Misheck Ndebele. Johannesburg

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APPLICATION OF THE INFORMATION, MOTIVATION AND BEHAVIOURAL SKILLS (IMB) MODEL FOR TARGETING HIV-RISK BEHAVIOUR AMONG ADOLESCENT LEARNERS IN SOUTH AFRICA Misheck Ndebele A thesis submitted to the Faculty of Humanities, University of the Witwatersrand, Johannesburg, in fulfilment of the requirements for the degree of Doctor of Philosophy Johannesburg April 2012

Copyright Notice The copyright of this thesis vests in the University of the Witwatersrand, Johannesburg, South Africa, in accordance with University s Intellectual Property Policy. No portion of the text may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, including analogue and digital media, without prior written permission from the University. Extracts of or quotations from this thesis may, however, be made in terms of Sections 12 and 13 of the South African Copyright Act No. 98 of 1978 (as amended), for non-commercial or educational purposes. Full acknowledgement must be made to the author and the University. An electronic version of this thesis is available on the Library webpage (www.wits.ac.za/library) under Research Resources. For permission requests, please contact the University Legal Office or the University Research Office (www.wits.ac.za). (i)

ABSTRACT The main aim of this study was to apply the Information, Motivation and Behavioural Skills (IMB) model in a school-based programme for the reduction of HIV-risk behaviour among adolescents in South Africa. The study also aimed at evaluating the effectiveness of the model in improving levels of information, motivation to act upon the information, and imparting behavioural skills aimed at reducing HIV-risk behaviour in high school adolescent learners. Prior to the main study, a preliminary study was conducted to identify existing and prior intervention initiatives targeting HIV-risk behaviour within the schools in Alexandra township, Johannesburg. This was a qualitative study in which participating learners from two secondary schools reported on the HIV and AIDS education they were exposed to prior to the main study and intervention. The study sample consisted of 259 Grade 11 learners of which 123 were from School 1 (ES) and 136 from School 2 (CS). The findings from the preliminary study indicate that, while much HIV/AIDS education was done through the LoveLife campaigns, important gaps still existed in the levels of HIV/AIDS information, motivation and behavioural skills among the learners in the participating schools. The main study was quantitative in nature, and involved the same sample as the preliminary study. Data was collected with the use of a questionnaire adapted from the Teen Health Survey instrument. School 1 (ES) was the Experimental group, while School 2 (CS) was the Control group. A baseline assessment (Time 1) was conducted at both schools. (iii)

This assessment was followed by a 3-week HIV/AIDS intervention programme at School 1 (ES) which focused on HIV/AIDS information, motivation and behavioural skills. A post-test (Time 2) was carried out at both schools. The intervention at School 1 (ES) was then repeated at School 2 (CS). This was followed by another post-test (Time 3) at both schools. A final test (Time 4) was done at both schools. This was followed by another post-test (Time 3) at both schools. A final test (Time 4) was done at both schools. Data was analyzed using repeated measures ANOVA including univariate ANOVA and paired t-tests. The results show significant increases in information across time for both schools. However, while there was clear change, it was not directly linked to the intervention. Overall estimates for all three variables, for instance, indicate that the mean scores at School 2 (CS) rose at Time 2, despite the absence of the intervention between Times 1 and 2 at that school. The fluctuating pattern of mean scores further attests to the deviation of the mean scores from the hypothesized pattern. In some of these fluctuations, the results showed the same trend for both groups, irrespective of the difference in the timing of the intervention. It is recommended, among other things, that when applied in the South African context, the IMB model should be used along with other HIV/AIDS prevention strategies to incorporate the social, cultural, economic and other structural challenges faced by learners. (iv)

DECLARATION I declare that this thesis is my own unaided work. It is submitted for the degree of Doctor of Philosophy at the University of the Witwatersrand, Johannesburg. It has not been submitted before for any other degree or examination at any other university.... Misheck Ndebele 30 th day of April 2012 (v)

ACKNOWLEDGEMENTS I wish to express my indebtedness to the people who helped me carry out this study. My heartfelt gratitude first goes to Dr Mambwe Kasese-Hara, my supervisor, who, through her genuine and personal interest in my success, gave me all the professional advice and expert guidance throughout this study. My sincere thanks goes to Michael Greyling, who, through his statistical background, rendered excellent support when I was analysing my data. wish to thank Noleen Pillay, who, despite her busy commitments, spared moments to assist me in the statistical part of my study. I also I wish to also sincerely thank Professor Ruksana Osman, Head of Wits School of Education, for her determination and commitment in ensuring that all obstacles were removed in my study towards a PhD. Her genuine interest and continuous support in my effort to get this qualification was second to none. (vi)

I am also indebted to the Transformation Office at the University of the Witwatersrand which, through its Carnegie Grant, made it possible for me to take Time-off, for a certain period of time during my study. The influence of Hugo Canham (in that office) is much appreciated. My sincerest thanks go to the principals, Life Orientation educators and learners at Kwa-Bhekilanga and East Bank High schools in Alexandra township, Johannesburg, South Africa. Their co-operation and participation in this study is particularly noted and highly appreciated. I am particularly grateful to my wife, Jacqueline, whose love and patience towards me, made her to contend with my continuous absence from home, sometimes being away in my office till the late hours of the night, working on my thesis. Her sweet voice, How far did you go today?, when I came home each day, will forever ring in my ears when I think of her support for my study. Last, but not least, my thanks also go to my children, Prince, Nontokozo, Thembisile and Zibusiso, for their continual social and emotional support for my study. Their often-expressed desire for a daddy with a PhD qualification, kept them asking, When are you finishing? Their question motivated me to carry on with even greater zeal and determination. (vii)

TABLE OF CONTENTS Page Copyright Notice... i Title Page... ii Abstract... iii Declaration... v Acknowledgements... vi Table of Contents... viii List of Figures... xiii List of Tables... xiv CHAPTER ONE - INTRODUCTION 1.1 Background... 1 1.2 Statement of the Problem... 3 1.3 Statement of Research Questions... 7 1.4 Aims of the Study... 8 1.5 Value of the Study... 9 1.6 Hypothesis... 10 1.7 Structure of the thesis... 10 CHAPTER TWO - ADOLESCENCE AND HIV/AIDS 2.1 Introduction... 12 2.2 Adolescence, Physical Development and Sexuality... 12 2.3 Adolescence and Cognitive Development... 17 2.4 Adolescent Risky Behaviour... 19 2.5 Vulnerability of Adolescents to HIV Infection... 21 2.5.1 Proximal Predictors... 21 2.5.2 Intermediate Predictors... 25 2.5.3 Distal Predictors... 26 2.6 Conclusion... 28 (viii)

CHAPTER THREE - SOCIAL COGNITION IN ADOLESCENTS 3.1 Introduction... 29 3.2 David Elkind s Social Cognition Theory... 29 3.2.1 The Imaginary Audience... 30 3.2.2 Personal Fable... 31 3.3 Bronfenbrenner s Ecology System... 32 3.4 Super and Harkness Developmental Niche... 33 3.5 Conclusion... 34 CHAPTER FOUR THEORIES OF BEHAVIOURAL CHANGE 4.1 Introduction... 35 4.2 Theory of Planned Behaviour... 35 4.3 AIDS Risk Reduction Model... 37 4.4 Information, Motivation and Behavioural Skills (IMB) Model... 39 4.5 Empowerment of Adolescents through the IMB Model... 41 4.5.1 Empowerment through HIV/AIDS Information... 42 4.5.2 Empowerment through Motivation... 42 4.5.3 Empowerment through Behavioural Skills... 43 4.6 Conclusion... 44 CHAPTER FIVE - METHODOLOGY AND DESIGN 5.1 Introduction... 45 5.2 Preliminary Study... 45 5.3 Main Study... 46 5.3.1 Research Design... 46 5.3.2 Setting... 46 5.3.3 Research Sample and Sampling Procedure... 50 5.3.4 Data Collection... 50 Pretest (Schools 1 and 2) Baseline Assessment... 53 Intervention: School 1 (ES) and School 2 (CS)... 53 5.4 Outcome Measures... 55 5.4.1 Measures of HIV Information... 56 5.4.2 Measures of Motivation... 56 5.4.3 Measures of Behavioural Skills... 58 (ix)

5.5 Method of Data Collection... 59 5.5.1 Biographical Information of Participating Grade 11 Learners... 59 5.5.2 Research Instrument: The Teen Health Survey... 59 5.5.3 Data Analysis... 59 5.5.4 Standardization, Reliability and Validity... 60 5.6 Procedures... 61 5.7 Ethical Considerations... 62 5.8 Conclusion... 63 CHAPTER SIX - RESULTS: PRELIMINARY STUDY 6.1 Overview... 64 6.2 Results on Preliminary Study... 64 6.3 Further Data Collection: lovelife Programme... 74 6.3.1 Interview with the lovelife Regional Trainer (Summary of lovelife Initiatives)... 74 6.3.2 lovelife on HIV/AIDS Information, Motivation and Behavioural Skills... 77 6.4 Discussion... 80 6.5 Conclusion... 82 CHAPTER SEVEN - RESULTS: MAIN STUDY 7.1 Overview... 84 7.2 Biographical Information... 84 7.2.1 Gender... 87 7.2.2 Age... 87 7.2.3 Language... 88 7.2.4 Who Learners Live With... 89 7.2.5 Parental Education... 90 7.2.6 Household Income... 91 7.3 Hypothesis... 92 7.4 Repeated Measures ANOVA and Mean Estimates: HIV/AIDS Information... 94 7.4.1 Multivariate tests: HIV/AIDS Information... 95 7.4.2 Test of Assumptions: HIV/AIDS Information... 96 7.4.3 Univariate tests: HIV/AIDS Information... 97 7.4.4 Paired t-tests of Mean Estimates: HIV/AIDS Information... 101 7.5 Findings on HIV/AIDS information... 111 7.5.1 Introduction... 111 7.5.2 Pre-intervention levels of HIV/AIDS information: School 1 (ES)... 113 7.5.3 Pre-intervention levels of HIV/AIDS information: School 2 (CS)... 115 7.5.4 Post-intervention increases in HIV/AIDS information: School 1 (ES)... 117 7.5.5 Post-intervention increases in HIV/AIDS information: School 2 (CS)... 119 7.5.6 Information: Mean Estimates and T-test Results... 121 7.5.7 Summary... 124 (x)

7.6 Repeated Measures ANOVA and Mean Estimates and t-test Results: Motivation... 127 7.6.1 Multivariate Tests: Motivation (Attitudes) to Perform HIV Preventive Behaviours.. 127 7.6.2 Test of Assumptions: Motivation (Attitudes) to Perform HIV Preventive Behaviours... 128 7.6.3 Univariate tests: Motivation (Attitudes) to Perform HIV Preventive Behaviours... 129 7.6.4 Paired t-tests of Mean Estimates: Motivation (Attitudes) to Perform HIV Preventive Behaviours... 131 7.7 Repeated Measures ANOVA and Mean Estimates: Motivation (Subjective Norms) to Perform HIV Preventive Acts... 151 7.7.1 Multivariate tests: Motivation (Subjective Norms) to Perform HIV Preventive Acts... 151 7.7.2 Tests of Assumptions: Motivation (Subjective Norms) to Perform HIV Preventive Acts... 152 7.7.3 Univariate tests: Motivation (Subjective Norms) to Perform HIV Preventive Acts... 153 7.7.4 Paired t-tests of Mean Estimates: Motivation (Subjective Norms) to Perform HIV Preventive Acts... 156 7.8 Repeated Measures ANOVA and Mean Estimates: Motivation (Behavioural Intentions)... 162 7.8.1 Multivariate tests: Motivation (Behavioural Intentions) to Perform HIV Preventive Behaviours... 162 7.8.2 Test of Assumptions: Motivation (Behavioural Intentions) to Perform HIV Preventive Behaviours... 163 7.8.3 Univariate tests: Motivation (Behavioural Intentions) to Perform HIV Preventive Behaviours... 164 7.8.4 Paired t-tests of Mean Estimates: Motivation (Behavioural Intentions) to Perform HIV Preventive Behaviours... 166 7.9 Repeated Measures ANOVA and Mean Estimates: Motivation (Vulnerability to HIV Infection)... 181 7.9.1 Multivariate tests: Vulnerability to HIV Infection... 181 7.9.2 Test of Assumptions: Vulnerability to HIV Infection... 182 7.9.3 Univariate tests: Vulnerability to HIV Infection... 183 7.9.4 Paired t-tests of Mean Estimates: Vulnerability to HIV Infection... 184 7.9.5 Summary.... 187 7.10 Repeated Measures ANOVA and Mean Estimates: Behavioural Skills... 189 7.10.1 Multivariate tests: Behavioural Skills... 189 7.10.2 Test of Assumptions: Behavioural Skills... 190 7.10.3 Univariate tests: Behavioural Skills... 190 7.10.4 Paired t-tests of Mean Estimates: Behavioural Skills... 193 7.11 Conclusion... 205 (xi)

CHAPTER EIGHT - DISCUSSION AND CONCLUSION 8.1 Overview of the Chapter... 206 8.2 General Discussion... 206 8.3 Limitations... 210 8.4 Summary... 213 8.5 Conclusions... 215 8.6 Recommendations... 216 8.7 Implications for further research... 221 (xii)

Appendices A: School 1 Subject Information Sheet for the School Principal... 223 B: School 2 Subject Information Sheet for the School Principal... 224 C: Subject Information Sheet for Parents/Guardians... 225 D: Subject Information Sheet for Grade 11 Learners... 226 E: Informed Consent Form for Learner Participants... 227 F: Questionnaire on Background Information... 228 G: Interview Schedule with lovelife Trainer... 230 H: Questionnaire on HIV/AIDS Information... 231 I: Questionnaire on Motivation... 234 J: Questionnaire on Behavioural Skills... 238 K: Intervention Activities Appendix K1: How a person gets HIV... 239 Appendix K2: You can t get AIDS by... 240 Appendix K3: Testing for HIV... 241 Appendix K4: What you know about testing... 242 Appendix K5: What is your risk?... 243 Appendix K6: Are you at risk?... 244 Appendix K7: The Partner Pyramid... 246 Appendix K8: Reasons to say NO... 248 Appendix K9: To delay or not to delay... 249 Appendix K10: Lines and more lines... 251 Appendix K11: Who s assertive?... 252 Appendix K12: Assertive messages... 253 Appendix K13: Your assertive message... 254 Appendix K14: Responding to persuasion... 257 L: Week One (HIV/AIDS Information Lesson Plans) Appendix L1: HIV/AIDS Information Lesson Plan: Day 1 (Week 1)... 261 Appendix L2: HIV/AIDS Information Lesson Plan: Day 2 (Week 1)... 262 Appendix L3: HIV/AIDS Information Lesson Plan: Day 3 (Week 1)... 263 M: Week Two (Motivation Lesson Plans) Appendix M1: Motivation Lesson Plan: Day 1 (Week 2)... 264 Appendix M2: Motivation Lesson Plan: Day 2 (Week 2)... 265 Appendix M3: Motivation Lesson Plan: Day 3 (Week 2)... 266 N: Week Three (Behavioural Skills Lesson Plans) Appendix N1: Behavioural Skills Lesson Plan: Day 1 (Week 3)... 267 Appendix N2: Behavioural Skills Lesson Plan: Day 2 (Week 3)... 268 Appendix N3: Behavioural Skills Lesson Plan: Day 3 (Week 3)... 269 P: Ethics Clearance Certificate... 270 References... 271 (xii)

LIST OF FIGURES 4.1: Theory of Planned Behaviour, adapted from Ajzen (1991)... 35 4.2: The Information, Motivation and Behavioural Skills model... 39 7.1: Hypothesis Graph... 92 7.2: Overall mean estimates for HIV/AIDS information for Schools ES & CS... 101 7.3: Overall mean estimates for Motivation for Schools ES & CS... 104 7.4: Overall mean estimates for Behavioural Skills for Schools ES & CS... 107 7.5: Participants Attitudes towards Delaying Sexual Intercourse... 131 7.6: Participants Attitudes towards Discussing Sexual Intercourse with Partners... 135 7.7: Participants Attitudes towards Acquiring Condoms... 138 7.8: Participants Attitudes towards Carrying Condoms... 141 7.9: Participants Attitudes towards Using Condoms... 144 7.10: Participants Attitudes towards Discussing Condoms with Partners... 147 7.11: Social Support from Participants Friends on Delaying Sexual Intercourse... 156 7.12: Social Support from Participants Partners on Delaying Sexual Intercourse... 159 7.13: Participants Intention to Delay Sexual Intercourse... 166 7.14: Participants Intention to Negotiate Sexual Intercourse with Partners... 168 7.15: Participants Intention to Acquire Condoms... 170 7.16: Participants Intention to Carry Condoms... 173 7.17: Participants Intention to Use Condoms... 175 7.18: Participants Intention to tell Partners to Use Condoms... 178 7.19: Participants Perceptions of their Friends Vulnerability to HIV infection... 179 7.20: Participants Perceptions of the Own Vulnerability to HIV infection... 186 7.21: Participants Own Fear of HIV/AIDS... 187 7.22: Participants Ability to Delay Sexual Intercourse... 193 7.23: Participants Ability to Refuse Sexual Intercourse... 194 7.24: Participants Ability to Acquire Condoms... 196 7.25: Participants Ability to Carry Condoms... 199 7.26: Participants Ability to Use Condoms... 202 (xiii)

LIST OF TABLES 5.1 Research Design... 51 6.1 Teaching of HIV and AIDS education at the participating schools... 64 6.2 Topics taught in HIV and AIDS education lessons at the participating schools 62 6.3 Methods used in HIV and AIDS education lessons at the participating schools 65 6.4 Feedback provided by learners on HIV and AIDS information on HIV and AIDS education lessons at the participating schools... 68 6.5 Feedback provided by learners on motivation on HIV and AIDS education lessons at the participating schools... 71 6.6 Feedback provided by learners on behavioural skills on HIV and AIDS education lessons at the participating schools... 72 6.7 A summary of information collected from an interview with the lovelife Regional Trainer... 75 7.1 Demographic characteristics of learner participants: gender, age, language, family, parental education, household income... 84 7.2 HIV/AIDS Information: Multivariate tests of significant differences for between and within subjects effects... 94 7.3 Mauchly s Test of Sphericity: HIV/AIDS Information... 95 7.4 Univariate tests of HIV/AIDS Information within subject effect of Time, and Time interaction with School... 96 7.5 School 1 (ES): T-test results for overall mean estimates on HIV/AIDS Information... 102 7.6 School 2 (CS): T-test results for overall mean estimates on HIV/AIDS Information... 103 7.7 School 1 (ES): T-test results for overall mean estimates on motivation... 105 7.8 School 2 (CS): T-test results for overall mean estimates on motivation... 106 7.9 School 1 (ES): T-test results for overall mean estimates on behavioural skills... 108 7.10 School 2 (CS): T-test results for overall mean estimates on behavioural skills... 109 7.11 Pre- and Post-intervention Percentage Results on HIV/AIDS Information... 111 7. 12 School 1 (ES): T-test results for HIV/AIDS information... 120 7.13 School 2 (CS): T-test Results for HIV/AIDS Information... 122 7.14 Motivation to Perform HIV/AIDS Preventive Behaviours: Multivariate tests Of significant differences for between and within subjects effects... 126 7.15 Mauchly s Test of Sphericity for within subjects effects of motivation... 127 7.16 Univariate tests of HIV motivation within subjects effect of Time and Time Interaction with School... 128 7.17 School 1 (ES): T-test Results for Attitudes towards Delaying Sexual Intercourse... 132 7.18 School 2 (CS): T-test Results for Attitudes towards Delaying Sexual Intercourse... 133 7.19 School 1 (ES): T-test Results for Attitudes towards Discussing Sexual Intercourse... 136 (xiv)

7.20 School 2 (CS): T-test Results for Attitudes towards Discussing Sexual Intercourse... 137 7.21 School 1 (ES): T-test Results for Attitudes towards Acquiring Condoms... 139 7.22 School 2 (CS): T-test Results for Attitudes towards Acquiring Condoms... 140 7.23 School 1 (ES): T-test Results for Attitudes towards Carrying Condoms... 142 7.24 School 2 (CS): T-test Results for Attitudes towards Carrying Condoms... 143 7.25 School 1 (ES): T-test Results for Attitudes towards Using Condoms... 145 7.26 School 2 (CS): T-test Results for Attitudes towards Using Condoms... 146 7.27 School 1 (ES): T-test Results for Attitudes towards Discussing Condoms... 148 7.28 School 2 (CS): T-test Results for Attitudes towards Discussing Condoms... 149 7.29 Multivariate tests for Subjective Norms regarding HIV Preventive Acts... 150 7.30 Mauchly s Test of Sphericity for Subjective Norms regarding HIV Preventive Acts... 151 7.31 Univariate tests for Subjective Norms regarding HIV Preventive Acts within Subject Effect of Time and Time interaction with School... 153 7.32 School 1 (ES): T-test Results for Social Support from Friends on Delaying Sexual Intercourse... 157 7.33 School 2 (CS): T-test Results for Social Support from Friends on Delaying Sexual Intercourse... 158 7.34 School 1 (ES): T-test Results for Social Support from Partners on Delaying Sexual Intercourse... 160 7.35 Multivariate tests for Significant Differences for Between and Within Subjects on Behavioural Intentions... 162 7.36 Mauchly s Test of Sphericity: Behavioural Intentions... 163 7.37 Univariate tests for Behavioural Intentions within Subject Effect of Time and Time interaction with School... 164 7.38 School 1 (ES): T-test Results for Learners Intention to Delay Sexual Intercourse... 167 7.39 School 2 (CS): T-test Results for Learners Intention to Delay Sexual Intercourse... 169 7.40 School 1 (ES): T-test Results for Learners Intention to Acquire Condoms... 171 7.41 School 2 (CS): T-test Results for Learners Intention to Acquire Condoms... 172 7.42 School 1 (ES): T-test Results for Learners Intention to Carry Condoms... 174 7.43 School 2 (CS): T-test Results for Learners Intention to Carry Condoms... 177 7.44 School 2 (CS): T-test Results for Learners Intention to Negotiate Condom Use with Partners... 179 7.45 Multivariate tests for Significant Differences for Between and Within Subjects on Vulnerability to HIV Infection... 181 7.46 Mauchly s Test of Sphericity for Within Subjects Effect of Time on Vulnerability to HIV Infection... 182 7.47 Univariate tests for Within Subject factors of Vulnerability to HIV Infection... 183 7.48 Multivariate tests: Behavioural Skills... 188 7.49 Mauchly s Test of Sphericity for Within Subjects Effect of Time on Behavioural Skills... 189 (xv)

7.50 Univariate tests: Behavioural Skills... 190 7.51 School 2 (CS): T-test Results for Learners Ability to Refuse Sexual Intercourse... 194 7.52 School 1 (ES): T-test Results for Learners Ability to Acquire Condoms... 196 7.53 School 2 (CS): T-test Results for Learners Ability to Acquire Condoms... 197 7.54 School 1 (ES): T-test Results for Learners Ability to Carry Condoms... 199 7.55 School 2 (CS): T-test Results for Learners Ability to Carry Condoms... 200 7.56 School 1 (ES): T-test Results for Learners Ability to Use Condoms... 202 7.57 School 1 (ES): T-test Results for Learners Ability to Use Condoms... 203 (xvi)

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