Greetings,
The high quality of the messages posted this week has given this forum an exciting launch. Thanks to all of those who have contributed and plan to send messages in the coming weeks. We will send our next message on Monday, March 21. We apologize for a technical error made yesterday in sending you all one participant's contribution. As advertised, we will continue to send only one e-mail a day.
The 15 messages below come from Finland, Ghana, India, Kenya, Malawi, Nigeria, Swaziland, Uganda, the United Kingdom, the United States, and several unidentified sites — a mixture of voices including providers, peer educators, program managers, academics, and researchers. This digest is long, but we want you to see all of the substantive ideas offered. Several contributions include specific studies and program examples. We encourage you to offer more of these types of concrete experiences to complement the general feelings many are expressing about challenges and various perspectives.
Below, Dr. Cates offers more comments on this digest.
Sincerely,
Ed Scholl for the Forum Coordinators
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I've organized the 15 contributions into three general sections: sources of information, service delivery/providers, and cultural norms/advocacy/leadership. While many messages touch on several topics, this structure helps provide unifying themes on the many points of view expressed.
Regarding information sources, peers are especially important for youth, and Joyce Kinaro reminds us of the importance of good training for these educators. Phyllis Andoh, herself a peer educator and counselor, emphasizes the importance and the difficulties in parent-child communication on sexuality issues. Raj Mohan calls for parents and faith-based groups to play an active role in educating youth on values regarding human relationships. Sara Nasserzadeh discusses what voices need to be included in the development of sexual health education curriculum (including youth) and the need for leadership and models for youth. Melanie Croce-Galis wraps up this group of contributions with a valuable summary of a recent study on what youth themselves think about sources of information for reproductive health and HIV issues, with a link to the study summary.
Regarding services and providers, Julie Wiltshire emphasizes the importance in Uganda of involving community resources and leadership, while matching services with the setting. From Malawi, Thomson Nhlane calls for values clarification exercises for providers. From Thailand, Duanne Punpiputt points out the common ground he sees with service challenges in other regions and offers two specific suggestions on quality of care approaches and training peer educators. R. Shabon reminds us of the critical importance in emergency humanitarian relief situations such as after the tsunami of providing reproductive health services for girls and young women.
On the power of cultural norms and the need for advocacy and leadership, we hear an array of voices, echoing some themes from earlier this week. The commentary on exchanging sex for money by PM Dlamini is especially sad. Calls for strong leadership and advocacy come from Chidi Ezegwu, Abel Mugenda, Temitope Fadiya, Effie Kamwendo, and Elvis Morris Donkoh – appealing to government officials, political leaders, education officials, teachers, and faith-based groups.
Sincerely,
Ward Cates
Forum Digest 3
Sources of Information
- Train Peer Educators
- Parent-Child Communication Essential
- Parents and Faith Groups: Educate on Values
- Sexual Health Education Materials: Keep Audience in Mind
- New Study: Adolescent's Views on Information Sources
Service Delivery/Providers
- Employ Local Strategies and Community Input, Uganda
- Challenges in Changing Provider Attitudes, Malawi
- Sensitizing Providers, Using Peer Educators
- In Emergency Services: Include RH
Cultural Norms/Advocacy/Leadership
- Poverty and Sexual Coercion
- Youth-Friendly Centers, Stronger Leadership
- Government Policies Critical Factor
- Problems in Conceptualizing and Reaching "Youth"
- Poverty, Sexual Coercion, Education
- Examine Cultural Practices, Ghana
Sources of Information
1. Train Peer Educators
Lessons learnt in RH program management is that youth receive information from various sources, including their peers. The youth also develop their language to communicate. Therefore, it important to train groups of youth who can disseminate information and low hormone pills, condoms, and emergency contraceptives in the community. This has the effect of reducing unwanted pregnancies and the consequences of unsafe abortion.
-- Joyce Kinaro, Senior Program Officer, Planned Parenthood Federation of America-International, Africa Regional Office, Nairobi, Kenya
2. Parent-Child Communication Essential
With regards to the challenges facing the youth of today, I agree that poverty is the main problem of youth in the less developed countries. If this issue is addressed, then we wouldn't have the number of teenage pregnancies that we have. Also, in some cases, because of poverty, parents influence their wards (especially their girls) into prostitution.
Also, the issue of communication between the parent and child should be looked into. This is a case whereby the child refuses to talk to the parent about issues affecting him or her and vice versa. This makes the children prone to peer pressure. They would prefer to talk to their friends about whatever their problem is. The parents, on the other hand, don't want to talk to the child because they feel that, if they talk to the child about sex, the child will go ahead and practise it.
It should be borne in mind that these children can receive all sorts of educational messages, some of which may be true and some of which may not. It is up to parents to sit their wards down and really talk to them. The wards, on the other hand, would like to hear and be heard. They would listen more if spoken to by someone who hears them.
Currently, I am a peer educator and a counselor, working with youth on HIV/AIDS issues. There was a young girl who had heard of sex and wanted to know more. She couldn't talk to her parents because they shout at her and let her down. Well, upon talking to her and counseling her, I realised she had wrong information from a friend and wanted to find out from an elderly fellow if what she heard was correct. So, with this, I think that parents should play an important role in the education of their wards.
One other issue: STREETISM should be looked at as an issue of teen pregnancy – that is, issues related to street children.
-- Phyllis Andoh
3. Parents and Faith Groups: Educate on Values
Lack of moral values is an important reason for irresponsible sexual behaviour of modern youth. The parents should make their children aware of healthy human relationships from childhood. The schools also have a very positive role to play for developing a healthy mind. At this stage, faith-based organisations can also inculcate good values of life, so that children, when they grow up, do not indulge in irresponsible sexual behaviour. There is a need for behavioural change in young people which can prevent AIDS.
-- Dr. Raj Mohan, Dept. of Health, Ranchi, India
4. Sexual Health Education Materials: Keep Audience in Mind
I am a research student at Middlesex University London, UK. I had the chance to conduct some research about sexual health of young women and sexual health educational materials in Iran. I also worked in projects involving teenage mothers and under-aged pregnant girls in London.
For my PhD, I am exploring the gaps between professionals' and adolescents' points of view regarding sexual health education materials and the way we deliver them to hard-to-reach adolescents (the ones who don't have access to mainstream education system). I am also involved in a project in which we try to understand the needs of unaccompanied minors around the issue of sexuality and sexual health in London. I think Dr. Cates summarized the whole research that has been done in this regards in his insightful e-mail. I only would like to add some small points which I found important while working with young people:
- For making policies regarding adolescents' issues, we need to consult professionals who are working in the field with young people on a daily basis. (Often, curriculum writers are not among people who work with young people directly.). We also need to know adolescents' opinions on these matters as well. I am well aware of the fact that because of individuals' differences and needs, it's not easy to have a policy which could work for all. However, policy makers should not take a small group of young people as representative of the larger group and draw policies based on only their ideas and needs.
- As previous research shows, professionals and authorities who should be consulted for this matter are: educational authorities and specialists, particularly the group of young people for whom we write the educational materials, governmental authorities who are going to implement the policies we make, etc. However, I want to draw your attention to two very important and rather little mentioned groups: cultural role models and religious authorities who can have a great impact on the policy that we make and the implementation of it and most importantly the way young people receive our messages and act upon them.
- Young people with lower socioeconomic backgrounds are more vulnerable to catch diseases or have unplanned pregnancies. The fact is, sexual health is not necessarily a priority for this group (e.g., for someone who sleeps in the street). When I talk to them, they say, "who cares, the sooner you die the better, it would be for you and the rest of the world." Or, having a baby of her own might be a life saver for a young refugee girl who came to a new country and needs someone to love or to be loved by. Some of these young people don't even have very basic life skills (let alone protecting themselves against sexually transmitted infections or unwanted pregnancies).
-- Sara Nasserzadeh, PhD Student, Middlesex University London, UK
5. New Study: Adolescent's Views on Information Sources
With respect to sources of information, an important thing to remember is what matters to adolescents themselves. The Alan Guttmacher Institute has recently completed an analysis (PDF, 405K) of 55 focus group discussions with in-school and out-of-school youth aged 14-19 in Burkina Faso, Ghana, Malawi and Uganda.
Young people in these groups cited four main sources of sexual and reproductive health information: the media, health care providers, schools and teachers, and family and friends. Overall, young people value a source's level of knowledge, experience with sexual and reproductive health issues, and trustworthiness. Some findings on sources of information:
- Media: one preferred source because it was reliable (Uganda), it reaches a wide audience (Ghana), information gets to young people quickly (Malawi), and there is no need to go somewhere for the information (Burkina Faso).
- Health Care Professionals: while cited as a preferred source because providers are knowledgeable, young people wanted providers with relevant skills and accepting attitudes who would be receptive to serving young, unmarried clients and protecting adolescents' privacy.
- Schools and Teachers: while most youth indicated that schools and teachers were a preferred source of information (Burkina Faso, Ghana, Malawi), some contended that it was difficult to talk to teachers - mostly due to privacy concerns.
- Family and Friends: The role of parents was subject to a lot of debate. Parents were seen as a good source of information because they were experienced (Ghana) and were a convenient source (Malawi) but were also seen as unable to address young people's needs without being judgmental or uncomfortable sharing information. Fathers were seen as especially unapproachable:
Given young people's discomfort with talking about sexual matters and their concerns about confidentiality, efforts to address adolescents' information needs could be better linked to doctors, nurses, and other kinds of trained health personnel who will respect young peoples' privacy. Linking schools with health clinics could also strengthen the information provided and improve health care utilization among young people, though again, issues of confidentiality remain paramount.
-- Melanie J. Croce-Galis, RN MPH, Communications Program Associate, The Alan Guttmacher Institute, New York
Service Delivery/Providers
6. Employ Local Strategies and Community Input, Uganda
From my experience in providing ASRH services in Uganda, broad generalizations are useful in planning services for youth. However, local distinctions are vital to increase the uptake of ASRH services. For example, both urban and rural youth in Uganda are vastly underserved in terms of actual ASRH services. Strategies engaged will have to depend on such local variables as general strategies cannot always be used.
Although urban youth in schools tend to have better access to information through school-based youth programs, they complain that they cannot access services or cannot afford contraceptives due to lack of service delivery points, poor provider attitudes, lack of supplies, and so forth. Urban out-of-school youth suffer the same problems as rural youth, who usually have poor knowledge about family planning/ASRH issues. Rural youth also face the additional cultural practices of early marriages, low priority of educating the girl child, and breakdown of traditional parent child relationships in areas of insurgency/insecurity.
These factors create additional challenges to overcome; therefore, targeted local communities need local solutions. Whether this involves expanding services, using existing faith-based organizations, creating new structures, etc., the interventions need to incorporate existing local resources for improved acceptance and success. Each target group of youth should have their needs clearly identified. Strategies to improve their ASRH will need to be multisectoral in approach.
As well as targeting existing health facilities to incorporate family planning in a wider range of services, raising awareness with the local communities is vital as well. There needs to be persistent, clear leadership (from political, cultural, and religious leaders) on promoting family planning to youth. Otherwise, "decampaigning" of family planning services is likely and will seriously undermine the likelihood of achieving improvements of ASRH indicators. (There is a great deal of ignorance about family planning in illiterate communities and myths and misconceptions abound in Uganda.)
I wish this forum a most fruitful discussion and look forward to learning much from other experiences shared elsewhere on how we can improve the lives of youth.
-- Julie Wiltshire, Health Care Provider
7. Challenges in Changing Provider Attitudes, Malawi
Indeed, health care provider attitudes towards adolescent sexuality leave a lot to be desired. I strongly believe that if we are going to reorient health care providers, the orientation should cover more than issues to do with ethics of profession. There is need for each health care provider to undergo values clarification exercise. There are several initiatives undertaken in Malawi whereby health providers have been trained on youth friendly health services. The training content covers values and attitudes in relation to adolescent sexual and reproductive health. Health providers are given an opportunity to examine and clarify their values and attitudes to sexuality matters.
However, with my experience in this area, we are faced with a challenge of mobilizing enough resources that will allow for reorientation of all health care providers. Worse still for the developing countries, we have frustrated health care providers within the health system due to poor working conditions and meager incentives. This is another reason for lack of respect for persons irrespective of age and several breaches of confidentiality.
For a developing country like Malawi, how do we deal with health care provider attitudes with the reality that the health delivery system is in bad shape? We have frustrated health providers due to poor working conditions and meager incentives and that there is lack of resources to reorient all healthcare providers?
--Thomson C. Nhlane, Population Services International, Malawi
8. Sensitizing Providers, Using Peer Educators
I have read thoughts and experiences shared by Dr. Cates and the participants and found them very interesting. Many social, cultural, economic, and rights-based aspects were expressed. I am confident that many countries in different regions and continents do share the same problems. Africa is not the only country finding that poverty is a crucial factor that forces young girls into prostitution. I just read, in the newspaper this morning, that a 16 year-old girl offered her virginity for Baht25,000 (about US$675) because she desperately needed money for her mother and two mentally disabled brothers.
I do agree with Babalola Faseru from Nigeria that attitudes of service providers can prevent or drive away clients, especially young people who have been thinking over and over and eventually decided to come for services. Service providers need to be trained to become more culture- and gender-sensitive. The International Planned Parenthood Federation (IPPF) has recently implemented a "Quality of Care" (QOC) programme with an emphasis on the needs of both service providers and clients. As a member of IPPF, the Planned Parenthood Association of Thailand (PPAT) has implemented a QOC project involving service providers in PPAT clinics. Suggestion boxes are available in every clinic and are the best way to learn and receive feedback from clients. Such information is useful to improve the performance of service providers and the activities and services of the clinics.
Another strategy that PPAT has applied and found very effective (in providing information and contraceptives – both condoms and oral contraceptives to young people) is peer educators/peer motivators. Young people feel much more comfortable to talk and share with their friends or persons of their age, rather than being 'told' from adults. Peer educators/peer motivators are trained about ASRH, HIV/AIDS, and other subjects so that they can disseminate such knowledge to their friends. Peer motivators of the PORT project (Peer Outreach for Reproductive Health in Thailand, which is implemented in the northern provinces) are very effective in educating their friends and selling condoms and contraceptives to their friends at low price. They emphasize the importance of correct and consistent condom use as the only tool that can prevent HIV/STIs infection. Cultural, religious, and social contexts of the target population should be carefully considered in designing projects and programmes that best meet specific needs of such population groups.
-- Duanne Punpiputt, Planned Parenthood Association of Thailand
9. In Emergency Services: Include RH
Reproductive Health (RH) and HIV/AIDS should be given priority during an emergency situation from the very start up during the program design. Addressing RH needs is the key to ensuring that people's rights are respected in emergencies, particularly but not exclusively those of women and young girls. RH and HIV/AIDS especially for youth and adolescent should be part of integrated package of emergency services and support during every humanitarian programming.
-- Dr. R. Shabon MD, MBA, DTM/DCP, Save the Children
Cultural Norms/Advocacy/Leadership
10. Poverty and Sexual Coercion
Thank you very much for this forum. It's an eye opener to the many issues we have as service providers. In Africa, issues of poverty, lack of education, gender bias, weak government policies, cultural barriers, and myths will contribute to more of our youth not only getting pregnant but becoming extinct. Recently, a young woman, after being trained as a peer educator, was asked by a man to have sex with her without a condom in exchange for 1,000 rands (about US$175). She wanted to know whether we, as trainers, wanted her realistic and honest answer. We asked for the honest answer. It was yes. This was her response: "AIDS would kill me maybe ten years from now. But, if I go hungry, I will die by next week."
Regarding attitudes of service providers, what we as service providers need is an effective monitoring and evaluation of our policies because it's one thing to have a policy but another to have an effective policy.
-- PM Dlamini, Youth Affairs Manager, FLAS, Swaziland
11. Youth-Friendly Centers, Stronger Leadership
In my area, poverty constitutes the greatest impediment to various campaign efforts against HIV/AIDS (especially so with youth). Youths want money in their pocket and are ready to make numerous sacrifices to get it, disregarding future consequences. In Eastern Nigeria, where we work, among out-of-school youths, our experience is that they believe that money is the answer to all things. Thus, the solution is to empower youths economically so the can be free to say no and not be tempted to yield to all kinds of pressures. The second is the hostile environment. There are little or no youth-friendly centres around where they can relax. Thus, they seek happiness elsewhere, and sex is one of the first options. The solution here is to create healthy environments and provide youth-friendly centres.
Most importantly, I believe that the most effective solution is to persuade the political leaders and parliamentarians to be sincere with the fight against the epidemic. Poverty in the third world is the function of bad leadership, and poverty helps HIV/AIDS to thrive. Also, the efforts being made locally and internationally have been politicised and, thus, suffer from the same socio-political problems of the third world. The government has the power to carry others along in line with local environment and cultural dimensions. Thus, I recommend strong advocacy.
-- Chidi Ezegwu, President, Anglican Students Movement, and Coordinator Core Youth Initiative Anambra State, Nigeria
12. Government Policies Critical Factor
Youth, especially in developing countries, seems to be a forgotten group. Increasing cases of drug abuse, HIV/AIDS, and unwanted pregnancies among youth are indications that this group is crying out for help, and society must respond. My hypothesis is that these issues are manifestations of deeper underlying causes and structural issues.
In addressing pregnancy among young girls, for example, we must have a clear conceptual model of causes at the structural levels. Governments have not really shown enough commitment in developing and implementing youth policies that address cultural, social, political and legal issues affecting this vulnerable group. Research, for example, shows that teenage girls are more likely to have sex with older men (say over 30 years) as a result of rape, coercion, promise of gifts, etc. This exposes these young girls to the dangers of HIV/AIDS, STDs, abortion, etc. Such policies must be informed by reliable data and the voices of youth, particularly the girl child. Where are these policies, and who is implementing them?
-- Abel Mugenda, Ph.D., Kenya
13. Problems in Conceptualizing and Reaching "Youth"
The sobering statistics from the HIV/AIDS pandemic in sub-Saharan Africa are a call for urgent action, particularly from the governments and people of the region who face issues of life or death. Permit me to quote some findings from research in this region and discuss how these relate to youth reproductive health and what schools, media, and faith-based organisations can do in order to help.
The first case of HIV was reported in Nigeria in 1986. Since then, the number of HIV seropositivity has risen from 1.8% in 1992 to 5.4% in 1999. By June 1999, the Federal Ministry of Health had recorded over 26,000 cases of full blown AIDS. So, within a short time span of just 7 years there was approximately a 20 fold increase in the prevalence of HIV/AIDS in Nigeria. I should also mention that in the sub-Saharan Africa, about one-third of those infected are women and men aged 15-24. This substantiates the fact that the youthful period of life calls for urgent attention from society -- schools, churches, mosques, the media, etc.
The question I'd like put forward to all discussants -- although, I will also try to put forward some answers -- is, who really is a "youth"? Why is this so "problematic"?I would like to address this issue from a sociological point of view. To me, a youth is that "unique individual" sandwiched between the features of an adolescent and adulthood. One of the key paradoxes is that, while youth refuse to be seen as adolescents, society denies them the rights of adults! So, this is a "crisis" period, as it were.
If schools, the media, and faith-based organisations are to better help this age group (particularly as it relates to the issue of pregnancy prevention in a time of HIV/AIDS), then this concept must be understood and put to use. We must build bridges of understanding linking the period of life of adolescent and adulthood, in order to reach out to "youths." School curricula in the developing world must, as a matter of policy, be reviewed and up-graded in order to reflect the challenges of the modern age. Subjects like "moral instruction" and "moral education" have to be "remodeled" to better reach out to these age groups.
-- Dr. Temitope Abayomi Fadiya, Dept. of Public and General Practice, University of Kuopio, Finland
14. Poverty, Sexual Coercion, Education
Poverty has been a major problem among the youth and has forced girl pupils to accept male teachers' advances so that they can get help from these teachers whether in cash or in kind. The media should play a role of disseminating messages on how the youth can prosper in small scale business.
Pupils do not know that they have the right to education and that they need to enjoy their rights responsibly, so, the media can play a role of disseminating messages on child rights especially girls' right to education.
Culture poses a great risk to the youth, especially the initiation ceremonies. Therefore, faith-based groups should play a role to help in modifying some of the cultural practices that pose a risk to the youth.
-- Effie Kamwendo, CARE Malawi, HIV/AIDS Coordinator in Basic Education, HIV/AIDS Support Project
15. Examine Cultural Practices, Ghana
Let's look at cultural practices. In Ghana, it's a taboo to talk to youth (and even adults) about sex. Unless some of these cultural barriers are broken, we will work in vain. This is because these youth don't know about their sexuality. How much more are you going to educate that youth when he/she wants to have sex? Some of the youth also feel shy to buy condom from the drug store. (Condoms are mainly sold in the drug stores in Ghana.) The drug seller may inform the parent about he/she buying the condom, so the youth would rather do the sex without the condom use.
I strongly believe that to prevent pregnancy and HIV/AIDS among youth some of our cultural practices should be carefully looked at. I would also like us to discuss more on behavior change and communication skills among youth.
-- Elvis Morris Donkoh
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