Attitudes to condom use among South African university students
2 views
Skip to first unread message
Ashley Coates
Oct 6, 2019, 7:37:25 AM10/6/19
to policy...@googlegroups.com
“I am aware of the risks, I am not changing my behaviour”: risky sexual behaviour of university students in a high-HIV context
Methods
The study was designed to investigate risky sexual behaviours of university students in Durban, South Africa. Using qualitative data drawn from twenty in-depth interviews (IDI) and one focus group discussion (FGD), the study gathered information on student’s perceptions regarding risky sexual behaviour. In-depth interviews allows for data to be collected independent of group dynamics. During in-depth interviews the researcher had the opportunity to clarify ambiguous issues and cases of inconsistencies or to probe when insufficient information was provided (Richardson, Dohrenwend, & Klein, 1965). Additionally, a focus-group discussion was employed because it provides a social context for research, and thus an opportunity to explore how people think and talk about a topic, how their ideas are shaped, generated or moderated through conversation with others (Lewis & Ritchie, 2003). They are also effective for collecting a large amount of information over a relatively short period of time (Mack, Woodsong, MacQueen, Guest, & Namey, 2005). It is advantageous to combine both focus group discussions and individual interviews as this presents an opportunity to clarify any issues that were not alluded to during the individual interviews while ensuring the dependability of the results obtained. The triangulation of data was employed to enhance data richness and test validity through the convergence of information. This exploratory study aimed to get intricate personal views and attitudes amongst university students. This cannot be effectively achieved through applying statistical procedures or any other quantifying procedures; instead employing a qualitative approach is more appropriate.
The study population was restricted to undergraduate university students, both male and females, and their ages ranged from 18 to 24 years old. The study sample of students constituted of those who were enrolled for their second, third and fourth years of study. First year students were excluded from this study because these students are still new to the university environment and they may have minimal exposure to the areas of interest of this research. Additionally they may be challenged with trying to adapt to the university environment. Students were sampled from different campuses of the university. For the purpose of this study the focus is on this age category because UNAIDS (2016) suggests a significant increase in the absolute number of new HIV infections worldwide among this age group. Additionally, inclusion of both males and females in the study population was to allow for a better understanding of the themes under investigation. Additionally, the focus was solely on heterosexual relationships. University students are of particular interest because they are increasingly involved in risk-related behaviours once they are more exposed to new social groups in the tertiary educational environment (Cherie & Berhane, 2012). Purposive sampling was used in this study because it enables the researcher to identify relevant individuals of interest instead of selecting a random sample of the population. Students were recruited from the different campuses on the basis of eligibility for the study as well as their willingness to participate.
Data from the in-depth interviews and the focus group discussion were recorded digitally, transcribed and analysed thematically using ATLAS.ti analytical software package. Thematic analysis was utilised to identify particular themes that emerged from the qualitative interviews. This was achieved through carefully going through the transcripts numerous times to correctly identify codes and themes and merge very similar outputs together.
Ethical considerations
Ethical approval was obtained from the University of Kwazulu-Natal Ethics committee. Prior to the interviews and focus group discussion, the researcher made it clear to the students that their participation in the research was voluntary and they were also assured of anonymity. They were informed that they may withdraw from the research at any time. Names of participants or any personal information was not obtained to ensure confidentiality. The students sat with the interviewer for sessions of approximately 45 to 60 minutes. The focus group discussion as well as in-depth interviews were conducted in a venue that ensured maximum privacy as well as a confidential atmosphere in which participants could share sensitive and personal information.
Results
The study sample consisted of 20 students for the in-depth interviews and 10 students for the focus-group discussion. There was an equal proportion of males and females in the study. The sample was restricted to undergraduate students aged between 18 and 24 years.
Risky sexual behaviour
Generally, most of the students have a fairly good understanding of the term “risky sexual behaviour”. The students were aware of the behaviours that place them at a heightened risk of pregnancy and HIV and AIDS. Students identified the risks associated with unprotected sexual intercourse. When students referred to unprotected sexual intercourse, most were referring to vaginal, penetrative intercourse. Students also identified sexual intercourse with multiple sexual partner as a risk-related behaviour. However many of the students were not against this because of the desire to be acknowledged within their social groups. Alcohol consumption was also associated with risky sexual behaviour.
I think risky sexual behaviour is when you engage in risky sexual intercourse such as unprotected sex … and engaging in sexual intercourse under the influence of alcohol. (IDI 1)
Engaging in sexual intercourse without actually protecting yourself, anal sex. (IDI 11) I don’t think it is a bad thing and people do have multiple sexual partners … but with me the whole concept of it, I’m okay with it. (IDI 3)
Generally individuals make decisions on the basis of strong negative emotions and those who desire novel and exciting activities are more likely to engage in risky sexual behaviours (Deckman & DeWall, 2011), however, there were some clear differences between male and female students and their reports of sexual risk-related behaviours.
More males than females reported that they were sexually active. Only two students (females) revealed that they had never had sexual intercourse previously. Their decision to abstain from sexual intercourse was motivated by religious reasons.
No I’m not sexually active and I’m not ready to start engaging in any sexual activities. (IDI 16)
Firstly, I am a Christian, so for me sex before marriage is wrong and is forbidden by God. (IDI 19)
Students also held strong negative attitudes towards premarital sex. They pointed out that according to their religion sex before marriage was not acceptable and it was therefore regarded as a ‘sin’. They preferred to delay sexual intercourse until marriage but most admitted that it was rare for young people to abstain.
Premarital sex is not allowed, it is ungodly, and God forbids sex before marriage. (IDI 19) In terms of premarital sex, according to my religion, it is against the law, it is not accepted. (IDI 4)
Additionally, students acknowledged the consequences associated with unprotected sexual intercourse; however, they still reported engaging in unprotected sexual intercourse.
Students are very much aware; they know what will happen after having unprotected sex. (IDI 11) We are always informed about this issue. It is just that we are ignorant, we are not prioritising, and we are not taking them seriously. But then I believe that, students are well equipped and informed; it’s just that they don’t want to take responsibility. (IDI 4)
Risk-related factors
There is widespread agreement that risky sexual behaviour is common among young people. The low socio-economic status of students has resulted in sex becoming commoditised. The respondents reported that many females (and some peers) are involved in sexual relationships with men in exchange for financial support. Students were asked about socio-economic factors that motivate students to engage in risky sexual behaviours. Students felt that the economic challenges that they face encourages risky sexual practices. They also believed that economic problems were the result of their family’s socio-economic background which meant that they were unable to access material possessions. They often compared themselves to their peers and they feel deprived and indicated that they would engage in sexual relationships in exchange for material possessions.
My friends are coming from families that can afford anything. So I will think what I can do to reach their standard, so I will start behaving recklessly. For instance, I will get a sugar daddy, somebody who is older than me because I want money. (IDI 5)
So in terms of it in the university it is very high due to the desire for things that your parents cannot afford so you end up exchanging in that way. (FGD 1)
The students mentioned that it was common for female students to occasionally engage in sexual relationships with men who could provide for them financially, especially to acquire expensive, material goods that they desire but cannot afford. These narratives highlight the measures young women are likely to use in order to secure material benefits. In difficult situations, particularly challenging economic circumstances, where families often lack the means to support all family members, young women sometimes look for other ways to financially support themselves, which may lead to transactional sex. It is equally important to note that there are females that have access to resources and therefore engaging in risk-related behaviours for material gain is not necessary.
So many people are doing it as a form of getting something and they exchange their bodies in order to get what they really want. I don’t know but it comes from us as men. (IDI 11)
This thing of having sex in exchange for money is dominant among girls. (FGD 1)
It is clear from the interviews that the university environment offers massive opportunities for risky sexual behaviours. Students were asked about the impact that the university environment has on the sexual behaviours of students. The majority of the students revealed that the campus environment as well as the environment where university residences are located, especially off-campus residences, has a strong influence on risky behaviours. This is because these areas are surrounded by entertainment spaces such as night clubs and bars which makes it easier for students to obtain alcohol and other substances.
Basically at residence there are places surrounding where I live that are basically for clubbing. You go there and people ask you out and some have that perception that they want to have sex with you. I feel like it does have an influence of actually making me
want to engage in sexual activities. (IDI 3)
Additionally, the venues on campus were viewed as spaces where sexual activity could easily occur without interruptions since there are places that are secluded and offer privacy.
Another thing, one of the factors that lead us to engage in unprotected sex for university students, you see having a girlfriend who doesn’t have a residence to stay, it is very hard but on campus there
are good venues. (FGD 1)
Peer pressure is one of the key drivers of risky sexual behaviours among youth between the ages of 15 to 24. It is not uncommon for the youth to want to impress their peers; therefore vulnerability to sexual risk amongst young people is strongly influenced by peer pressure (Bingenheimer, Asante & Ahiadeke 2015). In addition, students further reveal that young people are more likely to engage in sexual activities in order to conform to their social groups. There is a widespread desire to fit into society and they feel that this will enhance their acceptability amongst their peers. I would like to add peer pressure as one of the main things that can contribute to unwanted pregnancies and so forth because you will find that sometimes students, especially the guys, they are competing on how many women or girlfriends they sleep with or have had slept with during the weekend. (IDI 12)
There exists a sense of competitiveness among the male students. Male students feel that they have to demonstrate their masculinity by having many sexual partners. Young males are more likely to boast about their sexual conquests and this is likely to also elevate their status among their peers.
Guys would say ‘uyumpetha’ [you are the boss] because you have so many partners. Those stigmas really perpetuate multiple partners”. (IDI 5)
“Competition, peer pressure, ‘ukuthanda izinto’ [to love things] when you don’t become proactive and you just think about the situation, not what happens afterwards. (IDI 7)
For students, being acknowledged and accepted by peers is important. This acknowledgment and acceptance entails emulating their behaviour; in this instance, risky sexual behaviour is a means of gaining entry and certification into a desired social group.
Condom use
Consistent use of condoms is one of the most effective strategies for reducing the risks associated with sexual behaviour. Early sexual debut is likely to affect readiness and use of protection. Those who start sexual activities at an early age are often likely to engage in unprotected sex and engage in high sexual risk taking, involving multiple sexual partners (Zuma et al., 2010; Kastbom, Sydsjö, Bladh, Priebe, & Svedin, 2015). In the interviews it became clear that condoms are not used consistently, especially during the first sexual encounter. The majority of the students reported that they did not use condoms during their first sexual encounter because of their lack of adequate awareness. In addition, they were not prepared for the sexual encounter and therefore they did not have any condoms. No I didn’t use a condom because it was my first time engaging in sexual intercourse with someone who was already sexually active. So she wanted to teach me how sex was done. (IDI 15) No, because I think at that stage I wasn’t aware and there is this belief that if you are still a virgin, you shouldn’t use a condom. (FGD 6)
I was not familiar with the use of condoms, but I remember there was this day when I used it, I opened it using my teeth and it got twisted around my penis and it was painful. (IDI 11)
Despite the general awareness of risk-related behaviours and the consequences, students provided various reasons why they felt condoms were not used and why safer sex was not practiced frequently and consistently among students. It was fairly difficult, especially for female students, to negotiate condom use with their partners as they would insist on engaging in sexual intercourse without condoms. Inconsistent condom use is more common in stable, long-term relationships. Couples in more long-term relationships are expected to be loyal and faithful to their partners.
No, it is very hard to negotiate condom use with my partner because my partner doesn’t want to use condoms at all. (IDI 10)
The hardest part I think in most relationships is that we always argue about condom use whenever we engage in sexual intercourse. (IDI 8)
It was also discovered that some young people did not use condoms during their last sexual encounter because of the nature of their sexual partnership. Students believed that if they were in a stable, committed relationship then there was no need to consistently use condoms, or even use condoms at all, because it is expected that their partner would be faithful to them. The introduction of condoms during sex still raises suspicions of infidelity.
With my woman we don’t use a condom, we prefer to test regularly because we are very committed to each other. So we don’t use it and we’ve negotiated
that. (IDI 14)
These accounts of students shed light on the extent of inconsistent use of condoms among the sexually active young people as well as some of the reasons for not using them. Among students who reported condom use the reasons advanced were that of protection against the risks associated with unprotected sexual intercourse. These students reported using condoms for protection against the risk of unplanned pregnancies and STIs (including HIV). Consistent condom use was practiced among students who perceived a heightened risk of HIV and AIDS and unplanned pregnancy in their sexual encounters.
I did use condom because I knew that when you engage in sexual intercourse you need to use a condom and I was old the time I started engaging. (IDI 6)
Yes I did, because I was scared of falling pregnant
and getting infected. (IDI 5)
Yes, because I was told that one needs to protect themselves against sexual transmitted diseases when engaging in sexual activities. (IDI 3)
Many barriers stand in the way of safer sexual practices, and this results in the inconsistent use of condoms. Students were also asked about the challenges in changing risky sexual behaviours. Alcohol poses a challenge to the effective and consistent use of condoms. Students reveal that they are more likely to engage in risky sexual behaviours under the influence of alcohol. In addition, alcohol use enhances an individual’s willingness to engage in sexual activity.
Tequilas makes a girl desire sex then you would know that you’ve won her that night. (FGD 1) Most of the times they come and then they have that alcohol and then at the end of the day they will have sex. (IDI 4)
I think it is alcohol because my partner couldn’t even remember that we even had sex. So now if she couldn’t even remember that we did have sex, how can she remember we had used protection? (IDI 4)
Another factor that serves as an obstacle to condom use was the perceived poor quality of condoms available in public facilities. Males revealed that they would not feel as if they are ‘real’ men if they used condoms that are provided for free. In addition, they complained that they experienced breakages and slippages with these condoms. Men felt that they could not use these condoms with their female partners as they will be perceived as disrespecting women.
My brothers here can agree with me, you see the Choice condoms, we can say by using them you are also engaging in unprotected sex because firstly these condoms are too light and soft and they burst so easily, we can’t trust them. (FGD 1) She will say I don’t appreciate her if I use a Choice condom with her. (IDI 4)
If they [government/service providers] can come up with a solution to this problem because really we can’t use them, “Ayasilahlisa” [they make us lose respect] and they smell so bad. (IDI 2)
In addition to the dissatisfaction associated with the use of government sponsored condoms available in public facilities, students were discouraged from the use of these condoms as they were perceived as not being of a high quality and having an unpleasant smell.
Discussion
This study sought to explore the risky behaviours of university students in Durban, South Africa and to ascertain the use of protective measures, particularly condoms during their sexual encounters. The findings revealed that students have a fairly good understanding of what constitutes risky sexual behaviour. Students are equally aware of the risks associated with unprotected sexual intercourse. Youth in South Africa are at a higher risk of HIV infection in comparison to any other age group (Zuma et al., 2016). The epidemics are complex and are influenced by a number of behavioural, historical and structural factors (Coovadia, Jewkes, Barron, Sanders, & McIntyre, 2009). Despite having a fairly widespread understanding of risky behaviours, most students do not perceive themselves personally at risk, a finding consistent with other studies (Ferrer et al. 2007; Ntata, Muula, Siziya, & Kayambazinthu, 2008; Rahamfey et al., 2008). This is difficult to understand given that most students are familiar with the risky environment at universities; however, they continually engage in risk-related behaviours.
The study found there was a relatively small sample of students that reported that they were not currently sexually active while a few reported that they have never had sex. This decision may be attributed to personal, moral or religious influences. It is suggested that religion often provides a moral compass for sexual behaviour (Bangirana, Nadar & Reddy, 2017). Students refrain from engaging in risky sexual behaviours as they are guided by their moral and religious principles (Bangirana, Nadar & Reddy, 2017), however it is uncertain as to how many students regulate their sexual conduct because of religion.
The study found that it is not uncommon for young people to have multiple partners; however, male students were more likely than females to report multiple sexual partners. Male respondents continue to engage in sexual relations with many females despite their awareness of the risks associated with multiple sexual partners. For many male students, multiple sexual partners are associated with ‘real’ men and having many sexual partners elevated their status among their peers. The study found that it is socially acceptable for men to have multiple sexual partners and this is supported by peer pressure. Research suggests that sex without protection gives male students a sense of reassurance about their manhood and also, avoided any inferior labelling by peers (Kanda & Mash, 2018). This is supported by the findings of this study as young men suggested that they did not feel as if they are real men if they used condoms that are provided for free. These findings are consistent with those of Prata, Vahidnia, and Fraser (2005) who indicated that younger individuals are not personally worried about contracting HIV from having multiple sexual partners. In their study, Cherie and Berhane (2012) also highlight peer pressure as an important driver of risky sexual behaviours.
Across the globe, unintended pregnancies are attributed to an array of factors such as poor family planning and inadequate access to contraceptives, societal beliefs and norms, lack of inter-partner communication, and sexual violence (Glasier, Gülmezoglu, Schmid, Moreno, & Van Look, 2006; Cheng, Schwarz, Douglas, & Horon, 2009; Goicolea & San Sebastian, 2010; Khajehpour, Simbar, Jannesari, Ramezani-Tehrani, & Majd, 2013; Haffejee et al., 2018). In sub-Saharan Africa the risk of an unintended pregnancy remains high due to poor access to reproductive health care (Eliason, Baiden, Yankey, & Awusabo– Asare, 2014) and the non-use of condoms within sexual relationships because of the limited ability of women to negotiate safer sexual behaviours (Toska, Cluver, Boyes, Pantelic, & Kuo, 2015). This study found that students are aware of the consequences of not using condoms consistently and the risk of an unwanted pregnancy and therefore used condoms consistently to avoid this. These findings are consistent with that of existing research which suggests that one of the negative consequences of engaging in risky sexual behaviours is an unwanted pregnancy (Abousselam, Naudé, Lens, & Esterhuyse, 2016). Findings from Norton, Fisher, Amico, Dovidio, & Johnson. (2012) suggests that young adults are more concerned about experiencing an unplanned pregnancy than becoming infected with HIV. Similar findings from Steenkamp, Busolo, and von der Marwitz (2012) amongst university students suggested that there was an awareness of the heightened risk of an unplanned pregnancy and strong support for prevention of an unwanted pregnancy.
While the need for condom use is widely evident, especially since empirical evidence highlights the prevailing high rates of STI and HIV infection (Francis et al., 2018; Statistics South Africa, 2018), the consistency of condom use remains elusive, even among the segment of the population who are educated and aware of the consequences of risk-related behaviours. The study found students did not use condoms during their first sexual encounter because many are not adequately prepared for the encounter. In addition, students revealed that in stable, committed relationships condoms are not used because partners are expected to be faithful. Other studies (Higher Education and Training Health, Wellness and Development Centre [HEAids], 2010) found high condom use at last sexual intercourse among university students, but a notable decline of condom use in more stable, long-term relationships. Consistent condom use within more stable relationships was found to be limited. This is because the consistent use of condoms is complicated by the dynamics of trust within more stable, long-term relationships. However, it is important to advocate for the consistent use of condoms, even within more stable relationships, for the dual protection that condoms offer, especially within a high HIV context (Hoffman et al., 2017). The findings of this study are consistent with results from earlier studies that suggest that the use of condoms are not popular in more stable sexual relationships, reflecting that people normally do not view these relationships as risky (Adetunji, 2000; Maharaj & Cleland, 2005; Haddad et al., 2018).
Another factor deterring condom use was the perception of the poor quality of condoms provided by the government. Students were also discouraged from using condoms that were available from public facilities because they were seen as not trustworthy and less desired by their sexual partners. These findings are consistent with another study which suggests that there are negative perceptions of government sponsored condoms due to their quality, texture, smell and durability (Holland & French, 2012). Male students were opposed to these condoms and further indicated that they did not want to utilise the government provided condoms as they lead to negative perceptions of them by their partners. Additionally they were undesirable as they had an unpleasant smell. This highlights distrust in the efficacy of condoms and as a result this is likely to influence the decision to use condoms. Additionally, males were expected to show that they value their partners by using higher quality condoms.
A lack of socio-economic support from their families among students is often associated with the economic commodification of sex (the exchange of sex for material benefits). Prevalent economic challenges experienced across South Africa is a key factor in the involvement of risky sexual behaviours (Kaufman & Stavrou, 2004; Dunkle et al., 2004; Dunkle et al., 2007). This study found that students, particularly females, may engage in risky sexual behaviours for economic reasons. Students from poorer financial backgrounds were more likely to be involved in sexual encounters that involved the commodification of sex. These findings are supported by that of another study which suggests that females engage in sexual relationships for money and goods (Ranganathan et al., 2018). Mobile phones, perfumes, and expensive clothes are viewed as highly prized commodities, along with access to money for leisure activities, which are often provided by older boys or men (known as sugar daddies) in exchange for sex with adolescent girls (Katz et al., 2013; Potgieter, Strebel, Shefer, & Wagner, 2012). Unfortunately, many students cannot afford such items due to their financial situation and students felt that they had to have the same possessions as their peers. Peers are those that share a similar identity, are generally within the same age groups and educational categories and have common interests. However, what is also clear is that there are varying socio-economic positions that exists between peers within the university environment. Therefore, even though there are students with similar characteristics it is important to acknowledge that there are students that have access to sufficient resources and as a result, do not have to engage in sexual encounters for material benefits.
In South Africa, the dominant ideal of manhood emphasises toughness and strength in relation to sexual success. It is a particular notion of masculinity that both men and women desire; yet it is sexually risky and exacerbates gender inequality (Jewkes & Morrell, 2010). Risky sexual practices of men are highly associated with gender inequality (Morrell, 2010; Jewkes et al., 2006; Stephenson, 2010; Shai, Jewkes, Nduna, & Dunkle, 2012). In the South African context, authors have argued that male toughness, multiple sexual partners, and inconsistent condom use originate from notions of hegemonic masculinity (Shai et al., 2012; Jewkes & Morrell, 2010). These notions of masculinity may influence young men’s condom use behaviour, and acts as a barrier for reducing HIV risk.
There is a need for a change in behaviour among university students however, in order for a change in behaviour change to occur, the conditions under which the individual is to change their behaviour needs to be conducive to change. The findings of this study suggests that this is often not the case for students in tertiary environments as the university is associated with high risk behaviours (Crimmins & Seigfried-Spellar, 2014). Another barrier to condom use is the use of alcohol. Alcohol consumption increases an individual’s decision to engage in risky sexual behaviour because alcohol usually affects the ability of an individual to make responsible and informed decisions (Kaufman & Stavrou, 2004; Sarkar, 2008). Male students reported that they usually provided their female partners with alcohol prior to engaging in sexual activity with them to make the initiation of sex more acceptable. The use of alcohol enhances the willingness of individuals to engage in sexual intercourse, which is often unprotected.
The primary limitation of this study was the use of qualitative methodology. This is limiting as the study does not produce statistical results therefore, the researcher could not capture the prevalence rate of risky sexual behaviours among students. Thus, it is recommended that future studies pertaining to risky sexual behaviours measure the incidence and occurrence of student’s risky sexual behaviours. Additionally, the study was also limited to students residing in and around the university and thus the results of the study are reflective of urban experiences of risky sexual behaviour amongst students. Therefore, caution should be exercised when generalising results to differing settings.
The main policy implication of the findings of this study is that peer-related as well as sexual and reproductive health programs needs to be continually geared towards practical ways of providing young people with information, education, and health services, or equipping them with skills to protect them from risks. It is evident from the results of the study that peers have a powerful influence on behavioural outcomes and existing programs are not addressing this effectively as a factor of risky sexual behaviours. Despite the fact that social norms are one of the most widely studied drivers of human behaviour, there is a fine line between what they are, how they sustain behaviour, and how they can be changed (Cislaghi & Shakya, 2018). In order for programs and initiatives that are geared towards safer sexual practices to be effective, there needs to be a substantial effort through coordinated and complementary approaches that have proved to be effective and efficient in varying contexts. Unproductive approaches that have become uninteresting, monotonous and exhaustive should be abandoned so that new approaches can be explored. New approaches should include greater efforts towards prevention and expanding access to a wider range of needs (Chandra-Mouli, Lane & Wong, 2015). Campaigns and programmes should be executed in and around the university to ensure that messages reach as many young people as possible. These initiatives should aim to be socially influential towards young people to address existing norms that promotes risky sexual activity. Interventions should be specifically targeted towards gender and health. Policy-makers will need to consider health-seeking behaviours with regard to young people and risky sexual behaviours. A masculinities-based approach to promote gender equality should be considered as a means to address dominant notions of masculinity. This will assist with the transformation of gender norms at the individual, community and wider societal level. Programmes should capitalise on initiatives and interventions that are geared towards resisting peer pressure and promoting safer sexual health, especially within heterosexual relationships. This will assist in achieving sustainable and widespread gender equality transformation. Understanding this difference between women and men as well as empowering younger women is critical for STI (including HIV) prevention.
Conclusion
The study suggests that there is a fairly good understanding of risky sexual behaviour and the perceived consequences thereof among young men and women. Although there is evidence of students protecting themselves against HIV and STIs, their use of methods are not consistent which elevates their level of risk. This study suggests that female students are more likely to be engaged in risky sexual activity in exchange for material resources. However, men were more likely to report multiple sexual partners. Male students are more likely to want to demonstrate their sexual prowess by having multiple sexual partners. It is clear that peers have a powerful influence on one’s behaviour and although there is a relationship between religion and behavioural outcomes, it is unclear as to how many students are guided by their principles. It is recommended that there should be a greater investment in a co-ordinated effort to address risky sexual practices amongst students as well as to continually promote consistent condom use. Programmes should be appealing to students and should put more emphasis on a combination of risk reducing strategies.
ORCID
Pranitha Maharaj https://orcid.org/0000-0003-3518-8237
Shanaaz Rademeyer https://orcid.org/0000-0003-0292-0305
References
Abousselam, N., Naudé, L., Lens, W., & Esterhuyse, K. (2016). The relationship between future time perspective, self-efficacy and risky sexual behaviour in the Black youth of central South Africa. Journal of Mental Health (Abingdon, England), 25(2), 176–183. https://doi. org/10.3109/09638237.2015.1078884
Adeniyi, O. V., Ajayi, A. I., Moyaki, M. G., Goon, D. T., Avramovic, G., & Lambert, J. (2018). High rate of unplanned pregnancy in the context of integrated family planning and HIV care services in South Africa. BMC Health Services Research, 18(1), 140. https:// doi.org/10.1186/s12913-018-2942-z
Adetunji, J. (2000). Condom use in marital and nonmarital relationships in Zimbabwe. International Family Planning Perspectives, 26(4), 196–200. https://doi.org/10.2307/2648258
Ajayi, N. A., & Omotayo, B. O. (2010). Challenges of HIV/AIDS to undergraduate students: The librarians’ reaction. International Journal of Library and Information Science, 2(2), 88–94.
Alamrew, Z., Bedimo, M., & Azage, M. (2013). Risky sexual practices and associated factors for HIV/AIDS infection among private college students in Bahir Dar City, Northwest Ethiopia. ISRN Public Health, 2013, 1–9. https://doi.org/10.1155/2013/763051
Bangirana, A. B., Nadar, S., & Reddy, S. (2017). Sexual surveillance and student sexual agency: Catholic moral teaching and HIV prevention in a higher education context. Journal for the Study of Religion, 30(2), 105–121. https://doi.org/10.17159/2413-3027/2017/
v30n2a5
Bingenheimer, J. B., Asante, E., & Ahiadeke, C. (2015). Peer influences on sexual activity among adolescents in Ghana. Studies in Family Planning, 46(1), 1–19. https://doi. org/10.1111/j.1728-4465.2015.00012.x
Cheng, D., Schwarz, E. B., Douglas, E., & Horon, I. (2009). Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contraception, 79(3), 194–198. https://doi. org/10.1016/j.contraception.2008.09.009
Cherie, A., & Berhane, Y. (2012). Oral and anal sex practices among high school youth in Addis Ababa, Ethiopia. BMC Public Health, 12, 1–9. https://doi.org/10.1186/1471-2458-12-5
Cooper, M. L. (2002). Alcohol use and risky sexual behavior among college students and youth: Evaluating the evidence. Journal of Studies on Alcohol, 2002(s14), 101–117. https://doi.org/10.15288/ jsas.2002.s14.101
Coovadia, H., Jewkes, R., Barron, P., Sanders, D., & McIntyre, D. (2009). The health and health system of South Africa: Historical roots of current public health challenges. Lancet, 374(9692), 817–834. https://doi.org/10.1016/S0140-6736(09)60951-X
Crimmins, D. M., & Seigfried-Spellar, K. C. (2014). Peer attachment, sexual experiences, and risky online behaviors as predictors of sexting behaviors among undergraduate students. Computers in Human Behavior, 32, 268–275. https://doi.org/10.1016/j. chb.2013.12.012
Deckman, T., & DeWall, C. N. (2011). Negative urgency and risky sexual behaviors: A clarification of the relationship between impulsivity and risky sexual behavior. Personality and Individual Differences, 51(5), 674–678. https://doi.org/10.1016/j.
paid.2011.06.004
Desale, A. Y., Argaw, M. D., & Yalew, A. W. (2016). ‘Prevalence and associated factors of risky sexual behaviours among in-school youth in Lalibela Town, North Wollo zone, Amhara regional state, Ethiopia: a cross-sectional study design’. Science, 4(1), 57–64.
Dolphin, L., Fitzgerald, A., & Dooley, B. (2018). Risky sex behaviours among college students: The psychosocial profile. Early Intervention in Psychiatry, 12(6), 1203–1212. https://doi.org/10.1111/eip.12526
Doyle, A. M., Mavedzenge, S. N., Plummer, M. L., & Ross, D. A. (2012). The sexual behavior of adolescents in sub-Saharan Africa: Patterns and trends from national surveys. Tropical Medicine & International Health, 17(7), 796–807. https://doi. org/10.1111/j.1365-3156.2012.03005.x
Dunkle, K. L., Jewkes, R. K., Brown, H. C., Gray, G. E., McIntryre, J. A., & Harlow, S. D. (2004). Transactional sex among women in Soweto, South Africa: Prevalence, risk factors and association with HIV infection. Social Science & Medicine, 59(8), 1581–1592. https://
doi.org/10.1016/j.socscimed.2004.02.003
Dunkle, K. L., Jewkes, R., Nduna, M., Jama, N., Levin, J., Sikweyiya, Y., & Koss, M. P. (2007). Transactional sex with casual and main partners among young South African men in the rural Eastern Cape: Prevalence, predictors, and associations with gender-based violence. Social Science & Medicine, 65(6), 1235–1248. https://doi.
org/10.1016/j.socscimed.2007.04.029
Eliason, S., Baiden, F., Yankey, B. A., & Awusabo–Asare, K. (2014). Determinants of unintended pregnancies in rural Ghana. BMC Pregnancy and Childbirth, 14, 1–9. https://doi. org/10.1186/1471-2393-14-261
Ferrer, L., Cianelli, R., Guzman, E., Cabieses, B., Irarrázabal, L., Bernales, M., & Araya, A. (2007). Chilean university students:
Knowledge and concern about HIV/AIDS. The Journal of the Association of Nurses in AIDS Care: JANAC, 18(5), 51–56. https:// doi.org/10.1016/j.jana.2007.07.001
Francis, S. C., Mthiyane, T. N., Baisley, K., Mchunu, S. L., Ferguson, J. B., Smit, T., … Shahmanesh, M. (2018). Prevalence of sexually transmitted infections among young people in South Africa: A nested survey in a health and demographic surveillance site.
PLoS Medicine,15(2), e1002512. https://doi.org/10.1371/journal. pmed.1002512
Gerressu, M., & Stephenson, J. M. (2008). Sexual behaviour in young people. Current Opinion in Infectious Diseases, 21(1), 37–41. https://doi.org/10.1097/QCO.0b013e3282f3d9bd
Glasier, A., Gülmezoglu, A. M., Schmid, G. P., Moreno, C. G., & Van Look, P. F. (2006). Sexual and reproductive health: A matter of life and death. Lancet, 368(9547), 1595–1607. https://doi.org/10.1016/ S0140-6736(06)69478-6
Goicolea, I., & San Sebastian, M. (2010). Unintended pregnancy in the amazon basin of Ecuador: A multilevel analysis. International Journal for Equity in Health, 9, 1–11. https://doi.org/10.1186/1475-9276-9-14
Guo, J., Chung, I. J., Hill, K. G., Hawkins, J. D., Catalano, R. F., & Abbott, R. D. (2002). Developmental relationships between adolescent substance use and risky sexual behavior in young adulthood. The Journal of Adolescent Health, 31(4), 354–362. https://doi.org/10.1016/S1054-139X(02)00402-0
Haddad, L. B., Tang, J. H., Krashin, J., Ng’ambi, W., Tweya, H., Samala, B., … Phiri, S. (2018). Factors associated with condom use among men and women living with HIV in Lilongwe, Malawi: A cross-sectional study. BMJ Sexual & Reproductive Health, 44, 42–53. https://doi.org/10.1136/bmjsrh-2017-101825
Haffejee, F., O’Connor, L., Govender, N., Reddy, P., Sibiya, M. N., Ghuman, S., … Borg, D. (2018). Factors associated with unintended pregnancy among women attending a public health facility in KwaZulu-Natal, South Africa. South African Family Practice, 60(3), 79–83. https://doi.org/10.1080/20786190.2017.1396790
Higher Education and Training Health, Wellness and Development Centre (HEAids). (2010). HIV prevalence and related factors – Higher education sector study. South Africa, 2008–2009. Pretoria: Higher Education South Africa.
Hoffman, S., Levasseur, M., Mantell, J. E., Beksinska, M., Mabude, Z., Ngoloyi, C., … Smit, J. A. (2017). Sexual and reproductive health risk behaviours among South African university students: Results from a representative campus-wide survey. African Journal of AIDS
Research, 16(1), 1–10. https://doi.org/10.2989/16085906.2016.1
259171
Holland, K. J., & French, S. E. (2012). Condom negotiation strategy use and effectiveness among college students. Journal of Sex
Research, 49(5), 443–453. https://doi.org/10.1080/00224499.201
1.568128
Hoque, M. E. (2011a). ‘Reported risky sexual practices amongst female undergraduate students in KwaZulu-Natal, South Africa’. African Journal of Primary Health Care & Family Medicine,3(1), 1–6. https://doi.org/10.4102/phcfm.v3i1.281
Hoque, M. E. (2011b). ‘Sexual practices among male undergraduate students in KwaZulu Natal, South Africa’. The Southern African Journal of Epidemiology & Infection : Official Journal of the Sexually
Transmitted Diseases, Infectious Diseases and Epidemiological
Societies of Southern Africa, 26(3), 157–160. https://doi.org/10.108
0/10158782.2011.11441439
Jewkes, R., Dunkle, K., Koss, M. P., Levin, J. B., Nduna, M., Jama, N., & Sikweyiya, Y. (2006). Rape perpetration by young, rural South African men: Prevalence, patterns and risk factors. Social Science & Medicine, 63(11), 2949–2961. https://doi.org/10.1016/j. socscimed.2006.07.027
Jewkes, R., & Morrell, R. (2010). Gender and sexuality: Emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. Journal of the International AIDS Society, 13, 1–11. https://doi.org/10.1186/1758-2652-13-6 Jones, B. T., Eaton, S., Livingston, J. N., & Cliette, G. E. (2018). Substance use, risky sexual behavior and delinquency among students at a historically black college. Addict Drug Sensitize, 2(109), 53–59.
Kalichman, S. C., Ntseane, D., Nthomang, K., Segwabe, M., Phorano, O., & Simbayi, L. C. (2007). Recent multiple sexual partners and HIV transmission risks among people living with HIV/AIDS in Botswana. Sexually Transmitted Infections, 83(5), 371–375. https:// doi.org/10.1136/sti.2006.023630
Kanda, L., & Mash, R. (2018). Reasons for inconsistent condom use by young adults in Mahalapye, Botswana. African Journal of Primary Health Care & Family Medicine,10(1), 1–7. https://doi.org/10.4102/
phcfm.v10i1.1492
Kastbom, Å. A., Sydsjö, G., Bladh, M., Priebe, G., & Svedin, C. G. (2015). Sexual debut before the age of 14 leads to poorer psychosocial health and risky behaviour in later life. Acta Paediatrica (Oslo, Norway), 104(1), 91–100. https://doi.org/10.1111/apa.12803 Katz, I. T., Ybarra, M. L., Wyatt, M. A., Kiwanuka, J. P., Bangsberg, D. R., & Ware, N. C. (2013). Socio-cultural and economic antecedents of adolescent sexual decision making and HIV-risk in rural Uganda.
AIDS Care, 25(2), 258–264. https://doi.org/10.1080/09540121.201
2.701718
Kaufman, C. E., & Stavrou, S. E. (2004). ‘Bus fare please’: The economics of sex and gifts among young people in urban South Africa. Culture, Health & Sexuality, 6(5), 377–391. https://doi.org/10
.1080/13691050410001680492
Khajehpour, M., Simbar, M., Jannesari, S., Ramezani-Tehrani, F., & Majd, H. A. (2013). Health status of women with intended and unintended pregnancies. Public Health, 127(1), 58–64. https://doi. org/10.1016/j.puhe.2012.08.011
Klassen, B. J., Fulcher, K., Chown, S. A., Armstrong, H. L., Hogg, R. S., Moore, D. M., … Lachowsky, N. J. (2019). “Condoms are… like public transit. It’s something you want everyone else to take”: Perceptions and use of condoms among HIV negative gay men in Vancouver, Canada in the era of biomedical and seroadaptive prevention. BMC Public Health, 19, 1–13. https://doi.org/10.1186/ s12889-019-6452-7
Lewis, J., & Ritchie, J. (2003). Generalising from qualitative research. Qualitative research practice: A guide for social science students and researchers. London: Sage.
Mack, N., Woodsong, C., MacQueen, K., Guest, G., & Namey, E. (2005). Focus Groups. In Qualitative Research Methods: A data collector’s field guide (pp. 51–82). North Carolina, USA: Family Health International.
Maharaj, P., & Cleland, J. (2005). Risk perception and condom use among married or cohabiting couples in KwaZulu-Natal, South Africa. International Family Planning Perspectives, 31(01), 24–29. https://doi.org/10.1363/3102405
Marlatt, G. A., Larimer, M. E., & Witkiewitz, K. (Eds.). (2011). Harm reduction: Pragmatic strategies for managing high-risk behaviors. New York: Guilford Press.
Menon, J. A., Mwaba, S. O., Thankian, K., & Lwatula, C. (2016). Risky sexual behaviour among university students. International STD Research & Reviews, 4(1), 1–7.
Ndinda, C., Ndhlovu, T., & Khalema, N. (2017). Conceptions of contraceptive use in rural KwaZulu-Natal, South Africa: Lessons for programming. International Journal of Environmental Research and Public Health, 14(4), 1–17. https://doi.org/10.3390/ijerph14040353
Nicholson, J. (2012). Risky sexual behaviour among adolescents and young adults. Chapel Hill: University of North Carolina.
Norton, W. E., Fisher, J. D., Amico, K. R., Dovidio, J. F., & Johnson, B. T. (2012). Relative efficacy of a pregnancy, sexually transmitted infection, or human immunodeficiency virus prevention–focused intervention on changing sexual risk behavior among young adults.
Journal of American College Health, 60(8), 574–582. https://doi.
org/10.1080/07448481.2012.721428
Ntata, P. R. T., Muula, A., Siziya, S. & Kayambazinthu, E. E. (2008). Gender Differences in University Students’ HIV/AIDS-Related Knowledge and Sexual Behaviours in Malawi: A Pilot Study. SAHARA-J: Journal of Social Aspects of HIV/AIDS, 5(4), 201–205.
https://doi.org/10.1080/17290376.2008.9724920
Parsons, J. T., Halkitis, P. N., Bimbi, D., & Borkowski, T. (2000). Perceptions of the benefits and costs associated with condom use and unprotected sex among late adolescent college students. Journal of Adolescence, 23(4), 377–391. https://doi.org/10.1006/
jado.2000.0326
Potgieter, C., Strebel, A., Shefer, T., & Wagner, C. (2012). Taxi ‘sugar daddies’ and taxi queens: Male taxi driver attitudes regarding transactional relationships in the Western Cape, South Africa. Journal of Social Aspects of HIV/AIDS Research Alliance, 9(4), 192–199. https://doi.org/10.1080/17290376.2012.745286
Prata, N., Vahidnia, F., & Fraser, A. (2005). Gender and relationship differences in condom use among 15–24 year olds in Angola. International Family Planning Perspectives, 31(4), 192–199. https://
doi.org/10.1363/3119205
Rahamfey, O. H., Rivard, M., Ravaoarinoro, M., Ranaivoharisoa, L., Rasamindrakotroka, A. J. & Morisset, R. (2008). Sexual Behavior and Condom Use among University Students in Madagascar. SAHARA-J: Journal of Social Aspects of HIV/ AIDS, 5(1), 28–35.
https://doi.org/10.1080/17290376.2008.9724899
Ranganathan, M., Heise, L., MacPhail, C., Stöckl, H., Silverwood, R. J., Kahn, K., … Pettifor, A. (2018). ‘It’s because I like things… it’sa status and he buys me airtime’: Exploring the role of transactional sex in young women’s consumption patterns in rural South Africa (secondary findings from HPTN 068). Reproductive Health, 15, 1–21. https://doi.org/10.1186/s12978-018-0539-y
Richardson, S. A., Dohrenwend, B. S., & Klein, D. (1965). Interviewing: Its forms and functions. New York: Basic Books.
Sarkar, N. N. (2008). Barriers to condom use. The European Journal of Contraception & Reproductive Health Care, 13(2), 114–122. https:// doi.org/10.1080/13625180802011302
Shai, N. J., Jewkes, R., Nduna, M., & Dunkle, K. (2012). Masculinities and condom use patterns among young rural South Africa men: A cross-sectional baseline survey. BMC Public Health, 12, 1–9. https://
doi.org/10.1186/1471-2458-12-462
Shisana, O., Rehle, T., Simbayi, L. C., Zuma, K., Jooste, S., Zungu, N., & Onoya, D. (2014). South African national HIV prevalence, incidence and behaviour survey, 2012. Pretoria: HSRC Press.
Simbayi, L. C., Zuma, K., Zungu, N., Moyo, S., Marinda, E., Jooste, S., … Naidoo, I., & the SABSSMV Team. (2018). South African National HIV Prevalence, Incidence, Behaviour and Communication Survey, 2017. Cape Town: HSRC Press.
Statistics South Africa. (2016). Community Survey 2016 in Brief. Pretoria: Statistics South Africa Statistics South Africa. (2018). Mid-year population estimates 2018. Statistical Release. P0302. Pretoria: Statistics South Africa.
Steenkamp, L., Busolo, M., & von der Marwitz, J. (2012). ‘An innovative online HIV/STI prevention programme in higher education: Preliminary results NMMU’. South African Journal of
Higher Education, 26(5), 1066–1079. https://hdl.handle.net/10520/
EJC132750
Stephenson, R. (2010). Community-level gender equity and extramarital sexual risk-taking among married men in eight African countries. International Perspectives on Sexual and Reproductive Health, 36(4), 178–188. https://doi.org/10.1363/3617810
Toska, E., Cluver, L. D., Boyes, M., Pantelic, M., & Kuo, C. (2015). From ‘sugar daddies’ to ‘sugar babies’: Exploring a pathway among age-disparate sexual relationships, condom use and adolescent pregnancy in South Africa. Sexual Health, 12(1), 59–66. https://doi.
org/10.1071/SH14089
UNAIDS. (2014). The gap report. Geneva: UNAIDS.
UNAIDS. (2016). Global Aids update 2016. Geneva: UNAIDS.
UNFPA. (2010). Comprehensive condom programming. A guide for resource mobilization and country programming. New York: UNFPA.
UNICEF. (2011). Opportunity in Crisis: Preventing HIV from early adolescence to young adulthood. New York: UNICEF.
Warren, M., & Philpott, A. (2003). Expanding safer sex options: Introducing the female condom into national programmes.
Reproductive Health Matters, 11(21), 130–139. https://doi.
org/10.1016/S0968-8080(03)02178-5
Zuma, K., Setswe, G., Ketye, Y., Mzolo, T., Rehle, T., & Mbelle, N. (2010). ‘Age at sexual debut: A determinant of multiple partnership among South African youth’. African Journal of Reproductive Health, 14(2), 47–54.
Zuma, K., Shisana, O., Rehle, T. M., Simbayi, L. C., Jooste, S., Zungu, N., … Abdullah, F. (2016). New insights into HIV epidemic in South Africa: Key findings from the National HIV Prevalence, Incidence and Behaviour Survey, 2012. African Journal of AIDS
Research,15(1), 67–75. https://doi.org/10.2989/16085906.2016.1 153491
Zinhle Mthembu, Pranitha Maharaj & Shanaaz Rademeyer, African Journal of AIDS Research
01 October 2019
Copied below as fair use and available here: https://www.tandfonline.com/doi/abs/10.2989/16085906.2019.1655075
'Negative attitudes towards condoms continue to discourage students from using them consistently, especially those provided by the government. In light of this, it is recommended that rigorous efforts are directed towards challenging inaccurate perceptions about, and attitudes towards, condom use to promote consistency.'
Introduction
For decades, HIV infection has been a global health concern, posing many health-related challenges worldwide. Sub-Saharan Africa remains the most adversely affected region with the highest rates of HIV concentrated among the young population (Ajayi & Omotayo, 2010; UNAIDS, 2014). Younger populations are more likely to make decisions about the future without adequately considering the consequences (Guo et al., 2002; Nicholson, 2012). In South Africa, young people are severely affected by HIV and AIDS as well as high rates of unplanned pregnancies. The total fertility rate in South Africa has been declining steadily but the number of pregnancies among young women, often unplanned and outside of marriage, are still high. A recent national survey suggests that by age 19 years, almost 28% of young women reported ever having been pregnant (Statistics South Africa, 2016).
Studies suggest that risky sexual behaviours are fuelling the spread of HIV and AIDS and unwanted pregnancy among young people (Cherie & Berhane, 2012; Adeniyi et al., 2018). Risky sexual behaviour is widely defined in the literature as any behaviour that increases the probability of negative consequences associated with sexual contact, including HIV or other sexually transmitted diseases, as well as unplanned pregnancies (Hoque, 2011a; Hoque, 2011b; Desale, Argaw & Yalew, 2016). Risky sexual behaviour may include sexual encounters without a condom, multiple sexual partners, and engaging in unprotected sex while consuming substances (Marlatt, Larimer, & Witkiewitz, 2011). There is a significant association between young people and sexual behaviour (Gerressu & Stephenson, 2008). Among young people, multiple sexual partners are fairly common (Alamrew, Bedimo & Azage, 2013) and youth who are engaging in risky sexual relationships put their health and well-being in danger (Adeniyi et al., 2018). Young people, including students from tertiary institutions, are at a higher risk of contracting HIV due to their risky sexual practices (Cherie & Berhane, 2012). For many young people, first sexual debut occurs at an early age. A study by Richter et al. (2015) suggests that the median age of sexual debut in South Africa is 16 years for females and 15 years for males. This early onset of sexual activity is likely to lead to an elevated risk of an unplanned pregnancies and HIV and AIDS, including sexually transmitted infections (STIs). The high level of unwanted pregnancies and HIV and AIDS in South Africa underscores the need for effective options to provide dual protection.
Correct and consistent condom use remains a pivotal strategy in reducing new HIV infections and unplanned pregnancies. Sexual encounters with multiple partners increase the probability of contracting STIs (including HIV) (Kalichman et al., 2007). A study in Zambia among university students by Menon, Mwaba, Thankian, and Lwatula (2016) found that male students were more likely to report having had more than one sexual partner. However, they were more consistent in using condoms compared to female students. The study also revealed that final year students were more likely to report having experienced sexually transmitted infections than those in their first year. On the other hand, another study conducted among university students in South Africa by Hoffman et al. (2017) found that the fear of an unplanned pregnancy was a major determinant of consistent condom use. This study suggested that most students used condoms for pregnancy prevention whereas only a few students used condoms solely for disease prevention (Hoffman et al., 2017). To reduce the dual risk of pregnancy and HIV and AIDS, the behaviour of those that are sexually active needs to be altered. Individuals need to adopt more reliable methods of protection. Thus, one risk-reducing strategy that is widely promoted through government and Non-Government Organisation (NGO) campaigns, is the consistent use of condoms during every sexual encounter. Consistent condom use is influenced by knowledge about the associated health risks and benefits (Parsons, Halkitis, Bimbi, & Borkowski, 2000).
Condom promotion has been integrated into comprehensive HIV prevention programmes and has also been identified as an important strategy for addressing an array of sexual health challenges (Warren & Philpott, 2003; United Nations Population Fund, 2010). Recent studies suggest a sharp decline in condom use in South Africa for the period 2008 to 2012 (Shisana et al., 2014). In 2008, 85.2% of males aged 15–24 years used condoms and this significantly declined to 67.5% in 2012. In 2008, 66.5% of females aged 15–24 years used condoms and this significantly declined to 49.8% in 2012. According to the 2017 South African National HIV Prevalence, Incidence, Behaviour and Communication Survey produced by the Human Sciences Research Council (HSRC), 55.6% of individuals aged 15–64 years reported condom use at their last sexual encounter. Of those aged 25–49 years, both males (53%) and females (53.4%) had relatively similar proportions of condom use. Additionally, 68% of young males (15–24 years) reported condom use at their last sexual encounter in comparison to 47.3% of females of the same age (Simbayi et al., 2018). Literature documents the inconsistency of condom use especially among the younger population (Ndinda, Ndhlovu & Khalema, 2017; Klassen et al., 2019), and this is of concern because empirical evidence highlights constant and increasing rates of infection of both STIs and HIV infection (Francis et al., 2018; Statistics South Africa, 2018).
The focus on the sexual behaviour of youth is vitally important because they have a higher risk of HIV and AIDS and unplanned pregnancies (UNICEF, 2011; Doyle, Mavedzenge, Plummer, & Ross, 2012). Even though the youth are aware of the dangers associated with inconsistent condom use, they continually engage in risk-related behaviours (Alamrew, Bedimo & Azage, 2013). Risky sex behaviours specifically among college student populations are a growing public health concern and of interest to policy makers and public health professionals. Many authors have argued that students are likely to engage in risky sexual behaviours due to environmental and social pressures that they are exposed to in tertiary institutions (Cooper, 2002; Jones, Eaton, Livingston, & Cliette, 2018; Crimmins & Seigfried-Spellar, 2014). For educational or health interventions to effectively tailor messages and initiatives for young people, understanding their risk behaviours and their attitudes towards condoms is necessary (Dolphin, Fitzgerald & Dooley, 2018).
There is a need for more research to address behaviours that places young people at risk of HIV infection. Thus, this study examines risk behaviours among university students aged 18–24 years old, with particular emphasis on their use of condoms. Of course, university students constitute a privileged group. According to the 2016 Community Survey, only 4.1% of individuals aged 20 years and older in South Africa have a tertiary education (Statistics South Africa, 2016). Although they are not typical of young people, however, they are of particular importance for the future of the country and lessons can be learnt that may have relevance to the wider population of young people.
For decades, HIV infection has been a global health concern, posing many health-related challenges worldwide. Sub-Saharan Africa remains the most adversely affected region with the highest rates of HIV concentrated among the young population (Ajayi & Omotayo, 2010; UNAIDS, 2014). Younger populations are more likely to make decisions about the future without adequately considering the consequences (Guo et al., 2002; Nicholson, 2012). In South Africa, young people are severely affected by HIV and AIDS as well as high rates of unplanned pregnancies. The total fertility rate in South Africa has been declining steadily but the number of pregnancies among young women, often unplanned and outside of marriage, are still high. A recent national survey suggests that by age 19 years, almost 28% of young women reported ever having been pregnant (Statistics South Africa, 2016).
Studies suggest that risky sexual behaviours are fuelling the spread of HIV and AIDS and unwanted pregnancy among young people (Cherie & Berhane, 2012; Adeniyi et al., 2018). Risky sexual behaviour is widely defined in the literature as any behaviour that increases the probability of negative consequences associated with sexual contact, including HIV or other sexually transmitted diseases, as well as unplanned pregnancies (Hoque, 2011a; Hoque, 2011b; Desale, Argaw & Yalew, 2016). Risky sexual behaviour may include sexual encounters without a condom, multiple sexual partners, and engaging in unprotected sex while consuming substances (Marlatt, Larimer, & Witkiewitz, 2011). There is a significant association between young people and sexual behaviour (Gerressu & Stephenson, 2008). Among young people, multiple sexual partners are fairly common (Alamrew, Bedimo & Azage, 2013) and youth who are engaging in risky sexual relationships put their health and well-being in danger (Adeniyi et al., 2018). Young people, including students from tertiary institutions, are at a higher risk of contracting HIV due to their risky sexual practices (Cherie & Berhane, 2012). For many young people, first sexual debut occurs at an early age. A study by Richter et al. (2015) suggests that the median age of sexual debut in South Africa is 16 years for females and 15 years for males. This early onset of sexual activity is likely to lead to an elevated risk of an unplanned pregnancies and HIV and AIDS, including sexually transmitted infections (STIs). The high level of unwanted pregnancies and HIV and AIDS in South Africa underscores the need for effective options to provide dual protection.
Correct and consistent condom use remains a pivotal strategy in reducing new HIV infections and unplanned pregnancies. Sexual encounters with multiple partners increase the probability of contracting STIs (including HIV) (Kalichman et al., 2007). A study in Zambia among university students by Menon, Mwaba, Thankian, and Lwatula (2016) found that male students were more likely to report having had more than one sexual partner. However, they were more consistent in using condoms compared to female students. The study also revealed that final year students were more likely to report having experienced sexually transmitted infections than those in their first year. On the other hand, another study conducted among university students in South Africa by Hoffman et al. (2017) found that the fear of an unplanned pregnancy was a major determinant of consistent condom use. This study suggested that most students used condoms for pregnancy prevention whereas only a few students used condoms solely for disease prevention (Hoffman et al., 2017). To reduce the dual risk of pregnancy and HIV and AIDS, the behaviour of those that are sexually active needs to be altered. Individuals need to adopt more reliable methods of protection. Thus, one risk-reducing strategy that is widely promoted through government and Non-Government Organisation (NGO) campaigns, is the consistent use of condoms during every sexual encounter. Consistent condom use is influenced by knowledge about the associated health risks and benefits (Parsons, Halkitis, Bimbi, & Borkowski, 2000).
Condom promotion has been integrated into comprehensive HIV prevention programmes and has also been identified as an important strategy for addressing an array of sexual health challenges (Warren & Philpott, 2003; United Nations Population Fund, 2010). Recent studies suggest a sharp decline in condom use in South Africa for the period 2008 to 2012 (Shisana et al., 2014). In 2008, 85.2% of males aged 15–24 years used condoms and this significantly declined to 67.5% in 2012. In 2008, 66.5% of females aged 15–24 years used condoms and this significantly declined to 49.8% in 2012. According to the 2017 South African National HIV Prevalence, Incidence, Behaviour and Communication Survey produced by the Human Sciences Research Council (HSRC), 55.6% of individuals aged 15–64 years reported condom use at their last sexual encounter. Of those aged 25–49 years, both males (53%) and females (53.4%) had relatively similar proportions of condom use. Additionally, 68% of young males (15–24 years) reported condom use at their last sexual encounter in comparison to 47.3% of females of the same age (Simbayi et al., 2018). Literature documents the inconsistency of condom use especially among the younger population (Ndinda, Ndhlovu & Khalema, 2017; Klassen et al., 2019), and this is of concern because empirical evidence highlights constant and increasing rates of infection of both STIs and HIV infection (Francis et al., 2018; Statistics South Africa, 2018).
The focus on the sexual behaviour of youth is vitally important because they have a higher risk of HIV and AIDS and unplanned pregnancies (UNICEF, 2011; Doyle, Mavedzenge, Plummer, & Ross, 2012). Even though the youth are aware of the dangers associated with inconsistent condom use, they continually engage in risk-related behaviours (Alamrew, Bedimo & Azage, 2013). Risky sex behaviours specifically among college student populations are a growing public health concern and of interest to policy makers and public health professionals. Many authors have argued that students are likely to engage in risky sexual behaviours due to environmental and social pressures that they are exposed to in tertiary institutions (Cooper, 2002; Jones, Eaton, Livingston, & Cliette, 2018; Crimmins & Seigfried-Spellar, 2014). For educational or health interventions to effectively tailor messages and initiatives for young people, understanding their risk behaviours and their attitudes towards condoms is necessary (Dolphin, Fitzgerald & Dooley, 2018).
There is a need for more research to address behaviours that places young people at risk of HIV infection. Thus, this study examines risk behaviours among university students aged 18–24 years old, with particular emphasis on their use of condoms. Of course, university students constitute a privileged group. According to the 2016 Community Survey, only 4.1% of individuals aged 20 years and older in South Africa have a tertiary education (Statistics South Africa, 2016). Although they are not typical of young people, however, they are of particular importance for the future of the country and lessons can be learnt that may have relevance to the wider population of young people.
Methods
The study was designed to investigate risky sexual behaviours of university students in Durban, South Africa. Using qualitative data drawn from twenty in-depth interviews (IDI) and one focus group discussion (FGD), the study gathered information on student’s perceptions regarding risky sexual behaviour. In-depth interviews allows for data to be collected independent of group dynamics. During in-depth interviews the researcher had the opportunity to clarify ambiguous issues and cases of inconsistencies or to probe when insufficient information was provided (Richardson, Dohrenwend, & Klein, 1965). Additionally, a focus-group discussion was employed because it provides a social context for research, and thus an opportunity to explore how people think and talk about a topic, how their ideas are shaped, generated or moderated through conversation with others (Lewis & Ritchie, 2003). They are also effective for collecting a large amount of information over a relatively short period of time (Mack, Woodsong, MacQueen, Guest, & Namey, 2005). It is advantageous to combine both focus group discussions and individual interviews as this presents an opportunity to clarify any issues that were not alluded to during the individual interviews while ensuring the dependability of the results obtained. The triangulation of data was employed to enhance data richness and test validity through the convergence of information. This exploratory study aimed to get intricate personal views and attitudes amongst university students. This cannot be effectively achieved through applying statistical procedures or any other quantifying procedures; instead employing a qualitative approach is more appropriate.
The study population was restricted to undergraduate university students, both male and females, and their ages ranged from 18 to 24 years old. The study sample of students constituted of those who were enrolled for their second, third and fourth years of study. First year students were excluded from this study because these students are still new to the university environment and they may have minimal exposure to the areas of interest of this research. Additionally they may be challenged with trying to adapt to the university environment. Students were sampled from different campuses of the university. For the purpose of this study the focus is on this age category because UNAIDS (2016) suggests a significant increase in the absolute number of new HIV infections worldwide among this age group. Additionally, inclusion of both males and females in the study population was to allow for a better understanding of the themes under investigation. Additionally, the focus was solely on heterosexual relationships. University students are of particular interest because they are increasingly involved in risk-related behaviours once they are more exposed to new social groups in the tertiary educational environment (Cherie & Berhane, 2012). Purposive sampling was used in this study because it enables the researcher to identify relevant individuals of interest instead of selecting a random sample of the population. Students were recruited from the different campuses on the basis of eligibility for the study as well as their willingness to participate.
Data from the in-depth interviews and the focus group discussion were recorded digitally, transcribed and analysed thematically using ATLAS.ti analytical software package. Thematic analysis was utilised to identify particular themes that emerged from the qualitative interviews. This was achieved through carefully going through the transcripts numerous times to correctly identify codes and themes and merge very similar outputs together.
Ethical considerations
Ethical approval was obtained from the University of Kwazulu-Natal Ethics committee. Prior to the interviews and focus group discussion, the researcher made it clear to the students that their participation in the research was voluntary and they were also assured of anonymity. They were informed that they may withdraw from the research at any time. Names of participants or any personal information was not obtained to ensure confidentiality. The students sat with the interviewer for sessions of approximately 45 to 60 minutes. The focus group discussion as well as in-depth interviews were conducted in a venue that ensured maximum privacy as well as a confidential atmosphere in which participants could share sensitive and personal information.
Results
The study sample consisted of 20 students for the in-depth interviews and 10 students for the focus-group discussion. There was an equal proportion of males and females in the study. The sample was restricted to undergraduate students aged between 18 and 24 years.
Risky sexual behaviour
Generally, most of the students have a fairly good understanding of the term “risky sexual behaviour”. The students were aware of the behaviours that place them at a heightened risk of pregnancy and HIV and AIDS. Students identified the risks associated with unprotected sexual intercourse. When students referred to unprotected sexual intercourse, most were referring to vaginal, penetrative intercourse. Students also identified sexual intercourse with multiple sexual partner as a risk-related behaviour. However many of the students were not against this because of the desire to be acknowledged within their social groups. Alcohol consumption was also associated with risky sexual behaviour.
I think risky sexual behaviour is when you engage in risky sexual intercourse such as unprotected sex … and engaging in sexual intercourse under the influence of alcohol. (IDI 1)
Engaging in sexual intercourse without actually protecting yourself, anal sex. (IDI 11) I don’t think it is a bad thing and people do have multiple sexual partners … but with me the whole concept of it, I’m okay with it. (IDI 3)
Generally individuals make decisions on the basis of strong negative emotions and those who desire novel and exciting activities are more likely to engage in risky sexual behaviours (Deckman & DeWall, 2011), however, there were some clear differences between male and female students and their reports of sexual risk-related behaviours.
More males than females reported that they were sexually active. Only two students (females) revealed that they had never had sexual intercourse previously. Their decision to abstain from sexual intercourse was motivated by religious reasons.
No I’m not sexually active and I’m not ready to start engaging in any sexual activities. (IDI 16)
Firstly, I am a Christian, so for me sex before marriage is wrong and is forbidden by God. (IDI 19)
Students also held strong negative attitudes towards premarital sex. They pointed out that according to their religion sex before marriage was not acceptable and it was therefore regarded as a ‘sin’. They preferred to delay sexual intercourse until marriage but most admitted that it was rare for young people to abstain.
Premarital sex is not allowed, it is ungodly, and God forbids sex before marriage. (IDI 19) In terms of premarital sex, according to my religion, it is against the law, it is not accepted. (IDI 4)
Additionally, students acknowledged the consequences associated with unprotected sexual intercourse; however, they still reported engaging in unprotected sexual intercourse.
Students are very much aware; they know what will happen after having unprotected sex. (IDI 11) We are always informed about this issue. It is just that we are ignorant, we are not prioritising, and we are not taking them seriously. But then I believe that, students are well equipped and informed; it’s just that they don’t want to take responsibility. (IDI 4)
Risk-related factors
There is widespread agreement that risky sexual behaviour is common among young people. The low socio-economic status of students has resulted in sex becoming commoditised. The respondents reported that many females (and some peers) are involved in sexual relationships with men in exchange for financial support. Students were asked about socio-economic factors that motivate students to engage in risky sexual behaviours. Students felt that the economic challenges that they face encourages risky sexual practices. They also believed that economic problems were the result of their family’s socio-economic background which meant that they were unable to access material possessions. They often compared themselves to their peers and they feel deprived and indicated that they would engage in sexual relationships in exchange for material possessions.
My friends are coming from families that can afford anything. So I will think what I can do to reach their standard, so I will start behaving recklessly. For instance, I will get a sugar daddy, somebody who is older than me because I want money. (IDI 5)
So in terms of it in the university it is very high due to the desire for things that your parents cannot afford so you end up exchanging in that way. (FGD 1)
The students mentioned that it was common for female students to occasionally engage in sexual relationships with men who could provide for them financially, especially to acquire expensive, material goods that they desire but cannot afford. These narratives highlight the measures young women are likely to use in order to secure material benefits. In difficult situations, particularly challenging economic circumstances, where families often lack the means to support all family members, young women sometimes look for other ways to financially support themselves, which may lead to transactional sex. It is equally important to note that there are females that have access to resources and therefore engaging in risk-related behaviours for material gain is not necessary.
So many people are doing it as a form of getting something and they exchange their bodies in order to get what they really want. I don’t know but it comes from us as men. (IDI 11)
This thing of having sex in exchange for money is dominant among girls. (FGD 1)
It is clear from the interviews that the university environment offers massive opportunities for risky sexual behaviours. Students were asked about the impact that the university environment has on the sexual behaviours of students. The majority of the students revealed that the campus environment as well as the environment where university residences are located, especially off-campus residences, has a strong influence on risky behaviours. This is because these areas are surrounded by entertainment spaces such as night clubs and bars which makes it easier for students to obtain alcohol and other substances.
Basically at residence there are places surrounding where I live that are basically for clubbing. You go there and people ask you out and some have that perception that they want to have sex with you. I feel like it does have an influence of actually making me
want to engage in sexual activities. (IDI 3)
Additionally, the venues on campus were viewed as spaces where sexual activity could easily occur without interruptions since there are places that are secluded and offer privacy.
Another thing, one of the factors that lead us to engage in unprotected sex for university students, you see having a girlfriend who doesn’t have a residence to stay, it is very hard but on campus there
are good venues. (FGD 1)
Peer pressure is one of the key drivers of risky sexual behaviours among youth between the ages of 15 to 24. It is not uncommon for the youth to want to impress their peers; therefore vulnerability to sexual risk amongst young people is strongly influenced by peer pressure (Bingenheimer, Asante & Ahiadeke 2015). In addition, students further reveal that young people are more likely to engage in sexual activities in order to conform to their social groups. There is a widespread desire to fit into society and they feel that this will enhance their acceptability amongst their peers. I would like to add peer pressure as one of the main things that can contribute to unwanted pregnancies and so forth because you will find that sometimes students, especially the guys, they are competing on how many women or girlfriends they sleep with or have had slept with during the weekend. (IDI 12)
There exists a sense of competitiveness among the male students. Male students feel that they have to demonstrate their masculinity by having many sexual partners. Young males are more likely to boast about their sexual conquests and this is likely to also elevate their status among their peers.
Guys would say ‘uyumpetha’ [you are the boss] because you have so many partners. Those stigmas really perpetuate multiple partners”. (IDI 5)
“Competition, peer pressure, ‘ukuthanda izinto’ [to love things] when you don’t become proactive and you just think about the situation, not what happens afterwards. (IDI 7)
For students, being acknowledged and accepted by peers is important. This acknowledgment and acceptance entails emulating their behaviour; in this instance, risky sexual behaviour is a means of gaining entry and certification into a desired social group.
Condom use
Consistent use of condoms is one of the most effective strategies for reducing the risks associated with sexual behaviour. Early sexual debut is likely to affect readiness and use of protection. Those who start sexual activities at an early age are often likely to engage in unprotected sex and engage in high sexual risk taking, involving multiple sexual partners (Zuma et al., 2010; Kastbom, Sydsjö, Bladh, Priebe, & Svedin, 2015). In the interviews it became clear that condoms are not used consistently, especially during the first sexual encounter. The majority of the students reported that they did not use condoms during their first sexual encounter because of their lack of adequate awareness. In addition, they were not prepared for the sexual encounter and therefore they did not have any condoms. No I didn’t use a condom because it was my first time engaging in sexual intercourse with someone who was already sexually active. So she wanted to teach me how sex was done. (IDI 15) No, because I think at that stage I wasn’t aware and there is this belief that if you are still a virgin, you shouldn’t use a condom. (FGD 6)
I was not familiar with the use of condoms, but I remember there was this day when I used it, I opened it using my teeth and it got twisted around my penis and it was painful. (IDI 11)
Despite the general awareness of risk-related behaviours and the consequences, students provided various reasons why they felt condoms were not used and why safer sex was not practiced frequently and consistently among students. It was fairly difficult, especially for female students, to negotiate condom use with their partners as they would insist on engaging in sexual intercourse without condoms. Inconsistent condom use is more common in stable, long-term relationships. Couples in more long-term relationships are expected to be loyal and faithful to their partners.
No, it is very hard to negotiate condom use with my partner because my partner doesn’t want to use condoms at all. (IDI 10)
The hardest part I think in most relationships is that we always argue about condom use whenever we engage in sexual intercourse. (IDI 8)
It was also discovered that some young people did not use condoms during their last sexual encounter because of the nature of their sexual partnership. Students believed that if they were in a stable, committed relationship then there was no need to consistently use condoms, or even use condoms at all, because it is expected that their partner would be faithful to them. The introduction of condoms during sex still raises suspicions of infidelity.
With my woman we don’t use a condom, we prefer to test regularly because we are very committed to each other. So we don’t use it and we’ve negotiated
that. (IDI 14)
These accounts of students shed light on the extent of inconsistent use of condoms among the sexually active young people as well as some of the reasons for not using them. Among students who reported condom use the reasons advanced were that of protection against the risks associated with unprotected sexual intercourse. These students reported using condoms for protection against the risk of unplanned pregnancies and STIs (including HIV). Consistent condom use was practiced among students who perceived a heightened risk of HIV and AIDS and unplanned pregnancy in their sexual encounters.
I did use condom because I knew that when you engage in sexual intercourse you need to use a condom and I was old the time I started engaging. (IDI 6)
Yes I did, because I was scared of falling pregnant
and getting infected. (IDI 5)
Yes, because I was told that one needs to protect themselves against sexual transmitted diseases when engaging in sexual activities. (IDI 3)
Many barriers stand in the way of safer sexual practices, and this results in the inconsistent use of condoms. Students were also asked about the challenges in changing risky sexual behaviours. Alcohol poses a challenge to the effective and consistent use of condoms. Students reveal that they are more likely to engage in risky sexual behaviours under the influence of alcohol. In addition, alcohol use enhances an individual’s willingness to engage in sexual activity.
Tequilas makes a girl desire sex then you would know that you’ve won her that night. (FGD 1) Most of the times they come and then they have that alcohol and then at the end of the day they will have sex. (IDI 4)
I think it is alcohol because my partner couldn’t even remember that we even had sex. So now if she couldn’t even remember that we did have sex, how can she remember we had used protection? (IDI 4)
Another factor that serves as an obstacle to condom use was the perceived poor quality of condoms available in public facilities. Males revealed that they would not feel as if they are ‘real’ men if they used condoms that are provided for free. In addition, they complained that they experienced breakages and slippages with these condoms. Men felt that they could not use these condoms with their female partners as they will be perceived as disrespecting women.
My brothers here can agree with me, you see the Choice condoms, we can say by using them you are also engaging in unprotected sex because firstly these condoms are too light and soft and they burst so easily, we can’t trust them. (FGD 1) She will say I don’t appreciate her if I use a Choice condom with her. (IDI 4)
If they [government/service providers] can come up with a solution to this problem because really we can’t use them, “Ayasilahlisa” [they make us lose respect] and they smell so bad. (IDI 2)
In addition to the dissatisfaction associated with the use of government sponsored condoms available in public facilities, students were discouraged from the use of these condoms as they were perceived as not being of a high quality and having an unpleasant smell.
Discussion
This study sought to explore the risky behaviours of university students in Durban, South Africa and to ascertain the use of protective measures, particularly condoms during their sexual encounters. The findings revealed that students have a fairly good understanding of what constitutes risky sexual behaviour. Students are equally aware of the risks associated with unprotected sexual intercourse. Youth in South Africa are at a higher risk of HIV infection in comparison to any other age group (Zuma et al., 2016). The epidemics are complex and are influenced by a number of behavioural, historical and structural factors (Coovadia, Jewkes, Barron, Sanders, & McIntyre, 2009). Despite having a fairly widespread understanding of risky behaviours, most students do not perceive themselves personally at risk, a finding consistent with other studies (Ferrer et al. 2007; Ntata, Muula, Siziya, & Kayambazinthu, 2008; Rahamfey et al., 2008). This is difficult to understand given that most students are familiar with the risky environment at universities; however, they continually engage in risk-related behaviours.
The study found there was a relatively small sample of students that reported that they were not currently sexually active while a few reported that they have never had sex. This decision may be attributed to personal, moral or religious influences. It is suggested that religion often provides a moral compass for sexual behaviour (Bangirana, Nadar & Reddy, 2017). Students refrain from engaging in risky sexual behaviours as they are guided by their moral and religious principles (Bangirana, Nadar & Reddy, 2017), however it is uncertain as to how many students regulate their sexual conduct because of religion.
The study found that it is not uncommon for young people to have multiple partners; however, male students were more likely than females to report multiple sexual partners. Male respondents continue to engage in sexual relations with many females despite their awareness of the risks associated with multiple sexual partners. For many male students, multiple sexual partners are associated with ‘real’ men and having many sexual partners elevated their status among their peers. The study found that it is socially acceptable for men to have multiple sexual partners and this is supported by peer pressure. Research suggests that sex without protection gives male students a sense of reassurance about their manhood and also, avoided any inferior labelling by peers (Kanda & Mash, 2018). This is supported by the findings of this study as young men suggested that they did not feel as if they are real men if they used condoms that are provided for free. These findings are consistent with those of Prata, Vahidnia, and Fraser (2005) who indicated that younger individuals are not personally worried about contracting HIV from having multiple sexual partners. In their study, Cherie and Berhane (2012) also highlight peer pressure as an important driver of risky sexual behaviours.
Across the globe, unintended pregnancies are attributed to an array of factors such as poor family planning and inadequate access to contraceptives, societal beliefs and norms, lack of inter-partner communication, and sexual violence (Glasier, Gülmezoglu, Schmid, Moreno, & Van Look, 2006; Cheng, Schwarz, Douglas, & Horon, 2009; Goicolea & San Sebastian, 2010; Khajehpour, Simbar, Jannesari, Ramezani-Tehrani, & Majd, 2013; Haffejee et al., 2018). In sub-Saharan Africa the risk of an unintended pregnancy remains high due to poor access to reproductive health care (Eliason, Baiden, Yankey, & Awusabo– Asare, 2014) and the non-use of condoms within sexual relationships because of the limited ability of women to negotiate safer sexual behaviours (Toska, Cluver, Boyes, Pantelic, & Kuo, 2015). This study found that students are aware of the consequences of not using condoms consistently and the risk of an unwanted pregnancy and therefore used condoms consistently to avoid this. These findings are consistent with that of existing research which suggests that one of the negative consequences of engaging in risky sexual behaviours is an unwanted pregnancy (Abousselam, Naudé, Lens, & Esterhuyse, 2016). Findings from Norton, Fisher, Amico, Dovidio, & Johnson. (2012) suggests that young adults are more concerned about experiencing an unplanned pregnancy than becoming infected with HIV. Similar findings from Steenkamp, Busolo, and von der Marwitz (2012) amongst university students suggested that there was an awareness of the heightened risk of an unplanned pregnancy and strong support for prevention of an unwanted pregnancy.
While the need for condom use is widely evident, especially since empirical evidence highlights the prevailing high rates of STI and HIV infection (Francis et al., 2018; Statistics South Africa, 2018), the consistency of condom use remains elusive, even among the segment of the population who are educated and aware of the consequences of risk-related behaviours. The study found students did not use condoms during their first sexual encounter because many are not adequately prepared for the encounter. In addition, students revealed that in stable, committed relationships condoms are not used because partners are expected to be faithful. Other studies (Higher Education and Training Health, Wellness and Development Centre [HEAids], 2010) found high condom use at last sexual intercourse among university students, but a notable decline of condom use in more stable, long-term relationships. Consistent condom use within more stable relationships was found to be limited. This is because the consistent use of condoms is complicated by the dynamics of trust within more stable, long-term relationships. However, it is important to advocate for the consistent use of condoms, even within more stable relationships, for the dual protection that condoms offer, especially within a high HIV context (Hoffman et al., 2017). The findings of this study are consistent with results from earlier studies that suggest that the use of condoms are not popular in more stable sexual relationships, reflecting that people normally do not view these relationships as risky (Adetunji, 2000; Maharaj & Cleland, 2005; Haddad et al., 2018).
Another factor deterring condom use was the perception of the poor quality of condoms provided by the government. Students were also discouraged from using condoms that were available from public facilities because they were seen as not trustworthy and less desired by their sexual partners. These findings are consistent with another study which suggests that there are negative perceptions of government sponsored condoms due to their quality, texture, smell and durability (Holland & French, 2012). Male students were opposed to these condoms and further indicated that they did not want to utilise the government provided condoms as they lead to negative perceptions of them by their partners. Additionally they were undesirable as they had an unpleasant smell. This highlights distrust in the efficacy of condoms and as a result this is likely to influence the decision to use condoms. Additionally, males were expected to show that they value their partners by using higher quality condoms.
A lack of socio-economic support from their families among students is often associated with the economic commodification of sex (the exchange of sex for material benefits). Prevalent economic challenges experienced across South Africa is a key factor in the involvement of risky sexual behaviours (Kaufman & Stavrou, 2004; Dunkle et al., 2004; Dunkle et al., 2007). This study found that students, particularly females, may engage in risky sexual behaviours for economic reasons. Students from poorer financial backgrounds were more likely to be involved in sexual encounters that involved the commodification of sex. These findings are supported by that of another study which suggests that females engage in sexual relationships for money and goods (Ranganathan et al., 2018). Mobile phones, perfumes, and expensive clothes are viewed as highly prized commodities, along with access to money for leisure activities, which are often provided by older boys or men (known as sugar daddies) in exchange for sex with adolescent girls (Katz et al., 2013; Potgieter, Strebel, Shefer, & Wagner, 2012). Unfortunately, many students cannot afford such items due to their financial situation and students felt that they had to have the same possessions as their peers. Peers are those that share a similar identity, are generally within the same age groups and educational categories and have common interests. However, what is also clear is that there are varying socio-economic positions that exists between peers within the university environment. Therefore, even though there are students with similar characteristics it is important to acknowledge that there are students that have access to sufficient resources and as a result, do not have to engage in sexual encounters for material benefits.
In South Africa, the dominant ideal of manhood emphasises toughness and strength in relation to sexual success. It is a particular notion of masculinity that both men and women desire; yet it is sexually risky and exacerbates gender inequality (Jewkes & Morrell, 2010). Risky sexual practices of men are highly associated with gender inequality (Morrell, 2010; Jewkes et al., 2006; Stephenson, 2010; Shai, Jewkes, Nduna, & Dunkle, 2012). In the South African context, authors have argued that male toughness, multiple sexual partners, and inconsistent condom use originate from notions of hegemonic masculinity (Shai et al., 2012; Jewkes & Morrell, 2010). These notions of masculinity may influence young men’s condom use behaviour, and acts as a barrier for reducing HIV risk.
There is a need for a change in behaviour among university students however, in order for a change in behaviour change to occur, the conditions under which the individual is to change their behaviour needs to be conducive to change. The findings of this study suggests that this is often not the case for students in tertiary environments as the university is associated with high risk behaviours (Crimmins & Seigfried-Spellar, 2014). Another barrier to condom use is the use of alcohol. Alcohol consumption increases an individual’s decision to engage in risky sexual behaviour because alcohol usually affects the ability of an individual to make responsible and informed decisions (Kaufman & Stavrou, 2004; Sarkar, 2008). Male students reported that they usually provided their female partners with alcohol prior to engaging in sexual activity with them to make the initiation of sex more acceptable. The use of alcohol enhances the willingness of individuals to engage in sexual intercourse, which is often unprotected.
The primary limitation of this study was the use of qualitative methodology. This is limiting as the study does not produce statistical results therefore, the researcher could not capture the prevalence rate of risky sexual behaviours among students. Thus, it is recommended that future studies pertaining to risky sexual behaviours measure the incidence and occurrence of student’s risky sexual behaviours. Additionally, the study was also limited to students residing in and around the university and thus the results of the study are reflective of urban experiences of risky sexual behaviour amongst students. Therefore, caution should be exercised when generalising results to differing settings.
The main policy implication of the findings of this study is that peer-related as well as sexual and reproductive health programs needs to be continually geared towards practical ways of providing young people with information, education, and health services, or equipping them with skills to protect them from risks. It is evident from the results of the study that peers have a powerful influence on behavioural outcomes and existing programs are not addressing this effectively as a factor of risky sexual behaviours. Despite the fact that social norms are one of the most widely studied drivers of human behaviour, there is a fine line between what they are, how they sustain behaviour, and how they can be changed (Cislaghi & Shakya, 2018). In order for programs and initiatives that are geared towards safer sexual practices to be effective, there needs to be a substantial effort through coordinated and complementary approaches that have proved to be effective and efficient in varying contexts. Unproductive approaches that have become uninteresting, monotonous and exhaustive should be abandoned so that new approaches can be explored. New approaches should include greater efforts towards prevention and expanding access to a wider range of needs (Chandra-Mouli, Lane & Wong, 2015). Campaigns and programmes should be executed in and around the university to ensure that messages reach as many young people as possible. These initiatives should aim to be socially influential towards young people to address existing norms that promotes risky sexual activity. Interventions should be specifically targeted towards gender and health. Policy-makers will need to consider health-seeking behaviours with regard to young people and risky sexual behaviours. A masculinities-based approach to promote gender equality should be considered as a means to address dominant notions of masculinity. This will assist with the transformation of gender norms at the individual, community and wider societal level. Programmes should capitalise on initiatives and interventions that are geared towards resisting peer pressure and promoting safer sexual health, especially within heterosexual relationships. This will assist in achieving sustainable and widespread gender equality transformation. Understanding this difference between women and men as well as empowering younger women is critical for STI (including HIV) prevention.
Conclusion
The study suggests that there is a fairly good understanding of risky sexual behaviour and the perceived consequences thereof among young men and women. Although there is evidence of students protecting themselves against HIV and STIs, their use of methods are not consistent which elevates their level of risk. This study suggests that female students are more likely to be engaged in risky sexual activity in exchange for material resources. However, men were more likely to report multiple sexual partners. Male students are more likely to want to demonstrate their sexual prowess by having multiple sexual partners. It is clear that peers have a powerful influence on one’s behaviour and although there is a relationship between religion and behavioural outcomes, it is unclear as to how many students are guided by their principles. It is recommended that there should be a greater investment in a co-ordinated effort to address risky sexual practices amongst students as well as to continually promote consistent condom use. Programmes should be appealing to students and should put more emphasis on a combination of risk reducing strategies.
ORCID
Pranitha Maharaj https://orcid.org/0000-0003-3518-8237
Shanaaz Rademeyer https://orcid.org/0000-0003-0292-0305
References
Abousselam, N., Naudé, L., Lens, W., & Esterhuyse, K. (2016). The relationship between future time perspective, self-efficacy and risky sexual behaviour in the Black youth of central South Africa. Journal of Mental Health (Abingdon, England), 25(2), 176–183. https://doi. org/10.3109/09638237.2015.1078884
Adeniyi, O. V., Ajayi, A. I., Moyaki, M. G., Goon, D. T., Avramovic, G., & Lambert, J. (2018). High rate of unplanned pregnancy in the context of integrated family planning and HIV care services in South Africa. BMC Health Services Research, 18(1), 140. https:// doi.org/10.1186/s12913-018-2942-z
Adetunji, J. (2000). Condom use in marital and nonmarital relationships in Zimbabwe. International Family Planning Perspectives, 26(4), 196–200. https://doi.org/10.2307/2648258
Ajayi, N. A., & Omotayo, B. O. (2010). Challenges of HIV/AIDS to undergraduate students: The librarians’ reaction. International Journal of Library and Information Science, 2(2), 88–94.
Alamrew, Z., Bedimo, M., & Azage, M. (2013). Risky sexual practices and associated factors for HIV/AIDS infection among private college students in Bahir Dar City, Northwest Ethiopia. ISRN Public Health, 2013, 1–9. https://doi.org/10.1155/2013/763051
Bangirana, A. B., Nadar, S., & Reddy, S. (2017). Sexual surveillance and student sexual agency: Catholic moral teaching and HIV prevention in a higher education context. Journal for the Study of Religion, 30(2), 105–121. https://doi.org/10.17159/2413-3027/2017/
v30n2a5
Bingenheimer, J. B., Asante, E., & Ahiadeke, C. (2015). Peer influences on sexual activity among adolescents in Ghana. Studies in Family Planning, 46(1), 1–19. https://doi. org/10.1111/j.1728-4465.2015.00012.x
Cheng, D., Schwarz, E. B., Douglas, E., & Horon, I. (2009). Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. Contraception, 79(3), 194–198. https://doi. org/10.1016/j.contraception.2008.09.009
Cherie, A., & Berhane, Y. (2012). Oral and anal sex practices among high school youth in Addis Ababa, Ethiopia. BMC Public Health, 12, 1–9. https://doi.org/10.1186/1471-2458-12-5
Cooper, M. L. (2002). Alcohol use and risky sexual behavior among college students and youth: Evaluating the evidence. Journal of Studies on Alcohol, 2002(s14), 101–117. https://doi.org/10.15288/ jsas.2002.s14.101
Coovadia, H., Jewkes, R., Barron, P., Sanders, D., & McIntyre, D. (2009). The health and health system of South Africa: Historical roots of current public health challenges. Lancet, 374(9692), 817–834. https://doi.org/10.1016/S0140-6736(09)60951-X
Crimmins, D. M., & Seigfried-Spellar, K. C. (2014). Peer attachment, sexual experiences, and risky online behaviors as predictors of sexting behaviors among undergraduate students. Computers in Human Behavior, 32, 268–275. https://doi.org/10.1016/j. chb.2013.12.012
Deckman, T., & DeWall, C. N. (2011). Negative urgency and risky sexual behaviors: A clarification of the relationship between impulsivity and risky sexual behavior. Personality and Individual Differences, 51(5), 674–678. https://doi.org/10.1016/j.
paid.2011.06.004
Desale, A. Y., Argaw, M. D., & Yalew, A. W. (2016). ‘Prevalence and associated factors of risky sexual behaviours among in-school youth in Lalibela Town, North Wollo zone, Amhara regional state, Ethiopia: a cross-sectional study design’. Science, 4(1), 57–64.
Dolphin, L., Fitzgerald, A., & Dooley, B. (2018). Risky sex behaviours among college students: The psychosocial profile. Early Intervention in Psychiatry, 12(6), 1203–1212. https://doi.org/10.1111/eip.12526
Doyle, A. M., Mavedzenge, S. N., Plummer, M. L., & Ross, D. A. (2012). The sexual behavior of adolescents in sub-Saharan Africa: Patterns and trends from national surveys. Tropical Medicine & International Health, 17(7), 796–807. https://doi. org/10.1111/j.1365-3156.2012.03005.x
Dunkle, K. L., Jewkes, R. K., Brown, H. C., Gray, G. E., McIntryre, J. A., & Harlow, S. D. (2004). Transactional sex among women in Soweto, South Africa: Prevalence, risk factors and association with HIV infection. Social Science & Medicine, 59(8), 1581–1592. https://
doi.org/10.1016/j.socscimed.2004.02.003
Dunkle, K. L., Jewkes, R., Nduna, M., Jama, N., Levin, J., Sikweyiya, Y., & Koss, M. P. (2007). Transactional sex with casual and main partners among young South African men in the rural Eastern Cape: Prevalence, predictors, and associations with gender-based violence. Social Science & Medicine, 65(6), 1235–1248. https://doi.
org/10.1016/j.socscimed.2007.04.029
Eliason, S., Baiden, F., Yankey, B. A., & Awusabo–Asare, K. (2014). Determinants of unintended pregnancies in rural Ghana. BMC Pregnancy and Childbirth, 14, 1–9. https://doi. org/10.1186/1471-2393-14-261
Ferrer, L., Cianelli, R., Guzman, E., Cabieses, B., Irarrázabal, L., Bernales, M., & Araya, A. (2007). Chilean university students:
Knowledge and concern about HIV/AIDS. The Journal of the Association of Nurses in AIDS Care: JANAC, 18(5), 51–56. https:// doi.org/10.1016/j.jana.2007.07.001
Francis, S. C., Mthiyane, T. N., Baisley, K., Mchunu, S. L., Ferguson, J. B., Smit, T., … Shahmanesh, M. (2018). Prevalence of sexually transmitted infections among young people in South Africa: A nested survey in a health and demographic surveillance site.
PLoS Medicine,15(2), e1002512. https://doi.org/10.1371/journal. pmed.1002512
Gerressu, M., & Stephenson, J. M. (2008). Sexual behaviour in young people. Current Opinion in Infectious Diseases, 21(1), 37–41. https://doi.org/10.1097/QCO.0b013e3282f3d9bd
Glasier, A., Gülmezoglu, A. M., Schmid, G. P., Moreno, C. G., & Van Look, P. F. (2006). Sexual and reproductive health: A matter of life and death. Lancet, 368(9547), 1595–1607. https://doi.org/10.1016/ S0140-6736(06)69478-6
Goicolea, I., & San Sebastian, M. (2010). Unintended pregnancy in the amazon basin of Ecuador: A multilevel analysis. International Journal for Equity in Health, 9, 1–11. https://doi.org/10.1186/1475-9276-9-14
Guo, J., Chung, I. J., Hill, K. G., Hawkins, J. D., Catalano, R. F., & Abbott, R. D. (2002). Developmental relationships between adolescent substance use and risky sexual behavior in young adulthood. The Journal of Adolescent Health, 31(4), 354–362. https://doi.org/10.1016/S1054-139X(02)00402-0
Haddad, L. B., Tang, J. H., Krashin, J., Ng’ambi, W., Tweya, H., Samala, B., … Phiri, S. (2018). Factors associated with condom use among men and women living with HIV in Lilongwe, Malawi: A cross-sectional study. BMJ Sexual & Reproductive Health, 44, 42–53. https://doi.org/10.1136/bmjsrh-2017-101825
Haffejee, F., O’Connor, L., Govender, N., Reddy, P., Sibiya, M. N., Ghuman, S., … Borg, D. (2018). Factors associated with unintended pregnancy among women attending a public health facility in KwaZulu-Natal, South Africa. South African Family Practice, 60(3), 79–83. https://doi.org/10.1080/20786190.2017.1396790
Higher Education and Training Health, Wellness and Development Centre (HEAids). (2010). HIV prevalence and related factors – Higher education sector study. South Africa, 2008–2009. Pretoria: Higher Education South Africa.
Hoffman, S., Levasseur, M., Mantell, J. E., Beksinska, M., Mabude, Z., Ngoloyi, C., … Smit, J. A. (2017). Sexual and reproductive health risk behaviours among South African university students: Results from a representative campus-wide survey. African Journal of AIDS
Research, 16(1), 1–10. https://doi.org/10.2989/16085906.2016.1
259171
Holland, K. J., & French, S. E. (2012). Condom negotiation strategy use and effectiveness among college students. Journal of Sex
Research, 49(5), 443–453. https://doi.org/10.1080/00224499.201
1.568128
Hoque, M. E. (2011a). ‘Reported risky sexual practices amongst female undergraduate students in KwaZulu-Natal, South Africa’. African Journal of Primary Health Care & Family Medicine,3(1), 1–6. https://doi.org/10.4102/phcfm.v3i1.281
Hoque, M. E. (2011b). ‘Sexual practices among male undergraduate students in KwaZulu Natal, South Africa’. The Southern African Journal of Epidemiology & Infection : Official Journal of the Sexually
Transmitted Diseases, Infectious Diseases and Epidemiological
Societies of Southern Africa, 26(3), 157–160. https://doi.org/10.108
0/10158782.2011.11441439
Jewkes, R., Dunkle, K., Koss, M. P., Levin, J. B., Nduna, M., Jama, N., & Sikweyiya, Y. (2006). Rape perpetration by young, rural South African men: Prevalence, patterns and risk factors. Social Science & Medicine, 63(11), 2949–2961. https://doi.org/10.1016/j. socscimed.2006.07.027
Jewkes, R., & Morrell, R. (2010). Gender and sexuality: Emerging perspectives from the heterosexual epidemic in South Africa and implications for HIV risk and prevention. Journal of the International AIDS Society, 13, 1–11. https://doi.org/10.1186/1758-2652-13-6 Jones, B. T., Eaton, S., Livingston, J. N., & Cliette, G. E. (2018). Substance use, risky sexual behavior and delinquency among students at a historically black college. Addict Drug Sensitize, 2(109), 53–59.
Kalichman, S. C., Ntseane, D., Nthomang, K., Segwabe, M., Phorano, O., & Simbayi, L. C. (2007). Recent multiple sexual partners and HIV transmission risks among people living with HIV/AIDS in Botswana. Sexually Transmitted Infections, 83(5), 371–375. https:// doi.org/10.1136/sti.2006.023630
Kanda, L., & Mash, R. (2018). Reasons for inconsistent condom use by young adults in Mahalapye, Botswana. African Journal of Primary Health Care & Family Medicine,10(1), 1–7. https://doi.org/10.4102/
phcfm.v10i1.1492
Kastbom, Å. A., Sydsjö, G., Bladh, M., Priebe, G., & Svedin, C. G. (2015). Sexual debut before the age of 14 leads to poorer psychosocial health and risky behaviour in later life. Acta Paediatrica (Oslo, Norway), 104(1), 91–100. https://doi.org/10.1111/apa.12803 Katz, I. T., Ybarra, M. L., Wyatt, M. A., Kiwanuka, J. P., Bangsberg, D. R., & Ware, N. C. (2013). Socio-cultural and economic antecedents of adolescent sexual decision making and HIV-risk in rural Uganda.
AIDS Care, 25(2), 258–264. https://doi.org/10.1080/09540121.201
2.701718
Kaufman, C. E., & Stavrou, S. E. (2004). ‘Bus fare please’: The economics of sex and gifts among young people in urban South Africa. Culture, Health & Sexuality, 6(5), 377–391. https://doi.org/10
.1080/13691050410001680492
Khajehpour, M., Simbar, M., Jannesari, S., Ramezani-Tehrani, F., & Majd, H. A. (2013). Health status of women with intended and unintended pregnancies. Public Health, 127(1), 58–64. https://doi. org/10.1016/j.puhe.2012.08.011
Klassen, B. J., Fulcher, K., Chown, S. A., Armstrong, H. L., Hogg, R. S., Moore, D. M., … Lachowsky, N. J. (2019). “Condoms are… like public transit. It’s something you want everyone else to take”: Perceptions and use of condoms among HIV negative gay men in Vancouver, Canada in the era of biomedical and seroadaptive prevention. BMC Public Health, 19, 1–13. https://doi.org/10.1186/ s12889-019-6452-7
Lewis, J., & Ritchie, J. (2003). Generalising from qualitative research. Qualitative research practice: A guide for social science students and researchers. London: Sage.
Mack, N., Woodsong, C., MacQueen, K., Guest, G., & Namey, E. (2005). Focus Groups. In Qualitative Research Methods: A data collector’s field guide (pp. 51–82). North Carolina, USA: Family Health International.
Maharaj, P., & Cleland, J. (2005). Risk perception and condom use among married or cohabiting couples in KwaZulu-Natal, South Africa. International Family Planning Perspectives, 31(01), 24–29. https://doi.org/10.1363/3102405
Marlatt, G. A., Larimer, M. E., & Witkiewitz, K. (Eds.). (2011). Harm reduction: Pragmatic strategies for managing high-risk behaviors. New York: Guilford Press.
Menon, J. A., Mwaba, S. O., Thankian, K., & Lwatula, C. (2016). Risky sexual behaviour among university students. International STD Research & Reviews, 4(1), 1–7.
Ndinda, C., Ndhlovu, T., & Khalema, N. (2017). Conceptions of contraceptive use in rural KwaZulu-Natal, South Africa: Lessons for programming. International Journal of Environmental Research and Public Health, 14(4), 1–17. https://doi.org/10.3390/ijerph14040353
Nicholson, J. (2012). Risky sexual behaviour among adolescents and young adults. Chapel Hill: University of North Carolina.
Norton, W. E., Fisher, J. D., Amico, K. R., Dovidio, J. F., & Johnson, B. T. (2012). Relative efficacy of a pregnancy, sexually transmitted infection, or human immunodeficiency virus prevention–focused intervention on changing sexual risk behavior among young adults.
Journal of American College Health, 60(8), 574–582. https://doi.
org/10.1080/07448481.2012.721428
Ntata, P. R. T., Muula, A., Siziya, S. & Kayambazinthu, E. E. (2008). Gender Differences in University Students’ HIV/AIDS-Related Knowledge and Sexual Behaviours in Malawi: A Pilot Study. SAHARA-J: Journal of Social Aspects of HIV/AIDS, 5(4), 201–205.
https://doi.org/10.1080/17290376.2008.9724920
Parsons, J. T., Halkitis, P. N., Bimbi, D., & Borkowski, T. (2000). Perceptions of the benefits and costs associated with condom use and unprotected sex among late adolescent college students. Journal of Adolescence, 23(4), 377–391. https://doi.org/10.1006/
jado.2000.0326
Potgieter, C., Strebel, A., Shefer, T., & Wagner, C. (2012). Taxi ‘sugar daddies’ and taxi queens: Male taxi driver attitudes regarding transactional relationships in the Western Cape, South Africa. Journal of Social Aspects of HIV/AIDS Research Alliance, 9(4), 192–199. https://doi.org/10.1080/17290376.2012.745286
Prata, N., Vahidnia, F., & Fraser, A. (2005). Gender and relationship differences in condom use among 15–24 year olds in Angola. International Family Planning Perspectives, 31(4), 192–199. https://
doi.org/10.1363/3119205
Rahamfey, O. H., Rivard, M., Ravaoarinoro, M., Ranaivoharisoa, L., Rasamindrakotroka, A. J. & Morisset, R. (2008). Sexual Behavior and Condom Use among University Students in Madagascar. SAHARA-J: Journal of Social Aspects of HIV/ AIDS, 5(1), 28–35.
https://doi.org/10.1080/17290376.2008.9724899
Ranganathan, M., Heise, L., MacPhail, C., Stöckl, H., Silverwood, R. J., Kahn, K., … Pettifor, A. (2018). ‘It’s because I like things… it’sa status and he buys me airtime’: Exploring the role of transactional sex in young women’s consumption patterns in rural South Africa (secondary findings from HPTN 068). Reproductive Health, 15, 1–21. https://doi.org/10.1186/s12978-018-0539-y
Richardson, S. A., Dohrenwend, B. S., & Klein, D. (1965). Interviewing: Its forms and functions. New York: Basic Books.
Sarkar, N. N. (2008). Barriers to condom use. The European Journal of Contraception & Reproductive Health Care, 13(2), 114–122. https:// doi.org/10.1080/13625180802011302
Shai, N. J., Jewkes, R., Nduna, M., & Dunkle, K. (2012). Masculinities and condom use patterns among young rural South Africa men: A cross-sectional baseline survey. BMC Public Health, 12, 1–9. https://
doi.org/10.1186/1471-2458-12-462
Shisana, O., Rehle, T., Simbayi, L. C., Zuma, K., Jooste, S., Zungu, N., & Onoya, D. (2014). South African national HIV prevalence, incidence and behaviour survey, 2012. Pretoria: HSRC Press.
Simbayi, L. C., Zuma, K., Zungu, N., Moyo, S., Marinda, E., Jooste, S., … Naidoo, I., & the SABSSMV Team. (2018). South African National HIV Prevalence, Incidence, Behaviour and Communication Survey, 2017. Cape Town: HSRC Press.
Statistics South Africa. (2016). Community Survey 2016 in Brief. Pretoria: Statistics South Africa Statistics South Africa. (2018). Mid-year population estimates 2018. Statistical Release. P0302. Pretoria: Statistics South Africa.
Steenkamp, L., Busolo, M., & von der Marwitz, J. (2012). ‘An innovative online HIV/STI prevention programme in higher education: Preliminary results NMMU’. South African Journal of
Higher Education, 26(5), 1066–1079. https://hdl.handle.net/10520/
EJC132750
Stephenson, R. (2010). Community-level gender equity and extramarital sexual risk-taking among married men in eight African countries. International Perspectives on Sexual and Reproductive Health, 36(4), 178–188. https://doi.org/10.1363/3617810
Toska, E., Cluver, L. D., Boyes, M., Pantelic, M., & Kuo, C. (2015). From ‘sugar daddies’ to ‘sugar babies’: Exploring a pathway among age-disparate sexual relationships, condom use and adolescent pregnancy in South Africa. Sexual Health, 12(1), 59–66. https://doi.
org/10.1071/SH14089
UNAIDS. (2014). The gap report. Geneva: UNAIDS.
UNAIDS. (2016). Global Aids update 2016. Geneva: UNAIDS.
UNFPA. (2010). Comprehensive condom programming. A guide for resource mobilization and country programming. New York: UNFPA.
UNICEF. (2011). Opportunity in Crisis: Preventing HIV from early adolescence to young adulthood. New York: UNICEF.
Warren, M., & Philpott, A. (2003). Expanding safer sex options: Introducing the female condom into national programmes.
Reproductive Health Matters, 11(21), 130–139. https://doi.
org/10.1016/S0968-8080(03)02178-5
Zuma, K., Setswe, G., Ketye, Y., Mzolo, T., Rehle, T., & Mbelle, N. (2010). ‘Age at sexual debut: A determinant of multiple partnership among South African youth’. African Journal of Reproductive Health, 14(2), 47–54.
Zuma, K., Shisana, O., Rehle, T. M., Simbayi, L. C., Jooste, S., Zungu, N., … Abdullah, F. (2016). New insights into HIV epidemic in South Africa: Key findings from the National HIV Prevalence, Incidence and Behaviour Survey, 2012. African Journal of AIDS
Research,15(1), 67–75. https://doi.org/10.2989/16085906.2016.1 153491
Reply all
Reply to author
Forward
0 new messages