(Research Theme Lead: A/Prof Catherine Mathews)
In 2012, decades into the HIV epidemic, the incidence of HIV among young South African women 15 to 24 years of age was still high, 2.42%. It was higher than any other age group and 5 times as high as that of young males of the same age, based on findings from a national survey conducted by the Human Sciences Research Council. The National Antenatal Sentinel HIV Prevalence surveys confirmed that we have made no impact on HIV incidence among adolescents. Between the years 2007 and 2012, the prevalence hardly changed: it was 13% in 2007 and 12% in 2012. South Africa has made substantial progress in reducing mother-to-child transmission of HIV, and we have seen progress treating and extending the lives people living with HIV. However there has been little progress preventing new infections among young women and men.
The incidence of unintended pregnancies among South African adolescents has declined recently but the rates are still high. In 2010 the rate was 54 births per 10,000. Approximately 19% of South African women report having been pregnant during adolescence. There are substantial social and health costs associated with adolescent fertility.
South African adolescents are at high risk of intimate partner violence and sexual violence and this has adverse consequences on their sexual health. Gender-based violence including intimate partner violence, rape and sexual coercion increases women’s risk for sexually transmitted infections, and unwanted pregnancy. A significant proportion of mental health and social problems encountered in adolescents have their roots in the HIV-pandemic.
We are interested in developing and testing interventions for adolescents to prevent HIV and unwanted pregnancies, and to improve sexual and reproductive health and well-being. The SATZ (Promoting sexual and reproductive health: School-based HIV/AIDS prevention in sub-Saharan Africa), PREPARE (Promoting sexual and reproductive health among adolescents in southern and eastern Africa – mobilizing schools, parents and communities) and Respect4U (Encouraging safe dates: Reducing intimate partner violence in South African youth) projects are examples of work in this field. Until now, we have not managed to develop an intervention that has succeeded in reducing sexual risk behavior among South African adolescents. The SATZ study in Tanzania was effective in reducing sexual risk behavior. The analyses of the PREPARE study are currently underway, and we hope to show that we have had an impact of the factors that put adolescents at risk of sexually transmitted infections and unwanted pregnancies.
(Research Theme Lead: Prof Petrus de Vries)
Even though at least 50% of the serious mental illnesses of adulthood have its onset in adolescence, South Africa and Africa has extremely limited skilled staff and expert resources to screen for, detect and treat mental health problems. Mental health also a significant relationship with sexual and reproductive health decision-making, with adversity such as sexual abuse, violence and bullying and with intimate partner violence, both as risk markers and as consequences of these psycho-social events.
As highlighted, mental health systems and access to appropriate mental health care is a very significant challenge. In this AHRU theme, we are interested in mental health promotion (how to get simple mental health messages across to adolescents), early detection (through the evaluation and development of potential screening tools for use in school settings, including the Social Communication Questionnaire), in adolescent mental health training at a school- and community-based level (how to train teachers and other community-based workers to detect and provide ‘first step’ interventions), and in understanding pathways to care for adolescents with emerging mental health problems.
(Research Theme Lead: A/Prof Catherine Mathews)
Access to healthcare for adolescents (10 to 19 year olds) is a priority in many countries including South Africa, particularly for HIV/AIDS, sexual, reproductive, and mental health care. One of the global top priorities for adolescent sexual and reproductive health is to ensure access to appropriate sexual and reproductive health services and access to commodities such as condoms, contraception and HIV testing. Adolescents face a range of barriers to health care related to cost, transportation, clinic hours, privacy and confidentiality, lack of available services and health worker attitudes.
The PREPARE study has demonstrated the extent of the unmet need for contraception, condoms and HIV tests among very young South African adolescents (average age 14-15 years) who have had their sexual debut. Among girls who had had their sexual debut, only 32% had ever used contraception. Only 67% of girls and 78% of boys who had had their sexual debut had procured condoms and 36% of girls and 38% of boys had ever been tested for HIV. These findings reinforce the importance of special efforts to increase the accessibility of SRH services and commodities for young adolescents and especially for young adolescent girls. Out-of-facility approaches such as school health services can be important strategies for increasing access to health care for youth. We are interested in the effects of various methods to strengthen health systems to improve adolescent access to appropriate SRH and mental health services and interventions. The PREPARE study investigated the effects of a school health service on adolescent access to sexual and reproductive, and mental health services, and we are currently analyzing the findings.
The implementation of adolescent and youth friendly health services is an initiative to attract and adequately and comfortably meet the health care needs of adolescents. In South Africa there have been three national initiatives to implement adolescent and youth friendly services: the National Adolescent Friendly Clinic Initiative or NAFCI (2000-2005), the Youth Friendly Services or YFS (2006-2011) and the current revised Adolescents and Youth Friendly Services Model (2013-2017). We are interested in methods to improve the adolescent-friendliness of health services, particularly for Sexual/Reproductive Health and mental health, to ensure a positive impact on adolescent health. We have been involved in a consultancy capacity in a rapid assessment of the adolescent and youth friendly programming in South Africa, commissioned by UNICEF South Africa in collaboration with the National Department of Health and conducted by a team at the Human Sciences Research Council.
(Research Theme research Lead: Dr Loraine Townsend)
South Africa ratified the United Nations Convention on the Rights of the Child in 1995 and the African Charter on the Rights and Welfare of the Child in 2000. Both these instruments recognize a wide range of children’s rights, and require member states to ensure that legislative, administrative, social and educational measures are taken to protect children from a range of forms of violence, abuse, neglect, maltreatment or exploitation.
The focus on child abuse has its origins in these policy imperatives, and in the fact that South Africa has high rates of physical, sexual and emotional abuse of children perpetrated both by adults and peers. Under common law, South African parents and legal guardians have the power “to inflict moderate and reasonable chastisement on a child”, yet prevalence rates of child abuse in South Africa suggest that “reasonable chastisement” often devolves into physical and emotional abuse. Corporal punishment of school learners used by teachers and other school personnel as disciplinary measures or as a means to control the behaviour of learners has been prohibited by law since 1996, yet continues to be prevalent in many South African schools. Peer aggression and harassment, which is often erroneously considered part of normal interaction between peers, is known to evolve easily into the better-recognised, unacceptable bullying behaviour.
There is inadequate knowledge about the extent and nature of child abuse because the majority remains unreported. Evidence suggests there is a lack of awareness about what constitutes child abuse and its consequences, inadequate formal training about forms of abuse and how to detect abuse, a lack of knowledge about reporting procedures and their outcomes, and inadequate response to and support for victims of abuse. There is limited knowledge about the extent and nature of peer-on-peer bullying behaviour, misperceptions as to what constitutes bullying, a paucity of knowledge about the short- and long-term mental health and behavioural risks that being even an occasional bully, victim or both has for children, and very few efforts to address bullying in schools or elsewhere. The focus on child abuse will seek to fill these substantial gaps in knowledge.
(Research Theme Lead: To be appointed)
There is overwhelming evidence in South Africa and elsewhere that sexual violence and intimate partner violence are leading causes of reproductive health problems, including HIV, sexually transmitted infections and unwanted pregnancy for adolescents and adults. There appears to be no decline in levels of sexual violence and intimate partner violence in South Africa. Adolescent sexual relationships are marked by a high incidence of violence, particularly in first sexual encounters. National policies recognize this problem, and one adolescent intervention, Stepping Stones, had an impact on male perpetration. However, apart from Stepping Stones, there are no South African evidence-based intimate partner violence and sexual violence prevention programmes.
As part of the Respect4U and PREPARE projects, we have developed and evaluated an intimate partner violence prevention programme for young adolescents. Our future work will focus on analyzing the impact of the PREPARE intervention on intimate partner violence and sexual violence victimization and perpetration. We will also investigate whether our intervention influenced access to appropriate health care and social services for those adolescents who had been victims and/or perpetrators. As part of our focus on school health systems, we will be developing and evaluating a school health service model of care to identify children and adolescents who are at risk of such violence, and to refer and link them to the appropriate assessments and treatment.