Unsafe sexual behaviour in South African youth
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)
- et al.
High-school dropouts in a working-class South African communitySelected characteristics and risk-taking behaviour
Journal of Adolescence
(1995) - et al.
AIDS-related knowledge, attitudes and behaviour among South African street youthReflections on power, sexuality and the autonomous self
Social Science and Medicine
(1997) - et al.
“He forced me to love him”Putting violence on adolescent sexual health agendas
Social Science and Medicine
(1998) Women and AIDSThe imperative for a gendered prognosis and prevention policy
Agenda
(1998)- et al.
Reasons for lack of condom use among high school students
South African Medical Journal
(1992) - et al.
Women and AIDS in Natal/KwaZuluDeterminants of the adoption of HIV-protective behaviour
Urbanisation and Health Newsletter
(1994) - et al.
Teenagers seeking condoms at family planning services, Part 1A user's perspective
South African Medical Journal
(1992) - et al.
Off target messages—poverty, risk and sexual rights
Agenda
(1998) - et al.
HIV/AIDS and STD's
Black South African adolescents’ attitudes towards AIDS precautions
School Psychology International
(1997)