JOURNAL OF ADOLESCENT HEALTH 1992;13:351-354
CONFERENCE PROCEEDINGS
PRAMILLA SENANAYAKE, M.B.B.S.,
D.T.P.H.,
What is sexual health? It may mean different things to different people. Existing definitions of sexual health suggest a state of well-being in terms of expressions of sexuality, the prevention of sexually transmitted diseases including acquired immunodeficiency syndrome, prevention of unwanted pregnancy, the planning of wanted pregnancies and the achievement of safety and equality in sexual relationships (1). Education is one method of providing an opportunity for people to enjoy healthy sexuality. The approaches taken in sexual health education have to reflect the political, social, religious, and cultural milieux in which they is carried out. The term Family Life Education (FLE) is a culturally sensitive approach to sexual health education. By avoiding directly sexual terms it is more acceptable to societies, especially conservative countries like my own, Sri Lanka. This is symptomatic of the sensitiveness of sexual health education. The so-called “problem” that adolescents pose to the adult society in the sexual sphere stems from what might be termed a chronological mismatch between their biological potential to procreate and the social status which society awards them, in which sexuality plays no clear part. Although their behavior is a result of the interaction between biological changes and social environment, adults see the resulting sexual interests more as an inconvenience From the lnternationnl Planned Parenthood Federation, London, United Kingdom. Address reprint requests to: Pramilla Senanayake, M.B. B.S., D.T.P.H., Ph.D. Assistant Secretary General International Plunned Parenthood Federation, Regent’s College, inner Circle, Regent’s Park, London NW1 4NS, United Kingdom. This paper was presented at the 5th Congress of the International Association for Adolescent Health, july 3-6, 2991. Montreux, Switzerland. Manuscript accepted September29, 1991.
Ph.D.
than an inevitability. Many cultures have historically managed the consequences of young people’s sexual activity by minimizing the chronological mismatch; in industrialized societies and, to an increasing extent, in developing countries adolescence has been maximally extended mainly owing to economic reasons. The problems of adolescence which result from biological and social maturation are compounded by society’s inability/unwillingness to offer the necessary means to manage an artificially protracted period of adolescence (2). In (FLE) for young people it is particularly important to acknowledge their special needs. Some cultures consider that FLE for young people will encourage promiscuity, and this has precluded development of programs designed for youth. Since the 198Os, however, there has been an increasing acknowledgment of the needs of youth. The growing incidence of teenage pregnancy combined with high growth rates and falling mortality in the third world is producing fast-growing populations. During the 1980s governments have come to recognize this and have started to actively support family planning (FP) initiatives; however, these programs have seldom been geared to youth. Government programs for compulsory FLE in schools have, however, opened opportunities for FP organizations to expand approaches to reach other groups of young people. For example, in Mali the government in partnership with the International Planned Parenthood Federation (IPPF) member organization, AMPPF (Association Malienne pour la Protection et la Promotion de la Famille) have trained 150 extension workers to mobilize youth and introduce them to FLE. Who are the youth that these programs are targeting? They incorporatevariousseparate and overlapping categories of young people; girls and boys; students; those not in schools; married couples; em-
8 Society for Adolescent Medicine, 1992 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
351
352
SENANAYAKE
ployed; unemployed; street youth; sexually active youth those not yet sexually active; etc. No one approach can hope to cover all groups and FLE programs have to be directed and focused. A positive approach requires that the needs of the youth concerned be identified. It is important to be aware of what the youth themselves know, how they have acquired that knowledge, what they want to how, and how best to present this information to them. A prerequisite for any program of FLE is mental preparation of the adult population (3). Adults may acknowledge the need for FLE but shy away from the applications. Thus, training of adults is as vital as educating youth. An excellent effort was made at the Technical Discussions held during the World Health Assembly (WHA) 1989. The delegates to the WHA are Ministers of Health and Senior Government Health Officials who are no longer young. It was, however, considered important to ensure that these senior officials had a positive feeling for youth in order that they could stimulate the development of youth-oriented projects at country level. In the day and a half that was available for Technical Discussions, innovative approaches never before seen at WHA were utilized. Young people were invited to participate at these discussions. Through roleplay, they were able to depict major issues that concern youth and express their views and perceptions (4). The innovative nature of the presentation was effective in impressing on the adults the opinions of young people. Recent Asian and African programs illustrate how positive approaches to sexual health education can be developed. In Ethiopia, the Youth Counselling Services and Family Planning Education Project was set up in February 1990. It paid attention to gaining support from the senior government officials including educational offkers, Liaison with the government may not be appropriate in all circumstances and each country presents a unique situation. Similarly, publicity may not always benefit the project especially when it is culturally sensitive. In other hdances it can be a bonus as in the Ethiopian project which was publicized extensively on television, radio, and in the press. Another element of the Ethiopian project was the establishment of a committee providing professional advice to the volunteers (5). The outreach components of the Ethiopian project focus on youth in and out of school through vohnteer-run sexual health education activities. College students are reached through student distribution of information from the Youth Association Recreation Centre. Studies have shown that youth
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 5
seek information from their own peer group rather than from adults. This can sometimes lead to misinformation being handed from young person to young person. The methods applicable to each project, thus, have to be culturally specific. Various traditional and less traditional, formal and informal methods have been developed for FLE to youth. The most recent projects concentrate on youth-designed and youth-implemented projects. In the Ethiopian Project (housed in the Youth Association Recreation Centre) consideration was given to factors including working hours, staff attitude and hospitality toward the youths. Different methods have been used in youth projects to transfer information from young people to other young people. Some examples of these are: 1. Drama. A well-acted play is a means of attracting not only the target population but parents as well. A one-act play produced by young volunteers in Ethiopia was staged in 12 secondary schools to 30,000 youths and demonstrated the problems surrounding unwanted pregnancy. Drama has also been used in other projects as an effective method of passing on messages to youth. 2. Songs. One of the oldest and most effective ways of reaching youth is through songs. Songs were used in Ethiopia. They have also been used in countries like Zimbabwe. There, out of group discussions with young people, a song on “sugar daddies” was written and translated into the indigenous languages and produced commercially alongside a second song on responsible parenthood. 3. Roleplay. This form of art allows youth an easy forum to express their emotions without necessarily linking them directly to the individual. Roleplay has been a heavy emphasis of the working group sessions of the Youth for Youth Networking approach coordinated by IPPF. 4. Literature. In Zimbabwe young people designed a booklet of stories and cartoons depicting the problems of adolescents. Subtle changes in the approach, such as altering the title from “Advice to Young People” to “Facts about Growing Up” were important reflections on how youthdesigned projects can be more appropriate (6). In Ethiopia the Centre has a reading room and has distributed over 4,500 free FLE booklets to over 2,000 adolescents in a single year. 5. Videos and film shows. These are increasingly becoming a valuable method of reaching youth. In Zimbabwe, however, the “Village TV” used
July 1992
for FLE is simply a wooden box with a cloth screen which demonstrates innovation and flexibility in FLE approaches! The Ethiopian projects have video and film show sessions. This technology is flexible and easy to use on visits to outreach locations. 6. Radio. The “Swazi Teenager” is a radio program in Swaziland focusing on youth issues through articles, letters, and discussion. It has received much positive feedback from youth. It allows anonymous communication which is particularly favored by adolescents (7). 7. Telephone. A telephone hotline in Mauritius has been running since 1978 with an average of eight calls a day. The callers are often referred to clinics and counselors. A booklet has been produced from a summary of the youths’ concerns which included biological and psychological problems. A similar service is running in Hong Kong. The anonymous element is fundamental to this method’s attraction. Positive approaches to sexual health education often integrate FLE with another focus of development. For example: youth centers. As already mentioned the Ethiopia Youth Counselling Service is based in a pre- existing youth center. It is unusual in that it not only provides information but also contraceptive service delivery and has 1,925 registered condom clients after a single year. 2. Integration with income generation projects. In Mali and Togo skills training and income generation projects have FLE included acting as what has been described as a “springboard” for FLE (8). The development of economic independence supports the goals of sexual health. A particular example is in Seeulu, Mali, where single mothers are given access and training on sewing machines and support afterward in a collective. 3. Integration with non-governmental organizations (NGOs). The promotion of adolescent reproductive health through NGO collaboration is the theme of the Youth for Youth project. This project is the outcome of a the Better Health for Women and Children through Family Planning Conference held in Nairobi in October 1987, which emphasized the need to intensify education and services for youth in reproductive health by involving them in defining solutions to their own reproductive health problems. The conference sponsors, especially the United Nations Population Fund and the World Health Organi1.
EDUCATION FOR SEXL;AL HEALTH
353
zation, recommended that collaboration with international and national NGOs would provide an effective approach to dealing with this issue. This project, therefore, focuses on establishing collaboration (networks) of youths and NGOs at both the international and national levels to enable young people to maintain or improve their reproductive health (9). The Youth for Youth project that IPPF is coordinating in Senegal is also being carried out in four other countries-Colombia, Egypt, Jamaica, and Sri Lanka. These projects are diverse, covering a wide part of the community and deflecting concern that youthrelated NGOs are limited in the type of youth they can reach. For example, the five projects in Sri Lanka focus on 1) awareness regarding FLE in rural populations, 2) implementation of FLE in an urban slum area, 3) education for marriage to a selected population from youth-related NGOs, 4) creation of positive parent and teacher attitudes for FLE programs in schools, and 5) education of youth on the nature and dangers of unsafe or self-induced abortion.
These projects demonstrate that the opportunities resulting from NGO networking are vast (10).
Conclusions In Asia and Africa, as in other parts of the world, positive approaches to sexual health education do exist and are being developed. They have to incorporate a complexity of elements derived from the society in which they operate and the youth they serve. Many factors are important in project design from implementation considerations, to methodology, location, timing, and target group. No one approach is the correct approach, and many innovative and integrated projects are proving successful. In such projects it is of course difficult to estimate exactly the impact on attitudes and behavior, but qualitative evaluations can be carried out. For the future, it is important to maintain Sexual health education as a fundamental element and to reach more of the young population. An important development should be the integration of FLE into primary school in order to reach young people before they start dropping out of education. In Sri Lanka, for example., over 40% of youths primarily in rural areas, have left school by the age of 14 years. The out-of-school unemployed population are, thus, also an important target area. Integration of FLE into pre-existing programs with these youth would be a
354
SENANAYAKE
positive development. Asia and Africa contain a diversity of cultures, which is reflected in the variety of projects developed. There is plenty of potential for even more diversity in the future.
References I. Klouda T. Sexual health.
London: International Planned Parenthood Federation AIDS Unit, 1990. 2. Meredith P, ed. Adolescents: Planning contraceptive and counselling services. London: International Planned Parenthood Federation, 1985. 3. Kodagoda N. Guidelines on family health education from Sri Lanka. World Health Forum, 1986;7:281-5.
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 5
4. World Health Organization. Report of the technical discussions on the health of youth at World Health Assembly Geneva: WHO, 1989. 5. Meshesha B. Youth Counselling Services and Family Planning Education Project, Addis Ababa-Ethiopia, a paper prepared for presentation in the workshop on youth and sexuality-Paris, July 8-11 1991. 6. International Planned Parenthood Federation. Zimbabwe: a song, a book and a village TV. People 1989;16:23. 7. International Planned Parenthood Federation. Radio Programme, Swazi Teenager. Africalink 1990;2:12. 8. International Planned Parenthood Federation. 1990; Special Reports-Togo, Mali, Mauritius, Ethiopia. Africalink 1990; 2:5-l& 9. Intematicnal Planned Parenthood Federation. Youth for Youth summary pamphlet. London: IPPF, 1990. 10. International Planned Parenthood Federation. Youth for Youth progress report. London: IPPF, 1991.
CONFERENCE PROCEEDINGS
PRAMILLA SENANAYAKE, M.B.B.S.,
D.T.P.H.,
What is sexual health? It may mean different things to different people. Existing definitions of sexual health suggest a state of well-being in terms of expressions of sexuality, the prevention of sexually transmitted diseases including acquired immunodeficiency syndrome, prevention of unwanted pregnancy, the planning of wanted pregnancies and the achievement of safety and equality in sexual relationships (1). Education is one method of providing an opportunity for people to enjoy healthy sexuality. The approaches taken in sexual health education have to reflect the political, social, religious, and cultural milieux in which they is carried out. The term Family Life Education (FLE) is a culturally sensitive approach to sexual health education. By avoiding directly sexual terms it is more acceptable to societies, especially conservative countries like my own, Sri Lanka. This is symptomatic of the sensitiveness of sexual health education. The so-called “problem” that adolescents pose to the adult society in the sexual sphere stems from what might be termed a chronological mismatch between their biological potential to procreate and the social status which society awards them, in which sexuality plays no clear part. Although their behavior is a result of the interaction between biological changes and social environment, adults see the resulting sexual interests more as an inconvenience From the lnternationnl Planned Parenthood Federation, London, United Kingdom. Address reprint requests to: Pramilla Senanayake, M.B. B.S., D.T.P.H., Ph.D. Assistant Secretary General International Plunned Parenthood Federation, Regent’s College, inner Circle, Regent’s Park, London NW1 4NS, United Kingdom. This paper was presented at the 5th Congress of the International Association for Adolescent Health, july 3-6, 2991. Montreux, Switzerland. Manuscript accepted September29, 1991.
Ph.D.
than an inevitability. Many cultures have historically managed the consequences of young people’s sexual activity by minimizing the chronological mismatch; in industrialized societies and, to an increasing extent, in developing countries adolescence has been maximally extended mainly owing to economic reasons. The problems of adolescence which result from biological and social maturation are compounded by society’s inability/unwillingness to offer the necessary means to manage an artificially protracted period of adolescence (2). In (FLE) for young people it is particularly important to acknowledge their special needs. Some cultures consider that FLE for young people will encourage promiscuity, and this has precluded development of programs designed for youth. Since the 198Os, however, there has been an increasing acknowledgment of the needs of youth. The growing incidence of teenage pregnancy combined with high growth rates and falling mortality in the third world is producing fast-growing populations. During the 1980s governments have come to recognize this and have started to actively support family planning (FP) initiatives; however, these programs have seldom been geared to youth. Government programs for compulsory FLE in schools have, however, opened opportunities for FP organizations to expand approaches to reach other groups of young people. For example, in Mali the government in partnership with the International Planned Parenthood Federation (IPPF) member organization, AMPPF (Association Malienne pour la Protection et la Promotion de la Famille) have trained 150 extension workers to mobilize youth and introduce them to FLE. Who are the youth that these programs are targeting? They incorporatevariousseparate and overlapping categories of young people; girls and boys; students; those not in schools; married couples; em-
8 Society for Adolescent Medicine, 1992 Published by Elsevier Science Publishing Co., Inc., 655 Avenue of the Americas, New York, NY 10010
351
352
SENANAYAKE
ployed; unemployed; street youth; sexually active youth those not yet sexually active; etc. No one approach can hope to cover all groups and FLE programs have to be directed and focused. A positive approach requires that the needs of the youth concerned be identified. It is important to be aware of what the youth themselves know, how they have acquired that knowledge, what they want to how, and how best to present this information to them. A prerequisite for any program of FLE is mental preparation of the adult population (3). Adults may acknowledge the need for FLE but shy away from the applications. Thus, training of adults is as vital as educating youth. An excellent effort was made at the Technical Discussions held during the World Health Assembly (WHA) 1989. The delegates to the WHA are Ministers of Health and Senior Government Health Officials who are no longer young. It was, however, considered important to ensure that these senior officials had a positive feeling for youth in order that they could stimulate the development of youth-oriented projects at country level. In the day and a half that was available for Technical Discussions, innovative approaches never before seen at WHA were utilized. Young people were invited to participate at these discussions. Through roleplay, they were able to depict major issues that concern youth and express their views and perceptions (4). The innovative nature of the presentation was effective in impressing on the adults the opinions of young people. Recent Asian and African programs illustrate how positive approaches to sexual health education can be developed. In Ethiopia, the Youth Counselling Services and Family Planning Education Project was set up in February 1990. It paid attention to gaining support from the senior government officials including educational offkers, Liaison with the government may not be appropriate in all circumstances and each country presents a unique situation. Similarly, publicity may not always benefit the project especially when it is culturally sensitive. In other hdances it can be a bonus as in the Ethiopian project which was publicized extensively on television, radio, and in the press. Another element of the Ethiopian project was the establishment of a committee providing professional advice to the volunteers (5). The outreach components of the Ethiopian project focus on youth in and out of school through vohnteer-run sexual health education activities. College students are reached through student distribution of information from the Youth Association Recreation Centre. Studies have shown that youth
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 5
seek information from their own peer group rather than from adults. This can sometimes lead to misinformation being handed from young person to young person. The methods applicable to each project, thus, have to be culturally specific. Various traditional and less traditional, formal and informal methods have been developed for FLE to youth. The most recent projects concentrate on youth-designed and youth-implemented projects. In the Ethiopian Project (housed in the Youth Association Recreation Centre) consideration was given to factors including working hours, staff attitude and hospitality toward the youths. Different methods have been used in youth projects to transfer information from young people to other young people. Some examples of these are: 1. Drama. A well-acted play is a means of attracting not only the target population but parents as well. A one-act play produced by young volunteers in Ethiopia was staged in 12 secondary schools to 30,000 youths and demonstrated the problems surrounding unwanted pregnancy. Drama has also been used in other projects as an effective method of passing on messages to youth. 2. Songs. One of the oldest and most effective ways of reaching youth is through songs. Songs were used in Ethiopia. They have also been used in countries like Zimbabwe. There, out of group discussions with young people, a song on “sugar daddies” was written and translated into the indigenous languages and produced commercially alongside a second song on responsible parenthood. 3. Roleplay. This form of art allows youth an easy forum to express their emotions without necessarily linking them directly to the individual. Roleplay has been a heavy emphasis of the working group sessions of the Youth for Youth Networking approach coordinated by IPPF. 4. Literature. In Zimbabwe young people designed a booklet of stories and cartoons depicting the problems of adolescents. Subtle changes in the approach, such as altering the title from “Advice to Young People” to “Facts about Growing Up” were important reflections on how youthdesigned projects can be more appropriate (6). In Ethiopia the Centre has a reading room and has distributed over 4,500 free FLE booklets to over 2,000 adolescents in a single year. 5. Videos and film shows. These are increasingly becoming a valuable method of reaching youth. In Zimbabwe, however, the “Village TV” used
July 1992
for FLE is simply a wooden box with a cloth screen which demonstrates innovation and flexibility in FLE approaches! The Ethiopian projects have video and film show sessions. This technology is flexible and easy to use on visits to outreach locations. 6. Radio. The “Swazi Teenager” is a radio program in Swaziland focusing on youth issues through articles, letters, and discussion. It has received much positive feedback from youth. It allows anonymous communication which is particularly favored by adolescents (7). 7. Telephone. A telephone hotline in Mauritius has been running since 1978 with an average of eight calls a day. The callers are often referred to clinics and counselors. A booklet has been produced from a summary of the youths’ concerns which included biological and psychological problems. A similar service is running in Hong Kong. The anonymous element is fundamental to this method’s attraction. Positive approaches to sexual health education often integrate FLE with another focus of development. For example: youth centers. As already mentioned the Ethiopia Youth Counselling Service is based in a pre- existing youth center. It is unusual in that it not only provides information but also contraceptive service delivery and has 1,925 registered condom clients after a single year. 2. Integration with income generation projects. In Mali and Togo skills training and income generation projects have FLE included acting as what has been described as a “springboard” for FLE (8). The development of economic independence supports the goals of sexual health. A particular example is in Seeulu, Mali, where single mothers are given access and training on sewing machines and support afterward in a collective. 3. Integration with non-governmental organizations (NGOs). The promotion of adolescent reproductive health through NGO collaboration is the theme of the Youth for Youth project. This project is the outcome of a the Better Health for Women and Children through Family Planning Conference held in Nairobi in October 1987, which emphasized the need to intensify education and services for youth in reproductive health by involving them in defining solutions to their own reproductive health problems. The conference sponsors, especially the United Nations Population Fund and the World Health Organi1.
EDUCATION FOR SEXL;AL HEALTH
353
zation, recommended that collaboration with international and national NGOs would provide an effective approach to dealing with this issue. This project, therefore, focuses on establishing collaboration (networks) of youths and NGOs at both the international and national levels to enable young people to maintain or improve their reproductive health (9). The Youth for Youth project that IPPF is coordinating in Senegal is also being carried out in four other countries-Colombia, Egypt, Jamaica, and Sri Lanka. These projects are diverse, covering a wide part of the community and deflecting concern that youthrelated NGOs are limited in the type of youth they can reach. For example, the five projects in Sri Lanka focus on 1) awareness regarding FLE in rural populations, 2) implementation of FLE in an urban slum area, 3) education for marriage to a selected population from youth-related NGOs, 4) creation of positive parent and teacher attitudes for FLE programs in schools, and 5) education of youth on the nature and dangers of unsafe or self-induced abortion.
These projects demonstrate that the opportunities resulting from NGO networking are vast (10).
Conclusions In Asia and Africa, as in other parts of the world, positive approaches to sexual health education do exist and are being developed. They have to incorporate a complexity of elements derived from the society in which they operate and the youth they serve. Many factors are important in project design from implementation considerations, to methodology, location, timing, and target group. No one approach is the correct approach, and many innovative and integrated projects are proving successful. In such projects it is of course difficult to estimate exactly the impact on attitudes and behavior, but qualitative evaluations can be carried out. For the future, it is important to maintain Sexual health education as a fundamental element and to reach more of the young population. An important development should be the integration of FLE into primary school in order to reach young people before they start dropping out of education. In Sri Lanka, for example., over 40% of youths primarily in rural areas, have left school by the age of 14 years. The out-of-school unemployed population are, thus, also an important target area. Integration of FLE into pre-existing programs with these youth would be a
354
SENANAYAKE
positive development. Asia and Africa contain a diversity of cultures, which is reflected in the variety of projects developed. There is plenty of potential for even more diversity in the future.
References I. Klouda T. Sexual health.
London: International Planned Parenthood Federation AIDS Unit, 1990. 2. Meredith P, ed. Adolescents: Planning contraceptive and counselling services. London: International Planned Parenthood Federation, 1985. 3. Kodagoda N. Guidelines on family health education from Sri Lanka. World Health Forum, 1986;7:281-5.
JOURNAL OF ADOLESCENT HEALTH Vol. 13, No. 5
4. World Health Organization. Report of the technical discussions on the health of youth at World Health Assembly Geneva: WHO, 1989. 5. Meshesha B. Youth Counselling Services and Family Planning Education Project, Addis Ababa-Ethiopia, a paper prepared for presentation in the workshop on youth and sexuality-Paris, July 8-11 1991. 6. International Planned Parenthood Federation. Zimbabwe: a song, a book and a village TV. People 1989;16:23. 7. International Planned Parenthood Federation. Radio Programme, Swazi Teenager. Africalink 1990;2:12. 8. International Planned Parenthood Federation. 1990; Special Reports-Togo, Mali, Mauritius, Ethiopia. Africalink 1990; 2:5-l& 9. Intematicnal Planned Parenthood Federation. Youth for Youth summary pamphlet. London: IPPF, 1990. 10. International Planned Parenthood Federation. Youth for Youth progress report. London: IPPF, 1991.
