Introduction

In South Africa, Christian faith communities exert a powerful influence on attitudes and life style and have credibility in the society, perhaps one of their major assets. Furthermore, local churches are present in both urban and rural areas, and their extensive networks can be valuable in delivering health services such as HIV prevention to young people (Pfeiffer 2004). By providing individuals with education, rules, rituals and social networks among peers as well as across generations, the local faith communities create a structured social environment where young people can be socialized (Cooksey and Dooms 2010). The churches may serve as a social entity for those youth who attend religious services and can provide them with a sense of belonging, which is important during adolescence (Cooksey and Dooms 2010). In general, religion is described as a protective factor for young people with regard to sexual behaviour and can be associated with behaviours such as delayed sexual debut (Rostosky et al. 2004), lower likelihood of voluntary sexual activity (Holder et al. 2000) and fewer sexual partners outside romantic relationships (Miller and Gur 2002).

Since the mid-1980s, faith communities have provided care, treatment and support to those infected with and affected by HIV, including orphans and vulnerable children (Paterson 2009). However, the faith communities are facing major challenges in their response to the HIV epidemic, especially concerning HIV prevention. The difficulty for faith communities to address aspects of human sexuality other than morals is recognized as one of the major obstacles to their involvement in HIV prevention (Ecumenical Advocacy Allience 2009; Messer 2004; Ryan 2007). Although research on the response of the Christian faith communities to the HIV epidemic has increased (Oliver et al. 2006), large gaps still exist in our knowledge about how these communities may influence young people’s attitudes, beliefs and behaviours regarding sexuality and HIV prevention.

Christian Norms of Sexuality

Throughout church history, there has been a tendency to think of the body as “bad” and the spirit as “good” (The Lutheran World Federation 2007). This may be one reason why faith communities have difficulty in talking about issues related to sexuality (Khathide 2003). In general, Christianity in its various forms adopts the stance that sexual intercourse is reserved for the context of heterosexual marriage. Married partners are expected to be faithful to one other in a life-long commitment, and young people are taught that sexual abstinence prior to marriage is a Christian virtue.

In South Africa, findings from the Anglican Church in Cape Town revealed that 31 % of church-attending youth aged 12–19 years have had sex, whether vaginal, anal or oral (Mash and Kareithi 2005). Still, teachings about premarital abstinence and faithfulness within marriage remain the most common approach to HIV prevention in faith communities (Garner 2000; Krakauer and Newbery 2007; Parry 2005).

The HIV Epidemic Among Young People in South Africa

Although almost 80 % of the population in South Africa are Christian (Statistics South Africa 2001), few studies have addressed the extent to which religious teaching is related to attitudes towards prevention messages, experiences of relationships with the opposite sex and vulnerability to HIV infection among youth. In South Africa, HIV prevalence in the age group 15–24 years is 8.7 % (Shisana et al. 2009). In the same age group, there is a striking gender difference, with females having a three times higher HIV prevalence (13.6 %) than males (4.5 %) (UNAIDS 2010). Young people receive information on HIV in life skills programmes in secondary school, initiated by the South African government (Magnani et al., 2005) and through Lovelife, a non-governmental organization that uses television, radio messages, magazines and special youth events (Taylor et al. 2010). Still, young people perceive themselves as being at little risk of HIV infection (Anderson et al. 2007; Macintyre et al. 2004), although especially young men are engaged in high-risk partnering (Harrison et al. 2008). Furthermore, premarital sexual activity is strongly morally disapproved, especially for young women and their relationships with a male partner are therefore often hidden (Harrison 2008).

Insight into the attitudes of young people in faith communities towards HIV prevention messages from their churches is important in understanding the complexities of young people’s HIV risk in these communities. This study aimed at describing the messages relating to sexuality and HIV prevention, given to young people by three Christian denominations in South Africa, and how these messages relate to the reality in which these young people live and to the concerns and questions they have. The main outcomes for the church teaching were availability of education on sexuality and HIV prevention and the main messages of this education. The situation of the young respondents was reflected in questions about relationships with the opposite sex and perception of risk to themselves of HIV infection. The respondents were furthermore invited to formulate their individual concerns about sexuality and HIV/AIDS and about the possibilities of support and help from the church for young people. In this exploratory study, we used data from self-administered questionnaires answered by young people and collected in three denominations in KwaZulu-Natal, South Africa.

Methods

Study Setting and Characteristics of the Selected Denominations

The study was conducted in KwaZulu-Natal, the second most populated province in South Africa (Statistics South Africa 2009), with the highest HIV prevalence (15.3 %) among young people aged 15–24 years (Shisana et al. 2009). In Durban district, affiliation to the main religions and churches is, in descending order, to the Roman Catholic Church, Hinduism, the Zion Christian Church, other Christian churches, the Apostolic Church and Pentecostal/Charismatic churches (Statistics South Africa 2001). Although the aim was not to represent the Christian churches in general, the selection principle was to choose denominations that reflect some of the diversity of Christianity in South Africa. Three denominations were selected: the Roman Catholic Church, the Evangelical Lutheran Church in Southern Africa and the Assemblies of God (AOG), a Pentecostal church. A previous interview study with religious leaders from the same denominations concluded that religious leadership was ambivalent in its HIV prevention messages to young people (Eriksson et al. 2011). All three denominations promote messages of sexual abstinence before marriage, and faithfulness within marriage to prevent HIV infection; however, they differ by degree (Assemblies of God South Africa 2009; Southern African Bishops Conference 2001). Only the Lutheran Church officially encourages sexually active young people to use condoms (ELCSA 2004).

Study Participants and Sampling Procedure

A convenience sample of young people (n = 1,102) who affiliated themselves with one of the three denominations in the Durban and Pietermaritzburg area were invited to participate and to fill out a self-administered questionnaire between May and July 2009. The questionnaire was distributed to young people in the Catholic Church and the Lutheran Church during regional youth conferences. In the AOG, youth were reached at one regional youth conference and at three youth meetings in local churches. It was difficult to estimate the exact number of possible participants due to incomplete registration. We therefore invited all young participants in the meetings to take part in the study. In all settings, the young people received a short verbal introduction about the research, provided in English and/or Zulu, and were given instructions to read the information letter and fill in the questionnaire if they were willing to participate. The questionnaire did not contain the name of the respondent. We estimated that the completed questionnaires represented about 80 % of those present.

Survey Instrument

A questionnaire was developed by the principal investigator (E.E.) and study team for the purpose of this study. With permission, some questions were taken from an instrument used in the Fikelela AIDS Project among Anglican youth in Cape Town (Mash and Kareithi 2005).

The survey collected data on socio-demographic characteristics, sources of knowledge on sexuality and HIV/AIDS, the teachings of the churches on sexuality and HIV prevention, experiences of relationships, perceived risk of HIV infection and the influence of the church on their decisions regarding sexual behaviour. As an introduction to the items on sexuality, a definition of “sexuality” was given, as follows:

Sexuality is more than only physiological arousal and genital activity. Sexuality affects our thoughts, feelings and actions. It involves our spiritual, physical and emotional health. It includes being able to understand and weigh the risks, responsibilities and results of sexual action.

Direct questions about sexual behaviour were not used since the study needed permission from the regional church leadership in the province. Questions regarding relationships were asked to investigate whether the participants had experience of having a boyfriend or a girlfriend. Relationship in this study therefore relate to both relationship with sexual activity and relationships without sexual activity.

We included two items which participants could write about in their own words. Firstly, in order to obtain the views of young people about how their church could help them to adhere to messages on abstinence, we asked, “What can the church do to help young people to wait until they are married, before having sex?” Secondly, because self-generated questions can be used to gather information about more personal issues, we asked the participants to write questions that they might have about sexuality and HIV/AIDS.

To ensure approval for the study, we asked the leadership in the three denominations to comment on the questionnaire, but they suggested no changes. The questionnaire was piloted among church-attending youth in Durban, and two questions were rephrased in accordance with suggestions from the participants (n = 12). The questionnaire was in English, with an information letter in both English and Zulu.

Ethical Permission

Ethical clearance was obtained from the University of KwaZulu-Natal, South Africa, and the Medical Research Committee in Uppsala, Sweden.

Statistical Analysis

Differences between groups were tested with Pearson’s chi-square test on nominal data. No adjustment for multiple testing was made. In order to further analyse the relationship between religious affiliation, age and gender (independent variables); young people’s perceived risk of HIV infection, experiences of and attitudes towards relationships; and sexuality and HIV education in local churches (dependent variables), we used binary logistic regression analysis. To identify differences between denominations, youth from the AOG were the reference group. Regarding age, we compared the responses of 15–16-year-olds and 17–19-year-olds, both groups likely to be in secondary school, with those of youth likely to have completed secondary school, 20–21 and 22–24-year-olds. Concerning HIV testing, participants who had children were excluded from the analysis, as women who attend antenatal clinics in South Africa are often offered HIV testing. The interaction between gender and religious affiliation was also investigated. A p value of <0.05 was considered statistically significant for all tests.

Answers to the two questions written in their own words by the respondents were grouped into categories by the first author (E.E.), and the grouping double checked by the last author (P.A.). The Statistical Package for Social Sciences (SPSS) for Windows (18) (SPSS Inc., Chicago, IL, USA) was used for entering and analysing data (18).

Results

General Demographics

Out of the 1,102 respondents who completed the questionnaire, we analysed the data of unmarried individuals aged 15–24 years as this group is targeted by many HIV prevention interventions. The characteristics of the sample (n = 811) are presented in Table 1. As expected, the great majority (83 %) participated in youth groups and considered themselves religious (80 %).

Table 1 Background data of participants, and sexuality and HIV/AIDS education in church activities
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Education on Sexuality and HIV/AIDS

The HIV/AIDS education given in different youth activities in the churches was reportedly common (Table 1). Abstinence from premarital sex was the most frequently reported HIV prevention message, and youth viewed religious leaders as the most trusted educators on sexuality (Table 2). The respondents reported whom they had talked to about sex (defined as vaginal, oral and anal sex) during the previous year. The majority had talked to friends (65 %), and fewer had talked with family members such as parents (28 %), brothers/sisters (20 %) or other relatives (13 %). Few had talked with health workers (11 %) and church leaders/workers (11 %). The majority of respondents also indicated that they were likely to participate in an educational programme on HIV/AIDS if the churches would arrange a life skills programme on this topic in the future (Table 1).

Table 2 HIV prevention messages and educational leadership in churches, by percentage (n = 811)
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Experience of Relationships and Perceived Risk of HIV Infection

To assess young people’s experience of relationships, we asked the following questions: “Have you ever had a boyfriend or a girlfriend?” and “Do you have a boyfriend or a girlfriend right now?” The large majority of respondents (83.4 %) had experience of having a boyfriend or girlfriend, and the majority of respondents (58.3 %) were in a relationship at the time of the survey (Table 3). Furthermore, almost one-third of the respondents had been tested for HIV, and more than half (53.1 %) perceived themselves at risk of HIV infection (Table 3).

Table 3 The respondents’ experiences of relationships and perceived risk of getting HIV infection (n = 811)
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In order to analyse whether religious affiliation was associated with young people’s experiences of relationships and perceived risk of HIV infection, we used logistic regression models. The logistic regression showed that Catholic and Lutheran youth were significantly more likely to report ever having had a relationship than AOG youth (Table 4). Males were more likely to ever have been in a relationship than females. Lutheran respondents were also more likely to think that their partner had other sexual partners compared with AOG respondents. As expected, the perceived risk of HIV infection increased significantly with age (Table 5). The logistic regression further showed that the likelihood of being HIV tested was associated with increased age, being female and being Lutheran (Table 5).

Table 4 Multiple logistic regression of young people’s relationships, by age, religious affiliation and gender
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Table 5 Multiple logistic regression of education in churches, and young people’s perceived risk of HIV infection
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Finally, we analysed whether religious affiliation was associated with reported sexuality and HIV/AIDS education. The multiple logistic regression showed that Lutheran (odds ratio, OR = 5.99) and Catholic (OR = 1.78) youth were more likely than AOG youth to report HIV/AIDS education in youth groups (Table 5). Although 60.8 % of the respondents thought that the teaching of the church influenced their choices regarding sex, no significant associations with age, gender or denomination were found (data not shown).

Young People Requested Increased Sexuality and HIV Education in Local Churches

In total, respondents made 793 comments on what local churches can do to help young people abstain from premarital sex. The statements were grouped into six categories and some are quoted below, in descending order of frequency, to illustrate each category.

Most comments were related to promoting messages of abstinence and religious teachings: “… teach them that God made sex for marriage; therefore they must abstain”. The second most frequent category of comments related to requests for increased education on sexuality, pregnancy and sexually transmitted infections (STIs), to be offered by the churches: “… help them by educating them about sex”. Fewer comments mentioned HIV specifically: “It is important for us as the youth to know about sex and HIV; we need to be taught about it.”

Some respondents thought that the churches should provide more education on relationships: “Young people often think that the only way to keep a relationship going or to show that you love someone or to feel love is to have sex, so the church can help young people to know and understand what love is.” Creating activities for young people was also mentioned: “… keep them occupied with interesting events”. A few responded that they did not know what to suggest, or indicated that there was nothing the churches could do to help young people to abstain from premarital sex: “It’s up to the individual to make the right choice. I doubt there is anything more that they [the churches] can do.”

Concerns About Sexuality and HIV/AIDS

In total, participants asked 440 questions (males 132, females 308), which we grouped into four categories. Some of the questions are quoted below to illustrate the respondents’ main concerns about their sexuality and HIV/AIDS, in order of descending frequency.

Most questions related to, and revealed limited knowledge about, HIV transmission and treatment: “Is it possible to get HIV through kissing?” (male, 18 years old), “Why don’t parents want to talk about condomizing with each other and then come to us and teach us about something they don’t do?” (male, 18), “Why is it that the drug that rape victims receive within 72 h, which kills off the HIV, is not made available to the public?” (male, 21), “How can people be stopped from killing themselves when they test HIV-positive?” (female, 20).

General questions about sexuality, which showed that the topic was of great concern to young people, included the following: “Do we need to have sex to be accepted by our friends?” and “Must we have sex to please ourselves or to have fun?” (male, 16), “Is it true that boys can’t live without sex because they will get sick?” (female, 19), “Is oral sex wrong, if you and your partner know it won’t lead to vaginal sex?” (male, 19).

The moral conflict between sexuality and religious teaching was also revealed in the questions, for example, “I would like to know if God forgives you if you ask for forgiveness even though you knew it was wrong?” (female, 18), “What if I am not blessed with marriage, do I remain a virgin forever? How can I use the knowledge of the Bible to help me make wise decisions about sex now?” (female, 17), “In the Bible, kings had many wives but today we sin if we are unfaithful; why is it so?” (male, 20).

Questions about relationships and negotiating skills indicated that issues of trust within a relationship were a genuine concern: “Should it be a choice or an agreement to have sex? Can you be with someone without having sex?” (female, 21), “How does it feel to have sex with a guy and then he leaves you the next day?” (female, 15), “How should I know if my girlfriend is cheating on me while I’m willing to marry her in future, because I am faithful to her?” (male, 21).

Discussion

This study provides insight into HIV prevention messages reported by young people in faith communities in relation to their perceived risk of HIV infection, experiences of relationships, and concerns about sexuality and HIV/AIDS.

The great majority of respondents reported that they had received information about premarital sexual abstinence. This finding is supported by a study of the religious leaders in the same denominations (Eriksson, et al. 2011), and in the literature from KwaZulu-Natal (Diakonia Council of Churches 2008; Garner 2000; Gennrich and Gill 2004), Malawi (Trinitapoli 2006) and Nigeria (Agha 2009). Other preventive messages were less frequent, such as messages on faithfulness to one partner, HIV testing and condom use. Those youth who did receive messages about condoms represented mostly the Lutheran and Catholic churches. Similar findings have previously been reported from Mozambique (Agadjanian 2005), where Catholic leadership allows more dialogue on controversial issues, such as condom use, within their churches compared with leadership from faith healing churches such as the AOG.

Few respondents stated that they had talked to a church leader about sexuality. This observation is in agreement with findings from Brazil (Paiva et al. 2010), where religious leadership thought they were open to discuss sexuality, while youth said that sexuality was a difficult subject to discuss with the church leaders.

Although faith communities were in the forefront of responding to the HIV/AIDS epidemic, their prevention messages are still in line with the already existing, traditional messages regarding sexuality. Encouragingly, high motivation to participate in further life skills education suggests that, from a youth perspective, sexuality education for youth in churches may be viable. The respondents identified youth leaders as being most respected as sexuality educators, and their role in HIV prevention for young people needs to be further investigated. No increase in sexual activity among youth was found after they were exposed to sexuality and HIV education programmes including information on contraceptives and condom use (Kirby et al. 2007). Religious leaders should therefore not be afraid to educate young people about sexuality and the risks of HIV infection. The questions from the respondents in the present study indicate that issues related to HIV prevention still need to be addressed among young people in faith communities.

Almost one-third of the respondents had been tested for HIV, indicating that youth in faith communities who receive most education on HIV prevention (i.e. in Lutheran churches) are also more likely to go for HIV testing. However, in our study population, the perception of the risk of HIV infection was not associated with religious affiliation, and this observation has also been reported among university students in the U.S.A (Lefkowitz et al. 2004). Strong motivation among religious leaders to go for HIV testing has been observed previously within the studied denominations (Eriksson et al. 2011) and may indicate that religious leaders in South Africa can become role models for young people in this regard.

Religious affiliation was associated with the experience of relationships, with youth from Pentecostal churches being less likely to report having had a boyfriend or girlfriend. Similar denominational variations have been reported from Zambia (Agha et al. 2006) and in another South African study (Garner 2000). Practices of social control of young people in Pentecostal churches have been reported as one reason for these differences (Garner 2000; Helgesson 2006; Manglos 2010; Sadgrove 2007).

More male than female respondents reported that they had ever had a relationship. This indicates that gender differences in the number of partners among religious youth may be similar to those found in youth in the wider society (Harrison et al. 2008). Furthermore, results from a Mozambican study comparing religious youth with non-religious youth (Noden et al. 2010) concluded that religion had a minimal effect on multiple relationships.

From the questions formulated by the participants, it is clear that a major concern for young people is to find ways of relating to the opposite sex, and of handling sexual invitations and contacts. As reported previously from KwaZulu-Natal, prevention efforts need to focus more on the partnership context (Harrison and O’Sullivan 2010). Issues of trust could be addressed more thoroughly in local churches, to help young people build healthy relationships.

Religious affiliation was associated with several issues important to successful HIV prevention among youth, such as HIV education in youth groups, HIV testing and the experience of having a boy or a girlfriend. These variations may reflect differences between the denominations regarding existing polices on HIV, approaches to condom use, hierarchical or more independent leadership structures, and education of religious leaders on HIV. A possible explanation as to why information about HIV was more often reported by Lutheran and Catholic youths may be that these denominations have different policies on HIV. To our knowledge, the Catholic Church is the only denomination in South Africa that has adopted a national life skills programme for young people (Education for life 2011), and the Lutheran Church emphasizes the importance of starting education about HIV at a young age, already in Sunday school (ELCSA 2004). It appears that the policies of these denominations are having some impact on informing young people in their churches about HIV.

Since there is no way to systematically sample young people attending church services or religious activities, we chose to issue an open invitation to participate to young people attending a church conference. This method did not make it possible to give a response rate but the number of responses corresponded to the vast majority. This convenience sample included mainly young people who were actively involved in their churches and who perceived themselves as religious, and we believe that the findings can be seen as representative of young people in these faith communities. Researchers (Cotton et al. 2010) have emphasized the importance of considering the multiple dimensions of religion when studying the relationship between religion and adolescent health outcomes. In our study, the majority (60.8 %) of the youth appeared to have internalized the religious teachings and said they paid attention to them, when making decisions regarding their sexual behaviour. As reported by others, religious practices (Odimegwu 2005) and beliefs about appropriate sexual behaviour and congregational characteristics (Trinitapoli 2009) are more important than religious affiliation in determining sexual behaviour among young people. As permission from the regional church leadership in KwaZulu-Natal was required for the study, we did not ask questions about the participants’ sexual behaviour and HIV status. This information would have been of interest for comparison of our findings with other studies. As the province of KwaZulu-Natal has the highest HIV prevalence among young people in South Africa (Shisana et al. 2009), one should be cautious in generalizing our findings to populations with different HIV prevalence and religious patterns. The perceived risk of HIV infection among church-attending youth is likely to be different in settings with lower HIV prevalence. Despite these limitations, the results of this study identified issues that are important for the development and implementation of future educational programmes targeting Christian young people.

Conclusions

In conclusion, the young people in faith communities in KwaZulu-Natal perceived themselves at risk of HIV infection and had profound questions about their sexuality and relationships. Religious affiliation is strongly associated with HIV education in youth groups, suggesting an advantage for young people in the Lutheran and Catholic churches concerning learning opportunities. High motivation among youth to participate in life skills programmes suggests that further education initiatives in faith communities are feasible, along with increased promotion of HIV testing. However, the faith communities still focus very much on the moral aspects of sexuality, while giving less emphasis to information on sexuality and relationships. Thus, they fail to fully address the needs of young people, which must be met for successful HIV prevention among young people.