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Invited Commentary
Public Health
August 17, 2018

Primary Prevention of Perpetration and Experience of Forced Sex for South African Youth Requires Careful Attention to Risk in Context

Author Affiliations
  • 1Department of Community and Behavioral Health, University of Colorado School of Public Health, Aurora
  • 2Center for Innovative Public Health Research, San Clemente, California
JAMA Netw Open. 2018;1(4):e181222. doi:10.1001/jamanetworkopen.2018.1222

In the study by Jemmott and colleagues,1 we learn about the impact of Let Us Protect Our Future, an HIV risk-reduction program on youths’ risk for perpetrating forced sex. This is a secondary data analysis of data from a cluster randomized trial. The curriculum was grounded in social science theory and included 12 modules that were delivered in weekly 2-hour sessions for 6 weeks among grade 6 students in South Africa. Each of the 5 follow-up assessment periods, ranging from 3 months to 54 months postintervention, showed a significant reduction in the likelihood of perpetrating forced sex for youths who attended intervention sites vs control sites.

This study is particularly important because HIV prevention and healthy sexuality programs frequently include content that addresses healthy relationships and also dating violence.2,3 This inclusion is a reflection of the voluminous literature documenting the reduced odds of consistent condom use in relationships where dating violence is present.4,5 The study by Jemmott and colleagues1 is one of the first analyses to document the potential downstream impact that HIV prevention programs that include healthy relationship programming may have, not just on invigorating condom use, but also on reducing forced sex. It also speaks to the importance of conducting secondary analyses to explore unanticipated outcomes that HIV prevention and healthy sexuality programs may be affecting. Certainly, it is important to have a preidentified analytical plan; but it is important, too, that we allow latitude in our analytical strategy to identify these perhaps unexpected secondary benefits of our interventions.

In the South African setting, where HIV is the second leading cause of death for persons aged 15 to 44 years,6 a focus on HIV prevention remains paramount. Given that Let Us Protect Our Future was able to affect multiple outcomes, we should consider moving away from vertical, single-focus curricula and move toward more horizontal educational efforts that are focused on positive youth development. Such interventions promote bonding; resilience; social, emotional, cognitive, behavioral, and moral competence; self-determination; spirituality; self-efficacy; positive identity; and belief in the future and rewards positive, prosocial behavior and norms. In the United States, several decades of research on interventions that are intended to have an impact on multiple outcomes using a youth development framework has yielded impressive effects on substance use, conduct disorders, delinquent behavior, academic failure, teenage pregnancy, and sexually transmitted infections.7 Indeed, impacts that influence socioeconomic factors such as continued education have also been detected.7 Particularly for primary prevention, this has emerged as an efficient strategy for simultaneously preventing numerous negative outcomes before they manifest. Positive youth development has been applied in the South African setting as well.8 In environments with pressing epidemiologic priorities, such as environments where HIV is rampant, youth development programs could be either implemented alongside or integrated into programs focused on singular behaviors.

Jemmot and colleagues1 demonstrated evidence that Let Us Protect Our Future may have reduced sexual violence perpetration more for males than females. This is particularly significant given that males are more likely than females to report perpetration of forced sex: as noted by the authors, as many as 5% of girls and 20% of boys in sub-Saharan Africa have admitted to perpetrating forced sex.5 This highlights the importance of developing content that combats cultural norms that are more accepting of sexual violence, as well as the need to tailor messaging for boys and girls so that the information is salient and perceived as personally relevant for each sex.

The magnitude of the overall effect was small, with a 3% reduction in risk; however, it should be acknowledged that this difference is noted at 54 months, more than 4 years after the intervention was implemented. Persistent results of any magnitude are rarely detectable this far after the intervention has been completed; that the authors found a significant impact is laudable. That said, future sexual health studies might consider opportunities to increase the effect by strengthening their healthy relationships content or delivering boosters and ongoing programming throughout adolescence.

Certainly, the definition of sexual violence is broader than forced sex and includes experiences such as sexual coercion, attempted rape, sexual harassment, and even behaviors such as “flashing.”9 When a broader perspective is taken, it is perhaps not surprising that more youths are involved. Indeed, in our own work, we found that more the 50% of youths participating in a cross-sectional survey in Mbarara, Uganda, had experiences with sexual coercion.10 In future work, it may be useful to examine intervention impacts on this wider range of experiences to detect potentially larger effect sizes.

Jemmot et al1 have done important work in South Africa in exploring the extent to which an HIV prevention curriculum that includes healthy relationship programming may also affect reductions in forced sex perpetration. We suggest this promising work be mirrored by increased surveillance on forced sex in population-based surveys. We also urge others who include healthy relationships and other sociocultural factors in their HIV prevention and healthy sexuality programming to examine whether their interventions are having secondary effects on these sociocultural factors to contribute to our understanding of how these types of multilayered programs are affecting the health and behavior of the target populations.

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Article Information

Published: August 17, 2018. doi:10.1001/jamanetworkopen.2018.1222

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2018 Bull SS et al. JAMA Network Open.

Corresponding Author: Sheana Salyers Bull, PhD, MPH, Department of Community and Behavioral Health, University of Colorado School of Public Health, 13001 E 17th Pl, CU Anschutz, Ste B119, Aurora, CO 80045 (sheana.bull@ucdenver.edu).

Conflict of Interest Disclosures: None reported.

References
1.
Jemmott  JB  III, Jemmott  LS, O’Leary  A,  et al.  Effect of a behavioral intervention on perpetrating and experiencing forced sex among South African adolescents: a secondary analysis of a cluster randomized trial.  JAMA Open Netw. 2018;1(4):e181213. doi:10.1001/jamanetworkopen.2018.1213Google ScholarCrossref
2.
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Ybarra  ML, Bull  SS, Prescott  TL, Korchmaros  JD, Bangsberg  DR, Kiwanuka  JP.  Adolescent abstinence and unprotected sex in CyberSenga, an internet-based HIV prevention program: randomized clinical trial of efficacy.  PLoS One. 2013;8(8):e70083. doi:10.1371/journal.pone.0070083PubMedGoogle ScholarCrossref
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Andersson  N, Paredes-Solís  S, Milne  D,  et al.  Prevalence and risk factors for forced or coerced sex among school-going youth: national cross-sectional studies in 10 southern African countries in 2003 and 2007.  BMJ Open. 2012;2(2):e000754. doi:10.1136/bmjopen-2011-000754PubMedGoogle ScholarCrossref
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Statistics South Africa.  Mortality and Causes of Death in South Africa, 2015: Findings From Death Notification. Pretoria, South Africa: Statistics South Africa; 2015.
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Schwartz  KD, Theron  LC, Scales  PC.  Seeking and finding positive youth development among Zulu youth in South African townships.  Child Dev. 2017;88(4):1079-1086. doi:10.1111/cdev.12869PubMedGoogle ScholarCrossref
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Basile  C, Saltzman  L.  Sexual Violence Surveillance: Uniform Definitions and Recommended Data Elements. Atlanta, GA: Centers for Disease Control and Prevention; 2002.
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Ybarra  ML, Bull  SS, Kiwanuka  J, Bangsberg  DR, Korchmaros  J.  Prevalence rates of sexual coercion victimization and perpetration among Uganda adolescents.  AIDS Care. 2012;24(11):1392-1400. doi:10.1080/09540121.2011.648604PubMedGoogle ScholarCrossref
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