Elsevier

The Lancet

Volume 368, Issue 9547, 4–10 November 2006, Pages 1581-1586
The Lancet

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

https://doi.org/10.1016/S0140-6736(06)69662-1Get rights and content

Summary

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.

Introduction

With nearly half of new HIV infections worldwide occurring in young people aged 15–24 years,1 changing sexual behaviour in this group will be crucial in tackling the growing pandemic. Campaigns targeting young people have encouraged safer sex, either through condom use or avoiding penetration. Prevention efforts have often involved giving out condoms free of charge and providing information through school talks and leaflets.

Yet even where condoms have been freely available and awareness of sexual disease high, such campaigns have often had disappointing results. Qualitative research is starting to show that strong social and cultural forces shape sexual behaviour and is helping to explain why providing information and condoms—while important—are often not enough to change this behaviour. In particular, such work helps us understand why some HIV prevention programmes have been ineffective and how they might be improved.

Since the advent of HIV/AIDS, the number of studies in this field has grown. Previously the realm of sex specialists, sexual behaviour is now scrutinised by sociologists, anthropologists, and public-health specialists in a way that would not have happened before the epidemic. However, whereas earlier work sought to describe and understand sexual behaviour in general, current research tends to focus on identifying, explaining, and changing sexual practices relevant to HIV transmission.

Although quantitative research is effective at answering questions such as “what percentage of young people report using a condom the first time they had sex?”, it is less useful if we want to know the reasons for their behaviour; nor will it give a broad description of what happened during the sexual encounter. Qualitative research helps describe, and find the reasons for, behaviour and its social context.

Because this is a comparatively new field and qualitative work is usually published in specialist journals, such research tends not to be read by other researchers, clinicians, or policymakers. This systematic review provides a critical synthesis of existing qualitative evidence for a wider audience, to inform research and policy. We show how the findings illuminate our understanding of sexual behaviour, and help to answer key questions. Finally we ask: where does the research go from here? To our knowledge, this paper is the first comprehensive review of this literature.

We reviewed qualitative empirical studies of young people's (aged 10–25 years) sexual behaviour published in English between 1990 and 2004 inclusive. We included any study reporting empirical, non-numerical data on sexual behaviour even if the focus was elsewhere—eg, on drug use, but excluded studies focusing exclusively on commercial sex work or child sexual abuse because these added complexities beyond the scope of this review.

We searched these databases: BIDS:IBSS, BIDS: Ingenta, PsycInfo via Ovid, PubMed (NLM), CINAHL via Ovid, Ovid journals, Ovid Medline, Books via Ovid, Web of Science, EMBASE via Ovid, Anthropology plus. We used these search terms: (foc* group* OR grounded theory OR anthropol* OR ethnograph* OR qualitative) AND (sexual* OR risk behav*) AND (juvenile OR youth OR young people OR young male* OR young female* OR adolesc* OR teen* OR student* OR girl* OR boy*) where * indicates wildcard.

Searches for misspellings and MeSH terms were automatically added in PubMed searches. We also searched the catalogues of the M25 consortium of London University libraries (150 academic libraries in London) and Copac (merged online catalogues of major UK and Irish university research libraries, plus the British Library and the National Library of Scotland), following up references in review articles and book reviews, consulting experts in the field, and hand searching within London libraries. We hand-searched key journals: Culture, Health and Sexuality, Reproductive Health Matters, Sociology of Health and Illness, Lancet, Archives of Sexual Behavior, AIDS Care, and Social Science and Medicine.

We did a review and synthesis of qualitative work analogous to a quantitative meta-analysis. No particular method exists for analysing and synthesising qualitative studies. Unlike quantitative analyses, where focus and methods are defined a priori, qualitative analysis is guided by emerging findings. We developed a strategy that we name comparative thematic analysis from existing work on meta-analysis of qualitative data2, 3 and our own experience of qualitative analysis.4, 5 The method treats the research papers as documents, and analyses them using well-established qualitative techniques: first, we independently reviewed and coded the documents. Codes represented themes that emerged from the documents—eg, violence against women. We refined these dozens of codes through discussion and the use of constant comparison within and between codes to ensure that they accurately reflected the material. We then identified correlations between the different themes, grouping them into the broad overall themes.

Documents were classed as primary—of high quality or containing empirical data about sex (ie, specific reports about sexual events rather than about attitudes or opinions), or both, or they were classed as secondary—lower quality, with no empirical data about sex. High quality studies provided theoretical insight into sexual behaviour or contained thorough descriptions of particular contexts. For instance, they could include detailed, evidence-based descriptions of family expectations about young people's sexual behaviour. Lower quality referred to those with simple, non-detailed descriptions or failing to provide evidence for statements made, or both.

To ensure comprehensive coverage, we coded both primary and secondary documents, then refined the codes using the primary studies only. No additional themes emerged from the secondary studies. We took this to indicate that our final comparative thematic analysis covered the breadth of the literature reviewed, and that our selection and quality criteria were robust.

We identified 5452 reports, of which 2102 remained after exclusions because of the irrelevance of the title, and 268 after exclusions because the content in the abstract or the full text did not meet our inclusion criteria. 56 items had no abstract and could not be obtained from UK libraries or directly from the authors. The final sample for analysis contained 246 journal articles and 22 books, of which 121 items were primary documents. Summary data for these are shown in the webtable.

The sponsors of the study had no role in study design; collection, analysis, and interpretation of data; writing the report; or the decision to submit the paper for publication.

Section snippets

Results

Seven key themes emerged: five related to sexual behaviour in general and two (themes 1 and 3) to condom use in particular. There was considerable overlap between the studies, and so citations are representative rather than comprehensive (the webtable lists in full the themes in each study). Most studies in our final sample assessed behaviour in unmarried heterosexual young people, and this focus is retained here.

The research shows us that, worldwide, not only is sexual behaviour strongly

Discussion

Our review of research suggests that there are striking similarities in young people's sexual behaviour worldwide.

The seven common themes we have outlined can be used to help answer specific questions, for example why some young people are inconsistent condom users, even with high levels of knowledge and access to condoms. Young people may choose not to use a condom with a partner they perceive to be “clean” (theme 1); they may not have discussed sex with their partners in advance and so be

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