Transcript Youth for Youth (Y4Y) Program: Testing a Comprehensive

The Youth for Youth (Y4Y)
Program in Western Kenya
Y4Y
K-MET/
UCLA
Testing a Comprehensive
Adolescent Education and
Services Model to Reduce
HIV/STDs and Teen Pregnancies
by Paula Tavrow, PhD
UCLA School of Public Health
February 6, 2004
Acknowledgements

UCLA Globalization Research
Center – Africa (sponsors)

Edmond Keller, Director

Charisma Acey

UCLA Y4Y Development Team

Paula Tavrow, PI

Edith Mukudi, Co-PI

Rebecca Morris

Tarik Benbahmed

Karen Michail

Adesuwa Ogiamien

Kyle Pusateri

JC Walsh

Kenya Y4Y Management Team

Kitche Magak, K-MET

Albert Obbuyi

Vidalyne Omollo
All photos by Rebecca Morris
Webuye division, Bungoma district, Kenya
Adolescents worldwide:
Key facts

Nearly one-sixth of the
world’s population is
between 10-19 years old

About 84% of the world’s
adolescents live in
developing countries

Nearly one-half of new HIV
infections are occurring
among young people
Source: Youthnet (2003)
New HIV infections in 2003
Problem of HIV/AIDS in Africa

29 million Africans
estimated to be
HIV+; half under 25
years old

Young women in
Africa twice as likely
to get infected as
young men

One in seven
children in some
African countries
have lost one or
both parents to AIDS
Source: UNAIDS (2003)
Risk factors for African youth -1
Personal

Lack of knowledge; belief in low personal risk

Low self-efficacy, especially of girls

Low self-esteem

Belief in low personal risk

Male desire to be “masculine” or virile

Belief that abstinence can be injurious to boys’ health

Misconceptions or dislike of condom
Risk factors for African youth -2
Interpersonal

Peer pressure for early sexual activity

Belief that condoms signify mistrust, promiscuity

High incidence of coerced sex

Youths often barter sex for goods or services

Multiple sex partners
Structural

Barriers to youths’ acquisition of correct information
about reproductive health

Barriers to youths’ use of reproductive health services

Due to poverty and lack of life skills, youths are
vulnerable to older sexual partners, who may be HIV+
Location of project:
Kenya
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Bungoma
District
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
Sources: World Bank (2002), UNAIDS (2003),
Demographic and Health Survey (1998)
Population: 31.3 million
GDP per capita: $995
Literacy rate: 84%
Fertility rate: 4.3 births/ woman
Roads paved: 12%
Est’d HIV prevalence: 6.7- 9.4%
(~1.5 million have died of AIDS)
Est’d HIV prevalence (15-24 yrs):
Girls: 11-15%; Boys: 4-9%
Est’d AIDS orphans: 890,000
Kenyan teens reported being
pregnant or given birth: 20%
Adolescent sexual activity
<20%
Philippines
Rwanda
Peru
8.1%
14.2%
18.4%
21- 30%
Kazakstan
Brazil (NE)
Bolivia
Guatemala
Domin. Rep.
Colombia
Haiti
Zimbabwe
20.5%
22.5%
22.9%
25.0%
26.9%
29.6%
29.0%
29.7%
Percent of
adolescents
who report ever
had sex (10-19)
51- 60%
Burkina Faso
Ghana
54.1%
59.0%
31- 40%
Paraguay
Senegal
30.1%
35.4%
41- 50%
Namibia
U.S.
Kenya
Tanzania
42.4%
46.0%
46.1%
49.9%
61- 70%
Zambia
Niger
Uganda
Central Afr. Rep.
Mali
Côte d’Ivoire
Cameroon
60.5%
60.9%
61.6%
62.0%
66.0%
68.1%
68.5%
Sources: Demographic and Health Surveys (1998-2001) ; US data from Advocates for Youth (2003)
Adolescent contraceptive use
Percent of
sexually active
15-19 year olds
using any
contraceptive
method at last sex
<10%
Malawi
Niger
Rwanda
Zambia
Guatemala
Paraguay
7.9%
8.4%
7.5%
3.5%
6.1%
9.2%
11- 20%
Kenya
Madagascar
Senegal
Tanzania
Uganda
Bolivia
Domin. Rep.
Haiti
12.5%
13.7%
15.8%
16.5%
16.9%
14.8%
14.2%
14.3%
31- 40%
Nigeria
Côte d’Ivoire
Kazakstan
30.7%
34.9%
39.0%
21- 30%
Peru
Columbia
Brazil (NE)
Zimbabwe
Namibia
Mali
Ghana
C. African
Republic
Burk. Faso
22.7%
25.6%
22.5%
20.5%
22.5%
25.6%
22.4%
20.4%
21.3%
40% +
Cameroon
U.S.
52.7%
75.0%
Sources: Demographic and Health Surveys (1998-2001); US data from Advocates for Youth (2003)
Why Kenyan youth are not getting
reproductive health education & services

Parents traditionally do not talk
about sex with children

Teachers uncomfortable with sex
education: pick what to teach

Government’s latest AIDS
curriculum excludes condoms

Most churches and elders oppose
contraceptives education for youth:
believe leads to sexual immorality

Catholic churches preach HIV virus
can pass through condoms

Many health providers reluctant to
give youth contraceptives: believe
encourages promiscuity
Challenges in designing programs
to reach rural Kenyan youth

Less than 40% of youth
enter secondary school

About 90% of rural primary
schools and 50% of
secondary schools lack
electricity

Less than 10% of schools
have a library

Less than 1% of youth have
access to internet

Health facilities often
inaccessible to youth
(distance, hours, costs)
Lessons learned from other
adolescent programs
Education
• Train peers to convey sexuality information
• Use structured, comprehensive curriculum
• Develop relevant life skills
• Spend enough time and be interactive
• Train older youth to educate younger youth
• Include out-of-school youth
Services
• Combine education with services
• Use peers to deliver services
• Actively ensure services are youth-friendly
• Build on what exists and what youths want
• Be affordable and replicable
Goals of Youth for Youth (Y4Y)
To test whether a comprehensive adolescent reproductive
health education and services model in rural Africa can:

Increase youth’s knowledge about reproductive health

Reduce unwanted pregnancies and unsafe sex

Increase youth’s use of health clinics

Be sustained and replicated in-country
Main components of Y4Y
1. Extra-curricular education
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Peer sexuality education and skills-building in
secondary schools
Peer sexuality education and skills-building among
church-affiliated out-of-school youth
Mentor education and skills-building in primary schools
2. Adolescent-focused service delivery

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Development of a network of youth-friendly
health clinics
Teen peer providers in health clinics
3. Ongoing monitoring

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Youth satisfaction with health services
Regular meetings of peer educators (PALS)
Y4Y
K-MET/
UCLA
Conceptual framework of Y4Y
Church
Church
PALS*
2. Magic Bag of
puppets, games,
books
PALS*
(Peer
educators
)
Peer HIV/AIDS and
reproductive health
education
Peer
prov
ider
s)
1. 10-week structured curriculum
School
PAL
Features of
PALS-led
education:
Youthfriendly
health
facility
Peer
educato
r
Secondary
Peer
provider
health
facility
PALS*
(Mentor
s)
Primary
school
Primary
school
PALS: Peer Advocates for Life Skills
What is unique about Y4Y
1. Secondary schools as hub for sustainability
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PALS are elected, not selected
PALS have weekly meetings to discuss questions
PALS train new generation each year
Magic Bags stored at schools
2. Nearby primary schools & churches reached
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Time mapping: everything within 30 minutes
Nothing required for implementation except Magic Bags,
pens, exercise books and umbrellas
3. PALS curriculum:
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Comprehensive reproductive health and skills
New concepts: dream team, gender benders, top-5 list
Fully readable; requires little training
Very interactive: dialogues, games, role plays
4. Peers provide services in clinics
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Youth-friendliness assured
New monitoring cards: referral plus exit interview
Y4Y
K-MET/
UCLA
Research questions

Does Y4Y achieve significant improvements in
reproductive health knowledge among youth?

Does Y4Y reduce high-risk sexual behaviors
among youth?

Does Y4Y increase youth’s use of reproductive
health services?

Is Y4Y a logistically feasible and potentially
replicable model for achieving comprehensive
peer-led reproductive health education and
services for youth in:

Secondary schools?

Primary schools?

Churches?
Research methodology

Design: quasi-experimental pretest
posttest with a comparison group

Two neighboring divisions from
Bungoma district selected:
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Webuye division: intervention
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Kimilili division: comparison
Data collection (pre- and post-)

Self-administered questionnaires
- Knowledge, practices, self-efficacy

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School records
Clinic records
Examples of vignettes used in
questionnaire
1. Mary and John have been dating
for 3 months. They have been
playing sex for two months, but
Mary no longer wants to play sex
without a condom. She fears to tell
John because he likes skin-to-skin
contact.
1a. GIRLS: If you were Mary, do you
think you could persuade John to use
a condom?
□ Yes □ Maybe □ No
1b. BOYS: If you were John, would
you think badly about Mary for asking
you to use a condom?
□ Yes □ Maybe □ No
2. Josephine does not want to play sex
until she is married. She really likes
a boy at her church named Thomas.
After they go out a few times, he tells
her he wants to play sex. Josephine
does not want to break up with
Thomas, but does not feel
comfortable playing sex.
2a. GIRLS: If you were Josephine,
could you tell Thomas that you would
not play sex, even if it meant you would
break up?
□ Yes
□ Maybe
□ No
2b. BOYS: If you were Thomas, would
you break up with Josephine for not
wanting to play sex?
□ Yes
□ Maybe
□ No
Bungoma district
Western Province, Kenya
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Bungoma
District
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Sources: World Bank (2002), Demographic and
Health Survey (1998), Moi University data
Population: 1 million
Less than 20 years old: 60%
Number of divisions: 10
Main ethnic group: Luhya (Bukusu)
Religions: Friends, Anglicans,
Pentecostal, Catholics
Adult literacy: 70%
Occupations: Farmers 60%,
Employed 22%, Business 18%
Main crops: sugarcane, maize,
beans, bananas, sweet potatoes
Webuye town: Street scene
Webuye town: market day
Webuye sub-district hospital
Pan Paper Factory, Webuye
Transport in Bungoma district
Matatu (minibus)
Boda-bodas (bicycle taxis)
Y4Y program timeline

Pre-implementation
(June-Dec. 2003)

Baseline assessment
(Jan. 2004)

Implementation
(Jan.-Nov. 2004)

Evaluation
(Dec. 2004-Feb. 2005)
Pre-implementation
(May – Dec. 2003)

Phase 1: Program development at UCLA
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Literature review and dialogue
PALS curriculum designed
Selection of other curriculums
Baseline questionnaire, sample design
Phase 2: In-country preparation
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Hiring of Kenyan staff and office-set-up
Focus group discussions
Time mapping of target schools, churches and health
centers
Community mobilization and planning meetings
Pilot-testing of questionnaires and curriculum
Youth-friendly training of providers
From focus groups:
Misconceptions about AIDS, FP

“A friend of mine said: if you don’t
want to get AIDS, just play sex
without thinking about it.”
(Male, 15-19 yrs.)

“If a youth wants to prevent getting an
STI, he should eat well-cleaned and
well-cooked foods.”
(Male, 11-14 yrs.)

“The best way to avoid pregnancy is
to swallow aspirin.”
(Female, 11-14 yrs.)

“To avoid pregnancy you take yellow
medicine with milk before sex.”
(Female, 11-14 yrs.)
From focus group discussions, Webuye division, Kenya 8/03
From focus groups:
Interest in the Y4Y concept

“When a youth teaches you he can teach
you deeper, but if a teacher teaches you,
you may not understand it. With a youth
you can keep asking questions.”
(Male, 11-14 yrs.)

“Teens understand my problems better
than older people do.”
(Female, 15-19 yrs.)

“With fellow youth, you can tell him every
disease that you have and then he can
just tell the doctor so you get the right
medicines. Otherwise you might feel too
shy to tell the doctor all your diseases.”
(Male, 11-14 yrs.)
From focus group discussions, Webuye division, Kenya 8/03
Headquarters of local NGO (K-MET)
& Y4Y Bungoma staff
K-MET headquarters, Kisumu
Albert Obbuyi (Y4Y Coordinator),
Paula Tavrow (PI), and Vidalyne
Omollo (Y4Y Deputy Coordinator)
Y4Y office in Bungoma town
Bungoma
Y4Y office in Wing B of
Bungoma District Education Office
Interior of Y4Y office
PALS curriculum: Content
1:
2:
3:
4:
5:
Dreams & Goals
Gender Roles
Puberty & Relationships
Human Sexuality
Preventing STIs through Safe
Sex
6: HIV & AIDS: Facts & Feelings
7: Contraception: Avoiding
Unwanted Pregnancy
8: Resisting Pressure and Being
Assertive
9: Saying NO! to Sexual Violence
10: Protecting Your Future
Some pilot testers of PALS curriculum
with Rebecca Morris in
Webuye Division, Bungoma District
PALS curriculum: Skills
1: Setting career goals
2. Taking steps to accomplish goals
3: Negotiating fairer division of
chores at home
4: Communicating assertively
5: Building self-esteem
6: Using a condom
7: Negotiating condom use
8: Communicating with parents
9: Avoiding date rape
10: Negotiating with health providers
Pilot testing of PALS curriculum
Bungoma
Pilot testing of the PALS curriculum,
using posters and puppets
Interior of Y4Y office
Y4Y program statistics

Participating institutions in first year (2004):
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Secondary schools = 6
Primary schools = 8
Churches = 10
Health facilities = 6
Anticipated # of PALS to be trained: 185
Anticipated # of peer providers to be trained: 32
Anticipated # of youth to be reached: 5500
Schools participating in Y4Y - 1
Primary school, Webuye division,
Bungoma district
Interior of a primary school,
Webuye division, Bungoma
Schools participating in Y4Y - 2
Pan Paper High School,
Webuye division, Bungoma
Interior of secondary school,
Webuye Divison, Bungoma
Youth-friendly services
training of health providers
Content of 4-day
course:
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Characteristics of youthfriendly services
Service provider values
Adolescent development
Youth sexual and
reproductive health
Communication with youth
Creating youth-friendly
services
Nurses in Webuye division,
Bungoma district
What Bungoma youth told providers

“When you go to a clinic, you are treated so
harshly. It is like an interrogation: so many
questions. If I won’t answer, I am told to go
away.”

“We don’t like it when services are crowded. We
youths are impatient…we don’t want to wait 1-2
hours to talk to someone. It’s a waste of time.”

“Once I had a sexually-transmitted disease. The
doctor talked with me and then told me to wait. I
overheard him tell his son, who is in my class,
about my condition. I felt so betrayed I went
away. I waited 2 months before I went back.”

“When you go to a clinic, the doctor says your
parents have to come. Even if he agrees to see
you, he is not confidential. He passes on
anything you say to your parents.”
From panel discussion, Webuye division, Kenya 12/03
Monitoring of youth satisfaction
YOUTH SATISFACTION CARD
Youths have the right to receive reproductive
health services. Here are the facilities in
your division where providers have been
trained to offer youth-friendly services.

Lugulu Mission Hospital

Webuye Health Centre

Webuye Sub-District Hospital

Bokoli Health Centre

Annetta Annex (Webuye town)

Pan Paper Clinic
After you have received services, please take
a moment to fill in the reverse side of this
card. You can return it to any PAL or to
the Youth for Youth (Y4Y) office in the
District Education Office, Wing B, in
Bungoma town.
The answers that you provide are confidential.
Please do not write your name anywhere
on this card. Your responses will be used
to help improve health services here.
QUESTIONS ABOUT SERVICES
Where did you go? ________________Date: _______
Your age? ______ years
Your sex (gender)? _____
What services did you receive? (Tick all that apply.)
□ Counseling
□ Family planning
□ VCT
□ STI treatment
□ Other __________________
Did you feel free to ask any questions you had?
□Yes
□ Somewhat
□ No
Did you get the information or supplies you wanted?
□ Yes
□ Somewhat
□ No
Was any provider harsh or made you feel ashamed?
□ Yes
□ Somewhat
□ No
Did a PAL provide counseling services to you?
□ Yes
□ No
About how long did you have to wait? _______ minutes
What did you pay for services, if anything? ___ KSh
Would you recommend this place to other youths?
□ Yes
□ Maybe
□ No
Implementation plan (2004)

Baseline questionnaire and record review
(Jan-Feb. 2004)

Training of PALS
(Jan-Feb. 2004)

PALS train secondary schools
(Feb-April 2004)

Training of top PALS as peer providers
(April 2004)

PALS train upper primary schools and
out-of-school youth
(May-July 2004)

Peer providers start counseling in clinics
(May 2004-

Video taping for replication

Election of new PALS and in-school training
)
(June-August 2004)
(Sept-Nov 2004)
The need is great…
Bungoma
Interior of Y4Y office
Mural on primary school wall
concerning sexual harassment,
Webuye division, Bungoma district
A last word…
“For people in some of the countries
we are talking about, AIDS is a real
weapon of mass destruction. And
what are we doing about that?
Where is our common humanity?”
--Kofi Annan, UN Secretary General
November 30, 2003 in BBC interview