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This post is written by Callie Simon and originally appeared on Pathfinder International’s Field Journal in June 2011.
It’s astounding to think that there are 3 billion people under the age of 25 alive today, 1.8 billion of whom are between 10 and 24 years of age. I firmly believe that these young people—if they are healthy and empowered—can be productive, influential members of their communities and their countries. Unfortunately, young people are currently facing remarkably high rates of early marriage, unintended pregnancy, sexually transmitted infections, HIV, and maternal mortality and morbidity, as well as severely limited access to jobs, education, and political participation.
To address these challenges and give young people the opportunities they need to thrive, young people, national governments, and the international community are calling for multisectoral programs. Multisectoral programs acknowledge that young people’s problems are interconnected and include strategies to address two or more of the sectors that are central to young people as they transition into adulthood: health, education, livelihoods, and civic engagement. In multisectoral programs, each intervention plays a role in improving outcomes in the other sectors—just as the problems young people face are intertwined, so too are their solutions.
After working with diverse young people in different regions of the world, I agree that multisectoral programs are important for holistic youth development—but too often sexual and reproductive health is ignored. If multisectoral programs are to reach their full potential, they must include a strong sexual and reproductive health component. International research and Pathfinder’s experience shows that programs to prevent early marriage, unintended pregnancy, HIV, and other sexually transmitted infections not only improve young people’s health, but also result in noteworthy gains in education, livelihoods, and civic engagement.
The graphic above—an excerpt from our recent publication—illustrates exactly this point. It shows that young people’s journey to adulthood is fraught with difficulties and their sexual and reproductive health needs must be met in order for investments in other sectors to be beneficial. Only then can young people stay the course and fully contribute to the economic and social development of their communities
The newest publication from Pathfinder’s 3 Billion Reasons Campaign builds on this graphic and uses compelling data to argue that sexual and reproductive health must be a part of any multisectoral youth program. I encourage you to read it and visit our Three Billion Reasons campaign page for more information, including how you can get involved.
The South African HIV and AIDS Information Dissemination Service (SAfAIDS) launched a new regional program titled, “Young Women First!” (YWF!), which focuses on the sexual and reproductive health and rights (SRHR) for young women ages 15-24 years. The program mobilizes young women, empowers them to serve as advocates, and provides them with information and skills. Among other activities, it produces a newsletter for young women to raise awareness about sexual and reproductive health issues, and it offers advice and provides a platform for young women to share their stories related to SRHR. The following post was adapted from an article that appeared in their first newsletter, entitled “Sexual Abuse Preventing Progress on Education Targets.” The original article was written by Fred Katerere, who is a foreign correspondent based in Maputo, Mozambique.
Worrying statistics on sexual abuse in schools and high female drop-out rates mean Mozambique and other countries in the sub-Saharan Africa region may not reach the 2015 education and gender targets set out in the Millennium Development Goals (MDGs). In Mozambique, although authorities do not have exact figures, teenage girls often fall pregnant before reaching 16, the legal age of marriage, which usually puts an end to their education.
According to a 2008 report compiled by the Mozambique Ministry of Education and Culture, many of these pregnancies are not consensual and girls are impregnated by teachers who ask for sexual favors in exchange for passing grades. Not only are female students becoming pregnant, but they are also becoming exposed to sexually transmitted infections through their teachers. The report, entitled “Mechanism to stop and report cases of sexual abuse of girls,” documented that 70% of female students said a teacher had asked them for sexual favors in order to pass. Such abuse is not confined to Mozambique, but is so common in Africa that it has been labeled “sexually-transmitted grades” or “BF” which refers to “bordello fatigue,” when girls have had too much sex with teachers and are tired in the classroom.
A recent Plan International report, called “Learn without fear,” found that sexual abuse is institutionalized in many school systems in sub-Saharan Africa. It also noted “high levels of sexual aggression from boys and teachers towards schoolgirls… in Botswana, Ghana, Malawi, and Zimbabwe” and found that one third of all documented rape cases and abuse of schoolgirls in South Africa is committed by teachers.
As governments and world leaders meet to discuss the MDGs at the 10-year point, problems like these will remind them that there is a long way to go before we can reach the 2015 targets to eliminate gender disparity in education and women’s empowerment. According to the 2009 United Nations Human Development Index, Mozambique, a nation of more than 22 million, has an adult literacy rate of just 44%, and only 33% of its women are literate, much below the regional average. The UN also notes that the sub-Saharan Africa and Southern Asia regions are “home to the vast majority of children out of school.”
It is against this background that organizations like UNICEF in Mozambique have embarked on initiatives aimed at complementing the government’s program to call for zero tolerance of abuse of girls in schools. Carlos dos Santos, an education specialist at UNICEF, said that although cultural practices that disfavor girls are still mostly responsible for the higher numbers of boys being sent to school, there are many cases of girls who drop out after being impregnated or abused by teachers, other students, or members of the community.
“There is work that is being done in schools to help in reporting cases of sexual abuse of girls, and this will help in combating the phenomenon in communities and schools,” he said, noting that authorities confirm such cases are rife, especially in rural areas where most residents do not have much information on their rights. UNICEF and its partners are currently conducting research in order to come up with a database on the problem. It has also advocated for school councils that will be chaired by teachers, parents, and guardians of students.
Dos Santos said councils are headed by women from local communities who regularly meet with girls and receive reports about sexual abuse. Mozambique’s Ministry of Education and Culture has also created a Teacher’s Code of Conduct that, among other things, calls for disciplinary action against a teacher who sexually abuses a student. In 2008, two teachers in southern Inhambane province were expelled for allegedly impregnating three students, and three teachers were suspended pending dismissal on the same charges in Maputo province.
Ursula Paris, a child protection specialist at UNICEF in Maputo, said her organization was also working with officials from the justice and police departments to update them on new clauses in the country’s family law that further protects women and children. “It’s never too late to act, as each day which passes, a girl is made pregnant and her life is ruined,” she said.
Robyn Dayton is a technical officer at FHI where she works on the research utilization portfolio of youth reproductive and sexual health activities.
The findings of HPTN 052, that “men and women infected with HIV reduced the risk of transmitting the virus to their sexual partners by 96 percent through early initiation of oral antiretroviral therapy” (see full story here), give the HIV prevention community a new and potentially highly effective tool in its efforts to reduce the spread of HIV.
Simply put, starting antiretroviral therapy (ART) before it’s required for one’s own health can substantially decrease the risk that a person living with HIV will pass the virus on to his or her sexual partners—a discovery that could be an incredible boon for young people, the group that has the most new HIV infections per capita. (Every day, some 2,500 young people acquire HIV, and young people accounted for 41% of new infections in those over 15 in 2009.)
However, there are two clear prerequisites to realizing the promise of this approach for youth, and neither one of them is all that likely to be met. First and foremost, in order to start ART, a young person has to know his or her status—most young people infected with HIV don’t. (After all, if a young person can’t admit that she’s sexually active, she certainly doesn’t want to go seeking evidence, in the form of a positive HIV test, that this is the case.) Second, it’s often an older person who infects a younger one—especially older men having sex with young women—so young people knowing their status isn’t enough. Older people who have sex with young people need to not only know their status, but also care enough about their young partners to begin taking ARVs before it is necessary for the maintenance of their own health. But in societies where women have little value and young women need to seek out older partners in order to meet their financial needs, the power differential in this type of partnership doesn’t lend itself to both partners’ health having equal value.
So how likely are young people to benefit from this new finding?
If this sounds cynical, it isn’t meant to be. HPTN 052 offers hope for a number of people worldwide and is an incredible step forward in HIV prevention. However, it is important to think about whether those who most need a cutting edge HIV prevention strategy (youth) will have the opportunity to benefit from it. And if the answer is no, it’s up to the people who care about youth to work toward a world in which that opportunity is created.
Leonard Bufumbo is a research associate with FHI in Uganda. He worked on an operations research project focusing on voluntary counseling and testing with youth. The project was funded by USAID in 2000–2002 and implemented by Sociology Department of Makerere University, Kampala, Uganda.
As part of a youth assessment in Uganda, I led a team of data collectors in an effort to understand the sexual and reproductive health needs of youth. Our study consisted of focus group discussions with young people, interviews with government stakeholders, and assessments of health facilities that young people reported as being “youth-friendly.” Observations from this assessment confirmed that youth in Uganda face a number of challenges. Rates of teen pregnancy are high, use of family planning is low, and adolescents face many difficulties in accessing care.
After this trip, this is what I think. Youth have not yet been understood. The health workers think they understand them, but they don’t. That’s the biggest challenge! When young people present a complaint to a provider, the complaint often does not reflect what they truly need. When youth seek services, they often seek help with psychosocial issues that have more to do with relationships, both sexual and non-sexual, than they do with clinical issues. Sometimes, youth will even go to the clinic, not report anything at all, and just hang idly around. The youth do this because they believe it will provide them an entry point to services. These same youth will continue to try and access services, and sometimes they have to bring up the same problem at every visit to a clinic. Can you imagine? While this trend demonstrates positive health-seeking behavior among youth, it clearly shows that youth are not receiving the treatment that they really need. Furthermore, the service statistics reflect the issues youth initially report, NOT the real issues faced by youth.
In addition to the communication barriers, it seems clinic staff may simply not have enough time to deal with youth issues. Staff workload and staff shortages seem to take a toll on providers. Remember, these clinics are not only serving youth; there are many other members of the population that cannot be ignored.
Currently, there is an ‘impunity gap’ between national youth policies, guidelines, and strategies and the actual care provided at public health facilities. It is truly alarming! Something needs to be done structurally, behaviorally, and professionally to lessen this gap.
One way to immediately address this issue may be through peer networks. Peer educators can have great influences on peer members. Peer networks should focus on using positive deviance to sustainably change behavior; I believe this can be done without compromising the structure of the peer network.
While most of us enjoy working with youth because they are fun, we cannot forget that they are also vulnerable. There is still much that needs to be done to ensure that the reproductive health needs of young people are met.
Elizabeth Futrell is an associate technical officer at FHI, where she works on activities related to community-based family planning and youth sexual and reproductive health.
In late 2010, MTV aired No Easy Decision, a reality show that followed American teen mother Markai Durham and her partner James as they experienced a second unintended pregnancy before their firstborn child was a year old. A spinoff of the popular reality show 16 and Pregnant, No Easy Decision highlights the widespread problem of repeat adolescent pregnancy. In parts of the United States, one in four adolescent mothers experiences a repeat pregnancy within two years. In other regions of the world where early marriage is common and access to family planning services is scarce, the number is likely higher.
After the birth of her first child, Markai began using the injectable contraceptive Depo-Provera. Then Markai missed an appointment for Depo reinjection, but she didn’t worry. “I didn’t know that if you miss your Depo appointment that the Depo is completely out of your system. I thought I still had birth control inside of me.”
Markai is not alone. Among adolescents who have access to contraception, poor compliance, inconsistent use, and discontinuation are common and often result in unintended pregnancy. Longer-acting family planning methods—including contraceptive implants—provide more effective coverage than shorter-acting methods such as Depo-Provera and oral contraceptives (OCs). Researchers estimate that if 20 percent of the 17.6 million women using OCs and Depo in sub-Saharan Africa who wanted long-term protection switched to implants, more than 1.8 million unintended pregnancies could be averted over a five-year period.
According to the World Health Organization, implants are safe and appropriate for adolescents. Implants are discreet, easy to use, and effective for 3-5 years without any need for resupply or regular action by the user. In addition, implants remove the challenge of user compliance and therefore have a very low failure rate. Emerging research from Kenya shows that young women who plan to use OCs or injectables will often choose implants if they are appropriately counseled on this option. Preliminary results show that after six months, only 11 percent of young implant users switched methods or discontinued use compared to 42 percent of OC and Depo users. In this period, the young women using implants experienced no unintended pregnancies, while the young women using OCs or Depo had four unintended pregnancies and one intended pregnancy. Additional studies in the United States have reflected similar patterns. According to one study that tracked 309 adolescent mothers for two years, those using a method other than the implant or no method at all were 35 times more likely to experience a repeat pregnancy within a year than those using an implant.
Yet globally, relatively few adolescents are counseled on implants as a contraceptive option. In some cases, this is due to provider bias or unsubstantiated concerns about risks related to infertility, side effects, and patient acceptability. Furthermore, while many providers are trained to insert and remove implants, some report a low level of comfort or experience with this task. Anecdotal evidence also suggests that some providers in resource-poor settings save their limited supply of implants for older clients, whom providers assume are more sure they want to space or limit their pregnancies.
As No Easy Decision illustrates, adolescents face many social, cultural, financial, and geographical barriers to consistent use of family planning. These barriers include pressure from partners or family members to become pregnant or refrain from using a method; incomplete or incorrect knowledge of contraceptive options and how they work; and lack of access to youth-friendly services. Offering implants to more young clients—particularly adolescents who have already experienced a pregnancy and want to delay or limit future pregnancies—has the potential to greatly reduce rates of unintended pregnancy; unsafe abortion; and the related physical, social, financial, and emotional risks.
For more information, see the Extending Service Delivery project’s fact sheet, Implants for adolescents: An option worth considering for healthy timing and spacing of pregnancy and the FHI technical brief, Preliminary Report: Contraceptive Implants in Sub-Saharan Africa—Reaching Young Women.