Making sense of abstinence: social representations in young Africans’ HIV-related narratives from six countries

Abstract

Despite the prominence of abstinence promotion in HIV prevention for young Africans, there is little documentation concerning its reception and interpretation. With the purpose of informing programmatic practice, we examined how young Africans from six countries with contrasting HIV prevalence rates make sense of abstinence. ‘Scenarios from Africa’ scriptwriting contests invite young people to contribute ideas for short films about HIV. Using thematic narrative-based approaches, we analyzed a stratified random sample of 586 (~5%) of these narratives written in 2005 by young women and men aged 10–24 years from Senegal, Burkina Faso, South-East Nigeria, Kenya, Namibia and Swaziland. Abstinence was considerably more prominent as a theme in the samples from SE Nigeria, Kenya and Swaziland. It was articulated in relation to conservative Christian sexual morality and in opposition to condom use with particular intensity in SE Nigeria, with stigmatising implications for non-abstainers. However, cross-national commonalities were more striking than differences. Examples of non-stigmatising pro-abstinence messaging highlighted the appeal of discourses of romantic love and future plans across countries and demographic characteristics. The analysis yielded contextual understanding, youth-driven ideas, and recommendations to inform comprehensive HIV prevention efforts.

Introduction

In 2009, approximately 1.3 million Africans lost their lives to AIDS, while a further 1.8 million were newly infected with HIV (UNAIDS 2010). In sub-Saharan Africa, around 45% of all new infections are in young people between the ages of 15 and 24, and three-quarters of these are among young women. Despite their vulnerability, young people offer strong hope for reducing the spread of HIV and reversing epidemiological trends (UNAIDS 2008).

Defined by UNAIDS as ‘not engaging in sexual intercourse or delaying sexual initiation’ (UNAIDS 2004), abstinence is the most effective means of avoiding HIV/STIs and unwanted pregnancy when practised consistently. However, its high failure rate is often disregarded and its promotion has in recent years been dominated by an ideologically-driven agenda in lieu of a scientific evidence base (Santelli et al. 2006). Abstinence-only interventions have been criticized ‘for containing inaccurate information, portraying sex in a negative light, using a moralistic tone, and risking unintended consequences’ (Jemmott, Jemmott, and Fong 2010, 153). Unintended consequences include increased risk of unprotected sex following sexual initiation, given that these interventions do not prepare young people for a natural event that will almost inevitably occur at some point in their lives.

The promotion of abstinence has occupied a central place in HIV prevention for young people across sub-Saharan Africa in recent years, most notably through the priorities of the US President’s Emergency Fund for AIDS Relief (PEPFAR) (The United States President's Emergency Plan for AIDS Relief 2010). There is substantial evidence from sources including the United States Government Accountability Office that this has come at the detriment of other HIV prevention strategies (United States Government Accountability Office 2006; Graham 2009; Gayle 2006). There is an urgent need for a stronger research base to support the development of effective programmes that support abstinence in the context of comprehensive HIV prevention in sub-Saharan countries.

Most Africa-focused abstinence-oriented research has analyzed survey data to describe a range of factors associated with timing of first sex, intention to abstain, and self-reported primary abstinence (delaying of sexual debut) or secondary abstinence (abstaining from sex among those who have already been sexually active) among young people in individual countries (Koffi and Kawahara 2008; Fatusi and Blum 2008; Njau et al. 2009; Yeboah Tenkorang and Maticka-Tyndale 2008; Babalola 2004). Concerns about the uncertain validity, tenuous correlation with biological indicators, and limited explanatory power of survey data on sexual behaviours (Obermeyer 2005) argue for increased focus on qualitative approaches. A handful of recent qualitative studies provide a more holistic perspective via interviews and focus group discussions conducted with young Africans (Izugbara 2008; Izugbara 2007; Babalola, Ouedraogo, and Vondrasek 2006; Nobelius et al. 2010; Kahn 2006). Although this research has the advantage of linking sexual behaviours to their context and providing access to the perspectives of individual young people, its impact is limited by the fact that it is conducted in a small number of often highly circumscribed settings and without a clear point of comparison outside the study site. In the light of the cross-national impact of PEPFAR, evangelical Christian movements, and ideologies of companionate marriage, there is further need to situate youth perspectives on abstinence within a broad sub-Saharan context.

In this paper, we present an analysis of social representations (Moscovici 1981; Campbell et al. 2010) of abstinence in a substantial corpus of qualitative data, comprising 586 fictional narratives written by young people aged 10–24 years from six African countries/regions with estimated adult HIV prevalence rates ranging from 1 to 33%. Narratives are a source of insight into how people make sense of the world, and how they communicate those understandings to others (Bruner 1990). In this study, they provide access to the voices and imaginings of young Africans in a largely unmediated way, revealing their spontaneous mentions of abstinence, rather than their responses to specific interview or focus group questions. The narratives illuminate cultural resources available to young people in and across the six settings as they strive to make sense of HIV and the role of abstinence in its prevention, highlighting important commonalities and some differences in social representations across countries and demographic categories.

Despite the prominence of pro-abstinence messaging for young people in Africa, there is little documentation of its reception and interpretation. Although shared meanings and common understandings are critical to the success of health education efforts, the term abstinence is rarely clearly defined (Koffi and Kawahara 2008). In a study among Kenyan in-school youth, aged 13–19, only 48% fully comprehended the term (Lillie, Pulerwitz, and Curbow 2009). Here, we examine young people’s narratives to present a cross-national youth-based perspective on abstinence with the purpose of informing programmatic practice.

Methods

Since 1997, contests organised by the Scenarios from Africa communication process have invited young Africans, up to age 24, to contribute scripts for short fiction films to educate their communities about HIV and AIDS (Global Dialogues 2011; Winskell and Enger 2005). The young contest participants are mobilised by non-governmental and community-based organisations and local, national and international media across sub-Saharan Africa. A leaflet, available in several major languages, is used continent-wide to provide young people with instructions on how to participate. The winning ideas in each contest are selected by local juries and, following adaptation, transformed into short fiction films by leading African directors. Thirty-five films have been produced to date (Scenarios from Africa 2010) and are available in over 25 languages for television broadcast and use at community level. By 2008, the process had generated an archive of approximately 55,000 narratives written by young people from 47 countries. The lead author is one of the initiators of the Scenarios from Africa process and authors Mbakwem and Obyerodhyambo are national coordinators of the process in Nigeria and Kenya respectively. Given the framing of the contest in terms of health communication, the narratives submitted reflect and respond to existing education and communication efforts in a more direct way than other forms of qualitative data. They are therefore particularly well-suited to our applied research aims.

Study sample and population

The research described in this paper is part of a six-country study of young Africans’ social representations of HIV and AIDS. Our theoretical foundations, sampling procedures and analytical methods are described in detail elsewhere (Winskell, Obyerodhyambo, and Stephenson 2011). The narratives analysed here were submitted to the Scenarios from Africa contest held continent-wide from 1^st February to 15^th April 2005. Over 63,000 young people from 35 African countries participated in this contest, submitting approximately 23,000 narratives. The findings from participatory action research on this entire data set are described elsewhere (Winskell and Enger 2009). For this study, we selected six non-contiguous countries in which at least 500 submissions were received and with contrasting estimated adult HIV prevalence rates in 2005: Senegal (0.9%), Burkina Faso (2%), South-East Nigeria (3.9%), Kenya (6.1%), Namibia (19.6%), and Swaziland (33.4%) (UNAIDS 2006). A questionnaire completed by all participants provided data on socio-demographic variables (Table 1).

Table 1.

Demographic characteristics of participants in the 2005 Scenarios from Africa contest from six study countries (n=11,354)

	Total narratives submitted in 2005	Total participants	Mean age of author	% male author	% urban author	% author with TV at home
Swaziland	510	1,244	14.6	34%	26%	73%
Namibia	657	963	14.8	50%	13%	80%
Kenya	673	966	16.7	53%	69%	81%
Nigeria	1,869	2,712	16.7	30%	40%	85%
Burkina Faso	4,821	15,710	16.8	61%	66%	57%
Senegal	2,824	4,360	15.4	46%	80%	90%
TOTAL	11,354	25,955

Scenarios were ineligible for inclusion in the study sample if they were team-authored or written in response to one of the thirteen thematic story-starters provided on the contest leaflet (e.g. ‘Write a story about HIV/AIDS in a country experiencing armed conflict’). After eliminating these scenarios, we stratified our data by sex, urban/rural location and age (10–14, 15–19, 20–24) and randomly selected ten narratives from each of the twelve strata. In some countries certain strata contained fewer than ten narratives; hence some country samples have fewer than the maximum 120 narratives (Table 2). In light of the size and cultural diversity of the Nigerian population, only those narratives from the Igbo-speaking South-East were sampled. An overall sample of 586 texts for the six countries resulted.

Table 2.

Characteristics of study sample (n=586)

	Number of narratives	Mean age of author	% male author	% urban author
Swaziland	73	15.4	47	37
Namibia	75	17.2	55	31
Kenya	91	18.0	52	66
S-E Nigeria	120	17.1	50	50
Burkina Faso	120	16.8	50	50
Senegal	107	16.5	48	56
Totals	586	16.9	50	49

As contest participants self-select, the data is not representative of the youth populations; participants are likely to be better educated, and more knowledgeable and motivated about HIV than the general youth population. As a product of the same contest mechanism, however, these biases are likely to be consistent across the six countries hence the country samples, though not representative, are comparable for our purposes.

Data processing and analysis

The data were transcribed verbatim in English or French and entered into MAXQDA 2007 qualitative data analysis software (VERBI Software 1989–2010), where they were labelled with descriptive codes with reference to a detailed codebook covering a range of HIV-related themes, including abstinence. The abstinence code was applied when the term abstinence, a derivative, or an equivalent (e.g. not having sex, remaining chaste, etc.) was used in a text, or when a character had the explicit intention to avoid or delay having sex indefinitely or until a future time. A summary was written for each story and this was coded with up to six out of a possible 45 keywords, which included abstinence. These steps allowed us to isolate both individual text segments related to abstinence and those narratives in which abstinence was a central theme.

Interpretive codes were then identified, both inductively and deductively, for the analysis of the themes that emerged in all the abstinence-related data (Miles and Huberman 1994). Examples of interpretive codes included meanings, motivations, barriers, and skills. These interpretive codes were applied to the abstinence-related data, and analyzed to describe representations of abstinence and their distribution across the countries, sex and age of author.

This study, comprising the secondary analysis of existing data, was approved by Emory University’s Institutional Review Board. We cite the narratives verbatim. Country names are abbreviated as follows: SZ – Swaziland; NM – Namibia; KY – Kenya; NG – Nigeria; BF – Burkina Faso; and SN – Senegal. Excerpts are identified by the country, sex, age and geographic location of the author. For example, an excerpt followed by ‘(NM, F 15 R)’ comes from a 15-year-old female participant from rural Namibia.

Results

Narrative characteristics by demographics and country

Abstinence is mentioned in 131 of the 586 narratives (22%). As measured by keywords, it is a central theme in 35 (6%) of the stories. These are equally likely to be written by young women and young men, in urban and rural areas, and across all ages. Characters choosing to abstain are as likely to be male as female. Although authors are most likely to depict characters of their own sex abstaining, several narratives are notable for including compelling accounts of empowered characters of the other sex abstaining. Peer influence, both positive and negative, and condoms are the most prominent concurrent themes in abstinence-focused narratives across all demographic categories.

Abstinence is considerably more prominent as a theme in the samples from Swaziland, SE Nigeria and Kenya than in those from Senegal, Burkina Faso and Namibia. In the sample from SE Nigeria, abstinence is articulated in relation to conservative Christian sexual morality and in opposition to condom use with particular intensity, with stigmatising implications for those who do not abstain. The Nigerian narratives frequently take the form of cautionary tales, in which the inclination to abstain is thwarted by negative peer influence, libidinal pressures, or character flaws. The Swazi stories are, in contrast, framed more positively and include a mix of young characters who practise abstinence in defiance of peer sexual norms (“positive deviants”), peer or social support, and cautionary tales.

Meanings and beliefs

With the exception of language associated with conservative Christian sexual morality, seen in the samples from Nigeria and Kenya, and expressions derived from specific communication campaigns from those same countries, the terminology used to denote abstinence is similar across the country samples. There is little in the data to suggest that the concept of abstinence is misunderstood, albeit the term is often used in formulaic ways as one component of the ABC (Abstinence, Be Faithful, use Condoms) of prevention. Nonetheless, there is division among the young authors about what abstinence means. In some cases, abstinence is interpreted as meaning never having sex, with some characters seeing this as the only way to protect themselves in light of the scale of the epidemic. The most common understanding of abstinence, however, is not having sex before marriage. It is often, though not exclusively, associated with Christianity. ‘Having sex’ is presumed to mean penetrative penile-vaginal intercourse as there are few references to alternatives in the abstinence-themed data. In several Nigerian narratives, passing reference is made to oral and anal sex, in tandem, as risk behaviours for HIV, however no distinction is made between their associated levels of risk. Activities such as touching or kissing are mentioned infrequently and often in the context of an effort by one character to persuade the other to have penetrative sex.

Although the understanding of abstinence as being ‘until marriage’ is present in all country samples and equally distributed across male and female authors, the Nigeria sample alone accounts for two thirds of all such references. Here, abstinence is frequently referred to as God’s instruction. The obverse of abstinence, sex outside marriage, is described on several occasions as fornication, so that abstinence comes to signify ‘[a]bstaining from sexual immoralities’ (NG, F 21 R). In one Nigerian story, a young woman, who has dressed scantily under the influence of her peers, is brutally gang-raped. The story, which equates abstinence with self-management, closes with the words, ‘Jane did not manage her self and she end up been HIV(+)’ (NG, M 15U), suggesting that the failure to abstain occurred not through the act of rape, but with the decision to change her manner of dress.

Most of this commentary is gendered, with a premium placed on women’s virginity. However, some is explicitly gender neutral, and several male characters are described as living chaste and godly lives.

Another common understanding of abstinence is not having sex when one is young or not yet ‘ready’. While this may overlap with abstinence until marriage, it nonetheless accommodates the possibility of sex before marriage, and thus defines abstinence as an attribute of age, readiness or time of life. Couples may, for example, choose together ‘to wait until the right time’ (SZ, M 18 U). However, conflicting interpretations of when the right time is may lead to discord within couples. The male partner in a Senegalese narrative, for example, argues that his girlfriend should want to have sex ‘at her age’, implying that the right time for sex is culturally or developmentally determined (SN, M 16 R).

Motivations for abstaining

Across countries, male and female-authored narratives, and male and female characters, consideration of the potential impact of HIV on future prospects is a prominent motivation for abstaining from sex. Narratives identify the promise of a happy future free from HIV, a fulfilling and loving relationship, and educational or professional success as incentives to abstain. In the Kenyan and Namibian samples, the opportunity to support one’s family and escape poverty is a recurrent motivator.

Avoid HIV

The most frequently mentioned motivation for abstinence in the narratives is avoiding HIV and AIDS, illness and death. One Nigerian narrative touts abstinence as giving ‘100% guarantee from sex-related HIV and…peace of mind’ (NG, F 21 R). In several narratives, this motivation comes in response to seeing another character become ill or die. In a distinctive characteristic of the Kenyan sample, several narratives enlist orphans and vulnerable children as an emotional rationale for prevention: ‘you young men abstain. You can’t afford to leave your children suffering pain’ (KY, F 23 R). In every country except Senegal at least one narrative portrays protecting one’s country as a reason to abstain.

Happy marriage and family life

Across the data set, abstinence is repeatedly presented as facilitating a loving relationship, a happy future marriage and family life. Discourses of the role of abstinence in romantic love and as prelude to companionate marriage are voiced by male and female characters in narratives by both sexes, often with recourse to the notion that ‘true love waits’ (KY, M 18 R). One Swazi text rationalises this sentiment in terms of the affective foundation of a long-lasting relationship:

his relationship with me or other girl in the future will bring him a lot more joy if it is based on the lasting values of friendship and not just the desires of the body. (SZ, F 14 R)

In one male-authored Swazi narrative, a group of three young men succeed against the odds in changing the social norms in their AIDS-ravaged community through the force of their example and their message of ‘real love’. They are motivated by a desire to save their own and others’ lives and by an emotionally-charged vision of their future married life, which they ultimately realise in their domestic idylls.

Real love Nico I can describe in this way. It start from the heart, and it goes mutually, then you become a highly friend with that person. hang around together. dine together. Sex never come into your mind. The only thing which come to you is that you become happy when you see that girl or boy next to you. (SZ, M 17 R)

The importance of future dreams of procreation and family life are driven home by concerns expressed by some male characters that ‘misuse [of] their bodies in wrong time’ (SZ, M 17 R) can, for example, shorten ‘your life span as a father’ or lead to performance problems when married (NG, M 20 R). Performance and procreative anxiety is less common among female authors and characters. Here, abstinence is more likely to be framed as virginity, a woman’s wedding gift to her life’s partner (e.g. NM, F 14 R).

Professional and educational achievement

The framing of abstinence as a means of preserving one’s future prospects through educational achievement and professional success is prominent in almost all country samples. Not completing one’s education and not passing exams are the common consequences of failing to abstain for both male and female characters, while pregnancy is sometimes depicted, alongside HIV infection, as the reason female characters leave school.

Some characters, male and female, may decide to achieve certain life goals prior to sexual debut, such as completing college.

Ismael, 17, was always the target of mockery because he didn't have a girlfriend… he would tell his friends he was interested in his studies and he didn't want to be distracted or use up his energy. By concentrating on his studies he is preparing his future, and at the right time, he will have a girl to propose to who will become the woman of his life. (BF, M 20 U)

In other narratives, male and female characters either succeed or fail to be the professional of their dreams based on their abstinence choices.

Relevance and limits to effectiveness

Abstinence is shown to have limitations as a prevention strategy in several narratives. Texts from Burkina Faso, Senegal and Namibia voice the fact that abstinence is not a popular choice among young people and suggest it may not be a realistic proposition. When challenged by his elderly father, a young peer educator in a Burkinabè script argues, for example, that promoting premarital abstinence as the sole solution in today’s world would be an absurd imposition of outdated mores, and irresponsible in light of the rapidly spreading epidemic (BF, M 20 R).

Several of the Nigerian narratives, while advocating for abstinence, openly acknowledged its libidinal challenges, for both males and females, and criticise abstinence messaging that does not provide the skills necessary to abstain:

when a nineteen years old boy asked her, what she should do when she has the ‘urge’ for sex, the doctor struggled for an answer, trying to wish it away. He only told her to get that off his mind. (NG, F 14 R)

Multiple narratives, in their implicit take-home message, challenge the promotion of abstinence as the ultimate HIV-prevention solution. For example, Ulochi, who tells her friend she will be the ‘weakest of all women’ if she has sex with her boyfriend, finds herself desperate by the age of 36 because she was so choosy in her youth (NG, M 23 R). ‘She counted on her chastity and was over-confident of the fact that AIDS could not know anybody like her, given her “style”’, and she ultimately contracts HIV from her husband. Like her, other characters across the data set become infected within marriage, either because their premarital abstinence or fidelity is unilateral and/or because they fail to insist on testing before marriage.

In isolated cases, abstinence is represented as increasing the risk of HIV or sexual violence. In a Nigerian story, Emeka, frustrated by his girlfriend Ngozi’s persistence in refusing premarital sex and convinced that he cannot do without sex, frequents prostitutes. When Ngozi finally succumbs to his bargain ‘JUST ONCE and never again until I take you to the altar’, he infects her and ultimately, the child they conceive (NG, F 21 U). In more extreme cases from Kenya and Swaziland, a girlfriend’s refusal to have sex results in rape or attempted rape (KY, F 21 U; SZ, M 18 R).

Barriers to abstinence

Many characters who are motivated to abstain do not succeed. For others, abstinence is not an option for a variety of reasons. Prominent obstacles to abstinence include structural barriers, social norms, and a lack of negotiation skills and strategies.

Barriers for women

Barriers to abstinence faced by female characters may be structural, normative and relational. Sex may be motivated by poverty and/or by a man’s abuse of his power, which leads to sex being exchanged for a job, a scholarship, or a passing grade at school or university. Groups of women may pressure their peers to use their sexuality to secure consumer goods, or to acquire a heightened social status associated with being ‘modern’ or ‘urban’:

JENNIFER: But my mum says attending wild parties and having sex before marriage is wrong.

QUEEN: Babes come and see this girl from the bush. (NG F 20 R)

Sex may also be motivated by an emotional neediness, a desire to fit in, or a fear of losing a partner.

Barriers for men

Normative pressures around masculinity are depicted as primary barriers to male abstinence. Abstinent male characters endure mockery from their male peers, and occasionally from girls, for diverging from a culture of idealised masculinity, in which sexual desire, activity and assertiveness define manhood.

if your penis for decoration My own is for something, infact for sex And it has started working […] If you cannot do what others are doing, I doubt if your manhood is living. (NG, M 20 R)

This culture of masculinity incites men to expressions or acts of bravado and to risky or violent behaviour. For example, Steve’s sexually active friends gloat as they share their sexual conquests, and egg him on to ultimately rape his girlfriend (KY, F 21 U).

Interpersonal communication

Negotiating abstinence

Stories depicting couples negotiating sex within a relationship provide insights into arguments mobilised for and against abstinence from the perspective of young men and women. These are well illustrated by a Swazi script, in which a young woman living in poverty has the courage and skill to refuse sex with her millionaire soccer star boyfriend who has been giving her money (SZ, F 17 R). Where Gertrude references her autonomy, right to say no, and commitment to the ideal of a loving relationship that does not necessitate sex, Michael enlists the perceived normativity of premarital sex, an understanding of sex as an expression of love, and a cultural script whereby material gifts are reciprocated with sexual favours.

Michael: Let’s just enjoy ourselves by doing sex.

Gertrude: Why should we do it? It’s not the right time.

Michael: Just for fun and everybody is doing it.

Gertrude: I’m not everyone, I’m myself.

Michael: If you really love me you would.

Gertrude: If you would really love me you wouldn’t force me to do something I don’t want to do.

Michael: But we are in love so it’s okay. What wrong with you don’t you trust me.

Gertrude: I trust you but to be in love doesn’t mean we have to have sex and I’ve got the right to say no.

Michael: I guess there is no reason to go out together anymore.

Gertrude: You are right if sex is all you are looking for from me then go well!!

Girls who are successful in resisting pressure for sex explain to their partners that it is not that they do not want sex with them, but that they do not want sex at all, that either of them could have HIV and that they want their love to last.

Peer and parental support

While peer pressure is depicted as one of the primary challenges to abstaining, many narratives depict positive peer influence and support from parents as key factors in remaining abstinent. Where female peers are a positive influence, they provide valuable information and advice to one another, often helping them develop strategies and the resolve to negotiate abstinence. Positive male peer influence is more likely to come in the form of group solidarity than one-on-one advice-giving. Several male-authored narratives feature groups of young men banding together to resist what they perceive as negative influences.

They always refer [to] the shop as TMC the acronym for Temptation Management Corner. They believe that by the virtue of the fact that they gather at the place in the evening and pass time chatting, joking and sharing experiences they reduce temptations. (KY, M 18 R)

In the Nigerian sample in particular, authors repeatedly acknowledge the value of positive parental influence, young people’s desire to learn from their parents, and tragic endings when parents fail to guide their children. Those who benefit from parent-child dialogue often share what they learn with their peers, thereby disseminating the positive influence.

Abstinence and other prevention methods

The narratives provide insight into how young people understand abstinence in relation to other HIV prevention strategies. While some texts present premarital abstinence as the only means of preventing HIV, others present it as the best solution, with condom use as a contingency. Others, particularly in the Kenyan and Senegalese sample, present it as one option among several complementary strategies. The Nigerian texts are most outspoken in favour of ‘conduct not condom’ (M 23 R), while the Burkinabè narratives are most inclusive, extending the traditional ABC to include testing and often substituting ‘éviter le vagabondage sexuel’ (literally avoid ‘sexual tramping’ or promiscuity) for abstinence. While young authors may discuss the relative merits of different strategies, they rarely depict their characters employing more than one. For example, when abstinence fails, HIV prevention through condom use is rarely applied.

Several abstinence-themed stories disparage condoms in order to promote abstinence. Twice, misinformation that condoms are ineffective against HIV is used successfully as a tool to negotiate for abstinence (KY, F 15 R; SZ, M 18 R). In one Swazi story, Lebohang, sporting gumboots, takes his friend Mariom to a marsh for an experiment. As he advances into the swamp his trousers become dirty and the mud enters his gumboots. Lebohang explains: ‘The condom is not hundred per cent protective as the boots were not hundred per cent protective as I was in the marsh. So my friend, I love you, AIDS kills and abstain as I do’ (SZ, M 18 R).

Communication campaigns

Two pro-abstinence communication campaigns are explicitly reflected in the data: ‘Zip Up’ from Nigeria and ‘Nimechill’ (meaning ‘I have chilled’, using a combination of KiSwahili and English) from Kenya. Each is mentioned in 7% of their respective country samples. Both campaigns have the advantage of providing young people with a more youth-friendly terminology for talking about abstinence. Although the terms appear to have considerable resonance and uptake, they are occasionally applied in the context of cautionary tales which castigate characters for failing to abstain. One narrator recounts her words to a young woman infected with HIV through transactional sex:

I told her that if you get AIDS that’s not the end of the world the worse thing was that before she got infected she was a prostitution and the leader. […]It is not good for us children to have sex when we are still young say no to sex. (tume chill) (KY, F 13 U)

In another script, two characters exclaim, ‘At our age we do sex? are you mad? oh no! God help me. I’m gonna chill’ (KY, F 13 U).

Discussion

The narratives allow identification of arguments mobilised in favour of abstinence, perceived barriers to and facilitators of its practice, mediating social influences and the legacy of specific pro-abstinence communication campaigns. Commonalities across the country samples are much more notable than differences, although certain characteristics of individual country samples stand out. The religiously-infused moralising that is evident in much of the sample from SE Nigeria is, for example, distinctive and more congruent with Smith’s (2004) description of the influence of Christianity, particularly evangelical and Pentecostal, on the HIV-related beliefs and behaviours of Igbo youth than with the plural representations of abstinence that Izugbara (2008; 2007) found among rural men in one part of Igbo-speaking Nigeria. While diverse representations of abstinence, echoing some of Izugbara’s findings, were observed across the six-country sample, representations in the Nigerian narratives were, in contrast, one-dimensional and highly stigmatising.

The framing of premarital sex in terms of conservative Christian ideology was also evident in several of the Kenyan narratives. References to abstinence were rarest in narratives from predominantly Lutheran Namibia, Muslim Senegal and religiously diverse Burkina Faso. All study countries except Senegal and Burkina Faso are PEPFAR countries, although Swaziland was not one of the original ‘focus countries’ and has only received substantial country-specific PEPFAR funding since the late 2000s. No consistent relationship between HIV prevalence rates and representations of abstinence was evident. Additional research is needed to better understand cross-national variation in social representations of HIV and examine how this relates to bilateral or national policy, communication efforts, and local socio-cultural context. Future longitudinal research on narratives collected by ‘Scenarios from Africa’ between 1997 and 2011 will also allow us to track changes in social representations of HIV over time.

The uniform distribution of the abstinence-focused narratives across sex, age and urban/rural location of authors and across male and female characters suggests that abstinence as a prevention strategy has appeal across demographic groupings. However, we find few references to abstinence that are modulated to reflect age-related needs, suggesting a missed opportunity to tailor messaging in developmentally-appropriate ways.

The definitions of abstinence mobilised in the narratives illustrate the differing ways the concept has been framed. Their diversity suggests the need for public health communication to disseminate a clear definition of abstinence as a prevention strategy. Where culturally appropriate, this may include distinguishing between risks associated with various alternatives to penetrative sex, reference to which is largely absent from the data. Narratives using definitions of abstinence based on moral correctness often end in humiliating infection and death. The most inclusive definitions of abstinence are those least likely to be stigmatising, for example where it is defined as the exercise of agency to delay sex until marriage and until one feels ready and has the necessary prevention skills and resources (such as a condom or a monogamous partner’s negative HIV test result).

Certain motivations to abstain are consistent in narratives written from both religious and secular perspectives, for example, the appeal of a healthy future of romantic, family, educational and professional fulfilment. In some cases, this is explicitly linked to responsibilities to kin or country. The resonance of these emotionally-charged motivations with authors and characters of both sexes is striking. It is, nonetheless, questionable whether such messages would appeal to young people with more limited prospects. One Swazi author allocates his three abstinent male heroes to different races and social classes, as if in anticipation of these concerns. For young women in particular, the pursuit of achievement can serve to increase their risk when men resolved to abuse their power stand between them and their educational or professional goals.

The narratives that question the relevance of abstinence for young people and its effectiveness as a stand-alone prevention strategy identify challenges that should be acknowledged and addressed in HIV prevention programmes. The young authors of these narratives highlight the need for multiple prevention strategies which can be applied in varying circumstances. Certain narratives implicitly call for open acknowledgement of the limitations of premarital abstinence in the absence of premarital testing and mutual marital fidelity, recognising that ‘the suggestion [in abstinence-only programming] that marriage provides a safeguard against HIV may amount to a death sentence’ (Cohen and Tate 2006, 176). Isolated narratives also draw attention to situations where abstinence is apparently perceived by the young authors to increase the risk of HIV or sexual violence, and highlight the need to help young people develop skills that would allow them to recognise and extricate themselves from risky relationships. Deconstructing specific beliefs around masculinity that may normalise sexual violence (e.g. the belief that men cannot control their sexuality) would be an important companion lesson.

The barriers to abstinence identified in the narratives also both inform the feasibility of abstinence as an HIV prevention strategy and underline the importance of gender-specific programming. While both male and female characters face libidinal challenges and pressure from peers to be modern and grown-up, females face additional structural challenges and the added consequence of pregnancy. Although the dual benefit of abstinence for pregnancy and HIV prevention is alluded to, above all in cautionary tales, the fact that it is not more broadly referenced in the narratives suggests a missed opportunity in abstinence-related messaging. For male characters, peer pressure is particularly difficult to resist as it challenges their identity as men. However, positive deviant male characters assert other markers of masculine adulthood, which they win by virtue of their abstinence, such as professional and personal success. These findings echo Izugbara’s (2008).

Studies have repeatedly identified perceived self-efficacy to refuse sex as a strong predictor of the timing of sexual debut (e.g. Babalola, Ouedraogo, and Vondrasek 2006), highlighting the importance of skills development in pro-abstinence programming. Representations in the narratives of negotiations between couples and in peer-pressure scenarios provide examples both of normative gendered discourse and of strategies that may yield successful outcomes. The narratives thus offer a promising resource for the development of role plays or problem-based learning exercises in which young people can develop skills by anticipating challenges and exploring responses. They also provide rich contextualised examples both of negative peer pressure and of positive peer and parental support that can inform programmatic practice.

In contrast to stories which rely on misinformation about condoms, the Burkinabè narratives provide an inclusive and comprehensive take on the full range of prevention strategies, extending the ABC of prevention with testing and partner reduction. Studies in the US and elsewhere indicate that comprehensive sexuality education effectively promotes abstinence in addition to other protective behaviours, leaving young people better prepared at sexual debut (Santelli et al. 2006). With the exception of an abstinence programme for pre-teenagers, which recently demonstrated efficacy (Jemmott, Jemmott, and Fong 2010), abstinence-only programmes, in contrast, ‘have little evidence to warrant their widespread replication’ (Kirby 2008). Current PEPFAR policy promotes abstinence until marriage to young people and only allows condom provision to individual youth who ‘are identified as engaging in, or at high risk for engaging in, risky sexual behaviors’ (The United States President's Emergency Plan for AIDS Relief 2010). Our data support comprehensive HIV prevention programming across perceived risk levels, not least because the risk levels of the characters in our narratives change rapidly. Disconnecting abstinence from other prevention strategies leaves those who are unsuccessful in their intentions to abstain ill-prepared to protect themselves by other means, particularly when condoms are stigmatised and their effectiveness undermined.

The two communication campaigns clearly reflected in the narratives, Zip Up (Nigeria) and Chill (Kenya), were created in 2004 by PSI or its affiliates (Walker et al. 2006; Fatusi, Wang, and Anyati 2007–8). Both campaigns had the goal of making abstinence seem like the cool, smart, responsible and normative choice for youth. The term ‘Zip up’ is used in the narratives by both youth and adult characters, suggesting that, by providing a new and accessible vocabulary, it may be helping to alleviate barriers to adult-child dialogue. However, the Chill campaign in particular runs the risk of stigmatising those youth, particularly young women, who do not have the opportunity to remain abstinent by dint of their class or other structural factors. It also fails to mention other means of avoiding infection.

Throughout the data set, those narratives that use moralization or stigmatization to promote abstinence stand in contrast to those that mobilise positive attributes associated with abstinence within a comprehensive vision of HIV prevention. These positive examples suggest that attempts to promote a normative shift in favour of abstinence do not need to come at the expense of inclusion and respect either for other prevention strategies or for those individuals who have made – or been forced to make – different choices.

This study is not without limitations. As indicated above, the sample is not representative of the youth population. It is possible that the young authors’ motivation to tell what they consider to be a good HIV-related story – and thereby win the Scenarios contest – may be influencing the ways in which they represent abstinence. Despite these limitations, the data present valuable opportunities to gain insight into young Africans’ contextualised understanding of abstinence.

Conclusion

The largely unmediated voices and creative imaginings of young Africans, present in this cross-national sample, reveal the commonalities and some differences in the ways in which abstinence is framed in six countries with contrasting HIV prevalence rates. The narratives highlight pitfalls of some approaches and the promise of others and provide valuable youth-driven ideas and contextual understanding to inform HIV prevention efforts and the development of comprehensive sexuality education curricula. Based on our analyses, we recommend: greater tailoring of messaging by gender and in developmentally-appropriate ways; the dissemination of a clear definition of abstinence as a prevention strategy; highlighting non-stigmatising secular motivations for abstinence that have broad resonance; open acknowledgement of the limitations of abstinence; and the modelling of positive peer and parental support. Above all, positive attributes associated with abstinence should be mobilised and relevant skills nurtured within a comprehensive – and inclusive – vision of HIV prevention.