Digest No. 14

Greetings,

This time, we have six postings, from Brazil, Mali, the U.K., the U.S., and Vietnam. One posting addresses ABC, while the others continue our discussion on access to services, use of condoms, and sex education.

Leandro Vieira dos Santos of Brazil offers a youth perspective on the ABC approach. Le Thuy Duong observes that young people in Vietnam prefer to go to pharmacies rather than hospitals, clinics, and health centers. Ellen Brazier emphasizes the important role of nurses and midwives and describes a successful pilot project in three African countries. Clare Hanbury-Leu calls for parents, teachers, and health workers to rethink their attitudes toward youth. Abigail Haydon of the U.S. provides information on why youth use condoms. Dr. Binta Keita discusses the education, use of contraception, and how provider attitudes can be a barrier to youth.

In addition to these postings, we continue our approach of posting responses to a question about an ABC issue, which I posed to selected participants. The question for today is:  Many groups emphasize either "A" or "C" messages to youth, finding that it is difficult to communicate "B" messages to young people, and that they are frequently misunderstood. Do you know of examples where messages about fidelity or partner reduction have been successfully communicated to young people?

Below are four responses to the question I posed. Following those comments are the six digest postings.

Best regards,

Ed Scholl, Forum Moderator

On behalf of YouthNet, The INFO Project, and the Implementing Best Practices in Reproductive Health Initiative/World Health Organization

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From Edward (Ted) Green, a Senior Research Scientist at the Harvard Center for Population Studies and member of the Presidents Advisory Council for HIV/AIDS -- That's a good question! The "B" is usually left out of the ABC debate. In fact, the debate is almost always in the terms of the "culture wars" that have been raging in America: abstinence versus condoms.

Here is a section from a 2003 report of mine to USAID, based on research in Uganda and Zambia: "Some reluctance to have Be Faithful or partner reduction messages for youth was encountered in both countries, Uganda and Zambia. Religious and conservative groups are afraid this would seem to condone or countenance premarital sex, while liberal groups believe that it's unrealistic to try to fight human nature, moreover the interval between first sex and marriage is the time for sexual experimentation and having several partners, and no amount of education is likely to change this presumed universal pattern. However, most AIDS educators agree that it is wise to warn about the dangers of multiple partners, sometimes phrasing it that with each additional sex partner, chances of infection greatly increase. This might have the effect of frightening youth into monogamy or partner reduction, if not abstinence/delay. Perhaps the clearest evidence of this is found in Zambia, where USAID-funded organizations maintain a policy against "B" messages for youth (for liberal reasons), yet the greatest behavior change found in youth, both nationally and in response to the "A and C" secondary school peer education program, seems to have been monogamy/partner reduction."

I would add to that that Western AIDS experts often dismiss "B" (and "A" as well) as unrealistic. They often cite poverty and patriarchy as factors that make A or B impossible in Africa. However, according to DHS surveys since 1990, most (unmarried) youth 15-24 nowadays report not having had sex in the past year. If you average all countries in sub-Saharan Africa together, we find that in fact only 42.6% of males and 30.9% of unmarried females ages 15-24 report sexual intercourse in the past year. Moreover, among those having sex, most did not have multiple partners.

We MUST get away from thinking that because not everyone can abstain or remain monogamous, that no one can. Let's first of all base our discussion and debate on available evidence. In sum, I think "B" messages are appropriate for sexually active youth, everywhere. African youth are moving toward A&B behaviors with few interventions of this sort to date, so it would seem that if these two behaviors were actively promoted, levels of A&B ought to be even higher.

From Atanas Kirjakovski, peer educator working for the NGO, Hera, in Macedonia -- Being faithful is a component which has a strong social background. There is a trend among youth people, especially the male population, that if you have a lot of girls, you are the coolest guy in your group of friends. This social value leads to promotion of promiscuity and cheating the partner that you are with. This is in contradiction with "being faithful". What is the best way to break this social value and to replace it with faithfulness and honesty to a partner? The people who promote the ABC model, B especially, should create understanding and positive acceptance among youth of values like: respecting your partner, emphasizing the importance of marriage as a very important part of people's lives, education on the equality of the sexes… Being faithful also means to have courage to admit when you cheated your partner and to motivate young people to do that.

From Julie Pulerwitz, Research Director, and Ann McCauley, Youth Specialist, both with the Horizons Program at the Population Council (U.S.) --  Many programs have successfully talked to youth about fidelity and partner reduction, and they have done so in many interesting ways. Probably the most famous "B" message was Uganda's "zero grazing" slogan that reached most people in the country, including youth, and played a role in Uganda's falling HIV rates. The Horizons Program has assessed several programs that included "B" messages for youth. In Brazil , for example, a NGO called Instituto PROMUNDO is working with young men to help them examine how accepted gender norms for men — such as pursuing multiple sexual partners — can place them and their partners at risk of HIV and other STIs. Various participants have reported that being "macho" gets in the way of having a safe and mutually satisfactory relationship with one partner. The national program in the secondary schools of South Africa teaches youth about the increased health risks of having several partners and lets them know that they have the right to decide whether or not they have sex with someone. Thai programmers have developed a game in which youth analyze their risk of getting HIV and then learn the steps they can take — including monogamy — to reduce their risk. Many youth choose monogamy as the best option for them.

Sometimes, misunderstandings about "B" messages reflect confusion over the terminology but not the behavior. In schools in Naivasha and Molo, some Kenyan youth defined "be faithful" as being a trustworthy person but, at the same time, they identified having one partner as a way to prevent HIV infection. They were well informed about ways to prevent HIV, but they didn't share the exact meanings that we attach to the terms abstinence, be faithful, and use condoms.

For more detail about each of these projects, see the Horizons reports.

From Julie Wiltshire, health care provider in Uganda -- I agree that the 'be faithful' message is a particularly difficult one to get across to youth due to many reasons, including the fact that many pressures are on young people that make being faithful impossible (prostitution, sugar daddies — poverty related issues in general make life very difficult).  I do not know of any evaluated or documented examples of where promotion of being faithful has been successfully communicated, although I presume they may be successfully used where there are additional social structures to reinforce the message, such as strong cultural or family practices and religious institutions. For youth still in school, access to information and publications promoting faithfulness is usually better, and the role of education is a strong influence on promoting 'be faithful' messages.

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Forum Digest 14

1. ABC and Youth Sexual Autonomy
2. Pharmacies Popular
3. Nurses/Midwives, Private Clinics
4. Changing Attitudes Toward the Youth We Serve
5. Motivations for Condom Use
6. Contraceptive Use Increases with Schooling

1. ABC and Youth Sexual Autonomy

I'm a young person and an activist. I don't believe in the ABC approach. I believe in each adolescent being able to decide for him- or herself, working in a partnership with adults who are prepared to facilitate the decision-making process, but not decide for us. We need to be ready for our life, and autonomy of body and mind is important. Many studies are showing that this approach doesn't work because many young people who say yes to abstinence break the vow, without being prepared to have safe sex.

This amounts to control of young people's sexuality because adults are saying which young people are not prepared for sexuality and to have pleasure, to be human, and to decide about their future. This ABC approach is against human rights and sexual and reproductive rights, because it says I can't choose what is the best for me. There is just one way, and it's not my way!

-- Leandro Vieira dos Santos, Programa Vivendo a Adolescencia, Brazil

2. Pharmacies Popular

To continue with Ed Scholl's concern about an ideal place for offering youth-friendly services, I very much agree that we should think of pharmacies and some commercial outlets, even in "risky places," such as hotels, discotheque, and cafes, where young people often go.

Like many young people around the world, the youth here in Vietnam often obtain contraceptives in pharmacies, even medicine for STDs or RTIs. I recognize that people here have very bad attitudes regarding seeking health services. Normally, they feel hesitant to go to the hospital, clinic, or health center when having health problem, except when it is an emergency or when they feel sick. Instead of going to health facilities, they go to a pharmacy and tell the pharmacist what their symptoms are and get their medicine from them. This practice is even more common among the youth, as they have to face so many barriers when accessing health service, especially for health problems related to a STD or RTI. But, if the pharmacist cannot provide them with an accurate diagnosis, right medicine, and appropriate counseling, they face more risks.

More than two years ago, I participated in a survey, called "Mystery Client," that was administered by FHI in Vietnam. Playing the role of a client who had gonorrhea, I went to different pharmacies to explore how pharmacists deal with this matter. Surprisingly, approximately half of the pharmacists I met diagnosed me as having normal vaginitis. Some diagnosed me as having a STD, but they provided me with no counseling (nor did they even advise me to use a condom); they just sold me medicine. Regarding attitudes, some of them looked at me as if I was a sex worker or a "play girl." Someone asked me, "You had sex with multi-partners, didn't you?"

If we wish to consider the pharmacy as a place that can offer youth-friendly services, we should think of how to get pharmacists involved and how to help them provide youth-friendly service (i.e., provide tips and skills in diagnosing and counseling). (In Vietnam, there is a challenge to getting pharmacies involved, though, because most are private.)

One model of youth-friendly services that was rather successful in Vietnam was "the condom cafe." Youth could come here for drinks, coffee, or snacks (always on the first floor) and could get counseling and HIV testing (on the second floor). They could also get free condoms, leaflets, or other IEC materials at those cafes. However, this model was applied in the urban setting only.

What about having "condom or oral contraception vending machines" that are easy to use and access, affordable, and at places that young people often frequent? Any experiences or lessons learnt on that matter? Please share.

 -- Le Thuy Duong, ARH Program Officer, Save the Children/US, Hanoi, Vietnam

3. Nurses/Midwives, Private Clinics

In addition to commercial retail outlets and pharmacies, it is worth exploring the role that private sector nurses/midwives can play in meeting young people's needs for sexual and reproductive health services.

In 2002-2003, Family Care International implemented an 18-month pilot project with private sector providers in Kenya, Tanzania, and Uganda. Working with national associations of nurses/midwives in Tanzania and Uganda, and with selected private providers in Kenya, we provided in-service training to 107 nurses/midwives to orient them to key elements of youth-friendly services, address attitudinal barriers related to adolescent sexuality, and hone skills for counseling and serving young people.

In line with Maggie Kambalame's recommendation [see Digest 11, item No. 1], we involved youth in some of the trainings so that providers could hear directly from young people about their preferences and the barriers they face in accessing services. The trainings were small (15 to 20 participants) and hands-on in nature so that we could work in depth with providers to explore and address negative attitudes towards and assumptions about adolescents. This also allowed us to help each provider identify low-cost youth-friendly elements that could feasibly be introduced at her/his clinic.

Our evaluation focused on assessing the "youth-friendliness" of each provider's site during follow-up visits, which took place six to nine months after training. This included looking at both the attitudes of trained providers, as well as the physical set-up and administrative policies of each clinic (e.g. partition of space for adolescent clients, addition of services for adolescent clients, elimination of parental or minimum age requirements, etc.).

Overall, the evaluation indicated that, in settings where there is a viable network of private nurses/midwives, the private sector can be a key partner in meeting young people's needs. Some key results:

• More than three-quarters of the trained providers had tried to orient other staff at their clinics to youth-friendly services, and there were notable changes in the clinics' policies, and services.

• About half of the participating clinics took steps to ensure the privacy of their adolescent clients (e.g. by adding or partitioning rooms).

• 54% modified their clinic operating hours to accommodate young people's schedules.

• 94% of the clinics expanded the services they offer to adolescent clients. In Kenya and Tanzania, the most commonly-added service was services for men and boys, and, in Uganda, almost three-quarters of trained providers began offering emergency contraception for adolescent clients.

• The number of clinics where reproductive health services for adolescents were contingent on parental consent declined dramatically.

• The number of providers who offered free or reduced services to adolescents increased. This was despite the fact that these facilities operate on a for-profit basis.

• Exit interviews with adolescent clients and observations of client counseling sessions also indicated that the trained providers were providing respectful, non-judgmental care that met the needs and preferences of their adolescent clients.

While the project evaluation was encouraging, there were also some challenges encountered. Chief among them was inconsistent record-keeping among private providers (many of whom did not record clients' ages prior to the intervention). This made it difficult to assess changes in adolescent caseloads. Thus, a key "lesson learnt" was that record-keeping is a critical area for training and capacity-building; thus, it is worthwhile to review carefully with providers the types of data that will be needed for project evaluation.

It is also worth noting that the private clinics such as those with which we worked are small establishments. No matter how committed the owner is, there are few resources available to purchase BCC/IEC or other visual materials that appeal to youth. Therefore, it is strategic to budget for items such as games, BCC materials, posters, etc. that can help to draw in young people and make them feel more comfortable and welcome.

 -- Ellen Brazier, Family Care International, U.S.

4. Changing Attitudes Toward the Youth We Serve

Greetings and many thanks to all of you who have contributed so much to my understanding of how to approach these challenging problems regarding youth, pregnancy, and HIV infection. The solution is to change, or develop, the behaviour of young people so that they are able to make informed, healthy choices that enable them to reach their full potential. I believe that the only way in which we can change or develop others' behaviour is first to change or develop our own. If we, as parents, teachers, or health workers, can demonstrate and SAY to young people that we respect them (and what it is about them that we truly respect), then they will be prepared to hear what we have to say. If we listen to them (deeply and with our mouths shut), then they will feel that we understand the problems and issues as they affect them.

If they feel that we appreciate them, as our students or as our children, then they will know that we support them. This support does not mean rescuing them when they make mistakes but standing beside them and helping them to right their mistakes as best they can. If we are beside them, they will feel able to try new things out, to push their own boundaries, and, as a result, feel responsible. When they are responsible, they will grow into an independence in which they will be better able to make choices that will protect their future. It will also be an independence in which they will be able to look back and treasure us as their loving parents, their special teachers, or their unforgettable mentors. I suggest that these skills be layered throughout all this work: (a) showing respect; (b) being able to listen deeply; (c) finding ways to show that we understand them; (d) supporting, but not rescuing, them; and (e) providing them the means to develop their sense of responsibility in order to achieve independence. I believe that it is only with these skills imparted that we will see the impact we hope for.

Our efforts should no longer focus so much on content — isn't there enough stuff now out there? — but on looking deep into how we the facilitators, parents, or youth leaders approach our relationships with the young people we live and work with. If we go about it armed with the attitudes and skills outlined above, then they will join us to address these problems. Without them, no amount of fabulous curricula, expensive consultants, or donor funding will create the safer world that we are all striving for.

I have worked on a variety of health projects with children and young people, in multiple settings and in many countries. I am always astonished at the competence of even very young people when it comes to identifying problems or contextualising problems. These become, with a little support and guidance, solvable by the young people themselves. Once the young people become the solution, instead of the problem, then we will start to have a solution.

To develop these skills and attitudes, we need to work with young people from a position of respect for who they are. This requires profound changes in the way we relate to our colleagues, to our students, and to those closest to us. I am interested in working to support teachers, parents, mentors, and health professionals in order to help them make these changes so that they can do the best they can for the young people they are able to reach.

 -- Clare Hanbury-Leu, Adviser to the Child-to-Child Trust, Institute of Education, University of London, UK, and writer of materials on Lifeskills for HIV Prevention

5. Motivations for Condom Use

Dr. Shelton raised provocative questions about condom use among youth in his statement yesterday, including whether they can be used consistently. An important factor in use is motivation for use. I have compiled some research that addresses whether youth are primarily motivated for condom use to prevent against pregnancy or STIs, including HIV. Perhaps some of this summary and the attached citations will be useful to forum participants.

DHS survey data from Nigeria, Guinea, Kenya, and Bolivia show that women ages 15-19 were slightly more likely to report using condoms for family planning than for HIV/AIDS prevention¹. Other studies illustrate complex factors, as summarized briefly below.

Partner dynamics:

• Youth are more willing to acknowledge the need for protection from HIV and other STIs in encounters with casual partners. In focus group discussions with young men and women in South Africa² and Zambia³, participants associated condom use with commercial sex workers, "hit and run" sexual relationships, or relationships in which trust between partners had not yet been established.

• Because of their association with sexual promiscuity, condom use for disease protection with regular partners can raise suspicions of infidelity or infection⁴. In Ghana, female students reported that asking their long-term male partners to use condoms could lead to anger, accusations of unfaithfulness, and potential rejection⁵.

Social norms and the perceived social risks of pregnancy and STIs:

• In migrant communities in Nigeria, youth in premarital sexual relationships reported that the relationships were legitimized by love, commitment, and the moral character of both partners. They said they discussed condoms only in terms of contraception — if they were discussed at all — because they said that introducing condom use for STI protection would undermine the legitimacy of these relationships by implying infidelity or risky behavior on the part of one or both partners⁶.

• In Indonesia, Javanese and Chinese focus group participants were more concerned about pregnancy prevention to avoid the negative social consequences of unintended pregnancy. They did not believe they were at risk of STIs, perceived the consequences of contracting an STI as relatively insignificant, and were less concerned with disease prevention strategies⁷.

Gender differences:

• Among university students in the Dominican Republic, while both males and females described successful condom use, females emphasized pregnancy prevention as their primary motivation for condom use while males focused on STI prevention⁸.

• In focus group discussions, South African girls associated condom use with "love and protection" from both pregnancy and STIs, and therefore expected condoms to be used in serious relationships. Conversely, boys associated condoms with STI protection and felt their use was appropriate only with casual partners⁹.

Sources:

1. Demographic and Health Surveys from Bolivia, 1998; Guinea, 1999; Kenya, 1998; Nigeria, 1999.
2. Varga C. Sexual decision-making and negotiation in the midst of AIDS: youth in Kwazulu/Natal, South Africa. Health Transit Rev 1997;7(Sup 3):45-67.
3. Ndubani P, Hojer B. Sexual behavior and sexually transmitted diseases among young men in Zambia. Health Policy Plan 2001;16(1):107-112.
4. Population Council Operations Research Summary No. 50.
5. Goparaju L, Afenyadu D, Benton A. Gender, Power and Multi-partner Sex Implications for Dual Method Use in Ghana. Washington, DC: CEDPA, 2003.
6. Smith D. Premarital sex, procreation, and HIV risk in Nigeria. Stud Fam Plann 2004;35(4):223-235.
7. Simon S, Paxton S. Sexual risk attitudes and behaviours among young adult Indonesians. Cult Health Sex 2004;6(5):393-409.
8. Garcia S, Goldman L. Understanding Successful Condom Use in the Dominican Republic. Washington, DC: Population Council, 2005.
9. Harrison A, Xaba N, Kunene P. Understanding safe sex: gender narratives of HIV and pregnancy prevention by rural South African school-going youth. Reprod Health Matters 2001;17(9):63-71.

 -- Abigail Haydon, Associate Program Officer, Field, Information, and Training Services, Family Health International, NC, U.S.

6. Contraceptive Use Increases with Schooling

In Mali, the factor that explains the level of fertility and the poor utilization of contraceptive methods is the low level of education. The negative correlation between level of education and early childbirth among young women has been established by EDSM II. The level of education of the population of Mali is very low. Also, differences in education between the sexes and between different areas of the country are very marked. The rate of schooling for children of ages 6-15 years is 30%, among boys, and 22%, among girls. This discrepancy increases as age increases. At 16-20 years, 21% of males, compared to only 9% of girls, are being schooled.

Fifteen percent of the girls who have reached a secondary educational level or higher already had a child, or were pregnant, before age 15-19. For girls with only a primary education level, it is 36%. This phenomenon is accentuated even more for girls who do not receive any education (46%). Also, women who have a secondary educational level or more have, on average, three fewer children than those who never attended school (4.1 versus 7.1).

The prevalence of contraception, whether modern or traditional methods, increases in a very significant way with educational level. Four percent of women with no education use contraception, and only 2% use a modern method. Sixteen percent of women with a primary education use contraception, though, and 11% of them use modern methods. It is among the most educated women (those with secondary education) that use of contraception is highest, with more than two out of five women (41%) using some method.

Other, primarily sociocultural barriers also explain the low use of the contraceptives and the fertility level among young people. These include embarrassment in front of older people, fear of getting a bad reputation, false rumours about contraceptive products, early marriages, religious constraints, and the economic and social dependence of women.

The poor quality of health services only adds to these problems. Service providers often insult or mistreat young people, or tell other people about them. Certain service providers refuse to give IUD, Norplant, or injections to young women, for reasons of age. Some girls cite the distance of the health facility and their lack of money as major obstacles to getting access to contraceptives. To reverse this tendency, the Division of Reproductive Health, through the SRJA (Reproductive Health of Young Teenagers), organized several information sessions for service providers and community-based distributors and has decided to include a young adult reproductive health module in the training curriculum for schools of health.

 -- Dr Binta Keita, Mali

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