Multiple risky behaviours among High School Adolescents in Ngaka Modiri Molema District, South Africa

Multiple Riskv Behaviours among High School

Adolescents in Ngaka Modiri Molema District

South Africa

111111111111111111111111111111111111111111111111111111111111 060045586Y

by North-West University Mafikeng Campus Library

Yaw Johnson Arkaah

A Dissertation Submitted in Fulfillment of the Requirements for

the Degree of Doctor of

Philosophy in the Facu

lty of Human and Social Sciences at the

North West University, Mafikeng Campus

,

South Africa

Promoter

Prof. I. Kalule-Sabiti

August 2014

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Acknowledgement

rirsl and foremost, I would like to express my warmest gratitude to Prof. Ishmael Kalule -Se~biti, my promoter, and Prof. Acheampong Yaw Amoateng for guiding me throughout the conduct of this study. I would also like to express my sincere gratitude to principals of all the par1icipating schools. Without your help this study would not have come to this stage! Special thank you goes to all learners who provided valuable information for this study, they form the heart and blood of this piece of work.

Mrmy tl1anks go, in particular, to staff members of the Population Training and Research llr1it (PnpUnit) for their kindness and support during the course of my study. Words cannot , : .... prllSS my appreciation to my family for inspiring me to tal<e my academic life to this level. May God richly bless you.

1 o the ever-present God who provided the strength, good-health, knowledge and direction, I ::.ay a big thank you.

Declaration

I, Yaw Johnson Arkaah, declare that this thesis, 'Multiple Risky Behaviours among High Scl10ol Adolescents in Ngaka Modiri Molema Distr'ict, South Africa', is my own work, that it ltas not been submitted to any other university, college or instittttion for any award and that oil llle sources I have referenced have been indicated and acknowledged as complete.

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Abstract

Aclolescence, the transitional phase between childhood and adulthood, is a unique stretch nl time of discovery and experimentation of many risky practices. The present study sought ltJ till a research void on adolescent risky behaviours in the North West Province of South 1\lric<l by examining the socio-demographic and environmental correlates of seven sexual L1eiHwiours and patterns in three substance use behaviours of 1,067 Grade 9 and Grade 11 adolescents from eight high schools in the Ngaka Modiri Molema District of South Africa. Using chi-square tests, logistic regression and discrete-time hazard modelling techniques, a select number of socio-demographic and environmental factors were examined to find how tl1ey influence sexual engagement, age at first sex, sexual encounters in three months prior to tile survey, number of lifetime sexual partners, condom/contraceptive use among leat ners, condom refusal, and use of condoms during last sexual encounter and patterns in c.:igarette smoking, alcohol consumption, and marijuana use behaviours. A self-administered stuvcy questionnaire was used to collect the required data from the study participants.

Overall, about 14 percent of the learners indicated they had ever smoked cigarettes while nbout 38 percent also indicated they had ever drunk alcohol. Only 9 percent also indicated tlwy t1ad ever consumed hashish. Gender, age, place of residence, parental monitoring and suptll vision, parent marital status, parent worl< status and household wealth status were all found to be associated with cigarette smoking, alcohol and hashish consumption by lew t 1ers. Findings showed male and Grade 11 learners reporting less positive sexual behaviours than female and Grade 9 learners. Gender, grade level, peer sexual influence, perceptions about sex issues, substance use were t11e chief factors found to influence sexual behaviours of learners. In particular, while family-related factors were found to have positive influence on learner sexual behaviours, peers, especially those who exert psycl1ological control over their friends, seemed to influence the sexual behaviours of their friends negatively.

The findings from the study have implications for intervention programmes. It should, sper.ifically, assist policymakers, the North West Department of Education and educators in developing and implementing specific intervention programmes that seek to discourage the vat ious risl<y practices highlighted in this study. In particular, the Department of Education may consider developing a policy that seeks to educate and raise parents' awareness of the

possible use of substances such as tobacco and hashish by learners and to crave their full involvement in prevention efforts. A collective participation in the fight against such health 1 is I< practices by learners by parents, educators and the Department of Education would go R long way to help minimise the practice among high school learners. Again, a comrrehensive sexuality education programme which encourages sexual abstinence by learners can be developed and implemented in school settings. Under this programme, local and national renowned actors, artistes, athletes and musicians can be used as positive 1 ole models for learners as well as directing such personalities to deliver messages on the dangers of participating in such health risk practices. Lastly, the Department of Education may consider coming up with a policy that seeks to encourage learner participation in structured and supervised activities, such as the introduction of new school extracurricular activities including organising vacation camps for learners, and taking learners through various developmental and mentors hip programmes.

Contents

Abstract iv

Chapter 1 : Introduction 1

I . 1 Study Background

1

1 (' Adolescence

2

1.2.1

Biological Transition Period

3

1.

2

.2

Cognitive Transition Period

3

1.

2

.3

Social Transition Period

3

1.:3 Problem Statement

5

I . •I Thesis Rationale

6

15 Study Aim and Objectives

8

1.

5

.

1

Specific Study Objectives

9

1

.

5

.2

Substantive Research Questions

10

1.5.3

Research Hypotheses

10

l.G Study Significance

11

1./ Disseminations of Study Findings

1

2

1.8

Structure of Thesis

12

Ul Definitions of Key Terms and Assumptions

13

Chapter 2: Review of Related Literature 17

:>.

I Introduction

17

:! -~) The Theory of Planned Behaviour

17

:! :1 Contextualising Risk-Taking in South African Adolescents

19

2.3.1

Sexual Risk-Taking in South African Adolescents

19

2

.3.

2

Substance Use among South African Adolescents

21

:!A Important Determinants of Adolescent Risi<-Taking

22

2.5 Conceptual Framework

24

2.1i Substance Use Outcome Variables

26

2.6.1

Cigarette Smoking

26

2

.6.2

Alcohol Consumption

28

2.6

.

3

Hashish Consumption

30

2.7

Sexual Risk Behaviour Outcome Variables

32

2.7 2 Age at First Sexual Intercourse 33

2.7.3 Lifetime Sexual Partners 35

2.7.4 Condom Use and Refusal 35

2.7.5 Co-Occurrence of Risky Behaviours 39

::>.R Predictors of Risky Behaviours 40

2.8.1 Individual and Socio-Demographic Factors 41

2.8.2 Family-Related Factors and Processes 44

2.8.3 Environmental Factors 50

2.8.4 Knowledge and Perceptions of Health-Related Issues 57

2.9 Concluding Remarks 60

Chapter 3: Data and Methodology 61

:1. 1 Introduction 61

~1.2 Profile of Study Area 61

:1.3 Participants: Grade 9 and Grade 11 Learners 63

3.4 Sampling Design 63

3.4.1 Selecting the AOs 64

3.4.2 Selecting the Schools 64

3.4.3 Selecting the Learners 65

3.4.4 Sample Size Determination: Minimum Number of Learners 66

3.4.5 Sample Allocation 67

3.[, Data Collection Procedure 68

:Hi Measures of Variables 69

3.6.1 Background Characteristics 70

3.6.2 Family Lint< Measures 70

3.6.3 School Attachment, Religiosity and Peer Sexual Influence 71 3.6.4 ~<nowledge, Attitude, Perceptions and HIV/AIDS Awareness 72

3.6.5 Experience of Anti-Social Practices 73

3.6.6 Sexual Behaviour and Risk-Taking 73

3.6.7 Knowledge of Reproductive Health Issues 73

3.5.8 Sexual Media Content Exposure 74

~t l Procedure 74

3.7.1 Data Management 74

3.7.3

Reliability Analysis

3.7.

4

Receding and Variable Creation

3.

7

.5

Dealing with Multicollinearity in Categorical Data

3.7.6

Analytical Methods

3.11 Ethical Considerations

3.9 Study Limitations and Delimitations

3

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9.

1

Limitations

3.9.2

Delim italians 3.10 Concluding Remarks

Chapter 4: Exploratory Analysis of Background Characteristics

<1. I Introduction

'

1.

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Descriptive Statistics of Background Characteristics ·1.~~ Perception of Sex Issues

·lA Knowledge of HIV/AIDS Issues ·1.5 Substance Use

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.5.

1

Cigarette Smoking

4.5.2

Alcohol Consumption 4

.5.3

Hashish Consumption •I.G Concluding Remarks Chapter 5: Analysis of Sexual Behaviours 5.1 Introduction S.~) Sexual Activity

5.2.1

Bivariate Analysis of Sexual Engagement

5.2.2

Multivariate Analysis of Sexual Engagement 5.:1 Age at First Sex

5.3

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1

Simple Statistics on Age at First Sex 5.3.2 Bivariate Analysis of Age at First Sex

5.

3.

3

Survival Analysis of Age at First Sex

5.4

Sexual Encounters Prior to Survey

5

.4

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Bivariate Analysis of Sexual Encounters Prior to Survey

5.4.2

Multivariate Analysis of Sexual Encounters Prior to Survey

75

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96

100

103

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104

104

105

109

110

110

111

116

122

122

125

!.>.5 Number of Lifetime Sexual Partners

5.5.1 Bivariate Analysis of Lifetime Sexual Partners 5.5.2 Multivariate Analysis of Lifetime Sexual Partners b.C1 Condom Use

5.6. 1 Bivariate Analysis of Condom Use 5.6.2 Multivariate Analysis of Condom Use !l.l Condom Refusal

5.7.1 Bivariate Analysis of Condom Refusal 5.7.2 Multivariate Analysis of Condom Refusal !> t1 Condom Use at Last Sexual Encounter

5.8. ·1 Bivariate Analysis of Condom Use at Last Sex 5.8.2 Multivariate Analysis of Condom Use at Last Sex

!dl Concluding Remarks

128 128 132 133 134 136 137 138 142 143 144 146 147

Chapter 6: Discussion of Results, Implications and Recommendations 149

6. l Introduction

G.2 Theoretical Perspective

6.3 Principal Findings

6.3.1 l<nowledge of HIV/AIDS 6.3.2 Cigarette Smoking 6.3.3 Alcohol Consumption 6.3.4 Hashish Consumption 6.3.5 Sexual Activity

6.3.6 Age at First Sexual Intercourse 6.3.7 Condom Use

H.il Implications of Study Findings

G.!" Recommendations for Further Research Bibliography

Appendix A: Survey Questionnaire Appendix B: Missing Data Analysis

Appendix C: Cronbach Reliability Analysis Results Appendix 0: Multicollinearity Test Results

Appendix E: Study Cover Letter from Population Centre

149 150 151 151 152 153 154 155 157 158 159 162 164 196 207 209 212 269

Ust ofTables

I n1 easy location of tables, numbering of tables is done according to the chapters in which Jltey are displayed.

T al)le 3.1: Cumulative Distribution of Schools 64 1 able 3.2: Sampled Schools Included in the Study 65

I able 3.3: Samples from Each School Sampled 68

I Clble 3.4: Description of Composite Measures Created via Factor Analysis 77 I able 4.1: Distribution of Learner Perception about Sex Issues 92 rable 4.2: Bivariate Analysis of Cigarette Smoking 95 I nble 4.3: Logistic Regression of Cigarette Smoking Behaviour 96 Table 4.4: Bivariate Analysis of Alcohol Consumption 98 1 Cll)le 4.5: Logistic Regression of Alcohol Consumption Behaviour 99 1 nble 4.6: Bivariate Analysis of Hashish Consumption 101

1 able 4.7: Logistic Regression of Hashish Consumption Behaviour 102

I able 5.1: Proportion of Sexually Active Learners by Selected Predictive Factors 106 1 nble 5.2: Logistic Regression of Sexual Activity among Learners 109 1 ttl)le 5.3: Descriptive Statistics of Age at Sexual Debut 111 I nble 5.4: Bivariate Analysis of Age at Sexual Debut 113 I nble 5.5: Baseline Discrete-Time Hazard Model for Age at Sexual Debut 116

1 nble 5.6: Full Discrete-Time Hazard Model for Age at Sexual Debut 119

l Ftble 5.7: Bivariate Analysis of Sexual Encounters Prior to Survey 123 I'Cil)le 5.8: Logistic Regression of Sexual Encounters Prior to Survey 127 1 able 5.9: Bivariate Analysis of Liietime Sexual Partners 129 l nble 5.1 0: Logistic Regression of Lifetime Sexual Partners 133

Table 5.11: Bivariate Analysis of Condom Use 135

Table 5.12: Logistic Regression of Condom Use 137

1 nl)le 5.13: Bivariate Analysis of Condom Refusal 139

lable5.14: Logistic Regression of Condom Refusal 142 Cable 5.15: Bivariate Analysis of Condom Use at Last Sex 144 I able 5.16: Logistic Regression of Condom Use at Last Sex 147

list of Figures

I or easy location of figures, numbering of figures is done according to the chapters in which they are displayed.

f-Igure 2.1: The Theory of Problem Behaviour 18 rigure 2.2: Conceptual Frameworl< for Risky Behaviours 25

riUIIre 3.1: Map of the North West Province, South Africa 62

I inure 3.2: Municipal Districts of the North West Province, South Africa 62 I 1gure 3.3: Participating Schools from Ngaka Modiri Molema District 63

r

ioure 4.1: Learner Distribution by Grade and Sex 87 r-if)11re 4.2 Distribution of Learner Perception about Sex Issues 91 I ICJure 4.3 Distribution of Learner Knowledge about HIV/AIDS 93

r-igure 4.4: Cigarette Smol<ing 94

Fiqure 4.5: Alcohol Consumption 97

Houre 4.6: Hashish Consumption 100

I ioure 5.1: Sexual Activity among Learners 105

F1gure 5.2: Age at First Sexual Intercourse 112

I inure 5.3: Survival Function of Sexual Debut 117

r

igure 5.4: Hazard Function of Sexual Debut 117

f l{)llfe 5.5: Survival Function of Sexual Debut by Gender 120

Figure 5.6: Hazard Function of Sexual Debut by Grade 120

1-ioure 5.7: Survival Function of Sexual Debut by Grade 121

I IOUre 5.8: Hazard Function of Sexual Debut by Grade 121

1-igure 5.9: Sexual Encounters in the Three Months Prior to Survey 122

Huure 5.10: Number of Lifetime Sexual Partners 128

1 iame 5.11: Use of Condom 134

rigure 5.12: Condom Refusal 138

CHAPTER 1

Int

roduction

1.1 Study Background

Despite the surge in education on health-related risks in recent years, many c~ctolescents choose to adopt behaviours seen to have life-altering outcomes - sex -related behaviours and substance use. To fully recognize the importance of studies on aclolescent risk-taking behaviours is needed, it is equally important to understand the prevalence and costs of such behaviours. Given the dangers of the health-risk outcomes, it is precisely these forms of risk-taking behaviours that the study r:oncentrates on.

/\clolescence is seen as a developmental stage of human life where the youth are most responsive to reward (Galvan, Hare, Parra et al, 2006). If uncontrolled, this increased reward response can result in adolescents engaging in increasing amounts of risk -taking behaviours. During adolescence, a young person experiences physical, psychological and social changes and because these developments are incomplete during this developmental stage, adolescents tend to experiment with risky behaviours including sexual intercourse, having sex without condoms, cigarette smoking, alcohol consumption, and hashish/marijuana consumption, often with little awareness of the danger (Reyna and Farley, 2006). Adolescents represent one of the fastest-growing risk

nr

oups for sexually transmitted diseases, with teenagers being the most vulnerable. During adolescence, most adolescents are able to experiment with risky behaviours quite safely; however, there are also a significant number of adolescents who struggle to stay afloat without any repercussions.

Risky behaviours among high school adolescents is a s1tbject of greater concern to the South African government today than ever before and its nature and magnitude need to be clearly understood, if remedies were to be found to address the situation. Just as in the Western world, South African adolescents frequently engage in a range of high-risk activities. Evidence from a number of studies shows that South African adolescents use

alcohol, tobacco and other drugs, and engage in unprotected sex (James, Reddy, Taylor and Jinabhai, 2004; Panday, Reddy and Bergstrom, 2007). Recently, a nationally representative survey of risk behaviour among South African secondary school learners (grades 8 through 11) provided detailed prevalence estimates on these and other key fisk behaviours (Panday, Reddy and Bergstrom, 2007). In recent years, many intervention models have been designed and implemented by governments of many countries which aim to prevent adolescent risk behaviours. In post-apartheid South Africa, the government has been eager to address public health issues affecting youth, especially among previously disadvantaged populations, where multi-level factors mcluding personal, interpersonal, and environmental combine to compound vulnerability among high school learners (Nonnemaker, McNeely and Blum. 2006).

Although many studies have researched the sexual risky behaviour of adolescents, virtually none has involved such under-privileged schools in the North West Province of South Africa. Briefly stated, this study examines the role of socio-demographic characteristics and other important contextual correlates that come together in shaping the risky behaviour of high school adolescents in Ngaka Modiri Molema District of the No1 111 West Province, South Africa, with specific emphasis of Grade 9 and Grade 11 let~Jilers. The relationships of the various constructs used in this study with the 111unsures of risky behaviours in this study remain partly unexplored, judging particularly

hy

tile fact that most of the schools used in this study were from under-privileged locations. This gap in research is particularly significant because one of the primary foci of the present study was to address this gap.

1.2 Adolescence

Adolescence is a period of sexual maturity that transforms a child into a mature adult capable of sexual reproduction and the potential consequences of that sexual activity. The period spans approximately ten years with the onset of pubertal maturation. The World Health Organization defines adolescence as people aged 10-19 and this has been adopted throughout the world as the standard definition (World Health Organisation, 1989). The South African Republic Act of 1998 adopts exactly the same standard definition by the World Health Organisation. Adolescence is a period of

dramatic growth and change in an individual's lifetime. During this period, adolescents

go tllrougl1 three periods of psychological development as well as the context in which

these transitions occur. The three periods of transition include biological, cognitive and

social transition (Casey, Getz and Galvan, 2008).

1.2.1 Biological Transition Period

During adolescence, the adolescent develops physical changes in specific areas of the

maturing brain resulting in cognitive and behavioural changes (CRsey, Getz and Galvan,

2008). During this period, several aspects of brain maturation are linked to behavioural,

emotional and cognitive development (Casey, Tottenham, Liston and Durston, 2005). IJ111 mg adolescence there are also changes in the activity of central neurotransmitters

responsible for mental well-being mal<ing adolescents more prone to risky practices

including sexual risl< behaviours and substance use (Crews, He and Hodge, 2007; Rao r~ncl Chen, 2008; Steinberg, 2008). It is argued that these changes can elevate the risk

of cleveloping depression and anxiety during adolescence (Davey, Yucel and Allen,

2008; Crews et al, 2007).

1.2.2 Cognitive Transition Period

Dw ing adolescence, mental abilities, such as problem-solving and reasoning abilities, continue to develop (Luna, Garver, Urban, Lazar and Sweeney, 2004). The

development of these abilities is supported by specific core cognitive processes (Luna,

Garver, Urban, Lazar and Sweeney, 2004). During this transition period, changes in

cognitive functioning are of great importance since it helps adolescents to interact with

the environment and develop towards independence (Steinberg, 2008). For instance,

r.hanges in cognitive functioning help the adolescent to better understand the logical

r.onsequences following a specific behaviour as well as understanding abstract matters

and abstract reasoning (Steinberg, 2008).

1.2.3 Social Transition Period

Social transition period of adolescence encompasses the process of social redefinition

when adolescent separate from their parents and orient themselves towards adulthood

affiliate more with peers, a development that is seen to play a very crucial role in

adolescents. This period of transition is very important as by peer interaction helps in

the development of social skills among adolescents. While this period can be

constructive, resulting in increased self-confidence and autonomy, it can also be

destructive, as the period allows the promotion of risky behaviours including indulgence

in excessive alcohol consumption and illicit substance use (Steinberg 2005).

Steinberg (2008) reiterates that the context in which three periods of transition (biological, cognitive and social) occur during adolescence is related to such e11vironmental factors as the family, peers and school. During adolescence, the

inrlividual is generally more often involved in risky behaviours including unsafe sex and substance use, than in stages of an individual's lifespan (Casey et al, 2008). During adolescence, adolescents go through sexual conflicts; stressors that come with pubertal changes; demands for sexual activity; as well as dealing with fears of early unwanted pregnancy (Bezuidenhout and Dietrich, 2004). They have to fight to establish a

meaningful guide for their sexuality; overcome the problem of gender-role identification; lake on new challenges which they use to define and shape their identities, their

knowledge of the world, and their general behaviour (Bezuidenhout and Dietrich, 2004). According to Rao and Chen (2008), adolescent participation in risky behaviours tends to increase with the transition from child to adolescent, peak in mid-late adolescence, and

thereafter decrease during the transition from adolescence to young adulthood.

Uuring adolescence, people can be extremely lonely -a situation that may lead them to G111otional turmoil, conflicts with parents and risk-taking behaviours (Corey, 2004). Risk elevation during adolescence can, therefore, be regarded as part of normal development when transitioning into adulthood (Steinberg, 2008). The teen-year period

of adolescence is associated with tremendous growth and experience, and it is a period

when adolescents go through diverse experiences than children. This period is a period

of unevenness and paradoxes marked by extensive personal developments. Many

young people often find it extremely difficult coping with these changes. During this

teen-year period, adolescents may experience intense feelings of despair, anxiety,

is nenerally longer than that of girls, as in many societies girls can enter marriage or

courtship right after menarche (Smetana, Campoine-Barr and Metzger, 2006).

l.J Problem Statement

Adolescent risk-tal<ing behaviours, including sexual and substance use are a prominent iso..,ue confronting families and societies. Adolescent sexuality is a subject that attracts 1111Jch attention from governments, the media, parents, educators, teachers, and from

nclolescents themselves. Researct1 contends that various health-risk behaviours that arc developed during adolescence may often result in elevated risks of experiencing

severe levels of morbidity or mortality in adulthood (Kessler et al, 2005; Merikangas et nl, 201 0). Several factors, including socio-demographic, environmental and contextual, h<1ve been shown to play important roles in the development of risky behaviours in adolescents. The disturbing reality is that these risky practices are occurring at an

nlnrming frequency. From a practice perspective, the study of behavioural health issues ol ndolescence is particularly important, as the development of various forms of health -nsl< behaviours are oftentimes preventable (Kessler et al, 2005). Therefore, the present

str1dy investigates the factors that influence and predict risk-taking behaviours of high

srhool adolescents in the Modiri Molema Dis1rict, North West in South Africa.

/\ltl10ugh a number of research studies have been conducted on the reproductive health <111d substance use behaviour of adolescents in South Africa, to date, however, researchers have devoted little attention to the topic of sexual risk and substance use IJchnviours of high school adolescents in the region. More so, because the communities

111 which most of t11e participating schools are located are underprivileged, poverty -stlic:ken and rely heavily on the state for income in the form of social grants (Mosoetsa, 2011), the study is of utmost importance. The scope of this study is on risky sexual belmviours of and substance use among Grade 9 and Grade 11 learners in Ngaka Modiri Molema District of the North West Province, as well as levels of knowledge of IIIV/AIDS and sexual health issues. Understanding the adolescents' sexual behaviour will be helpful to all stakeholders in health and education in coming up with intervention to reduce such risky practices among adolescents in the district. It is important for

ol tllese risl<y practices among high school learners in the chosen district in particular, and the North West Province, in general. Therefore, the problem becomes, how prevalent are these risky behaviours that high school adolescents in Modiri Molema District engage in and what are the key socio-demographic, environmental and contextual that promote these behaviours among this group of adolescents?

1.4 Thesis Rationale

Adolescent risky sexual behaviour is an issue that everyone needs to be concerned witll, because it affects the lives of all individuals as taxpayers, parents and educators, as well as the national and provincial governments. The health and economic burdens resulting from the frequent outcomes associated with adolescent sexual behaviour are huge and it is imperative to evaluate the relevant antecedents that contribute to the c-ontext of adolescent sexual behaviour with particular reference to high school r:ulolescents in Ngal\a Modiri Molema of the North West Province in South Africa. Given the risi\S of unprotected sexual activity during adolescence, it is equally imperative to obtain a comprehensive understanding of those factors associated with protective behaviours like sexual abstinence, as well as addressing the needs of high school mlolescents in the province. The rationale for this study includes, therefore, and is not restricted to, examining risk markers of adolescent sexual behaviours, such as sexual intercourse, and examining the factors that contribute to such behaviours with specific reference to Grade 9 and Grade 11 high school adolescents in Ngaka Modiri Molema District of the North West Province.

As sensitive as the subject of this study is, most of the related studies available did not involve most of the schools and varying locations covered in this study. It was, therefore, important to conduct this study in covering locations that varied widely socio-economically as well as in prevalence of these behaviours. The results of this study can be used for initiating some policy actions by the Nort11 West Provincial Health Department and the national government, but the main objective of the study is to attract the attention of all participants in the provincial health sector, principals and researchers to design more effective preventive programmes to deal with the practice. It is also believed that the interaction of the risky behaviours used in this study requires

sustained work and has the potential to contribute substantially to decreasing the

burden associated with these behaviours among high school students in the Ngaka Moc.liri Molema District, in particular, and South Africa, in general.

This study is specifically important in terms of future practice and research. In practice,

the study is important for all l<ey players iri the provincial health sector. Health

acllllinistrators, health educators, education administrators, and provincial health

researchers could 11tilize these findings in multiple ways. Health administrators may

want to use the results from this study to determine what risk factors are most prevalent in high school learners in public high schools throughout the North West Province. These important stakeholders in the provincial health sector have the responsibility to

address health problems, to attempt to determine the most effective ways of communicating health issues and information, and to deliver appropriate services, especially to high school learners.

In nddition, this study could provide guidance in policy development and assessment.

Thn findings from the current study may help in the development of social work prevention programmes targeting adolescents in Ngaka Modiri Molema Municipality.

Study results could subsequently form the basis for developing more effective strategies

to 1 educe t11e rate of risky sexual behaviours among adolescents in the municipality. In

aclclition, the results from the current study could serve as reference for local public healtll practitioners and may inform local policy advocates who support regulations rcoarding the cigarette and marijuana smol<ing, alcohol consumption and their relationships with risky sexual behaviours among learners in the municipality. Moreover,

researchers in the health field may also find the results to be convincing in assessing

the relevant policies, especially those that are directly related to the health of adolescents. Health authorities can use the findings from this study to investigate and

alter policy in risk management, curriculum and instruction for learners to determine the

focus directed toward various risky behaviours. Those specializing in risk management

may be able to refer to the results of this study to identify the prominent health risks of

adolescents in order to make policy decisions related to risk behaviours. For instance, if alco11ol abuse among all learners in a specific location is on the rise, then the relevant

health authorities may want to make the consequences for underage drinking more

scvere in hopes of discouraging such behaviour.

l.!i Study Aim and Objectives

Risl\ hehaviours in the current study are identified and measured by five health risk and 1111 P.e substance use measures -sexual activity, age at first sexual encounter, number

nl sexual partners, condom use, condom use at last sexual encounter, condom refusal,

cruarette smoking, alcohol consumption, and hashish consumption. Although there are vmious streams of influence on adolescent health risk behaviours, the current study is df;limited to the investigation of the patterns in and chief determinants of the various risl<y behaviours of Grade 9 and Grade 11 high school adolescents in Ngaka Modiri Molema District of the North West Province, South Africa with the view of suggesting possible ways and means to prevent these risk behaviours and thereby improve the health status of high school adolescents. Also, the study intends to contribute to the general knowledge on high school adolescent risk-taking behaviours. As indicated unrlier, this study particularly focuses on two important risky behaviours - sexual b0.haviours and substance use -seven different risl<y sexual bel1aviours are considered

c1tlcl lhree substance use behaviours.

As the topic of this study depicts, adolescents are normally faced with various risky bcl1aviours during stage of human development. In this study, the multiple sexual b0.l1aviours considered included seven (7) behaviours -sexual engagement, age at first

sexual intercourse, number of sexual partners, sexual encounter in the three months plior to the survey, condom use, condom use at last sexual encounter, and condom 1 (:fusal. In addition, patterns of three substance use behaviours of learners - cigarette

smol<ing behaviour, alcohol consumption behaviour, and hashish (marijuana/dagga)

consumption behaviour - were explored, as well as their association with a select number of socio-demographic, environmental and contextual factors.

1.5.1 Specific Study Objectives

rhis thesis has considered all the aspects that constitute the major predictors of adolescent sexual behaviour including ten socio-demographic factors, six environmental

factors, and eight psycho-social factors. The socio-demographic factors include school,

grade, sex, age group, place of residence, caregiver, parenUguardian educational level,

pa1 ent/guardian marital status, parent/guardian worl< sta1us and household wealth status. The six environmental factors include parental monitoring and supervision,

parent value of children, parent-child communication, school attachment, peer (sexual)

influence and religiosity. The eight psychosocial factors include experience of anti-social practices, l1aving a boyfriend/girlfriend, sexual media content exposure, perceptions

nbout sex issues, knowledge of HIV/AIDS, cigarette smoking status, alcohol

consumption status, and hashish use status. The aforementioned objectives apply solely to high school adolescents in the North West Province. Specific objectives of the study, among others, include:

• Examining the differences in learner attitudes, perceptions, normative beliefs, and perceived behaviour efforts to condom use as they relate to risky sexual

behaviours.

• Exploring the patterns of seven different risky sexual behaviours of learners -sexual activity, age at first sexual intercourse, lifetime sexual partners, sexual

encounters in the three months prior to the survey, consistent condom use,

condom use at last sexual encounter, and condom refusal.

• Assessing the significance and strength of association between the various risky

sexual behaviours and selected socio-demographic and environmental factors and the chief correlates of the various sexual behaviours.

Investigating the patterns of substance use behaviours of learners - cigarette

srnol<ing, alcohol consumption, and hashish (marijuana/dagga).

• Examining the significance and strength of association between the various

substance use behaviours and selected socio-demographic, environmental, and

1.5.2 Substantive Research Questions

The role of socio-demographic and environmental factors on the risk-taking behaviours nmong adolescents has been widely studied. Researches, l1owever, do not spell out

whether, if these same effects, when present in young adolescents, function as

precursors to subsequent risky sexual behaviour. The role of individual cognitive

abilities, personality characteristics, motivational factors, the influence of the family,

pP.ms, community, religion, school are all potential influences on risky behaviours in

adolescents. A better understanding of adolescent's cognitive, social, emotional, and physical development in a contextual sense is lherefore crucial. Social practices, such .ts alcohol consumption, cigarette smoking and hashish consumption, currently being

111itinted by some high school adolescents, are potential indirect risk factors for early

inilicttion and unprotected sex among adolescents, as they lower inhibitions and cloud

Jtldument. With this background and stated research objectives, the following research

f!Uestions, as well as others, have been formulated:

• Do the various sexual behaviours and substance use behaviours of learners

under study have any relationships with the selected socio-demographic,

environmental and contextual factors variables?

• What are the chief socio-demographic, environmental, and contextual factors

influencing the various sexual behaviours and substance use behaviours of

learners involved in this current study?

• Do learners differ in perceptions about sex issues, knowledge levels about

HIV/AIDS and knowledge about reproductive health issues as they relate to the

various sexual behaviours?

• Do learners differ in attitudes toward condoms, normative beliefs about condom use, bel1avioural efforts to condom/contraceptive use, and perceived behavioural

efforts to condom use as they relate to the various sexual behaviours?

• What are the key socio-demographic, environmental, and contextual factors that

predict the various sexual behaviours and substance use behaviours among

1.5.3 Research Hypotheses

Based on the study objectives, related literature and the stated research questions, the following research hypotheses were generated:

• The sexual behaviours and substance use behaviours of learners have signilicant relationship with the selected socio-demographic, environmental and

contextual factor variables.

• Each of the selected socio-demographic, environmental, and contextual factors

used in the study influence the various sexual behaviours and substance use

behaviours of learners.

• Learners do not differ significantly in perceptions about sex issues, knowledge levels about HIV/AIDS and knowledge about reproductive health issues.

• Learners do not differ significantly in attitudes toward condoms, normative beliefs about condom use, behavioural efforts to condom/contraceptive use, and

perceived behavioural efforts to condom use.

• All the selected socio-demographic, environmental, and contextual factors used in the study simultaneously predict the various sexual behaviours and substance use behaviours among learners.

l.G Study Significance

Attainment of healthy sexual practices among high school adolescents is important to

families, societies and governments, in general. This thesis provides an in-depth

Llllderstanding of the dynamics of risl<y behaviours (sex-related behaviours and substance use behaviours) of high school adolescents in the Ngaka Modiri Molema

Dist1 ict of the North West Province in South Africa. Findings from this study will

complement other studies and help policymakers and the Provincial Government to l1ave deeper insights into the factors that influence risky behaviours of high school lec-11ners in the North West Province. Also, based on the findings from this study, the

recommendations could go a long way to helping the provincial government on the

ill least, at the provincial level. The study can also provide provincial health authorities

w1111 information to design effective programmes for adolescents in the province.

Tile current study also contributes to the field by providing additional information on the relationship between some social factors and risky behaviours among high school adolescents. In addition to directly educating and assisting learners, the results derived

from this study will help enrich the body of knowledge that enables provincial health

educators to enhance the academic integrity of both themselves and the institutions

they represent. The study may also be of significance to national researchers. These

practitioners would be able to build upon the findings from this study to examine the co-oc'currence of risk behaviours among learners throughout South Africa and assess

whether health risl< behaviours are different in different locations. In summary, this study

could provide information that could allow these professionals to collaborate and design

11 H! most effective intervention methods to help manage the practices among learners.

1. 7 Dissemination of Study Findings

lhe objective of this study is to provide information that could be used by decision -moker s and the provincial government to help design and implement intervention

programmes to address the sexual health needs of adolescents and young adults in the

Ngal<a Modiri Molema District. It is also the researcher's view that research output be

made available to the general public in a form of scientific publications in journals and other mass media including the Internet. Initially, the results will appear as departmental worl<ing papers, and will be available free of charge through the Population Unit's

website. For target publications, the researcher aims at journals including Population l >cvelopment Review, African Population Newsletter, and Population Bulletin of the I Jnited Nations, South Africa Journal of Demography and African Population Studies.

1.8 Structure of Thesis

I lle study is organized into six chapters with Chapter 1 presenting the study

bacl<ground. Chapter 2 presents a review of the literature related to this current study

wl1ile Chapter 3 discusses, in detail, the research design and methodology. Chapter 4

factors that are subsequently used in the latter chapters as well as the exploration of the

levels of learner knowledge of HIV/AIDS, knowledge of sexual health issues, learner

perceptions about sex-related issues, attitudes toward condom/contraceptive use, and

patterns in cigarette smoking, alcohol consumption, and hashish consumption. Chapter 5 focuses solely on seven different aspects of risky sexual behaviour - sexual activity, age at first sexual intercourse, number of sexual partners, sexual encounter in the three mont11s prior to the survey, condom use, condom use at last sexual encounter, and condom refusal. Chapter 6 presents a brief discussion of the findings, implications of the study findings, and conclusion.

1.9 Definitions of Key Terms

f11e following terms were used in the study, necessitating their definition below:

Adolescence

Adolescence is defined as a period of transition between child-hood and adulthood. It

includes teenage (13-19 years) and may overlap with youth (15-24 years). Adolescent refers to a boy or girl who is between the ages of 10 and 20 (Berk, 2007).

AIDS

AIDS is an abbreviation for Acquired Immune Deficiency Virus. AIDS is a pathological condition of the immune system defined by a set of signs and symptoms attributed to infection by the Human Immunodeficiency Virus (FPD, 2005). When an individual has a

full-blown AIDS, the immune system breaks down and as such the body gets to a point of being unable to fight off the infections that a normal and an intact immune system could suppress (AIDSONLINE, 2003).

Alcohol and Alcohol use

In the context of this study, alcohol refers to such beverages as beer, wine and spirits. Alcohol use involves drinking beer, ciders, wine, or hard liquor.

Attitudes

Specific personal internalizations of values - specific reference to ideas, perceptions,

parsons and groups. Tendencies to act based on one's norms and values (Ward et al,

2006).

C:ondom Use Attitudes

In the context of this study, condom use attitudes refer to the participants' attitudes

tuward their own or their partner's use of condoms.

Health Risk Behaviours

Fo1

the purpose of this study, health risk behaviours are defined as sex-related

bt~havioms and substance use behaviours.

H/V I< now/edge

HIV is an acronym for Human Immunodeficiency Virus. HIV lmowledge refers to participants' knowledge of facts about HIV transmission.

1-1/V Risk Behaviours

For the purpose of this study, HIV risk behaviours refer to behaviours that place an

i11dividual at risk lor contracting and/or transmitting diseases, unprotected sex, sexual

.tt t1v1ty with multiple sexual partners, condom use and refusal, the use of tobacco,

nlc:ohol and hashish.

Llvmg Arrangement

Living arrangement refers to the physical composition of the family, whether it is a two

-p<trent household, single-parent family, or any other forms.

Patent-Child Communication

In the context of this study, parent-child communication refers to how clear

communication is between a parent and child.

Pment-Child Relationshig

In the context of this study, parent-child relationship refers to the four relationship

dimensions such as psychological control, involvement, parental warmth and

Parental Involvement

111 the context of this study, parental involvement refers to parents' dedication to help

tlrcir adolescent children in their scl1ool activities, personal involvement and cognitive/

111lellectual involvement.

protective Factor

!1

1

the context of this study, a protective factor is a factor that helps to reduce the impact

on n health risk behaviour and enhances the likelihood of socially desirable and positive

outcomes in adolescents.

r

(efigiositv

In the context of this study, religiosity refers to the level of adolescents' engagement in

d ll 1 rcll activities and thereby measures the level of spirituality.

H1sk Behaviours

nncl<less behaviour including those behaviours that incorporate strong associations of

S<'J ious negative consequences, personal injury or death, or other events that may have

long term negative impact.

s·~:xual Behaviour

111 the context of this study, sexual behaviour refers to safe sex. This includes sexual

r1ctivity (vaginal sex), age at first sex, sexual encounter three months prior to survey, number of sexual partners, condom use, condom use at last sexual intercourse and LOIIciOITI ref I JSal.

Sel(ual Knowledge

:1nxual l<nowledge is a comprehension of general human sexual development, contraceptive methods, human reproductive anatomy, and sexually transmitted c fl!,eases.

Sexually Risky Behaviour

111 tile context of this study, sexual risk behaviour refers to having vaginal sex without trsing a condom or condom refusal by a partner or both during sexual intercourse.

Sexual Health

In the context of this study, sexual health refers to the awareness of appropriate sexual

behaviours, practices or situations.

Sexually Transmitted Disease

A sexually transmitted disease (STD) is an infection spread from one person to another

through sexual contact. It is commonly known as sexually transmitted infection (STI). In

the context of this study, STI and STD may be used interchangeably.

Substance Use

111 the context of this study, substance use refers to adolescents ever smoking cigarette a11ct consuming alcohol or hashish/marijuana.

•

C

HAPTER 2

Rev

ie

w

of Related Literature

2.1 Introduction

Adolescence is described as a period of increased autonomy and experimentation of

risl<y practices. It is a period of major physical, psychological, economic and social rnteraclions and relationship (UNFPA, 2006). The literature describes adolescence as a

ponod in one's lifetime when the risl< of engagement in potentially risky behaviours

I>P-come a prominent area of concern to families and governments (Brown and Rinelli, ?010; Veselska, Gecl<ova, Orosova, Gajdgosova, van Dijl<, and Reijneveld, 2009;

l<ostelecky, 2005; Laible, Carlo and Roesch, 2004). In their published work, Smylie et al (?006) described the adolescence as a period characterized by heightened potential for

risk-taking behaviours that have important long-run health implications. It is a period whon several factors - socio-demographic, environmental and contextual - become rrrcreasingly important. According to World Health Organisation (201 0), there are an

P.Stimated 1.2 billion adolescents in the world today and more than four fifth of them live

i11 developing countries.

I h1s chapter explores literature relevant to the study in terms of adolescent risk-taking behaviours considered in the study. In order to understand the risk-taking behaviours

nmong adolescents, it is important to rirst understand who adolescents are, the size and

global geographic spread. It is equally important also to reflect on the theory of planned

behaviour that underlines intentions to perform a particular behaviour and ultimately lead to risky behaviours among adolescents.

2.2 The Theory of Planned Behaviour

fhe Theory of Planned Behaviour is a framework applied in behavioural research to

predict a variety of health behaviours including sexual risk behaviours and substance trse (Kisamore and Stone, 201 0; Robinson and Doverspike, 2006). According to this theory, an individual's intention to perform a specific behaviour is the best predictor of that specific behaviour (Blue, Marrero and Black, 2008; Francis et al, 2004). The Theory

predicting intentions to perform specific behaviours and for understanding health behaviours such as condom use, breastfeeding, smoking behaviour, and dietary chnnges (Arden and Armitage, 2008; Bai, Middlestadt, Peng and Fly, 2009; Abraham a11d Sheeran, 2004; Blue and Marrero, 2006; Bledsoe, 2006).

Figure 2.1 depicts the Theory of Planned Behaviour framework. According to the Theory of Planned Behaviour, an individual's intention to perform a particular behaviour is

predicted by attitudes, subjective norms, and perceived behavioural control. As shown

in the framework, indirect beliefs include behavioural beliefs, normative beliefs, and control beliefs. Ajzen (2011) argues that these beliefs form the basis of attitude fo11nation, subjective norm, and perceived behavioural control. Attitude toward the bP.Ilaviour depicts an individual's overall positive or negative evaluation of the behaviour while a subjective norm reflects an individual's belief about whether an individual pc1 forms is approved or disapproved by many. Approval or disapproval of a behaviour l)t1tng performed by an individual is cemented by normative beliefs - the views of other people about this particular behaviour being performed by the individual. Perceived behavioural control is the level of control an individual has over the behaviour.

Behav1oural Beliefs Control Beliefs 1--- - i ... 1--- - 1 ... Altitude toward the behaviour Subjective Norm Perceived Behaviour Control

Figure 2.1: The Theory of Planned Behaviour (Azjen, 2011)

According to Ajzen (2011 ), the performance of a particular behaviour not only depends

on motivation, but also the individual's control of that particular behaviour. All together, tlw three constructs - attitude, subjective norm and perceived behavioural control -wort< to influence an individual's intention to perform a particular behaviour, and thereby impacting on the behaviour itself. Each construct has its own determinants that have the potential to influence an individual's final behaviour, providing the opportunity to pinpoint thn determinants that have a substantial impact on a particular behaviour as well as those that do not have as great of an influence. Interventions can then be developed to alter these influential determinants, subsequently impacting intention and ultimately, the performance of the particular behaviour.

2.3 Contextualising Risk-Taking In South African Adolescents

According to WHO (2007), sub-Saharan Africa accounts for nearly 3.3 million of the 5.4 million adolescents aged 15-24 living with HIV. The UNA IDS (2006) global report revealed that adolescents, especially those within the 15-24 year age group, are most susceptible to sexual risk behaviours. In their paper, Lesch and Kruger (2004) reported tl1c insufficiency of information on adolescent sexual behaviour in various contexts and irnr>lored tllat it is imperative that adolescent sexuality within South Africa's diverse contexts be investigated. A deeper understanding of adolescent risk-taking behaviours m various contexts, as well as the factors influencing such behaviours has important implications for the development of prevention programmes for adolescents, such as tile high school adolescents being investigated in this study.

2.3.1 Sexual Risk-Taking among South African Adolescents

Risky sexual behaviour among the adolescents in South Africa is a salient problem. It is argued that adolescents of the more recent years seem sexually active at younger ages than the years before and have little experience of health-related issues (Zwane, Mngadi and Nxumalo, 2004 ). According to UNA IDS (2006), sub-Saharan Africa remains the worst affected area in the world with high prevalence of sexually-transmitted diseases, including HIV/AIDS, citing South Africa as one of the countries having the

highest prevalence rates worldwide. In the South African National Youth Risk Behaviour

rel)orted having one or more sexual partners (The National Department of Health of South Africa, 2002). A national survey on HIV and sexual behaviour among South African adolescents aged 15-24 revealed that, by province, the highest overall HIV p1evalence was in l<waZulu-Natal with 14% prevalence rate (Pettifor, Rees, Steffenson, lllongwa-Madikizela, Macphail, Vermaak and Kleinschmidt, 2004). This is supported by a similar finding in Shisana et al (2005) in which the researchers also found that t<waZulu-Natal Province as having the highest HIV prevalence rate (about 16%) while

tllC Western Cape Province having the lowest HIV prevalence rate (2.3%). In their st11cly, Rehle et al (2007) found that of all new HIV infections in South Africa, about 34% oct:urred in adolescents aged 15-24.

In .1 study by Visser (2003), the author establisl1ed that adolescents of both genders typically display early age of onset of sexual behaviour and put the mean age of onset ol !;exual intercourse at 12-15.5 years for boys and 13.6-15.9 for girls. The studies fu1lller reveal that the majority of those involved in their studies engaged in unprotected intercourse, which typically involved more than one lifetime partner. Flisher et al {2003) sl10wecl in their study a high turnover of sexual partners which indicated that a Slqnificant larger number of younger adoles~ents barely know their sexual partners for ll!·;•, tllan one week, in comparison to their older counterparts. In their independent study also, Shisana and Simbayi (2003) identified a similar trend towards earlier sexual tit: I >ul amongst younger respondents, where the median age at first sex for respondents aqed 15-24 year was found to be 16 years. Shisana and Simbayi (2003) noted, in pe11licular, that sexually active boys uniformly typically engage and experience a much P<ulier onset of sexual activity than their female counterparts.

According to Shisana and Simbayi (2003), there seems to be a pattern in the levels of condom use in South Africa - more males tend to use condoms than females - with 111ore men using condoms at last sex than women. And the practice appears to gain pop11larity in men as years go by. There was, however, a cause for concern in the case ol adolescents as there appears to be a downward trend of condom use among adolescents and men who have had multiple sexual partners (Shisana and Simbayi, 2003}. In a study by Eaton et al {2003), findings showed that in South Africa almost half of tile adolescents interviewed indicated making their sexual debut by the age of 16

I

years with adolescent_ males making their sexual debut a bit earlier than adolescent girls

and Black adolescents being more likely than other race groups to start sexual activity

111 their teens (Eaton et al, 2003). Empirical studies show the mean age for sexual debut

among adolescent males to be 16.4 years and 17 years for girls (RHRU, 2004; Fonn,

2003). With regards to condom use among adolescents in South Africa, the

Reproductive Health Research Unit (2004) revealed that 52% of adolescents aged 15

-24 used a condom at last sexual intercourse, and that more males than females reported condom use. Consistent condom use however is low with nearly a third of

respondents reporting always using a condom, and 31 percent reporting never having

used a condom (RHRU, 2004).

More adolescent males (66.4%) also reported having more than one sexual partner in l11eir lifetime than adolescent females (38.1 %) (RHRU, 2004 ). Other studies have

established links between risky sexual behaviour among adolescents and substance 11sc. l<aufman et al (2004) argued that the use of alcohol and illicit drugs increases the likelihood of sexual intercourse among adolescents. It is, therefore, clear that South

African adolescents are engaging in highly risky sexual behaviour and that many of them feel that they are not at risk of any of the consequences of sexual intercourse,

especially contraction of the deadly HIV virus, which reduced the motivation to take the

necessary precautions to ensure safe sexual behaviour (Eaton et al, 2003).

2.3.2 Substance Use among South African Adolescents

Within the context of the literature, substance use among adolescents encompasses

d~Jalelte smoking, alcohol consumption, and marijuana use. In a number of studies,

adolescence has been found to be part of the lifespan during which individuals are most

lil\cly to begin using substances and are also most at risk for developing serious

substance abuse issues that may persist into adulthood (Brown and Rinelli, 201 0; Mason, Hitch, Kosterman, McCarty, Herrenkohl and Hawkins, 201 0; Kostelecky, 2005).

Regarding adolescent substance use in the South African context, a number of studies

have found interesting results while statistics show that alcohol is the dominant substance of abuse followed by cannabis/marijuana (Piuddemann et al, 2002). A study

substance use with cigarette smoking having a prevalence rate of 10.6% and alcohol

use, a prevalence rate of 39.1 %. Another study by Parry et al (2004) concluded that

marijuana use is the most common substance of use for which adolescents seek clinical

treatment. In addition, marijuana use remains the single illicit substance most likely to

be consumed by high school learners in South Africa, a finding that depicts past South

African and international studies (Parry et al, 2004).

2.4 Important Determinants of Adolescent Risk-Taking

l={isl<-tal<ing decision making is a process that has been studied across many populations and ages, and has been investigated in numerous disciplines (Reyna, 2004;

Reyna and Lloyd, 2006; Branas-Garza et al, 2007). The effects of power, framing, and social pressure on risk-taking decision making are also common bases in risk-taking decision research (Gardner and Steinberg, 2005; Maner and Schmidt, 2006). The in fit tences that parents, peers, and society, in general, have on adolescents' behaviours and decision-making processes are also a common basis in developmental research (Maner and Schmidt, 2006). Although the reason of many adolescent risky behaviour

interventions is to enhance the accuracy of risk perceptions, adolescents typically ovGtestimatc important risks such as their ·chances of contracting HIV or developing

lu119 cancer (Reyna and Farley, 2006). Despite a provable decrease in perceived

vulnerability as one grows older, risk-taking and decision-making tend to decrease with agH (Gardner and Steinberg, 2005).

f-ie9arding adolescent risky decision-making, authors such as Gardner and Steinberg

(2005), argue that factors, apart from the adolescent's own mode of information processing and cognitive maturity, can also shape their decisions regarding risky

-behaviours. Peers have also been shown to have a significant influence on the decision mal<ing processes in adolescents (Gardner and Steinberg, 2005). Previous studies have shown that peer behaviours are one of the strongest predictors of adolescent problem bel1aviours (Garnier and Stein, 2002). According to Steinberg and Monahan (2007), two

reasons are thought to have significance of peer influence in adolescence. One, during adolescence, group membership becomes prominent, and normative regulation occurs

•

because of an increased need to fit in during adolescence, peer pressure becomes very

r.rucial (Steinberg and Monahan, 2007).

Family environment and set-up are thought to have significant impact on adolescent risl\-tal~ing behaviour (Garnier and Stein, 2002). A family environment that promotes values of care and kindness in their children produces adolescents with more

generative life narratives while a parental commitment to values that focus on traditional

achievement and authority, as well as humanism or egalitarianism, lead to fewer ck~linquent behaviours in adolescence (Garnier and Stein, 2002). Research studies also have found that adolescents with high levels of spirituality or religiosity are less likely to

engage in antisocial behaviours while positive perceptions of religion by adolescents have been shown to relate to less delinquent behaviour in adolescents (Sinha et al.,

2007). Other research studies in risky decision-making among adolescents have shown

lhrtl to a greater extent, safer sexual behaviour is influenced by feelings of moral

obligation (van l<esteren et al, 2005).

In South Africa, substance use, including cigarette, alcohol, and marijuana, is a

C0111mon problem amongst high school adolescents (Taylor, Jinabhai, Naidoo, et al,

2003). In particular, sexual risk and substance use are of particular concern in South

Aflica, one of the countries with the highest rates of HIV in the world (Pithey and

Mnrojele, 2002), and more importantly, the prevalent high infection rates among

adolescents aged 15 to 24 years (Darrington et al., 2006; Pettifor et al., 2004 ). According to Darrington et al (2006), about one-quarter of HIV-infected individuals in

South Africa are under the age of 25, and AIDS is responsible for 71% of all deaths in !110 15-49 year age group. Regarding sexual behaviour, about 67% of South African

adolescents aged 15-24 have been found to have engaged in penetrative sex, 9% of

sexually-active Grade 11 learners reported having a sexually transmitted infection, and 13%, reported having been pregnant or making someone pregnant (Pettifor et al, 2004;

Reddy et al, 2003).

Past studies on adolescents in South Africa have documented the widespread

substance use - 72% reporting lifetime use of alcohol, cigarettes, marijuana, or inhalants by Grade 9 (Patrick et al, 2008). According to Parry (2005) and Parry, Myers,

Morojele el al (2004), alcohol is the primary substance of abuse in young adolescents,

with lifetime use prevalence rates of between 25% and 40%. Parry (2004) puts the prevalence of lifetime tobacco smoking amongst South African adolescents aged between ·12 and 17 years at 22%. In a study by Bonomo and Proimos (2005), the prevalence of marijuana use in high school learners was found to be generally lower than that of tobacco and alcohol. In particular, a South African study by Madu and Matla

(2003) found t11e prevalence of illicit substance use to be 12% in Grade 8 and Grade 10

learners. Marijuana was found to be the most common illicit substance used in South Africa, with a prevalence of 5% to 10% amongst adolescents with a higher prevalence

i11 males and urban locations and amongst Coloured and White learners compared to

otlwr racial groups (Madu and Matla, 2003).

2.5 Conceptual Framework

In research, a conceptual framework is used to outline possible courses of action or to p1 esent a preferred approach to a system analysis project. The framework is

constructed from a set of concepts linked to a planned or existing system of methods, bel1aviours, functions, relationships, and objects. In part, this thesis will be guided by a

number of frameworl<s focusing on adolescent risl<y behaviours and health-related issuP.s. This study conceptualizes adolescent risk-taking behaviours as being influenced

by a variety of factors including bacl<ground factors, socio-demographic, environmental

ancl contextual factors.

Attilttdes, perceptions, beliefs and lmowledge always precede behaviour. Adolescents' socio-dernographic characteristics and environment shape their attitudes and

lmowledge that in turn determine their behaviour. Because adolescents' attitudes are not yet firmly established during adolescence, they are easily swayed into adapting to messages that seem appealing, most potentially influencing their behaviours. One

potential source of such messages is through peers. Adolescents' religiousness, family bacl<ground and socio-demographic characteristics shape their beliefs, attitudes and

pet ceptions about llealth-related practices which could eventually influence risky

behaviours including sex-related practices and substance use. Knowledge of reproductive health and exposure to sexually explicit content media also seem to

influence adolescent sexual behaviour. The above concepts are pictorially presented in Figure 2.2.

Risky Behaviour _{Sexual Practices}

• Ever had sexual intercourse _{• Age at First Sexual Intercourse} • Number of Sexual partners

• Ever smoked cigarette • Ever consumed alcohol

• Ever smoked hashish (dagga)

• Frequency of sexual activity

• Frequency of condom/contraceptive use

School and Socio-Demographic Factors

• School • Grade • Sex • Age • Place of residence ~ • Household arrangement • Caretaker

• ParenVguardian highest educational level • ParenVguardian marital status

• ParenV guardian work status • Household wealth status

Family Characteristics

• Family strenglhs

• Parental monitoring and supervision,

• Parent values

• Parent-child communications

Peers and Religion

. _ _ • Sexual influences from friends

• Level of religiosity

Knowledge

• Knowledge of HIV/AIDS related issues

• KnoWledge of sexual/reproductive heallh

Attitudes, Beliefs, Behavioural Efforts

• Attitudes toward condom/contraceptive use • Beliefs about condom/contraceptive

• Behavioural efforts to condom/contraceptive use