcohol, movie tickets), as well as some expensive fancy shoes, expensive clothes). When probed on items, (e.g., expensive phones). Reasons given for want- whether phones or perfume were actual needs, re- ing these items were to be able to identify with certain sponses indicated that they were considered un- role models either within their peer group as illustrated affordable needs; reasons ranged from needing to by this quote: conform (‘because nowadays other people are using Blackberry’), to needing to boosting their status P3: Even if you can bath and wear nice clothes but if (‘perfume is attractive to me because when I smell it you didn’tput make-upaah…you are not really from someone smelling good, like from teachers, then (young woman’s name]. I tell myself that it’sanexpensive perfume, sothat is why it becomes attractive to me’). Some young women P4: It is just because most of the young women nowadays showed efforts to practice safe sexual behaviours by they like fashion, that is why if you don’thavemake-up mentioning birth control and condoms as needs (‘We you will not feel good. Table 3 Needs and Wants categories Groupings Items Need Want Personal Enhancement Items Expensive perfume Need Hair extensions Need Lingerie (fancy underwear (such as Jockey) Need Toiletries (scented soap, skin cream, body lotion, Need powder, roll-on deodorant) Make-up (eyebrow pencil, mascara, false eye Want lashes, eye liner) Cosmetics (Moisturising cream, nail polish (Cutex), skin-brightening cream, lip balm, Want bag, hair control) Salon treatment (hairdressing/hair highlighting, relaxing, dyeing, manicure, waxing) Want Accessories (watches/handbag) Want Jewellery (bracelets, earrings, necklace, gold tooth) Want Body piercings (belly-ring nose-ring, tongue-ring, tattoo) Want Practical Items Clothes Need Ordinary cell phone and airtime Need Shoes Need Female items (underwear, sanitary pads) Need Food, groceries Need School uniforms/supplies Need Transport to school/work Need Birth control/condoms Need Expensive Items Expensive clothes (skinny jeans, hlokoloza (mini skirt), tekkies (trainers), branded clothes Need Fancy shoes (high heels, Carvela (expensive Italian branded shoes) Need Expensive phones (blackberry/camera phone/Nokia/×2) Want Expensive foods (chocolate, yoghurt, grapes, restaurant) Want Entertainment/leisure Beer/alcohol Want Cold drinks and chips, Ultramel (ready-made custard), Lays (potato crisps) Want Movies/music and travelling Want Pocket money Want Ranganathan et al. Reproductive Health (2018) 15:102 Page 10 of 21 Focus group 4, high socio-economic status P3: Even if you can bath and wear nice clothes but if you didn’t put make-up aah…you are not really [role Some items were classified both as a ‘need’ and a model’s name]. ‘want’ based on their perceived value. For example, staple food (e.g., maize) was a need and expensive P4: It is just because most of the young women nowadays food items (e.g., chocolate) were considered wants. they like fashion, that is why if you don’thavemake-up Interestingly, “ordinary clothes and shoes” as well as you will not feel good. “expensive clothes and shoes” were both considered needs. Furthermore, owning expensive clothes were Focus group 4, high socio-economic status represented by many participants as ‘needs’ similar to the need for food. Hence, it is the ‘perception of But possessing certain expensive items enables a need’ rather than an ‘actual need’ that is important, young woman to send a signal to her peer group that as from the perspective of these rural young women, she is a ‘cool, modern woman’, making her the object owning expensive clothes or expensive shoes is of envy among her peers, and in turn enhancing her construed as a necessity in their lives. It therefore ap- self-esteem. pears that young women are motivated by materialis- tic desires, as well as the pressure to conform to peer P: [I want these items] because they are needed and group expectations through adopting symbols of so- that everyone wish they can have it...that if I found phistication and a modern lifestyle. myself having this I will be ‘the’ person among the However, some young women acknowledged the dif- people and when people see me coming from there ferences between expensive and basic items. They recog- they will turn their heads and look at me. nised that coveting unaffordable items did not imply need and that the perception of needs (and wants) is In-depth interview 2, aged 21y relative and based on an individual’s household socio- economic status. However, it appears that many of the perceived needs are also about social standing among peers. For I: I heard someone say that Blackberry is unnecessary. example, wearing nice uniforms are necessary to Can you please tell me why? avoid being teased and humiliated by classmates, more than being ‘real’ barriers to school attendance. P2: Blackberry is too expensive and I’m still a This did not seem to differ between different socio- school child, and parents cannot afford to buy me economic focus groups, as illustrated by the two Blackberry. I will be fine if I can have cell phone quotes below: worth R150 [£9]. The most important thing is to communicate. I: Ok. What happens if you do not have one of the items that you need? P3: It is necessary to have Blackberry, because you will chat for free on Facebook and Blackberry P2: Like school uniform, I won’t go to school without messenger. enough uniform. And when I wear a skirt that is tearing [torn] and then my friends laugh at me. P1: It is not necessary because even if you don’t chat it doesn’t mean that you are not a human being. Focus group 3, low socio-economic status. P3: That is why I said my need is not your need. P1: Like if you go to school you need to wear proper school uniform because the school children will laugh Focus group 4, high socio-economic status at you. P3: Even if you can bathe and wear nice clothes but if The role of peer pressure and socio-economic status you didn’t put make-up aah…you are not really (certain Peer group pressure played an important factor in in- role model in the village). fluencing young women’s perceptions that certain items were ‘needs’ and motivating them to acquire Focus group 4, high socio-economic status such items. This pressure had many components. The first was to identify with certain role models within Status among friends and perceived “ranking” within a their peer group: social order was of importance to young women. Ranganathan et al. Reproductive Health (2018) 15:102 Page 11 of 21 P1: We want to make ourselves beautiful so that Funding consumption patterns people can recognise us. Parents For many young women (n = 18), particularly in the P3: That’s what I was saying if you didn’t put make-up focus groups, parents or primary caregivers paid for people say you’re a traditional girl [I:we laughed], if you items considered needs or ‘practical items’,suchas have put make-up people recognise you that you are transportation to school,aswellasitems of female South African. personal enhancement and hygiene that require regular monthly replenishment, such as roll-on de- P1: Because people from Mozambique they don’t put odorants. Some young women also indicated that make-up, so if you don’t put make-up they will compare parents, on occasion, bought their daughters hair you with them. pieces and earrings. Items that parents did not pay for were mostly entertainment-related, such as movie Focus group 4, high socio-economic status tickets, beer/alcohol or expensive phones or expen- sive creams. Overall, in the in-depth interviews there was not much In particular, young women felt that their parents were variation by socio-economic status in the responses traditionalists, compared to their own ideas of modern around needs and wants, except for in a couple of in- living, as shown by the following quote on the modern- terviews where the young women recognised the con- day use of body creams compared to traditional items straints of their household’s socio-economic situation. that had been used by parents: They acknowledged that despite having desires, the items were unaffordable, but they were hopeful for P3: And our parents say that when they were the future. These have been illustrated by the follow- young they were not using fancy cream that smells ing excerpts: good they were using “Nhlampfura” (Oil of nut or fruit) in older days… [I: they laughed] and why do P: If you use make up it wastes your time, some they have to spend money for us on fancy creams years back at school l could see that something was whereas in older days they were using “Nhlampfura” wrong about me using make up. You find that we and men proposed them even if they don’tsmell are in class at school and people have put their good…. make up; you have finished your make-up and you don’t have money to buy. You will feel like you are Focus group 2, high socio-economic status very poor. So l stopped using make up because it was not good to use make up when you are still a When probed in the focus groups on how young student. women from higher socio-economic households ob- tain items, the general response irrespective of the I: How do they (make-up) make you feel? socio-economic status of the group was that parents from these households have the means to afford P: It made me feel like other children because I can see non-essential items when compared to those from that I’m different to them, but I feel ok about the way l poorer households. Some participants mentioned the am. l believes that one day l will be successful. choices that young women from richer households have in terms of the security of family support and In-depth interview 14, aged 19 years the ability to demand something and have these de- sires met. This, as a result, makes them more P: I don’t care even if I don’t have Cutex (nail polish) confident (when compared to young women from ...but my heart is painful when I go to school and poorer households). didn’t braid my hair and others will laugh at me saying that I’ve aged......Even if they don’t laugh at me P2: And some our situation is different it might they gossip about my hair.....I have an afro hair so I happenthatmyfriendiscoming fromthe richer just braid it without using hair extension.. I feel family and I from poorer family and they will able good (when they gossip) because I told myself that to buy her fancy things and at home they will not whom are they going to gossip about, if they don’t afford to buy me something because they cannot gossip about me. You must accept because people afford it because we don’t get things easily because are gossiping. of not having money. In-depth interview 14, aged 19 years Focus group discussion 2, high socio-economic status Ranganathan et al. Reproductive Health (2018) 15:102 Page 12 of 21 In contrast, parents from poorer households only place young women at risk of contracting diseases. bought items they considered essential, such as food and Young women acknowledged that (other) young clothes. Thus, the budget constraint in low socio- women chase sugar daddies and stated that hard- economic households dictated items considered essential ships at home compel these young women to en- by parents. gage in such sexual relationships. The hope was that sugar daddies would help them afford items P: Like when their mom got a piece [part-time] job that would enhance their appearance. from other households, like to sweep the yard then when she get paid she buy these items like food for P2: Because youth want expensive thing and parents their children and things that they can make them won’t afford it like hair-piece, a parent won’t take you look able [healthy]. to the salon to do your hair, but if you are involved with an old man he can be able to take you to salon Focus group discussion 3, low socio-economic status and do your hair. However, not all poorer families bought their Focus group discussion 2, high socio-economic status. children only essential items. For example, a young woman from a low-income family described P2: Sugar daddies have money and I want their how, in her friend’s family, the use of cosmetics money… [I: we laughed]. So nowadays girls want to was not encouraged, as her parents perceived it to make themselves beautiful, look nice and wear nice be something which would attract untoward atten- clothes. Some other girls when you give them money tion. However, they did encourage cultivation of they go to the shop and buy snacks… [I: we laughed] but an aesthetic sense and provided the young woman look at me I eat well because I have a relationship with with nicer clothes to help her fit in. Young women a sugar daddy. noted that parents were aware of their need to maintain status. But, many of these families were Focus group discussion 5, low socio-economic status. supported by social grants and did not have the financial means to buy ‘items of need’.Thisre- In contrast, during in-depth interviews, young sulted in young women resorting to other ways of women were more reticent in their responses obtaining items, as illustrated by the following when probed about their personal engagement quote: with sugar daddies. This might be because young women in the interviews were asked questions re- P5: Because like when they buy them make-up they lated to their personal situations, compared to the will think she will start to be a prostitute. focus groups, when the discussion was more gen- eral. There was agreement that the desire to be I: Mmm…Ok, so what about those who like it? with a sugar daddy arises from materialistic moti- vations and peer pressure. P3: They want their children to be beautiful and be recognised. P: [I don’t want sugar daddies] because he is too old and on the other hand I abuse my body. ….. Focus group discussion 3, low socio-economic status Some they want clothes and expensive cell phone like ‘Samsung Galaxy’ [expensive smartphone]. You find that they like it and sometimes this is Sugar daddies cause by peer pressure. You find that my friends ‘Sugar daddies’ were mentioned as sources of fund- are having a relationship with a sugar daddy ing for items parents did not provide. When and she had sex with him then he buys her some probed on the definition of a sugar daddy, the re- items or expensive clothes like label clothes or an sponse was: “an older person (>10 years older), expensive cell phone. I like it then I start to more established in his career, more financially involve myself [with a sugar daddy] to get the stable that solicits younger women primarily for items that I need. sex.” During focus groups, the discussion related to sugar daddies was not positive; there was open ac- In-depth interview 10, aged 20y. knowledgement of the associated social stigma as- sociated with sugar daddy relationships and the fact Yet, there was recognition, even in the focus groups that that sexual relationships with sugar daddies that any sexual relationship with a sugar daddy placed Ranganathan et al. Reproductive Health (2018) 15:102 Page 13 of 21 young women at risk of abusive behaviour and of con- I: What would you do if he didn’t buy you things you tracting HIV, as detailed here: want like airtime? P: Sugar daddy is a person who has a family. If P: I will just leave him, why doesn’t he buy me airtime you are in relationship with him is like he is it will mean he buy it for someone else… abusing you because he is older than you and has his wife. In-depth interview 17, aged 20y. In-depth interview 11, aged 19y. P2: Yes it happens. To have a relationship with someone who own a nice car because when I am P1: Like you find that she’s in a relationship with a sitting with my friends I will tell them that I ride sugar daddy and you don’t know his [HIV] status and with a nice car. And then I will influence them he’s just buying her so he can sleep with her and leave not to have relationships with school boys. They her with diseases. have to date those who are working. Focus group discussion 3, low socio-economic status Focus group discussion 1, low socio-economic status. In the focus groups, when probed on motivations Boyfriends foryoung womentobeinrelationships,two-thirds In contrast to sugar daddies, there was a percep- of young women explicitly said that it was for tion that “a boyfriend is a person you love. A sugar money or material goods. The remainder of young daddy is a boyfriend with benefits...like airtime. women in the focus groups were more reticent about In-depth interview 6”, age 21). The perception was money being their main motivation. Privately, in the that receiving money or gifts from a sugar daddy interviews, most young women were likely to back can almost be likened to prostitution, as the ex- away from group consensus to say that it was love pectation of sex with the provision of money or that made them engage in sexual relationships with giftsisovert,whereas receiving giftsormoney men. Nevertheless, even though love featured in from boyfriends of similar age did not have the most young women’s responses, there was a clear, same level of explicit expectation of sexual ex- but implicit understanding that the need for money change. Boyfriends’ provision of financial and ma- and gifts were important in all relationships. It ap- terial support was mentioned extensively by young pearsfromthis datathatthe rulesand normssur- women in both focus groups and interviews as a rounding sex in exchange for money/gifts are reason for becoming involved in relationships. intricate and sometimes ambiguous; gifts and money Some focus group participants openly expressed are important even in relationships characterised by their preference for being with a partner of similar love. Yet, money exchange does have one constant: a age, but commented that the likelihood of these sexual relationship does not exist without the ex- men having a lucrative job was slim, hence were pectation of a male-to-female transfer of money or less able to act as providers. Similarly, as most gifts. But, young women did make the distinction young women were young and inexperienced, they between “being opportunistic” and “feeling provided aspired for a ‘perceived better life’ filled with po- for and looked after”. tential, such as with a man who can provide. Thus, aspirations to “fit into the crowd” drove I: Mmm… the one you had a relationship with, where their desire to engage in relationships. Some did you meet him? young women mentioned that receiving gifts help increase their social acceptance among friends. P: At school. I wanted him to help me. Like when I They did not report feeling obliged to have sex need money to use he was able to help me things like with their boyfriends in exchange for these items hair extensions. When I wanted it he was able to give (“he buys me things that I should have it as a me money to buy it… I was feeling happy about it girl”, In-depth interview 8,aged 20y). [receiving money]. P: [the reasons I am with him] are because I like things… I: Tell me did you feel like you had to have sex with it’sa status.Hebuysme airtime.Icallhimand friends. him to receive money or gifts. And boast on them that I have been bought airtime. I feel good, something like that. P: No. It was the issue of love. Ranganathan et al. Reproductive Health (2018) 15:102 Page 14 of 21 In-depth interview 18, aged 20y. young women aged 15–25 in an urban township of Durban, South Africa. Madlala’s findings showed that Overall, it is important to mention that social the practice of transactional sex is best illustrated by pressure demands that young women speak of rela- a continuum, where rewards or gifts can vary between tionships as being ‘for love’,and whilethisiscer- what are generally perceived to be ‘needs’ and what tainly a key element of their relationships, the are generally understood as ‘wants’. However both are potential for material gain is also a significant com- always represented and expressed as ‘needs’ [36]. Fur- ponent. Few young women felt that they had to ther, our study illustrated that the pursuit of expen- have sex because of receiving gifts, but gift giving sive or personal enhancement items was not just a was still considered an essential component of their mere exercise of consumption, but one that is per- relationships. ceived to be necessary for survival from social exclu- sion or loneliness. As articulated by Stoebenau et al. Discussion (2013) the term “economic vulnerability” initially This is one of the first and only studies to quantita- coined by Kuate-Defo captures relationships that are tively explore the relationship between transactional motivated by “survival” as well as conformity, social sex and consumption patterns in a cohort of young status and pride among peer group members [37]. women in rural South Africa. Our quantitative results Thus, in contrast to Maslow’sframework,where a showed that transactional sex was associated with al- sense of belonging is linked to the development of most a three-fold increased odds of young women self-worth and recognition, one can infer that young consuming items for entertainment (e.g., movie women’s notions of survival extend beyond just bio- tickets), items that are considered indicators of risky logical and physiological needs (food, clothing, shel- sexual behaviours (e.g. alcohol) and items that are in- ter) and that the need for a sense of belonging to dicators of sexual activity (e.g., birth control and con- their peer group, and for self-esteem are perceived to doms), but this did not vary by household socio- be essential to their survival. Hence, the findings sug- economic status. There was, however no evidence of gest that transactional sex linked to subsistence or to an association between transactional sex and young consumerism are not necessarily mutually exclusive. women’s consumption of practical items, such as This aligns with research in South Africa by Adato et food, school uniforms and transportation to school. al. (2016) and in Kenya by Mojola (2014) that demon- Furthermore, our qualitative data offers unique in- strates how issues related to the articulation of gen- sights into young women’s classification of items that dered needs (e.g., deodorants, skin creams) and non- are considered ‘needs’ versus ‘wants’. It is one of the material needs (e.g., peer pressure, social status and first studies that links these qualitative conceptualisa- conformity) shape young women’s decisions to engage tions to young women’s consumption patterns using in transactional sex [38, 39]. the framework of Maslow’s hierarchy of needs to cat- This study also showed that young women aspire egorise and understand young women’sneedsand for a variety of items, but their household economic wants. It suggests that the distinction between ‘need’ situation, along with circumscribed economic oppor- and ‘want’ is ambiguous and that motivations for tunities in the area, imposes spending constraints. In obtaining such items are not driven merely by sur- turn, relationships appeared to fill this funding gap vival or consumerism, but by higher order psycho- for young women’s consumption. This was especially social needs such as the need to belong to a peer the case when parents were not willing or able to group. These results illustrate that Maslow’shierarchy provide an extra allowance to obtain items that are of needs does not apply strictly to young women’s considered ‘non-essential’. This aligned with Allison needs and wants. In situations of considerable pov- Pugh’s (2009) research in the United States demon- erty, unstable household structure, scarce economic strating the commodification of childhood in the opportunities and a rapidly globalising economy, United States and the dilemma facing low income young women in rural South Africa have ‘admitted’ parents when dealing with their children’sgrowing needs (for items that are considered necessary, such materialistic desires [40]. According to Pugh, these as food or clothes) and ‘hidden’ needs (such as for parents had clear spending constraints, hence only expensive clothes, cosmetics) that are their ‘wants’. bought essential items and maybe indulged their chil- Hidden needs appear to play a pivotal role in these dren occasionally, despite being empathetic to their young women’s quest for enhancing their self-esteem children’s needs and wants [40]. As a result, some and status and feeling like they belong to and are young women enter similar age relationships with accepted by their peer group. This aligns with boyfriends or become involved with sugar daddies to Leclerc-Madlala’s (2004) research with unmarried have a steadyconduit throughwhich moneyor gifts Ranganathan et al. Reproductive Health (2018) 15:102 Page 15 of 21 flow. Participants (particularly in the focus groups) From our quantitative results, as transactional sex is frequently mentioned the existence of sugar daddies associated with the consumption of entertainment re- and that (other) young women have relationships with lated items, such as alcohol, an argument could be them either to fulfil basic needs, but more often to made based on the literature that young women who satisfy their consumerist desires. Interestingly, none of engage in the “game” of alcohol-sex exchange may to the participants admitted to personally engaging with some extent use it as a form of entertainment, both sugar daddies when probed in the in-depth interviews. in the procurement of alcohol and related socialisa- There was a negative connotation associated with tion that occurs in these venues [49]. Research by sugar daddies as a person who was ‘abusive’,was sub- Watt et al. in South Africa suggests that alcohol- stantially older and disrespectful towards young serving venues provide a space to foster social iden- women. There was recognition that in a context of tity with peer groups and to deal with boredom that economic deprivation, sugar daddies were a source by comes with circumscribed employment opportunities which young women could access things they might and lack of recreational activities [50, 51]. Other re- not be able to afford otherwise. In addition, in a set- search in similar settings has shown that gender in- ting where awareness of diseases, including HIV in- equalityand povertyprovideacontext in whichthe fection, is high; many young women mentioned that alcohol-sex exchange can become an attractive strat- sugar daddies would put them at risk of disease, egy for young women [52]. along with the social stigma associated with engaging A theme that also emerged from the qualitative with one. As has been shown in the literature, young research is that young women seek boyfriends out womenengaginginsexualrelationships with older of an aspiration for social mobility, economic inde- men are considered to be at much higher risk of HIV pendence or simply a life enhanced by status, in- acquisition compared to a young woman engaging cluding expensive clothes and fancier items. Our with a similar age male peer [41, 42]. Thus, overtly quantitative results complemented this picture by engaging in sexual relations for money or gifts with a showing that engagement in transactional sex does sugar daddy was considered closer to sex work, as not vary by socio-economic status. In fact, rural the negotiation in the exchange was explicit, whereas young South African women are engaging in trans- having a relationship with a similar age boyfriend actional sex to also purchase entertainment items, (even if it is a source for money or gifts) was still nu- which suggests that young women are aspiring for a anced in its meaning and significance. This finding lifestyle, which is not just about dire need, but also indicates that relationships with sugar daddies are not about choice and entertainment. This finding also necessarily rampant as previously suggested [43]and aligns with research from other settings in South that young women were aware of the associated risks. Africa, Zimbabwe and Kenya [53–56]thatalsodis- Further, as shown by other research conducted by this cuss the commodification of young women’scon- study authors using the same sample of young sumption patterns and the role of transactional sex. women [44], similar-age relationships appear to be Further, in the context of post-apartheid South morethenorm, even if therewas atransactional Africa, through the lifting of restrictions of Black component. people’s movements, improved road infrastructure to Related to this, our qualitative results show a far rural areas, the influx of goods from other counties more nuanced relationship between sex, love and the and increased access to visual and print media, pre- provision of gifts. Women want to be the object of viously “remote” rural areas in South Africa have love (and desire) from their similar age male part- gradually opened socially and geographically. These ners, but also expect to receive money or gifts as an macro-level changes have played a role in exposing expression of this desire. This has also been young women to globalised images and availability discussed in multiple studies throughout the sub- of goods [11]. In addition, one could also argue that Saharan African region (South Africa, Malawi, there are different role models for this generation Tanzania) [45–48]thatdemonstrate thedegreeto than there might have been for previous genera- which love and money are tightly intertwined in re- tions. During apartheid, there was not the same ac- lationships. A number of young women rationalise cesstoimagesofsuccessful Blackpeopleasthere their behaviour of coveting material items or gifts are now, which makes it easier for young Black and genuinely believe that they are in the relation- women to identify with role models [11]. Thus, ship for love (that they engage in sex for love). If irrespective of young women’s household socio- they have a boyfriend, they do expect either money economic position, aspirations for items might also or gifts, but in all these cases the implication is love be influenced by access to media and advertise- and not sex for gifts/money [44]. ments, peer groups, globalisation or macroeconomic Ranganathan et al. Reproductive Health (2018) 15:102 Page 16 of 21 changes in the country, television shows and a that in South Africa, condoms are distributed for strong desire to be socially accepted. free by the government Department of Health and dispensed by local authority clinics. [57] Thus, Strengths and limitations young women might not need to engage in transac- This study has a number of strengths and limitations. tional sex in order to obtain condoms. However, The use of laptops and ACASI software for data col- there was a perception among young people that lection allowed for increased privacy in the quantita- government provided free condoms were of lower tive survey. By removing the face-to-face component status and quality [58] resulting in young women of surveys, the social-desirability aspect of responses preferring the fancier, more expensive condoms. The was partially addressed, thereby tackling the potential government has recently embarked on a new cam- issue of over or under-reporting of sensitive ques- paign to provide free condoms in school in order to tions, such as transactional sex. To address the social increase availability, but also re-brand them, so that stigma around the reporting of sexual behaviours, they appeal to young people. This should hopefully one-on-one interviews were conducted in a private increase the uptake of free condoms [58]. setting, such as the participant’s house, and partici- Finally, due to time and monetary constraints, we pants were assured that the research was going to were unable to interview boys or men and get their benefit the community and that interview data would perspectives on young women’s motivations for being be kept anonymous. We found that focus group dis- in relationships. Hunter’s (2010) historical analysis of cussions and in-depth interviews complemented each love and masculinities in rural KwaZulu-Natal [45] other well, as the focus groups permitted free flow of and Bhana and Pattman’s research [46]inatownship information in a group setting. Young women were outside Durban, KwaZulu-Natal discusses provider less hesitant to speak about the sexual behaviours, as roles as an important feature in feelings of masculin- they were explicitly asked to talk generally in the ity in South African men and how it frames their re- focus groups. In fact, they were more open discussing lationships with women. Future research in the same sugar daddies in the focus groups than in the in- studysiteshould explore men’sperspectivestocom- depth interviews. Thus, the larger themes around pare responses and enrich these findings [45, 46]. their motivations to have a sexual relationship were Moreover, the cross-sectional nature of the data better explored privately in the interviews. means that we cannot make any claims about the This analysis is however limited by the sample for causal direction of these relationships, preventing us the qualitative data, which limits our ability to ex- from understanding to what extent consumption mo- trapolate these results to other individuals, including tivates sexual behaviour. For example, young women young women that are under 18-year olds and/or do reporting transactional sex are using money for not attend school. Moreover, eligibility criteria for entertainment-related items; entertainment might be a being part of the main trial (that young women and consequence of the transactional relationship rather their parents/guardians had to have documentation than a reason for it. We have tried to address this to open a bank account), meant that poorer young limitation through qualitative work where questions women who have limited access to basic services during in-depth interviews explore the types of items and social grants could not enrol in the study. It young women consider a need and want and the mo- may be that transactional sex in this subset of dis- tivations for obtaining such items. Recall bias is also advantaged young women is less consumerist- a potential issue, as the variables to measure transac- oriented and more subsistence-driven. Hence the re- tional sex, young women’s consumption patterns and sults need to be interpreted with caution. Further, all the potential confounders are self-reported. Ques- we recognise that birth control and condoms are tion time-frames were chosen to be consistent with separate items and have different meanings in terms other studies (where applicable) and to facilitate recall of their use; birth control methods do not require (e.g., sexual partners over the past 12 months or past negotiation between partners and the choice of their month consumption). use is with the young woman, whereas, condoms re- quire up-front negotiation between partners, result- Conclusion ing in a potential loss of control for young women. This study offers evidence of an association between However, as this was a secondary analysis of survey transactional sex and consumption patterns among data, and both the items were already together, we young women in rural South Africa. It demonstrates are not able to separate them out. Hence, for this that young women who engage in transactional sex analysis, we have considered them together as birth have higher odds of consuming items for entertain- control/condoms. It is also important to mention ment that might also lead to risky sexual behaviours. Ranganathan et al. Reproductive Health (2018) 15:102 Page 17 of 21 Thus, an underlying driver for transactional sex is annual study visits. Study participants were eligible the need to close a gap in the funding of certain for inclusion in the trial if they were females aged 13 consumer-oriented items. However, the qualitative to 20 years; enrolled in grades 8, 9, 10 or 11 at se- findings also suggest that young women seem aware lected schools in the AHDSS study site; and had a of the risks associated with sugar daddy relation- bank or post office account to receive the transfer. ships. Relationships between young women and men The participants were excluded if they were pregnant of similar age appear to be more prevalent than or married at baseline. Both parental/legal guardian sugar daddy relationships. In these relationships, the consent and young woman consent/assent were re- male to female exchange of commodities is common quired to participate. and expected, but not explicitly linked to sexual ac- tivity. The motivations given for the acquisition of specific lifestyle-related items suggests that they were Appendix 2 not related either to subsistence or consumerist de- Construction of effect modifier and confounding variables sires, but to the fulfilment of psycho-social needs for belonging, peer acceptance and self-esteem. This  The age of young women, was recorded as a study shows that young women are willing to take continuous variable from 13 to 20 years and was certain risks in order to be able to have a degree of re-categorised into two groups of 13–15; 16–20 for financial independence. Interventions that provide al- equal sample size in each category. ternative methods of attaining this independence,  The age of first vaginal and/or anal sex was constructed such as the provision of cash transfers, may have po- from the questions “how old were you when you first tential in preventing them from engaging in transac- had vaginal sex? How old were you when you first tional relationships [59]. However, the psycho-social had anal sex?” and re-categorised into two groups - reasons that drive young women’smotivations for < 15 years and 15 years and older. consumption needs within a rural, but globalising  Employment status of the young woman was recorded context needs to be better understood. In particular, as a binary variable and constructed it from the peer-led education programmes have shown to be question “Did you do any work for pay or family capable of providing vulnerable youth with psycho- gain,including paymentinkindsuchas foodor social support, as well as information and decision housing?” making skills [60]. These programmes will also lever-  Educational level of primary caregiver was measured age youth resilience and protective skills within the as a categorical variable with four categories: none, confines of difficult economic and social circum- primary, secondary, matric (year 12) and adult basic stances to allow them to successfully navigate safer education. sexual relationships [61, 62].  Orphan status (defined as either one or both parents deceased), was binary and constructed from the Appendix 1 question, if the mother was alive and if the father HPTN 068 trial baseline sztudy design: was alive. Data collection was conducted from March 2011–  Young women’s number of sexual partners in the December 2012 in the sub-district of Agincourt in past 12 months was recorded from 0 to 15 and was rural Mpumalanga Province, north-east South Africa, categorised into 4 groups: 0, 1, 2, > 3. an area with high levels of poverty, unemployment  Per capita household consumption as a measure of and labour migration [23–25]. The Medical Research living standards was calculated using the module on Council (MRC)/Wits University Rural Public Health food and non-food spending and consumption in and Health Transitions Research Unit runs the the household questionnaire. This was done by Agincourt Health and Socio-Demographic Surveillance summing all household spending and consumption System (AHDSS) in this area and this was the plat- on food and non-food items and by dividing it by form for identifying eligible households and young the number of household members (total spending women [52]. The trial sought to explore whether pro- and consumption per capita) [32]. A categorical viding cash transfers to young women and their household consumption measure was then obtained households - conditional on school attendance - re- by dividing this measure into deciles (1–10). For this duces HIV incidence among young women [26]. The analysis, we re-categorised the variable from deciles intervention involved individually randomising young to three groups for total amount spending/consumption women aged 13 to 20 to receive a monthly cash per capita: low (ranging from $1.3 to 15.4), transfer, conditional on school attendance. Control medium (ranging from $15.5 to 32.6) and high participants received no cash transfer but attended (above $32.10). Ranganathan et al. Reproductive Health (2018) 15:102 Page 18 of 21 Appendix 3 Fig. 3 Flowchart for analysis between transactional sex and consumption patterns Ranganathan et al. Reproductive Health (2018) 15:102 Page 19 of 21 Appendix 4 Fig. 4 Factor loadings for 12 items from consumption module Acknowledgements Chapel Hill Institutional Review Board (IRB) (no reference number), and the The authors would especially like to thank the young women and their Department of Health and Education, Mpumalanga Province, South Africa (no guardians for their participation in this study, the field staff (Rirhandzu, reference number) where the research was conducted. Violet, Nestor and Ellah), as well as the analysts at HPTN 068 and the Agincourt HDSS who spent many months collecting the data and organising Competing interests the study. Without the time and generosity of both participants and field staff, The authors declare that they have no competing interests. this work would not have been possible. For this we are very grateful. Funding Publisher’sNote This research was supported by the STRIVE research programme consortium Springer Nature remains neutral with regard to jurisdictional claims in funded by UKaid from the Department for International Development. published maps and institutional affiliations. However, the views expressed do not necessarily reflect the department’s official policies. Overall support for the HIV Prevention Trials Network (HPTN) Author details was provided by the National Institute of Allergy and Infectious Diseases Department for Global Health and Development, Faculty of Public Health (NIAID), the National Institute of Mental Health (NIMH) and the National and Policy, The London School of Hygiene and Tropical Medicine, London, Institute on Drug Abuse (NIDA) of the National Institutes of Health (NIH) UK. Wits Reproductive Health and HIV Institute, University of Witwatersrand, under Award Numbers UM1AI068619 (HPTN Leadership and Operations Johannesburg, South Africa. MRC/Wits Rural Public Health and Health Center), UM1AI068617 (HPTN Statistical and Data Management Center), Transitions Unit (Agincourt), School of Public Health, Faculty of Health and UM1AI068613 (HPTN Laboratory Center). Additional funding was Sciences, University of the Witwatersrand, Johannesburg, South Africa. provided in part by the Division of Intramural Research, NIAID. The School of Health & Society, University of Wollongong, Wollongong, NSW, study was also funded under Award Number 5R01MH087118–02 and Australia. Department of Epidemiology, University of North Carolina at P2C HD050924 to the Carolina Population Center. The content is solely Chapel Hill, Chapel Hill, NC, USA. Carolina Population Center, University of the responsibility of the authors and does not necessarily represent North Carolina, Chapel Hill, NC, USA. Umeå Centre for Global Health the official views of the National Institute of Allergy and Infectious Research, Division of Epidemiology and Global Health, Department of Public Diseases or the National Institutes of Health. Health and Clinical Medicine, Umeå University, Umeå, Sweden. International Network for the Demographic Evaluation of Populations and Their Health Availability of data and materials (INDEPTH) Network, Accra, Ghana. Department of Population, Family and The datasets generated during and/or analysed during the current study are Reproductive Health, Johns Hopkins Bloomberg School of Public Health and not publicly available because they contain participant identification numbers JHU School of Nursing, Baltimore, MD, USA. but are available from the corresponding author on reasonable request. Received: 9 September 2017 Accepted: 10 May 2018 Authors’ contributions Conceived and designed the study: MR AP CW LH CM. Analysed the data: MR, CM, HS, RJS. Wrote the paper. 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Reproductive HealthSpringer Journals

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