'Parents are gudlists!' Experiences of puberty and parent-child sexual communication in rural KwaZulu-Natal, South Africa.

This paper explores young people's experiences of puberty and their perspectives on parent-child sexual communication in rural northern KwaZulu-Natal. In-depth individual interviews, focus group discussions, and participatory visual research methodology were employed with 18 and 19-year-old young women (n = 30) and young men (n = 16) attending three primary health care facilities and a local high school in Jozini municipality. The findings suggest a complex interplay between unequal gender and socio-cultural norms that results in divergent puberty experiences and ambiguous and inconsistent patterns of parent-child sexual communication. Young people referred to their parents as gudlists, a local colloquialism for someone who is evasive, vague, ambiguous and indirect. Lack of open parent-child sexual communication hinders discussion of healthy sexuality, neglecting the sexual and reproductive health education and needs of young people. Reflective of their desire for change, young women in particular contest current parenting norms and suggest returning to cultural practices linked to traditional forms of courtship and sexual communication among young Zulu people.

Why Men Rape: Perspectives From Incarcerated Rapists in a KwaZulu-Natal Prison, South Africa.

Sexual offending is a global problem but is particularly prevalent on the African continent and in South Africa. Childhood experiences related to abuse, alcohol use, and criminal activities in the household and community has been associated with an increased risk for violence perpetration in adulthood. Less is known about sexual violence perpetration, especially in the South African context. In this study, the experiences of incarcerated male perpetrators of rape in South Africa are investigated along with the collective social context and individual childhood experiences that potentially contribute to rape perpetration. Eighteen male perpetrators of rape who were inmates at Westville Correctional Services in KwaZulu Natal, South Africa, were interviewed. The semi-structured in-depth qualitative interviews were transcribed, coded and annotated using an interpretive paradigm and thematic analysis approach. Five main themes emerged from the research and included (1) childhood trauma and adverse events, e.g., an absent father, being raised without parents, exposure to criminal or violent behavior, physical abuse, sexual abuse and poverty, (2) understanding rape, e.g., rape as sex by force and without consent, rape as a violent act, rape as sex with a minor, myths about rape (3) substance abuse, e.g., history of alcohol and drug use, and intoxication during rape perpetration, (4) gender roles and avoiding responsibility, e.g., victim blaming, rape as male prerogative, transactional sex, being framed or set-up, ignoring an ancestral call and (5) recidivism. The findings revealed that all rape perpetrators were exposed to at least one childhood trauma type. Family and community violence and criminality was common. Most participants avoided taking responsibility for their actions and blamed the victim and recidivism/prior convictions were often reported. The findings demonstrate the complex personality dynamic involved in the cycle of abuse and the evolution of criminal behavior, starting as a victim and ending as a perpetrator. The findings also highlight the need for interventions aimed at reducing childhood trauma exposure and improving the social and relational context of those at risk for childhood neglect and abuse.

"Theyabduct usand rapeus": Adolescents' participatory visual reflections of their vulnerability to sexual violence in South African townships.

The abduction and sexual violation of adolescents, especially in township contexts, has increasingly made headlines in South Africa. These incidents are evocative of jackrolling, a phenomenon that plagued townships during the apartheid upheavals in the late 1980s. The abduction of adolescents on their school journeys has been reported in several South African townships. In this paper, we report on a study in which we used participatory visual methods (i.e., cellphilms: short videos made with cellphones) to explore how 19 adolescent girls and boys living in the Inanda, Ntuzuma, and KwaMashu (INK) township precinct, outside Durban reflected on their vulnerability to sexual violence. Although the question was broad, our analysis of the visual data suggests that adolescents believed that their vulnerability to abduction and rape was almost inevitable. As such, in their cellphilms, they chose to portray their risk and vulnerability to abduction, rape, and even murder on their daily journeys to and from school. We found that through this methodology, adolescents were able to illustrate and/or articulate their fear of sexual violence. For them, violence was an inescapable reality that created fear and helplessness. This underscores the need for interventions, including the provision of safe scholar transport and visible policing in the community.

Using the Emanuel Framework to Explore the Ethical Issues Raised in a Participatory Visual Research Project in Rural South Africa.

Participatory visual research can offer critical insight into the experiences of those most affected by health issues. As these methods are increasingly used to research sensitive topics, there is a need for a clear ethical framework to guide best practice on the part of researchers and research ethics committees. Here we reflect on a project where we used digital storytelling as a participatory visual methodology to explore HIV treatment adherence in rural South Africa, with a focus on the ethical issues we encountered during the lifetime of the project. To ground our reflections, we use the framework for ethical research developed by Emanuel et al., and the adaptation of this framework for social science proposed by Wassenaar and Mamotte. We suggest that fellow PVM practitioners and REC members draw on this holistic framework to support the optimal application of PVM in health research.

Community engagement with HIV drug adherence in rural South Africa: a transdisciplinary approach.

Digital storytelling (DST) is an emerging participatory visual method which combines storytelling traditions with computer and video production technology. In this project, at the heart of the HIV epidemic in KwaZulu-Natal, South Africa, we used DST to create a culturally grounded community engagement intervention. Our aim was to use narratives of people living with HIV on antiretroviral therapy (ART) to stimulate dialogue among the wider community and to encourage reflection on the contextual factors that influence ART adherence in this setting. We also wanted to explore whether exposure to the personal narratives might influence health literacy around HIV and ART. We ran two DST workshops, where 20 community participants were supported to create short digital stories about personal experiences of adherence. We then hosted 151 screenings of the digital stories at seven local health facilities and evaluated the impact of the intervention using a three-tiered mixed methods approach. We conducted two independent quantitative surveys of healthcare users (852 respondents during the preintervention round and 860 people during the postintervention round), five focus group discussions and observation of practice. Exposure to the digital stories did stimulate rich dialogue among community members, which broadened from the focus on ART adherence to other aspects around the impact of HIV and its treatment on individuals and the community. In the independently conducted surveys, we found no clear difference in knowledge or understanding of HIV and ART between the people exposed to the digital stories and those who were not exposed. Our findings provide support for the use of DST as an engagement intervention, but highlight some of the challenges in delivering this type of intervention and in evaluating the impact of this approach.

What Does It Mean to Be a Young African Woman on a University Campus in Times of Sexual Violence? A New Moment, a New Conversation.

Sexual violence in the higher education is an epidemic of global proportions. Scholars conclude that the individual and collective silence that surrounds such violence enables its perpetration and that violence will only be eradicated when we break this silence. In this paper, we used two participatory visual methods (PVM), collage and storytelling, to explore what sexual violence at university looks like and what it means to woman students. Two groups of student teachers in two South African universities were engaged in collage and storytelling workshops in late 2017 and early 2018, respectively. We thematically analyzed the issues that emerged from the data, drawing on transformative learning theory to explore how our approach might help women students to break the silence around sexual violence and stimulate critical dialogue to address it. Our analysis suggests that these visual tools enabled deep reflections on the meaning and impact of sexual violence, particularly for women. In addition, the participatory process supported introspection about their experiences of sexual violence and their responses to it as bystanders in and around campus. More importantly, they discussed how they, as young women, might break the silence and sustain new conversations about gender and gender equality in institutions and beyond.

The Hidden Curricula of Medical Education: A Scoping Review.

PURPOSE: To analyze the plural definitions and applications of the term "hidden curriculum" within the medical education literature and to propose a conceptual framework for conducting future research on the topic. METHOD: The authors conducted a literature search of nine online databases, seeking articles published on the hidden, informal, or implicit curriculum in medical education prior to March 2017. Two reviewers independently screened articles with set inclusion criteria and performed kappa coefficient tests to evaluate interreviewer reliability. They extracted, coded, and analyzed key data, using grounded theory methodology. RESULTS: The authors uncovered 3,747 articles relating to the hidden curriculum in medical education. Of these, they selected 197 articles for full review. Use of the term "hidden curriculum" has expanded substantially since 2012. U.S. and Canadian medical schools are the focus of two-thirds of the empirical hidden curriculum studies; data from African and South American schools are nearly absent. Few quantitative techniques to measure the hidden curriculum exist. The "hidden curriculum" is understood as a mostly negative concept. Its definition varies widely, but can be understood via four conceptual boundaries: (1) institutional-organizational, (2) interpersonal-social, (3) contextual-cultural, and/or (4) motivational-psychological. CONCLUSIONS: Future medical education researchers should make clear the conceptual boundary or boundaries they are applying to the term "hidden curriculum," move away from general musings on its effects, and focus on specific methods for improving the powerful hidden curriculum.

Understanding Specific Contexts of Antiretroviral Therapy Adherence in Rural South Africa: A Thematic Analysis of Digital Stories from a Community with High HIV Prevalence.

Near-perfect adherence to antiretroviral therapy (ART) is required to achieve the best possible prevention and treatment outcomes. Yet, there have been particular concerns about the challenges of adherence among patients living in resource-limited settings in sub-Saharan Africa. The primary objective of this study was to explore adherence in a low-resourced, rural community of high HIV prevalence in South Africa and to identify specific individual and structural factors that can either challenge or support adherence in this context. We applied digital stories as a qualitative research tool to gain insights into personal contexts of HIV and ART adherence. Through an inductive thematic analysis of twenty story texts, soundtracks and drawings, we explored experiences, understandings, and contexts of the participants and identified potential barriers and facilitators for those on lifelong treatment. We found that many of the stories reflected a growing confidence in the effectiveness of ART, which should be viewed as a key facilitator to successful adherence since this attitude can promote disclosure and boost access to social support. Nevertheless, stories also highlighted the complexity of the issues that individuals and households face as they deal with HIV and ART in this setting and it is clear that an overburdened local healthcare system has often struggled to meet the demands of a rapidly expanding epidemic and to provide the necessary medical and emotional support. Our analysis suggests several opportunities for further research and the design of novel health interventions to support optimal adherence. Firstly, future health promotion campaigns should encourage individuals to test together, or at least accompany each other for testing, to encourage social support from the outset. Additionally, home-based testing and ART club interventions might be recommended to make it easier for individuals to adhere to their treatment regimens and to provide a sense of support and solidarity.

Photo-voice as a tool for analysis and activism in response to HIV and AIDS stigmatisation in a rural KwaZulu-Natal school.

OBJECTIVE: This paper focuses on the use of participatory approaches to research and intervention and explores the uses of photo-voice as a methodology and a means of promoting childhood and youth activism in the context of HIV and AIDS. METHOD: Photo-voice, a visual participatory methodology, was used with 21 Grade 8 and 9 learners in one of three schools participating in a larger project, to identify, understand and interpret incidents related to stigma and discrimination against people living with and affected by HIV and AIDS, as well as the strategies proposed by the learners to possibly reduce stigma. RESULTS: Three themes emerged: awareness of HIV and AIDS, awareness of HIV-related stigma and its impacts, and acceptance of personal agency and taking action. CONCLUSIONS: Understandings of and perceptions about HIV and AIDS are improving, yet significant pockets of ignorance about the dynamics of HIV infection still remain among the youth. Negative attitudes towards people infected with and affected by the virus remain, and stigmatisation continues. The use of photo-voice and other participatory methodologies offers alternative strategies for involving youth in their own knowledge production, as well as in the development of an individual sense of agency for taking action.