The Journal of School Nursing
2021, Vol. 37(2) 128-138
© The Author(s) 2019
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DOI: 10.1177/1059840519855372
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Saloshni Naidoo, MB ChB, PhD1 , and Myra Taylor, PhD1
A better understanding of the social influences, self-efficacy, and communication with parents, peers, and teachers associated with teenage pregnancy is required owing to the consequences of teenage pregnancy. This article aimed to determine the prevalence of teenage pregnancy and to understand the association between social influences, self-efficacy, and communication about teenage pregnancies, among high school students in KwaZulu-Natal, South Africa. Grade 11 students at 20 randomly selected schools in two districts completed an anonymous questionnaire on sociodemographics, social influences, self-efficacy communication, and teenage pregnancy. Teenage pregnancy was associated with age, being female, and exposure to communication discouraging pregnancy. Students living with both parents, or where family and peers believed that the adolescents should abstain from sex, or who experienced positive social pressure discouraging pregnancy were unlikely to have had a pregnancy. This study identified sociodemographic and sociobehavioral influences associated with teenage pregnancy that can assist school nurses in their work.
teenage, pregnancy, students, gender differentials, South Africa, school nurse
Despite national preventative efforts in several countries, teenage pregnancies remain a cause for concern. The World Health Organization (WHO, 2016) reported in 2014 that the average global birth rate among 15–19 years of age was 49 per 1,000 with a range from 1 to 299 births per 1,000 with the highest rates seen in sub-Saharan Africa. The WHO reports that worldwide the figure has reduced from 65/1,000 in 1990 to 47/1,000 in 2015 (WHO, 2016). Far higher incidences were reported in sub-Saharan Africa with ranges from 187/1,000 adolescents in Burkina Faso to 121/1,000 adolescents in Ethiopia (Sedgh, Finer, Bankole, Eilers, & Singh, 2015). The incidence of teenage pregnancy in developed countries ranged between from 8/1,000 adolescents in Switzerland in 2011 (Sedgh et al., 2015) to 20.3/1,000 adolescents in the United States in 2016 (Martin, Hamilton, Osterman, Driscoll, & Drake, 2018). In South Africa, findings from three rounds (2002, 2008, and 2011) of the South African Youth Risk Behavior Survey indicated that the teenage pregnancy prevalence was 11.0%, 10.6%, and 11.6%, respectively (Jonas, Crutzen, van den Borne, Sewpaul, & Reddy, 2016). In 2015, Statistics South Africa (2015) reported the teenage pregnancy prevalence at 5.3% for 14- to 19-year-olds, ranging between 0.6% (14-year-olds) and 9.7% (19-year-olds).
Teenage pregnancy is associated with short- and longterm health risks and consequences. The mortality risk in infants born to teenage mothers and among teenage mothers themselves is far higher than in other groups (WHO, 2016). Data from the Africa Centre’s Demographic Surveillance Area in KwaZulu-Natal, South Africa, indicated that teenage mothers (17 years and younger) had a higher risk of dying when compared to women who delayed their pregnancy until the age of 20 or later (Ardington, Menendez, & Mutevedzi, 2015).
A systematic review of the literature on complications in teenage pregnancies found that while teenage pregnancies had increased maternal–infant complications, such complications were more frequent in the infant. Prematurity, low birth weight babies, and infant mortality were significantly greater among teenage mothers than older women. Maternal complications included preeclampsia, eclampsia, premature rupture of membranes, and abortions (Azevedo, Diniz, Fonseca, Azevedo, & Evangelista, 2015). In addition to the health risks and their consequences undoubtedly, the social and economic impacts as a result of teenage pregnancies are a concern globally but more so in developing countries.
In developed countries, the implementation of comprehensive sexual health education programs and improved access to services has contributed to a decline in the prevalence of teenage pregnancies (Lindberg, Santelli, & Desai, 2016; Sedgh et al., 2015). Programs that focused on comprehensive sexual education and built individual responsibility and decision-making in relationships have contributed to this decline (Carter, 2012). Increasing access to preventative and contraceptive services has also contributed to declines in teenage pregnancy rates (McNicholas, Madden, Secura, & Peipert, 2014; Secura et al., 2014). In South Africa, implementation of youth-friendly services that are sensitive to the needs of adolescents and that create a safe and comfortable environment has contributed to improved access and utilization of sexual health services among the youth (Mendelsohn et al., 2018).
Teenagers who get pregnant are more likely to have dropped out of school (Ardington et al., 2015) affecting their future economic status. Research with respect to teenage mothers found that those who have teenage pregnancies have poorer social and economic outcomes in adulthood (Odu, Ayodele, & Isola, 2015), which may also adversely affect their children. While there is limited evidence on gender differentials, Mollborn (2010) showed that teenage mothers and fathers were equally unlikely to finish high school by the age of 26. In South Africa, there is documented evidence of a failure to complete school among women who have teenage pregnancies. Using longitudinal demographic surveillance data from the Agincourt subdistrict in South Africa, school enrollment is associated with a far lower risk of teenage pregnancy compared to nonenrollment (Rosenberg et al., 2015). Children born to teenage mothers in South Africa have worse educational outcomes even when maternal socioeconomic circumstances are taken into account (Branson, Ardington, & Leibbrandt, 2013).
In attempting to reduce the prevalence of teenage pregnancies and its long-term impact on teenagers’ lives, it is important to understand the impact that social influences, self-efficacy, and communication have on preventing teenage pregnancies and the inherent gender differentials which may exist. Social influences such as norms and modeling may positively or negatively influence teenage pregnancies. Social norms such as being embarrassed about falling pregnant have been shown to be associated with a lower likelihood of reporting a teenage pregnancy (Mollborn, Domingue, & Boardman, 2014). Additionally, social modeling behavior suggests that teenagers whose mothers or sisters had teenage pregnancies are more likely to report a teenage pregnancy themselves (Wall-Wieler, Roos, & Nickel, 2016). Pregnancy may be seen as socially desirable and acceptable due to the peer influences and pressure (Kanku & Mash, 2010). Among males, data from the National Longitudinal Study of Adolescent Health in the United States showed that greater birth control selfefficacy was associated with a 44% reduction in teenage fatherhood among participants (Garfield et al., 2016).
Research also shows that increased parental communication decreases risky sexual behavior among adolescents. A meta-analysis of parent–adolescent communication about sex and adolescent safer sex behavior found that parent–adolescent communication was positively associated with safe sex behavior and significantly stronger among girls as compared to boys (Widman, Choukas-Bradley, Noar, Nesi, & Garrett, 2016). There appears to be a gap in the literature with respect to gender differences, pregnancy outcomes, and the impact of social influences, self-efficacy, and communication on teenagers in developing countries.
The Integrated Model for Behavior Change (I-Change; De Vries, 2017; De Vries et al., 2014) provided the conceptual framework for this study, since this has been used successfully in our previous studies with high school students in KwaZulu-Natal (Naidoo, Sartorius, de Vries, & Taylor, 2017; Naidoo & Taylor, 2015). With a view to developing targeted interventions, the researchers investigated associations with motivational factors and, in particular, the social influences and self-efficacy associated with students’ risky behavior that can lead to teenage pregnancy. Further because teenage pregnancy is a prevalent health and social problem in South Africa, it was important to consider the influence of communication about teenage pregnancy. The aim of this article was to determine the prevalence of teenage pregnancy among male and female students and to understand the association between social influences, self-efficacy, and communication about teenage pregnancies, among male and female students attending high school in KwaZulu-Natal, South Africa.
This study was conducted among students attending high schools in Ugu (rural) and eThekwini (urban), 2 of 11 districts in KwaZulu-Natal, South Africa. A complete list of 47 urban and 35 rural schools was obtained from the KwaZulu-Natal Department of Basic Education. A random selection of 10 rural and 10 urban schools, in which there was a total of approximately 17,000 students, were chosen for participation in the study. There are two to three Grade 11 classes per school. In the rural schools, the number of students per class ranges from 50 to 65 and in urban schools, the number of students per class ranges from 45 to 60. In each school, a single Grade 11 class was randomly chosen and all students in the selected class were invited to participate in the study. Information about the study for the parent was sent home with the student. The researchers made themselves available to meet with parents to answer queries. All parents of all children who attended school on the day of data collection gave written informed consent and all students gave written informed assent prior to participating in the study. Full ethical approval was obtained from the Human and Social Sciences Research Ethics Committee (HSS/105/09) of the University of KwaZulu-Natal. The KwaZulu-Natal Department of Basic Education and the principals of the participating schools gave permission for the study to be conducted.
Appointments were scheduled at each school and a fixed time was allocated in the school day for students to complete the questionnaire. Trained research assistants explained the project and distributed the anonymous questionnaires which students took approximately 45 min to complete, thereafter placing the completed questionnaire in a self-sealing envelope before returning it to the research team.
The questionnaire was developed using the I-Change Theoretical Model (De Vries et al., 2014). The questionnaire was pilotedintwoGrade11classesinanurbanandarural school not included in the main study with relevant changes being made for use in this study. Data were collected on sociodemographic factors including household composition and socioeconomic status (SES) of households.
Students’ responses to questions on social influences included social norms regarding getting pregnant, unprotected sex and sexual abstinence, modeling behavior, and social pressure. Students were also asked about their selfefficacy to prevent risky behavior and regarding communication messages regarding not falling pregnant. Their responses were assessed on a 5-point Likert-type scale ranging from strongly disagree to strongly agree, and further details and the Cronbach’s α for each are presented below. The questionnaire thus addressed the social influences covering social norms, modeling, and social pressure encouraging or discouraging risky behavior likely to result in a teenage pregnancy. There were questions on norms relating to family and peer belief with five questions each on family and peer beliefs that students should not get pregnant (Cronbach’s α ¼ .80) that students should not have unprotected sex (α ¼ .87) and about abstaining from sex (α ¼ .80). There were a further five questions on modeling behavior where family and peers displayed behavior which encouraged teenage pregnancy (α ¼ .54). The questions on modeling behavior included two questions each asking whether family and peers displayed behavior which encouraged abstinence (α ¼ .78) and condom use (α ¼ .85), respectively. Regarding social pressure, there were four questions that asked students whether family and peers discouraged getting pregnant (α ¼ .69). The questions on self-efficacy which prevented risky behavior which could result in a teenage pregnancy covered self-efficacy in one’s daily activities (routine) and under special circumstances, for example, at parties (situational), was explored. For this construct, six questions tested selfefficacy in routine settings (α ¼ .72) and two questions each tested situational and stress self-efficacy (α ¼ .83). Communication by parents, caregivers, teachers, and peers encouraging students not to get pregnant was tested with six questions (α ¼ .80).
Data were processed and analyzed using Stata Version 13.0 (StataCorp. 2013; Stata Statistical Software: Release 13; College Station, TX: StataCorp LP). The dependent variable was categorical with female students being asked whether they had ever been pregnant and male students were asked whether they had ever made a female pregnant. Age was categorized as 13–17 years and 18–25 years, since in South Africa 18 years of age denotes adulthood. Demographic variables relating to residence, presence of parents, home language, and religion were categorical. Multiple correspondence analysis (MCA) was employed to weight the following categorical variables (employment, asset ownership, and hunger) when creating an aggregated SES index score. The MCA-based index was chosen because it is better suited to categorical data (Howe, Hargreaves, & Huttly, 2008). The weights used for MCA indices were those from the first dimension (the category with the largest contribution and largest fraction of total variance in the data set). Each factor was given a weight based on the first dimension score and then an overall SES score was created based on a sum of the scores for each variable. This score was then broken into five groups with the lowest used to delineate the “lowest” SES group. Those households in the lowest 20th percentile of this aggregated score were classified as “lowest SES” and employed in the analysis. A single composite independent variable was created for each construct relating to social influences, self-efficacy, and communication based on a summation of the students’ responses to the questions relating to the specific construct. The dependent variable under study was “ever been pregnant” or “ever made a female pregnant” for female and male students, respectively.
Survey weights were incorporated using the “svyset” command that is provided by the Stata Software Package (Version 13) given the complex multistage random sampling strategy of the study and utilized in the analysis to correctly weight point estimates and calculate 95% confidence intervals (CI). Frequencies and means with 95% CI were calculated for categorical and continuous variables, respectively. Svy: tab and Svy: mean commands were used to test for significance of associations between categorical and continuous variables and sex, respectively. Survey weighted multivariable logistic regression analysis was used to test for associations between the independent variables and the dependent variable (ever being pregnant or having made a female pregnant). Factors associated with the dependent variable were also assessed using bivariate logistic regressions. Factors with a p value cutoff <.05 in the bivariate analysis were selected for entry into an adjusted multivariable logistic model. Model fit and adequacy were assessed.
A total of 656 students participated in the study from 20 schools. More females participated than males. Female students (mean: 17.29 years; 95% CI [17.14, 17.44]) were significantly younger than male students (mean: 17.85 years; 95% CI [17.68, 18.03; p < .001; not shown). Compared to the proportion of females, more males were aged 18–25 years (p ¼ .024). More female students (n ¼ 223; 62.24%) were Christian compared to male students (n ¼ 129; 45.65%; p ¼–.005) and more female students (n ¼ 43; 11.96%) reported ever being pregnant, when compared to male students (n ¼ 27; 9.09) reporting ever causing a pregnancy (p ¼ .036; Table 1).
Social norm scores where family and peers believed students should not get pregnant, not engage in unprotected sex and abstain from having sex, were higher among female students when compared to male students. Social pressure scores discouraging pregnancy were significantly higher among female students when compared to male students. Female students displayed better self-efficacy routinely and situationally to resist risky sexual activity, when compared to male students (Table 2).
Female and male students who reported either ever being pregnant (p <.01)oreverhavingmadeafemalepregnant (p ¼ .002) were significantly older than females and male students who had never been pregnant nor ever made a female pregnant, respectively. Female students who had ever been pregnant were significantly less likely to live with both of their parents, when compared to female students who reported never being pregnant (p < .001; Table 3).
Female students who had ever been pregnant were less likely to have family members and peers who believed that an adolescent should abstain from sex when compared to female students who had never been pregnant. The female students who had ever been pregnant were more likely to have been exposed to modeling behavior among family and peers which encouraged falling pregnant, when compared to female students who had never been pregnant. In addition, female students who had ever been pregnant were more likely to have been exposed to communication discouraging pregnancy, when compared to female students who had never been pregnant. Female students who had never been pregnant also displayed better routine self-efficacy and situational self-efficacy to resist risky sexual activity, when compared to female students who had ever been pregnant. In addition, those who had never been pregnant were more likely to have experienced positive social pressure discouraging pregnancy, when compared to female students who had ever been pregnant (Table 4).
Male students who had never made a female pregnant were more likely to have been exposed to modeling behavior which encouraged them to abstain from sex, when compared to male students who had ever made a female pregnant. Male students who had never made a female pregnant also had higher routine self-efficacy to resist risky sexual activity, when compared to male students who had ever made a female pregnant (Table 4).
Being older was associated with ever being pregnant/having made a female pregnant while females were more likely to have had a pregnancy. Students who lived with both parents were less likely to have been pregnant/made a female pregnant. Where family and peers believed that the student should abstain from sex, students were less likely to have been pregnant/made a female pregnant. Students who had been exposed to modeling behavior which encouraged them to abstain from sex were less likely to have been pregnant/made a female pregnant, and similarly students experiencing positive social pressure discouraging pregnancy were less likely to have been pregnant/made a female pregnant. Being exposed to communication discouraging pregnancy remained associated with ever being pregnant/made a female pregnant among students. However, this finding may be reflective of temporal bias in the study (Table 5).
Understanding the impact social influences, self-efficacy, and communication have on preventing teenage pregnancies, and the gender differences that exist between these elements among students, is very important in developing interventions to address the issue of teenage pregnancies. This study found that social norms and influences were clearly focused on the female student, with females significantly more likely to be exposed to norms and influences that discouraged falling pregnant. Probably owing to this exposure, female students also displayed significantly greater self-efficacy to resist risky sexual activity. Routine self-efficacy was significantly higher among females aged 13–17 years when compared to males of the same age-group (p < .001), although there was no significant difference between males and females aged 18–25 years. Okigbo, Kabiru, Mumah, Mojola, and Beguy (2015) studying young people living in the slums of Nairobi found that mother–son and father–daughter communication were important in delaying sexual onset. Widman, Choukas-Bradley, Noar, Nesi, and Garrett (2016) in their meta-analysis of parent–adolescent communication on youth safe sex behavior reported stronger associations between parent–adolescent communication and safer sexual behaviors among girls than boys. This highlights the need for teenage pregnancy interventions to also include a focus on the boys who were students and their role in preventing teenage pregnancies.
Macleod and Jearey-Graham (2016) write about the impact of “peer pressure” and “peer normalization” on youth sexual activity. The need to be included in peer groups and being able to participate in conversations through having had similar sexual experiences can pressure youth to indulge in risky behavior. However, youth may choose to engage in peer-endorsed behaviors that are “peer normalized” and accepted in their social circle (Macleod & Jearey-Graham, 2016). In this study, females who had been pregnant were significantly more likely to have been exposed to family and peers who themselves had a teenage pregnancy. Kanku and Mash (2010) in a study of adolescent girls in Taung, North West Province, South Africa, report that adolescent girls experienced peer pressure from pregnant friends which influenced their behavior to get pregnant themselves.
In a similar vein, positive influences tend to influence adolescent behavior in a positive manner. Vesely et al. (2014) in their study of inner-city youth from two mid- Western towns in the United States reported that positive role models are strongly associated with reduced sexual behavior, including never having had sexual intercourse among adolescents. This study found that positive modeling behavior among family and peers which encouraged behavior preventing pregnancy was protective against making a girl pregnant among adolescent males.
School programs have been implemented successfully in other countries that provide comprehensive sexual education and promote individual responsibility and decision-making in relationships. Such programs have the potential to encourage and support peer norms that contribute toward reducing teenage pregnancy (Berne & Huberman, 2000). Providing adolescents with access to preventative and contraceptive services is necessary in order to reduce teenage pregnancy rates (McNicholas et al., 2014; Secura et al., 2014). Despite this being an important concern, the implementation of youth-friendly services for adolescents needs further attention. School nurses need training and support on presenting sexuality education and contraception (Brewin, Koren, Morgan, Shipley, & Hardy, 2014).
Being older was significantly associated with pregnancy among male and female students which highlights the need for preventive interventions on risky sexual behavior and pregnancy to start at a much younger age. Interventions that target children when still in primary school could prove beneficial in reducing the burden of teenage pregnancy. In the United States, an evaluation of a 3-year comprehensive sex education program among sixth graders followed up until eighth grade found that 16% fewer boys and 15% fewer girls had sex by the end of eighth grade, as compared to boys and girls who had not received the program (Grossman, Tracy, Charmaraman, Ceder, & Erkut, 2014), confirming that interventions should target younger agegroupstobeeffectiveinadolescence. Experts working in the ambit of child sexual education suggest that interventions should begin as early as age 5 to ensure positive health outcomes (Haberland & Rogow, 2015). In a study of “mother–daughter” communicationinaninformalsettlement in Nairobi, Kenya, the participating adolescents also indicated a need for communication on pregnancy prevention to start at a much earlier age (Crichton, Ibisomi, & Gyimah, 2012). Mothiba and Mabutle (2012) in their study of factors contributing to teenage pregnancy in Limpopo South Africa reported that 62% of their study participants had become sexually active between the ages of 13 and 15 years highlighting the need for interventions at a younger age in South Africa.
In this study communication, discouraging pregnancy was strongly associated with having been pregnant among female adolescents. This may reflect the advice that teenagers receive in the postnatal period. Studies in South Africa have shown that most teenage mothers mainly receive contraceptive counseling in the postnatal period (Cooper et al., 2004; MacPhail, Pettifor, Pascoe, & Rees, 2007). This study asked about past pregnancy history and so the participants would have received the counseling at the time of their pregnancy, hence they reported high levels of communication discouraging pregnancy, when compared to adolescents who had not fallen pregnant.
This study found that living with both parents was protective against falling pregnant among female adolescents. Family structure plays an important role in influencing teenage development, behavior, personal skills, and choices. Adolescents raised in the absence of a father have lower self-esteem, engage in sexual activity at an earlier age, and are low achievers (East, Jackson, & O’Brien, 2006). Brahmbhatt et al. (2014) reporting on the prevalence and determinants of adolescent pregnancy in urban disadvantaged settings found that in the cities of Baltimore, United States, and Johannesburg, South Africa, being raised by a single parent was a determinant for teenage pregnancy. A study of family and parental influence on young people’s sexual and reproductive health in rural Tanzania found that single-mother-headed households had higher levels of poverty and with mothers away at work there was little control of the children. Where parents were less able to provide for their daughters, the greater the incentive was for sexual relationships (Wamoyi, Wight, & Remes, 2015). Teenagers who get pregnant are more likely to come from households of a lower socioeconomic standing and teenagers from single-parent households are more likely to indulge in risky sexual behavior with the possibility of a pregnancy. In South Africa, Mothiba and Maputle (2012) reported that only 12% of their study participants depended on both parents’ income while 44% of their participants depended on a single mother’s income. Participants also reported that family breakdown and poverty contributed to teenage pregnancy.
Gender-based violence (verbal, physical, and sexual) is also prevalent in South Africa (Decker et al., 2015), and young people are socialized in a patriarchal society where masculine hegemony reduces the options that young women have for ensuring safe sexual practices (Enderstein & Boonzaier, 2015). It is thus important that both sexes take adequate responsibility to prevent teenage pregnancy. Further, communication with students needs to avoid teenage pregnancy becoming only a female student’s problem, if males and females are exposed to different messages within families regarding whose responsibility it is to prevent teenage pregnancy occurring. The lack of communication experienced by young women within their families is exemplified by Samano et al.’s (2017) Mexican study. This emphasizes the important role of the school nurses in contributing to bridging the communication gap to reduce teenage pregnancy.
While the findings of this study are important there are certain limitations related to the study, which need to be considered when interpreting the data. To increase the validity of the study, students were informed about the purpose of the study and the questionnaires were coded so that only numbers were used ensuring complete confidentiality and each student placed his or her questionnaire in a sealed envelope on completion. Students were however asked to self-report and there could have been an element of reporting bias in students’ responses, which may have overestimated or underestimated associations. For instance, male students may have underreported histories of having fathered a child owing to the pressure to be seen to conform to socially acceptable norms. However, the prevalence of having fathered a child in this study (9%) isonly2% less than that reported in the South African Youth Risk Behavior Survey (11%) among school attendees (Jonas et al., 2016).
Further, students could have been reporting on their current SES and the social norms, pressures, and modeling behavior that they were currently experiencing and not those prior to or at the time of the pregnancy event. This is evident by the fact that females who had a teenage pregnancy were significantly more likely to have received communication discouraging pregnancy. They may have received this at the time of their pregnancy and postpregnancy to prevent another pregnancy and not prior to the event. This could have exaggerated the significant associations found in this study. The low Cronbach’s a for modeling suggests that this construct needs to be further explored to improve the accuracy of this measure.
The study population comprised adolescents attending school and thus the findings can only be generalized to adolescents attending school. Teenagers who are out of school and possibly at higher risk for teenage pregnancy were not included. If such a group of participants were included, then the associations reported may have been biased toward the null.
Importantly, this study found that age, gender, and communication about pregnancy were factors associated with having been pregnant/made a female pregnant. Positive social norms, modeling, and self-efficacy reduce the risk of having been pregnant/made a female pregnant among teenagers. Despite the limitations of this study, the findings are important for developing school-based programs aimed at reducing and preventing teenage pregnancy among youth attending school in South Africa.
Since 2012, school health has received national attention in South Africa with it being made a national priority program and the implementation of an “Integrated School Health Policy” aimed at improving the health of children. School health teams comprising nursing staff are tasked to oversee the health of schoolchildren within schools in a health district. Services include provision of sexual health education for schoolchildren (Shung-King, Orgill, & Slemming, 2013–2014). The findings of this study are important in that they can be used at a national and district level to inform school nurses in the development of interventions to address teenage pregnancies. At the microlevel, interventions aimed at preventing teenage pregnancy should start at a much earlier age in South African schools. Currently, such programs target middle and senior school attendees. Prevention programs need to focus and include the male adolescent, as their contributory role to teenage pregnancies has to be acknowledged and addressed. Positive role models for male adolescents are important to reinforce positive behavior practices.
At the macrolevel, socioeconomic interventions that reduce poverty and address household income while maintaining the family structure are important to ensure the presence of both parents in the lives of adolescents. Single-parent households and in particular female-headed households need further support to ensure mothers are more often present rather than absent in the lives of their adolescents.
Saloshni Naidoo contributed to acquisition, analysis, or interpretation; drafted the article; critically revised the article; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy. Myra Taylor contributed to conception, design, acquisition, analysis, or interpretation; critically revised the article; gave final approval; and agreed to be accountable for all aspects of work ensuring integrity and accuracy.
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the South African Netherlands Research Programme on Alternatives in Development (P08/55).
Saloshni Naidoo, MB ChB, PhD https://orcid.org/0000-0002-8844-0160
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Saloshni Naidoo, MB ChB, PhD, is a senior lecturer in the Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
Myra Taylor, PhD, is an honorary associate professor in the Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa.
1 Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
Corresponding Author:Saloshni Naidoo, MB ChB, PhD, Discipline of Public Health Medicine, School of Nursing and Public Health, College of Health Sciences, University of KwaZulu-Natal, Room 274, 2nd Floor, George Campbell Building, Howard Campus, Durban 4013, South Africa.Email: naidoos71@ukzn.ac.za
