National cross sectional study of views on sexual violence and risk of HIV infection and AIDS among South African school pupils
http://www.100md.com
《英国医生杂志》
1 Centro de Investigación de Enfermedades Tropicales (CIET), Universidad Autónoma de Guerrero, Apdo Postal 182, Acapulco, Mexico, 2 CIETafrica, Postnet 123, Pvt Bag X2600, Houghton 2041, South Africa
Correspondence to: N Andersson neil@ciet.org
Abstract
In South Africa sexual violence is probably exacerbated by the country's violent past. The endemic violence is now highly sexualised and is aimed at the most vulnerable members of society.1 2 HIV infection and AIDS have spread widely as a result of unprotected and forced sex.3 4
The consequences of sexual abuse during childhood are well recognised as is the link between sexual violence and HIV infection.5-9 In South Africa, several studies in youth have shown that they are affected by sexual violence, that there is a high prevalence of misconceptions about sexual violence and about the risk of HIV infection and AIDS, and that responses to communication about behaviour change may be less positive than expected.10-18 We investigated the views of South African school pupils towards sexual violence and towards the risk of HIV infection and AIDS.
Methods
Between September and November 2002 we invited 5162 classes in 1418 South African schools to take part in our study. Overall, 283 576 youth agreed to participate. Their ages ranged from 10 to 22 years. We excluded those over 20 years of age, leaving 269 705 participants (average age 14.8 years). The questionnaire was returned by all participants. The non-response rate to individual questions was between 0% and 4.3% (tables 1, 2, 3).
Table 1 Beliefs and views among South African youth on sexual violence. Values in brackets are weighted by province or metropolitan, urban, or rural area. Values are numbers (percentages) of respondents
Table 2 Misconceptions among South African youth about sexual violence and about risk of HIV infection. Percentages in brackets are unweighted
Table 3 Misconceptions among South African youth about risk of HIV infection. Values are numbers (percentages; unweighted)
Males were more likely than females to have misconceptions about sexual violence (table 1). The younger respondents (10-14 years) were more likely than the older ones (5-19 years) to believe that sexual violence does not include touching, that if you know someone, forcing sex is not sexual violence, and that girls have no right to refuse sex with their boyfriend. Respondents who were male or lived in a rural area were more likely to express three or more of the eight views (table 2).
Knowledge, views, and beliefs about risk of HIV infection
Condoms
Overall, 57.1% (weighted value based on 147 416/258 080) of respondents stated that condoms could prevent pregnancy, 49.8% (weighted value based on 131 021/262 977) that they can prevent sexually transmitted diseases, and 59.6% (weighted value based on 159 637/267 795) that they can help prevent HIV infection. In urban areas, younger females were significantly less likely than older females to believe that condoms could prevent the spread of HIV infection and AIDS (odds ratio 0.71, 95% confidence interval 0.70 to 0.73; 16 904/32 123 v 144 643/237 582).
HIV test
Around 60% of respondents intended to have an HIV test. A gradient was seen between rural and urban or metropolitan or capital areas, with little difference between ages or sex (table 2).
Talking about sex
In total, 34.0% (weighted value based on 108 284/269 705) of respondents reported that they never spoke to anyone about sex. When they did report having talked to someone it was associated with the intention of being tested for HIV (odds ratio 1.34, 95% confidence interval 1.32 to 1.37); of those who intended to have a test, 60.9% (98 318/161 421) had someone to talk to and 53.7% (58 122/108 284) did not have someone to talk to. Overall, 15.7% (19 720/124 120) of males and 14.4% (20 303/141 184) of females said they would not tell their family if they were HIV positive (table 3).
High risk behaviour
Overall, 15.8% (42 658/269 704) of respondents said they would have unprotected sex and 15.7% (weighted value based on 41 904/266 903) said they would spread the infection intentionally. These views were expressed most by older (15-19 years) males from rural areas (table 3).
Virgin myth
The belief that sex with a virgin could cure HIV infection or AIDS was reported by 12.7% (34 014/266 910) of respondents and was more common in youth from rural areas (table 3). Those respondents who had learnt from school about the risk of HIV infection were significantly less likely to believe this myth (odds ratio 0.84, 0.82 to 0.87). This protective effect remained after taking into account other sources of information on HIV, age, sex, and history of sexual abuse.
Links between sexual violence and risk of HIV infection
Overall, 8.6% (weighted value based on 27 118/269 705) of respondents said they had been forced to have sex in the past year. Younger males were more likely to report this than younger females (figure). In the older age group, more females than males reported having been forced to have sex in the past year.
Proportion of children who had been forced to have sex in year before survey (percentages weighted by province)
Respondents of either sex who had been abused in the past year were more likely to have misconceptions about sexual violence and about the risk of HIV infection and AIDS (table 2). Sexually abused youth were more likely to believe they were HIV positive (odds ratio 1.90, 1.85 to 1.92; 43.0% (36 235/84 321) who reported sexual abuse v 28.6% (52 237/182 921) who did not report sexual abuse). Respondents who had been sexually abused in the past year were more likely to have no intention of taking an HIV test, more likely to say they would not inform their family if they were HIV positive, and more likely to believe that sex with a virgin could cure HIV infection or AIDS (tables 2 and 3). Youth who had been forced to have sex were more likely to say that they would intentionally spread HIV (odds ratio 2.39, 2.34 to 2.44; table 4). This attitude did not differ between the sexes.
Table 4 Factors associated with claim among South African youth that they had forced someone else to have sex
Overall, 33.0% (weighted value based on 88 932/268 622) of respondents thought that they were HIV positive. This response was more common in youth from rural areas. Those respondents who had never had sex (25.8%; 34 987/135 708) still feared they might be HIV positive. They were also more likely to say they would spread the infection if they were HIV positive and were more likely to believe the myth about virgins (table 3).
Attitudes associated with sexual abuse perpetrated by youth
No less than 65.8% (9159/13911) of males and 71.2% (4428/6216) of females who admitted to forcing someone else to have sex had themselves been forced to have sex. The influence of forced sex was especially pronounced on females (odds ratio 7.0, 6.7 to 7.4; table 4). Perpetrators were also twice as likely to believe that sex with a virgin could cure HIV infection or AIDS (odds ratio 2.13, 2.07 to 2.20; 22.6% (4988/22 114 v 12.% (30 705/255 771). This association could not be explained by age, sex, school grade, urban or rural area, type of school, language, attitudes to sexual violence, and other attitudes to risk of HIV infection.
We found an association between misconceptions about sexual violence (one has to have sex to show love, girls like violent guys, girls enjoy being raped, girls mean yes when they say no) and the claim to have forced someone else to have sex.
Discussion
Bowley DM, Pitcher GJ, Beale PG, Joseph C, Davies MR. Child rape in South Africa—an open letter to the minister of health. S Afr Med J 2002;92: 744.
Jewkes R, Levin J, Penn-Kekana L. Risk factors for domestic violence: findings from a South African cross-sectional study. Soc Sci Med 2002;55: 1603-17.
Jewkes R, Abrahams N. The epidemiology of rape and sexual coercion in South Africa: an overview. Soc Sci Med 2002,55: 1231-44.
Armstrong S. South Africa's rape epidemic fuels HIV epidemic. WorldAIDS 1993, 27.
Buzi RS, Tortolero SR, Roberts RE, Ross MW, Markham CM, Fleschler M. Gender differences in the consequences of a coercive sexual experience among adolescents attending alternative schools. J Sch Health 2003;73: 191-6.
Blumenthal S, Gudjonsson G, Burns J. Cognitive distortions and blame attribution in sex offenders against adults and children. Child Abuse Negl. 1999;23(2): 129-43.
García-Moreno C, Watts CH. Violence against women: its importance for HIV/AIDS prevention. AIDS 2000;14(suppl 3): S253-65.
Koenig MA, Lutalo T, Zhao F, Nalugoda F, Kiwanuka N, Wabwire-Mangen F, et al. Coercive sex in rural Uganda: prevalence and associated risk factors. Soc Sci Med 2004;58: 787-98.
Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet 2002,359; 1232-7.
Wood K, Mafirah F, Jewekes R. "He forced me to love him": putting violence on adolescent sexual health agendas. Soc Sci Med 1998;47: 233-42.
Taylor M, Dlamini SB, Kagoro H, Jinabhai CC, de Vries H. Understanding high school students' risk behaviors to help reduce the HIV/AIDS epidemic in KwaZulu-Natal, South Africa. J Sch Health 2003;73: 97-100.
Eaton L, Flisher AJ, Aaro LE. Unsafe sexual behaviour in South African youth. Soc Sci Med 2003;56: 149-65.
Peltzer K. Opinion on AIDS prevention and education among rural secondary school pupils in the northern province of South Africa. Psychol Rep 2000;87: 593-5.
Kim J, Mmatshilo M. "Women enjoy punishment": attitudes and experiences of gender-based violence among PHC nurses in rural South Africa. Soc Sci Med 2002;54: 1243-54.
Hartung TK, Nash J, Ngubane N, Fredlund VG. AIDS awareness and sexual behaviour in a high HIV prevalence area in rural northern Kwazulu-Natal, South Africa. Int J STD AIDS 2002;13: 829-32.
Varga CA. How gender roles influence sexual and reproductive health among South African adolescents. Stud Fam Plann 2003;34: 160-72.
Campbell C, McPhail C. Peer education, gender and the development of critical consciousness: participatory HIV prevention by South African youth. Soc Sci Med 2002;55: 331-45.
Mitchell C, Smith A. `Sick of AIDS': life, literacy and South African Youth. Cult, Health Sex 2003;5: 513-22.
Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 1959;222: 719-48.
Andersson N, Mitchell S. CIETmap: free GIS and epidemiology software from the CIET group, helping to build the community voice into planning. World Congress of Epidemiology, Montreal, Canada, 19 Aug, 2002.(Neil Andersson, scientifi)
Correspondence to: N Andersson neil@ciet.org
Abstract
In South Africa sexual violence is probably exacerbated by the country's violent past. The endemic violence is now highly sexualised and is aimed at the most vulnerable members of society.1 2 HIV infection and AIDS have spread widely as a result of unprotected and forced sex.3 4
The consequences of sexual abuse during childhood are well recognised as is the link between sexual violence and HIV infection.5-9 In South Africa, several studies in youth have shown that they are affected by sexual violence, that there is a high prevalence of misconceptions about sexual violence and about the risk of HIV infection and AIDS, and that responses to communication about behaviour change may be less positive than expected.10-18 We investigated the views of South African school pupils towards sexual violence and towards the risk of HIV infection and AIDS.
Methods
Between September and November 2002 we invited 5162 classes in 1418 South African schools to take part in our study. Overall, 283 576 youth agreed to participate. Their ages ranged from 10 to 22 years. We excluded those over 20 years of age, leaving 269 705 participants (average age 14.8 years). The questionnaire was returned by all participants. The non-response rate to individual questions was between 0% and 4.3% (tables 1, 2, 3).
Table 1 Beliefs and views among South African youth on sexual violence. Values in brackets are weighted by province or metropolitan, urban, or rural area. Values are numbers (percentages) of respondents
Table 2 Misconceptions among South African youth about sexual violence and about risk of HIV infection. Percentages in brackets are unweighted
Table 3 Misconceptions among South African youth about risk of HIV infection. Values are numbers (percentages; unweighted)
Males were more likely than females to have misconceptions about sexual violence (table 1). The younger respondents (10-14 years) were more likely than the older ones (5-19 years) to believe that sexual violence does not include touching, that if you know someone, forcing sex is not sexual violence, and that girls have no right to refuse sex with their boyfriend. Respondents who were male or lived in a rural area were more likely to express three or more of the eight views (table 2).
Knowledge, views, and beliefs about risk of HIV infection
Condoms
Overall, 57.1% (weighted value based on 147 416/258 080) of respondents stated that condoms could prevent pregnancy, 49.8% (weighted value based on 131 021/262 977) that they can prevent sexually transmitted diseases, and 59.6% (weighted value based on 159 637/267 795) that they can help prevent HIV infection. In urban areas, younger females were significantly less likely than older females to believe that condoms could prevent the spread of HIV infection and AIDS (odds ratio 0.71, 95% confidence interval 0.70 to 0.73; 16 904/32 123 v 144 643/237 582).
HIV test
Around 60% of respondents intended to have an HIV test. A gradient was seen between rural and urban or metropolitan or capital areas, with little difference between ages or sex (table 2).
Talking about sex
In total, 34.0% (weighted value based on 108 284/269 705) of respondents reported that they never spoke to anyone about sex. When they did report having talked to someone it was associated with the intention of being tested for HIV (odds ratio 1.34, 95% confidence interval 1.32 to 1.37); of those who intended to have a test, 60.9% (98 318/161 421) had someone to talk to and 53.7% (58 122/108 284) did not have someone to talk to. Overall, 15.7% (19 720/124 120) of males and 14.4% (20 303/141 184) of females said they would not tell their family if they were HIV positive (table 3).
High risk behaviour
Overall, 15.8% (42 658/269 704) of respondents said they would have unprotected sex and 15.7% (weighted value based on 41 904/266 903) said they would spread the infection intentionally. These views were expressed most by older (15-19 years) males from rural areas (table 3).
Virgin myth
The belief that sex with a virgin could cure HIV infection or AIDS was reported by 12.7% (34 014/266 910) of respondents and was more common in youth from rural areas (table 3). Those respondents who had learnt from school about the risk of HIV infection were significantly less likely to believe this myth (odds ratio 0.84, 0.82 to 0.87). This protective effect remained after taking into account other sources of information on HIV, age, sex, and history of sexual abuse.
Links between sexual violence and risk of HIV infection
Overall, 8.6% (weighted value based on 27 118/269 705) of respondents said they had been forced to have sex in the past year. Younger males were more likely to report this than younger females (figure). In the older age group, more females than males reported having been forced to have sex in the past year.
Proportion of children who had been forced to have sex in year before survey (percentages weighted by province)
Respondents of either sex who had been abused in the past year were more likely to have misconceptions about sexual violence and about the risk of HIV infection and AIDS (table 2). Sexually abused youth were more likely to believe they were HIV positive (odds ratio 1.90, 1.85 to 1.92; 43.0% (36 235/84 321) who reported sexual abuse v 28.6% (52 237/182 921) who did not report sexual abuse). Respondents who had been sexually abused in the past year were more likely to have no intention of taking an HIV test, more likely to say they would not inform their family if they were HIV positive, and more likely to believe that sex with a virgin could cure HIV infection or AIDS (tables 2 and 3). Youth who had been forced to have sex were more likely to say that they would intentionally spread HIV (odds ratio 2.39, 2.34 to 2.44; table 4). This attitude did not differ between the sexes.
Table 4 Factors associated with claim among South African youth that they had forced someone else to have sex
Overall, 33.0% (weighted value based on 88 932/268 622) of respondents thought that they were HIV positive. This response was more common in youth from rural areas. Those respondents who had never had sex (25.8%; 34 987/135 708) still feared they might be HIV positive. They were also more likely to say they would spread the infection if they were HIV positive and were more likely to believe the myth about virgins (table 3).
Attitudes associated with sexual abuse perpetrated by youth
No less than 65.8% (9159/13911) of males and 71.2% (4428/6216) of females who admitted to forcing someone else to have sex had themselves been forced to have sex. The influence of forced sex was especially pronounced on females (odds ratio 7.0, 6.7 to 7.4; table 4). Perpetrators were also twice as likely to believe that sex with a virgin could cure HIV infection or AIDS (odds ratio 2.13, 2.07 to 2.20; 22.6% (4988/22 114 v 12.% (30 705/255 771). This association could not be explained by age, sex, school grade, urban or rural area, type of school, language, attitudes to sexual violence, and other attitudes to risk of HIV infection.
We found an association between misconceptions about sexual violence (one has to have sex to show love, girls like violent guys, girls enjoy being raped, girls mean yes when they say no) and the claim to have forced someone else to have sex.
Discussion
Bowley DM, Pitcher GJ, Beale PG, Joseph C, Davies MR. Child rape in South Africa—an open letter to the minister of health. S Afr Med J 2002;92: 744.
Jewkes R, Levin J, Penn-Kekana L. Risk factors for domestic violence: findings from a South African cross-sectional study. Soc Sci Med 2002;55: 1603-17.
Jewkes R, Abrahams N. The epidemiology of rape and sexual coercion in South Africa: an overview. Soc Sci Med 2002,55: 1231-44.
Armstrong S. South Africa's rape epidemic fuels HIV epidemic. WorldAIDS 1993, 27.
Buzi RS, Tortolero SR, Roberts RE, Ross MW, Markham CM, Fleschler M. Gender differences in the consequences of a coercive sexual experience among adolescents attending alternative schools. J Sch Health 2003;73: 191-6.
Blumenthal S, Gudjonsson G, Burns J. Cognitive distortions and blame attribution in sex offenders against adults and children. Child Abuse Negl. 1999;23(2): 129-43.
García-Moreno C, Watts CH. Violence against women: its importance for HIV/AIDS prevention. AIDS 2000;14(suppl 3): S253-65.
Koenig MA, Lutalo T, Zhao F, Nalugoda F, Kiwanuka N, Wabwire-Mangen F, et al. Coercive sex in rural Uganda: prevalence and associated risk factors. Soc Sci Med 2004;58: 787-98.
Watts C, Zimmerman C. Violence against women: global scope and magnitude. Lancet 2002,359; 1232-7.
Wood K, Mafirah F, Jewekes R. "He forced me to love him": putting violence on adolescent sexual health agendas. Soc Sci Med 1998;47: 233-42.
Taylor M, Dlamini SB, Kagoro H, Jinabhai CC, de Vries H. Understanding high school students' risk behaviors to help reduce the HIV/AIDS epidemic in KwaZulu-Natal, South Africa. J Sch Health 2003;73: 97-100.
Eaton L, Flisher AJ, Aaro LE. Unsafe sexual behaviour in South African youth. Soc Sci Med 2003;56: 149-65.
Peltzer K. Opinion on AIDS prevention and education among rural secondary school pupils in the northern province of South Africa. Psychol Rep 2000;87: 593-5.
Kim J, Mmatshilo M. "Women enjoy punishment": attitudes and experiences of gender-based violence among PHC nurses in rural South Africa. Soc Sci Med 2002;54: 1243-54.
Hartung TK, Nash J, Ngubane N, Fredlund VG. AIDS awareness and sexual behaviour in a high HIV prevalence area in rural northern Kwazulu-Natal, South Africa. Int J STD AIDS 2002;13: 829-32.
Varga CA. How gender roles influence sexual and reproductive health among South African adolescents. Stud Fam Plann 2003;34: 160-72.
Campbell C, McPhail C. Peer education, gender and the development of critical consciousness: participatory HIV prevention by South African youth. Soc Sci Med 2002;55: 331-45.
Mitchell C, Smith A. `Sick of AIDS': life, literacy and South African Youth. Cult, Health Sex 2003;5: 513-22.
Mantel N, Haenszel W. Statistical aspects of the analysis of data from retrospective studies of disease. J Natl Cancer Inst 1959;222: 719-48.
Andersson N, Mitchell S. CIETmap: free GIS and epidemiology software from the CIET group, helping to build the community voice into planning. World Congress of Epidemiology, Montreal, Canada, 19 Aug, 2002.(Neil Andersson, scientifi)