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Research has shown a positive relationship between substance use and delinquent-type behaviours among adolescents. The aim of this study is to explore the temporal relationships between these outcomes through secondary data analysis of a longitudinal study of high-school students' risk behaviours. Two regression models were compared and gender, socioeconomic status and repeating a grade were found to be consistent predictors of delinquent-type behaviour. Alcohol (OR: 1.26, CI: 1.02-1.55, p = 0.03) and drug use (OR: 1.10, CI: 1.03-1.16, p = 0.002) in the ordinal regression models were significantly associated with delinquent-type behaviours at Time 2 only. A transition model use was then used to measure delinquent-type behaviours as predicted by the previous time period, and results indicated that gender and delinquency were predictive of delinquency. Smoking also significantly interacted with delinquent-type behaviour to increase future risk of this behaviour. The findings point to the need for intervening early with adolescents who show delinquent-type behaviour. (Contains 4 tables.)

The AIDS pandemic has resulted in a dramatic rise in the number of orphans in South Africa. This study was designed to investigate the associations between family, peer, and community factors and resilience in orphaned adolescents. Self-report questionnaires were administered verbally to 159 parentally bereaved adolescents (aged 10-19) in an economically deprived urban area. Questionnaires included measures of depression, anxiety, and self-esteem. The results of a hierarchical multiple regression analysis indicate that cumulative stress exposure, losing a parent to a cause other than HIV and AIDS, and being cared for by a nonrelative were associated with an increased risk of internalizing symptoms. Family regulation and respect for individuality, peer connection, and community connection and regulation were significantly associated with greater emotional resilience. The findings support a main-effects model of resilience in which risk factors and protective factors contribute additively to the prediction of the outcome, without interaction. (Contains 4 tables.)

Objective: To investigate whether methamphetamine use is associated with sexual risk behavior among adolescents. Method: A cross-sectional survey of 1,561 male and female high school students in Cape Town (mean age 14.9 years) was conducted using items from the Problem Oriented Screening Instrument for Teenagers (POSIT) HIV Risk Scale. Results: Nine percent of the students had tried methamphetamine and 30% of male and 17% of female students reported sexual debut. Multinomial logistic regression analyses showed that methamphetamine use in the past year was significantly associated with being in a higher HIV/STI risk category (RRR = 2.1, 95% CI: 1.10-4.03, p less than 0.05). Conclusions: Methamphetamine use, coupled with a high HIV prevalence in South Africa, raises serious cause for concern about the potential for methamphetamine to further exacerbate the prevalence and spread of HIV in Cape Town. (Contains 2 tables and 1 figure.)

This paper has the following aims: (i) to explore the extent to which students who received an intervention involving HIV/AIDS and sexuality perceived that their teacher cared for their health and well-being, (ii) to investigate the characteristics of students who reported to have caring teachers and (iii) to document the association between students' perceptions of care and reported onset of sexual activity. Data were obtained from the second follow-up survey of a prospective study carried out among high school students in South Africa (Cape Town and Mankweng). We analyzed data from 3483 students who met the inclusion criteria. Students from the intervention group perceived greater care from teachers than students in the control group. Female students and students from Cape Town perceived having received more care, and their perception of care was associated with the number of lessons received, how often students expressed their opinions in class and how often teachers talked about HIV/AIDS, condoms and abstinence. Students who perceived that their teacher cared for their health and well-being were less likely to initiate sexual intercourse. This is the first paper to demonstrate the salience of the concept of care in studies of school-based HIV/AIDS prevention programs in sub-Saharan Africa.

This study was designed to evaluate the efficacy of the HealthWise South Africa HIV and substance abuse prevention program at impacting adolescents' polydrug use and sexual risk behaviors. HealthWise is a school-based intervention designed to promote social-emotional skills, increase knowledge and refusal skills relevant to substance use and sexual behaviors, and encourage healthy free time activities. Four intervention schools in one township near Cape Town, South Africa were matched to five comparison schools (N = 4040). The sample included equal numbers of male and female participants (Mean age = 14.0). Multiple regression was used to assess the impact of HealthWise on the outcomes of interest. Findings suggest that among virgins at baseline (beginning of eighth grade) who had sex by Wave 5 (beginning of 10th grade), HealthWise youth were less likely than comparison youth to engage in two or more risk behaviors at last sex. Additionally, HealthWise was effective at slowing the onset of frequent polydrug use among non-users at baseline and slowing the increase in this outcome among all participants. Program effects were not found for lifetime sexual activity, condomless sex refusal and past-month polydrug use. These findings suggest that HealthWise is a promising approach to HIV and substance abuse prevention.

Characteristics of learners who become peer educators are rarely explored despite the potential relevance to the success of peer education programmes. Fifteen high schools selected to implement peer education HIV prevention programmes in South Africa were recruited. A total of 2339 Grade 10 learners were surveyed and comparisons were made between socio-demographic characteristics, key skills, school experience and sexual behaviour of those students who had volunteered or been chosen by teachers to be peer educators (n = 295) and their fellow students (n = 2044), the potential recipients of the programme. On most of the socio-demographic variables, school experiences, aspirations, sexual debut and use of condoms at last sex or whether they had been tested for HIV status, there were no significant differences between the two groups. Volunteers and teacher-chosen peer educators tended to be younger than their classmates (16.19 versus 16.52, P less than 0.0001), score higher on a goal-orientation scale (3.27 versus 3.15, P =less than 0.0001) and had more access to basic resources [electricity (97.9% versus 94.0%, P = 0.006), a bicycle (41.9% versus 32.7%, P = 0.004) or car (50.2% versus 41.0%, P = 0.005)]. Further research is needed to explore specific peer educator characteristics and recruitment and selection approaches that are associated with effective HIV prevention interventions.

A 14-item human immunodeficiency virus/acquired immunodeficiency syndrome knowledge scale was used among school students in 80 schools in 3 sites in Sub-Saharan Africa (Cape Town and Mankweng, South Africa, and Dar es Salaam, Tanzania). For each item, an incorrect or don't know response was coded as 0 and correct response as 1. Exploratory factor analyses based on polychoric correlations showed two separate factors for all sites. Two-parameter item response theory (IRT) analysis (bifactorial multiple indicators multiple causes confirmatory factor analysis models) consistently showed a general first factor and a second "method" factor. One single global latent variable seemed to sufficiently well capture most of the systematic variation in knowledge. Some items did not discriminate well between levels of the underlying knowledge latent variable and information values were highest for low levels of knowledge. The scale might be improved by adding items, in particular items that are more difficult to answer. Some differential item functioning effects related to site and socioeconomic status were identified. Scores on the latent knowledge variable were particularly low among females in Dar es Salaam and Mankweng, and were negatively associated with socioeconomic status. This study illustrates advantages of using IRT analysis instead of more conventional approaches to examining psychometric properties of knowledge scales.

In this paper we explore the perceived desirable characteristics of South African Life Orientation teachers for teaching sexuality and HIV/AIDS. We also investigate the extent to which these characteristics can be understood as parts of a role script for teaching HIV/AIDS and sexuality. Data were collected from teachers who taught Grade Eight and Grade Nine students in South African public high schools. The teachers particularly emphasised the importance of personality and life experience as important characteristics for teaching sexuality and HIV/AIDS. In addition, they felt that it was challenging to create an open dialogue in the classroom and at the same time maintain classroom discipline. The teachers did not perceive that teaching about sexuality and HIV/AIDS was a role that a teacher could step in and out of. On the other hand, they were accustomed to playing different roles with respect to the students, such as parent, friend, counsellor and social worker. (Contains 2 notes.)

The aims of this study were to examine whether use of tobacco, alcohol, and illicit drugs predicts dropout among secondary school students in Cape Town, South Africa. A self-report instrument was administered to 1,470 Grade 8 students. The proportion of students that dropped out of school between the onset of the study and 4 years later was 54.9%. After adjusting for a range of confounders, dropout was significantly predicted by absenteeism, poverty (as assessed by a possession index), and past month cigarette use, but not by past month alcohol use and lifetime illicit drug use. Contrary to findings from developed countries, alcohol and illicit drug use did not predict dropout. It is possible that predictors of dropout documented elsewhere may not be pertinent in developing countries. (Contains 2 tables.)

Background: Children and adolescents with mental health problems have poor service cover in low- and middle-income countries. Little is known about the resources that would be required to provide child and adolescent mental health services (CAMHS) in these countries. The purpose of this study was to calculate the human resources and associated costs required to scale up CAMHS in South Africa. Methods: A spreadsheet model was developed to calculate mental health service resources, based on an estimation of the need for services in a given population. The model can be adapted to specific settings by adjusting population size, age distribution, prevalence, comorbidity, levels of coverage, service utilisation rates, workloads, length of consultations and staff profile. Steps in the modelling include population identification; estimates of prevalence, service utilisation and staffing; and costing. Results: Using a nominal total population of 100,000 (of which 43,170 would be children and adolescents under 20 years of age), the following full-time equivalent staff are required at minimum coverage level: 5.8 in PHC facilities, 0.6 in general hospital outpatient departments (OPDs), 0.1 in general hospital inpatient facilities, 1.1 in specialist CAMHS OPDs, 0.6 in specialist CAMHS inpatient facilities, 0.5 in specialist CAMHS day services, and 0.8 in regional CAMHS teams. This translates into roughly $21.50 and $5.99 per child or adolescent per annum nationally for the full coverage and minimum coverage scenarios respectively. When comparing the results of this model with current realities in South Africa, there remains a substantial shortfall in existing levels of CAMHS provision. Conclusions: The model can be used as an advocacy tool to engage with planners and policy makers on a rational basis. It can also be adapted for use in other countries, and is intended to support wider calls for a global scaling up of mental health services.

Early coital debut is a risk factor for HIV. In this paper we investigate the predictors of young adolescents' transition to first intercourse using a social cognition theoretical framework. The analyses reported here were based on a longitudinal study of 2360 students in the schools allocated to the control arm of a cluster-randomized controlled trial to investigate the effect of a school-based HIV prevention programme among Grade 8 students in Cape Town. Structural equation modelling was performed with Mplus version 3.11. Of the 1440 students who were virgins at baseline, 1144 remained virgins 15 months later and 296 (20.6%) reported having had their first sexual intercourse. Transition to first sexual intercourse was more likely among males than females, among older students and among students with a lower socio-economic status. Transition to first sexual intercourse was significantly associated with intentions to have sexual intercourse, poor self-efficacy to negotiate delayed sex and intimate partner violence. The model predicted 35% of the variance in intentions and 16% of the variance in transition. These findings indicate some of the factors that influence young adolescent's transition to first intercourse and that need to be addressed when designing effective interventions. (Contains 3 tables and 1 figure.)

This prospective cohort study investigated whether leisure boredom predicts high school dropout. Leisure boredom is the perception that leisure experiences do not satisfy the need for optimal arousal. Participants completed a self-report questionnaire which included the Leisure Boredom Scale. The original cohort of grade 8 students (n=303) was followed up twice at 2-yearly intervals. Of the 281 students at the second follow-up, 149 (53.0%) students had dropped out of school. The effect of leisure boredom on dropout was investigated using logistic regression taking into account the clustering effect of the schools in the sampling strategy, and adjusting for age, gender and racially classified social group. Leisure boredom was a significant predictor of dropout (OR=1.08; 95% CI: 1.01-1.15) in students 14 years and older, but not so in younger students (OR=1.0; 95% CI: 0.95-1.05). The study has shown that measuring leisure boredom in grade 8 students can help identify students who are more likely to dropout of school. Further research is needed to investigate the longitudinal association between leisure boredom and school dropout.

This article describes rates of missing item responses in personal digital assistant (PDA) assessments as compared to paper assessments. Data come from the evaluation of a classroom-based leisure, life skills, and sexuality education program delivered to high school students in Cape Town, South Africa. Analyses show that the paper assessments had much higher rates of missingness than PDA assessments. This association is moderated by item order. Certain analyses also suggest that paper assessments have higher rates of missingness for items pertaining to participants' sexual behavior. Implications of these results for evaluation research will be discussed. (Contains 5 tables, 1 figure, and 2 notes.)

Background: Little is known about the prevalence of partner violence among adolescents, nor of the factors with which it is associated. The objectives of this study were to document prevalence rates for partner violence among high school students in Cape Town, and to explore factors that are associated with such violence. Method: The sample consisted of 596 Grade 8 and 11 students attending public high schools in Cape Town, who were selected using a multistage cluster design. They completed an anonymous and confidential questionnaire. The dependent variable was whether they had ever perpetrated partner violence, or intended to do so. The independent variables, which were derived from a modified version of the Theory of Planned Behaviour (TPB), included attitudes, subjective norms (general and peer social influence and outcome expectancy) and self-efficacy. Separate multiple logistic regression models were developed of partner violence intentions or behaviours on the scales derived from the TPB and demographic variables. Regression coefficients from adjusted models were used to examine the potential mediating role of partner violence intentions in the association between each scale and partner violence behaviours using the Sobel test. Results: Among participants who reported being in a relationship, 20.7% reported perpetrating partner violence, and 16.4% reported intending to do so. After adjusting for demographic characteristics and other predictor scales, perpetration of partner violence was significantly associated with attitudes and outcome expectancy, while intention to perpetrate partner violence was significantly associated with attitudes and general social influence. The influence of attitude and general social influence on violent behaviours were each partially mediated by partner violence intentions. Conclusions: There are high levels of partner violence among high school students in Cape Town. Interventions to address this problem should focus on violence-related attitudes and outcome expectancy.

Reporting bias in adolescent behavioural research may be overcome with the use of personal digital assistants (PDA) or other computer based technologies. However, there is little insight into the use of these tools among adolescents in low resource settings. We compared self-administered paper questionnaires with PDA questionnaires to collect sexual behaviour data from a sample of 11-19 year olds living in a periurban, Xhosa-speaking community in South Africa. There was a high level of agreement between sexual risk behaviour data collected via each method (kappas greater than or equal to 0.50). Data collected from the PDA questionnaires were more complete. Subjectively, adolescents found the use of PDA to be simple and confidential. PDA may be a useful method to collect sensitive, self-reported information from adolescents in resource-limited settings.

Objectives: To examine the prevalence of bullying behavior in adolescents from Cape Town and Durban, South Africa, and the association of these behaviors with levels of violence and risk behavior. Method: Five thousand and seventy-four adolescent schoolchildren in grade 8 (mean age 14.2 years) and grade 11 (mean age 17.4 years) at 72 Government schools in Cape Town and Durban, South Africa completed self-report questionnaires on participation in bullying, violent, anti-social and risk behaviors. Results: Over a third (36.3%) of students were involved in bullying behavior, 8.2% as bullies, 19.3% as victims and 8.7% as bully-victims (those that are both bullied and bully others). Male students were most at risk of both perpetration and victimization, with younger boys more vulnerable to victimization. Violent and anti-social behaviors were increased in bullies, victims and bully-victims compared to controls not involved in any bullying behavior (p less than 0.01 in all cases). Risk taking behavior was elevated for bullies and bully-victims, but for victims was largely comparable to controls. Victims were less likely to smoke than controls (odds ratio .83, p less than 0.05). Bully-victims showed largely comparable violent, anti-social and risk taking behavior profiles to bullies. Bully-victims showed comparable suicidal ideation and smoking profiles to victims. Conclusions: Results were in keeping with Western findings. Involvement in bullying is a common problem for young South Africans. Bullying behavior can act as an indicator of violent, anti-social and risk-taking behaviors.

This paper provides a process evaluation of a 6-day teacher training programme which forms part of a sexuality education project. The training aimed at providing teachers with the necessary knowledge and skills to effectively teach a 16-lesson Grade 8 (14 year olds) life skills curriculum consisting of participatory exercises on sexual reproductive health, human immunodeficiency virus (HIV), sexual decision-making, abstinence, consequences of sexual activity, safe sex practices, substance abuse and sexual violence. Questionnaires administered prior to the training, on completion of the training and at two follow-up time periods were analysed as well as participant observation notes. Findings indicate that teachers reported increased confidence and comfort in teaching the sexuality curriculum. However, many struggled with the transfer of sexual reproductive knowledge and facilitative teaching methods into the classroom context. This highlights the need for HIV education to form part of teacher trainee programmes. Ongoing support and engagement with teachers is needed to encourage alternative teaching practices.

This study aimed to disentangle the influence of depression and self-esteem on suicidal behaviour in adolescence. Grades 8 and 11 students in Cape Town, South Africa (n=939) completed questionnaires assessing suicidal ideation and behaviour, depression, and self-esteem with respect to family, peers, school, sports/athletics, body image and global self-worth. Data were analysed using a series of multinomial logistic regression models adjusted for gender, grade, race and the sampling strategy. Results indicated that depression and low self-esteem in the family context were independently associated with suicide ideation and attempts. Moreover, low family self-esteem significantly differentiated suicide attempters from ideators. Screening for depression and low self-esteem in the family context is discussed as a possible strategy for helping to identify adolescents at risk for suicide attempts.

Background: This study investigated associations among adolescents' self-esteem in 6 domains (peers, school, family, sports/athletics, body image and global self-worth) and risk behaviours related to substance use, bullying, suicidality and sexuality. Method: A multistage stratified sampling strategy was used to select a representative sample of 939 English-, Afrikaans- and Xhosa-speaking students in Grades 8 and 11 at public high schools in Cape Town, South Africa. Participants completed the multidimensional Self-Esteem Questionnaire (SEQ; DuBois, Felner, Brand, Phillips, & Lease, 1996) and a self-report questionnaire containing items about demographic characteristics and participation in a range of risk behaviours. It included questions about their use of tobacco, alcohol, cannabis, solvents and other substances, bullying, suicidal ideation and attempts, and risky sexual behaviour. Data was analysed using a series of logistic regression models, with the estimation of model parameters being done through generalised estimation equations. Results: Scores on each self-esteem scale were significantly associated with at least one risk behaviour in male and female adolescents after controlling for the sampling strategy, grade and race. However, specific self-esteem domains were differentially related to particular risk behaviours. After taking the correlations between the self-esteem scales into account, low self-esteem in the family and school contexts and high self-esteem in the peer domain were significantly independently associated with multiple risk behaviours in adolescents of both sexes. Low body-image self-esteem and global self-worth were also uniquely associated with risk behaviours in girls, but not in boys. Conclusions: Overall, the findings suggest that interventions that aim to protect adolescents from engaging in risk behaviours by increasing their self-esteem are likely to be most effective and cost-efficient if they are aimed at the family and school domains.

This paper aims to provide surveillance information about the extent and consequences of alcohol and other drug (AOD) use by adolescents for three sentinel sites in South Africa (Cape Town, Durban and Gauteng province). From 1997 to 2001, data were gathered from multiple sources, including specialist treatment centres, trauma units, school students, rave party attenders, and arrestees. Since the start of surveillance, an increasing proportion of South African adolescents are using AODs. Surveys point to high levels of alcohol misuse among high school students, with alcohol being the most common substance of abuse. Cannabis is the most frequently reported illicit drug of abuse among adolescents. This is reflected in the large proportion of adolescents receiving treatment for cannabis, cannabis-positive arrestees, and cannabis-positive trauma patients. Cannabis smoked together with methaqualone is the second most common primary drug of abuse in Cape Town. Arrestee data highlights the potentially negative effect of adolescent methaqualone use. Cocaine and heroin are emerging as problem drugs of abuse among adolescents in large metropolitan centres. Ecstasy (MDMA) use occurs mainly among adolescents who attend rave parties and clubs. The study points to the need for AOD intervention programmes that target young people and the need for continued monitoring of adolescent AOD use in the future.

Aim: To identify social and neighbourhood correlates of drunkenness among adolescents. Design: A cross-sectional, community study. Participants: A multi-stage cluster sampling strategy was used to select 90 adolescents aged 11-17 years from nine distinct communities in Cape Town, South Africa. The sample was stratified by race, income, and gender. Randomly selected adolescents from each household were interviewed by trained interviewers. Instrument: A questionnaire that included questions on substance use behaviour, peers, neighbourhood factors and recreational activities. Results: A third of the sample indicated having been drunk at least once in their lifetime. Older adolescents and adolescents whose friends drink were significantly more likely to have been drunk. The risk of having been drunk was also associated with being white and with being exposed to public drunkenness on a daily or at least weekly basis. Gender was not associated with reporting of lifetime drunkenness. Attendance at religious services (at least weekly) was found to be a significant protective factor against drunkenness. Conclusion: The study highlights a number of environmental factors that should be considered in tackling adolescent drunkenness.

Objective: The aim of this article is twofold: first, to examine the prevalence of being the victim of actual and attempted rape among a large representative sample of Cape Town high school students; and second, to identify the correlates of sexual assault for both boys and girls, including alcohol, tobacco and other drug use, behavioral problems, and suicidality. Method: Data for this study were derived from the 1997 South African Community Epidemiology Network on Drug Use (SACENDU) school survey. A stratified sampling procedure was used to select students in Grades 8 and 11 at non-private high schools in Cape Town. A total of 2,946 students completed a survey consisting of socio-demographic questions and items about substance abuse, sexual activity, and other adolescent health risk behaviors. A subsample of 939 was randomly selected to complete items about sexual violence. Results: The results revealed that 8.4% of respondents were victims of attempted rape, while 5.8% were victims of actual rape. Ordinal logistic regression showed that girls were 3.9 times more likely than boys to have been victims of sexual abuse. Family structure was also significantly related to rape as persons who lived with a single parent (OR = 1.74, CI = 1.00-3.04) and those who resided with one biological parent and one step parent (OR = 2.59, CI = 1.34-5.01) were more likely to have been have been victims of sexual abuse than those living with both biological parents. Alcohol use (OR = 2.0, CI = 1.10-3.62), anti-social behavior (stolen property, caused physical damage to property, bullied others, or been in physical fights) (OR = 1.44, CI = 1.12-1.86), suicidal dialogue (OR = 2.48, CI = 1.19-5.19), and suicidal attempts (OR = 3.2, CI = 1.65-6.30) were also significant predictors of sexual abuse victimization. Racially classified social groups (RCSG), age, drug use, and cigarette smoking were not significant predictors of sexual abuse victimization, while socioeconomic status was found to be marginally significant. Conclusion: This study reinforces the importance of multiple factors including alcohol use, anti-social behavior, suicidal thoughts and actions, and family structure with respect to sexual assault of adolescents in South Africa. Establishing and strengthening intervention programs, school based child protective protocols, professional education of teachers and school personnel, community prevention programs, and initiatives could help prevent adolescent sexual violence and reduce the sequelae associated with this problem.

There is a paucity of test-retest reliability data for adolescent self-reports of a wide range of risk behaviours. Grade 8 and 11 Students (N=358) completed a questionnaire on two occasions between 10 and 14 days apart. It included items about use of various substances, violent behaviour, suicidality, and sexuality. Cohen's kappa was almost perfect for 1 item (@k=85.4%); in the substantial range (61-80%) for 4 items; and in the moderate range (41-60%) for 3 items. For the remaining 7 items, the percentage agreement was higher than 92.0%. The questionnaire thus demonstrates adequate test-retest reliability.

Associations among six different domains of self-esteem (peers, school, family, sports/athletics, body image, and global self-worth) and risk behaviors related to substance use and suicidality were investigated in a sample of South African adolescents. Students enrolled in Grades 8 and 11 at independent secondary schools in Cape Town (N = 116) completed the Self-Esteem Questionnaire (SEQ) and a questionnaire that asked about their participation in a range of risk behaviors. Logistic regression analyses indicated that particular domains of self-esteem were differentially associated with indicators of alcohol, cigarette and drug use and suicidal ideation or behaviors in adolescents. Family self-esteem showed the strongest overall pattern of associations with the risk behaviors. Overall, the findings of this study suggest that interventions which aim to protect adolescents from engaging in risk behaviors by increasing their self-esteem are likely to be most effective and cost-efficient if they are aimed at the family and school domains.

Study seeks to examine, for South African adolescents, the reliability of the Communities that Care Youth Survey of risk and protective factors for drug use and anti-social behavior, and the extent to which drug use can be predicted from community, family, school, and peer factors. Findings support use of the survey with slight revisions for South African high school students. (Contains 24 references and 4 tables.) (GCP)

The aim of the study was to document the correlates of receiving counseling services at the University of Cape Town, South Africa. Results reveal that non-English speakers, humanities students, undergraduates, first-year students, students who were eligible to receive financial assistance, and students from outside Cape Town were significantly more likely to receive counseling. (Contains 57 references.) (GCP)