Encouraging Behavior Change

Gaps in Research

1.
Effective programs (as described in this resource) must be expanded to reach many more young people, especially young people who are most neglected such as very young adolescents, out-of-school youth, young people living with HIV, homeless and rural youth.
2.
Greater efforts are needed to help young people personalize HIV risks.
3.
Sex education and condom promotion programs need to take into account the different motivations among young men and women for engaging in unsafe sex.
4.
Clear policies and legislation supporting access to information and services are needed to reduce the risk of HIV transmission among young people.
5.
Interventions are needed to counter gender norms, such as those which value girls’ sexual ignorance and virginity, which place girls at risk for HIV transmission.
6.
Interventions are needed to reduce cross-generational sex and marriage.
7.
Further interventions are needed to help female OVCs reduce risky sexual behaviors and protect them from sexual violence.
8.
Interventions are needed for adolescents to reduce acceptance of gender-based violence and stigma against HIV-positive people.
9.
Policies are needed to provide no-cost education so that students do not have to pay school fees.
10.
Interventions are needed to bring men and women, youth and parents together to focus on the positive aspects of sexuality.
11.
Interventions are needed to guide girls ages 8 to 14 concerning menses and puberty.
12.
Teachers need increased training and clear educational policies regarding sexuality education to effectively provide AIDS education.
13.
Interventions are needed to reduce sexual coercion and rape of both boys and girls, create awareness in communities that violence against children is unacceptable, strengthen child statutory protection systems, and conceptualize and implement appropriate child protection services in developing countries.

1. Effective programs (as described in this resource) must be expanded to reach many more young people, especially young people who are most neglected such as very young adolescents, out-of-school youth, young people living with HIV, homeless and rural youth. [See also Orphans and Vulnerable Children] Studies found adolescent girls did not know that anal sex increased the risk of HIV acquisition, did not use condoms, and did not know that oral sex carries a low risk of HIV acquisition. Out-of school-youth were at high risk of early sexual debut.

Gap noted globally for girls 15 to 19, as the proportion of these girls in school is quite low (Haberland and Rogow, 2007). Gap also noted, for example, in Lao PDR (Sychareun et al., 2011); Pakistan (Farid-ul-Hasnain and Krantz, 2011); Cameroon (Tsala Dimbuene and Kuate Defo, 2011); Jamaica (Ishida et al., 2011); Yemen (Al-Serouri et al., 2010); Zambia (Carnevale et al., 2011); Nepal (Upreti et al., 2009); Nicaragua (Manji et al., 2007); Ethiopia (Alemu et al., 2007; Erulkar et al., 2006); over 30 countries in Africa and four countries in Asia (Dixon-Mueller, 2009).

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2. Greater efforts are needed to help young people personalize HIV risks. Studies found that knowledge about HIV prevention was superficial and that young people believed that they were not personally at risk of HIV acquisition despite risky behaviors and that condoms were not used because of “trust in partners.” Another study found that one adolescent girl reported she did not need to test for HIV as the only people at risk for acquiring HIV were those “who go to beer halls and pubs – prostitutes” (Ferrand et al., 2011).

Gap noted, for example, in Zimbabwe (Ferrand et al., 2011); Uganda (Kayiki and Forste, 2011); Taiwan (Tung et al., 2010); Malaysia (Anwar et al., 2010); South Africa (Tenkorang et al., 2011; Anderson et al., 2007; Stadler et al., 2007); and Burkina Faso, Ghana, Malawi and Uganda (Biddlecom et al., 2007).

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3. Sex education and condom promotion programs need to take into account the different motivations among young men and women for engaging in unsafe sex. Studies found that boys complained about reduced sensation with condoms to cover their fear of losing their erection when putting on a condom; girls believed that unsafe sex proved their love and trust in their partner.

Gap noted, for example, in Thailand (Vuttanont et al., 2006); Brazil (Mane et al., 2001; Juarez and Martin, 2006); South Africa (Moyo et al., 2008); Mozambique (Machel, 2001).

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4. Clear policies and legislation supporting access to information and services are needed to reduce the risk of HIV transmission among young people. Studies found that sex education was lacking.

Gap noted, for example, in Antigua and Barbados, Bahamas, Bolivia, Colombia, Costa Rica, Chile, Dominica, Ecuador, El Salvador, Guyana, Haiti, Honduras, Jamaica, Mexico, NicaraguaPanama, Paraguay, Peru, Venezuela, Dominican Republic, Santa Lucia, Suriname, Trinidad and Tobago and Uruguay (DeMaria et al., 2009); India (McManus and Dhar, 2008).

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5. Interventions are needed to counter gender norms, such as those which value girls’ sexual ignorance and virginity, which place girls at risk for HIV transmission. [See also Transforming Gender Norms] Studies found that gender norms valued sexual ignorance of girls and therefore girls were at risk of HIV acquisition. Some studies found that women did not know anything about HIV until they became HIV-positive.

Gap noted, for example, in 29 countries in Africa and Latin America (Clark et al., 2006); a review of more than 150 studies (Collins and Rau, 2000; Gupta et al., 2003 cited in Gillespie and Kadiyala, 2005); South Africa (Bhana and Pattman, 2011); Zimbabwe (Feldman and Maposhere, 2003); Ethiopia, Malawi and Haiti (Mathur et al., 2003); and Tanzania (Silberschmidt and Rasch, 2001). 

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6. Interventions are needed to reduce cross-generational sex and marriage. Studies found that young women relied on older men to pay their school fees in exchange for sex. Numerous studies found significant numbers of young girls having sexual relationships with older men, who are more likely to be HIV-positive and seek sexual partnerships with younger women. Suggestions include informing girls that older men are more likely to be HIV-positive. Studies also found that due to poverty, parents encouraged transactional sex and that efforts are needed to address parental pressures.

Gap noted, for example, in a review of 45 quantitative and qualitative studies in sub-Saharan Africa (Hope, 2007); Liberia (Atwood et al., 2011); Botswana, Namibia and Swaziland  (Cockcroft et al., 2010); Botswana, Malawi and Mozambique (Underwood et al., 2001); Tanzania (UNICEF et al., 2011a; Silberschmidt and Rasch, 2001); Zimbabwe (Munjoma et al., 2010); Peru (Sandoval et al., 2009); Cameroon (Hattori and DeRose, 2008); Uganda (Nobelius et al., 2011; Samara, 2010); South Africa (Ott et al., 2011; Jewkes et al., 2002 cited in Jejeebhoy and Bott, 2003); South Africa and Uganda (Geary et al., 2008; Katz and Low-Beer, 2008); Burkina Faso, Ghana, Malawi and Uganda (Bankole et al., 2007); Botswana (PHR, 2007a); Kenya (Longfield et al., 2004); Ghana (Goparaju et al., 2003); Zimbabwe (Gregson et al., 2002).

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7. Further interventions are needed to help female OVCs reduce risky sexual behaviors and protect them from sexual violence. Studies found that female orphans had higher rates of early sexual debut and were more likely to have had coerced sex.

Gap noted, for example, in Egypt (Nada and Suliman, 2010); Kenya (Machera, 2009); Rwanda (Boris et al., 2008); South Africa (McGrath et al., 2009; Thurman et al., 2007); South Africa and Swaziland (Poulsen, 2006); Tanzania (UNICEF et al., 2011a); Zimbabwe (Kang et al., 2008; Birdthistle et al., 2008; Nyamukapa et al., 2008; Dunbar et al., 2010).

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8. Interventions are needed for adolescents to reduce acceptance of gender-based violence and stigma against HIV-positive people. A study found high rates of stigma among adolescent girls. A nationally representative survey of youth in Tanzania found high rates of acceptance for a husband to beat his wife if she goes out without telling him; argues with him; burns food; or refuses to have sex with him.

Gap noted, for example, in the Cameroon (Arcand and Wouabe, 2010); Tanzania (UNICEF et al., 2011a); Thailand (Ishikawa et al., 2011a); Bolivia, Chile and Mexico (Lopez Torres et al., 2010).

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9. Policies are needed to provide no-cost education so that students do not have to pay school fees. A study found that when students were responsible for paying their school fees, they were less likely to use condoms or be tested for HIV, in addition to having lower knowledge concerning HIV. [See also Advancing Education]

Gap noted, for example, in Kenya (Maticka-Tyndale, 2010).

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10. Interventions are needed to bring men and women, youth and parents together to focus on the positive aspects of sexuality. Studies found sexual education focuses on disease, burdening girls with prohibitions, yet neglecting boys.

Gap noted, for example, in Kenya (Njoroge et al., 2010).

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11. Interventions are needed to guide girls ages 8 to 14 concerning menses and puberty. Studies found girls as they reach puberty have not had guidance on menses and basic HIV knowledge.

Gap noted, for example, in Sub-Saharan Africa (Sommer, 2011); Tanzania  (Sommer, 2010) and Pakistan (Ali and Rizvi, 2010). 

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12. Teachers need increased training and clear educational policies regarding sexuality education to effectively provide AIDS education. A study found that teachers did not have adequate training and support to provide AIDS education; students preferred health personnel to provide AIDS education and that the Ministry of Education did not have clear policies on what can be taught.

Gap noted, for example, in Kenya (Njue et al., 2009). 

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13. Interventions are needed to reduce sexual coercion and rape of both boys and girls, create awareness in communities that violence against children is unacceptable, strengthen child statutory protection systems, and conceptualize and implement appropriate child protection services in developing countries. A study found that in a large sample of over 1,000 males and over 1,000 females had experienced high rates of physical punishment, emotional abuse and sexual abuse i.e. touching of sexual organs when not wanted or sex due to force or coercion prior to age 18 and that incident HIV infections were more common in women who suffered emotional abuse, sexual abuse and physical punishment. Sexual abuse in men was associated with alcohol abuse and depression. Other studies found high rates of sexual coercion and high-risk behaviors among street children.

Gap noted, for example, in South Africa (Jewkes et al., 2010b); Egypt (Nada and Suliman, 2010); India (Bal et al., 2010); Namibia, Swaziland, Uganda, Zambia and Zimbabwe (Brown et al., 2009b).

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