By: Nelly Ntuli

Social and Behavioral Research on Adolescent Sexuality and HIV Prevention

Background

HIV/AIDS, other sexually transmitted diseases and unwanted teenage pregnancy are at epidemic proportion in South Africa, where about 16% of pregnant women aged 15-19 are HIV infected.  Integrated interventions that address HIV/AIDS, STD's and teenage pregnancy are high national health priorities.

Various models of behavioural interventions for youth exist, but few have been evaluated in terms of their impact on HIV/STD incidence.  Interventions that incorporate a gender perspective are particularly important.

The setting

The research I am involved in is carried out in the Hlabisa district in Northern KwaZulu Natal, South Africa.  This is a rural area, with approximately 220,000 predominantly Zulu-speaking residents. The area is divided into 4 tribal authority areas. The study site is one of the wards, which has 40 secondary schools.

People who are involved in this project:

The Medical Research Council has conducted research in KwaZulu Natal since the early 1990's.  This has included extensive research on HIV prevention and sexually transmitted diseases, including a prevention trial based on an intervention aimed at improving quality of care among nurses in primary care clinics.  The HIV Prevention and Vaccine unit is one of the lead projects of the MRC. There are close ties to the Department of Health, and the MRC president reports to the Minister of Health, as HIV/Aids is also a presidential lead project.

Overview of Research

The research with adolescents began in 1998.  The first phase of the research on adolescents, a group of integrated formative research studies, was funded by the Wellcome Trust in collaboration with the South African Medical Research Council and Africa Centre for Population Studies.  The people involved in the adolescent research are:  

Phase I

Formative Research, Feasibility and Acceptability Studies (1998 -2000) The two-year funding was granted for a study to conduct formative research with young people and adult role models, and to assess the feasibility of developing an intervention trial.

Goals of the Formative Research Phase:

The qualitative research among young people consisted of peer group discussions with youth from two secondary schools.  This aspect of the research investigated decision making and negotiation, risk perception, and health seeking behaviour. Methods used were the peer group discussion using qualitative with essay and narrative research, in-depth interviews including use of personal diaries.  In repeated group discussions with 14-15 year old girls and 16-19 year old boys (the age group of their likely sexual partners), the study explored young people's perceptions and understanding of safe sex and how this influences safe sex behaviour.  Findings from this qualitative research highlight the overwhelming importance of gender issues in determining sexual risk behavior among this population.

Repeat findings from both qualitative research and several school surveys indicate that despite high HIV/STD awareness, adolescents' ability to protect themselves in risky situations is low.  For instance, in one school survey, fewer than half of adolescents in three Hlabisa schools could articulate an explanation of safer sex in response to an open-ended question.  Even among the older group of students (Grades 11&12, age range 14 to 28, median age 18), fewer than 50% of sexually active respondents had ever used condoms.  And among the younger group (Grades 8-10, age range 12 to 28, median age 16), only 17% of all sexually active students had used condoms, with significant differences between boys and girls.

These qualitative findings show the overwhelming role played by gender as an underlying influence on HIV risk behaviour.  In findings from the longitudinal peer group study, separate male and female safe sex paradigms emerged, with boys less likely to perceive themselves as "at risk" and more likely to use condoms.  Girls had not used condoms, wished to delay involvement in sexual relationships, and feared pregnancy as well as HIV/AIDS.  Both boys and girls viewed the condom as a male domain, and deemed it difficult for girls to introduce condoms in relationships.  Girls saw condoms as a sign of love and protection, whereas boys tended to use them with casual partners.  A lack of decision-making autonomy within relationships and a fear of violence further constrained girls' attempts to practice safer sex.   Further, gender stereotypes dominated young women's perceptions of relationships and romance.  Relationships for them were structured around social rules in which boys initiated romance. This control over the domain of romance was also perceived to have a sexual side.  Males are perceived to have a more highly charged sex drive, and therefore to have the right to assert this by seeking relationships and sex.

The situation analysis consisted of research with Teachers, Principals and School Governing Boards to document and review sexuality education in secondary schools, to assess teachers, principals and parents' norms and attitudes towards sexuality and their understanding towards youth sexual risk, and to assess feasibility of a school based risk reduction intervention.  The target groups were the teachers, principals and the school governing board, which consists of parents and teachers also students at secondary schools, age between 13-19 years.

We conducted interviews in 20 rural secondary schools in Hlabisa district, KZN. 2-3 interviews were conducted per school, with the principal or deputy; biology, life skills or guidance teachers; plus others doing youth activities.  Focus group discussions were conducted with 4 school governing boards of teachers, parents and students. Informed consent was obtained from the school Inspectors in the region, meeting was held with all the principals of this area with the aim of getting full participation and involvement of all people concerned.

20 secondary schools were visited- 3 teachers per school were interviewed using a semi structured questionnaire.  Participants were informed about confidentiality and safe record keeping.  The interviews were done in a private room and lasted for about 30- 40 minute per participant.  Audio tape recorder and small cassettes were used to collect data as well as manual writing of additional information.  Language used depended on the interviewee interest, which was sometimes both in Zulu and English.

Translation, transcribing and data analysis was done. Qualitative data were analysed using thematic coding.  Quantitative data were analysed using EpiInfo 6.

Findings from this aspect of the study indicate that:

Phase II and Phase III

2001-2003

Phases II and III consist of intervention design, implementation and pilot evaluation.  For this phase of research, we have received funding from the NICHD, USA in collaboration with the HIV Center for Clinical and Behavioural Studies, New York, USA.  This study - Promoting Dual Protection among Youth in Rural Hlabisa District - is a partnership that builds on a long-standing collaboration between the HIV Center, Columbia University and the MRC in South Africa.

The aim of this study is to develop an intervention to promote use of dual protection among youth aged 14-17 in this rural area.  The findings from our formative research indicated that pregnancy and HIV are major concerns among youth, thus suggesting an opportunity to introduce dual protection as a prevention strategy.  Furthermore, dual protection is a highly appropriate prevention strategy in this setting of high HIV prevalence.  In addition, our formative research showed gender issues to be the main underlying factor in use or non-use of prevention, particularly for young women.  Thus, the intervention will focus on strategies to empower women and men and improve their decision-making and negotiation skills within relationships.

The intervention will be co-developed and co-facilitated by both peer educators and influential role models for young people such as teachers, primary health care nurses and parents. The intervention will include the training of peer educators, nurses and teachers in a series of three workshops. The workshops will address the following:

1) Knowledge of HIV/AIDS and STD's transmission

2) Risk and protective factors;

3) Increasing perception of personal risk for HIV/AIDS;

4) Gender roles; and

5) Dual protection and how it can be enhanced.

The initial stage of the project involves the project team in reviewing interventions that have been shown to be effective in other settings.  The review process involves reviewing modules from the intervention manuals from these effective interventions.  From this, a draft intervention manual will be developed.  Then, the workshops will review and refine the modules and exercises to develop a dual protection intervention appropriate for youth in this setting.

Phase III:  Intervention Implementation and Pilot Evaluation

After the year of intervention development, implementation will be done in selected schools to further establish the effectiveness of the intervention.  Outcome will be examined at two levels:  among youth and among adult role models, such as (principals, teachers and the school governing bodies). Outcome measures among youth will be increased condom use (number of protected intercourse events, or abstinence/delay in sexual initiation). Recommendations will be made to implement the intervention District wide.

Gender Considerations within the Project:

Equal representation for both boys and girls in focus groups and interviews and in the development of manuals A focus within the research on following topics

Obstacles and problems to project implementation

Lessons Learnt

Problem solving strategies

The Impact of the Project

The formative research has already had an impact in terms of assisting us to design the second phase of the study, the intervention.  Also, we have gained a greater understanding of youth sexuality and HIV risk behaviour at both the level of youth and adult role models.

The future impact of the intervention study is expected to be:

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