Browsing by Author "Duby, Zoe"

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    A qualitative exploration of high school dropout and retention among adolescent girls and young women (AGYW) in South Africa
    (2025) Kleinhans, Crystal; Knight, Lucia; Duby, Zoe
    In South Africa high school attrition and disengagement rates have been problematic for the past decade with adolescent girls and young women (AGYW) more likely to dropout of school than their male counterparts, especially those AGYW from socio-economically disadvantaged communities. Increased levels of education, a social determinant of health, strongly correlates with better health outcomes for youth. The disengagement and dropout of AGYW in high school is a public health concern. AGYW are at a greater risk of HIV infection and other sexually transmitted infection (STI) due to biological, cultural, religious, socio-economic and structural factors, and efforts to increase their retention and completion of high school, a protective factor, will increase the likelihood of better health outcomes in this population group. This study was a qualitative analysis of AGYW and stakeholders across five provinces from urban, semi-urban and rural districts. The transcripts were thematically analysed to explore the perceptions of and attitudes to high school completion and dropout and the factors which may contribute to either. Findings revealed that AGYW valued their high school education and associated it with future success and independence but several context specific factors on the individual, interpersonal and institutional levels influenced their retention and likelihood of dropping out of high school. An understanding of the multiple factors which influence high school dropout and retention, as indicated on the different levels of the socio-ecological model, may inform more target specific interventions to increase the retention and completion of high school of AGYW in South Africa.
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    Adolescent girls and young womens' perspectives of how their lives were impacted by participating in a combination HIV-prevention intervention in South Africa: a qualitative study
    (2020) Verwoerd, Wilmé; Duby, Zoe; Swartz, Alison
    Background: HIV incidence among adolescent girls and young women (AGYW) aged 15-24 in sub-Saharan Africa remains exceptionally high. Evidence shows that no single HIV prevention strategy will be effective in controlling the HIV pandemic. Research in recent years demonstrates the need for combination HIV prevention efforts, including biomedical, behavioral, and structural interventions. Given the urgent need to identify strategies that effectively reduce HIV risk among AGYW, it is crucial to understand how best to maximize the impact of combination HIV prevention interventions. This qualitative study explored the perceived impacts of a combination HIV-prevention intervention on the lives of AGYW in South Africa. Methods: The study is based on the findings from a qualitative evaluation of the RISE Club Programme, one component of a combination HIV intervention for AGYW. Using 24 focus group discussions and 63 in-depth interviews with 237 AGYW, we explored participants' experiences and perceptions of participating in a combination HIV prevention intervention and how it was perceived to impact their lives. Results: From the perspectives of AGYW, the intervention was perceived to positively impact their ability to communicate and develop and maintain healthy relationships with family, peers and partners. The findings show that the intervention helped increase their sexual and reproductive health (SRH) knowledge which improved their sexual self efficacy while also encouraging positive behavioural choices such as contraceptive uptake. It was also perceived to improve AGYW lives and personal development, specifically their self confidence and self esteem. However, logistical challenges with the implementation of the intervention and unmet expectations, created frustration and negative perceptions of the intervention in some instances. Conclusions: Overall, the findings demonstrate that intervention recipients perceived mostly positive impacts on their lives as a result of participating in the RISE programme. Understanding the perspectives of AGYW, is helpful in order to assess the benefits and perceived impacts of such an intervention on the lived realities of intended beneficiaries. Taking these perspectives into consideration and understanding some of the unforeseen negative impacts of the intervention can help to inform the design and implementation of future combination HIV prevention interventions for a similar sub-group of the population.
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    An exploration of the determinants of sexual risk behaviour among adolescent girls and young women aged 15-24 years in South Africa: a sub-study of the 2019-2022 HERStory2 study
    (2024) Chamuka, Paidashe; Knight, Lucia; Duby, Zoe
    Objective: The study aims to understand why South African adolescent girls and young women (AGYW) engage in sexual risk behaviours, such as unsafe sex and transactional and inter-generational sexual relationships. These behaviours lead to adverse sexual and reproductive health (SRH) outcomes, including HIV, STIs, unplanned pregnancies, and forced sex. By exploring the perspectives of AGYW and community stakeholders, the study seeks to enhance future interventions aimed at reducing the risk of STIs, including HIV, and unintended pregnancies among AGYW. Methods The study is based on the qualitative component of the HERStory2 study, a mixed-methods evaluation of an SRH intervention for AGYW in six South African districts. Data from in-depth interviews with twenty-seven participants were thematically analysed using the social-ecological model as a theoretical framework. Results The findings showed that the reasons for AGYW's engagement in sexual risk behaviour are nested within individual, interpersonal, community, and structural levels. At the individual level, participants reported that AGYW may engage in sexual risk behaviours due to their age, low perception of risk, problematic alcohol consumption, and the need for high grades at school. At the interpersonal level, social media-induced peer pressure was cited as a reason for AGYW's engagement in sexual risk behaviours. Community-level factors included lack of safety and economic activities such as mining. At the structural level, poverty, negative attitudes from public healthcare providers at clinics, and social and gender norms were perceived to influence AGYW's sexual risk behavior. Conclusion The results suggest that AGYW's sexual risk behaviour is influenced by many complex factors beyond the individual. The results call for targeted holistic interventions to reduce sexual risk behaviour and improve the SRH outcomes for AGYW in this high HIV burden context.
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    Factors influencing adolescent girls and young women’s participation in a combination HIV prevention intervention in South Africa
    (2021-02-27) McClinton Appollis, Tracy; Duby, Zoe; Jonas, Kim; Dietrich, Janan; Maruping, Kealeboga; Abdullah, Fareed; Slingers, Nevilene; Mathews, Catherine
    Background For interventions to reach those they are intended for, an understanding of the factors that influence their participation, as well as the facilitators and barriers of participation are needed. This study explores factors associated with participation in a combination HIV prevention intervention targeting adolescent girls and young women (AGYW) aged 15–24-years-old, as well as the perspectives of AGYW, intervention implementers, and facilitators who participated in this intervention. Methods This study used mixed-methods approach with quantitative household survey data from 4399 AGYW aged 15–24-years-old in six of the ten districts in which the intervention was implemented. In addition, qualitative methods included a total of 100 semi-structured in-depth interviews and 21 focus group discussions in five of the ten intervention districts with 185 AGYW who participated in one or more of the key components of the intervention, and 13 intervention implementers and 13 facilitators. Thematic analysis was used to explore the perspectives of participating and implementing the intervention. Results Findings reveal that almost half of AGYW (48.4%) living in the districts where the intervention took place, participated in at least one of the components of the intervention. For both 15–19-year-olds and 20–24-year-olds, factors associated with increased participation in the intervention included being HIV negative, in school, never been pregnant, and having had a boyfriend. Experiencing intimate partner violence (IPV) and/or sexual violence in the past 12 months was associated with increased levels of participation in the intervention for 20–24-year-olds only. In our analysis of the qualitative data, facilitators to participation included motivating participants to join the interventions through explaining the benefits of the programme. Barriers included misguided expectations about financial rewards or job opportunities; competing responsibilities, interests or activities; family responsibilities including childcare; inappropriate incentives; inability to disrupt the school curriculum and difficulties with conducting interventions after school hours due to safety concerns; miscommunication about meetings; as well as struggles to reach out-of-school AGYW. Conclusion Designers of combination HIV prevention interventions need to address the barriers to participation so that AGYW can attend without risking their safety and compromising their family, childcare and schooling responsibilities. Strategies to create demand need to include clear communication about the nature and potential benefits of such interventions, and the inclusion of valued incentives.
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    Heterosexual anal sex in the age of HIV : an exploratory study of a silenced subject
    (2008) Duby, Zoe; Ju
    This dissertation serves as a discursive exploration into the underdiscussed topic of heterosexual anal sex and pervading penile-vaginal heteronormativity. To understand the origins and character of the seemingly universal ambivalence towards heterosexual anal intercourse I attempt to situate it historically. There is general ignorance concerning the prevalence of this sexual behaviour, but there exist deep-seated taboos and undertones of immorality and abnormality associated with it. All these factors play a part in individual sexual decision making; an attempt is made at exploring the motivations and personal choices that culminate in an act of heterosexual anal intercourse.
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    Heterosexual penile/anal intercourse and HIV in five sub-Saharan African countries
    (2015) Duby, Zoe; Colvin, Christopher J
    The HIV epidemic in sub-Saharan Africa is understood to be primarily 'sexually transmitted'. The majority of HIV prevention efforts in the region have focused on 'heterosexual sex' as the key transmission vector, without defining what 'heterosexual sex' refers to. Penile-anal intercourse (PAI) has the highest per act risk of HIV acquisition sexually and potentially accounts for a large proportion of HIV infection. Inclusion of PAI in HIV programming has typically only been in reference to men who have sex with men. Despite evidence suggesting that heterosexual PAI is common practice in sub-Saharan Africa, and is likely to be a significant contributor to HIV transmission, it has been largely excluded from HIV interventions. Greater understanding of sexual decision-making and risk-taking related to heterosexual PAI would enable evidence-based HIV intervention. This thesis presents data on conceptualisations and perceptions of heterosexual PAI and associated practices in sub-Saharan Africa, language and discourse pertaining to PAI, as well as challenges in conducting research on it. Qualitative data were gathered in five sub-Saharan African countries between 2010 and 2014. These findings demonstrate that heterosexual PAI is practiced in sub-Saharan Africa for a variety of reasons, some of which have implications for HIV transmission. Many of the factors that influence sexual decision-making and risk-taking related to heterosexual PAI are specific to this sexual behaviour. In addition, the relationship contexts in which heterosexual PAI takes place, gendered power dynamics, sexual agency and 'sexual scripts' framing PAI behaviour, are distinct from those for penile/vaginal intercourse. HIV transmission risks associated with PAI are exacerbated by taboos, social stigmatisation and sexual communication norms, impeding effective communication and safe sex negotiation, limiting individuals' ability to make informed decisions, and impacting on the reporting of PAI in research and clinical settings. Drawing on socio-behavioural theories to guide the data analysis, I developed theoretical models to explain and understand heterosexual PAI practice. The findings presented in this thesis make a unique contribution to the field, being the first in-depth description and analysis of heterosexual PAI behaviour and related practices in sub-Saharan Africa. This research highlights the importance of paying careful attention to the role of heterosexual PAI in HIV transmission in Africa.
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    Negotiating access and buy-in from communities in the context of a South African combination HIV prevention intervention for adolescent girls and young women
    (2020) Armien, Rizqa; Duby, Zoe; Colvin, Christopher
    Background: In response to the persistently high incidence of HIV in adolescent girls and young women in South Africa, the Global Fund invested in a combination HIV prevention intervention aimed at adolescent girls and young women in 10 high priority districts. The HERStory study evaluated the combination HIV prevention intervention after two years of implementation. Using the findings of the HERStory evaluation, this study aims to contribute towards the literature related to understanding factors related to successfully accessing communities and gaining community buy-in or support for community based interventions. The HERStory study explored the identification of the gaps and challenges in the intervention components and the intervention implementation to be able to revise and improve the intervention and its implementation. Methods: In-depth interviews and focus group discussions with community leaders, program implementers and intervention facilitators were conducted. The data consisted of 32 transcripts; a subset of the qualitative data collected for the HERStory evaluation. The analysis for this study sought to better understand the barriers and facilitators of community access and the importance of community buy-in using the HERStory evaluation. Thematic analysis of the data was conducted, supported by Nvivo 12 qualitative data analysis software. Results: The main themes of this secondary analysis were 1) the complexity of negotiating access to communities through key stakeholders, 2) challenges to gaining buy-in, and 3) facilitators and barriers to community based intervention implementation. There were clear facilitators to community access and intervention buy-in such as creating clear communication lines between stakeholders and scheduling regular meetings. Delayed or rushed community engagement resulted in misunderstandings and was identified as barriers to community access and intervention buy-in. Conclusion: Quality community engagement was essential in the facilitation of access and intervention buy-in to promote successful intervention implementation. Recommendations for future interventions include planning enough time for community engagement throughout the intervention including the design phase and establishing clear and effective communication channels between intervention implementers and community stakeholders.
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    What are we missing? a qualitative exploration of sexual agency and the related behaviours of AGYW in two HIV interventions in South Africa.
    (2025) Fowler, Chantal; Swartz, Alison; Duby, Zoe
    In Sub-Saharan Africa, Adolescent Girls and Young Women (AGYW) aged 15-24 years bear a significant HIV prevalence rate of 20.6%. Additionally, AGYW experience a disproportionate burden, being 3.3 times more likely to contract HIV compared to their male counterparts. This group has remained a key focus for global HIV interventions, yet high incidence has been sustained. While several contributing social, behavioural, and structural factors have been identified, research suggests that interventions may not sufficiently address complexities located within the lived experiences of intervention beneficiaries. Some of these less explored areas within lived experience of sexual agency and subsequent behaviour choices may be contributing to the sustained incidence but may be less understood due to a lack of research that adopts a lens prioritising this focus. The legacy of colonial history in the study of sexuality in Africa may also be contributing to this sustained incidence. This research adopted a qualitative approach to explore experiences of AGYW navigating sexual decision-making and who meet the criteria for being recipients of two large-scale HIV reduction interventions — one of which is one of the largest HIV interventions for AGYW in the world. Methods: I used Critical Discourse Analysis (CDA) to conduct a document review of programmatic documents of the two interventions outlining specific details of the background of the programme, its programme design, implementation, service delivery and monitoring and evaluation. Further to this, I used thematic analysis to analyse twenty nine interviews with AGYW, teachers, and implementers who lived and worked in intervention sites across South Africa, and who met the criteria for intervention (n=29). These interviews were comprised of a combination of primary and secondary data. I worked in the process evaluations of two large HIV interventions and used transcripts that were generated during this work as secondary data, as they provided data that was relevant to my PhD questions. I also conducted interviews with participants whom I sourced from my work with these evaluations which comprised my primary data set. Results: The document review revealed that the two interventions frame AGYW as lacking in knowledge and unable to enact agency. Further to this, they are described as being too concerned with daily priorities which compete with Sexual and Reproductive Health (SRH) priorities. These ‘misplaced' priorities are what is problematised in the narrative, with the burden for change being placed on AGYW to shift them. Interviews with AGYW and community members revealed that advice from parents, teachers and interventions about sex is experienced largely as warnings about the dangers of sex and chastisement to “stay away from boys”; messages grounded in the sex- negative paradigm. As a result, AGYW express feelings of shame and fear of judgement if they are seen to be sexually active and subsequently attempt to hide their sexual activity. AGYWs' agency in sexual decision-making is diminished as they are afraid of shaming and judgement from adult caregivers should they try to enact sexual agency by accessing HIV prevention services for example. AGYW reported personal experiences of sex to be positive, resulting in peers encouraging each other to have sex and to ignore the warnings of adults, leaving AGYW confused and ambivalent as to which messages to believe and act on. I assert that as researchers, we need to better understand the experience of AGYW trying to adopt more sex positive attitudes in a context so heavily shrouded in sex negative paradigms. I offer suggestions around the need to create social structural conditions that can facilitate and support AGYW in their development of sexual agency. I conclude that currently, intent is not strong enough to shift toward a more decolonised approach to sexual empowerment of AGYW due to colonial legacies that persist in public health discourse and rhetoric around SRH.