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. Author manuscript; available in PMC: 2024 Jul 1.
Published in final edited form as: Cult Health Sex. 2022 Aug 12;25(7):929–943. doi: 10.1080/13691058.2022.2108501

Social resources, resilience, and sexual health among South African adolescent girls and young women: Findings from the HERStory study

Ashleigh LoVette a,*, Adam Sullivan a, Don Operario a, Caroline Kuo a, Abigail Harrison a, Catherine Mathews b
PMCID: PMC9922337  NIHMSID: NIHMS1848356  PMID: 35960862

Abstract

Socioecological factors, including social resources, influence South African adolescent girls’ and young women’s sexual health. Few studies have explored how these multi-level social factors relate to both resilience and sexual health in the community. This study examines if social resources mediate associations between resilience and two sexual health outcomes. A weighted-sample of 7,237 South African girls and young women (aged 15-24 years) completed a cross-sectional survey conducted from 2017-2018 which included a validated measure of resilience, along with measures of sexual health and social resources. Using multivariable logistic regression models and bootstrapping methods, two types of social resources were assessed as potential mediators. Data were analysed using SPSS and R software. Increased resilience was negatively associated with early sexual debut and engagement in transactional sex. Social support mediated associations between resilience and engagement in transactional sex but did not mediate associations between resilience and early sexual debut. Of all the types of social support measured, social support from a special person mediated the largest proportion of the association between resilience and transactional sex. Examining underlying social and community dynamics related to resilience and sexual health can guide the development of future contextually-relevant programming and policies.

Keywords: resilience, social support, sexual health, transactional sex, young women

Introduction

Young people’s sexual decisions and behaviours are influenced by the broader socioecological context of their relationships and communities (Kelly and Ntlabati 2002; Govender et al. 2019). In South Africa, sexual decisions and behaviours take place within one of the largest HIV epidemics in the world (Simbayi et al. 2019). Socioecological factors influencing sexual health occur within and across multiple levels of the socioecological framework (Bronfenbrenner 1992), with individual agency, interpersonal dynamics related to family, peers and partners, and cultural norms around gender, playing a particularly important role for South African girls and young women (Eaton, Flisher and Aarø 2003; Jewkes and Morrell 2012).

Sexual risk behaviours, such as early sexual debut and engaging in transactional sex, can influence the sexual health of girls and young women. Specifically, each of these behaviours is associated with poor sexual health outcomes among South African girls and young women (Jewkes et al. 2012; Zuma, Mzolo and Makonko 2011). Several studies have linked early sexual debut, or sex before the age of 15 years, to increased lifetime HIV risk in sub-Saharan Africa (Stöckl et al. 2013; Wand and Ramjee 2011). A recent national-level survey reported that engagement in early sexual debut slightly increased (5.0% to 7.6%) over a five-year time period (2012 to 2017) in South Africa (Simbayi et al., 2019). Engaging in transactional sex has also been associated with increased risk for HIV and other sexually transmitted infections (STIs) in South Africa and other low- and middle-income countries (Krisch et al. 2019; Wamoyi et al. 2016) While transactional sex can be defined as the informal exchange of sex in return for goods or money, or the expectation of goods or money, it is not necessarily considered sex work within the Southern African context, but rather part of the dynamics of young people’s relationships, which also include explorations of sexuality and love (Bhana and Pattman 2011; Wamoyi, Ranganathan et al. 2019). It is important to note sexual behaviour among South African girls and young women is not only associated with risk and lack of safety, and that within transactional sex interactions and relationships, young women can exercise individual agency, most notably in partner choice (Ranganathan et al. 2017).

Together, these social and behavioural factors create a context of heightened adversity that South African girls and young women must engage with to maintain optimal sexual health and well-being. Many health promotion efforts use deficit-based approaches focused solely on reducing individual risk to address the health issues faced by South African girls and young women. However, focusing on risks and deficits limits opportunities to build upon existing strengths and positive health behaviours demonstrated by those successfully navigating contexts of adversity. Resilience, which is defined as the multi-level processes related to overcoming adversity, offers a strengths-based framework to promote sexual health for adolescents and young people (Fergus and Zimmerman 2005; Khanlou and Wray 2014). Definitions of this concept have previously been limited to individual psychological processes, but current conceptualisations have also considered the importance of cultural and social processes, resulting in a multidimensional and ecological conceptualisation (Ungar 2012).

With its emphasis on ecological co-occurring processes, a resilience-based approach also creates an opportunity to more closely examine the social factors placing South African girls and young women at increased sexual risk (Masten 2016; Theron and Liebenberg 2015). Many South African researchers have contributed significantly to the multidimensional conceptualisation of resilience used to frame this study, especially among young people within the South African context (Ebersöhn and Ferreira 2011; Moletsane and Theron 2017). Current resilience literature emphasises the importance of understanding multi-level processes of resilience related to mental health and calls for further examination of the social protective and promotive factors frequently associated with positive mental health outcomes. However, resilience-based research exploring how social resources are associated other health outcomes, including sexual health outcomes associated with increased HIV risk, remains limited (Ungar and Theron 2020). Existing literature about sexual health and resilience within this context has documented resilience as one way in which South African girls and young women negotiate and challenge gendered assumptions about sex in the context of sustained HIV risk and gender-based-violence (Haysom 2017; Singh and Naicker 2019).

Many programmes to promote adolescent sexual health acknowledge the larger socioecological environment, but at the same time focus primarily on individual level behaviour change. However, sexual experiences are inherently interpersonal, being driven by relationships as well as social and community resources. There is growing interest in better understanding the mediating effect of these social resources on the pathway between resilience and health outcomes (Armstrong, Birnie-Lefcovitch and Ungar 2005; Pinkerton and Dolan 2007). That is, the conceptual relationship between resilience and health may be explained by the impact of resilience on social resources which, in turn, can contribute to sexual health outcome. Two specific social resources are particularly relevant to understanding associations between resilience and health: social support and social capital. Social support often focuses on dynamics at an interpersonal level, such as those involving family, peers, and significant others (Zimet et al. 1988). The related concept of social capital considers these dynamics at a larger community and societal level (Szreter and Woolcock 2004). Through connection, relationships and trust, social capital can facilitate access to resources and also shape expectations about behaviour of others (Szreter and Woolcock 2004). One South African study found resilience and select dimensions of social capital, such as trust at a bridging level (e.g. traditional leadership and community-based organisations), were both significantly associated with good self-rated health among adolescents living with HIV (Dageid and Grønlie 2015). Existing research in this area can be expanded by examining social resources related to both resilience and sexual health.

By investigating the potential mediating effect of social resources between associations between resilience and sexual health outcomes, this study builds upon an emerging body of literature focused on resilience and sexual health. Drawing from a large household representative sample of South African girls and young women, this paper seeks to address a gap in the literature by exploring community and social factors in relation to resilience and sexual health among adolescent girls and young women. To evaluate the influence of these social resources on resilience and sexual health, this study assesses whether two types of social resources mediate associations between resilience and sexual health outcomes among South African girls and young women. Study results can support the need for resilience-based programming seeking to improve sexual health among this population.

Methods

Study Design

The data for all analyses were generated from the HERStory Study, an evaluation of combination HIV prevention programming for South African adolescent girls and young women at heightened risk for HIV due to behavioural and interpersonal interactions shaped by sociocultural norms and structures around sex, education and relationships. This cross-sectional survey was conducted from 2017 to 2018 in six districts located within five provinces in South Africa where combination HIV prevention programs were implemented. HIV prevention programmes were implemented in these areas to address the increased vulnerability to HIV among girls and young women across various geographic, cultural and socioeconomic contexts that influence sexual health and well-being, including poverty and healthcare access. Data for this paper are drawn from this representative household survey of adolescent girls and young women aged 15 to 24 years living in these six districts. The HIV prevalence within the surveyed districts, which included the City of Cape Town (Western Cape Province), Ehlanzeni (Mpumalanga Province), OR Tambo (Eastern Cape Province), Tshwane (Gauteng Province), King Cetshwayo and Zululand (KwaZulu-Natal Province), ranged from 18.6 to 38.5% highlighting the importance of HIV prevention for this population (South African National Department of Health 2013). These districts represent areas where South African adolescent girls and young women face significant HIV risk and reflect diversity in population density as well as prevalence of formal and informal dwellings.

The HERStory study used a stratified sampling design with districts as the primary strata. After using census data to create sampling areas, a systematic random sample of 35% of the available households within the sampling areas across the 6 districts were selected. The overall sample realisation was 60.6% across the surveyed districts. Sample weights, which were based on the sampling probability of the primary sampling units in each district, and the systematic probability of households within each sampling area, were adjusted within each district to match the planned sample size. We used a weighted sample size of 7,237 observations for study analyses.

All adolescent girls and young women aged 15 to 24 years in sampled households were invited to participate. A trained interviewer administered the survey to each eligible participant via a tablet after receiving informed consent. Reflecting the diversity of South Africa, the survey was available in five languages (English, isiZulu, Sotho, Afrikaans, isiXhosa) and the research staff administering the survey spoke multiple languages, often aligned with the most commonly spoken languages within the survey district. To address issues around literacy, trained research staff read aloud questions and responses to participants in the survey language chosen by the participant. Sections of the electronic questionnaire with sensitive questions, including sexual experiences, were read aloud and then completed privately by the participants to diminish social desirability bias that might otherwise affect the quality of data. Participants could choose not to answer any survey questions and were reimbursed for the time they spent completing survey. Ethical clearance for this study was provided by the South African Medical Research Council Research Ethics Committee (ref. no. EC036-11/2016) and by the Center for Global Health Associate Director for Science, US Centers for Disease Control and Prevention (CDC) (ref. no. CGH 2017-194a). All study team members, including staff administering the survey, received training in the ethical conduct of research. No ethical issues flagged by the review committees went unresolved and the study team clearly and regularly communicated with both ethical review committees.

Measures

Sociodemographic Characteristics

Age and self-identified race/ethnicity were included in the survey. While those who did not self-identify as either “African” or “Coloured” are included in descriptive analyses, these participants were not included in the final analyses since they comprised less than 1% of the total sample.

Resilience

Resilience was measured using the 10-item version of the Connor-Davidson Resilience Scale (CD-RISC-10), which is a validated unidimensional measure of positive functioning in the face of adversity (Campbell-Sills and Stein 2007). The CD-RISC-10 can range from 0 to 40 points with higher scores indicating greater psychological resilience and has previously demonstrated strong psychometric properties among South African adolescents (Jorgensen and Seedat 2011). Internal reliability of the scale was good (Cronbach’s alpha α= 0.83).

Sexual Health Measures

Two sexual health measures related to HIV risk, transactional sex and age of sexual debut, were assessed in the survey via self-report. Participants who reported having sex at least once (n=5,005) were asked to report their age the first time they had sex. Those who reported sexual debut prior to age 15 were included in the early sexual debut group (Stöckl et al. 2013; Wand and Ramjee 2011). All participants were asked about engagement in transactional sex behaviour. To measure transactional sex, participants were asked if they had ever given oral, anal, or vaginal sex to someone for any of the following reasons: money, transport, food for myself/family, clothes/shoes, shelter, school fees/school uniforms, airtime, cell phone, items for children/family, cosmetics, other. If they responded affirmatively to any of these options, they were classified as having engaged in transactional sex. Dichotomous variables indicating participation in transactional sex, and early sexual debut, were used for all analyses.

Social Support

Social support was measured with the Multidimensional Scale of Perceived Social Support (MSPSS) (Zimet et al. 1988). The MSPSS is a 12-item scale designed to measure perceived social support from three sources: family, peers/friends, and a special person (e.g. significant other, dating partner, romantic partner). The MSPSS previously demonstrated strong psychometric properties among South African young people (Bruwer et al. 2008). Within the current study population, the scale presented good reliability from all three sources, family (Cronbach’s alpha α= 0.85), peers (Cronbach’s alpha α= 0.88), and a special person (Cronbach’s alpha α= 0.77).

Social Capital

For social capital, we measured support from groups and citizenship activities using an adapted version of the social cohesion scale of the short version of the Adapted Social Capital Assessment Tool (SASCAT) (De Silva et al. 2006). This measure has previously been used within South Africa and was originally validated in lower- and middle- income countries (De Silva et al. 2007; Pronyk et al. 2008). For group support, participants indicated if they had received emotional or economic help, or assistance in knowing or doing things from the following groups over the past 12 months: club, youth/student group, community group, religious group, volunteer group, political group. The positive responses were then added to create a possible maximum group support score of 6. Citizenship activities in the SASCAT measured whether the participant joined together with other community members to address a problem or common issue or spoke with a local authority or governmental organisation about problems in the community over the past 12 months. For citizenship activities, participants received 1 point for each positive response for a potential maximum score of 2. Internal reliability for this dimension was acceptable (Cronbach’s alpha α= 0.71).

Statistical Analyses

Descriptive analyses were used to examine sample characteristics related to resilience, sexual health, and demographics. We then used bivariate analyses to determine potential mediators and to identify variables to adjust for in the final models. These analyses also identified dimensions of social capital to include in each model. Next, we examined if social support and the previously determined dimensions of social capital mediated the effect of associations between resilience on sexual health outcomes using the statistical package and methods outlined by Tingley and colleagues (2014). Multivariable logistic regression models were created to examine if the effect of each social resource mediated a significant proportion of the effect of resilience on the selected sexual health outcome. All models employed bootstrapping techniques to provide average effect estimates and confidence intervals over 1,000 simulations. All tests were two-tailed (p < .05). Descriptive and regression analyses were conducted using SPSS statistical software version 27 and mediation analyses were completed using R version 3.5 (IBM Corp 2017; R Core Team 2017).

Results

Table 1 presents descriptive statistics for all variables of interest as well as sociodemographic characteristics of the study sample. Participants reported a mean resilience score of 24.57 points as measured by the CD-RISC-10 (Range: 0-40 points; Standard Deviation (SD): 7.64 points), which is comparable to mean scores of similarly aged populations in various countries (Davidson 2018). Results across the study’s age groups (15-19 and 20-24) were similar across most characteristics, including resilience and social resources, with the exception being older participants (aged 20-24) reporting more engagement in citizenship activities than younger participants (aged 15-19). There were also observed differences in sexual health measures by age group. At the time of the survey, approximately 70% of the overall sample reported ever having penetrative vaginal or anal sex, but the percentage was lower (~53%) among the younger age group (15-19). Among participants who had ever had sex (n=5,005), 9% reported having sex before the age of 15 years, which accounted for 6% of the total weighted sample (N=7,237). Out of all the study participants, 9.5% reported ever engaging in transactional sex. Differences in early sexual debut and engagement in transactional sex among the two study age groups were also observed, which resulted in age being accounted for in the following models.

Table 1.

Participant characteristics of weighted-sample of South African girls and young women, aged 15-24 years, 2017-2018

Ages 15-24
(N=7237)
Mean (SD)
Frequency (%)		 Ages 15–19
(N=4101)
Mean (SD)
Frequency (%)		 Ages 20-24
(N=3136)
Mean (SD)
Frequency (%)
Sociodemographic Characteristics
Age 19.09 (2.74) 17.03 (1.41) 21.79 (1.38)
Self-Identified Race/Ethnicity
  African 6500 (89.8) 3666 (89.4) 2834 (90.4)
  Coloured 701 (9.7) 418 (10.2) 283 (9.0)
  Other 36 (0.5) 17 (0.4) 19 (0.6)
Resilience
CD-RISC (10-item) Score 24.57 (7.64) 24.13 (7.59) 25.13 (7.68)
Sexual Health
Ever had sex
  Yes 5005 (69.2) 2167 (52.8) 2838 (90.5)
  No 2232 (30.8) 1934 (47.2) 298 (9.5)
  Sexual Debut
   Early Sexual Debut (<15 years) 443 (8.9) 262 (6.4) 181 (5.8)
   Later Sexual Debut (≥15 years) 4562 (91.1) 1905 (87.9) 2657 (84.7)
Transactional Sex
  Yes 685 (9.5) 290 (7.1) 395 (12.6)
  No 6552 (90.5) 3811 (92.9) 2741 (87.4)
Social Resources
Social Support: MSPSS
  Family Support Score 5.14 (1.50) 5.14 (1.49) 5.13 (1.52)
  Peer Support Score 4.74 (1.60) 4.87 (1.53) 4.57 (1.66)
  Special Person Support Score 5.18 (1.50) 5.17 (1.49) 5.21 (1.52)
Social Capital: SASCAT (Adapted)
  Support from Groups
  No support reported 5421 (74.9) 3082 (75.1) 2338 (74.6)
  At least one type of support 1816 (25.1) 1019 (24.8) 798 (25.4)
 Citizenship Activities
  No reported activities 5917 (81.8) 3492 (85.2) 2425 (77.3)
  At least one activity 1320 (18.2) 609 (14.8) 711 (22.7)
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Two types of social resources, social support and social capital, were assessed as potential mediators of associations between resilience and two sexual health outcomes, sexual debut and transactional sex. We adjusted for sociodemographic variables in each model. In the models with transactional sex as the outcome, models were adjusted for age and self-identified race/ethnicity. Table 2 provides the results of each model with transactional sex as the outcome along with the proposed mediators. Results from these analyses indicated that, on average, resilience had a small significant negative direct effect on having ever engaged in transactional sex. These results also showed a significant proportion of the direct effect of the association between resilience and transactional sex is mediated by all three sources of social support but is not mediated by the social resource of social capital. Social support from a special person, or significant other, mediated the largest percentage of the association between resilience and transactional sex at 17.5% (95% Confidence Interval (CI): 0.10 - 0.36; p <.001). Social support from family mediated, on average, 16.3% of the effect on the association between resilience and transactional sex (95% CI: 0.09 - 0.35; p <.001) and social support from peers mediated, on average, 11.8% of the effect on the association between resilience and transactional sex (95% CI: 0.06 - 0.25; p <.001). Although social support significantly mediated associations between resilience and transactional sex, the social resource of social capital, as measured by participation in citizenship activities, did not appear to significantly mediate these associations.

Table 2.

Models assessing average effects on associations between resilience on transactional sex (Reference group: no transactional sex)

Average Effect Estimate (95% Confidence Interval)
(n=4,383)
Mediator: Social Support
(Family)		 Mediator: Social Support
(Peer)		 Mediator: Social Support
(Special Person)		 Mediator: Social Capital
(Citizenship Activities)
Total Effect −0.017 (−0.024, −0.010)*** −0.018 (−0.025, −0.010)*** −0.018 (−0.024, −0.010)*** −0.018 (−0.025, −0.010)***
Direct Effect on Outcome −0.014 (−0.022, −0.010)*** −0.016 (−0.023, −0.010)*** −0.015 (−0.021, −0.010)*** −0.017 (−0.024, −0.010)***
Mediated Effect −0.003 (−0.004, 0.000)*** −0.002 (−0.003, 0.000)*** −0.003 (−0.004, 0.000)*** −0.001 (−0.001, 0.000)
Proportion of Mediated Effect 0.163 (0.089, 0.350)*** 0.118 (0.059, 0.250)*** 0.175 (0.096, 0.360)*** 0.028 (−0.004, 0.070)
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*

p <.05

**

p <.01

***

p <.001

Models with sexual debut as the outcome were adjusted for age and self-identified race/ethnicity. The results for these models can be found in Table 3. Results indicated that on average, resilience had a small significant negative direct effect on sexual debut across all models. However, neither social support nor social capital, as measured by support from groups, appeared to significantly mediate the average effect on the association between resilience on early sexual debut

Table 3.

Models assessing average effects on associations between resilience on sexual debut (Reference group: later sexual debut)

Average Effect Estimate (95% Confidence Interval)
(n=2,999)
Mediator: Social Support
(Family)		 Mediator: Social Support
(Peer)		 Mediator: Social Support
(Special Person)		 Mediator: Social Capital
(Support from Groups)
Total Effect −0.015 (−0.023, −0.010)** −0.015 (−0.023, 0.000)** −0.015 (−0.023, −0.010)** −0.015 (−0.023, −0.010)**
Direct Effect on Outcome −0.014 (−0.022, 0.000)** −0.014 (−0.022, 0.000)** −0.014 (−0.022, 0.000)** −0.015 (−0.023, −0.010)**
Mediated Effect −0.001 (−0.002, 0.000) −0.0004 (−0.001, 0.000) −0.001 (−0.002, 0.000) <.001 (−0.000, 0.000)
Proportion of Mediated Effect 0.063 (−0.009, 0.240) 0.024 (−0.027, 0.110) 0.038 (−0.056, 0.180) <0.001 (−0.036, 0.020)
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*

p <.05

**

p <.01

***

p <.001

Study results identified social support components within resilience-promoting programmes as having a greater potential effect on outcomes compared to social capital components. Additionally, social support mediated the average effect of associations between resilience and engagement in transactional sex but did not appear to mediate the association of resilience and sexual debut. Overall results, especially around associations between resilience, social support, and transactional sex, support the need for a deeper understanding of the underlying social dynamics influencing associations between resilience and sexual health outcomes among adolescent girls and young women living in a context of heightened adversity.

Discussion

This study’s findings add to emerging research emphasising greater understanding of how the context of relationships and social resources influences sexual health outcomes among adolescents and young people (Coyle et al. 2014; Matson et al. 2021). Findings raise important questions for resilience-focused interventions aiming to improve the sexual health of South African girls and young women facing increased adversity. Study findings showing differences in mediation by type of social resources also offer preliminary data that indicates how different types of social resources emphasised within programmes could have varying effects on sexual health outcomes of interest.

More specifically, findings indicated that all three types of social support mediated associations between resilience and transactional sex, which may support the integration of social support from multiple sources, such as family, peers and a special person (significant other) into resilience-focused interventions aiming to decrease engagement in transactional sex. However, this approach may be limited in terms of feasibility and implementation. If focusing on one type of social support, findings suggest building on support from a special person, or significant other, may be a promising approach based on results that a special person mediated the largest percentage of the association between resilience and transactional sex. For example, a resilience-focused intervention could use a dyadic design, specifically a couples’ approach, or include healthy relationship content aimed at strengthening this support, with the ultimate goal of promoting sexual health among South African adolescent girls and young women.

Study findings also raised the question of why social support mediated associations between resilience and transactional sex, but not resilience and sexual debut among this population. One explanation for this finding is that sexual debut occurs only once, while engagement in transactional sex has the potential to occur multiple times over an extended period for adolescent girls and young women, and therefore may be more amenable to ongoing influence by social context. Previous literature highlighting the complex social dynamics related to transactional sex provides another rationale for social resources only mediating the effect on transactional sex. Studies from Zimbabwe offer insight into the complexities of transactional sex, with one using social mapping techniques to explore social and community dimensions among of transactional sex among young women in Zimbabwe, and finding distinct differences based on context (Chiyaka et al. 2018), and the other noting that depending on context some women engage in transactional sex on their own terms in an effort to obtain prestige and social status (Masvawure 2010). Another South African study using qualitative methods described the nuanced contextual nature of transactional sex, and how it is deeply embedded in young women’s intimate relationships (Ranganathan et al. 2017). While transactional sex has been associated with increased HIV risk quantitatively, qualitative research conducted in South African among young women adds additional nuance to this practice by recognising the sexual agency and desire of young women and argues for a more critical position of transactional sex that more fully considers the complexities of this practice (Shefer, Clowes and Vergnani 2012). Future research should continue to explore other potential social and community resources related to resilience and sexual health, with a particular focus on how context and social resources shape engagement in transactional sex practices. Also noteworthy is the stronger mediation observed when social resources focused on relationships (e.g. support from significant others), rather than participation in community activities and groups. This is consistent with research exploring the concept of “relational resilience” among girls and young women within and outside this context (Jordan 2013; van Breda and Theron 2018). Health programming focused on this relational domain of resilience can co-occur alongside of programming promoting individual agency and psychological processes, an approach that is well-aligned with current multilevel and multidimensional conceptualisations of resilience.

It is important to contextualise these findings within the complex social and political context impacting South African girls and young women (Zembe et al. 2013). Many young women who engage in transactional sex within this context do so as active participants, and for a variety of reasons, including prestige and social status (van der Heijden and Swartz, 2014). A literature review of more than 300 studies examining girls and young women’s motivations for transactional sex in sub-Saharan Africa identified three main explanations for this practice: (1) sex for basic needs; (2) sex for improved social status; and (3) sex as a material expression of love (Stoebenau et al. 2016). This review also identified common structural factors shaping these paradigms, including gender inequities and economic issues. Thus, transactional sex is not an inherently exploitative practice, but rather may become harmful when shaped by context-specific cultural norms related to transactional sex, or power imbalances related to gender and social status (Wamoyi, Heise et al. 2019). With consistently high rates of gender-based violence and unemployment, future research needs to consider this more nuanced understanding of transactional sex along with the multi-level and structural factors driving decisions around sex, choice of partner, and income (Abrahams et al. 2012). Focusing on these factors and advocating for changes in policy and structure can help us move beyond addressing solely individual-level drivers of poorer sexual health among, and towards upstream drivers that may ultimately reduce the need for adolescent girls and young women to be extremely resilient in order to thrive.

In some settings within South Africa, transactional sex is considered a stigmatised behaviour linked to negative sexual health outcomes and has historically been associated with the concept of age-disparate relationships (Leclerc-Madlala 2008; Luke 2003). More recently within the South African context, this phenomenon has been described as relationships between “blessers and blesses” where more affluent, usually older men, called blessers, provide money and gifts to young women, called blessees, in return for sexual favours (Mampane 2018). The disparities in age and gender dynamics of this phenomenon can result in an imbalance in power within these relationships. This power imbalance driven by structural factors was acknowledged among young participants in a South African study using participatory action research to explore contextual resilience-enabling factors as well as the ‘blesser’ phenomenon (Varjavandi 2017). This context is also important considering social support from a special person, or significant other, was found to mediate the largest amount of the association between resilience and transactional sex. Resilience-based policy and programming should consider the nuanced and contextual aspects of this phenomenon by recognising the structural and social factors driving these power differentials, avoiding language of individual shame, and by also acknowledging the sexual agency and desires of girls and young women within this context.

Limitations

Several study limitations are acknowledged. This study used cross-sectional data, which prevents us from making inferences around causality. It also used only quantitative data from a larger dataset that does not necessarily account for the complex sociocultural dynamics in South Africa, or potential differences in developmental stage (i.e. late adolescence, emerging adulthood), that might influence the sexual health of girls and young women in this setting. Future work could also include qualitative data, and/or a mixed-methods study design, to better account for these issues, and to explore possible differences due to age. Additionally, while resilience was framed as the primary predictor in these analyses, we acknowledge that resilience and social resources are strength-based concepts that often occur together over time. Future research should seek to measure resilience and other individual and social factors at multiple time-points to address limitations related to direction of associations and temporality. Furthermore, this study uses self-reported data, which is subject to social desirability bias and recall limitations. We attempted to limit social desirability bias by using tablets to administer the questionnaire, and having participants respond to sensitive questions related to sexual behaviour privately. It is also important to acknowledge that the survey questionnaire providing data for this study focused largely on cisgender and heterosexual experiences and relationships. Future research should consider a range of questions to allow for greater representation of the experiences of girls and young women with other sexual orientations and gender identities.

Conclusions

This paper contributes to the growing area of research examining socioecological factors associated with resilience and health among South African girls and young women facing adversity. Findings highlight associations between resilience and sexual health while acknowledging the importance of the role of different types of social resources, especially social support, on the pathway between resilience and engagement in transactional sex. Study findings identifying mediation between resilience and sexual health indicate that researchers and professionals using resilience-based approaches to improve sexual health should recognise the importance of social and community factors as determinants of health among adolescent girls and young women and may wish to include these influential factors within programming to promote sexual health among members of this population. Additional research, especially longitudinal and mixed-methods research, must continue to examine resilience, sexual health, and social resources over time and across contexts to increase our knowledge of these multi-dimensional, and dynamic concepts, and to channel research findings into improved programme and policy outcomes.

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