|
SÉGOU, Mali -- The Ségou bus station, not far from the aquamarine
waters of the Niger River, is a bustling transportation hub ringed by
small shops and a colorful sea of traders carrying wares to market. It is
also home to the only program that provides contraceptives and
reproductive health services to adolescents in this small city and its
surrounding rural region.
In a small but clean office on the second floor of the bus depot, two
health educators greet young people who come by to ask questions, buy
condoms or seek information on sexually transmitted diseases (STDs).
"The office has become something of a drop-in center," says
Boncana Haidara, a former midwife and now one of three professional health
educators who staff the Programme des Adolescents (PRADO) office in the
depot. "It is easier for a girl to tell us that she is worried about
not getting her period than to tell her mother."
PRADO is an activity of the Association de Soutien au Développement
des Activités de Population (ASDAP), based in the capital city of Bamako.
In 1995, ASDAP became the first organization in Mali to develop
contraceptive and reproductive health services targeting young adults.
Adolescents desperately needed these services, says Fatoumata Traoré
Toure, ASDAP president. "We started as a pilot project for a year
with support from the Centre for Development and Population
Activities" (CEDPA), she says. "We trained peer educators and we
found that it was an excellent approach." With support for a more
comprehensive program, the effort has since been expanded to involve rural
and urban zones such as Koulikoro, Koutiala and Ségou.
Girls and boys trained in counseling and other educational activities
help promote contraceptive use among their peers. The program in Ségou
trains two or three young people in each neighborhood it serves to become
peer educators. These educators are 10 to 20 years old, and of the 65
trained so far, two-thirds are females. "Girls talk more among
themselves," says Haidara, who is convinced that working through
girls is the way to reach other girls, and the earlier the better.
A 1999 survey confirms that young women want to know more, earlier.
"If you could change the past," the survey asked, "which
information would you have wanted to have about sex?" The most common
response -- by 41 percent of women surveyed -- was that they wished that
as adolescents they had known better how to prevent pregnancy and STDs and
cited age 12 as the appropriate age to begin receiving information. Survey
participants reported that lack of information was one obstacle to
reproductive health in the Ségou region; other obstacles included
distance to health services, lack of contraceptive methods and cost.1
 |
|
Bocana Haidara of PRADO |
Dr. Mohamadou Hachimi, health director for the Ségou region, points to
the survey as evidence that new strategies are needed to serve young
adults. But he says traditional values and societal pressures for recently
married girls to prove their fertility discourage formal health services
from reaching adolescents effectively. "In general, it is taboo to
talk to young people about sexuality or reproductive health," Dr.
Hachimi says. "Here it is taken badly if you talk about family
planning with young people, but we need to, considering the problems of
undesired pregnancies and STDs."
Another 1999 survey in Mali, conducted by CEDPA and the Futures Group
International, found that about one in every four unmarried young adults
in the Ségou region reported having had intercourse at least once (23
percent of women and 27 percent of men ages 15 to 24). One in five (22
percent women, 19 percent men) reported having had a sexually transmitted
infection in the prior 12 months, yet fewer than one out of 13 reported
that they were currently using contraception.2 "By 18
years old, 81 percent of adolescents in Mali have already initiated sexual
activity," reported a nationwide Demographic and Health Survey.3
Tea and notebooks
When PRADO peer educators organize discussion groups in their
neighborhoods, they usually ask one of the three professional health
educators to assist, primarily to provide support when difficult questions
are posed. "They serve traditional tea with mint," Haidara
explains and smiles. "ASDAP provides the tea."
Incidental expenses such as providing drinks for gatherings or gasoline
for transportation can add up, and programs such as this often wrestle
with issues of sustainability. To curtail expenses and provide an
incentive for peer educators, PRADO encourages educators to sell condoms
during discussion groups and similar events. Peer educators keep half of
the proceeds for themselves, returning the rest to ASDAP. Young people who
seek services in the office above the bus depot receive free counseling
and pay a small fee to obtain condoms, spermicidal tablets or oral
contraceptives.
Each peer educator keeps a notebook, recording useful details about
home visits, discussion groups, or counseling sessions -- themes
discussed, number of female and male participants, how many were younger
than 25 years old. Such information helps staff strengthen and focus their
assistance.
Certain health concerns, such as the health risks of female
circumcision, are difficult to discuss. More than 83 percent of young
women and men in Ségou report being willing to have their girl children
circumcised.4 The Bamako office provides audiocassette tapes on
female circumcision to help initiate discussions. ASDAP also publishes an
attractive magazine on adolescent reproductive health that targets young
people, and is partly written by young people.
"You have to involve adolescents in everything you do," says
Traoré, the ASDAP president. "You should not propose all the
strategies. Young people themselves have a lot to add. You have to know
how to listen to them. Young people do not like people to tell them what
to do. Involve them, listen to them. If you arrive with preconceived
ideas, you will not advance."
Many components of the PRADO program are consonant with World Health
Organization (WHO) recommendations on action for adolescent health. For
example, WHO's framework for country programming recommends providing
information in a safe and supportive environment for young people and
involving youth systematically.5 The PRADO program offers young
people a convenient place to access services, with both male and female
educators at the bus depot office. The program is built on a framework of
youth involvement, yet also sponsors events that involve parents and the
community, including the school system.
"Each month we go to the schools to explain what reproductive
health is," says Haidara. "First we ask, 'What do you know about
AIDS?' Then we point out which of their comments are true, and we get into
more detailed explanations of points that need better understanding."
In this traditional ethnic Bambara town, Haidara says, the subjects of
reproductive health, family planning, STDs and sexuality are taboo in
family discussions. But young people are hungry for information.
"Some students ask about monthly periods, consequences of abortion,
STDs, and how to take pills," she says.
Haidara says being an effective health educator takes persistence and a
high level of comfort in talking about sensitive issues. "I think you
really have to work at continuing to communicate and raise
awareness of the issues," she emphasizes. "The staff have to be
very comfortable with young people and with the subject of reproductive
health. Every single day you see a new face, so you have to keep
working."
 |
|
Aminata Barry Touré (right) with community leaders. |
Neighborhood women
Even in Bamako, where health services are more widely available than in
Ségou, there is an urgent need for adolescent services. In some
neighborhoods, individual women pick up the slack, often addressing a
range of needs including health, education, employment and recreation.
Aminata Barry Toure, who organizes biweekly discussion groups on
reproductive health for adolescents in the Doumanzana neighborhood of
Bamako, says young people need information to make responsible choices.
"There is a lot of boredom," says Barry, president of the
Association Malienne pour la Sauvegarde du Bien-être Familial.
"Young people initiate sexual activity even at 15 or 16 years old.
There are no cinemas, no places for games. There is nothing to do but have
sex."
Barry is known among young people in her neighborhood for her activism.
She raised funds to purchase a donkey, allowing teenagers to earn money by
carting away neighborhood trash. She spearheaded the establishment of a
dispensary in Doumanzana, possibly the only neighborhood clinic in Bamako
with laboratory facilities and reagents to do tests for gonorrhea,
syphilis and sickle cell anemia.
"Here we do not talk in the family about sexuality,"
continues Barry, a professional accountant and mother of six. "It is
thought that if you do this, you are pushing them into making love. We
think it is best if they wait until they are married. But kids are
sexually active anyway. They just hide it."
It is a hot afternoon, and the dusty streets are filled with young
people. Barry sends out the word, and soon a group of teenagers assembles
in a simple, dirt-floored preschool her organization built for children of
market women. They speak openly about sex and reveal fears stemming from
both lack of information and misinformation, such as the incorrect notion
that condom use can cause a woman to hemorrhage.
One student wants to know whether a woman can get pregnant if a man's
preejaculatory fluid and a woman's natural lubrication touch outside the
body. The young people laugh at each other's questions but listen intently
to the answers. "How can you withdraw without leaving the condom
inside the woman?" a boy asks. "How long does it take for a
woman's fertility to return after using oral contraceptives or Depo
[Provera]?" a girl asks.
Many of their questions are practical. Others address deeply ingrained
cultural perceptions, such as the notion that forced sex is a matter of
passion, not violence.
When a young woman says she has friends who have been raped, boys jump
in and say "men cannot control themselves" and "between men
and women it is fire and gas: if they get together everything catches
fire!" It is clear that many of the young people in the group are
aware of forced sex, and attitudes towards it vary along gender lines.
Nationwide, one out of five young women reported that their first
experience with intercourse was not consensual.6
"The important thing is opening the channels of communication with
young people," Barry says. Not many adolescents come to the
dispensary for contraception, she says, but many others seem interested in
the discussion groups. Many participants purchase condoms after such
talks, when she has them.
Sitting in her office, her normally cheerful face is pinched. She
mentions that a young girl she knows recently died from an abortion.
"The news has really hit me hard," she says. "She was so
beautiful. Really beautiful."
Barry wants to create "listening centers" for young people,
where trained adults and peer leaders would listen and give advice,
including referrals for medical care. She envisions renting or building a
youth center with a video machine and conference room where young people
could get together. Perhaps if mixed groups of boys and girls learn to
begin talking at an early age about relationships and how to prevent
pregnancy and STDs, she muses, the stage will be set to discuss
reproductive health decisions as couples.
In this context of widespread poverty and insufficient health services,
women leaders such as Barry are playing an important role in identifying
and filling the gaps. "Health, family planning, legal aspects of
female circumcision, small commerce and income generation, gardening, the
care of young children and girls, environment, reforestation," Barry
lists, and sighs. "Women do everything."
-- Elizabeth T. Robinson
References
- Connaissances, attitudes et comportements des jeunes
(15-25 ans) vis-à-vis de la santé de la reproduction. Unpublished
paper. Ministère de la Santé, des Personnes Agees et de la Solidarité;
Direction Nationale de l'Action Sociale; Centre National
d'Information, d'Éducation et de Communication pour la Santé
(CNIECS), 1999:27,65.
- Enquête CAP sur la santé reproductive: rapport
d'analyse (version finale). Unpublished paper. The Centre for
Development and Population Activities (CEDPA) and The Futures Group
International, 1999:58,66,114.
- Coulibaly S, Kicko F, Moussa Traoré S, et al.
Enquête Démographique et de Santé Mali 1995-1996. Bamako and
Calverton, MD: Cellule de Planification et de Statistique, Ministère
de la Santé, de la Solidarité et des Personnes Agées, Direction
Nationale de la Statistique et de l'Informatique, and Macro
International, Inc., 1996:94.
- Enquête CAP sur la santé reproductive: rapport
d'analyse (version finale).
- Action for Adolescent Health: Towards a Common
Agenda. Geneva: World Health Organization,
1997.
- Connaissances, attitudes et comportements des jeunes
(15-25 ans) vis-à-vis de la santé de la reproduction, 35.
For more information, visit Family Health International's Website at www.fhi.org
Go to FHI's Network |
Copyright