Adolescent choices and caregiver roles: Understanding individual and interpersonal influences on sexual decision-making in South Africa

Abstract South African adolescents are at-risk for HIV infection. Understanding the factors influencing sexual decision-making is crucial for developing effective HIV prevention strategies. We conducted a qualitative study with adolescents and caregivers in Rustenburg, South Africa to explore individual and interpersonal factors that influence adolescent sexual decision-making. Focus Group Discussions (FGDs) were conducted in English and Setswana with 17 adolescents (13 females and 4 males) and 19 caregivers (17 females and 2 males) between April and July 2018. Thematic analysis revealed that while adolescents had access to sexual education from various sources, where the knowledge does not translate into healthy sexual decision-making. A contributing barrier was the lack of effective communication and support between caregivers and adolescents in discussing topics related to sexual activity. Although adolescents expressed a strong need to be understood and supported by caregivers regarding their sexual activity, there was perceived distrust, judgemental attitude from caregivers, poor role models of a father figure, and the traditional taboo of having these discussions with caregivers. While female adolescents and female caregivers discussed sensitive matters, this type of communication was limited with adolescent males. Male adolescents were uncomfortable communicating with either caregiver, fearing caregiver judgemental attitudes and being misunderstood. Female caregivers perceived male caregiver roles to be absent and non-engaging when it came to adolescent education and support in sexual matters. Caregivers desired to support their children, yet they seemed to doubt their skills. Communication tools and guidance on how adolescents and caregivers could communicate about sensitive matters could create enabling environments for adolescents to make informed, healthy decisions regarding their risky sexual behaviours. To address adolescent intention-behaviour gap, future interventions could consider gain-framed messaging within intervention packages to promote healthy sexual choices. Competing Interest Statement The authors have declared no competing interest. Funding Statement This work was funded by IAVI and the United States Agency for International Development (USAID). The full list of IAVI donors is available at http://www.iavi.org. The contents of this manuscript are the responsibility of the authors and do not necessarily reflect the views of USAID or the US Government. Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The study was approved by the University of the Witwatersrand, Human Research Ethics Committee (ref. no 170607). I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Footnotes ↵# Affiliation at the time of study concept Data Availability We are loading data on a Figshare account, and will be made available prior to publishing.