International Journal of Sexually Transmitted Diseases

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Research Article Open Access
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  • Risk Reduction Intervention Services for In-school Adolescents in the rural Areas of Abia State of Nigeria

    Enwereji, E.E. 1   Onyemechi, P.E.N 1  

    1College of Medicine Abia State University, Uturu, Nigeria.

    Abstract

    Introduction

    Risk reduction intervention is meant to provide enhanced and desirable interventions for HIV prevention among adolescents especially the in-school. Adolescents have been identified as the most vulnerable groups that can easily acquire human immunodeficiency virus (HIV) and other sexually transmitted diseases (STDs). Therefore, adolescents are the appropriate target for HIV prevention efforts. Most interventions for adolescents focus on providing AIDS-related education with the assumption that improving knowledge would enable adolescents to protect themselves from sexually transmitted infections. Numerous studies have shown that using class-room education alone is insufficient in reducing adolescents’ risky sexual behaviours. Therefore,

    this study used role-plays and peer facilitation for the study.

    Materials and Method

    The study used role-play and peer facilitation for the intervention strategy. The theme of the role-play was ‘My Future is My Choice’ (MFMC) intervention which was aimed to reduce HIV risk behaviours among sexually inexperienced adolescents. The role-play was carried out by 4 peer leaders who were trained in the theoretical framework of role-plays and peer facilitation by a consultant. With mastery and experience they carried out the role play in a regular classroom section for over 3 class periods, co-facilitated with the assistance of a volunteer teacher. A unique feature of this intervention was the dual focus on strategies that influenced both individual risk factors (i.e., attitudes, behavioural skills) and social environments (e.g., peer resources).

    A school was chosen by simple random sampling for the intervention. In the school chosen, a total sample of 65 students in senior secondary classes 2&3 ( SS2&3) were included in the study. These were the students considered to be sexually active who can respond to the questions in the questionnaire. Self-administered pre-and post-questionnaire were completed by the students. The results were analysed using frequency tables, descriptive and inferential statistics.

    Results

    The students studied were between the ages of 13-18 years. There was evidence that the role play ‘My Future is My Choice’ (MFMC) intervention created positive effects on reduction of HIV risk behaviours among the sexually inexperienced participants aged 13–18. Perceptions on methods of preventing risk reduction behaviours were also positively impacted by the intervention as 12(18.5%) and 34(52.3 %) of the respondents realized after post- intervention that having sex with someone outside marriage and being transfused with infected blood respectively Will constitute risk to HIV infection.

    Conclusion

    The role play which used the theme ‘My Future is My Choice’ (MFMC) intervention provided safer choices for reducing one or more measures of sexual risk behaviours among the sexual inexperienced respondents. It created the opportunity for the students to recognize that engaging in unprotected sex constitutes high risk for HIV, other sexually transmitted infections and pregnancy.

    Author Contributions
    Received 07 Jan 2021; Accepted 15 Feb 2021; Published 23 Feb 2021;

    Academic Editor: , Department of Sociology, Faculty of the Social Sciences, University of Ibadan, Ibadan, Nigeria.

    Checked for plagiarism: Yes

    Review by: Single-blind

    Copyright ©  2021 Enwereji, E.E, et al.

    License
    Creative Commons License     This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

    Competing interests

    The authors have declared that no competing interests exist.

    Citation:

    Enwereji, E.E., Onyemechi, P.E.N (2021) Risk Reduction Intervention Services for In-school Adolescents in the rural Areas of Abia State of Nigeria. International Journal of Sexually Transmitted Diseases - 1(1):9-19.

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    Introduction

    The burden of HIV among adolescents in sub-Saharan Africa calls for urgent interventions. With the burden of HIV in sub-Saharan Africa, some countries have the sero-prevalence among young adults exceeding 30% 1, 2. The poor economic situations in most developing countries including Nigeria, have made biomedical prevention and treatment methods for HIV simply not affordable to most citizens 3, 4. Therefore, using intervention strategy to reduce sexual risk behaviours is the best option for preventing HIV infection among adolescents, especially the in-school adolescents.

    Although there is abundant literature on behavioural interventions for adolescents’ training and practice in specific skills on condoms use, there is growing evidence that such interventions when adapted to the local culture can positively influence adolescents’ sexual risks, perceptions and knowledge on HIV infection but proof is lacking on their effectiveness in reducing unprotected sex among adolescents 5.

    Research has shown that it is extremely difficult to achieve behavioural change among adolescents who have already initiated sexual activity. It is therefore, more beneficial to prevent HIV infection among sexually-inexperienced adolescents than the sexually active ones 6, 7. Meanwhile, studies have found that the increasing prevalence of HIV infection among adolescents, gave rise to implementing numerous educational and behavioural interventions that produced varying successes in reducing sexual risks 8, 9.

    Research has provided some evidences showing that ‘My Future is My Choice’ intervention can reduce rates of HIV sexual risk behaviours among sexually inexperienced adolescents. In addition to this, researchers have also argued that adolescents can reduce the practice of unprotected sexual activity if intervention strategies that encourage them to adopt competencies in all aspects of HIV prevention measures are used 10. However, some researchers have advised that HIV prevention interventions which are expensive, time-consuming, and extraordinarily difficult to implement because of the need to include counseling for safer sex, treatment for sexually transmitted infections, as well as monitoring participants’ adherence to the interventions provided should be avoided 11.

    The differential effects of HIV risk intervention on sex have been reported among adolescents, thereby, prompting some researchers to recommend sex-specific intervention programmes for adolescents rather than that of generic. Issue of concern in intervention for adolescents is that of the effects of emphasizing ‘safer sex’ through ‘abstinence only’ to the sexually inexperienced adolescents. Some researchers argue that using interventions that focus on discussions on sexual relationships may hasten the initiation of sexual intercourse 12. Others contend that if adolescents engage in high rates of unprotected sex before participating in HIV risk reduction interventions, that such adolescents are not likely to abstain totally from having further sexual activity 13, 14. Others maintain that in the post-intervention period, that virgins who have initiated sex will be more likely to use condoms during sex than others. Though few studies specifically addressed this issue, researchers have found that role plays that stress more on ‘safer sex’ intervention will prolong virginity among adolescents and also enable them experience positive intervention effects especially those that were sexually inexperienced at baseline or pre-intervention 15.

    Although increased sexual activity for those with multiple sexual partners who do not use condom will escalate the risk of HIV infection, available studies demonstrate that a behavioral intervention that targets risk reduction can decrease HIV incidence among these adolescents 16, 17. However, researchers have suggested role plays as feasible intervention strategy that can assess the efficacy of risk-reduction counseling on sexually active adolescents 18, 19. Realizing that schools are ideal settings to reach sexually inexperienced adolescents, before they initiate in sexual activity, the study concentrated on in-school adolescents for the study. In this study, role play was used for sex specific adolescents as an intervention strategy for HIV risk reduction that will be capable of disseminating effective behavioral interventions.

    Materials and Methods

    The study adopted role play which focused on MFMC strategy. The study used a randomly selected sex specific (girls) secondary school in the community. The girls’ secondary school chosen represented the sex specific sample used for the intervention. In this study, all the SS2&3 students in the selected girls’ secondary community school were studied. These were the students considered to be sexually active who can respond to the questions in the questionnaire. The study was conducted in May 2020.

    The role-play was carried out by 4 peer leaders after being trained in the theoretical framework of role-plays and peer facilitation by a consultant. With mastery and experience after the training, the peer leaders carried out the role play in a regular classroom section for over 3 class periods. This was co-facilitated with the assistance of a volunteer teacher in the school. A unique feature of this intervention was the dual focus on strategies that influenced both individual risk factors (attitudes, behavioral skills) and social environments (peer resources). Also, the intervention sessions had varieties of narratives, facts, exercises as well as time for questions and discussions. There were emphases on abstinence and on how to protect selves from unwanted sexual intercourse.

    The role play consisted of theoretically-based interventions that incorporated behavioural skill training and other strategies that are aimed at improving adolescents’ attitudes to HIV prevention. The theoretical aspect of the role play focused on the understanding measures for HIV risk reduction and these were expanded to include behavioural and emotional factors associated with HIV risks. The comprehensive primary prevention approach used ensured that adolescents who are not engaging in high-risk behaviours received prevention services before they initiate themselves in risky sex. The target approach to the study was to minimize new cases of HIV infection among in-school adolescents. The role play presented provided the researchers with several potential advantages which included: having access to larger numbers of adolescents, the likelihood of positively influencing behaviour change at individual and peer group levels, as well as the possibility of monitoring adolescents’ behavioural change longitudinally. During the role play, the following four intervention areas were stressed: group-based interactive HIV prevention intervention, motivation to adopt abstinence for HIV risk reduction, safer sex building skills and intensive AIDS education. Condom use was avoided so as not to infuriate the school authorities who felt that emphasizing condom use during the intervention will result to negative effects like increasing the sexual desires of the adolescents.

    The study used self-administered pre- and post-questionnaires. These were retrieved by the researchers at the completion of each set of the questionnaire. Data were analysed qualitatively and quantitatively using tables, percentages and inferential statistics.

    Ethical Consideration

    The ethical committee of the Abia State University Teaching Hospital approved the project before starting. The consents of the Director Ministry of Education as well as that of the Principal of the community school studied were got before the commencement of the study. The teachers’ written consent was obtained prior to the administration of the questionnaire. The students' consent was obtained orally before the questionnaire administration and the respondents’ anonymity was protected by ensuring that no individual identifiers existed in the instruments or in the electronic data set.

    Results

    Respondents’ Demographic Characteristics

    The respondents studied were between the ages of 13-18 years with mean age 15.75 years (SD ± 0.936). See Table 1, Table 2.

    Table 1. Respondents’ Ages in years
    Age in years Frequency Percentage
    13 – 15 25 39.1
    16 – 18 40 60.9
    Total 65 100

    Table 2. Mean age of the respondents
    Variable Mean Medium Mode Std. Dev. Variance Range Min Maximum
    Age as at last birthday 15.75 16 16 0.936 0.875 4 14 18

    The respondents and the people they live with were explored. From Table 3, a good number of the respondents 38(59.4%) are living with their fathers and mothers. See Table 3 for details.

    Table 3. Respondents and people they are living with
    Those respondents live with Frequency Percentage
    Father and mother 38 59.4
    Mother only 11 17.2
    Father only 3 4.7
    Close relation 12 18.8
    Total 65 100

    The respondents and their classes are stated in Table 4 below. From the table, 38(58.5%) of the respondents are in SS3.

    Table 4. Class of the respondents
    Variable Frequency percentage
    SS2 27 41.5
    SS3 38 58.5
    Total 65 100

    The respondents’ knowledge on causes of HIV was explored. From Table 5, 52(80%) and 63(96.9%) of the respondents at pre-intervention and post intervention respectively, were aware that HIV is a virus infection. Also 9(13.8%) of the respondents during the pre- intervention and 1(1.5%) during the post-intervention were not sure whether HIV is caused by either virus, bacteria or fungi.

    Table 5. Respondents’ knowledge on causes of HIV infection
    Causes of HIV Pre-and post-intervention Total
    Pre-intervention Post-intervention
    Virus 52(80%) 63(96.9%) 115(88.5%)
    Bacteria 1(1.5% ) 0(0%) 1(.77%)
    Bacteria and fungi 3(4.6%) 1(1.5%) 4(3.1%)
    None of the above 9(13.8%) 1(1.5%) 10(7.7%)
    Total 65(100%) 65(100%) 130(100%)

    The respondents’ knowledge of what constitutes risk for HIV infection was assessed. From Table 7, 28(43%) of the respondents during the pre-intervention had no idea of what constitutes HIV risk, while during the post-intervention, only 1(1.5%) of the respondents had no idea. Table 6 contains details of the responses.

    Table 6. Respondents and risks of HIV infection
    Risks of HIV infection Pre-intervention Post-intervention Total
    Having sex with anyone outside marriage 9(13.8%) 12(18.5%) 21(16.2%)
    Having sex with animals 0(0%) 1(1.5%) 1(.77%)
    Sitting close with an infected person 5(7.7%) 0(0%) 5(3.8%)
    Shaking hands with infected person 7(10.8%) 0 (0%) 7(5.4%)
    Using the same toothbrush with an infected person 2(3.1%) 8(12.3%) 10(7.7%)
    Wearing same dress or shoes with someone with HIV 4(6.2%) 0(0%) 4(3.1%)
    Using the same needle for injection 2(3.1%) 9(13.8%) 11(8.5%)
    Using public toilet 3(4.6%) 0(0%) 3(2.31%)
    Being transfused with infected blood 5(7.7%) 34(52.3 %) 39(30%)
    No idea 28(43%) 1(1.5%) 29(22.3%)
    Total 65(100%) 65(100%) 130(100%)
          P=.742

    The respondents were also asked how HIV can be transmitted from one person to another. From their responses, 5(7.7%) of the respondents stated during the pre-intervention that one can be infected by sharing needles or razor blades with others while 17(26.2%) respondent during the post-intervention responded that sharing needles or razor blades with others can cause HIV infection. Table 7 contains other views of the respondents.

    Table 7. Respondents and common modes of transmitting HIV
    How HIV can be transmitted Pre-intervention Post-intervention Total
    By hugging infected person 12 (18.5%) 0(0%) 12(9.2%)
    By sharing food with infected person 6(9.2%) 0(0%) 6(4.6%)
    By using public toilets 5(7.7%) 3(4.6%) 8(6.2%)
    By using same Razor blades or needles with others 5(7.7%) 17(26.2%) 22(16.9%)
    By using same bath towels with infected person 10(15.4%) 2(3.1%) 12(9.2%)
    By kissing others 11(16.9%) 22(33.8%) 33(25.4%)
    By having unprotected sex 7(10.8%) 21(32.3 %) 28(21.5%)
    By shaking hands with others 7(10.8%) 21(32.3 %) 28(21.5%)
    Total 65(100%) 65(100%) 130(100%)

    The respondents were asked to state whether they have shared needles and razor blades with others. The responses in Table 8 showed that 17(26.2%) of the respondents during the pre-intervention and 23(35.4%) during the post intervention accepted that they have shared needles and razor blades with others.

    Table 8. Respondents who have shared needles with others
    Have shared needles and razor blades with others Pre-intervention Post-intervention Total
    Yes 17(26.2%) 23(35.4%) 40(30.8%)
    No 48(73.9%) 42(64.6%) 90(69.2%)
    Total 65(100%) 65(100%) 130(100%)
    Chi-Square Test
    Test statistics Value Df Asymp. Sig (2-sided) Exact Sig. (2-sided) Exact Sig. (1-Sig. sided)
    Pearson Chi-Square 1.173a 1 .279    
    Continuity Correction .797 1 .372    
    Likelihood Ratio 1.177 1 .278    
    Fisher’s Exact Test       .342 .186
    Linear-by-Linear Association 1.164 1 .281    
    N of Valid Case 130        

    a 0 cells (.0%) have expected count less than 5. The minimum expected count is 19.84
    b Computed only for a 2x2 table

    The test is not statistically significant (Fisher’s Exact test) of P value <0.05 with Fisher’s Exact test of P value of .342 of double sided.

    The respondents who have been approached for sexual relationships were assessed. Table 9 shows that 26(40%) of the respondents have been approached for sexual relationships.

    Table 9. Respondents who have shared needles with others
    Have been approached for sex Frequency Percentage
    Yes 26 40
    No 39 60
    Total 65 100

    The respondents who have had sexual relations with those who approached them for sex were also explored. Table 10 showed that 4(6.2%) of the respondents said they have had sexual relations with those who approached them for sex.

    Table 10. Respondents who have been approached for sexual relationships
    Have had sex Frequency Percentage
    Yes, I have had sex with males 4 6.2
    No, I have not had sex with anybody 22 33.8
    Not applicable 39 60
    Total 65 100

    The respondents who said they have had sex were asked what they used to prevent pregnancy and HIV infection. From the responses in Table 11, 8(12.4%) of the respondents said they used nothing to protect themselves from pregnancy and HIV infection while others said they used medicine, lubricant and condom. See table for details.

    Table 11. Things used to protect pregnancy and HIV infection
    What is used to protect pregnancy and HIV infection Frequency Percentage
    use lubricant during sex 1 1.5
    Takes medicine after sex 2 3.1
    Uses condoms for sex 1 1.5
    Nothing is used 8 12.4
    Not applicable 53 81.5
    Total 65 100

    The respondents were asked to suggest how their mates can prevent HIV infection and pregnancy. Table 12 contains their suggestions. From the table, 22(33.8%) said not having boyfriend will help to prevent pregnancy and HIV infection while 20(30.8%) said not visiting boys in their houses. See table for other suggestions.

    Table 12. Respondents’ suggestions on how to prevent HIV infection and pregnancy to other school mates
    suggestions Frequency Percentage
    Avoid having boyfriends 22 33.8
    Avoid visiting boys in their houses 20 30.8
    Having sex with the opposite sex only 9 13.8
    Not having sex at all 14 21.5
    Total 65 100

    Discussion

    The positive outcome measures of the MFMC intervention for the in-school adolescents focused on reduction in HIV infection, and sexual risk behaviours. The results of the pre-intervention and post-intervention when compared showed that successes were recorded on abstinence and safer sex decision-making as well as on HIV risk intentions and perceptions. Chi-square statistics were employed for statistical testing in these comparisons and there were no statistically significant effects at each interval.

    The research which used ‘My Future is My Choice’ (MFMC), intervention that succeeded in reducing HIV risk behaviours among sexually inexperienced participants showed that the emphasis on ‘Safer Choices’ reduced the desire for unprotected sex as 22(33.8%) and 20(30.8%) of the respondents suggested that not having boyfriends and visiting boys in their houses respectively will help to prevent HIV infection and pregnancy. These suggestions are capable of delaying initiation of sex. This finding also collaborated with that of 10, 14 which argue that if HIV risk reduction intervention is expanded to include behavioural skills training and strategies that will improve attitudes to HIV prevention, that adolescents who have not engaged in high-risk behaviours are likely not to initiate in risky sex thereby, result to the greatest impact on reducing new cases of HIV among them.

    The fact that 5(7.7%) of the respondents during the pre-intervention had the view that one can be infected by sharing needles or razor blades with others and after the intervention, 17(26.2%) of the respondents realized that sharing razor blades or needles with others constitutes risk for HIV infection showed that successes were recorded after the MFMC intervention to the adolescents. Also as high as 28(43%) of the respondents during the pre-intervention had poor knowledge of what constitutes HIV risks and after the post-intervention, only 1(1.5%) of the respondents showed poor knowledge suggest the benefits of the intervention. These positive intervention effects appear to have been contributed primarily by changes among the respondents’ perception on what constitutes HIV risk reduction.

    The MFMC intervention used appears to have encouraged the adolescents to freely discuss their past sexual experiences among themselves. Although the rates of discussion were equal both during pre-intervention and post-intervention periods, respondents easily reported their past sexual relationships and other HIV risk behaviours. About 26(40%) of the respondents reported that they have been approached for sexual relationships and 4(6.2%) of them said they have had sex with those who approached them for sex. Also 17(26.2%) of the respondents during the pre-intervention and 23(35.4%) during the post intervention accepted that they have shared needles and razor blades with others. However, an insignificant number of the adolescents 1(1.5%) respectively reported that they use lubricants, take medicines and use condom after sex to protect themselves from HIV infection and pregnancy, while 8(12.4%) said they use nothing after sex.

    Conclusion

    The MFMC intervention for the in-school adolescents was associated with decrease in intentions to share sharp objects and to engage in multiple sex partners. Also it was associated with increase in adolescents’ knowledge on what constitutes risk to HIV infection. However, the desire to adopt abstinence and safer sex intentions increased at baseline (pre- intervention) and this increase became even greater during the post-intervention period, although the difference was not statistically significant. Therefore, national implementation of ‘My Future is My Choice’ intervention for adolescents is encouraged. It will be important to corroborate the self-reports of the intervention effects by using specific sex population instead of generic. Monitoring the effects of the intervention will also be necessary so as to help ensure that the adolescents are indeed given every opportunity to positively shape their futures. For more acceptability of MFMC intervention, emphasis on condom use for sexually inexperienced adolescents should be minimized for HIV risk reduction.

    In summary, based on the findings of the study, and those of a few other investigators carried out in relevant cultural settings, MFMC is an ideal strategy for in-school adolescents and could also be cautiously used for other classes of adolescents, though adaptation process requires significant time and resources to achieve. Finally, considerations should be given to the benefits of using sex-specific interventions for adolescents.

    Implications of the Findings

    The findings of the study provide evidences on several important issues that are relevant to the control of HIV infection among sexually inexperienced in-school adolescents in a developing country like Nigeria. First of all, there is the understanding that properly designed face-to-face HIV risk-reduction interventions can reduce HIV risk behaviours among adolescents 13. Realizing the limited time and resources to develop interventions for HIV risk reduction,it is therefore necessary to adapt the intervention strategies that will meet what is socially and culturally acceptable to the geographical settings of Nigeria. The practice of laying much emphasis on condom use for HIV prevention among sexually inexperienced adolescents was minimized because emphasizing condom use among adolescents who are initially sexually inexperienced can give rise to erratic supply of condoms and thereby result to abuse in the usage. The main concern of the researchers with the use of this approach was to stress on abstinence so that the respondents will understand the meaning of risk and protective behaviours associated with safer sexual practices in consonance with the culture. Thus, creating full awareness on the benefits of abstinence encouraged successful adaptation of the intervention. This study suggests that using MFMC as intervention strategy for in-school adolescents will result in reductions in sexual risk behaviours.

    A second issue addressed by the findings is that of the effects of the intervention according to sex. This intervention is grounded on the assumption that intervention on decision-making for sexual activity is a function of both sexes in the relationship, but the investigation by 14 argues that this is not applicable in all settings, that interventions are more effective when specific sexes are separately studied. The study therefore, considered it important to use only one sex ( females in the present study) so as to record the extent to which they benefit from MFMC. The findings showed evidence that the use of specific sex in the intervention produced improved result during the post-intervention period. In summary, as also reported by other studies, that using specific sex for MFMC intervention will be more beneficial than using both sexes 18.

    Another issue of concern in the finding is the effects of stressing ‘safer sex’ and ‘abstinence’ to sexually inexperienced adolescents. There is the concern by school authorities during the study that interventions that focus on discussions on sexual relationships for sexually inexperienced adolescents will aggravate the desire to initiate sexual intercourse thereby, giving rise to high rates of unprotected sex at the time of the sexual initiation. However, others contend that there is no evidence to support this view, and that rather, adolescents who did not participate in such interventions before the time of sexual initiation are likely to engage in unprotected sex. However, the findings of the study did not provide any evidence that discussing safer sex and abstinence aggravated sexual initiation among the intervention participants rather, the discussion on safer sex and abstinence gave the adolescents the opportunity of reporting their sexual experiences which enabled the researchers to note areas to focus on.

    Acknowledgements

    We wish to thank the tertiary education trust fund (TETFUND) Nigeria, for funding this project. We also want to thank the teachers in the school studied for helping the researchers to make ‘My Future is My Choice’ intervention a reality.

    References

    1.Flisher A J, Klepp K-I. (2009) School-based HIV/AIDS prevention in Sub-Saharan Africa.
    2.Frank S, Esterhuizen T, Jinabhai C C, Sullivan K, Taylor M. (2008) Risky sexual behaviours of high-school pupils in an era of HIV and AIDS. South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde. 98(5), 394-8.
    3.Hoffman S, O’Sullivan L F, Harrison A, Dolezal C, Monroe-Wise A. (2006) HIV risk behaviors and the context of sexual coercion in young adults’ sexual interactions: results from a diary study in rural South Africa. Sexually transmitted diseases. 33(1), 52-8.
    4.Heeren G A, Jemmott J B, Ngwane Z, Mandeya A, Tyler J C. (2013) A Randomized Controlled Pilot Study of an HIV Risk-Reduction Intervention for Sub-Saharan African University Students. AIDS and behavior. 17(3), 1105-15.
    5.Peltzer K, Davids A, Njuho P. (2011) Alcohol use and problem drinking in South Africa: Findings from a national population-based survey. African journal of psychiatry. 14, 30-7.
    6.Morojele N K, Brook J S, Kachieng’a M A.Perceptions of sexual risk behaviours and substance abuse among adolescents in South Africa: a qualitative investigation. AIDS care. 2006;18(3): 215–9. Publication Type:. , Journal Article. [PubMed]
    7.Johnson B T, Carey M P, Marsh K L, Levin K D, Scott-Sheldon L A. (2003) Interventions to reduce sexual risk for the human immunodeficiency virus in adolescents, 1985–2000: a research synthesis. Archives of pediatrics & adolescent medicine. Apr;157(4): 381–8. [PubMed]
    8.Jemmott J B, Jemmott LS 3rd, O’Leary A, Ngwane Z, Icard L D et al.School-based randomized controlled trial of an HIV/STD risk-reduction intervention for South African adolescents. Archives of pediatrics & adolescent medicine. 2010 Oct;164(10): 923–9. [PMC free article] [PubMed] .
    9.Johnson B T, Scott-Sheldon L A, Huedo-Medina T B, Carey M P. (1985) Interventions to reduce sexual risk for human immunodeficiency virus in adolescents: a meta-analysis of trials. Archives of pediatrics & adolescent medicine. 2011 Jan;165(1): 77-84.
    10.Oladepo O, M. (2011) Perceptions about sexual abstinence and knowledge of HIV/AIDS prevention among in-school adolescents in a western Nigerian city. BMC Public Health11: 1-10.
    11.Kalichman S C, Simbayi L C, Kaufman M, Cain D, Jooste S. (2007) Alcohol use and sexual risks for HIV/AIDS in sub-Saharan Africa: systematic review of empirical findings. Prevention science : the official journal of the Society for Prevention Research. Jun;8(2): 141–51. [PubMed]
    12.Paul-Ebhohimhen V A, Poobalan A, van Teijlingen ER. (2008) A systematic review of school-based sexual health interventions to prevent STI/HIV in sub-Saharan Africa. , BMC Public Health 8, 4.
    13.Palen L A, Smith E A, Flisher A J, Caldwell L L, Mpofu E. (2006) Substance use and sexual risk behavior among South African eighth grade students. The Journal of adolescent health : official publication of the Society for Adolescent Medicine. 39(5), 761-3.
    14.Jemmott J B, Jemmott LS 3rd, O’Leary A, Ngwane Z, Icard L D et al. (2010) School-based randomized controlled trial of an HIV/STD risk-reduction intervention for South African adolescents. Archives of pediatrics & adolescent medicine. 164(10), 923-9.
    15.Helleve A, Flisher A J, Onya H, Mathews C, Aarø L E et al. (2011) The association between students’ perceptions of a caring teacher and sexual initiation. A study among South African high school students. Health education research. 26(5), 847-58.
    16.Fisher J C, Bang H, Kapiga S H. (2007) The association between HIV infection and alcohol use: a systematic review and meta-analysis of African studies. Sexually transmitted diseases. 34(11), 856-63.
    17.Jackson C, Geddes R, Haw S, Frank J. (2012) Interventions to prevent substance use and risky sexual behaviour in young people: a systematic review. Addiction (Abingdon. , England 107(4), 733-47.
    18.Iyaniwura C A, Daniel O J. (2007) Adelowo OO: Attitude of Youths to Sexual Abstinence as a strategy for HIV prevention. Nigerian Medical Practitioners. 52(2), 33-37.
    19.Weed S E. (2012) Sex education programs for schools still in question: a commentary on meta analysis. , American Journal of Preventive Medicine 42(3), 313-15.