title: Cultural consensus modeling to measure transactional sex in Swaziland: Scale building and validation.
abstract: Transactional sex is associated with increased risk of HIV and gender based violence in southern Africa and around the world. However the typical quantitative operationalization, "the exchange of gifts or money for sex," can be at odds with a wide array of relationship types and motivations described in qualitative explorations. To build on the strengths of both qualitative and quantitative research streams, we used cultural consensus models to identify distinct models of transactional sex in Swaziland. The process allowed us to build and validate emic scales of transactional sex, while identifying key informants for qualitative interviews within each model to contextualize women's experiences and risk perceptions. We used logistic and multinomial logistic regression models to measure associations with condom use and social status outcomes. Fieldwork was conducted between November 2013 and December 2014 in the Hhohho and Manzini regions. We identified three distinct models of transactional sex in Swaziland based on 124 Swazi women's emic valuation of what they hoped to receive in exchange for sex with their partners. In a clinic-based survey (n = 406), consensus model scales were more sensitive to condom use than the etic definition. Model consonance had distinct effects on social status for the three different models. Transactional sex is better measured as an emic spectrum of expectations within a relationship, rather than an etic binary relationship type. Cultural consensus models allowed us to blend qualitative and quantitative approaches to create an emicly valid quantitative scale grounded in qualitative context.
authors.affiliation: University of California, San Diego, 9500 Gillman Drive #0507, San Diego, CA, 92093, United States. Electronic address: rfieldingmiller@ucsd.edu.
authors.forename: Rebecca
authors.initials: R
authors.lastname: Fielding-Miller
authors.affiliation: South African Medical Research Council, 1 Soutpansberg Road, Pretoria, 0001, South Africa.
authors.forename: Kristin L
authors.initials: KL
authors.lastname: Dunkle
authors.affiliation: Emory University, 201 Dowman Drive, Atlanta, GA, 30322, United States.
authors.forename: Hannah L F
authors.initials: HL
authors.lastname: Cooper
authors.affiliation: Emory University, 201 Dowman Drive, Atlanta, GA, 30322, United States.
authors.forename: Michael
authors.initials: M
authors.lastname: Windle
authors.affiliation: Emory University, 201 Dowman Drive, Atlanta, GA, 30322, United States.
authors.forename: Craig
authors.initials: C
authors.lastname: Hadley
mesh_terms: D000293:Adolescent; D000328:Adult; D017280:Condoms / Q000706:statistics & numerical data; D032921:Consensus; D003466:Cultural Characteristics; D013541:Eswatini / Q000453:epidemiology; D005260:Female; D015658:HIV Infections / Q000453:epidemiology; D006801:Humans; D008960:Models, Psychological; D036301:Qualitative Research; D015203:Reproducibility of Results; D011477:Sex Work / Q000523:psychology*; D012923:Social Class; D055815:Young Adult
keywords: Consensus modeling; HIV/AIDS; Mixed methods; Scale validation; Southern Africa; Swaziland; Transactional sex