The effects of gender and socioeconomic status on youth sexual risk norms ajar 2010[1]


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The effects of gender and socioeconomic status on youth sexual risk norms ajar 2010[1]

  1. 1. African Journal of AIDS Research 2010, 9(4): 355–366 Copyright © NISC (Pty) Ltd Printed in South Africa — All rights reserved AJAR ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2010.545639The effects of gender and socioeconomic status on youth sexual-risknorms: evidence from a poor urban community in South AfricaMichael Rogan1*, Michaela Hynie2, Marisa Casale1, Stephanie Nixon3, Sarah Flicker4, Geoff Jobson1 andSuraya Dawad11 University of KwaZulu-Natal, Health Economics and HIV/AIDS Research Division (HEARD), Westville Campus, J Block/Level 4, Durban 4001, South Africa2York University, Department of Psychology, Behavioural Sciences Building, Room 101 BSB, 4700 Keele Street, Toronto,Ontario M3J 1P3, Canada3University of Toronto, Department of Physical Therapy, 160–500 University Avenue, Toronto, Ontario M6G 1V7, Canada4York University, Faculty of Environment Studies, Room 109 HNES, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada*Corresponding author, e-mail: HIV and AIDS remains one of the most serious problems facing youths in many sub-Saharan African countries. Among young people in South Africa, gender is linked with a number of HIV-risk behaviours and outcomes. The literature suggests that factors such as socioeconomic status, intimate partner violence, and several psychosocial factors contribute to gendered differences in sexual behaviour among youths in South Africa. However, the existing body of literature scarcely addresses the interaction between gender, confounding factors (particularly peer norms) and sexual behaviour outcomes. This study uses a survey design (n = 809) to examine how gender and socioeconomic status moderate the effects of norms and attitudes on higher-risk sexual behaviours among secondary school learners in a low-income community in South Africa. The findings suggest that gender interacts significantly with peer norms to predict sexual behaviour. Peer norms and the experience of intimate partner violence were significantly associated with sexual risk behaviour among girls participating in the study. The article discusses both the wider implications of these findings and the implications for school-based and peer-facilitated HIV interventions. Keywords: behaviour change, HIV/AIDS, prevention, sexual behaviour, sexual health, social cognitive models of health, youthsIntroduction Jewkes, 1997; Wood, Maforah & Jewkes, 1998; Walker & Gilbert, 2002; Varga, 2003; Dunkle, Jewkes, Brown, Gray,The past few decades have demonstrated a worrying inability McIntyre & Harlow, 2004a; O’Sullivan, Harrison, Morrell,to influence sustainable behaviour change among many Monroe-Wise & Kubeka, 2006; Hendriksen, Pettifor, Lee,population groups at higher risk of HIV infection (Coates, Coates & Rees, 2007; Jewkes et al., 2008), the ways inRichter & Caceres, 2008). In South Africa, HIV prevalence which gender is linked to HIV and sexual behaviour amongamong young females between the ages of 15 and 19 is young people is likely to be more complex than is oftenmore than twice that of males in the same age group (2.5% depicted because of the unique challenges of adoles-and 6.7%, respectively). And among young adults between cence. Adolescence is characterised by heightened risk ofthe ages of 20 and 24, the gender differential is even greater exposure to HIV because it is the stage at which: sexual(i.e. 21.1% among females versus 5.1% among males) experimentation often begins (Kalipeni, Craddock & Ghosh,(HSRC, 2008). Despite the widespread realisation that young 2004); the effects of peer pressure are experienced mostwomen face increased risk of exposure to HIV, there is little acutely (Dillard, 2002; Njau, Mtweve, Barongo, Manongi,consensus on how to prevent new infections in this group or Chugulu, Msuya et al., 2006); and gender inequalitieshow to effect sexual behaviour change among young South become entrenched (Harrison, 2008). In addressing sexualAfricans more generally (Harrison, Newell, Imrie & Hoddinott, behaviour and gender among the youth in South Africa,2010). Against this backdrop, evaluations of HIV-prevention research has focused largely on a number of confoundinginterventions aimed at youths (aged 15–24 years) have, on factors for HIV risk, including socioeconomic status (SES),the whole, not demonstrated an impact on sustained changes sexual violence and coercion, and a range of psychosocialin sexual behaviour (Jewkes, Nduna, Levin, Jama, Dunkle, factors. However, little is known about the ways in whichPuren & Duvvury, 2008) or biological outcomes (Harrison et peer norms and attitudes interact with these factors, particu-al., 2010). larly in the South African context. While the South African and international literature This study aims to test the hypothesis that gender andhave linked gender to risk of HIV infection (e.g. Wood & SES can moderate the effect of peer norms and attitudes African Journal of AIDS Research is co-published by NISC (Pty) Ltd and Routledge, Taylor & Francis Group
  2. 2. 356 Rogan, Hynie, Casale, Nixon, Flicker, Jobson and Dawadto sexual behaviour on sexual behaviour outcomes among also inextricably linked to gendered HIV-risk behavioursschool-age young people in South Africa (see Figure 1). (Jewkes, Levin, Loveday & Penn-Kekana, 2003; Morrell, Epstein, Unterhalter, Bhana & Moletsane, 2009). Jewkes,Factors affecting HIV risk among young people in Dunkle, Koss, Levin, Nduna, Jama & Sikweyiya (2006)South Africa and Jewkes & Morrell (2010) argue that there are deeplyIn order to examine these interactions, the study employs entwined associations between particular constructions ofa social cognitive approach to measuring attitudes, beliefs, gender roles and risk of sexual coercion, intimate partnerintentions and perceived control over sexual behaviour. violence and HIV, which place young South African womenWhile social-cognitive models have been used extensively at heightened risk of HIV infection. Research in South Africain the planning and implementation of HIV-prevention suggests that intimate partner violence and sexual coercionprogrammes (Campbell, 2003), few studies have investi- are associated with having multiple sexual partners, earlygated how individual-level factors (e.g. SES, gender and sexual debut, more recent sexual activity, unprotected sex,age) interact with norms and attitudes towards sexual inconsistent condom use, unintended pregnancy and beingbehaviour among young people. The following section HIV-positive (Andersson, Ho-Foster, Matthis, Marokoane,reviews the confounding factors commonly associated with Mashiane, Mhatre et al., 2004; Dunkle et al., 2004a;HIV risk among young people in South Africa. Hoffman, O’Sullivan, Harrison, Dolezal & Monroe-Wise, 2006; Jewkes, Dunkle, Koss et al., 2006; Jewkes, Dunkle,Socioeconomic status Nduna, Levin, Jama, Khuzwayo et al., 2006; Maharaj &Chief among the factors linking gender and HIV risk, socioe- Munthree, 2007). Moreover, Wood, Lambert & Jewkesconomic disadvantage significantly influences a wide range (2008) argue that gender-based violence in South Africaof sexual risk behaviours among both females and males often occurs in the context of the perceived ‘naturalness’(Eaton, Flisher & Aaro, 2003; Kalichman, Simbayi, Kagee, of gender inequality in many communities, and in relationToefy, Jooste, Cain & Cherry, 2006). SES is likely to have a to the endemic use of violence against women as a part ofparticularly significant effect on gendered sexual-behaviour everyday life.outcomes and, among South African youths, low SEShas been found to have more consistent negative effects Psychosocial factors, including peer normson female risk behaviours than on male risk behaviours Behavioural and social cognitive studies have identified(Hallman, 2004). For young women, lower SES has been a number of psychosocial processes and factors (such asfound to be associated with earlier sexual debut (Hallman, self-efficacy, self-mastery, risk perceptions and beliefs,2005; Dinkelman, Lam & Leibbrandt, 2007), higher reporting peer and social norms, and self-esteem) that contributeof transactional sex (Dunkle, Jewkes, Brown, Gray, McIntyre to sexual risk behaviour among young people in South& Harlow, 2004b; Hallman, 2004 and 2005) and coerced sex Africa (Eaton et al., 2003; Visser, Schoeman & Perold,(Hallman, 2004 and 2005), higher risk of early pregnancy 2004; Brook, Morojele, Zhang & Brook, 2006). While many(Hallman, 2004), having multiple partners (Hallman, 2005), of these studies have ignored structural and individual-lower chances of secondary sexual abstinence (Hallman, level factors (Eaton et al., 2003), several social-cognitive2004), and lower instances of condom use at last sex studies have begun to explore how factors such as gender(Hallman, 2005; Hargreaves, Bonnell, Morison, Kim, Phetla, and SES might be direct or indirect determinants of higher-Porter et al., 2007). The relationship between gender, SES risk behaviour (cf. Brook et al., 2006). It is the interac-and HIV is not universally accepted, however, and a number tions between individual beliefs, norms and attitudes, andof studies have revealed either no clear causal relationship structural and individual-level factors, however, that are(cf. Booysen, 2004) or the opposite relationship between likely to provide a more nuanced understanding of sexualSES and HIV-risk behaviours and sexual experiences (cf. risk behaviour among young people (Eaton et al., 2003).Wojcicki, 2005). Of the psychosocial processes, the interaction between gender and peer norms, in particular, is perhaps the leastSexual violence and coercion explored in the existing literature. However, earlier work inThe very high rates of sexual violence and coercion in other countries has suggested that gender may interact withSouth Africa, including within the school environment, are peer norms in important ways. A study of sexual behaviour among young people in Zambia (Magnani, Karim, Weiss, Bond, Lemba & Morgan, 2002), for example, found that the perception that peers were sexually active was positively associated with ever having had sex among both boys and Peer norms Gender girls. Among boys, peer influence was positively associated and attitudes Sexual with both sexual activity and the number of lifetime partners. to sexual behaviour Socioeconomic behaviours Protective behaviours involving more consistent condom status use among girls, however, were significantly associated with some measures of peer influence (Magnani et al., 2002). In the South African context, peer pressure among young people is strongly associated with negative views of condom use and positive views of engaging in sexual activityFigure 1: Schematic of the research hypothesis, applied toadolescents in South Africa (MacPhail & Campbell, 2001; Brook et al., 2006). Eaton et al.
  3. 3. African Journal of AIDS Research 2010, 9(4): 355–366 357(2003) note that the South African literature finds that the population census, 32% of the population was aged 0–19peer pressure to be sexually active is generally high for both years; 44% of working-age adults were employed, 21%boys and girls, but that boys seem to be more influenced by were unemployed and 35% were not economically activeit than girls. On the whole, the available literature seems (Statistics South Africa, 2001). The majority of peopleto suggest that boys are more susceptible than girls to living in the study area are black South Africans (64%),the influences of peer pressure, ‘deviant peers’ and social followed by Indians (16%), whites (15%) and colouredsnorms around sexual behaviour (MacPhail & Campbell, (5%) (Statistics South Africa, 2001).1 A large number of2001; Brook et al., 2006). However, some evidence does residents live in informal settlements, with a few living insuggest that girls are influenced to remain abstinent more formal dwellings and classified as low-to-middle-incomestrongly by ‘positive’ peer norms than are boys (Dlamini, households. The area is flanked by established medium-to-Taylor, Mkhize, Huver, Sathiparsad, De Vries et al., 2009). high-income residential areas (Odendaal, 2002).Moreover, peer influences are unlikely to act on their ownand several studies demonstrate how poverty and wellbeing, Datain particular, moderate the effect of peer pressure on The data used in the present study were taken from thesexual behaviour outcomes (Jama, Jewkes, Levin, Nduna, quantitative component of a quasi-experimental retrospec-Khuzwayo, Duvvury & Koss, 2004; Brook et al., 2006). tive evaluation of the impact of a five-year multifaceted Despite the important influences of SES, partner violence, HIV-prevention intervention aimed at secondary schooland psychosocial processes (particularly peer norms) learners. The survey consisted of a self-administeredon sexual risk behaviour among young people, empirical questionnaire distributed to 809 learners in Grade 11, atevidence is needed to understand how gender interacts with two schools implementing the intervention and two controlthese factors to shape sexual behaviour. This gap in the schools, all in Cato Manor. Fieldwork was conductedliterature seems particularly significant in the South African between October 2007 and March 2008. A self-adminis-context, where gender has been so closely associated tered survey tool was created using largely validatedwith a number of confounding factors — such as partner research instruments. It was refined for greater clarity andviolence and low SES. Furthermore, this is a context in for the local context after being pilot-tested with youths andwhich peer influences on sexual behaviour have been found programme mentors. All questionnaires were printed in bothto be particularly strong. Underlining the importance of English and Zulu, with the two versions presented simulta-understanding the gendered effects of peer norms, a recent neously on facing pages in each questionnaire booklet.evaluation of Stepping Stones, the only HIV-prevention Bilingual facilitators assisted learners by introducing theintervention aimed at young people in South Africa that project and survey instrument, presenting simulations withhas demonstrated a biological impact (i.e. a reduction in ‘test questions’ and then going through the survey with thethe prevalence of HSV-2: Jewkes et al., 2008), offers a learners, question by question. The questionnaires werepotentially important lesson. The intervention went beyond administered at the schools, with boys and girls separatedproviding information on HIV and sexual behaviour and was into different classrooms.based on a participatory approach that addressed gender The survey had four main components. The first partinequities and encouraged group communication (Jewkes collected sociodemographic information, informed byet al., 2008). The relative success of this programme past research with South African youths. The seconddemonstrates the potential use of harnessing information on part measured the frequency of behaviours and experi-how peer norms contribute to gendered sexual behaviour ences related to sexuality and sexual health, including pastoutcomes. participation in an HIV-prevention programme and past As such, this article explores how gender and SES sexual behaviour. The third part measured psychosocialmoderate the effects of norms and attitudes about higher- variables and employed internationally validated scales torisk sexual behaviour among secondary school learners in measure hope (Snyder, Lopez, Shorey, Rand & Feldman,a low-income community in KwaZulu-Natal province, South 2003), optimism (Scheier & Carver, 1985), self-esteemAfrica. We argue that improving the evidence base on (Rosenberg, 1965) and self-mastery (Pearlin & Schooler,how gender and SES impact on peer norms will improve 1978). The fourth part of the survey was based on theour understanding of some of the challenges facing both theory of planned behaviour (Ajzen, 1985) and captured theHIV-prevention efforts and progress towards gender equality respondents’ attitudes, norms and intentions relating to keywithin South African schools. HIV-risk-taking behaviour. The survey data were recorded and analysed using SPSS 15.0 and Mplus. Ethical approvalMethods was granted by the three partner universities undertaking the study.SettingThe study was conducted in an urban semi-formal Outcome variablescommunity, Cato Manor, located within Durban, KwaZulu- The two main outcome variables considered in the analysisNatal Province, on the east coast of South Africa. Cato are sexual activity (self-reported sexual debut) and reportedManor has a long and politically charged history — number of lifetime sexual partners (see Table 1).2 Sexualperhaps most famously as a site of forced removals during debut is recorded as a dummy variable. Analyses of thethe apartheid period, followed by land invasions in the number of sexual partners included only those learnersearly years of the democratic era. According to the 2001 who reported ever having had sex. The number of sexual
  4. 4. 358 Rogan, Hynie, Casale, Nixon, Flicker, Jobson and Dawadpartners is a continuous variable, which, after removing individual-level factors (age, gender, experience of partneroutliers more than three standard deviations from the abuse, SES and exposure to HIV-prevention interventions).median, ranged from ‘1’ to ‘10.’ Both of the outcome indica- Socioeconomic status was self-reported and taken fromtors used in this study are well-established risk indica- a question in which the learners were asked to select thetors in the context of HIV (Eaton et al., 2003; Jewkes, statement that best described their respective households.Dunkle, Nduna et al., 2006) as suggested by the fact that The five options ranged from not having enough money forHIV-prevention programmes often aim to encourage sexual food or other basic items to having enough money for foodabstinence and reduce the number of sexual partners as well as luxury items. The responses were then recoded(MacPhail & Campbell, 2001; Magnani, MacIntyre, Karim, into a three-point scale representing low, medium and highBrown & Hutchinson, 2005). SES. All continuous independent variables were mean centred.Explanatory variablesThree clusters of independent variables (hypothesised to be Analysiseither potential risk factors or protective factors) are consid- Basic descriptive analyses were used to identify significantered in the multivariate analysis in the following section. The associations between the two dependent variables andindependent variables (see Table 1) hypothesised to predict a number of independent variables as well as the gendera respondent having sexually debuted and the number of differences in sexual behaviour outcomes. In the multivar-sexual partners reported; this included: 1) attitudes to sexual iate analyses, a binary logistic model was used to identifybehaviour (attitude to sex in the next three months, attitude the predictors of sexual debut (i.e. ever having had sex),to sex before marriage, and beliefs about risks associated with not having had sex coded as ‘0’ and having had sexwith sex); 2) perceived social and peer norms (prescrip- as ‘1.’ A classic linear regression model was used to identifytive parent norms and prescriptive partner norms about the predictors of the number of sexual partners reportedpremarital sex, sexual risk-taking norms, descriptive norms by the learners who had sexually debuted. All independentabout adolescent sexual behaviour, and prescriptive peer variables demonstrating a significant bivariate associa-norms about having sex in the next three months); and 3) tion with the respective outcome variable (i.e. ever hadTable 1: Overview of the outcome variables and explanatory variablesVariable Indicator Number of items Response typeOutcome variablesEver had sex Ever engaged in vaginal or anal penetration (data 2 Yes/No captured through a binary question and through the Continuous reported number of lifetime sexual partners).Number of sexual partners Total number of reported lifetime sexual partners. 1 ContinuousExplanatory variablesNegative attitude to not Displays a negative attitude to abstaining from 3 5-point Likert-type scale*having sex until marriage premarital sex or displays an intention to engage in sex before marriage.Opposed to premarital sex Is opposed to the idea of sex before marriage. 3 5-point Likert-type scale*Belief in HIV and sexually Acknowledges the specific health risks (i.e. HIV/STIs) 7 5-point Likert-type scale*transmitted infection (STI) associated with sexual activity.risksAvoiding premarital sex: Perceives that parents are opposed to sex before 2 5-point Likert-type scale*parent norms marriage.Avoiding premarital sex: Perceives that most recent partner is opposed to sex 2 5-point Likert-type scale*partner norms before marriage.Prescriptive peer norms Feels that it is acceptable for both male and female 4 5-point Likert-type scale*supporting sexual activity peers to be sexually active.Descriptive peer norms Perception that male and female peers are abstaining 2 5-point Likert-type scale*supporting abstinence until from sex before marriage.marriageExperienced partner abuse Ever been ‘punched or kicked’ by a partner. 1 Yes/NoExposed to an HIV Ever participated in or been exposed to any type of 1 Yes/Nointervention HIV-prevention programme (no definition provided).Socioeconomic status 3-point scale (low, medium and high), collapsed from 1 5-point,single response the 5-point self-assessment. self-assessment of household wellbeing.*5-point Likert-type scale: ‘Strongly disagree’ to ‘Strongly agree’Note: ‘Number of items’ refers to the number of questions used to measure each indicator; several individual-level explanatory variables arenot included in this table due to the simplicity of their construction (e.g. gender and age).
  5. 5. African Journal of AIDS Research 2010, 9(4): 355–366 359sex or the number of lifetime partners) were included in all learners in the sample, girls, for example, reported signif-the multivariate models. Thus, the final regression models icantly lower intentions to have sex in the next three monthsincluded all variables that: 1) were significantly associated (F(1, 792) = 60.749; p = 0.0001) and lower intentionswith the outcome variable at the 5% level of confidence; 2) to engage in sex before marriage (F(1, 785) = 6.856; p =mediated the effects of the other independent variables on 0.009). Girls reported significantly less support from theirthe outcome variable; 3) displayed a significant interaction parents to have sex in the next three months (F(1, 787) =with gender, or gender and SES; or 4) had a strong theoret- 52.397; p = 0.0001) and less support to have sex beforeical basis for inclusion. marriage (F(1, 789) = 62.536; p = 0.0001) as compared As in other studies exploring gender differences in sexual with the male learners. Each of these associations holdsbehaviour (cf. Magnani et al., 2002), gender interactions when controlling for both age and sexual debut; however,were included in the models in order to capture the effect of the association between gender and the intention to havegender and the interactions between gender and the other sex before marriage was not significant (p = 0.105) whenindependent variables over and above the main effects. controlling for age and sexual debut.Therefore, in both models presented in the following section,second- and third-order interaction terms were added to Sexual activityexplore the moderating effects of gender and of gender Ever had sexand SES, respectively. Main effects were entered in the first Several key bivariate associations (not shown) with havingstep; two-way interactions (with gender) were entered in the sexually debuted suggest that hypothesised factors — suchsecond step; and three-way interactions (with gender and as SES and intimate partner violence, in particular — maySES) in the third step. The interaction steps were accepted be important predictors of earlier sexual debut. Among theif the R2 change was significant at the 5% level. sexually active learners, a significantly larger number of female learners reported partner violence compared with theResults females who were not sexually active. Significantly fewer of the sexually active females described their householdsSample description as having a high SES in comparison to the sexually activeThe age of the participants (n = 809) ranged from 16 to males and the non-sexually active females. Interestingly, a23 years. Respondents who were under age 16 or who significantly larger proportion of the sexually active femalespoke neither English nor Zulu were removed from the learners reported having been exposed to an HIV-preventionsample (n = 26). An overwhelming majority (98.9%) classi- programme or intervention as compared with the malefied themselves as black and 90.6% indicated Zulu as learners who had sexually debuted.their home language. Of the participating learners, 44.8% In the multivariate analyses, both main effects andwere males and 55.2% were females. Just over half of two-way interactions were significant. Table 3 shows the netthe respondents (50.7%) indicated that they had repeated effects of the predictor variables on ever having had sex,a school year due to failing. Roughly 50% reported either using a logistic regression model. Measures of attitudes andnot having enough money for food or for other basic items, norms towards premarital sex were included in the model,while just 2.9% reported coming from households with but attitudes to having sex in the next three months wereenough money for luxury items. The mean household size not significantly associated with sexual debut and werewas 5.7 members, and most learners (63.6%) reported that therefore excluded. In the first step, those learners opposedtheir mother was the primary caregiver. to premarital sex were shown to have lower odds of having As in other studies of adolescents in South Africa, the sexually debuted. Prescriptive norms supporting sexualboys reported having more sexual partners than did the activity among peers were associated with increased oddsgirls, and a significantly larger proportion of boys (70.6%) of having sexually debuted. Parent norms were not signifi-than girls (46.5%) reported having sexually debuted by cantly associated with sexual debut, but the perception thatthe time of the survey (Table 2). Sexually active boys also potential sexual partners would abstain from sex beforereported a significantly younger median age at sexual marriage (partner norms) significantly reduced the odds ofdebut (age 14) compared with sexually active girls (age 16). having sexually debuted. As expected, older learners andAmong sexually active girls, 19.2% reported having ever those who had been exposed to partner violence had signif-been diagnosed with a sexually transmitted infection (STI) icantly higher odds of having sexually debuted. Participation(cf. 18.9% of the sexually active boys) and 9.3% reported in some form of HIV-prevention programme and beinghaving ever been forced to have sex by a partner. Just over female significantly reduced the odds of having sexuallyone-fifth of sexually active girls participating in the study debuted. Controlling for the other factors, the effect of SESreported having been pregnant at some point in the past. on sexual debut falls away.Partner violence among the sample was high, with 28.2% of In the second step (two-way interaction model), genderthe girls (and 7.2% of the boys) having reported being struck (being female) moderated the effects of several a partner at some point. A significantly higher percentage Gender and age form a significant interaction, with olderof the sexually active girls (63.4%) had been tested for HIV girls more likely to have had sex. In the main-effects model,compared with only 16% of the sexually the active boys. a stronger belief in the risk of HIV or STIs was positively The girls participating in the study also reported signifi- associated with having sexually debuted, but being femalecantly different sexual behaviour intentions and social and reverses the relationship between sexual debut andpeer norms compared with their male counterparts. Among understanding the risks associated with having sex. In
  6. 6. 360 Rogan, Hynie, Casale, Nixon, Flicker, Jobson and DawadTable 2: Proportion and means of selected HIV-risk indicators for the Grade 11 learners, by gender Males Females p-value (n = 362) (n = 446)Ever had sex 70.6 46.5 0.0001Had sex in the past year 27.3 20.6 0.025Age at sexual debut* 14 16 0.0001**Median number of lifetime sexual partners* 5 1 0.0001**Ever been pregnant* – 20.9 –Ever impregnated* 9.2 – –Ever been tested for HIV* 16.0 63.4 0.0001Ever been diagnosed with an STI* 18.9 19.2 0.319Ever been physically abused by a partner 7.2 28.2 0.0001Ever been physically forced to have sex* 7.8 9.3 0.353Ever engaged in transactional sex* 11.0 7.1 0.338Participated in any HIV-prevention programme 56.4 67.7 0.001Low socioeconomic status 53.3 47.3 0.295*Includes only those reporting ever having had sex (245 males; 197 females)**p-value for F-statistic for difference in means; all other p-values are reported for χ2 analysesaddition, being female and perceiving that both male and Discussionfemale peers were abstaining from sex before marriage(descriptive norms) significantly reduced the odds of having The results of this study contribute to the existing bodysexually debuted. Three-way-interaction variables modelling of literature on gender and HIV risk in two ways. First,gender, SES, and selected norms and attitudes were not they demonstrate that the effect of peer norms on sexual-significant and are not described here. behaviour outcomes differs between males and females. Moreover, the results provide empirical evidence concerningMultiple sexual partners the direction of the relationships (i.e. risk-enhancing versusTable 4 demonstrates the effects of the independent protective effects) between peer norms and different sexualvariables on the number of sexual partners reported by behaviours. Perhaps most notably, the finding that thesexually active learners. As the model suggests, age, perception that their peers are abstaining from premaritalhaving experienced partner violence, attitudes to having sex sex has a protective effect against both sexual debut andin the next three months, and prescriptive peer norms about the number of lifetime partners among girls (but not amongsex were all significantly associated with having a greater boys) is important. Second, the study demonstrates that,number of sexual partners. Gender is highly significant (p ≤ over and above the effects of all the other explanatory0.0001) in the first step, with being female resulting in fewer variables, having experienced partner violence is stronglypartners, but is not significant after the interaction variables and positively associated with both sexual debut and aare included. Being exposed to an HIV intervention of some greater number of lifetime partners. Overall, the study’stype and being opposed to premarital sex among peers findings point to the role that gender plays in moderatinghad significant negative associations with the number of the effects of attitudes and norms on sexual behavioursexual partners in the main-effects model. After controlling outcomes. In particular, the results suggest that peer normsfor other variables, the number of sexual partners was not and experience with partner violence are particularly strongsignificantly associated with SES or with perceived parent factors associated with gendered sexual behaviour, whileor partner norms. SES (when controlling for other factors) was not found to be Two second-order interaction variables add to the explan- a significant predictor.atory power of the model. Female learners seem to beparticularly affected by perceived peer norms about avoiding Lessons about gender and peer normssex before marriage (i.e. perceiving that their peers are Most studies in South Africa have found boys to be moreabstaining from sex before marriage), as gender interacted sensitive to peer influences than are girls (e.g. MacPhailsignificantly with this set of norms to predict having had & Campbell, 2001; Eaton et al., 2003; Brook et al., 2006).fewer sexual partners (p < 0.05). The effect of attitudes on However, the findings presented here suggest that girls’premarital sex was less clear, as being female moderates perceptions of what their peers are doing are likely to bethe effect of being opposed to premarital sex, such that very important to them, and, as in other studies (e.g. Dlaminibeing female and being opposed to having premarital sex et al., 2009), these perceptions are found to impact on theiris associated with having had a higher number of sexual decision to remain abstinent. As such, more work shouldpartners. Perceived parent and partner norms about be directed to understanding the different types of peerpremarital sex did not interact with gender. Once again, the influences and the ways in which young males and femalesthree-way-interaction variables were not significant and so respond. Efforts to standardise the way that peer influencesthis step was not included in the final equation. are measured would contribute to our greater understanding
  7. 7. African Journal of AIDS Research 2010, 9(4): 355–366 361Table 3: Adjusted odds ratios (with confidence intervals) for ever having had sex (n = 809 adolescents) Block 1 Block 2AttitudesNegative attitude to not having sex until marriage 1.510 0.861 (0.805–2.831) (0.334–2.220)Opposed to premarital sex 0.701** 0.639** (0.572–0.860) (0.452–0.905)Belief in HIV and STI risks 1.292 2.200** (0.869–1.921) (1.119–4.323)NormsAvoiding premarital sex: parent norms 0.971 0.937 (0.819–1.152) (0.724–1.213)Avoiding premarital sex: partner norms 0.837** 0.880 (0.716–0.980) (0.699–1.109)Prescriptive peer norms supporting sexual activity 1.284** 1.308* (1.068–1.543) (0.952–1.798)Descriptive peer norms supporting abstinence until marriage 0.932 1.128 (0.803–1.081) (0.886–1.435)Individual-level factorsAge 1.403*** 1.175 (1.232–1.598) (0.959–1.440).Female (vs. male) 0.570** 0.565** (0.392–0.827) (0.383–0.832)Experienced partner abuse (vs. ‘not’) 2.166** 2.129** (1.370–3.413) (1.327–3.45)Exposed to an HIV intervention 0.669** 0.658** (0.471–0.951) (0.459–0.944)Socioeconomic status 0.960 0.971 (0.758–1.216) (0.683–1.382)InteractionsGender * age 1.365** (1.043–1.786)Gender * descriptive peer norms supporting abstinence until marriage 0.723** (0.528–0.990)Gender * belief in HIV and STI risks 0.463* (0.197–1.090)Nagelkerke R2 0.335 0.362Model χ2 222.79*** 244.177***Block χ2 222.79*** 21.378***p ≤ 0.10**p ≤ 0.05***p ≤ 0.0001of the effects of peer norms on sexual behaviour. less likely to have sexually debuted. An especially interesting finding is that being female andperceiving that males and females of a similar age are Lessons about violence and coercionabstaining from sex decreased the odds of having sexually The high prevalence of rape, intimate partner violence,debuted. Perceived abstinence among peers was even and sexual coercion in South Africa (Jewkes et al., 2003;associated with having fewer sexual partners among the Andersson et al., 2004) and the level of reported partnergirls who had already sexually debuted. This finding, in violence in this study lead to the unfortunate conclusion thatparticular, is an important addition to the South African litera- violence against women remains a common occurrenceture in light of the prevailing view that peer norms, especially and implies that violence is a significant risk factor for HIVamong males, encourage sexual risk behaviour (rather than among female youths (over and above the effects of allhaving a protective effect). Earlier work (Dlamini et al., 2009) other factors). While the findings related to gender, attitudes,has offered preliminary evidence of the protective effects and perceived peer norms emphasise the gendered natureof peer norms among females in South Africa, but did not of sexual decision-making, the role of partner abuse cannotcontrol for other factors (i.e. in a multivariate context). In be ignored. In both models, having experienced partneraddition to the protective effects of peer norms, there is also violence in the form of striking or punching (admittedly, aevidence that females are acting on an understanding of the fairly narrow definition of partner violence) was highly signif-risks involved in engaging in sex, as the female learners icant as a main effect and it remained significant after thewith a higher recognition of the risk of HIV and STIs were interaction variables were included.
  8. 8. 362 Rogan, Hynie, Casale, Nixon, Flicker, Jobson and DawadTable 4: Multiple regression coefficients (with standard errors) for variables predicting the number of sexual partners reported by the sexuallyactive Grade 11 learners (n = 442) Block 1 Block 2Intercept 5.546*** 5.401*** (0.195) (0.200)AttitudesNegative attitude to not having sex in the next three months 0.987** 1.948** (0.415) (0.575)Opposed to premarital sex –0.349** –0.537** (0.126) (0.172)NormsAvoiding premarital sex: parent norms 0.014 0.036 (0.104) (0.130)Avoiding premarital sex: partner norms 0.004 0.040 (0.101) (0.129)Prescriptive peer norms supporting sexual activity 0.217* 0.271* (0.118) (0.164)Descriptive peer norms supporting abstinence until marriage 0.127 0.362** (0.105) (0.146)Individual level factorsAge 0.246** 0.301** (0.084) (0.114)Female (vs. male) –3.514*** –1.784 (0.282) (3.015)Experienced partner abuse (vs. not) 0.568** 0.597** (0.296) (0.298)Exposed to an HIV intervention –0.387* –0.323 (0.228) (0.226)Socioeconomic status 0.220 0.101 (0.159) (0.202)InteractionsGender * opposed to premarital sex 0.510** (0.254)Gender * descriptive peer norms supporting abstinence until marriage –0.504** (0.211)R2 0.481 0.513R2 change 0.481*** 0.032**F 25.395*** 15.713*** (df1 = 14; df2 = 384) (df1 = 25; df2 = 373)F change 25.395*** 2.242***p ≤ 0.10**p ≤ 0.05***p ≤ 0.0001 As noted in many studies, we find that being the victim of Lessons about socioeconomic statuspartner abuse is almost exclusively the domain of females SES was not found to be a significant predictor in eitherand that it is positively associated with sexual risk behaviour of the models and did not interact with gender and(in this study, having sexually debuted and having multiple selected norms and attitudes. This may be the case, insexual partners) after controlling for other factors. Moreover, part, due to the subjectivity of the SES measure employedthe finding that, among girls, being opposed to premarital (self-reported) and to the fact that the majority of thesex was associated with having had a higher number of learners reported medium or low SES. The validity ofsexual partners suggests that some of the girls had likely self-reporting SES among youths in a developing-countryexperienced coercion. This particular interpretation, while context, where the respondents live in the same impover-certainly plausible, illustrates the difficulties associated with ished community and have relatively similar levels of SES,making causal inferences with respect to norms, attitudes to the best of our knowledge, has not been reviewed in theand sexual-behaviour outcomes. However, the link between literature. Moreover, while several studies (e.g. Jama etpartner violence and various sexual risk behaviours — such al., 2004; Brook et al., 2006) have found that poverty or aas unprotected sex, early sexual debut, multiple partner- low SES can moderate the effects of peer influences, theships, sex with older men, coerced sex and transactional relationship between SES and sexual-behaviour outcomessex — has been well noted in the South African literature is far from clear, with much of the variance in the findings(Andersson et al., 2004). based on the different measures of SES employed (Wojcicki,
  9. 9. African Journal of AIDS Research 2010, 9(4): 355–366 3632005). While the findings of this study offer no indication that where males and females can collectively ‘renegotiate theira low (or high) SES has any bearing on sexual-behaviour peer identities’ and where individuals may gain confidenceoutcomes or on the effects of peer norms, we argue that it is while learning how to negotiate sexual interactions. Strikingstill important to control for SES (in spite of the challenges) a balance between recognising the different role of peerwhen modelling the determinants of sexual behaviour — influences among males and females while allowingparticularly in light of the emphasis in the recent literature both genders to collectively form peer identities appearson SES and sexual risk behaviour. to be a key challenge. The findings of this study suggest that partner violence and sexual coercion should not beImplications for policy and programming overlooked when peer identities are negotiated. Indeed,The findings presented here have important implications for Campbell (2004) emphasises that peer education interven-policy and programming. Not only are sexual-risk profiles tions are less likely to succeed in affecting peer norms if thedifferent for girls, but the determinants of sexual-behaviour participants are not able to adequately address the socialoutcomes are significantly different between girls and boys. factors (e.g. partner violence) impeding behaviour change.HIV prevention, ‘life orientation’ and reproductive health The findings here, together with those from the evalua-interventions need to take these differences into account. tions of Stepping Stones (Jewkes et al., 2008) and IMAGEThe finding that perceived peer norms are more important (Pronyk et al., 2008), clearly point towards the need tofor girls than for boys might suggest that group interventions move beyond health-awareness approaches and to explic-and other forms of support may influence girls more than itly address the underlying gender roles and inequities thattheir male peers. As such, the school environment is likely facilitate gender-based violence and sexual risk be an important space for shaping peer norms and thispresents a unique opportunity in light of emerging evidence Study limitationsthat school-based peer-education programmes can impact Finally, several caveats must be offered. First, the studyon peer-group norms (see Visser, 2007). Community-wide cannot claim to be representative of young people in Southinterventions may also form an important part of addressing Africa or even of young people in Cato Manor. The samplingpeer influences. While discussing the significance of peer design was intended to match control and treatmentinfluences in the Zambian context, Magnani et al. (2002) groups and not to be representative of young people fromnoted the growing conviction that community interventions the community. Second, as with most studies that rely onmay be the most effective way of combating negative peer self-reports of respondents’ sexual behaviour (cf. Magnani etinfluences among young people. al., 2002; Karnell, Cupp, Zimmerman, Feist-Price & Bennie, In terms of the content and structure of interventions, 2006; Jewkes et al., 2008), the possibility of reporting biaslessons from the existing body of literature on gender and and error must be declared when the questionnaires askHIV risk in South Africa seem to suggest that interven- young people to self-report sensitive information abouttions that focus on changing sexual behaviour or health their personal or sexual lives. In this study, this bias mayknowledge, rather than on the gender norms that shape have been exacerbated by a lack of privacy as the youthsbehaviours, are less likely to succeed (Harrison et al., completed the questionnaire. While all efforts were made to2010; Jewkes & Morrell, 2010). Morrell et al. (2009) further ensure that the learners had sufficient desk space to ensureargue that many approaches to achieving gender equality privacy, the reality is that the classrooms were crowded andin South African schools have been challenged by the need some learners had to share a desk. Third, this study onlyto effectively reach peer groups through which gender looked at two sexual risk-taking behaviours and did notnorms and identities are created. Conversely, programmes consider condom use, for example, among sexually activesuch as Stepping Stones (Jewkes et al., 2008) and IMAGE youths. Fourth, the question format and the scales that were(Pronyk, Kim, Abramsky, Phetla, Hargreaves, Morison et included in the questionnaire were validated in a Westernal., 2008) have met with some success due, in large part, setting. A concerted effort, however, was made to adapt theto their emphasis on ‘collective critical thinking,’ group language to fit the local context; to that end, the question-communication, and normative gender identities (Harrison naire was carefully piloted prior to being distributed to theet al., 2010). Notably, these relative successes have been respondents.observed despite the well-known difficulties in implementing Fifth, and perhaps most critically, causality cannot bepeer education programmes (for a fuller discussion, see inferred from the analyses presented here. As in otherCampbell & MacPhail, 2002). The findings of this study social cognitive models, both independent and dependentcan contribute to the design of similar inventions and may variables may be ‘reciprocally determining’ (Bandura, 1977),help to identify which types of peer norms are important in and one cannot necessarily make assumptions about theshaping gender roles and norms. direction of causality between, for instance, attitudes to We argue that understanding the effects of peer norms, having sex in the immediate future and having had sexin particular, is a critical first step towards engaging with the in the past. For example, among the girls, it is not clearformation of gender identities and the design of interventions why being opposed to having premarital sex was associ-that can impact on established gender norms in the context ated with having had a greater number of sexual partners.of HIV and AIDS. It is crucial, however, that interventions As outlined above, one possible interpretation may be thattake into account the role of partner violence in the relation- negative sexual experiences (e.g. coercion or forced sex)ships of young people. As Campbell (2004) and Campbell have created this view. Another interpretation is that there& MacPhail (2002) argue, peer education requires a space are contradictions in youths’ perceptions of ideal behaviours
  10. 10. 364 Rogan, Hynie, Casale, Nixon, Flicker, Jobson and Dawadand actual outcomes, among females, in particular. These research interests include: gender, survey and sampling methodol-caveats notwithstanding, the findings presented here offer ogies, health, poverty and inequality, evaluation methodologies andimportant insights into the gendered differences in sexual reproductive health.behaviour and decision-making among young people in Michaela Hynie is an associate professor in the DepartmentSouth Africa. of Psychology and an associate director of the York Institute of Health Research at York University. She is generally interested in how to use research as a means for social change, both directly,Conclusions through the process of research itself, and indirectly, by generating research findings that can be used for activism. The content of herThis study addresses a critical gap in the South African research falls into three broad categories: culture, immigration andliterature in terms of the relationship between gender, social health inequities; how basic interpersonal or social-psychologicalnorms and sexual behaviour among adolescents in South processes are affected by culture; and, sexual behaviour and saferAfrica. In particular, the findings suggest important ways of sex, with a focus on culturally appropriate interventions and theunderstanding how gender relates to behavioural outcomes. evaluation of international initiatives.Interventions seeking to effect behaviour change among Marisa Casale is a researcher with HEARD at the University ofyoung people should acknowledge gender differences and KwaZulu-Natal, and a doctoral candidate with the Department of Psychology at the University of Cape Town. Her research focusesattempt to develop context-appropriate ways of addressing on southern Africa, with key interest in HIV prevention amongpeer influences through, for example, the use of peer youths, and caregiver and child health.educators, group and community interventions, and school- Stephanie Nixon is an assistant professor in the Department ofbased life-orientation programmes. However, such interven- Physical Therapy and the Dalla Lana School of Public Health, astions should not shy away from the social or individual-level well as academic director of the International Centre for Disabilityfactors (chief among these being partner violence) that and Rehabilitation, at the University of Toronto. She is also acould prevent adolescents’ behaviour change. research associate with HEARD at the University of KwaZulu-Natal. The need for a ‘collective negotiation of peer identities’ Sarah Flicker is an assistant professor in the Faculty ofsuggests that peer-based interventions, in particular, should Environmental Studies at York University, and an Ontario HIVtarget communication between boys and girls. Similarly, the Treatment Network Scholar. Her expertise is in the areas of adoles- cent HIV prevention and support, participatory methodologies, andresults of this study also suggest that such interventions community-based research.would do well to avoid emphasising traditional constructions Geoff Jobson (previously a researcher at HEARD) is a seniorof girls as passive actors in regard to sexual decision-making. researcher at the Peri-Natal HIV Research Unit at the University of theOn the whole, the findings suggest that the relationship Witwatersrand. His research interests include: masculinity and sexuality,between gender and HIV risk is more complex than often and HIV-prevention and care models for people living with HIV.conceptualised and is significantly associated with a combina- Suraya Dawad is a researcher at HEARD at the University oftion of individual-level and psychosocial factors. Future work KwaZulu-Natal; her interests include health systems and the costingshould seek to identify, in greater detail, the specific types of comprehensive-care models.of peer norms or pressures that are linked with sexual-behaviour outcomes in the South African context. In terms Referencesof programming, this study highlights the imperative thatHIV-prevention programmes should move beyond focusing Ajzen, I. (1985) From intentions to actions: a theory of plannedon health knowledge to directly address the underlying behavior. In: Kuhi, J. & Beckmann, J. (eds.) Action-Control: Fromfactors that impact on gender norms and behaviours. 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