Elsevier

Social Science & Medicine

Volume 56, Issue 1, January 2003, Pages 149-165
Social Science & Medicine

Unsafe sexual behaviour in South African youth

https://doi.org/10.1016/S0277-9536(02)00017-5Get rights and content

Abstract

A growing body of evidence points to the complexity of sexual behaviour. HIV risk behaviour is influenced by factors at three levels: within the person, within the proximal context (interpersonal relationships and physical and organisational environment) and within the distal context (culture and structural factors). This paper presents the findings of a review of research on the factors promoting and perpetuating unsafe sexual behaviour in South African youth. Papers included in the review were dated between 1990 and 2000 and addressed sexual behaviour of youth between the ages of 14 and 35 years. Both published works and unpublished reports and dissertations/theses were included. The review concluded that at least 50% of young people are sexually active by the age of 16 years; the majority of school students who had ever experienced sexual intercourse reported at the most one partner in the previous year, with a persistent minority of between 1% and 5% of females and 10–25% of males having more than four partners per year; and between 50% and 60% of sexually active youth report never using condoms. In terms of explanations for unsafe sexual behaviour among South African youth, the findings illustrate the powerful impact of the proximal and distal contexts, and in particular, the pervasive effect of poverty and social norms that perpetuate women's subordination within sexual relationships. Personal factors and the proximal and distal contexts interact to encourage HIV risk behaviour in ways that are not fully captured by social-cognitive models. The findings will be of interest to researchers and practitioners in the fields of adolescent sexual behaviour and HIV prevention in developing countries.

Introduction

The poorest, most underdeveloped region in the world, Sub-Saharan Africa, faces by far the highest rate of HIV infections. Although this region accounts for only 10% of the world's population, 85% of AIDS deaths have occurred here (World Bank, 2000). Young people have the fastest-growing infection rates. In 1998, the HIV infection rates among South Africans aged 14–19 years and 20–24 years were 21.0% and 26.1%, with percentage increases from 1997 of 65.4% and 32.5%, respectively (Adler & Qulo, 1999).

Several major theories of behaviour have been applied to understanding HIV-risk behaviour. These include the Health Belief Model (Becker (1974), Becker (1988); Janz & Becker, 1984; Rosenstock, 1966); the Theory of Reasoned Action (Azjen & Fishbein, 1970) and its revised form, the Theory of Planned Behaviour (Azjen, 1985); and Social Cognitive Learning Theory1 (Bandura (1986), Bandura (1991)). These theories (dubbed “social-cognitive” within the health psychology literature) mainly deal with factors within the triad: behaviour, personal factors, interpersonal factors and processes. (For an overview of such theories, see Conner and Norman, 1996.) One's behaviour is seen to be primarily a function of beliefs and subjective evaluations. The key cognitions and evaluations addressed by these theories include: vulnerability to a health risk; perceived severity of the health outcome; likelihood that changed behaviour will protect against the risk; confidence in changing one's behaviour effectively; the costs versus benefits associated with risky behaviour; perceived emotional and social consequences of heath-related behaviours; and perceptions about social norms (what other people think and feel, and whether the individual is motivated to comply with these perceived pressures). These variables may influence behaviour itself or the intention to behave in a certain manner (Azjen & Fishbein, 1970).

These social-cognitive theories have been found to be valid and useful, especially within the contexts in which they were designed (that is, within Western societies). But they cannot be applied blindly in all circumstances and to all problems. This is particularly apparent in developing countries, where factors beyond the individual have an impact that warrants special consideration. Social-cognitive theories do recognise the relevance of factors beyond the individual. However, they tend to emphasise personal processes and the subjective aspects of social influences, to the neglect of the objective aspects of social influences and the distal societal and cultural context.

The need to consider objective social, economic, environmental and political factors has been recognised by AIDS researchers in Africa (Webb, 1997), as well as by the designers of health intervention models such as the PRECEDE–PROCEDE model (Green & Kreuter, 1991) and the PEN-3 model (Airhihenbuwa, 1995). These models do not, however, offer predictive theories of behaviour, and do not suggest how social context interacts with factors at the individual and interpersonal levels of analysis.

If we wish to understand sexual risk behaviour in Southern Africa, we need to consider the interactive effects of factors at three levels: within the person, within his or her proximal context, and within the distal context. Personal factors include cognitions and feelings relating to sexual behaviour and HIV/AIDS, as well as thoughts about one's self (such as self-efficacy and self-esteem). The proximal context comprises interpersonal relationships and the physical and organisational environment. The distal context includes culture and structural factors. Culture comprises aspects such as traditions, the norms of the larger society, the social discourse within a society, shared beliefs and values, and variations in such factors across subgroups and segments of the population. Structural factors include legal, political, economic or organisational elements of society. The importance of cultural and structural factors and the neglect of such factors in health behaviour research have been recognised in recent publications (Cockerham, 1997; Dressler & Oths, 1997; Eakin, 1997). Fig. 1 presents a framework for organising the relationship between sexual behaviour, personal factors and the proximal and distal contexts.

As is the case with Social Cognitive Theory (Bandura, 1986) and a recent European version of value-expectancy models (Kok, Schaalma, De Vries, Parcel, & Paulssen, 1996), the present model is meant to include both subjective and objective influences on behaviour. Since we shall apply the model to understanding influences on sexual behaviours specifically, we depict a one-way process where individuals and their immediate environment are influenced by broader social conditions. It should be noted, however, that in general terms all these factors are potentially reciprocally determining (Bandura, 1977).

Section snippets

Youth sexual risk behaviour in South Africa

The question under consideration in the present review was this: Why is it that South African youth in the 1990s continued to practice unsafe sex (as evidenced in the spiralling rates of HIV infection), despite the concerted efforts of educational and HIV prevention campaigns to influence their behaviour? The aim was to integrate disparate research findings in order to derive a larger scale view of the factors that promote or perpetuate unsafe sexual behaviour in the South African context. We

Evidence of high-risk sexual behavior

The present review addresses the three types of sexual risk behaviour that have received the most research attention in South Africa: being sexually active (as opposed to abstaining from or postponing sexual activity); having many partners (either serially or concurrently); and practicing unprotected sex (which includes the irregular or incorrect use of condoms). Other risk or protective behaviours have received too little attention in the literature to warrant their discussion in the present

Factors that promote or perpetuate unsafe sexual behaviour

The factors that promote risk behaviours or create barriers to safer practices will be structured according to three domains of analysis: personal factors; the proximal environment (including interpersonal factors, and the immediate living environment); and the broader social context (including structural and cultural factors). We will then illustrate how these three categories of factors interact with each other to influence sexual behaviour.

References (86)

  • C.O. Airhihenbuwa

    Health and cultureBeyond the western paradigm

    (1995)
  • I. Azjen

    From intention to actionsA theory of planned behavior

  • I. Azjen et al.

    The prediction of behavior from attitudinal and normative beliefs

    Journal of Personality and Social Psychology

    (1970)
  • A. Bandura

    Social learning theory

    (1977)
  • A. Bandura

    Social foundations of thought and actionA social cognitive theory

    (1986)
  • A. Bandura

    A social cognitive approach to the exercise of control over AIDS infection

  • M.H. Becker

    The health belief model and personal health behavior

    Health Education Monographs

    (1974)
  • M.H. Becker

    AIDS and behavior change

    Public Health Reviews

    (1988)
  • M.S. Blecher et al.

    AIDS—knowledge, attitudes and practices among STD clinic attenders in the Cape Peninsula

    South African Medical Journal

    (1995)
  • Bodibe, C. R. (1994). Investigating the sexual knowledge, attitudes and behaviour of black adolescents. Unpublished...
  • B.E. Boult et al.

    Black teenage pregnancy in Port Elizabeth

    Early Child Development and Care

    (1991)
  • G.A.B. Buga et al.

    Adolescent sexual behaviour, knowledge and attitudes to sexuality among school girls in Transkei, South Africa

    East African Medical Journal

    (1996)
  • Cassimjee, N. (1998). The role of gender in black adolescent sexuality: An ecosystemic approach. Unpublished masters...
  • W.C. Cockerham

    Lifestyles, social class, demographic characteristics, and health behavior

  • M. Conner et al.

    Predicting health behaviour

    (1996)
  • T. De Ridder

    Boys pay unbearable price to survive prison

  • Disler, S. A. (1990). Health related lifestyles of adolescents. Unpublished masters dissertation, University of Cape...
  • W.W. Dressler et al.

    Cultural determinants of health behavior

  • G.E. Du Plessis et al.

    Study of knowledge, attitudes, perceptions and beliefs regarding HIV and AIDS (KABP) among the general public

    (1993)
  • J.M. Eakin

    Work-related determinants of health behaviour

  • Elkonin, D. S. (1993). Acquired immune deficiency syndrome: Knowledge, attitudes, and sexual activity among university...
  • Everatt, D., & Orkin, M. (1993). “Growing up tough”: A national survey of South African youth. CASE National Youth...
  • A.J. Flisher et al.

    Youth attending Cape Peninsula day hospitalsSexual behaviour and missed opportunities for contraceptive counselling

    South African Medical Journal

    (1992)
  • A.J. Flisher et al.

    Risk-taking behaviour of Cape Peninsula high-school students, Part VIIISexual behaviour

    South African Medical Journal

    (1993)
  • R.H. Friedland et al.

    Perceptions and knowledge about the acquired immunodeficiency syndrome among students in university residences

    South African Medical Journal

    (1991)
  • Goliath, C. G. (1995). Sekondereskoolleerlinge se persepsies van VIGS en VIGS-opvoeding. [Secondary school pupils’...
  • V. Govender et al.

    Perceptions and knowledge about AIDS among family planning clinic attenders in Johannesburg

    South African Medical Journal

    (1992)
  • L.W. Green et al.

    Health promotional planningAn educational and environmental approach

    (1991)
  • Harvey, B. M. (1997). A quantitative survey of knowledge, attitudes and behaviour related to AIDS/HIV among...
  • Health Systems Development Unit (1998). Adolescent sexuality and reproductive health in the Northern Province....
  • N.K. Janz et al.

    The health belief modelA decade later

    Health Education Quarterly

    (1984)
  • M. Kau

    Sexual behaviour and knowledge of adolescent males in the Molopo region of Bophuthatswana

    Curationis

    (1991)
  • Kelly, K. (2000). Communicating for action: A contextual evaluation of youth responses to HIV/AIDS. Pretoria:...
  • Cited by (0)

    View full text