Sexual and reproductive health and rights knowledge, perceptions, and experiences of adolescent learners from three South African townships: qualitative findings from the Girls Achieve Power (GAP Year) Trial

Introduction

Adolescence is a time of dynamic psycho-social, physiological and sexual change, accompanied by an increase in health-related risks¹. Understanding this for young people in sub-Saharan Africa is particularly important where approximately 3 out of 10 unmarried adolescents have ever had sex², and more than 50% of rural adolescent girls and young women (AGYW) (15–24 years of age) are estimated to have been pregnant before the age of 18³. With an increased vulnerability to early and unintended pregnancy, sexually transmitted infections (STIs), gender-based violence (GBV) and human immunodeficiency virus (HIV)⁴, AGYW in sub-Saharan Africa account for one quarter of new HIV infections, even though they comprise only 10% of the population⁵. Adolescent girls (aged 15–19 years) are particularly vulnerable, comprising 80% of all new HIV infections in sub-Saharan Africa, and twice as likely to get HIV than their male counterparts⁶. This is driven by multiple cross cutting socio-economic and structural factors, including harmful gender norms and inequalities, social and cultural norms, transactional and age disparate sex, sexual and intimate partner violence, and poor access to social and health-related services^7–9. Access to knowledge is also of concern – with HIV-knowledge in sub-Saharan Africa being low¹⁰, for example only 36.4% and 29.8% of young men and women, respectively, were shown to have a basic knowledge about HIV prevention³.

The situation in South Africa mirrors trends in sub-Saharan Africa. Young people, particularly AGYW, are disproportionally affected by HIV: young people (aged 15–24) represented more than a quarter of all new infections in 2017, and AGYW were three times more likely to be infected with HIV than their male counterparts¹¹. AGYW have a 1.5% incidence and 26.3% prevalence of HIV infection¹². A study in rural KwaZulu-Natal in South Africa, demonstrated high STI prevalence in 15–24 year olds – 14% of all had a curable STI (chlamydia, gonorrhoea, syphilis or trichomoniasis), and the prevalence of bacterial vaginosis was 41.1% in women aged 15–19 years¹³. GBV rates are high in South Africa, with between 25–40% of women having reported experiencing sexual and/or physical intimate partner violence in their lifetime¹⁴, and 17% of women receiving HIV treatment reported sexual violence in their lifetime¹⁵. Due to the underreporting of violence, the true incidence of GBV is likely to be higher^16,17.

Poverty and unemployment rates are high in South Africa. In the first quarter of 2021, 32.4% of 10.2 million young people (aged 15–24) were not in employment, education or training¹⁸. Consequently, young people may be motivated to engage in transactional relationships with older partners for financial or material gain^19,20, known as the “sugar daddy” or “sugar mommy” phenomenon^21,22, and as “blessers” and “blessees” in South Africa^23,24. Due to the inequitable power dynamics in these relationships, many young women may be subjected to GBV²¹ and may not be able to negotiate condom use^25,26, putting them at increased risk for unintended pregnancies, STIs and HIV acquisition^20–22,27.

Adolescents face numerous barriers when accessing sexual and reproductive health (SRH) and, more specifically, contraceptive services. Adolescents in sub-Saharan Africa have unmet needs in relation to contraception²⁸. The main barriers facing young people accessing contraceptive services include fear of stigma, shame and embarrassment, lack of privacy, provider attitudes and lack of knowledge about services and contraceptive options^29–31. There are also barriers relating to providers being judgemental, and gaps in their contraceptive knowledge, skills and training to respond to the specific needs of adolescents^31–33. In South Africa, there are several initiatives and programmes to dismantle barriers and standardise the package of adolescent and youth friendly services^34–36. This is supported by government guidelines which emphasise the importance of accessible and acceptable services for young people^37–40. However, although these guidelines exist, implementation at facility level has been challenging, and service provision is not always youth friendly³⁵.

Adolescent contraceptive use and knowledge is poor in Sub-Saharan Africa²⁸. Evidence from demographic health surveys (DHS) in sub-Saharan Africa showed that most adolescents (92.4%) (aged 15–19 years) reported no contraceptive use, although 21.6% reported recent sexual activity⁴¹. A later review of DHS data reported that only 24.7% of AGYW (15–19 years) in 29 sub-Saharan African countries used modern contraceptives⁴², with the majority preferring injectable contraceptives (39.9%) and oral pills (31.4%)⁴¹.

In South Africa more specifically, the most recent DHS in 2016⁴³ showed that 60% of sexually active women were currently using a method of contraception, and 19% of sexually active women had an unmet need for contraception⁴³. The 2012 National HIV Prevalence, Incidence, and Behaviour Survey⁴⁴, found that about a third of women aged 15–19 were using modern contraception⁴⁵. Furthermore, 33.5% of women had reported a pregnancy in the last five years, and only a third of these had desired to be pregnant⁴⁴. Specifically, only 10.1% of women 15–19 years, and 20.9% of women aged 20–24 years had desired the pregnancy⁴⁴. Of those women who reported a pregnancy in the past five years, only 12.8% of 15–19 year olds, and 19.7% of 20–24 year olds, had been using contraception⁴⁴. In terms of method preference, injectables are the predominant method used, followed by oral contraceptive pills⁴⁵. The implant was introduced into South Africa in 2014, but only 4% of South African women were using it in 2016^40,46. Research on adolescents in South Africa (Limpopo Province) demonstrated that most did not have knowledge about the emergency contraceptive, intrauterine device (IUD) or female condom⁴⁷. Contraceptive preferences are shaped by choice, provider bias and training, demand creation, availability, misinformation and side effects^48,49. Other factors affecting uptake and use are linked to pressure from male partners, fear of parental reaction, poor contraceptive education, and counselling⁴⁷. Therefore, ensuring contraceptive choice is critical for adolescents to have options when making contraceptive use decisions.

Age-appropriate sexuality education is seen as an important intervention for mitigating against risk in young adolescents. Early adolescence is seen as an ideal time to conduct education with a focus on gender and rights, before harmful gender norms become entrenched, enabling improved SRH and non-violent outcomes⁵⁰. School and curriculum based educational interventions have been implemented globally, seeking to improve adolescent SRH outcomes⁵¹. This has largely been informed by a rigorous evidence review of over 77 randomised controlled trials and systematic reviews conducted by UNESCO⁵², evaluating the impact of Comprehensive Sexuality Education (CSE). The findings clearly demonstrate that CSE produces favourable outcomes, specifically reducing sexual behaviours that put them at increased risk, sexual debut, number of sexual partners whilst improving health seeking behaviour, knowledge and uptake of preventative services such as contraception and condoms. Peer-led interventions have demonstrated moderate effectiveness at improving behavioural outcomes, such as increasing HIV-related knowledge and improving condom usage⁵³. The importance of locating CSE within the context of a sex positive approach focussing on sexual pleasure, sexual preferences and expression of sexuality within the context of safety and rights has also been advanced as an important dimension of risk reduction and sexual health promotion strategies^54,55.

Young adolescence (10–14 years) in particular, is the time of onset of puberty and sexual maturation and is a transitional period that shapes later adolescent and adult health behaviours^50,56,57, including SRH behaviours which may cause diseases later in life¹⁰. There is very little research on the SRH of this younger adolescent population, for both males and females. There is a need to focus on this missed and neglected age group to promote optimal SRH in future¹⁰. Therefore, this research included younger adolescents (from 12 years of age) seeking to further understand their knowledge, experience and needs.

Girls Achieve Power (GAP Year) Trial

Girls Achieve Power (GAP Year), a cluster randomised controlled trial (cRCT), was a social asset building intervention focussing on SRH, across 26 schools in Gauteng and the Western Cape Provinces in South Africa⁵⁸. It provided SRH information aligned to the CSE curriculum and sought to contribute to and complement the CSE programme⁵⁹. The schools were in three peri-urban townships: 14 schools in Khayelitsha (Western Cape Province), six schools in Soweto, and six schools in Thembisa (Gauteng Province). Schools were selected in collaboration with the Department of Basic Education using the following inclusion criteria: mixed sex public high schools in three townships; in quintiles 1–3¹ which had not been exposed to any asset building interventions in the past six months. A one-to-one (1:1) random stratification scheme was employed, assigning each school to either intervention or control groups, with 13 schools in each study arm.

The GAP Year Trial tested the effectiveness of a four-pronged ecological intervention: a sports-based peer facilitated after-school asset-building intervention, a parent/guardian component, linkage to care, and school safety. The intervention is described in further detail in Kutywayo, et al⁵⁸. For the after-school intervention, a two-year curriculum (of 44 sessions in total) was designed and implemented, delivered after school by peer coaches, covering different aspects of SRH and rights, HIV, STIs, contraception, decision making, sex and gender. The trial aim was to reduce school dropout among adolescent girls between grades 8–10 and increase reporting of GBV. Complimenting these outcomes, the intervention sought to improve adolescent girls’ agency and safety while shifting gender attitudes and encouraging positive behavioural change among adolescent boys.

For this manuscript, we explore the SRH knowledge and behaviour, including risks faced, of grade 9 and 10 learners, from three townships in the Western Cape and Gauteng Provinces, who participated in this intervention. We focus on four thematic areas: adolescent learners’ knowledge about SRH and understanding of sexual risk, risk reduction and rights; perceptions related to transactional sex and age disparate relationships; health seeking behaviour and experiences; and contraceptive method preferences and decision-making practices.

Methods

Ethical approval and considerations

The University of the Witwatersrand’s Human Research Ethics Committee (HREC) approved the GAP Year trial (#M160940) in October 2016. FGDs formed part of the trial and were included in the ethics approval from the onset. The provincial research committees at the Western Cape and Gauteng Department of Basic Education, and each participating school also provided written approval. Parents or guardians provided written informed consent and written assent was provided by participating learners for participation in the FGD and for the FGD to be audio recorded. The participating schools, parents and learners were fully informed about the voluntary nature of participation in the study, and of confidentiality of data management.

Results

Discussion

Adolescents in this study demonstrated that they had acquired SRH knowledge during the GAP Year intervention, including information on SRHR, risk reduction and where to obtain services. They also learnt about HIV and STI acquisition and prevention, dual protection, as well as about various contraceptive methods.

Our findings confirm that transactional sexual and age disparate relationships were occurring in these communities. As has been reported elsewhere, adolescents engage in these relationships for material gain – sometimes for survival, especially in poor communities, and sometimes for improved lifestyles^19,20,27. In this study, it was also reported that in some cases adolescents engage in these relationships to seek love and affirmation which they do not get at home. This reinforces the blurred line between transactional sex in exchange for money/goods, and relationships based on need, intimacy and love²⁷. Despite the perceived benefits of these relationships, adolescents in the FGDs had an awareness that they could also have negative consequences, where power imbalances result in gender inequalities, and the potential for risk of GBV. Lack of power was also seen to reduce capacity to negotiate safer sex practices. These negative factors can result in increased sexual health risk - including pregnancies, HIV and STI transmission. However, despite the perceived risks of these transactional relationships, participants described some level of acceptability and support, also noted elsewhere⁷⁰, especially in the context of poverty, and where such relationships lead to improved living conditions for an individual and their family⁷¹. It is therefore also important to be cognisant of the contextual factors framing transactional sex and social norms whereby it is acceptable and sometimes sanctioned as a viable source of income and means for procuring both essentials such as school fees and food, and non-essentials such as lifestyle-related commodities²⁷. The awareness of age disparate relationships was not explored, and this is of concern, given the association with increased risk of HIV⁸. Of particular importance for this paper, is the perspective that interventions such as educational programmes need to be cautious not to judge and cast all transactional sex as inherently wrong, but rather strike the balance between acknowledging the potential motivations and benefits on the one hand, and on the other, discussing strategies to mitigate risks and protect themselves^27,72

Adolescent access to SRH services is a challenge globally, and more specifically in sub-Saharan Africa^29–31. Similarly, most adolescents in this study reported barriers to accessing SRH services, largely related to provider attitudes and fear of stigma. A few even chose not to access these services because of barriers, putting them at increased risk of unintended pregnancies, STIs and HIV acquisition. Reassuringly, some participants described positive experiences accessing SRH services at healthcare facilities, largely related to strategies they had developed to improve their experiences, for example choosing to attend a healthcare facility with a reputation for being youth friendly, or accessing services with a parent, to avoid judgmental attitudes. A few participants described making use of traditional healers or home remedies for health-related concerns.

Preference, choice and uptake of contraceptive methods has been linked to access to and knowledge about methods^49,73. Perceived benefits and challenges with contraceptive use are impacted on by personal situations and understandings of use, further compounded by myths and misinformation around particular methods. The GAP Year intervention provided information on male and female condoms, the injection, emergency contraception, the implant and the IUD. Participants demonstrated an understanding of the benefits of long-acting reversible contraception (LARC), and also mentioned emergency contraception.

The most preferred contraceptive method in this study was the injectable, reported in other research in South Africa and sub-Saharan Africa^41,43,74. Young females in this study also had positive perceptions about LARCs (including both the IUD and implant). The reasons for this were similar to those associated with using injectable contraceptives – the fact that they do not need to remember to use it daily, and also because of the less frequent need to access healthcare services when using these methods, also found in research with implant users⁴⁶. This is important as South Africa’s method mix is still dominated by injectables, and awareness and use of long acting methods is low⁴⁵. The promotion and awareness of LARCs is emphasised in the DOH guidelines⁷⁵, as well as the promotion of informed choice, including implants and IUDs. LARCs have a higher efficacy and continuation rate^45,76 and are suitable for use by adolescents⁷⁷. Adolescent preferences for LARCs and injectables could also have implications for long-acting HIV prevention methods, including injectable PrEP and vaginal rings – where less frequent access to healthcare services is required. Similarly, several participants noted a challenge with the oral contraceptive pill in terms of remembering to take it daily, and this too needs to be taken into account with daily oral PrEP. Individual product attributes should be considered together with these perceived advantages when designing information sessions and promotional activities for long-acting HIV prevention products.

Individuals also expressed concerns about some methods, and many of these were related to side effects (real or perceived) and misconceptions, especially regarding the implant, in particular the belief that it is stolen from the arm and used for drugs, the misconception that it can rust in one’s arm, stunted growth, infertility, and low efficacy. Such concerns and misconceptions have been noted elsewhere⁴⁶ and can discredit the use of methods. It is therefore important that rumours and misconceptions are addressed in order that they do not undermine contraceptive programmes and method choice^48,78.

Decision making about contraceptive method uptake and choice was largely made together with parents (mothers in particular), or by the adolescent females themselves. This could be linked to the fact that the GAP Year intervention engaged parents, encouraging parent-child communication. Given that evidence shows that parents experience challenges discussing SRH issues with their children⁷¹, more needs to be done in future programmes focusing on parents/guardians and how to communicate effectively about sex. Only a few young females reported that their partners played a role in their contraceptive choice and use, this differs from research which shows that male partners influence contraceptive uptake and use in other areas in South Africa⁷⁹.

The GAP Year intervention provided these learners with important SRHR information and strategies to reduce sexual risk. One benefit that participants noted was that they learnt how to use both male and female condoms. This was covered in the Year 2 curriculum but then reinforced during the graduation events, where a local adolescent SRH organisation repeated these practical demonstrations. The importance of not only promoting condom use and dual protection in HIV/SRH prevention programmes, but also providing practical guidance on the use thereof is important, and sometimes neglected^80,81. However, it is also important to note that knowledge about condoms does not always translate to being able to, or wanting to, practice safer sex practices. This underscores the need to discuss risk, condom use and HIV prevention within the context issues related to sexual pleasure, intimacy, gendered power, and sexuality, in other words, unpacking the complex factors that influence condom use⁸².

There are several recommendations that can be made based on the findings from this study. Adolescents need to be provided with education and information on SRH rights and contraceptive methods, relative benefits of each, mechanisms of action, and side effects, as well as on service delivery points. Furthermore, these programmes need to address myths and misinformation and replace them with facts to ensure informed decision making and choice, and to strengthen uptake and correct method use. the viability of improving access to contraception at schools needs to be further researched and explored³³. Increased dose of programmes/interventions and reinforcement of information is necessary to ensure that myths and misinformation are not perpetuated. Practical demonstration and discussions about condom use in the context of young people’s sexual lives also needs to be included. Although the afternoon sessions focussed on SRH within the context of gender disparities, gender-based violence and SRH rights, closer attention to locating SRH within a holistic framework of sexuality education is recommended. This needs to be included in the training of facilitators conducting the sessions and allows for the shifting of sex from the realm of problems and risk to a more sex positive approach, where SRH is discussed within the context of safe sexual pleasure, sexual relationships and self-expression^54,83.

This can be done via school-based education programmes²⁹ like the GAP Year intervention which complements the current CSE curriculum in schools and reinforces health-seeking behavior and use of peer mentors. To this end, linking school-based educational programmes with services responsive and sensitive to the needs of young people is vital, coupled with healthcare provider training and education to address knowledge gaps and judgmental attitudes^10,33,84. In addition, providing adolescent health services at a community level, at health education events, could increase uptake and acceptability of services. Cash transfer systems and other structural interventions have been demonstrated to reduce HIV risk behaviours such as transactional sex in young girls, and should be further considered^85,86. Finally, as has been suggested elsewhere⁵⁰, using evidence from studies on adolescents is important for informing future policies and programmes that are effective and relevant to adolescents.

Conclusions

There is a paucity of literature exploring SRH and contraceptive knowledge and perceptions of younger adolescents in South Africa. This research has been important in providing information on the SRHR knowledge and perceptions of a group of adolescent learners. Furthermore, these learners demonstrated that they had acquired knowledge during the GAP Year intervention, highlighting that an afterschool model of education provision within a school setting is a feasible model for provision of SRHR education to learners.

Findings from this study highlight what can be included in future interventions. Youth focussed interventions should focus on information provision to facilitate understanding and informed decision making. For example, the mechanism of action of contraceptives should be described to address and dispel myths around method use. Full information about different methods available, including LARCs, are important for method choice. In addition, condom promotion should provide practical information and instructions on condom use. The provision of information enables informed choice, decision-making, and method use, and could facilitate uptake of contraceptives. Furthermore, more work needs to be done to limit barriers to accessing healthcare services and to facilitate more youth friendly facilities, including reconsidering healthcare training strategies. Finally, discussions about HIV/SRH prevention need to integrate together with messages about choice and informed decision-making relating to both HIV prevention and contraceptive options.