Author: Social Impact Assessment and Policy Analysis Corporation
The study was carried out because Botswana has one of the highest rates of HIV prevalence in the world. Currently, almost 40% of the population aged 15-49 is HIV positive and, in the north, prevalence has reached 50%. HIV infection is the main challenge to the reproductive health of young Batswana, but other factors such as sexually transmitted infections (STIs), pregnancy, and gender roles in sexual decision-making are also important.
Purpose / Objective
This study was carried out to collect information about the sexual and reproductive health of young people in Botswana. The information will be used to measure the impact of programmes implemented in Botswana over the next five years.
Quantitative data (statistical data) was collected using questionnaires filled in during interviews. 2,100 interviews were conducted with 10-14 year olds, 900 with 15-19 year olds, 900 with 20-24 year olds, and 428 with adult caregivers. In total, over 4,000 people were consulted. Qualitative data (explanations and opinions) were collected using focus group discussions. Eight were held with adults, ten with 10-14 year olds, ten with 15-19 year olds, and ten with 20-24 year olds. Most participants in the study were very cooperative.
Key Findings and Conclusions
Although most young people in Botswana have heard about many aspects of sexual and reproductive health, far fewer have detailed knowledge. Most youth can name the symptoms of AIDS, but few can accurately name all the modes of transmission. Worryingly, many name incorrect modes of transmissions such as kissing or sharing plates with a person with HIV. Many young people believe that HIV is always transmitted from mother to child and very few can accurately describe the progression of HIV to AIDS. This means that they have little understanding of how the virus is linked to AIDS-related illnesses and, therefore, cannot fully comprehend the concept of living positively with HIV. Without a deeper knowledge of HIV and AIDS, young people find it hard to personalise their risk of HIV infection and remain ill-equipped to avoid high-risk activities.
Comparisons with Previous Findings
Compared to studies carried out in the early 1990s, the 2001 survey suggests that youth are slightly more aware of STIs than in the past. Awareness of AIDS was already 100% in the early 1990s, and this remained at 100% in the 2001 study. As with findings from the mid-1990s, knowledge of methods to prevent pregnancy remained high. Knowledge of condoms appears to have been almost universal among those aged 13 and older from the mid-1990s, and remained so in the current survey. Youth who had attended a condom demonstration had increased significantly since the mid-1990s. Condom source preferences did not change from the mid-1990s, but the fact that condoms could be obtained for free was mentioned more often in 2001 than in previous years.
HIV is still not real to the majority of Batswana youth. Many do not realise that it is relevant to them and their families; they assume that they are very unlikely to contract the virus and do not believe that their friends may be HIV positive. This lack of recognition has meant that there is still a great stigma attached to having HIV and only 11 people have ever gone public about their status in Botswana. Many young people feel that anyone known to have HIV or AIDS should be isolated from the rest of the community, regardless of whether they show any symptoms or not. For example, the majority believe that a teacher with HIV should not be allowed to carry on teaching and many admit that they would not go to a shop if they thought the shopkeeper was infected. Although attitudes are very positive about condom use, the main reason for using condoms is the prevention of pregnancy and some girls use two types of contraceptive simultaneously. Most young people feel it is unrealistic to believe that a condom can be used during every sexual act. This attitude and the denial of personal risk of HIV infection clearly undermine the significance of the positive attitudes about condom use. Also, many girls feel that they could not insist on using a condom if the boy refused, even if she suspected that he had an STI. Again, this belief does not seem to include the fear of HIV, but only of other more visible STIs.
Comparisons with Previous Findings
Findings from the mid-1990s compared to 2001 suggest that attitudes towards condoms have not changed significantly over time. Nevertheless, actual practices regarding condom use have improved considerably but still not to the extent that young people believe they can negotiate safer sexual practices on all occasions. Overall, there appears to be a higher realisation of personal risk than in the early-1990s, which previous surveys suggest has been increasing since the mid-1990s. However, the risk of pregnancy and STIs are acknowledged to a greater extent than the risk of HIV infection, possibly because these are visible risks. There seems to be a considerable improvement in the level of compassion for those who are living with HIV or who have AIDS, particularly in comparison with the early 1990s. Compassion seems to be linked to personal knowledge of someone with HIV, therefore young people are still less compassionate than adults.
Sexual Behaviours and Practices:
Behaviours that are recognised to help prevent HIV transmission among youth are consistent condom use, reduction in the number of sexual partners, voluntary testing for HIV and the delay in the onset of sexual activity. Although more young people claim to be using condoms now than in the mid 1990s, these statistics may be subject to reporter bias and need to be looked at against the incidence of STIs and pregnancy rates. Unfortunately, statistics remain high for both pregnancy and STIs (including HIV) for Batswana youth. It has also been found that young people have more sexual partners now than five years ago. Not all young people are delaying their first sexual experience either from peer pressure or due to sexual coercion.
Comparisons with Previous Findings
By the age of 20, half of all males and females had had sex. This is below figures from the mid-1990s, but still shows that the onset of sexual activity is not being delayed significantly. The average age at first sexual intercourse was 17, the same as it was in the early 1990s, showing that young people who do become sexually active are doing so at a young age. Condom use rates were quite high, at 80%, which is similar to the findings from the mid-1990s, but many sexual events were not planned in advance. The number of casual sexual partners of sexually active youth may even have risen, but the average number of regular sexual partners appears to have declined. While more young people are using condoms now than in the past, many are having problems with these condoms and do not use them on all occasions.
Health Seeking Behaviours:
Young people claim to be willing to be tested for their HIV status, but less than 5% of people under 24 years have actually been tested. This may reflect their belief that they are at very little risk of infection. A significant number of these tests have been carried out during antenatal care as part of the prevention of mother-to-child transmission (PMTCT) programmes. Few young people are using the sexual and reproductive health services available to them, but it is unclear why that is. The small percentage that have used the services have found them friendly, but suggest that there should be more privacy.
Comparisons with Previous Findings
Past studies had only looked into STIs, rather than health seeking behaviours. The percentage suffering from a sexually transmitted infection appears to be much lower now than in the 1990s. For 15-24 year olds, the rate was about 10%, while for 1994, 1993 and 1992, the rates averaged over 20%.
The findings from the study reveal that programme interventions are still clearly needed in Botswana. Suggestions for these interventions are outlined below using the UNICEF programme framework. This framework aims to promote behavioural change by ensuring that young people are involved throughout the implementation of all programmes and have: correct knowledge to make informed decisions; skills to act upon this knowledge (life skills); accessible services - health, education; and safe and supportive environments at home and in the wider community.
Young people absorb knowledge effectively when they believe it is relevant to their lives. The ABC message has raised awareness of HIV and AIDS, but a deeper understanding of the virus is now critical. Correct knowledge can be passed on to young people using a variety of different methods, both within school and outside: peer education, videos made in Botswana (e.g. showing people living with HIV and AIDS and the progression of HIV to AIDS), talks by people living with HIV and AIDS, and youth-focused books and posters.
Skills to Act on Knowledge
In order to pass on skills to young people, practical approaches are needed. These could include: interactive condom demonstrations, youth workshops on life skills, and training in skills of income generation.
Access to Services
Investigation into why so few youth use sexual and reproductive health services is necessary, as is the continued effort to make these services youth-friendly. Increased access to counselling, ante- and post-natal care, family planning and HIV-testing services is critical. Plans to expand access to testing services should proceed as it provides HIV-positive people access to counselling and encourages HIV-negative people to stay uninfected.
Safe and Supportive Environment
It is important to consider the effects on young people of growing up in an AIDS environment. An expansion of counselling services may well be necessary. It is also necessary that the home environment is supportive and that adult caregivers feel able to talk to young people about issues of sexual and reproductive health. Specific interventions targeting adult caregivers may be necessary. There is a continuing need to focus on gender roles in sexual decision-making, particularly female initiation of condom use. Increasing the availability of the female condom may be an important intervention. The environment also needs to be safe for people living with HIV and AIDS to go public with their status. Home-based care programmes have helped to overcome some of the stigma, but other actions are also needed. Behavioural change must come from within each individual, but if young people feel that they have external support from adult caregivers, health workers, teachers and the legal system, they are more likely to be able to behave in sexually responsible and risk-free ways.
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HIV/AIDS - Young People
UNAIDS, Population Services International (PSI Botswana), Government of Botswana, African Youth Alliance of Botswana