Violence exposure across multiple contexts (home, community, school) can be related to psychological distress, drug use and sexual risk-taking in youth. These effects may be exacerbated if children are also exposed to the type of political violence (violence to obtain or maintain political power) that occurred in South Africa during apartheid (1948-1994). Exposure to political violence may interact with exposure to other forms of violence to foster poor child outcomes including psychological distress and risk behaviors such as drug use1. Political violence may also influence child outcomes indirectly by impacting the behavior of caregivers and other significant adults in the child's life who were directly exposed to the violence. These findings may increase our understanding of the factors related to drug use and HIV risks in South Africa since high levels of current exposure to violence are well documented for South African youth and many of these children were exposed to political violence either directly (e.g., witnessing violence) or indirectly via trauma to family or friends (e.g., having a parent jailed or killed) during apartheid. In light of these findings, this study will examine the independent and cumulative impact of exposure to violence in multiple contexts (home, community, school, political) on psychological functioning, alcohol, tobacco and other drug use (ATOD), and HIV/AIDS risk behaviors in a multi-ethnic (African/Black, Colored (mixed race), White, Indian) representative sample of male and female high school students (n=2000;grades 8-11) who will participate in the upcoming 2011 South Africa Youth Risk Behavior Survey (SAYRBS). The SAYRBS, like the U.S./CDC-Youth Risk Behavior Survey on which it is modeled, is a school-based, self-administered nationally representative survey to monitor priority health-risk behaviors. Preliminary findings from the SAYRBS 2002 &2008 datasets (n=20,000+) revealed significant relationships between interpersonal violence (i.e., physical fights, sexual violence), psychological distress, and drug use, and indicated that drug use is a primary vector for exposure to HIV in South African youth. The proposed study will extend these findings by adding a second set of survey instruments to the 2011 administration to generate more comprehensive assessments of exposure to home, community, school, and political violence, psychological functioning, drug use, and HIV risks in the SAYRBS sample of students in the Western Cape Province of South Africa (n = 2000). The SAYRBS data on frequency of drug use, drug use during sexual activity and condom use, in addition to the data collected for the proposed study, will be used to develop a predictive model to identify subgroups of South African youth who, based on their exposure to political and other forms of violence, may be at high risk for drug use and HIV exposure, and should be targeted for prevention and/or intervention programs. To identify potentially modifiable protective factors that could be addressed in drug and/or HIV prevention programs for South Africa youth exposed to violence, we will add instruments to the 2011 SAYRBS survey to examine the roles of youth emotional regulation and coping mechanisms in our entire survey sample of students (n=2000). As an exploratory aim, we will also conduct separate interviews with a random sample (n=200) of maternal caregivers of these students to examine the influence of caregiver risk behaviors, psychological functioning, and communications about violence, drug use and HIV/AIDS on youth outcomes and the feasibility of a larger future study. Based on an eight-year collaboration, this study will be directed by Kathy Sanders- Phillips, Ph.D., from Howard University, and Priscilla Reddy, Ph.D., the SAYRBS PI and Director of the National Health Promotion Research and Development Office at the Medical Research Council (MRC) in South Africa. This study is submitted in response to PA-09-021 - International Research Collaboration on Drug Abuse and Addiction Research (R21) - whose primary goal is to "build on unique resources and special opportunities including access to resources, populations and/or environmental conditions in other countries that will speed scientific discovery." The PA identifies "links between HIV/AIDS and drug abuse" as a priority research area. A second goal of the PA is to "conduct activities that build research capacity;develop bilateral interchanges to share research knowledge for mutual benefit;and expand capabilities of non-U.S. addiction researchers". The proposed study comprehensively addresses these goals and priorities by (1) capitalizing on the unique opportunity of the 2011 SAYRBS and building on the resources and staff of a survey that is supported and conducted by the premier health research institution in South Africa;(2) utilizing the SAYRBS sampling procedures to recruit a nationally representative sample;(3) leveraging minimal U.S. funds to collect added data on the 2000 students who will complete the SAYRBS in the Western Cape Province of South Africa;(4) capitalizing on the historical opportunity to examine the first post-apartheid generation in South Africa to expand our limited knowledge of the effects of exposure to political violence on youth and caregivers and (5) providing capacity building and data sharing activities and opportunities to South Africa drug addiction researchers in violence exposure research. The proposed study also addresses the recommendations of South Africa researchers and the South Africa Department of Health that "studies of the contribution of environmental risk factors like violence exposure to drug use and HIV risk are critical to the ability to prioritize targets for intervention and prevention programs in South Africa" and that "preventing drug use is an important strategy for addressing the AIDS epidemic in South Africa"2-10. Finally, since the methods and instruments for this project are based on currently funded NIH studies (R01, Biological and Social Correlates of Drug Use in African American Emerging Adults, Sanders-Phillips, PI;Research Training in the Prevention of Drug Abuse and AIDS in Communities of Color, Sanders-Phillips, PI, 1R24DA021470;Mediators of Violence Exposure and Drug Use in Youth, Kliewer, PI, R21 DA 020086), findings for South Africa and the U.S. can be compared. In sum, by building on the existing SAYRBS survey and current U.S. studies, this study is a cost-efficient strategy that leverages U.S. funds to collect data on an environmental risk factor (i.e., violence in multiple contexts) that can be addressed in drug and HIV/AIDS programs for South African youth and their caregivers, and increases our understanding of the effects of children's exposure to political violence on health risks and outcomes.
To develop more effective drug abuse and HIV/AIDS prevention programs for South African children, it is important to identify the youth who should be targeted;determine how drug use and HIV/ AIDS prevention programs should be structured;and describe the risk factors related to poor outcomes and protective factors that may foster resiliency. Findings suggest that violence exposure in multiple contexts (home, community, school) may be associated with psychological distress, drug use and sexual risk- taking in youth. Exposure to violence in one context (e.g., home) may also exacerbate the effects of exposure in other contexts (e.g., community, school) - particularly if children are directly or indirectly exposed (through losing a caregiver and/or witnessing the trauma of friends and/or family) to the type of political violence (violence to gain or maintain political power) that occurred in South Africa during the era of apartheid Therefore, this project will assess the (1) independent and cumulative effects of violence exposure in four contexts (home, community, school political) on psychological functioning, drug use and sexual risk-taking, (2) roles of youth coping mechanisms and emotional regulation as potential protective factors;and (3) caregiver factors that may promote resiliency for youth in high violence communities. To increase future research on violence exposure, drug use, and HIV risks in South African youth, In addition, the project will provide capacity building activities for South African drug abuse researchers.