Greetings,
I read with great interest the 11 postings included below in our second digest, coming from Guatemala, Kenya, Madagascar, Malawi, Uganda, United Kingdom, United States, Vietnam, and three unidentified sites. From this diversity of settings, I hear a consistent call for providing more information about sexuality and reproductive health issues to youth but many challenges in providing both information and services. Amina Alli courageously shared a personal experience of how poverty and lack of information affected sexual decisions. Belai Habte-Jesus and Gustavo Castellanos described how their programs try to provide information and services. Several participants emphasized segmentation of messages:
Thomson Nhlane identified the need to provide girls with skills to help them make informed decisions; Lanto Rakototiana pointed out challenges in reaching rural youth; Adavi Abraham saw differences in married and unmarried youth; and Eugene Darteh called for reflections on how information campaigns can recognize the heterogeneity of youth.
Two contributors addressed issues related to abstinence. Anke Franz raised questions about research in this area, and Odette Salden addressed some of the difficulties with abstinence as an intervention, including the fact that many girls are forced to have sex. YouthNet's YouthLens issues on abstinence (No. 8) and on nonconsensual sex (No. 10) provide some guidance on these points.
Interventions in Jamaica, South Africa, Thailand, and Zambia contributed to a delay in sexual initiation and some increase in secondary abstinence. These studies emphasized that a comprehensive and segmented approach is needed to reach youth, recognizing that many youth are sexually active. Attention is growing on the need for reproductive health and HIV prevention programs to focus on coercive sex, including social and economic factors involved. In addition, FHI has advocated for a comprehensive "ABC…Z" approach to HIV (and other sexually transmitted diseases) prevention. Targeting "A" to youth is one important step in our society-wide prevention effort. This "Common Ground" approach is supported by a broad consensus of public health, religious, and political leaders (Halperin, Lancet, Nov. 2004).
Le Thuy Duong and Margaret Bukenya raise important issues about the need to engage parents, teachers, community members, and providers in changing social norms and providing assistance with youth education and programs. YouthNet has worked successfully with a participatory learning and action (PLA) process in Ethiopia, Namibia, and Tanzania, where youth-led workshops provided ways for youth to share their knowledge and perspectives on reproductive health issues with community members. These projects led to greater understanding of youth's needs and the development of several interventions among policy-makers and faith-based organizations. Research with parents is limited, and more work needs to be done. Johns Hopkins University is beginning to gather information on interventions involving parents and youth in the reproductive health field. Experiences that participants in this forum have to offer would be useful for that study.
Odette Saldon and others raise issues about integration of family planning and HIV/AIDS services. I welcome more discussion on this important question.
One good resource is the U.S. Agency for International Development publication Family Planning/HIV Integration: Technical Guidance for USAID-Supported Field Programs (PDF, 255K).
The contributions in this digest number 2 raise a number of important topics that I look forward to hearing more about.
Sincerely,
Ward Cates
Forum Digest 2
- Youth Lack Information
- Empowering Youth with Information and Advocacy
- Multi-Services Approach Might Work Best
- Promote Condom Efficacy among Girls
- Access to Information, Services Limited
- Married and Unmarried Youth: Different Needs
- Consider the Heterogeneity of Youth
- Does Encouraging Abstinence Work?
- Integrating Sexual/RH and HIV/AIDS Prevention a Challenge
- Include Parents, Teachers, Providers, and Policy-Makers in Interventions
- Youth-Friendly Services, Parents, Communities
1. Youth Lack Information
I think poverty has to do with the topic of discussion and also lack of information. From my own experience, I was not aware of the need to keep away from sex. I was not informed earlier about the importance of abstinence, and after I knew of the consequences, I did not stop having sex due to fun I got from it and sometimes the financial effect is having on me. I strongly believe that youths should know the importance of completing their education and effects of unsafe abortions, which can damage their womb and prevent them from having children so as to reduce death rate.
-- Amina Alli
2. Empowering Youth with Information and Advocacy
I am writing to congratulate all of you for addressing the critical issues of our time: Prevention, Early Intervention and Holistic Rehabilitation of at-risk populations for pregnancy/STD/HIV infections. Empowerment is key.
Education delivered in the most appropriate settings (home, school, church, mosques, workplace and at leisure activities) is critical. We are talking about life and death issues and we need every one to be informed.
I believe the most important and results-oriented approach is to have reproductive health issues such as sexuality, pregnancy, infectious diseases, etc to be introduced in the normal, healthy environment of school, home, church, etc., where the physiological and basic anatomy classes in biology is presented to children and youth. Surely, our children can understand the physiology concept from age 10 onwards. I have children. I am a pediatrician and epidemiologist and know what I mean.
Yes, culture matters. But, it is never more important than life itself. If our children can do math, read classical civilizations and study Shakespeare, then, learning physiology and anatomy is nothing. Biology and economy (basic finance like budgeting) should be taught early in life. So developing a universal curriculum that is culturally and linguistically appropriate to the user community is the real issue. Sex is an integral part of our life and we need to respect it by paying attention early. The education or information should be given to all age groups. I believe the communication should be tailored to all age groups in every civilization on earth.
I work as a Clinical Director of one of the best HIV Clinics in Washington DC area, and I see these problems first hand and day to day. We need to change our paradigm completely. I am for empowerment and advocacy based on sound information exchange.
-- Belai Habte-Jesus, MD, MPH
3. Multi-Services Approach Might Work Best
We at the Center of Human Development of Guatemala (CDHG) started in the late 70s to offer sex education stressing the facts around early child bearing. A decade later, we started to introduce the topic of STD/HIV/AIDS due to the onset of the epidemic in our country and the world. We went into a re-organizational endeavour and stopped the program for a few years and then started again a peer counselors program with emphasis on HIV/AIDS prevention. We missed those first years when we were also approaching topics as dating, marriage choices and contraception, but we needed to let them know that self-care skills were a matter of life and death. Now, more than a decade later, we are back in the effort of offering sex education which includes pregnancy and STD/HIV/AIDS. Because now that there are more persons living with HIV/AIDS and they can have a good quality of life and the right to a sex life, it is more necessary to integrate HIV and pregnancy prevention services for youth.
We appreciate how Dr. Cates shows the differences of needs according to age, sex, or marital status of youth. The challenge for us who provide services to youth is to consider offering the services necessary to fulfill the needs of the particular group we are serving. I do tend to think, as some of us who have worked in the area for some years -- and I would like some comments from anybody - that the old model of youth centers with multi-services approach could be an ideal model for youth services that are really friendly to their needs and interests.
-- Dr. Gustavo Castellanos, Center of Human Development of Guatemala
4. Promote Condom Efficacy among Girls
With my vast experience in working with young people in the arena of sexual and reproductive health in Malawi, I would like to agree with you that greater efforts need to be made in order to help young people especially girls prevent pregnancy as well as remain protected from HIV. I once worked as a coordinator for an adolescent reproductive health project funded by UNFPA, and this project is still being implemented. Key activities in this project include creating a network of community based distributors of contraceptives, behavioral change interventions, and referring young people in need of sexual reproductive health services at health facilities. The project also takes advantage of the existing network of clinics run by a local NGO called BLM. The project's focus is to increase access to contraceptives and treatment of sexually transmitted diseases. Therefore young people aged between 10 - 25 years are trained as peer educators and distributors of contraceptives, including oral contraceptives and condoms. They are also able to refer young people for clinic/health facility based reproductive health services.
In the course of implementing the project, it became evident through the monthly reports that many girls were opting for birth control pills as their concern was pregnancy rather than HIV. Furthermore, many girls involved in sexual relationships were not comfortable enough to carry condoms as they thought their partners would look at them as prostitutes.
Therefore, the responsibility to carry and use condoms was mostly left to males. This was compounded by the fact that many girls lacked decision making and negotiation skills, hence the onus to use or not to use a condom is left to males.
Therefore, there is a need for projects to focus on providing girls with skills that will enable them to make informed decisions as well as negotiate for condom use -- even for those who are on other contraceptives. Interventions also need to focus on increasing risk perception among girls, promoting abstinence for those who have never had sex and those who have had sex a few times. Knowing one's HIV status can also play a crucial role in pregnancy prevention in a time of AIDS. This will only work if young people are able to access VCT services and there are post-test support services. As you have rightly said, young people are a heterogeneous group with differing needs; therefore interventions need to be highly focused in terms of addressing the different needs of young people.
-- Thomson Nhlane, Malawi
5. Access to Information, Services Limited
The best way to promote pregnancy prevention and prevention of STIs/HIV for youth concerns these three points: 1) sexuality and family life education; 2) support from parents, the community and policies that enable them to practice responsible sexuality; and 3) and access to quality services and contraceptives when they are needed. But, right now, what is most available is information given by peer educators and, at the same time, the utilization of religion to encourage the adoption of abstinence.
In our country, youth are vulnerable to pregnancy and HIV, too. Their access to information is very limited. Most youth live in rural areas, and they leave class after three years in primary school. These situations constitute a big barrier to the IEC/CCC for youth. The access to quality service and contraceptives are not available in some areas and generally parents don't agree to talk sexuality with youth.
-- Dr. Lanto Barthelemy Rakototiana, SAF FJKM Moramanga, Madagascar
6. Married and Unmarried Youth: Different Needs
There are urgent needs of youth for pregnancy prevention in a time of AIDS for obvious reasons; First, to safeguard the unwanted and the unborn baby.
Often, young boys and girls do engage in various risky behaviour that can easily lead to unwanted pregnancy. When their intercourse leads to pregnancy, this often results in abortion, which may be conducted in unsanitary conditions and lead to HIV. The reproductive health needs of the married and unmarried youths vary in two ways: One, the married youth seeking reproductive health needs to avoid getting pregnant too often because they believe that way they will become aged quickly. Two, the unmarried youth engages in sexual activities just for pleasure and adventure alone, and, as such their reproductive health needs thus vary.
The married ones needs a reproductive preventive measure pending when they are ready to have issues (baby). The needs of the [sexually active] unmarried youth is that which will give them opportunity to engage safely in sexual activity. Therefore, a pregnant mother and married and unmarried youth need to prevent themselves from passing the HIV/AIDS epidemic to the unborn child.
-- Adavi Abraham
7. Consider the Heterogeneity of Youth
As we discuss pregnancy prevention in a time of AIDS, I would like members of the forum to reflect on how programs for adolescents are structured by programmers in developing countries -- specifically, IEC [information, education, and communication] messages. These are often designed as if adolescents are homogeneous. I want to thanks Dr. Cates for the categorization of the adolescents and mentioning that they are heterogeneous. Most of the time, this heterogeneity is lost when programs are being designed. I think we should avoid the "one size fits all" approach when dealing with young people and the challenges they face.
-- Eugene K.M Darteh, African Population and Health Research Center, Nairobi, Kenya
8. Does Encouraging Abstinence Work?
I read your thoughts in this email with interest. I am in my first year of a PhD in the area of teenage pregnancy at Roehampton University, UK, and am therefore only just starting out in this field. My focus is also on developed countries and therefore probably limited to knowledge about issues present in these settings. However, one question popped into my head when I read your first point on the needs to be addressed, and I am looking forward to hearing your view on it. This concerns the need for self-esteem, communication, and self-protection skills to continue abstaining among young people prior to sexual initiation. What would interest me here is to know from your experience: Is encouraging young people to abstain from sex successful? I have to admit that most literature I have found regarding this point has been very mixed. Also, I am wondering if it might not be more effective to accept adolescents' sexuality as given and to put all the effort into teaching them to be able and willing to act responsibly towards themselves and their partners. I am aware that this is not as straightforward as it sounds here, but I have extremely simplified the problem, but I hope you'll reply nevertheless.
-- Anke Franz, Ph.D. Student, Roehampton University, U.K.
9. Integrating Sexual/RH and HIV/AIDS Prevention a Challenge
Thank you very much for your elaborate and inspiring opening remarks. The topic is a very challenging one and demands well-thought deliberations on how to integrate sexual and reproductive health in HIV/Aids prevention programmes and the other way around. The title should actually be "The Need of Integrating Sexual and Reproductive Health Services in HIV/Aids Prevention for Youth."
Therefore and firstly, I am glad to read that you do not only focus on women but also on men and young people who do not have sexual intercourse yet — different groups, but all sexual beings. Every young person has sexual and reproductive health needs, but their needs are diverse. I think a relevant point that is left out in your remarks is the recognition that young people are sexual human beings who have sexual and reproductive rights. In this context, I would rather suggest "self-esteem and recognition of their sexual and reproductive rights, communication and self-protection/negotiating skills to decide to have sex or not," rather than "continue abstaining." Moreover, research and evidence from examples from practice have shown that abstaining does not lead to lower rates of STIs or HIV/Aids. Further, predicting abstaining does not recognise the fact that abstaining is often not an option for young people, in particular women who are often subordinate to men and forced to have sex.
Further, I underscore your argument that young people should be supported by parents, the community, and policies that enable them to practice responsible sexuality. But besides respect, young people's sexual and reproductive rights should be acknowledged to enable them to take responsible decisions with regard to their sex life. I would finally suggest to expand "sexuality and family life education" with "human [sexual and reproductive] rights education."
Second, I am happy with your suggestions put forward with regard to integrating HIV/Aids prevention services with family planning services.
Since the prevention of HIV/Aids is such an urgent topic, often money is drawn away from primary health care services and sexual and reproductive health care services. I look forward to hearing from you and the others, more examples on how we can realise the integration of sexual and reproductive health services with HIV/Aids prevention. The integration of these services sounds logical, is efficient, and cost-effective. But how do we realise it in practice?
-- Odette Salden, World Population Fund
10. Include Parents, Teachers, Providers, and Policy-Makers in Interventions
First of all, I would like to say a big "thank you" to YouthNet, the INFO project and WHO for creating such an interesting online forum with very interesting topics. And another big "thank you" to Dr. Ward Cates for his very informative opening remarks. Secondly, I want to share some information about Youth and HIV/AIDS in Vietnam.
- Approximately 30% of Vietnamese are sexually active prior to marriage. The average age for beginning sexual activity is about 19.
- Approximately 300,000 young women under 20 in Vietnam become pregnant every year. Adolescents account for approximately one third of the total abortion rate nation-wide.
- 50% of new HIV infections occur in young people and 40% of people living with HIV/AIDS (PLWH) are between the ages of 15 and 24.
- HIV epidemic is moving into the general population due to the scale of sex work, and clients of sex work (often 5-15% of male population per year to sex workers)
- There's a strong link between sex work and IDUs [injecting drug use]. Among IDUs, 30% infected nationally, even 60% plus in some areas. Most of those people (sex workers and IDUs) are young.
Thus, it's clearly seen that there is a huge need for Vietnamese youth in terms of HIV and pregnancy prevention. And I also agree that they need the three basic needs that Dr. Cates had mentioned: 1) sexuality and family life education; 2) support from parents, the community, and policies that enable them to practice responsible sexuality; and 3) and access to quality services and contraceptives when they are needed.
However, I think, in Vietnam, we have to do the behavior change interventions in parallel with others to meet the above needs. Because in our country, sexuality is still considered a taboo, and people dare not talk about it openly, especially in public. The adults normally say "you will know it when you grow up" when their children come to them with sexual-related questions. No sex education is provided in school except some biology in the 9th grade main curriculum. And most teachers feel shameful when they handle this session. Thus, if adolescent and youth want to search answers for their questions/concerns, they have to approach other sources (peers, books, mass media, internet, etc.), which might not provide quality and correct information/knowledge. Also, we still lack youth-friendly services when it comes to services and contraceptives.
Young people hesitate to go to public health centers, as they are ashamed of buying contraceptive pills, and especially condoms. Adults often think that "you must be having sex, or going to have sex, or thinking of having sex" when young people ask sexual related questions or ask for contraceptive methods. Partly because of that, sometimes even when the services or contraceptives are available, young people still have unprotected sex. They still may get pregnant, or more serious, acquire STDs, including HIV.
To change someone's behaviors is very difficult and it takes time. We need to change not only young people's behaviors in terms of seeking information and services, making informed and healthy decisions, but also adults' behaviors (parents, teachers, service providers, policy makers,
etc.) in terms of sex education, parent-child open communication on ARSH issues, and providing youth-friendly services. I think all of us clearly know that youth have many needs in order to prevent pregnancy, but the question is "how can we meet these needs?"
-- Le Thuy Duong, ARH Program Officer, Save the Children/US, Hanoi, Vietnam
11. Youth-Friendly Services, Parents, Communities
I wish to congratulate Dr. Cates for such an informative and elaborate discussion on the "Needs of Youth for Pregnancy Prevention in a time of AIDS." There seem to be a lot of challenges especially for parents and the youth themselves, as well as policy-makers -- more so in the developing world. Youth-friendly policies have been enacted, but not implemented, due to a number of factors, the major one being lack of or limited funds for a multitude of commitments. Where youth-friendly health services have been tried, they are concentrated in urban settings at the expense of rural majority.
Also, regarding the three basic needs mentioned, Dr. Cates went to great length discussing access to quality services and contraceptives for the youth. It would also be good for us to get his views about the other two needs because it is not uncommon to find that parents/communities do not have the capacity and necessary information to support youth, as far as sexuality, STIs and AIDS, and pregnancy are concerned. How can parents and society in general be assisted so as to provide the necessary support to the youth? How can they overcome some of the taboos associated with sexuality in their cultures? Does Dr. Cates have some related experiences especially from Africa and the far East?
-- Margaret Musoke Bukenya, Program Manager, AMREF Uganda
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