This article was downloaded by: [University of Bristol] On: 19 November 2014, At: 00:35 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

African Journal of AIDS Research Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/raar20

South Africa youths’ higher-risk sexual behaviour: an eco-developmental analysis a

Monde Makiwane & Zitha Mokomane

a

a

Child, Youth, Family and Social Development , Human Sciences Research Council , Private Bag X41, Pretoria, 0001, South Africa Published online: 19 May 2010.

To cite this article: Monde Makiwane & Zitha Mokomane (2010) South Africa youths’ higher-risk sexual behaviour: an ecodevelopmental analysis, African Journal of AIDS Research, 9:1, 17-24, DOI: 10.2989/16085906.2010.484538 To link to this article: http://dx.doi.org/10.2989/16085906.2010.484538

PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http:// www.tandfonline.com/page/terms-and-conditions

African Journal of AIDS Research 2010, 9(1): 17–24 Printed in South Africa — All rights reserved

Copyright © NISC (Pty) Ltd

AJAR

ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2010.484538

South Africa youths’ higher-risk sexual behaviour: an eco-developmental analysis Monde Makiwane and Zitha Mokomane*

Downloaded by [University of Bristol] at 00:35 19 November 2014

Child, Youth, Family and Social Development, Human Sciences Research Council, Private Bag X41, Pretoria 0001, South Africa *Corresponding author, e-mail: [email protected] Despite their high levels of knowledge about HIV and AIDS, young people ages 15–24 years in South Africa remain disproportionately affected by the epidemic. Young people’s continued susceptibility to HIV infection has been consistently linked to intractable higher-risk sexual behaviours. This paper uses multivariate techniques and secondary data from two nationally representative surveys to illuminate individual and socio-structural factors that play a significant role in youths’ continued engagement in higher-risk behaviour, despite their high awareness about HIV and AIDS. The findings show that notwithstanding progress in terms of increased condom use and reduced incidence of other sexually transmitted infections, the average age of sexual debut remains low, multiple sexual partnerships are prevalent, and inconsistent condom use is widespread among young people. Factors significantly associated with these risk behaviours occur at the individual and structural levels and include issues of race, gender, poverty and susceptibility to peer pressure. The paper concludes by recommending that future HIV-prevention interventions in South Africa should aim at building resilience among youths by promoting affirmative, supportive interventions that emphasize the potentials of young people. Keywords: attitudes, HIV/AIDS, HIV prevention, relationships, risk assessment, social ecology, social systems, socio-cultural factors, youth

Introduction South Africa was one of the signatories to the declaration taken at the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) in 2001, where governments agreed, among other things, to ensure that “by 2010 at least 95% of young men and women aged 15 to 24 have access to the information, education, including peer education and youth-specific HIV education, and services necessary to develop the life skills required to reduce their vulnerability to HIV infection” (United Nations, 2001, p. 7). South Africa has made great strides in the provision of basic HIV and AIDS education and information to young people (Transitions to Adulthood Study Team, 2004; Monasch & Mahy, 2006). Largely because of this effort, virtually every young person aged 15–24 years in the country (99.6%) has now heard about HIV and AIDS (Kaiser Family Foundation, 2007). Furthermore, The Kaiser Family Foundation noted a high awareness of national HIV and AIDS media programmes, with 91% of youths stating that they had heard of ‘Soul City’ (a multi-media health-promotion and socialchange project), 86% had heard of loveLife (a national HIV-prevention programme for youth), and 61% had heard of the government’s Khomanani campaign. There is ample evidence, however, that this high level of awareness has only established a slight downturn in HIV prevalence among youths. For example, a trend analysis of the results of the 2002, 2005 and 2008 versions of South

African National HIV Prevalence, HIV Incidence, Behaviour and Communication Survey (Shisana, Rehle, Simbayi, Zuma, Jooste, Pillay-van-Wyk et al., 2009) indicated that the decline in HIV prevalence among young people was only observed between 2005 and 2008, when it decreased from 10.3% to 8.6%. Prevalence data for this age group in antenatal surveys — which may serve as a proxy marker for the number of recently acquired HIV infections (Rehle, Setswe, Pillay, Metcalf, Jooste, Rispel & Sekhobo, 2007) — also shows that HIV prevalence among young pregnant women has been consistently more than 10%. Indeed, it has been reported that South Africans account for roughly 15% of all HIV infections globally in the 15–24-year-old age group (Transitions to Adulthood Study Team, 2004). It has been shown that higher-risk behaviour underlies young South Africans’ continued vulnerability to HIV infection. It has been noted, for example, that despite a high level of self-reported condom use (Pettifor, Rees, Steffenson, Hlongwa-Madikizela & MacPhail, 2004; Kaiser Family Foundation, 2007), and decreases in other sexually transmitted infections (particularly syphilis: National Department of Health, 2008), average age of sexual debut remains early, with at least 50% of South African youths being sexually active by age 16 (Eaton, Flisher & Aarǿ, 2003) and 89% of those in the 20–24-year-old age group having had sex (Pettifor et al., 2004). Other prevalent higher-risk sexual behaviour among young people includes: • Low level of condom use at sexual debut. A study by

African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group

18

Downloaded by [University of Bristol] at 00:35 19 November 2014









Makiwane and Mokomane

Pettifor et al. (2004) found that only 46% of young people used a condom during their sexual debut, and only 56% reported condom use during first sexual intercourse with their most recent partners. This behaviour may also be reflected in the common occurrence of early and unplanned births to many South African women, which is usually followed by a more controlled childbearing trajectory (Makiwane, 1998). Inconsistent condom use. Available data also show that fewer than half of young people consistently practice safer sex. For example, Pettifor et al. (2004) found that only 33% of young people who had had sex in the preceding year reported that they always used a condom with their most recent partner, while 31% reported that they never used a condom with their most recent partner. Similarly, only 45% of the youths in a 2006 survey by the Kaiser Family Foundation reported that they always used a condom during sexual intercourse, while 17% reported that they never used condoms (Kaiser Family Foundation, 2007). These results are of particular concern given that 42% of all young people who said they were sexually active in the 12 months preceding the survey were either unsure whether their partners were having unprotected sex with other people or else they knew in fact that their partners were having unprotected sex with others (Kaiser Family Foundation, 2007). Multiple and concurrent sexual partnerships. South African research also shows that multiple sexual partners are common in sexual relationships among young people (Eaton et al., 2003). Shisana et al. (2009) for example showed that the proportion of young males who reported having more than one sexual partner in the past 12 months was 23% in 2002, 27.2% in 2005, and 30.8 % in 2008. The corresponding figures for young females were 8.8% for 2002, and 6% for both 2005 and 2008. Qualitative research (Parker, Makhubele, Ntlabathi & Connolly, 2007) has also shown that concurrent sexual partnerships are also normative in South Africa, including among young people. Low uptake of HIV testing. Although HIV testing is one strategy that has been shown to influence condom use and behaviour change among young people (Denison, Lungu, Dunnett-Dagg, McCauley & Sweat, 2006), less than one-third of South African youths have also been tested for HIV. In a study by Pettifor et al. (2004), only 20% of young people reported that they had ever been tested for HIV, while the corresponding proportion in the 2006 survey by the Kaiser Family Foundation (2007) was 30%, including 41% of those who were sexually active. In both studies, females were significantly more likely than males to report having been tested for HIV. Available data suggests that there is an unmet need for voluntary HIV counselling and testing, however; in studies by Pettifor et al. (2004) and the Kaiser Family Foundation (2007), 60% and 72% of the young people stated respectively that they were interested in knowing their HIV status and that they would be willing to get an HIV test if it were offered to them. Anal and oral sex. Against the large number of studies

that have demonstrated a significantly increased risk of HIV transmission from anal sex relative to vaginal intercourse (Johnson & Budlender, 2002), the apparent common experimentation with other forms of sexual activities among young South Africans is also noteworthy. According to ‘The 2006 National Survey of Young South Africans, Broadcast Media and HIV/AIDS Awareness’ about 20% of young people have had oral sex, and about 9% have had anal sex by age 20 (Kaiser Family Foundation, 2007). This paper uses secondary data and multivariate techniques to analyse — within an eco-developmental framework (see Szapocznik & Coatsworth, 1999) — the most significant factors that may explain the foregoing areas of intractability. The eco-developmental framework is a conceptual model that posits that understanding risk and protective factors for adolescents’ problem behaviours requires a thorough examination of individual developmental processes, as well as careful consideration of the social systems within which the risk, protection and behaviours occur (Perrino, Gonzalez, Pantin & Szapocznik, 2000). The eco-developmental framework describes the link between three primary, integrated elements: 1) socialecological theory, drawn from Bronfenbrenner’s (1979) work on the social ecology of human development, which emphasises that while individuals are responsible for instituting and maintaining the lifestyle changes necessary to reduce risk and improve health, individual behaviour is also determined to a large extent by the social environment, such as interpersonal relationships, community norms and values, regulations, and policies; 2) developmental theory, which is a developmental perspective that emphasizes the changing nature of youth across time as a function not only of the adolescent’s current social context but also of changing conditions in the social context throughout the child’s life. For example, adolescent substance abuse, a predictor of unsafe sexual behaviour (Bailey, Pollock, Martin & Lynch, 1999), is influenced not only by the youth’s current social context, as manifested in family cohesion and parental monitoring, but also possibly by previous levels of family support and of parent-child conflict (Pantin, Schwartz, Sullivan, Prado & Szapocznik, 2004); 3) social interactions, wherein it is postulated that risk and protection are expressed in the patterns of relationships and direct transactions between individuals within, and across, the different contextual levels of the social ecology (Pantin et al., 2004). For example, the amount of social support experienced by parents is directly predictive of the harshness or supportiveness of their parenting, which in turn may affect the likelihood of adolescent HIV-risk behaviours (Pantin et al., 2004). These social systems can be represented by a set of nested systems, including: microsystems (settings in which the child participates directly, such as the family, peers, the school and neighbourhood systems), mesosystems (relations between microsystems that influence the child indirectly, such as parental monitoring of peers), exosystems (those that influence the child indirectly through their effects on other family members, such as parents’ social support networks), and macrosystems (defined as society’s

African Journal of AIDS Research 2010, 9(1): 17–24

broad ideological, political, social and cultural patterns). The latter one may include cultural influences on behaviour and expectations, as well as the political and economic influences in individuals and families (Perrino et al., 2000; Pantin et al., 2004).

Downloaded by [University of Bristol] at 00:35 19 November 2014

Methods Data sources The secondary data analysed were obtained from datasets of two nationally representative surveys: ‘The 2003–2004 Status of Youth Report’ (see Richter, Panday, Emmett, Makiwane, Du Toit, Brookes et al., 2005), and ‘The 2006 National Survey of Young South Africans, Broadcast Media and HIV/AIDS Awareness’ (see Kaiser Family Foundation, 2007). These datasets were the only two that were available to the authors during the project on which this paper is based. The surveys are briefly described below. ‘The 2003–2004 Status of Youth Report’ This was a nationally representative survey of young people aged between 18 and 35 years (however, for the purpose of this paper, only data relating to young people aged 18–24 years were considered), conducted in November and December 2003, and analysed in 2004. A self-weighting sample was designed, based on the most recent available data from Statistics South Africa. Households were selected to render a national sample of 3 500 young people, representative of all population groups and provinces in South Africa. The fieldwork, however, targeted 3 600 young people, so as to allow for refusals and incomplete questionnaires. The response rate to the targeted sample of 3 600 was 98.4%, which is 1.2% more than the original sample design. All eligible young people (ages 18–35 years) in every household selected for interview were identified from a brief conversation with a principal respondent in the household. Within each household, if there was more than one young person within the ages 18 to 35, one person was randomly selected through a blinding process, where other attributes such as specific single age, gender or race, were taken into account in selecting one out of all eligible young respondents. If only one person was eligible in the household, that person was interviewed and the random selection process did not apply. Based on consideration for the critical aspects of youth development as highlighted in the literature on youth development and transition to adulthood, the survey questionnaire had six sections: 1) general demographic and other background information on the respondents; 2) employment; 3) education; 4) community and civic engagement; 5) health and disability; and 6) social development. Each section of the questionnaire consisted of questions that aimed at establishing the external conditions of young people, as well as their views and attitudes on issues affecting them. (More details on the study methodology can be found in the complete study report: see Richter et al., 2005.) ‘Young South Africans, Broadcast Media, and HIV/AIDS Awareness: National Survey’ Conducted between August and December 2006 by

19

the Kaiser Family Foundation and the South African Broadcasting Corporation (SABC) (hereafter referred to as the 2006 Kaiser/SABC Survey), this was a nationally representative survey of nearly 4 000 young South Africans, aged between 15 and 24 years. The survey entailed face-to-face interviews conducted in seven of South Africa’s official languages (English, Afrikaans, Zulu, Xhosa, Sotho, Pedi and Tswana). Questions were designed to: 1) gauge what media young people use and how often they use it; 2) assess the general attitudes of young people towards broadcast media programming in relation to HIV and AIDS; 3) measure exposure to, and attitudes about, various HIV/ AIDS-communications campaigns that have run on radio and television; 4) determine young South Africans’ general feelings about their hopes and their future; 5) assess the general level of HIV/AIDS awareness and knowledge among young people; and 6) measure sexual behaviour patterns and perceptions of risk of HIV infection. The survey sample was designed as a probability-based, nationally representative sample using data from the 2001 South African Census. Sampling was done in three stages: the first stage was a random selection of enumeration areas (EAs) in the country; the second stage was a random selection of dwelling units/stands within the EAs; and the third stage was a random selection of an eligible respondent (aged 15–24) within the dwelling. The final sample consisted of 3 926 young people. All survey results were weighted to be representative of the South African population in the age group 15–24 years, by province, age, race and gender. The margin of sampling error for the results based on total respondents was ±2 percentage points. (More details on the study methodology can be found in the complete study report: see Kaiser Family Foundation, 2007.) Data analysis Cox and logistic regression techniques were applied to examine the net effect of selected eco-developmental factors on some of the identified areas of intractability in the sexual behaviour of young South Africans: namely early sexual debut, unprotected sexual debut, inconsistent condom use, and multiple sexual partnerships. The selection of the examined factors was determined largely by the availability of relevant variables in the datasets used for this paper. Cox regression is a method that assesses the relationship between independent variables and a dependent variable that is continuous and censored by the interview process. Therefore, using the 2003–2004 Status of Youth Report (SYR) dataset, Cox regression was used to determine the extent to which the timing of sexual debut is associated with selected independent variables. By its nature, the technique was able to assess the median time even though some young people interviewed were still sexually inexperienced at the time of the survey. The first step was to include all variables in the data set that can theoretically influence the timing of sexual debut. These were: childhood residence, childhood economic status, race and gender. Thereafter, stepwise deletion was performed. This involves a repetitious removal of the least significant variable. The analysis was repeated and the process continued until only the significant

Downloaded by [University of Bristol] at 00:35 19 November 2014

20

independent variables remained. The 95% confidence level was used as a cut off point for inclusion in the model. Logistic regression, on the other hand, is a model used for prediction of the probability of occurrence of a dichotomous event or outcome; it uses several predictor variables that may be either numerical or categorical. In the present analysis, the model was used to determine the most significant factors that influence young people’s use or non-use of condoms during their first sexual intercourse. Data from the 2003 SYR dataset was used to examine the following theoretically important independent variables: race, gender, migration, childhood residence, economic status of childhood residence, and childhood financial situation. Logistic regression was also applied to the 2006 Kaiser/ SABC Survey dataset to assess factors associated with young people not using condoms consistently and the factors associated with having multiple sexual partners, also based on a set of theoretically important independent variables at all levels of the eco-developmental model: race, gender, having a main partner, perceived risk of contracting AIDS, and a number of psychological factors, namely: level of satisfaction with life; importance placed on having friends and family, or being admired by friends; and feeling pressured to do things when against them. As with the Cox regression, stepwise deletion was used to arrive at the logistic regression models, which show the odds ratios of young South Africans using condoms at sexual debut, using condoms consistently, and having multiple sexual partners. Data limitations A major limitation of both data sets is their cross-sectional design, which hampers causal inferences from the data, as well as the determination of temporality. Another limitation is that none of the datasets used for the study included variables that could be used to measure eco-developmental factors at the level of the mesosystem or exosystem. Thus, the analysis only focused on factors at the levels of the individual, the microsystem and the macrosystem. The results, therefore, should be interpreted cautiously in relation to the overall eco-developmental framework. Findings Early sexual debut The chance of having an early sexual debut was tested against a number of factors: race, gender, migration from the childhood area, childhood residence, economic status of the childhood residence, and whether or not the young person had dropped out of school. Contrary to previous findings (cf. Eaton et al., 2003) the analysis showed no significant difference in the timing of sexual debut between male and female youths. Migration also did not have a significant impact on the timing of their first sexual intercourse. Therefore, as shown in Table 1, only race and type of childhood residence, leaving school early, and change in childhood economic status emerged as the most significant eco-developmental factors influencing early sexual intercourse among young South Africans.

Makiwane and Mokomane

In general, the data show that black youths have earlier sexual debut compared to their counterparts in other racial groups, while Indians start sexual activity later than all other groups. In terms of childhood residence, young people who grew up in an urban area are more likely to have early sexual debut compared those who grew up in a rural area or informal settlement. Those who grew up in a farm area are the least likely to engage in early sex. Leaving school before completion and a change in the economic status of the household in which the young person grew up are associated with early sexual debut. Unprotected sex debut The association between factors associated with having an unprotected sex debut was also tested. Gender is the only factor that was eliminated from the model, while the most significant factors were: race (where black youths were less likely and white youths were more likely than those from other race groups to use condoms at sex debut), migration from the childhood area, having grown up in an urban area, constancy in the economic status of the childhood household, and having grown up with basic necessities such as food and clothes (Table 2). Inconsistent condom use Factors found to have a positive relationship with using a condom during every instance of sexual activity were: race, gender, age, general satisfaction with life, importance of a successful career, importance of friends and family, and HIV-risk perception (Table 3). Overall, the analyses revealed that young people are more likely to use condoms consistently if they are white, male, older, somewhat satisfied with life in general, and perceiving career success, friends and family as very important. Contrary to our expectations, those who perceived their risk of getting HIV as small or none were more likely to use condoms consistently relative to those who thought they were at some risk of HIV. While this finding warrants further interrogation, it may also be related to gender power inequities, as noted in studies by Pettifor et al. (2004) and Moyo, Levandowski, MacPhail, Rees & Pettifor (2008). Those studies found condom-use inconsistency among young South African women who reported having less decision-making powers in relationships even if they felt or knew that they were at risk of HIV infection. The eliminated factors from the model were: importance of being admired by friends, feeling pressured to do things that they do not want or agree with, and not having a main sexual partner. Multiple sexual partners Consistent with previous research, the odds of having multiple sexual partners was found to be higher for males, for those young people who perceived themselves to be at no or small risk of HIV infection, and for those who did not currently have a main partner (Table 4). Factors that were eliminated from the model were: race, age, level of satisfaction with life, not perceiving friends and family as important, and feeling pressured to do things against one’s own will.

African Journal of AIDS Research 2010, 9(1): 17–24

21

Downloaded by [University of Bristol] at 00:35 19 November 2014

Table 1: Cox regression of early sexual debut and selected social factors (bold type denotes the reference category) Variable B Standard error Race: Black 0 Coloured –0.205 0.089 Indian –0.637 0.136 White –0.336 0.079 Childhood residence: Farm 0 Urban area 0.374 0.131 Informal settlement –0.028 0.145 Rural area 0.102 0.133 Economic status of the childhood household: Stayed the same 0 Got worse –0.142 0.076 Got better –0.050 0.069 Left school early 0.119 0.062 Source: Computed from ‘The 2003–2004 Status of Youth Report’ dataset (see Richter et al., 2005)

Significance level

Odds ratio

0 0.021 0 0

1.000 0.815 0.529 0.715

0 0.004 0.844 0.443

1.000 1.454 0.972 1.108

0.043 0.012 0.351 0.050

1.000 0.868 0.951 1.126

Table 2: Logistic regression function showing the relationship between use of a condom during sexual debut and selected social factors (bold type denotes the reference category) Variable B Standard error Race: Black 0 Coloured 0.257 0.173 Indian 0.627 0.263 White 0.723 0.164 Migration: Moved from childhood area 0.618 0.130 Childhood residence: Urban area 0 Farm –1.273 0.290 Informal settlement –0.878 0.317 Rural area –0.966 0.288 Economic status of childhood household: Stayed the same 0 Got worse –0.496 0.124 Got better –0.085 0.113 Childhood financial situation: Had extra things Not enough money –1.940 0.231 Enough money for food and clothes –1.427 0.222 Had most important things –0.851 0.234 Left school early 0.888 0.145 Constant 0.443 0.373 Source: Computed from ’The 2003–2004 Status of Youth Report’ dataset (see Richter et al., 2005)

Discussion and conclusions The foregoing multivariate analyses demonstrated that there is no single factor or event that could solely explain the continuous involvement of young South Africans in unsafe sexual behaviour, despite their knowledge about the HIV risk involved. Rather, the results clearly show that the influences on young people’s sexual risk behaviours are myriad and varied, and that the factors are interconnected within and across multiple social systems that engage in ongoing transactions and influence each other. Overall,

Significance level

Odds ratio

0 0.138 0.017 0

1.000 1.293 1.873 2.061

0

1.855

0 0 0.006 0.001

1.000 0.280 0.416 0.381

0.002 0 0.451

1.000 0.609 0.919

0 0 0 0 0 0

1.000 0.144 0.240 0.427 2.430 4.179

the most significant factors were: race, gender, the type and economic status of the childhood residence, as well as the importance of family and peers on young people’s behaviours and decision-making. These findings are consistent with those of previous studies, such as by Hendrikensen, Pettifor, Lee, Coates & Rees (2007) who found that changes in sexual behaviour (including condom use among young adults in South Africa) took place at multiple levels, with the most significant predictors to condom use being condom use at sexual debut, talking with one’s first sexual partner about condoms, high

22

Makiwane and Mokomane

Downloaded by [University of Bristol] at 00:35 19 November 2014

Table 3: Logistic regression function showing the relationship between consistent condom use with most recent partner and selected social factors (bold type denotes the reference category) Variable B Standard error Significance level Race: Black 0 0 Coloured –0.668 0.168 0 White 0.877 0.274 0.001 Indian 0.283 0.427 0.507 Gender: Females 0 0 Males 0.664 0.087 0 Age –0.092 0.018 0 Satisfaction with life in general: Very satisfied 0 0 Somewhat satisfied 0.465 0.110 0 Not too satisfied 0.413 0.130 0.002 Not at all satisfied –0.326 0.132 0.014 Importance of career success: Very important 0 0.019 Not at all important –0.564 0.541 0.297 Not too important –1.383 0.492 0.005 Somewhat important –0.236 0.207 0.253 Friends and family important: Strongly agree 0 0 Strongly disagree –0.869 0.205 0 Somewhat disagree –0.802 0.202 0 Somewhat agree –0.441 0.129 0.001 Perceived risk of getting HIV: No risk 0 0.001 Great risk –0.268 0.131 0.041 Some risk –0.457 0.173 0.008 Just a small risk –0.155 0.175 0.376 Source: Computed from the 2006 Kaiser/SABC Survey dataset (see Kaiser Family Foundation, 2007)

Odds ratio 1.000 0.513 2.403 1.327 1.000 1.943 0.913 1.000 1.592 1.511 0.722 1.000 0.569 0.251 0.790 1.000 0.420 0.448 0.644 1.000 0.765 0.633 1.168

Table 4: Logistic regression function showing the relationship between having multiple sexual partners and selected social factors (bold type denotes the reference category) Variable B Standard error Significance level Gender: Females 0 0 Males –2.071 0.104 0 Perceived risk of getting HIV: Great risk 0 0.009 No risk 0.322 0.133 0.016 Small risk 0.452 0.155 0.004 Some risk 0.207 0.150 0.168 Currently have a main sexual partner 0.551 0.161 0.001 Constant 1.019 0.170 0 Source: Computed from the 2006 Kaiser/SABC Survey dataset (see Kaiser Family Foundation, 2007)

condom use self-efficacy, optimism about the future, and reported behaviour change attributable to knowledge of HIV and AIDS. By the same token, Moyo et al. (2008) found that consistent condom use in South African youths’ most recent sexual relationships was significantly associated with factors such as the level of communication between the sexual partners, the relationship’s type and duration, the individual’s educational attainment and their history of HIV testing. Similar to what Meschke & Patterson (2003) noted in the United States, these multiple factors often overlap

Odds ratio 0.124 0.126 1.000 0.380 0.572 1.230 1.735 2.770

and create a web surrounding a youth, which may protect the youth from higher-risk behaviour, or, conversely, the interconnections could increase the risk of engaging in unsafe behaviour, depending on the nature of the factors. For example, the impact of poverty is pervasive on HIV risk through poor prospects and opportunities for young people as they grow up (Fenton, 2004). For young women this could often translate into coercive sexual relations which put the young women in a difficult position to negotiate when and where to have sex, and whether or not protection is

Downloaded by [University of Bristol] at 00:35 19 November 2014

African Journal of AIDS Research 2010, 9(1): 17–24

used (Jewkes, Levin & Penn-Kekana, 2003; World Bank, 2003; Tsafack Temah, 2007). Additionally, race, which was significant in all but one of the models used here, is in many respects a marker of former social disadvantage in South Africa, and it still functions as a proxy for a host of socio-cultural factors related to higher-risk sexual behaviours, such as residence in poor neighbourhoods, participation in labour migration, poor access to health information and services, and mythical beliefs about the origins of HIV (Anderson, Beutel & Maughan-Brown, 2007). Against this background it is imperative that HIV-prevention interventions are comprehensive and build on the synergy of multiple interventions, as well as tailored to address risks and opportunities at all levels (UNAIDS, 2004; Wood, Maxwell, Aggleton, Tyrer & Infante, 2006; Coates, Richter & Caceres, 2008). As Coates et al. (2008) posit, to the extent that HIV transmission is a dyadic event that occurs in social contexts, behavioural HIV interventions working with social units might have greater potential than those interventions involving individuals in isolation. Additionally, interventions working across many levels of influence might be more likely to affect behaviour than those working at only one level. Effective HIV-prevention programmes must include a complex set of biomedical, behavioural, and community interventions and approaches (Bertozzi, Laga, Bautista-Arredondo & Coutinho, 2008). These can include programmes that help individuals to prevent HIV transmission, broader-based initiatives that alter the norms and behaviours of social groups, and increased access to tools that reduce the biological likelihood of transmission, such as treatment for sexually transmitted infections (Global HIV Prevention Working Group, 2008). The construct of resilience, described as an adaptive process involving interactions between risk and protective factors across multiple levels of an individual’s life experience (Meschke & Patterson, 2003; Oliver, Collin, Burns & Nicholas, 2006), becomes particularly relevant in this regard. According to Luthar & Ciccheti (2000), resilience does not exclusively represent an individual’s personality traits or attributes but also considers his or her exposure to adversity (negative life circumstances, such as poverty, which are statistically associated with adjustment difficulties) and positive adaptation, which describes behaviourally manifested social competence, or success at meeting stage-salient development tasks (Luthar & Ciccheti, 2000; Peacock-Villada, 2006). Therefore, in this context, resilience does not imply invulnerability to risk, but rather the capacity to successfully adapt to change and negative events in healthy and constructive ways (Oliver et al., 2006). Resilience is associated with the clustering of assets that have the potential to create support and guidance for youths’ positive development despite adversity (PeacockVillada, 2006). These assets are conceived as social networks and relationships that model and promote norms for safer behaviour; economic and political actions that promote positive educational opportunity; employment and health opportunities; competencies; values; and the self-perception that youths need to be healthy, principled and productive. Available research has shown that among young people exposed to adversity, those who possess

23

these protective assets manage better than those who do not (Peacock-Villada, 2006; Wood et al., 2006). To this end, it is important for future HIV-prevention interventions in South Africa to aim at building resilience among young people by promoting affirmative, supportive interventions that emphasize the potentials of young people. The framework developed by Breinbauer & Maddaleno (2005) is worthy of consideration in this regard. This framework divides into two categories the factors that impact on young people’s growth and development, and that potentially influence their risk behaviours: external assets and internal assets. External assets focus on youths’ positive experiences with people and institutions, while internal assets refer to helping youths develop internal qualities that guide choices and provide them with a sense of purpose, focus and centeredness. Breinbauer & Maddaleno (2005) give examples of the assets as follows: support (family support and love, positive family communication, parental involvement in schooling); empowerment (youths’ perceptions that a community values youths, encouraging youths to participate in community activities); boundaries and expectations (family, school, neighbourhood rules, monitoring, and the consequences of positive peer influences); and constructive use of time (participating in sports, clubs, school or community organisations). Internal assets could include instilling commitment to learning (for example, active school engagement), positive values (accepting and taking personal responsibility for one’s actions), social competencies (resisting negative peer pressure), and positive identity (such as possessing high self-esteem, and an optimistic view of one’s personal future). It will be important, however, for interventions to consider how external and internal assets could be maximised within any given context, particularly where resources are scarce. Acknowledgments — This work was conducted in 2008 during a project commissioned by Volunteer and Service Enquiry Southern Africa (VOSESA), on behalf of loveLife South Africa, which we undertook with Professor Arvin Bhana, with contributions from Dr Saadhna Panday. We thank VOSESA and loveLife for permission to publish these findings. The authors — Monde Makiwane and Zitha Mokomane are both senior research specialists in the Child, Youth, Family and Social Development programme at the Human Sciences Research Council, South Africa.

References Anderson, K.G., Beutel, A.M. & Maughan-Brown, B. (2007) HIV-risk perception and first sexual intercourse among youth in Cape Town, South Africa. International Family Planning Perspectives 13(3), pp. 98–105. Bailey, S.L., Pollock, N.K., Martin, C.S. & Lynch, K.G. (1999) Risky sexual behaviors among adolescents with alcohol-use disorders. Journal of Adolescent Health 25, pp. 179–181. Bertozzi, S.M., Laga, M., Bautista-Arredondo, S. & Coutinho, A. (2008) Making HIV prevention programmes work. The Lancet 372(9641), pp. 831–844. Breinbauer, C. & Maddaleno, M. (2005) Youth: Choice and Change. Promoting Health Behaviors in Adolescents. Washington, D.C., Pan American Health Organization.

Downloaded by [University of Bristol] at 00:35 19 November 2014

24

Bronfenbrenner, U. (1979) The Ecology of Human Development: Experiments by Nature and Design. Cambridge, Massachusetts, Harvard University Press. Coates, T.J., Richter, L. & Caceres, C. (2008) Behavioural strategies to reduce HIV transmission: how to make them work better. The Lancet 372(9639), pp. 669–684. Denison, J.A., Lungu, N., Dunnett-Dagg, W.A., McCauley, A. & Sweat, M.D. (2006) Social Relationships and Adolescents’ HIV Counseling and Testing Decisions in Zambia. Horizons Research Summary, Washington, D.C., The Population Council. Eaton, L., Flisher, A.J. & Aarǿ, L.E. (2003) Unsafe sexual behaviour in South African youth. Social Science and Medicine 56, pp. 149–165. Fenton, L. (2004) Preventing HIV/AIDS through poverty reduction: The only sustainable solution? The Lancet 364(9440), pp. 1186–1187. Global HIV Prevention Working Group (2008) Behavior Change for HIV Prevention: (Re)Considerations for the 21st Century. Available at: . Hendrikensen, E.S., Pettifor, A., Lee, S., Coates, T.J. & Rees, H.V. (2007) Predictors of condom use among young adults in South Africa: The Reproductive Health and HIV Research Unit National Youth Survey. American Journal of Public Health 97(7), pp. 1241–1248. Jewkes, R.K., Levin, J.B. & Penn-Kekana, L.A. (2003) Gender inequalities, intimate partner violence and HIV-preventive practices: findings of a South African cross-sectional study. Social Science and Medicine 56, pp. 125–134. Johnson, L. & Budlender, D. (2002) HIV Risk Factors: A Review of the Demographic, Socio-Economic, Biomedical and Behavioural Determinants of HIV Prevalence in South Africa. Cape Town, South Africa, Centre for Actuarial Research, University of Cape Town. Kaiser Family Foundation (2007) ‘Young South Africans, Broadcast Media, and HIV/AIDS Awareness: Results of a National Survey. March 2007. Menlo Park, California, Henry J. Kaiser Family Foundation. Available at: . Luthar, S. & Cicchetti, D. (2000) The construct of resilience: a critical evaluation and guidelines for future work. Child Development 71(3), pp. 543–562. Makiwane, M. (1998) Fertility in rural South Africa. PhD thesis, University of the Witwatersrand, Johannesburg, South Africa. Meschke, L.L. & Patterson, J.M. (2003) Resilience as a theoretical basis for substance abuse prevention. The Journal of Primary Prevention 23(4), pp. 483–514. Monasch, R. & Mahy, M. (2006) Young people: the centre of the HIV epidemic. In: Ross, D.A., Dick, B. & Ferguson, J. (eds.) Preventing HIV/AIDS in Young People: A Systematic Review of the Evidence from Developing Countries. Geneva, World Health Organization. Moyo, W., Levandowski, B.A., Macphail, C., Rees, H. & Pettifor, A. (2008) Consistent condom use in South Africa’s youths’ most recent sexual relationships. AIDS Behaviour 15, pp. 431–440. National Department of Health (2008) The National HIV and Syphilis Antenatal Sero-Prevalence Survey in South Africa: 2007 Report. Pretoria, South Africa, the National Department of Health. Oliver, K., Collin, P., Burns, J. & Nicholas, J. (2006) Building resilience in young people through meaningful participation. Advances in Mental Health 5(1), pp. 34–40. Pantin, H., Schwartz, S.J., Sullivan, S., Prado, G. & Szapocznik, J. (2004) Ecodevelopmental HIV-prevention programs for Hispanic adolescents. American Journal of Orthopsychiatry 74(4), pp. 545–558. Parker, W., Makhubele, B., Ntlabathi, P. & Connolly, C. (2007)

Makiwane and Mokomane

Concurrent Sexual Partnering amongst Young Adults in South Africa: Challenges for HIV Prevention. Johannesburg, South Africa, Centre for AIDS Development, Research and Evaluation (CADRE). Peacock-Villada, P. (2006) Resiliency Pilot Program Evaluation: Zambia and South Africa 2006. November 2006. Atlanta, Georgia and Washington, D.C., CARE and USAID. Perrino, T., Gonzalez, S.A., Pantin, H. & Szapocznik, J. (2000) The role of families in adolescent HIV prevention: a review. Clinical Child and Family Psychology Review 3, pp. 81–96. Pettifor, A.E., Rees, H.V., Steffenson, A., Hlongwa-Madikizela, L. & MacPhail, C. (2004) HIV and Sexual Behaviour among Young South Africans: A National Survey of 15–24-year-olds. Johannesburg, South Africa, University of the Witwatersrand, Reproductive Health Research Unit. Rehle, T., Setswe, G., Pillay, V., Metcalf, C., Jooste, S., Rispel, L. & Sekhobo, J.P. (2007) Assessing the Impact of HIV and AIDS Prevention and Care Programmes in South Africa. Report to the Department of Science and Technology. Cape Town, South Africa, Human Sciences Research Council. Richter, L., Panday, S., Emmett, T., Makiwane, M., Du Toit, R., Brookes, H., Potgieter, C., Altman, M. & Mukhara, M. (2005) The 2003–2004 Status of Youth Report: Young People in South Africa. Commissioned by the Umsobomvu Youth Fund, November 2005. Cape Town, South Africa, HSRC Press. Shisana, O., Rehle, T., Simbayi, L.C., Zuma, K., Jooste, S., Pillayvan-Wyk, V., Mbelle, N., Van Zyl, J., Parker, W., Zungu, N.P., Pezi, S. & the SABSSM III Implementation Team (2009) South African National HIV Prevalence, Incidence, Behaviour and Communication Survey, 2008: A Turning Tide Among Teenagers? Cape Town, South Africa, HSRC Press. Szapocznik, J. & Coatsworth, J.D. (1999) An ecodevelopmental framework for organizing the influences on drug abuse: a developmental model of risk and protection. In: Glantz, M. & Hartel, C. (eds.) Drug Abuse: Origins and Interventions. Washington, D.C., American Psychological Association. Transitions to Adulthood Study Team (2004) Transitions to Adulthood in the Context of AIDS in South Africa. New York, The Population Council. Tsafack Temah, C.T. (2007) Gender Inequality and the HIV/AIDS Epidemic in Sub-Saharan Africa [unpublished conference paper]. Available at: [Accessed 25 September 2008]. UNAIDS (2004) At the Crossroads: Accelerating Youth Access to HIV/AIDS Interventions. Geneva, UNAIDS. United Nations (2001) UNGASS: Declaration of Commitment on HIV/AIDS. United Nations General Assembly Special Session on HIV/AIDS, 25–27 June 2001. Online posting at: [Accessed 31 March 2008]. Wood, K., Maxwell, C., Aggleton, P., Tyrer, P. & Infante, C. (2006) HIV Prevention with Especially Vulnerable Young People: Case Studies of Success and Innovation. Southampton, UK, Centre for Sexual Health Research, University of Southampton. World Bank (2003) HIV/AIDS and Gender Equality: Gender and Development Briefing Notes. July 2003. Washington, D.C., The World Bank, PREM Gender and Development Group. Available at: [Accessed 26 September 2008].

South Africa youths' higher-risk sexual behaviour: an eco-developmental analysis.

Despite their high levels of knowledge about HIV and AIDS, young people ages 15-24 years in South Africa remain disproportionately affected by the epi...
171KB Sizes 3 Downloads 8 Views