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SOWETO, South Africa – On a clear August
afternoon, about 400 high school students filled the large courtyard at
the Mafori Mphahlele High School in Soweto, South Africa, waiting for the
AIDS awareness program to begin. Marie, 16, Nomomde, 17, Mbali, 16, and
Margaret, 17, laughed together in the afternoon sun, placing on their
school uniform skirts and sweaters stickers reading "Safe Sex Saves
Lives" and "Protect the Ones You Love." Marie had made
earrings out of several stickers. Boys also were spreading stickers over
their own uniforms and bodies.
The long afternoon program at Mphahlele High School
included guest speakers, student skits, condom demonstrations, music, an
appearance by the "Trust" condom man, poems and songs written by
students, and a candle lighting for all those living with AIDS. Students
remained patient during the program, which stretched well beyond the end
of school. The most remarkable moment of the afternoon came when
18-year-old Michelle spoke.
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| Students from Mafori Mphahlele High School in
Soweto, South Africa, at a recent AIDS awareness program. |
"I did not have a positive mind when I was in
school," she told the students. "I was sexually active. I only
thought about boyfriends." She paused, then turned to the audience,
her hand in the air. "Are you living for sex?" Michelle asked
the students. Many of them yelled back, "No!" "Because in
the fun, there’s pregnancy, sexually transmitted infections, AIDS. Do
you ever stop to think about that? We have dreams. I thought I might be a
dancer or a musician, but all we think about is sex. I wish I was in your
footsteps now. I got pregnant. The guy ran away. He couldn’t take the
responsibility."
Michelle, poised and alone before the 400 students,
continued. "After the birth, I wanted to breastfeed the baby, but
they called a doctor and a counselor in. They told me I was HIV-positive
and couldn’t breastfeed her. I didn’t know what to do. I was going to
die." She paused, looking out directly at the students. "So what
we need to do is to change our behavior. When you drink, you lose yourself
a bit. Whatever people say you might do, you do. Respect your parents. Be
thankful they’re giving us advice. Sex is a gift for married people, not
for young people like us. Parents and teachers, we need you to guide
us."
Vulnerable and resilient
The students at Mphahlele High School, like their
peers around the world, are both vulnerable and resilient. Meanwhile, new
allies for young people are increasingly becoming available, complementing
the support youth may get from parents, teachers, peers, and traditional
community resources. New initiatives for youth are addressing the dangers
youth face, many of which are tied to behaviors related to sexuality (see Youth
in Danger).
In the last 10 years, a broader understanding of
the sexual and reproductive health needs of youth has emerged. Studies
have found that the age of first sexual activity is dropping in many
countries and the age of marriage is rising, resulting in more possible
years of sexual activity with multiple partners.1 The different
cultural norms for boys and girls are getting more attention, highlighting
gender violence and generating new opportunities for both girls and boys.
As gender norms change, for example, girls may have more ability to
negotiate when they want to have sex, and boys may incorporate more
nurturing and less risky behaviors.2 Early studies showed that
youth had limited access to services and information about reproductive
health. For example, providers were not willing to provide unmarried youth
with services at family planning clinics, including the provision of
condoms.3
"There is a lot more consciousness about the
needs of adolescents," says Dr. Nancy Williamson of FHI, who is
director of YouthNet, a new $85 million, five-year program to improve
adolescent reproductive health, funded in part by the U.S. Agency for
International Development (USAID). "Slowly, over the last decade,
barriers are falling. There is more sex education in schools, for example.
Policies are changing so that more providers will actually serve unmarried
youth, and we are beginning to learn more about which types of services
are most effective."
What services work?
Reaching youth requires techniques different than
those used to reach older adults. Most youth do not seek reproductive
health services on their own. In order to encourage them to seek services,
programs need to increase adolescents’ awareness of reproductive health
issues.
The World Health Organization, the United Nations
Population Fund, the FOCUS on Young Adult Project funded by USAID, and
other groups have identified several keys to effective design of youth
programs:4
- Identify the target group; analyze assets and
needs
- Involve youth
- Work with the community, including parents
- Build on and link existing interventions
- Use materials designed by and for youth
- Make accessible needed services, as identified
by youth.
Evaluate interventions
Programs are attempting to incorporate these
components into projects ranging from outreach services and youth-friendly
clinics to school-based education, media campaigns, and hotlines. In the
process, various organizations have identified the approaches they have
found to work best. For example, analyzing its work with youth service
delivery projects in eight countries from 1995 to 2000, U.S.-based John
Snow, Inc. identified 22 lessons it learned. Having a "champion"
for youth within a clinical setting, for example, can help maintain a
youth-friendly environment. Peer- education approaches are valuable. Help
is needed to address community resistance to youth interventions. Starting
a separate project or intervention is not necessary to serve youth
effectively.5
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| The AIDS awareness program in Soweto, South
Africa, encouraged open discussions of behaviors affecting
reproductive health. |
Evaluations of specific types of programs offer
some helpful data for program planners:
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Multipurpose youth centers most often attract boys, older youth, or
young adults, and a low proportion of youth center attendees come for
reproductive health information. Youth centers run by family planning
organizations "are often stigmatized by the community and youth
themselves," a recent Population Council study found. "Many
youth, especially girls, do not want to be associated with family
planning organizations because it suggests sexual activity or because
young people brand [the centers] as places for those with sexually
transmitted infections."6
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Scouting projects can successfully reach both in-school and
out-of-school youth although extra time is needed to train the
leaders, who are not used to addressing reproductive health issues.
One project concluded that youth respond better to reproductive health
programs that are integrated with scouting activities than those
offered independently.7
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Hotlines and radio call-in programs can be efficient ways to reach
many youth. "They provide youth with convenient, confidential,
interactive, and compassionate access to information, counseling, and
referrals," according to a report of these projects by FOCUS on
Young Adults. Evaluating and monitoring these programs is challenging
because confidentiality is important. Sustaining them may also be
difficult, although a hotline in the Philippines received support from
a telephone company after donor support ended.8
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Combining mass media, school-based, and community-based approaches
can be effective, as demonstrated by Arte y Parte/PROMES in Paraguay,
which targeted youth ages 15 to 19 years through in-school workshops,
street drama, an hour-long weekly radio program, and peer educators.
An evaluation found that the project reached 44 percent of youth in
major cities but was not as successful in reaching low-income and
out-of-school youth. Mass-media efforts are especially effective when
targeted to specific demographic groups of youth and when combined
with access to more interactive resources.9
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Confidentiality. Peer educators in Kenya were found to be
judgmental about premarital sex, and only 42 percent of youth
interviewed trusted peer educators to keep information confidential.
"Special attention needs to be paid to addressing staff attitudes
and quality of care" with lay staff, the study concluded.10
Little research is available on the role of male
youth in reproductive health and HIV/AIDS programming. A recent study by
the Panos Institute found that young men, ages 15 to 24 years, have more
sexual partners than any other group and do not widely use condoms.
"Most HIV/AIDS programs either target young people in general or just
young women," says Thomas Scalway, author of the study report.
"Young men are the most likely sector of the population to be
involved in activities associated with HIV/AIDS risk, yet remain largely
ignored in awareness and prevention programs."11
Also, experts agree that little careful evaluation
and research has been done on involving youth, cost effectiveness,
sustainability, and impact. A review of youth programs supported by the
Gates Foundation found that two-thirds used the strategy of making
clinical health services youth-friendly, mainly targeting unmarried youth,
even though numerous studies have pointed out the difficulty of getting
large numbers of youth to use these facilities, and none of the grantees
have documented success with this approach.12 Another review of
programs found that "constraints on financial and human resources,
coupled with the great size of the youth population, highlight the need to
find less costly ways to reach young people."13
Expanding projects
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| A student performs a role in a skit during the
AIDS awareness program in Soweto, South Africa. |
As projects for youth expand, lessons learned from
previous efforts influence program development. But funding sources, the
situation of each country, personalities, and other factors also help
shape program decisions. In South Africa, for example, many projects are
competing for resources, attention, and access to adolescents.
The Society for Family Health (SFH), a social
marketing and educational outreach organization working since the early
1990s, has begun to focus more of its efforts on youth at locations such
as Mphahlele High School and others in Soweto, as well as in its
television and film productions. The South Africa Department of Health has
operated a large anti-AIDS campaign called "Beyond Awareness
Consortium," which included the highly visible "Soul City"
project, a conglomerate of groups working with educational ventures
throughout the country. The newest and largest major initiative, loveLife,
began in 1999, with a well-financed, multimedia project and public health
campaigns to promote a healthy lifestyle among youth (see Campaign
Encourages Youth to Talk about Sex and Sexuality).
"South Africa is much more complicated than
other African countries," says Rob Giger, who worked with condom
social marketing campaigns in Zaire, Guinea, and the Ivory Coast before
coming to Johannesburg in 1999 to head the SFH program. "There is an
infrastructure here, which is hopeful, and AIDS is a high visibility
subject, which is good. But it is bad when organizations are competing. In
the Ivory Coast, we covered 75 percent of the country. Here, it’s much
more difficult." With multiple sources, types, and prices of condoms,
consumers have to make more choices, and providers must compete for
consumer loyalty.
The government has supported a widespread free
distribution of condoms. "The danger in this is that people will
expect the government to solve your problem and give you the condom
free," says Giger. People have to take responsibility, reducing the
number of partners as well as using condoms. People need to say, ‘I’ve
got a role to play.’"
– William R. Finger
References
- McCauley AP, Salter C, Kiragu K, et al.
Meeting the needs of young adults. Popul Reports
1995;J(41):3-9.
- Finger WR. Some cultures tolerate risky
male behaviors. Network 2000;20(3):21-23; Barnett B. Gender norms
affect adolescents. Network 1997;17(3):10-13.
- Abdool Karim Q, Preston-Whyte E, Abdool
Karim SS. Teenagers seeking condoms at family planning services: part
I. A user’s perspective. S Afr Med J 1992;82:356-59.
- WHO/UNFPA/ UNICEF. Action for
Adolescent Health: Towards a Common Agenda: Recommendations from a
Joint WHO/UNFPA/ UNICEF Study Group. Geneva: World Health
Organization, 1997; Senderowitz J. Reproductive Health Outreach
Programs for Young Adults. Washington: FOCUS on Young Adults, 1997;
Senderowitz J. Thematic evaluation on adolescent reproductive health
– global report submitted to UNFPA. Unpublished paper. Geneva:
United Nations Population Fund, 1996; Johnson S, Finger WR, Rivera R,
et al. Reproductive Health of Young Adults: Contraception, Pregnancy
and Sexually Transmitted Diseases. Research Triangle Park, NC: Family
Health International, 1997.
- Newton N. Applying Best Practices to
Youth Reproductive Health: Lessons Learned from SEATS’ Experience.
Arlington, VA: John Snow, Inc., 2000.
- Overview of youth center assessments in
Kenya, Zimbabwe and Ghana. Unpublished paper. Population Council,
2000.
- Kahuthia G, Radeny S. Project
highlights: using scouting as a vehicle for reaching out-of-school
youth. Program for Appropriate Technology in Health, 2001. Available
from: http://www.pathfind.org/Project%20Highlights/Scouts%20Kenya.htm.
- Moch L, Stevens C. In focus: reaching
adolescents through hotlines and radio call-in programs. FOCUS on
Young Adults, 1999. Available from: http://www.pathfind.org/IN%20FOCUS/PDF/dec99.pdf.
- Aguilar P, Booking SM. Project
highlights: combining mass media, school, and community-based
approaches. FOCUS on Young Adults, n.d. Available from: http://www.pathfind.org/Project%20Highlights/paraguay.htm.
- Operations Research Technical
Assistance, Africa Project II. Programme Briefs: Adolescents:
Population Council, n.d.
- Scalway T. Young Men and HIV: Culture,
Poverty and Risk. London: Panos Institute, 2001.
- Shepard B, Nuñez JG, Helfenbein S.
Youth program strategies in the Bill and Melinda Gates Foundation’s
Global Health Program: a strategic assessment. Unpublished paper.
Gates Foundation, 2001.
- Hughes J, McCauley AP. Improving the
fit: adolescents needs and future programs for sexual and reproductive
health in developing countries. Stud Fam Plann
1998;29(2):233-45.
Campaign
Encourages Youth to Talk about Sex and Sexuality
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A large billboard looms above
the vegetable stands beside the sprawling taxi and bus stops at the
edge of Soweto, South Africa, where tens of thousands of people
catch their ride daily to nearby Johannesburg. Drawings of two
people and the words "His and Hers" loom in large pink
print against a vibrant purple background amidst the dusty roads and
empty sky. "loveLife: Talk about it," reads the catch line
at the bottom. Is the message reaching the right people? And what
does it mean? Does "loveLife" refer to loving one’s life
or is it meant to emphasize one’s love life with a sexual partner?
"This message is about a
state of mind, about a hope for the future," says Jonathan
Stadler of the Research Health Research Unit, University of
Witwatersrand, and research director for loveLife. Sitting in his
office in Baragwanath Hospital, across from the Soweto taxi stand,
Stadler describes how the loveLife campaign is trying to
"create a new culture. It’s a motivational program to
encourage people to stand up and talk about life with each
other." The campaign includes billboards, community
mobilization efforts, a hotline, and other elements.
The loveLife campaign seeks to
build awareness of reproductive health and life skills issues. In
addition, it launched a multipronged service delivery component in
2000. It has developed eight youth service delivery centers (called
Y-centers), worked to make existing clinics more youth friendly,
funded peer education and outreach activities through the Planned
Parenthood Association of South Africa (PPASA), and sponsored the
loveLife games (an annual sports competition).
One of the Y-centers is at
Orange Farm, a low-income rural black township about 45 minutes from
Soweto. Khanyisile Khumalo, a PPASA nurse, works out of this
Y-center, which is just beginning and has one other employee plus
peer educators. Khumalo shares information through talks at schools
and offers clinical services at the Y-center in the afternoon.
"We also offer life skills workshops, where we discuss
sexuality, pregnancy, sexually transmitted infections, sexual abuse,
and life skills," she says. "I’m optimistic. The more
information you give youth, the more you address myths they have. We
use motivational programs to empower them about how to relate to
their partners." The center is also beginning to offer
activities that it hopes will attract girls as well as boys, such as
drama, jazz dance, aerobics, and net ball, a version of basketball
played by girls and women in South Africa.
How well the loveLife project
can achieve its ambitious goals remains to be seen. A survey of
1,000 people found that more than half of every 10 respondents had
heard about loveLife. (Participants included 600 youth ages 12 to 17
years and 400 individuals over age 25.) About one-third of those
surveyed had heard of the project through the television show
S’canto, which follows the journeys of young people who travel the
country talking to other youth about sex and sexuality. Campaign
billboards were also recognized by many. More than 90 percent of
those who were aware of loveLife identified it as a symbol of hope
and communication about sex, sexuality, and HIV/AIDS.1
Another study of youth centers
in South Africa found that awareness of loveLife centers is high,
compared to other youth centers, probably because loveLife centers
are new, large, and colorful. Visitors to the loveLife centers were
balanced by gender, and focused on recreational activities.
"Providing recreational facilities for young people may go a
long way in satisfying a program’s developmental objectives,"
according to study researchers. "However, linkages between
providing recreation and positive health outcomes are not
clear-cut."2
Some are skeptical of the
loveLife project, saying that it is very costly without having a
clear sense of direction. "The project does not have a model,
it has an approach," says Warren Parker, director of Center for
AIDS Development, Research and Evaluation, a research organization
based in Johannesburg that has analyzed national AIDS awareness and
condom distribution programs in South Africa. "loveLife is a
public relations engine on top of an idea. Its high-cost mass media
activities place very little emphasis on condom promotion. We need
more work on more specific issues such as addressing condom
stockouts and increasing consistent access for youth, particularly
in rural areas."
– William R.
Finger
References
- Stadler J. Looking at loveLife
the First Year: Summaries of Monitoring and Evaluation,
September 1999 - September 2000. Bertsham, South Africa:
Reproductive Health Research Unit, Baragwanatah Hospital, n.d.
- Erulkar AS, Beksinska M,
Cebekhulu Q. An Assessment of Youth Centres in South Africa. New
York: Population Council, 2001.
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Soweto is the black township
on the southwestern side of Johannesburg where youth-led, often
violent protests against the apartheid government of South Africa
dominated life in the 1970s and 1980s, closing many schools. Today,
Soweto – with some four million people – has returned to a more
normal life, including fully functioning schools.
But the Soweto youth in
post-apartheid South Africa face a new kind of danger. It is a type
of danger facing many of the 1.5 billion young people in developing
countries, about one of every four people. Youth are even more
vulnerable than adults to HIV and other sexually transmitted
infections (STIs). About one-third of the world’s 34 million
HIV-infected people are between ages 10 and 24 years, with girls
disproportionately affected by HIV infection for both biological and
cultural reasons.1 In addition, in developing countries,
some 13 million births occur each year to women ages 15 to 19 years,
many of whom are unmarried. Nearly always, the young unmarried
mothers drop out of school to raise the baby, without help from the
father.2 The World Health Organization (WHO) estimates
that between 1 million and 4.4 million abortions are performed each
year among women ages 10 to 24 years, with most of them performed
illegally under hazardous conditions.3
– William R.
Finger
References
- Young People and Sexually
Transmitted Diseases, Fact Sheet No. 186. Geneva: World Health
Organization, 1997; Report on the Global HIV/AIDS Epidemic.
Geneva: Joint United Nations Programme on HIV/AIDS, 2000.
- Barnett B, Eggleston E, Jackson
J, et al. Case Study of the Women’s Centre of Jamaica
Foundation: Program for Adolescent Mothers. Research Triangle
Park, NC: Family Health International, 1996.
- Young People and Sexually
Transmitted Diseases: WHO Fact Sheet No. 186. Geneva: World
Health Organization, 1997.
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