Mapping Sexuality: Understanding the knowledge, attitudes and perceptions of adolescent females towards sexuality and sexual and reproductive health in KwaZulu-Natal, South Africa Gina Kirsten Coetzee 213570198 Dissertation presented in fulfilment of the Degree of Master of Social Science, at the Centre for Communication, Media and Society, School of Applied Human Sciences, College of Humanities, University of KwaZulu-Natal, Howard College, Durban, South Africa Ethical Approval Number: HSS/0724/016M June 2017 DECLARATION I, Gina Kirsten Coetzee (Student number 213570198), declare that: 1. The research reported in this dissertation, except where otherwise indicated, is my original and unaided work. 2. This dissertation has not been submitted for any degree or examination at any other university. 3. This dissertation does not contain other persons’ data, pictures, graphs or other information, unless specifically acknowledged as being sourced from other persons. a. Their words have been re-written, but the general information attributed to them has been referenced. b. Where their exact words have been used, their writing has been placed inside quotation marks, and referenced. 4. This dissertation does not contain text, graphics or tables copied and pasted from the internet, unless specifically acknowledged, and with the source being detailed in the dissertation and bibliography. Candidate: Gina Coetzee Supervisor: Dr Eliza Govender Signature: ____________________ Date: 20 June 2017 ! "! I dedicate this work to My mother, Rowena Coetzee, for always being on the other side of the phone in the moments when I was ready to give up To my friend, Margie Rogers, for always reminding me I am going to be okay … and for pineapples “When we talk about ‘reproductive rights’ this is what we mean. It’s the difference between people as objects, and people as agents; between regarding people as pawns on the policy chessboard and recognising them as the players, the decision- makers, the drivers of policy; autonomous individuals intimately concerned with the directions of their own lives. Under these conditions women, especially, enjoy better health and live fuller lives.” – Nafis Sadik, Special Adviser to the UN Secretary General “The essence of global health equity is the idea that something so precious as health might be viewed as a right.” – Dr Paul Farmer “Young people everywhere have the right to the knowledge, tools and services they need to make informed decisions about their bodies and live full, healthy and productive lives.” – Jill Sheffield, Founder and President of Women Deliver II ACKNOWLEDGEMENTS I would firstly like to thank the Centre for Communication, Media and Society at the University of KwaZulu-Natal for igniting in me a new and deep passion for research, health communication and social development. The last three years at the department have been integral to the trajectory of my academic career. To Dr Eliza Govender, thank you for your support and guidance through this process. I am grateful for your commitment to me as my supervisor, through all the ups and downs of writing this dissertation. Your work ethic and dedication are an inspiration, and I look forward to continuing to work with you in the future. To Lungelo Khanyile, the person who has made me laugh in the darkest times. The list of things that I am grateful for is unending, Angelo. Thank you for understanding the emotional roller coaster this has been. Thank you for always being the most optimistic person I know, where you always believe ‘tomorrow will be better’! Here’s to one day being ladies who luncheon together, laughing at all the times we Kim K cried during this time. To my mum, dad and brother, thank you for your continued support over the last 25 years. Thank you for always encouraging me to be the best version of myself. The way you celebrate my victories and empathise with me through my struggles is the reason I am where I am today. Thank you. I am waiting for my prize for being the first person to get a master’s degree in the family, by the way! To my friends Tim, Margie, Duncan, Luca, Jael, Miranda and Henry. Thank you for not giving up on me when study stress had the better of me! Each of you has supported me in a way that you probably will never fully comprehend. This has been a long, emotional journey, and all of you have reminded me that I am incredibly lucky to have friends who believe in me, even when I have not believed in myself. To the young ladies at Mayville Secondary School, without you none of this would be possible, and I am deeply grateful. Thank you for welcoming me so warmly, for being excited about my study and for committing time so I can add my piece to the sexual and reproductive health field. The future of our country is hopeful with young women like you! III To Hope2Educate, thank you for your support during the data collection process of this research. Specifically, thank you to Khethiwe and Nqobile for helping me facilitate the bodymapping workshop. Thank you for the work you are doing in helping create a society of young, empowered women. Lastly, to the company who put the billboard up on the highway last year that said, “You can. And you will.” I read that at the exact moment when my self-doubt had exceeded my self-worth. If I had not read that, this dissertation would never have been completed. For anyone who reads this dissertation, in whatever life stage you are in, always remember to believe that you can, and you will. IV ABSTRACT Within sub-Sahara Africa, adolescent girls bear a disproportionate burden of sexual and reproductive health (SRH) risks, where the dual risk of HIV infection and adolescent fertility is faced. Specifically in South Africa, it is estimated that nearly 2 000 adolescent girls and young women between the ages of 15 and 24 years are infected by HIV every week. Furthermore, it was estimated that, by 2016, 15,6% of females between the ages of 15 and 19 years old in South Africa had begun childbearing. It is for these reasons that adolescent girls have been identified as a key population. This study was located at Mayville Secondary School, in the eThekwini district of KwaZulu-Natal (KZN). This area reports high levels of HIV infection, with notably high adolescent fertility rates at this school. This study had three aims: to understand the influences on adolescent female sexuality, to outline the perceptions of SRH self-care among adolescent females, and to understand the perceptions of art- based methodologies in researching sensitive topics. By understanding adolescent sexuality, this study aimed to highlight the influence this had on the self-care capabilities of adolescent females in maintaining their SRH. A culture-centred understanding of Orem’s self-care model guided the study. A participatory action research design was adopted, where data collection was threefold: a bodymapping workshop, group discussion and individual interviews. Key findings highlighted parental relationships and SRH-specific health communication programmes as the most influential in the understanding of sexuality among adolescent females. However, lack of agency in preventing risk, such as rape, and the negative perceptions of health care workers were identified as the main self-care deficits among adolescent females. Furthermore, this study identifies the effectiveness of art-based methodologies in researching and communicating with adolescent females about sexuality. This study highlighted the need for greater understanding of the socio-cultural perceptions of health care workers’ understanding of adolescent sexuality, and the provision of SRH services. This study emphasises the need to reduce significant socio-cultural barriers to SRH, in order to ensure adolescent females have the ability to be effective self-care agents in maintaining good SRH. V ACRONYMS AND ABBREVIATIONS AGYW Adolescent Girls and Young Women AIDS Acquired Immunodeficiency Syndrome ANC African National Congress ARV Antiretroviral Therapy AYFS Adolescent and Youth Friendly Services CCA Culture-Centred Approach DOE Department of Education DOH Department of Health HIV Human Immunodeficiency Virus IUD Intrauterine Device KZN KwaZulu-Natal NAFCI National Adolescent Friendly Clinic Initiative NPO Non-Profit Organisation PAR Participatory Action Research PHC Primary Health Care RSA Republic of South Africa SABC South African Broadcasting Corporation SANAC South African National Aids Council SRH Sexual and Reproductive Health STI Sexually Transmitted Infection UKZN University of KwaZulu-Natal UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund WHO World Health Organization YFS Youth Friendly Services VI LIST OF TABLES Table 2.1 Table illustrating the various modern contraceptive methods available at public health facilities (South Africa) 32 Table 3.1 Relationship of the three theories in Orem’s general theory of nursing 64 Table 3.2 Influences on self-care in relation to the requirements for effective living 68 Table 3.3 Nurse and patient roles in nursing situations as specified by methods of helping 71 Table 4.1 Phases of thematic analysis 95 VII LIST OF FIGURES Figure 1.1 Diagram representing the transmission network of HIV between HIV-positive men and adolescent girls and young women 2 Figure 1.2 Google Earth image showing location of Mayville Secondary School 9 Figure 3.1 The culture-centred approach to health communication 55 Figure 3.2 The role of identities in nurse-adolescent relationship negotiation 58 Figure 3.4 Representation of demand versus ability in self-care 70 Figure 3.5 Basic nursing systems 76 Figure 3.6 Culture-centred self-care model 79 Figure 4.1 Participatory action research 86 Figure 4.2 Icebreaker played with the participants before the bodymapping workshop 90 Figure 4.3 Bodymapping workshop conducted at Mayville Secondary School 91 Figure 4.4 Debriefing discussion conducted after the bodymapping workshop 92 Figure 5.1 Culture-centred self-care model 124 VIII