Digest No. 4/Week 1 Summary

Greetings,

Thanks to all the participants for a great first week of the Youth Forum on Pregnancy Prevention in a Time of AIDS. Counting the 12 items below, we posted 45 submissions. Next, we will send out an introduction to Week 2, focusing on young women and girls. The following day, we will send out the next digest, which will include postings received since Digest 4. You may continue to comment on themes that arose in week 1 if you wish; the weekly themes provide some focus but are all part of the same month-long topic.

These 12 postings echo many of the themes heard in the first three digests. Olaoluwa Akinwale, Julie Wiltshire, and Sammy Jacobs Abbey emphasize the importance of parents, faith-based groups, and community leaders in working with youth. Nassoro Ally calls for accessible services, and Mgesi Juma notes how social norms contribute to the dangers of prostitution for girls.

A number of contributors point out the need for interventions to address changes in social norms and more specifically, how those norms affect youth sexual behavior (see postings from  Hajh Amad, Anna Karani, Bishan Wagle, and Oladehinde Unity). Olusola Fagbemi identifies the value of drama as a tool for communication and advocacy, while Binta Keïta identifies five specific programs that have contributed to positive changes in his country.

Twesigye Kaguri describes the need youth have for information on their sexuality and asks for suggestions. A starting point to offer is the manual, My Changing Body: Fertility Awareness for Young People, a 137-page resource designed for adults who teach young people about human development and fertility.

Below is a summary of Week 1 from Dr. Cates.  Following his summary are the Digest 4 postings.  We look forward to your continued ideas and comments. Please provide specific examples of interventions and projects where possible, including Web links to studies, reports, or project descriptions.

Sincerely,

Ed Scholl, Moderator

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Greetings,

Participating this week in the Youth Forum on Pregnancy Prevention in a Time of AIDS has been a privilege for me. Hearing voices from 18 different countries on many issues critical for youth reproductive health and disease-free future reinforces many of my views about how public health professionals can address such deep-rooted problems. Many postings throughout the week pointed out the inevitable connection of pregnancy and AIDS, as sexual behaviors are the key point that links the two. Social norms, sexuality and family life education, and the role of parents, faith institutions, and communities may not distinguish between pregnancy and HIV/AIDS prevention. When they do focus on AIDS, for example, in taking care of orphans, basic sexual health issues eventually arise, as the orphans become adolescents.

Throughout the week, I heard two primary issues: 1) the needs youth have for information and services and 2) the importance of addressing social norms and the key stakeholders that influence youth with these norms (faith institutions, parents, etc.). Within these two general categories, three issues arose frequently that I want to address briefly here: abstinence as an intervention, faith institutions/parents, and school-based sexuality education.

Abstinence

One participant from the UK asked if encouraging young people to abstain from sex can be successful and wondered if we should just accept adolescent sexual activity as a given. Another participant from the World Population Fund pointed out that many young people are forced to have sex and do not have the option of abstaining.

When designing messages (either in the classroom or via a communications campaign) for young people, appropriate messages need to be targeted to different ages, while also providing comprehensive information when appropriate. Information needed by youth includes:

• the benefits of continued abstinence for those who have not yet started sexual activity or a return to abstinence for those who have already had sex

• the benefits of correct and consistent condom use for lowering the risk of HIV, other STIs, and pregnancy

• the benefits of other forms of pregnancy prevention, such as oral contraceptives, injectables or Norplant, all of which are more effective than condoms at pregnancy prevention but provide no protection against HIV/STIs

• information on forms of "dual protection" against pregnancy and HIV/STIs, including: abstinence, a primary method for pregnancy prevention plus condoms, condoms plus emergency contraceptive pills (if a condom is not used, breaks or slips), or a primary method for pregnancy prevention plus a low-risk partner (e.g. monogamous union and mutual STI testing).

Regarding whether campaigns encouraging young people to abstain from sex can be successful, a major six-country study in developing countries found that programs that included abstinence messages achieved delays in sexual initiation of about one year. YouthLens No. 8, on abstinence, provides further information about these evaluation results.  Another review (PDF, 257K) of rigorously evaluated developing country programs found three successful programs that effectively increased abstinence in Cameroon, Kenya and Zimbabwe.

Each of these programs included comprehensive information about abstinence and contraception.

As mentioned in an earlier digest, FHI/YouthNet suggests a comprehensive "ABC…Z" approach, which I explained in an article in FHI's publication Network 22(4), an issue focusing on barrier methods of contraception.

Faith Institutions/Parents

Several participants commented on the importance of moral values in influencing sexual and reproductive health behaviors among youth, and the role that faith-based organizations and parents may play in shaping these values.  Researchers have found that both church attendance and conservative attitudes toward premarital sex are both considered "protective factors" for risky adolescent sexual behavior. (See the result -- PDF, 9K -- of Doug Kirby's research in this area. Kirby's research also classifies having positive attitudes about condoms and contraception as a protective factor, as well as perceived self-efficacy in using condoms or contraception).

Many other factors can be just as strong, or stronger, than moral values in influencing young people's sexual behavior. Peer pressure, role models, and poverty were some of the points that forum participants have pointed out as influencing youth's attitudes toward sexual activity.  As we have been reminded throughout this week, many young women are forced to barter sex for food or to be able to go to school and are practicing the moral imperative of personal survival. 
 
Faith-based organizations can be places where moral values are formed and strengthened, but they are certainly not the only places where values are formed. Parents, teachers, the media, and friends all influence young peoples' beliefs and values. Prevailing social norms also heavily influence individual moral values. If social norms sanction female premarital sexual activity (such as not allowing pregnant teenagers to stay in school), but excuse or even promote male premarital sexual activity, individual values and behaviors will likely reflect those social norms.

As public health practitioners, it is not our job to teach values but rather to provide scientifically accurate information that will help young people make decisions within the context of their own values. However, it is our job to engage both young people and adults who influence youth (parents, providers, etc.) in the process of "values clarification," i.e., giving them the opportunity to reflect and articulate how they would want to react in various hypothetical situations (youth) or provide leadership and support to youth (adults). Oftentimes, young people will gain confidence and support from their peers for the behaviors they wish to practice when given the chance to talk about real-life situations and alternative ways of responding. 

School-based Sexuality and Family Life Education

We heard many participants speak to the importance of schools providing sexuality and family life education. I couldn't agree more. We can provide youth friendly services throughout the countries we live in, but education needs to go hand in hand with the provision of services. School-based sexuality and family life education remains controversial for some who believe that talking about sexuality in schools can lead young people to become more sexually active.  Research has found this assumption to be incorrect. The World Health Organization (WHO) and the U.S. National Campaign to Prevent Teen Pregnancy conducted the two most exhaustive reviews of studies in this field and both concluded that sex education programs do not promote or lead to an increase in sexual activity among young people. Rather, some of them were able to show among sexually active youth a decrease in the number of sexual partners and an increase in the use of condoms and other contraceptives.  For more information about these studies and about school-based sex education programs in general, please see YouthLens No. 2.

Again, thanks for being a part of this Week 1 conversation. I could say much more, and I'm sure you all have plenty of additional thoughts as well. I will stop now and give you time to frame more submissions to the forum.

Best wishes,

Ward Cates

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Forum Digest 4

1. Parents Lack Sex Ed Knowledge
2. Involving Parents, Communities Works
3. Cultural Traditions and Church Teachings on Sex
4. Make Reproductive Health Centers More Accessible
5. Pregnant Girls at Risk for Prostitution
6. Government Policies Tie Up Condom Distribution, Sudan
7. Interconnected Issues
8. Inform, Educate, Focus on Behavior Change
9. Teen Pregnancy, Poverty, and Overpopulation
10. Drama as a Tool in Sexual Health Advocacy
11. Examples of Successful Reproductive Health Programs in Mali
12. Orphaned Children Lack Sexual Health Information

1. Parents Lack Sex Ed Knowledge

A few participants have raised some issues about the need to engage parents, particularly in ARSH issues. I participated in a project recently on "parent-child communication on sexuality education." As many of the parents interviewed lacked communication skills on ARSH, I believe that more work needs to be done in the area of teaching and helping parents to acquire the skills necessary for communication on ARSH.

--Olaoluwa Pheabian Akinwale, Research Fellow, Public Health Division, Nigerian Institute of Medical Research, Lagos, Nigeria

2. Involving Parents, Communities Works

Last year I coordinated several workshops in a rural township in Uganda to help sensitize communities about adolescent friendly services. The response from both the adolescents and their parents was overwhelmingly positive. We found that parents had the same knowledge gaps about HIV/AIDS, unwanted pregnancy and STDs as their children. The workshops fostered better communication about these issues in families, promoted better child/parent relationships, and allowed parents to gain a better understanding of the needs of adolescents.

We included local religious and cultural leaders in the workshops to broaden the discussions and improve the acceptance of adolescent friendly services in the community. As a result, the community developed a better understanding of what adolescent friendly services meant. I would suggest the above is a useful strategy to use when establishing or promoting adolescent friendly services (whether general clinics, HIV/AIDS, maternity or family planning) in rural or semi rural areas in developing countries.

 -- Julie Wiltshire, Health Care Provider, Uganda

3. Cultural Traditions and Church Teachings on Sex

Traditional thinking in most African societies respected and revered sex and sexuality so much that it was never talked about, especially across the sexes and age groups. Parents almost never discussed sex openly with their children. Instead, they referred the young people to relatives such as aunts, uncles, and grandparents. Among age-mates, the topic was discussed in parables and veiled in words that were implicit rather than explicit -- and done more for fun than for serious discussion. This meant that children hardly got the right information from parents. As contact with grandparents and the extended family has lessened due to urbanization, such information has become even less available to children.

This respect and reverence for sex and sexuality led to beliefs that controlled practices in most African groups. In some communities, such as the Luo in Kenya, sex with one's wife (or wives) preceded every major event (planting and harvesting, for example) to show unity and oneness of the family unit. It was also done as part of the re-uniting process following bereavement in the family. Conversely, couples also abstained from sex during certain difficult times in the family.
The Bible is very explicit about sex and sexuality with a view to encouraging its wholesome enjoyment under certain conditions -- marriage. Neither the Old nor the New Testament hide anything about sex, be it the good that results from sex used in context or the evils of sex used outside of the defined boundaries. However, many churches have stuck with the traditional thinking on sex -- adopting the approach of "see no evil, touch no evil, and talk no evil" when it comes to sex, making it look like something evil rather than like a wholesome celebration of life.

The assumption is that young people will learn about sex when they come of age and are ready to enjoy it in the right context. But, while the church waits for them to grow up, young people are watching TV, visiting pornographic Internet sites, and talking with peers. And getting the wrong information about sex and sexuality. The sad result is that millions of young people never reach adulthood (due to STDs). Those who are lucky to live long enough face these problems sometime in their married lives because they never learned to handle sexuality appropriately in their growing years.

-- Sammy Jacobs Abbey, West Africa Youth Network liaison to ECOWAS, Ghana

4. Make Reproductive Health Centers More Accessible

Based on this week's forum discussion, most of us are aware that both married and unmarried young people need accurate reproductive health information, especially on the behavioural change and communication concept. For Tanzania and most other African countries, the typical barrier here is not only poverty; we also have problems in structuring and allocating our project areas. Also, we lack enough skilled personnel to serve as health providers to the RH centres.

From my point of view, in-school youth need a RH centre in or near their school for easy access and anonymity. Female youth normally feel shy to reveal their sexual secrets to unreliable source particularly of a different gender. To help make youth more comfortable, health providers should serve only same-sex clients.

I prefer that RH centres be allocated to both in-school and out-of-school premises with skilled providers of both genders. Abstinence-only education has sometimes been a failure, and, so, provision of both abstinence and spiritual education at once might help to serve these innocent young ones.

 -- Nassoro Ally, JSI BCC Advisor, DSM, Tanzania

5. Pregnant Girls at Risk for Prostitution

Global attention is now being given to prostitution. Yet, in some countries, it is legally accepted as a source of income and taxed. This is mostly affecting youth, especially young ladies. We need to prevent this kind of disaster in our societies. Two factors contribute to pregnant girls being at greater risk for prostitution: (1) less freedom in life; (2) poor health maintenance, as she cannot meet basic nutritional requirements. (I have only given two factors, although I hope others have been touched on by contributors.) When a lady is pregnant, especially in our societies, and she is not married, she will always be ousted by her family. And, this will cause her to involve herself with prostitution. Eventually, she will end up with HIV/AIDS. Furthermore, she will suffer from poor health due to poor meals. Ultimately, she will die with her child. We must educate and develop mechanisms that will help make youth aware of the effects of pregnancy in relation to AIDS.

-- Mgesi Juma, Executive Director, National Youth Development Agency, Tanzania

6. Government Policies Tie Up Condom Distribution, Sudan

I think the contributions so far are very illuminating. But, the more I see the problems in all parts of the world, I feel more stressed about the situation in our country, Sudan, with the rigidity of all sex related education here. Here, the condom is taken as a symbol of immorality. One example: UN agencies (UNFPA, WHO, etc.) got some containers of condoms as part of UNAIDS prevention policy, agreed upon with the government. What happened? These were left to expire without delivery from the customs warehouse. The Government of Sudan uses delaying tactics, and the UN bureaucracy is known to comply with the governments. In the case of Sudan, it becomes overdone. I can continue with endless citations that show that our system of governance does not differentiate between pornography and sex education. I hope this will be articulated more forcefully in the age of HIV/AIDS.

-- Hajh Amad, Sudan

7.  Interconnected Issues

There is a great need to have peer educators and involve faith-based organizations and institutions of higher learning in addressing abstinence, pregnancy, and safer sex. Other issues to be addressed include poverty and use of media in sharing information. Counselling is an essential component in all fields, and user-friendly youth clinics or centers should be introduced. Drug abuse, sexually transmitted infections (including HIV/AIDS), rape -- all issues affecting youth -- should be addressed comprehensively by all those concerned with a healthy youth for a healthy future.

 -- Dr. Anna Karani, Department of Nursing Sciences, University of Nairobi, Nairobi, Kenya

8. Inform, Educate, Focus on Behavior Change

The first and foremost need of this time, I believe, is a result-oriented approach to inform and educate adolescents regarding reproductive health issues such as sexuality, safe and unsafe sex, pregnancy, STI/HIV/AIDS – and also a sincere effort and attempt to change their behavior through effective behavior change communication interventions.

I strongly see the necessity of informing and educating as well as communicating with the adolescents at the right time, i.e. during adolescence, the age when youth are especially vulnerable to practicing high-risk behaviors. (Recent research indicates that the highest percentage of sex-initiation age falls between 15-17 years in urban Nepal.)

The need to equip every adolescent with the necessary knowledge on pregnancy and sexuality is of great importance at this time where every individual is at risk of contacting HIV, and it is made worse by the high rate of teenage pregnancy as well as prostitution. Besides informing and educating them, more interventions have to be implemented in order to change people's behavior in terms of sexuality and reproductive health. And, this should be done respecting sociocultural contexts.

Currently working towards my Masters thesis on "Reproductive Health Awareness among the Adolescents of Kathmandu Valley," I have come across various research findings and literatures which indicate that lack of proper knowledge and low level of reproductive health awareness are the chief causes of teen pregnancies, unsafe abortions, maternal deaths, etc. We still live in societies where a pregnant woman gives birth in the cowshed, and the newborn infant's umbilical cord is cut with a help of a grass-cutting sickle. The need to inform and educate rural adolescents is important, as they have fewer means and sources of correct reproductive health information compared to urban adolescents.

 -- Bishan B. Wagle, Research student/Health communication professional, Nepal

9. Teen Pregnancy, Poverty, and Overpopulation

I have been going through the forum for about five days now, and I have seen that youths have diversified problems depending on the area you are writing from. One major problem comes from the fact that there is overpopulation in the world today. This arises mainly because people, especially youths, cannot determine what they want and how they want to go about it, and this has led to many cases of teenage pregnancy.

The result of pregnancy often is poverty, because youths have not prepared fully for the obligation of being a mother or father. This mainly affects the ladies. Poverty has led to many wrong things happening in our world today, from lack of information and basic amenities of life to untimely death and HIV/AIDS infection. All of this has shown that, if we can manage our population, we can indeed have a better world. If teenagers can prevent teen pregnancy, we will be able to battle the HIV/AIDS crisis without compounding it.

 -- Oladehinde Unity, Nigeria

10. Drama as a Tool in Sexual Health Advocacy

We should not overlook drama as a tool for advocacy on sexual/reproductive health issues. In Nigeria, some people are already campaigning for such issues to be integrated into our school curricula, especially for secondary school students. Between 1995 and 1999, a youth organisation in Jos, Middle belt on Nigeria produced a play, "Had I Known," which was presented over 150 times. It was a huge success; people cried out that this was their story. I believe drama can help a great deal in this advocacy.

Also, the issue of abstinence cannot be over emphasized. In Africa it is becoming obvious that we are not likely to have a permanent solution to the problem without strongly considering abstinence. Can you believe that some think it is better for a young girl to become pregnant out of wedlock than to contract HIV/ AIDS? It is time to speak out: Abstinence is the Solution.

 -- Olusola Fagbemi, Nigeria

11. Examples of Successful Reproductive Health Programs in Mali

Young people are the majority of the population of Mali, like in other sub-Saharan African countries. The DHS survey carried out in 2001 (EDSIII) showed:

• 29% of the population was between 10 and 24 years.

• 26% of 15 to 19 year olds had their first sexual encounter at 15 years. And, 37% of age group had had sexual relations during the last four weeks; 62% of those did not use any contraceptive method.

• 40% of girls aged 15 to 19 years were already mothers or pregnant

• 12% of girls aged 15 to 24 years, compared with 10% of boys, admitted having had an STI.

And, to add, 29% of girls aged 15 to 24 years had at least one abortion (CERPOD, 1999) and lack of follow-up to pregnancy.

The interruption of studies, the difficulty of when youth have transgressed prevailing social values, youth have to interrupt studies and find difficulty in being accepted by society. In Mali, specific programs have targeted at teenagers' real needs for reproductive health information and services:

• PRADO, initiated by the NGO ASDAP in two cities in Mali (Bamako and Ségou), uses a strategy of health education and offering condoms to teenagers by peer educators in their community.

• Through its youth project, the Mali Family Planning Association facilitates youth centers in three cities to inform, educate, and communicate with teenagers. It also distributes contraceptives.

• The family life education project EVF/EMP intervenes primarily in educational establishments by developing modules on the anatomy and physiology of the reproductive organs, contraceptive methods, the relationships between fertility and behaviors favorable to health, and the provision of contraceptives to schools.

• The YOUNG PEOPLE project was set up by the Ministry for Youth and Sports in three cities in private, medical clinics for young people. They undertake the activities of family planning, curing and preventing STIs, and conducting voluntary testing for HIV/AIDS. The project also uses peer educators in information, education and communication for the prevention of STI/HIV/AIDS and the distribution of contraceptives in the community. It also carries out debates and radio broadcasts for young people.

• The Ministry of Health also readjusted the hours and locations of RH services to facilitate better access for young people. The next DHS survey, planned for 2006, will follow these indicators.

-- Dr. Binta Keïta, Head of Health Division, Reproduction/National Direction of Health Ministry, Mali

12. Orphaned Children Lack Sexual Health Information

We have a school that provides free education, basic healthcare, and vocational training. Right now, we have only four levels of primary education with plans to expand. Some of the kids, especially girls, started late (12-13 yrs old). We place all kids in foster (or extended) families since they are all orphans. The problem we are facing is lack of information on sex education and other health-related matters affecting youth. These kids are poor, and the families they stay with cannot afford buying newspapers or batteries to listen to the radio. Our teachers have done a great job, but, still, not all of the children share with them everything related to their health.

I grew up in this setting where no one talks about sex, and I must confess that things have not changed much, if at all. Growing up, the number of girls who became pregnant was less than today because they were scared or had deep respect for their parents. Most of the orphans have no parents or other adults to play this role.

Something has to be done. Our nurse, who does weekly visits, is not enough. Our girls do not know what menstrual periods are, and many are caught off guard in public. Boys end up making fun of them, and, as a result, some have dropped out of school because they are ashamed. We need your help and suggestions.

 -- Twesigye Jackson Kaguri, Director, Nyaka AIDS Orphan School, Uganda

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