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“Half the World,” your source of the most up-to-date news and information on youth sexual and reproductive, is now fully integrated into the IYWG website! We will still share exciting updates from the field, expert opinions, youth voices, and more in our new location. We know you will enjoy our new look and easier access to even more information and materials that our blog’s full integration with our new and improved IYWG website will provide. Continue to follow us, share our posts, and comment on “Half the World” here: http://www.iywg.org/blog

 

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We are working hard to provide our readers with the best experience possible and that is why we are building you an even better blog! This spring our blog will be fully integrated into our new and improved IYWG website. Stay tuned and in the meantime, follow us on Twitter, find us on Facebook and check out some of our friends’ blogs:© 2010 Subhankar Bhaduri, Courtesy of Photoshare

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This is the fifth post in our series, Adolescent Girls, Microbicides, and HIV Prevention Trials.  It was written by Ms. Doreen Bangapi, community recruitment officer. Ms Bangapi and Dr. Sylvia Kaaya, local principal investigator, are with Muhimbili University of Health & Allied Sciences (MUHAS) and work with FHI 360 on the study.

A total of 135 participants, ages 15 to 21,  have been recruited and enrolled into an ongoing mock clinical trial as part of the study entitled “Adolescent Women and Microbicide Trials: Assessing the Opportunities and Challenges of Participation.” A number of strategies have been used to recruit these adolescents and young women including information sessions for potential participants organized through community and ‘girl power’ meetings, meeting with students at their schools, word-of-mouth to relatives and neighbors of the study staff, and recruitment of regular clinic clients of the Infectious Disease Centre (IDC) where the study is being conducted. Other strategies included working with FHI 360’s local Tanzanian partners through NGOs and representatives who work with adolescent girls in the community.  In addition, some study participants recruited their friends, relatives and neighbors.

Locating interested participants is only the first challenge; there are also special logistical issues related to adolescent participation. For example, many potential participants lacked bus fare/transport to get to the clinic because they are financially dependent upon their parents or guardians. Others didn’t have a phone, which made it difficult to schedule clinic visits.  All of this was complicated by the fact that many participants did not want to disclose their study participation to parents or guardians and therefore could not ask for their assistance.

One recruitment strategy that was helpful for some participants was group recruitment.  While many participants were recruited as individuals, others were recruited as a group.  Some of the groups were comprised of friends from a neighborhood, others of classmates from school, others of a mix of friends and strangers recruited through a community information session. The group dynamics of coming in with friends or school peers was particularly supportive to the recruitment process.

Another helpful recruitment strategy was providing transport for some participants for baseline visits. Local daladalas,  or mini buses, were hired to bring potential participant groups to the clinic for study information sessions, including viewing a video by the International Partnership for Microbicides (IPM) about microbicides trials.  For other participants, a community recruitment assistant helped transport potential participants to the clinic through public transport by paying their bus fare and accompanying them to the clinic.

Once potential participants reached the study clinic, determining study eligibility was particularly challenging. To be eligible for the study, the young women needed to be between 15 and 21 years old, HIV negative, not pregnant and not wanting to have a child within the next 6 months, sexually active in the past three months, and able to attend the clinic for scheduled appointments.  While pregnancy testing was not an issue for the young women, some were not willing to get tested for HIV—especially those who came from high-risk populations, such as commercial sex workers.  Age verification was the most challenging aspect for determining eligibility. Many young women do not have documents like birth certificates, voting cards, health facility cards, or school records that could verify their age.  Study staff therefore had to (1) ask participants to complete an age verification form that asked a series of questions to help validate self-reported age and then (2) call a trusted adult who was familiar with the girl’s age for verification without revealing that the girl was participating in the study.

Once a participant is recruited into the study, retention is the next challenge. Our study staff are working hard to retain participants by calling them and making home visits. Other strategies include picking up participants from home and bringing them to the clinic for follow-up visits, informing them how important it is for them to attend their scheduled appointments, and explaining that the follow-up visits are shorter than the baseline visit. Some of the retention challenges include high mobility among adolescents (moving in and out of the city), loss of phone contact, and loss of peer support when a friend becomes ineligible to participate in the study at a follow-up visit (for example because she became pregnant between baseline and follow-up).  In summary, recruiting and retaining adolescents in a clinical trial can be challenging, but with special effort by the study team, they can be successful participants in HIV prevention trials.

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A young woman from Zimbabwe writes about adolescent pregnancy and the experiences of her peers as part of our Stories Behind the Statistic series, produced by the IYWG for the Gates Foundation blog, Impatient Optimists.

Working directly with young people in Zimbabwe, I have seen how adolescent pregnancy is a harsh reality that many young girls encounter. For these young girls, becoming pregnant is an ordeal that is hardly ever planned and is often the result of social, economic and financial circumstances that rob them of their autonomy.  

Because of very difficult economic conditions, many young women engage in intergenerational relationships.

For example,  one 14-year-old girl told me how being offered small gifts including sweets and chips resulted in her sexual relationships with older men, causing her to become pregnant, get married early, and endure an unsafe abortion. Other young girls hope to contribute to their family’s income by working on farms, and one girl told me how this has increased her risk of sexual violence. She has to travel long distances to fetch firewood and work in the fields. Being so far away from her home, without many people around, puts her at risk of sexual abuse. Sexual abuse or rape while working in the fields has left some young girls unwillingly pregnant and exposed to HIV and STI infection.

Sometimes young girls and women are overpowered by societal pressure exerted on them to get married early.

Society gives unmarried women nicknames such as “Chipo Chiroorwa,” which means “get married now or risk becoming ridiculed.” I have seen how, by succumbing to such pressure, these girls then have to deal with the overwhelming psychological trauma of becoming pregnant very young, giving up their dreams, and being forced into parenthood without necessarily being prepared for it. 

Natsai, aged 18, told me how becoming pregnant when she was 15 resulted in nothing but loss: loss of love, time, education and physical health. The first four months of the pregnancy were traumatic because she suffered quietly. She did not dare share her news with anyone because she feared rejection, stigma and discrimination from her family and community.

When her aunt discovered Natsai was pregnant, her aunt chased her from home, and she eloped with her boyfriend who was unemployed. She dropped out of school to look for a job on a nearby farm to fend for herself and her baby.  Natsai’s story typifies those of many girls and young women whom I have seen putting on brave smiles that hide sad stories about the detrimental effects that adolescent pregnancy has had on their lives.

Most young women I know who became pregnant were not ready to get married or drop out of school. Many were exposed to HIV infection, underwent unsafe abortions, and will deal with rejection all their lives. They have faced many adverse consequences as a result of getting pregnant before they are physically, emotionally, and socially mature enough to be mothers.

There is an African proverb that says, “It takes the whole village to raise a child.” Likewise, the issue of early and unintended pregnancy is not one individual’s responsibility; everyone has a role to play in preventing adolescent pregnancy. Young women need increased access to equal opportunities, education in sexual and reproductive health, youth-friendly services, social support, education, employment, and empowering life skills, so that unplanned childbearing does not hinder the achievement of their dreams at a young age.

To learn more about adolescent pregnancy visit the Interagency Youth Working Group’s “Adolescent Pregnancy” topic page.

Are you inspired to act on behalf of women and girls who deserve the opportunity to determine their own futures; who desperately need access to family planning education and contraceptives? Keep an eye out for ongoing information about, and ways to pledge support for, the upcoming Family Planning Summit on July 11, 2012. The Summit is being hosted by the Gates Foundation and the UK’s Department for International Development (DFID) with the aim of addressing the unmet need for contraceptives for the 120 million women in the poorest countries who, over the next eight years, will want and need but don’t have access to them. It’s about investing in women and girls and putting family planning front and center on the global agenda. Join the conversation with @gatesfoundation and check Impatient Optimists regularly for details.

We want to hear from you! We are currently conducting an online survey to find out what our readers think of us. Sharing the most up-to-date and relevant information on youth sexual and reproductive health is important to us. We want to be sure that the information we provide is useful to your work and helps reach the goal of improving the sexual and reproductive health of young people worldwide. 

We want to know what you have learned from the IYWG-supported activities and how your work might have benefitted from this information. Please take a few moments to fill out our online survey and share your thoughts. We’re grateful for your opinions!

Emma Brathwaite is a senior adolescent/youth health technical advisor at the Nossal Institute for Global Health (University of Melbourne) with 10 years of experience in HIV, AIDS, and sexual reproductive health. Her expertise focuses on program design and implementation and operational research for advocacy to develop national HIV responses. She specializes in HIV prevention programming with and for most-at-risk adolescents and youth and HIV and adolescent sexual reproductive health integration.

PLAY peer educators

Millions of young people around the world face very high risks of HIV infection and other negative outcomes. In Asia, 95 percent of new HIV infections among young people are in “key populations at higher risk,” who comprise only 5 percent of young people.[1]

Two behaviors of greatest risk for the transmission of HIV are penetrative sex (vaginal or anal) with multiple partners without using condoms, and sharing used needles and syringes to inject drugs. Unprotected vaginal sex is a risk not only for HIV transmission but also for other sexually transmitted infections and unplanned pregnancy.[2]

Kamus Peer Educators

The public health response has focused primarily on risk-reduction behavior change models for HIV prevention, which essentially rely on people being willing and able to change their behavior to reduce their own individual risk.

Sound easy? Perhaps not.

We asked young people in Indonesia what they thought. These young people are peer educators. Many of them sell sex and use drugs (sometimes both), and all of them are actively involved in HIV prevention activities.

PSA Peer Educators

They explain that behavior change is not easy. They say it takes time, practice, and patience. Behavior change takes much more than education alone. There are many characteristics of young people that need to be taken into consideration, especially for programs and also for policy. These include age and sex, whether or not they are attending school or work, what type of work, marital status, economic dependence, family relationships (and support), friendships (and peer pressure), and where they live (in urban or rural environments). All of these factors are interconnected, shape how young people act and interact, and can be a source of both risk and protection.

Adi explains: Sometimes you are the student, the son, the friend, sometimes you have to make money for the family – it’s like being an actor, you know. You play different roles all the time and this can be hard when you’re young because there’s so much going on. You’re not a child but you’re also not an adult – but people expect you to make adult decisions but then treat you like a child!

Adolescence is also a period of curiosity, risk-taking, and first-time experimentation with many things, sometimes including drugs and alcohol.

Ayo explains:

Friends have a really big influence on what we do, how we dress, the music we listen to, the type of phone we have…but also on the things you do—like having sex, trying drugs, motorbike racing. It depends on what group you’re hanging with, like punks, emos, b-boys. It’s not like they are pressuring you by saying “hey, try this” but it is the non-verbal pressure to do things, try things, and keep up. Being part of a group is important.

Perception of risk is a very important factor for adopting protective behavior, and it is critical in applying behavior change HIV prevention models.

Yuan explains:

It’s not just the risk behavior you have to think about. Most of us know the risk factors from trainings—unsafe sex, sharing needles. We know this! Everyone tells us “don’t do this, don’t do that!” But when we think about ourselves and our friends and we really think about whether we are at risk, then it becomes a bit personal and much harder. We might know (deep down) that we are in the “risk” category because of something we do, but it’s hard to admit that to ourselves, and admitting that, really knowing your own risk status means you have to make big changes in your life, and sometimes those changes are hard because it means changing who you are.

AYOMI Peer Educators

There remains much we don’t know about what influences risk perception, especially in youth, and the multi-level influences on behavior and health. Currently, the majority of youth HIV prevention programs operate on a series of overlapping assumptions: that young people are able to assess their own risk and know their risk status; that their individual perceptions of risk fit with program definitions of risk; that young people identify as belonging to an “at-risk” population; and that young people are suitably skilled, resourced, and empowered to access relevant services or attempt behavioral changes. As we work toward effective HIV prevention for young people, we also need to consider the following:

  • Adolescent risk behavior is often less fixed than adult behavior.

Karim explains:

Sex and drug use are sometimes experimental and might not continue. Sometimes young people might try something just to see what it’s like—it might be risky but it’s not permanent.

  • Young people are less likely to identify as a member of a high-risk or at-risk group.

Anyes explains:

Because unprotected sex or selling sex might happen only a few times, we think—it’s only this once…it doesn’t mean I am a “sex worker,” it means occasionally it might happen. Even if you do things and you know it’s risky—like injecting drugs—it doesn’t mean you think, “aha, I am an ‘injecting drug user.’” Being part of a group is important for young people in Indonesia but it doesn’t mean we are grouped as injecting drug users or sex workers. There is still a lot of stigma.
  • Young people are more easily exploited and abused.

Karla explains:

Getting clients [of sex workers] to use condoms is very difficult because the clients have all the power. When you first start working, you don’t even know what you’re entitled to, what your rights are, how to negotiate safety, where to get advice. Sometimes clients are violent, and for young people with less experience, it’s hard to know how to get out of the situation safely.

  • Young people are often less willing to seek out services.

Rahma explains:

Even if you know you need to see the doctor or need some advice, actually knowing where to go can be a barrier for some young people. But also, some things are illegal, like pre-marital sex, and so young people worry that if they go to a health service they might get in trouble or they worry that their parents will be informed and they worry they will bring shame to the family.

Aceh Partnerships in Health

The 2006-2008 Aceh Partnerships in Health (APiH) Facility was a health program designed to develop the capacity of local organizations to deliver quality health services. The first phase of the program commenced in February 2006. The facility focused on HIV, adolescent health, disability, policy, mental health, and organizational development. Phase two and phase three of this program continue its work in adolescent health, with a special focus on including HIV prevention in preparation for a coordinated provincial HIV response; HIV prevention among most-at-risk young people (particularly young transgender sex workers, young female sex workers, male street youth, and young drug users); design and implementation of the Life Skills in Schools Program; and a life skills out-of-school program. For further information: click here.

Peer educators: The youth-friendly medical clinic is co-located with a youth drop-in center (considered the headquarters for the peer education groups) and linked to the peer education programs. Together they provide a safe and supportive environment for young people, helping to increase clinic access, fostering positive peer/adult relationships, building HIV knowledge and communication/negotiation skills, and strengthening protective factors for young people. There are four main groups of peer educators connected to this program. All are actively working in Aceh Province in Indonesia. These young people are critical to the success of the program.

All young people involved in this story have given their consent (for photos and narrative). Names have been changed to protect their identity.

For more information, contact Emma Brathwaite: emmacb@unimelb.edu.au

 


[1] Presented to Mr. Ban Ki-moon, UN Secretary General. Redefining AIDS in Asia: Crafting an Effective Response. Report of the Commission on AIDS in Asia. 2008.

[2] UNICEF Regional Office for South Asia (UNICEF ROSA). Guidance Note: HIV prevention among most-at-risk and especially vulnerable adolescents and young people in South Asia. 2009.

When we surveyed our readers, you told us you wanted a more dynamic Web site. You asked for content that was updated more frequently to reflect the quick pace at which our field is growing and changing. And you requested an opportunity to participate in the conversation. We heard you! Welcome to Half the World, the new blog of the Interagency Youth Working Group.

Why “Half the World “? Because nearly half of the 7 billion people alive today are younger than 25, and almost 2 billion are between the ages of 10 and 19. This statistic isn’t news to most of you, but it bears repeating. Because this half represents some of the world’s most vulnerable people, who are also our future leaders, innovators, healers, parents, peacemakers, and educators.

Half the World will bring you regular updates on news about youth sexual and reproductive health. We’ll feature new programs, research, resources, and events. We’ll bring you stories from the field, written by guest bloggers around the world. But most importantly, we want to hear from you. We hope you’ll share your experiences and knowledge. Let us showcase your successes and find out how you’ve handled challenges. Use our blog as a platform for networking with other experts on youth and for learning from one another.

So please, comment, share, send your suggestions, and volunteer to blog on a topic that you care deeply about. Together, we can translate words on youth into improved health, safety, and well-being for young people worldwide.

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This blog is brought to you by the Interagency Youth Working Group (IYWG) with financial assistance from the U.S. Agency for International Development and the U.S. President's Emergency Plan for AIDS Relief. The content is managed by FHI, which functions as the secretariat for the IYWG.
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