Adolescent knowledge, values, and coping strategies: implications for health in sub-Saharan Africa

Improving educational and reproductive outcomes for adolescent mothers in South Africa: A cross-sectional analysis towards realising policy goals

Adolescent mothers face numerous challenges. This study aimed to address the operationalisation of the new South African national policy for young mothers by testing the associations of potential protective provisions with three policy goals: School return, grade promotion, and pregnancy/HIV prevention. Adolescent mothers aged 12-24 from rural and urban communities of South Africa's Eastern Cape completed study questionnaires between 2017-2019. Using multivariate multi-level analysis, we simultaneously estimated associations between hypothesized provisions and protective variables and all policy-aligned goals. School return was associated with using formal childcare services, higher confidence and self-efficacy scores, and remaining in school throughout pregnancy. Grade promotion was associated with greater exposure to friendly and respectful health staff, using formal childcare services, higher confidence and self-efficacy scores, and remaining in school throughout pregnancy. Pregnancy/HIV prevention (condom use) was moderately associated with greater exposure to friendly and respectful health staff. There was evidence of synergies of provisions whereby a combination of protective characteristics showed larger positive effects than receipt of any single factor alone. This study provides essential evidence for operationalising South Africa's new policy on the Prevention and Management of Learner Pregnancy in Schools, and points to implementation strategies that provide low-cost opportunities to promote educational and health outcomes for adolescent mothers.

Social and Biological Transgenerational Underpinnings of Adolescent Pregnancy

Adolescent pregnancy (occurring < age 20) is considered a public health problem that creates and perpetuates inequities, affecting not only women, but societies as a whole globally. The efficacy of current approaches to reduce its prevalence is limited. Most existing interventions focus on outcomes without identifying or addressing upstream social and biological causes. Current rhetoric revolves around the need to change girls' individual behaviours during adolescence and puberty. Yet, emerging evidence suggests risk for adolescent pregnancy may be influenced by exposures taking place much earlier during development, starting as early as gametogenesis. Furthermore, pregnancy risks are determined by complex interactions between socio-structural and ecological factors including housing and food security, family structure, and gender-based power dynamics. To explore these interactions, we merge three complimentary theoretical frameworks: "Eco-Social", "Life History" and "Developmental Origins of Health and Disease". We use our new lens to discuss social and biological determinants of two key developmental milestones associated with age at first birth: age at girls' first menstrual bleed (menarche) and age at first sexual intercourse (coitarche). Our review of the literature suggests that promoting stable and safe environments starting at conception (including improving economic and social equity, in addition to gender-based power dynamics) is paramount to effectively curbing adolescent pregnancy rates. Adolescent pregnancy exacerbates and perpetuates social inequities within and across generations. As such, reducing it should be considered a key priority for public health and social change agenda.

Significant rates of risky sexual behaviours among HIV-infected patients failing first-line ART: A sub-study of the Europe-Africa Research Network for the Evaluation of Second-line Therapy trial

There are limited data on the prevalence of risky sexual behaviours in individuals failing first-line antiretroviral therapy (ART) and changes in sexual behaviour after switch to second-line ART. We undertook a sexual behaviour sub-study of Ugandan adults enrolled in the Europe-Africa Research Network for the Evaluation of Second-line Therapy trial. A standardized questionnaire was used to collect sexual behaviour data and, in particular, risky sexual behaviours (defined as additional sexual partners to main sexual partner, inconsistent use of condoms, non-disclosure to sexual partners, and exchange of money for sex). Of the 79 participants enrolled in the sub-study, 62% were female, median age (IQR) was 37 (32-42) years, median CD4 cell count (IQR) was 79 (50-153) cells/µl, and median HIV viral load log was 4.9 copies/ml (IQR: 4.5-5.3) at enrolment. The majority were in long-term stable relationships; 69.6% had a main sexual partner and 87.3% of these had been sexually active in the preceding six months. At enrolment, around 20% reported other sexual partners, but this was higher among men than women (36% versus 6.7 %, p < 0.001). In 50% there was inconsistent condom use with their main sexual partner and a similar proportion with other sexual partners, both at baseline and follow-up. Forty-three per cent of participants had not disclosed their HIV status to their main sexual partner (73% with other sexual partners) at enrolment, which was similar in men and women. Overall, there was no significant change in these sexual behaviours over the 96 weeks following switch to second-line ART, but rate of non-disclosure of HIV status declined significantly (43.6% versus 19.6%, p <0.05). Among persons failing first-line ART, risky sexual behaviours were prevalent, which has implications for potential onward transmission of drug-resistant virus. There is need to intensify sexual risk reduction counselling and promotion of partner testing and disclosure, especially at diagnosis of treatment failure and following switch to second- or third-line ART.

Review Article: A review of studies of sexual behaviour of school students in sub-Saharan Africa

Aims: This is a review of articles on sexual behaviour of school students in sub-Saharan Africa published between 1987 and 1999. The objective was to describe what is known in this regard and identify gaps in knowledge. Methods: Literature search using electronic databases and a thumb search of relevant journals identified 47 articles reporting sexual behaviours of school-based young persons aged between 14 and 24 years. Results: The fi ndings indicate a relatively low number of articles when one considers the scope of the problems related to adolescent sexual behaviour in the region; high prevalence rates of sexual intercourse; infrequent use of condoms and other contraceptives; and signifi cant proportions of adolescents who have two or more lifetime sexual partners. More data are needed on the extent to which adolescents engage in non-penetrative sexual behaviour and penetrative sex other than heterosexual vaginal intercourse; characteristics of the sexual partners of adolescents; and proximal psychosocial antecedents of sexual behaviour and consistent risk-reduction behaviours. Conclusions: Cultural infl uences on sexual behaviour, the sensitivity of such research in adolescent populations, and the opportunity afforded by school systems for intervention suggest a need for additional exploratory and methodological studies. Placing such information fi rmly within sociocultural contexts in which young people are raised will better inform effective interventions that both delay the onset of sexual intercourse and encourage use of risk reduction strategies.

The Perceptions of Adolescents, Parents and Teachers on the Same Adolescent Health Issues

The aim of this study was to explore and compare the views of Hong Kong Chinese adolescents, parents and teachers on the same adolescent health issues. A total of 22 focus groups were conducted with Form 1 students (aged from 11 to 13) who attended the Basic Life Skills Training program organized by the Student Health Service, Department of Health in Hong Kong. The program covered a wide range of topics including emotions, self-image, stress management, drinking, smoking and substance abuse, self-esteem and interpersonal skills. Responses from the three types of participants were somewhat different and inconsistent on the issues of changes during puberty, stress and stress management, smoking, drinking and substance abuse. Compared to the West, Chinese adolescents tended to report more stress from studying and under-report socially undesirable behaviour. The use of focus groups was recommended as an effective method of collecting qualitative data with Chinese populations. Focus groups can help maximize data collection, and sometimes, the groups can also help different individual members to gain more insights or new ideas.

Storytelling for Empowerment for Latino Teens

Latino adolescents are disproportionately impacted by HIV, but researchers have documented few programs to prevent and reduce HIV risk. The Storytelling for Empowerment (SFE) HIV StoryBook was designed with an innovative ecodevelopment approach combining empowerment, family communication, and positive cultural identity. A mixed method design used both a randomized control group design, as well as grounded theory coding of semi-structured focus group interviews. For the quantitative method, a total of 96 adolescents (85% Latino, M age = 12.2) were randomized to either the SFE HIV StoryBook condition or a control condition and then tested at baseline and at 4 months post-baseline. Study findings indicated that teens who participated in the HIV StoryBook condition maintained sexual abstinence, increased their ability to communicate about sex, increased their intention to stop sexual advances, and increased their HIV prevention knowledge. For the qualitative method, seven focus groups of 38 participants, including staff, madres, teen participants, and graduates created rich description. Axial coding produced emergent themes, including an appreciation for the culturally affirming curriculum, increased family communication, and the embodiment by teens resulting in restraint and integrity. Results indicate that SFE has promise to stem HIV infections.

"Bend a fish when the fish is not yet dry": adolescent boys' perceptions of sexual risk in Tanzania

Despite decades of effort, the spread of HIV/AIDS continues among many African young people. A key contributor is unsafe sexual behavior that is desired, persuaded, or coerced. We explored the masculinity norms shaping pubescent boys' perceptions of and engagement in (unsafe) sexual behaviors in Tanzania. Through a comparative case study in rural and urban Tanzania, qualitative and participatory methods were used with 160 adolescent boys in and out of school to better understand the social and contextual factors promoting unsafe sexual behaviors. Adolescent boys in both the rural and urban sites reported struggling with intense sexual desires, strong peer pressures to have sex, and social norms dissuading condom use. A growing "normalization" of AIDS suggests messages promoting the dangers of HIV infection may be less effective. Findings reinforce the need for interventions with very young adolescents. Research is needed to identify more effective approaches for promoting safer sexual practices among boys in sub-Saharan Africa. Harm reduction approaches and gender transformative approaches might prove more effective than current HIV prevention efforts focused on youth.

Ecological factors influencing HIV sexual risk and resilience among young people in rural Kenya: implications for prevention

Most new HIV infections in Kenya occur among young people. The purpose of this study was to understand ecological factors that influence HIV-related sexual risk and resilience among young people in rural Kenya and to elicit their ideas for HIV prevention interventions. Nine focus groups (N = 199) were conducted with both female (55%) and male (45%) participants (ages 14-24 years) living in rural communities in Kenya. Findings were organized into thematic areas related to the following systems of influence: (i) intrapersonal (substance use, HIV knowledge), (ii) interpersonal (peer pressure, lack of parent-child communication, interpersonal sexual violence), (iii) institutional/community (pornography, transactional sex, 'idleness', lack of role models) and (iv) socio-cultural/policy (Kikuyu culture, Western influence, religious beliefs, HIV-related stigma and gendered sexual scripts). Results regarding the types of HIV prevention programs that participants believed should be developed for young people in rural Kenya revealed seven primary themes, including (i) HIV prevention community/group workshops, (ii) condom distribution, (iii) job skills trainings, (iv) athletic and social clubs, (v) HIV-related stigma reduction campaigns, (vi) community-wide demonstrations and (vii) other HIV/AIDS activities led by young people. Implications for the development of culturally and developmentally appropriate HIV prevention interventions for young people in rural Kenya are discussed.

Dynamics of parent-adolescent communication on sexual health and HIV/AIDS in Tanzania

Communication between parents and their adolescent children has been identified as one of the potential protective factors for adolescent sexual health. Qualitative exploration of sexual health communication with adolescents aged 12-15 (N = 114) and a sub-group of the parents (N = 20) was carried out. Four major themes emerged: reasons for parent-adolescent communications, or lack thereof; the focus of parental messages; the moral of the message; and the barriers to communication between parents and adolescents. Findings revealed similarities and discrepancies in views and perceptions between parents and adolescents. Adolescents and parents suggested that some sexual health communication was happening. Parents were reportedly likely to use fear to ensure that their children do not engage in risky sexual activities, while adolescents reported that conversations with their parents were mostly ambiguous and filled with warnings about the dangers of HIV/AIDS. Several communication barriers were reported by parents and adolescents. Parents of adolescents would benefit from HIV/AIDS specific communication skills.

Parents' experiences of reporting child sexual abuse in urban Tanzania

This article reports parental experiences of legally reporting child sexual abuse in Tanzania. Based on in-depth interviews, four types of sexual abuse incidents are portrayed. Each evokes different reactions from parents and the community. An incident characterized as the innocent child was associated with a determination to seek justice. The forced-sex youth elicited feelings of parental betrayal of their child. The consenting curious youth resulted in uncertainty of how to proceed, while the transactional-sex youth evoked a sense of parental powerlessness to control the child because of low economic status. Differentiating between types of sexual abuse incidents may increase awareness of the complexities of child sexual abuse reporting. Education on laws regulating sexual offenses and a functional national child protection system are needed to address child sexual abuse complexities and safeguard the rights of children in Tanzania.

Prevalence rates of sexual coercion victimization and perpetration among Uganda adolescents

Coercion is consistently reported as a risk factor for HIV in sub-Saharan Africa (SSA). Because of the gendered nature of previous research, however, little is known about male victims or female perpetrators. To address this gap, we report survey data from 354 sexually experienced secondary school students in Mbarara, Uganda. Findings suggest that females are more likely to report involvement in coercive sex compared to males (66% vs. 56%, respectively). Of those involved, females are most likely to report being a victim-only (40%) and males, perpetrator-victims (32%). Although involvement in violent and coercive sex is gendered, 47% of males report victim experiences and 25% of females report perpetration behavior. Furthermore, about one in ten female and male perpetrators reported using physical force or threats to compel sex. When all potentially influential factors were considered simultaneously, several characteristics seem to differentiate youth by their coercive sex (in) experience. For example, victims are more likely to have lower levels of social support from their families and feel that they have an above average or very strong chance of getting HIV compared to otherwise similar youth with no experience with coercive sex. Perpetrators are more likely to have had an HIV test but use condoms less than half the time or never compared to their otherwise similar, yet uninvolved peers. They also are significantly more likely to report dating violence perpetration. Perpetrator-victims share some similarities with other involved youth, as well as some differences. Findings underscore both the importance of asking all youth, irrespective of biological sex, perpetrator and victimization questions; and also the need for more work to be done to help youth plan for a healthy and wanted first sexual experience.

Protein and micronutrient supplementation in complementing pubertal growth

For several reasons, adolescence is considered as a nutritionally critical period of life. The dramatic increase in physical growth and development puts greater pressure on the need for nutrients, as it is during this period when adolescents experience a weight gain equivalent to 65% of their weight at the beginning of the period or 40% of their final weight, and a height gain equivalent to 15% of their adult height. The requirement of some of the nutrients is as high as, or higher in adolescents than in any other age groups. Moreover, adolescence is a time where the life-style and food habits are influenced by socio-cultural factors resulting in an imbalance in nutrient intake and nutrient inadequacy can result in delayed sexual maturation and can arrest or slow linear growth. With the increasing prevalence of hidden malnutrition among Indian children, adolescence can be the second opportunity to catch up growth and cover the deficits suffered during childhood and to meet the demands of physical and cognitive growth and development, provide adequate stores of energy for illnesses and pregnancy, and prevent adult onset of nutrition-related diseases. Adolescents should be recognized as a priority target group as an integral part of health promotion and optimal nutrition through balanced diet and nutrient supplementation should be promoted in conjunction with healthy eating habits and physical activity.

Widening the aim of health promotion to include the most disadvantaged: vulnerable adolescents and the social determinants of health

Growing numbers of adolescents are marginalized by social factors beyond their control, leading to poor health outcomes for their families and future generations. Although the role of the social determinants of health has been recognized for many years, there is a gap in our knowledge about the strategies needed to address these factors in health promotion. Drawing on a review of literature on health promotion for marginalized and out-of-school adolescents, this paper highlights some urgent areas of focus for researchers and policy makers addressing adolescent health. Social determinants of health affecting marginalized adolescents identified by the review were education, gender, identity, homelessness, poverty, family structure, culture, religion and perceived racism, yet there is little solid evidence as to how to best address these factors. More systematic research, evaluation and global debate about long-term solutions to chronic poverty, lack of education and social marginalization are needed to break the cycle of ill health among vulnerable adolescents.

Transactional sex amongst young people in rural northern Tanzania: an ethnography of young women's motivations and negotiation

BACKGROUND

Material exchange for sex (transactional sex) may be important to sexual relationships and health in certain cultures, yet the motivations for transactional sex, its scale and consequences are still little understood. The aim of this paper is to examine young women's motivations to exchange sex for gifts or money, the way in which they negotiate transactional sex throughout their relationships, and the implications of these negotiations for the HIV epidemic.

METHOD

An ethnographic research design was used, with information collected primarily using participant observation and in-depth interviews in a rural community in North Western Tanzania. The qualitative approach was complemented by an innovative assisted self-completion questionnaire.

FINDINGS

Transactional sex underlay most non-marital relationships and was not, per se, perceived as immoral. However, women's motivations varied, for instance: escaping intense poverty, seeking beauty products or accumulating business capital. There was also strong pressure from peers to engage in transactional sex, in particular to consume like others and avoid ridicule for inadequate remuneration.Macro-level factors shaping transactional sex (e.g. economic, kinship and normative factors) overwhelmingly benefited men, but at a micro-level there were different dimensions of power, stemming from individual attributes and immediate circumstances, some of which benefited women. Young women actively used their sexuality as an economic resource, often entering into relationships primarily for economic gain.

CONCLUSION

Transactional sex is likely to increase the risk of HIV by providing a dynamic for partner change, making more affluent, higher risk men more desirable, and creating further barriers to condom use. Behavioural interventions should directly address how embedded transactional sex is in sexual culture.

Health promotion needs of physically disabled individuals with lower limb amputation in Rwanda

PURPOSE

The objectives of the study were to identify the health-related behaviors among physically disabled individuals with lower limb amputation resident in Rwanda, the factors that influenced these behaviors, and the major issues that should be targeted in health promotion programs for physically disabled individuals with lower limb amputation.

METHOD

A cross-sectional survey, utilizing a self-administered questionnaire, was carried out among 334 lower limb amputees who volunteered to take part in the study. In addition, a sub-sample of 15 participants was purposely selected for in-depth face-to-face interviews.

RESULTS

Many participants did not engage in physical exercises (64.7%). Others abused alcohol on daily basis (14.4%), smoked 11-20 cigarettes daily (13.2%), and used recreational drugs such as marijuana, opium and cocaine (9.6%). There were significant associations between the age group of the participants and participation in exercises (P=0.001), and consuming alcohol, tobacco and recreational drugs (P=0.001). In-depth interviews revealed factors influencing the behavior of participants.

CONCLUSIONS

Participants were found to be at risk of secondary complications because of poor lifestyle choices. There is a need to develop and promote wellness-enhancing behaviors in order to enhance the health status of physically disabled individuals in Rwanda who have lower limb amputations.

Young people's sexual partnerships in KwaZulu-Natal, South Africa: patterns, contextual influences, and HIV risk

Certain sexual partnering practices, such as multiple, concurrent, or age-discrepant partnerships, are known to increase HIV risk. Yet the underlying dynamics of young people's relationships are less clearly understood. Using household survey and qualitative data, this study examines partnership dynamics and characteristics in the context of HIV risk, including number of partners, age differences, partnership duration and concurrency, and frequency of contact among young people aged 15-24 in rural KwaZulu-Natal, South Africa. One-third of the men surveyed reported multiple and/or concurrent partnering, and one-fourth of the women had partners who were five years older than they were. Nonparticipation in civic organizations or school was correlated with higher-risk partnerships for women but not for men. On average, relationships lasted more than a year for the women and men surveyed, and were frequently characterized as "serious." Qualitative findings pointed to the sequential and overlapping nature of relationships, however, with distance and mobility being important influences. These fluid partnership patterns are an important feature of young people's sexual risk in the context of South Africa's severe HIV epidemic.

The Mpondombili Project: preventing HIV/AIDS and unintended pregnancy among rural South African school-going adolescents

Unintended pregnancy, HIV and other sexually transmitted infections are major threats to the health of South African youth. Gendered social norms make it difficult for young women to negotiate safer sex, and sexual coercion and violence are prevalent. Sexual activity among adolescents is influenced strongly by conservative social norms, which favour abstinence. In reality, most young people are sexually active by the end of the teen years. Girls' decision to have sex is often a passive one, influenced by partners. The Mpondombili Project is a school-based intervention in rural KwaZulu-Natal that aims to promote delay in the onset of sexual activity and condom use as complementary strategies for both sexually experienced and inexperienced youth. Interactive training was carried out with peer educators, teachers and nurses over a 15-month period, and a manual developed. The intervention was implemented in late 2003 with 670 adolescents in two schools. Issues covered included HIV/STI transmission, risk behaviours, HIV testing, pregnancy and contraception, gender inequality, sexual communication and negotiation, managing abusive situations, fear of AIDS, stigma and discrimination and sexual rights. The diversity of young people's relationships and vulnerability to sexual risk call for the promotion of both risk avoidance (delay in sexual initiation) and risk reduction (condom use) together, regardless of ideology, especially where HIV is well-established, to protect their health.

Factors that shape young people's sexual behaviour: a systematic review

BACKGROUND

Since nearly half of new HIV infections worldwide occur among young people aged 15-24 years, changing sexual behaviour in this group will be crucial in tackling the pandemic. Qualitative research is starting to reveal how social and cultural forces shape young people's sexual behaviour and can help explain why information campaigns and condom distribution programmes alone are often not enough to change it. We undertook a systematic review to identify key themes emerging from such research, to help inform policymakers developing sexual health programmes, and guide future research.

METHODS

We reviewed 268 qualitative studies of young people's sexual behaviour published between 1990 and 2004. We developed a method of comparative thematic analysis in which we coded each document according to themes they contained. We then identified relations between codes, grouping them accordingly into broader overall themes. Documents were classified as either primary or secondary depending on their quality and whether they contained empirical data. From the 5452 reports identified, we selected 246 journal articles and 22 books for analysis.

FINDINGS

Seven key themes emerged: young people assess potential sexual partners as "clean" or "unclean"; sexual partners have an important influence on behaviour in general; condoms are stigmatising and associated with lack of trust; gender stereotypes are crucial in determining social expectations and, in turn, behaviour; there are penalties and rewards for sex from society; reputations and social displays of sexual activity or inactivity are important; and social expectations hamper communication about sex. The themes do not seem to be exclusive to any particular country or cultural background, and all themes were present, in varying degrees, in all countries assessed.

INTERPRETATION

This study summarises key qualitative findings that help in understanding young people's sexual behaviour and why they might have unsafe sex; policymakers must take these into account when designing HIV programmes. Considerable overlap exists between current studies, which indicates the need to broaden the scope of future work.

Contradictory sexual norms and expectations for young people in rural Northern Tanzania

There has been a long-running debate as to whether sexual cultures in sub-Saharan Africa are permissive or characterised by restrictive rules, rituals and self-restraint. This paper, based on participant observation data, outlines the main features of sexual culture in rural northern Tanzania and highlights both permissive and restrictive norms and expectations for young people. It also illustrates how sexual beliefs are socially constructed and subject to social change. Sexual activity is constrained by clear norms of school pupil abstinence, female sexual respectability and taboos around the discussion of sex. However, these norms are incompatible with several widely held expectations: that sexual activity is inevitable unless prevented, sex is a female resource to be exploited, restrictions on sexual activity are relaxed at festivals, and masculine esteem is boosted through sexual experience. Differential commitment to these norms and expectations reflects conflicts between generations and genders. Young people appear to manage the contradictions in these norms by concealing their sexual relationships. This almost certainly contributes to their short duration and the high levels of partner change, since relationships are not reinforced through social recognition and there is little scope to develop intimacy through non-sexual contacts.

West African Youth Initiative: outcome of a reproductive health education program

PURPOSE

To describe the implementation and evaluation of an adolescent reproductive health peer education program in West Africa. The program, known as the West African Youth Initiative (WAYI), was developed to improve knowledge of sexuality and reproductive health, and promote safer sex behaviors and contraceptive use among sexually active adolescents in Nigeria and Ghana.

METHODS

Between November 1994 and April 1997, two organizations, the Association for Reproductive and Family Health (ARFH), based in Nigeria, and Advocates for Youth, based in Washington D.C., supported community-based youth-serving organizations in the two countries to implement peer education projects. Consultants from the African Regional Health Education Centre (ARHEC) in Nigeria provided technical assistance in designing and conducting a quasi-experimental process and outcome evaluation of the projects.

RESULTS

There were significant differences over time and between intervention and control groups concerning reproductive health knowledge, use of contraceptives in the previous 3 months, willingness to buy contraceptives, and self-efficacy in contraceptive use.

CONCLUSIONS

Overall, the project provides evidence that peer education is most effective at improving knowledge and promoting attitudinal and behavior change among young people in school settings.

Understanding safe sex: gender narratives of HIV and pregnancy prevention by rural South African school-going youth

In South Africa's HIV/AIDS epidemic, young people, especially women, are at high risk due to an apparent gap between awareness and practice. In repeated peer group discussions with girls aged 14-15 and boys aged 16-19, we explored influences on safe sex behaviour. Separate male and female safe sex paradigms emerged, with boys less likely to perceive themselves as 'at risk' and more likely to use condoms. Girls had not used condoms, would have preferred to delay sexual relationships and feared pregnancy as well as HIV/AIDS. Both sexes deemed it difficult for girls to initiate condom use, although both sexes viewed condoms favourably. Girls saw condoms as a sign of love and protection, whereas boys tended to use them with casual partners. A lack of decision-making autonomy within relationships further constrained girls' ability to practice safer sex. Involvement of peer participants in review of their own narrative data helped to ensure representation of participants' voices in the findings. Overall, these findings point to the need for programmes to address gender inequalities and emphasise behavioural skills in the years before sexual activity begins.

Using focus group methods with middle school children

Focus group methods are an effective way to clarify middle school children's perceptions of health and illness. Children between 11 and 14 years of age, who are undergoing the developmental transition from child to adolescent, tend to be reticent when talking with adult strangers. However, they are more relaxed and willing to share perceptions when discussions are held with a group of peers. Conducting focus groups involves developing an interview guide, arranging the meeting place, supporting group building, and encouraging participation by the group members while discouraging domination by influential members. Data analysis begins during the focus group session as issues emerge in the context of group discussions.