This document summarizes a study that examined the life experiences and perceptions of sexual and reproductive health among 25 young women aged 15-19 in rural KwaZulu-Natal, South Africa. [1] The study found that the women faced significant challenges like poverty, disrupted family structures, and experiences of trauma, which shaped their health perceptions and behaviors. [2] Many of the women were already mothers or pregnant by age 19, and most were in relationships with older men, which influenced their agency and vulnerability. [3] The women's narratives revealed how their difficult life contexts and lack of support presented barriers to achieving healthy behaviors and positive sexual and reproductive health outcomes.

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Culture, Health & Sexuality
An International Journal for Research, Intervention and Care
ISSN: 1369-1058 (Print) 1464-5351 (Online) Journal homepage: http://www.tandfonline.com/loi/tchs20
Young women’s life experiences and perceptions
of sexual and reproductive health in rural
KwaZulu-Natal South Africa
Aliza M. Waxman, Hilton Humphries, Janet Frohlich, Sarah Dlamini &
Fanelesibonge Ntombela
To cite this article: Aliza M. Waxman, Hilton Humphries, Janet Frohlich, Sarah Dlamini &
Fanelesibonge Ntombela (2016): Young women’s life experiences and perceptions of sexual
and reproductive health in rural KwaZulu-Natal South Africa, Culture, Health & Sexuality, DOI:
10.1080/13691058.2016.1182215
To link to this article: http://dx.doi.org/10.1080/13691058.2016.1182215
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2. Culture, Health & Sexuality, 2016
http://dx.doi.org/10.1080/13691058.2016.1182215
Young women’s life experiences and perceptions of sexual
and reproductive health in rural KwaZulu-Natal South Africa
Aliza M. Waxman, Hilton Humphries, Janet Frohlich, Sarah Dlamini and Fanelesibonge
Ntombela
Centre for the AIDS Programme of Research in South Africa, Durban, South Africa
ABSTRACT
Women in South Africa bear a disproportionate burden of the HIV
epidemic. Female-controlled HIV prevention methods offer promising
interventionstoreducethisburdenbutcannotbeeffectivelyemployed
without a better understanding of young women’s perceptions of
their sexual and reproductive health. This study examines social,
environmental and cultural factors contributing to young women’s
perceptions of, and experiences with, sexual and reproductive
health to identify the challenges of engaging adolescent girls in HIV
prevention. Twenty-five 15–19-year-old women were interviewed
using semi-structured in-depth interview questions to discover
their life context, future goals and relationships with men, and to
understand how these factors influence their sexual and reproductive
health decisions and outcomes. A thematic analysis of interview
findings indicates that although participants are aware of the risks
posed by engaging in risky sexual behaviour, life context shapes
their perceptions and prioritisation of their health, which presents a
barrier to achieving healthy behaviours and positive health outcomes.
These findings may influence future research into how young women’s
health perceptions influence their sexual health behaviours, and how
they utilise sexual and reproductive health services in a clinical setting.
This has implications for introducing forms of female-controlled HIV
prevention for this population.
Introduction
Young women in South Africa continue to bear a disproportionate burden of the HIV epi-
demic (Ramjee and Daniels 2013). Among South Africans aged 15–24 years, HIV prevalence
is four times greater in women (11.4%) than men (2.9%) (Simbayi et al. 2014).
KwaZulu-Natal has the highest HIV prevalence in South Africa; HIV prevalence among
women attending antenatal clinics in KwaZulu-Natal was 40% in 2013, compared to 29.7%
nationally (National Department of Health, South Africa 2013). Women living in resource-
limited settings, especially in rural areas, face additional barriers to accessing adequate
primary and sexual and reproductive health services (Yao, Murray, and Agadjanian 2013).
Women accessing antenatal care have high HIV infection rates and low knowledge of status
(Marlow et al. 2014). Since women become increasingly vulnerable to HIV infection as they
© 2016 Informa UK Limited, trading as Taylor & Francis Group
KEYWORDS
Sexual behaviour; sexual
and reproductive health; HIV
prevention; young women;
South Africa
ARTICLE HISTORY
Received 17 September 2015
Accepted 20 April 2016
CONTACT Aliza M. Waxman alizawaxman@gmail.com
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3. 2 A. M. Waxman et al.
progress from youth to adulthood (Abdool Karim et al. 2012), providing young women with
effective sexual and reproductive health services prior to sexual debut and first pregnancy
is crucial in reducing HIV incidence in this population.
Research is underway to develop optimal female controlled HIV prevention methods,
(vaginal gels, vaginal rings, long-acting injectables and others), which, if widely utilised, may
improve sexual and reproductive health programmes for women. It is essential to determine
how to best introduce such sexual and reproductive health methods and services to young
women (Rees 2015) who are highly vulnerable and often not accessible through school-
based outreach interventions.
Many young women in South Africa, particularly in rural settings, come from unstable
homes lacking adequate familial support, often discontinuing enrolment from school, and
are disconnected from other youth-friendly services and settings in which they can access
health and education (Jukes, Simmons, and Bundy 2008).These factors increase their risk of
acquiring HIV and other sexually transmitted infections (STIs) (Jukes, Simmons, and Bundy
2008), in comparison to young women who remain enrolled in school (Barnighausen et al.
2007). Each additional year of school-based education in KwaZulu-Natal, South Africa is
estimated to reduce the risk of acquiring HIV by 7% (Barnighausen et al. 2007). Regardless
of schooling, young women are also likely to enter into relationships with men of unequal
power balance and control. This can affect their sexual agency and can also increase their
vulnerability to gender-based violence (Jewkes, Levin, and Penn-Kekana 2003).
This study (CAPRISA 079) aimed to engage young South African women in narrative
discussions about their individual sexual and reproductive health perceptions and experi-
ences to inform the process for including vulnerable young women in HIV prevention science
research.
Methods
Caprisa
An HIV survey conducted by the Centre for the AIDS Programme of Research (CAPRISA), a
South African research institution undertaking research that contributes to understanding
HIV pathogenesis, prevention and epidemiology as well as the links between Tuberculosis
and AIDS care, in two rural schools in KwaZulu-Natal, was designed to expand HIV surveil-
lance in one of the highest burdened districts in South Africa, and highlighted the importance
of expanding health services for school aged women in KwaZulu-Natal (Kharsany et al. 2012).
A school-based sexual and reproductive health service was established with support from
the local ministries of health and education. A young people’s programme focused initially
on information provision, HIV counselling and testing and referral to local primary care for
sexual and reproductive health services (Frohlich et al. 2014). Given the low utilisation of
clinic services, a mobile sexual and reproductive health service was later initiated in schools
and in the community. Group discussions engaged young people in defining their health
needs, preferred modes of access and barriers and facilitators to their health and wellbeing.
These group discussions served as the impetus for the present qualitative study.
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4. Culture, Health & Sexuality 3
Theoretical approach
Two theoretical approaches informed the design of the present study.We used social justice
theory (Pillay 2014), which emphasises the importance of upholding the human rights and
dignity of the oppressed. This approach has been used to advance research promoting
human rights of South African youth after Apartheid.We also incorporated theoretical meth-
ods from advocacy ethnography, which advocates for the rights of populations treated
unjustly (Smyth and McInerney 2013). Participation in this research process enables these
marginalised young women, who have historically been excluded from research, to advocate
for their needs through a collective narrative voice (Smyth and McInerney 2013).
Sample
We used snowball sampling to recruit 25 participants at CAPRISA’s Vulindlela Research Site,
a rural centre located about 150 km west of Durban. We interviewed participants between
April and August 2014. The first nine participants were recruited from the youth health
services programme and, after completion of their interviews, were trained (through peer-
recruitment strategies) to recruit 16 other study participants. The nine participants were
trained via discussions about vulnerable young women in their peer group and were asked
for suggestions on how to engage additional vulnerable young women in this study. The
inclusion criterion for the first nine participants was to be a woman aged 15–19 years who
was already engaged in CAPRISA’s programme. The same criterion applied to the next 16
recruits, except that they had never been enrolled in a CAPRISA programme. This strategy
was selected to engage a more diverse cohort of young women.
Data collection
Two experienced counsellors from CAPRISA’s adolescent programme were trained to conduct
interviews in isiZulu. A field guide informed by the two theoretical approaches described
above was used to guide the semi-structured interviews. This guide included broad topics
and open-ended questions to facilitate participants’ability to describe how their life’s context
has shaped their health perceptions and experiences. The aim was to understand young
women’s sexual and reproductive health and how this would influence their engagement
and access to HIV prevention services. These broad topics included life history and context
(e.g., memories, family, school, loss), future goals (e.g., family planning, life goals, needs and
challenges), women’s health (e.g., sexual and reproductive health including contraceptive
use and microbicides [a gel that can be applied inside the vagina or rectum to protect against
STIs including HIV], hygiene, self-worth and risky behaviour) and relationships (e.g., trans-
actional sex, monogamy, sex, violence and rape). The interviews, with written participant
consent, were audio recorded and lasted 30–120 minutes.
After completing the first 9 interviews, preliminary interviews and feedback were used
to refine the field guide for the remaining 16 interviews. The refined guide elaborated on
topics frequently discussed by the first participants and included new topics beyond the
scope of the original questionnaire, notably rape and abuse, which were identified as signif-
icant to young women in the study community. The refined guide restructured major the-
matic areas into key topics to ensure a more thorough and consistent approach and to
engage participants who were less outwardly vocal in their descriptions.
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5. 4 A. M. Waxman et al.
The audio recordings and feedback session were translated and transcribed into English
by a professionally certified translator. A random selection of interviews was back-translated
to validate the reliability of the transcription process. This analysis presented here is based
on the English transcripts of the isiZulu interviews.
Ethical considerations
The CAPRISA 079 study was conducted under the ethical oversight of the University of
KwaZulu-Natal Humanities and Social Sciences Research Ethics Committee (HSS
REC/0,019/014). All participants signed an informed consent document provided in English
and isiZulu prior to enrolment. For participants younger than 18 years, a parent or guardian
signed the informed consent with participant assent. Each participant was given a small
snack and hand lotion to acknowledge their participation. All participants were offered
transport to and from the study site.
Data management, coding and analysis
The thematic analysis was guided by the ethnographic approach and interview topics that
informed the study’s exploratory narrative and iterative design. In line with our broader
research commitments, we engaged participants in a manner that enabled them to identify
pressing issues in their lives that we could incorporate into research intended to empower
them to improve their health outcomes.
The quotes presented below are attributed to participants using fictional names.Themes
were coded for the frequency at which they were discussed during the interviews and their
relevance to the study aims.
The themes guiding qualitative data analysis were selected based on the study’s theo-
retical construct and the relevance of the topics to the study population. Coding was itera-
tively based on multiple readings of the data. Members of the primary research team met
to discuss and gain consensus on emerging themes.
Our findings highlighted important contextual factors influencing the health perceptions
of young people.We identified several overarching themes, beginning with the life context
of our participants that informed their experiences, their awareness of their sexual and repro-
ductive health risks and future plans, and how these experiences shape their perceptions
of themselves, their health and their health decision-making. The three broad categories
and themes within each category are listed in Table 1.
Findings
Demographic characteristics
Participants’ main demographic characteristics (mean age, 18) are listed in Table 2. There
were no notable differences in overall responses between the first group of 9 participants
and the second group of 16 participants. Of the 25 participants, 8 had dropped out of school,
mainly for reasons related to pregnancy; 10 participants already had one child (40%) and 3
were pregnant during the study (12%), thus, 13 of the 25 participants had already been
pregnant by their 19th birthday. Most (84%) participants had an ongoing relationship with
a man; 11 had a boyfriend up to 2 years older than themself, 4 had boyfriends 3–4 years
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6. Culture, Health & Sexuality 5
older, 3 had boyfriends 5–7 years older and 2 had boyfriends 8–10 years older. No significant
differences in behaviour were noted between girls in relationships with men older by
0–2 years versus 8–10 years.
Key thematic areas
The experiences and narratives of participants’sexual reproductive health were embedded
within certain key thematic areas.These areas included: (1) life context and future goals, (2)
intimate partner relationships and (3) experiences and perceptions of health.
Life context and future goals
The most common challenging life event described by participants was the loss of a parent
or close relative. Many described this experience by recollection of illness or sudden death.
Several participants described disturbing childhood memories, such as distrust at home,
parents’dysfunctional relationships and experiences of rape:
When I was five my mother was stabbed; she broke up with my father and started a new rela-
tionship – she was stabbed [to death] by the girlfriend of her new boyfriend … when I try to
picture my mother in my mind I only have the one in the photographs at home. (Sarah, aged 19)
Poverty and disrupted family structures were common. A total of 11 of the 25 participants
lived with extended family members as their parents were deceased, had relocated for work
and or could not afford to look after them. Many of these participants also lived off child
support grants and income from an extended family member who also provided for other
family members. Some lived in homes where there was not enough food to eat:
When my grandmother passed away my life changed. I went to live with my aunt, her two sons
and my brother … my aunt started to abuse me by always taking her children’s side … she
Table 1. Interview questionnaire categories and themes.
Category Themes
1. Life experiences
1a. Life context
1b. Future goals
Family, (childhood) memories, schooling, family planning, life ambitions,
present challenges
2. Intimate partner relationships Transactional/intergenerational relationships, monogamy and
concurrent sexual partners, sex, violence/abuse and rape
3. Experiences and perceptions of health Women’s general health, contraceptives, notions of the female body,
risky sexual behaviour, teen pregnancy, menstruation and use of/
acceptance of/acceptance of microbicides
Table 2. Demographic data.
Age of participant 15 16 17 18 19 Total
Number of participants 1 1 6 6 11 25
Schooling Dropped out of school 1 1 3 3 8
Attending school 1 3 1 2 7
Completed school 1 2 5 8
Failed out of school 1 1 2
Pregnancy Already had a child 1 1 3 5 10
Pregnant during study 1 1 1 3
Never pregnant 1 4 2 5 12
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7. 6 A. M. Waxman et al.
complained about food saying that I do not contribute towards groceries; sometimes I wouldn’t
eat and only ate at school during lunch, the neighbours sometimes helped me. … My father
used to give me money [for food] while I was still studying …. [We no longer communicate with
one another] because he said he does not work anymore so he does not have money. I then
decided to fend for myself. (Thandi, aged 17)
Some participants described living in homes with alcohol abuse and other forms of tension
and stress. Some described their experience with domestic and emotional abuse:
Things are not going well. My uncle drinks too much and he’s troublesome … [he] brings his
friends around and we don’t feel safe since we are girls. (Precious, aged 19)
Given the many challenges faced at home, completing basic education was a struggle for
many participants. The importance of school , the desire to complete school or to return to
school for those who had dropped out, and to complete tertiary education was a recurrent
theme:
Nowadays we are nothing without education, in order to have a better future you have to be
educated. … I want to study further [so that I can] fix most things at home; I want to provide
for my family. … None of my family members are educated [and] so I am the only one who will
[be able to] fix my home. (Jess, aged 18)
Many participants aspired to becoming psychologists, doctors, teachers, policewomen, social
workers, civil engineers, paramedics, pharmacists or nurses and other health professionals.
Five participants who discussed this topic said they planned to further their tertiary educa-
tion to obtain a job. However, of the eight who had completed school, only two said that
they were working.
Visibility and interaction with young women who do not attend school is difficult.
According to participants, girls who do not attend school are hidden and‘difficult to locate
because they avoid places where others are studying’ (Nondu, aged 19). According to the
participants, young women can be found wandering in the streets, because they are not
educated and have limited alternative ways to earn money:
Some of them are found at community halls or hanging at local pubs; they get money to go
to these places from their boyfriends …. Some girls exchange sex for money because they are
not educated, they need money but they are limited in terms of education. (Danielle, aged 19)
Girls who stay at home mislead each other, feed each other with nonsense. Before it was kuber
[Kuber is a highly addictive form of tobacco and is chewed or made as a tea and drunk. It contains
tetrahydrocannibinol (THC)] and now they are using some drugs called nsu [a snuff tobacco],
which they eat, they put it on their lower lip.They claim it makes them hot when having sex and
they said my boyfriend will leave me if I don’t take it. (Ntombe, aged 19)
Although all participants described their desire to complete or further their schooling, and
to postpone starting a family, becoming pregnant presented a barrier to almost all
participants:
Having sex was a mistake since I got pregnant and had to drop out of school. Some girls are
responsible for their homes so they run out of options, drop out of school and become prosti-
tutes. (Zinhle, aged, 18)
Some who give birth leave their babies with their parents and go back to school to then realise
they can’t afford to further their studies or that it is too difficult. (Ayesha, aged 19)
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8. Culture, Health Sexuality 7
Intimate partner relationships
Participants’propensity to enter into and remain in relationships with men where they have
limited sexual agency was influenced by structural barriers shaped by their lives. These
included poverty, disrupted family structures, experiences of abuse, economic struggles and
the inability to remain in school, leading to risky behaviours and poor sexual and reproduc-
tive health outcomes. Participants gave several reasons for engaging in risky behaviours to
maintain their relationships with men, including to obtain food, for material gain, to satisfy
their desire for an older, more experienced man and to obtain a man’s love. Interviews with
participants highlighted the nuanced dynamics that affect intimate partner relationships
and the diversity of reasons why young women engage in relationships that affect their
vulnerability.
Some participants described their engagement in transactional sex with men for material
gain and to obtain food or other basic needs. Typically, girls who engaged in transactional
sex were out of school, living in child-headed homes and very poor:
In exchange for sex most girls want money, and some want [popular franchise food items such as]
chicken from men. (Wandile, aged 19)
Some participants described their willingness to engage in forms of sexual behaviour, which
had the potential to result in them becoming infected with an STI or having an unwanted
pregnancy, in order to maintain a relationship with a man:
Girls want to get sick and fall pregnant, in order to hold on to their man, and some expect love
in return for sex with men. (Wandile, aged 19)
Many of their men engaged in sexual relations with multiple partners, which participants
reported they accepted.This is despite the knowledge that having multiple partners increases
risk for HIV and STIs, since their men mostly did not use condoms:
Girls in my community take sexual risks – by sleeping with an HIV-positive person and continuing
to sleep with other men even after finding out they have HIV. (Wandile, aged 19)
The influence of family context and mentors on young women’s willingness to accept abuse
may be socially sanctioned:
When he discovered that I was cheating on him … he beat me up until I admitted that I was
cheating. I told my sister and she said I’d be okay since I was the one who was on the wrong
and we laughed about it as she also was being beaten up in her relationship. (Thando, aged 19)
If a woman’s husband beats her up with the intention to seriously harm her, he can be arrested.
However if it’s not violent; like getting three slaps or [hit with] a belt, its ok. (Gugu, aged 19)
Many participants that reported being abused by their families also experienced abuse by
their boyfriends and expressed a tolerance for different degrees of this behaviour:
I misbehave by cheating on him, so he beat me. … I felt like he doesn’t love me. [Yet] as much
as he was physically abusing me he was also helping me because he even told me that if a par-
ent gives their child a hiding it is not because they hate the child but because they love them.
(Thando, aged 19)
Although participants described various experiences of being abused by their partner, they
hesitated to disclose this information. Many cited their lack of trust in the police and authority
figures such as teachers and family members as a reason for this:
My aunt told me that women must accept that men beat them, it’s how it’s done. If you tell
police they will just say they do not entertain cases of people having an affair. If he has beaten
me a lot then I would be forced to report him to the police …. A lot is if he beats me up after
each and every small mistake I make. (Bianca, aged 19)
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9. 8 A. M. Waxman et al.
Interestingly, some young women who engaged in cross-generational sex entered into vul-
nerable relationships to satisfy their desire for a more experienced man, who they described
as more sexually satisfying than younger men, highlighting a sense of sexual agency when
choosing a partner:
[My friend said] she doesn’t feel [anything] with men her age when having sex, while the matured
ones satisfy her sexually. (Monique, aged 18)
Participants described older men as more controlling in their relationships than younger
men:
They are coercive, they do not treat you as you want, they do not understand young women
have dreams for the future. (Zinhle, aged 18)
Experiences and perceptions of health
Notions of health was another important theme that emerged, highlighting the gendered
narratives of health by women. Several participants defined health as looking after oneself,
being happy, loving oneself, living in a clean place and eating healthy food:
When you bathe, you avoid having germs that cause sores or rashes. (Caitlin, aged 19)
Some participants described young women’s lack of health engagement to be a conse-
quence of their not valuing health, for example not practising safe sex, not behaving‘prop-
erly’and getting too drunk or dressing provocatively:
We are told how to behave but somehow don’t practise what we are taught – like how to have
safe sex, and how to protect ourselves when helping someone. (Kayla, aged 19)
If you are going to be quiet you will end up getting abused without realising it. You have to be
vocal, be able to converse and just be good. (Siphokazi, aged 17)
A woman should love herself even if she drinks but should not drink at the taverns because she
might get raped while drunk, she should not wear short clothes showing off her body to men
… a woman should drink in her house. (Thando, aged 19)
Thando’s quote, above, connects to her earlier comments, demonstrating how life context
and experiences of abuse shaped the gendered perspectives of participants, who often
blamed themselves for their vulnerability to the men they encountered.
Participants described various practices regarding sexual health and hygiene:
Before sex some people in my community use a gel-like substance, I don’t know what they call
it and there is what they call NSU snuff in a black small container with a yellow lid that is used
by grandmothers. (Zanele, aged 18)
Participants felt that men affect their health and increase their vulnerability to sexual risk:
Women are put under pressure in sexual relationships. Men drink; want to have sex by force ….
Men’s health differs because men walk alone at night and nothing happens to them, instead
they are the ones who abuse women … whereas women’s health differs a lot because they can
take care of children and help other families. (Gugu, aged 19)
Interestingly, the value participants placed on women’s health was described in terms of
their belief that a woman’s role is to give birth to men, highlighting the importance of men
in health narratives.
When asked to describe their understanding of HIV and AIDS, most participants described
HIV as a virus transmitted via unprotected sex, which they claimed cannot be cured but can
merely be halted. The participants felt the need to be better educated in general. Several
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10. Culture, Health Sexuality 9
participants claimed that women should be taking responsibility for their health, specifically
with regards to HIV prevention:
The problem is that we as women do not care about ourselves so that we don’t transmit the
infection. You should be able to think about the outcome of your actions because there are
condoms. (Natasha, aged 19)
When asked about their plans for childbearing and contraceptive use, many young
women said that they would like to have financial stability before having children due to
the importance of clinical visits, medical aid and clothing and food for the baby. Several
participants who had been previously pregnant (10/25) regretted having become so.
According to some participants, young women become pregnant for a variety of reasons,
including obtaining government grants, keeping a man in a relationship, avoiding family
planning clinics due to fear and preferring not to use contraceptives. When asked how the
community reacts to teen pregnancy, several participants said that the community chases
away girls who become pregnant. Although young women may want to return to school
after giving birth, many end up staying out of school because they cannot afford to further
their studies, which increases the likelihood they will engage in risky sexual behaviour, such
as having unprotected sex with men who are involved in multiple concurrent sexual
partnerships.
Of the 25 participants, 13 said they preferred Depo-Provera (an injectable contraceptive)
as their method of contraception, some citing its long duration of protection. However,
several participants said that they stopped using Depo-Provera due to bleeding, pain, irri-
tation during urination, bloating, weight gain and water retention. One participant described
hearing that:
The injection makes you boring in bed – water accumulates in the body, which does not stimulate
your partner enough. (Nandi, aged 18)
Of the 25 participants, 11 said that they had heard of microbicides. A majority (16/25) said
they would use microbicides and would want to involve family and friends in this discussion.
Some participants said that microbicides cause tension for couples: partners believe that
women who use microbicides may have been‘sleeping around’. Participants believe micro-
bicides can help women, especially if women ‘behave well sexually’ by avoiding engaging
in risky sexual behaviour.
Discussion
This study identifies some the individual contexts and life experiences described by young
women from rural KwaZulu-Natal, South Africa, which have shaped their unique perceptions
and reasons for engaging in sexual behaviour within the context of relationships with men,
often leading to poor sexual and reproductive health outcomes.
Our findings highlight the importance of different structural barriers influencing young
women’s experiences, behaviours and perceptions of how they think about their sexual and
reproductive health. Major contextual factors contributing to these barriers related to eco-
nomic disruption and poverty, loss of family structure and cultural and societal norms gov-
erning the role expected of many young women, including the increased acceptability of
intimate partner violence in the face of economic benefit.These barriers shape participants’
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11. 10 A. M. Waxman et al.
experiences of home life, education, health access and health empowerment, and inhibit
participants from prioritising their sexual reproductive health needs.
Many participants reported intra-family abuse and gender-based violence in the context
of high reliance on partners and families.This has negative consequences for their perception
of self-worth and their ability to make decisions about their health independently. These
findings are congruent with other qualitative research examining how young women con-
struct femininity and exercise agency (Jewkes, Morrell, and Christofides 2009). Our findings
also demonstrate that gender inequities enable men to exercise power and relationship
control over young women, specifically those living in poverty, by providing material goods
in exchange for sex (Jewkes, Morrell, and Christofides 2009).
Participants in this study presented a conflicting view of gender-based violence, for
instance a familial willingness to accept it and transactional reasons, while simultaneously
identifying that it is unacceptable. Participants seemed willing to concede protective sexual
and reproductive health behaviour, and tolerate abuse, if a partner would provide economic
stability, with sex providing a means of obtaining economic agency often sanctioned by
family and peers. This type of behaviour has been described as a coping mechanism in a
society where the lack of women’s agency and response to abusive and unequal relationships
are navigated through relationships of material gain and survival sex (Kambarami 2006).
The importance of relationships, and relationships as currency for avoiding negative eco-
nomic consequences, was perceived by many participants as a viable solution to their own,
and often their family’s, financial problems, often leading them to enter into age-disparate
relationships with men. Within this context, the priority of health, autonomy and absence
of an abusive relationship or‘keeping your man’are outweighed by the need for survival.
To address the existing social and structural barriers to achieving positive health percep-
tions for young women (such as a lack of support from older females), it will be important
to include in further research all key stakeholders – including healthcare workers – to gain
support of relevant community members and stakeholders.
Experiences of abuse in adolescence and in their relationships with men as teenagers
shaped participants’ perception of physical value and how they perceived their physical
health and wellbeing.Violent sexual acts are important factors affecting women’s self-worth
and their potential for poor sexual and reproductive health outcomes, including HIV infec-
tion.This finding is similar to the finding that unreported rape and lack of legal action against
perpetrators of rape reduce a woman’s sense of self-worth and significantly increase her risk
for negative health outcomes, including HIV (Jewkes and Abrahams 2002). The ability of
vulnerable and disconnected young women to exercise agency is‘restricted by the tragedy
of their social circumstances’, which offers them ‘minimal resources and little protection
against sexual violence’(Bhana 2012, 356) and other poor health outcomes.
The vulnerability experienced by young women, and notions of self-worth that are heavily
dependant on a partner, may be influenced by the experience of neglect, social isolation
and struggling to meet basic needs to survive and overcome challenges. Several participants
described the loss of a parent to a sudden illness as a significant life event that needs to be
addressed as part of any intervention to support the needs of the study population. The
neglect and social isolation experienced by these young women influences the value they
give to themselves, which in turn influences their entry into vulnerable relationships with
men, and make decisions concerning their health based on the opinions of more powerful
social agents, such as their partner.
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12. Culture, Health Sexuality 11
The protection offered by schooling (Hargreaves et al. 2008), by reducing feelings of
isolation and improving access to health resources, is critical. Those attending school were
also less likely to engage in risky sexual behaviour than girls not attending school, reducing
their risk of HIV infection.This finding supports previous epidemiological work (Hargreaves
et al. 2008) examining the association between school attendance, HIV infection and sexual
behaviour in rural South African youth. As girls develop poor perceptions of self-worth, this
influences their health-seeking behaviours and hinders their willingness to prioritise their
access to health services. Improving access to health services by supporting young women
to complete school is clearly a valuable opportunity.
One of the most critical sexual and reproductive health issues affecting young women
in this community is pregnancy. Our findings suggest that young women’s pregnancy out-
comes are strongly influenced by external societal factors, and may not be based on a con-
scious decision to have a child.This finding is similar to that of Evens and colleagues (2015),
who reported that economic concerns, family structure and experiences with contraceptives
influencedbothwomen’sdesireforpregnancyandabilitytoachievethosegoals.Furthermore,
actively planning for pregnancy was not a salient concept to the majority of participants.
Our findings suggest that improving acceptance and adherence of contraceptives in the
study population (particularly when using Depo Provera) may be achieved by expanding
knowledge and awareness of alternatives to injectable contraceptives.
Despite the challenges of convincing young people to use sexual and reproductive health
services, particularly in rural settings (van der Hoeven, Kruger, and Greeff 2012), some of the
study participants articulated the belief that women should take responsibility for their
health behaviours and acknowledged that their health decisions may negatively impact the
health of others. This idea of ‘behaving well’, according to society’s perception of what it
means to be a good woman, and taking responsibility for ones own actions brings us back
to the participants experiences, which often shape the perception that negative health
outcomes are their own fault, rather than an integral part of the existing social and predom-
inantly patriarchal structure of society. Thus, young women may develop the perception
that they are entirely responsible for their sexual and reproductive health, when in reality
their options are seriously limited by social circumstances.
Several participants described how girls who are not attending school can be found in
taverns. Previous work has demonstrated how alcohol has been used as‘a currency for sexual
exchange’and how this increases risky behaviour including rape, multiple partners and HIV
infection (Watt et al. 2012).
Our findings suggest that one effective approach to improving young women’s sexual
and reproductive health may be to create programmes that support them through an explo-
ration of their hopes and desires and an exploration of avenues for empowering them to
assert control in their sexual relationships. Key to empowering young women is economic
empowerment (Pronyk et al. 2006), which has implications for reducing intimate partner
violence.
These findings will help determine how to work within the existing context of these
participant’s lives to introduce positive health perceptions through notions of agency and
self-empowerment, while simultaneously addressing barriers to access education and sexual
and reproductive health services. For example, it will be important to engage the peers of
disconnected vulnerable women to help identify the best methods to target them with
health services and to better engage those not attending school, who are often hidden. It
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13. 12 A. M. Waxman et al.
will also be important to identify, train and support mentors for delivering these services,
and to effectively reduce gender bias and promote young women’s empowerment. These
findings will also help determine how to design further research examining how these con-
textual factors influence the feasibility of introducing to this population microbicides and
other female-controlled biomedical and behavioural health interventions.
In developing a strategy to work with young South African women, it is important to take
into account how women’s health has historically and culturally been valued in South African
society. Further research may examine how the transformation of women’s health percep-
tions over time, in the changing context within post-apartheid South Africa, has impacted
on women within the larger context of their sexual and reproductive health.
In building upon this research, it might be useful to develop an explanatory model to
examine the relationship between young women’s understanding of gender, the value they
assign to their sexual and reproductive health and how this influences their health-seeking
behaviour. This value has been noted as one where young women often assume responsi-
bility for sexual and reproductive health needs and prevention of disease but are not empow-
ered to make these decisions in the context of their social or relational situation (Jewkes,
Morrell, and Christofides 2009). In addressing this issue, it will be important to teach men
from a young age the importance of women’s rights, and to challenge patriarchal notions
of sexuality. The longer-term goal of this research is to determine how a positive sexual
health belief model can be better incorporated into the existing structures of these partic-
ipant’s lives.
Evidence from the literature suggests that young vulnerable women require multiple
sources promoting an active discourse around their sexual health to achieve positive and
empowering health perceptions, which ultimately may lead to better health outcomes.
Specifically, young women need to be empowered to believe that investing in their sexual
health is essential and that they deserve to be healthy and aware of how they can access
sexual health services tailored to their specific needs (Campbell and Cornish 2012). Until
young women can recognise the value of their health, they will continue to be vulnerable
to engaging in damaging sexual behaviours (Eaton, Flisher, and Aaro 2003).To achieve this,
young women’s access to sexual and reproductive health products or services must be pro-
vided in a manner contextually appropriate to their‘particular personal and social circum-
stances’(Headley et al. 2014, 8). Simultaneously, it is important to incorporate strategies to
improve young women’s access to basic material resources, (e.g., food, clothing, feminine
hygiene products, transportation and school materials) and to develop a social support
structure specifically to empower them. Furthermore, girls need to be better educated about
family planning and how to improve their decisions around pregnancy intentions for improv-
ing long-term sexual and reproductive health. Finally, working with both young men and
women to foster more meaningful and equitable relationships will help empower young
women to build more trusting and balanced relationships with shared responsibility for
health decisions.
Limitations
Findings from this study must be interpreted within the specific context of post-apartheid
South Africa. While they may be generalisable to other rural contexts in South Africa, they
may not be applicable to other sub-Saharan African countries, where the cultural context
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14. Culture, Health Sexuality 13
and the structural barriers may be very different. Another limitation is that we only collected
data on the perceptions of young women. Understanding the perceptions of both men and
of older women is critical, as they likely influence the perceptions of young women. Further
analysis of social imagery, in particular gender representations, will also require work with
men and older women. Another limitation is that the interviews were conducted by two
counsellors from CAPRISA’s young people’s programme, where the first cohort of participants
was recruited.This may have posed a threat to the reliability and validity of the results, since
participants were already familiar with CAPRISA’s work.
Conclusion
As we continue to design interventions to improve sexual and reproductive health outcomes
for young South African women, it is important to recognise that the diversity of young
women’s individual experiences and life contexts necessitates that programmes be tailored
to each unique situation. Essential resources are required in the form of health centres,
multiple sexual and reproductive health options and health education to enable young
women to engage in an active discourse around their sexual health. Future interventions to
improve health outcomes for young women in KwaZulu-Natal will likely need to empower
the women to believe that investing in their sexual health is essential, that they deserve to
be healthy and to improve their access to sexual health services tailored to their needs.
Interventions that increase access to education may also empower them to access health
services. By giving participants a voice to describe their experiences, we hope to help foster
the development of interventions more effective at empowering and enabling young women
to complete school, even when they become pregnant.This increased understanding adds
value to existing data by providing a more in-depth understanding of the participants’lives
and how to improve access and acceptance of sexual and reproductive health.
Acknowledgements
We would like to thank the study participants in Vulindlela for sharing their time and narratives with
us. The team would like to especially thank Quarraisha Abdool Karim, Associate Scientific Director at
CAPRISA and Principal Investigator for the CAPRISA Clinical Trials Unit for mentoring Aliza Waxman
throughout the course of this study and through the writing of this manuscript. We would also like to
acknowledge the support provided by staff at CAPRISA’sVulindlelaTrial Site, specifically, Makhosazana
Mdladla and Lorraine Mhlongo for conducting the 25 interviews.We thank Lyle McKinnon and Deanna
Kerrigan, for their insightful comments and helpful suggestions in preparing this manuscript.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
Aliza Waxman was supported by a Fulbright-Fogarty Public Health Fellow, through a research grant
funded by the US Department of State’s Fulbright Programme and Fogarty International Center,
National Institutes of Health. This study was supported by the Centre for the AIDS Programme
of Research in South Africa (CAPRISA), and the MACAIDS Fund through the Tides Foundation
(Grant #TFR11 01545).
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15. 14 A. M. Waxman et al.
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