African Journal of AIDS Research 2010, 9(4): 355–366 Printed in South Africa — All rights reserved

Copyright © NISC (Pty) Ltd

AJAR

ISSN 1608–5906 EISSN 1727–9445 doi: 10.2989/16085906.2010.545639

The effects of gender and socioeconomic status on youth sexual-risk norms: evidence from a poor urban community in South Africa Michael Rogan1*, Michaela Hynie2, Marisa Casale1, Stephanie Nixon3, Sarah Flicker4, Geoff Jobson1 and Suraya Dawad1 University of KwaZulu-Natal, Health Economics and HIV/AIDS Research Division (HEARD), Westville Campus, J Block/ Level 4, Durban 4001, South Africa 2York University, Department of Psychology, Behavioural Sciences Building, Room 101 BSB, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada 3University of Toronto, Department of Physical Therapy, 160–500 University Avenue, Toronto, Ontario M6G 1V7, Canada 4York University, Faculty of Environment Studies, Room 109 HNES, 4700 Keele Street, Toronto, Ontario M3J 1P3, Canada *Corresponding author, e-mail: [email protected]

1

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, youths

Introduction The past few decades have demonstrated a worrying inability to influence sustainable behaviour change among many population groups at higher risk of HIV infection (Coates, Richter & Caceres, 2008). In South Africa, HIV prevalence among young females between the ages of 15 and 19 is more than twice that of males in the same age group (2.5% and 6.7%, respectively). And among young adults between the ages of 20 and 24, the gender differential is even greater (i.e. 21.1% among females versus 5.1% among males) (HSRC, 2008). Despite the widespread realisation that young women face increased risk of exposure to HIV, there is little consensus on how to prevent new infections in this group or how to effect sexual behaviour change among young South Africans more generally (Harrison, Newell, Imrie & Hoddinott, 2010). Against this backdrop, evaluations of HIV-prevention interventions aimed at youths (aged 15–24 years) have, on the whole, not demonstrated an impact on sustained changes in sexual behaviour (Jewkes, Nduna, Levin, Jama, Dunkle, Puren & Duvvury, 2008) or biological outcomes (Harrison et al., 2010). While the South African and international literature have linked gender to risk of HIV infection (e.g. Wood &

Jewkes, 1997; Wood, Maforah & Jewkes, 1998; Walker & Gilbert, 2002; Varga, 2003; Dunkle, Jewkes, Brown, Gray, McIntyre & Harlow, 2004a; O’Sullivan, Harrison, Morrell, Monroe-Wise & Kubeka, 2006; Hendriksen, Pettifor, Lee, Coates & Rees, 2007; Jewkes et al., 2008), the ways in which gender is linked to HIV and sexual behaviour among young people is likely to be more complex than is often depicted because of the unique challenges of adolescence. Adolescence is characterised by heightened risk of exposure to HIV because it is the stage at which: sexual experimentation often begins (Kalipeni, Craddock & Ghosh, 2004); the effects of peer pressure are experienced most acutely (Dillard, 2002; Njau, Mtweve, Barongo, Manongi, Chugulu, Msuya et al., 2006); and gender inequalities become entrenched (Harrison, 2008). In addressing sexual behaviour and gender among the youth in South Africa, research has focused largely on a number of confounding factors for HIV risk, including socioeconomic status (SES), sexual violence and coercion, and a range of psychosocial factors. However, little is known about the ways in which peer norms and attitudes interact with these factors, particularly in the South African context. This study aims to test the hypothesis that gender and 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

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to sexual behaviour on sexual behaviour outcomes among school-age young people in South Africa (see Figure 1). Factors affecting HIV risk among young people in South Africa In order to examine these interactions, the study employs a social cognitive approach to measuring attitudes, beliefs, intentions and perceived control over sexual behaviour. While social-cognitive models have been used extensively in the planning and implementation of HIV-prevention programmes (Campbell, 2003), few studies have investigated how individual-level factors (e.g. SES, gender and age) interact with norms and attitudes towards sexual behaviour among young people. The following section reviews the confounding factors commonly associated with HIV risk among young people in South Africa. Socioeconomic status Chief among the factors linking gender and HIV risk, socioeconomic disadvantage significantly influences a wide range of sexual risk behaviours among both females and males (Eaton, Flisher & Aaro, 2003; Kalichman, Simbayi, Kagee, Toefy, Jooste, Cain & Cherry, 2006). SES is likely to have a particularly significant effect on gendered sexual-behaviour outcomes and, among South African youths, low SES has been found to have more consistent negative effects on female risk behaviours than on male risk behaviours (Hallman, 2004). For young women, lower SES has been found to be associated with earlier sexual debut (Hallman, 2005; Dinkelman, Lam & Leibbrandt, 2007), higher reporting of transactional sex (Dunkle, Jewkes, Brown, Gray, McIntyre & Harlow, 2004b; Hallman, 2004 and 2005) and coerced sex (Hallman, 2004 and 2005), higher risk of early pregnancy (Hallman, 2004), having multiple partners (Hallman, 2005), lower chances of secondary sexual abstinence (Hallman, 2004), and lower instances of condom use at last sex (Hallman, 2005; Hargreaves, Bonnell, Morison, Kim, Phetla, Porter et al., 2007). The relationship between gender, SES and HIV is not universally accepted, however, and a number of studies have revealed either no clear causal relationship (cf. Booysen, 2004) or the opposite relationship between SES and HIV-risk behaviours and sexual experiences (cf. Wojcicki, 2005). Sexual violence and coercion The very high rates of sexual violence and coercion in South Africa, including within the school environment, are

Peer norms and attitudes to sexual behaviour

Gender Socioeconomic status

Sexual behaviours

Figure 1: Schematic of the research hypothesis, applied to adolescents in South Africa

also inextricably linked to gendered HIV-risk behaviours (Jewkes, Levin, Loveday & Penn-Kekana, 2003; Morrell, Epstein, Unterhalter, Bhana & Moletsane, 2009). Jewkes, Dunkle, Koss, Levin, Nduna, Jama & Sikweyiya (2006) and Jewkes & Morrell (2010) argue that there are deeply entwined associations between particular constructions of gender roles and risk of sexual coercion, intimate partner violence and HIV, which place young South African women at heightened risk of HIV infection. Research in South Africa suggests that intimate partner violence and sexual coercion are associated with having multiple sexual partners, early sexual debut, more recent sexual activity, unprotected sex, inconsistent condom use, unintended pregnancy and being HIV-positive (Andersson, Ho-Foster, Matthis, Marokoane, Mashiane, Mhatre et al., 2004; Dunkle et al., 2004a; Hoffman, O’Sullivan, Harrison, Dolezal & Monroe-Wise, 2006; Jewkes, Dunkle, Koss et al., 2006; Jewkes, Dunkle, Nduna, Levin, Jama, Khuzwayo et al., 2006; Maharaj & Munthree, 2007). Moreover, Wood, Lambert & Jewkes (2008) argue that gender-based violence in South Africa often occurs in the context of the perceived ‘naturalness’ of gender inequality in many communities, and in relation to the endemic use of violence against women as a part of everyday life. Psychosocial factors, including peer norms Behavioural and social cognitive studies have identified a number of psychosocial processes and factors (such as self-efficacy, self-mastery, risk perceptions and beliefs, peer and social norms, and self-esteem) that contribute to sexual risk behaviour among young people in South Africa (Eaton et al., 2003; Visser, Schoeman & Perold, 2004; Brook, Morojele, Zhang & Brook, 2006). While many of these studies have ignored structural and individuallevel factors (Eaton et al., 2003), several social-cognitive studies have begun to explore how factors such as gender and SES might be direct or indirect determinants of higherrisk behaviour (cf. Brook et al., 2006). It is the interactions between individual beliefs, norms and attitudes, and structural and individual-level factors, however, that are likely to provide a more nuanced understanding of sexual risk behaviour among young people (Eaton et al., 2003). Of the psychosocial processes, the interaction between gender and peer norms, in particular, is perhaps the least explored in the existing literature. However, earlier work in other countries has suggested that gender may interact with 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 girls. Among boys, peer influence was positively associated with both sexual activity and the number of lifetime partners. Protective behaviours involving more consistent condom 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 activity (MacPhail & Campbell, 2001; Brook et al., 2006). Eaton et al.

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(2003) note that the South African literature finds that the peer pressure to be sexually active is generally high for both boys and girls, but that boys seem to be more influenced by it than girls. On the whole, the available literature seems to suggest that boys are more susceptible than girls to the influences of peer pressure, ‘deviant peers’ and social norms around sexual behaviour (MacPhail & Campbell, 2001; Brook et al., 2006). However, some evidence does suggest that girls are influenced to remain abstinent more strongly by ‘positive’ peer norms than are boys (Dlamini, Taylor, Mkhize, Huver, Sathiparsad, De Vries et al., 2009). Moreover, peer influences are unlikely to act on their own and several studies demonstrate how poverty and wellbeing, in particular, moderate the effect of peer pressure on sexual behaviour outcomes (Jama, Jewkes, Levin, Nduna, Khuzwayo, Duvvury & Koss, 2004; Brook et al., 2006). Despite the important influences of SES, partner violence, and psychosocial processes (particularly peer norms) on sexual risk behaviour among young people, empirical evidence is needed to understand how gender interacts with these factors to shape sexual behaviour. This gap in the literature seems particularly significant in the South African context, where gender has been so closely associated with a number of confounding factors — such as partner violence and low SES. Furthermore, this is a context in which peer influences on sexual behaviour have been found to be particularly strong. Underlining the importance of understanding the gendered effects of peer norms, a recent evaluation of Stepping Stones, the only HIV-prevention intervention aimed at young people in South Africa that has demonstrated a biological impact (i.e. a reduction in the prevalence of HSV-2: Jewkes et al., 2008), offers a potentially important lesson. The intervention went beyond providing information on HIV and sexual behaviour and was based on a participatory approach that addressed gender inequities and encouraged group communication (Jewkes et al., 2008). The relative success of this programme demonstrates the potential use of harnessing information on how peer norms contribute to gendered sexual behaviour outcomes. As such, this article explores how gender and SES moderate the effects of norms and attitudes about higherrisk sexual behaviour among secondary school learners in a low-income community in KwaZulu-Natal province, South Africa. We argue that improving the evidence base on how gender and SES impact on peer norms will improve our understanding of some of the challenges facing both HIV-prevention efforts and progress towards gender equality within South African schools. Methods Setting The study was conducted in an urban semi-formal community, Cato Manor, located within Durban, KwaZuluNatal Province, on the east coast of South Africa. Cato Manor has a long and politically charged history — perhaps most famously as a site of forced removals during the apartheid period, followed by land invasions in the early years of the democratic era. According to the 2001

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population census, 32% of the population was aged 0–19 years; 44% of working-age adults were employed, 21% were unemployed and 35% were not economically active (Statistics South Africa, 2001). The majority of people living in the study area are black South Africans (64%), followed by Indians (16%), whites (15%) and coloureds (5%) (Statistics South Africa, 2001).1 A large number of residents live in informal settlements, with a few living in formal dwellings and classified as low-to-middle-income households. The area is flanked by established medium-tohigh-income residential areas (Odendaal, 2002). Data The data used in the present study were taken from the quantitative component of a quasi-experimental retrospective evaluation of the impact of a five-year multifaceted HIV-prevention intervention aimed at secondary school learners. The survey consisted of a self-administered questionnaire distributed to 809 learners in Grade 11, at two schools implementing the intervention and two control schools, all in Cato Manor. Fieldwork was conducted between October 2007 and March 2008. A self-administered survey tool was created using largely validated research instruments. It was refined for greater clarity and for the local context after being pilot-tested with youths and programme mentors. All questionnaires were printed in both English and Zulu, with the two versions presented simultaneously on facing pages in each questionnaire booklet. Bilingual facilitators assisted learners by introducing the project and survey instrument, presenting simulations with ‘test questions’ and then going through the survey with the learners, question by question. The questionnaires were administered at the schools, with boys and girls separated into different classrooms. The survey had four main components. The first part collected sociodemographic information, informed by past research with South African youths. The second part measured the frequency of behaviours and experiences related to sexuality and sexual health, including past participation in an HIV-prevention programme and past sexual behaviour. The third part measured psychosocial variables and employed internationally validated scales to measure hope (Snyder, Lopez, Shorey, Rand & Feldman, 2003), optimism (Scheier & Carver, 1985), self-esteem (Rosenberg, 1965) and self-mastery (Pearlin & Schooler, 1978). The fourth part of the survey was based on the theory of planned behaviour (Ajzen, 1985) and captured the respondents’ attitudes, norms and intentions relating to key HIV-risk-taking behaviour. The survey data were recorded and analysed using SPSS 15.0 and Mplus. Ethical approval was granted by the three partner universities undertaking the study. Outcome variables The two main outcome variables considered in the analysis are sexual activity (self-reported sexual debut) and reported number of lifetime sexual partners (see Table 1).2 Sexual debut is recorded as a dummy variable. Analyses of the number of sexual partners included only those learners who reported ever having had sex. The number of sexual

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partners is a continuous variable, which, after removing outliers more than three standard deviations from the median, ranged from ‘1’ to ‘10.’ Both of the outcome indicators used in this study are well-established risk indicators in the context of HIV (Eaton et al., 2003; Jewkes, Dunkle, Nduna et al., 2006) as suggested by the fact that HIV-prevention programmes often aim to encourage sexual abstinence and reduce the number of sexual partners (MacPhail & Campbell, 2001; Magnani, MacIntyre, Karim, Brown & Hutchinson, 2005). Explanatory variables Three clusters of independent variables (hypothesised to be either potential risk factors or protective factors) are considered in the multivariate analysis in the following section. The independent variables (see Table 1) hypothesised to predict a respondent having sexually debuted and the number of sexual partners reported; this included: 1) attitudes to sexual behaviour (attitude to sex in the next three months, attitude to sex before marriage, and beliefs about risks associated with sex); 2) perceived social and peer norms (prescriptive parent norms and prescriptive partner norms about premarital sex, sexual risk-taking norms, descriptive norms about adolescent sexual behaviour, and prescriptive peer norms about having sex in the next three months); and 3)

individual-level factors (age, gender, experience of partner abuse, SES and exposure to HIV-prevention interventions). Socioeconomic status was self-reported and taken from a question in which the learners were asked to select the statement that best described their respective households. The five options ranged from not having enough money for food or other basic items to having enough money for food as well as luxury items. The responses were then recoded into a three-point scale representing low, medium and high SES. All continuous independent variables were mean centred. Analysis Basic descriptive analyses were used to identify significant associations between the two dependent variables and a number of independent variables as well as the gender differences in sexual behaviour outcomes. In the multivariate analyses, a binary logistic model was used to identify the predictors of sexual debut (i.e. ever having had sex), with not having had sex coded as ‘0’ and having had sex as ‘1.’ A classic linear regression model was used to identify the predictors of the number of sexual partners reported by the learners who had sexually debuted. All independent variables demonstrating a significant bivariate association with the respective outcome variable (i.e. ever had

Table 1: Overview of the outcome variables and explanatory variables Variable Outcome variables Ever had sex

Number of sexual partners Explanatory variables Negative attitude to not having sex until marriage Opposed to premarital sex Belief in HIV and sexually transmitted infection (STI) risks

Indicator Ever engaged in vaginal or anal penetration (data captured through a binary question and through the reported number of lifetime sexual partners). Total number of reported lifetime sexual partners. Displays a negative attitude to abstaining from premarital sex or displays an intention to engage in sex before marriage. Is opposed to the idea of sex before marriage. Acknowledges the specific health risks (i.e. HIV/STIs) associated with sexual activity.

Number of items

Response type

2

Yes/No Continuous

1

Continuous

3

5-point Likert-type scale*

3 7

5-point Likert-type scale* 5-point Likert-type scale*

2

5-point Likert-type scale*

2

5-point Likert-type scale*

Avoiding premarital sex: parent norms Avoiding premarital sex: partner norms

Perceives that parents are opposed to sex before marriage. Perceives that most recent partner is opposed to sex before marriage.

Prescriptive peer norms supporting sexual activity

Feels that it is acceptable for both male and female peers to be sexually active.

4

5-point Likert-type scale*

Descriptive peer norms supporting abstinence until marriage Experienced partner abuse Exposed to an HIV intervention Socioeconomic status

Perception that male and female peers are abstaining from sex before marriage.

2

5-point Likert-type scale*

Ever been ‘punched or kicked’ by a partner. Ever participated in or been exposed to any type of HIV-prevention programme (no definition provided). 3-point scale (low, medium and high), collapsed from the 5-point self-assessment.

1 1

Yes/No Yes/No

1

5-point,single response 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 are not included in this table due to the simplicity of their construction (e.g. gender and age).

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sex or the number of lifetime partners) were included in the multivariate models. Thus, the final regression models included all variables that: 1) were significantly associated with the outcome variable at the 5% level of confidence; 2) mediated the effects of the other independent variables on the outcome variable; 3) displayed a significant interaction with gender, or gender and SES; or 4) had a strong theoretical basis for inclusion. As in other studies exploring gender differences in sexual behaviour (cf. Magnani et al., 2002), gender interactions were included in the models in order to capture the effect of gender and the interactions between gender and the other independent variables over and above the main effects. Therefore, in both models presented in the following section, second- and third-order interaction terms were added to explore the moderating effects of gender and of gender and SES, respectively. Main effects were entered in the first step; two-way interactions (with gender) were entered in the second step; and three-way interactions (with gender and SES) in the third step. The interaction steps were accepted if the R2 change was significant at the 5% level. Results Sample description The age of the participants (n = 809) ranged from 16 to 23 years. Respondents who were under age 16 or who spoke neither English nor Zulu were removed from the sample (n = 26). An overwhelming majority (98.9%) classified themselves as black and 90.6% indicated Zulu as their home language. Of the participating learners, 44.8% were males and 55.2% were females. Just over half of the respondents (50.7%) indicated that they had repeated a school year due to failing. Roughly 50% reported either not having enough money for food or for other basic items, while just 2.9% reported coming from households with enough money for luxury items. The mean household size was 5.7 members, and most learners (63.6%) reported that their mother was the primary caregiver. As in other studies of adolescents in South Africa, the boys reported having more sexual partners than did the girls, and a significantly larger proportion of boys (70.6%) than girls (46.5%) reported having sexually debuted by the time of the survey (Table 2). Sexually active boys also reported a significantly younger median age at sexual debut (age 14) compared with sexually active girls (age 16). Among sexually active girls, 19.2% reported having ever been diagnosed with a sexually transmitted infection (STI) (cf. 18.9% of the sexually active boys) and 9.3% reported having ever been forced to have sex by a partner. Just over one-fifth of sexually active girls participating in the study reported having been pregnant at some point in the past. Partner violence among the sample was high, with 28.2% of the girls (and 7.2% of the boys) having reported being struck by a partner at some point. A significantly higher percentage of the sexually active girls (63.4%) had been tested for HIV compared with only 16% of the sexually the active boys. The girls participating in the study also reported significantly different sexual behaviour intentions and social and peer norms compared with their male counterparts. Among

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all learners in the sample, girls, for example, reported significantly lower intentions to have sex in the next three months (F(1, 792) = 60.749; p = 0.0001) and lower intentions to engage in sex before marriage (F(1, 785) = 6.856; p = 0.009). Girls reported significantly less support from their parents to have sex in the next three months (F(1, 787) = 52.397; p = 0.0001) and less support to have sex before marriage (F(1, 789) = 62.536; p = 0.0001) as compared with the male learners. Each of these associations holds when controlling for both age and sexual debut; however, the association between gender and the intention to have sex before marriage was not significant (p = 0.105) when controlling for age and sexual debut. Sexual activity Ever had sex Several key bivariate associations (not shown) with having sexually debuted suggest that hypothesised factors — such as SES and intimate partner violence, in particular — may be important predictors of earlier sexual debut. Among the sexually active learners, a significantly larger number of female learners reported partner violence compared with the females who were not sexually active. Significantly fewer of the sexually active females described their households as having a high SES in comparison to the sexually active males and the non-sexually active females. Interestingly, a significantly larger proportion of the sexually active female learners reported having been exposed to an HIV-prevention programme or intervention as compared with the male learners who had sexually debuted. In the multivariate analyses, both main effects and two-way interactions were significant. Table 3 shows the net effects of the predictor variables on ever having had sex, using a logistic regression model. Measures of attitudes and norms towards premarital sex were included in the model, but attitudes to having sex in the next three months were not significantly associated with sexual debut and were therefore excluded. In the first step, those learners opposed to premarital sex were shown to have lower odds of having sexually debuted. Prescriptive norms supporting sexual activity among peers were associated with increased odds of having sexually debuted. Parent norms were not significantly associated with sexual debut, but the perception that potential sexual partners would abstain from sex before marriage (partner norms) significantly reduced the odds of having sexually debuted. As expected, older learners and those who had been exposed to partner violence had significantly higher odds of having sexually debuted. Participation in some form of HIV-prevention programme and being female significantly reduced the odds of having sexually debuted. Controlling for the other factors, the effect of SES on sexual debut falls away. In the second step (two-way interaction model), gender (being female) moderated the effects of several variables. Gender and age form a significant interaction, with older girls more likely to have had sex. In the main-effects model, a stronger belief in the risk of HIV or STIs was positively associated with having sexually debuted, but being female reverses the relationship between sexual debut and understanding the risks associated with having sex. In

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Table 2: Proportion and means of selected HIV-risk indicators for the Grade 11 learners, by gender Males (n = 362) Ever had sex 70.6 Had sex in the past year 27.3 Age at sexual debut* 14 Median number of lifetime sexual partners* 5 Ever been pregnant* – Ever impregnated* 9.2 Ever been tested for HIV* 16.0 Ever been diagnosed with an STI* 18.9 Ever been physically abused by a partner 7.2 Ever been physically forced to have sex* 7.8 Ever engaged in transactional sex* 11.0 Participated in any HIV-prevention programme 56.4 Low socioeconomic status 53.3 *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 analyses

addition, being female and perceiving that both male and female peers were abstaining from sex before marriage (descriptive norms) significantly reduced the odds of having sexually debuted. Three-way-interaction variables modelling gender, SES, and selected norms and attitudes were not significant and are not described here. Multiple sexual partners Table 4 demonstrates the effects of the independent variables on the number of sexual partners reported by sexually active learners. As the model suggests, age, having experienced partner violence, attitudes to having sex in the next three months, and prescriptive peer norms about sex were all significantly associated with having a greater number of sexual partners. Gender is highly significant (p ≤ 0.0001) in the first step, with being female resulting in fewer partners, but is not significant after the interaction variables are included. Being exposed to an HIV intervention of some type and being opposed to premarital sex among peers had significant negative associations with the number of sexual partners in the main-effects model. After controlling for other variables, the number of sexual partners was not significantly associated with SES or with perceived parent or partner norms. Two second-order interaction variables add to the explanatory power of the model. Female learners seem to be particularly affected by perceived peer norms about avoiding sex before marriage (i.e. perceiving that their peers are abstaining from sex before marriage), as gender interacted significantly with this set of norms to predict having had fewer sexual partners (p < 0.05). The effect of attitudes on premarital sex was less clear, as being female moderates the effect of being opposed to premarital sex, such that being female and being opposed to having premarital sex is associated with having had a higher number of sexual partners. Perceived parent and partner norms about premarital sex did not interact with gender. Once again, the three-way-interaction variables were not significant and so this step was not included in the final equation.

Females (n = 446) 46.5 20.6 16 1 20.9 – 63.4 19.2 28.2 9.3 7.1 67.7 47.3

p-value 0.0001 0.025 0.0001** 0.0001** – – 0.0001 0.319 0.0001 0.353 0.338 0.001 0.295

Discussion The results of this study contribute to the existing body of literature on gender and HIV risk in two ways. First, they demonstrate that the effect of peer norms on sexualbehaviour outcomes differs between males and females. Moreover, the results provide empirical evidence concerning the direction of the relationships (i.e. risk-enhancing versus protective effects) between peer norms and different sexual behaviours. Perhaps most notably, the finding that the perception that their peers are abstaining from premarital sex has a protective effect against both sexual debut and the number of lifetime partners among girls (but not among boys) is important. Second, the study demonstrates that, over and above the effects of all the other explanatory variables, having experienced partner violence is strongly and positively associated with both sexual debut and a greater number of lifetime partners. Overall, the study’s findings point to the role that gender plays in moderating the effects of attitudes and norms on sexual behaviour outcomes. In particular, the results suggest that peer norms and experience with partner violence are particularly strong factors associated with gendered sexual behaviour, while SES (when controlling for other factors) was not found to be a significant predictor. Lessons about gender and peer norms Most studies in South Africa have found boys to be more sensitive to peer influences than are girls (e.g. MacPhail & Campbell, 2001; Eaton et al., 2003; Brook et al., 2006). However, the findings presented here suggest that girls’ perceptions of what their peers are doing are likely to be very important to them, and, as in other studies (e.g. Dlamini et al., 2009), these perceptions are found to impact on their decision to remain abstinent. As such, more work should be directed to understanding the different types of peer influences and the ways in which young males and females respond. Efforts to standardise the way that peer influences are measured would contribute to our greater understanding

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Table 3: Adjusted odds ratios (with confidence intervals) for ever having had sex (n = 809 adolescents)

Attitudes Negative attitude to not having sex until marriage Opposed to premarital sex Belief in HIV and STI risks Norms Avoiding premarital sex: parent norms Avoiding premarital sex: partner norms Prescriptive peer norms supporting sexual activity Descriptive peer norms supporting abstinence until marriage Individual-level factors Age Female (vs. male) Experienced partner abuse (vs. ‘not’) Exposed to an HIV intervention Socioeconomic status

Block 1

Block 2

1.510 (0.805–2.831) 0.701** (0.572–0.860) 1.292 (0.869–1.921)

0.861 (0.334–2.220) 0.639** (0.452–0.905) 2.200** (1.119–4.323)

0.971 (0.819–1.152) 0.837** (0.716–0.980) 1.284** (1.068–1.543) 0.932 (0.803–1.081)

0.937 (0.724–1.213) 0.880 (0.699–1.109) 1.308* (0.952–1.798) 1.128 (0.886–1.435)

1.403*** (1.232–1.598) 0.570** (0.392–0.827) 2.166** (1.370–3.413) 0.669** (0.471–0.951) 0.960 (0.758–1.216)

1.175 (0.959–1.440). 0.565** (0.383–0.832) 2.129** (1.327–3.45) 0.658** (0.459–0.944) 0.971 (0.683–1.382)

Interactions Gender * age

1.365** (1.043–1.786) 0.723** (0.528–0.990) 0.463* (0.197–1.090)

Gender * descriptive peer norms supporting abstinence until marriage Gender * belief in HIV and STI risks Nagelkerke R2 Model χ2 Block χ2 *p ≤ 0.10 **p ≤ 0.05 ***p ≤ 0.0001

of the effects of peer norms on sexual behaviour. An especially interesting finding is that being female and perceiving that males and females of a similar age are abstaining from sex decreased the odds of having sexually debuted. Perceived abstinence among peers was even associated with having fewer sexual partners among the girls who had already sexually debuted. This finding, in particular, is an important addition to the South African literature in light of the prevailing view that peer norms, especially among males, encourage sexual risk behaviour (rather than having a protective effect). Earlier work (Dlamini et al., 2009) has offered preliminary evidence of the protective effects of peer norms among females in South Africa, but did not control for other factors (i.e. in a multivariate context). In addition to the protective effects of peer norms, there is also evidence that females are acting on an understanding of the risks involved in engaging in sex, as the female learners with a higher recognition of the risk of HIV and STIs were

0.335 222.79*** 222.79***

0.362 244.177*** 21.378**

less likely to have sexually debuted. Lessons about violence and coercion The high prevalence of rape, intimate partner violence, and sexual coercion in South Africa (Jewkes et al., 2003; Andersson et al., 2004) and the level of reported partner violence in this study lead to the unfortunate conclusion that violence against women remains a common occurrence and implies that violence is a significant risk factor for HIV among female youths (over and above the effects of all other factors). While the findings related to gender, attitudes, and perceived peer norms emphasise the gendered nature of sexual decision-making, the role of partner abuse cannot be ignored. In both models, having experienced partner violence in the form of striking or punching (admittedly, a fairly narrow definition of partner violence) was highly significant as a main effect and it remained significant after the interaction variables were included.

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Table 4: Multiple regression coefficients (with standard errors) for variables predicting the number of sexual partners reported by the sexually active Grade 11 learners (n = 442)

Intercept Attitudes Negative attitude to not having sex in the next three months Opposed to premarital sex Norms Avoiding premarital sex: parent norms Avoiding premarital sex: partner norms Prescriptive peer norms supporting sexual activity Descriptive peer norms supporting abstinence until marriage Individual level factors Age Female (vs. male) Experienced partner abuse (vs. not) Exposed to an HIV intervention Socioeconomic status

Block 1 5.546*** (0.195)

Block 2 5.401*** (0.200)

0.987** (0.415) –0.349** (0.126)

1.948** (0.575) –0.537** (0.172)

0.014 (0.104) 0.004 (0.101) 0.217* (0.118) 0.127 (0.105)

0.036 (0.130) 0.040 (0.129) 0.271* (0.164) 0.362** (0.146)

0.246** (0.084) –3.514*** (0.282) 0.568** (0.296) –0.387* (0.228) 0.220 (0.159)

0.301** (0.114) –1.784 (3.015) 0.597** (0.298) –0.323 (0.226) 0.101 (0.202)

Interactions Gender * opposed to premarital sex Gender * descriptive peer norms supporting abstinence until marriage R2 R2 change F F change *p ≤ 0.10 **p ≤ 0.05 ***p ≤ 0.0001

As noted in many studies, we find that being the victim of partner abuse is almost exclusively the domain of females and that it is positively associated with sexual risk behaviour (in this study, having sexually debuted and having multiple sexual partners) after controlling for other factors. Moreover, the finding that, among girls, being opposed to premarital sex was associated with having had a higher number of sexual partners suggests that some of the girls had likely experienced coercion. This particular interpretation, while certainly plausible, illustrates the difficulties associated with making causal inferences with respect to norms, attitudes and sexual-behaviour outcomes. However, the link between partner violence and various sexual risk behaviours — such as unprotected sex, early sexual debut, multiple partnerships, sex with older men, coerced sex and transactional sex — has been well noted in the South African literature (Andersson et al., 2004).

0.481 0.481*** 25.395*** (df1 = 14; df2 = 384) 25.395***

0.510** (0.254) –0.504** (0.211) 0.513 0.032** 15.713*** (df1 = 25; df2 = 373) 2.242**

Lessons about socioeconomic status SES was not found to be a significant predictor in either of the models and did not interact with gender and selected norms and attitudes. This may be the case, in part, due to the subjectivity of the SES measure employed (self-reported) and to the fact that the majority of the learners reported medium or low SES. The validity of self-reporting SES among youths in a developing-country context, where the respondents live in the same impoverished community and have relatively similar levels of SES, to the best of our knowledge, has not been reviewed in the literature. Moreover, while several studies (e.g. Jama et al., 2004; Brook et al., 2006) have found that poverty or a low SES can moderate the effects of peer influences, the relationship between SES and sexual-behaviour outcomes is far from clear, with much of the variance in the findings based on the different measures of SES employed (Wojcicki,

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2005). While the findings of this study offer no indication that a low (or high) SES has any bearing on sexual-behaviour outcomes or on the effects of peer norms, we argue that it is still important to control for SES (in spite of the challenges) when modelling the determinants of sexual behaviour — particularly in light of the emphasis in the recent literature on SES and sexual risk behaviour. Implications for policy and programming The findings presented here have important implications for policy and programming. Not only are sexual-risk profiles different for girls, but the determinants of sexual-behaviour outcomes are significantly different between girls and boys. HIV prevention, ‘life orientation’ and reproductive health interventions need to take these differences into account. The finding that perceived peer norms are more important for girls than for boys might suggest that group interventions and other forms of support may influence girls more than their male peers. As such, the school environment is likely to be an important space for shaping peer norms and this presents a unique opportunity in light of emerging evidence that school-based peer-education programmes can impact on peer-group norms (see Visser, 2007). Community-wide interventions may also form an important part of addressing peer influences. While discussing the significance of peer influences in the Zambian context, Magnani et al. (2002) noted the growing conviction that community interventions may be the most effective way of combating negative peer influences among young people. In terms of the content and structure of interventions, lessons from the existing body of literature on gender and HIV risk in South Africa seem to suggest that interventions that focus on changing sexual behaviour or health knowledge, rather than on the gender norms that shape behaviours, are less likely to succeed (Harrison et al., 2010; Jewkes & Morrell, 2010). Morrell et al. (2009) further argue that many approaches to achieving gender equality in South African schools have been challenged by the need to effectively reach peer groups through which gender norms and identities are created. Conversely, programmes such as Stepping Stones (Jewkes et al., 2008) and IMAGE (Pronyk, Kim, Abramsky, Phetla, Hargreaves, Morison et al., 2008) have met with some success due, in large part, to their emphasis on ‘collective critical thinking,’ group communication, and normative gender identities (Harrison et al., 2010). Notably, these relative successes have been observed despite the well-known difficulties in implementing peer education programmes (for a fuller discussion, see Campbell & MacPhail, 2002). The findings of this study can contribute to the design of similar inventions and may help to identify which types of peer norms are important in shaping gender roles and norms. We argue that understanding the effects of peer norms, in particular, is a critical first step towards engaging with the formation of gender identities and the design of interventions that can impact on established gender norms in the context of HIV and AIDS. It is crucial, however, that interventions take into account the role of partner violence in the relationships of young people. As Campbell (2004) and Campbell & MacPhail (2002) argue, peer education requires a space

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where males and females can collectively ‘renegotiate their peer identities’ and where individuals may gain confidence while learning how to negotiate sexual interactions. Striking a balance between recognising the different role of peer influences among males and females while allowing both genders to collectively form peer identities appears to be a key challenge. The findings of this study suggest that partner violence and sexual coercion should not be overlooked when peer identities are negotiated. Indeed, Campbell (2004) emphasises that peer education interventions are less likely to succeed in affecting peer norms if the participants are not able to adequately address the social factors (e.g. partner violence) impeding behaviour change. The findings here, together with those from the evaluations of Stepping Stones (Jewkes et al., 2008) and IMAGE (Pronyk et al., 2008), clearly point towards the need to move beyond health-awareness approaches and to explicitly address the underlying gender roles and inequities that facilitate gender-based violence and sexual risk behaviour. Study limitations Finally, several caveats must be offered. First, the study cannot claim to be representative of young people in South Africa or even of young people in Cato Manor. The sampling design was intended to match control and treatment groups and not to be representative of young people from the community. Second, as with most studies that rely on self-reports of respondents’ sexual behaviour (cf. Magnani et al., 2002; Karnell, Cupp, Zimmerman, Feist-Price & Bennie, 2006; Jewkes et al., 2008), the possibility of reporting bias and error must be declared when the questionnaires ask young people to self-report sensitive information about their personal or sexual lives. In this study, this bias may have been exacerbated by a lack of privacy as the youths completed the questionnaire. While all efforts were made to ensure that the learners had sufficient desk space to ensure privacy, the reality is that the classrooms were crowded and some learners had to share a desk. Third, this study only looked at two sexual risk-taking behaviours and did not consider condom use, for example, among sexually active youths. Fourth, the question format and the scales that were included in the questionnaire were validated in a Western setting. A concerted effort, however, was made to adapt the language to fit the local context; to that end, the questionnaire was carefully piloted prior to being distributed to the respondents. Fifth, and perhaps most critically, causality cannot be inferred from the analyses presented here. As in other social cognitive models, both independent and dependent variables may be ‘reciprocally determining’ (Bandura, 1977), and one cannot necessarily make assumptions about the direction of causality between, for instance, attitudes to having sex in the immediate future and having had sex in the past. For example, among the girls, it is not clear why being opposed to having premarital sex was associated with having had a greater number of sexual partners. As outlined above, one possible interpretation may be that negative sexual experiences (e.g. coercion or forced sex) have created this view. Another interpretation is that there are contradictions in youths’ perceptions of ideal behaviours

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and actual outcomes, among females, in particular. These caveats notwithstanding, the findings presented here offer important insights into the gendered differences in sexual behaviour and decision-making among young people in South Africa. Conclusions This study addresses a critical gap in the South African literature in terms of the relationship between gender, social norms and sexual behaviour among adolescents in South Africa. In particular, the findings suggest important ways of understanding how gender relates to behavioural outcomes. Interventions seeking to effect behaviour change among young people should acknowledge gender differences and attempt to develop context-appropriate ways of addressing peer influences through, for example, the use of peer educators, group and community interventions, and schoolbased life-orientation programmes. However, such interventions should not shy away from the social or individual-level factors (chief among these being partner violence) that could prevent adolescents’ behaviour change. The need for a ‘collective negotiation of peer identities’ suggests that peer-based interventions, in particular, should target communication between boys and girls. Similarly, the results of this study also suggest that such interventions would do well to avoid emphasising traditional constructions of girls as passive actors in regard to sexual decision-making. On the whole, the findings suggest that the relationship between gender and HIV risk is more complex than often conceptualised and is significantly associated with a combination of individual-level and psychosocial factors. Future work should seek to identify, in greater detail, the specific types of peer norms or pressures that are linked with sexualbehaviour outcomes in the South African context. In terms of programming, this study highlights the imperative that HIV-prevention programmes should move beyond focusing on health knowledge to directly address the underlying factors that impact on gender norms and behaviours. Notes 1

2

We use the same racial classifications employed by Statistics South Africa in its household surveys and censuses. This article focuses exclusively on these two sexual behaviour outcomes and not on condom use (or other protective behaviours) at last sex. Forthcoming work will examine condom use and intentions to use condoms in the context of both the intervention and gendered sexual behaviour.

Acknowledgments — This work was supported by the Health Economics and HIV/AIDS Research Division (HEARD) at the University of KwaZulu-Natal (South Africa), York University (Canada) and the University of Toronto (Canada). We acknowledge the important contribution of our entire multicounty research team, in particular our field researchers. We also thank all of the learners, teachers and school administrators that gave so generously of their time. The authors — Michael Rogan (previously a researcher at HEARD) is currently a part-time lecturer and doctoral fellow at the School of Development Studies at the University of KwaZulu-Natal. His

Rogan, Hynie, Casale, Nixon, Flicker, Jobson and Dawad

research interests include: gender, survey and sampling methodologies, health, poverty and inequality, evaluation methodologies and reproductive health. Michaela Hynie is an associate professor in the Department 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, through the process of research itself, and indirectly, by generating research findings that can be used for activism. The content of her research falls into three broad categories: culture, immigration and health inequities; how basic interpersonal or social-psychological processes are affected by culture; and, sexual behaviour and safer sex, with a focus on culturally appropriate interventions and the evaluation of international initiatives. Marisa Casale is a researcher with HEARD at the University of KwaZulu-Natal, and a doctoral candidate with the Department of Psychology at the University of Cape Town. Her research focuses on southern Africa, with key interest in HIV prevention among youths, and caregiver and child health. Stephanie Nixon is an assistant professor in the Department of Physical Therapy and the Dalla Lana School of Public Health, as well as academic director of the International Centre for Disability and Rehabilitation, at the University of Toronto. She is also a research associate with HEARD at the University of KwaZulu-Natal. Sarah Flicker is an assistant professor in the Faculty of Environmental Studies at York University, and an Ontario HIV Treatment Network Scholar. Her expertise is in the areas of adolescent HIV prevention and support, participatory methodologies, and community-based research. Geoff Jobson (previously a researcher at HEARD) is a senior researcher at the Peri-Natal HIV Research Unit at the University of the Witwatersrand. His research interests include: masculinity and sexuality, and HIV-prevention and care models for people living with HIV. Suraya Dawad is a researcher at HEARD at the University of KwaZulu-Natal; her interests include health systems and the costing of comprehensive-care models.

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