Thesis (PhD)--Stellenbosch University, 2015 / ENGLISH ABSTRACT : In 2010, young people aged 15–24 years accounted for 42% of new HIV infections globally. In 2009, about five million (10%) of the total South African population was estimated to be aged 15–19 years. Current South African national sero-prevalence data estimate the prevalence of HIV to be 5.6% and 0.7% among adolescent girls and boys aged 15–19 years, respectively. HIV infections are mainly transmitted via sexual transmission. Adolescent sexuality is multi-faceted and influenced at multiple levels. In preparing to enroll adolescents in future biomedical HIV prevention trials, particularly prophylactic HIV vaccine trials, it is critical to provide counseling services appropriate to their needs. At the time of writing, there was no developed psychosocial intervention in South Africa for use among adolescent vaccine trial participants. Thus, the aim of the present study is to adapt and pilot-test a psychosocial intervention, namely, the Centers for Disease Control and Prevention (CDC) risk reduction counseling intervention of Project Respect, an intervention tasked at being developmentally and contextually appropriate among potential adolescent participants in HIV biomedical trials in the future. To achieve this overall aim, I qualitatively explored adolescent sexuality and risk factors for HIV among a diverse sample of participants aged 16–18 from Soweto. Thereafter, I developed a composite HIV risk scale in order to measure the variance in HIV risk among the sample of adolescents studied. The study followed a two-phased, mixed method research design and was informed by ecological systems theory and integrative model of behavioral prediction. The aim of Phase 1, split into phases 1a and b, was to conduct focus group discussions (FGDs) and to undertake a cross-sectional survey, respectively, to determine psychological (for example, self-esteem and depression), behavioral (specifically, sexual behavior) and social (specifically, social support, parent-adolescent communication) contexts that placed adolescents at risk for HIV infection. Phase 1a was qualitative, with data collected via nine FGDs: three involved parents of adolescents, four involved adolescents aged 16–18 years and two counselors. Nine key themes related to adolescent sexuality and risks for HIV acquisition were identified, namely: (1) dating during adolescence; (2) adolescent girls dating older men; (3) condom use amongst adolescents; (4) teenage pregnancies; (5) views about homosexuality; (6) parent-adolescent communication about sexual health; (7) the role of the media; (8) discipline and perceived government influence; and (9) group sex events. Phase 1b was quantitative and the data were collected via a cross-sectional survey to investigate the variance of risk for HIV. For Phase 1b, the sample consisted of 506 adolescents with a mean age of 17 years (interquartile range [IQR]: 16–18). More than half the participants were female (59%, n = 298). I used a three-step hierarchical multiple regression model to investigate the variance in risk for HIV. In step 3, the only significant predictors were “ever threatened to have sex” and “ever forced to have sex”, the combination of which explained 14% (R2 = 0.14; F (12, 236) = 3.14, p = 0.00). Depression and parentadolescent communication were added to steps 2 and 3, respectively, with both variables insignificant in these models. In Phase 2, I adapted and pilot tested the CDC risk reduction counseling intervention. The intervention was intended to be developmentally and contextually appropriate among adolescents from Soweto aged 16–18 years, viewed as potential participants in future HIV biomedical trials. Participants in Phase 2 were aged 16–18 years; the sample was mainly female (52%, n = 11) and most (91%, n = 19) were secondary school learners in grades 8 to 12. Participants provided feedback about their experiences of the adapted counseling intervention through in-depth interviews. I identified three main themes in this regard, namely: benefits of HIV testing services, reasons for seeking counseling and HIV testing services, and participants’ evaluation of the study visits and counseling sessions. The adapted CDC risk reduction counseling intervention was found to be acceptable with favorable outcomes for those adolescents who participated in the piloting phase. This study adds to the literature on risks for HIV among adolescents in Soweto, South Africa, by considering multiple levels of influence. Reaching a more complete understanding of ecological factors contributing to sexual risk behaviors among adolescents in the pilot-study enabled the development of a tailored counseling intervention. The findings showed the adapted CDC risk reduction counseling intervention to be feasible and acceptable among adolescents likely to be participants and eligible to participate in future HIV biomedical prevention trials. Thus, this study provides a much needed risk reduction counseling intervention that can be used among adolescents, an age group likely to participate in future HIV vaccine prevention research. / AFRIKAANSE OPSOMMING : In 2010 het jongmense tussen die ouderdomme van 15 en 24 jaar 42% van nuwe MIV-infeksies wêreldwyd uitgemaak. In 2009 was omtrent 5 miljoen mense (10%) van die Suid-Afrikaanse bevolking tussen 15 en 19 jaar oud. Volgens data oor die huidige Suid-Afrikaanse nasionale sero-voorkoms, word die voorkoms van MIV onderskeidelik op 5.6% en 0.7% onder tienermeisies en -seuns tussen die ouderdomme van 15 tot 19 jaar beraam. MIV-infeksies word hoofsaaklik deur seks oorgedra. Adolessente seksualiteit het baie fasette en word op verskeie vlakke beïnvloed. Ter voorbereiding van die werwing van adolessente vir toekomstige biomediese proewe, veral proewe oor profilaktiese MIVentstowwe, is dit van kritiese belang dat beradingsdienste verskaf word wat geskik is vir hul behoeftes. Op die tydstip wat hierdie tesis geskryf is, het daar nog geen psigososiale intervensie in Suid-Afrika bestaan vir gebruik onder adolessente deelnemers aan entstofproewe nie. Daarom is die doel van hierdie studie om ʼn psigososiale intervensie ‒ die Centers for Disease Control and Prevention (CDC) se Projek Respek, ʼn beradingsintervensie vir die vermindering van risiko ‒ aan te pas en met ʼn loodsprojek te toets. Hierdie intervensie is geskik vir die ontwikkelings- en kontekstuele vlak van adolessente deelnemers aan toekomstige MIV- biomediese proewe. Ten einde hierdie oorkoepelende doelwit te bereik, het ek adolessente seksualiteit en die risikofaktore vir MIV onder ʼn diverse steekproef deelnemers tussen die ouderdomme van 16 en 18 jaar van Soweto kwalitatief ondersoek. Daarna het ek ʼn saamgestelde MIV-risikoskaal ontwikkel om die variansie van MIV-risiko onder die groep adolessente te meet. Die studie se navorsingsontwerp het uit twee fases en gemengde metodes bestaan, en is gebaseer op ekologiesestelsel-teorie en die integrerende gedragsvoorspellingsmodel. Die doel van fase 1, wat in fases 1a en 1b verdeel is, was om onderskeidelik fokusgroepbesprekings te hou en om ʼn deursnitopname te doen om die sielkundige kontekste (byvoorbeeld elemente van selfbeeld en depressie), gedragskontekste (spesifiek seksuele gedrag) en sosiale kontekste (spesifiek sosiale ondersteuning en ouer-adolessent-kommunikasie) te bepaal waarin adolessente die risiko loop om MIV-infeksie op te doen. Fase 1a was kwalitatief en data is deur middel van nege fokusgroepbesprekings ingesamel: drie met die ouers van adolessente, vier met adolessente tussen 16 en 18 jaar oud en twee met beraders. Nege sleuteltemas is geïdentifiseer wat verband hou met adolessente seksualiteit en risiko’s om MIV op te doen: (1) verhoudings tydens adolessensie, (2) tienermeisies wat verhoudings met ouer mans het, (3) die gebruik van kondome onder adolessente, (4) tienerswangerskappe, (5) sienings oor homoseksualiteit, (6) ouer-adolessent-kommunikasie oor seksuele gesondheid, (7) die rol van die media, (8) dissipline en die ervaarde regeringsinvloed en (9) groepseksgeleenthede. Fase 1b was kwantitatief en data is deur middel van ’n deursnitopname ingesamel om die variansie van risiko vir MIV te ondersoek. Vir Fase 1b het die steekproef bestaan uit 506 adolessente met ’n gemiddelde ouderdom van 17 jaar (interkwartielwydte [IKW]: 16–18). Meer as die helfte van die deelnemers was vroulik (59%, n = 298). Ek het ’n hiërargiese meervoudige regressiemodel met drie stappe gebruik om die variansie van risiko vir MIV te ondersoek. Die enigste beduidende voorspellers in stap 3 was “ooit gedreig om seks te hê” en “ooit geforseer om seks te hê”. Die kombinasie hiervan het 14% (R2 = 0.14; F (12, 236) = 3.14, p = 0.00) verklaar. Depressie en oueradolessent- kommunikasie is onderskeidelik in stappe 2 en 3 bygevoeg, en albei veranderlikes was onbeduidend in hierdie modelle. In Fase 2 het ek die CDC se intervensie vir die verlaging van risiko aangepas en met ’n loodsprojek getoets. Die intervensie was bedoel om geskik te wees vir die ontwikkelings- en kontekstuele vlakke van 16- tot 18-jarige adolessente van Soweto wat beskou is as potensiële deelnemers aan toekomstige MIV- biomediese proewe. Deelnemers in Fase 2 was 16 tot 18 jaar oud, die steekproef was hoofsaaklik vroulik (52%, n = 11) en die meeste van die deelnemers (91%, n = 19) was in grade 8 tot 12 op hoërskool. Deelnemers het tydens indringende onderhoude terugvoering oor hulle ervarings van die aangepaste beradingsintervensie verskaf. Ek het drie hooftemas in hierdie verband geïdentifiseer, wat die volgende insluit: voordele van MIV-toetsingsdienste, redes waarom berading en MIV-toetsingsdienste verlang word, en die deelnemers se evaluering van die studiebesoeke en beradingsessies. Daar is bevind dat die aangepaste beradingsintervensie van die CDC aanvaarbaar was en gunstige uitkomste gelewer het vir die adolessente wat aan die loodsfase deelgeneem het. Hierdie studie dra by tot die literatuur oor MIV-risiko’s vir adolessente in Soweto, Suid-Afrika, deur meervoudige invloedsvlakke te oorweeg. Die feit dat ’n meer volledige begrip tydens die loodsondersoek verkry is van die interaksie van die ekologiese faktore wat tot seksuele risikogedrag onder adolessente bydra, het die ontwikkeling van ʼn doelgemaakte intervensie deur berading moontlik gemaak. Die bevindings het getoon dat die aangepaste beradingsintervensie van die CDC lewensvatbaar en aanvaarbaar is vir gebruik onder adolessente wat waarskynlik geskikte deelnemers aan toekomstige biomediese proewe oor MIV-voorkoming kan wees. Hierdie studie verskaf dus ʼn noodsaaklike beradingsintervensie om die MIV-risiko onder adolessente ‒ ʼn ouderdomsgroep wat waarskynlik aan toekomstige biomediese navorsing oor MIV-voorkoming sal deelneem ‒ te verminder.

Depuis les travaux de Pinel à la fin du XVIIIème, l'orientation du malade mental criminel s'est faite dans la recherche d'un juste équilibre entre soin et peine, plaçant l'expertise psychiatrique pénale au centre du dispositif judiciaire. Ces dernières années, de nombreuses critiques ont émergé à l'encontre de l'expert psychiatre et de l'institution psychiatrique, tandis que de nouvelles préoccupations sécuritaires envahissaient nos sociétés. Dès lors, la tentation de criminaliser le malade mental, marqué du sceau de la dangerosité, grandit, tandis que l'article 122-1 révèle davantage l'ambiguïté de son second alinéa. Afin de mieux appréhender cette population de malades mentaux criminels, cette thèse s'articule sur deux démarches complémentaires. L'une détermine le cadre socio-historique de la recherche, l'autre est une étude descriptive rétrospective sur l'application de l'article 122-1 second alinéa. L'analyse des résultats à l'aune de cette double lecture permet de tracer plusieurs pistes de réflexions pour une réactualisation intégrative dynamique et cohérente de l'articulation santé-justice. / Since the works of Pinel, The orientation of the criminal mentally ill person was made in the search for a just balance between care and punishment, placing the penal psychiatric expertise in the center of the judicial device. These last years, numerous criticisms appeared against the expert psychiatrist and from the psychiatric institution, whereas new security concerns invaded our societies. From then on, the temptation to criminalize the mentally ill person, marked with the seal of the dangerosité, grows , whereas the article 122-1 reveals more the ambiguity of its second paragraph. To dread better this population of criminal mental patients, this thesis articulates on two additional steps. The one determines the socio-historic frame of the research, the other one is a retrospective descriptive study on the application of the article 122-1 second paragraph. The analysis of the results in the alder of this double reading allows to emit several tracks of reflections for an updating dynamic and coherent intégrative of the articulation health-justice.

This chapter reviews the literature applying health behavior theories to indoor tanning. Few studies have tried to fit full versions of health behavior models to indoor tanning. Theoretical models from the family of theories referred to as the reasoned action approach (e.g., theory of planned behavior, behavioral alternative model, prototype willingness model, etc.) have been most commonly used to study indoor tanning. Results indicate that these models fit indoor tanning data moderately to extremely well. Two lesser known models, problem behavior theory and the terror management health model, have also demonstrated a reasonable fit. Two other common models, the health belief model and social cognitive theory, have never been fully tested with indoor tanning. However, key constructs from these models (e.g., perceived susceptibility and threat, modeling) have been used to understand indoor tanning. Empirical research conducted represents a solid start toward developing strong, comprehensive models of indoor tanning that can guide intervention efforts. This initial work needs to be expanded by conducting longitudinal studies and by including a broader age range in studies because the majority of existing work has focused on young adults. Incorporating findings related to tanning dependency, peer group affiliation, media influences and other constructs into these foundational models will also improve our understanding and ability to develop efficacious interventions to reduce engagement in this health risk behavior.