Greetings,
We've had an exciting beginning to our month-long forum. In addition to the seven postings shown below, we got a number of messages from readers who plan to post comments or simply expressed thanks for the forum. The postings came from Belize, Finland, Ghana, Nigeria, Thailand, and the U.S. Even this small group illustrates the purpose for this forum: to provide a way for all of us to learn and specifically, to learn from the connection between global technical leadership and experiences in developing countries.
Hopefully, this forum will reflect the "research-to-practice "continuum of international public health where:
- field experiences lead to hypotheses about what is needed to improve efficiencies and/or outcomes;
- these hypotheses in turn lead to research activities - behavioral, biological, and operational;
- research findings and technical leadership efforts result in new knowledge and policies;
- expanded knowledge leads to new field practices, experiences, wisdom, and advocacy;
- and then this symbiotic circle continues with still more hypotheses.
In this forum, we encourage participants to pose questions that push us to a more substantive conversation, as some have done below. And, we urge those who make strong assertions — as others below have done — to provide the evidence for those assertions, either with research or with personal/program experience. We believe that "evidence" as we are calling it here can stem from the various points on the continuum described above — research, technical leadership, individual and program experiences, new hypotheses. We also welcome specific questions, which we will address as space allows.
Below, Dr. Cates offers some comments and responses to the first day's digest.
Sincerely,
Ed Scholl for the Forum Coordinators
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Thanks for the opportunity to comment briefly on these thoughtful postings.
As a group, they pose for me one of the challenging paradoxes in our field — the importance of seeing youth pregnancy prevention and HIV issues within broad social and cultural issues while at the same time keeping focused in terms of specific program actions. Margaret Thuo and Temitope Fadiya raise the complex issue of poverty and its role in pregnancy and HIV/AIDS for youth. R. Shabon encourages us to keep important international documents in mind that emphasize a rights-based approach. Babalola Faseru, Martin Foreman, and others emphasize barriers to services, especially the attitudes of providers. Emmanuel Edudzie raises challenging questions about the role of faith-based institutions.
Yet, with this array of cultural issues to consider, let's focus on two of the crucial questions Martin Foreman and Michelle Turton raise: First, how can the media, schools, and faith-based groups help support youth-friendly services to help prevent unintended pregnancy and STIs? Second, how can programs and youth better utilize emergency contraception in appropriate ways? I hope participants will address the questions posed here, including how they work with this paradox.
A few resources might help address some of the questions raised. Regarding youth services and provider attitudes, YouthNet has compiled an online annotated guide with links to 16 resources developed by the World Health Organization and leading international nongovernmental organizations, which can help guide communities and programs on many aspects of youth-friendly services. The Web page also provides background information including summaries of projects that have had positive results in improving services.
Regarding the request for information about emergency contraception, a growing number of resources exists, including a pill dedicated for this need and far more information. Yet much more needs to be done to educate youth and providers about emergency contraceptive pills. The International Consortium for Emergency Contraception provides excellent information and resources on its Web site.
I look forward to more comments as the week goes on.
Sincerely,
Ward Cates
Forum Digest 1
- Broad Context of Challenges
- Addressing Poverty Critical for African Youth
- Rights Based Approach
- Provider Attitudes Are Impediment
- Examples of Putting Ideas into Practice Needed
- What Has Worked with Faith-Based Institutions?
- Information on Contraception, including Emergency Contraception
1. Broad Context of Challenges
Even as we discuss all possible strategies for pregnancy and HIV prevention, it is critical to discuss major challenges facing youth today. A critical one is lack of parent-adolescent communication on sexuality matters. The second is lack of/inadequate youth-friendly services. The third is poverty that pushes adolescents to engage in sex in exchange for some kind of goods and services. Could we get experiences on research undertaken on these issues?
-- Margaret Thuo
2. Addressing Poverty Critical for African Youth
These are the days of increased sexual activity in view of the various media where "sex" has become a commodity to be traded. I quite agree with Dr. Cates that there are different categories of youth and each group has to be approached in a unique way. But, there are the African youths who are still living in a different world. I would like to say that unless the issue of poverty is addressed in the developing world, the necessary skills needed to negotiate sex will still be ignored. What I mean is that young people need education and training both from the society and the family to develop skills on how to negotiate sex with the opposite partner.
However, in a situation where there is poverty, then what is more important to the youth will be to have sex and get some money in her pocket. I have worked in a teaching hospital as a houseman in Nigeria before coming to Finland for studies in MPH, and I'd like to say that in the African society, the awareness about contraception in still low, because of a lot of myths about contraception!
I agree with Dr. Cates that youths are sexually active and all means to help protect them from the deadly HIV/AIDS must be adopted as a matter of policy. I admit, young ladies with HIV in the African society will be better off if provided with the appropriate contraception, but the ARVs [antiretrovirals], honestly speaking are still beyond the reach of many! It may remain so, until policy-makers will have a change of attitude towards this pandemic!
-- Temitope Abayomi Fadiya, MD, University of Kuopio, Finland
3. Rights Based Approach
I think we should take the right base approach in this issue. This will be in line with Universal Declaration of Human Rights, 1948; Convention on the Elimination of All Forms of Discrimination Against Women, 1979; Programme of Action, International Conference on Population and Development, Cairo 1994; and Platform for Action, Fourth World Conference on Women, Beijing 1995.
-- Dr. R. Shabon MD, MBA, DTM/DCP, Save the Children
4. Provider Attitudes Are Impediment
I think we need to look inwards. The situation of unmet adolescent reproductive health needs in the developing world must be examined from the point of an impediment within the health care system. Permit me to describe the impediment as "stigmatization and discrimination with regard to adolescent sexuality." These attitudes have made it difficult for youths to discuss their reproductive health needs with health care providers, some of who invariably are the perpetrators of such acts of discrimination and stigmatization because of lack of respect for persons irrespective of age and several breaches of confidentiality. I know many of these youths would rather go on the internet to find information when compared with one-on-one counseling because of fear of being chastised by people who are supposed to render assistance.
Therefore, the risks of HIV infections and unwanted pregnancy from unprotected sexual exposures are heightened by the attitude of health workers. These negative attitudes in most cases, especially in the developing countries are deeply rooted in culture. It is highly imperative for health care workers in the developing countries especially Sub-Saharan Africa to face reality. As much as it is expedient to emphasize abstinence as the best and sure way of protecting against unwanted pregnancy and HIV/AIDS, we should realize that the age of sexual debut has dropped.
The situation of HIV and AIDS calls for a reorientation of health care providers. Health care providers need to consider the ethics of their profession which is not restricted to curative medicine or research but also to preventive medicine as well. Youths have a right to information without the fear of victimization, stigmatization and discrimination especially from those who are supposed to care.
-- Babalola Faseru, Department of Community Medicine, University College Hospital, Nigeria
5. Examples of Putting Ideas into Practice Needed
I very much appreciated Ward Cates' analysis of the different groups of young people and their needs. However, I'd like to take the discussion further by looking for examples which show how to put these ideas into practice. I have three questions. Answers from participants giving their own experiences would be very useful.
- Young People Prior to Sexual Initiation. What is the best forum to pass on skills and information to this group? Schools? Faith-based organizations? the media? And what are the obstacles and advantages of each forum?
- Sexually Experienced Young People, Unmarried. Many of these will have left school, reducing the options to pass on information. Many will be transient as they look for work. What are the options here for providing information and training in communication skills?
- While it is relatively simple to provide services, it is a much greater challenge to ensure that those services are used. How can cultural barriers to reproductive health services among young people be overcome?
-- Martin Foreman, consultant in HIV and sexuality based in southeast Asia, chair of the YouthNet Technical Advisory Group
6. What Has Worked with Faith-Based Institutions?
I think that there could be no better way to summarise the issues in the way Dr. Cates has. What is more impressive is the categorisation of those with the unmet need. But what I would even say here may be to solicit a further breakdown of the categories is the issue of religious interference/beliefs that hamper the use of contraceptives. Do we have some experiences of what has worked elsewhere in addressing this kind of situation?
-- Emmanuel Edudzie, Youth Employment Summit Ghana Network
7. Information on Contraception, including Emergency Contraception
I think two very important points were highlighted by Dr. Cates — making contraception available to young women with HIV and getting information out about emergency contraception.
I would like to share a brief story of a young female friend of mine. She is in a common-law relationship with a man and got pregnant. During her pregnancy, she had sex with her partner and later found out that he had unprotected sex with other partners. She was horrified to find this out because she realized that he had put both her life and that of their unborn child at risk if he had become infected with HIV.
This story made me realize the importance of educating and making contraception available not only to young women infected with HIV, but also [making protection against HIV available] to those who are pregnant. Our young men also need to be educated on this issue so that they realize that their irresponsible behavior endangers not only one life (their own) but the lives of two more (mother and child).
I believe much more education needs to be done on the topic of emergency contraception. It would be very helpful if a little more information could be given on this topic.
-- Michelle Turton, BFLA, Belize
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