‘I think condoms are good but, aai, I hate those things’:

Abstract

Levels of heterosexually transmitted HIV infection are high amongst South African youth, with one recent survey reporting levels of 18.9% amongst 17–20 year olds and 43.1% amongst 21–25 year olds. In these groups levels of knowledge about HIV are high, but perceived vulnerability and reported condom use are low. Much existing research into youth HIV in developing countries relies on survey measures which use individual knowledge, attitudes and reported behaviour as variables in seeking to explain HIV transmission amongst this group. This paper reports on a focus group study that seeks to complement existing individual-level quantitative findings with qualitative findings highlighting community and social factors that hinder condom use amongst youth in the township of Khutsong, near Carletonville. Study informants comprised 44 young women and men in the 13–25 year age group. Data analysis highlighted six factors hindering condom use: lack of perceived risk; peer norms; condom availability; adult attitudes to condoms and sex; gendered power relations and the economic context of adolescent sexuality. Informants did not constitute a homogenous group in terms of their understandings of sexuality. While there was clear evidence for the existence of dominant social norms which place young peoples’ sexual health at risk, there was also evidence that many young people are self-consciously critical of the norms that govern their sexual behaviour, despite going along with them, and that they are aware of the way in which peer and gender pressures place their health at risk. There was also evidence that a minority of youth actively challenge dominant norms and behave in counter-normative and health-enhancing ways. The actively contested nature of dominant sexual norms provides a fertile starting point for peer education programmes that seek to provide the context for the collective negotiation of alternative sexual norms that do not endanger young peoples’ sexual health.

Introduction

Against the background of the growing HIV epidemic in South Africa, it is increasingly being argued that preventive interventions in this region may be most effective if directed at young people below the age of 16 years. Thus, for example, a recent survey in the South African township of Khutsong, our community of interest in this paper, indicated that HIV infection was almost non-existent in the 13–16 year age group, followed by a sharp increase in the 16–18 year age group (18.9%), with the peak infection rates of 43.1% for the community as a whole being experienced by the 21–25 year age group (Williams, Campbell, & MacPhail, 1999).

This paper reports on a study that aims to increase our understandings of the influences on adolescent sexuality within a broader interest in HIV-prevention in southern Africa. In using the terms adolescent and young person we refer to a group aged between 13 and 25 years. Through the presentation of findings from focus groups with young township residents, we seek to highlight a range of factors that militate against condom use by this group of young people, despite high levels of knowledge about HIV infection and of the sexual health-enhancing benefits of condoms. Such factors include individual-level perceptions of health and vulnerability, community-level factors such as peer and parental pressure, and wider social influences including the social construction of male and female sexuality and gendered power relations, as well as economic constraints — all of which we will argue serve to inhibit condom use by young people, and to place them at risk of HIV infection.

However, mindful of the fact that young people do not always constitute a homogenous grouping, and that there will always be a range of variations in the extent to which young peoples’ behaviour serves to reproduce or resist dominant social norms, we also seek to highlight examples of young people with counter-normative behaviours and views.

Much research into adolescent sexuality has treated adolescents in a stereotyped and one-dimensional way (Aggleton, 1991; Aggleton & Campbell, 2000) with inadequate attention to young people whose views and behaviours challenge dominant stereotypes. One of the aims of sexual health promotion is to provide the context for the renegotiation of dominant high-risk behavioural norms by young people, and for the collective establishment of new norms of behaviour. It is therefore vital that research focuses not only on the way in which dominant norms place young peoples’ sexual health at risk, but also on the ways in which particular young people resist these norms, sometimes leading to alternative and less risky sexual behaviours and practices.

Young people in South Africa have received much of their knowledge of sexual health promotion from government mass media campaigns (Friedland et al., 1991). More recently there has been a move towards participatory peer education approaches. However, such approaches appear to have made limited impact on the epidemic, which continues to rise. The rising epidemic is particularly focused among young people, with females being especially influenced (see Table 1). Understandings of the influences on sexual behaviour and the mechanics of sexual behaviour change are still limited, particularly in the southern African context. Due to these inadequacies in our knowledge, we have limited tools for understanding what is driving the epidemic amongst young people. Greater knowledge of the influences driving the epidemic will allow for a better understanding of the factors helping or hindering existing programmes and could potentially help with improving existing intervention programmes.

In a review of the academic literature on the evaluation of HIV prevention programmes in developing countries, MacPhail (1998) highlights the dominance of survey approaches, generally based on the KAPB model of sexual behaviour. Information gleaned from KAPB surveys does not enable developers of intervention programmes to consider the contexts in which knowledge is gained and sexuality negotiated (Joffe, 1996), therefore giving only a partial picture of the complex factors shaping sexuality. In addition, the success of HIV intervention programmes is frequently evaluated using these narrow KAPB variables despite the realisation that increased knowledge does not impact on future behaviour (Elliot, Crump, McGuire, & Bagshaw, 1999). Furthermore, while programmes have begun to incorporate participatory methods in intervention, the community change that they aim to generate remains unevaluated due to the strong adherence to KAPB surveys which lack the potential for measurement of this kind (MacPhail & Campbell, 1999).

Kippax and Crawford (1993) have criticised the concept of ‘sexual behaviour’ used in these studies. They argue that sexuality is too complex a phenomenon to be conceptualised in terms of decontextualised and quantifiable individual behaviours (e.g. condom use, anal sex) of the type measured in KAPB studies. Critics such as Holland and collegues argue for a more complex and contextualised definition of sexuality. Holland, Ramazanoglu, Scott, Sharpe, and Thomson's (1990, p. 339) definition of sexuality forms the basis for the research reported below.

• By sexuality we mean not only sexual practices, but also what people know and believe about sex, particularly what they think is natural, proper and desirable. Sexuality also includes people's sexual identities in all their cultural and historical variety. This assumes that while sexuality cannot be divorced from the body, it is also socially constructed.

It is within this context of understanding the societal, normative and cultural contexts in which individual-level phenomena such as knowledge, attitudes and behaviour are negotiated or constructed that the current research is located.

Much of previous research, particularly in developing countries, has concentrated on the phenomenon of sexuality at the level of the individual, while neglecting societal, normative and cultural contexts. Focusing on the individual-level assumes that sexual behaviour is the result of rational decision-making based on knowledge. In reality, the complex nature of sexuality means that adolescents conduct their sexual lives through experiences and beliefs that have been generated through their membership of particular societies and communities. A wider view of the other levels of influence therefore needs to be utilised (Campbell, 1997; Campbell & Williams, 1998). Attempts to study the sexual behaviour of young people have concentrated on these individual-level indicators that have been easily measured through the use of quantitative methods. However, the use of quantitative methods in the evaluation of HIV prevention programmes provides answers limited to whether an intervention has worked rather than promoting an understanding of why the intervention has worked. In addition, in many instances when working within the field of HIV, researchers are still attempting to understand rather than to measure. Quantitative methods do not allow researchers to consider the processes at work but rather limit them to the final outcome. In this paper we address both issues through moving beyond the individual and using qualitative approaches.