Social Instability and Risk-Taking Behaviors in Rural KZN

1. Social Instability and Violence in Relation to the Risk-Taking Behaviors of Very Young Adolescents in Rural KwaZulu/Natal, South Africa Dana Cernigliaro, MPHc1 Aliza Monroe-Wise MSc2 Abigail Harrison, PhD1 1 Brown University Medical School, Department of Medicine, Program in Public Health and the Population Studies and Training Center at Brown University 2 Stanford University Medical School

2. South Africa Post apartheid concerns • Rapid social change • Continued social and political instability • Destabilizing factors • Poverty (50% pop below poverty line) • Increased Violence • Influence of HIV/AIDS Burden of HIV epidemic • Highest number of HIV infections globally • 15 percent of global youth infections (15-24 year olds) • Age structure of population means high number of youth infections HIV/AIDS Prevalence (%) All ages 10.8 Ages 15 to 24 10.3

3. Research Setting: Rural sub-district, KwaZulu/Natal (KZN) • Northern KZN • Population of 210 000 • Scattered multigenerational homesteads of varying size (1–100 people) • Annual per capita income is US $1730 • Isolated, under-resourced, socially conservative • Migrant labor common • Ethnically homogeneous, Zulu language and culture • HIV prevalence: 2002: 11.7% 2005: 16.5%

4. Study Aim To better understand contextual factors, especially social instability and violence through ethnographic research, in relation to the development of health risk-taking behaviors among very young adolescents in rural KZN

5. Rationale/ Importance • Few studies in developing countries have focused on very young adolescents • This study targets an age when life decisions and risk taking behavior begin • Prior studies have targeted older adolescents, who are more likely to already be sexually active  • A disconnect has been found to occur between awareness and behavior when the individual becomes sexually active • The ethnographic study design allowed for intimate look at pre-adolescent thoughts, feelings and personal histories

6. Domains of research • Life histories • Future aspirations • Violence • Sexual initiation • HIV/AIDS knowledge • Risk perception

7. Methods • Study design: Ethnographic research study with qualitative and quantitative methodology • Site: Higher primary school in one sub-district • Selection of sample: Complete classroom lists (grades 5 through 8) • Eligibility criteria: • Students attending the Higher Primary School • Students 10 to 14 years of age • Availability to participate outside school hours • Students who received parental consent

8. Methods: Qualitative component Phase I • 11 Participants, ages 11-14 • Life history interviews (home visits) Phase II • 30 Participants, ages 11-14 • 4 Single sex peer group discussions (6-8 participants each) • In-depth interviews • Data coded and analyzed using NVivo 2.0

9. Methods: Quantitative component Phase III • Self administered survey • 30 questions divided into 5 sections • 126 student participants, ages 10 to 14 • Conducted among students that had not participated in the previous phases • Data was analyzed using SAS

10. ResultsQuantitative Analysis: Demographics

11. Results on Life History:Household experiencesQualitative results: In depth interviews • Most participants had moved at least once • Most had experienced a death in the family • 6 out of 11 participants had experienced the death of at least one person in their household • Almost every house had one transient person

12. Results on Life History: Perceptions of self and futureQualitative results: In depth interviews • Most appeared happy and comfortable • Clear and defined future goals • 4 out of 11 wanted to be doctors, 9 wanted to go to college or further • Strong self confidence • “Anything I do I do it with confidence” • Most had role models • Highly educated members of community or family members

13. Example of Life History: Death in the Family • Interviewer: Is there any big event that has happened in your family. It can be a death or the birth of an important person or any event you regard as big? • The aunt: It is the death of many family members who were shot dead. Even the father of the participant was shot in Johannesburg

14. Results on Violence • Most violence condemned, but occasionally accepted • Most participants agreed that certain violence was okay in school and occasionally at home • Violence against women was tolerable in certain situations

15. Gender Violence: Example from peer group discussion • Interviewer:Do you think there are any situations where it is okay for someone to hit, beat, or physically hurt someone? • Resp:Yes, sometimes girls do make boys angry and boys beat them. • Interviewer:Do you think the boy do the right thing by that? • Resp:Yes.

16. Results on Sexual behavior and HIV/AIDS risk

17. Results on Sexual behavior and HIV/AIDS risk • Projected age of sexual initiation: • Self (18 to 28) • Peers (12 to 15) • Gender differences and sexual initiation: • Boys: pressure from friends or “just for fun” • Girls: financial reasons and force • General realistic risk perception • Fair knowledge of HIV/AIDS

18. Discussion • Large amount of transition and mobility • High level of exposure to violence • Interesting paradox between future aspirations and self perception vs. social environment • Clear signs of early risk behaviors • Levels of HIV/AIDS knowledge • Context of sexual behavior (girls vs. boys) • Acceptance of violence in certain situations What impact will these factors have on future decisions regarding the health and well being of these participants in light of the increasing prevalence of HIV/AIDS during adolescence?

19. Future Studies These preliminary findings pave the way to look at specific links that may impact risk behavior as these adolescents get older, and are faced with major life decisions affecting their health and their future in the era of HIV/AIDS in South Africa.

20. Acknowledgements We thank the World Health Organization for financial support of this study through a grant to the South African Medical Research Council (WHO grant A05092 for Social Science Research on Adolescents). The research assistance of Musa Mpanza, Nokukhanya Vilakazi and Pinky Kunene is gratefully acknowledged.