Acta Psychologica 230 (2022) 103757

Contents lists available at ScienceDirect

Acta
Psychologica

Impact of you only live once: A resilience-based HIV prevention intervention

to reduce risky sexual behaviour among youth in South Africa
Fungai Mbengo a,*, Esther Adama a, Amanda Towell-Barnard a, Arvin Bhana b, c,
Ebenezer Afrifa-Yamoah d, Maggie Zgambo a
a
School of Nursing & Midwifery, Edith Cowan University, Joondalup, WA 6027, Australia
b
Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu-Natal, Durban 4041, South Africa
c
Health Systems Research Unit, South African Medical Research Council, Tygerberg 7505, South Africa
d
School of Science, Edith Cowan University, Joondalup, WA 6027, Australia

ARTICLEINFO
ABSTRACT
Keywords:
HIV prevention intervention Impact Purpose: Interventions focused on promoting resilience or protective
Resilience factors of youth have been proposed as a strategy for reducing risky
Risky sexual behaviour South Africa behaviours associated with HIV infection among youth; however few
Youth studies have explored their effectiveness. This study assessed the
impact of a resilience-based HIV prevention intervention (You Only
Live Once) on risky sexual behaviours, resilience and protective
factors of youth.
Methods: A one-group pretest-posttest design was used. One hundred
and ninety-seven youth aged 15–24 years
were conveniently recruited from a non-profit organisation in Maluti-a-
Phofung Local Municipality, South Africa and participated in a 12-
session, resilience-based HIV intervention delivered over a 1-week
period by trained adult facilitators. Outcomes of interest were
assessed at baseline and 3-month follow-up using validated risky
sexual behaviour measures, and Child and Youth Resilience
Measure. Mixed effect logistic and linear regression models were
formulated to assess the impact of the intervention on risky sexual
behaviours; resilience and protective factors respectively.
Results: Compared to baseline, participants at 3-month follow-up
were 68 % less likely to have unprotected sex, 22 % less likely to
regret their decision to engage in sexual activity and 0.4 % less likely
to be pregnant or made someone pregnant. Conversely, participants
at the 3-month follow-up had a higher propensity to engage in multiple
sexual partnerships, transactional sex and intergenerational sex than
baseline. Participants at 3-month follow-up had significant
improvements in their scores of resilience, individual capacities and
contextual factors that facilitate a sense of belonging (p < 0.05).
Conclusion: You Only Live Once intervention appeared to have
mitigated some risky sexual behaviours, and improved resilience and
protective factors over a 3-month period. These findings suggest that
the intervention has ability to reduce risky sexual behaviours
associated with HIV, and improve resilience and protective factors
among youth in South Africa. Further evaluation of the intervention
with a rigorous study design, larger sample size and longer period for
follow-up is warranted.

1. Introduction they accounted for 34 % of new infections in 2020 (Joint United

Nations Programme on HIV/AIDS, 2021; Statistics South Africa,
South Africa has the highest number of people living with Human 2021a). Youth are at high risk for HIV due to a range of multi-level
Immunodeficiency Virus (HIV) in the world, about 7.8 million (Joint factors which affect risky sexual behaviours (Kaufman et al., 2014;
United Nations Programme on HIV/AIDS, 2021). Youth (15–24 years) Max et al., 2015). Pre- vious research has identified several
are disproportionately impacted by the disease (Human Sciences challenges facing young people, including lack of parental support and
Research Council, 2017; Mabaso et al., 2021; World Health Organiza- communication, limited sexual health knowledge, peer pressure, poor
tion, 2016). Despite youth making up 16 % of South Africa's population, role models, harmful social norms, alcohol or drug abuse, gender
disparities, lack of school
 * Corresponding author.
E-mail addresses: [email protected] (F. Mbengo), [email protected] (E. Adama), [email protected] (A. Towell-Barnard), arvin.bhana@gmail.
com (A. Bhana), [email protected] (E. Afrifa-Yamoah), [email protected] (M. Zgambo).

https://doi.org/10.1016/j.actpsy.2022.103757
Received 29 September 2021; Received in revised form 12 July 2022; Accepted 21 September 2022
Available online 28 September 2022
0001-6918/© 2022 Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 F. Mbengo Acta Psychologica 230 (2022)

attendance, unemployment and poverty, which impact their ability to 2010). The
adopt healthy sexual behaviours (Khuzwayo & Taylor, 2018; Mabaso
et al., 2021; Visser, 2017). In addition, engagement in risky sexual be- intervention contains 12 sessions that promote individual protective
haviours, such as non-condom use, early sexual debut, multiple sexual factors: self-identity; self-esteem; self-efficacy/confidence [sessions 1,
partnerships, intergenerational sex, transactional sex, unintended 2 and 6]; communication skills [sessions 3 and 11]; decision-making
pregnancies and sex under the influence of drugs or alcohol increases skills [session 12]; skills in dealing with emotional and social
the risk of HIV infection among youth (Visser, 2017; Zgambo et al., challenges [session 9]; and knowledge on sexual health, HIV,
2018; Zgambo et al., 2022). unintended preg- nancies, contraception, sexual and reproductive
To curb the spread of HIV among youth, effective HIV prevention rights, risky sexual behaviour [sessions 4, 5, 7 and 8], and
strategies focused on reducing risky sexual behaviours are urgently environmental protective factors: improved relationships with parents,
needed. However, systematic reviews suggest that interventions tar- peers and community members [session 10]; and access to basic
geting youth are more successful at changing non-behavioural out- services [sessions 4, 5, 7, 8, 9] (Live- Moya, 2018; South African
comes, such as sexual health knowledge, and less successful at Department of Social Development, 2016). In this study, the
changing behavioural outcomes, such as multiple sexual partnerships intervention was delivered in two sessions per day
(Mwale & Muula, 2017; Sani et al., 2016; Scott-Sheldon et al., 2013). with each session lasting 1–2 h, over a period of one week. Five
The limited intervention impact on behavioural outcomes has been trained adult facilitators delivered the sessions in a mixed-gender
attributed to the failure of the interventions to successfully address group format
numerous factors influencing risky sexual behaviours among young of 15–20 youth using a variety of participatory approaches, such as
people (Visser, 2017). Resilience-based interventions have been group discussions and dialogues, participant reflections, role-plays,
suggested as a multifaceted approach to avert risky sexual behaviours short seminars and take-home activities. To enhance session atten-
linked to HIV infection among youth (Fergus & Zimmerman, 2005; dance, the sessions were conducted on days and times agreed
LoVette et al., 2019; Wang et al., 2015). Resilience theory suggests between the youth and facilitators, and in venues located in the same
that individual protective factors, such as sexual health knowledge, and neigh- bourhood where the youth and facilitators live (mostly in
environmental protective factors, such as parental support promote facilitators' homes).
resilience in people and prevent them from engaging in risky sexual
behaviours (Fergus & Zimmerman, 2005; LoVette et al., 2019; Wang et 2.2. Study design
al., 2015). Previous research has estab- lished positive associations
between resilience or protective factors and healthy sexual behaviours This study was part of a larger project evaluating the You Only
(Govender et al., 2019; Hodder et al., 2018; McNair et al., 2018; Pilgrim Live Once intervention using a mixed methods approach. The current
& Blum, 2012). Research from United States of America provides study reports findings from the quantitative component which utilised a
evidence for the impact of resilience-based HIV prevention one- group pretest-posttest design to assess the impact of the
interventions in reducing young people's risky sexual be- haviours intervention on risky sexual behaviours, resilience and protective
(Sieving et al., 2011, 2013). factors. A one-group pretest-posttest design is used when the study
In South Africa, little is known about the effectiveness of resilience- seeks to examine cau- sality between an intervention and outcome
based HIV prevention interventions aimed at reducing risky sexual be- (Knapp, 2016).
haviours among youth. To address this gap, this study sought to
evaluate the impact of a resilience-based HIV prevention intervention 2.3. Setting
(You Only Live Once) on risky sexual behaviours, resilience and
protective factors among youth in South Africa. It was hypothesized The study was conducted at a not-for-profit organisation imple-
that the intervention would (1) reduce risky sexual behaviours and (2) menting the You Only Live Once intervention in Maluti-a-Phofung
improve resilience and protective factors at 3-month follow-up. Local Municipality, South Africa. The organisation provides a range of
free services, including HIV prevention programmes to vulnerable
2. Materials and methods children
and youth based on the South African Children’s Act [No.38 of, 2005).
2.1. Intervention The You Only Live Once intervention was first introduced at the
orga-
You Only Live Once curriculum was developed in 2016 by the South nisation in 2017. Maluti-a-Phofung Local Municipality is located within
African Department of Social Development (South African Department the Thabo Mofutsanyana District in the Free State Province. It is
of Social Development, 2016). Over the past few years, South African bordered by the KwaZulu-Natal Province to the east, Dihlabeng Local
Department of Social Development in partnership with the South Afri- Municipality to the west, the Kingdom of Lesotho to the south and
can National AIDS Council, Government Capacity Building and Support Phumelela Local Municipality to the north. The municipality is about
programme, community-based organisations and not-for-profit organi- 4421 km2 in size and has a population of about 336,000 people with
sations has implemented the You Only Live Once intervention in most black South Africans of the BaSotho tribe comprising majority of the
geographical areas of South Africa with high HIV prevalence (Kgaphola total population (Municipal Demarcation Board, 2018). Youth below
& Jacob, 2020; LiveMoya, 2018). The intervention targets youth (15–24 the age of 20 years constitute nearly half of the municipality's total
years) to reduce new HIV infections by building resilience or promoting popu- lation (Statistics South Africa, 2021b). The municipality has high
protective factors that enable them to overcome multi-level factors levels of poverty and unemployment (Statistics South Africa, 2021b).
which influence risky sexual behaviours (South African Department of Maluti-a- Phofung Local Municipality had HIV prevalence of 11.3 % in
Social Development, 2016). You Only Live Once intervention is based 2017 (Free State Provincial Council on AIDS, 2018).
on an integrated theoretical framework that comprises aspects of the
socio- ecological model and theory of change (LiveMoya, 2018). The 2.4. Participants
socio- ecological model provides a framework for understanding multi-
level factors influencing risky sexual behaviours among youth A convenience sampling approach was used to recruit 197 partici-
(Kaufman et al., 2014; Max et al., 2015). The theory of change is a pants from 216 youth who had been identified by the not-for-profit
device for formulating solutions to complex social problems and organisation to participate in the You Only Live Once
describes the causal mechanism on how the intervention's activities will intervention
result in achieving expected outcomes (Akintobi et al., 2016; Brest, [Fig. 1]. To be included in the study, youth had to be: (1) 15–24 years;
(2)F.Never
Mbengo
participated in the You Only Live Once intervention before; Acta Psychologica 230 (2022)

(3) Able to read, understand and write English and/or Sesotho; (4)
Willing and able to provide informed consent/assent. According to
Krejcie and Morgan (1970)'s method of determining sample size for
research pur- poses, the sample size required for a population of 216
youth is 140 youth. Anticipating a 40 % attrition to follow-up, the initial
sample size would increase to 196 youth. Therefore, the sample
size of 197
 F. Mbengo Acta Psychologica 230 (2022)

Approached and invited to be part

of the study (n = 216)

Did not contact the principal

researcher to indicate interest in the
study (n = 19)
Contacted principal researcher, indicated interest in
the study, assessed for eligibility and signed
consent/assent form
Excluded (n = 0)

Completed questionnaire at baseline

(n = 197)

Fig. 1. Flow of study participants from recruitment to final analysis sample.

Participated in the You Only Live Once
intervention (n = 197) English to enable participants to
answer the questionnaire in their
preferred language. Translation of
Lost to follow-up at 3-month follow-up due
the questionnaire from English into
to migration (n = 5), attending school (n = 1)
Sesotho was undertaken using
recommended translation
guidelines by Tsang et al. (2017).
Completed questionnaire at 3-month
Furthermore, the questionnaire was
follow-up (n = 176) piloted among

Included in analysis (n = 176)

participants was considered adequate.

2.5. Procedure
The study was approved by the Edith Cowan University Human Sesotho and
Research Ethics Committee in Australia (reference number 2019– 10 youth who were not part of the You Only Live Once intervention to
00925) and Human Sciences Research Council Research Ethics ensure its relevance to the South African socio-cultural context.
Committee in South Africa (reference number 5/19/02/20). Permission Participants were assured of their privacy, confidentiality, and their
was also obtained from the management of the not-for-profit right to withdraw from the study at any time without penalty. To
organisation. enhance anonymity, participants were instructed to write same unique
Five You Only Live Once facilitators at the non-for-profit identifiable number (e.g., date of birth and identity numbers) on the
organisation were approached face-to-face by the principal researcher questionnaire instead of their real names each time they completed
(FM) to assist him with participant recruitment. The facilitators were the questionnaire. To reduce social desirability bias, participants were
briefed on the study objectives and recruitment procedures. The informed about the importance of responding honestly as their re-
principal researcher and facilitators explained the study to the youth sponses would be used to create interventions for other youth.
before giving them information sheets and consent/assent forms. Youth Measures to prevent the spread of Coronavirus disease of 2019
who were inter- ested in the study were requested to contact the (COVID-19) such as mask wearing, social distancing and hand
principal researcher, and an appointment was made to meet them in washing were adhered to. Participants received no financial incentives
their preferred location. Participants aged 18 years and older were for completing the ques- tionnaire. However, refreshments were
asked to provide written informed consent, and those below 18 years provided to the participants at the end of each session and a
were requested to give written assent and parental consent if they certificate of attendance given at the end of the intervention.
agreed to participate.
Data collection was conducted from October 2020 to February
2021. Participants completed a self-report questionnaire at baseline (n 2.6. Study measures
= 197) and 3-month follow-up (n = 176) [Fig. 1]. The
questionnaire took The questionnaire was made up of three sections which included;
approximately 15–20 min to complete. The completion of the ques- sociodemographic characteristics of participants; and measures of
tionnaires took place at the intervention venue and was supervised by risky sexual behaviours, resilience and protective factors.
the principal researcher. Participants read and answered the question-
naire on their own. In South Africa, 94 % of the youth are able to 2.6.1. Sociodemographic characteristics
speak, write and read in their respective languages (Statistics South This section collected information on variables, such as age,
Africa, 2016, 2017). Thus, the questionnaire was written in both gender, race, religion, level of education, living arrangement and
 F. Mbengo Acta Psychologica 230 (2022)
number of You
 F. Mbengo Acta Psychologica 230 (2022)

Only Live Once sessions attended.

Table 1
Sociodemographic characteristics and Chi square test
results.
2.6.2. Risky sexual
Sociodemographic Baseline n = 197 3-month follow-up Attrition n = 21 X2 p-
behaviours characteristics value
Seven questions
which have been
previously used
among young
people in South Africa (Govender et al., 2017, 2019; Human Sciences n = 176

Research Council, 2017; Reddy et al., 2010, 2013; Shisana et al., n (%) n (%) n (%)
2014; Visser, 2017) were used to collect data on risky sexual Gender 1.173 0.279
behaviours.
Participants were asked the age Male 77 (39.1 67 (38.1 10 (47.6
of sexual debut (<15 years/15 %) %) 108 %)
Female 119 11 (52.4
years and more/never had sex).
Youth who reported their age of
sexual debut as
<15 years/15 years and more
were regarded as sexually
active.
Furthermore, participants responded
questions on non-condom use at to (60.4 %) (61.4 %) %)
Transgender
last sex, multiple sexual 1 (0.5 %) 1 (0.6 %)
partnerships, pregnancy Age 28.489 0.001
incidence, sexual
regret, transactional sex and 15–17 years 110 100 14 (66.7
intergenerational sex in the last (55.8 %) (56.8 %) %)
three months. A positive answer 18–20 years 53 (26.9 47 (26.7 4 (19.1
to each of the questions was %) %) %)
21–23 years 28 (14.2 23 (13.1 2 (9.5 %)
given a score of one. %) %)

2.6.3. Resilience and protective

factors
The Child and Youth Resilience Measure [CYRM-28] (Resilience 24 and above 6 (3 %) 6 (3.4 %) 1 (4.8 %)
Research Centre, 2016) which has been previously used among youth Religion 2.400 0.301
in
South Africa
contexts and in similar
(Govender et al.,
Christianity 142 128 15 (71.4
2017; Kaunda-
Khangamwa
al., 2019) wasetused
al., 2020; van Rensburg et
to measure (72.1 %) (72.7 %) %)
Islam
resilience and
The internal protective of
consistency factors.
the in-
1 (0.5 %) 1 (0.6 %)
Traditional 6 (28.6

strument in the present study was 53 (26.9 46 (26.1

high (Cronbach's alpha = 0.89). %) %) %)
The Other
instrument is made up of 28 1 (0.5 %) 1 (0.6 %)
Education level 0.368 0.985
items that are grouped into
three subscales, including
individual capacities/resources
(11 items), relationship with
primary caregiver (7 items) and
contextual factors that facilitate
a sense
of belonging (10 items). The %) %) 133
individual capacities subscale Secondary education 148 19 (90.5
comprises of
items addressing the
following protective factors:
personal skills (5
items), peer support (2 Tertiary education Race (75.1 %) (75.6 %) %)
27 (13.7 23 (13.1
times) and social skills (4
%) %)
questions). The rela- 9.975 0.002
tionship with primary
caregiver subscale is
made up of items
describing the following
protective factors: physical
caregiving (2 items) and
psy-
chological caregiving
The contextual factors(5that
items). Black 194 174 19 (90.5
facilitate a
sense of belonging
addressing consists
the following of items
protective (98.5 %) (98.7 %) %)
Coloured
factors: spiritual support (3 items),
F. Mbengo 3 (1.5 %) 2 (1.3 %) 2 (9.5 %) Acta Psychologica 230 (2022)
education support (2 items) and Living arrangement 4.466 0.813
cultural support (5 items). The items are
F. Mbengo
Both parents 62 (31.5 58 (33 %) 8 (38.1
Acta Psychologica 230 (2022)
responded to on a 5-point Likert
scale: 1 not at all, 2 a little, 3
= = = = = %) 102
(51.8 %)
%)
somewhat, 4 quite a bit, 5 a One parent 88 (50 %) 11 (52.4
%)
lot, with a higher score
representing high resilience or
protective factors.
2.7. Data analysis Another relative 22 (11.2 20 (11.4 2 (9.5 %)
%) %)

Unique identifiable numbers,

such as date of birth and identity
numbers were used to match You Only Live Once
participants' baseline and 3- sessions attended

month follow- up data. Descriptive

statistics were used to analyse
sociodemographic
characteristics and distribution of
risky sexual behaviours,
resilience

and protective factors scores. Differences in socio-demographic char- 1–3 2 (1.1 %)

4–6 5 (2.8 %)
acteristics between the participants who remained in the study at 3- 7–9 4 (2.3 %)
month follow-up and those lost to follow-up was assessed using the 10–12 165
(93.8 %)
Chi-square test. Mixed effect logistic regression models were used to
examine the impact of the intervention on risky sexual behaviours. n = frequency; % = percentage; X2 = Chi-square; p-value = level of significance
Mixed effect linear models were used to determine the impact of the <0.05.
intervention on resilience and protective factors. The analyses adjusted
for sociodemographic characteristics, such as gender, age, religion, the participants (75.1 %) had secondary education. More than half of
level of education and living arrangement. The p value of <0.05 was the participants (51.8 %) were living with one parent. Chi-square test
considered as the level of significance. Data were analysed using the R ana- lyses did not reveal any significant differences in
Statistical Software, version 4.0.2. sociodemographic characteristics between participants who remained
in the study at 3- month follow-up and those lost to follow-up except
3. Results for age and race. Majority of the participants who remained in the
study at 3-month
3.1. Sociodemographic characteristics follow-up (93.8 %) indicated that they attended 10–12 sessions.
(Table 1).
The sociodemographic characteristics of the participants are shown
in Table 1. The majority of the participants (98.5 %) reported their race 3.2. Impact of the intervention
as black South Africans and more than half of the participants (60.4 %)
identified their gender as female. The age group 15–17 years 3.2.1. Risky sexual behaviours
comprised more than half of the participants (55.8 %). Nearly three Between baseline and 3-month follow-up, there was a 7.4 %
quarters of the increase in the number of youth who were sexually active. Table 2
participants (72.1 %) were Christians and more than three quarters of shows the impact of intervention on non-condom use, multiple sexual
 F. Mbengo Acta Psychologica 230 (2022)
) 80, 59,
Table 2
Univariable and multivariable mixed effect logistic regression estimates for risky contextual factors that facilitate a sense of belonging were mostly
sexual behaviours before and after the intervention. larger compared to instances of negative impacts. Overall, there was
Outcome Measurement Crude Adjust
a signif- icant improvement in the mean resilience scores at the 3-
=
ed month follow- up compared to baseline (115 vs 120, p 0.013).
Est Odd Est Od =
(se) s (se) ds Individual capacities scores increased at 3-month follow-up (44 vs 47;
[95 [95 p 0.004). There were significant differences in the mean scores of
% %
CI] CI]
contextual factors that facilitate a sense of belonging between
Non-condom
use
Baseline 0.921 2.51
1
1.132 3.
10
baseline and 3-month follow-up (42 vs 44, p 0.007). At 3-month follow-
2
up, improvements were seen in the mean scores of relationship with a
(0.535 [0.8 (0.599) [0.9
primary caregiver; however there
7.167]
=
9.912] resilience-based HIV prevention
improvements were not significant (p =
0.943) [Table 3]. intervention has potential to mitigate
—
some risky sexual behaviours
— 4. Discussion associated with young people's
vulnerability to HIV. At 3-month follow-
This study assessed the impact of a up, participants had less like- lihood to
resilience-based HIV prevention have unprotected sex, regret their
intervention (You Only Live Once) on decision to engage in sexual activity and
risky sexual behaviours, resilience and be pregnant or made someone
protective factors among youth in South pregnant. On the other hand, the
Africa. Findings suggest that a intervention did not positively impact
some risky sexual behaviours
3-month follow-up (Ref) (Ref) part-
linked to HIV infection among nerships, transactional
intergenerational sex and
sex. Also, a
Transactional sex youth including multiple sexual slight in-
Baseline 0.388 —0.680 0.507
—0.947
(1.080)
were sexually active
(1.063) [0.048, [0.061,
3.113] 4.207] was observed
crease in the number between baseline and
of participants who 3-month follow-up,
implying that the
3-month follow-up (Ref) (Ref) Furthermore,
intervention did not delay findings indicate that the
intervention has ability to
initiation of sexual activities. improve resilience
Intergenerational sex Baseline —0.281 0.755 —0.294 0.746
(0.435) [0.322, (0.442) [0.314, observed in
and protective resilience and
factors of youth. protective factors:
Significant individual
improvements were capacities and
3- 1.772] 1.772]
(Ref) (Ref) up. However,
mon contextual
the intervention
th factors that
follo did not
facilitate a
w- significantly
sense of
up impact
belonging at 3-
protective
month follow-
NB: The reported adjusted odds estimates are also age-gender adjusted. The
0.507; 95 % CI 0.061 to 4.207). Furthermore, par- ticipants at 3-month
estimates provided are for the “yes” responses to the risky sexual behaviours follow-up were 34 % more likely to engage in intergenerational sex in
before and after the intervention, with ‘no’ responses as the reference group. the last three months than baseline (OR = 0.746; 95 % CI = 0.314 to
1.772).
partnerships, pregnancy incidence, sexual regret, intergenerational sex
and transactional sex. The intervention seemed to have positively 4.1.1. Resilience and protective factors
impacted non-condom use, sexual regret and pregnancy incidence, Fig. 2 depicts the individual response to the intervention on the
whilst multiple sexual partnerships, transactional sex and intergenera- scales of resilience and protective factors. Individuals responded
tional sex were not positively impacted. At 3-month follow-up, partici- differently to the measures, but it can be observed that the magnitude
pants were 68 % less likely to have unprotected sex during sexual of positive impacts of intervention on the scores of resilience and
intercourse compared to baseline (odds ratio [OR] 3.102; factors: relationship with primary caregiver.
= 95 % con- Findings of this study concur with those of previous research, for
fidence interval [CI] 0.959 to 9.912). Participants at 3-month follow- up
= example, an evaluation an intervention targeting female youth in
were 22 % less likely to regret their decision to engage in sexual
activity in the last three months than baseline (OR 1.278; 95 % CI United States of America by Sieving et al. (2011, 2013) also found that
=
0.430 to 3.797). Additionally, at 3-month follow-up participants =
were the intervention reduced non-condom use. It is important to note that
0.4 % less likely to be pregnant or made someone pregnant in the last the intervention evaluated by Sieving et al. (2011, 2013) differed to the
three months compared to baseline (OR 1.004; = 95 =
% CI 0.149 to one in the present study in that it was 18 months in length.
6.776). Furthermore, Castillo-Arcos et al. (2016) in their intervention targeting
Conversely, participants at 3-month follow-up were 66 % more likely youth in Mexico also observed that the intervention did not positively
to have multiple sexual partnerships in the last three months than impact risky sexual behaviours. Castillo-Arcos et al. (2016) did not
baseline (OR 0.603; 95 % CI 0.243 to 1.494). Additionally, at 3- month mention the length = of their= intervention. However, findings of the
follow-up, participants were 97 % more probably to be involved in present study are inconsistent with those of Sieving et al. (2011, 2013)
transactional sex in the last three months compared to baseline (OR who found that the intervention significantly improved youth's
= =
 F. Mbengo Acta Psychologica 230 (2022)
relationship with parents.
You Only Live Once curriculum included topics on sexual health
knowledge including HIV and risky sexual behaviours which may have
increased participants' awareness of the consequences of engaging in
risky sexual behaviours and in turn positively influenced some risky
sexual behaviours, such as non-condom use. Factors that may have
contributed to the limited impact of the intervention on some risky
sexual behaviours, such as multiple sexual partnerships, transactional
sex and intergenerational sex include the immediate and wider
context within which the intervention was implemented; the dosage,
duration and content of the intervention; and methodological
limitations.
The immediate and wider context within which the You Only Live
Once intervention was implemented could have contributed to the
limited impact of the intervention. Evidence suggests that several
factors such as poverty, limited resources (Mwale & Muula, 2017),
gender and cultural issues (Chandra-Mouli et al., 2015; Dancy et al.,
2014) hinder the implementation of interventions targeting youth. It is
possible that the intervention was not able to adequately deal with
these challenges. The dosage, duration and content of the
intervention could have contributed to the limited impact of the
intervention. The intervention comprised of 12 sessions, as such the
dosage of the intervention may have been inadequate to influence
risky sexual behaviours. Moreover,
 F. Mbengo Acta Psychologica 230 (2022)

No formal 5 (2.5 4 (2.3 1 (4.8 %)

education %) %)
Primary 17 (8.6 16 (9.1 1 (4.8 %)
education
A friend 5 (2.5 4 (2.3 %)
%)
Alone 4 (2 4 (2.3 %)
%)
Other 2 (1 2 (1.1 %)
%)
3-month (Ref) (Ref)
follow-
up
Multiple sexual Baselin 0.508 0.602 0.50 0.60
e 6 3
partnerships (0.448) [0.250
, (0.463
) [0.2
43,
1.446] 1.49
4]
3-month (Ref) (Ref)
follow-
up
Pregnancy Baselin 0.006 1.006 0.004 1.00
e 4
incidence (0.947) [0.157 (0.974 [0.1
, ) 49,
6.440] 6.77
3-month (Ref) (Ref) 6]
follow-up
Sexual regret Baseline 0.255 1.291 0.245 1.27
8
(0.494) [0.490
, (0.556
) [0.4
30,
3.401] 3.79
7]

Fig. 2. Distribution of individual's response to the You Only Live Once intervention across resilience and protective factors.

Table 3
Mixed effect model estimates for measuring the impact of the intervention on resilience and protective factors, adjusting for key demographic variables.
Resilience Individual capacities
Relationship with primary caregiver Contextual factors that facilitate a sense of belonging

Mean (se) p-value Mean (se) p-value Mean (se) p-value Mean (se) p-value

Measure Baseline ¡2.966 (1.182) 0.013 ¡1.580 (0.545) 0.004 —0.028 (0.396) 0.943 —1.258 (0.460) 0.007
3-month follow-up (Ref) (Ref) (Ref) (Ref)
Gender Male (Ref) (Ref) (Ref) (Ref)
Female 0.889 (2.079) 0.670 —0.328 (0.894) 0.714 —0.030 (0.769) 0.969 1.186 (0.766) 0.124

Age
Religion
 F. Mbengo Acta Psychologica 230 (2022)
Transgender 4.828 (13.467) 0.720 —1.351 (5.788) 0.816
4.007 (4.983) 0.422 0.575 (4.965) 0.908
Education level 15–17 (Ref) (Ref)
(Ref) (Ref)
18–20 —0.771 (2.365) 0.745 —0.399 (1.016) 0.695
—1.287 (0.863) 0.138 0.985 (0.876) 0.263
21–23 —0.772 (3.093) 0.803 0.013 (1.328) 0.992
—1.409 (1.129) 0.214 0.805 (1.146) 0.483
Living arrangement 24 and above —5.833 (5.621) 0.301 —2.585 (2.414) 0.286
¡4.253 (2.051) 0.040 0.823 (2.083) 0.693
Christianity (Ref) (Ref)
(Ref) (Ref)
Islam ¡31.528 (13.155) 0.018 ¡12.579 (5.685) 0.028
—6.350 (4.912) 0.198 —12.693 (4.889) 0.010
Traditional 1.845 (2.237) 0.411 0.613 (0.967) 0.527
0.852 (0.835) 0.309 0.222 (0.832) 0.790
Other —17.028 (13.155) 0.197 —5.079 (5.685) 0.373
—7.850 (4.911) 0.112 —4.193 (4.889) 0.392
No formal education (Ref) (Ref)
(Ref) (Ref)
Primary education —0.313 (7.482) 0.967 —0.219 (3.221) 0.946
1.188 (2.762) 0.668 —1.781 (2.765) 0.520
Secondary education —3.268 (6.792) 0.631 —0.322 (2.924) 0.912
—0.473 (2.508) 0.851 —2.848 (2.510) 0.258
Tertiary education —2.929 (7.250) 0.687 0.234 (3.121) 0.940
—0.984 (2.677) 0.714 —2.141 (2.680) 0.425
Both parents (Ref) (Ref)
(Ref) (Ref)
One parent 0.563 (2.241) 0.802 0.594 (0.969) 0.541
—0.849 (0.783) 0.280 0.800 (0.839) 0.342
Another relative —0.456 (3.435) 0.985 0.493 (1.486) 0.740
—1.582 (1.200) 0.189 0.731 (1.287) 0.571
A friend —12.681 (6.849) 0.066 —1.832 (2.962) 0.537
¡11.707 (2.393) <0.001 0.306 (2.565) 0.905
Alone —2.5-056 (6.849) 0.764 1.793 (2.962) 0.546
¡4.967 (2.393) 0.040 1.556 (2.565) 0.545
Other 14.819 (9.528) 0.122 7.293 (4.121) 0.079
2.043 (3.329) 0.540 5.431 (3.568) 0.130

Bold text indicates significance effect at 5 % level of significance. Italicised text indicates a trend towards significance.

the intervention was implemented over a period of one week and is an

inadequate period to expect change of behaviours, and a more
extended period should have been included. Research shows that
interventions delivered with higher dosage or for a longer duration are
more effective

than shorter interventions (Chandra-Mouli et al., 2015; Ibrahim &

Sidani, 2014; Scott-Sheldon et al., 2013; Sieving et al., 2011, 2013),
perhaps because such interventions allow for more in-depth
discussion and reflection on topics that have powerful effect on
changing individual
 F. Mbengo Acta Psychologica 230 (2022)

behaviours. Additionally, the intervention's lack of content addressing This research was financially supported by the Edith Cowan Uni-
structural drivers of risky sexual behaviours among youth (Dana et al., versity, Australia through a Higher Degree by Research Scholarship
2019; Sathiyasusuman, 2015; Onoya et al., 2015) could have contrib-
uted to the limited impact of the intervention on risky sexual behav- awarded to the first author. The funder had no role in the study con-
iours. Addressing structural determinants of young people's risky ceptualisation and design; in the collection, analysis and interpretation
sexual behaviours, such as poverty, unemployment and harmful social of data; in the writing of the article; and in the decision to submit the
norms improves the impact of the intervention in reducing risky sexual article for publication.
be- haviours (Baird et al., 2012; Mavedzenge et al., 2014; Stoner et al.,
2020; Svanemyr et al., 2015). Declaration of competing interest
The present study had methodological limitations which may have
contributed to the limited impact of the intervention. The length for The authors declare that they have no competing interests.
follow-up was short (three months), and because health-related behav-
iours are known to take time to adopt and become routine (Rogers, Acknowledgements
2003), it is possible that the short duration for follow-up could have
contributed to the limited impact of the intervention on risky sexual The authors express sincere gratitude to the research participants
behaviours. The use of a one-group pretest-posttest design which does for their informed consent/assent, and management of the non-profit
not have a comparison group and control other factors beside the organisation for granting permission to undertake the study.
intervention, such as history, maturation and testing effects could have
mitigated the true impact of the intervention. Moreover, the study References
findings are based on self-reported data, therefore because of the sen-
sitive nature of some questions, some participants may have provided Akintobi, H. T., Trotter, J., Zellner, T., Lenoir, S., Evans, D., Rollins, L., & Miller, A. (2016).
socially desirable answers. Furthermore, the sample size used to Outcomes of a behavioral intervention to increase condom use and reduce HIV risk
among urban African American young adults. Health Promotion Practice, 17
assess the impact of the intervention was small (n 176) which
= (5), 751–759. https://doi.org/10.1177/1524839916649367
Baird, S. J., Garfein, R. S., McIntosh, C. T., & O¨ zler, B. (2012). Effect of a cash transfer
could have limited the study's statistical power to detect effects of the
programme for schooling on prevalence of HIV and herpes simplex type 2 in Malawi: A
intervention. In addition to the likely influence of methodological cluster randomised trial. The Lancet, 379(9823), 1320–1329. https://doi.org/
limitations on the impact of the intervention, the present study had 10.1016/S0140-6736(11)61709-1
Brest, P. (2010). The power of theories of change. Retrieved from Stanford Social Innovation
other limitations. A convenience sampling approach was used to recruit Review, 8(2), 47–51 https://sc4ccm.jsi.com/wp-content/uploads/2016

participants, it is possible that there was selection bias in participants /07/The-Power-Of-Theories-Of-Change.pdf.

Castillo-Arcos, L. D. C., Benavides-Torres, R. A., Lo´pez-Rosales, F., Onofre-
who agreed to be in the study. In addition, the study was conducted Rodríguez, D. J., Valdez-Montero, C., & Maas-Go´ngora, L. (2016). The effect of an
internet-based intervention designed to reduce HIV/AIDS sexual risk among Mexican
among youth in a single organisation, therefore findings may not be adolescents. AIDS Care, 28(2), 191–196. https://doi.org/10.1080/
generalizable to all South African youth. Nonetheless, the study's 09540121.2015.1073663
strengths includes the matching of participants' baseline and 3-month Chandra-Mouli, V., Lane, C., & Wong, S. (2015). What does not work in adolescent sexual
and reproductive health: A review of evidence on interventions commonly accepted
follow-up data for analysis, low as best practices. Global Health: Science and Practice, 3(3), 333–340. https://doi.org/
attrition rates and use of validated instruments. 10.9745/GHSP-D-15-00126
The study suggests areas of improvements for future research. Dana, L. M., Adinew, Y. M., & Sisay, M. M. (2019). Transactional sex and HIV risk among
More rigorous evaluation approaches for the intervention are adolescent school girls in Ethiopia: mixed method study. 2019. https://doi.org/
10.1155/2019/4523475
recommended. Future studies should examine the factors that Dancy, B. L., Jere, D. L., Kachingwe, S. I., Kaponda, C. P., Norr, J. L., & Norr, K. F. (2014).
influence the outcomes of the intervention to guide future research and HIV risk reduction intervention for rural adolescents in Malawi. Journal of HIV/AIDS
intervention development. Finally, future studies should investigate Social Services, 13(3), 271–291. https://doi.org/10.1080/15381501.2013.864173 Fergus, S.,
& Zimmerman, M. A. (2005). Adolescent resilience: A framework for
whether using a large sample size; improving the content of the understanding healthy development in the face of risk. Annual Reviews Public Health, 26,
399–419. https://doi.org/10.1146/annurev.publhealth.26.021304.144357
intervention to address structural determinants of young people's risky
Free State Provincial Council on AIDS. (2018). Free state provincial implementation plan
sexual behaviours (e.g., gender- based violence, poverty and for the response to HIV; TB; and STIs (2017-22). Bloemfontein: Free State Provincial
unemployment); and increasing the dura- tion and dosage of the Council on AIDS. https://sanac.org.za/wp-content/uploads/2019/02/PIP_FreeState_
intervention, and length for follow-up improves the impact of the Final.pdf.
Govender, K., Cowden, R. G., Asante, K. O., George, G., & Reardon, C. (2017). Validation of
intervention. the child and youth resilience measure among south African adolescents. PloS one,
12(10), Article e0185815. https://doi.org/10.1371/journal.pone.0185815
5. Conclusion Govender, K., Cowden, R. G., Asante, K. O., George, G., & Reardon, C. (2019). Sexual risk
behavior: A multi-system model of risk and protective factors in South African
adolescents. Prevention Science, 20(7), 1054–1065. https://doi.org/10.1007/s11121-
019-01015-3
Overall, there is limited literature on the effectiveness of resilience- Hodder, R. K., Homer, S., Freund, M., Bowman, J. A., Lecathelinais, C., Colyvas, K., &
based HIV prevention interventions aimed at reducing risky sexual be- Wiggers, J. H. (2018). The association between adolescent condom use and individual
haviours among youth in South Africa. Findings indicate that the and environmental resilience protective factors. Australian and New
intervention positively impacted some risky sexual behaviours, and Zealand Journal of Public Health, 42(3), 230–233. https://doi.org/10.1111/1753-
6405.12744
resilience and protective factors, whilst some risky sexual behaviours Human Sciences Research Council. (2017). South African National HIV prevalence,
and protective factors where not positively impacted. To the authors' incidence, behaviour and communication survey. SABSSM V.. https://www.hsrcp
ress.ac.za/books/south-african-national-hiv-prevalence-incidence-behaviour-and-
knowledge, this study is the first impact evaluation of a resilience-
communication-survey-2017.
based HIV prevention intervention aimed at reducing risky sexual Ibrahim, S., & Sidani, S. (2014). Community based HIV prevention intervention in developing
behaviours among youth in South Africa. The study provides initial countries: A systematic review. Advances in Nursing, 2014. https://dow
evidence about the potential of resilience-based HIV prevention nloads.hindawi.com/archive/2014/174960.pdf.
Joint United Nations Programme on HIV/AIDS. (2021). AIDSinfo: Global data on HIV
intervention to reduce risky sexual behaviours, and improve resilience epidemiology and response. https://aidsinfo.unaids.org/.
and protective factors in South African youth. Given the methodological Kaufman, M. R., Cornish, F., Zimmerman, R. S., & Johnson, B. T. (2014). Health behavior
limitations highlighted in this study, there is need for further evaluation change models for HIV prevention and AIDS care: Practical recommendations for a
multi-level approach. Journal of Acquired Immune Deficiency Syndromes, 66(Suppl. 3),
of the intervention with a rigorous study design, larger sample size and Article S250. https://doi.org/10.1097/QAI.0000000000000236 (1999).
longer period for follow- up to strengthen evidence on the impact of the Kaunda-Khangamwa, B. N., Maposa, I., Dambe, R., Malista, K., Mtagalume, E., Chigaru,
intervention. L., & Manderson, L. (2020). Validating a child youth resilience measurement (CYRM-
28) for adolescents living with HIV (ALHIV) in Urban Malawi. Frontiers in Psychology,
11, 1896. https://doi.org/10.3389/fpsyg.2020.01896
Funding Kgaphola, H. K., & Jacob, C. (2020). Monitoring and evaluation lessons from the design and
implementation evaluation of the ‘You Only Live Once’ social behaviour change
 F. Mbengo Acta Psychologica 230 (2022)
programme for adolescents: A partnership between the United States Agency for review and meta-analysis. BMC Public Health, 16(1), 1–26. https://doi.org/10.1186/
International Development, Department of Social Development, South African National s12889-016-3715-4
AIDS Council, Pact SA and Mot MacDonald. African Evaluaton Journal, 8(1), Article Sathiyasusuman, A. (2015). Associated risk factors of STIs and multiple sexual relationships
a468. https://doi.org/10.4102/aej.v8i1.468 among youths in Malawi. PLoS One, 10(8), Article e0134286. https://
Khuzwayo, N., & Taylor, M. (2018). Exploring the socio-ecological levels for prevention of doi.org/10.1371/journal.pone.0134286
sexual risk behaviours of the youth in uMgungundlovu district municipality, KwaZulu-Natal. Scott-Sheldon, A. J. L., Walstrom, P., Harrison, A., Kalichman, C. S., & Carey, P. M.
Retrieved from African Journal of Primary Health Care and Family Medicine, 10(1) (2013). Sexual risk reduction interventions for HIV prevention among South African
https://phcfm.org/index.php/phcfm/article/view/1590/2381. Youth: A meta-analytic review. Current HIV Research, 11(7), 549–558. https://doi.
Knapp, T. R. (2016). Why is the one-group pretest-posttest design still used? Clinical org/10.2174/1570162x12666140129105726
Nursing Research, 25(5), 467–472. https://doi.org/10.1177/1054773816666280 Krejcie, R. Shisana, O., Rehle, T., Simbayi, L. C., Zuma, K., Jooste, S., Zungu, N., & Onoya, D.
V., & Morgan, D. W. (1970). Determining sample size for research activities. (2014). South African national HIV prevalence, incidence and behaviour survey,
Educational Psychological Measurement, 30(3), 607–610. https://doi.org/10.1177/ 2012. https://www.hsrcpress.ac.za/books/south-african-national-hiv-prevalence-
001316447003000308
LiveMoya. (2018). Final report on yolo design & implementation evaluation. Johannesburg: incidence-and-behaviour-survey-2012.
LiveMoya. Sieving, R. E., McMorris, B. J., Beckman, K. J., Pettingell, S. L., Secor-Turner, M., Kugler,
LoVette, A., Kuo, C., & Harrison, A. (2019). Strength-based interventions for HIV prevention K., & Bearinger, H. L. (2011). Prime time: 12-Month sexual health outcomes of a clinic-
and sexual risk reduction among girls and young women: A resilience- based intervention to prevent pregnancy risk behaviors. Journal of
focused systematic review. Global Public Health, 14(10), 1454–1478, 1080/ Adolescent Health, 49, 172–179. https://doi.org/10.1016/j.jadohealth.2010.12.002 Sieving,
17441692.2019.1602157. R. E., McRee, A., McMorris, B. J., Beckman, K. J., Pettingell, S. L.,
Mabaso, M., Maseko, G., Sewpaul, R., Naidoo, I., Jooste, S., Takatsana, S.Zungu, N., … Bearinger, L. H., & Garwick, N. W. (2013). Prime time sexual health outcomes at 24
(2021). Trends and correlates of HIV prevalence among adolescents in South Africa: months for a clinic-linked intervention to prevent pregnancy risk behaviors. JAMA
Evidence from the 2008, 2012 and 2017 South African National HIV Prevalence, Incidence Pediatrics, 167(4), 333–340. https://doi.org/10.1001/jamapediatrics.2013.1089 South
and Behaviour surveys. AIDS Research and Therapy, 8, 97. https://doi.org/ African Children’s Act [No.38 of 2005], n.d., South African Children’s Act [No.38
of 2005].
10.1186/s12981-021-00422-3
South African Department of Social Development. (2016). “YOLO” facilitator’s manual: A
Mavedzenge, S. N., Luecke, E., & Ross, D. A. (2014). Effective approaches for programming
programme for the reduction of HIV Infections, teenage and unplanned pregnancy.
to reduce adolescent vulnerability to HIV infection, HIV risk, and HIV- related morbidity and
Statistics South Africa. (2016). ‘Community survey 2016’. Statistical release P0301.
mortality: A systematic review of systematic reviews. Journal
Statistics South Africa. (2017). Education series volume III educational enrolment and
of Acquired Immune Deficiency Syndromes, 66, S154–S169. https://doi.org/10.1097/
achievement, 2016. Report No. 92-01-03.
QAI.0000000000000178
Statistics South Africa. (2021a). Mid-year population estimates 2021. Statistical Release
Max, J. L., Sedivy, V., & Garrido, M. (2015). Increasing our impact by using a social-
P0302. Retrieved from https://www.statssa.gov.za/publications/P0302/P030220 21.pdf.
ecological approach. Washington, DC: Administration on Children, Youth and
Statistics South Africa. (2021b). Maluti a Phofung. https://www.statssa.gov.za/?pag e_id
Families, Family and Youth Services Bureau. https://www.healthyteennetwork. org/wp-
993&id maluti-a-phofung-municipality.
content/uploads/TipSheet_IncreasingOurImpactUsingSocial-Ecolog icalApproach.pdf. Stoner, M. C. D., Kilburn, K., Hill, L. M., MacPhail, C., Selin, A., Kimaru, A., & Pettifor, A.
McNair, O. S., Gipson, J. A., Denson, D., Thomson, D. V., Sutton, M. Y., & Hickson, D. A. (2020). The effects of a cash transfer intervention on sexual partnerships and HIV in the
(2018). The associations of resilience and HIV risk behaviors among black gay, HPTN 068 study in South Africa. Culture, Health & Sexuality, 22(10), 1112–1127.
bisexual, other men who have sex with men (MSM) in the Deep South: The MARI https://doi.org/10.1080/13691058.2019.1655591
Study. AIDS Behavior, 22, 1679–1687. https://doi.org/10.1007/s10461-017-1881-8 Svanemyr, J., Amin, A., Robles, O. J., & Greene, M. E. (2015). Creating an enabling
Municipal Demarcation Board. (2018). Municipal capacity assessment: Maluti-Phofung environment for adolescent sexual and reproductive health: A framework and
FS194. https://www.demarcation.org.za/site/free-state_mca2018/. promising approaches. Journal of Adolescent Health, 56(1), S7–S14. https://doi.org/
Mwale, M., & Muula, A. S. (2017). Systematic review: a review of adolescent behavior change 10.1016/j.jadohealth.2014.09.011
interventions [BCI] and their effectiveness in HIV and AIDS prevention in Tsang, S., Royse, C. F., & Terkawi, A. S. (2017). Guidelines for developing, translating, and
sub-Saharan Africa. BMC Public Health, 17(1), 1–9. https://doi.org/10.1186/s12889- 017- validating a questionnaire in perioperative and pain medicine. Saudi Journal of
4729-2 Anaesthesia, 11(Suppl. 1), S80. https://doi.org/10.4103/sja.SJA_203_17
Onoya, D., Zuma, K., Zungu, N., Shisana, O., & Mehlomakhulu, V. (2015). Determinants of van Rensburg, A. C., Theron, L. C., & Ungar, M. (2019). Using the CYRM-28 with south
multiple sexual partnerships in South Africa. Journal of Public Health, 37(1), african young people: A factor structure analysis. Research on Social Work Practice,
97–106. https://doi.org/10.1093/pubmed/fdu010 29, 93–102. https://doi.org/10.1177/1049731517710326
Pilgrim, N. A., & Blum, R. W. (2012). Protective and risk factors associated with adolescent Visser, M. (2017). Rethinking HIV-prevention for school-going young people based on
sexual and reproductive health in the English-speaking Caribbean: A current behaviour patterns. Journal of Social Aspects of HIV/AIDS, 14(1), 64–76.
literature review. Journal of Adolecent Health, 50(1), 5–23. https://doi.org/10.1016/ https://doi.org/10.1080/17290376.2017.1376704
j.jadohealth.2011.03.004 Wang, J. L., Zhang, D. J., & Zimmerman, M. A. (2015). Resilience theory and its
Reddy, S. P., James, S., Sewpaul, R., Koopman, F., Funani, N. I., Sifunda, S., & implications for Chinese adolescents. Psychological Reports, 117(2), 354–375.
Omardien, R. G. (2010). Umthenthe Uhlaba Usamila – the South African youth risk https://doi.org/10.2466/16.17.PR0.117c21z8
behaviour survey 2008. Cape Town: South African Medical Research Council. World health Organization. (2016). Consolidated guidelines on HIV prevention, diagnosis,
Reddy, S. P., James, S., Sewpaul, R., Sifunda, S., Ellahebokus, A., Kambaran, N. S., & treatment and care for key populations – 2016 update. https://www.who.
Omardien, R. G. (2013). Umthente Uhlaba Usamila: The 3rd South African national int/publications/i/item/9789241511124.
youth risk behaviour survey 2011. Cape Town: South African Medical Research Zgambo, M., Arabiat, D., & Ireson, D. (2022). “We just do it… we are dead already”: Exploring
Council. http://repository.hsrc.ac.za/handle/20.500.11910/2487. the sexual behaviors of youth living with HIV. Journal of Adolescence, 94 (1), 34–44.
Resilience Research Centre. (2016). The Child and Youth Resilience Measure (CYRM) Child https://doi.org/10.1002/jad.12003
Zgambo, M., Kalembo, F. W., & Mbakaya, B. C. (2018). Risky behaviours and their
Version. https://www.resilienceresearch.org/files/CYRM/Child%20-%20C YRM correlates among adolescents living with HIV in sub-Saharan Africa: A systematic
%20Manual.pdf. review. Reproductive Health, 15(1), 1–12. https://doi.org/10.1186/s12978-018-
Rogers, E. M. (2003). Diffusion of innovations (5th ed.). New York: Free Press. 0614-4
Sani, A. S., Abraham, C., Denford, S., & Ball, S. (2016). School-based sexual health education
interventions to prevent STI/HIV in sub-Saharan Africa: A systematic