World Journal of AIDS, 2011, 1, 43-49
doi:10.4236/wja.2011.12008 Published Online June 2011 (
Copyright © 2011 SciRes. WJA
Cameroonian Preadolescents’ Perspectives of an
HIV Prevention Intervention
Comfort Enah, Linda Moneyham, Gwendolyn Childs, Carrie Ann Gakumo
School of Nursing, University of Alabama, Birmingham, USA.
Received April 30th, 2011; Revised May 20th, 2011; Accepted May 27th, 2011.
Purpose: Determining and incorporating the perspective of the target population is important to the developments of
effective and sustainable HIV prevention efforts. Cameroonian preadolescent females remain at high risk for contract-
ing HIV and have not benefitted from targeted HIV prevention efforts. In this report, findings are presented from data
collected from 60 Cameroonian preadolescent females; ages 10 - 12 years; following their completion of an HIV pre-
vention intervention. Methods: The theory-based intervention utilized the World Health Organizations Responsible
Behavior: Delaying Sex curriculum which had been tailored for the target population with the assista nce of Cameroo-
nian experts. The data reported here were collected as part of a questionn a ire participan ts comp leted po st-in terventio n.
Results: With only a few exceptions, participants perceived the intervention to be appropriate and relevant. No signifi-
cant differences were found in participants assessment of the intervention across different ages and ethnic groups.
Discussion: Evaluating the appropriateness of interventions to the developmental level, gender, and culture of partici-
pants is an essential step in developing effective and sustainable interventions. Findings in this study are encouraging
and indicate that interventions adapted with the assistance of local experts can be perceived relevant and appropriate
by participants.
Keywords: HIV Prevention, Adolescent He alth, Intervention Research, Participants Perspectives, Cameroon, Africa
1. Introduction
According to the 2009 AIDS epidemic update by the
Joint programs on AIDS [1], sub-Saharan Africa remains
the most heavily affected region in the world, accounting
for over 68% of new infection in recent years. In addition,
women and girls in sub-Saharan Africa continue to be
disproportionately affected by HIV/AIDS [1]. While
tremendous strides have been made in improving access
to HIV treatment, the epidemic continues to outpace the
response. Although there are numerous evidence-based
preventio n interventions with demonstrated effectiv eness,
most have been developed in western countries with cul-
tures and other characteristics distinctly different from
sub-Saharan Africa. In addition, few HIV prevention
interventions have been designed specifically for young
adolescent females.
In recent years, considerable progress has been made
in identifying factors that contribute to the transmission
of the disease in countries that are disproportionately
affected by HIV/AIDS such as Cameroon, Africa. Sev-
eral approaches have been used in Sub-Saharan Africa in
an attempt to decrease HIV infection rates in adolescents.
Included in these strategies are peer education, social
marketing, mass media awareness campaigns, voluntary
testing and counseling, and school-based programs [2].
School-based approaches are often advocated because of
the ability to reach large numbers of adolescents in a
short period of time in an environment suitable for
learning and evaluation. It is generally recommended that
school-based primary disease prevention interventions
should begin at the primary school level because school
attendance drops dramatically in most countries in this
region as students transition from primary, secondary,
high school and college levels [3]. The focus of HIV
prevention efforts on primary school students is limited,
however, by the “one size fits all” approach to interven-
tions targeting adolescents. Little consideration has been
given to the developmental differences of younger and
older adolescents, as well as their level of engagement in
sexual activity. Key to intervention effectiveness is the
match between the in terven tion an d the target p opu latio n .
Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention
As part of a larger study to assess the potential efficacy
of an HIV prevention intervention tailored for use with
Cameroonian preadolescents [4,5] we explored the ac-
ceptability and relevance of the intervention to primary
school age Camero onian girls.
The magnitude of the impact of AIDS in Sub-Saharan
Africa is unparalleled in human history. In this region of
the world, the disease will cripple the economies of many
countries if urgent preventative interventions are not im-
plemented [1,6]. The disease is a threat to people in the
most productive phases of their lives, with devastating
effects on families and entire cultures and popu lations [6].
In Cameroon, a third of those who are infected are aged
14 - 19 [7]. Among young people, the full impact of
AIDS is hidden by the lengthy incubation period of the
disease. Those diagnosed in youn g adulthood were likely
infected during their adolescent and preadolescent years
[8]. There is growing recognition of the need to target
young adolescents and preadolescents for HIV preven-
tion efforts prior to their engagement in sexual activity
There is increasing recognition of the need to target
HIV prevention efforts in Camero on on females. Females
in Cameroon are at increased risk of being infected be-
cause they initiate sexual activity at an earlier age than
their male counterparts; they also tend to initiate sexual
activity with older men who have higher infection rates
than younger males [11,12]. In addition, many females
engage in sexual relationships for economic benefits, due
in part to the generally lower socio-economic status of
women. In Cameroon men are more likely to complete
high school, attend college and subsequently get better
paying jobs than women. Women also tend to get mar-
ried at younger ages than men. In addition, cultural
norms dictate that the man is the head of the household
and the decision-maker. All these factors translate to a
subordinate role for women and the economic depend-
ence of many females on their husband or sexual partners
There is a paucity of HIV prevention intervention
studies focusing on preadolescents or young adolescents
in Cameroon. Although two intervention studies con-
ducted in Cameroon have been reported [15,16], there
are no known efforts to tailor HIV prevention interven-
tions to be culturally sensitive, gender specific, and de-
velopmentally appropriate for u se with Cameroonian pr e-
and young adolescents. Considering that most HIV pre-
vention interventions were developed in the western
world, assessment of the relevance and acceptability of
such interventions strategies is key to maximizing their
effectiveness for specific populations such as Cameroo-
nian preadolescents. The aim of the research reported
here was to assess the perceived relevance and accept-
ability of an HIV prevention intervention to preadoles-
cent Cameroonian females.
2. Methods
We analyzed post intervention data from a one group
pretest posttest design study. The focus of the larger
study was to determine the feasibility of recruiting and
enrolling Cameroonian girls in HIV prevention studies,
estimate the efficacy of the intervention, and assess cul-
tural sensitivity of the intervention and study protocols.
The findings reported here focus on the analysis of rele-
vance and acceptability of the intervention to participants.
Approval for the study was obtained from the primary
author’s institutional review board and the board of edu-
cation of the school in Cameroon. In addition, parents
provided written informed consent and participants pro-
vided written assent to participate in the study.
Setting and Sample: The study was conducted in a
public school located in a university town which is also
the capital of the South W est Province of Cameroon. The
town is also located in one of the provinces with the
highest HIV/AIDS prevalence rates in Cameroon. All
female students attending the school, aged 10 - 12, who
could read and write, were considered eligible for the
study. Sixty girls, who constituted 100% of those eligible,
participated in the study.
Procedures: The study was advertized on school bul-
letin boards and flyers were distributed to all students
attending the school. Consent forms were sent home with
eligible students for their parents to complete. Transpor-
tation was provided to and from the school. The study
was implemented on a Saturday so as to allow partici-
pants to participate in all school activities during week-
All parental consent and student assent forms were
collected and reviewed for completeness when student
arrived at the study site. At the beginning of the day, par-
ticipants completed a brief survey which in cluded demo-
graphic characteristics and correlates of HIV risks in
preadolescence. Participants took about 10 minutes to
complete the questionnaire. Because the questionnaire
focused on sensitive issues related to sexual behavior,
strategies to encourage open and honest responses were
implemented [17]. Strategies used in this study included:
1) explaining the importance of honest responses to
questions because there were no right or wrong responses;
2) assuring participants that their responses would be
kept confidential; 3) using code numbers instead of
names on questionnaires; and 4) asking participants to
deposit completed questionnaires in a sealed box instead
of directly to the investigator.
The Intervention: The intervention was a day long
workshop that was delivered in a group format. The
Copyright © 2011 SciRes. WJA
Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention
Copyright © 2011 SciRes. WJA
workshop topics are outlined in Table 1. At the begin-
ning of the intervention a lecture on bodily changes dur-
ing puberty and HIV information such as nature of the
HIV virus, modes of transmission and groups at risk in
Cameroon was presented. The second part included spe-
cific units that focused on values clarification and build-
ing of specific HIV prevention behavioral skills. Each
unit incorporated small group activities and a discussion.
These units were completed in small groups of 10 stu-
dents each. The investigator moved from group to group
encouraging participation, answering questions, and fa-
cilitating activities. After each unit was completed,
groups shared a summary of their discussions and activi-
ties with other participants and answered questions.
The intervention was built on the World Health Or-
ganization’s (1994) Responsible Behavior: Delaying Sex
curriculum, which allows content and protocols to be
tailored to the specific needs, culture, and gender of the
target population [18]. This curriculum includes a
teacher’s guide, students’ guide, and a sample of ques-
tions that can be used to evaluate the curriculum. The
primary investigator, a nativ e of Cameroon, worked with
local experts to adapt the intervention so that it matched
the culture, age, and ge nder of participan ts. The interven-
tion was extended with the addition of the theme: Be
Proud! Be Responsible! [19], to enhance personal, gen-
der, and cultural pride. Activities in the intervention
aimed at influencing attitudes, control beliefs, and be-
havioral norms about delaying sex, which are antece-
dents of intention and behavior. As part of the interven-
tion participants were assisted in preparing planned cul-
turally appropriate responses that could be used when
they were faced with pressures to have sex. Examples of
planned responses included refusing (“No, I am leaving”),
delaying (“Let me think about it and we can talk again
tomorrow”), and bargaining (“I won’t do that but maybe
we can do…”). Interactive activities that were also part
of the intervention included: affirmations, life mapping,
the use of role-plays, decision making in real-life sce-
narios, assertive communication scenarios, question and
answer sessions, and group discussions (See Table 1)
Measures: A questionnaire administered prior to and
immediately after the workshop intervention was used to
measure demographic data and study variables. The
relevance and acceptability of the intervention was as-
sessed using 10 items developed specifically for use in
the study with the help of a panel of seven Cameroonian
health educators and teachers. The items were statements
about the intervention that included understanding of the
intervention, ease of reading the items, comfort with
content, missing content, likelihood of recommending
the intervention to others, and suggestions for modifying
the intervention. For each item, participants completed
Table 1. Outline of intervention workshop curriculum guide.
Section Content
Theme: Be proud! Be Responsible! Target Variable
Section 1 Lecture: Introduction, bodily changes during puberty, and HIV prevention
information Lecture Knowledge and
Section 2 HIV prevention: Delaying Sexual intercourse
Unit 1 Activity: Discuss a variety of reasons for delaying sex until older or married Attitudes and Norms
Unit 2 Activity: Discussing the decisions to delay or not to delay: Why young people make
these decisions and the consequences, life mapping, and affirmations Norms and behavior
Unit 3 Activity: Students practice responding to typical arguments that are used to pressure
girls to have sex Subjective norms and
behavior control
Unit 4 Make students aware that they are not alone in delaying sex and providing guidelines
to assist students Subjective norms
Unit 5 Activity: Students practice guidelines for delaying sex in role-plays. Use guidelines
provided in previous unit. Facilitator communicate that delaying sex is not always
easy but specific behaviors skills can help
Behavior control
Unit 6 Activity Expressing Affections without sex: Students discuss ways to demonstrate
affection that do not include sex. Behavior control
Unit 7 Activity: Deciding how far to go ahead of time Behavior control
Unit 8 Discuss passive, assertive, and aggressive behaviors Behavior control
Unit 9 Activity: Learning to be assertive: students practice assertive communication Behavior control
Unit 10 Activity: Responding to persuasion: Using the Refuse, Delay, Bargain approach.
Student practice using this approach in role-plays Behavior control
Unit 11 Activity: Dealing with threats of violence: Discuss potential compromising situa-
tions, incentives for sex from older persons, threats of violence Behavior control
Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention
two tasks. First, participants responded “yes” or “no” as
to whether the item was true. Second, participants were
asked to provide written comments about the aspect of
the intervention addressed in the item. The items were
administered immediately following completion of the
Data Management and Analysis: Descriptive statistics
were used to summarize responses to sociodemographic
items and the yes/no responses to the 10 items assessing
the relevance and acceptability of the intervention. To
explore differences in perceptions of appropriateness of
the intervention, Fisher-exact tests were conducted to
assess differences in responses to yes/no items in relation
to differences in age, living conditions, educational level
of parents, household income, and provinces or origin.
The content of the written responses to each of the 10
items were analyzed and categorized into common
themes related to the acceptability and relevance of the
3. Results
The sociodemographic characteristics of participants are
summarized in Table 2. The age of students ranged from
10 - 12 years with a mean age of 10.5. The majority of
participants lived with both parents (66.7%). All partici-
pants reported they had not yet engaged in sexual activity.
The literacy rate for participant’s parents (98%) was
much higher than the national reported adu lt literacy rate
of approximately 77% [20].
Participants hailed from eight different English-
speaking areas of Cameroon, and the majority (85%) was
from English speaking provinces. Reported household
incomes for the majority of participants (64%) were
higher than national median incomes and most students
(61.7%) had at least one member of their household who
held a college degree.
The responses to the 10 items assessing the interven-
tion are summarized in Table 3 . The majority of the par-
ticipants (78%) reported favorable perceptions of the
intervention. There were no significant differences in
responses to the 10 items due to age or ethnicity. How-
ever a trend was noted in rating of the intervention con-
tent, with participants from the No rwest Province report-
ing less understanding of content (50%) as compared to
Table 2. Sample characteristics (N = 60).
Variable N %
10 years old 34 56.7
11 years old 21 35
12 years old 5 8.3
Living with
Both parents 40 66.7
One parent 9 45
Grand parents 6 10
Other relatives 5 8.3
Monthly Household Income
Below 50,000 CFA 20 33.3
50,000 CFA - 100,000 CFA 8 13.3
100,000 CFA - 200,000 CFA 12 20
Above 200,000 CFA 19 31.7
Unreported 1 1.7
Highest Educational level in Household
No Formal Education 1 1.7
Primary School 4 6.7
Secondary School 8 13.3
High School 6 10
University or Above 37 61.7
Other (Professional Diploma) 4 6.7
Table 3. Summary of responses to relevance and acceptability items.
Item Frequency (Percentages)
Yes No
1. Comfort with content 44 (73.3%) 15 (25%)
2. Study help change mind 41 (68.3%) 12 (28.3%)
3. Expected content not covered 7 (11.6%) 52 (86.7%)
4. Some content should be left out 6.7 (40.2%) 52 (86.7%)
5. Learned new skill 44 (73.3%) 16 (26.7%)
6. Would recommend study to others 43 (71.7%) 16 (26.7%)
(Note: Total sample was 60).
Copyright © 2011 SciRes. WJA
Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention 47
participants from other provinces (81% - 88%); they
were also less likely to agree to having learned new skills
(60%) than participants from other provinces (83% -
89%) Twenty five percent of the participants reported not
feeling comfortable with the topics covered in the inter-
vention. However, participants failed to explain what
specifically made them uncomfortable. Among those
who provided explanations, their discomfort was associ-
ated with discussions of sexual behavior in general. Most
participants indicated that the content of the intervention
was sufficient. However, sixteen percent of the partici-
pants indicated that there was additional content that
should be included in the intervention, including infor-
mation about the progress being made toward the devel-
opment of an HIV vaccine and current treatment modali-
ties. A small portion of participants (6.7 %) indicated that
certain content should be omitted howev er; they failed to
provide specific information on what content this might
In general, most participants (78%) reported that they
had learned new skills, and would try to share skills th ey
had learned with family members. They also indicated
that they would recommend the intervention to others
because they had learned new skills that would be useful
to other people they knew.
4. Discussion
This was the first study that had directly assessed the
relevance and acceptability of school-based HIV preven-
tative interventions to preadolescents Cameroonian fe-
males. Considering that most HIV prevention interven-
tions were developed for use with Western populations
and do not target preadolescents, assessments of the
relevance and acceptability of such interventions are
warranted. In this study, most participants, including the
youngest age group perceived the intervention appropri-
ate. The impact of HIV/AIDS in Cameroon and the lack
of age appropriate interventions that equip these students
to protect themselves from the disease might have con-
tributed to this positive perception. Participants were
highly likely to have known at a personal level people
who were suffering from or had died from the disease.
To date, HIV preventative strategies in the country have
focused almost exclusively on media campaigns promot-
ing condom use and HIV testing. The relevance of the
intervention to the target population likely resulted from
the inclusion of strategies for protecting oneself from the
disease. The importance preadolescent females and their
parents attached to protection from the disease was evi-
dent in the 100% positive resp onse of parents to allo wing
their children to take part in the study.
Findings in this study which suggest that the interven-
tion was contextually appropriate are consistent with
findings in other school-based studies in sub-Saharan
Africa [21-24]. In these studies western change theories
were integrated with qualitative information from local
experts and the resulting interventions were perceived
contextually relevant. In line with these studies, a num-
ber of steps were taken in the process of developing the
intervention to ensure that students in Cameroon would
be able to understand the content. Evaluation of interv en-
tion content and strategies by teachers involved in the
educational system in Cameroon during the adaptation
phase and the resulting modifications made from this
evaluation contributed to the perceived appropriateness
from even the youngest of participants. Furthermore,
participants were aware that th e primary investigator was
native to the region, and this may have added to positive
perceptions of the intervention.
When responses on appropriateness of the interv ention
were examined by age, no relationship was found be-
tween age and perceived appropriateness. It is worth
noting that the majority of the participants (58.3%) were
10 year-olds, and proportionately more 10 year-old par-
ticipants than older participants thought the intervention
was appropriate. The proportionately more favorable
perceptions from 10 year-old students might be a devel-
opmental or a social desirability issue or simply due to
chance since the difference among age groups were not
The responses on appropriateness of the intervention
were also examined by ethnicity. Participants were from
two major English speaking ethnic regions or provinces
of the country; the Northwest and Southwest provinces.
A few of the participants (15%) were from various other
provinces in the country and were all grouped under
“other”. In general, students from all ethnic divisions
considered the in tervention and its components appropri-
ate. However there were some non-significant differ-
ences between participants from different ethnic regions
in their responses to some of the items concerning ap-
propriateness of the intervention. More participants (81%)
from the Southwest province reported that they under-
stood the content of the study than participants from the
Northwest province (50%) while more participants from
the Northwest province (83%) reported having learned
new skills than participan ts from the Southwest provin ce
(60%). These findings have to be interpreted with caution
considering the convenience sample and the relatively
small number of participants (20%) from the Northwest
province. These differences might be a reflection of
variations in cultural norms related to sexuality issues
between the two regions. In at least one descriptive study
[10] conducted in the Northwest Province, researchers
examining socio-cultural factors associated with risky
sexual behaviors found differences among participants
Copyright © 2011 SciRes. WJA
Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention
from different provinces which were attributed to differ-
ences in sexual permissiveness among ethnic groups. In
the same study, participants from the Northwest Province
were found to have initiated sexual activity earlier than
their counterparts from other provinces [10]. Regional
differences were also observed in a study on early initia-
tion of sexual activity [25]. The percentage of women
who were sexually active in adolescence and before mar-
riage varied from 8% in some regions of the country to
69% in other regions [25]. Reports could not be found in
the literature that provided any specific difference in
cultural practices in these provinces that could account
for the difference. Further exploration of these differ-
ences is warranted.
It must be noted that the choice of measures for ap-
propriateness of the intervention might have influenced
results obtained. The choice of a yes/no response format
has the advantage of being more appealing to participants
because it demands less concentration, but variability in
the responses is also lost by using this format [26] The
open-ended sections of the questions added to elicit more
in depth information were often not used by participants.
For those who used it, responses were often brief or
cryptic and provided little to understanding participants’
perceptions. Face to face interviews would have been a
better approach in eliciting more in depth information. In
addition because of the sensitive nature of the topic of
the intervention, the age, and gender of participants the
influence of social desirability bias cannot be ruled out.
In all, HIV infections pose a serious threat to the
health of young Cameroonians. The prevalence rate con-
tinues to rise at an alarming rate in this population. Ex-
perts have identified equipping pre-adolescent females
with skills necessary to reduce their vulnerability as an
effective strategy towards reversing the epide mic. Evalu-
ating the appropriateness of interventions to the devel-
opmental level, gender, and culture of participants is an
essential step in developing effective and sustainable
interventions. Find ings in this study ar e encouraging and
indicate that the intervention was appropriate from the
participants’ perspective. However these results need to
be interpreted with caution because the small sample size
and the convenien ce sampling approach used. In addition,
there are limits to generalizability of the findings as the
intervention was tailored based on knowledge of the de-
velopmental level and culture of participants. In spite of
the limitations, findings and practical lessons learned
from the study could inform other more rigorously de-
signed HIV preventions interventions studies in Camer-
oon or studies targeting preadolescents.
[1] Joint United Nations Program on HIV/AIDS, “AIDS
Epidemic,” Update December 2009, Retrieved 21 January
[2] Joint United Nations Program on HIV/AIDS, “Epidemi-
ological Fact Sheet on HIV and AIDS, Core Data on
Epidemiology and Response, Cameroon,” 2008.
[3] United Nations Children’s Fund, “Information on STI and
[4] C. Enah, “An Intervention to Increase Intentions and Be-
havioral Skills to Postpone Sexual Activity in Cameroo-
nian Preadolescent Female Students,” Dissertation Ab-
stracts International 65/05, 2342B, 2004.
[5] C. Enah, M. Sommers, L. Moneyham, C. Long and G.
Childs, “Piloting and HIV Prevention Intervention for
Cameroonian Girls,” Journal of Nurses in AIDS Care,
Vol. 21, No. 6, 2010, pp. 512-521.
[6] World Health Organization, “HIV/AIDS Epidemiological
Surveillance Report for the WHO African Region,” 2007.
[7] World Health Organization, “2006 AIDS Epidemic Up-
date,” 2006.
[8] G. Burkholder, L. Harlow and J. Washkwich, “Social
Stigma, HIV/AIDS Knowledge, and Sexual Risk,” Jour-
nal of Applied Biobehavioral Research, Vol. 4, No. 1,
1999, pp. 27-44.
[9] P. T. Tebon, “Cameroon National Composite Policy In-
dex Report 2008,” 2008.
[10] M. Sommer, “An Overlooked Priority: Puberty in
Sub-Saharan Africa,” American Journal of Public Health,
Vol. 101, No. 6, 2011, pp. 979-981.
[11] Joint United Nations Program on HIV/AIDS, “Report on
the HIV/AIDS Epidemic,” 26 February 2007.
http: www.unaids.html
[12] M. Rwenge, “Sexual Risk Behaviors among Young Peo-
ple in Bamenda, Cameroon,” International Family Plan-
ning Perspectives, Vol. 26, No. 3, 2000, pp. 188-123,
[13] D. Meekers and A. Calves, “Main Girlfriends, Girlfriends,
Marriage, and Money: The Social Context of HIV Risk
Behavior in Sub-Saharan Africa,” Health Transitions Re-
view, Vol. 7 (Supplement), 1997, pp. 361-375.
[14] N. Lydie, N. Robinson, B. Ferry, E. Akam, M. De Loen-
zien, L. Zekeng and S. Abega, “Adolescent Sexuality in
Yaoundé, Cameroon,” Journal of Biosocial Sciences, Vol.
36, No. 5, 2004, pp. 597-616.
Copyright © 2011 SciRes. WJA
Cameroonian Preadolescents’ Perspectives of an HIV Prevention Intervention
Copyright © 2011 SciRes. WJA
[15] J. Speizer, B. Taambashe and S. Tegang, “An Evaluation
of the ‘Entre Nous Jeunes’ Peer-Educator Program or
Adolescents in Cameroon,” Studies in Family Planning,
Vol. 32, No. 4, 2001, pp. 339-351.
[16] D. Meekers, S. Agha and M. Klein, “The Impact on
Condom Use of the ‘100% Jeune’ Social Marketing Pro-
gram in Cameroon,” Journal of Adolescent Health, Vol.
36, No. 6, 2005, p. 530.
[17] B. Mensch, P. Hewett and A. Erulkar, “The Reporting of
Sensitive Behavior among Adolescents: A Methodologi-
cal Experiment in Kenya,” Demography, Vol. 40, No. 2,
2003, pp. 247-268.doi:10.1353/dem.2003.0017
[18] World Health Organization, “Responsible behavior: De-
laying Sex,” In Curriculum Planners’ Handbook, WHO/
UNESCO, Geneva, 1994.
[19] L. Jemmott, J. Jemmott and K. McCaffee, “Be Proud! Be
Responsible! Strategies to Empower Youth to Reduce
Their Risk of AIDS,” Columbia University School of
Nursing, New York, 1996.
[20] World Health Organization, “2006 AIDS Epidemic Up-
date,” 2006.
[21] J. Jemmott, L . Jemmott, A. O’Leary, Z. Ngwane, L. Icard,
S. Bellamy, et al., “School-Based Randomized Controlled
trial of an HIV/STD Risk Reduction Intervention for
South African Adolescents,” Archives of Pediatric Medi-
cine, Vol. 164, No. 10, 2010, pp. 923-929.
[22] A. Karnell, P. Cupp, R. Zimmerman, S. Feist-Price and T.
Bennie, “Efficcacy of an American Alcohol and HIV
Curriculum Adapted for Use in Aouth Africa: Results of a
Pilot Study in Five Townships,” AIDS Education and
Prevention, Vol. 18, No. 4, 2006, pp. 295-310.
[23] M. Fitzgerald, B. Stanton, N. Terreri, H. Shipena, X. Li, J.
Kahihuata, et al., “Use of Western-Based HIV Risk-
Reduction Interventions Targeting Adolescents in an Af-
rican Setting,” Journal of Adolescent Health, Vol. 25,
1999, pp. 52-61.
[24] K. Klepp, S. Ndeki, M. Leshabari, P. Hannan and B. Ly-
imo, “AIDS Education in Tanzania: Promoting Risk Re-
duction among Primary School Children,” American
Journal of Public Health, Vol. 87, No. 12, 1997,
[25] B. Kuate-Defo, “Premarital Sexual Intercourse during
Adolescence: Trends and Determinants of Regional Dif-
ferences,” In: B. Kuate-Defo, Ed., Sexuality and Repro-
ductive Health during Adolescence in Africa with Special
Reference to Cameroon, University of Ottawa Press, Ot-
tawa, 1998, pp. 121-140.
[26] R. Devellis, “Scale Development: Theory and Applica-
tions,” Sage Publications, Newbury Park, 1991.