TITLE PAGE UNDERSTANDING PERCEPTIONS OF RISK AMONG YOUTH
IN A SOUTH AFRICAN TOWNSHIP
By
MICHELLE L. NEBERGALL
Submitted in partial fulfillment of the requirements for the degree of
Doctor of Philosophy
Department of Anthropology
CASE WESTERN RESERVE UNIVERSITY
August 2014 COMMITTEE APPROVAL SHEET CASE WESTERN RESERVE UNIVERSITY SCHOOL OF GRADUATE STUDIES
We hereby approve the thesis/dissertation of
Michelle L. Nebergall
Candidate for the degree of Doctor of Philosophy*.
Committee Chair
Dr. Janet McGrath
Committee Member
Dr. Jill Korbin
Committee Member
Dr. Eileen Anderson-Fye
Committee Member
Dr. Scott Frank
Date of Defense
28 March 2014
*We also certify that written approval has been obtained for any proprietary material contained therein.
2 COPYRIGHT © 2014
Michelle L. Nebergall
All rights reserved TABLE OF CONTENTS
TITLE PAGE ...... 1
COMMITTEE APPROVAL SHEET ...... 2
COPYRIGHT © 2014 ...... 3
TABLE OF CONTENTS ...... 4
LIST OF TABLES ...... 11
ACKNOWLEDGMENTS ...... 13
LIST OF ABBREVIATIONS ...... 15
UNDERSTANDING PERCEPTIONS OF RISK AMONG YOUTH ...... 16
CHAPTER 1. INTRODUCTION ...... 18
1.1 Study Framework ...... 18
1.2 Study Objectives ...... 19
1.3 Significance ...... 21
1.4 Chapter Overview ...... 22
CHAPTER 2. BACKGROUND AND SIGNIFICANCE ...... 24
2.1 Anthropological Perspectives on Adolescence and Youth ...... 25
2.2 Anthropological approaches to study of risk ...... 34
2.2.1 The Concept of Risk ...... 34
2.2.2 Risk Perception ...... 51
2.2.3 Risky Environments ...... 60
2.2.4 Gender and Risk ...... 67 2.4 Conclusion to Background and Significance ...... 72
CHAPTER 3. THE SOUTH AFRICAN CONTEXT ...... 74
3.1 Introduction ...... 74
3.2 Historical Context ...... 78
3.3 Socio-Economic Context ...... 85
3.4 HIV and AIDS in South Africa ...... 102
3.5 Youth in South Africa ...... 109
3.6 Description of Field site ...... 118
3.7 Entering the Field ...... 126
CHAPTER 4. METHODS ...... 130
4.1 Overview ...... 130
4.1.1 Study Phases ...... 130
4.1.2 Research Assistants ...... 131
4.1.3 Language ...... 131
4.1.4 Pilot Testing Data Collection Instruments and Procedures ...... 132
4.2 Sampling and Recruitment Procedures ...... 132
4.2.1 Overview ...... 132
4.2.2 Phase 1 Sampling and Recruitment ...... 133
4.2.3 Phase 2 Sampling and Recruitment ...... 135
4.2.3.1 Second Youth Sample ...... 135
4.2.3.2 Key Informant Sample ...... 137
4.2.3.3 Community Leader Sample ...... 137
4.2.3.4 Youth Samples 1 and 2 ...... 138
5 4.3 Data Collection Procedures ...... 139
4.3.1 Phase 1 Data Collection Procedures ...... 139
4.3.1.1 Focus Groups ...... 139
4.3.1.2 SMS and MXit on Cell Phones ...... 141
4.3.1.3 Diaries ...... 143
4.3.2 Phase 2 Data Collection Procedures ...... 143
4.3.2.1 Structured Risk Assessment Questionnaire ...... 143
4.3.2.2 Youth Interviews ...... 144
4.3.2.3 Community Leader Interviews ...... 145
4.3.2.4 Key Informant Data ...... 145
4.3.2.5 Participant Observation ...... 146
4.4 Data Management and Analysis Procedures ...... 146
4.5 Ethical Considerations ...... 151
4.5.1 Ethics Review ...... 151
4.5.2 Informed Consent ...... 151
4.5.3 Protections and Service Referrals ...... 152
4.5.4 Incentives for Participation ...... 152
4.6 Scope and Limitations ...... 154
CHAPTER 5. FOCUS GROUP DATA ...... 156
5.1 Overview ...... 156
5.2 Focus Group Sample Characteristics ...... 156
5.3 How the risk of HIV infection is perceived in everyday life ...... 158
5.4 Perceptions of Other Inter-Related Risks in Daily Life ...... 170
6 5.5 Strategies used by youth to manage risks ...... 177
5.6 Contextual Factors ...... 189
5.7 Summary ...... 196
CHAPTER 6. DIARY DATA ...... 199
6.1 Introduction ...... 199
6.2 Method ...... 200
6.3 Analysis ...... 200
6.4 Findings ...... 201
6.5 Discussion ...... 214
6.6 Evaluation of the method ...... 215
CHAPTER 7. INTERVIEW DATA ...... 216
7.1 Overview ...... 216
7.2 Interview Youth Sample Characteristics ...... 216
7.3 Risks ...... 217
7.4 HIV Risks ...... 236
7.5 Risk Management Strategies ...... 240
7.6 Summary ...... 249
CHAPTER 8. CELL PHONE BASED DATA ...... 251
8.1 Overview ...... 251
8.2 Background and Rationale ...... 251
8.3 Methodology ...... 253
8.3.1 SMS ...... 253
7 8.3.2 MXit ...... 254
8.3.3 Procedures ...... 256
8.3.4 Data Management ...... 256
8.3.5 Data Analysis ...... 257
8.3.6 SMS Questions ...... 257
8.3.7 MXit Questions ...... 258
8.4 Response Rates and Results ...... 259
8.4.1 SMS Response Results ...... 259
8.4.2 MXit Response Results ...... 261
8.5 Findings Regarding Language Use ...... 263
8.6 SMS Message Contents ...... 266
8.6.1 Daily Life ...... 266
8.6.2 Choices and Decisions ...... 267
8.6.3 Health and Illness ...... 270
8.6.4 Dating and Romantic Partners ...... 270
8.6.5 Challenges ...... 271
8.6.6 Behavioral Choices to Manage Challenges ...... 271
8.6.7 Risk Environment ...... 271
8.7 MXit Chat Contents ...... 272
8.7.1 Checking In ...... 273
8.7.2 Making plans ...... 273
8.7.3 Asking questions of the researcher ...... 273
8.7.4 Seeking Assistance ...... 274
8 8.7.5 Dating, Love and Relationships ...... 275
8.8 How youth are using MXit ...... 275
8.8.1 When Participants Use MXit ...... 276
8.8.2 Self-Presentation through MXit Profiles ...... 276
8.8.3 Who to Chat With and Why ...... 279
8.8.4 Perceptions of MXit ...... 286
8.9 Exploratory Analysis of the Methods ...... 288
8.9.1 The SMS Method ...... 289
8.9.2 The MXit Method ...... 291
8.10 How Cell Phones Are Used ...... 292
8.10.1 Access to cell phones and sharing phones ...... 292
8.10.2 Airtime and Pay as You Go ...... 294
8.10.3 Social Connectedness ...... 295
8.10.4 Status ...... 297
8.10.5 The Changing Social Network Landscape ...... 298
8.11 Implications for future research ...... 300
CHAPTER 9. DISCUSSION ...... 304
9.1 Summary of Findings ...... 304
9.2 Risk Perception ...... 306
9.2.1 The Role of Social Proximity to HIV ...... 309
9.2.2 Social Risk ...... 312
9.3 Gender and Risk ...... 314
9.4 Risk Environment and Syndemics ...... 317
9 9.5 Summary ...... 320
CHAPTER 10. CONCLUSIONS ...... 323
10.1 Summary ...... 323
10.2 Future Directions for Research ...... 324
10.3 Cell phones as research tools: Potential Applications and Recommendations
327
10.4 Listening to youth: Strategies to address youth vulnerability ...... 328
APPENDICES ...... 330
Appendix A. Chronology of South African History and HIV/AIDS Epidemic ...... 330
Appendix B. Diary Instructions ...... 336
Appendix C. Youth Interview Guide ...... 338
Appendix D. Risk Assessment Questionnaire ...... 350
LITERATURE CITED ...... 365
10 LIST OF TABLES
Table 4a. Data Collection Activities by Study Phase and Participants………..131
Table 4b. First Youth Sample………………………………………………………………..134
Table 4c. Second Youth Sample……………………………………………………………136
Table 4d. Key Informant Sample…………………………………………………………..137
Table 4e. Community Leader Sample……………………………………………………138
Table 4f. Total Youth Sample……………………………………………………………….139
Table 5a. Focus Group Participants……………………………………………………….157
Table 5b. Selected Focus Group Characteristics……………………………………..158
Table 5c. Themes Related to HIV Risk Perceptions………………………………..160
Table 5d. Inter-Related Risks Reported in Focus Groups………………………..170
Table 5e. Strategies to Manage Risks in Daily Life………………………………….177
Table 6a. Table of Diary Participation……………………………………………………199
Table 7a. Age and Sex of Interview Youth Sample…………………………………..216
Table 7b. Most Frequently Reported Challenges in Previous Year……………217
Table 7c. Most Frequently Reported Issues Causing Stress Often or All the
Time……………………………………………………………………………………………………….218
Table 7d. Challenges Most Frequently Reported in Interviews…………………219
Table 7e. Reported Lifetime Sexual Partners…………………………………………231
Table 7f. Relationship of Knowing Someone with HIV to Feeling at Risk..238
Table 7g. Reported Strategies to Manage HIV and Pregnancy…………………241
Table 7h. The last time you had sex, did you or your partner use a condom?....243
Table 7i. What did you do to prevent pregnancy the last time you had sex?...... 246
Table 7j. What did you do to prevent HIV the last time you had sex?...... 246
11 Table 8a. Age and Race of South African MXit Users (MXit 2014)…………………255
Table 8b. SMS Questions……………………………………………………………………..258
Table 8c. MXit Questions and Topics……………………………………………………259
Table 8d. SMS Participation…………………………………………………………………260
Table 8e. MXit Participation………………………………………………………………..263
Table 8f. Youth Language Examples…………………………………………………….264
Table 8g. Regular Daily Activities…………………………………………………………267
Table 9a. Most Frequently Reported Risks and Strategies to Manage Them
305
Table 9b. Structural and Contextual Factors Influencing Youth Risk……….306
12 ACKNOWLEDGMENTS
First and foremost I would like to thank my committee, Drs. Janet
McGrath, Jill Korbin, Eileen Anderson-Fye and Scott Frank, for their guidance and support throughout my long and windy path through graduate training.
Professor McGrath in particular, thank you for your tireless mentorship and dependable assistance as I planned and completed this dissertation. Your careful review of my work has made it much stronger. Thank you Dr. Scott Frank for encouraging me to find my way as an interdisciplinary researcher. I also wish to express my gratitude to Rachel Chapman, my first graduate advisor, for putting me in the field early in my training, inspiring me to ask better questions, and for pushing me to have courage in my work.
I am incredibly grateful to the many people in South Africa who helped make this project possible. In particular, I wish to acknowledge Dr. Linda-Gail
Bekker and Dr. Melissa Wallace for their guidance and support of this research.
To everyone at the Desmond Tutu HIV Foundation, you are an inspiring group of people. Thank you for providing a welcoming environment and essential logistical support for me during fieldwork. There are so many of you I wish to thank, and I especially wish to recognize Wadi Dyani and Nikki Davies for their always helpful advice and Edgar October for your dedication and for never leaving me behind.
To my capable research assistants, Sesethu Nyengane and Asanda
Khawuve, thank you for your hard work, dedication, and good humor. Your ideas, energy, and assistance made this a better project. I learned more from you both than I can ever put into words, and for that I am deeply grateful.
13 I am extremely appreciative of my fellow graduate students and colleagues in Cleveland, Seattle, and South Africa who have kept me going through graduate school and who offered new ideas, a sense of perspective, companionship and much-needed laughter, particularly Elizabeth Carpenter-Song, Joe Galanek,
Nadia El-Shaarawi, Sarah Rubin, Colleen Walsh, Maggie Zraly, and my graduate cohort. I am also grateful to Erik Schwab for critical formatting assistance.
This dissertation would not have been possible without the help of my family, both my biological family and my family that has been expanded through marriage, who stuck with me and supported me throughout graduate school. To my husband especially, Shaun Franklin, thank you for pushing me to keep going, for your unfaltering encouragement and support, and for cooking me healthy and delicious food while I wrote the dissertation. I truly could not have done this without you.
Finally, I wish to recognize the beautiful and brave young people in South
Africa who so openly shared their time, experiences, and feelings with me.
14 LIST OF ABBREVIATIONS
ABC Abstinence, Be Faithful, [Use] Condoms
AIDS Acquired Immune Deficiency Syndrome
ANC African National Congress
ART Antiretroviral Therapy
ARV Anti-retroviral [drug]
DA Democratic Alliance
EC Eastern Cape Province
HCT HIV / AIDS Counseling and Testing
HIV Human Immunodeficiency Virus
MDG United Nations Millennium Development Goals
MXit Message Exchange It
PMTCT Prevention of Mother to Child Transmission of HIV
RDP Reconstruction and Development Programme
RSA The Republic of South Africa
SMS Short Message Exchange
TB Tuberculosis
UNAIDS Joint United Nations Programme on HIV and AIDS
VCT Voluntary Counseling and Testing
VOC Verenigde Oostindische Compagnie (Dutch East India Company)
WC Western Cape Province
ZAR Zuid Afrikaanse Republiek (Afrikaans for South African Republic)
ZAR Zuidafrikaanse Rand (South African Rand) (currency)
15 Understanding Perceptions Of Risk Among Youth
In A South African Township
Abstract
By
MICHELLE L NEBERGALL
This dissertation project investigated how a sample of youth living in a
South African township community perceived and managed the interconnected risks of daily life. The community was conceptualized as a risk environment
(Rhodes et al 2005) wherein youth were at elevated vulnerability to HIV through political, economic, and social factors in addition to locally high HIV infection rates. Specific objectives were to examine 1) how youth perceived risk in daily life,
2) how HIV risk in particular was perceived, 3) youth strategies for managing risks, and 4) pilot cell phone based data collection methods. Data were collected in two phases. In Phase 1, focus group discussions, participant diaries and cell- phone based data gathering using SMS and the social network MXit were conducted with a sample of 36 youth. In Phase 2, individual interviews, structured paper-based questionnaires, SMS and MXit data collection were conducted with a second sample of 40 youth. Youth described how concerns about the future and their ability to secure the necessary education and employment to build a better future for themselves and their families were paramount. Youth narratives also revealed hope for the future and described protective factors present in their lives. Findings demonstrate that risks were perceived in terms of both their physical and social consequences. Strategies used to manage risks in daily life included engaging with local health and educational
16 services, focusing on future goals, uniting together to address community issues, and developing supportive, loving and trusting relationships. Risk perceptions and risk management strategies were shaped by each youth’s individual life circumstances and specific contexts within which risks occurred, highlighting the centrality of structural, sociocultural and economic dynamics in mediating youths’ vulnerability and responses to risks in daily life. Findings contribute to anthropological models of risk perception and risk management, specifically the concepts of social proximity and social risk. The syndemic and risk environment models are particularly relevant to understanding findings in this study. Finally, this research contributes to methodological questions concerning the effectiveness of cell-phone based data collection tools in social science research.
17 Chapter 1. Introduction
1.1 Study Framework
The concept of risk and the experiences of adolescents are long-standing subjects of anthropological inquiry. This research investigates the ways vulnerable youth perceive and manage risk in every-day life whilst living in challenging environments. This research was conducted between 2012 and 2013 with youth living in a South African township. The local environment is characterized by multiple, inter-related health and socio-economic risks including entrenched economic and racial inequality, poverty, unemployment, limited educational opportunities, high rates of migration, overcrowded living conditions, and widespread crime, in addition to elevated rates of HIV and tuberculosis infection. South Africa has the largest number of HIV/AIDS cases in the world (UNAIDS 2010) and the majority of new infections in South Africa occur in youth, especially young girls aged 15-24 (UNAIDS 2010).
Vulnerable youth are often stigmatized as being both at risk for ill health and reduced life chances including low educational and employment attainment; and as contributors to risk, threatening societal wellbeing through their behavior
(Stephens 1995; Korbin 2003). Their stigmatization is intensified by social anxieties about youth behavior such as sexual activity (Glaser 2005; Leclerc-
Madlala 1997; Posel 2005; Ran-Rubin 2008; Wood 2005). This double- stigmatization of being simultaneously at risk and a risk highlights the vulnerability of youth and the central relevance of structural factors in shaping vulnerability. In this context it is important to understand youths’ perspectives and how youth perceive the risks in their lives.
18 1.2 Study Objectives
This dissertation project examines how a sample of youth living in a South
African township community in a country with a high prevalence of HIV perceive and manage the myriad risks in their daily lives, given that HIV is only one of many interrelated risks faced by youth. The township community is conceptualized as a risk environment (Rhodes et al 2005) wherein youth are at elevated vulnerability to HIV through political, economic, and social factors of the environment. The specific objectives of this study are to:
1. Examine how youth perceive risk in daily life.
a. What are the different risks that youth consider to be the primary
risks in their lives?
b. How are these risks perceived in terms of their physical and social
consequences?
c. What are the factors, such as age and gender, that influence how
risks are perceived?
2. Examine how the risk of HIV infection in particular is perceived by youth
in daily life.
a. How is HIV perceived by youth in daily life?
b. How is HIV perceived in terms of its social and physical risks?
c. What are the range of factors, such as age and gender, influencing
perceptions of HIV?
3. Examine the range of responses youth report in response to physical and
social risks in the context of a risk environment.
19 a. What behavioral strategies have youth adopted in order to manage
the risks in their lives?
b. What behavioral strategies do youth report to manage the risk of
HIV in particular?
c. What factors, such as age or gender, influence the range of
strategies adopted by youth?
4. Pilot and assess the use of cell phone based data collection methods in this
population, specifically assess the usefulness of asking participants to
respond to questions via SMS (short message service, also known as
texting), and chatting one-on-one with participants in private chats on the
social network platform MXit1.
a. What are the existing patterns of cell phone ownership, usage, and
social network usage in this population?
b. Is SMS an effective data collection tool in this population?
c. Is MXit an effective data collection tool in this population?
d. What are the best practices for use of these methods in social
science research?
In order to address these objectives, data collection was conducted in two phases. In Phase 1, focus group discussions, participant diaries and electronic data gathering using SMS and MXit were conducted with a sample of 36 youth.
In Phase 2, individual interviews, a structured paper survey, and electronic data
1 MXit is a social networking and instant messaging application that works on mobile phones and provides users with a low-cost way to chat and send messages and media files to others on MXit. Popular amongst youth, MXit was the largest social network in South Africa during the data collection phase of this project.
20 gathering using MXit were conducted with a second sample of 40 youth.
Interviews were also conducted with five community leaders and interviews and participant observation were conducted with ten key informants.
1.3 Significance
Anthropologists have advocated for studies of risk that define risk more specifically and expand the concept to account for the diversity in how risk is experienced in daily life (Nichter 2003; Nichter 2008). This study examines how individual youth perceive and respond to risks, including the physical and social consequences of these risks, in their local context. As such, this work seeks to broaden anthropological models of risk perception and risk management. This project further examines the individual relationships and contexts within which risk perception and behavior may occur in order to make visible the contextual sociocultural and economic dynamics that mediate vulnerability and responses to various threats in daily life (Douglas and Wildavsky 1982; Douglas 1992; Parker
2001; Farmer 2004). In contrast to universalizing theories of risk experience
(Caplan 2000), ethnographic methods locate both risk and people in local time and space, which enables observation of local particularities and differences amongst individuals.
This research advances our understanding of how risk is defined in contexts of vulnerability through examining the ways youth perceive the risks in their daily lives. Specifically, this research contributes to anthropological theories of how risks are perceived by vulnerable youth, including the ways youth define and assess the related concepts of threat and risk in daily life and the ways the social versus physical, including health, consequences of risks are perceived.
21 Secondly, this research addresses models of HIV risk perception in an environment where HIV rates are rising amongst youth, despite high levels of knowledge about the disease and how it is spread (Parker 2001; Smith 2003;
Ramin 2007), indicating the relevance of structural factors to HIV infection.
Thirdly, these data inform questions as to how risks are managed in contexts of vulnerability, wherein individual behavior may be constricted by environmental factors and complicated by the presence of multiple, overlapping risks.
Finally, this research contributes to methodological questions concerning the effectiveness of using cell phones to collect data regarding youth risk, especially HIV-related risk, from vulnerable populations. This study employed a multi-faceted data collection plan that utilized observation, focus groups, individual in-depth interviews, self-administered paper surveys, and developed cell phone-based questioning methods. The advantages and disadvantages of cell phone data collection methods as well as the different types of data generated by these methods are assessed and critically discussed.
This project contributes specific, local perspectives of youth risk experience in order to inform broader processes of how conditions of risk are perceived and managed in cultural context. This study is informed by and contributes to medical and psychological anthropology theories of risk perception, public health literatures on risk perception and risk behavior, as well as theories of risk and youth experience more broadly.
1.4 Chapter Overview
This chapter outlines the study framework including the study objectives and significance of the findings. Chapter 2 reviews the background and
22 significance of the study, especially in relation to anthropological literature on the topics of youth and adolescence and anthropological approaches to the study of risk. Chapter 3 contextualizes the study within the setting of South Africa, beginning with a brief history of the country and its people, the trajectory of
HIV/AIDS in the region, and a summary of selected social science research, especially anthropological research, relating to South Africa and to the South
African HIV/AIDS epidemic. A description of the field site is also provided in this chapter. Chapter 4 outlines the methods used in this study including sampling, recruitment, informed consent, data collection and data analysis procedures.
Study findings are presented in Chapters 5 through 9. Focus group data are presented in Chapter 5, diary data in Chapter 6, interview and risk assessment survey data in Chapter 7, and electronic data collected via cell phones in Chapter 8. Focus group and diary data presented in chapters 5-6 were collected in the first half of this study and served to establish context for the interview and risk assessment survey data which were collected in the second half of the study and are presented in Chapter 7. Electronic data were collected throughout the study; electronic data and an exploratory analysis of cell-phone based data collection methods are discussed in Chapter 8. In Chapter 9, findings from each method are tied together and connected to a broader discussion of youth risk in contexts of vulnerability. The contribution of these findings to current anthropological models of youth and risk is presented. Chapter 10 summarizes the study, suggests potential applications of study findings and concludes with recommendations for future research.
23 Chapter 2. Background and Significance
This research project is an ethnography of the daily lives of a sample of youth living in a peri-urban South African township. The purpose of this ethnography is to examine how risk is perceived and experienced in the daily lives of these youth and to document the ways youth respond to and manage these risks in a context of multiple, interconnected environmental threats contributing to youth vulnerability. The results of this research will inform literature examining how the diverse experiences of youth are differentially shaped by risk and vulnerability.
This project is informed by theoretical literature on the anthropology of risk, the anthropology of HIV, the anthropology of adolescence and of youth.
Each of these literatures is vast and encompasses a broad range of theoretical concepts spanning decades of research. This chapter outlines concepts and theories relevant to this study and provides a brief discussion of how these concepts and theories have developed over time in the discipline of anthropology.
This chapter presents an overview of how the category of youth and the concept of risk have been theorized in anthropology and contextualizes my research within these bodies of literature. The chapter begins by outlining the demographic and social significance of youth and briefly discusses anthropological studies of adolescence and youth. Next, the chapter examines how the concepts of risk and risk perception have developed over time in anthropology and their relevance to studies of HIV and youth. Finally, the relevance of the syndemic concept and risk environment model to the anthropological study of HIV is presented. The intersections of youth and risk in
24 anthropology and the methodological and analytical strengths and weaknesses of anthropological work on youth and risk are presented. Finally, new research questions addressed in this dissertation study are identified.
2.1 Anthropological Perspectives on Adolescence and Youth
Anthropology’s long standing interest in the adolescent life stage began with Margaret Mead’s landmark 1928 study of adolescence in Samoa. Mead’s examination of what “coming of age” meant for Samoan girls challenged the universalizing theory of adolescence as a time of “storm and stress” (Mead 1928).
Mead demonstrated how the experiences of adolescents vary across social and cultural contexts. Anthropologists have since examined key aspects of adolescent experience and social development, including rites of passage, initiation ceremonies, and adolescent sexuality among many other topics (examples include Whiting and Whiting 1975, Condon 1987, Worthman and Whiting 1987,
Schlegel and Barry 1991). Psychological anthropology in particular considers the ways adolescence is shaped by both the rapid psychological and biological changes that occur during this stage of human development and by culture
(Korbin and Anderson-Fye 2011).
“Youth” and “adolescent” are conceptually distinct terms. However, the terms are often used interchangeably in reference to young people. The term youth is used to refer to participants in this study instead of adolescents because youth is a culturally salient category in South Africa. Young people in South
Africa’s townships refer to themselves as youth, and there is considerable public discourse in South African media about the state of the country’s youth. In South
Africa’s townships references to youth are largely mapped onto the age range that
25 anthropologists and researchers in other fields recognize as the life stage of adolescence, suggesting that the terms may be somewhat interchangeable. By choosing the term youth, this project focuses on the local language used by youth themselves. Significantly, however, this project’s analysis of youth experience is grounded in psychological anthropology’s life stage focus. The influence of human development including psychological, biological, and cognitive developmental changes on the experiences of young people is central to this study’s concept of youth. This project brings together scholarship examining both youth cultural practice and adolescent experience.
Defining adolescence is difficult for a number of reasons. First, the experience of each individual varies depending on his or her physical, emotional, and cognitive development. For example, brain development and puberty occur at different rates in different individuals. Second, countries vary in their definition of adolescence and interpretation of the rights, responsibilities, and accepted activities for adolescents. For example, ability to marry, military participation, ability to obtain employment or to obtain health care varies across countries. Finally, defining adolescence as a discreet life stage is complicated by the fact that many adolescents regularly perform adult tasks, such as paid employment, caring for children, and entering into marriage. While there is no universally accepted definition of adolescents, the United Nations defines adolescents as individuals aged 10-19 (UNICEF 2011).
Defining the category of youth is equally challenging. The United Nations defines youth as males and females of ages 14-24 years, but UNICEF uses the terms adolescent, youth, and young people interchangeably to describe males and
26 females aged 10-24 (UNICEF 2011). UNICEF emphasizes the need to recognize the specific developmental needs of young people as they transition from childhood to adulthood, and focuses less on age because people of the same age may have different needs because of their developmental stage or life circumstances. In South Africa, youth is a broad category that in some contexts, such as political organizing, includes those up to 35 years of age (Mokwena 1999).
Currently, over 75% of South Africa’s population is under the age of 35
(Nsamenang 2002). Full adult status in many of South Africa’s cultures requires employment, marriage and children (Nsamenang 2002), conditions that are difficult for many to meet due to poverty and lack of economic opportunity (Bray et al 2010).
While youth and adolescence are defined differently in different cultures, the terms generally connote a life stage characterized by transition between childhood and full adulthood (Schlegel and Barry 1991; Brown and Larson 2002;
Korbin and Anderson-Fye 2011). How this transition is experienced by different youth in different cultures varies tremendously, especially along gender, economic, and social lines (Weisner and Lowe 2005). Youth is a social category and age is one grouping, along with gender, class, and race, that index relationships and power dynamics between people (Durham 2004). Youth is therefore a contested category and through negotiations about how to define youth, wider social and cultural notions of morality, authority, and responsibility are revealed (Durham 2004). Durham argues that youth can therefore be examined as a social shifter (Durham 2004) where power struggles such as autonomy and interdependence are played out (Durham 2004).
27 Existing models of adolescence tend to have a Western bias that does not necessarily fit all African populations (Nsamenang 2002). Western milestones such as school attainment, entering into marriage, beginning employment, and childbearing are often seen as markers of the transition from youth to adulthood in many societies (Fussell and Greene 2002). However, these milestones are becoming more and more out of reach for many of the world’s youth due to poverty, economic inequality and socio-political changes, including in impoverished South African communities. Many theories of adolescence are
Eurocentric and do not fully capture the essence of adolescent in sub-Saharan
Africa (Nsamenang 2002). The experience of adolescence is furthermore highly variable throughout sub-Saharan Africa, especially along economic lines and between rural versus urban youth (Nsamenang 2002).
Youth in sub-Saharan Africa face significantly different circumstances than youth elsewhere in the world (Fussell and Greene 2002). Youth form a large proportion of the overall population in sub-Saharan Africa. Resources that are necessary for young people to fully participate in society such as those for education, job creation, and health care provision are scarce. The AIDS epidemic has devastated South Africa, with millions suffering death and disability from the disease. AIDS has cut into youth support networks by taking parents and other trusted adults away from youth. South African adults are experiencing high rates of premature disability and death from HIV/AIDS during their most productive years, causing South African youth to carry responsibility for the country’s socio- economic development (Fussell and Greene 2002). These difficult circumstances have inspired a scholarly focus on the risks to Africa’s youth, including
28 examinations of how being at risk has led youth to become sources of risk, such as in the case of youth violence, for example child soldiers (Boyden and De Barry
2004; Rosen 2007), youth vigilantism (Smith 2006), and youth violent crime
(Ran Rubin 2008).
Contextual factors such as political and socio-economic dynamics significantly structure the paths to adulthood that are open to youth as well as the opportunities and challenges they face on these paths. Anthropologists researching throughout sub-Saharan Africa have provided ethnographic evidence regarding the changing paths to adulthood. For example, among a group of young women in Madagascar, lack of jobs combine with demand for consumer goods to create conditions where many young women engage in transactional sex with tourists as a way to obtain class and social mobility (Cole 2004). Women are able to establish independent households and support their families with their earnings. However, this is a departure from the traditional path to adulthood, marriage, and thus gender and kin relations are disrupted by these women’s break from established social norms (Cole 2004).
South Africa, like other African nations, is heavily influenced by Western ideas. This exposure to Western standards and assumptions began with colonialism and continues today through participation in global culture. This mix of local and global cultures is what Nsamenang calls a “confusing cultural braid” or Africa’s “triple inheritance” (Nsamenang 2002). Nsamenang’s triple inheritance refers to the mix of endogenous African cultures and exogenous
Western / Christian influences and Eastern / Arabic influences that now infuse contemporary African society. Nsamenang argues that the African adolescent is
29 heavily constructivist (Nsamenang 2002). The child in African cultures is seen as an active agent, and becoming an adult is a gradual process “of incremental maturation” (Nsamenang 2002:69). This study examines this claim by describing the daily lived experience of a sample of township youth and how these youth experience the path to adulthood.
Youth are an increasingly dominant demographic group worldwide
(Brown and Larson 2002), making them an important population for anthropological study (Worthman 2011). Youth under the age of 25 make up 43% of the world’s population (UNFPA 2012), and 89.7% of these youth live in developing and emerging economies, especially Africa and the Middle East
(Euromonitor International 2012). In South Africa, youth between the ages of 10 and 24 make up 29% of the country’s total population (UNPD 2013). The study of youth experience in South Africa is, therefore, an important contribution to our understanding of larger demographic and social trends worldwide.
Youth are often on the forefront of cultural change (Comaroff and
Comaroff 2005; Levine 2011); therefore youth are an important category from which to examine questions of globalization, political engagement, economic development and labor, new media and technologies, global media consumption and consumerism (e.g. Nieuwenhuys 1996; Suarez-Orozco and Suarez-Orozco
2001; Anderson-Fye 2003; Weisner and Lowe 2005). This is particularly relevant in Africa, where youth form a large proportion of the population. Anthropological studies of youth and adolescence have therefore brought a renewed focus on globalization and social change, examining such topics as global youth culture, youth identity, and the situated, changing nature of youth as a social category.
30 Anthropological studies of youth therefore emphasize the importance of analyzing youth as cultural actors in their own right (Bucholtz 2002), examining youth’s own agency, concerns, and struggles in different contexts. Youth are seen as cultural actors who are both shaped by political, social and economic forces and agents who are themselves re-shaping culture and influencing global processes (LeVine 2011). “Youth” as a concept focuses analysis on youth as a social category, and the “here and now” of experience (Bucholtz 2002), examining such issues as youth culture and youth identity. “Youth” is thus differentiated from the “adolescent”, wherein young people’s experiences are analyzed in relation to life stage development including how these experiences shape their future adult selves (Bucholtz 2002; Cole 2004; Durham 2004).
Youth studies and their concern with youth cultures builds upon the work from the 1970’s and 1980’s at the Centre for Contemporary Cultural Studies at the
University of Birmingham. The Birmingham School, as it is known, took a heavily
Marxist approach to cultural theory, examining youths’ position in terms of class and examined how youth created their own subcultures in ways that challenged dominant social norms. The focus on class has been expanded upon by psychological anthropology, which also considers other factors that impact youth social status including sexuality, gender, ethnicity, race, and identity.
The concept of youth shares many similarities with the concept of adolescence, especially in its relational state in between childhood and adulthood. A primary difference between the two conceptual categories is that adolescence refers to a specific period of psychological and biological development, whereas youth refers to a social category in a particular moment in
31 time (Bucholtz 2002) that is not necessarily tied to a specific biological or psychological developmental phase. Bucholtz suggests that the term adolescence is limiting in that it only focuses on adolescent development and change, albeit from both the individual and cultural level (Bucholtz 2002). However, recent work in the field of psychological anthropology embraces the notion of adolescents as cultural actors that shape social and cultural processes while they are simultaneously shaped by these large-scale forces, both as individuals
(Korbin and Anderson-Fye 2011) and as adolescent cohorts (Levine 2011). Youth, adolescence, and childhood involve significant developmental changes and are also culturally constructed categories that vary across cultures and through time
(Mead 1928; Aries 1962; Stephens 1995).
Researchers have long been concerned with the risks perceived to be inherent in adolescence (Stephens 1995; Korbin 2003; Korbin and Anderson-Fye
2011), and so-called youth risk behavior such as sexual activity has been the target of a multitude of intervention programs worldwide. In today’s world of increasing globalization (Weisner and Lowe 2005; Worthman 2011), youth are often labeled by global health and policy organizations as both at risk for increased morbidity and mortality and as contributors to risk threatening societal wellbeing through their behaviors (Reynolds 1995; Stephens 1995; Ramphele
2002; Korbin 2003). These risk labels often reflect adult concerns about possible health risks and may not necessarily represent youth perspectives. Many South
African youth report high levels of uncertainty about their futures due to the significant social, economic and health challenges they face and a growing awareness of the role global inequality plays in their daily lives (Bray et al 2010).
32 It is therefore important to understand how risk discourses interact with youths’ own experiences in local context to influence youth risk perceptions.
The conceptual linking of adolescence and risk is illustrated in the development of anthropological studies of adolescent sexuality. Early studies focused on culturally specific sexual practices of adolescence, and examined how adolescent sexuality and sexual activity is shaped and socialized by adults, especially regarding sexual activity outside of marriage (see for example Whiting et al 1986; Schlegel and Barry 1991). For example, studies of adolescent pregnancy that prioritize adult perceptions of teenage pregnancy as a social problem obscure the way that pregnancy may display youth agency, for example in Burbank’s study of Aboriginal adolescence where pregnancy is sometimes a way for adolescent girls to reject the marital arrangements made for them by their parents (Burbank 1988). The emergence of HIV/AIDS has led to anthropological inquiry into how youth themselves view sexual activity; however this inquiry is often in relation to sexually transmitted infections (STI’s) including HIV/AIDS (Obbo 1995; Leclerc-Madlala 1997). Another aim of this project, therefore, is to further examine how youth themselves perceive sexual activity, and the meanings sex has in their lives and for their identities, in addition to how sex is viewed in relationship to STIs. The section below (2.2) provides a closer examination of how youth, especially youth behavior, is regarded in terms of risk.
In sum, this project aims to understand how youth experiences are situated and experienced in a South African township and how individual youth experience risk in daily life. Analysis of the youth experience considers both
33 youth cultural practice as well as the influence of the developmental stage of adolescence on the experience and situated nature of youth.
2.2 Anthropological approaches to study of risk
This section begins by discussing how risk has been conceptualized in anthropology and in particular the centrality of the risk concept to the anthropology of HIV/AIDS and youth. The second part of this section discusses how the risk concept has been theorized in terms of emic risk perception, with particular attention to how risk perception is theorized in anthropological studies of HIV/AIDS with a focus on youth. The third part of this section broadens the risk concept beyond individual experience to encompass concepts of risky environments and examinations of how risk is structured through macro-level processes such as social and political dynamics. Finally, this section outlines the way the concept of risk is used in this study and describes how collected data inform contemporary debates regarding concepts of risk, risk perception, and risky environments, especially with regards to youth and HIV/AIDS.
2.2.1 The Concept of Risk
Epistemologies of risk assert that the risk concept first came into use in the
Middle Ages to refer to the possible dangers of maritime voyages and resultant loss and damage of valued goods (Lupton 1999). At that time, risk was seen as stemming from natural events such as storms, and not seen as the fault or responsibility of human actions (Lupton 1999). This conceptualization evolved during periods of increasing industrialization in the seventeenth and eighteenth centuries to reflect larger cultural shifts towards scientific or so-called rational thought and the growing belief that it was possible to discover objective truths
34 about the world (Giddens 1991). Newly developed statistical sciences took an important role in calculating norms and probabilities in attempts to control hazards in the environment (Lupton 1999). This positivist or scientific concept of risk is used in the insurance industry to mitigate, avoid, and compensate for the negative impact of risk (Lupton 1999) and to disperse risk across groups to limit individual culpability (Ewald 1991). In the nineteenth century, concepts of risk further expanded to include risks located not only in nature but also in the behaviors of individuals and groups (Ewald 1991). The analysis of risk factors was increasingly applied by physicians in clinical settings to prevent diseases such as coronary heart disease in patients (Rothstein 2003).
Cultural Theory of Risk
Anthropology’s significant examination of risk began with the work of
Mary Douglas. Cultural theory focuses on the politicization of risk, and argues that the recognition and prioritization of risks for action is a social process deeply embedded in social institutions and collective social beliefs. Risks in a particular society are those dangers that society deems problematic; they are therefore not necessarily objective but are rather societal judgments. The cultural theory of risk acknowledges the external reality of risks and does not question technical risk assessment; however cultural theory centers on the assertion that identifying risks is a social process; claiming that risk is primarily cultural and not physical, and the identification of risks is a reflection of society’s belief systems.
Douglas’ cultural theory of risk was heavily influenced by Evans-
Pritchard’s structural approach and built upon her earlier scholarship on the symbolic power of dirt, pollution, taboo and danger in what was at the time
35 known as the Belgian Congo (Douglas 1966). Douglas claims that risk and taboo are similar in that they both are mechanisms for demarcating social boundaries and social categories (Douglas and Wildavsky 1982). But Douglas also differentiates the concept of taboo from the concept of risk based on her analysis that taboo is tied to certainty of action and fate, whereas risk deals with calculated uncertainty (Douglas and Wildavsky 1982). Risk also has moral and justice dimensions, differentiating between just risks (risks one chooses to take freely) and unjust risks (those imposed by society) (Douglas 1992) whereas taboos are wholly negative and forbidden. Considerations of justice relating to risks raise questions of morality and determinations of who is accountable for the impact of risks (Douglas 1992). Various risks are then ranked in terms of their potential for producing ill effects threatening the social group, and this ranking thus becomes a moral activity, reflecting social and cultural mores and the interests of powerful institutions (Douglas and Wildavsky 1982).
The cultural theory of risk has been criticized for its extreme relativism
(Rosa 1998), and for its inability to take into consideration diversity in individual contexts, individual agency, or change over time (Boholm 1996), and for suggesting that individual perception is influenced by the patterning of social relationships more than by other factors (Boholm 2003).
Uncertainty
Some examinations of the ways societies define dangers have focused on the study of uncertainty. Anthropological studies of uncertainty can be traced back to Evans-Pritchard’s work amongst the Azande (1937) and Victor Turner’s study of the Ndembe (1957). Evans-Pritchard and Turner examined the ways
36 cultural groups deal with uncertainty related to misfortune. Whyte’s ethnography of how the Nyole people handle misfortune in Bunyole, Uganda demonstrates how the Nyole actively engage with uncertainty and take concrete steps to improve the situation when experiencing misfortune such as marital conflict or disease (Whyte 1997). The key question asked by the Nyole when misfortune occurs is “why you” – a practical and moral question which directs inquiry into the external agents that have caused the misfortune; the answer to which will inform the appropriate action needed to improve the situation (Whyte 1997).
Whyte shows how in daily life, uncertainty about affliction reveals parallel uncertainties about social relations. Whyte argues that the Nyole take a pragmatic approach to misfortune, and engage in a quest for security and not certainty (Whyte 1997:3).
Uncertainty about outcomes is a central aspect of how risk is experienced, especially in relation to HIV and AIDS. Uncertainty around HIV and the origins of AIDS in sub-Saharan Africa is responded to in many different ways. For example, uncertainty about HIV is sometimes addressed through accusations of witchcraft; such has been documented in South Africa (Ashforth 2002) and in
Zimbabwe (Rodlach 2006). While many individuals struggle with doubts regarding their beliefs in witchcraft (Ashforth 2002), witchcraft often remains a component of the HIV/AIDS explanatory landscape in southern Africa.
Witchcraft beliefs exist alongside biomedical understandings of disease in many communities in South Africa including this dissertation study’s community.
Witchcraft in southern Africa has in fact been described by some anthropologists as “a thoroughly modern manifestation of uncertainty,” (Comaroff and Comaroff
37 1999) and is used to address questions surrounding the uncertainty and unpredictability of who becomes infected, where HIV comes from, and whom is to blame (Rodlach 2006).
Uncertainty is an important part of the risk experience and is therefore considered in this dissertation study’s understanding of risk construction.
Uncertainty is however distinguishable from risk in that uncertainty refers simply to unknowns or the possibilities of multiple outcomes that may or may not pose a risk to the self (Lupton 1999) whereas risk is something one has a stake in, and therefore uncertainty itself is not a separate object of inquiry in this study.
Equating Risk with Danger
Douglas defines risk as “the probability of an event, combined with the magnitude of losses and gains that it will entail,” (Douglas 1992:40). Risks can be positive or a negative (Douglas and Wildavsky 1982), yet contemporary risk concepts tend to focus on risk’s possibility of physical or social danger or harm and focus on the mitigation of a risk’s negative outcomes. Risk has come to be seen as “potential danger” (Douglas 1992) or even “anticipated catastrophe”
(Beck 1998).
Some theorists suggest that equating risk with danger or negative outcomes reflects larger cultural shifts towards scientific explanations for misfortune, replacing spiritual or religious concepts such as sin, fate, witchcraft or supernatural forces (Douglas 1992) with modern concepts such as risk that suggest humans are able to control or prevent misfortune (Giddens 1990; Lupton
1999). Modern concerns with risk reflect larger societal anxieties over loss of control, conflict and lack of trust in interpersonal relationships, and the high
38 levels of uncertainty that characterize modern society (Beck 1992; Giddens 1990;
Lupton 1999), in addition to a greater awareness of objective risks in our environment.
Risk Society
Western modern society has been theorized as a risk society (Beck 1992), or a world risk society (Beck 1999), characterized by inherent social, ecological, and individual risks that are uncontrollable and not visible to the human senses, and which thus require scientific confirmation of their existence (Beck
1992,1996). In the risk society model, modern risks are unknowable and largely unanticipated (Giddens 1991), yet ironically within the risk society, highly developed institutions, most notably science, attempt to calculate and anticipate risks in order to provide an illusory sense of control over danger and uncertainty
(Giddens 1990,1991). Technology itself is, however, viewed as a source of risk and as a force that distributes risks across space (Beck 1992). Combining the ubiquity of technology, lack of control individuals have over their exposure to technology, and social dependence on this same technology (and science) creates feelings of vulnerability inherent in the risk society (Beck 1992).
The risk society model describes modern Western society, and may not be an appropriate frame for understanding modern society in sub-Saharan Africa especially in contrasting modernity with so-called tradition (Appadurai 1996;
Caplan 2000). South African society is characterized by pronounced social, economic, and racial inequality, and a mix of Western and southern African cultures. Diverse cultural traditions are protected by the Constitution and
Western culture and morals permeate South Africa via global media,
39 international aid and globalized programs. The risk society model may therefore be a useful frame to understand how risks are constructed, understood, and responded to at the social level, albeit with particularities unique to the South
African context.
Constructivist and Phenomenological Concepts of Risk
Anthropological theories of risk expand upon Giddens’ and Beck’s concepts of modernity and the risk society to include the role of culture in structuring the distribution of risk and social responses to risk (Caplan 2000).
Social constructivist theories of risk highlight the influence of social, cultural, and political structures in identifying, defining, and managing risks. Constructivist theories posit that risks exist only after they are perceived as a risk.
Phenomenological approaches examine individual lived experience of risk and the social and economic consequences of being labeled at risk or a risk (Lupton
1999) in order to identify the ways individuals interpret risk experiences, imbue risks with meanings, and construct risk in social interactions within sociocultural context (Caplan 2000).
Constructivist theories show how ideas of risk are used in sociocultural context to delineate normative behavior, moral standards, and acceptable versus unacceptable practices (Douglas 1992), and therefore to demarcate boundaries between the self and other (Lupton 1999:25) where the other invites risk by transgressing group norms. For example, so-called traditional African culture has been blamed for the disproportionately large burden of the HIV/AIDS pandemic in countries like Uganda and South Africa (Leclerc-Madlala 2002; Preston-Whyte
2008). For example, low attendance to biomedical care has been attributed to
40 beliefs that HIV is caused by witchcraft. Similarly, invoking reports of men raping babies (or other young virgins) to cure themselves of HIV also attribute blame to local culture (also see Gausset 2001; Posel 2005; Bhana 2009 for analysis of masculinity and HIV risk, as well as Preston-Whyte 2008; Seathre and Stadler
2009; Smith 2009 for further discussion on how African culture is blamed for the spread of HIV). This invoking of cultural practices is a process of blame that fails to acknowledge the role of factors such as inequality, poverty, and lack of access to health care in the spread of HIV, and is reminiscent of racist colonial medical discourses about African inferiority (Setel 1999). Furthermore, other work has suggested that it is the erosion of cultural traditions, such as adolescent initiation rites, that contributes to increased HIV risk (Leclerc-Madlala 2001; Glaser 2005).
Definitions of risk are constantly being negotiated and refined within social contexts. Social constructivist examinations of risk do not measure “real” or “objective” risks faced by individuals or groups, but instead seek to assess the process by which individual and institutional practices and dominant discourses shape knowledge and concepts of risk (Lupton 1999:33). Constructivists posit that risk is a negotiated perception of the world and that risk is equal to representations of it (Rosa 1998: 21). An example of how risk is constructed is the designation of HIV risk groups.
Risk Groups and HIV/AIDS
In the 1980’s the first HIV/AIDS cases were recognized in the United
States. At the time, particular groups who were observed to be disproportionately impacted by HIV infection were identified. These groups became known as the 4
H’s: hemophiliacs, heroin users, homosexuals and Haitians, and later included
41 categories such as commercial sex workers, military personnel, long-distance truckers, and Africans. These populations already experienced stigmatization and their label as HIV risk groups exacerbated their already marginalized social position (Bolton 1995; Castro and Farmer 2005; Farmer 1992; Treichler 1992;
Schoepf 2001; Stoller 1998). For example, Farmer (1992) reports that the risk group label as applied to Haitians slowed tourism to the island, resulting in a loss of national income, and led to discrimination against Haitians living in the
United States such as by denying them housing and employment.
Researchers emphasize that risk is not simply tied to risk groups or specific categories of people (Brummelhuis 1995; Kane and Mason 1992;
Owczarzak 2009). Group membership does not determine individual behavior. It is rather contexts of vulnerability such as lack of access to health care services and specific behaviors such as condom-less sex with infected partners or sharing needles with infected people that contribute to the spread of HIV.
Mann, Tarantola, and Netter (1992) have thus suggested examining factors that increase vulnerability to HIV infection. Mann and Tarantola (1996) defined “vulnerability” as susceptibility or factors related to individuals or groups that could increase or decrease the risk of an adverse event occurring.
Vulnerability has individual, program- or services-dependent, and societal dimensions (Mann and Tarantola 1996). Nichter identifies six sources of health vulnerability: 1) trait-based, 2) state-based, 3) place-based, 4) factors that cause a mild illness to transform to a more serious state, 5) cumulative sources of negativity and 6) exposure to risk information (Nichter 2008: 54-55). How
42 people perceive risk and choose to act in order to reduce harm is influenced by the source of vulnerability (ibid).
Nichter argues that the concept of vulnerability is more specific than the risk concept and better describes “the actual feeling of susceptibility to illness or misfortune,” (Nichter 2003:14), thus allowing for observations of uncertainty and change over time (Nichter 2003). He therefore advocates for ethnographies of risk management in households and communities so as to understand how individuals deal with states of vulnerability; and to examine how perceptions of both social and health risks influence the actions people take to reduce harm, especially when they believe the factors making them vulnerable are out of their control (Lupton 1999; Nichter 2008).
The HIV epidemic in South Africa is a generalized epidemic, meaning that although the spread of HIV may have initially been concentrated in particular vulnerable groups, infection is now widespread throughout the general population. Nonetheless certain segments of the population are observed to have higher infection rates, such as pregnant women aged 15-24 (20.5% prevalence)
(DoH 2012) and black females aged 20-34 (33% prevalence) (RSA 2010). In
South Africa, HIV is predominantly spread through heterosexual activity and the segments of the population observed to have the highest infection rates are mostly infected through condom-less sex.
The concept of MARPs (most at risk populations) is often used to identify and target specific sub-populations for HIV prevention programs. MARPs are populations with a higher than average HIV prevalence when compared to the general population (UNAIDS 2010). MARPs specific to the South African context
43 are black females aged 20-34 (33% prevalence), black males aged 25-49 (24% prevalence), followed by people with disabilities, high-risk drinkers, men who have sex with men (MSM), recreational drug users, and males over the age of 50
(RSA 2010). These groups are more vulnerable to HIV infection due to a number of inter-related factors including inadequate access to health care services, lack of resources, or more frequent exposure to the virus (RSA 2010). These trends demonstrate that while females are at higher risk of infection than men, age and structural dynamics also mediate risk in ways that go beyond gender.
Risk Behaviors and HIV/AIDS
Risk behaviors are specific practices considered to have a high likelihood of spreading HIV infection, such as sharing needles, condom-less sex with an infected partner or multiple concurrent sexual partnerships. A component of many HIV/AIDS prevention programs is to identify and prevent risk behaviors in a given population by disseminating information about risk and developing interventions to modify individual behavior to reduce risk behaviors2 and adopt
“safe” practices.
Risk reduction programs are therefore sometimes seen as tools of social control, aiming to influence health and behavior of citizens (Lupton 1999). Seen through the lens of governmentality, which is the process of population regulation and control through government attempts to organize and influence individual behavior in ways that meet the needs of the state (Foucault 1991), risk
2 Related to the observation in public health that the leading causes of death in the United States are attributable to what are called “modifiable behavioral risk factors”. See for example Mokdad et al. 2004. Actual Causes of Death in the United States. JAMA 291(1):1238-1245.
44 becomes a moral technology that justifies the regulation and control of citizens
(Ewald 1991) by delineating “normal” and “abnormal” behavior. Over emphasizing individual behavior thus places responsibility for health and illness on the shoulders of individuals in ways that blame the victim and obscure the social, economic, and political conditions that structure risk.
The focus on risk behaviors is also insufficient for understanding HIV transmission because it ignores the realities of daily life of vulnerable individuals and the influence of economic, cultural, and social dynamics that influence individual behavior (Goldstein 2004). The Health Belief Model developed in the
1950’s posits that individuals will be motivated to take action to avoid negative health outcomes, if they feel susceptible to the risk, if they think the risk is severe, if they believe their actions will be effective in reducing their risk, if they believe they are capable of taking the action, and if significant barriers to taking the action can be removed (Janz and Becker 1984; Rosenstock et al 1994).
It is widely recognized that people’s knowledge and awareness of
HIV/AIDS alone does not directly translate into the extent to which they act to protect themselves (Azjen and Fishbein 1980; Parker 2001; Ramin 2007; Smith
2003) and that a focus on individual risk factors alone is insufficient for addressing HIV risk (Susser 2004). Health behavior change, especially in the case of sexual behavior, is influenced by a number of individual factors such as perceptions of severity and susceptibility to HIV/AIDS risk (Rosenstock et al
1994) as well as by complex socio-cultural factors such as gender and economics
(McGrath et al 1993). Furthermore, the role of social factors such as low education, racial segregation, individual and area level poverty, and income
45 inequality have been shown to contribute significantly to a number of deaths in the United States (Galea et al 2011).
Examining how individuals experience being labeled as a risk group or having their behavior labeled as risk behavior demonstrates how the label of “at risk” obscures the influence of social and structural factors that affect individual choice and behavior (Rhodes et al 2005) and can contribute to blaming the victim for outcomes that are not necessarily within their personal control (Ryan 1971).
Labeling individuals as members of a risk group reduces the multiple levels of identity that people have into a single defining characteristic and labeling practices as “risk behaviors” obscures the complex meanings and motivations individuals may have for engaging in these behaviors. This dissertation study therefore focuses on how risks are constructed in the study community, the conditions that create vulnerability to risk and that structure individual choice regarding health and sexual behavior.
While anthropologists generally agree that the social construction of risk is influenced by social, cultural, economic and political contexts (Douglas and
Wildavsky 1982), asserting that social context influences risk is insufficient to understand the dynamics of risk in context (Nichter 2008; Wallman 1996).
Determining which aspects of context count, to what extent, and under what circumstances (Wallman 1996) is not well understood. The challenge lies in determining which level of the context to focus on for analysis: the social, cultural, community, family, or individual level. These levels are inextricably linked and each level influences the others and must all be taken into
46 consideration. Understanding risk therefore requires ethnographic methods examining risk in everyday experience.
Similarly, the social-ecological model developed in the field of public health examines multiple, interacting levels that impact health behavior and health outcomes across the lifespan including the individual, interpersonal, community, societal and policy levels when designing prevention programs
(DiClemente et al 2005). The socio-ecological model steers away from victim blaming by examining the ways individual factors interact with social-structural factors to influence individual health behavior and health outcomes (McLeroy et al 1988; Baral et al 2013). The socio-ecological model further emphasizes that health behaviors and outcomes are not the result of a single factor but rather that of multiple factors that interact in specific contexts (March and Susser 2006). In
HIV prevention for example, recognition of social and structural factors including inequality as determinants of vulnerability to HIV underlies HIV prevention programs that address multiple levels of risk when designing prevention programs (DiClemente et al 2005; March and Susser 2006; Auerbach et al 2011;
Baral et al 2013).
Social Risks
Examining risk in daily life reveals how risks can be social and not only physical. Social risks are those that pose a threat to social relationships, status and individual identity (Nichter 2003; Smith 2009). Social risks vary according to actors’ social position. Wallman’s (1996) work in Kamwokya, Uganda, for example, documents how women construct risk concepts to include the risk of
HIV as well as risks to status and reputation. Youth may also focus on the social
47 risks of sex such as how sex can expand or limit their social networks, and the emotional and psychological risks of sex such as feeling safe with their partners, whereas youth may perceive that adults focus on the physical risks such as unwanted pregnancy (Bourne and Robson 2009).
The concept of social risk situates behavior in the context of people’s lives and considers how factors such as economic constraints, access to social resources gained through social status and personal reputation, or maintenance of social relationships influence behavior (Smith 2009). For example, many HIV prevention programs narrowly define specific acts, such as condom-less sex, as a risk behavior in need of changing, which may blame the person having condom- less sex for their behavior and ignores the multitude of reasons why condom-less sex may make sense in the context of daily life. The concept of social risk examines this behavior in socio-economic context and illustrates how condom- less sex may be reasonable under the circumstances, for example by promoting trust and protecting the strength of the relationship. Social risk thus helps us understand how concerns over social status and access to social resources are prioritized over physical risks such as HIV infection (Nichter 2008; Hirsch et al
2009).
Youth and Risk
Youth are frequently viewed through the lens of risk and are increasingly seen as both at risk and as contributors to risk (Korbin 2003; Stephens 1995).
South African township youth are particularly stigmatized in this way. Youth living in South Africa’s townships are largely regarded in public discourses as being at risk for a variety of negative outcomes including low educational
48 attainment, teenage pregnancy, and contracting infectious diseases such as HIV.
Township youth are further stigmatized as being a risk that threatens societal wellbeing (CASE 1993; Van Zyl Slabbert et al 1994; Seekings 1996). Reports of the high rates of sexual violence experienced and perpetrated by youth (Posel
2005; Wood 2005), violent crime committed by youth (Ran-Rubin 2008), and sexually active HIV-positive youth (Glaser 2005; Leclerc-Madlala 1997) are often sensationalized in the media and serve to intensify their stigmatization. This double-stigmatization of being simultaneously a risk and at risk highlights the vulnerability of township youth.
The tendency to equate youth risk with the possibility of danger expresses an adult worldview largely concerned with protecting youth from the negative outcomes of certain activities such as sex. This worldview, however, may not necessarily reflect the perspective of youth. Many youth conceptualize risks differently from adults (Bourne and Robson 2009). This is best seen in the example of sexual activity. Adults may emphasize the risks of youth sexual activity (Nichter 2008) because of adult concerns about teenage pregnancy, for example. However, many youth see sexual activity as a positive means for achieving intimacy and expanding social networks (Preston-Whyte 2008).
Furthermore, risk-taking is often considered a “natural” part of the youth life stage, a means to develop identity and independence (Le Breton 2004). Risk- taking is sometimes seen as positive behavior (Zaloom 2004) carrying possibilities for great reward such as love and intimacy (Reddy and Dunne 2007).
The experiences of youth demonstrate the ways risk can be utilized as a conceptual frame, recasting uncertainty as a bounded set of possibilities, linking
49 objects of risk to objects at risk, and establishing the risks’ consequences (Nelkin
2003).
In summary, anthropologists have advocated for studies of risk that both define risk more specifically and expand the concept to account for the diversity in how risk is experienced in daily life (Nichter 2008). Studies are needed that examine the diversity of risk experience and individual and group responses to physical and social risks (Nichter 2003; Nichter 2008). Anthropological studies of risk utilize long-term ethnographic field research to study groups in cultural context (Lindenbaum 2001). Ethnographic methods locate both risk and people in local time and space, which enables observation of local particularities and differences between groups as opposed to universalizing theories of risk experience (Caplan 2000). Placing ethnographic subjects in cultural context makes visible the dynamics of power, agency, economics, and social networks that mediate vulnerability to various risks (Douglas 1992; Douglas and Wildavsky
1982; Farmer 2004; Parker 2001). This dissertation project contributes to this field through the use of ethnographic methods to examine how township youth conceptualize risk and manage risk in daily life.
In this dissertation risk is conceptualized as “a situation or event where something of human value (including humans themselves) has been put at stake and where the outcome is uncertain”(Rosa 1998:28) from the perspective of youth. This definition follows the work of Beck 1992; Boholm 2003; Douglas and
Wildavsky 1982; Harthorn and Oaks 2003; Longfield 2008; McGrath et al 1992;
Parker 2001; Saethre and Stadler 2009; Stoffle et al 1991. Risks can therefore be social or physical or both. The concept of risk itself is often not part of the
50 everyday discourse of youth (Bray et al 2010), pointing to the importance of understanding how risk and uncertainty are conceptualized by youth themselves.
2.2.2 Risk Perception
Emic Risk Perception in the Anthropology of HIV/AIDS
In the 1990’s anthropologists became increasingly concerned with issues of emic risk perception in relationship to HIV infection as the global HIV/AIDS pandemic continued to spread rapidly. Emic risk perceptions play a significant role in health decision-making (Nichter 2003), especially regarding HIV/AIDS.
Emic risk perceptions are important to understand because of the widespread acknowledgment that simply having knowledge about risk does not result in behavior change. Anthropologists writing in the late 1990s and early 2000s sought to broaden concepts of sexual risk and risk perception to show the complexities of individual behavior, for example by highlighting the social, cultural, and emotional dynamics of sexual risk behavior and perception (see
Boholm 1998; Longfield 2008; Slovic 2000; Stoffle 1991), the meanings sexuality and sexual behavior hold for individuals (Brummelhuis 1995; Parker 2001), and by describing structural constraints on individual’s choices and behaviors
(Farmer 2004; Harthorn and Oaks 2003; Pfeiffer 2002; Susser 2009).
A good example is condom use. Condoms have been heavily promoted for
HIV/AIDS prevention (UNAIDS 2010). However, individual decisions whether or not to use condoms are heavily influenced by socio-cultural, political and economic factors, gender dynamics, and individual factors such as reproductive wishes, social risks, perceptions of partners and relationship factors such as their partner’s preferences (Burja 2000; Caplan 2000; Chapman 2006; Longfield
51 2008; Oppong and Kalipeni 2004; Smith 2003; Wojcicki and Malala 2001), as well as by structural factors such as gender inequality. Condoms themselves can be perceived as risky or dangerous because they imply that there is a lack of trust in the relationship (Burja 2000) and condoms are widely associated with promiscuity (Setel 1996), HIV infection and not HIV prevention (Hirsch et al
2009; Smith 2009). In some cultures, “flesh to flesh” sex is highly prized
(MacPhail and Campbell 2001; Dilger 2003), and “the very definition of sex [is] to ejaculate into a woman or to receive a man’s sperm; using a condom [is] said to be ‘dirtying oneself’,” (Setel 1996). Condoms are therefore rarely used in marital or other relationships characterized by love and trust (Parikh 20007;
Preston-Whyte 2008; Varga 1997). In some cases, individuals strategically choose not to use a condom in order to build a sense of legitimacy or to construct the image of trust in the relationship (Smith 2009; Sobo 1995).
Condoms are also often not used because they impede reproduction (Bond and Vincent 1997). For example, youth living in the Bukoba district of Tanzania where HIV prevalence was high, reported choosing not to use condoms because they desire to reproduce early in life in order to leave their legacy on the world and continue on with life (Rugalema 2004). In this instance, choosing not to use a condom is a strategy used by youth to carry on with life in light of the
HIV/AIDS epidemic (Rugalema 2004). HIV is perceived in this context as a
“dangerous side effect of life” (Rugalema 2004).
Cultural Theory and Risk Perception
52 Anthropological theories of risk perception are grounded in Mary Douglas’ cultural theory3, which states that the perception of risk is a social process heavily influenced by moral judgments and encoded in social institutions and that risk perceptions therefore vary according to shared social beliefs (Douglas and
Wildavsky 1982). Cultural theory sees risk as “as a joint product of knowledge
[which can be either certain or uncertain] about the future and consent [which can be complete or contested] about the most desired prospects,” (Douglas and
Wildavsky 1982:5 brackets added). Because knowledge of risks is always incomplete and agreement is always contested, risks and how to handle them are perpetually debated. Societies are therefore continually constructing categories of
“safety” versus “risk” and actively working to displace danger and blame onto others (Douglas 1982). Social, cultural, and political processes, as opposed to scientific observations, are therefore the primary mechanisms through which risks are identified, defined, and perceived (Douglas and Wildavsky 1982), infusing the process of risk perception with issues of morality, social value, and responsibility. Douglas therefore conceptualizes risk as the socio-cultural process by which vulnerability and danger are understood, assessed and responded to at the individual and social level (Douglas and Wildavsky 1982).
Risk perceptions are constructed in sociocultural context (Chapman 2010) and laypersons often perceive risk differently from “experts” such as public health practitioners (Douglas and Wildavsky 1982). For example, biomedical concepts of “safe sex” may focus on minimizing the exchange of bodily fluids,
3 Cultural theory starts by assuming that a culture is a system of persons holding one another mutually accountable (Douglas 1985).
53 public health program may promote monogamy in order to prevent the risk of
HIV infection, and lay conceptions of safe sex may emphasize emotional and psychological safety and focus on developing loving, trusting relationships to minimize risk of both emotional harm and infectious disease (Bourne and
Robson 2009). In another example, Smith’s research in Nigeria demonstrated how some young Nigerian migrants perceive HIV risk in moral and ethical terms, and thus assess their personal risk along a moral axis that perceives danger in the stigmatized, immoral “other” (Smith 2003). Moral concepts of risk are strongly influenced by religious discourses of Pentecostal Christian churches found throughout Nigeria (Smith 2004) and Mozambique (Pfeiffer 2004).
Risk perceptions are heavily influenced by a multitude of factors, and the socio-cultural and political context often plays a stronger role in emic risk perceptions than does the nature of the risk itself (Beck 1992; Boholm 2003;
Douglas and Wildavsky 1982; Douglas 1992; Nelkin 2003). Emic risk perceptions are influenced by factors including beliefs about danger, uncertainty, morality, love, trust, power, vulnerability, structure and agency, choice, blame, social identity, gender, knowledge, among many other variables and experiences (see
Chapman 2010; Leclerc-Madlala 2003; Longfield 2009; McGrath et al 1992;
Nichter 2003; Parikh 2009; Saethre and Stadler 2009; Silberschmidt and Rasch
2001; Slovic 2000; Smith 2009; Stoffle 1991; Susser 2009).
In one example, Setel describes how “moral demographies” of AIDS and fertility shape risk perceptions in the Kilimanjaro, Tanzania (Setel 1999).
Demographic and structural positions intersect with economic and gender inequality in the social landscape of this region of Tanzania to push people into
54 migrant labor and commercial sex work which creates an “ecology of risk in which hierarchies of gender, generation, HIV, and political economy all intersect to create an epidemic,” (Setel 1999). Women have historically been stigmatized as reservoirs of disease such as syphilis (Setel 1999), and with the spread of
HIV/AIDS this view has been taken up in new discourses that blame women and supposed female promiscuity for spreading HIV (Dilger 2003; O’Neil et al 2004).
However, in the case of the Haya, women are unable to inherit land making them structurally vulnerable to prostitution and thus HIV risk (Setel 1999). (Structural forces creating risk will be discussed further below in the Risky Environments section). Setel argues that the intersection of fertility and migration form the heart of HIV risk perception in Tanzania because migrant laborers were perceived to have bad moral character (“excessive tamaa”) related to their migrancy and thus at risk of AIDS (Setel 1999). “Through moral demography various actors produce knowledge about the location of bodies [migration], their status [morbidity and mortality], and the consequences of reproductive action
[fertility],” (Setel 1999 brackets added).
Risk perceptions are constructed from multiple, contradictory and often incomplete sources of risk information (Douglas and Wildavsky 1982; Pfeiffer
2004) such as medical clinics, rumor, gossip (Stadler 2003), churches (Smith
2004), traditional healers (Green 1994; Vincent 2008), media, family, experience, and other sources in the daily environment (Bray et al 2010). This produces uncertainty regarding risk and strategies for risk reduction (Boholm
2003). Risk messages can conflict with each other (Pfeiffer 2004) and may result in unintended and unanticipated behavioral results (Campbell 2008), especially
55 when global risk messages conflict with other local notions of risk or risk messages (Pfeiffer 2004). For example, the promotion of male circumcision as an
HIV prevention tool can alter masculine identity, which in turn may reduce risk perceptions and increase sexual behavior (Cassell et al 2006). Global HIV/AIDS prevention messages interact with local ideas of risk, pleasure, and love in ways that shape youth identity and behavioral choices (Parikh 2007). Individuals are therefore actively engaged in constructing, perceiving, and resisting risk in local context as opposed to being merely passive recipients of risk information
(Douglas and Wildavsky 1982).
Risk Perception in the Context of Multiple Risks
While HIV services drive the health service sector in the study community, this dissertation study hypothesizes that local response to these interventions is largely determined by how the community judges the risk of HIV in relation to other competing or connected risks in their lives as has been observed in other contexts (Chapman 2010; Nichter 2008; Singer et al 2006; Smith 2009). “The formal health care sector can only add its voice to a social and cultural environment that already has its own very powerful epistemology of AIDS,” (Setel
1996).
Furthermore, it has been observed in other contexts that social risks such as stigma or malicious gossip often outweigh physical risks when individuals are making health decisions, especially in the case of HIV/AIDS, depending on how individuals perceive their risk (Nichter 2008; Smith 2009). This dissertation project therefore examines the ways social risks influence youth risk perceptions
(Nichter 2008).
56 Risk perceptions also vary across circumstances and change over time.
Youth, for example, often perceive sexual activity and attendant risks differently depending on the context within which the sex occurs (Karlyn 2005). For example, Karlyn’s work among youth in Maputo, Mozambique demonstrates that youth who engage in saca cena (one night stands) acknowledge sex as both pleasure and risk, which leads to more condom use and thus safer sex (Karlyn
2005). In the case of vulnerable youth, such as young boys living on the streets in
Tanzania, youth may submit to coercive sexual encounters as a means to ensure protection and inclusion in a social network (Lockhart 2002). In this example, the boys were not concerned with the risk of HIV because they viewed the sexual acts as part of the temporary and situation specific stage called kunyenga, thus viewing the acts as “not sex” - as opposed to real sex (Lockhart 2002). Lockhart’s example shows how perceptions of safety and danger shape behavior in the context of social and economic marginalization where HIV is not the only, nor necessarily the most pressing, risk to the self. This dissertation will also describe the ways that youth risk perception and the behavioral choices available to youth are influenced by interlocking environmental and social risks.
Social Proximity
MacIntyre and Kendall (2008) theorize that social proximity to HIV creates a high level of HIV risk perception and awareness which results in behavior changes. Social proximity is conceptualized as “reflecting both personal and communal experiences [of HIV/AIDS] through AIDS-related illness or death of family members, friends, and/or significant community members…and the reactions to these experiences” (Macintyre and Kendall:62-63). High levels of
57 denial, stigma, and silence are present when social proximity is low. Denial, stigma, and silence act to maintain perceived social distance from HIV, and therefore behavior change does not occur (Macintyre and Kendall 2008). Susser and Stein (2004) have demonstrated that social proximity does in fact increase individual perception of HIV risk; “As people observe the deaths of family members, infants, and neighbors infected with HIV, their awareness of their own risk becomes more firmly internalized,” (Susser and Stein 2004:134). However, behavior change is not as easily implemented because behavior change depends on many other factors such as personal agency.
Social proximity to HIV is likely a powerful concept for understanding youth risk perception in this study’s community. South Africa has the most cases of HIV of any single country in the world with the majority of new cases occurring in township youth, especially girls (UNAIDS 2010). HIV/AIDS has significantly reduced national life expectancy, orphaned millions of youth, and over-burdened service infrastructures. Bhana (2008) reports, however, that denial, silence, and stigma maintain perceived social distance from HIV in South African communities.
The role of social proximity in shaping risk perception is therefore an important question in this dissertation study and findings are relevant to understanding the process of risk perception in high prevalence contexts such as
South Africa’s townships. The HIV epidemic has profoundly impacted people’s everyday lives and perceptions throughout impacted African countries. Youth in
Burkina Faso have reported that the HIV epidemic has led to feelings of living in a risk society and of being at heightened risk (Samuelsen 2006). These feelings,
58 combined with structural problems such as unemployment and poverty, contribute to general feelings of uncertainty which have, in turn, spurred youth in
Burkina Faso to prioritize the identification of intimate partners who can be trusted to be faithful or to use condoms (Samuelsen 2006).
In summary, the fact that risk and risk perceptions unfold in a larger context is widely agreed upon in anthropology. How to assess this process, how to consider contextual factors and their impact on risk perception, however, poses a greater challenge. Medical anthropology suggests studying the social contexts and individual relationships within which risk behavior may occur, revealing diversity in risk experience, the meanings that particular risk behaviors have for people, and how people manage risk in their daily lives (Nichter 2008; Susser
2009).
This dissertation project employs youth narratives in order to understand how risk perceptions are formed in sociocultural contexts, the meanings youth attach to risk perceptions, and the ways risks are managed in daily life. As part of developing an understanding of youth risk perception, this project also assesses the level of social proximity study participants have to HIV/AIDS and how level of social proximity impacts HIV risk perception and related behaviors. In this study, a behavior is considered HIV-related when it has been observed to impact
HIV infection in the South African context, such as sexual abstinence or condom use, and if it is considered HIV-related by youth in the study, as, for example, building trust in relationships. This study contextualizes risk perception within a risk environment, described below.
59 2.2.3 Risky Environments
Anthropologists theorized risk as more than individual-level risk such as individual behaviors like condom use). This approach to risk considers structural- or macro-level risks that structure the extent to which an individual may be at risk for HIV by examining environmental factors such as poverty outside of individual control. HIV/AIDS is a global pandemic; however, HIV infection is concentrated among the world’s poor and marginalized populations
(Farmer, Connor and Simmons 1996). This epidemiological observation has led anthropologists to study the mechanisms by which HIV risk is distributed unequally amongst disenfranchised populations and to examine how the dynamics of larger social, cultural, and political economic environments pattern
HIV infection rates.
The unequal distribution of HIV infection cannot be explained through risk behavior alone, pointing to the relevance of structural, social, and environmental factors that influence risk on a local scale by patterning sexual networks and influencing disease spread (Kalipeni et al 2004; Schoepf 2004;
Setel 1999). The “risky environment” is a conceptual frame that seeks to address the intersection of structural forces and risk in local contexts by drawing upon scholarship examining the political economy of health, critical medical anthropology, gender, inequality, social networks and structural violence (for example, see Rhodes et al 2005; Schoepf 2004). A brief description of the theoretical underpinnings of the risk environment concept is presented below, followed by a description of how the concept is used in this study.
The Risk Environment
60 The risk environment (Rhodes et al 2005; Strathdee et al 2010; Rhodes et al 20011) is a central concept in this study. The risk environment is defined by
Rhodes and colleagues as “the space, whether social or physical, in which a variety of factors exogenous to the individual interact to increase vulnerability to
HIV,” (2005:1026). Understanding HIV risk in terms of risk environments places a focus on social situations, structures, and places in which risk is produced rather than focusing only on individual behavior and decision-making (Rhodes et al 2005:1027). The HIV risk environment is a product of interplay in which social and structural factors intermingle, but where political-economic factors may play a predominant role in creating an environment that increases individuals’ risk of
HIV infection. The combined impact of these factors is synergistic and varies across time and space. For example, in South African townships, it is assumed that interrelated economic and social factors such as poverty and gender inequality create sexual networks in a way that results in high rates of intergenerational and transactional sex (Leclerc-Madlala 2003; Leclerc-Madlala
2008), which in turn influences the elevated rate of HIV among young girls in
South Africa’s townships. Another example is taken from New York City, where high rates of HIV, substance abuse, and incarceration rates among young men of color has been analyzed in terms of the ways in which the intersection of race, class, and gender inequality help to create environments of health inequality
(Schulz et al 2006).
The risk environment model has two key dimensions of environmental influence: 1) type, which can be physical, social, economic, or policy and 2) level, which can be micro, meso, or macro (Rhodes et al 2005). Micro, meso, and
61 macro forces combine to “structure” environments wherein HIV risk is produced and reproduced (Rhodes et al 2005:1028). Micro-level forces are those at the level of interpersonal relationships, meso-level factors are at the level of social and group interactions, and macro-level forces are large-scale institutional, organizational, political and economic levels of society (Rhodes et al 2005). An example of different levels of the risk environment is taken from the case of injection drug users. Many factors structure and produce HIV risk among IDU’s, including micro-level forces such as negotiating the sharing of injecting equipment amongst users, meso-level factors such as group norms for appropriate injecting behaviors, and macro-level forces such as policing policies
(Rhodes et al 2005).
Each level of the risk environment interacts with the other levels, which has a synergistic and sometimes contradictory impact on HIV infection, and which creates interplay of factors that results in locally specific risk environments. In the case of IDU’s, Rhodes et al (2005) identified a number of social and structural factors that interplay and cut across macro, meso, and micro dimensions of the physical, social, economic and policy environment. These factors include cross-border trade and transport links, population movement and mixing, urban or neighborhood deprivation and disadvantage, the presence of specific injecting environments such as shooting galleries, peer groups and social networks encouraging injection drug use, social capital, neighborhood factors, political or economic transition, political, social and economic inequities in relation to ethnicity, gender and sexuality, social stigma and discrimination of injection drug users, policies and laws that negatively impact injection drug
62 users, and complex emergencies such as natural disaster (Rhodes et al 2005).
These factors are inter-related but also mutually reinforcing, creating an
“interplay” of factors that generates an environment this is riskier than if these factors were found in isolation.
The risk environment incorporates the syndemic concept of disease, which presents an analytical frame for examining how two or more co-existing diseases or stresses can synergistically reinforce each other to amplify the negative impact on individual and population health (Singer and Clair 2003). The syndemic perspective conceptualizes disease in terms of both “its interrelationships with noxious social conditions and social relationships, and as one form of expression of social suffering” and “multiple, interacting deleterious conditions among populations produced by the structural violence of inequality,” (Singer and Clair
2003:434). For example, in South Africa’s Western Cape townships, overcrowding and inadequate housing combine with high rates of latent tuberculosis disease and a large population of immuno-suppressed HIV positive individuals to create the worst HIV / TB co-infection crisis in the world (RSA
2012).
Rhodes and colleagues (2005) emphasize the importance of conceptually separating community and personal relationships from larger structural forces and to avoid the lumping of these disparate forces into the single category of
“context”. Disparate factors must be distinguished in order to understand the process by which risk is distributed through society. Rhodes and colleagues thus suggest we follow the example of Wallman et al (1996) whose study of the health care seeking and decision making process for women in Kamwokya (Uganda),
63 analytically separated the individual, household, neighborhood, and city level and separately examined the impact of each level on health care behavior.
The risk environment concept is well suited to this dissertation study. Data are analyzed to define the characteristics of the study community as a risk environment in terms of micro-, meso-, and macro-level factors and the interplay of these factors on structuring conditions of HIV risk for youth in the study community. Data analysis also examines the impact of components of the risk environment on youth experience and identity, on youth experiences of risk, and assesses the utility of the risk environment concept for understanding youth risk, especially regarding HIV/AIDS, in South African townships.
Theoretical Development of Risk Environment Concept
This risk environment concept is grounded in critical medical anthropology (CMA) (Baer et al 2003) and the political economy of health
(Farmer, Connors and Simmons 1996). CMA and political economy consider the social origins of disease by examining how macro-level forces such as gender and class inequalities create conditions of risk on a local scale and weaken protective factors (Farmer, Connors and Simmons 1996; Morsy 1996; Baer et al 2003;
Schoepf 2004b). People are immersed in the micro-politics of daily life and “do not experience political economy directly,” (Whyte 1997:3). Therefore, in order to investigate the political economy of health, Whyte suggests examining the practices of individuals and the intentions of those practices in order to focus on individual agency while still attending to the social and cultural context without over-emphasizing either agency or context (Whyte 1997). Risk is tightly linked to considerations of agency, control, and power (Douglas and Wildavsky 1982).
64 Individual and community capability to enact health behavior change relates to some extent to their level of control (Wallman 1996). Ethnography is thus used in this dissertation study to examine the impact of macro-level social, political and economic processes on youth agency in managing risk (Schoepf 2004b:16).
Structural violence is a closely related concept. Structural violence is defined as the constellation of social arrangements, including unequal economic, political, legal, religious and cultural structures, that hinder one’s ability to satisfy human needs and potential (Galtung 1969). Structural violence has been used as a framework to examine the links between history, political economy and biology to understand how infectious diseases such as HIV become entrenched in poor areas and marginalized communities where HIV is one of multiple risks faced in daily life (Bourgois 2003; Fassin 2007).
Structural violence is often criticized for lack of conceptual clarity, failing to distinguish between disparate forces such as violence and gender inequality and for its moralizing discourse (Wacquant, response to Farmer 2004). Despite these criticisms, the concept has been widely used in anthropological studies of inequality, particularly with regards to HIV/AIDS in Africa (for example, Fassin
2007; Schoepf 2004a).
Inequality
Inequality is a central aspect of the risk environment in South Africa’s townships. Social inequality, economic inequality, gender inequality, and racial inequality strongly influence daily lived experience for South Africans, and many aspects of life such as where one lives are heavily structured by the overlapping dynamics of these inequalities, with significant ramifications on individuals’
65 health, education, job opportunities, and life chances. Inequities are systematic, avoidable, and unjust inequalities in health between groups of people (WHO
2008). It has been observed in other contexts that socioeconomic inequality is highly correlated with poor health outcomes for the entire society (Nguyen 2003;
Parker 2001; Pfeiffer 2002). The social determinants of health, defined as the social, economic, and political circumstances in which people are born and live, as well as the larger socio-economic and political forces that shape those conditions, are widely recognized as key factors influencing the health of individuals and communities (Marmot and Wilkinson 2005; WHO 2008; Dean and Fenton 2013).
Risk is largely regarded as the primary mechanism through which social inequality becomes embodied in individuals and thereby results in disproportionate rates of disease and poor health outcomes in marginalized groups (Nichter 2008). Seen this way, risk is defined as a “measure of social violence, capturing how power distributes unevenly down the social ladder,”
(Nguyen 2003:457) or as “a fluctuating, socially seismic field in which definitions of danger, harm, safety and blame are constantly shifting. Social difference and health inequality figure largely in the cultural landscape of risk precisely because risk is used in the production of health inequality,” (Harthorn and Oaks 2003:4).
This dissertation project assesses youth experiences of inequality, such as gender, racial, and economic inequality, and the role of these inequalities in structuring the local risk environment.
66 2.2.4 Gender and Risk
Gender, and gender inequality in particular, is a significant factor in the risk environment that mediates vulnerability to HIV/AIDS in South Africa, especially amongst youth. Gender inequality is defined as the unequal treatment, unequal perception, or unequal access to resources, opportunities, or social and economic roles of individuals based on their gender. The majority of new HIV infections occur in women, especially young girls (Abdool Karim 2005; Susser
2009). The gender inequality embodied in elevated rates of HIV experienced amongst young females in South Africa has prompted South African Health
Minister Motsoaledi to say, “HIV/AIDS in my country…is a disease brought on by males but suffered by females. Unfortunately, because…. [of] intergenerational sex, that is quite older people who are having sex with these young girls and infecting them. That’s why there is that difference.”4
The dynamics of gender inequality play a role in the elevated rate of HIV observed in women and young girls. The mechanisms by which gender inequality places women at elevated risk of HIV infection have been thoroughly investigated by anthropologists (for example, see Burja 2000; Farmer, Connors, Simmons
1996; Mantell, Stein and Susser 2008; McGrath et al 1992; Schoepf 2001; Susser and Stein 2004; Susser 2009; Varga 1997; Wood, Lambert and Jewkes 2007).
This discussion will first focus on work demonstrating the ways that ideals of feminine behavior and power imbalances between men and women in South
4 Quote taken from the transcript of Kaiser/CSIS Forum with South African Minister of Health, Kaiser Family Foundation, Washington, D.C., March 29, 2011. Accessed at http://globalhealth.kff.org/~/media/Files/KGH/Support%20Files/2011/032911KFFCSIS_ transcript.pdf
67 African society result in a power imbalance in sexual encounters, which thereby increases vulnerability of women to HIV. Secondly, works that describe the ways ideals of masculinity encourage sexual conquest increase men’s vulnerability to
HIV are reviewed (Campbell 1997; Hunter 2005; Setel 1996). Finally the intersections of gender inequality with other forms in power imbalance, such as age, are also examined.
Normative local gender roles (Bhana 2009; Delius and Glaser 2002;
Mantell et al. 2008; Morrell 2001; Ratele et al 2007; Shefer et al 2005; Simpson
2007; Vincent 2008; Walker 2005) masculine identities valorizing sexual conquest (Smith 2009; Walker 2005), marginalization of same-sex sexualities
(Reddy et al 2009), gender inequality (Schoepf 2004; Susser and Stein 2004), gender-based violence (Jewkes et al 2006; Jewkes et al 2003; Swart et al 2002;
Wood, et al. 2007), coercive sexual practices including intergenerational sex between young women and older men (Leclerc-Madlala 2003; Leclerc-Madlala
2008), transactional sex (Cole 2004), and the interaction of gender with other inequalities such as age, racial and economic inequality (Walker and Gilberg
2002) increase female vulnerability to HIV. Limited female-controlled HIV prevention strategies further exacerbate female vulnerability because women depend on men, for example, to wear condoms in order to prevent HIV (Susser
2009; Susser and Stein 2004).
While most scholarship focuses on the status of women, there is a growing recognition that many men are also marginalized globally. Western-developed
HIV interventions targeted at changing African men’s behavior have been criticized for framing risk as the result of “exotic” African culture, and for their
68 focus on changing individual behavior and choice while obscuring social and global inequities that impact men’s behavior (Farmer 2004; Hirsch et al 2009;
Parker 2001; Smith 2009). As Smith shows in urban Nigeria, many married men are expected to take a younger lover and if they do not, they face social risks of having their masculinity questioned and ostracism from male social networks, which can have economic ramifications (Smith 2009). In the context of economic inequality and increased globalization in Nigeria, these extramarital affairs are a mechanism for men to display masculinity and economic privilege (Smith 2009).
Married men face increased pressure to perform masculine identities and demonstrate economic means in this context, and having girlfriends and sexual encounters outside the marriage is one socially sanctioned, albeit a risky and
“secret” mechanism to do so (Smith 2009).
State policies can be macro-level factors in the risk environment when they structure gendered behavior and risk. In example, Vietnam’s transition to a market economy and deregulation of public and private life contribute to a shifting of responsibility for societal welfare from the state to individuals and families (Phinney 2009). In this context, men are expected to provide economically for their families and men’s extramarital affairs are tolerated as long as they do not make time or financial demands on the men that would detract from supporting their “Happy Family,” (Phinney 2009). Seen in this light, risk is redefined as threats to the State’s Happy Family policy and affairs with commercial sex workers thus become a “safer” choice than affairs with other lovers because commercial sex workers are much less likely to make demands for long-term commitment or resources from men than are lovers (Phinney 2009).
69 Although these extramarital affairs may place wives at risk for HIV in cases where husbands do not use condoms with sex workers, wives are not in an empowered position to question the affairs because doing so could threaten the marriage and the image of a happy family (Phinney 2009).
Married couples must negotiate changing gender roles and expectations whilst maintaining social and economic status in their communities, and therefore often prioritize the avoidance of social risks over the risk of HIV infection. Yet gender inequality is reproduced through the keeping of secrets regarding marital infidelity (Hirsch 2009). While both men and women actively protect infidelity secrets, it is the men who benefit through greater access to pleasure and resources such as expanded social networks through extramarital affairs. Women often risk divorce, loss of their husband’s financial support, and loss of social status if they confront their husbands’ infidelity (Hirsch 2009;
Smith 2009). Women may also risk being seen in the community as failing in their moral and pragmatic obligations to maintain a marriage, family with children, and reputation (Smith 2009:105). Women are often at elevated risk of
HIV compared to men in contexts of economic insecurity, when they are disempowered and have few resources at their disposal (Farmer 1996; Schoepf
2004; Susser 2009).
Gender roles and gendered expectations heavily influence views of reproduction and parenthood and play a significant role in shaping sexual and behavioral choices (Mantell, Stein and Susser 2008; Smith 2003) including choices about pregnancy and HIV prevention strategies. Gender roles and gendered expectations are central influences as to whether and how new HIV
70 prevention technologies will be adopted and used (Mantell, Stein and Susser
2008).
Youth risk and risk perceptions are impacted by gender and gender inequality at the individual, social, and environmental level. Understanding the role of gender, gender inequality, and the intersection with age to impact risk perceptions and behavioral choices are thus central components of this study.
The risk concept has developed over time to encompass descriptions of hazards in the natural world, how social groups manage threats to the self and to the group, as a frame within which to explain and manage uncertainty, and as a discursive concept employed to demarcate boundaries between the self and other, socially acceptable versus unacceptable behavior, and to answer questions of responsibility and blame for misfortune. Risk perceptions are constructed in social, cultural and economic contexts. Recently, theories of risk as a structural concept have served as a central frame within which to examine the experiences and social dynamics of HIV/AIDS in vulnerable populations.
Risk is conceptualized in this study as the uncertainty of a chance outcome where something of value is at stake (Rosa 1998) from the perspective of youth.
Risks can therefore be positive or negative, physical or social, or both. Risk perception is defined as the process by which vulnerability and danger are understood, assessed and responded to at the individual and social level. The theory of social proximity guides analysis of risk perception data collected in this study. The specific aspects of the township risk environment are analyzed in terms of their influence on youth risk perception and youth responses to risk, from the perspective of youth. Gender and gender inequality in particular are
71 focused on describing the local particularities of the study community as a risk environment.
2.4 Conclusion to Background and Significance
This study examines the experiences of youth in the context of a South
African township. The concept of risk in relation to HIV/AIDS is used as a frame to examine youth vulnerability and youth responses to this vulnerability, including risk perceptions, actions youth take to manage vulnerability in daily life, and the conditions that structure youth exposure to risk as well as the choices that are available to youth in managing vulnerability in the township. The concept of risk itself is interrogated by examining youth-centered conceptualizations of risk through youth narratives.
The term youth is used to describe young people in the study community because youth is a locally salient term in South Africa’s townships. This study utilizes the anthropological literature on youth cultures regarding youth as a lived social category and focusing on the immediacy of youth experience. However, the narrow focus of the youth cultures literature does not adequately address issues of life stage and human development that are central to understanding youth experience in South Africa’s townships. This study considers the concept of youth as closely related to adolescence and views youth as a life stage best described through the lens of human development. This project therefore combines the literature on youth cultures with that of psychological anthropology theories of adolescence in order to suggest a conceptualization of contemporary youth experience in a South African township that captures both the immediate, lived
72 reality of youth and also places this immediate experience in the context of the life course in South Africa.
The study township is characterized as a risk environment (Rhodes et al
2005), wherein youth must manage the interlocking dynamics of entrenched racial and gender inequality, poverty, unemployment, lack of educational opportunities, urban crowding, violence, and rapid population growth amidst the world’s highest rate of HIV/AIDS (UNAIDS 2010). The local particularities of the study community as a risk environment and its relation to HIV/AIDS risk for youth will be described. Because HIV risk is a significant aspect of youth risk in this environment, the concept of social proximity guides analysis of collected data regarding youth experience with HIV in order to understand the ways youth perceive and manage the risk of HIV infection and the other interrelated threats in daily life.
This research advances our understanding of youth experience in the context of risk and vulnerability. Specifically, this research addresses anthropological questions of how risk, especially health risk, is perceived and responded to by vulnerable youth in daily life and how youth construct risk perceptions in the context of a risk environment, especially with regards the
South African HIV epidemic, which is currently driven by youth sexual behavior in contexts of structural inequality (James et al 2004; Parker 2001). This research is highly relevant in South Africa, which has the largest number of
HIV/AIDS cases in the world, most of which occur in township youth (UNAIDS
2010), and in populations in other parts of the globe at high risk for HIV/AIDS as well as other behaviorally transmitted diseases.
73 Chapter 3. The South African Context
3.1 Introduction
This chapter provides a brief history of the Republic of South Africa
(“South Africa”) and its people and traces major historical events up to 2011, with a focus on the history and people of the Western Cape, where this study took place. The current socio-economic and political context, particularly the
HIV/AIDS epidemic and issues impacting youth are discussed. A description of the field site is provided at the end of this chapter. This chapter merely scratches the surface of South Africa’s complex history and cultures, which are vast topics beyond the scope of this dissertation. A brief chronology of South Africa and its people, a brief history of the HIV/AIDS epidemic in South Africa, and suggestions for further reading are provided as an Appendix.
Geography and Economy
South Africa is located on the southern tip of the continent of Africa. South
Africa has a total land area of 1,219,090 square kilometers and shares borders with Namibia, Botswana and Zimbabwe to the north, Mozambique and Swaziland in the east, and completely surrounds the borders of Lesotho. South Africa is considered a middle-income emerging market with a large mining industry due to its significant mineral and other natural resources. It is the world’s largest producer of platinum, gold, and chromium (CIA 2014). The country’s infrastructure is relatively well developed compared to other sub-Saharan African countries but the economy struggles with significant and widespread unemployment, economic and social inequality, electricity shortages and poverty with over 31% of the population living under the poverty line (CIA 2014). Even
74 though Gross National Income (GNI) has increased by 14% since 1980 (UNDP
2013), 13.4% of the population is living in multidimensional poverty and 13.8% is living below $1.25 PPP per day. Adults achieve a mean of 8.5 years of education5
(UNDP 2013) and educational access is equal between males and females.
Demographics
South Africa’s population of an estimated 52,980,000 million people
(Stats SA 2013) is diverse. Approximately 51% of the population is female (Stats
SA 2013). 79.8% of South Africans are classified as black African, 9% as coloured6, 8.7% as white, and 2.5% are classified as Indian or Asian (Stats SA
2013). The country recognizes eleven official languages, including isiZulu (the first language for 22.7% of the population), isiXhosa (16%), Afrikaans7 (13.5%),
English (9.6%), Sepedi (9.39%), Setswana (8.2%), Sesotho (7.93%), Xitsonga
(4.44%), siSwati (2.66%), Tshivenda (2.28%), isiNdebele (1.59%) (Stats SA 2011a;
CIA 2014). Another 0.5% of the population speaks a language other than the eleven official languages listed above as their primary language. Most South
5 Defined as the average number of years of education received in a life-time by people aged 25 and older. 13.1 years are expected for children of school-entrance age (UNDP 2013). 6 Coloured is a very heterogeneous ethnic category created under apartheid to describe South Africans of KhoiKhoi, eastern slave, and mixed heritage; including those of mixed European, Khoisan, and Bantu ancestry. In the Western Cape, 48.8%% of the population is coloured, and a distinct Cape Coloured and related Cape Malay culture developed there. Coloureds also comprise 40.3% of the Northern Cape population and 8.3% of the population in the Eastern Cape (South African Census 2011). Most coloureds speak Afrikaans as their first language. Bilingualism is common amongst coloureds as it is with many South Africans. 7 Afrikaans is a language derived from Dutch that evolved in South Africa amongst the Dutch-heritage settlers. Over time Afrikaans developed distinct differences to Dutch in morphology, pronunciation, and accent but Afrikaans and Dutch remain mutually intelligible. Other languages found in South Africa during colonialism, such as KhoiKhoi, Cape Malay, Zulu, British, and Portuguese languages, influenced Afrikaans.
75 Africans are bilingual and speak additional languages in addition to their first or
“home” language. English is widely spoken as a second language and is used as the primary language of business and education.
South Africa is divided into nine provinces. Most provinces are comprised of a black African majority and a white minority population. However, the
Western Cape (WC), where this study took place, and Northern Cape provinces are unique in that their populations are comprised of large coloured populations and an African minority. The Western Cape also has a much larger percentage of white people than other provinces in the country. In the Western Cape, Afrikaans is the most common first language (spoken by 2,820,643 or 49.7% of the WC population) followed by isiXhosa (1,403,233 / 24.7%) and English (1,149,049 /
20.2%) (Stats SA 2011a). Gauteng Province is the most populated, with 24% of the country living in Gauteng (Stats SA 2013).
South Africa is also religiously diverse. The most common religion is
Christianity in various forms (72% of the population), including Protestant
Christianity (36.6% of the population), which encompasses the Dutch Reformed,
Anglican, Pentecostal, Methodist, and Zionist Christian denominations. Other significant religions include Catholicism, Islam, and other Christian religions.
Traditional African religions based on oral traditions and belief in the spiritual power of the ancestors exists alongside Christianity for most black Africans.
Population Trends
Life expectancy at birth for South Africans in 2013 was estimated to be
57.7 years for males and 61.4 for females (Stats SA 2013). This is a significant increase after life expectancy fell from 62 years in 1992 to 53 years in 2010
76 (World Bank 2013) mainly due to the HIV/AIDS epidemic. The recent recovery is related to the rapid government rollout of HIV treatment programs across the country. HIV/AIDS is a major force shaping population demographics. The national HIV prevalence rate is approximately 10%, with an estimated 5.26 million people living with HIV (Stats SA 2013). In the 15-49 year age group,
15.9% of the national population is HIV positive (Stats SA 2013).
South Africa’s population growth rate is estimated to be between -0.45%
(CIA 2014) to .99 (Stats SA 2013), which is one of the lowest in the world (CIA
2014). South Africa’s fertility rate is 2.34 children born to each woman, a decline from 2.71 in 2002 (StatsSA 2013). The infant mortality rate is estimated at 41.7 per 1,000 live births which is lower than the 2002 estimate of 63.5 (Stats SA
2013) yet still ranked as the 51st highest rate in the world (CIA 2014). The birth rate is 19.14 births / 1,000 population, which is average compared to the rest of the world. The death rate, however, is 17.36 deaths per every 1,000 persons in the population, which is the highest death rate in the world (CIA 2014).
South Africa’s population is young, with 29.2% of the population aged 15 or younger and only 7.8% of the population (4,150,000 people) is 60 years or older (Stats SA 2013). Youth aged 14-35 comprise 41% of South Africa’s population and 70% of the population is under the age of 35 (Stats SA 2011), reflecting a “youth bulge”. There was a large increase in young adult deaths between 1997 and 2008 due to deaths from infectious diseases, but this trend has started to reverse since 2006 (Bradshaw, Dorrington and Laubscher 2012).
Roughly 62% of the population is urban (UNDP 2013). Rural to urban migration is a significant trend shaping the country. The rural Eastern Cape and
77 Limpopo Provinces experienced a net out-migration of 264,449 and 227,919 people between 2006 and 2011, respectively, and during the same period urban centers in Gauteng and Western Cape Provinces experienced a net in-migration of approximately 1,046,641 and 307,411 people respectively (Stats SA 2013).
3.2 Historical Context
Colonial History (Thompson 2001)
South Africa experienced two major periods of colonization. The first period was when Dutch spice traders from the Dutch East India Company established the Dutch Cape Colony in present-day Western Cape in 1652 under the leadership of Jan van Riebeeck. The traders were in search of a halfway point on the spice trading route between the Netherlands and the Far East and founded the city of Cape Town as a refreshment station for ships on the trade route.
The Cape Colony was at the time inhabited by the KhoiKhoi, whom initially developed bartering relationships with the Dutch. However, as the Dutch encroached further into KhoiKhoi land, establishing farms and importing slaves, conflicts between the settlers and KhoiKhoi increased. Many KhoiKhoi were pressed into service for the colonists and the Dutch farmers, known as trekboers8,
8 Trekboers are direct ancestors of the Voortrekkers. The Voortrekkers are Boers who left the Cape Colony en masse beginning in 1835 in a series of large-scale migrations called the Great Trek. Boers are primarily Dutch descendants but also included small numbers of French Huguenots, German and British Protestants. Boer culture is strongly influenced by Calvinism and the majority of Boers to this day are members of the Reformed Church. Boers are distinct from the Cape- based Afrikaner identity and culture. Paul Kruger, a well-known historical figure after whom Kruger Park is named, was a Boer. Boers established Orange Free State and the Transvaal as Boer Republics, which later became part of the Union of South Africa in 1910. Boer identity remains a politicized issue in South Africa today and Kleinfontein was recently established in Gauteng Province as a community exclusive for Boers who identify with Voortrekker history.
78 pushed further inland and ultimately overtook the KhoiKhoi population.
Descendants of the KhoiKhoi comprise part of the current-day mixed-race group included in the coloured racial and social category.
The second period of colonialism was the formation of the British Cape
Colony, the period when the British seized the Cape Colony from the Dutch and occupied the land in 1795. The British Cape Colony was briefly returned to the
Dutch in 1802 and then re-occupied by the British in 1806. Dutch settlers then traveled north to found their own republics inland. Slavery was abolished in
Britain and British colonies, emancipating slaves in the Cape Colony in 1834. The abolishment of slavery was a point of contention between the British and Boers9 and was a contributing factor to the Great Trek, which was a mass emigration of
Boers out of the Cape and into the interior.
At the same time, the great Zulu king Shaka rose to power. Shaka united the Northern Nguni people, descendants of present-day Zulu, and led his armies south from Eastern Africa into present-day South Africa, conquering, dispersing, and overtaking the populations he encountered. This period of tremendous warfare and social upheaval is known as the mfecane. The mfecane transformed the agricultural societies conquered by the Zulu, and wrought tremendous suffering on the people living in the southeast. Many non-Zulu people including the southern-Nguni Xhosa were pushed into the Cape Colony in search of subsistence.
9 Boer is the Afrikaans and Dutch word for farmer. Boers are a distinct sub-group of Afrikaner culture. Descendants of Dutch-speaking settlers in South Africa that came to be known as Boers were originally known as the Trekboers because of their “trek” out of the Cape in order to escape British colonialism and the frequent border wars.
79 Colonists began moving further east, which brought them into contact with the Xhosa-speaking populations residing in what is now the Eastern Cape
Province. These interactions resulted in some trading and intermittent warfare.
During this time, the colonists [which were a mix of Dutch, German, and French
Huguenots] began to lose their identification with Europe and started to develop identities centered on belonging in Africa. The Afrikaner10 identity began to take form. The 1800’s were thus marked by a series of Cape frontier wars between the
Xhosa and the British and between the British and the Boers over land, water and cattle. Xhosa resistance fell apart following the great Xhosa cattle-killing crisis of
1856-1857 and subsequent famine and mass starvation of the Xhosa11. The 19th century was also the period when European missionaries began exploring
10 Afrikaner is the Dutch word for African and is a political and cultural term used to describe Afrikaans-speaking descendants of the Cape Colony founded by Jan Van Riebeeck. Approximately 5% of the South African population is Afrikaner. The first person to reportedly identify himself as an Afrikaner was Hendrik Biebouw, who stated “ik ben een Afrikaander” (I am an African) while resisting his expulsion from the Cape Colony. Afrikaners are often known as Cape Dutch because they established roots in the southwestern Cape region. Afrikaners, like Boers, are strongly Calvinist Christian. Today, Die Voortrekkers is a youth movement popular amongst Afrikaners in South Africa and Namibia that promote Afrikaner cultural and Christian values. A minority of contemporary Afrikaners have controversially established Orania in the Northern Cape as an exclusive Afrikaner community. 11 Xhosa-speaking peoples experienced years of conflict and violence over land and governance disputes with British Governors and British colonialists in the contested land then known as the Ciskei, a Bantustan. Xhosa chiefs and their subjects endured constant humiliation, violence, and threats to their people at the hands of the British and a few notably cruel British Governors. In 1856, a young Xhosa girl named Nongqawuse received a prophecy from her ancestors that if the Xhosa killed their cattle and burned their crops, the British would be swept into the sea and the Xhosa cattle and crops would be replenished so that the Xhosa could again flourish. Paramount Chief of the Gcaleka, Sarhili, ordered that the prophecy be followed, resulting in a mass cattle killing movement and subsequent famine and mass starvation amongst the Xhosa. When the prophecy proved to be false, Nongqawuse was arrested by the British authorities and imprisoned on Robben Island.
80 Southern Africa, documenting their interactions with the people they encountered, and proselytizing English education, health care, and Christianity.
The Discovery of Diamonds and Gold
The discovery of diamonds in 1867 and of gold in 1886 drove tremendous wealth and immigration to South Africa from Europe that led to the further marginalization and subjugation of native Africans. Conflict between the British and the Dutch Boers continued, culminating in the Boer War (1899-1902). The
British defeated the Boers, but in 1910 the Boers and British began ruling together and the Cape Colony united with three other colonies in South Africa12 to form the Union of South Africa.
Racially Repressive Laws
Repressive laws and policies entrenching white minority power were soon enacted, including reserving skilled work for whites, the Masters and Servants
Act, pass laws, the Native Poll Tax and 1913 Land Act which reserved 90% of the country’s land for white ownership. Resistance movements began to grow, including the establishment of African National Congress (ANC) in 1912 and resistance by the Indian population led by Mahatma Gandhi. Disagreements continued amongst the whites as well, and a group of Afrikaners broke away from the ruling South African Party to form the conservative National Party.
In the post-World War I period, South African workers began to form unions and strike. In 1919 the Industrial and Commercial Workers’ Union of
South Africa and the South African Indian Congress were formed. Mine workers
12 These colonies were the Afrikaner Orange Free State, the Transvaal, and the newly formed Natal (1897) following the defeat of the Zulu by the British army following years of war between the Zulu and British.
81 successfully went on strike for higher wages in 1920. The ANC began to align itself with anti-colonial efforts across the continent of Africa, and participated in the second congress of the Pan African Movement in 1921. In 1924 the
Nationalists’ Hertzog was elected Prime Minister of South Africa, after the
National Party garnered increased support following a white mine workers’ strike that was violently suppressed by the previous Prime Minister Smuts. Hertzog worked to further entrench white power and lessen British control over the
Union13. In 1944 the ANC Youth League was formed and Nelson Mandela, Oliver
Tambo, and Walter Sisilu were its early leaders.
The Policy of Apartheid and the ANC Defiance Campaign
In 1948, the National Party, which mostly represented Afrikaner interests, was voted into power. The National Party implemented a policy of apartheid, which mandated separate development of the races and which prioritized the white minority population at the expense of the black majority. In 1950, the
Population Registration Act classified all citizens by race, the Group Areas Act divided the land according to race and in 1952 pass laws were enacted restricting the movement of blacks. In 1953 the government created homelands or
Bantustans and thousands of blacks were forcibly relocated to these remote areas. Two Bantustans, Ciskei and Transkei, were reserved for Xhosa-speaking people.
The Bantu Education Act of 1953 placed African education under government control, enforced racially separated educational facilities and a
13 Due to declining popularity, Hertzog was forced to form a coalition government with Smuts in 1933 and the two joined to form the United Party. Extreme Afrikaner nationalists broke from this party and formed the Nationalist Party.
82 racially discriminatory curriculum wherein different standards of education were provided for whites, Indians, coloureds and for blacks. Bantu education denied educational opportunity to non-whites and especially to black South Africans, denigrated black cultures, and perpetuated the disadvantaged position of non- whites; leaving a lasting legacy that continues to impact South African society.
During the 1950s and 1960s, high-paying and skilled jobs were reserved for whites. When statutory job reservations were abolished in the 1970s, white people maintained their hold on these jobs because they had access to better education than coloured and black people. The Coloured Labour Preference
Policy required employers to give preferential hiring to coloured workers over black workers. Black workers were further limited from job opportunities by the pass laws that prevented blacks from physically entering areas where jobs were available.
The ANC thus began its decades-long defiance campaign in the struggle for equality as the Nationalist government increasingly acted to marginalize the non-white population. The Freedom Charter, declaring principles of equality and non-racialism was signed on June 26, 1955 at the Congress of the People and
Soweto. In response, the government charged 156 leaders of the ANC and its allies with high treason, though the accused were acquitted in 1961 following the longest trial in South African history.
The 1960’s brought increasing radicalization and violence in the struggle.
Apartheid had entrenched policies of separate development, and the government divided black Africans into ethnic “nations” assigned homelands with the goal of each homeland eventually achieving independence from South Africa. Opposition
83 to the National Party was led by the ANC liberation party. Following the
Sharpeville Massacre on March 21, 1960, when the police killed 69 unarmed protestors, a State of Emergency was declared and the ANC and other such organizations were declared illegal, forcing them underground. The ANC responded by forming an armed wing called Umkhonto we Sizwe (The Spear of the Nation) that carried out acts of sabotage against government installations.
In 1963-1964, the infamous Ravonia Trial sentenced key ANC leaders including Nelson Mandela and Walter Sisilu to life in prison for sabotage.
Repression and racial segregation were heightened. In response, strikes and militant resistance increased. Violence overflowed following the Soweto student uprising of June 16, 1976. Youth were protesting a new law requiring the language of instruction to be Afrikaans beginning in the last year of primary school, and police fired on the protestors, most of whom were unarmed learners
(students). June 16 is now marked as a national holiday, Youth Day, to commemorate the youth that died in the uprising. Despite public outrage, the
Apartheid Government continued to press its policy of separate development, and the Transkei14 was deemed independent at the end of 1976, stripping residents of South African citizenship. Violence and mass resistance continued throughout the country, fueled by these and other events such as the Soweto
Uprising and the death of the Black Consciousness movement’s leader Steve Biko
14 The Transkei was a Bantustan, an area of land set aside by the white government for Xhosa-speaking black Africans. By declaring the Transkei independent, its residents were stripped of their nationality, ruled by a dictator and marginalized as an internationally unrecognized and unstable state.
84 in police custody in 1977 due to police brutality. Violence in the country escalated over the next decade.
In 1989, Prime Minister Botha began secret negotiations with an imprisoned Mandela. Botha resigned; FW de Klerk became Prime Minister and continued negotiations and released Walter Sisilu and other political prisoners.
In 1990, de Klerk lifted restrictions on opposition groups including the ANC and released Mandela from prison. The government began dismantling discriminatory legislation amidst continued violence, especially in the townships.
Democratic South Africa
Finally, following decades of agitation and protests, as well as international sanctions against the Apartheid Government, the country’s first multi-racial elections were held in 1994, ending apartheid and establishing majority rule under the ANC-led government. In 1996, a new constitution was adopted granting equality for all citizens. Racially restrictive policies including residential restrictions, pass laws, and bans on interracial marriages were abolished. Resources were allocated away from rich areas to the education and health facilities in poor communities. Government grants, especially child- support grants, were expanded and provided essential aid to many poor parents.
South Africa continues to struggle to address the social and economic inequalities created by apartheid and access to housing, sanitation, jobs, health care, and education remains a challenge for many of the country’s residents.
3.3 Socio-Economic Context
Despite many achievements, severe social, racial, and economic inequalities persist and the vast majority of South Africa’s citizens, most of whom
85 are black Africans, face poverty, lack of employment and educational opportunities and a host of other social and economic problems. This section will introduce the primary issues relevant to the risk environment of the study community. Inequality and the related issues of poverty, housing, and access to services are reviewed. The interconnected issues of migration, unemployment, and education are briefly presented. Issues of health and especially HIV/AIDS are examined separately in Section 3.4.
Inequality
South Africa has some the highest income inequality in the world when calculated using the pre-tax Gini coefficient15 (Stats SA 2013 and World Bank
2013). Inequality permeates all aspects of South African society, including housing, employment, education, and health outcomes. Land distribution is also highly unequal, with 85% of the country’s agricultural land owned by white farmers (World Bank 2013). In terms of wealth distribution, the top 10% of the wealthiest South Africans control 51.69% of the country’s income (World Bank
2013).
The white minority population holds the vast majority of the country’s wealth and property and most white people are relatively rich compared to
15 The Gini coefficient represents the income distribution of a nation’s residents by measuring “the extent to which the distribution of income or consumption expenditure among individual households within an economy deviates from a perfectly equal distribution.” (World Bank 2013). A Gini coefficient of zero represents perfect equality where all individuals have the same income. A Gini coefficient of 1, which is 100 on the percentile scale, represents maximal inequality, for example if only one individual held all of the nation’s income. The measure was developed by Italian statistician and sociologist Corrado Gini and described in a paper called Variability and Mutability published in 1912. South Africa’s Gini coefficient is estimated between 0.6.8 and 0.7.
86 coloured and black populations. Furthermore, the majority of poor people and township residents are black Africans. However a growing class of black Africans is joining the ranks of the elite and middle class (sometimes referred to in popular culture as “black diamonds”). Class is therefore becoming a primary divider of South African society. South Africa remains highly segregated along both racial and economic lines, and the vast majority of the population resides in a neighborhood surrounded by people of the same race. Race therefore remains a very salient issue (Seekings 2008).
In 1994, the new ANC-led government created the White Paper on
Reconstruction and Development that focused on the empowerment of women, youth, disabled persons and rural populations in order to redress the social and economic challenges faced by these groups as a result of discriminatory policies under the Apartheid Government.
Poverty
While the poverty rate has declined from 50% in 2000 to 34.5% in 2011, largely due to a significant expansion of social grants provided by the government, entrenched poverty remains concentrated in the black population
(World Bank 2013). The UNDP states that 2.4% of South Africans are in severe poverty, 13.8% are below the income poverty line, and 22.2% are vulnerable to poverty. By April 2011, 10.5 million children had received a Child Support Grant
(DoH and DBE 2012), which provides beneficiaries with a small monthly stipend to cover food and health costs, and exemption from paying school fees.
87 Poverty conditions are amplified by widespread lack of adequate housing and basic services, unequal educational and employment opportunities, and unequal access to health care services.
Housing
Access to adequate housing is a significant issue impacting youth wellbeing in South Africa, especially in townships. Under apartheid, non-whites were systematically dispossessed from the land and their housing options were extremely restricted. The Land Act of 1913 relegated classified black Africans to
“homelands” or Bantustans far from the city centers and the 1950 Group Areas
Act limited the areas where black and coloured Africans were allowed to live and move about. Forced removals of non-whites from designated white areas under the Group Areas Act displaced tens of thousands of South Africans, including the forced removal of residents from District Six in the Western Cape to the Cape
Flats area in the 1960’s. Thus when the ANC took power in 1994, South Africa was facing a severe housing crisis. Millions of South Africans, mostly black
Africans, were homeless or living in substandard conditions such as crowded hostels or temporary structures lacking basic sanitation and protection from the elements. The ANC thus enshrined the right to housing in Section 26 of the
Constitution of the Republic of South Africa (1996) as follows: (1) Everyone has the right to have access to adequate housing. (2) The State must take reasonable legislative and other measures within its available resources, to achieve the progressive realisation of this right.
Adequate housing is defined as a permanent residential structure with secure land tenure that provided privacy and protection from the elements and is
88 located in an area with health, educational and economic amenities, potable water, sanitation including waste disposal and electricity supply (RSA 1994). A number of policies were developed in order to realize this right, including the
Reconstruction and Development Programme (RDP) of 1994 and the Housing
Act, 1997 (Act No. 107 of 1997). Developing proper housing for the population was seen as an integral component of social and economic national development as well as an important step for ensuring equality and the creation of sustainable, viable communities for all of South Africa’s citizens irrespective of race.
Nearly twenty years later, in 2012, strides had been made in housing provision yet millions still lack adequate housing. The vast majority of South
Africans live in formal housing. In the Western Cape, 80% of the population lives in formal housing, and 20% live in informal or other type of housing (Stats SA
2011). The rural Eastern Cape has the smallest proportion of the population living in formal housing, with only 63% in formal housing, 28.2% in traditional
(rondaval) housing, the remaining in informal or other housing (Stats SA 2011).
However, the vast majority of those living in informal dwellings (shacks in informal settlements, on farms, or in backyards) are black South Africans.
The RDP program provides state subsidies for home construction and gives preference to vulnerable groups, such as households headed by women, and in 2011 15.3% of South African households lived in RDP homes with another
13.3% of households on the waiting list (Stats SA 2012). RDP homes have been criticized for building homes of poor quality that do not comply with building regulations. Widespread poverty, lack of resources and infrastructure, rapid
89 urbanization and widespread corruption in the subsidy and land tenure system are some of the challenges in housing provision.
High rates of migration and urbanization further complicate housing provision. The population is rapidly urbanizing, and people are moving away from the rural areas into the city centers such as Johannesburg and Cape Town for employment and education opportunities at rates too high for the municipalities to keep up with. Cities do not currently have enough affordable housing available for these migrants, and most migrants move into the townships and informal areas that surround urban centers. As a result, the townships surrounding city centers are becoming increasingly overcrowded and shack homes are expanding into informal settlements on completely unserviced land lacking roads, sanitation services, electricity and running water not to mention clinics, schools and other services such as police.
A township is a designated residential area where land ownership is recognized by the state. In South Africa, a township historically referred to an urban residential area created for black migrant labor. Townships began under apartheid, following the creation of the Group Areas Act, and were created as specific locations where laborers classified as black or coloured that were working in the urban areas would live. Under the strict apartheid Pass Laws, a township resident needed permission to be in the township. This was part of the Apartheid
Government’s larger plan of influx control to limit the number of rural to urban migrants. Townships usually exist beyond town or city limits and most cities and towns have one or more associated townships. Sometimes townships are referred
90 to as “locations”, lokasie in Afrikaans and ilogishi in Xhosa. Townships have formal development plans organized by the state.
An informal settlement in contrast is “an unplanned settlement on land which has not been surveyed or proclaimed as residential, consisting mainly of informal dwellings (shacks),” (Stats SA 2004:11). Sometimes referred to as squatter settlements, informal settlements are growing rapidly, generally on the fringes of townships to accommodate the massive influx of people moving from the rural to urban areas where the urban areas do not have sufficient housing to house the newcomers. People in informal settlements live in informal dwellings, which are defined as a “makeshift structure not erected according to approved architectural plans,” (Stats SA 2004:6).
In a township, landowners have rights to their land and are entitled to municipal services such as schools, roads, police, sanitation, etc. In informal settlements, residents (or squatters as they are often called) have no right or legal claim to residing on the land and can be evicted by the state. This issue becomes quite complicated however in the context of South Africa’s constitution which guarantees the right to housing for all citizens, making it difficult for the state to evict squatters in the absence of an alternate place to house them16. With the
16 The rights of individuals evicted from privately owned land on which they are squatting have been tried in a number of high profile court cases, notably Government of the Republic of South Africa and others v Grootboom and others [heard in the Constitutional Court in 2000] and City of Johannesburg v. Blue Moonlight Properties and another [heard by the South African Supreme Court of Appeal in 2011]. At issue in these cases is what the obligation of the state is to provide evicted squatters with alternative housing. In the case of Grootboom, the High Court upheld Grootboom’s right to have state provided housing under Sections 26 (the right to housing) and 28(1)(c) (the right of children and their parents to housing) of the Constitution. In practice however, this socio-economic
91 current population pressure on townships and economic need leading many to build shacks on their yards and rent them out, there are informal dwellings in both informal settlements and townships. Further demonstrating the financial stress on households is the observation that the percentage of households where individuals live with relatives or other acquaintances rent-free rose from 7.7% in
2008 to 15.5% in 2011.
While townships had racial connotations under apartheid, today’s legal definition of township is related to holding land titles for erfs (or stands on which the land is divided) and has no racial connotations, though in practice the majority of township residents are still those previously classified as black or coloured. In contrast, the term suburb is generally used to refer to residential areas within the limits of a city where historically white people lived. The historical racial segregation of residential areas largely persists today.
Informal settlements and dwellings are most common in urban areas. In
2011, the percentage of households living in informal dwellings was 20.4% in
Gauteng (where Johannesburg and Pretoria are), 18.5% in North West province and 15.1% in the Western Cape (where Cape Town is) and the rural provinces of
Limpopo and Eastern Cape has the smallest prevalence of informal dwellings
(4.5% and 6.5% respectively) (Stats SA 2012).
The government’s Comprehensive Housing Plan (CHP) for the
Development of Integrated Sustainable Human Settlements (Breaking New right is difficult to enforce, and in the case of Grootboom, the state did not have the resources to provide such housing, and Grootboom died homeless and penniless in 2008. The cases can be viewed at http://www.saflii.org/za/cases/ZASCA/2011/47.html and http://www.saflii.org/za/cases/ZACC/2000/19.html
92 Ground (BNG)) aims, among other things, to eradicate informal settlements in the shortest possible time frame by providing a range of housing options in addition to improved municipal engineering and facilities such as schools and clinics in the townships. The government provides single family, 40 square meter homes as part of the CHP. The homes include two bedrooms, a separate bathroom with a toilet, shower and hand basin, kitchen/living room, and electrical board in areas with electricity
(www.gov.za/aboutgovt/programmes/breaking_new_ground?index.html). The program claims to have reduced the number of informal settlements from 2,700 in 2009 to 2,450 in 2011. However, informal settlements continue to grow and the fastest growing informal settlement in the country can be found outside of
Cape Town surrounding the township of Khayelitsha.
The study community started as an informal settlement for black laborers working in the surrounding white communities and early residents were subject to numerous forced removals to other townships. The people continually returned, however, and in the 1990’s, the squatter area was officially incorporated as a township.
Migration
Migration from the rural provinces such as Limpopo and the Eastern Cape to South Africa’s urban areas such as Johannesburg in Gauteng Province and
Cape Town in the Western Cape Province has a profound impact on South
Africa’s provincial demographics. Between 2006 and 2011, Gauteng experienced the greatest in-migration in South Africa with a net inflow of 1,046,641 migrants, and 56% of people counted in Gauteng during the last census were born there,
93 compared to 94% in the rural Eastern Cape (Stats SA 2011a). The Western Cape experienced the second highest rate of in-migration with an influx of 307,411 additional people (Stats SA 2013). In the last census (2011), 28.1% of people counted in the Western Cape were born outside of the Western Cape. The majority of those born outside of the Province were born in the Eastern Cape
(16.2%) (Stats SA 2011a). In addition, 4.7% of people in the Western Cape and
9.5% of people in Gauteng Province were born in countries other than South
Africa (Stats SA 2011a).
The vast majority of these migrants are school age or working-age young people in search of educational and work opportunities. Population migration between the rural and urban areas has a significant impact on the lives of youth in this study, as will be discussed in later chapters.
Unemployment and Wage Gap
South Africa has high rates of unemployment. The Western Cape, where this study took place, has the lowest unemployment rate, and Eastern Cape and
Limpopo have the highest. Black Africans have a significantly higher unemployment rate, approximately four times as high, than white South Africans
(27.7% unemployment compared to 6.7% for whites) (Stats SA 2011a). Black workers also earn on average 5.5 times less than white workers (Oyedemi 2009).
White South Africans are making on average 450% more than black South
Africans, and 400% more on average than coloured South Africans (Oyedemi
2009).
Youth bear the brunt of high rates of unemployment. In 2011, South
Africa’s unemployment rate was 25% and 70% of the unemployed were youth
94 aged 14-35, especially impacting black and coloured youth (Stats SA 2011a;
Treasury 2011)17. Furthermore, more females are unemployed than are males
(Treasury 2011). Unemployment is related to the paucity of available jobs, and also to the inadequate education and work experience available to youth.
Unemployment rates are lower amongst those with higher levels of education
(NYDA 2011).
To address inequalities in unemployment, the Broad-Based Black
Economic Empowerment Act 53 of 2003 (known as “BEE”) was created. BEE mandates all government and private companies must ensure preferential hiring of black women, followed by black men, followed by coloured women, then coloured men, then white women and lowest priority given to white men.
Education
South Africa has 13 years of formal schooling, starting in Grade R
(“reception year”) through Grade 12. School is compulsory through Grade 9. The final three years of secondary school (Grades 10-12) culminate in the matriculation exam. Students (referred to as learners in South Africa) in Grade 12 are therefore often referred to as matriculants or “matrics” for short.
South Africa has relatively good access to education and educational access is guaranteed by the constitution. Over 95% of children between 7 and 14 years of age and 85% of 16-18 year olds attending school in 2011 and males and females are attending equally (Stats SA 2011a; DBE 2013). However, high levels
17 In 2010, President Zuma introduced The Employment Tax Incentive Act, commonly referred to as the youth wage subsidy, to address youth unemployment by providing incentives for employers to hire youth workers for a period of up to two years. The subsidy was heavily opposed by COSATU (Congress of South African Trade Unions) but ultimately came into effect in 2014.
95 of enrollment mask the widespread challenges in the nation’s educational system, including the unequal quality of schools, unequal school completion rates, frequent grade repetition, high drop-out rates, and significantly lower educational attainment amongst poor and black students. Matric completion remains low and access to higher education remains extremely limited (DBE
2013). While 8.6% of the country has received no schooling, 28.4% had completed matric (Grade 12 of high school), and only 12.1% had schooling beyond high school (Stats SA 2011a). Participation amongst disadvantaged black and coloured youth in all levels of education have steadily increased since 1994, however high levels of school dropouts remain at grades 10, 11, and 12 (NYDA
2011). Furthermore, black youth on average take longer to attain the same level of schooling than do White youth and fewer black youth overall attain matric or secondary schooling that do white youth (NYDA 2011).
Grade repetition is fairly common, especially for grades 10 and 11, and many learners spend a few years in these grades and then drop out before completing the matric examination (grade 12) (DBE 2013). When you take these factors into consideration, the proportion of youth passing matric is likely only
40% with the remaining 60% dropping out prior to taking the examination (DBE
2013). Furthermore, even among those who do pass matric, many are leaving school with inadequate literacy and math skills (DBE 2013). On top of these issues, the school system struggles with issues of poor school infrastructure, lack of transport to school, textbook delivery, teacher quality, inequality in learner performance, low pass rates, and dropout rates (DBE 2013). During fieldwork, the matric exam was under public scrutiny. 2013 showed an increased percentage
96 of matriculants passing the exam, however the standards required to achieve a pass had been lowered significantly and the majority of learners passing were not achieving a level high enough to qualify them for tertiary education or other opportunities.
Access to services
Access to services such as piped water, electricity, and waste removal is unevenly distributed along rural/urban, racial, and economic lines. Services are more available in the urban areas and service delivery in rural areas lags behind the rest of the country. For example, 1 in every 8 households in the Eastern Cape has no toilet facilities, the highest rate of no toilets in the country (Stats SA 2011).
Within urban areas, better services are available in business districts and white residential areas than in township areas, and many informal settlements are completely lacking service delivery.
In the Western Cape townships, and across the country, lack of municipal services in the rapidly expanding townships has resulted in considerable social unrest that regularly intensified in service delivery protests. Differences are observed in black versus white households. 89.1% of black African households have access to piped water, compared to 99.3% of White households (Stats SA
2011). Furthermore, the vast majority of white households have tap water inside their homes, whereas black African households are more likely to have a tap in their yard or share a communal tap compared to both white and coloured households (Stats SA 2011).
Similarly, the majority of white, Indian/Asian, and coloured households have flush toilets in their homes, whereas nearly half of black households lack
97 flush toilets (Stats SA 2012). The percentage of homes connected to main electricity grids actually decreased between 2010 and 2011 in Gauteng and
Western Cape provinces (Stats SA 2012) because of the tremendous increase of population migration into these provinces wherein most new residents are living in informal, unserviced areas. Informal areas must use paraffin or wood instead of electricity, increasing the risk of fire in these homes. Observed racial disparities in access to services is conflated with economic disparity, wherein the majority of residents in the rural Eastern Cape, urban townships and informal settlements, where services are poor, are poor black Africans.
Access to Cell Phones and Internet
Over the past decade, global access to the internet and mobile (such as cell phone) devices has increased rapidly. However, access remains unequal, with access rates in many African countries much below the rest of the world
(Hoveyda and Sinha 2011). This “digital divide” wherein access to information, internet and communications technologies varies along geographic and socio- economic lines (Hoveyda and Sinha 2011) limits poorer populations’ connection to the economy and global culture.
The digital divide exists across the continent of Africa as well as within
South Africa, where there is variation regarding cell phone ownership, use, and access along racial, socio-economic and geographic lines (Beger and Sinha 2012).
South Africa has the greatest access to internet and communications technologies on the continent. Cell phone access has grown exponentially over the last 10 years, and 86% of South Africans have access to a cell phone (SAARF AMPS
98 2013), which is the highest cell penetration18 on the continent (Beger and Sinha
2012). Yet cell phone ownership is higher amongst whites as compared to blacks and amongst urban individuals over the age of 16 than in the rural areas or amongst younger youth (Beger and Sinha 2012)19. Access to internet and cell devices is complicated in South Africa by the unequal access to basic infrastructure such as reliable sources of electricity.
Under apartheid, telecommunications infrastructure was largely focused on wealthy, largely white, residential areas that housed less than 10% of the country’s population (Kreutzer 2009), and infrastructure development was stalled in the rest of the country. Because of this, access to telecommunications in
South Africa only became widely accessible with the increased availability of cell phones (Kreutzer 2009). In 1999, 11% of South African adults had access to a cell phone and in 2009 that percentage rose to 70% (SAARF 2009). In 2012, 72% of
15 to 24 year olds reported having a cell phone (Beger and Sinha 2012).
The relatively low cost of SIM cards, low-end handsets and pre-paid pay- as-you-go services have made cell phones much more accessible to lower income individuals. The majority of South African SIM cards are registered to prepaid or
“pay as you go” accounts as opposed to service contracts (Deumert and
18 Penetration is a measurement of access, normally calculated by dividing the number of subscribers to a specific telecommunications, in this case cell phones, by the number of people in the population and multiplying by 100. Source: International Telecommunication Union (ITU). 2009. Glossary, Acronyms and Abbreviations. http://www.itu.int/ITU- D/ict/publications/wtdr_99/material/glossary.html accessed 29 January 2014. 19 It is unclear whether a gender gap exists in terms of cell phone and internet access. Some research indicates greater access and use by males than females (Muller 2011) whereas other surveys reveal the opposite (e.g. RIA 2009 as cited in Beger and Sinha 2012).
99 Masinyana 2008; Beger and Sinha 2012). Prepaid services are considerably more affordable than contracts, as they require only the cost of purchasing a SIM card20 (which is R3, or roughly $.30) and subscribers can buy only as many minutes as they need, when they need them. Contracts, in contrast, require connection fees and minimum charges per month, in addition to requiring address and bank account information, which many low-income South Africans do not have. Instant messaging applications such as MXit and WhatsApp are increasingly popular cell phone services that allow people to maintain contact at a low cost.
It is very common in South Africa for individuals, especially those using prepaid services, to have more than one SIM card, which means many individuals have multiple phone numbers, often on more than one network provider
(Sutherland 2008) making it difficult to obtain accurate numbers of cell phone users. GSMA (Groupe Speciale Mobile Association) reports that South Africa’s real cell penetration per unique subscribers was 66% in 2012 (GSMA 2012).
GSMA identified multiple SIM ownership and excluded inactive SIMS and machine-to-machine communications to measure the actual number of individuals (subscribers) with cell phones as opposed to measuring the number of registered SIMs (connections). When only examining the number of SIMs,
GSMA shows that 138% of South Africans are connected (GSMA 2012), showing that there are more cell phones than people in the country.
20 A SIM card (subscriber identity module) is a small, printed circuit board that includes subscriber details, security information and memory for contacts information (ITU 2004).
100 Cell phones are now the main means of electronic communication in the country, in contrast to relatively low distribution of internet and landlines (Stats
SA 2011). Levels of fixed-line telephone penetration remain below 10% (GSM
Association and A.T. Kearney Ltd 2011; ITU 2010). Data from the 2011 South
African census show 12,850,874 households have cell phones compared to
2,088,147 with landlines (Stats SA 2011). Obtaining accurate numbers of cell phones, landlines, and internet access for the country of South Africa is a challenge (Sutherland 2008). The SA government and a number of private media companies each collect their own data. In 2011, telecommunications provider
Telkom estimated that South Africa had five million landlines, compared to forty- two million cell phones.
Cell phones are also much more common than other media tools such as
TV sets and computers (Kreutzer 2009; SAARF 2009). The most common uses of cell phones are to send SMS messages and Please Call Me’s. (SAARF 2009). Cell phone service providers allow users to send a fixed number of “Please Call Me”
(PCM) messages each day, usually five to seven, to another person on any South
African network asking them to call you. It’s free and a useful way of getting in touch without using airtime to make calls or send SMSs. PCM messages contain the sender’s name, phone number, the words “Please Call Me”, advertisements, and usually have limited space, 10-15 characters, for a personalized message.
Despite the wide distribution of cell phones, access to the internet remains quite limited. Altogether, only 35.2% of South African households have access to internet (Stats SA 2011). Internet access varies according to race. Black African households mostly access the internet from their cell phones (1,865,153) and
101 70.6% of black African households (8,018,179 households) have no internet access at all, whereas only 30% of white households have no internet access.
(Stats SA 2011).
Research conducted at the end of 2011 found that internet access has grown to 8.5 million people, and that 2.48 million of these people only accessed the internet on their phones but that 90% of people regularly used their cell phones to access the internet in addition to using computers (World Wide Worx
2012).
3.4 HIV and AIDS in South Africa
South Africa has an established generalized HIV epidemic with an estimated prevalence of 17.3% in the adult population (ages 15-49) and 29.5% prevalence amongst pregnant women (DOH 2012). Approximately 5.63 million people are living with HIV (NSP 2012:22); including an estimated 2,100,000
AIDS orphans (DOH 2012). The number of newly infected children has decreased recently, largely due to the fact that more than 95% of HIV positive pregnant women are receiving medication for prevention of mother to child transmission
(PMTCT) (DOH 2012).
HIV/AIDS disproportionately impacts young women in South Africa. HIV prevalence among 15-24 year old pregnant women remains high at 20.5% (DOH
2012) despite a slight decrease in prevalence amongst 15-19 year old females in recent years (DOH 2012). Women aged 30-34 have the highest HIV prevalence in the country, at 42.2% (DOH 2012). Furthermore, HIV kills adults who are in their most economically productive years. This creates a significantly high dependency
102 ratio, which is the proportion of the young and elderly populations that are economically dependent upon employed adults.
History of HIV/AIDS in South Africa21
South Africa’s first HIV infections were detected in the 1980’s. Early cases were found amongst white men who had sex with men, and amongst segments of the black population tied to high rates of mobility and migration and interaction with Africans from other, highly HIV-impacted countries on the continent, in particular Malawians working in South Africa’s mines. By 1987, HIV prevalence was eight times higher in black South Africans than in white South Africans, and prevalence was doubling every 6 months (Iliffe 2006:44). By the 1990s, the dominant strains of HIV that were found across Central Africa were also found in
South Africa, linking South Africa’s epidemic to the larger continental epidemic.
HIV was also found to have high prevalence in areas located along truck routes between South Africa and Swaziland and Mozambique and in the southern
KwaZulu-Natal (KZN) province which has a dense rural population and high rates of population mobility and migration linking rural to urban areas.
By July 1991, the number of heterosexually transmitted HIV cases equaled that of homosexually transmitted cases, and heterosexual transmission has since dominated (Whiteside and Sunter 2000). South African HIV cases peaked between 1993 and 1998, during which time tuberculosis cases increased six-fold.
Thus the HIV epidemic peaked in South Africa at the same time of rapid social and political upheaval associated with the government changeover. The medical
21 A comprehensive timeline of South Africa’s national HIV/AIDS response is included as an Appendix.
103 system and newly elected ANC government were overburdened with the stresses of dramatic change and limited funds. As a result, the HIV epidemic in South
Africa was neglected during the period of its greatest expansion.
By 2003 South Africa had the world’s largest epidemic, with an estimated
5.3 million people infected (Iliffe 2006).
National Response
The African National Congress (ANC) took an early leadership role in forming a national response to HIV prior to assuming the leadership of the government. The ANC helped to create the National AIDS Convention of South
Africa (NACOSA) in 1992; they included HIV/AIDS in both the Reconstruction and Development Programme (RDP) (ANC 1994:48) and the ANC’s National
Health Plan for South Africa (ANC 1994:17). NACOSA created a National AIDS
Strategy that promoted a broad approach to HIV including prevention, research, human rights, counseling, welfare, and coordination of multiple government departments (AVERT). Within months of the ANC gaining control of the government in 1994 the ANC adopted South Africa’s National AIDS plan. At the
ANC’s 50th National Congress in 1997 a resolution was passed ordering that the
President of the ANC lead a national HIV prevention campaign (Resolution on
HIV/AIDS of the 50th National Congress of the ANC).
Despite these initial indications of strong political support, South Africa’s plan to address HIV never came to fruition. The newly elected ANC government faced large political challenges including widespread poverty, and Nelson
Mandela remained silent on the issue of HIV/AIDS throughout his presidency.
The AIDS Programme Director was placed in the Ministry of Health instead of
104 the President’s Office as had been demanded in the National AIDS Plan, resulting in a policy strictly related to health as opposed to a multi-sectorial government policy that would have carried more weight. “It was also a time when the new government would prioritize positive programmes, such as housing, jobs, education, and wider health care issues. AIDS warnings and the message of safer sex were not subjects congenial to those savouring the euphoria of freedom,”
(Van der Vliet V, South Africa Divided Against AIDS: A Crisis of Leadership).
Denialism and Conspiracy Theories
The situation further deteriorated when Mbeki became president. A number of scandals characterized Mbeki’s response to HIV, including the testing of the dangerous chemical virodene22. The most famous controversy emerged in
1998. Two drugs tested abroad, AZT and Nevirapine were shown to prevent mother to child transmission. Advocates demanded the drugs be made available to pregnant women in South Africa. However, the ANC-led provinces rejected its use on the grounds that it was cost prohibitive and claimed the government should focus on prevention and not treatment, despite the fact that PMTCT was considered prevention. Observers speculated that the ANC feared the overburdened health system would be unable to implement AZT provision, and felt threatened that they would be obliged to roll out a national antiretroviral plan
22 Researchers at the University of Pretoria were testing a drug called Virodene on a small number of research participants. The Medicines Control Council (MCC) ordered the trials be stopped, because they believed Virodene, which was based on antifreeze, to be dangerous and that the official protocol was not being followed. The Health Minister Dlamini-Zuma then pressured the chair of the MCC, accusing him of being disloyal to the ANC for refusing to support Virodene. Mbeki was involved in trying to push Virodene forward.
105 that they could not afford nor administer, which would cut into the ANC’s other development goals (Iliffe 2006).
The Western Cape, run by the DA (Democratic Alliance) went against the national government and started providing AZT in 1999. An AZT program conducted in Khayelitsha in partnership with Medicins sans Frontieres halved transmission. Despite this evidence, Mbeki claimed that AZT was toxic and a month later the health minister questioned AZT’s effectiveness. The ANC’s refusal to provide PMTCT inspired the creation of the Treatment Action
Campaign (TAC) led by Zachie Achmat. After the TAC’s combined grassroots organizing, advocacy, civil disobedience, and legal action, the courts ordered that
PMTCT be made available in provinces throughout the country.
Yet Mbeki still did not change his views and expressed anger that Western
AIDS researchers were racist and accusing black Africans of being immoral, lust- driven and carriers of germs. In April 2001, when the Pharmaceutical
Manufacturers Association of South Africa stopped their campaign to prevent the importation of generics, the government approved Nevirapine for PMTCT and started testing the drug in spite of Mbeki’s views. In December, the Pretoria High
Court and The Constitutional Court ordered that the drug be made available nationwide, a decision supported by members of cabinet, Mandela, and leaders of the Health Department. Finally, by 2003, most provinces were complying.
Controversy also surrounded the provision of ARTs. HAART was available as early as 1996, but they were purchased outright by wealthy South Africans or through health schemes or companies and were out of reach to the general population. In 2001, when drug prices had fallen substantially, government
106 dragged its feet citing an overburdened health system without capacity to deliver the treatment. In 2001, MSF ran a pilot program in Khayelitsha, providing ART to the poorest and most acute cases. They showed an 86% survival at 24 months.
In 2003, following years of internal government conflict, the Cabinet funded and enacted a plan that still prioritized prevention and primary health care but also committed to providing at least one ARV treatment site in each of the country’s
53 health districts, with a plan to cover all people needing treatment in the following five years. Three months after the plan was approved, not a single person had started treatment on the plan except in the Western Cape. This was partially because the health system was overburdened and many health posts were vacant. TAC again threatened legal action, and by 2005 about 30,000 people were on treatment.
Due to these controversies, Health Minister Dlamini-Zuma was replaced by Dr. Manto Tshabalala-Msimang (known as Manto). This change was initially seen as positive. However, Manto and Mbeki were both outspoken in their doubts about PMTCT drugs. Mbeki claimed AZT was toxic, and Manto claimed AZT weakened the immune system and caused mutations in babies. Their arguments expanded to include questioning of all antiretroviral drugs. Manto and Mbeki questioned whether HIV caused AIDS, and suggested that AIDS was caused by poverty, inequality and “lifestyle” choices. Manto and Mbeki excluded scientists from their HIV/AIDS advisory panels, and a huge rift between the medical and scientific community and Mbeki was created. Mbeki’s actions severely stalled
South Africa’s response to the HIV epidemic until the ANC asked Mbeki to step down from the presidency in 2008.
107 President Zuma, Mbeki’s replacement, placed HIV prevention at the forefront of the national agenda. In 2009, the government rolled out an accelerated Prevention of Mother-to-Child Transmission (PMTCT) programs more widely. The PMTCT initiative has been successful. By 2011, the mother-to- child transmission rate was below 4%.
In 2010, President Zuma launched a HIV prevention campaign that focused on reducing stigma and promoting HIV testing with the goal of testing 15 million South Africans by 2011. At the launch Zuma took a test in public in order to combat stigma about HIV that prevents some from seeking HIV testing. Zuma reported that the test was negative. This initiative was highly successful. Since the launch of the campaign, 20.2 million people have tested for HIV. Between 2010 and 2013, South Africa has worked to decentralize HIV services and expanded the number of clinics providing ART from 490 to 3,540. The availability of testing and ARVs has allowed positive South Africans to live longer, and has also caused the prevalence rate to rise from 29.4% in 2009 to 30.2% in 2010 (DOH 2012).
The current HIV/AIDS strategy is a comprehensive approach including a rights-based framework that addresses poverty, gender inequity, migration and other structural drivers of HIV infection in addition to a combination of prevention and treatment strategies including HIV counselling and testing
(HCT), prevention of mother-to-child transmission (PMTCT) and ART provision in conjunction with the “know your status” campaign encouraging early and regular HCT. Free male condom provision, medical male circumcision, treatment, and life skills training are other key components of the national plan to stop the spread of HIV. Tuberculosis control is an integral component of the
108 national strategic plan because of extremely high rates of HIV/TB co-infection.
South Africa has the third highest TB burden in the world, which is largely fueled by the HIV epidemic. Over 70% of TB patients are co-infected with HIV (NSP
2012). The majority of TB cases are found in those aged 30-39 who are living in townships or informal settlements, highlighting the relationship of TB to poverty and related issues of overcrowding (NSP 2012).
3.5 Youth in South Africa
Defining Youth and Youth Development
South Africa defines youth as any person between the ages of 14 and 35
(NYDA 2011). This broad definition is based on the mandate of South Africa’s
National Youth Commission, NYC Act, 1996 and the NYP 2000. Youth are broadly defined as up to age 35 in order to consider both the historical and current conditions placing youth at a disadvantage in South Africa, such as by taking into consideration discrimination faced by young people under the
Apartheid Government (NYP 2009). This recognizes that historical imbalances have yet to be addressed fully (NYP 2009). This definition is also consistent with the African Youth Charter (AU, 2006), which defines youth as between the ages of 15 and 35. However, the NYP segments youth into age, sex, race, gender, and class cohorts in order to recognize the diversity in situations and needs of youth of different ages.
The definition of youth however varies across different contexts. The
Children’s Act (Act 35 of 2005) defines a child as a person up to the age of 18 years. The Correctional Services Act (Act III of 1998) defines young offenders as those between the ages of 14 to 25 years (Department of Correctional Services,
109 2003), and the National Youth Development Policy Framework proposes that youth be defined as those aged 15 to 28 years (NYP 2009).
South Africa ratified the United Nations Convention on the Rights of the
Child (UNCRC 1989) in 199523 and has since placed youth empowerment at the forefront of national discourse. Youth empowerment and youth development are considered central to South Africa’s vision of a non-racial and non-sexist democratic society (NYP 2009) as well as the future economic and social stability of the country. Youth in South Africa are considered active agents working to develop South Africa’s economic and social future and not as passive recipients of government services.
Over the past two decades, South Africa has developed and attempted to implement a comprehensive youth development policy designed to socially and economically integrate youth into society. Despite strong political commitment they have to date had little success (NYDA 2011)24. South African youth face high rates of unemployment, underachievement in education and a limited ability to become economically independent (NYDA 2011). Youth struggle from other disadvantages as well. In one example, the 2008 General Household Survey counted approximately 3.95 million orphans in South Africa, which accounts for roughly 21% of all children in the country (Hill, Hosegood, and Newell 2008).
Youth Sexual and Reproductive Health
23 United Nations Treaty Collections, Chapter 11, South Africa ratification. http://treaties.un.org/Pages/ViewDetails.aspx?src=TREATY&mtdsg_no=IV- 11&chapter=4&lang=en (Accessed 31 January 2014). 24 National Youth Development Agency (NYDA), Act Number 54 of 2008
110 The social determinants of health such as poverty, housing, access to clean water and sanitation as described above influence youth health and wellbeing in
South Africa. South African youth also face issues of HIV/AIDS, high rates of teenage pregnancy, high maternal mortality, and difficulty accessing sexual and reproductive health services (NYP 2009). There are approximately 300,000 HIV- infected children in South Africa, with 50,000 new infections occurring each year. Youth become increasingly vulnerable to HIV infection as they get older; the proportion of young people becoming infected with HIV increases significantly between childhood (2-14 years) and youth (15-24 years).
The HIV/AIDS epidemic has significant social, economic, and health consequences for South Africa’s youth including premature death of parents, teachers, and other caretakers in youth’s lives, economically burdening families with health care and funeral costs especially when family members are too sick to work, and threatening the health of youth through high rates of infection amongst sexually active youth. Youth impacted by HIV / AIDS are also more likely to drop out or underperform at school due to a variety of social and psychological pressures including financial strain, grief, discrimination and stigma.
The Second South African Youth Risk Behavior survey of learners at school found that 24.4% of females reported having been pregnant (Reddy,
James, Sewpaul et al 2010). The 2010 National Antenatal Sentinel HIV and
Syphilis Prevalence Survey found that 14% of pregnant youth aged 15-19 years and 9.4% of those aged 10-14 years were HIV positive (National Department of
Health 2010). Abortion rates were found to be high amongst youth. A study
111 conducted in Soweto, South Africa, found that 23% of pregnancies among 13-16 year old girls and 14.9% among 17-19 year old girls ended in abortion
(Buchmann, Mensah, and Pillay 2002). Another study conducted in four provinces with youth aged 18-24 found that 16.2% of females had an unwanted pregnancy and 6.7% had ever terminated a pregnancy (Mchunu et al 2012).
Mental health issues are under-addressed in the youth population. The
2010 Youth Health Risk Behavior survey, conducted by the Medical Research
Council (MRC), found that amongst youth attending school, 20% had considered committing suicide and 21.4% had attempted suicide, and when surveying out of school youth the rates were even higher, with 25% considering suicide and nearly a third (32.7%) having attempted suicide (Reddy, James, Sewpaul et al 2010).
Substance use is also very high amongst youth in school. 37.6% of learners report smoking tobacco and 49.6% report drinking alcohol (MRC Health Risk Behavior
Survey 2008).
South Africa has developed a number of policies aimed at promoting youths’ access to medical and sexual health care. For example, under the
Children’s Act young people are legally allowed to consent to medical treatment,
HIV testing, abortion, and contraception from the age of twelve on their own without the consent of a parent or legal guardian. However, policies designed to protect children can conflict with each other, placing children in a vulnerable position where their health and wellbeing are at risk. An example of this is the recent controversy over what is known as the Sexual Offences Act.
The Criminal Law (Sexual Offences and Related Matters) Amendment Act,
2007 (Act No. 32 of 2007), also referred to as the Sexual Offences Act, codified
112 the laws pertaining to sexual offenses in a single act. It criminalized all forms of sexual abuse and exploitation and establishes the age of consent to be 16. The act criminalized consensual sexual activities between children aged 12 to 16. This places children under the age of 16 in need of counseling or reproductive health services at risk of prosecution if they seek guidance or services from a nurse, teacher, or other social worker25.
In October 2013, the Constitutional Court ruled that the provision criminalizing consensual sexual activity between children aged 12 to 16 violated the Constitution (section 172(2) (a)), following a similar ruling in the Gauteng
High Court in 201226. The age of sexual consent remains 16, however children between the ages of 12 and 16 can no longer be prosecuted for engaging in consensual sexual activity with another child aged 12-16, or with a child aged 16-
17 provided that there is no more than a two year age gap between sexual partners (Case CCT 12/13 [2013] ZACC 35).
School Health Programs
In his 2010 State of the Nation address, President Jacob Zuma pledged to reinstate health programs in all public schools, which to date were only available in some schools and with inconsistent quality and resources. In October 2012, the
Integrated School Health Programme (ISHP) was launched, providing a variety of services to learners including immunization, de-worming, and counseling for
25 These provisions were being contested in court during this study. The institutions where this dissertation research was based developed procedures and policies in response to the Sexual Offences Act; these were adhered to throughout the course of the research. 26 For further reading on this, see precedence set in the Teddy Bear Clinic for Abused Children and RAPCAN v. Minister of Justice and Constitutional Development, case number 73300/10, heard in the North Gauteng High Court.
113 sexual and reproductive health issues. Health education curriculum was to be incorporated into the Life Orientation courses, including sexual and reproductive health, contraception, teenage pregnancy, termination of pregnancy, STIs including HIV/AIDS, HIV counseling and testing, male circumcision including male medical circumcision, among other topics such as nutrition, and suggested extra time is provided to cover sexual and reproductive health topics (DoH and
DBE 2012). Sexual and reproductive health services were to focus on preventing pregnancy and STIs and providing HCT.
Despite these positive developments, challenges remain in access to sexual health services for youth. One example is condom provision in school. President
Zuma declared that condoms would only be distributed in a school if doing so was first approved by the school’s School Governing Body (SGB), and the ISHP draft guidelines gives SGB’s power to block condom distribution in their schools.
“Routine advice on contraceptives, and the on-site provision of condoms where the School governing body has approved this, should start from Grade 8 learners
(or equivalent age 12),” ISHP 2012:83). On this matter, Minister of Education
Montshekga’s office was quoted as saying “We have children in our schools.
Sexual consent is above 16 and we cannot encourage them to break the law,”
(http://www.sowetanlive.co.za/news/2012/10/05/sex-education-drive-may-hit- legal-snags).
Health Minister Motsoaledi has called for free condom provision, and the
Children’s Act, Section 134 states that “No person may refuse to sell condoms to a child over the age of 12 years; or to provide a child over the age of 12 years with condoms on request where such condoms are provided free of charge”.
114 Overall, South Africa has undertaken a number of initiatives to promote the health and wellbeing of youth. Numerous challenges remain in implementing these initiatives and achieving their goals. However, the nation has clearly demonstrated a commitment to youth and great efforts aimed at promoting youth development have been undertaken by national, provincial, and local governments.
Youth Experience in South Africa
As demonstrated above, youth in South Africa are at the forefront of the national policy agenda. Youth have also been heavily impacted by the massive social and political changes that have been ongoing in South Africa for decades. A number of South African anthropologists have examined the experience of childhood in South Africa in order to understand the dynamics of growing up amidst such dramatic social and political change. Early work focused on the negative impact of apartheid and its attendant forced relocation, resource restriction, and social marginalization on black South Africans. Key works examining the everyday lives of South African children and adolescents under apartheid include Burman and Reynolds’ Growing Up in a Divided Society: the
Contexts of Childhood in South Africa (1986), Reynolds’ ethnography of the everyday lives and cognition of children in New Crossroads (a township outside
Cape Town) (1989), and the lives of children living with their families in male migrant labor hostels (Jones 1993).
In the 1980’s and 1990’s, a number of studies focused on a subset of youth that were active participants in the political protest and violence that was widespread during those times in South Africa (for example Seekings 1993;
115 Marks 2001). Dlamini (2005) later explored the ways young people tried to construct ordinary lives amid the widespread violence and politicization of everyday life. The transition to democracy in the mid-1990’s led to a ‘moral panic’ over the ‘lost generation’ of youth (for example, CASE 1993; Van Zyl Slabbert et al
1994). Reports of township youth who had boycotted school, dropped out, fought with security forces in the streets, acted violently against neighbors in the name of ‘the struggle’, and defied parental and teacher authority fueled fears of a lost generation of “marginalized youth” who undermined the transition as well as the security and morality of the future of the country (Seekings 1996; Bray et al
2010).
After the peaceful transition in 1994, concerns about youth shifted away from the fear of older youth to the problems facing younger children, such as street children or AIDS orphans (Bray 2003a). Research began to focus on specific problems faced by children and adolescents, especially those living in poverty and in families that were separated or otherwise placed under stress by apartheid. Examples include work by psychologists such as Childhood and
Adversity; Psychological Perspectives from South African Research (Dawes and
Donald 1994) and Addressing Childhood Adversity (Donald et al 2000).
Ramphele (2002) also studied the lives of children in New Crossroads, and described the challenges teenagers face achieving their goals in the face of parental neglect, material hardship, inadequate schooling and negative pressure from peers. Barbarin and Richter (2001) examined data from the Birth to Ten study, which followed a cohort of children born in the Johannesburg area in 1990 designed to examine behavioral, emotional, and academic problems faced by
116 children living in environments with high levels of violence, poverty, and strained families.
Bray and colleagues (2010) conducted a comprehensive study of the everyday lives of children and adolescents residing in the Southern Cape
Peninsula of the Western Cape, comparing the experiences of youth living in a black, a coloured, and a white community in close proximity to each other. Their study includes an analysis of the impact of interaction as well as the non- interaction of youth with youth of other races (Bray et al 2010). Other studies have examined the experiences of children in racially mixed schools (for example
Dolby 2001; Soudien 2007), but Bray’s team takes this a step further in examining the consequences of racial interaction on youth in everyday life.
Previous work has shown that race continues to be a relevant category for youth, though only in some and not all contexts (Soudien 2007) and that most young people use the apartheid-era categories of white, coloured, or black to describe themselves (Seekings 2008).
Bray’s goal was to examine the everyday lives of ordinary children and adolescents. This work contrasts with the existing literature that focused on exceptional groups such as street children or political activist youth. Bray and colleagues included youth from a wide age range, three major racial groups and across poor, middle-class and upper class groups in order to examine the ways that the new political environment impacts youth in all these groups. Bray and colleagues examined everyday interactions of these so called ordinary children, in order to analyze the ways that their actions, relationships, and wellbeing were influenced by their social worlds, and to examine the extent to which their agency
117 is able to shape these worlds (Bray et al 2010:31). They employed a mixed methodology that included in-depth qualitative study of youth from the three communities in the valley, and used data gathered through the Cape Area Panel
Study (CAPS) that was conducted by the Centre for Social Science Research at the
University of Cape Town. CAPS followed a large, representative sample of nearly
5,000 adolescents aged 14-22 from the Cape Town area from 2002 to the present.
CAPS asked questions about experiences with education, employment or job searching, sexual health, and family and household experiences. The goal of
CAPS was to understand youth experience and how opportunities for South
Africans have, or have not, changed since the end of apartheid. Bray and colleagues’ work in particular was very influential in informing this dissertation study.
3.6 Description of Field site
The study community is a peri-urban township located 35 kilometers outside of Cape Town in the Western Cape of South Africa. Since colonialism whites had primarily occupied the area, but in the 1960’s a community was established to house coloured people who had been forced out of their homes in nearby areas. In the 1980’s, black Africans began establishing homes in the area to be near their places of work despite the fact that it was illegal for them to do so under the Group Areas Act, which had designated the land for whites. The settlers had jobs as domestic workers and cleaners in restaurants in the nearby white towns and as laborers on local farms. Settlers were primarily isiXhosa- speaking black Africans who had migrated to the area from the rural Eastern
Cape in search of work opportunities. Settlers would clear small patches of land
118 and build temporary shack structures made out of found materials such as scrap metal or cardboard to sleep in.
The study community initially grew on unclassified land. However, the government would regularly raid this area and forcibly remove its settlers to a different designated black location over 40 kilometers away. Settlers continually resisted these forced removals and would return to rebuild their homes. The study community started this way with a few hundred residents, and its population steadily grew through the 1980’s and early 1990’s. In the 1990’s apartheid began to unravel, enabling settlers to establish more permanent residence on the land. In the mid-1990’s the area was officially recognized as a township and the local government began building roads, setting up basic services such as electricity and running water, and made plans to build proper homes for residents.
By 2010 the community had over 17,000 residents densely packed into an area of just over one square kilometer and the population continues to grow rapidly (DTHF 2010). The population is very young. 75% of residents are under the age of thirty-five (DTHF 2007), reflecting a demographic trend seen throughout South Africa (Mokwena 1999). In 2010, 23% of the population was under the age of fifteen, adolescents between the ages of 15 and 19 comprised
7.7% of the population, and 55.5% of the population was between the ages of 20 and 39 (DTHF 2010). Many residents are migrants from the rural Eastern Cape who have traveled to Cape Town in search of work or educational opportunities.
Most residents maintain extremely close ties with their families and homes in the
Eastern Cape, and travel as often as possible to the Eastern Cape to visit family or
119 to participate in cultural rituals. The study community’s population is therefore highly mobile and population movements are constant and very fluid.
The study community is also home to a small number of immigrants from
Zimbabwe, Malawi, and Somalia who run most of the local spaza shops (small convenience stores run by an independent merchant where residents can purchase basic supplies such as food, electricity and cell phone airtime) or work in restaurants or as domestics. Immigrants at times face hostility from South
African natives, some of whom see the immigrants as stealing their jobs and undermining economic opportunity for South Africans by accepting lower wages for work.
The community has a formal sector characterized by paved roads, water and sewage removal, grid electricity and a large number of brick and
“matchstick” or Reconstruction and Development (R&D) homes, as well as an informal sector. The informal sector is comprised of densely packed informal shack homes, a few shebeens (unlicensed taverns) and spaza shops. A small stream running through a portion of the informal sector floods during rains, causing sewage to spill into the streets. There are no paved roads and no services such as electricity in the informal area. Residents obtain electricity by making their own connection wires that they hook up to power lines in the formal parts of the township. Water is collected at shared pumps or communal toilets and paraffin is commonly used for cooking fires.
In 2010, the formal sector was comprised of 1,238 formal plots, also called erfs, upon which 5,583 dwellings were built housing 12,509 people (DTHF 2010).
Each plot had anywhere from one to twenty-seven houses built on them, with an
120 average of 4.6 houses per erf, and a range of one to twenty-three people living on each erf with an average of 21.1 people per erf (DTHF 2010). In the informal sector in 2010, 1,476 dwellings were erected (DTHF 2010). The number of dwellings in the informal sector has grown rapidly between 2010 and the time of this writing. In addition, numerous informal shack dwellings are built alongside permanent dwellings to house relatives or renters.
The community has a brick and mortar primary school with over 1,000 learners and a high school with over 600 learners, and a number of privately and government run crèches for very young children. The community has relatively high quality educational opportunities when compared to other townships in the
Western Cape and in comparison to parts of the rural provinces. Many rural areas are completely lacking in formal schools, or schools have abysmal infrastructure such as no running water or electricity, or often learners attend classes in shipping containers with no windows or desks. The high school is new, built in the last five years. Before the school was built learners attended high school classes in shipping containers located behind the primary school.
Community youth led a protest demanding better school facilities and received considerable media attention locally and nationwide. After 3 days of protests, clashes with the police, and political pressure placed on local ANC (African
National Congress) politicians by community residents, the Western Cape
Department of Education (which was run by the Democratic Alliance or DA, the
ANC’s primary challenging political party) agreed to build the high school. In
2009 its doors opened to its first class of high school learners. Youth are therefore very proud of their high school and their role in its being built.
121 The community has a municipal clinic that provides primary medical care and, in partnership with a local non-profit HIV/AIDS treatment organization, tuberculosis screening and treatment, HIV testing and treatment, and comprehensive health care for HIV positive patients. The clinic implemented a national tuberculosis control program based on the World Health Organization
Directly Observed Treatment, Short Course (DOTS) strategy and since 2002 performs routine HIV screening of incident tuberculosis cases. Youth receive their childhood vaccinations at the Clinic. Many local youth prefer not to attend the clinic for health problems because of the long waits, the lack of privacy in the waiting room and fear of running into a family member or other adult who will gossip about you visiting the clinic, and because of stigma resulting from community perceptions that if you are at that clinic then you are presumed to be
HIV positive.
A well-run, donor-supported library runs a number of popular educational programs for youth, a large number of churches offer after school and weekend activities such as choir practice for youth, and a variety of non-governmental agencies operate in the township. Some NGO’s offer soccer or other sports activities for youth, though recreational opportunities for youth are extremely limited. A recently opened youth centre offering recreational, educational, and health services to youth helps to fill the critical gap in services and opportunities available to local youth.
The community has no formal businesses, only informal shebeens, which are unlicensed taverns that sell alcohol, and spaza shops (informal convenience stores selling basic food as well as household items and other goods). Shebeens
122 and taverns are often run out of family homes or nearby shipping containers. The community is, however, in close proximity to formal services because of its location near white and coloured areas. A shopping center with clothing stores and a grocery store is nearby and many residents walk or take a short taxi ride
(cost is R5, or about $.75) to do their shopping at the shopping center. The nearest hospital is five kilometers away. A taxi to the hospital costs R6 (about
$.85). Proximity to more developed (white) areas and the associated services is an advantage that most townships in the Cape Town area lack.
South Africa’s residential areas remain highly segregated (Christopher
2001, 2005) and this pattern is reflected in the vicinity of the study community.
With a few exceptions, the population of the study community is almost exclusively black African. The community is in close proximity to a large coloured community, and a number of white, lush suburbs. In the area near the study community, 45% of the population is white, compared to 19% of Cape Town (Bray et al 2010). This proximity to primarily coloured and white areas shapes the local experience in ways that differentiate it from the other townships surrounding
Cape Town. Some other townships, despite having estimated populations of over
2 million residents, are geographically isolated communities exacerbating problems such as lack of service delivery, access to jobs and access to education.
The study community, in contrast, is in relative close proximity to richer white areas, which can translate into economic and educational opportunities for residents. The vicinity is also relatively well serviced, with most residents having access to piped water and electricity, whereas these and other basic human and
123 sanitation services are famously lacking in the townships east of Cape Town27.
Infrastructure in the study community has been developed by the city, including house construction and service delivery provision. It is also relatively small compared to other townships in the Western Cape, and has better job opportunities (which residents attribute to their proximity to white employers and white businesses). The community however is newer than many other townships, and therefore is not as formalized as older Western Cape townships and established townships such as Soweto outside of Johannesburg (Bray et al
2010).
Tremendous inequities observed in the area mirror the social dynamics observed throughout the country. Unemployment is 8% in the nearby white community, 24% in the neighboring coloured community, and 61% in the study community (Bray et al). In younger people, unemployment is 10%, 31%, and 73%, respectively (Bray et al). Most of the high-paying and skilled workers in the area are white, skilled and semi-skilled workers are coloured, and black residents in
27 During fieldwork, a series of high-profile service delivery protests were carried out in some of Cape Town’s townships. The Democratic Alliance (DA), who runs the Western Cape province, claimed that these service delivery protests were part of the ANC’s pledge to make the Western Cape “ungovernable” as part of the ANC’s campaign to regain political control over the Western Cape. However, service delivery in these townships is seriously lacking, causing tremendous suffering for residents. In example, the Mail and Guardian reported a number of deaths resulting from the lack of toilet facilities in Khayelitsha, which led residents to run across the N2 highway in order to relieve themselves in areas away from the residences. This is incredibly dangerous and a number of residents had been struck by cars and killed doing this. In another example, vigilante justice groups, frustrated at the lack of police response to crime in the townships, had participated in a number of highly publicized attacks on accused criminals in the townships. Much controversy surrounds these vigilante justice groups and the lack of due process for the accused.
124 the area are largely unskilled laborers, domestic workers, and security guards
(Bray et al 2010).
Education in the area, like in the rest of the country, varies along racial and economic lines. The best schools are in the white areas, followed by the coloured areas and the schools in the study community are the lowest resourced and have the lowest achievement rates. Four out of five adults (aged 20 or more) in the white suburb had matric or post-matric in 2001 versus one in five in the coloured community and study community (Bray et al 2010). In both the study community and coloured community, nearly 25% of the adult population has completed less than grade-7 schooling (Bray et al 2010). While education levels in the coloured and black communities are roughly equivalent, the coloured community has a significantly higher employment rate and workers are in higher-paying jobs than in the black community, showing how preferential and discriminatory hiring practices of the apartheid era last through present day.
Income disparity is one result of this. The poorest fifth of households in the valley have incomes of less than R10,000/year, whereas the wealthiest fifth make more than R150,000/year. The poorest households are mostly in the study community, the middle-income households mostly in the coloured community, and the wealthiest in the white suburb (Bray et al 2010).
The South African Police Service has a police station nearby the study community. However, community trust in the police is very low and police corruption is a documented problem throughout South Africa. Residents have therefore developed local groups charged with maintaining safety in the community. One group started in the 1990’s when problems of violence and
125 crime were very high throughout South Africa. In its early days, the local safety group imposed a curfew, and group members would patrol the streets during the night, stopping and searching individuals on the streets who were breaking the curfew. Today, the group takes a less active role in policing and partners with the police for serious crimes. They are now known for investigating petty crime, such as theft, for finding and interrogating individuals accused of stealing, and for locating stolen goods and returning stolen goods to their owners. Many youth feared the group because of their reputation for aggressively going after individuals accused of crimes, though youth are generally appreciative of the group because they see them as an important community service and crime deterrent.
Residents in the study community, like other township residents in the
Western Cape, suffer from elevated rates of tuberculosis and HIV. TB notification rates have rapidly increased over the last ten years and in 2010 were documented at 2000/100,000. 26% of the population is HIV positive, and over 40% of new
HIV infections are in youth under the age of 25 (DTHF 2007).
3.7 Entering the Field
I was affiliated with a registered non-profit organization dedicated to lessening the impact of the HIV epidemic28. They provide HIV testing, treatment, education and outreach services in greater Cape Town, with a focus on providing service to vulnerable populations. Among other services, the organization has a youth center where this research was housed.
Youth Center
28 The organization’s name is withheld to protect their identity.
126 The study community had recently opened a youth center (YC). Recently, a series of focus groups were held with community residents to understand the needs of local youth regarding HIV/AIDS prevention and treatment. The result of these focus groups was clear support from the community to develop a youth center for local youth to receive HIV/AIDS services in addition to a variety of other health and development services. Many youth reported avoiding the existing community clinic due to the HIV stigma attached to the clinic or out of fear that family members or other community elders would see them receiving sexual health services at the clinic, which is generally looked down upon by elders in the community. Community and clinic leaders therefore undertook a planning and fundraising effort to develop and raise funds for the youth center. In 2011 the
YC was opened.
The YC is open to local youth aged twelve to twenty-two. The YC has a holistic and youth-centered philosophy and runs education, recreation, and health programs including sexual health services Monday through Friday in the after school hours, in addition to community-wide health and education initiatives. The YC receives funding from a variety of public and private granting agencies and donors.
Establishing an office at the Youth Centre (YC)
Upon arrival in South Africa, I began visiting the YC while it prepared to officially open its doors. I participated in YC staff meetings and met with staff working at the community clinic. I was given my own office with soundproof walls in an ancillary building on the property where I could conduct focus groups and interviews in a confidential environment. I was therefore able to establish a
127 presence at the YC and form relationships with YC staff and local youth while I prepared to begin my study.
Working with the Community Advisory Board (CAB)
The YC worked closely with the local Community Advisory Board (CAB).
CAB membership is voluntary and comprised of community members and stakeholders from NGO’s, churches, and schools in the community. The
Community CAB was created in 2003. The CAB meets monthly to discuss planned and active research carried out by the nonprofit research organization in their community and to discuss any important community issues relevant at the time, for example if there have been delays in receiving basic service delivery such as electricity or waste removal. They advise researchers and service providers about community perspectives regarding research studies, and they play a key role in educating the community about HIV/AIDS research and programs happening in the community. Prior to starting my research, I attended a CAB meeting, gave a presentation about my planned research project, and moderated a discussion about my project where I answered questions about the study and listened to feedback provided by CAB members. The CAB provided their endorsement for the research.
At the request of local youth, a youth CAB comprised of youth members under the age of 25 was established in the community. They advise researchers and service providers about research and issues relating to youth. The researchers in turn support the youth CAB by providing them leadership opportunities and HIV/AIDS educational trainings. The youth CAB networks with similar youth CAB’s at HIV/AIDS research sites across South Africa. Prior to
128 implementing this dissertation study, I discussed my project with the Youth CAB, participated in a conference call with youth CAB representatives from around
South Africa, and received feedback from these youth on the research activities and topics.
129 Chapter 4. Methods
4.1 Overview
This research utilized mixed methods conducted in two phases over the course of twelve months from 2012 to 2013. Methods included focus groups, a free listing exercise, participant diaries, SMS and MXit, in-depth interviews and a structured risk assessment questionnaire.
4.1.1 Study Phases
Phase 1: A sample of 36 youth between the ages of 14-22 was recruited from the local community using the local youth center attendance registry. Phase
1 participants were asked to complete two focus group discussions each, a free listing exercise, and to either write in diaries, answer questions via SMS or chat with the researcher on MXit. Data collected in the first study phase addressed
Study Objectives 1-4, provided contextual data, and informed the design of the interview guides and the questionnaire used in the second study phase.
Phase 2: A second sample of 40 youth between the ages of 14-22 was recruited from the local community using door-to-door recruitment. Phase 2 participants were asked to complete a structured risk assessment questionnaire, at least one in-depth interview, and to chat with the researcher on MXit. Data collected from the second youth sample in Phase 2 informed study objectives 1-4.
Also in Phase 2, a sample of ten key informants between the ages of 14-22 was recruited from the local community to complete open-ended interviews on the topics relating to Study Objectives 1-3. Finally, a sample of five community leaders was recruited using purposive sampling to complete an in-depth interview on the topic of youth risk.
130 Participant observation and informal interviewing were conducted in the community throughout the study. These data were used to supplement and contextualize study data across the study objectives. Data collection procedures are outlined in Table 4a.
Table 4a. Data Collection Activities by Study Phase and Participants
Phase Participants Data Collection Procedures Phase 1 Youth Sample #1 (n = 36) Focus Groups Free List Participant Diaries SMS or MXit Phase 2 Youth Sample #2 (n = 40) Risk Assessment Questionnaire Interview MXit Community Leaders (n = 5) Interview Key Informants (n = 9) Interview
4.1.2 Research Assistants
Two research assistants, one male and one female, both 20 years of age and residents of the study community, assisted with study activities. These two assistants were employed as Interns at the local youth center. The internship was a competitive post, and selection required success in multiple interviews and reference checks, high school completion, excellent language ability in both
English and isiXhosa, and a demonstration of basic administration skills. I was part of the intern selection process. I trained the assistants in human subject protections, principles of informed consent, research ethics, basic principles of social science research, study recruitment, and data collection methods.
4.1.3 Language
Data were collected in both English and isiXhosa. The study community is a mixed English and isiXhosa language environment and participants were
131 capable in both languages. I completed isiXhosa training prior to starting data collection. Two native isiXhosa-speakers from the local community (the interns described above) were trained to assist with translation during study activities.
4.1.4 Pilot Testing Data Collection Instruments and Procedures
Data collection instruments, including focus group guides, interview guides, the free listing exercise, participant diaries, SMS and MXit tools, and structured risk assessment questionnaire, were informed by relevant scholarly literature and refined through pilot testing in the study community. Instruments and procedures were piloted with research assistants, youth center interns and youth advisory board members who were from the study community and between the ages of 14 and 22, prior to implementation in the field. These data collection tools were refined based on the results of pilot testing and feedback received from youth during pilot testing. Feedback included appropriateness of questions for the study population and clarity of question wording.
Participant diary instructions, SMS’ing procedures, MXit chatting procedures, and the questions posed in each of these methods were further refined based on guidance from research assistants and youth center interns.
Research assistants and interns provided additional guidance in choosing the physical notebook to be used as a diary.
4.2 Sampling and Recruitment Procedures
4.2.1 Overview
Seventy-six youth between the ages of 14-22 years, ten key informants between the ages of 14-22 years, and five community leaders were recruited for participation in this study. Recruitment was conducted in two phases. In the first
132 phase, 36 youth were recruited to complete Phase 1 data collection procedures. In the second phase, 40 youth, ten key informants, and five adult community leaders were recruited to participate in Phase 2 data collection activities. It was anticipated that data saturation would be achieved with these sample sizes
(Sandelowski 1995).
Individuals were excluded from participation if they were unable to provide written informed consent or, in the case of minors, written assent and written parental permission, or if they were unable to commit to completing research activities.
4.2.2 Phase 1 Sampling and Recruitment
The first sample of 36 youth aged 14-22 was systematically drawn from the local youth center database. The database detailed age, date of birth, gender, address, cell phone number, home language, and date(s) of center attendance for every youth entering the youth center. A copy of this database was provided at the start of the study and was used as the sampling frame from which to draw a representative sample of youth registered at the center (Bernard 2011).
The database was organized and cleaned to filter out youth outside the study age range and to remove duplicate and erroneous entries, resulting in a total of 1,047 youth, including 666 females and 381 males. The database was then divided into sub frames based on the following two variables: gender
(male/female) and date of birth resulting in 18 strata29. Then, each stratum was
29 I originally intended to further stratify the database according to frequency of youth center attendance; however it was ultimately not possible to do this.
133 numbered, and the fifth name in each stratum was selected for recruitment.
These steps were repeated until a sample of 36 youth had been recruited.
Youth drawn for recruitment were contacted via SMS messages, phone calls, and in person at the youth center. I and/or one of the two research assistants called and sent SMS messages to the phone number provided by the youth in the database inviting them to meet with the researcher and discuss study participation. Youth drawn for participation were also approached if they came to the youth center. This was facilitated by the youth center rule that youth must register at the front desk when they arrive. At least three attempts were made to contact each individual before giving up and drawing a new person from the database to recruit. The informed consent process was conducted with youth and with parents of youth aged 14-17 who expressed interest in study participation
(see section 4.5.2 for a description of the informed consent process). These steps were repeated until a sample of 36 youth had been recruited.
Some of the recruited youth ultimately did not show up for focus groups despite repeated attempts to contact them. Because of this, another seven youth were selected for recruitment using the procedure described above in order to complete the recruitment target of thirty-six.
The final sample is described in Table 4b below.
Table 4b. First Youth Sample
Male Female Total Age 14 – 15 4 1 5 Age 16 – 17 1 6 7 Age 18 – 19 6 5 11 Age 20 – 21 6 3 9 Age 22 1 3 4 Total 18 18 36
134 4.2.3 Phase 2 Sampling and Recruitment
4.2.3.1 Second Youth Sample
Forty youth between the ages of 14-21 were recruited to complete Phase 2 study activities. The original study design included youth aged 22, as was done in the focus group sample. However, during the first half of the study it became clear that age 22 was often too old to be included in the category of “youth.” By age 22, most individuals no longer consider themselves youth and others in their families and communities similarly see them as playing more of an adult role.
Significantly, other study participants viewed 22 year olds as senior to them and more like adults than like youth. Because of this, 22 year olds were not recruited to be part of the interview sample.
The second youth sample was drawn from the study community in order to broaden recruitment beyond those attending the local youth center. It is possible that youth attending the youth center were somehow different from youth who did not attend the youth center. Sampling from the community was therefore designed to recruit youth that would have otherwise been missed if sampling were limited to youth registered in the youth center database.
A map of the community was used as a sampling frame. Originally, I intended to use the community census in order to draw a stratified representative sample using the procedures described above with the youth center database.
However, due to practical considerations such as the difficulty of reaching youth and high rates of migration in the community, including youth regularly moving in and out of the community or moving to different households within the same community since the last census, random sampling was not practical within the
135 constraints of this study. Research assistants suggested a street-based sample using a map of the community would be a more effective sampling method.
The community was organized along 20 different roads or in the case of the informal sector (which does not have paved roads), sections. One youth was recruited from each road or section before moving on to the next road. Once 20 youth had been recruited, the process started over and another 20 youth were recruited in the same way, one from each road or section. Convenience methods of identifying youth were used; specifically, youth who were visible inside or outside their homes after school or during school holidays were approached first for study participation. In this community, people can often be found outside in their yards or in their homes with the windows and doors open, making homes approachable. If a young person expressed interested in study participation, their contact information was collected and the informed consent process was conducted. Recruitment activities took place during school holidays and after school because these are the times when youth can be found at their homes.
These steps were repeated until 40 youth had been recruited. The final sample is described in Table 4c. Because of the convenience recruitment methods and the greater participation of males than females, the final sample may not be representative of community youth as a whole.
Table 4c. Second Youth Sample
Male Female Total Age 14 – 15 9 4 13 Age 16 – 17 5 5 10 Age 18 – 19 4 5 9 Age 20 – 21 7 1 8 Total 25 15 40
136 4.2.3.2 Key Informant Sample
A purposive sample of nine youth between the ages of 14 and 22 living in the study community was recruited for key informant interviews for the purpose of providing context and in-depth data regarding themes that arose during the first study phase. These individuals were identified during the first study phase.
Some key informants participated in the focus groups during the first phase of the study and others were active in the local youth center. Youth were chosen for key informant interviews because of their extensive knowledge of study objectives and the study community, having experiences relevant to the study objectives, and willingness and ability to discuss the study topics in depth. These youth were contacted on their cell phones or in person at the youth center. If they were interested in participating in interviews, a meeting time was arranged to discuss the study activities and to conduct the informed consent process. The key informant sample is described in Table 4d.
Table 4d. Key Informant Sample
Male Female Age 14 – 16 0 1 Age 17 – 19 0 1 Age 20 – 22 5 2
4.2.3.3 Community Leader Sample
Finally, a purposive sample of five community leaders working with youth in the study community was recruited for individual interviews to provide data regarding Study Objectives 1-3. These individuals were identified during the first phase of the study. A list was made of service organizations operating in the community such as churches, schools and clinics. With the help of research
137 assistants and key informants, individuals working at these organizations known as leaders in the community were identified. Notably, key informants and research assistants stated that so-called “outsiders”, individuals working in a service role in the community but residing outside the study community and who were often white and much wealthier than community residents, would not be as knowledgeable about the study topics nor about the experiences of community youth because of their outsider status. Following the advice of these youth, recruitment focused on service providers and community leaders with long- standing relationships in the community. This resulted in a list of 25 community leaders who were approached for study participation. These individuals were contacted by e-mail, phone, or in person at their office or homes to discuss study participation. If these individuals were interested in study participation, the informed consent process was conducted. Using these procedures, nine individuals were recruited for study participation. Five completed interviews.
A description of the community leader sample is described in Table 4e.
Table 4e. Community Leader Sample
Male Female Age 25 2 0 Age 31-34 1 0 Age 42-65 2 0
4.2.3.4 Youth Samples 1 and 2
A total of 76 youth were enrolled in the study, across the two phases.
Because random sampling was not used, it is not known how representative youth samples are of the larger community. In 2010 a door-to-door census was conducted in the study community, enumerating 2,803 youth aged 14-22 living in
138 the community. Adjusting for the time that had passed between the census and the start of this study, it was estimated that there were approximately 2,756 youth aged 14-22 split nearly evenly between boys and girls in the community at the start of the study. At the time of recruitment, 1,047 youth aged 14-22 had visited the youth center, which is an estimated 38% of the target population.
The Phase 2 sample specifically enrolled youth not attending the youth center in the event that youth who attended the youth center were different from those who did not.
The total youth sample is described in Table 4f.
Table 4f. Total Youth Sample
Male Female Total Age 14 – 15 13 5 18 Age 16 – 17 6 11 17 Age 18 – 19 10 10 20 Age 20 – 21 13 4 17 Age 22 1 3 4 Total 43 33 76
4.3 Data Collection Procedures
Data was collected in two phases as described below.
4.3.1 Phase 1 Data Collection Procedures
In Phase 1, Youth Sample #1 participated in focus groups, free listing, and a subset completed participant diaries, SMS, or MXit activities.
4.3.1.1 Focus Groups
Youth in sample #1 participated in two focus groups each. Youth were divided into six groups of six participants. Groups were created according to age and gender as follows: Group 1 = all boys aged 14-17, Group 2 = all girls aged 14-
139 17, Group 3 = all boys aged 18-22, Group 4 = all girls aged 16-22, Group 5 = half boys/half girls aged 14 − 17, Group 6 = half boys/half girls aged 18 − 22. Due to participant availability, actual focus group composition ultimately varied from this plan.
A total of 18 focus groups were conducted in order to ensure all participants attended two focus groups each. Focus group size ranged from three to six youth in each discussion. Most groups had four to six participants. Thirty- four participants completed both focus groups. Focus group discussions were held in a private room and audio recorded. Hand-written notes about the discussion were taken.
Focus group 1: In the first focus group participants were asked to discuss perceptions of the community, daily life and activities, dating and relationship norms, challenges, and hopes for the future. In addition, participants completed a free listing exercise at the end of the discussion. Youth were given a choice of two of the following four topics: 1) Things that make life good, 2) Things that make life hard, 3) Reasons for having sex, and 4) Types of relationships. Youth worked independently on their lists and they were seated separately so that they could not see what other youth were writing. Each participant was provided with pencil and paper. Youth were instructed to: "List all the [x] you can think of." X = the topics listed above. I was present while youth completed the free lists to answer questions or provide assistance when necessary.
Focus group 2: At the second focus group participants were asked to discuss gender, relationship and sexual norms, threats, perceptions of HIV and
HIV risk, wellbeing, and strategies to manage threats. Because of scheduling
140 difficulties participants were not always in a group with the same people for the second focus group that they were with in the first focus group.
4.3.1.2 SMS and MXit on Cell Phones
Following the first focus group, participants were asked to answer questions via SMS or chatting with the researcher on MXit30.
SMS (SMS stands for short message service, also known as texting) is a basic technology that all youth are familiar with and that works on any phone, including extremely low-end, inexpensive phones.
MXit is a free online instant messenger and social network service developed in sub-Saharan Africa. MXit can be used on cell phones or on web browsers, but in South Africa MXit is used primarily on cell phones. At the time of this study MXit was the most popular social networking platform in South
Africa, especially amongst youth. To chat on MXit, users must log into the application using their individual user name and password. Messages sent from one user to another are private; they are sent and received within the MXit application and cannot be viewed by a third party. MXit does not store messages sent on its platform, does not collect any personal information about users except cell phone number, area of residence (discerned from phone number), and which
MXit applications each user has accessed. Private MXit messages can only be viewed by the user when that user is logged into their MXit account.
30 Chatting on private Twitter accounts was planned as a third option at the beginning of the study. However, early in the study it became apparent that participants had never used Twitter and were unfamiliar with the application so this option was dropped. At the time of this study Twitter was much less popular in South Africa than other social media, with only 55,000 users in the country. Youth were therefore given the choice of either SMS'ing or MXit.
141 To be eligible for SMS or MXit data collection activities, participants were required to own a cell phone that was not shared and have previous experience with MXit and/or SMS'ing. Youth electing to send messages via SMS or MXit chose four days during the week, including at least one weekend day, and two times during those four days when they were available to send messages. Each youth chose a code word to include at the end of every message sent to me so that
I would know it was them sending the message. For youth sending SMS messages, on the previously agreed upon days and times I would send a question via SMS for them to respond to. The questions are included in Chapter 8.
For youth chatting on MXit, youth were to log into their MXit accounts at the previously agreed upon days and times to find the question that I had sent them as a message and to respond to the question. The questions are included in
Chapter 8. Youth were not obligated to send any additional messages after responding to the question, but in practice there was a back and forth chatting on
MXit with each participant. The method of chatting on MXit changed over time as I became more comfortable with the technology. Chatting on MXit was therefore much more fluid than SMS'ing. Chatting would last anywhere from two minutes to an hour with any given participant, depending on time of day and interest of the youth in chatting.
Topics covered included every day activities and events, feelings, and daily choices. The types of questions and topics that would and would not be discussed over SMS and MXit were discussed with participants ahead of time. Because of privacy and confidentiality concerns related to chatting on cell phones such as the possibility of having a phone lost or stolen, question topics were focused on daily
142 activities and thoughts and feelings. Sensitive information about HIV, health or sexual health was not solicited electronically.
4.3.1.3 Diaries
Youth who chose not to participate in SMS or MXit or who did not have a cell phone were asked to complete paper diaries. These participants were provided with paper diaries and asked to spend two times a day, four days a week for four weeks tracking their daily activities, thoughts and feelings about their day and the choices that they had to make about their personal wellbeing in that four week period. Participants were instructed to focus their writing on their thought process, feelings, and motivations related to decisions.
Some youth expressed that writing about decisions was too difficult. After discussion with these youth, it was mutually decided that they would instead write about what happened that day, including the good and difficult parts of their days, who they were with, where they were, and how they were feeling.
4.3.2 Phase 2 Data Collection Procedures
In Phase 2, Youth Sample #2 participated in interviews, a structured survey, and a subset of Youth Sample #2 participated in MXit chatting.
Community leaders and key informants participated in interviews in Phase 2.
4.3.2.1 Structured Risk Assessment Questionnaire
Participants in youth sample #2 completed a paper based, self- administered structured risk assessment questionnaire in order to establish baseline for each participant regarding risk and protective behaviors and environmental risk factors impacting participants’ health and wellbeing. The
143 questionnaire was comprised of closed-ended, multiple choice, scaled, and a few open-ended questions. The questionnaire is provided as an appendix.
Participants were given a pencil, a privacy envelope, and the questionnaire. The questionnaire was explained to the youth, and youth were given access to a private room and instructed to complete the survey on their own and return it to the researcher in the privacy envelope when complete. Most youth chose to take the survey home with them and return it a day or two later.
Surveys were marked with participant codes and youth were instructed to keep the surveys private and to not write any identifiable information on the survey in order to protect participant privacy.
4.3.2.2 Youth Interviews
Participants in youth sample #2 participated in an in-depth interview.
Interviews were designed to elicit participant narratives of threat perceptions,
HIV perceptions, daily threats, sex, love, dating, relationships, gender, health risk behavior, health promoting behaviors, wellbeing, risk management strategies, resources and protective factors.
Interviews were conducted in a private room. Youth were given the option of having a translator present so that they could conduct interviews in isiXhosa, however most youth chose to be interviewed in English. Interviews were audio recorded with participant permission and hand-written notes were also taken.
Of the 40 youth recruited to participate in interviews, three did not complete an interview. Two youth were unavailable because of busy schedules and one youth passed away before we were able to complete an interview.
144 4.3.2.3 Community Leader Interviews
Community leaders completed a semi-structured interview on the topics of the risk environment for HIV, environmental threats to youth wellbeing, community protective factors for youth, community strategies to address youth health and wellbeing, and facilitators and barriers youth health and wellbeing.
Data gathered in these interviews included descriptions of the local context and community attitudes towards youth (Jaspan et al 2008). Interviews were conducted in English and at least one research assistant was present during interviews for isiXhosa translation as necessary.
4.3.2.4 Key Informant Data
Key informants completed multiple in-depth, open-ended interviews. The purpose of key informant interviews was to provide insight into data collected via other methods, especially regarding risk, wellbeing, HIV, and behavior choices in the township (Bernard 2011). Sample size was small to allow for continued, in- depth data gathering. Key informant interviews also provided data on local language used to discuss research topics, community attitudes towards risk and
HIV, normative use of cell phones and social networks for communication and information sharing amongst youth, and details of the local environment. Key informants helped to pilot test and refine data collection tools to ensure local appropriateness. When feasible, interviews were audio recorded with participant permission and hand-written notes were taken. When recording was not feasible, hand written notes were taken and later transcribed.
145 4.3.2.5 Participant Observation
Observations and informal interviewing were conducted in public places throughout the study community, at the local youth center and at some participant homes for the duration of fieldwork. Participant observation has been shown to be a reliable method for studying sensitive topics with vulnerable populations (Cleland 2004; Ware et al. 2009; Wood 2008). Unstructured interviews with service providers and youth that occurred during observations allowed individuals to raise topics that they felt were important and to discuss topics related to the study objectives in their own words.
Observation data was used to contextualize data collected via other methods (Bernard 2011) and to establish youth patterns and preferences of cell phone and social network that informed the cell phone component of this project
(Deumert and Masinyana 2008; Kreutzer 2009). No specific individualized information about individuals not enrolled in the study was sought or recorded during observations.
4.4 Data Management and Analysis Procedures
Data collected in this project include both qualitative and quantitative data. Qualitative data addressing study objectives 1-3 included data collected via focus groups, interviews, participant diaries, SMSs, MXit chats, and observational and descriptive field notes. Quantitative data addressing study objectives 1-3 included free listing data, structured questionnaire data, and participant demographic data. Study objective 4 was addressed through SMS data, MXit data, field notes, and methodological memos written during analysis.
146 All collected data were transcribed. Transcripts were stripped of identifying information such as names and labeled with participant codes.
Focus Group and Interview Data Management
Focus groups and interviews were audio recorded and hand-written notes were also taken. Recordings were transcribed and translated into English when necessary. Translations were spot checked with multiple native isiXhosa speakers for accuracy. Some interviews were not audio recorded due to participant preference; extensive hand-written notes were taken during these interviews and then transcribed.
Diary, SMS and MXit Data Management
Diary entries, SMS and MXit messages were transcribed into word documents, compiled in Excel tables, and uploaded into Atlas.ti for coding.
Field note Data Management
Observations, descriptions of events, and unstructured interview data were documented in field notes. Field notes were hand written or typed notes taken both in real time and as soon as possible after the observations or conversations occurred. Field notes were almost always written the same day that the documented observations or conversations occurred. Field notes were saved as text files and organized by date. Field notes were then grouped according to data collection phase, and used to supplement formal notes taken during data collection activities such as notes taken during focus groups and interviews.
Free List Data Management
Free list data were compiled, transcribed into a single word document, and counted for analysis. No identifiers were collected with free list data.
147 Questionnaire and Demographic Data Management
Structured risk assessment survey data were entered into Excel and uploaded into SPSS for basic descriptive and univariate statistics. Demographic data such as age, gender, education level, type of home, and access to water was collected from each participant. Demographic data was compiled in Excel tables and uploaded into SPSS for basic descriptive and univariate statistics.
Interim Qualitative Data Analysis
Interim analyses were conducted in the field on data collected in the Phase
1 in order to identify important themes related to study objectives 1-3 for follow- up during the second phase of data collection. Interim data analysis included expedited content analysis of field notes, focus group transcripts, diary and electronic data to identify key themes and their frequencies. A table was created to describe the content, themes, and frequencies of themes compiled in free list data. This preliminary analysis guided design of the interview and structured risk assessment questionnaire instruments. Interviews and questionnaires were then designed to identify important themes related to study objectives 1-3, to recognize and fill in explanatory gaps discovered during the earlier phases of the project, and assess the cultural consensus of risk concepts and perceptions collected in earlier phases of data (Bernard 2011).
Coding and Codebook Development
Field notes, focus group, interview, participant diary, SMS and MXit transcripts were uploaded into Atlas.ti and coded in four steps: 1) open coding and code generation, 2) code clarification and definitions, 3) coding using the codebook and 4) looking for relationships between codes.
148 First, a random 10% sample of focus group and interview transcripts were reviewed to develop a preliminary list of codes related to study objectives 1-3.
Codes were created directly from data. Next, open coding and the constant comparative method were employed to code remaining transcripts in order to add to the preliminary code list. The relationship between codes related to study objectives 1-3, especially relating to risk perception and risk management was assessed in order to further refine the codebook.
The list of codes and their definitions was then compiled, refined, and finalized in a codebook. After all of the transcripts had been coded once, each transcript was reviewed a second time using the final codebook. Data were coded for both the presence and absence of key themes including risk perception, HIV risk perception, and risk management strategies in order to identify discrepant data. Extensive memo’ing and concept mapping was conducted throughout the coding process. The codebook was continually refined during the coding process.
Data Analysis
Coded transcripts were analyzed to identify the range and patterns of emic understandings of risk and wellbeing, the relationship of risk perceptions to risk management strategies, and document the components and characteristics of the local risk environment and their role in shaping youth risk perception and risk management strategies (Huberman and Miles 1994; Lofland and Lofland 1995).
Focus group data provided context for data collected via other methods. Field notes were reviewed as needed during analysis to provide additional context and insight into coded transcripts. Within-case analyses were then conducted to examine the consistency of individual changes in perceptions and risk
149 management strategies. Cases were compared in cross-case analysis to analyze differences between the genders and between the different ages. Identified themes were then grouped together to assess their relationships to study objectives 1-3.
Analytic and methodological memos were written throughout the transcription and coding process (Miles and Huberman 1994). Analytic memos were used to identify key themes in the data and document the relationship of themes to theory relevant to study objectives 1-3. Methodological memos were written throughout coding to assess the data collection process especially SMS and MXit data collection for analysis relating to study objective 4.
Quantitative Data Analysis
Participant demographics and structured risk assessment questionnaire data were compiled in tables in Excel, labeled with participant codes, and uploaded into SPSS for analysis. Basic descriptive and univariate statistics such as frequencies were conducted to identify the range of frequencies of risks experienced and risk-related behaviors. Cases were compared to identify possible differences between males and females and between different ages on variables and findings relating to study objectives 1 - 3.
Data Triangulation
Data collected via different methods were compared during final analysis in order to triangulate findings and maximize validity (Bray et al 2010; Mitchell and Smith 2003). A case summary was written for each participant that combined the data collected from each participant via different methods. A table was then made comparing each case according to demographic and key study
150 themes in order to conduct thematic analysis across cases. Data were compared between males and females and between participants of different ages. Due to the small sample size, analysis was limited to a description of themes and descriptive comparisons between genders and ages.
Strategies to avoid potential biases and threats to validity included triangulating data from multiple sources and specifically seeking discrepant data and contradictory cases in analysis.
In the final stage, analyzed data were compiled in order to develop a model of youth risk perception and of youth risk management strategies. Models were then applied to coded data to assess their explanatory fit for data collected in this study. Models were then analyzed in relation to existing theories relating to risk perception and risk management strategies to identify areas where data fit existing theories as well as areas where existing theories could be refined.
4.5 Ethical Considerations
4.5.1 Ethics Review
This study was reviewed and approved by the Case Western Reserve
University Institutional Research Board and the University of Cape Town Human
Research Ethics Committee. The local Community Advisory Board approved of the research. Permission was obtained from the Youth Center to conduct data collection activities there.
4.5.2 Informed Consent
Written informed consent was obtained from participants aged 18 and older. Written assent and parental permission was obtained from participants aged 14 - 17. Consent documents were available in both English and isiXhosa.
151 Signed consent forms were stored in a secure, limited-access office.
Confidentiality and privacy protections during data collection, data analysis and data dissemination was discussed with participants and, when applicable, parents. Verbal confirmation of consent / assent was obtained from participants prior to each data collection event. Participants were reminded at the beginning of each data collection event that they did not have to answer any questions or discuss any topics they were not comfortable with and they could leave the study at any time.
4.5.3 Protections and Service Referrals
Interviews and focus groups were conducted in private locations. Focus group participants were advised to maintain privacy and confidentiality. Diaries and written surveys were labeled with participant code to protect participant confidentiality. Participants were counseled on strategies to maintain the privacy of diary, cell phone (SMS and MXit), and questionnaire data. Collected data were securely stored throughout the course of the study.
Nurses, counselors and support staff and local service providers were available for participants requiring service referrals to ensure participant safety and wellbeing. Participant privacy and confidentiality was maintained and individual participant answers to questions were not shared with staff, service providers or parents.
4.5.4 Incentives for Participation
In this context, it was considered appropriate and expected for researchers to provide incentives for study participation. Participants were therefore provided with the following small incentives:
152 Focus Groups: Participants received a food or phone airtime voucher valued at R40 (40 South African Rand) (approximately $5) for each focus group that they completed, up to a maximum of two focus groups per participant. Focus group participants were asked to complete one free listing exercise; this activity was considered part of the focus group. Light snacks (such as juice or small sandwiches) were provided during focus groups.
Electronic (SMS or MXit) Data: Participants received up to R64 (about $8) in airtime vouchers for completing these activities. Participants were expected to send up to 32 SMS’s in this study. The cost of each SMS was compensated. Each
SMS costs approximately R1 (approximately 12 cents). For each SMS sent for research purposes, the participant was compensated for the cost of another two
SMS’s. This means that each participant could receive airtime vouchers to cover
32 SMS’s plus up to another R64 in airtime vouchers. At the beginning of each participant’s four week period, the participant’s cell phone was loaded with twice the amount of data time needed to complete one week’s worth of data collection.
If the participant responded to 75% (6) of the SMS’s, this process was repeated the following week, and so on for the four-week period. At the end of the four- week period, participants would receive an extra R1 bonus for each SMS sent not to exceed R32. Compensation was prorated to the amount of research SMS’s sent.
For example, for every SMS sent, the participant was given R3 in airtime, not to exceed R24 (four SMS’s a week) a week.
Diary Completion: Participants completing diaries were compensated at the same rate as those sending SMS, receiving up to R64 (about $8) in food or airtime vouchers. Participants were asked to turn in their diaries for review.
153 Compensation was prorated depending on number of diary entries made.
Participants received R1 per diary entry.
Interviews: Participants received an airtime voucher in the amount of R10
(approximately $1.25) for each interview they completed and/or for completing the paper survey, with a maximum of three interviews per participant.
Observations and Informal Interviews: No compensation was provided for these activities because they are unobtrusive and occurred during the course of every day interaction and conversation. Specific individualized information was not sought during observations or informal interviews.
4.6 Scope and Limitations
This research had several limitations due to sampling and methodology.
First, purposive sampling was used to engage the limited population of community leaders, potentially resulting in a non-representative sample.
However, because of the small size and difficulty in accessing this population, purposive sampling was the most effective method. Second, door-to-door sampling methods used to recruit the second youth sample may be non- representative of youth in the community because youth found at home may differ from youth not found at home. The initial study design planned to utilize a community census to draw a stratified random sample of youth living in the community. Due to logistical challenges including high rates of migration and frequent residence changes, this ultimately was not feasible to do. Therefore, given the difficulty in accessing this hard to reach population, door-to-door methods were the most effective method for recruiting and every street in the community was sampled. Third, sexual behavior and HIV are sensitive topics
154 and, as in all research into these topics, there is the potential for self-presentation bias and under-reporting of sexual activity, HIV status, and knowledge about HIV in written surveys, focus groups, and interviews. However, the ethnographic component of this study including long term engagement with participants including follow up interviews to minimize potential barriers to disclosure on these topics. These measures promoted rapport with participants and improve confidence in study findings.
155 Chapter 5. Focus Group Data
5.1 Overview
This chapter reports the results of a series of focus groups conducted during the first study phase with Youth Sample #1. Focus groups addressed research objectives 1-3 using a focus group discussion guide covering topics of daily life, dating and relationship norms, perceptions of risks, perceptions of HIV, and behavioral norms for managing risks.
This chapter begins with a description of the study sample. Next, data pertaining to the study objectives are presented; starting with the ways the risk of
HIV infection is perceived by youth in the study community followed by a discussion of how youth perceive the other related, inter-connected risks in their lives. Reported strategies participants have developed to manage these risks are then described, followed by a discussion of relevant contextual factors. The chapter concludes with a summary of key themes raised by focus group participants and a description of how these themes establish the context for subsequent data chapters.
5.2 Focus Group Sample Characteristics
The sample consisted of 36 youth drawn from the youth center attendance registry. The sample was evenly split between males (n=18) and females (n=18).
Participant age range was 14-22 years, with the majority of participants aged 17-
20 (n=21). One youth did not complete either focus group. Of the remaining 35, one completed one focus group and the remainder all completed two focus groups.
Participant age and sex are displayed in Table 5a.
156 Table 5a. Focus Group Participants
Sex Total Age Female Male 14 0 1 1 15 1 3 4 16 4 0 4 17 2 1 3 18 1 4 5 19 4 2 6 20 2 5 7 21 1 1 2 22 3 1 4 Total 18 18 36
Just over half of participants were born in the Eastern Cape (n=19) and had migrated to the study community. Participants’ reasons for migration included better educational opportunities in the study community, to live with parents who had migrated to seek employment, because of family conflicts or for a chance to start a new life. Half of participants were living with one or both parents (n=18). Those not living with parents lived alone, with older siblings or with an aunt (it is unknown who five participants were living with). Thirteen youth reported that at least one parent had passed away (five reported their mother had passed away and eight reported their father had passed away), and seven participants reported never knowing neither their mother (n=1) nor their father (n=6). Two participants, males aged 19 and 21, lived alone in their own place on their family’s property. Other participants shared their homes with anywhere from one other person up to ten other people, with most participants sharing a home with three to five other people.
Participants were not asked about their HIV status and no youth disclosed their status. Other sample characteristics are described in Table 5b.
157 Table 5b. Selected Focus Group Characteristics
Selected Demographic Characteristics Number Language English and Xhosa 21 English, Xhosa + at least one other language 15 Schooling Finished high school 4 In high school 23 In primary school 2 Dropped/failed out 4 Unknown 3 Housing Shack (communal water supply outside) 19 Advanced Shack (has multiple rooms + functioning kitchen) 1 Shack Bungalow (one room, communal water supply outside) 5 Habitat House (provided by government with indoor plumbing) 2 Brick house (+ indoor plumbing) 4 Flat (apartment with indoor plumbing) 1 Unknown 4 Place of birth Study Community 8 Other township 6 Eastern Cape 19 Unknown 2
5.3 How the risk of HIV infection is perceived in everyday life
Extremely diverse HIV perceptions were reported in focus groups. In general, HIV was largely feared as a devastating illness impacting young people.
Participants expressed a heightened awareness of the elevated rates of HIV infection locally and nationally, especially amongst youth, leading to feelings of vulnerability. “The generation we live in is at risk,” (male, age 19). HIV was thought to be “everywhere” and participants were therefore concerned that it was very easy to become infected. While this perception was dominant it was not universal and perceptions of HIV risk were nuanced. For example, in one focus group of older males, participants discussed how HIV was a social problem,
158 rather than an individual problem. In this group, participants felt that the primary impact of HIV was largely felt on society as a whole rather than on individuals, unless they or a family member became infected. “HIV is a problem,
I know it’s there, but it’s not my problem. It’s a social problem,” (male age 21).
Whether or not participants discussed feeling personally at risk for HIV was highly individualized and varied according to each participant’s specific life circumstances and perspective. In general, many participants discussed uncertainty about their risk because some factors, such as using condoms or having a trusting relationship, were largely seen as in their control while other factors such as making a mistake or inadvertently coming into contact with an infected person’s blood were viewed as not always in their control. Individual risk perceptions further varied across relationships. Participants justifiably felt that they were not at risk of HIV if they were abstaining from sex or using condoms every time they had sex. Participants reported that risk increased if they did not know about their partners’ status or other relationships.
A variety of factors outside their individual circumstances also influenced
HIV risk perceptions, such as the high HIV prevalence locally and nationally, concerns about making a “mistake” and having condom-less sex, especially with a new partner, and the concern that condoms were not 100% effective or could break. Participants discussed concerns that other youth were behaving in ways that spread HIV in the community such as by sleeping with many partners. HIV remained a highly stigmatized disease and infection was largely hidden and rarely discussed, contributing to a concern amongst participants that it was not
159 possible to discern whom was infected, which could therefore result in being exposed to the virus without knowing.
These factors led to an overall sense of vulnerability to HIV infection amongst a portion of participants, though feelings of personal vulnerability varied between individuals and across situations.
The most common themes related to HIV risk perceptions that arose in discussions are outlined in Table 5c and described in detail below.
Table 5c. Themes Related to HIV Risk Perceptions
Theme 1 Fear Theme 2 HIV is everywhere Theme 3 Uncertainty Theme 4 Blaming the “wrong” behavior of others Theme 5 Stigma and Silence
Fear of HIV
HIV was largely perceived as a devastating illness and participants overwhelmingly discussed fearing HIV. For example:
“I don’t want imeva [thorn]… It strikes you, imeva, it doesn’t forgive you.
Even [if] you say sorry it won’t forgive you. Because it’s all over your body
and I really don’t want that,” (male, age 15).
HIV was recognized as an illness that could be managed through proper treatment which allowed infected persons to live a long life, yet even with treatment HIV was viewed by some participants as devastating. HIV was discussed by some participants as a death sentence, despite participant knowledge of treatment and the availability of free treatment locally. For example:
160 “Although they’ll get told that ok if they get HIV can be cured or you can be
better you can last for longer or things, but they don’t care about that they
know at last they gonna die. See. They won’t be (sic – die) soon or alone
but they gonna die,” (male, age 20).
Other participants emphasized feelings of hopelessness tied to HIV infection, for example:
“If you have HIV then like, you get frustrated, you don’t know what to do
with life, even if you’re working, you see, what am I working for because
you’re just going to die soon, so what’s the use of you working? If it’s like
ok we’re gonna die now. So you don’t have any trust. So you just decide to
let everything go,” (male, age 20).
Some focus group discussions, especially amongst females, centered on fears of the negative impact HIV would have on their bodies. In general, HIV was perceived as a disease that could cause an infected person to rapidly lose weight, become very sick and die. Therefore in a portion of the focus groups, a minority of participants claimed it was sometimes possible to know who was infected with
HIV based on how they looked. One participant also felt that if he looked healthy he could be confident he was HIV negative, saying, “I can see in my physical body that I’m still 100%,” (male, age 15).
Three of the female focus groups discussed concerns about what HIV treatment would do to their body “shape”. “We scared to lose our shapes,”
(female, age 20) and, “they say if you on HIV (meaning treatment) you balloon.
You lose your shape,” (female, age 19). Their perception was that ARVs would cause their thighs and buttocks to become skinny and their stomachs to become
161 exaggeratedly large. This body shape is associated with the first line of HIV treatment to become available in South Africa which is now outdated, but the image persists. Other physical risks relating to HIV discussed in focus groups included having to take pills every day and fearing the side effects of HIV treatment, such as the drugs causing you to feel dizzy and sleepy.
Some participants disagreed with the above perceptions and expressed other views, for example: “You can be HIV positive but if you take care of yourself you won’t lose your shape…you can remain you even if you HIV positive” (female, age 20). Other participants discussed the fact that HIV could be successfully managed with treatment and taking proper care of yourself.
HIV is everywhere
Participants had learned about the high rates of HIV locally and nationally in school and in outreach programs led by local clinics. A common theme in focus groups was thus the belief that HIV was “everywhere”, for example: “It’s [HIV] all over,” (male, age 18). Some groups discussed feeling overwhelmed by the scope of the epidemic. In the words of one participant, “More people are getting more exposed to it in a way that it’s easy to get,” (male age 20). One participant felt that
HIV had become part of regular everyday life: “part of life yeah,” (male age 19).
In three of the focus groups, participants discussed that HIV was so common that it would be impossible to ever eliminate it. “There is so much AIDS around you won’t be able to get rid of it. There is more of it,” (female age 16). One participant theorized that “HIV won’t go away,” (female age 19), but that it would become like other diseases such as tuberculosis where people still become infected but can be cured. One participant (female age 15) agreed and further
162 believed that other health concerns, especially diabetes, were more severe and that more resources should be concentrated on diabetes than on HIV.
The related worry that the continued spread of HIV around the world was unavoidable was raised in two focus groups. “HIV/AIDS is becoming part of our culture…it will always be a part of our culture because everyone wants to have sex and have babies,” (male age 20). Another participant worried that nothing could be done to stop HIV and AIDS because “everybody wants to leave their ID on the planet,” (male, age 18), meaning they want to create babies in order to make their mark on the world. Another participant agreed with this saying that therefore
“HIV is here to stay,” (male age 22).
Uncertainty
The fact that HIV infection does not immediately manifest in disease or signs of sickness was discussed in the focus groups as increasing uncertainty about who was infected and who was not, which in turn increased participant concerns about being unknowingly exposed to the virus. Pervasive stigma surrounding HIV and AIDS created an environment where HIV status was a tightly held secret, adding to the uncertainty. Participants discussed feelings of uncertainty and worry about the possibility that someone they were dating might be infected and not know it, and therefore might be unknowingly spreading infection. “Some are unaware of their virus…because it’s hidden,” (male age 20).
One participant reported motivation to use condoms to protect against hidden infection: “that guy have HIV but why don’t he die? So I must try it, see, this condom thing,” (male age 20).
163 Two all-female focus groups discussed the uncertainty about who would become infected and the possibility that it might “come to me”. “You don’t know who’s gonna get it,” (female age 19). Females in these groups felt that HIV infection was to some extent out of their control because they could not be certain of their boyfriends’ HIV status or past behavior. They also discussed how it did not always make sense to them who did and did not become infected. They had heard of instances where “good girls” became infected but girls who were
“looking for it” (which meant having condom-less sex outside of committed relationships) did not become infected. This is the opposite of what they expected. They speculated in the groups that it was therefore still possible to become infected with HIV even if you were faithful to your boyfriend, were
“staying at home”, “being honest”, and “acting right” because your boyfriend might “bring HIV home to them”. “You just sit and wait, and then your boyfriend gonna bring you the AIDS,” (female, age 19). This seemingly contradictory observation led the groups to discuss increased uncertainty about their personal risk of HIV, and a fear that infection might be out of their control.
Blaming the “wrong” behavior of others
A theme raised in many discussions was the worry that other youth were spreading HIV through wrong behavior, such as having multiple relationships at the same time, which they feared would place their partners and other youth at risk for HIV. For example,
“…The HIV thing, graph is increasing…cause if x is dating me, he’s my
boyfriend, he will also date N, and N also dating y, and y also cheating.
164 And then if I have HIV it infect him. Then it goes like a chain…sometimes
they have unprotected sex and they be a chain,” (female age 20).
In the majority of focus groups it was asserted by both males and females that the relationship ideal was to only have one sexual partner at a time.
However, in many focus group discussions, participants reported concerns that some youth had multiple partners at once. A number of participants blamed such other youth for spreading HIV through having condom-less sex with multiple people or by cheating on their boy/girlfriends.
One participant suggested that other youth did not fear HIV because they considered HIV to be an inevitable part of human life. However, no participants expressed that they actually held this viewpoint themselves. Rather, “other” youth were accused of having this view. Another participant expressed frustration that youth continued to become infected with HIV despite widespread education about the disease, its dangers and the ways that it can spread. For example,
“There is HIV and it’s dangerous but they still like, they aren’t safe…the
average of HIV is increasing by each and every year but people are
trying…like to stop HIV and giving out messages it’s like, they don’t
listen,” (male age 18).
One participant believed youth, especially males, don’t listen to HIV prevention messages because they only care about enjoying life while they are still young and before they become men and will be expected to act differently:
“They say they want to have fun while they can,” (male age 15).
Another participant suggested that HIV positive youth became infected simply because they “don’t know the facts” (male age 19) meaning they lack
165 proper knowledge about how the disease spreads. One participant suggested that
HIV positive youth fear going through treatment and dying alone. Another participant agreed with this, saying in the abstract: “I can’t take it on my own. I can’t die alone…I’m not gonna have this alone,” (female, 19).
One participant believed that HIV would continue to threaten youth until all people took responsibility for their actions. This participant expressed the opinion that all youth needed to be responsible enough to use condoms when having sex, saying:
“It will take someone responsible, it depends what kind of person you are.
If you are responsible enough, you might use a condom…we never having
a generation from AIDS until we responsible enough yebo,” (male age 22).
One female expressed a similar view, saying “a responsible guy who knows what he wants in life and knows that he is not ready to be a father will get up and get a condom,” (female, age 16).
One focus group of young males expressed the fear that people from outside the community were spreading HIV in their community. Participants in this group were particularly concerned about men who visited the local shebeens, saying:
“They gonna bring us disease, cause they all over the place…they gonna
hook up with other girls in [other communities], and then they hook up
with your girl. And maybe let’s say you know your girl, you only dating that
girl you not using condom. Like you’ve been dating for a long time. Then
come these guys (who) hook up with them. And you won’t know anything,
like where was she the previous night,” (male, age 18).
166 Stigma, Silence and Gossip
Stigma surrounded HIV in the study community, as well in South Africa generally, and focus group discussions indicated prevailing silence and secrecy around HIV. A minority of participants mentioned knowing someone with HIV, such as a friend or family member. However, the number of participants who knew someone with HIV is not precisely known. Participants reported that only one person in their community had disclosed their HIV status publicly.
Participant discussions emphasized that HIV positive youth would not reveal their status, or be reluctant to do so, for fear of being stigmatized, and of suffering social isolation and rejection from the opposite sex: “Our age group won’t tell…If you a guy, no girl will ever want to have you (if you have HIV)…I’ll
[sic – an HIV positive person will] never find a girl,” (male, age 21).
Some female focus group participants discussed feeling that they could not easily speak to their parents or other elders about HIV. Reasons for feeling that they were not able to discuss HIV included being uncomfortable raising the topic, because participants were concerned that if they broached the topic they would be judged negatively, or participant concerns that their parents would assume that they were doing “wrong things” such as having sex, or “they will think you are HIV (infected with HIV) already,” (female, age 15). Some participants feared that their parents might even punish them if the parents suspected their child was having sex.
Focus group discussions were generally mixed regarding the topic of discussing HIV at home and with their families. In some groups, participants reported that HIV and HIV prevention were discussed in their families, and some
167 participants described having a relative such as a sister or aunt who talked about
HIV and HIV prevention with the teens in their family. Other participants reported the opposite, that the topic of HIV was not discussed in their homes or by members of their families.
Participants also described how HIV diagnoses were generally hidden and kept as tightly held secrets, even within families. This theme was supported by findings in other parts of this study. For example, one participant reported in the diary discovering a family member’s HIV infection by overhearing a conversation amongst other relatives about it.
The silence surrounding HIV/AIDS was contrasted with the fact that in a portion of the focus groups participants describe being bombarded with
HIV/AIDS education and messages at school and on TV:
“AIDS has been talked about since primary [school]…It’s been taught
through all strategies from the grassroots level but still there is no change,
there still is number of AIDS are growing, of people having HIV. But each
and every day…on TV, the advert [advertisement] says ‘it begins with
you’…but still no change,” (male, age 22).
In two of the focus groups, participants described how speculation regarding others being infected was sometimes a subject of gossip. According to these participants, if a person was observed to have lost a lot of weight rapidly, gossip about the person’s HIV status was soon to follow. The assumption was that they had HIV: “Cause the question is, why did she lose weight? Why? If nothing else is wrong with her? We gonna say it’s AIDS,” (male, age 21). And, “Here…if I
168 were to get sick and then lose a lot of weight, they will always go HIV. She has
HIV,” (female age 19).
Three of the focus groups explained that when gossiping about HIV, HIV is sometimes referred to indirectly using slang. For example, HIV is sometimes referred to as “the disease” or “having something”, for example, “She’s got something,” (male, age 21). Youth used a number of slang terms playing off the three letter acronym for HIV, for example, one way of gossiping that someone has
HIV is to point at the person with the three fingers and say, she or he is “MTN”
(referencing a cell phone network) or “KFC” (referencing Kentucky Fried
Chicken). The play on three letter acronyms was reportedly sometimes used to refer to HIV without calling the disease by name.
Two related themes that arose in focus groups were the fear of social isolation and negative treatment from others should they become infected with
HIV on the one hand, and distancing from people with HIV on the other:
“You must know all the facts about it [HIV] because it’s a very dangerous
disease and I am so scared of it. I don’t even want them (infected
individuals) around. For instance, if x had AIDS and she was sitting right
next to me, I wouldn’t want her around because, yho! I don’t know how to
say, but I’m scared of a person who has HIV… I have so much fear for the
disease, it’s crazy, like when I see people who have it, when they get sick,
yho!” (female age 15).
However, other participants disagreed with this sentiment, and asserted that people no longer judge you if you have HIV. One participant described how
HIV positive people are accepted in the community, saying: “they accept you even
169 though you know you HIV,” (female, age 19). Yet the fear and stigma around HIV strongly persist, as demonstrated by another participant who argued that while
HIV positive people could be accepted by others, it remained unacceptable to cover up the fact that they were “wrong”, meaning they had behaved irresponsibly which led to their infection. One other participant said that while an infected person could be accepted by others, in the abstract it was smarter not to be in a relationship with an HIV positive partner (female, age 19) because it was unnecessary to knowingly place yourself at risk of infection.
5.4 Perceptions of Other Inter-Related Risks in Daily Life
Focus group discussions consistently revealed a number of risks, which participants termed “challenges”. Participants described the inter-related nature of these risks and feelings of vulnerability to each risk’s negative consequences.
The primary challenges or risks raised in discussions included alcohol and drugs, fears of cheating boy/girlfriends, teenage pregnancy, poverty, and risks to their futures especially related to education and lack of jobs. The most common risks described by participants are listed in Table 5d and described below.
Table 5d. Inter-Related Risks Reported in Focus Groups
Risk 1 Alcohol and Drugs Risk 2 Fears of Cheating Boy/Girlfriends Risk 3 Teenage Pregnancy Risk 4 Poverty Risk 5 Risks to the Future: Education and Lack of Jobs
Alcohol and Drugs
Alcohol and drug use was discussed as a challenge facing young people in the community. This was seen more as a general challenge in the community, not
170 necessarily a challenge for participants themselves, yet participants felt it was an important issue impacting youth. Participants were frustrated by what they perceived to be easy access to alcohol and drugs and by peer pressure to drink or smoke tik or dagga (marijuana). Drug and excessive alcohol use was seen to lead to challenges for youth, such as dropping out of school, robbing to get money to buy drugs, acting strangely, and pulling away from friends and family.
The theme that youth alcohol and drug use fueled the spread of HIV in the community also arose in focus groups. The perception was raised that when other youth drank alcohol they would be more likely to have sex without using a condom: “How will you use a condom when you’re drunk?...They end up having
HIV and AIDS because they end up sleeping with someone while they under the influence and then catching it,” (female, age 18) and then spread the disease further to their boyfriends or girlfriends. “They will go to some place, sleep with guys who have HIV and then go back to their boyfriends. So HIV spreads. So it’s like a chain. It carries on,” (female, age 19).
Cheating Boy/Girlfriends
Both male and female participants overwhelmingly stated that monogamy in romantic relationships was the ideal, and indeed a number of participants reported that they were in mutually monogamous relationships. However, the fear of being cheated on by their boy/girlfriends was a widespread concern raised in focus groups, especially by females. Participants discussed how cheating partners placed them at risk for HIV, and carried additional risks such as social conflict, embarrassment, having their feelings hurt and losing their boy/girlfriend. When partners were suspected or found to be cheating, this
171 reportedly led to fights between boyfriends and girlfriends, fights or competition between the different partners, and feelings of sadness, embarrassment, or being hurt or angry when youth discovered their partners were cheating. Cheating could also result in ending the relationship.
During male focus groups some participants discussed feeling pressure from their friends to have as many girlfriends as possible. Other male participants discussed that while they felt that they should have only one girlfriend, described as a “one and only,” it may not be possible to be faithful to their partners. One participant said he was “still young” and “wanted to have fun”
(male, age 15). Another participant described how he loved multiple girls equally and found it difficult to choose one over the others (male, age 20).
However, other male participants discussed being faithful to a girlfriend they loved and yet others described how they only wanted one girlfriend.
Teenage Pregnancy
Approximately one quarter of focus group participants (n=8) reported having a child, six females aged 17-22 and two males both aged 20. Participants discussed the challenges of having a baby at a young age. Males discussed the challenge of providing financially for the child and mother if they were still in school or not working. Females reported challenges including balancing the demands of school work with caring for a child, challenges of finishing school after having a child, feeling judged by their peers, and the challenges of maintaining their relationships after the child was born.
Participants with children all described the pregnancy as an accident or a mistake that “just happened”. However, in the focus group discussions,
172 participants whom did not have children themselves questioned whether pregnancies were mistakes. For these participants, especially females, pregnancy was largely regarded as a personal choice and those who fell pregnant were often blamed for allowing the pregnancy to happen. For example: “There are no mistakes,” (female, age 19), or: “Everybody has a choice… They’re doing it because it’s their choice” (male, age 21), and: “Seriously these days if you fall pregnant you wanted to have a baby, don’t come and tell me it’s a mistake?
Because at this day and age there are clinics, for us teenagers even. We have pills, injection, and condoms, for free, it’s easy,” (female, age 15).
In some focus groups, participants without children suggested that teenage pregnancy was “the fashion” and speculated that youth wanted to become pregnant because their friends were. In two of the female focus groups participants further asserted that pregnancy was intentional to please boyfriends:
“If your boyfriend says he wants a child then they are willing to risk everything to get pregnant,” (female, age 20).
Despite discussions about how teenage pregnancy was a challenge for youth, some participants reported that it was manageable with social support.
One older male voiced the opinion that while teenage pregnancy can lead to problems such as girls dropping out of school and placing financial strain on the fathers, ultimately, youth could find a way to manage the pregnancy because there would always be support and care for the child under any circumstances:
“To us having a baby is not a, is not a problem. Cause I can have a baby
even if I’m not working. But one thing I know, my baby, my parents are
there, her parents are there. My baby cannot suffer…cause if ever the baby
173 is suffering, it’s fine that way cause we grew up in suffering…So if the baby
is struggling, it’s fine. It’s learning life the hard way. It’s learning about life
the hard way you understand. As long as they there gonna make means for
her,” (male age 21).
Other participants with children further discussed that while having a baby at a young age, especially while they were still in school and when the parents were not working, presented considerable challenges, having a child also brought them feelings of love and happiness.
Poverty and Lack of Jobs
Poverty and lack of jobs was another risk raised in focus group discussions. High levels of poverty created challenges such as not having enough food or not having enough money for school fees or school uniforms which led to missing school. One participant saw his parents struggling with poverty and attributed his parents’ inability to get jobs to the fact that black people were denied access to education under the policies of apartheid which resulted in limiting their job opportunities to part time or irregular, low-wage labor such as cleaning houses. Another participant discussed relatives moving to cities such as
Cape Town in search of work, only to be forced to return to the Eastern Cape when they were unsuccessful. Participants who were out of school described their struggles to obtain employment. Job opportunities were extremely limited and young people in particular struggled to obtain stable employment.
Risks to Their Futures
Virtually all participants envisioned a future for themselves that involved completing their educations, obtaining stable, respectable employment, living in
174 a spacious house in a nice neighborhood, driving a nice car, and living with their spouse and their one to two children. However, youth face tremendous barriers in achieving this near-universal ideal. Risks to youths’ futures included challenges in accessing education, lack of available jobs, and persistent social and economic inequality placing township youth at an educational and economic disadvantage.
Education
Participants spoke about the very high value placed on education as a means to a better life, obtaining respectable employment, and avoiding the
“wrong” path:
“We have to be like going in the wrong direction to get money if you not
educated you see. Because if you not educated like, you would go other
side. Sell drugs. So that is because you not educated so education is really
important factor in the youth…education is key to success,” (male, age 15).
Participants therefore emphasized the importance of attending school, studying hard, and achieving high marks so that they could qualify for post-secondary school or training.
Attending school was discussed by some participants as a challenge.
Barriers to attending school reported by focus group participants included being
“chased” out of school for failure to pay school fees which they could not afford, pregnancy, and dropping out due to alcohol or drug problems or problems at home. Each of these barriers was reported by at least one focus group participant.
Three male participants (all aged 18) were forced to be out of school for at least a year because they could not afford the fees to register. Four male participants
175 briefly attended a nearby school but dropped out citing rampant gangsterism and a fear of experiencing violence while at the school. Another participant (male, age
21) had been out of school for a couple years due to “family problems” and had recently returned to finish school via night classes. However, he was years behind, and at age 21, had not yet finished high school.
Pressure to obtain English language skills for achieving employment and educational opportunities was emphasized in some focus group discussions, primarily in the female groups. English was taught in the schools but participants often had limited opportunity outside of school to practice their skills, putting them at a disadvantage compared to other communities where English was a first language or more commonly used in social interactions. This was particularly a challenge for participants whom had recently relocated from the Eastern Cape where English is less commonly used. One participant explains,
“You must know English. Wherever you go, it’s a must. For example, if you
go for an interview, you can’t just go there and be like molweni, molo and
talk your language. No. It’s a must, you must know English. And
everything is written in English,” (female, age 15).
However, despite the pressure to obtain English language abilities, two participants with advanced English skills discussed how their peers labeled them a “coconut” [black on the outside, white on the inside], and being made fun of, accused of trying to be white, or becoming isolated from others in the community because of their English skills.
176 5.5 Strategies used by youth to manage risks
Participants discussed a variety of strategies they used to manage the risks, referred to as “challenges” that they faced in their lives. Participants actively sought out ways to mitigate the negative consequences of risks, promote their overall wellbeing, and endeavor for a better future.
Cross-cutting themes raised in focus groups were the importance of making good decisions for their futures, giving and receiving social support in their relationships and in the community as a whole, and youth in general
“coming together” (uniting) towards common goals, acting responsibly, and working together to make their community a better place for youth. The strategies available to youth were sometimes limited due to pervasive challenges in the environment, such as lack of resources, and strategies to prevent HIV were particularly complicated for some participants to use.
The primary individual strategies discussed by focus group participants are outlined in Table 5e and described in detail below.
Table 5e. Strategies to Manage Risks in Daily Life
Managing HIV Risk HIV Testing Condoms Choosing Partners Wisely and Developing Trusting Relationships Managing Teenage Condoms Pregnancy Birth Control Social Support Managing Drugs, Believing in Oneself Alcohol, and Crime Participating in Positive Activities (such as soccer) Avoiding Peer Pressure Positive Social Support Community Uniting together Managing Risks to Education the Future Educational Support
177 Managing the Risk of HIV
For many focus group participants, HIV testing, using condoms, and developing trusting relationships were the most commonly reported strategies for preventing HIV. A minority of participants worried that there was nothing they could do to avoid HIV infection because there were too many risks that they could not control, for example, being raped (female, age 19), making a single mistake which meant to have condom-less sex with a partner whom one did not yet know well and might be infected (male age 20), or touching an infected person’s blood, for example by touching someone who was bleeding from being injured in a car accident (male, age 15).
HIV Testing31
Twenty-six focus group participants (13 males, 13 females) reported ever receiving an HIV test (two participants said they had never had an HIV test and eight did not say either way). Reported reasons for testing included because it was compulsory, such as when testing was required for participation in a student leadership program or if testing was required prior to going for traditional circumcision (for males). Other reasons included they were receiving birth control services and the service provider recommended the test, because they wanted to know their status, or they were considering condom-less sex with their boy/girlfriend. One participant chose to receive an HIV test following a “mistake”
(meaning condom-less sex with someone he did not know) that “just happened,”
31 Free, confidential HIV testing and treatment was available at a number of locations in the community or nearby. A national HIV prevention campaign to “know your status” encouraged young people to test for HIV.
178 (male, age 20). Four participants reported testing during public testing initiatives such as programs that provided vouchers as an incentive for testing.
Both males and females discussed the importance of both partners testing prior to having condom-less sex as an HIV prevention strategy. “If she don’t wanna use condom, you don’t wanna use condom, best thing you can do is come clinic…test everything here, STI, HIV, everything…then you can sleep with that girl now,” (male, age 18). However, in a portion of the focus group discussions youth described that negotiating HIV testing with a new partner could be difficult or uncomfortable:
“It’s always hard when you’re meeting someone for the first time and you
say, can you go for an HIV test, cause they always turn it around as though
you saying, you seem like you have an HIV can’t you go and have an HIV
test,” (female age 21).
According to one participant, requesting an HIV test of your partner can bring conflict into the relationship:
“You are bringing conflict between the two of you ‘cause you will fight
about that. She will say to you, what have you been up to, why do you want
me to test now? Don’t you trust me? So it’s a matter of the mindset and the
morals that we have concerning such things,” (male age 21).
Another barrier to HIV testing raised was fear of a positive test, and subsequently having your partner gossip about you or leave you if you tested positive. In the words of one participant: “If you test with a partner and they find out you are positive they will leave you,” (male, age 18). This participant thus felt it was safer not to test with a partner rather than risk a positive test result
179 becoming public. Participants also commonly reported that going for an HIV test was stressful because they feared the outcome and one participant also described fearing the counseling that happened during the testing process because it caused him to question his past behavior and wonder if he had ever made a mistake.
Using Condoms
In the majority of focus groups, participants discussed how condoms were an effective way to protect against HIV. However, a portion of participants also discussed how condoms were not always an ideal strategy, especially in a trusting relationship. For example: “The only thing I believe is that like, my girlfriend that
I’m in love with, she sleep with me only. So then like most of the time I don’t use a condom. I use a condom when I feel like, you see,” (male, age 20). One female
(age 15) reported that she didn’t use condoms in order to please her boyfriend because she was more afraid of losing her guy than of contracting HIV. Another participant tried to change this participant’s mind on this matter, saying: “Let him go. You will find the right person,” (female, age 15). Condoms were reported to often be complicated and sometimes contested issue in relationships.
Focus group discussions also revealed that condoms were not always completely trusted. Many participants reported concerns that condoms could break. “Condoms are not 100% safe,” (female, age 20). “Condom, it [sic] not always safe, it can just burst,” (female, age 15). “You can’t say use a condom, because a condom can burst…and some they use the condoms but some they get
HIV although they use the condoms,” (male, age 20). A few male participants felt that because condoms could burst, they must use multiple condoms at once to protect themselves in the case of breakage:
180 “It’s a risk [to only use one condom], totally a risk here in [the
community]. Do you know that every time they go and a guy come and go
out of here he got HIV, that’s why we doing more than one [condom]. You
must use three at the same time,” (male, age 15).
Condoms were tied to a number of negative associations in some focus group discussions. Some participants discussed peer pressure not to use a condom, saying friends will tell them “awuyityi ibanana ene xolo (meaning do not eat banana without peeling it),” (female, age 16). Other participants discussed not liking condoms, and one male reported that condoms were important but cost prohibitive, because the free condoms were not always available. “I am not a risk taker but basically it’s costing cause, eish, I have to go and buy them,” (male, age 20). One participant described feeling ambivalent about condoms all together, saying: “you agree to it, ok now let’s use this [condom], if you don’t want to it’s fine no problem, I can also work with, you know,” (male, age 20).
Another participant discussed using condoms even though he didn’t like them in order to be safe.
Condom use was considered a matter of choice, and to have sex without a condom was largely viewed as a risk in focus groups: “if you don’t want to [use condoms] you must face the consequences you know what’s gonna happen after you don’t use it,” (male, age 20). However, condom use was not always a realistic strategy for participants. Condoms were not always available or easy to access.
Some males discussed how condom-less sex was a “careless mistake” that “just happens” and typically wasn’t planned. For example, “It’s all about the feeling,”
(male, age 20) because sometimes sex “just happens” “unexpectedly”:
181 “You both connect you know. And then that’s whereby intend to it
happens, at that moment there’s nobody carrying a condom. So it’s gonna
happen [snaps fingers] then. Then, it happened without using a condom.
It’s like you stealing each other if I may put it that way,” (male, age 20).
Such mistakes would however be tremendously stressful for youth, leading them to worry about HIV infection.
Choosing Your Partners Carefully and Developing Trusting Relationships
Choosing a partner that cared about you and whom you could trust was a primary theme discussed in focus groups as a strategy not only for HIV prevention but for developing loving and supportive relationships. Focus group participants also discussed strategies to determine when it was safe, both emotionally and physically, to have sex with their partners. In female focus groups, some females expressed the importance of getting to know boyfriends prior to having sex, and letting him “show his love first” in order to determine if he could be trusted. “For a guy, I need to wait at least six to nine months getting to know him – no sex. Let’s not jump into sex first; let’s spend some time getting to know each other. If he really loves you he will wait for you,” (female, age 16).
One female group discussed unspoken pressure to have sex, because of fear that abstaining from sex would cause the guy to leave them. As one participant said, “It happens like if you have a popular person and you want to keep that person and if that person wants to have sex, you will because you’re under pressure. You don’t want to lose that person,” (female, age 16). Another female participant described the difficulties in waiting to have sex, saying, “I know I’m weak, ndiyacengeka mna (I am easily persuaded), ndingumntu
182 ndinemizwa (I am human and I have feelings),” (female, age 16). One participant described how waiting to have sex wasn’t always easy, because she was worried that her boyfriend had sex with another girl while he waited for her to be ready.
In this example, the participant was proud of her decision to wait to have sex despite the difficulty she faced, saying: “If he is in love he will wait. So I’ve waited…Clearly he didn’t love her,” (female, age 16).
A minority of older males, (n=3, aged 19-21) discussed avoiding HIV by, among other things, choosing girlfriends wisely. They discussed choosing girlfriends they felt looked healthy and who acted “right”, meaning they did not have reputations for having sex with a lot of people.
Developing trusting relationships was important to both male and female participants. To trust one’s partner included being assured that his or her partner was open and honest and was not also dating someone else. For a number of participants, trusting relationships were sources of happiness and social support.
For other participants, establishing trust was an ideal that was difficult to achieve in some relationships. For example, “trust comes from within depending on how much you love that person and trust, so if you trust her with all your heart then, but I would say always expect the unexpected,” (male age 20). One male discussed that it’s important to never trust too much, because over time trust deteriorates. “Always have space for disappointment in a way that your girlfriend is gonna disappoint you at some point in time. Say maybe not now but at some point in time,” (male, age 20). “But you can’t wait for that” (male age 20).
Furthermore, one group of older males discussed how it was not easy to be honest because, “sometimes the truth hurts,” (male, age 20). These males
183 suggested that girls would leave boyfriends that cheated, so boyfriends would not tell if they cheated because, “It’s like you doing it for the sake of protecting yebo,”
(male, age 20). Similarly, one group of females was mixed as to whether or not they would want to know if their boyfriend had other girlfriends. One female stated that if her boyfriend made it obvious he was dating other girls, it would be disrespectful to her and an indirect way of ending their relationship:
“It’s better if you’re respecting your girlfriend, your girlfriend doesn’t
know you’re dating. But if the girl knows that you’re dating and if you go
passed that girl with another girlfriend, it’s not respecting her. So in other
words he’s dumping you,” (female, age 16).
Females’ discussions about how they would react if boyfriends had other girlfriends were mixed, ranging from feeling embarrassed to hurt to breaking up with him. For example one participant says: “I say “it’s over” immediately.
Because if you upset me and I forgive you, I won’t be precious to you anymore,”
(female, age 15) and another replied that: “I can endure it, but I will speak up and tell him I don’t like what he’s doing,” (female, age 16). Males similarly discussed that being cheated on was a social embarrassment.
Strategies to Prevent and Manage Pregnancy
Male and female participants overwhelmingly reported that the best time to have a child is after completing school and begin working in order to provide support for the child. Therefore preventing pregnancy in dating relationships was reportedly a concern amongst a number of participants.
Many female participants discussed how using condoms or birth control such as the pill or injection could prevent pregnancy. However, birth control
184 methods were not always easy to access. In addition, a minority of females discussed fearing the side effects of available birth control methods, such as making your body shake, fears that the pill causes you to be overweight, or fears that the injection would “dry up” your reproductive organs (stop or slow their menstrual cycles). These participants felt that the side effects were not worth the benefits of pregnancy prevention. A subset of other females (n=2) discussed not using birth control because they did not like to take pills or receive injections.
Two females discussed how they did not access birth control at all because they were scared to go to the clinic. During focus groups other females encouraged these participants to “yiya eclinic (go to the clinic) xa nifikele kula level (when you get to maturity),” (female, age 16) in order to obtain birth control. Some participants described avoiding the clinics for fear of others in the community seeing them and discovering that they were sexually active.
The recently opened youth clinic in the community was an important development for this issue, especially for participants who could not speak to their parents about birth control: “it’s not easy because you won’t tell your parents, ‘Mum I went for family planning and I am getting birth control pill.’ You can’t do that!” (female, age 16). Therefore having a place where youth could access birth control, without involving their parents and at a place where they could feel confident that their privacy would be upheld, was important for facilitating access.
Male participants regularly discussed talking to their girlfriends about birth control. However, according to one older male, it could be difficult to ensure one’s girlfriend was on birth control outside of long-term relationships.
185 Participants with children utilized a number of strategies to manage having a child when they did become pregnant (or “fall pregnant”). For female participants who became pregnant while still in school, having social support from their family and/or the father of their child made the pregnancy easier to manage, such as by receiving help with child care or providing necessities for the child. A few of the females reported being forced to drop out of school to care for their baby: “If you are pregnant in the middle of the year you drop. You have to,”
(female, age 19). However, two other female participants were able to stay in school because their mothers were willing to help care for the child. “If your mother’s willing to help you…if your parents are willing to help then you can [stay in school]” (female age 20).
Taking steps to provide for their child was reportedly highly valued by male participants and gave males a sense of pride when they were able to do so.
Male participants with children sought support from their own families or sought work in order to provide for their children. Another male discussed taking a job in order to support his child. Providing financial support to their children posed particular challenges for males whom were still in school or whom were unable to find employment. One male found having a child to be difficult but manageable:
“it’s not a big deal…I can handle the situation you see,” (male, age 20).
Male participants with children reported that they must “take responsibility” and put the baby first, which involved supporting the mother and child both financially and socially. For two female participants who did not receive support from the father or from their families, they held part time jobs in addition to attending school in order to support their children. Two participants
186 sent their children to live with their own parents or other relatives in the Eastern
Cape who cared for the child while the participant finished school.
Strategies to Manage the Risks of Drugs, Alcohol, and Crime
Believing in themselves, avoiding peer pressure, social support from friends and family, having access to positive activities such as soccer, and uniting the community together to address these challenges were the main protective factors described by participants for avoiding drugs and alcohol. A few participants were concerned that there was “no solution” to the challenges presented by drugs, alcohol, and the related issue of crime in their community.
There were no services in the community for young people, most of whom were males, struggling with drugs or alcohol and therefore, youth were then required to manage these challenges on their own.
A few male participants felt that peer pressure was so strong that the only way to avoid drugs and alcohol was to not have friends. For example,
“My friends, most of them, end up going to jail, and some of them are, end
up being drug addictors [sic - addicted to drugs]. And that’s why it is that
I’d rather be alone…so that I can live my life without any violent (violence)
or something like that,” (male age 20).
Participants also discussed the difficulties in always doing the “right thing” and making the “right choices” and how they sometimes struggled to do what they believed was best for them. In two of the focus groups, participants discussed that although their behaviors were their choices, and that it was up to them to make the right choice, this was not always easy to carry out. “You must
187 always try to make the right choice at all times. But then sometimes you don’t always make the right choice, so. That’s the hard thing,” (male age 15).
Two focus groups of male participants believed the key to improving these challenges was for the community to come together, for example, “We should come together as a group…to make our community safe and good,” (male, age
15). The theme of coming together as a community was often discussed by males as a key strategy for addressing the challenges they faced.
A few focus group participants had been involved in successful community mobilizations in the past. For example, some participants were involved in a toyi- toyi that happened in the community for a new school. A toyi-toyi is a Southern
African dance involving stomping feet and chanting that has been widely used in
South Africa for political protest. They succeeded in getting the school built, which proved to the participants that they had political power, as demonstrated by this quote:
“Only the youth can make things happen, if they have the courage to stand
up and ask for what they want it will happen. For example [the high
school]. The youth got the school after the parents were not able to,” (male
age 19).
Strategies to Protect the Future
Participants were primarily concerned with building a better life and a better future for themselves than what their parents had experienced. Education was overwhelmingly perceived as the primary means to accessing a good future and improving their life circumstances. Many participants viewed education as an important right provided to their generation, in contrast to their parents’
188 generation many of whom were denied quality education under the apartheid government. Some participants migrated to the study community for the better education offered there. A number of participants spent considerable time in extra tutoring classes at the school and local library to increase their chances of continuing their studies after matric. Other participants dedicated time and energy to activities they felt would better themselves, such as drama programs, sports teams, or other activities that would help them develop their skills.
Despite these extra measures, access to tertiary education remained largely unavailable to many youth. A number of participants attended vocational school after matric and one participant who received sponsorship was able to attend university. However the vast majority of participants were unable to continue their schooling post-matric.
Participants nonetheless described focusing their energies on improving their life circumstances and discussed a drive to do well in school so that they could obtain further schooling and find stable, respectable employment when their schooling was complete. Participants continually strove to keep moving forward towards a better future despite setbacks. In the words of one participant,
“Many things happen in [community], but then if you [are] wondering how do people think and how do they react towards their actions, they say they don’t care, as long as they are going forward,” (female age 19).
5.6 Contextual Factors
Focus group discussions provided significant contextual data about the experiences of youth that was used to situate interview and questionnaire data
(collected in Phase 2 of the study and presented in Chapter 7) in the context of
189 youth daily life. Key contextual data, including community resources, dating relationship norms and love, and concerns over competition and style are described below.
Community Resources
Participants discussed the relative availability in their community compared to other townships of services such as good schools, clinics, a library, and close proximity to wealthy areas and businesses, which are seen as places of possible employment. Some also mentioned local churches as a positive aspect of the community. A number of participants emphasized that having somewhere to go, like the library or soccer practice, was important for keeping them away from
“bad things”.
The community was often described as a friendly place, where people look after others and take care of their families, where residents are social and chat with each other, and where people support each other. The community was small enough that it was possible to know everyone, which made young people feel safe.
“Here, anytime I want to go out, even 9:00 or later I just go…I’m not scared of what can happen to me cause I know everyone here,” (male, age 22).
In addition to these positive aspects of the community, participants also discussed how townships were places of relative depravation when compared to wealthy, white residential areas, called “suburbs”. Participants discussed how high levels of poverty, overcrowding, and extremely high rates of migration and rapid expansion of the informal areas of the township placed economic and social strain on the community’s resources, and contributed to what was at times a chaotic environment. Levels of crime and violence in the community were
190 perceived as being on the rise in recent years, which concerned a number of participants.
Participants also discussed the relative lack of positive activities available to them, and how this impacts their motivation. For example:
“There’s nothing that just inspires people. And there’s this thing here, if
you here [in the township] you will never succeed. But if you go
somewhere else then you would come back in a year or something with a
nice car and stuff but what when you were here you were just nobody. It’s
just the theory we have here,” (female, age 20).
The lack of positive activities was frequently blamed for drawing young people into unsafe places such as taverns, which led to unsafe behaviors. “Everything around here revolves around boyfriends, taverns, and all the negative stuff,”
(female age 20).
Dating Relationship Norms and Love
Dating and sex were described as expected, normal parts of participants’ lives for youth who were old enough and felt ready. According to focus groups, youth generally started dating by the age of 14 or 15. The actual age of starting to date for each participant is unknown. Dating was often discussed as exciting, related to love, social support and experiencing happiness in addition to acknowledging risks such as HIV and pregnancy. Many participants reported currently dating (five males and two females reported not dating), four younger males (ages 14-16) reported not being sexually active though most reported having girlfriends, and some participants did not report their experiences either way. Some participants discussed avoiding dating completely in order to focus on
191 their futures. The vast majority of participants, both male and female, reported dating individuals that were the same age or close to their own age.
In addition to the positive aspects of dating such as love and trust, participants also discussed dating challenges, including fears of cheating and preventing pregnancy and HIV in relationships. A few males expressed frustration that girls don’t want to date them because they don’t have money:
“The girls, they don’t want to date the people who live here because we
don’t have the money…to buy them the clothes…the girls that are living
here they don’t want to date someone that don’t have the car,” (male, age
22).
Female participants however did not report choosing boyfriends based on this.
Females in turn complained that guys were not honest about their age and about having other girlfriends. One all-male focus group discussed this accusation, and commented that guys do what they need to do to get a girl to date them. For example, “If I come to you and tell you I have three girlfriends, are you going to date me? We will say what we need to do to date you,” (male, age 22).
Some males in a subset of the focus groups suggested males were expected to have “many” girlfriends, indicating social desirability for males to project the appearance of sexual experience.
Overall, sex was discussed by older participants as a normal, expected part of dating relationships when both partners were ready, with positive benefits such as excitement, happiness, receiving and demonstrating love. Sex was also seen as carrying risks such as HIV and pregnancy. One participant (female, age
192 21) described how sexual relationships could provide new experiences for youth and could also be a way to explore one’s identity and learn about oneself.
According to a number of the female focus group members, despite the possible risks such as HIV, sex was part of love and what made life good and something that “everyone” eventually wants (female, age 16) once they are ready.
“Sex is also part of life. And boys yeah. Cause in life you won’t die having no boyfriend; die a virgin,” (female, age 17). Three younger females described how having sex made them feel mature, which was both positive and negative. For example, “you don’t want to listen to your parents because you see yourself as old. And then your behavior at school will start to be low,” (female, age 17).
Some participants discussed how having sex was closely linked with seeking and expressing love. For example, “As long as intliziyo yakho ithithanda andina ndxaki (As long as my heart feels him and is loving there is no problems)”
(female age 21). For younger females in particular, “It’s all about having the itliziyo (“heart or love”) for someone,” (female age 16). While some female participants discussed worrying that others would gossip about them and who they were dating, other females in the focus group offered advice such as to go after someone they loved and not worry about the gossipers. For example, “The people that talk behind your back are not going to give you that love…” (female age 16). “Love is love. Just grab at the opportunity,” (female age 16).
Competition and Style
Competition amongst youth over boy/girlfriends added to social pressure of sex and dating for some participants. Some participants discussed the pressures of competing for guys/girls and social status tied to their relationships.
193 Some participants also suggested that there was competition to become pregnant, for example by accusing other girls of becoming pregnant intentionally: “it’s like I want to show my boyfriend’s girlfriend that she won’t have him anymore because he’s the father of my baby now. If I fall pregnant, I’ll be the one and only,”
(female, age 16). Some males also discussed how other males compete with friends over having children, or over who had the most beautiful girlfriends.
Some male participants criticized females in the community they felt were susceptible to outsiders with money and fancy cars. Some males complained that men of greater means seduced local girls with their money and style and promises to buy gifts such as clothes. However, females in turn also discussed the risk for girls when they accepted gifts from men in situations where the male would then feel as if the girl would be obligated to the man. “They don’t have a choice, because the guys gave them money. They bought them,” (female, age 20).
Females and males thus both spoke negatively about doing this and no participants discussed doing this themselves.
Style and fashion were common themes raised in nearly all focus groups.
Having fashionable clothes was an important status symbol for males and females. A specific type of loafer shoe that cost around R1,000 (which at the time of fieldwork was over $100), was particularly desirable for younger males. Some participants discussed using fashion and dressing in “the style” to project an image of themselves as “being on top”, especially on Fridays. Another participant described her observation of other girls focusing on fashion, for example: “On
Friday, I should look my best. I should put on make-up. It doesn’t matter if it matches. It doesn’t matter if it doesn’t. As long as I have status,” (female age 21).
194 Some females did not welcome the emphasis on fashion, for example: “weekends are boring cause you have to figure out what to wear every weekend, you have to have something to wear, something beautiful to wear,” (female age 19).
Two of the female focus groups discussed the pressure to have expensive, name brand clothes when they could not afford them:
“Yes. Like there’s this shoe that everybody should have from Khayelitsha,
and it costs R1300. And my parent cannot afford it. Sometimes we can all
have it if your mother gets money. But if you are not wearing that skinny
jeans from Guess clothing, cardigan by Aca Joe you out of fashion and you
wear from Mr. Price. You are nothing. You’re cheap,” (female age 15).
For two participants attending wealthier schools, the lack of fashionable clothes made them feel self-conscious and isolated from the other learners at their schools who could afford nicer clothing. These participants described how that in order to fit in they must have the right clothes, or Iimpahla ezintle [Nice clothing], and discussed wishing for these clothes that they could not afford. But their concern with having the right clothes was tied to larger issues of upward social mobility. The issue is illustrated in the following quote:
“…it’s a competition. It’s not competition but you must show expression to
other people. You have friends in higher places. I could say to have friends
in higher places because me, gosh, I’ve got friends who wear expensive
stuff. It’s like a struggle because I am struggling too…they don’t force me
to buy expensive stuff but, to me, it feel like I have to because I have to fit
in. Because to me, it feels like I don’t fit in with my friends, you know. So,
ja. So I always wanna fit it. I know I’m in, we’re friends. We’ve been
195 friends for a very long time but I must also show myself out” (female age
15).
In a few of the male focus group discussions, particularly with younger males, concerns over style and competition were also salient and centred around issues of gangsterism and local “crews”. A number of local “crews” had developed in the community and each crew exhibited a particular style, such as a style of dressing for example wearing a particular loafer shoe, or exhibiting a lifestyle such as playing music. At times the crews would compete with each other over girls or status in the community. Crews of young males were seen as both positive, providing positive social support for the males, and negative, for increasing conflict between different crews.
5.7 Summary
Focus group discussions introduced the risks impacting youth daily life and strategies used to manage them. The primary reported issues were risks to their futures including lack of educational and employment opportunities.
Discussions also revealed participants’ fears that they or their peers would fall victim to other risks they identified in their environment, including crime and violence in the community, gangsterism, poverty, high rates of HIV, anxieties about cheating in romantic relationships, and drugs and alcohol. Issues of competition, style, and status were woven into focus group discussions of everyday challenges. Outside of day-to-day concerns, participants were primarily focused on building a better life and a better future for themselves than their parents had had.
196 HIV was perceived as a significant risk and participants discussed feeling vulnerable to infection, even if they took measures to protect themselves, because of factors such as their awareness of the nationally and locally elevated HIV rate or the fear that a single mistake such as a condom breaking could result in HIV infection. Participants wanted to prevent HIV infection and endeavored to do so by avoiding risky relationships, by developing trusting, loving, and monogamous relationships, and, in cases where it was feasible and made sense for the couple, testing for HIV and wearing condoms. Male and female participants were concerned about what they described as the bad behavior of other youth for spreading HIV or for causing conflict in dating relationships; this was discussed in general and not in relation to their own experiences.
Participants strove to manage these day-to-day risks in their lives. Positive aspects of the community such as it being a small place where people help each other and the availability of certain programs such as soccer, tutoring, and drama groups were reportedly helpful to youth in managing risk and promoting wellbeing. Working hard in school, participating in sports, having supportive relationships, helping out their families, uniting the community to make the community a safer place for youth, and focusing on the future were discussed as important strategies for youth to promote their wellbeing. Participants however also discussed fears about making a mistake that could result in “wrong things” such as HIV infection or falling into drug addiction. Participants talked about how it wasn’t always easy to make the right choices and avoid challenges such as becoming involved with negative peer influences.
197 The themes identified in focus group data established youth perceptions of local social norms and the social context in which participants understood, talked about, and managed risk in everyday life. Interim data analysis was conducted on focus group data in the field and key themes identified in this analysis were incorporated into the interview and risk assessment questionnaire tools for follow-up in the second study phase with the second sample of youth. [Results presented in Chapter 7.]
198 Chapter 6. Diary Data
6.1 Introduction
Focus group participants were offered the chance to continue to participate through written diaries. The goal of the diaries was to gather data regarding youth daily activities and the thoughts and feelings youth had about their daily lives that would inform research questions regarding youth daily life and the risk environment. Sixteen participants elected to write in diaries and were given a diary, a pencil, and instructions. Of these sixteen, nine completed diary entries, four males and five females. The most common reasons the other seven participants provided for why they chose not to write in diaries included losing their diary or changing their mind about wanting to keep a diary. Table 6a details the number of entries completed by each participant. One participant’s diary was burned in a home fire resulting in lost diary entries which were not counted. Due to the small sample size, findings are descriptive but still of interest for providing in-depth participant narratives about study objectives.
Table 6a. Table of Diary Participation
PTID Age Sex Number of Entries FG04 15 M 7 FG09 20 F 5 FG10 18 M 26 FG15 20 M 27 FG18 20 M 16 FG20 22 F 67 FG28 17 F 15 FG31 15 F 17 FG35 21 F 7
199 6.2 Method
Each participant was provided with a diary, a pencil or pen, and instructions. Diaries were nondescript, small size notebooks with a semi-hard cover. Instructions were taped to the inside cover of each diary (Appendix D).
Participants were instructed to answer the questions listed in the instructions and to focus on the who, what, where, when, and how of daily events, as well as their feelings about events. Participants were given counseling on how to maintain the privacy of their diaries.
Participants were instructed to bring in their diaries at the end of 4 weeks.
A discussion was held with each participant about the diaries and participant feedback on the method. Field notes were taken during these discussions. Diaries where photocopied and then returned to participants for them to keep.
One participant chose to diarize through drawings and photographs taken on a digital camera. The participant explained each image to me at the concluding interview and field notes about the discussion were taken. The original drawings were returned to the participant. Descriptions of each photograph were transcribed and original photographs were deleted. Each discreet event recorded by the participant was counted as a single entry. For example, multiple photos taken of an evening out with friends was considered one entry.
6.3 Analysis
Photocopies of the diaries, descriptions of images including image content and field notes were transcribed. A summary of each diary was created and diaries were coded for themes.
200 6.4 Findings
Daily Activities
Males reported daily activities such as soccer practice, school drama practice, and spending time with friends. Females reported their activities at school, shopping or spending time with family. One female participant described the chores that she was responsible for in her home, including caring for her young daughter. Five participants were in their matric (final) year of high school.
Matric is a busy time for students, and matrics often have extra classes in the evening during the week and on Saturday. Participants in matric reported frequent study sessions and exam preparations after school and in the evenings.
Participants described the positive impact certain activities had on their lives. Males particularly reported the benefits of soccer, church, and spending time with friends and females frequently wrote about the positive impact of school, church, and family. Females also wrote that having money to go shopping for food, laughing at jokes and being with supportive friends were positive events.
Male and female participants wrote that taking excursions outside of the community, such as a trip to Table Mountain with family, to see a church choir perform or to visit nearby cinemas, were sources of enjoyment. One female participant took an excursion to a beach, which made her very happy, but sad at the same time, because she compared the beach community to her own community and she felt as if her own community was not fun.
Dating and Sex
All three of the males who wrote diaries but none of the females mention the topic of sex in their diaries. Females and males both wrote about dating. One
201 male participant wrote about breaking up with his girlfriend, which made him sad, and then getting back together with her which made him happy because he wrote that he loved her. Another male participant described feelings for a girl who was already in a relationship, preventing him from dating her, and he reported fearing that his feelings were disrespectful towards the girls’ partner.
Another male participant described a critical attitude towards girls in the community, saying that girls only wanted to date guys they thought had money as demonstrated by nice clothes or having a car. This participant reported that it was difficult to date because of the expectation that he needed money in order to impress and keep a girl.
One female reported that her boyfriend broke up with her. The situation left her feeling confused and angry and she no longer trusted him because he lied to her. Another female participant had recently met a guy that she “loved”. She liked that he was “beautiful” and wore “nice clothes”, but she wanted to “check and see if he was the right guy” for her before she started dating him. She wrote that she wouldn’t date him without knowing “where he comes from and how did he treat himself before he came to me.”
One female participant wrote that she was very happy with her boyfriend because he introduced her to his family, which is a big step. She was nervous about how they would react to her because her boyfriend’s family lives in a more affluent community that she does. When they reacted well to her and treated her nicely, she wrote about feeling “shocked” but very happy, especially when they asked to meet her child.
202 Health
Four participants (three males and one female) reported regularly exercising and one female participant wrote that it was important to stay healthy and “protect myself from wrong things and going at night.”
Three participants (two males and one female) reported an illness in the diaries. One participant went to the hospital because of a severe stomach pain that prevented sleep. Another participant was suffering from a persistent problem that included weakness and pain throughout the body that made it difficult to sleep. One of these participants is also kept up at night with bad dreams related to a death in the family. One female participant became ill during trial exams at school, which caused her to do poorly on one of her trial exams. “I manage to write but unfortunately the time was over my heart was so broken because I did not finish all the questions mmm it a bad day for me!!!”
Death
Three participants reported a total of five deaths in their families. Three of the deaths occurred during the diary period including one participant who experienced two deaths in the immediate family. One participant reported two family deaths that occurred prior to the diary period but that the participant still found troubling, including the sudden death of the participant’s father. This led the participant to have feelings of vulnerability, writing that because the father died suddenly, death could come anytime. One participant lost a sibling close in age to the participant, who fell ill and was vomiting and unable to eat. The participant’s sibling traveled home with her parents in the Eastern Cape in order
203 to receive care “from the special doctor”, but the sibling unfortunately died in the hospital.
Social Proximity to HIV and AIDS
HIV was mentioned in two of the diaries. In the first case, a female participant decided to become educated about HIV and AIDS after chatting in the focus group about HIV and AIDS. In the second case, a participant discussed a sibling infected with the virus. The sibling did not disclose this status to the participant; rather the participant found the sibling’s ARV medications and asked the sibling’s partner, who confirmed that the sibling was HIV positive. The participant was devastated by the news and struggled with being unable to talk about the issue, even with family, but wrote that the situation must be kept secret: “its painful to keep it inside me but for [sibling] I promise to die with it.” This discovery was particularly confusing for the participant: “I was so angry and confuse [sic] on how did this happen because [sibling] was the one who was telling us about condoms all the time” and “am so sad because [sibling] had to upstain [sic – abstain] and be faithful.” The participant wrote about the importance of acting to avoid HIV, for example: “[I] would like to pass this message to our youth out there, that life is not to play you must upstain [sic – abstain] be faithful and condomize all the time.” The participant further wrote that “I must choose the right way to do things and think for your future”.
Environmental Risks
A lack of opportunities for schooling or employment after matric was evidenced in two participant diaries. These participants had completed school but
204 were unable to find work and thus wrote regularly about being bored and having nothing to do.
Poverty and precarious financial situations were discussed in four of the diaries. Some participant diaries described how parents struggled to provide food for their children. Another participant (female) worried she would not be able to attend her matric ball because the family member that was going to pay for her to attend had passed away. A third participant (female) was not attending school because the school had billed learners (students) for educational expenses and the participant did not have the money and her mother could not afford the cost.
The participant was stressed about this situation and ultimately the participant’s boyfriend gave her the money she needed, which made her feel as if he really cared about her and that she could trust him.
Another participant (male) reported feelings of loneliness and insecurity about living in poverty, such as fears that richer people would make fun of the participant’s way of life. This participant discussed how poverty causes feelings of isolation and being alone, because it is difficult to share the “poor side” of life with others and because of the damage that poverty, including having to beg for food and not having enough money for basic necessities, has done to the participant’s family’s sense of wellbeing. After this participant’s father died, the participant’s eldest sister was forced to drop out of school, move to a nearby city, and seek employment to support the family. This participant’s family finally found financial relief in an unfortunate circumstance that resulted in receiving insurance money, which allowed them to build a house and temporarily alleviate their poverty: “Life started to be a life.”
205 One participant (male) wrote that extreme poverty was also destroying the community. “The poor and hungry is killing them” and “its hunger, poorness that make [community] to be poor or unemployed.” The participant wanted to change this situation, and “not let hungry [sic] and poverty to abuse our people.”
Reporting concerns about the wider community was a theme in some young males’ diaries (n=3). Reported concerns included poverty, youth using drugs and smoking, and alcohol use amongst youth; easy access to drinking alcohol in shebeens (slang for unlicensed tavern); inadequate infrastructure in the community for sanitation such as lack of waste removal; and failure of the law to protect people from harm. For example, one participant described the problems of living in the informal (un-serviced) sector of the community. In the winter during the rainy season, a stream running through the informal sector tended to flood over its banks, flooding homes in the nearby area. A flood is often devastating, because people’s possessions are ruined, and shacks in the informal sector tend to have non-permanent floors which easily become muddy and don’t dry quickly, making the shack damp for long periods of time and sometimes bringing rats and other vermin through the area. The flooding also spreads trash around, because people pile their trash in an area near the stream but the trash does not always get picked up and removed by the municipality, resulting in flood waters spreading the trash throughout the area and causing unsanitary conditions. Volunteer groups in the community regularly work to clean up flood- affected areas but not much can be done for a flooded shack. This participant was frustrated by the lack of services provided by the government but also blamed
206 residents themselves for the situation, complaining that they should not be dumping their trash.
Two male participants reported that youth drinking was a widespread problem in the community. One complained that it was too easy for underage youth to obtain alcohol and the other reported feeling disappointment in youth that drank alcohol. Nonetheless, one of these participants also explained that walking around at night and congregating around the taverns in order to chat with other residents and listen to music was a popular activity for many youth, and a fun way to chat with friends and meet new people.
Lack of services to address crime was also raised in some diaries. For example, one male participant described a crime against his younger sister that he found very distressing. The participant was frustrated by what he considered to be lack of attention from police about the incident, writing “our law does not defend us.” This participant also fears crime in the community in general, writing
“to all the parents and our sisters be careful on the streets because you could lose your life for something that you own.”
Discussions of migration in the diaries revealed the positive and negative aspects of population mobility on the lives of youth. For example, migration and mobility creates situations where youth are often living far away from a parent or other family members who may be sources of support for youth and therefore being away from them may create vulnerability. Yet mobility also creates conditions that are helpful for youth such as a way to escape interpersonal or family conflict or in order to access health care or educational services. Some male and female participants wrote about the number of different communities
207 in which they had lived. One male participant moved out of the study community to another community nearby to escape a conflict he was having with another person. Another female participant moved to a township on the other side of the city because a relative asked her to stay in his shack while he was living in the
Eastern Cape. One female participant described preparations to travel to the
Eastern Cape during the holiday season to visit family.
Risk Management: Youth Choices and Strategies
Participants wrote about the choices they made in order to manage reported challenges such as poverty, youth alcohol use, bullying, feelings of loneliness stemming from poverty and an inability to share feelings with others.
One participant wrote about how faith in God helped manage challenges. Some participants were faced with difficult choices. For example, one female participant wrote about choosing to end her relationship with her father following her parents’ divorce because “I was deeply hurt to see my mom so hurt like that” and “I had to make a choice, that do I have to hate my father for hurting my mom and left here [sic – her] without anything.”
Another female participant reported her choices relating to the challenges of caring for her child while still in school. When her child became ill, the participant was scared and felt like a bad parent. “I was feeling scared and telling myself that I am an irresponsible mom and feeling the pain of my child.” This participant wrote that her child was the most important thing to her, and she chose to stay up that night helping her child instead of sleeping even though she was writing an exam the next day at school.
208 Being able to alleviate financial shortages in their families was written about as making a few participants happy. For example, one participant reported feeling good about herself because she was able to buy food for her house with the voucher she received as part of focus group participation. One female participant wrote that she realized she must choose to use money for needs such as food and not for wants such as clothes, because she saw how her mother always tried for her and her siblings to ensure they had the things they need. “My choice was to always use new money when you got it but use it by the right way, the right way is to buy your needs not to buy even [every] want example buy food for at home wants are buy sweets and chips while you don’t have food at home. The thing that made me do this choice or choose this choice is that I can’t just look at my mother always trying for us without anyone who’s with her.”
A number of youth described the strategies they use to avoid what they consider to be the negative influences in their community, such as gangs, smoking and drugs. For example, one male writes that “The reason why I’m happy is because soccer is the best sport ever and it gets me away from all the bad thing that happen around my community (smoking drugs or smoking etc.)” and
“Right now what am focused on is playing soccer and reading my Shakespeare so
I don’t really care about gangs.” One male chose to stop hanging out with certain friends because they had started to smoke.
One female reported choosing to increase her knowledge of HIV and AIDS, which she called “becoming aware”, and to test for HIV every three months
(which was recommended by the Department of Health) following discussions of
HIV/AIDS in the focus group in order to avoid becoming infected with the virus.
209 The focus group discussion also led her to resolve to find out if a boyfriend was the “right boyfriend” for her, which she would determine by asking herself, for example, if he took good care of her and took the time to get to know her. This participant described that these were important steps she must take in order to take care of her personal wellbeing.
Focusing on the future and on school was one strategy youth reported for overcoming challenges posed by the risk environment. One male coped with poverty by working hard in school, writing: “I pushed so hard to learn and make my parents proud and make my home a better place that people will respect and honour with dignity and respect.” One participant coped with a troubling past by committing himself to focusing on the future and not thinking about the past:
“And caring as usual from now onwards I am going to look on my future but not past, focus on my school work and ignore the issues and learn how to face my fears…everything that has happened to me all these years made me realise how life is important because life doesn’t go back it moves on and so do I…”.
One participant (male) wrote that the way to address challenges in the risk environment is for the community to come together to “share and help one another and build togetherness.” This participant wrote that youth in particular must come together and “believe in themselves and believe in their dreams to make the community a better place”, and felt strongly that older youth must set a good example for younger youth in their actions because drinking and smoking sends a negative message to young youth. This participant wrote about the steps he thought were important in his own life for doing this, starting with facing his fears and standing up to fight for his rights.
210 Social and Instrumental Support
Social support was an important factor reported in participant diaries for managing challenges. Both males and females reported seeking advice from their mothers (two females and one male) about health problems, from siblings of the same gender (one male), and from friends (two females). Youth also reported receiving support from cousins and friends in completing chores and managing challenges.
Simply sharing their troubles with others was helpful for a number of youth. For example, one female writes “My day was bad, I was hurt but I am feeling more better than before because I will be sharing my pain with someone who will be reading my diary.” One male participant regularly discussed how sharing his feelings about the challenges in the community with others made him happy and the importance of his friends reacting supportively, positively, or by sharing their own feelings in feeling better himself. Some participants sought support outside of their communities where they feel that they were freer to share their problems without being judged.
One female reported offering social support to a friend of hers who was pregnant. The friend feared her parents’ reaction to the pregnancy and the participant described encouraging her friend, writing, “I decided to encourage her as a friend my encouraging words from me to her was…your parents will forgive you as time goes on and maybe you are pregnant the president of tomorrow or the person who can change this world to the better world…” and
“even at church I prayed for her and I wish god could give her good idea about her life.”
211 Receiving financial support was reported by a subset of participants as an important aspect in feeling socially supported, such as the case of the participant who’s boyfriend gave her money for school fees. Two female participants wrote about how it made them happy when their fathers or the father of their own children bought gifts or essentials such as shoes for their child. One participant wrote “I was so happy because when my family is happy am also happy.”
Social media was only mentioned twice in diaries but in both instances social media was used to seek support from friends. In one instance, a male participant sought advice from friends on Facebook on what could be done to improve their community. In the other instance, a female participant reported logging on to MXit to chat with friends for an hour or so at night before sleeping when the participant felt bored or lonely. In both of these instances, the participants were using social media to connect with friends, either to receive advice or to engage socially on an otherwise lonely day.
Structural Support
Structured activities such as soccer teams, school drama programs, and school trips to nearby colleges reportedly provided youth with positive activities, provided motivation not to smoke and drink, and helped youth decide on their plans for the future. For example, one participant wrote, “Well today is the day that most people go out and party with all the [other] guys, but what I’ll do is I’ll stay at home & watch movies…” because he was waking up early for soccer practice the next day. Another participant was able to make a plan for post- matric studies following a school trip to a local tertiary institution. These
212 activities are therefore important tools that assist youth to manage vulnerability in the risk environment.
Government services were valued by youth as means to address factors in the risk environment. For example, one male participant described at length the new lights that had been erected by the local government in the informal area, saying that the lights provided much-needed security and a sense of safety for residents. When the area is dark and unlit, the participant felt vulnerable to break
– ins and attacks by gangsters.
A subset of participants sought health care from nearby hospitals and municipal clinics for illnesses. The study community was fortunate to have relatively good access to health care facilities, unlike many townships where residents must travel greater distances to access a facility.
Gender
The diaries revealed few differences between males and females. However given the small sample size, conclusions that can be drawn from this are limited.
Regarding daily activities, all four males reported participating in soccer teams but none of the females discussed any type of sports participation. Three females reported having children for whom they were primary caretakers compared to zero of the males. Males (three out of four) tended to report frustration with the general problems they see amongst youth in their communities such as poverty, lack of basic services or youth alcohol use, whereas this was not mentioned in the females’ diaries. Females instead wrote about challenges that they, their families or friends were facing.
213 Three males wrote about experiencing peer pressure from other males but females did not discuss peer pressure. One male reported peer pressure to have a girlfriend to the extent that his friends left him for not having one. This participant writes, “All my friends left me because I have no girl, and they make me feel stupid.” Another male participant wrote about pressure to drink alcohol and another was told by his sister’s husband that he “must be strong” and that “A man doesn’t cry” when he was suffering from severe pain that kept him awake at night, but the husband did ultimately advise the participant to visit the hospital the next day.
Males and females both reported challenges in dating relationships and both genders reported trying to determine if they were dating the “right” person for them. Females wrote about establishing trust in relationships and males acknowledged sexual activity in relationships whereas females did not.
6.5 Discussion
Due to the small sample size, conclusions that can be drawn from diary data are limited. However, diary data raised themes for follow-up in interviews and questionnaires. Overall diaries revealed the impact that lack of adequate services in the community, poverty, peer pressure, alcohol, illness and death in the family can have on youth daily life. Participant concerns also focused on school, dating and relationships, and addressing challenges such as the future.
Participants described numerous strategies to manage these concerns, especially seeking support from friends and family and thinking about what would be best for them in the future when making choices. Doing well in school and achieving an education were considered by youth as key strategies for achieving a better life
214 and ending poverty. Participants therefore placed great emphasis on doing well in school in their diaries, especially on exams during their matric year. The importance of giving and receiving support to friends, family, and boy/girlfriends and uniting the community together to address community challenges were other key themes in diaries.
6.6 Evaluation of the method
The diary method was most effective with youth who enjoyed writing. The diary method was least effective for youth who were busy with school, work, or family responsibilities and therefore did not have time to write diary entries. A primary benefit of the diary method for the project was increased rapport building with participants. Participants opened up in diaries about aspects of their lives that they did not feel comfortable expressing in the focus group setting.
Regular meetings with participants about the diaries provided an opportunity for participants to discuss their daily lives, including positive experiences as well as challenges they were facing, strategies they used to address these challenges and their feelings about the events in their lives. The diary was therefore a helpful tool in the ethnographic project for a subset of participants.
215 Chapter 7. Interview Data
7.1 Overview
This chapter reports the findings gathered from in-depth interviews and paper-based structured risk assessment questionnaires with a sample of 40 youth between the ages of 14-21 years recruited from the community as described in
Chapter 4. Interviews and the questionnaire addressed research objectives 1-3.
The interview guide and questionnaire are included as Appendices.
This chapter begins with a description of the study sample. Data regarding study objectives are presented, beginning with participant risk perceptions and moving into perceptions of HIV. Next, participants’ risk management strategies are described. The chapter concludes with a brief summary of findings.
7.2 Interview Youth Sample Characteristics
Forty youth completed the questionnaire (see Table 7a). Three participants did not complete an interview; two females (aged 14 and 16) were lost to follow up and one 15 year old male passed away during the study. The data from the interviews and questionnaires are discussed together but data from these three persons are included in the discussion of the questionnaire results, but excluded from the discussion of interviews.
Table 7a. Age and Sex of Interview Youth Sample Age Female Male Total 14 1 5 6 15 3 4 7 16 2 2 4 17 3 3 6 18 4 2 6 19 2 1 3 20 1 2 3 21 0 6 6 TOTAL 16 24 40
216 7.3 Risks
Interview participants described a number of risks impacting their physical and social wellbeing. Participants generally referred to risks as
“challenges”. Data collection instruments and this chapter therefore utilize the term challenges in order to reflect the way participants themselves spoke about risk. Participants also discussed occasionally feeling stress in response to a particular challenge.
Findings from interviews and questionnaires regarding perceived risks and challenges that caused stress paralleled data collected from the focus group sample. Interviews provided additional insight into sensitive topics such as HIV, pregnancy and poverty.
Challenges Reported in Questionnaires
Participants were asked to report the challenges they had experienced in the previous year. The seven most frequently reported challenges in questionnaires are listed in Table 7b
Table 7b. Most Frequently Reported Challenges in Previous Year*
Challenge Number Reporting the Challenge 1. I was sick 15 2. My parent was sick 14 3. School trouble 11 4. Friend died 9 5. Sibling died 9 6. Parent not working 9 7. Fights with friends 9 *The questionnaire allowed participants to give more than one response.
Issues Causing Stress
The most frequently reported issues causing participants stress all of the time or often are reported in Table 7c. The most commonly reported issue
217 causing stress for participants was worrying about their futures. In the questionnaire, 34 youth reported that thinking about the future caused them stress all of the time or often. The remaining five participants reported that thinking about the future caused them stress sometimes. Fifteen youth reported that fear of HIV caused them stress, and an additional 14 youth reported that fear of HIV stressed them out “sometimes”.
Table 7c. Most Frequently Reported Issues Causing Stress Often or All the Time*
Stressful Issue Number Reporting Stress 1. Thinking about the future 34 2. Crime in the community 29 3. Violence in the community 26 4. Drugs or Alcohol 22 5. My responsibilities at home or in family 21 6. Jobs 19 7. Not having money for things I need 18 8. My health 17 9. Preventing STI’s 17 10. Preventing pregnancy 16 11. Noise pollution 16 12. HIV in the community 15 13. Fearing HIV 15 *The questionnaire allowed participants to give more than one response.
Challenges reported in Interviews
The themes reported in the focus groups: concerns about the future especially lack of educational and job opportunities, poverty, migration, concerns over misbehaving youth, alcohol and drug abuse, crime and violence and related gangsterism, fears of cheating in dating relationships, pregnancy and the risk of
HIV (treated separately in the next section), were further elaborated upon in the interview as challenges facing youth. Additional challenges including health, family members sick with HIV, deaths in the family, and jealous relatives were
218 also described. The challenges most frequently reported in interviews are listed in Table 7d. The challenges described in the questionnaires and in interviews are discussed in detail below.
Table 7d. Challenges Most Frequently Reported in Interviews
Challenge 1 Education, Jobs, and the Future Challenge 2 Migration Challenge 3 Poverty and Inequality Challenge 4 Other Youth Have Risky Behavior Challenge 5 Drugs and Alcohol Challenge 6 Gangsterism, Crime and Violence Challenge 7 Dating and Sex Challenge 8 Pregnancy and HIV Challenge 9 Jealousy, Evil Spirits, and Sabotage
Education, Jobs and the Future
Participants had very high expectations for their futures, with almost all of the participants reporting that they expected within the next five to ten years to be married with one or two children, finished with school and working in a successful career, living in a nice house and driving a nice car. All of the males and all but one female reported on the questionnaire that they believed their
“success in life depended on themselves” (one female age 19 reported she did not know). However, young people in this community faced tremendous barriers to educational access and employment opportunities that placed them at a disadvantage in achieving these dreams.
All participants expressed a strong belief that in order to secure a better future for themselves they needed a good education. Education was seen as necessary for obtaining stable, respectable employment that would allow participants to have a home and support a family. Finishing school and qualifying
219 for continued education and training was a primary goal for many participants.
“Education correlates to success” (male, age 18) and education leads to better jobs where youth can earn money “the right way” (male, age 18). Participants described how a lack of education led to unemployment or underemployment in sporadic low-level jobs such as labor and domestic work that in turn fed into crime as a means to obtain money. Participants thus universally reported educational attainment as essential to their futures: “Without education man you go nowhere” (male age 17).
Education was thus an expressed priority for participants. Challenges to completing schooling were reported by some participants. A minority of participants dropped out of school for reasons ranging from pregnancy to caring for sick parents to problems with drug and alcohol abuse. Lack of money resulted in additional participants dropping out of school and training programs because they could not afford tuition, uniforms or transportation costs related to their schooling. A number of participants described the challenges related to switching schools during the course of their education, particularly for participants who had relocated from a different community.
The national education system faced a number of widespread challenges, including low scores on matriculation exams, limited openings in universities for learners (students), and limited financial support (such as bursaries) to fund additional schooling. Because of these shortcomings in the national education system, participants were largely unable to qualify for university or bursaries to support post-matric schooling. Desirable employment opportunities were equally scarce, particularly without any post-matric training. These issues were of
220 profound concern for participants because the integrated educational and employment challenges, exacerbated by high rates of youth unemployment nationally, left most participants who were out of school stuck at home with nothing to do and no money, which undercut youths’ abilities to find a partner, get married, move into a home, start a family and build a future for themselves.
Some participants therefore felt a sense of frustration and uncertainty about the future, including feeling that their community would never change. For example, one participant felt proper houses for residents to live in would never be built because corrupt politicians would steal money allocated for homes, or they simply would not take any action to build homes. A couple participants also felt discouraged about their own lives, and felt that they themselves would never succeed and their difficult life circumstances would never change. Other participants had a sense that while things might change for others, such as white people, the changes never came to their community. Male participants who were out of school and were struggling to find employment, education, or other endeavors to become involved in, in particular, expressed a prevailing sense of hopelessness regarding their futures. “There’s no more hope, I’m sure of it.”
(male, age 21). There was furthermore a perception amongst a subset of participants that no one from their community had ever succeeded, despite the considerable talent of many community residents, and one participant therefore felt that in order to succeed in the future he had to leave the community: “They say if you want to make it “up there” you must move away from here and [then] you will be successful” (male, age 17).
In contrast, other participants remained hopeful about the future.
221 Migration
Migration between the Eastern Cape and Western Cape and frequent moving between households within the same area was a common occurrence amongst the interview sample. Participants maintained close ties with relatives in the Eastern Cape, making frequent trips back to visit relatives, participate in ceremonies, or celebrate holidays, provided they could afford the travel costs. The
Eastern Cape was seen as “home” where relatives, ancestors, and family homes were based. Significant life events and traditional cultural ceremonies occurred in the Eastern Cape. In contrast, the study community was often seen as more of a temporary home for those seeking education or jobs in the Western Cape.
The most common reasons for migration to the study community were: to live with parents who had previously migrated in search of work; because their caretakers in the Eastern Cape had lost their jobs, become ill or died and were therefore no longer able to care for the participants; to attend school; or to escape situations of poverty or problems in the home. Depending on the particular circumstances, migration and movement between households benefited some participants through increasing their access to important resources such as school or social support but had negative consequences for other participants such as placing youth in crowded living situations or in homes with scarce resources, which could result in marginalization of the youth.
The minority of participants who migrated to the study community from other urban townships described how life was better in the study community, which was smaller than other townships and therefore had relatively less crime, less violence, and fewer gangsters. In contrast, participants who migrated to the
222 study community from rural areas discussed struggling with the new pressures and challenges of living in an urban township, such as lack of proper housing and crowding. Most participants struggled to fit into their new household due to scarce resources, new rules, difficulty developing relationships with half-siblings or cousins living in the home, and learning to get along with the parent or other relative that they were now living with, especially if this was the first time they were living with them. Many parents were already struggling to make ends meet for their families and had little time or money to provide participants with attention or money for school fees and clothes.
For example, one female (age 15) who had recently migrated to the study community in order to live with her mother, described frequent conflict with her mother who did not give her money for what she needed, even though she regularly babysat the other children at home. The participant struggled keeping up in school, but mostly the participant felt that living in a new community and being exposed to new friends and new social expectations caused her to change.
She says “I am not that girl anymore (that I used to be), I feel different now here”.
She started wearing makeup, had a boyfriend for the first time, and struggled to make new friends and deal with peer pressure to be “in the local fashion” which meant to dress stylishly and to act like your friends.
Migrating to live with relatives who had established other families sometimes resulted in participants feeling sidelined in the new home, especially in contexts of limited resources. Some participants discussed feeling like they received unequal treatment, such as having to do more chores or receiving less food than the other children in the home. For example, one female (age 17)
223 migrated to the study community from the Eastern Cape to live with her father after her mother passed away from complications due to AIDS. This participant had no relationship with her father prior to living with him, and she had difficulty adjusting to the rules of his home and fitting in with the family he had established. She at times felt angry that he did not give her money for clothes when, from her perspective, the other children had everything they needed.
However, for participants escaping extremely difficult home situations, migration to the study community was a positive development in their lives. For example, one female (age 18) moved households at least three times before she found a stable home. She was born in the Eastern Cape where she lived with her mother. After her mother died of an illness she went to live with her aunt in another part of the Eastern Cape. After a period of time, her aunt could no longer afford to provide her with food, a school uniform, or proper shoes. She was therefore sent to live with another aunt in the study community who offered to buy her school uniform and provide food and money for school fees so the participant could finish school. Another female (age 17) moved to the study community to live with her father, after her father discovered she had been living alone in the Eastern Cape because her mother was not looking after her properly, sometimes leaving the participant to care for herself for extended periods with no money. In these cases, participants clearly benefited from moving to a new household in the study community where they were cared for.
Poverty and Inequality
Poverty was reportedly a struggle for many participants. Their parents or guardians were often not working, or working sporadic jobs such as domestic
224 work. These participants frequently did not have enough money for essentials like electricity, food or school fees. Other participants went through periods of temporary homelessness or were forced to move if, for example, their shack burned in a fire, a risk in the informal areas. To get by, some families join a community stokvel, which is a group of twelve families that pool their money together. Stokvel members are expected to contribute a fixed amount on a regular basis, and then every month a different family receives the money in the fund.
The impact of poverty, including not having school uniforms or living in poorly constructed shacks that did not adequately protect against the elements, took a toll on participants’ self-esteem. One participant described how not having money to buy clothes made her feel like she was not a person: “I didn’t feel like a person, I didn’t have any clothes…when she [her aunt] bought me clothes then I felt like a person” (female, age 18). These feelings are compounded by evident inequality in South African society. Participants were acutely aware of their relative poverty and limited access to services such as medical care as compared to wealthier communities, leading participants to report frustration and feelings of inadequacy and inferiority compared to residents in wealthier communities.
Some participants discussed wanting to leave behind their lives of relative deprivation and achieve the educational, financial and material successes and status they observed among wealthier people.
Other Youth Have Risky Behavior
Participant concerns that the local youth population was behaving in a way that threatened the future of wellbeing of the entire community was a common theme in interviews. For example:
225 “Ay the youth scares me. I don’t know what’s going on with the youth. It
scares me a lot. So like, who is going to lead in the right way for us? Who’s
going to be the next president? They [youth] not disciplined. I don’t know
who’s going to lead us the right way. If the youth are doing these kind of
things, bad things” (male age 18).
Participants described how the bad behavior of other youth negatively impacted the entire community. Some participants were particularly concerned about other youths’ “wrong” behaviors, asserting that other youth were using alcohol and drugs leading to them having condom-less sex with multiple partners, not respecting elders, and eschewing school work in favor of going out with friends or spending time in taverns. For example, one participant was concerned about the future and the overall wellbeing of youth in the community:
“Youth don’t take care of themselves. We should take care of ourselves
because we are the future. But youth don’t – especially those girls they
don’t take care. They go to shebeens. Girls go with guys with nice cars…it’s
not good,” (Male age 21).
However, alcohol and drug use, especially before sex, was not commonly reported by participants themselves. Only five participants, two females and three males, reported on the questionnaires that they had used alcohol or drugs before the last time they had sex; however, these participants all reported using a condom during that particular encounter.
Three of the older male participants and two of the older females discussed how youth misbehavior was caused by a lack of belief in themselves and hopelessness over the future. The majority of participants also discussed the
226 challenges of managing negative peer pressure that lead youth into damaging behaviors, and that in turn had negative ramifications for the community as a whole such as increased crime and increased rates of HIV infection.
Drugs and Alcohol
Four male participants reported former or current substance addiction.
One male (age 21) began using substances to deal with the many stresses in life and became addicted. Two males (ages 17 and 18) struggled with addiction that was causing them to fall behind in school and that led them to feel a lot of stress and isolation from the rest of the community. Participants dealing with addictions were sensitive to the fact that their drug addictions had given them negative reputations in the community and they discussed wanting to change their reputations. They expressed a desire to get better and to show their parents and the community that they were better and were actively seeking assistance to end their addictions. Two of these males were about to “go to the mountain” for traditional circumcision32, the rite of passage marking transition from boyhood to manhood, and possibly wanted to demonstrate a change before assuming their new roles as men. There were no recovery resources in the community for youth,
32 Traditional male circumcision is a very secretive and sacred rite of passage practiced by Xhosa (Vincent 2008), called “going to the mountain” or “going to the bush,” because the initiation schools are located in rural areas of the Eastern Cape. Boys go for circumcision any time between the ages of 16 and 25 though ages 18-21 are the most common ages in the study community for boys to go for circumcision. The ritual marks a boy’s transition to manhood, and therefore involves a change in social status and a new identity for the males. Traditional circumcision is a time when initiates are schooled in important social and cultural norms of the Xhosa. They are provided knowledge about how to become socially responsible, respectable men in Xhosa society and to respect the history, traditions, and beliefs of the amaXhosa. In practice, many males in the study community viewed circumcision as a rite of passage to start a period of responsibility in all aspects of their lives.
227 except for one religious-based support group which the participants were not comfortable attending. Therefore participants struggling to manage addiction were often forced to manage it on their own, often without social support if they also attempted to hide their addictions from their families. Other participants who described overcoming previous addiction described how they were still managing the negative consequences of their past addictions, particularly lagging behind in school.
Gangsterism, Crime, and Violence
Participants were frustrated by what they felt were high levels of crime and related violence and gangsterism in the community. For example, participants were concerned about going to the shops or to the toilets at night for fear of being robbed. Participants often blamed crime on local “gangsterism” or on youth they believed were robbing in order to obtain money to buy drugs. Gangsterism was described by a number of participants, and the meanings of being involved with gangsterism ranged from adopting a certain style of dress to accusations of being involved with robbing others.
A minority of older male participants discussed past involvement in gangsterism. These participants reported negative views of gangsterism because in their views it often involved smoking, robbing, and pursuing large numbers of girls to demonstrate status. These participants described leaving gangsterism behind when they became older, which they saw as a positive step in their lives.
A minority of younger male participants described current involvement in gangsterism, which they called crews; however, smoking and robbing were not central to their crews. Rather, crews for younger participants was tied to social
228 status and having a certain style that included owning expensive shoes, dressing well, and claiming to have lots of girlfriends. As was reported by focus group participants, crews competed with each other for social status as measured through status symbols such as their shoes and beautiful girlfriends.
Gangsterism was perceived to result from a mix of peer pressure and youth obsession with social status. Participants described how other youth tried to emulate activities such as gangsterism happening in larger townships or on television as a way to “become famous” or be known in the community. Another participant described being led to gangsterism through peer pressure:
“We call this ekasi, it means like a township. Where big things happen. It’s
a small township but big things happen. There’s a lot of crime, gangsters
and smoking like yeah. We tried not to get involved with those things…but
sometimes life you know takes you where you don’t wanna go” (male age
21).
Dating and Sex
Dating, and sex as part of dating, were considered normal and expected aspects of life for youth once they felt old enough and ready, and important ways of demonstrating and receiving love. According to questionnaire data, just over half of participants had experienced sexual debut by age seventeen. The most commonly reported ages of sexual debut were ages fifteen (n= 8) and sixteen (n =
10). Over half (63%) of participants reported current sexual activity (n = 26). Of those that were currently sexually active, 10 participants (6 females and 4 males) reported having one sexual partner in the last three months.
229 Participants who reported that they were currently abstaining from sex reported a variety of reasons for abstaining including not being ready (two females), not finding the right person (one female, one male) and worrying about pregnancy and HIV (one male, one female). For example, one participant
(female, age 14) described choosing not to have sex with her boyfriend despite feeling pressure from her friends to do so because she felt she was too young, and that sex was for people after the age of sixteen, saying: “It makes me feel like I am not a good person if I were to have sex now” (female, age 14). Furthermore, this participant feared pregnancy and diseases such as HIV, and therefore she reported planning to obtain condoms and birth control prior to having sex for the first time. One male (age 16) refused to have sex completely because “there are too many risks” and abstaining allowed him to feel “safe”.
Other participants acknowledged that sex involved a level of risk, but that there were steps they could take to minimize these risks. For example, “Sex can be risky but not really…you can protect,” (female, age 15).
Having sex was described by many participants as a way to express and receive love in addition to part of social status and fitting in with other youth.
However, expectations were sometimes different for males versus females. Some females reported wanting to wait until they were ready to have sex. Some males were under social pressure to have sex with multiple girls, whereas it was reportedly valued for girls to be less sexually experienced. Many male and female participants reported pressure from their friends to have sex with their boy/girlfriends. Some participants who were reportedly abstaining from sex,
230 especially males, reported being teased by their friends for abstaining, and that they risked ostracism from their friends who were having sex.
Reported dating expectations also varied amongst participants. For example, a number of participants reported relationships characterized by love, trust, and open communication where they “talked about everything”. These relationships were described as supportive and making participants very happy.
Some other females reported that they were expected to please their boyfriends by doing things such as being agreeable, offering emotional support, avoiding taverns, or understanding their boyfriends’ needs. In turn, females in general expected their boyfriends to show them affection, be honest and be faithful.
Despite the stated ideal of faithfulness, as mentioned above, some males discussed how in general males were expected to demonstrate their status partially through giving the appearance of sexual experience and having multiple girlfriends at once. The social pressure for males to demonstrate sexual experience was also observed in response to the questionnaire question about lifetime number of sexual partners. Males tended to report higher numbers of partners than did females. These results are described in Table 7e.
Table 7e. Reported Lifetime Sexual Partners*
Lifetime # of Males Females Total Partners 1 1 3 4 2-3 6 4 10 4-5 3 5 8 6-8 6 1 7 11-35 4 0 4 Don’t know or 0 2 2 “many” Did not say 4 2 6 * Reported in the questionnaire
231 Monogamy in relationships was overwhelmingly reported by participants as the ideal for relationships, though participants often also discussed that it was common for males to have multiple girlfriends. Conflict related to males dating multiple girls was sometimes discussed by participants as a source of gossip. One female participant (age 18) believed that “all guys” in the community had multiple girlfriends, so she chose to date outside of the community in order to avoid conflicts with other females over guys, saying: “So you could accidentally date some girl’s man. So I don’t like dating [here]” (female age 18).
Providing emotional and instrumental support to boy/girlfriends was generally discussed as an important part of dating relationships. A minority of females reported that they would ask their boyfriends for financial assistance when they needed it. Some males reported feeling happy when they were able to buy small gifts for their girlfriends, but males also discussed how they often did not have the means to provide much more than very limited financial support to their girlfriends. One female participant (female, age 18) was dating someone with a stable job who was therefore able to buy her gifts such as clothes and airtime which made this participant feel special and loved, and she felt the gifts gave her positive social status amongst her peers.
Pregnancy and HIV
The risk of pregnancy and sexually transmitted infections including HIV were salient concerns for young people, particularly when they felt there were problems in their relationship or if they did not trust that their partner was being faithful to them. In the words of one participant who reported having problems with his girlfriend, “It [the relationship] is not good. We are just going to get
232 AIDS,” (male age 15). The dynamics of trust, fear of STIs, and pregnancy in relationships were complex and varied. The majority of participants discussed their desire for trusting, monogamous relationships. For some participants, part of a trusting relationship involved having condom-less sex. Other participants reported using condoms regularly regardless of the relationship. A number of participants described how raising the issue of condoms risked introducing conflict or mistrust into a relationship. One male (age 21) said that if a girl asked him to use a condom, he would think the girl didn’t really want to be with him or that he was not “the one” meaning her primary boyfriend that she loved.
Pregnancy and HIV prevention were reportedly not easily discussed openly between partners. Some participants reported confidence raising these topics with their partners, but for the majority of participants conversations about preventing STI’s and pregnancy were not easy to have, largely due to their inexperience, insecurities, discomfort, or not knowing how to bring these topics up. For these same reasons a subset of participants reported not discussing condoms, pregnancy or HIV prevention with partners.
Teenage pregnancy was raised as an issue for a number of interview participants. Three females (between the ages of 17 and 18) and five males (one aged 17 and four between the ages of 19-21) already had children and another male’s (age 21) girlfriend was pregnant during the study. As described by participants, the ramifications of pregnancy were much higher for females than for males. For example, one female (age 19) was forced to drop out of high school when she became pregnant. She never returned to school, and, now that she has two children, is unable to finish school or take night classes because there is no
233 one to look after her children. Her relationship with her boyfriend, the children’s father, was good but he did not have a job and was therefore unable to provide full support for her and the children; however both of their families were helping.
Two other female participants described the challenge of getting their boyfriends to acknowledge paternity for their child. According to the Xhosa traditions as practiced in the study community, when a female becomes pregnant her family traditionally approaches the male’s family to obtain acknowledgment of paternity and to negotiate payment to the girl’s family. When the practice is strictly followed, the pregnant girl herself is not allowed to speak during these conversations and her family speaks on her behalf. Despite reported difficulties, the boyfriend of one of these participants did ultimately recognize the child as his when the child was a newborn.
Notably the vast majority of males expressed a desire to “take responsibility” when their girlfriends become pregnant, which included paying money to the family of the girl who is pregnant as was traditionally done. Because of poverty and the difficulty males have obtaining employment, some discussed being unable to pay the girl’s family themselves and they often relied on their families to help them pay. Becoming parents at a young age is universally described as challenging by both males and females, and was complicated by limited resources and related difficulties with education and employment.
However, participants with children ultimately described loving their children and accepting the child as a “blessing”.
Some participants described how other males might want to have babies if their friends had babies, and a few participants discussed feeling this way
234 themselves at times. The participant whose girlfriend was pregnant described how his friends had children, which made him want to have a child also; saying,
“Wow I wish I could have a baby also” (age 21). However, this participant went on to explain that he was not ready to be a father because he did not have a job to support the baby, and that the pregnancy was an accident although he had accepted it: “Sometimes we get drunk and then like never use a condom. That’s how it happened. I don’t really want a baby now. But then if it happened, it happens” (male, age 21). This participant was seeking work to support the child.
Jealousy, Evil Spirits, and Sabotage
Finally, a subset of participants reported fearing evil spirits or witchcraft from jealous relatives. Particularly when participants were doing well in school or sports or in their final year of high school (Grade 12 or matric), they were concerned that relatives would become jealous of their achievements and use witchcraft to try to sabotage them. These participants would sometimes seek out protection from a traditional healer or sangoma. Witchcraft is different from culture and cultural traditions. Many participants participated in cultural ceremonies with traditional healers, but did not seek out traditional healers for protection from witchcraft.
It is not clear how widespread fears of witchcraft were amongst participants because it was not directly investigated. Some participants discussed not believing in witchcraft and some discussed not believing in traditional healers, particularly participants whom were very involved in the Christian religion. However, fears of witchcraft and jealousy were raised by nearly half of participants. Issues of jealousy and fears of witchcraft led to suspicion and
235 conflict within families. For example, one female (age 18) began experiencing seizures during Grade 12, which led her and her family to conclude that her aunt had become jealous of her because the participant was doing better than her cousins in school. The participant sought out assistance from a traditional healer in the Eastern Cape, who gave her medicine for protection.
7.4 HIV Risks
Perceptions of HIV
Interview participants almost universally perceived HIV as a risky and dangerous disease. “I do worry about HIV. It’s very risky because you can’t know when you are gonna die” (male, age 19). Uncertainty about who was or would become infected heightened the sense of risk to HIV infection. For example, “You can never know who got it. You can’t tell who has it by looking. And you never know what could happen in the future, who can get it,” (Female, age 16).
Participants feared the risk of HIV from sex, which heightened fears of cheating in relationships. Participants also feared the risk of infection from accidentally touching an infected person’s blood, which might happen in a car accident or when sharing a home with HIV infected relatives.
Interview participants largely stigmatized and blamed other youth for spreading HIV by not taking HIV seriously and by not taking responsibility for their own lives. A number of participants suggested that young people should “act properly” in order to stop HIV. For example, one participant stated: “We can stop
HIV if people can do things properly and keep things real. People should save sex for after marriage” (male age 19). Two participants worried that they were at risk
236 of HIV infection from people who hid their HIV infection, for example “Some people…they don’t like tell people that I’m HIV positive” (male, age 18).
A new theme that arose in interviews was the perception that people infected with HIV who did not accept their status were dangerous. “If they don’t accept it as it is, then that’s where it gets dangerous cause you have to accept it and then you have to treat it” (male, age 21). Participants believed that those who were in denial about their status and refused treatment placed themselves and others at risk. Six interview participants reported having family members who were infected, and among these six some had observed their relatives become sick or die because of denial and refusal to take treatment.
Social Proximity to HIV
Sixteen participants reported on the questionnaires that they knew someone infected with HIV. Ten of these 16 participants (six males, four females) stated that they know of a neighbor or community member with HIV and six female participants report having a family member with HIV. No participants reported having a friend that was HIV positive. In addition, three participants who did not report knowing someone with HIV on the questionnaire did report knowing someone, usually a relative, with HIV during the in-depth interviews.
Knowing someone with HIV did not have a clear impact on whether participants felt at risk for HIV themselves. Amongst females reporting an infected family member, half (n=3) reported feeling at risk themselves. One participant with HIV positive family members felt at elevated risk for HIV but attributed this feeling to the high rates of the disease amongst youth locally (male
237 age 20). Table 7f reports the relationship of feeling at risk for HIV to knowing someone with HIV.
Table 7f. Relationship of Knowing Someone with HIV to Feeling at Risk
Do you feel at risk for Know someone with Don’t know anyone HIV? HIV with HIV Yes 7 10 No 4 10 Maybe 3 3 Not Sure 1 1 I don’t wish to say 1 0
Participants who knew someone with HIV often described in interviews how finding out that a family member or other person they knew had HIV led to a realization that it was not possible to tell who did and who did not have HIV simply by looking at the person. It also led to feelings that HIV could impact anyone, not just those who were judged to be behaving in a risky manner
(females ages 16, 18, 19 and male age 20). For example, one participant says “it’s a wakeup call you see for me. Cause I know now HIV is available you see. Ja it’s here and somebody can die,” (male age 20).
Participants who knew someone with HIV discussed HIV as a scary disease, and about half believed HIV was a disease without hope. For example, while some participants felt treatment provided hope, one participant said “an
HIV diagnosis is without hope to me. There is no medicine to get rid of it. There is only treatment” (male age 19). Of the participants reporting knowing someone with HIV, twelve of them also reported feeling that HIV was a “life sentence”.
Participants were for the most part uncomfortable with or unable to talk to infected relatives and friends about HIV because of prevailing silence and stigma
238 around the disease. “It’s a pretty sensitive topic to talk about with them, so I don’t even bring it up…it’s too private…you don’t wanna make him feel offended” (male age 21). One female (age 19) knew multiple people with HIV, including family members. However, none of them spoke directly with her about HIV. “They are scared to talk about it. They are scared people will be judging them or making jokes so I can’t talk to them about it”. This participant learned of her relatives’
HIV positive status indirectly when she discovered the relative’s clinic card outlining a treatment plan. This participant was incredibly scared of HIV because
“I see what it does to people. It doesn’t have a cure” and she reported feeling stressed about the high levels of HIV locally. This participant tested for HIV on a regular basis, and also stated that she trusted her partner and that they were faithful to each other.
One participant did report openness in her family about a relative who was
HIV positive. “They called us together and told us” (female, age 16) and a friend had also confided in her about being positive. However, this participant was still not comfortable talking with them about HIV for fear of offending them: “people are embarrassed to talk about it…and [to talk about] sex” (female, age 16).
Participants described the danger of silence about HIV and the related inability to accept their diagnosis. One participant lost a 25 year old cousin to
HIV. The participant believed that her cousin died because she was unable to accept her HIV positive status, saying: “my cousin had HIV but never accepted it.
She died because she didn’t accept it, and didn’t ever take the treatment. So I have learned that you must accept it and God will treat it” (female, age 15).
239 Having a family member with HIV caused most participants to fear HIV and want to protect themselves from the disease. Strategies for protecting often focused on finding partners that they could trust. One participant (female, age
18) reported that her mother was positive and her aunt had died years before of
HIV. This participant began using condoms after falling pregnant the year before, however she stated that the condoms were used to prevent pregnancy and not
HIV. In contrast, for another participant, knowing people with HIV changed her view of the disease and made her realize it was not possible to know who was infected. “You never know who got it. You can’t tell who has it by looking, and you never know what could happen in the future, who can get it” (female, age 16).
This participant felt at risk for HIV even though she was not having sex, because she could for example come into contact with an infected person’s blood. During the study, this participant was working up the courage to take her first HIV test.
7.5 Risk Management Strategies
Participants described a number of strategies to manage risk in day-to-day life. For some participants, spending time at church or participating in sports teams allowed them to feel supported and relieved of stress. Believing in oneself and one’s own value was discussed in interviews as an important strategy for taking care of oneself and making decisions that would benefit themselves and their futures. Participants also discussed the importance of having someone they could trust to talk to about the challenges in their lives. The person could be a friend, boyfriend, sibling, or other person whom participants felt could be understanding and non-judgmental.
240 A few participants described a wish to speak more openly with parents about challenges such as HIV and pregnancy because parents were perceived as having life experience and knowledge about those topics in particular. However, for a number of participants the topics of sex, pregnancy and HIV were too difficult to bring up with parents or other trusted adults because parents were thought to be judgmental, too busy to talk or unable to understand the perspective of youth. Significantly, some female participants who described being able to talk with their mothers or grandmothers about sex also tended to discuss how their mothers encouraged them to use condoms and birth control and obtain
HIV testing once they became sexually active.
Strategies related to managing HIV and pregnancy are listed in Table 7g and discussed in detail below.
Table 7g. Reported Strategies to Manage HIV and Pregnancy
Strategy 1 Trusting Your Partner Strategy 2 Condoms Strategy 3 The Injection Strategy 4 The Pill Strategy 5 Nothing Strategy 6 HIV testing (with partner)
HIV and Pregnancy Prevention
The ability to trust your partner was overwhelmingly viewed as one of the most important aspects of reducing risk in romantic relationships. Loving and trusting relationships were described as bringing great happiness to participants.
Some participants described struggling with fears related to trusting their partner and others described concerns that if their partner cheated on them they would be at risk of HIV infection. Developing trusting relationships was thus a universal
241 ideal stated by male and female participants, for example: “People must be honest and take time and know well each other (sic - know each other well)”
(male age 19). However, fears about their partners cheating were commonly reported in interviews. These fears were especially pronounced among female participants. While cheating was in general viewed negatively, two participants discussed cheating on their partners in order to protect themselves emotionally from getting hurt by their partners. For them, having another partner was a way to guard against emotional vulnerability and the risk of being left alone.
Nearly all participants reported on the questionnaires that they felt “it’s up to me to prevent HIV” (n=38). However, not all participants reported feeling completely in control as to whether or not they would be able to do so. On the questionnaires, sixteen participants reported feeling that they could control whether or not they became infected with HIV, yet seven participants said they could not control whether they became infected. Ten participants said maybe or they didn’t know if they could control whether or not they became infected.
The vast majority of participants reported in the questionnaires that they took measures to prevent both pregnancy and HIV. Most participants (n = 27) reported using a condom the last time they had sex (see Table 7h). When asked what they did to prevent pregnancy or HIV the last time they had sex (see Tables
7i and 7j), 3o reported using a condom. Twenty-six participants stated that they used the condom to prevent pregnancy, and two of these participants used the condom plus the injection to prevent pregnancy, whereas four participants used the condom to prevent HIV.
242 Seven participants reported that they used the injection and one participant reported using the pill to prevent pregnancy. Three participants
(males, ages 18, 20 and 21) reported taking no measures to prevent pregnancy the last time they had sex. Two participants reported taking no measures to prevent HIV (female age 18 and male age 19). Nine participants reported going for an HIV test with their partner in order to prevent HIV. Five of these nine participants also reported condom use.
Table 7h. The last time you had sex, did you or your partner use a condom? Male Female Total Yes 19 8 27 No 4 5 9 Don’t Remember 0 1 1
Table 7i. What did you do to prevent pregnancy the last time you had sex? Male Female Total Condom Only 16 8 24 Injection Only 2 3 5 Condom + Injection 0 2 2 Pill Only 0 1 1 Nothing 3 0 3
Table 7j. What did you do to prevent HIV the last time you had sex? Male Female Total Condom 14 11 25 Went for testing 6 3 9 Nothing 1 1 2
While contraceptive use was reported by a number of participants on the questionnaires, other participants revealed a lack of trust in contraception during interviews. For example, “I don’t trust contraception. I like condoms because I don’t want another child,” (Female age 19).
243 HIV Testing
Questionnaire results indicated that the majority of youth (n=32) believed regularly testing for HIV would protect them from infection. This was confirmed by interview data. For example, one female, (age 16) looked forward to her first
HIV test as taking a major step in her life towards protecting her health.
The vast majority of participants reported on the questionnaires only having sex with partners that they believed to be HIV negative. As reported in interviews, a partner’s status was verified based on discussions, appearances and/or trust. On the questionnaires, only one participant (male, age 20) reported ever having sex with someone who was HIV+ and one participant (male, age 14) reported not knowing if he had ever had sex with someone who was positive.
A majority of participants (30) reported testing for HIV at some point in their lives, with most testing at least once in the previous year (n=23). Of participants reporting testing, only one reported receiving a positive HIV diagnosis, which was disclosed to a parent. Twenty-five participants reported testing negative; one participant did not know the test results and six chose not to disclose their results on the questionnaire. Despite the fact that participants discussed sharing their HIV test results with their sexual partners as an HIV prevention strategy, only four of the participants reported actually doing so (3 females and 1 male). Participants described how HIV testing was a difficult topic to discuss with their partners. Because of the intense stigma surrounding an HIV diagnosis, it is especially difficult for youth to discuss HIV status.
Alongside the reportedly high testing rate, many participants reported being afraid to test for fear they would test positive. HIV testing was a very scary
244 experience for many participants and was also seen as a possible risk to their social status. Because youth feared testing positive, going for an HIV test often took tremendous courage. Some participants were concerned that others would gossip and judge them if they tested positive and their HIV status became known, so some participants avoided testing rather than risk the social isolation and loss of social status that would come with a positive test.
Interestingly, four of participants who reported regular testing did so not because they were concerned about their HIV status, but because they felt that they were safe and did not have to fear the results. For example, “I always test every three months because I’m not scared of anything because I have one girlfriend” (male age 21). This participant reported multiple sexual partners, but he was serious with one of them and therefore considered her his only girlfriend.
Another participant who was confident that he would test negative explained:
“It’s not a problem for me to test. I am glad to know my status” (male, age 19).
Participants, especially males, who were uncertain about whether or not they had been infected, were more likely to discuss avoiding testing out of fear.
Condoms
Participant reports of condom use were mixed. In general, participants described the importance of using condoms to prevent pregnancy and diseases, for example “Condoms are good…without condoms there is no hope” (male age
19). Yet ultimately whether or not participants chose to use condoms often depended on the specific circumstances of the relationship or circumstances of the sexual encounter. Older male participants discussed using condoms with girls that they did not know well, because they did not know the girl’s sexual history,
245 which led to fears of HIV infection. In other cases, if a male believed that a girl was a “good girl” he might not use a condom. For example, “if she behaves well and she handles herself well, I would never use a condom” (male age 21).
A number of participants reported that they preferred to use condoms for pregnancy prevention because they did not trust contraception, such as the injection or the pill. However, this sometimes placed participants in a difficult situation because some were uncomfortable talking freely with their partners about using condoms for preventing pregnancy. Females in particular discussed their difficulties bringing up these topics with their boyfriends. In addition, participants regularly reported not trusting condoms, fearing they could break.
While some participants stated a preference to use condoms all the time in order to reduce the risk of HIV and pregnancy, for other participants the decision about whether or not to use a condom often depended on each individual and their feelings about their partner and their relationship. For example, a subset of females discussed how they would not use a condom if the boyfriend refused in order to to please their boyfriends. However, three female participants (two aged
17 and one aged 18) insisted they would refuse to have sex if their partner did not wear a condom because they were protective of their health and believed the right guy would be supportive of their preference to use a condom. One male (age 21) also said he would refuse to have sex without a condom, saying:
“You see, it’s a wakeup call to me, why does she, why does she don’t want
to use condom? So ah ah. I just told myself no. There’s something wrong. I
mustn’t just, I mustn’t do it. Cause it’s not safe. There’s no one on the
Earth man can tell me not to use condom” (male, age 21).
246 Respecting Who You Are: Culture and Tradition
Maintaining a relationship with the ancestors, keeping the ancestors happy and participating in culture was seen by many participants as an important part of protecting one’s identity and wellbeing. Two males discussed how culture was protected in South Africa as a human right; for example, “culture is my bill of rights,” (Male, age 16). A number of participants discussed the importance of following cultural traditions in order to maintain health and wellbeing. For example,
“Culture, you have to do it. It’s a force. As time goes by you need it or you’ll
do bad things…all black persons need a goat (having a ceremony where
you are “introduced” to your ancestors and a goat is slaughtered) or they
will get sick” (female age 19).
Going “to the mountain” for traditional circumcision to become a man was described as one of the most significant life events for male participants (see footnote 1) and brought significant changes to their status in their families and communities. Males discussed how following circumcision, which generally happened between the ages of 18 and 20, they would be treated as a person as opposed to as a child. “That’s when they start seeing you as a person,” (male age
17). For example, “right now…they don’t treat you like a person. They treat you like a child. Like you still a boy [inkweni]. So we don’t have a say in anything…they will disregard whatever you say...but when you a man, you can stand up even in front of the whole family…and they will listen to you…they will regard your point.” (Age 17). Being listened to in their families and having their opinions count was an important and valued aspect of receiving respect following
247 initiation. Participants described how following initiation, they must demonstrate respect to others, change their “mindsets” and start “taking control” of their lives.
A number of male participants described changing their behavior after returning from the mountain, such as no longer being involved with gangsterism or smoking. Other participants discussed taking life more seriously after returning from the mountain. For example, one participant described how he decided to take his romantic relationships more seriously following initiation:
“When I came back from manhood I thought I must make it real. To me.” (Male age 20).
Education, Jobs, and the Future
As discussed above, participants had very specific goals and dreams for the future but many also often felt a sense of worry or, in some cases, uncertainty in relation to their future educational and job prospects. Participants had a variety of responses to this sense of worry or uncertainty. Some chose to accept the situation and adapt to difficult life circumstances. For example, “We have already gotten used to it because we have been living like that [sic – this] many years. So we don’t have too many problems because our minds are already there [in difficult circumstances], our roots, like, how do we take care of ourselves when there is a lot of worry” (male age 21).
Other participants held out hope for their circumstances to change. Signs of development, such as the building of the new high school, the opening of the local youth center and the number of educational support programs in the community were seen as positive developments and evidence that it was possible for their community to transform to a more positive place for young people.
248 However, social inequality was a salient concern and a number of participants were troubled that they had fewer opportunities available to them than did people from wealthier communities. This concern was complicated by some of their participation in NGO-run tutoring and educational programs that were frequently staffed by volunteers from wealthier areas. Participants would sometimes compare themselves to the volunteers, who were often one to three years younger than they were yet further along in their schooling than were many community residents. Some participants took this as evidence that they were receiving a sub-standard education.
As noted above, education was seen as the key to improving life circumstances. “Schooling is the best option because when you’ve got education you can like be able to get the job that you wanted and then support your own family” (male, age 21). Unfortunately, educational opportunities were extremely limited across the country and participants lacked the necessary resources or matric scores to go further with their studies. Many participants instead pursued job skills training at a technical school, and others began a search for work.
Availability of these opportunities was also limited. Participants dedicated considerable time and effort to these goals and most were still endeavoring to obtain these opportunities at the end of the research period.
7.6 Summary
Reported risk perceptions and risk management strategies were highly diverse. Data collected in questionnaires and interviews were consistent with the focus group data and provided additional insight into participant risk perceptions as well as their experiences managing the risks in their lives.
249 Interview participants disclosed a higher rate of social proximity to HIV than focus group members did; however there was no clear relationship between social proximity to HIV and risk perception or risk management strategies. Many participants discussed struggling with difficult life circumstances including limited resources at home and sick parents, while at the same time managing the stresses relating to risks to their social status and to their futures. The importance of trust, open communication, and support in addition to worries about conflict in dating relationships were common themes reported in interviews, and issues of social status, love, and ability to trust were salient issues for participants in their romantic relationships.
Overall, interviews revealed the majority of participants were highly concerned about their future prospects while at the same time many felt vulnerable to more immediate risks such as their health, HIV, violence and crime.
Participants were engaged in a number of positive strategies to mitigate the effects of daily risks and achieve a positive future. Strategies primarily centered on adopting a range of HIV prevention methods including HIV testing and using condoms, developing honest and trusting relationships, strengthening social networks, achieving in school, endeavoring to make good decisions for themselves, striving for a positive future, and having fun and enjoying life.
250 Chapter 8. Cell Phone Based Data
8.1 Overview
Cell phones were used to ask participants questions via SMS (short message service, also known as texting) and to chat with participants in private chats using the social network33 MXit. MXit is a free instant messaging and social networking application. The goals of cell phone based data collection were to 1) collect data from youth about their daily activities and thoughts and feelings about these activities in real time and 2) to assess the effectiveness of using these two cell-phone based methods with youth in social science research. Eleven youth participated in SMS’ing and twenty youth participated in chatting on MXit.
This chapter will describe the rationale for collecting data using cell phones in this project, the methodology, a description of findings and exploratory analysis of how these methods functioned in this study.
Due to the small sample size, findings are necessarily descriptive. In addition, the novelty of these data collection methods limits the nature of the analysis so these data should be considered to be exploratory. Nonetheless, these data serve to help understand the role of cell phones and social networks in the lives of participants.
8.2 Background and Rationale
There is significant interest in the potential for using cell phones and social networks as data collection tools, particularly with patient populations in
33 Social networks are defined as any web-based service that allows individuals to 1) construct a public or semi-public profile within a bounded system 2) articulate a list of other users with whom they share a connection and 3) view and traverse their list of connections and those made by others within the system. The nature and nomenclature of connections varies by site (Boyd and Ellison 2007).
251 developing nations (Chan and Kaufman 2010) and with youth (Jaspan et al 2007;
Mapham no date; UNAIDS 2010). Cell phones are ubiquitous throughout South
Africa, including in townships34. An estimated 93% of South Africans have access to cell phones, either by renting, owning or sharing a phone and up to 40% of
South Africans use cell phones as their primary means to access the internet
(Chan and Kaufman 2010; Kreutzer 2009). The vast majority of cell phone subscribers in South Africa use pay as you go or prepaid services (Deumert and
Masinyana 2008), which is substantially more affordable than phone contracts because it avoids connection fees and allows users to purchase only as much airtime35 to send messages and make calls as they need, when they need it.
A study conducted in 2008 indicated that virtually all youth including low income youth have access to cell phones and use them on a regular basis
(Kreutzer 2009). The most popular uses for cell phones reported by these youth were personal communication (91%) including instant messaging using social media applications (47%) (Kreutzer 2009). The study also found that 47% of respondents used MXit on a typical day, and that only 20% had Facebook or
MySpace profiles (Kreutzer 2009). The vast majority of youth reported using pay as you go phones instead of contracts (Kreutzer 2009). Interestingly, 25% of youth in Kreutzer’s study did not own their own phone, yet phone ownership did not significantly influence usage patterns in cell phone owners versus those who
34 A complete background on cell phone access and cell phone use in South Africa is provided in Chapter 3. 35 Airtime, also called top-ups or recharge, are prepaid mobile (cell) credits that can be purchased at a shop, ATM, online, or in the form of scratch cards or vouchers with a PIN number. Airtime is stored on the phone after purchase and can be shared with other prepaid customers using the same network service provider.
252 borrowed phones (Kreutzer 2009). Kreutzer’s study found gender differences in how cell phones were used, with instant messaging, calling and texting to be more common amongst males.
Pilot work conducted in the study community confirmed many of
Kreutzer’s findings. Cell phones were ubiquitous amongst male and female youth, youth expressed willingness to communicate with researchers on their phones, and SMS and MXit were reported as the most popular ways to communicate via phones. At the start of this study, MXit was the most widely used instant messaging and social media site in South Africa (Hoveyda and Sinha 2011) and pilot work confirmed this in the study community. MXit’s terms of service include robust privacy and protections for users including third party policies on anonymity and user confidentiality. For these reasons SMS and MXit were chosen for cell phone based data collection in this study.
8.3 Methodology
8.3.1 SMS
Texting using the local SMS service allows messages of up to 160 characters to be sent or received to a subscriber’s cell phone. SMS service is a familiar technology that is available on all digital networks, works on all phones, and is consistent across all types of phones. SMS services are always “on” the cell phones, compared to social networking sites where users must be logged in to view or send messages.
SMS especially automatically generated messages and bulk messaging has become popular in ehealth programs (UNAIDS 2010). Examples include
253 YoungAfricaLive36 and ProjectMasiluleke37. There is further great interest in
SMS’s potential as a data collection tool. At the start of this study however, very little data existed on best practices for using SMS to collect data. Therefore the methods used in this project were uniquely designed to be appropriate for the local population, accounting for factors such as phone sharing and using prepaid airtime (discussed below).
8.3.2 MXit
MXit, shorthand for “message exchange”, is a free instant messenger and social networking application that launched in South Africa in 2004 (prior to
Facebook in South Africa). MXit was designed to offer youth a cheaper alternative to SMS for sending text and photo messages. MXit has since grown to become a full-fledged social networking application. Users can send and receive private text and multi-media (such as photos and music) messages, set up a
“multi-mix” group chat with their contacts, or (for a small fee) join public chat rooms. You must be at least 13 years of age to set up an MXit account.
MXit remains the most widely used social media application in South
Africa, with millions more users on MXit than on FB, Twitter, or other social networks popular in the United States. In 2011, over 350 million messages were sent on MXit every day, which was seven times more than on Twitter globally
(MXit 2011). 6.5 million of the 7.4 million active monthly users on MXit are in
South Africa (Beger and Singha 2012; MXit 2014). MXit estimates they have at
36 More information at www.praekeltfoundation.org/young-africa-live.html 37 More information can be found at poptech.org/Project_M
254 least 38 million unique users (Beger and Singha 2012), though there are millions more registered accounts because many people have multiple MXit accounts.
The majority of South Africa MXit users are urban youth (49% in Gauteng,
14% in Western Cape), with a roughly equal proportion of males (54%) and females (46%) (MXit 2014). MXit’s core user group in South Africa is young, comprised primarily of 18-24 year old Black Africans followed by 13-17 year old
Black Africans (MXit 2014).
South African MXit user demographics are described in Table 8a.
Table 8a. Age and Race of South African MXit Users*
Age Percentage 13-14 5.7% 15-17 19.4% 18-24 48% 25-34 19% 35+ 8% Race Percentage Black 67% Coloured 21% White 8% Malay/Indian 4% *Data drawn from MXit 2014
MXit can be used on a wide variety of cell phones or on web browsers, but in South Africa MXit is used almost exclusively on cell phones. Sending a message on MXit costs a small fraction of what it costs to send an SMS – cents compared to one Rand38. MXit reduces the cost by sending messages over data
(using the GPRS system on 3G) instead of airtime. In a context of extreme poverty, and where youth want to send many messages, MXit is significantly more affordable than SMS’ing. However, not all youth in the study community
38 1 South African cent is roughly equivalent to 0.1 cents US. 1 South African Rand is roughly equivalent to 0.1 American dollars.
255 have MXit on their phones. Some youth are using very basic cell phones that don’t support MXit, some cannot afford the data required to download MXit to their phones, and some simply choose not to have MXit on their phones. Youth were therefore given a choice to chat via SMS or MXit.
8.3.3 Procedures
Focus group youth were given a choice of corresponding via SMS or MXit
(or do a diary). Interview youth could elect to chat on MXit. In order to be eligible for this activity, youth were required to have their own cell phone that was not shared and prior experience with the method they chose, SMS’ing or MXit.
Individual meetings were held with youth electing to participate in this activity. During this meeting, youth received detailed instructions and counseling on how to maintain confidentiality of the messages. Each youth chose four days during the week and two times during each of those four days when they were able to chat on their phones. Youth were given information about the types of questions they would be asked via their cell phones so that they had a chance to ask any questions they had ahead of time and to clarify any misunderstandings prior to the chatting. Each youth then chose a code word to include at the end of every message sent that would uniquely identify them as the message sender.
Youth provided me with their cell phone numbers and youth chatting via MXit provided their MXit contact details so that I could add them to my contacts in order to chat with them.
8.3.4 Data Management
An SMS back-up and restore application saved all of the sent and received
SMS messages on my phone. The application saved the message content as well
256 as the date, time, contact name, and contact number associated with each message that could be exported into a secure, password-protected Excel file and emailed. As an extra precaution, each message was transcribed into a Word document within 24 hours of receipt.
MXit has a built-in chat saving function that included content, date, time, user name, and the status message of each user. After each chat with a participant, the chat would be saved and exported to my computer in a text file.
Field notes including process notes and conversations with participants about these methods were taken throughout the SMS and MXit activities.
8.3.5 Data Analysis
SMS’s were grouped according to participant. The number of sent and received SMSs for each participant was counted and a percentage response rate was calculated. The number and duration of MXit chats held with each participant was counted. The contents of each message or chat was summarized and analyzed for relevance to study themes. Summaries for each participant were created. For MXit summaries included descriptions of participant user names, status messages, time and date of chats, and chat content.
8.3.6 SMS Questions
Questions sent via SMS centered around four main topics: 1) daily activities, 2) feelings about the day and what made the day a good or bad day, 3) challenges faced by the participant, and 4) choices or decisions that participants made. Exact wording of questions was tweaked throughout the process for clarity in response to participant feedback. The questions are provided in Table 8b.
257 Table 8b. SMS Questions
Question Topic Version Question Number Activities 1 What are you up to right now? Where are you, who are you with, what are you doing, and how are you feeling? Day 1 As u look back on ur day, how r u feeling about it? Was it a good day or a bad day? Why do you feel this way? 2 Did you have a good day or a bad day today? Please explain why it was good or bad. 3 What was the best thing that happened 2day? What was the worst thing that happened 2day? Why do u feel this way? Challenges 1 What challenges have u faced this week? How did u deal with them? 4 example did u talk it over with a friend. How do u feel about the challenges you've been facing? Choices 1 Did you make any choices today? The choice can be big And or small. For example choices about school, life or Decisions friends like should I go to school today or like what should I do about a fight with my friends. Can you tell me a bit about the choice and how you made your decision? For example, did you ask for advice? 2 What decisions have you made today? Can you describe how you made the decision? How do you feel about the decision that you made? Health 1 Have u made any decisions about ur health or wellbeing Choices today? Can u describe how u made the decision? How And do u feel about the decision that u made? Decisions 2 Have u made any choices about ur health or wellbeing today? The choice can be big or small. Can u describe the choice and how u made your decision? 3 How r u? What did u do 2day that was good 4 ur health? What did u do 2day that was not good 4 ur health?
8.3.7 MXit Questions
The original study design planned to pose the same questions on MXit and
SMS. However, structuring MXit chats as single question and answer exchanges did not work. The MXit medium follows its own set of rules for communication and is characterized by fluid exchanges. Chatting was more effective when
258 participants initiated the chat and led the topics. Thus for the duration of MXit chatting, my questions were limited to how are you and what are you doing. All other chatting was participant – directed. Table 8c. lists the most common chatting topics.
Table 8c. MXit Questions and Topics
Most common Researcher-Directed Questions 1 HUD? [How are you doing?] 2 WUD [What are you doing?] Most common Participant-Directed Questions 1 Hai [Hi or hello] 2 HRU? [How are you??] 3 WUD? [What are you doing?] 4 WUW? [Who are you with?] 5 Where do you stay [live]? 6 When will we have an interview?
8.4 Response Rates and Results
8.4.1 SMS Response Results
Eleven youth chose the SMS activity; three females aged 16-19 and eight males aged 15-20 (mean age = 17). Two of these youth, both females, responded to 100% of sent SMS’s over four weeks. Four youth responded to 50 - 71% of the
SMS questions. Two youth responded to 42-45% of the SMS questions, two youth responded to 22-31% of the SMS questions, and one youth did not respond to any
SMS questions. Summaries of message volume and response rates are provided in Table 8d. Response rates were highest amongst female participants who owned their own phone that was not shared with others39. Response rates were
39 Participants were required to have their own phone that was not shared in order to be eligible for cell-phone based data collection activities. However, despite reporting having phones that they did not share, some participants revealed during data collection activities that their phones were at times shared
259 lowest amongst male participants with little experience using SMS and amongst participants without their own phone40.
Table 8d. SMS Participation
Date Date # of Q’s # of % Sex Age Began Ended Sent Responses Response F 16 5-May 27-Jul 30 19 63 F 16 24-Apr 5-Jul 36 39 108 F 19 12-Jul 23-Aug 39 46 118 M 15 5-May 15-May 9 6 66.7 M 15 5-May 30-May 32 10 31% M 17 5-May 3-Jun 11 5 45.5 M 18 9-May 3-Jun 19 8 50 M 18 N/a N/a 0 0 0 M 19 14-Aug 21-Aug 9 2 22 M 20 1-Jul 30-Jul 14 6 42.9 M 20 24-Apr 28-Apr 7 5 71.4
The most frequently responded to questions were about activities, followed by questions about the day. The least responded to questions were about health choices or decisions, followed by choices or decisions in general.
Participants overwhelmingly reported that they most enjoyed responding to the activity question because it was “fun” and “interesting” for example. In contrast, participants reported that the questions about health choices / decisions were not relevant to them, and a number of participants reported that they did not like the question about choices because they did not have any choices to talk about that day. One participant (female, age 16) reported not liking the question about challenges because it was “very deep and hard to think about” and caused this with others out of necessity such as a family member losing their phone and needing to borrow another one until the phone could be replaced. 40 See previous footnote.
260 participant to feel sad. Another participant became bored with the SMS’ing over time and the repetitiveness of the questions (female, age 16) and therefore stopped responding to messages.
The two most common reasons participants gave for responding to the
SMS’s were that they had agreed to do so and because answering the questions was fun. A number of participants cited lack of time or being busy with other activities such as studying for exams or being busy with family as reasons why they did not respond to the SMS questions. One participant’s phone broke and he did not have the money to replace it (male, age 20). Another participant (male, age 16) became occupied over the school break with various holiday programs and was too busy with that to send SMS’s. Two participants (males, age 15 and
20) asked to switch to the diary after a couple weeks of the SMS’ing.
8.4.2 MXit Response Results
Eighteen females aged 14-21 and fourteen males aged 15 – 21 drawn from both the focus group and interview samples chose the MXit activity. Ultimately 13 females aged 16-21 and 7 males aged 15-20 participated in chatting on MXit.
Participants were initially responsive on MXit; however, participant responses quickly dropped off after the initial chats and became much more sporadic.
The original study design planned to chat on MXit using the same schedule as the SMS activity, where youth chose four days a week and two times during each day when they were available to chat. However, chatting at previously agreed upon times did not work. Youth were busy with other activities during those times, they often did not have sufficient airtime to log onto MXit,
261 they did not want to log on, or they already had other, regular times when they logged on to MXit which they preferred.
Four female and two male participants spontaneously began chatting with me on the instant messenger application WhatsApp instead of on MXit because they preferred WhatsApp. WhatsApp chats are not included in this analysis.
Youth generally use MXit periodically throughout the day, most days of the week. The most common times youth log on to MXit were in the morning before walking to school, during school breaks, immediately after school before heading home, in the evenings after dinner and right before going to sleep at night. Evenings were the best time to chat with participants, because when they used MXit during the day it was generally for very brief periods to check in with friends or family or to make plans, and they often did not have time for other chatting.
The times when I logged on to MXit were adjusted to fit the youths’ existing usage patterns. The vast majority of MXit chats were conducted in evenings, were initiated by the participants, and did not go beyond basic greetings (i.e. saying hello) or asking how I was doing. For these reasons, response rates were not calculated for MXit and only chats that included substantial content were analyzed for study themes (see Table 8e.).
262 Table 8e. MXit Participation
Number of chats included in PT Sex PT Age thematic analysis F 16 3 F 16 3 F 17 4 F 17 4 F 17 4 F 18 2 F 18 6 F 19 1 F 19 3 F 19 3 F 19 10 F 20 6 F 21 3 M 15 4 M 17 4 M 18 1 M 18 5 M 20 5 M 20 5 M 20 6
8.5 Findings Regarding Language Use
As will be demonstrated in the findings reported below, MXit has its own language that youth use when corresponding via the MXit platform. The language also spills over into communicating on SMS. MXit calls the unique language
“MXit speak”, and study participants call it “the youth language”. The youth language is oral as well as written, and is used not only on MXit but also in face- to-face interaction when youth are chatting with other youth. The youth language is generally not used when speaking with adults because to do so is considered disrespectful, though of course there are instances when youth do use youth
263 language with adults. The youth language mixes English with Xhosa words and uses numerous slang words. Furthermore, on MXit and SMS youth use abbreviations and non-standard spellings for English words that are mostly phonetic. Language switching between English and Xhosa is constant and unpredictable. Participants thus taught me the youth language and how to use it to chat on MXit and to understand their SMS messages. Examples of the youth language can be found in Table 8f.
Table 8f. Youth Language Examples
Youth Language English Translation HAY How are you? HUD How you doing? L2M Listening to music LIB Lying in bed JC Just chillin’ Gudnyt Good night Mxm Whatever / I don’t care [phonetic. When spoken this sounds like a tisking sound] Intro Plz Introduction please. Tell me who you are – your age, race, and where you stay Msng my 1 nd only Missing my one and only [one and only love] Ask da 1 nxt 2 u Ask the one next to you In syd am beutfll Inside I am beautiful
When chatting on MXit, the majority of youth communicated primarily in isiXhosa in addition to using the youth language and heavy use of abbreviations.
This is in contrast to SMS, where youth primarily sent messages in English using abbreviated spellings (for example, ‘2day’ instead of today or ‘lyk’ instead of like).
When abbreviating English words, youth tended to use phonetic spellings. For example, one participant wrote “am abwt 2 go 2 da church with ma frndz”, which means “I am about to go to church with my friends”. However, when chatting in isiXhosa, participants switched to using full sentences and spelling out each word
264 in its entirety. Thus chatting on MXit required a fuller understanding of isiXhosa as well as the youth language. Key informants and research assistants thus provided me with essential training in how to chat on MXit.
Observed patterns of language use in SMS messages supports previous research indicating the use of abbreviations, phonological approximations, and paralinguistic restitutions in SMS messages sent by youth (Thurlow 2003;
Deumert and Masinyana 2008). Abbreviations and phonological approximations include dropping letters from words, such as using ‘u’ for you, ‘4’ for for, ‘plz’ for please, or ‘bcz’ for because for example. Paralinguistic restitutions, such as using all capitals or exclamation points to express emotions, include examples such as typing smiley faces [ : ) ]. However, whereas Deumert and Masinyana (2008) found abbreviations and phonological approximations only in a minority of SMS messages, the opposite was observed in this study. Nearly all of the SMS messages received in this study contained abbreviations and phonological approximations. Paralinguistic restitutions were largely absent from SMS’s both in Deumert and Masinyana’s study and in this study, excepting a few instances where participants in this study sent Please Call Me messages in all caps to express urgency (example, Plz call [participant name] NO AIRTIME). While many abbreviations, such as ‘2’ for to and ‘4’ for four, are recognizable in a variety of contexts to English speakers, other abbreviations were unique such as ‘2dae’ for today, ‘mic’ for miss, ‘maslf’ for myself, ‘bux’ for books, and ‘da’ for the.
Observed patterns of language use in MXit chats share some similarities with SMS language use, such as using abbreviations and phonological approximations for English words, but also differs from the language in SMS,
265 particularly in the greater use of isiXhosa, fully spelling out words in isiXhosa, and the tendency to type out complete sentences. Part of this difference is likely due to the fact that SMS limits the number of characters that can be contained in a single message, whereas MXit does not have the same limitation. MXit uses less airtime and lends itself to lengthy free-flowing chats.
However, Duemert and Masinyana (2008) found that even in SMS, isiXhosa was not abbreviated, expressed with alternate spellings, or supplemented with paralinguistic restitutions whereas SMS’es in English were, indicating different norms for communicating in isiXhosa versus English. Part of this difference is possibly due to language knowledge and abilities in isiXhosa as compared to English. Literacy rates remain low throughout South Africa, especially in under-resourced areas, yet many youth possess “SMS” or “MXit” literacy (Banda 2003) even when lacking Standard English reading and writing literacy, especially in the urban areas.
8.6 SMS Message Contents
SMS messages centered around the major themes of daily life, choices and decisions, health and illness, dating and romantic partners, challenges, strategies to manage challenges, and the risk environment. Each theme is described below.
Because of the small sample size, findings are descriptive.
8.6.1 Daily Life
Regular daily activities reported by youth are included in Table 8g.
266 Table 8g. Regular Daily Activities* Type of Activity Specific Activity Social and Spending time with friends, family, or boy/girlfriend (n=11) Community Going to church (n=7) Activities Soccer (n=3) Netball (n=1) Surfing (n=1) Chatting on MXit (n=1) Doing hair (n=2) School Activities Homework (n=6) Drama Practice (n=2) Extra matric classes (n=1) University applications (n=1) Home Activities Chores (n=3) Cooking (n=3) Other Watching television (n=5) Sleeping (n=3) Part-time job (n=1) *Participants could report multiple activities.
Participants most often reported spending time at the library, at home, at friend’s houses, at church or walking the streets with friends. Two participants
(both females) spent time near shebeens (taverns). Two participants (one male and one female) who had completed or dropped out of school had very little to do and reported spending most of their time at home sleeping or watching television.
8.6.2 Choices and Decisions
When asked about choices or decisions, the most common response from all youth was that they did not have to make any choices that day. When youth did report a choice, the choices were most often choosing whether or not to complete homework (n=4, 1 male age 19, 3 females ages 16 (2) and 19) or how to spend their time. These youth reported choosing the activities they thought would most benefit their futures or wellbeing such as school or church.
267 One participant (female, age 16) reported making a number of choices about how to spend her time, such as whether or not to go to church, to school or to drama practice. This participant almost always chose church over other activities because she believed church was important, and that “God is everything”. When deciding between non-church activities, she chose to attend whichever activity she felt would most benefit her future, such as going to school or to drama practice over other activities such as doing chores at home or hanging out with friends. This participant discussed prioritizing activities that she believed would contribute to a successful future, such as school, even when her friends did not understand or support her choices.
A second participant (Female, age 16) also reported making a number of choices about her schoolwork or spending time with her family. This participant regularly chose to spend time on the weekends, holidays, and some evenings visiting her family, who were spread out over a number of townships in the
Western Cape and Eastern Cape provinces because she missed her family and seeing them made her happy. On numerous other occasions this participant chose to spend her time focusing on school and homework instead of socializing with friends because she considered doing well in school to be important for her future. She writes: “The choices dat I made 2dae is 2 stay at home da whole dae, nd read ma bookz nd check ma school diary, the othr choice dat I have made 2dae is 2 work hard on ma studies nd spend les tym with ma frndz. I made the choice by thnkng of what do I really want in lyf/future not living ma lyf 4 other's, I am happy because I haven't thought of what do I really what in future” (The choices that I have made today is to stay at home the whole day and read my books and
268 check my school diary. The other choice that I have made today is to work hard on my studies and spend less time with my friends. I made the choice by thinking of what do I really want in life and the future; (I am) not living my life for others.
I am happy because I have not thought of what I really want in the future
(before).)
A third participant (male age 19) also chose to commit his time to studying so that he could have a better future. He writes: “i've made a decision that I will gv my slf time 2 read my bux even if its 30 min b4 I go 2 bed, i thnk ths wll help me 2 boost my marks, ths is a very huge favour that am doing 4 ma self, am doing ths bcz i wnt 2 enter at any institution nxt year, i am a dreamer n i wnt my drms
2 come true n i realise that education is the most pwrful wpn tht i cn use 2 chnge my wld”. (I have made a decision that I will give myself time to read my books even if it’s (only) 30 minutes before I go to bed. I think this will help me to boost my marks (grades). This is a very huge favor that I am doing for myself. I am doing this because I want to enter at any institution next year. I am a dreamer and I want my dreams to come true and I realize that education is the most powerful weapon that I can use to change my world.)
Other choices reported by participants included choosing to be positive in order to have a better life (male age 19): “2day i made a decision that i wll alwyz do pstv thngs bcz i blv that my atittude determines my altittude. i thnk ths wll work 4 me a lot,” (Today I made a decision that I will always do positive things because I believe that my attitude determines my altitude (how high I can go in life). I think this will work for me a lot.); and choosing not to buy dagga
(marijuana) (male age 15): “it waz (was) a good day because i made a choice of
269 wanting not to buy dagga muffin and i feel very happy and satisfied about my self,”.
8.6.3 Health and Illness
One participant (female age 19) reported that sleeping, taking walks, exercising, and eating healthy food were good things she did for her health. One participant (female age 16) was “watching my figure” and didn’t want a “big stomach” so she refused to eat food she thought would make her fat. This participant chose not to exercise if she wasn’t “that fat” at the moment. One female reported unhealthy things she had done such as eating junk food, walking in the rain, and not getting enough rest (female, age 19). Males did not report any activities they did for their health or wellbeing, though one male did describe a persistent health problem that he had to date been unable to resolve. Four participants (2 males and 2 females) reported having the flu at least one point during the SMS’ing which required them to stay in bed all day to rest.
8.6.4 Dating and Romantic Partners
Dating or romantic partners were not common themes brought up by participants during the SMS activity, which is not unexpected because this was not asked about explicitly. However, three participants did report issues relating to the theme of dating. One participant reported spending time with his girlfriend
(male, age 16), one participant was stressed and down because her boyfriend moved away (female, age 16), and another participant broke up with his girlfriend
(male, age 18). He writes: “i had a bad day because i broked up with my girlfriend and i was not redy 4 something like that 2 happen” (I had a bad day because I
270 broke up with my girlfriend and I was not ready for something like that to happen).
8.6.5 Challenges
Participants reported some challenges via SMS. For example, three male participants (ages 15, 18, and 20) reported having nothing to do which led to feelings of boredom or frustration. One participant (female, age 19) found completing bursary (scholarship), university and job applications to be stressful, one participant (female, age 16) experienced an attempted break-in at her home, one participant’s cousin brother passed away (female, age 16), one participant felt challenged by constant changes in her life (female, age 16), and one participant lost everything when his home was destroyed in a fire (male, age 19). One participant (female, age 16) was worried and stressed because her brother had
“gone to the mountain” for traditional circumcision and she was scared “bcz othrz die there,” (because others die there). Her brother did return from the ceremony, which made her very relieved.
8.6.6 Behavioral Choices to Manage Challenges
There were a small number of reports regarding the strategies participants use to address challenges. Two female participants (ages 16 and 19) sought help from teachers for schoolwork and filling out applications and one male participant (age 19) sought the researcher’s help in seeking medical care. No other strategies were reported via SMS.
8.6.7 Risk Environment
Aspects of the risk environment were revealed during the SMS activity, in particular the related issues of inadequate housing and poverty. Inadequate and
271 crowded housing was evidenced by the participant whose home burned down. In the informal sector where electricity is limited or not available, people heat their homes with paraffin stoves which easily catch fire, and homes in the area are extremely close together so it’s easy for fires to spread from one shack to the neighboring shacks. One participant (female, age 19) described sharing a bed with two other family members and how the roof of her shack leaked when it rained: “the wost (sic – worst) that my house rainy inside it water falling inside”.
One participant (female, age 19) was also unsettled by violence in the community after she witnessed fights at a local shebeen.
8.7 MXit Chat Contents
At the start of this study, very little research was published on the topics that MXit users discussed while on MXit. One notable exception is UNICEF’s
2011 study authored by Hoveyda and Sinha which found that the most common topics discussed on MXit were love life and dating (46%), gossiping with friends and family (22%), and talking about music, fashion, sports, etc. (19%) (Hoveyda and Sinha 2011). MXit’s own research has also found that the most common topics chatted about on MXit are love and dating (MXit 2010). These findings are largely supported by the data collected in this study, though key differences were found in the content chats between the researcher and participants, described below. It is to be expected that chat contents would vary when chatting with friends or boyfriends/girlfriends as compared to with researchers.
MXit chats for this study were in general very brief, lasting only a few minutes and centering on simple queries such as how are you and what are you doing. Most of the MXit chats never expanded beyond these simple exchanges.
272 Among the more substantial MXit chats, chatting themes included checking in, making plans, asking questions about the researcher, seeking assistance, and dating, love, and relationships. Chat themes revealed the challenges facing youth, such as not having enough money to buy clothes to keep warm and needing financial assistance to continue schooling. One chat also described an aspect of cultural expectations of males, particularly the emphasis Xhosa males place on circumcision as a defining feature of manhood. Each theme is described below.
Due to small sample size, findings are descriptive.
8.7.1 Checking In
MXit chatting in my experience was most often used for simple exchanges such as saying “hello” and “how are you?” and to send quick messages or check in with others that one had not seen in a while. Ten participants regularly checked in with me and chatted for just a few minutes before ending the chat.
8.7.2 Making plans
Participants used chatting on MXit to ask about upcoming focus groups
(for example, to confirm the time of the next focus group) or to schedule an interview or follow-up meeting (for example, female, 18, asked when she could finish her interview). One participant (female, age 17) asked questions about what topics would be discussed in her upcoming interview. Other participants used MXit to find information about events and activities happening at the local
Youth Centre (3 females, all age 18).
8.7.3 Asking questions of the researcher
Two participants (female, age 20 and male, age 20) primarily used MXit to ask me questions about myself. For example, one female (age 20) asked me
273 where I lived and what it was like there, and one male (age 20) used MXit to ask me questions about my schooling, where I lived, and my opinion about living in
South Africa.
8.7.4 Seeking Assistance
Two participants used MXit to ask for assistance. One female (age 19) logged onto MXit to ask for assistance in obtaining information about school bursaries because she wanted to study journalism. “Lol in this lyf u got 2 be smebody in oder 4 u 2 cucced in lyf nd a beta education that’s why I wnt 2 study futher” [Laugh out loud, in this life you’ve got to be somebody and in order for you to succeed in life you need a better education that’s why I want to study further]. One participant asked if she could have my old clothes that I no longer wore [sharing clothes was reportedly very common amongst participants in the community]: “…cn u plz gve me ur old clthes that u dnt wear them any more plz if its okay with u,” [Can you please give me your old clothes that you don’t wear anymore please if its okay with you].
One participant (male age 18) asked for information about where a friend of his could receive medical circumcision. His friend’s culture did not have traditional circumcision as in Xhosa culture, but the friend wanted to be circumcised another way because he was living in a Xhosa community and was being teased by other Xhosa men for being uncircumcised. This caused him to be excluded socially because circumcised men would ask him to leave during conversations when his Xhosa friends “talked about manhood”: “b.coz at work he filx rejectd coz wen we twk manhood thngx we tel hm to go.” [Because at work he feels rejected ‘cause when we talk manhood things we tell him to go.]
274 This participant also asked for assistance obtaining counseling for anger management to help him with his relationship with his girlfriend, with whom he had a child. “I rly do, coz am ruining my relationship wit my g.f n i dnt want dat to hapn nw dat the z a chld involvd”. [I really do [need counseling] ‘cause I am ruining my relationship with my girlfriend and I don’t want that to happen now that there is a child involved.]
8.7.5 Dating, Love and Relationships
On occasion, participants would raise the topic of dating, but this was rare.
One participant (female, age 18) wrote that she loved her boyfriend and that
“when am with him I’do feel gud,” [when I am with him I do feel good]. Another participant (male age 20) gave me a hard time for watching a romantic comedy on TV with my husband while we were chatting, saying that I was getting too much love if I watched movies about love on TV while I was in a relationship. “Yu r geting lv 4rm yo guy bt yu stl hv 2 watch sumthin abwt lv. Ppl die 4rm lv overdose, wen yu hv 2 mch lv around yu,” [You are getting love from your guy but you still have to watch something about love [on television]. People die from love overdose, when you have too much love around you].
8.8 How youth are using MXit
Trends of how participants used MXit in daily life were observed through
MXit data collection activities and qualitative data collected throughout the study. Observed trends include when and how often participants used MXit, how they presented themselves on MXit through their profiles, whom they chatted with on MXit and why, and perceptions of MXit. These data are summarized below.
275 8.8.1 When Participants Use MXit
Participants generally logged on to MXit multiple times in a single day when they had enough airtime to afford to do so. Participants most often logged on to MXit to chat in the evenings after dinner or for an hour or so before going to sleep. Other times when participants chatted on MXit were in the mornings before school, during school breaks, and after school. The frequency and duration of participant log-ins on MXit was extremely variable, and depended on any number of factors including available airtime, access to a cell phone, free time to chat, and interest in chatting. A number of participants would go through periods of frequent chatting, logging on to MXit every night for a week or more. Other participants would do the opposite, and choose not to log on for stretches of time or even temporarily delete MXit from their phones in order to focus on other activities, such as studying for school exams. In general, participants were either using MXit frequently or rarely to not at all.
These observed patterns are supported by MXit’s own analysis. MXit has found that that 79% of their users log in more than once per day with an average of four - six log-ins on a given single day (MXit 2012). Users spend an average of
87 minutes online per week (MXit 2012).
8.8.2 Self-Presentation through MXit Profiles
MXit profiles generally include a chosen user name, gender, age, a picture, a status message and sometimes a short description of themselves. Participants’ profiles largely masked their real identities. Some participants included their faces in their profile pictures, making them identifiable; but more than half of participants used profile pictures that obscured their real identity. Real names
276 were not used, and the only identifying personal details shared on profiles were age, gender, and occasionally town of residence, though some participants were vague or playful about this information. For example, one participant (female, age 16) stated her location was “next door”, one participant (female, age 20) stated she was from Cape Town and Toronto, Canada and another participant’s
(female, age 19) profile said she was from “everywhere in this world”.
Participant profiles were often crafted to strategically invent and project a particular image or version of him or her. In this way MXit was used by youth, males and females, to create particular identities for themselves, such as gender- based or racially-based identities (as found by Bosch 2008). For males, MXit identities could emulate music and rap stars whereas for females, MXit identities could highlight their style in model-esque photos. Some profiles were related to love and romance for both males and females but more often for females. In some cases, profile names and status messages were designed to attract attention from the opposite sex. For example, a number of male participants emulated pop culture with their profile names and status messages, such as by adopting music star names as their user names, and using profile pictures ranging from pictures of fancy cars to pictures of piles of cash, in order to imitate social status in pop culture. Some females had glamorous profile pictures or playful profile names such as 2cute2care (in order to maintain confidentiality, this example is taken from MXit and was not the profile name of a participant). Previous research has similarly found that MXit is a place where young people especially females experiment with their sexuality (Bosch 2008).
277 Some participants presented themselves as being either older or younger than their real ages. One participant (female, age 15) exaggerated her age, saying she was 19 when in actuality she was 15. Another female participant did the opposite; with her profile saying she was 14 when in reality she was 20 years old.
Other participants used pictures of an activity they enjoyed, such as soccer or church. Finally, some participants chose to be straightforward and transparent with their profiles and provided an identifiable picture of them or a picture of them in everyday situations as opposed to dressed up in their finest clothes.
Each profile included a “status message” where users could write a brief sentence that would appear underneath their photos. Status messages, pictures and emoticons were used to express their personalities and sometimes their feelings at that moment. Status messages varied considerably. Status messages were occasionally related to love and dating and were sometimes directed to an individual. For example, one 19 year old male’s status message was
“ndiyakuthanda bbs nd I wl alwz in ma heart mic u…” [I love you babe and I will always in my heart miss you…]. A majority of other participants used their status messages to express their love for their boyfriend or girlfriend, and a minority of participants eschewed status messages altogether.
Some participants frequently changed their status updates to reflect what was happening in their lives that day. For example, one female participant (age
19) posted a status message that she was panicking. When asked about it, the participant responded that she was waiting for important test results. Another participant’s (female, age 20) status message said she was missing her one and only and was lost without him. “One and only” is a phrase youth used to describe
278 the person that they love, indicating a serious relationship with someone that is the “one and only” person they are dating and with whom there may be the potential for a future together.
8.8.3 Who to Chat With and Why
Participants reported chatting on MXit with their friends, cousins, romantic partners, and with strangers in an attempt to meet new people, including potential romantic partners. Previous research indicates that youth use
MXit primarily to chat with people they already know to maintain and strengthen existing relationships with friends (Chigona et al 2009). Participants in this dissertation study did use MXit for maintaining and strengthening social connections; yet reports of using MXit to meet new people were also found.
Participants also used MXit for entertainment when they were bored or had nothing else to do.
Finding new boy/girlfriends was a reportedly popular use of MXit for participants. Both males and females would exchange MXit details with someone they met in person, and chat on MXit in order to get to know the person better and decide if they wanted to date them or spend time with them in person.
Others would search for someone on MXit that they had seen in real life in order to start a conversation with them over MXit. For example, one participant
(female, age 21) was chatted by a guy on MXit who said he admired her for four years prior to contacting her. She continued to chat with him, and later agreed to meet him in person, and they eventually started an in-person relationship.
Some participants would meet new people on MXit itself. Questionnaire data found that 46% of interview participants report chatting with people on
279 MXit that they wouldn’t otherwise talk to in person and that 48.7% of interview participants report dating someone that they met chatting on social media, most often MXit. These reports are much higher than other research reporting 16% of youth on MXit talk to strangers and new friends on MXit, 11% chat on MXit to get a girlfriend and 5% chat on MXit to get a boyfriend (Hoveyda and Sinha 2011).
However, MXit’s own research has found that the most common reasons people give for chatting on MXit are to meet strangers and to share information (MXit
2010). A study carried out on the MXit platform amongst MXit users found that
42% of survey respondents chatted with strangers on MXit, and 33% did so at least once a week (Hoveyda and Sinha 2011). Qualitative data collected in this study further support the finding that MXit is one of many places for youth in the study community to meet new romantic partners. Participants overwhelmingly report using MXit to meet new people, chat with strangers and flirt with members of the opposite sex.
Some gender differences were observed in how males versus females went about chatting with new people, but due to small sample size no conclusions can be drawn. Males tended to chat with females in their own community. “You do chat with people you already know and then you do meet new people on MXit cause you can just search people. From Cape Town. I can just like see [users from] [community]. And it depends if you know them or you want to know them.
That’s when you like make new friends see. and most of the time we like to do that,” (male, age 21). Females, in contrast, were more likely to report chatting with guys outside their community in an attempt to meet non-local people. For
280 example, “Sometimes the guy you meet in the chat room is much more charismatic and appealing instead of the Xhosa guys,” (female, age 21).
Participants eventually want to know the “real” identity of the people they chat with. One participant (female, age 16) explained that when chatting with new people on MXit, she would ask for an “introduction”, often via the shorthand
“intro plz”, inviting the person to reveal information about their real selves such as their age. This is similar to findings from a 2011 UNICEF study conducted over
MXit which reported that 79% of their survey respondents would ask for “ASLR”
– age, sex, location and race when chatting with strangers on MXit (Hoveyda and
Sinha 2011). The shorthand ASLR was not commonly used amongst participants in this dissertation study, and one participant (female, age 16) said that a proper introduction involved the person telling her about himself more generally, and then she would tell him about herself, followed by chatting about what they were doing and what their upcoming plans were. If she were still interested in him, she would then share her address or designate another place where they could meet in person.
While participants reported sometimes meeting the strangers that they met on MXit in person (as has also been reported in other work, e.g. Beger and
Sinha 2012), meeting in person was not always the goal for participants when chatting with new people on MXit. For example, three female participants report becoming bored after meeting an online friend in person. As one participant puts it, “yeah but, you see, now it’s kind of boring because they always want to meet with you. So when you meet someone just, you lose interest in them. But when you don’t know them, it’s just interesting” (female, age 20).
281 One female participant reported chatting with people she didn’t know on
MXit simply because it was “fun” (Female, age 20). Two female participants (ages
19 and 20) discussed chatting with people they don’t know on MXit in order to get advice from people they don’t know. Chatting with strangers was perceived as a way to receive advice without being judged or having your privacy compromised. This was explained by one of the participants:
“it’s to make a conversation on MXit, making new friends, meeting new
people and sometimes it’s best to share you problem with a stranger
because they [people you know] judge you. People who already know you
find it hard not to judge you. A stranger does not judge at all,” (female, age
19).
A number of female participants also report chatting with strangers on
MXit because they want to “explore the world,” and perceived meeting new people as a way to do so because it allowed participants to chat with people living outside the community and around the country. In this example, MXit was perceived as a venue to expand social networks and choice of romantic partners, especially outside of their own community, and a way to learn about the lives of people perceived to be different from themselves. In an environment where participants sometimes felt excluded from certain segments of society, meeting new people on MXit, in addition to using cell phones to access the internet, was an important way for participants to explore and connect with the wider world.
Participants did however report a number of concerns about the strangers they met on MXit. First, there was a concern about who the person “really” was and what their intentions were. Many female participants report that it was easier
282 to chat with guys on MXit rather than face to face, but the downside to this strategy was that most of the people they became friends with on MXit were males who “want love” – “They don’t know you, they just want love,” (Female, age
21). Two male participants reported using MXit because they thought they would meet more girls on MXit than in person. For example, “But maybe if maybe can you chat on MXit with this girl and you are so to her (meaning you say nice things to her to make her like you and you ask her to meet). And she says ok lets meet…”
(males ages 15 and 16).
Secondly, many participants, especially females, believed they could not trust the people they met on MXit because it was easy to fabricate on social networks. Female participants in particular expressed concern that guys they chatted with on MXit were not honest. For example, “People are a whole new person on Facebook and MXit. People lie all the time. It’s especially easy to lie on
Facebook and MXit. People’s profiles are all lies. They just say what will make them cool,” (21 year old female). Some participants described how youth’s profiles were sometimes venues to compete with each other by projecting an image of having money or nice clothes for example in order to “be on top”
(female, age 20). Some females claimed however that they could tell when a male was lying on MXit because males tended to brag about being at parties, drinking alcohol, and driving fancy cars which indicated to females that they were making things up to sound impressive.
Some female participants reported occasionally fabricating on MXit.
Females said they sometimes obscured the truth about their age, where they live, where they were at that moment, about having jobs or being in school. Some
283 females reportedly did this to experiment with new identities, which MXit allows them to do in a relatively safe way with potentially no ramifications. One participant claimed “MXit is so nice [sic – fun] when you lying,” [female, age 20].
One female participant reported that she will only fib if she feels she is being deceived: “you can tell when someone is lying to you and you lie back. You don’t lie with someone who’s not lying but you can see where oh this one is lying. I bought this and this today…why are you always shopping?” (female, age 20).
Female participants also reported obscuring the truth as a strategy to maintain a sense of distance and safety from those with whom they are chatting.
One female participant (age 21) said she was less likely to obscure her identity if she felt there was no risk of her real identity being discovered. For example, this participant used her real name when chatting with someone from a community where she knew they would never run into each other or have friends in common.
Third, some females reported feeling pressured by guys they chat with on
MXit to meet in person. Another participant (female, age 20) reported that she was repeatedly pressured by guys who would chat her on MXit, often within the first two or three minutes of chatting with them. She found this disturbing and would end the chats with them. Some participants did consider meeting someone new on MXit, for example: “I wonder if I should give other guys a chance too,”
(female, age 20). Some male participants also reported inviting girls on MXit to meet in person, such as “let’s chat you see I’m bored come over let’s watch a movie or stuff,” (male, age 21) or inviting them to meet face-to-face.
Participants’ own concerns raise the question as to whether meeting new people on MXit increases their exposure to risky situations, such as being
284 pressured by strangers. However, as described above, participants employed a number of strategies to maintain safety. Furthermore, participants reported often refusing to meet strangers they met online and deleting strangers from their contacts if they were uncomfortable. Finally, when participants did meet people from MXit face to face, they reportedly worked these individuals into their existing social networks and patterns of meeting guys/girls, thus utilizing the same strategies they use in face-to-face interactions to maintain personal safety.
Participants, particularly females, also reported chatting with friends on
MXit. However, some participants reported that they would only say a quick hello or how are you to a friend on MXit, and would not chat for extended periods of time. “Your friends are with you,” (Female, 19 years old), meaning they are with you in person, so there is no need to chat with them on MXit. Some participants felt “it’s boring to chat with people you know,” (female, 20). This contradicts
Hoveyda and Sinha’s 2011 report that 68% of MXit users primarily chat with family and friends on MXit. However, no conclusions can be drawn from the findings of this dissertation study because of the small sample size and because it was not explicitly investigated who participants primarily chatted with.
Male and female participants both reported a tendency to avoid relatives on MXit. One female participant reported logging off of MXit if she saw that a sister or a cousin was online, for fear that that person will ask her to do something for them. Males similarly report logging off if they see a relative on
MXit such as in this example:
P1 (male age 21): I try to avoid as much as possible my cousins cause yho! When
I’m with my cousins on MXit or social networking it ends up a mess. Yhu.
285 P2: (male, age 18). Run. Just run. [laughing]
These males reportedly avoided their relatives because they were worried about getting roped into making plans, and because they were concerned about relatives knowing too much about them and where they were spending their time and who they were spending their time with. Males described wanting a sense of privacy and didn’t want all of their relatives knowing everything that they did.
8.8.4 Perceptions of MXit
Participants perceived MXit as youth space where they chat with friends, romantic partners, strangers, and at times siblings and cousins without interference from parents or other adults. MXit provided a venue for participants to carve out “personal space” (Bosch 2008) where they could experiment with their identity, develop relationships, and meet new people. MXit chats and profiles are private, and users must add people as contacts before they can chat with them. This provides youth with control over whom they do and do not chat with. MXit was therefore an appealing space for participants to engage with other youth. In contrast to MXit, the social networking applications Facebook and 2Go had reputations of being for older people. For example, as one participant stated she preferred MXit because “Facebook is for old people. So I might chat wrong or do wrong things on Facebook. MXit is for young people. It’s better to chat with teens and not your elders,” (female, age 15).
Participants generally felt that parents and other adults did not approve of their children using MXit. A number of participants hid their MXit use from their parents because they believed their parents would not approve. One participant, a
15 year old female, used MXit regularly but her mother did not know about it.
286 “She [my mother] says that MXit is for older people, and it’s a distraction and I shouldn’t be doing it.” On occasion MXit received public criticism in the media for things like exposing youth to dangerous people or for distracting youth away from their studies. In a highly publicized controversy in 2006, parents blamed the site for low exam scores across the country.
Perceptions about the positive and negative aspects of MXit were mixed.
While many participants report MXit to be fun and a great way to stay connected to friends and boyfriends/girlfriends, many reported negative perceptions of
MXit. Some participants saw MXit as a distraction, preventing them from focusing on more important activities such as schoolwork or chores. For example,
“MXit takes away your brain. Even if you’re Mixing and you’re cooking, disaster,”
(female, age 20). Other participants described MXit as addicting and stated that chatting on MXit could easily dominate a youth’s time, preventing youth from socializing with family members, completing homework or sleeping. “You won’t sleep at night, you won’t do anything [else] with MXit [when you are using
MXit],” (Female, age 20). Two males similarly compared MXit to an addiction that overtakes their lives, such as in the following example:
P1 (age 20): “We are all on MXit. But…there’s a side effect of it. You don’t
sleep.
P2 (age 18): and it fries your brain
P1: you don’t sleep, can’t focus. Like you see now at home when they giving
you chores…
P2: now you don’t gonna do it
P1: but now I’m busy texting…it’s like you’re a MXit junkie
287 Other participants said MXit causes you to not think straight: “ I don’t like
MXit. MXit makes you not to think straight. Yho my mom hates MXit,” and “You can’t do things properly when you’re on MXit” (female, age 16). Some participants would therefore avoid chatting on MXit for days or weeks at a time in order to focus on schoolwork, and participants said they would at times delete
MXit from their phones for a period of time so that they could focus on school.
A number of participants held a negative view of chatting about important issues on MXit, especially in romantic relationships. For example, in the words of one participant, “Chatting on MXit is not right. They [people on MXit] have the guts to say anything cause it’s not face-to-face. If you fight with girlfriend then don’t chat on MXit. Ayikhoright (it’s not right). Talk face to face,” (male, age 15).
Because of these negative perceptions, some participants refused to have
MXit on their phones. “I don’t want MXit. They [people chatting on MXit] doesn’t tell anybody when they going because she’s doing things alone, talking alone as if she’s mad,” (20 year old female). This participant joked that parents say when their children are on MXit, they act crazy, as if they are losing their minds, because they will be laughing even though they are alone in the room, so it seems as if they are laughing alone. Participants also claim teens become addicted to MXit, or Facebook, and they don’t sleep because they are up all night chatting.
8.9 Exploratory Analysis of the Methods
The goal of using SMS and MXit was to chat with participants as the events of their daily lives took place in order to gather data about experiences and feelings in real time. This goal was achieved to a limited extent. Youth were less
288 likely to respond to SMS’s or to log on to MXit if they were busy doing other things or if they were with other people. If participants found the questions required thought and focus to respond to appropriately, they would wait until they were free to reflect and respond instead of responding in real time.
Furthermore, when participants were chatting on MXit that was the main activity they were engaged in at that time.
Many participants ultimately did not respond on SMS or MXit. Whether or not participants chose to follow through with the SMSs or MXit, outside of barriers such as lost or broken cell phones, lack of airtime, or being busy with other activities, often rested on participant’s perception of how fun it was to do so and how much free time they had to respond to the questions or to chat.
8.9.1 The SMS Method
The SMS method required considerable time in the field for set up and training. SMS’ing started slowly, and it took a number of weeks of training before participants responded to the SMS questions regularly.
A number of barriers prevented youth from participating in the SMS, as well as MXit, activity, even though they expressed a desire to participate. The most common barrier was a lost, stolen or broken phone, followed by youth lending or sharing their phones for extended periods to friends or relatives.
Participants could not afford to purchase new phones. Two participants (males, age 16 and 18) were unable to send SMS messages because they had downloaded music applications onto their phones that “ate” their airtime, making it so whenever airtime was loaded onto their phones the application immediately used it up, leaving them with no airtime to send SMS’es or make calls. One participant
289 had her phone confiscated by a teacher for the remainder of the school term as punishment for using the phone during class, leaving the participant without a phone during this part of the study (female, age 15). Another participant (male, age 15) did not know how to SMS and required extensive training. Some youth chose not to participate in this activity at all due to the expense of SMS’ing, despite the fact that the cost of their SMS’s for this activity would be compensated. In addition, on multiple occasions SMS’s were “lost” on the network and never received.
Among those who participated in SMS’ing, 100% report that their favorite questions were What are you doing? Where are you? Who are youth with? What are you up to? and How are you feeling? 100% report that their least favorite questions were about health choices and health decisions because they often felt that the question was not relevant or did not apply to them that day. Response rates were highest for the favorite question, and lowest for the least favorite question, indicating that participants were more likely to respond when they found the question to be relevant or interesting to them.
Significantly, data collected via SMS yielded few notable insights that could not be gathered through face-to-face methods. However, the SMS method had the benefit of increased rapport with participants. One participant revealed a very personal medical problem over SMS and nine of the SMS participants began visiting me on a regular basis to discuss the topics raised in the SMSs as well as other issues in their lives. SMS is an effective way to supplement data collected via other methods, but cannot replace interviews or other face-to-face methods.
290 8.9.2 The MXit Method
In contrast to SMS’ing, the MXit method was effective shortly after set-up.
However, after initial success participant responses on MXit quickly dropped off and remained low for the duration of the study. When asked about why this was, participants reported not using MXit on a regular basis, lack of airtime, and preferring to use MXit to chat with boyfriends and girlfriends as opposed to with researchers.
A number of additional barriers limited participant ability to complete
MXit data collection activities, including lack of airtime or running out of airtime during chats; being busy with other activities and not having time to chat on
MXit, and not having access to a cell phone with MXit. In addition, participants would not log onto MXit unless they had time and interest to dedicate to chatting.
Thus youth tended to log on to MXit at times that they were previously accustomed to or as the need arose in order to check in with a friend or other person and not during pre-scheduled times where they would only chat with the researcher. This was despite participants choosing their own times to chat with the researcher.
MXit provided the opportunity for longer, in-depth chats than did
SMS’ing, but in practice youth were using MXit for other purposes such as chatting with boyfriends/ girlfriends or with new people, and there was little incentive for participants to take the time to chat with the researcher on MXit.
Furthermore, participants had established patterns of MXit use and entrenched perceptions about the purpose and value of chatting on MXit within which this research study did not fit.
291 The primary benefits of using MXit were that it provided participants with the opportunity to ask the researcher questions or ask for assistance with sensitive issues. MXit was an effective tool for developing rapport with participants, but it was not an effective method to gather targeted information.
Given the ubiquity of MXit amongst youth, who are frequently chatting on MXit with other youth, the MXit activity benefitted this study by providing insight into youth experiences with MXit chatting and how MXit fits into the landscape of youth daily life.
8.10 How Cell Phones Are Used
8.10.1 Access to cell phones and sharing phones
The study community, similar to other townships across South Africa, is underserved in terms of communications infrastructure including phone lines, computers, and internet connections. In recent years cell phones have filled this gap in the community, as well as in other South African townships. All participants had access to a cell phone. However, phones were often shared amongst a number of family members as opposed to individually owned. Younger participants most often shared phones and it was more common for older participants to have their own cell phone that was not shared. A subset of participants, primarily younger males, did not have their own phone but would give out the phone number belonging to a friend or relative with whom they spent most of their time so that callers could get in touch with them or get a message to them via the friend or relative.
Even when participants had their own phone, participants commonly lent their phones to friends or family members for periods of time. For example,
292 participants might leave their phone with a relative who needed the phone during the school day or to a friend who had lost their own phone. A number of participants also temporarily switched phones with their friends but kept their own SIM card and therefore kept their phone number, contacts and airtime. For example, if a participant had airtime and wanted to use it to chat on MXit or
Facebook but the participant’s phone did not have this type of capability, they would trade their phone with a friend who had a higher end phone, place their own SIM card in the friend’s phone, log onto to social media using their own account information and chat. The participant would then switch the phones back at a later time. Thus participants with low-end phones lacking social media capabilities could still access social media by swapping phones with friends and cousins.
A few participants would allow their boyfriend or girlfriend to check their cell phones to see if their partner was receiving messages from other guys/girls.
These participants described how one way of demonstrating trust in a relationship was to leave their cell phone with their partner for a full day so that the partner could monitor calls or messages coming in and thus check to see if their partner was receiving any messages from other guys/girls.
Cell phone access was therefore extremely variable. Disparities exist in cell phone ownership, in the types of phones participants could afford to purchase and the amount of airtime and data participants could afford. To address issues of access, cell phones and airtime tended to be fluid and shared with friends, families and boyfriends/girlfriends in such a way that cell phones and messages were therefore not always kept private.
293 8.10.2 Airtime and Pay as You Go
In the study population, instead of purchasing an expensive phone contract, youth used the significantly more affordable prepaid, also known as pay as you go, service for their phones. Youth could go to any shop or vendor and buy
“minutes” or “airtime” that are used to make calls or send SMS’es. Data bundles could also be purchased to access the internet and chat on social media. It is possible to access internet and social media via credits purchased as minutes; however using minutes for data services is extremely expensive and therefore using minutes for data services is avoided. Because minutes are relatively expensive for youth participants, youth were provided with enough airtime to complete the chatting for the study.
Airtime was an important commodity amongst participants. Airtime is relatively easy to access in the study community and can be purchased at most nearby stores or informal spaza shops. However, participants do not always have sufficient funds to purchase airtime. Others can purchase airtime for you and send the airtime to your phone from another user by sending an airtime pin or voucher via SMS. Youth often share airtime with friends and relatives. Males reported sometimes buying airtime for their girlfriend or friends, creating a situation where airtime becomes important currency in relationships as a way to demonstrate sharing and support. On a number of occasions, participants would post on Facebook ‘plz send airtime’, with an explanation of why the airtime was needed [usually to call family about an important family situation or to make calls inquiring about an employment opportunity]. Because the cost of airtime was expensive for participants, many participants would conserve airtime by
294 avoiding using their phones during “peak” usage hours (during the weekday) when usage rates are higher and would chat with social networks on MXit instead of calling or sending SMS messages.
8.10.3 Social Connectedness
Cell phones fill a critical need for participants: social connectedness
(Kreutzer 2009). Poverty limits opportunities for recreation, transportation to events, and access to communications such as computers, internet, and phones.
Crowded living conditions in townships further restrict youth’s privacy and youth must develop creative strategies to find private space where they can develop relationships with peers and potential dating partners. The cell phone and in particular MXit and the ability to access the internet over phones has been overwhelmingly adopted by youth as a mechanism to increase social connectedness in their lives.
Participants used cell phones to keep in touch with parents and other family members, chat with friends or romantic partners, download and share music, play games, and use the internet. Previous research conducted with school-going township youth similarly found that the most popular uses for cell phones were personal communication such as phone calls, SMS messages or
Please Call Me’s (91%), entertainment such as music or photos, accessing web sites (71%) and instant messaging (47%) (Kreutzer 2009).
However, not all participants in this study used cell phones to chat on social networks. Out of 41 survey respondents, nine participants (7 males, aged
14-21 and 2 females, ages 15 and 17) state that they do not chat on their cell phones. Of those that do chat on their cell phones, nine participants (3 males and
295 6 females) report chatting 1-2 hours a day, eleven participants (5 males and 6 females) report chatting 2.5-6 hours a day, seven participants chat 7-16 hours a day, and four participants chat all the time, or “24/7”.
Given the economic constraints of the environment, participants strategically use their cell phones to get in touch in ways that do not cost them money. When participants were short on airtime, they utilized “Please Call Me”
(PCM) services for communication. Participants often utilized the limited space to send information (this was also found by Deumert and Masinyana 2008). For example, one participant sent me the following message using a PCM: “Please call
[participant name] NO AIRTIME [participant phone number] Stand a chance to win the jackpot of R15 million this Saturday! Register & play MTN Lotto. Dial
*121*3777#. T&Cs apply.”
Another way of using cell phones to get in touch with others without using airtime is to “flash” another person’s cell phone. Flashing means you call another person’s phone, allow the phone to ring a couple times so that the other person can see you have called them, and then hang up before the call is answered. This alerts the other person that you are trying to get in touch with them. Participants frequently utilized PCM messages and flashing to get in touch with researchers regarding the study such as setting up times for interviews and focus groups.
Cell phones offer the possibility of connecting with social networks at all times. However, in practice this was not always possible. Participant cell phones were often lost, broken, turned off, shared with another person, or out of airtime to make calls or send messages. While cell phones do increase opportunities for connecting with social networks, and provide tools such as PCM and flashes to
296 get in touch with friends, family and romantic partners, they cannot replace face to face communication and are simply another mechanism for communication with social networks that is wrapped into existing patterns of staying in touch.
Participants frequently used their cell phones to take and share pictures, and also to download and share music. Females in particular greatly enjoyed taking pictures of what they were doing, who they were with, and what they were wearing. Participants enjoyed sharing the pictures on their phones with friends.
Females in particular enjoyed posting pictures of themselves in fashionable clothes or looking beautiful onto social networks as a way to craft and project an identity of them as fashionable and “in the style”.
Few participants could afford to use the internet on their phones on a regular basis and thus took advantage of every opportunity to use the internet, such as using computers at the local library. Participants regularly read about sports, various hobbies, and celebrities in order to learn about how other people live their lives, a topic of great interest to many participants. Participants also did research for school and enjoyed reading the news online and via social networks and many followed South African current events and politics.
8.10.4 Status
Cell phones were seen as an important status symbol and a significant component of individual style. Participants would therefore purchase the best phone they could afford. The majority of participant phones were very low-end phones without data or social media capabilities or basic phones with limited media capabilities such as music downloading and MXit. Many participants, especially younger participants, had used phones handed down to them by older
297 siblings or parents. Some participants had feature phones, and a minority of participants, mostly older youth, had a Blackberry. A subset of participants had more than one phone, often one phone would be used for chatting on social networks and a second phone would be used to make calls, send and receive SMS messages.
Higher end phones such as Blackberries or feature phones were highly prized amongst participants. Blackberries were coveted because they were in the style. In the words on one participant: “A girl without a Blackberry is not worth knowing,” (Female, age 19). Blackberries were also valued because of their BBM capabilities – BBM stands for BlackBerry Messenger, which allows users to send messages for free to other Blackberry users via BBM. Feature phones were valued because of their social media capabilities, including Facebook, MXit, and other message services such as WhatsApp and 2Go. Participants’ choice of instant messaging applications was therefore often driven by the capabilities of their phones. “Ja on BBM, it’s only people that have the Blackberry. So it’s not like everyone have the Blackberry. And on WhatsApp WhatsApp is only for people that have Blackberry and Nokia. And on MXit other people they don’t like the
Facebook and they don’t have the BBM’s and WhatsApp. So I chat with them on
MXit. Yeah.” (male, age 22).
8.10.5 The Changing Social Network Landscape
At the start of this study, MXit was by far the most popular social network in South Africa, especially amongst youth. Older females (aged 17-21) used MXit much more frequently than younger females (aged 14-16), and for males MXit use was low in the 14-15 age group but rose starting with age 16.
298 During fieldwork, the social networking landscape in South Africa changed considerably. At the end of fieldwork, SMS remained a popular use of cell phones across the country and with study participants and instant messaging applications grew tremendously, especially amongst urban cell phone users. In
2012 WhatsApp became the leading instant messaging application amongst
South Africans aged 16 and up living in cities and towns (World Wide Worx
2012). At the end of 2013, Facebook surpassed MXit to become the largest social network in South Africa (World Wide Worx 2014). However, MXit’s active user base remained stable at 6.5 million (World Wide Worx 2014 South Africa Social
Media Landscape 2014 Report), indicating that people are active on multiple social networks. Facebook primarily grew amongst older users with those aged over 30, especially the 60 and up age group, comprising the majority of new users; Facebook had slower growth amongst those aged 19 and under (World
Wide Worx 2014)41. BBM, Twitter and to a lesser extent 2Go also grew in popularity. Significantly, over 80% of users access social networks on their phones (World Wide Worx 2014).
These trends were also observed amongst study participants and in the larger study community. Facebook was popular among older youth (age 19 and up) and adults; whereas for participants with higher end phones capable of running WhatsApp, WhatsApp was preferred for instant messaging with researchers, and MXit use remained stable amongst youth. BBM was used
41 When looking at adult use, the most popular instant messengers are WhatsApp (53%, or 4.6 million users), Facebook Chat (45%), MXit (25%), and BBM (21%, 3.3 million users) (Mobility 2014); yet MXit remains popular with younger South Africans (World Wide Worx 2014).
299 primarily by older youth and adults with the resources to afford a Blackberry.
2Go was generally seen as boring, and mostly used by older people, though some young people said they would use 2Go to stay in touch with family members.
Facebook was used to see what other people were doing and to gather news about people they knew, their communities, and about celebrities such as music performers, athletes, and TV and movie stars.
The age gap in Facebook use was marked. Many of the older participants
(aged 19-22) did have Facebook profiles and they most often used Facebook to post status updates, comment on other people’s statuses, post pictures, and send messages. As noted above, posting pictures of oneself wearing fashionable clothes was very popular, especially amongst females. In contrast, a subset of younger participants used Facebook, but often did not have their own profiles. Instead, many would log onto their parents’ or older relatives Facebook profile to send messages, follow celebrities or look at pictures of people they knew. For these youth, browsing Facebook could be done in private but messages and posting pictures or status updates was not because their parent or relative controlled the
Facebook profile and could see these activities. These findings are supported by other research demonstrating that as youth get older, they tend to use Facebook more and use MXit and SMS less (Beger and Sinha 2012).
8.11 Implications for future research
SMS and MXit are potentially valuable data collection tools. They are most effective when combined with face to face methods and used to supplement data collected via other methods. Implementation of SMS and MXit methods in the ethnographic field requires a significant investment in planning and participant
300 training. It is essential to understand what electronic media participants are already using, their patterns of use, social norms for each medium, and the context within which participants use these tools. Participant training is necessary because research projects ask participants to use familiar tools but in a different way, which can be confusing and requires training so that participants are clear as to what is expected of them.
Each social network has its own unofficial rules of use that must be followed in order to use it effectively. Participant willingness to chat on a social network with researchers largely depended on whether the participant was already using the social network and how the research activities fit into their patterns of existing use. Furthermore, the relative popularity and frequency of use of specific social networks changes rapidly. When planning a project, youth may be active on one particular social network, but by the time of project implementation the social network landscape may have changed and youth may no longer use the social network researchers had planned to use. This can be problematic as there is no incentive for a population to return to an outdated social network.
The electronic methods in this study produced different kinds of data from face to face methods, and there are additional differences in the type of data received from SMS’ing versus MXit. The SMS questions elicited focused responses to the questions asked by the researcher; whereas MXit was more fluid, resulting in basic chitchat that increased rapport with participants. Despite the fact that SMS messages are limited to a few characters and have a relatively
301 higher cost that limits the volume of messages that can be sent, SMS nonetheless was more successful and thus provided richer data than did MXit in this study.
SMS is better suited to gathering specific, focused information through targeted questions. MXit is better suited towards voluntary, once-off large-scale surveys targeting MXit users where survey users can select themselves for participation. Because of the way MXit is used by participants, MXit did not lend itself to the targeted data collection set up in this project and participants were not interested in using MXit to chat for research purposes. Furthermore, participants chat quantitatively and qualitatively differently with researchers on
MXit than they chat with friends, family, and new people. Therefore the research chats on MXit must be analyzed in the context of the relationship of the people chatting. However, the process of learning how to use MXit and examining how
MXit is used and perceived by study participants yielded important insights into the centrality of MXit to participant’s social lives, the ways MXit fits into the landscape of everyday life and relationships as well as the unofficial rules and social norms for chatting on MXit.
An area rich for future study is an examination of how cell phones and social networks fit into daily life for vulnerable youth living in South Africa’s townships. Township youth struggle to overcome the “digital divide” and lack of media literacy that is necessary for successful participation in the global economy. However, addressing these concerns must take into consideration the proliferation of cell phones in townships and the strategies youth use to close the digital divide through cell phones and by developing “mobile [cell] literacy”
(Kreutzer 2009). Youth in townships largely remain at a disadvantage because
302 economic constraints limit their ability to obtain higher end phones with greater internet and social network capabilities. Poverty also limits the amount of data and airtime youth can afford which therefore limits their access to internet and social networks on phones. However, as described above youth have developed a number of strategies to maximize their use of these technologies.
Findings in this study suggest that youth see cell phones as a gateway to the larger world and as a tool to increase social connectedness in their lives. Cell phones and social media served to enhance existing relationships as well as create opportunities to meet new people. Cell phones and social media fit into existing patterns of behavior and relationship norms as opposed to changing behavior. Social networks did broaden social connections to a certain extent by providing opportunities for youth to meet new people; however social networks did not necessarily result in new in-person contacts. Social networks especially
MXit mostly resulted in face-to-face meetings when both individuals lived in the same community. Thus, whereas social networks did allow youth to meet new people, the people they met in person were generally from their own community and social networks rarely resulted in connections in communities where youth were not already spending time or meeting people. As cell phones become more and more integrated into daily life and as a tool of social connectedness, greater understanding of the ways cell phones enhance social relationships, especially amongst youth, is important.
303 Chapter 9. Discussion
9.1 Summary of Findings
This research utilized a mixed methods approach to investigate the ways vulnerable youth perceive and manage risk in everyday life in the context of a risk environment characterized by multiple, interconnected risks. Data collected in focus groups (see Chapter 5) during the first study phase served to establish a contextual frame through which to organize and interpret data collected in the second study phase. Interviews and structured risk assessment questionnaires were conducted during the second study phase (see Chapter 7). Diary data (see
Chapter 6) and electronic (SMS and MXit) data (see Chapter 8), while limited due to small sample sizes, provided additional insight into study objectives and served to increase rapport with a subset of participants. Findings were highly diverse between participants and consistent across data collection methods.
Participants simultaneously described hope for their futures and concern about the challenges in achieving future goals, especially the uncertainty of securing the necessary education and employment to build their own families and homes. Participants viewed their environment in terms of both its positive features such as friendliness and a smallness that provided a sense of safety and security and in terms of the everyday risk which they needed to manage. Notably, significant stigma and silence surrounded HIV in the community and in society in general. Risk management strategies focused on striving to obtain education and training, developing loving and trusting relationships, strengthening social relationships and community unity. The most frequently reported themes from all data sources are outlined in Tables 9a and 9b.
304 Table 9a. Most Frequently Reported Risks and Strategies to Manage Them* Risk Risk Management Strategy Uncertain future • School completion • Pursue additional education and job skills training Lack of jobs • School completion • Pursue additional education and job skills training • Develop English skills Limited educational • Migrate to areas with more educational resources opportunity • Seek out bursaries to support schooling • Seek out tutoring and educational support Crime, Violence, • Community must come together (unite) and take Gangsterism action • Job creation • Increase access to positive activities for youth (such as church or soccer teams) Drugs and Alcohol • Community must come together (unite) and take action • Youth must believe in themselves • Increase access to positive activities for youth Poverty • Create educational opportunity • Increase access to stable employment • Adequate housing provision • Drawing on social networks Health • Basic service provision in community (such as waste removal, housing, health care) • Eat healthy food • Exercise HIV • Build trusting relationships • Honesty in relationships • Open communication in relationships • Choose partners carefully • HIV testing • Condoms Pregnancy • Condoms • Obtaining birth control at clinics Other youth not • Youth must believe in themselves behaving properly • Youth must have self-respect • Providing positive mentorship for youth Cheating in • Honesty in relationships relationships • Open communication in relationships • Develop trust in relationships *From all data sources combined.
305 Table 9b. Structural and Contextual Factors Influencing Youth Risk* Reported Structural and Contextual Reported Structural and Risk Factors Contextual Protective Factors • Poverty • Small community providing • Inequality – economic, racial, social sense of safety and security • Legacy of historical inequalities • Friendly community • Limited employment opportunity • People in community help • Limited educational opportunity each other • Inadequate housing and services • Health services such as • Inadequate police protection clinics available • Overcrowded living conditions • Churches • Stigma and Silence surrounding • Sports teams HIV • Having a new school • HIV is “everywhere” • Educational programs • Peer pressure • Supportive social networks *From all data sources combined.
These findings contribute to anthropological literatures on risk and HIV, especially risk perception, social risk, gender and risk, as well as the literature on syndemic and risk environment models of disease. Main study findings and the relationship of study findings to these bodies of literature are discussed below.
9.2 Risk Perception
Mary Douglas defined risk as “the probability of an event combined with the magnitude of the gains and losses that it will entail” (Douglas 1992:40). In an attempt to manage uncertainty, risk essentially means danger (Douglas 1992). In this study, risk was understood as a potential danger to be avoided, such as HIV infection. HIV risk was often attached to moralizing ideas of “wrong” or dishonest behavior and was often located amongst the stigmatized “other” (Parker and
Aggleton 2003); such as youth acting in “the wrong way” by having condom-less sex outside of committed relationships. HIV was simultaneously located
“everywhere” wherein everyone was at risk independent of their behavior.
306 Participants expressed feeling safer from the risk of HIV infection when they were not having sex, had a partner they trusted, were regularly testing for HIV, or were using condoms, findings that support previous research (Smith 2003).
A portion of participants remained uncertain about their risk of HIV infection irrespective of their own behavior because of the high HIV rates amongst youth nationally and locally and because they knew of individuals who were “good” and acted “right” but still became infected. Fears of ‘accidental’ infection such as by a condom breaking, touching an infected person’s blood or making a mistake and having condom-less sex was raised by a portion of participants.
Furthermore, the inability to visibly discern if a person was infected heightened uncertainty and contributed to an overall feeling of vulnerability to
HIV infection. Similar to work in other geographic locations, uncertainty and the anxiety it produced was a key theme related to participant perceptions of risk to
HIV (Whyte 1997; Haram 2005).
Participants were simultaneously hopeful yet uncertain about their futures, job and educational prospects. Thus uncertainty itself was an important element of youth discussions of risk. The role of uncertainty overall in youth risk perceptions emerged as a focus of these youth.
Participants described HIV risk primarily in terms of HIV being both everywhere and in relationships where trust was lacking or uncertain. Fears of losing their partners, being accused of cheating or introducing conflict into the relationship could make it difficult for some participants to discuss their fears of
HIV, or to take precautionary measures such as condom use. The stated ideal of
307 monogamy in relationships existed alongside social expectations for males to give the appearance of having multiple girlfriends. Some male participants, but not all, did report having multiple girlfriends. These findings relate to the literature on social risk examining fidelity and its relationship to risks to social status and
HIV infection (Hirsch et al 2009), discussed below.
Overall, male and female participants demonstrated a very thorough understanding of the factors placing them and their peers at risk for HIV that matched epidemiological trends of HIV infection. However, participants described how it was not always easy to act on this understanding consistently over time and across relationships in a way that gave them confidence they were protected. Smith suggests this is because of their “personal stakes in the very circumstances that produce the problem” (Smith 2009:105). Smith suggests that social expectations and goals relating to marriage, reproduction, and reputation can overshadow a decision to act in a way that reduces the risk of HIV infection.
Whereas findings from this study demonstrate that social expectations were one factor shaping young people’s HIV risk and HIV prevention strategies, structural and social dynamics were also found to be central factors. Making a mistake or trusting someone later found to be untrustworthy were additional factors raised by youth. Participants’ young age and relative inexperience and reluctance to risk introducing conflict into relationships further contributed to risk and the difficulty they sometimes had negotiating HIV prevention in their sexual relationships. Other participants chose to completely eschew dating and/or having sex altogether in order to avoid perceived risks such as HIV or pregnancy, which these participants felt would in turn protect their futures.
308 Similar to findings in other youth populations, participants considered sex as a normal and natural part of life and dating relationships when both partners felt they were old enough and ready to have sex. Sex was seen as carrying many benefits including intimacy, happiness, demonstrating love, social support and social status amongst peers in addition to risks such as possible HIV exposure.
These findings are in line with research that has been conducted in other youth populations (Bourne and Robson 2009).
Overall, males and females were invested in developing trusting, monogamous relationships in order to create a sense of safety and happiness in their relationships. Requesting condoms or HIV testing of one’s partner could risk undermining trust and introducing conflict into the relationship as has been reported in other research (Burja 2000). Because of the benefits some youth found in having boy/girlfriends and, when relevant, having sex, decisions about managing the risks of sex were often weighed against the social risks of upsetting the relationship. This finding is consistent with research in other populations on social risk, which places behavior in socio-economic context and accounts for the importance of self-presentation, social status and social reputation in sexual decision-making (Nichter 2008; Smith 2009), discussed below.
9.2.1 The Role of Social Proximity to HIV
The theory of social proximity posits that the more experience individuals have with others infected with HIV, the more likely they will be to perceive themselves as at risk for HIV and adopt HIV-prevention behaviors such as wearing condoms and limiting sexual partners (Macintyre and Kendall 2008). In the context of the study environment, where the HIV infection rate is high
309 especially among young people, and with over half of study participants reporting knowing someone with HIV, social proximity and resultant HIV risk avoidance behavior was expected to be high. However, the theory of social proximity was not clearly supported by findings from this study. In the context of this study,
HIV risk perceptions did not meaningfully vary across age, gender, or social proximity to infected individuals. Participants with infected family members report increased fear of HIV and a realization that anyone could be infected with
HIV, but perceptions of one’s own risk of HIV was reportedly more influenced by their behavior or the context of their sexual relationships rather than by knowing someone with HIV. For example, participants most likely to feel at risk for HIV were those who felt they could not trust their partner, as has been reported in other contexts (e.g., McGrath et al 1992). In turn, risk perceptions were also not necessarily reduced amongst participants who knew someone with HIV, a finding supported by previous research (Beutel and Anderson 2013).
Social proximity to HIV was furthermore reduced through the considerable silence and stigma that continues to surround HIV and AIDS
(Bhana 2008). An HIV diagnosis was a tightly held secret, even in families and especially among young people who fear social isolation if others became aware of their status. Nationwide, there is a tendency to not disclose HIV as a cause of death on death certificates, resulting in a much lower than expected HIV death rate and perpetuating societal silence around HIV (Bradshaw, Dorrington and
Laubscher 2011). Participants collectively reported being unable to talk to infected family members or friends about their HIV status because it is a senstive topic and participants feared offending the infected person. One result of this
310 silence is the continued stigmatization of infected individuals and considerable social and emotional distancing from the disease.
Overall, participants were split as to whether or not they personally felt at risk for HIV. Amongst interview participants, over a third (35%) said they felt at risk, 30% said they did not feel at risk, and the remainder reported that they weren’t sure or were possibly at risk. Participants generally reported that because
HIV was “everywhere” and could impact “anyone” they were at theoretical risk for infection. But largely, personal HIV risk perceptions depended on each individual’s life situation and experience, and risk perceptions varied for each youth across situations. Often, participants felt at risk for HIV if they were not confident that they could trust their partner. Other participants were confident that they were not personally at risk for HIV because they perceived themselves and their partners as trustworthy, if they regularly used condoms, if they and their partners both recently tested negative, or if they were not having sex.
Thus social proximity may have heigthened awareness of HIV and increased participants’ desires to prevent HIV but actual experiences of risk and risk management strategies were highly dependent on individuals’ life circumstances. Participants had clearly absorbed standard HIV prevention messages of testing, using condoms, and being faithful to partners. Yet these strategies were not always effective for all participants all of the time. Prevention messages may not take into consideration the wide range of realities of youth sexual and dating practices, the relative inexperience of youth with regards to dating, sex, and condom use, and the influence of concerns over demonstrating and receiving love and developing trust between partners on young people’s risk
311 management strategies. Condoms, testing, and fidelity were also sometimes contradictory to youths’ own concerns of developing trust or maintaining social status through their relationships. Other factors such reduced agency of younger youth in particular in accessing prevention services due to feeling uncomfortable or scared to seek services, and practical considerations such as fear of testing, not having access to condoms or not trusting condoms because they could break also influenced participant adoption of these prevention strategies.
9.2.2 Social Risk
Social risks are risks that threaten social relationships, status and individual identity (Nichter 2003, Smith 2009). Social risk was a significant factor, though by no means the only factor, influencing risk perception and risk management behaviors for participants in this study. The biological risk of HIV infection was high in this context; however, the physical risk of HIV infection was only one of many risks in the environment such as poverty and uncertain futures.
Furthermore, avoiding social risks such as risks to their relationships was sometimes more salient than the risk of HIV infection, particularly if the risk of
HIV was uncertain or perceived to be low. Concerns over relationships and social status are paramount during adolescence and, for youth populations around the world, may take precedence over uncertain risks such as HIV.
HIV infection or the appearance of infection is highly risky to youths’ social status. Some participants who were uncertain about their risk of HIV were afraid to test for fear of what a positive diagnosis would do to their status within their communities. (Participants also feared HIV infection itself.) Other participants were more likely to report testing if they felt confident that their
312 results would be negative. The risk of losing social status carried over into dating relationships, and could make it difficult to negotiate condom use and HIV testing within relationships. Some participants feared the possible consequences of either requesting condom use or of testing. These anticipated consequences included their partner feeling accused of being HIV positive or the partner suspecting that the participant is HIV positive. In contrast, other participants prioritized HIV prevention in relationships even if it meant losing their partner to do so. Yet some other participants avoided dating altogether in order to protect their futures by avoiding the perceived risks of dating such as pregnancy or HIV.
In this study, both male and female participants expressed wanting to create faithfulness, trust, and love in their dating relationships, and the fear of
HIV infection further motivated this desire. In some relationships, condoms undercut the process of building trust in the relationship for both males and females. Social resources are crucial for managing relationships and everyday life
(Hirsch et al 2009). Therefore, research in other populations describing how a female may have condom-less sex with a partner that they suspect to be unfaithful to them is understood in the context of social risks such as losing the partner, being accused herself of cheating, or of her partner losing his trust in her
(Smith 2009). These social risks are even more profound in a context of limited resources. It has also been observed in multiple contexts that women may be reluctant to negotiate condom use in relationships that they desire to be committed and mutually monogamous (Sobo 1995; Leclerc-Madlala 1997). This study found that the same process can occur for some young men as well.
313 Male participants in turn faced social pressure to demonstrate their status through having multiple girlfriends, which has been documented in previous research (Vincent 2008). Male participants with multiple girlfriends could have an elevated physical risk of HIV infection through this expectation, yet could also face the social risk of social isolation if they abstained from sex or stayed faithful to one girl. In fact some males in this study did report exclusion from their social groups if they did not have at least one girlfriend.
Overall, in this study, about half of participants report feeling not at risk for HIV infection, which aligns with previous research (Beutel and Anderson
2013). No significant age or gender patterns were found. Existing data on the influence of gender on risk perceptions in South Africa also shows mixed results.
Some research has found higher risk perception amongst young females than males, and other research has found HIV risk perceptions to be equally high amongst both (Shisana et al. 2005; Anderson et al 2007). Other research suggests that certain sexual behaviors, such as timing of sexual debut, may be transiently associated with HIV risk perceptions for females but not for males (Kenyon et al
2010). In this study, it was found that having sex and not using condoms increased participant HIV risk perceptions.
9.3 Gender and Risk
Gender inequality and its role in shaping risk to HIV infection has been thoroughly discussed in the South African context (Jewkes et al 2003; Schoepf
2004 Susser 2009). The epidemiological observation that young South African women are becoming infected at a higher rate than males has focused scholarly attention on the relative powerlessness of women in relation to men. Much of this
314 work examines the mechanisms of gender inequality that increase female vulnerability to infection such as reduced female autonomy to negotiate the timing of sex and condom use and socially sanctioned male infidelity. Other literature argues that social desirability of childbearing or social pressure for males to have many sexual partners are factors increasing females’ risk.
Less recognized is how gendered expectations of male behavior, specifically having multiple sexual partners, can increase male vulnerability as well (Hunter 2005; Shefer et al 2005; Simpson 2007; Vincent 2008). Three other factors considered to be driving higher rates of infection in young girls, multiple sexual partnerships (described above), intergenerational relationships and transactional sex (addressed below) are discussed. However, because HIV status was not collected from participants, the conclusions that can be drawn about actual risk to HIV infection for males as compared to females cannot be fully addressed by this dissertation study.
Intergenerational relationships between young women and older men are often considered to be a factor driving the disproportionately high rate of HIV infection in women ages 14-24 when compared to men (Leclerc-Madlala 2008;
Longfield 2004). Concerns over young girls having “sugar daddies” and engaging in transactional sex often assume that girls are either victims in these relationships, constricted by factors such as economic necessity or their relative powerlessness compared to males; or that girls see sugar daddies as means to achieve financial benefit. Transactional sex was not directly investigated in this study, and it was not independently reported by participants. Rather, reported benefits of relationships included feeling loved, excitement, and social status.
315 Furthermore, in this study participants reported dating people close to their own age, although a subset of female participants did discuss how older men can be perceived positively for having greater maturity (Cole 2004; Leclerc-Madlala
2008). In the few instances where participants reported ever giving or receiving gifts such as clothes to or from a partner, the gifts were discussed as only an occasional occurrence in the relationship and not the driving force behind the relationship.
Research in the realm of intergenerational and transactional sex has until recently given less attention to male desires to provide gifts and financial resources as a way to demonstrate his masculinity, success, and status (as noted by Smith 2009). Demonstrating love and support by providing small gifts to girlfriends was discussed by a few of the participants in this study. For these participants, giving financial support to girlfriends led to positive feelings about their ability to provide for their girlfriends. However, while reports of “mutual exploitation” (Leclerc-Madlala 2008) wherein females often use males for status and financial rewards and males use females for status and sexual conquest was briefly discussed in a few of the focus groups as something “other” youth might do, it was not reported as general practice by participants.
Finally, participants in this study largely perceived themselves to be active decision makers in their dating and sexual relationships, however decision making in relationships was reportedly not always an easy process for youth.
Furthermore, the consequences of sexual decisions were at times greater for females than for males. For example, among participants with children, mothers were often forced to drop out of school to care for the child whereas fathers were
316 able to stay in school. Parental support was instrumental for the girls who were able to stay in school after having a child. Females also tended to carry the bulk of financial and time requirements associated with raising a child. Males with children helped when they were able but due to poverty, some were unable to provide the level of financial support they stated that they would have liked to provide.
9.4 Risk Environment and Syndemics
The risk environment model posits that social, political and economic factors outside of individual control can interact within a local context to increase vulnerability to HIV infection, and that these structural factors may play a larger role than individual behavior in shaping risk to HIV infection (Rhodes et al
2005). The syndemic concept of disease extends the risk environment idea to examine how two or more co-existing diseases or stresses can synergistically reinforce each other to amplify the negative impact on individual and population health (Singer and Clair 2003). Critically, the syndemic model of disease specifically conceptualizes disease in terms of its interrelationships with harmful social conditions and social relationships and as “multiple, interacting deleterious conditions among populations produced by the structural violence of inequality” (Singer and Clair 2003:434).
This study identified specific structural factors shaping youth vulnerability to HIV in the study community. From the participants’ perspectives, the following factors were found to be the most influential in structuring vulnerability: uncertain futures, lack of employment opportunities, limited educational opportunity, economic inequality tied to racial inequality, poverty,
317 peer pressure, gendered expectations of behavior for males and females, HIV- related stigma, silence and denial of HIV, lack of mentorship for youth by adults or older youth, superficial knowledge of HIV and AIDS, lack of caring about the future amongst other youth, and uneven access to health and reproductive services. These factors are clearly overlapping and closely interrelated and interdependent. In this way, the risk environment/syndemic models highlight the myriad components of risk facing youth.
The risk environment/syndemic approach necessitates consideration of the broader political environment shaping individual experiences of risk. In this case, South Africa’s uneven and controversial response to HIV from the beginning of the epidemic resulted in delayed implementation of HIV prevention and treatment programs during a period of rapid disease spread. This response, in tandem with the economic problems facing the country, massive social change, an overburdened health sector, and pervasive stigma and discrimination surrounding HIV/AIDS, continue to impact on efforts to combat HIV/AIDS.
Stark economic inequality that overlaps with persistent racial inequality is a dominant feature of society. To date, residents in the study community and in other under-resourced communities have not achieved widespread social, educational, political or economic successes that have been observed in other groups, such as in the new middle class, and they continue to struggle for basic achievements such as housing. The study community was in close proximity to communities of higher social and economic status. This had the positive effects of increasing the educational and employment opportunities available to the community and increased access to medical services. However, it also heightened
318 youths’ awareness of the social and economic inequalities of South African society and created a sense of frustration at the relative lack of resources in the study community as compared to neighboring communities.
Participants clearly observed their relative deprivation in everyday life, such as the fact that they lived in a community that had been underdeveloped, had fewer resources, and fewer educational and employment opportunities. This contributed to tremendous anxiety about the future. The harsh inequalities of society existed alongside a universal desire among participants to achieve the education and employment necessary in order to purchase a home in a nice neighborhood and to support their families. Under current socio-economic conditions, this desire remains out of reach for the majority of youth. In this study, apprehension about the future was participants’ greatest reported concern.
Conceptualizing the HIV epidemic in this population in terms of the risk environment and syndemic models is well suited to understanding findings from this study. Together these concepts link individual-, relationship-, social- and structural-level risk factors that interact to increase vulnerability to HIV and other negative health and social outcomes for participants and for other youth residing in South Africa’s townships. In particular, the interaction of poverty, persistent economic and racial inequality, inadequate and crowded housing, migration, and silence and stigma surrounding the topics of HIV and HIV prevention interact to increase youths’ vulnerability to HIV infection.
Finally, the presence of environmental risks should not obscure the fact that for participants in this study, there were also positive aspects to the environment that promoted youth wellbeing such as social and community
319 support, local services, and a certain sense of safety stemming from being in a smaller community where “everyone knows everyone”. As with any environment, risk environments are situated in wider contexts comprised of both risk and protective factors.
9.5 Summary
Study findings contribute to anthropological models of risk. Social risk was found to be an important concept to assess the influences on youth risk perceptions and risk management strategies in social context. The risk environment/syndemics concept of disease is particularly relevant to model the ways that the multiple, interconnected risks present in participants’ lives reinforced each other to create conditions under which youth were vulnerable to both poor health and negative social outcomes, such as HIV infection or underemployment.
South Africa is a diverse and complex country with a highly mobile, cosmopolitan population. Yet economic inequality is entrenched and conflated with social and racial inequality. There is tremendous public will for social change but overburdened social service and health sectors combined with the challenges of widespread poverty and the devastating impact of the HIV/AIDS epidemic have stalled the country’s progress towards redressing inequalities and reducing the impact of HIV/AIDS. Despite the emergence of a strong black middle class over the last twenty years, created mostly through government jobs, the vast majority of the country’s residents remain in poverty and struggle with inadequate housing and limited access to educational and employment opportunities. In an environment of limited resources, social support found in
320 relationships and in a united community are essential to managing everyday life and for accessing the limited resources and opportunities that do exist.
In this study, participants emphasized completing their educations, obtaining respectable, stable employment, uniting their community to support youth, making good decisions for their futures, and projecting a positive, often fashionable, image of him- or her-self. Their focus demonstrates that youth desire to move forward and fully engage with the larger world that they fear is leaving them behind. Through television, social networks, and interactions with wealthier, more educated, and well-traveled individuals, participants are keenly aware of the additional opportunities for social, educational, and economic advancement available to those with means. Participants studied hard, built positive and supportive relationships as a way to enjoy life and endeavor to project a positive self image in the hopes it would help build a better life and bring them opportunities for a brighter future. Thus participants were invested in minimizing risks in their lives, especially interrelated risks to their health, social relationships, reputations, the community, and their futures. It is in this stressful context that decisions about the future, sex, dating, family planning, and
HIV/AIDS prevention were made.
Youth are often stereotyped in several contradictory ways: as drivers of
HIV through presumed risky sexual behavior; as victims of the global HIV/AIDS pandemic; or as the “future” or “hope” of ending HIV (UNAIDS 2010). These simplistic and one-sided views of youth obscure the complexity of their situations and serve to isolate “youth” into a category removed from other age groups, instead of recognizing the reality that youth are embedded in multi-age
321 relationships, families and communities. Faulty stereotypes of youth that overgeneralize youth as being victims or risk-takers do not reflect a realistic, nuanced view of young people’s actual lives, needs or concerns. This dissertation research demonstrates that the particularities of each youth’s life circumstances must be considered when evaluating their experiences, perceptions, and risk management strategies.
322 Chapter 10. Conclusions
10.1 Summary
This dissertation research examined youth perceptions of risk and the ways they manage these risks on a daily basis in a context of vulnerability, a peri- urban township in South Africa’s Western Cape. Mixed methods and anthropological models of risk and risk perception were employed in order to address study objectives. The township was conceptualized as a risk environment, characterized by multiple, interrelated socio-economic risks including lack of employment and educational opportunities, economic and racial inequality, high rates of migration and population mobility, urban crowding, pervasive crime, and poverty, all occurring in conjunction with one of the highest
HIV infection rates in the world. These risks are deeply rooted in South Africa’s history of institutionalized inequality. Progress has been made in addressing these challenges since the new government came to power in 1994; however, an overburdened health care system, persistent poverty, entrenched racial and economic inequality, an under-resourced public education system, the impact of widespread HIV/AIDS disease and rapid socio-political change complicate the country’s development.
Youth living in South Africa’s urban townships are particularly vulnerable to a myriad of risks, which they refer to as “challenges”. Youth struggle with the day-to-day challenges that arise from poverty and life in under-resourced and overcrowded communities. High rates of HIV infection among youth, especially young girls, are complicated by pervasive silence and stigma surrounding the disease and uneven access to prevention and treatment resources. Dating and
323 sex, which are normal and expected aspects of youth experience and development, occur in contexts of risk wherein youth are at increased vulnerability to HIV infection. Youth must manage these risks while simultaneously contending with an uncertain future due to continued lack of educational and employment opportunities. In this context, youths’ risk management strategies vary according to individual life circumstances and the different resources available to each youth. This study demonstrates the importance of addressing the social structural factors influencing youth vulnerability in models of risk, including HIV risk.
10.2 Future Directions for Research
The findings of this research raise a number of questions for further investigation. First, the topics of gender relations and the changing expectations of gendered behavior are timely issues to explore in South Africa. The South
African Constitution guarantees gender equality as a fundamental right. The government has enacted a number of policies and laws to promote gender equality in political, economic, and social spheres. Social and cultural expectations of the genders are changing at different rates and in varied ways across different contexts. Social science research tends to focus on the status of females as relatively powerless as compared to males, and research into gender inequality often focuses on the unique vulnerabilities of females (Schoepf 2004;
Susser 2009). Recent research has called for a focus on males and how gendered expectations for masculinity are placing young men at risk, as well (Lockhart
2002; Ratele et al 2007). Gendered expectations of behavior for male participants increased male vulnerability to HIV infection in a way that also
324 increased female vulnerability. For example, social pressure for males to have multiple girlfriends can increase males’ exposure to the risk of HIV or other STI infection, which in turn increases females’ exposure to HIV, and also serves to undermine trust in romantic relationships. Male and female vulnerability are thus interdependent. Examinations of how gender inequality influences everyday life and how gendered expectations of behavior for males and females are interwoven and mutually reinforcing are thus important areas of study in the
South African context. Further study of how gendered expectations for both males and females are changing, albeit it in different ways, will pave the way to more nuanced models of vulnerability. Viewing vulnerability from the perspective of one gender over another is incomplete.
Second, examining the experience of pregnancy among youth is a vast and important topic for anthropological inquiry. The high rate of teenage pregnancy and different ways pregnancy in relationships was experienced by males versus females observed in this study raises important questions about reproductive choice, reproductive desires, social desirability for childbearing, decision-making about family planning and the meaning attached to childbearing in young people’s relationships.
Third, the continued spread of HIV among youth and the pervasive silence and stigma surrounding the disease indicate the importance of examining the specific social and structural dynamics that make youth vulnerable to HIV infection in local context. The risk environment/syndemic approaches to disease are particularly well suited to examine the multiple socio-economic and health risks in South African contexts and their relationship to elevated rates of
325 HIV/AIDS amongst youth. The syndemic model, in particular, is now gaining favor in public health and additional efforts to apply anthropological methods and data to provide additional theoretical and empirical support for this approach is warranted.
Similarly, additional research investigating youth perceptions of HIV and the social risks inherent in managing the risk of HIV can guide the development of interventions that are relevant and appropriate for youth. These approaches must take structural factors, gender and sexual norms into consideration. Recent monitoring data indicate that rates of HIV may be slowing among South African youth; however young people remain at elevated risk for HIV infection, especially young girls. New approaches for HIV prevention that address structural aspects of risk, fit within the realities of youth sexual behavior and acknowledge the needs of young people are therefore urgently needed for youth in South Africa.
Finally, education is regarded by youth as the key to improving their life circumstances. While most South African youth are able to access education, the quality of the education provided remains highly variable and unequal. Many youth remain unable to access sufficient educational resources and opportunities that prepare them for future employment. This raises a number of practical and theoretical questions relating to the role of education in structuring youth daily life, risk, and vulnerability as well as larger issues related to youth wellbeing and development in South Africa. Further research into the intersection of education and risk is, therefore, of great importance.
326 10.3 Cell phones as research tools: Potential Applications and
Recommendations
Incorporating cell phones into the research process, both for communication with participants and for data collection, is a logical development in social science research. Young people’s communication is evolving in tandem with the greater availability of cell phones and social networking applications, which are becoming increasingly central to social life for people of all ages. Cell phone communication cannot replace face to face interaction but can and should serve as an important supplementary tool in social science research, as it does in social life. Cell phones raise important questions regarding confidentiality and privacy in research, especially in contexts such as South Africa where cell phones are often shared among multiple users. The possibility for misunderstanding, which is always present in interactions between researchers and participants, is even higher in communication conducted over the phone, thus cell phone based methods are most effective when combined with face-to-face interaction.
The use of social networking applications in the research process, on the other hand, is fraught with issues of rapidly changing popularity and availability of different social networking applications, lack of control over privacy on many social networks, and the necessity of adopting each social network’s own culture and social rules of engagement in order to be used effectively. Social networking applications are an important object of research for the social sciences, especially examining the role of social networking applications in daily life and in forging and maintaining relationships. However, using social networking applications as a data collection tool is challenging. Understanding the study population’s
327 preferences for and patterns of use of social networking applications and the privacy and confidentiality policies of various applications is essential to effectively incorporating them as research tools in the social sciences.
10.4 Listening to youth: Strategies to address youth vulnerability
Conducting research with vulnerable youth on sensitive topics such as risk and HIV/AIDS is challenging. The mixed methods approach used in this study facilitated validity of collected data, provided context and revealed the underlying motivations and meanings attached to reported perceptions and behaviors
(Plummer et al 2004). Youth risk, dating and gender norms, and rates of
HIV/AIDS and pregnancy vary across time, context, relationships, and the life span. In-depth, contextualized research into these topics can provide insight into the factors driving observed trends in pregnancy, HIV, and STIs among youth and can facilitate an understanding of the specific services youth want and need in different contexts and life stages. This is especially critical in places such as
South Africa and other locations where youth are experiencing elevated rates of
HIV or unplanned pregnancy.
Services and policies targeting youth must take into consideration the ways youth themselves perceive the risks in their lives, the strategies youth themselves have developed to manage these risks, and the role of social and structural dynamics in shaping youth risk. HIV/AIDS and sexual health services in particular will be most effective when provided in a safe, nonjudgmental environment and when providers endeavor to understand how youth themselves perceive their sexual relationships and sexual behaviors, including youths’ own conceptualizations of the risks and benefits of sex and dating. Efforts must also
328 be made to listen to youth in order to appreciate the social and structural factors that influence the choices available to youth, and to grasp youths’ goals relating to sex, reproduction, and their own strategies for risk management. This will enable service providers to better support youth and develop risk management services that are appropriate for youths’ individual circumstances.
329 APPENDICES Appendix A. Chronology of South African History and HIV/AIDS Epidemic
B.C. San and Khoikhoi inhabiting modern-day southern Africa. These hunter- gatherer groups are ancestors of the Khoisan (Khoikhoi and San; also called “Hottentots” and “Bushmen” by European settlers)
By AD 300 Mixed farmers, ancestors of the Bantu-speaking majority of the modern population, begin to settle south of the Limpopo River
1100’s Increasing migration of Bantu-speaking people into present-day South Africa
1487 Portuguese expedition led by Bartholomeu Dias lands in Mossel Bay (Present Day Western Cape)
1500’s Xhosa (Southern Nguni) began settling area now known as Western Cape
1652 Van Riebeeck arrives at the Cape of Good Hope Dutch East India Company establishes a refreshment station at the Cape of Good Hope (Present Day Western Cape)
1657 Nine Dutch East India Company employees were released from their contracts and given land to farm in the Cape of Good Hope
1652-1795 Genesis and expansion of the Afrikaners (Boers); Khoisan conquered; slaves imported from Indonesia, India, ceylon, Madagascar (Malagasy), and Mozambique
1795 British seize the Cape Colony from the Dutch Londom Missionary Society formed
1803 Treaty of Amiens: The Dutch (Batavian Republic) regain the Cape Colony
1806 Britain reconquers the Cape Colony after the Battle of Blaauwberg. Dutch settlers travel north to found their own republics.
1811-12 British and colonial forces expel Africans from the territory west of the Fish River
1813 Wesleyan Methodist Missionary Society formed.
1815 Slagtersnek rebellion, or rising of the frontier Boers
1816-28 Shaka creates the Zulu kingdom Shaka leads Zulu army south into present day South Africa
330 Warfare, migration and upheaval among Africans throughout much of southeastern Africa due to Shaka (the Mfecane [Zulu], crushing or scattering. Also known as Difaqana [Sesotho])
1820 British settlers arrive in the Cape Colony
1828 Cape colonial government repeal pass laws
1834-1838 Cape colonial slaves emancipated
1838 Battle of Blood River: Afrikaners defeat the Zulu army
1834-35 Xhosa defeated by British and colonial militaries
1835-40 The Great Trek: Five thousand Afrikaners (later called Voortrekkers) leave the Cape Colony with their “coloured” clients and workers.
1846-1847 Xhosa defeated by by British and colonial forces
1852 Sand River Convention created the South African Republic or in Dutch, Zuid-Afrikaansche Republiek, “ZAR”. (Not to be confused with the Republic of South Africa, the ZAR, also known as the Transvaal, was in independent Boer-ruled country in Sourthern Africa. In 1910 it became the Transvaal Province of the Union of South Africa.)
1854 Bloemfontein Convention (created the Orange Free State Republic)
1856-1857 The Great Xhosa Cattle Killing
1867 Diamonds discovered; mining begins in Griqualand West
1870 Discovery of more diamonds; Kimberley founded
1880-1881 First Anglo-Boer War
1881 Pretoria Convention (re-established independence of the South African Republic)
1884 London Convention (granted full independence to the South African Republic)
1867 Diamonds discovered in South Africa
1886 Gold discovered in South Africa
1886 Gold mining begins on the Witwatersrand
331
1899-1902 Second Anglo-Boer War Ended with Vereeniging Peace Treaty in 1902
1910 The Cape Colony, Natal, the Transvaal, and Orange Free State join to form the Union of South Africa. The Cape Colony is renamed the Cape of Good Hope.
1912 South African Native National Congress (NNC) founded; later becomes African National Congress (ANC)
1913 Natives Land Act no. 27 limits African land ownership to the reserves, totaling roughly 13% of the country. This is the first of a series of segretation laws.
1914 – 1918 World War I. South Africa fights in support of British despite Boer resistance
1914 Maritz Rebellion. Boer South Africans rebel against the Union of South Africa, refusing to fight against the Germans and for the British in World War I. The Rebellion is squashed.
1917 Anglo American Corporation of South Africa founded
1920 Native Affairs Act
1921 Communist Party of South Africa formed
1944 ANC formed
1946 Natal Indian Congress formed, fuelled by anger over the introduction of a bill that would restrict the residence, property ownership and movements of Indians.
1948 The Afrikaner National Party wins general election. Implements Apartheid policy.
1950 The Population Registration Act classifies people by race Group Areas Act makes people live in racially zoned areas
1951 Bantu Authorities Act: deported blacks to designated homeland reserves (Bantustans) which were established as tribal authorities. Blacks were citizens of the Bantustans and stripped of South African citizenship.
1952 ANC and allies launch The Defiance Campaign; a passive resistance campaign
332 1953 Apartheid Government seizes control of African education
1955 The Freedom Charter is signed at the Congress of the People in Soweto, demanding freedom and equality based on principles of human rights and non-racialism
1960 Sharpeville Massacre: police killed 69 unarmed anti-pass law protestors ANC, PAC and other black groups declared illegal Whites only-referendum to allow status as a British Commonwealth Realm to lapse narrowly passes by a 52% majority UN General Assembly calls for economic sanctions against the apartheid government
1961 The Union of South Africa becomes the Republic of South Africa Umkhonto we Sizwe (The Spear of the Nation; later to become the armed wing of the ANC) commit acts of sabotage at government installations
1962 Nelson Mandela arrested and sentenced to three years for incitement
1963 Ravonia Trial: ANC leaders, including Mandela and Walter Sisilu, arrested and charged with sabotage
1964 Mandela and Sisilu sentenced to life in prison on Robben Island
1966 Prime Minister Verwoerd was assassinated in parliament, making Vorster Prime Minister
1969 South African Students’ Organization (SASO) founded to resist apartheid. Later became Black Consciousness Movement.
1976 Soweto Uprising 16 June (present day Youth Day): Soweto youth marched to protest a new law requiring school instruction to be in Afrikaans. Police shot at the youth.
1977 SASO founder and Black Consciousness leader Steve Biko dies in police custody due to police beatings.
1982 First case of HIV in South Africa identified
1989 Mandela begins secret negotiations with Prime Minister Botha FW de Klerk becomes Prime Minister de Klerk releases Walter Sisilu and other political prisoners
1990 de Klerk lifts restrictions on ANC and other banned organizations Mandela released from prison Fourth International Conference on Health in Southern Africa
333 1992 National AIDS Convention of South Africa (NACOSA) created
1993 Chris Hani, leader of the Communist Party, assassinated de Klerk, Mandela, and leaders of 18 other parties endorse interim constitution
1994 Governments of the Bophuthatswana and Ciskei “homelands” collapse ANC wins first non-racial election Nelson Mandela sworn in as President and form Government of National Unity Democratic Party (present day Democratic Alliance) replaces the Nationalist Party as the official opposition group
1995 Racial conflict in police force Inauguration of the Constitutional Court Constitutional Court abolished the death penalty University disturbances Inkatha withdraws from Constituent Assembly Inauguration of the Commission for the Restitution of Land Rights Truth and Reconciliation Commission starts
1996 Permanent Constitution enacted by Constituent Assembly The National Party withdraws from Government
1997 Government adopts a multi-sectoral HIV prevention policy, including behavior change communication, HCT, PMTCT, and ART. Plan is never implemented.
1998 Truth and Reconciliation Report published
1999 ANC wins 60% of the general election vote Mandela retires; succeeded by Thabo Mbeki Strikes led by government workers, including teachers Western Cape Province (run by the Democratic Alliance) is the only province that starts providing AZT.
2000 13th international conference on AIDS meets in Durban
2003 Cabinet funds a plan providing at least one ARV site in each health district. Takes over a year to begin.
2004 Third democratic election; ANC retains power Thabo Mbeki assumes Presidency
2005 Cabinet approves the roll-out of ART (DoH Antenatal 2011)
2007 Jacob Zuma replaces Mbeki as President of the ANC
334 20 million locally manufactured condoms recalled due to defectiveness
2008 Mbeki resigns Presidency of South Africa Kgalema Motlanthe appointed caretaker president
2009 South Africa’s 4th democratic elections ANC wins 65% of the vote; Zuma becomes President Democratic Alliance wins control of the Western Cape and 16.7% of the vote in the national election
2011 HIV prevalance is 29.5% in antenatal population (17.3% general population) HIV prevalance in 15-19 year olds drops to 12.7% (down from 14% in 2010)
Bibliography
Comaroff, Jean and John Comaroff. 1991. Of Revelation and Revolution: Christianity, Colonialism, and Consciousness in South Africa Volume 1. Chicago: University of Chicago Press.
Iliffe, John. 2006. A History of The African AIDS Epidemic. Athens: Ohio University Press.
Thompson, Leonard. 2001. A History of South Africa Third Edition. New Haven: Yale University Press.
335 Appendix B. Diary Instructions
Diary Inside Front Cover:
Thank you for agreeing to keep a diary. This diary is specifically interested in YOUR day-to-day experiences.
Please try to fill in the diary every evening, by looking back over the day and thinking of times, places or events that happened that are important to you, in either a positive or negative way. Please be sure to write both during the week and the weekend!
If you have any questions about your diary, contact Michelle at xxx xxx xxxx
REMEMBER TO BRING YOUR DIARY TO MICHELLE AT THE YOUTH CENTRE EVERY WEEK!
336 Diary First Page, Opposite Inside Front Cover:
GUIDELINES
In completing your diary, please try to include the following:
• Date and time of day • What happened today? • Where were you? • Who else was involved? • How did it make you feel? • Did you make any choices today? What was the choice and how did you make it? • Was today a good day or a bad day? Why?
Please don’t worry about grammar, spelling or handwriting.
You and your diary entries will remain confidential.
Thank you!
337 Appendix C. Youth Interview Guide
DATE: TIME: PARTICIPANT NAME: LOCATION: INTERVIEWER: TRANSLATOR:
YOUTH INTERVIEW
INTRODUCTION
Hello. If you will remember, my name is Michelle, I am a student based at the Youth Centre. I am here to learn more about youth and the challenges that they face in life. When we last talked [fill in with when, such as last week] you said you would be interested in talking with me about your life and your experiences. Are you still interested in talking to me and telling me about your life and experiences?
(If yes) (If no) Thank you! The interview will take Thank you for your time. about an hour. Where can we speak where we won’t be disturbed? End
ICE BREAKER
1. Please share your name, the story of your name, and one thing I wouldn’t know about you just by looking at you. I’ll do the same.
2. Before we get started, is there anything you’d like to ask me?
3. How are you feeling today? Why are you feeling this way?
338 BACKGROUND
I’d like to start with some basic questions about you, your family, and where you stay. 4. How many years old are you?
5. Where were you born?
FAMILY
6. Can you tell me about your family?
7. Do you have any brothers or sisters? If yes, probe for details about siblings, such as: 7.1. What are their ages? 7.2. Where do they stay? 7.3. Can you tell me about them? 7.4. How is your relationship with them?
8. Can you tell me about your mom? Possible probes: 8.1. Where does your mom stay? 8.2. How often do you see her? 8.3. How would you describe your relationship with your mom?
9. Can you tell me about your dad? Possible probes: 9.1. Where does your dad stay? 9.2. How often do you see him? 9.3. How would you describe your relationship with your dad?
CHILDREN
10. Do you have any children? If no, Continue to Next Section
If yes:
339
11. Can you tell me about them? Probe for details about children. Possible probes: 11.1. What is your child’s age? 11.2. Who is the child’s father / mother? Are you still with him / her? 11.3. Where does your child stay? 11.4. Who is helping to raise them him / her?
12. Can you tell me the story of how you /your partner became pregnant? Possible probes: 12.1. When did you first find out that you’d be a parent? 12.2. How did you feel? 12.3. How did the people in your life react to you being pregnant? 12.4. How did their reactions make you feel?
HOME
13. Who do you stay with at home?
14. What kind of house do you live in?
15. Where do you get your water, inside or outside the house?
16. Do you feel safe there? Why or why not?
*If participant says that they do not feel safe, stop the interview and determine if there is an immediate threat to the participant’s safety. If so, make service referrals as necessary.
Confirm whether participant is able to continue with interview or if they need to stop before going any further. If necessary, end the interview and work with participant to identify appropriate service referrals.
340 MIGRATION TO THE COMMUNITY
17. When did you move to The community?
18. Why did you move to The community?
19. Do you see The community as a hopeful place? Why or why not?
20. Do you plan to stay in The community? Why or why not?
EDUCATION AND SCHOOL
21. Are you in school now?
If yes: 22. What grade are you?
23. How many hours a day do you spend on homework?
If no: 24. When did you leave school?
25. How do you feel about school? Possible probes: 25.1. Do you like school? Why or why not?
WORKING
26. Are you working? What do you do?
27. Is anyone in your house working? What do they do?
341 ACTIVITIES –CHORES, RESPONSIBILITIES, and SOCIAL MEDIA
Now let’s talk about your chores and fun activities.
Chores and Expectations 28. What chores are you responsible for in your house? Does anyone help you?
29. What are your other responsibilities as a young girl / guy?
Probe participant perception of responsibilities and expectations. Possible probes: 29.1. How are you expected to behave as a young girl / guy? 29.2. What must you do to be respected in your family? Amongst your friends? 29.3. Is it easy to behave the way you are supposed to? 29.4. Why or why not?
Activities and fun 30. What do you like to do for fun?
31. Do you belong to any groups, clubs, or organizations? If yes, probe for details about group activities: 31.1. What groups do you belong to? 31.2. What activities are you involved in?
Social Media 32. Do you have a cell phone?
33. Do you like to chat on: 33.1. MXit? 33.2. 2go? 33.3. BBM? 33.4. WhatsApp? 33.5. Facebook 33.6. Any others? 33.7. How often do you chat? 33.8. Who do you chat with? 33.9. What do you chat about? 33.10. Do you ever go on other sites like Twitter or YouTube?
342 BELIEFS, TRADITIONS, AND RELIGION
These next questions are about your personal beliefs.
34. What religious beliefs are important to you? For example, Do you attend any churches?
35. What Xhosa traditions and beliefs are important to you? Probe for perceptions of important beliefs or traditions. Possible probes for guys: 35.1. Have you been to the mountain or plan to? [circumcision initiation] 35.2. Can you tell me what the experience was like for you? Possible probes for girls: 35.3. Have you gone through any rituals or participated in any traditions? 35.4. Can you tell me what the experience was like for you?
HEALTH Next let’s talk about your overall health and wellbeing.
36. How would you describe your health in general?
37. Do you have any concerns about your health? Probe for details about health concerns if necessary. Possible probes: 37.1. Can you tell me a little bit about what your concerns are? 37.2. Have you ever had a serious illness or been sick in your life? 37.3. What caused you to be sick? 37.4. What did you do to get better?
Now I’m going to ask you some questions about places you go when you are sick or need care. 38. Have you ever gone to any of the following places: 38.1. The community clinic 38.2. Youth Centre clinic 38.3. [Local] Hospital 38.4. One of the doctors in The community 38.5. A sangoma [traditional healer] 38.6. Any where else? [please name]
343
39. Why did you go to these places?
40. What do you do to stay healthy?
41. Is it easy to stay healthy? Why or why not?
42. How important do you think it is to be healthy?
CHALLENGES Now let’s talk about some of the challenges you face in your life.
43. What are the challenges that you face in your life? Probe for details about each challenge listed by the participant one by one. Possible probing questions: 43.1. Can you describe these challenges more specifically? 43.2. How does [this challenge] make you feel? 43.3. What causes [this challenge]? 43.4. How do you deal with [this challenge]? 43.5. What could make it better for you? 43.6. How do these challenges impact your relationships with people that you are close to?
*IF DRUG ABUSE, ONGOING ABUSE OR OTHER THREATS TO PARTICIPANT’S IMMEDIATE SAFETY ARE MENTIONED, stop interview and ask: Are you receiving help? Would you like me to help you find support services for you or your friend? Discuss appropriate service referrals. If necessary, end the interview and work with participant to identify appropriate service referrals.
RELATIONSHIPS & SOCIAL SUPPORT
Now let’s talk more about the people in your life.
344
44. Who is the most important person in your life? Can you tell me about him or her?
45. Who is the greatest source of support in your life? Probe participant’s social support. Possible probes: 45.1. What do they do to support you? 45.2. Who do you have in your life that you trust? 45.3. Who do you go to when you have a problem?
46. Who are your best friends? Probe for details about friends. Possible probes: 46.1. What are your friends like? 46.2. Are you in any groups or crews?
SEX AND DATING
47. Do you have a boyfriend / girlfriend? If yes, probe for details about the relationship. Possible probes: 47.1. How old is he / she? 47.2. Where did you meet him / her? 47.3. How long have you been dating? 47.4. How do you feel about your relationship with him / her? 47.5. What will happen in the future with your boyfriend / girlfriend? 47.6. What are you expected to do as a boyfriend / girlfriend?
48. What worries do you have about your boyfriend / girlfriend?
49. How many girls / guys do you want to date at a time? Why?
50. Have you ever been “in love”? 50.1. Can you tell me about it?
Now let’s talk about sex. I want to remind you that you don’t have to answer any questions that make you feel uncomfortable. If you don’t want to talk about something, just say no comment and I will move on to the next topic.
51. Have you ever had sex? If no, continue to Q58 If yes:
345 52. How old were you the first time you had sex?
53. Are you having sex now?
54. How do you feel about having sex? Probe feelings about sex. Possible probes: 54.1. What does sex mean to you in your life? 54.2. How does sex make you feel about yourself? 54.3. What concerns do you have about sex?
55. In your opinion, do you think sex is risky? Why or why not? Probe for thoughts about risks with sex. Possible probes: 55.1. Can you talk about why you think this? Why or why not? 55.2. Do you think the risks are the same for guys and girls? Why or why not?
56. In your opinion, do you or your friends take risks with sex? Probe for perceptions of risk with sex: 56.1. What are the risks that you take with sex? 56.2. Why do you take them? 56.3. How do you deal with these risks?
57. Who is responsible for protecting against risks with sex? Why? 57.1. Does it happen this way? Why or why not?
58. What discussions take place with your boyfriend / girlfriend before you have sex? For example, do you talk about what will happen the next day? About condoms? Family planning?
59. How would you describe safe sex?
60. What do you think would motivate you to have “safe sex”? Why do you feel this way?
61. Have you ever felt pressured in any way to have sex? Can you talk about what happened? How did it make you feel?
*IF YES: Stop the interview and determine if participant is currently in a situation where he/she feels pressure to have sex. Discuss appropriate service referrals. If necessary, end the interview.
346 PREGNANCY 62. Have you ever been pregnant or gotten someone pregnant?
If no, skip to Q66
If yes: 63. Can you tell me what happened? Possible follow-ups: 63.1. How old were you? 63.2. How did you feel when you found out you were pregnant / had gotten someone pregnant? 63.3. Who is the father / mother? 63.4. Where is the child now? 63.5. Do people treat you differently now that you are a parent? How so?
64. Are you [is your girlfriend] on family planning? Why or why not?
65. Who do you talk to [go for advice] about pregnancy and family planning?
HIV / AIDS These next questions are about HIV and AIDS. I want to remind you that you don’t have to answer any questions that make you uncomfortable. You can simply say for example “no comment” if there is something that you don’t want to talk about.
66. Can you tell me what you know about HIV and AIDS? For example, What causes HIV to spread?
67. What concerns do you have about HIV / AIDS?
68. Do you feel at risk for HIV?
69. Why or why not?
70. Do you take any risks with HIV / AIDS? Do your friends?
71. What risks are you taking? Can you describe them?
347 72. Can you remember a time in your life when you were worried about getting HIV? What happened?
73. Have you ever been tested for HIV? Why or why not?
74. Do you ever disclose your status? Why or why not?
If no: continue to Q79
If yes: 75. To whom do you disclose? When? Why do you disclose?
76. How do they react when you disclose? How did their reaction make you feel?
77. What do you do in your life to prevent HIV/AIDS from spreading?
78. How does HIV / AIDS make you feel about life? About the future?
79. Do you see HIV / AIDS as a disease with or without hope? Why do you feel this way?
SOCIAL PROXIMITY to HIV / AIDS Now I have some questions about experiences you have had with HIV/AIDS and people that you know with HIV/AIDS. As a reminder, you don’t have to answer any questions that make you uncomfortable.
80. Are you impacted by HIV / AIDS in any way? Why or why not?
81. How close do you think HIV is to you in your everyday life?
82. Do you know anyone with HIV / AIDS [yes or no – please do not reveal names]? Probe personal experience knowing someone with HIV / AIDS. Possible probes: 82.1. How many people do you know with HIV or AIDS? 82.2. What do they tell you about their disease? 82.3. What are your feelings about them? 82.4. How has knowing this person impacted your view of HIV / AIDS?
348 82.5. Do you know anyone who has died of HIV or AIDS?
Those are all of my questions about HIV, pregnancy, and dating. Do you have any questions for me? Would you like information about where you can go for services or to learn more about these topics? Arrange for any appropriate referrals if necessary.
STRUGGLE
Next let’s talk about the struggles facing youth today and your hopes for the future.
83. In your opinion, what is the struggle facing youth of your generation? For example, the struggle for your parent’s generation was ending apartheid. What is the struggle for today’s youth? Probe their thoughts on the stuggle facing youth today. Possible probes: 83.1. How has [this struggle] impacted your life? 83.2. What can be done about it?
FUTURE HOPES, DREAMS, AND PLANS
And finally, I’d like to ask you about your hopes and plans for the future.
84. Where do you see yourself in 5 years? In 20 years?
CONCLUSION
Those are all the questions I have for today.
85. Is there anything that we didn't talk about that you would like to add?
86. Do you have any questions for me?
Thank you for all of your time, I really appreciate it. If you have any questions or concerns, please call me or SMS me any time.
349 Appendix D. Risk Assessment Questionnaire
YOUTH SURVEY
To Be Completed By Study Personnel:
Date:
Time:
Location:
Participant Code:
INTRODUCTION [read to participant]
I want to ask you some questions about your understanding of health and wellbeing. There are no right or wrong answers. The purpose of these questions is to understand your thoughts about health.
Some of the questions are very personal. If there is a question that you do not feel comfortable answering that is ok. You can leave questions that you are not comfortable answering blank.
Answer the questions about what you really do. Please be honest! As a reminder, this information is completely confidential and will not be shared with your parents or teachers.
INSTRUCTIONS [read to participant]
I am going to give you this survey to fill out on your own. You can mark your answers in the spaces provided. Answer every question that you feel comfortable answering. When you are finished with the survey, please place it in the envelope provided.
It will take you about 45 minutes to answer all the questions.
Do you have any questions?
350 SECTION 1. BASIC INFORMATION These questions ask you basic information about yourself.
1. How old are you? ______years
2. What is your sex? A. Male B. Female
3. How did you do on your matric exam? A. I have not taken the matric exam B. My score was______C. Pass D. Did not pass E. I do not wish to say
4. How many hours of TV do you watch a day on average? A. ______hours [fill in number of hours B. I do not watch TV
5. How many hours a day do you chat on your phone on average? Chatting includes SMS, MXit, 2go, WhatsApp, BBM, or Facebook. A. ______hours [write in number of hours] B. I do not chat on a phone
6. How many hours a day do you spend on homework or reading? A. ______hours [write in number of hours] B. I do not do homework or read
SECTION 2. STRESS These next questions ask you your thoughts about stress. Please answer every question that you feel comfortable answering.
7. How do you define stress in your own words?
351
8. Please list the things that have been stressful for you over the last week or so.
9. Please read the following list. For each item in the list, please circle how often it makes you to feel stressed.
A. School work i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
B. Teachers i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
C. Romantic relationships [boyfriends or girlfriends] i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
D. Peer pressure i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
E. Fights with friends i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
352 F. Thinking about the future i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
G. Life at home i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
H. My responsibilities at home or in my family i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
I. Time [such as not having enough time to do everything] i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
J. Money [for example, not having enough money for things I need] i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
K. Family problems i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
353 L. Parents [for example, parents not understanding you] i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
M. Brothers and sisters i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
N. Housing i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
O. HIV in my community i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
P. HIV in family i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
Q. Fear of HIV i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
354 R. My health i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
S. My family’s health, for example someone in my family is sick or ill i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
T. Worrying about jobs i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
U. Crime in my community i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
V. Violence in my community i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
W. Drugs or alcohol i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
355 X. Sex i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
Y. Preventing pregnancy i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
Z. Preventing STI’s i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
AA. Noise pollution [for example, too much noise in my neighborhood] i. Never ii. Rarely iii. Sometimes iv. Often v. All the time
10. What helps you to feel better when you are stressed?
11. In the last year, have any of these challenges happened to you? [circle the things that have happened to you]
A. Parent was sick B. Brother or sister was sick C. I was sick
356 D. Parent died E. Sibling died F. Close friend or relative died G. I got pregnant or my girlfriend got pregnant H. Drugs or alcohol I. Drugs or alcohol in my family J. Trouble at school K. Fights with friends L. I was bullied M. Violence or being physically hurt by someone N. Moved to a new place O. Parent not working P. Other challenge [write here]______
☐ Check this box if you would like to speak with someone about helping you with your stress or challenges. Remember that what you write on this form will NOT be shared. Checking this box only means that you would like [researcher] to help you find someone to talk to about stress. [researcher] will NOT share your answers with that person.
SECTION 3. FEELINGS ABOUT YOURSELF These next questions ask you how you feel about yourself. Circle the option that is most true for you.
12. I feel good about myself. a. This is very true for me. b. This is a little bit true for me. c. This is not very true for me. d. This is not true for me at all. e. I don’t know.
13. Overall I am satisfied with myself. a. This is very true for me. b. This is a little bit true for me. c. This is not very true for me. d. This is not true for me at all. e. I don’t know.
357
14. I like the kind of person I am. a. This is very true for me. b. This is a little bit true for me. c. This is not very true for me. d. This is not true for me at all. e. I don’t know.
15. My success in life depends on me. a. This is very true for me. b. This is a little bit true for me. c. This is not very true for me. d. This is not true for me at all. e. I don’t know.
16. My success in life depends on my circumstances. a. This is very true for me. b. This is a little bit true for me. c. This is not very true for me. d. This is not true for me at all. e. I don’t know.
SECTION 4. DATING AND SEX These questions are about dating and sex. Remember that your answers are confidential and that there are no right or wrong answers.
17. Do you ever chat with people on MXit, 2Go, WhatsApp, BBM or Facebook that you would not otherwise talk to? A. Yes B. No C. Sometimes
18. Have you ever dated someone that you met online or chatting? A. Yes B. No C. Other [please explain]______
19. Have you ever had sex? A. Yes B. No C. I don’t know D. I don’t wish to say
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20. How old were you the first time you had sex? ______years old Or ☐ Check this box if you have never had sex.
21. The first time you had sex, how old was the person that you had sex with?
Age______Or ☐ Check this box if you have never had sex.
22. In your life, how many people have you had sex with? ______people Or ☐ Check this box if you have never had sex.
23. During the past 3 months, how many people did you have sex with? a. I have never had sex b. I have had sex, but not in the past 3 months c. ______people [write in]
24. Think about the last time you had sex. Did you drink alcohol or use drugs before you had sex? A. Yes B. No C. I don’t know D. I don’t wish to say
25. Think about the last time you had sex. What did you or your partner do to prevent pregnancy when you had sex? a. I have never had sex b. We did nothing to prevent pregnancy c. Birth control pills d. Condoms e. Injection
359 f. Withdrawal or some other method g. Not sure
26. The last time you had sex, what did you or your partner do to prevent HIV and STI’s? A. I have never had sex B. Condom C. We went for testing D. Other [please write]:______
27. Have you ever changed your mind about sex? For example, was there a time when you didn’t want to have sex but then you changed your mind and did have sex, or you did want to have sex and then changed your mind and did not have sex? A. I have never had sex B. Yes C. No D. Not sure
28. The last time you had sexual intercourse, did you or your partner use a condom? a. I have never had sex b. Yes c. No d. I don’t know or I don’t remember
29. Have you ever had sex with someone you knew was HIV+? A. I have never had sex B. Yes C. No D. I don’t know E. I don’t wish to say
30. Have you ever felt pressured to have sex when you did not want to? A. I have never had sex B. Yes C. No D. I don’t wish to say
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31. Have you ever pressured anyone to have sex when they did not want to? A. I have never had sex B. Yes C. No D. I don’t wish to say
32. In the last year, did someone you were dating or going out with physically hurt you on purpose? (For example beat you, hit or slapped you, threw you against something, or injured you with an object, liquid or weapon.) A. I did not date or go out with anyone during the last year B. Yes C. No D. I don’t wish to say
☐ Check this box if you would like to speak with someone who can answer your questions or help you with the problems you have with sex or dating. Remember that what you write on this form will NOT be shared. Checking this box only means that you would like [researcher] to help you find someone to talk to about stress. [researcher] will NOT share your answers with that person.
SECTION 5. HIV / AIDS These next questions ask you your thoughts about HIV / AIDS. Please try to answer every question, but if there is a question that you are not comfortable answering it is ok to leave it blank.
Remember that your answers are confidential and that there are no right or wrong answers.
33. True or false: Testing for HIV regularly will keep me safe from HIV. A. True B. False C. I don’t know
34. True or false: HIV is a life sentence. A. True B. False C. I don’t know
361 35. Do you know anybody with HIV / AIDS? [circle all that apply] A. No – I don’t know anybody with HIV / AIDS B. Yes – neighbors or people in my community C. Yes – friends D. Yes – family members E. I don’t wish to say
36. Do you feel at risk for HIV? a. Yes b. No c. Maybe d. Not Sure e. I don’t wish to say
37. Why or why not [feel at risk for HIV]?
38. I control whether or not I get HIV. A. True B. False C. Not sure D. I don’t wish to say
Explain your answer______39. It is up to me to prevent HIV. A. True B. False C. Not sure D. I don’t wish to say
Explain your answer______
40. I believe there will be a cure for HIV someday. A. Agree B. Disagree C. Maybe D. I don’t know
362 41. When was your last HIV test?
MONTH AND YEAR:______Or ☐ Check this box if you have NEVER had a test ☐ Check this box if you don’t wish to say
42. What was your test result? A. Positive B. Negative C. I don’t know D. I don’t wish to say E. Other______[please explain]
43. Who have you disclosed your status to? [for example, a friend or your mother] A. I disclosed to______B. I do not know my status C. I do not wish to say
☐ Check this box if you would like to speak with someone about HIV. Remember that what you write on this form will NOT be shared. Checking this box only means that you would like [researcher] to help you find someone to answer your questions or concerns about HIV. [researcher] will NOT share your answers with that person.
Exercise and healthy food These last questions ask about how often you exercise and eat healthy food.
44. During the last week, on how many days did you exercise? a. 0 days b. 1 c. 2 d. 3 e. 4 f. 5 g. 6 h. every day
363 45. During the last week, on how many days did you eat fruit or vegetables? i. 0 days j. 1 k. 2 l. 3 m. 4 n. 5 o. 6 p. every day
This is the end of the survey. Thank you for your help!
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