Youth for Youth _Y4Y_ Program_ Testing a Comprehensive

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					The Youth for Youth (Y4Y)
Program in Western Kenya

              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
n   UCLA Globalization Research
    Center – Africa (sponsors)
     n  Edmond Keller, Director
     n  Charisma Acey

n   UCLA Y4Y Development Team
     n Paula Tavrow, PI
     n Edith Mukudi, Co-PI
     n Rebecca Morris
     n Tarik Benbahmed
     n Karen Michail
     n Adesuwa Ogiamien
     n Kyle Pusateri
     n JC Walsh

n   Kenya Y4Y Management Team
     n  Kitche Magak, K-MET
     n  Albert Obbuyi
     n  Vidalyne Omollo

                                   Webuye division, Bungoma district, Kenya
    All photos by Rebecca Morris
Adolescents worldwide:
      Key facts
          n   Nearly one-sixth of the
              world’s population is
              between 10-19 years old

          n   About 84% of the world’s
              adolescents live in
              developing countries

          n   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
n   29 million Africans
    estimated to be
    HIV+; half under 25
    years old
n   Young women in
    Africa twice as likely
    to get infected as
    young men
n   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

  n   Lack of knowledge; belief in low personal risk
  n   Low self-efficacy, especially of girls
  n   Low self-esteem
  n   Belief in low personal risk
  n   Male desire to be “masculine” or virile
  n   Belief that abstinence can be injurious to boys’ health
  n   Misconceptions or dislike of condom
Risk factors for African youth -2
  n   Peer pressure for early sexual activity
  n   Belief that condoms signify mistrust, promiscuity
  n   High incidence of coerced sex
  n   Youths often barter sex for goods or services
  n   Multiple sex partners
  n   Barriers to youths’ acquisition of correct information
      about reproductive health
  n   Barriers to youths’ use of reproductive health services
  n   Due to poverty and lack of life skills, youths are
      vulnerable to older sexual partners, who may be HIV+
                    Location of project:
                                             n   Population: 31.3 million
                                             n   GDP per capita: $995
                                             n   Literacy rate: 84%
                                             n   Fertility rate: 4.3 births/ woman
                                             n   Roads paved: 12%
                                             Ø   Est’d HIV prevalence: 6.7- 9.4%
                                                 (~1.5 million have died of AIDS)
                                             Ø   Est’d HIV prevalence (15-24 yrs):
                                                  Girls: 11-15%; Boys: 4-9%
                                             Ø   Est’d AIDS orphans: 890,000
                                             Ø   Kenyan teens reported being
                                                 pregnant or given birth: 20%
Sources: World Bank (2002), UNAIDS (2003),
Demographic and Health Survey (1998)
        Adolescent sexual activity
                              Percent of
        <20%                  adolescents
Philippines       8.1%        who report ever                           51- 60%
Rwanda           14.2%
Peru             18.4%        had sex (10-19)                  Burkina Faso          54.1%
                                                               Ghana                 59.0%

       21- 30%                        31- 40%
Kazakstan         20.5%         Paraguay        30.1%                     61- 70%
Brazil (NE)       22.5%         Senegal         35.4%          Zambia                 60.5%
Bolivia           22.9%                                        Niger                  60.9%
Guatemala         25.0%               41- 50%                  Uganda                 61.6%
Domin. Rep.       26.9%         Namibia         42.4%          Central Afr. Rep.      62.0%
Colombia          29.6%         U.S.            46.0%          Mali                   66.0%
Haiti             29.0%         Kenya           46.1%          Côte d’Ivoire          68.1%
Zimbabwe          29.7%         Tanzania        49.9%          Cameroon               68.5%

  Sources: Demographic and Health Surveys (1998-2001) ; US data from Advocates for Youth (2003)
       Adolescent contraceptive use
Percent of
sexually active 15                         11- 20%                         21- 30%
-19 year olds                     Kenya              12.5%          Peru             22.7%
                                  Madagascar         13.7%          Columbia         25.6%
using any                         Senegal            15.8%          Brazil (NE)      22.5%
contraceptive                     Tanzania           16.5%          Zimbabwe         20.5%
method at last sex                Uganda             16.9%          Namibia          22.5%
                                                                    Mali             25.6%
                                  Bolivia            14.8%
                                                                    Ghana            22.4%
                                  Domin. Rep.        14.2%
          <10%                                                      C. African
                                  Haiti              14.3%          Republic         20.4%
  Malawi             7.9%
  Niger              8.4%                                           Burk. Faso       21.3%
                                          31- 40%
  Rwanda             7.5%
  Zambia             3.5%        Nigeria              30.7%                  40% +
  Guatemala          6.1%        Côte d’Ivoire        34.9%
                                                                   Cameroon           52.7%
  Paraguay           9.2%        Kazakstan            39.0%
                                                                   U.S.               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
n   Parents traditionally do not talk
    about sex with children
n   Teachers uncomfortable with sex
    education: pick what to teach
n   Government’s latest AIDS
    curriculum excludes condoms
n   Most churches and elders oppose
    contraceptives education for youth:
    believe leads to sexual immorality
n   Catholic churches preach HIV virus
    can pass through condoms
n   Many health providers reluctant to
    give youth contraceptives: believe
    encourages promiscuity
Challenges in designing programs
  to reach rural Kenyan youth

                   n   Less than 40% of youth
                       enter secondary school
                   n   About 90% of rural primary
                       schools and 50% of
                       secondary schools lack
                   n   Less than 10% of schools
                       have a library
                   n   Less than 1% of youth have
                       access to internet
                   n   Health facilities often
                       inaccessible to youth
                       (distance, hours, costs)
Lessons learned from other
   adolescent programs
          • 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

          • 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:
        n   Increase youth’s knowledge about reproductive health
        n   Reduce unwanted pregnancies and unsafe sex
        n   Increase youth’s use of health clinics
        n   Be sustained and replicated in-country
        Main components of Y4Y
1. Extra-curricular education
  n   Peer sexuality education and skills-building in
      secondary schools
  n   Peer sexuality education and skills-building among
      church-affiliated out-of-school youth
  n   Mentor education and skills-building in primary schools

2. Adolescent-focused service delivery
  n   Development of a network of youth-friendly
      health clinics
  n   Teen peer providers in health clinics

3. Ongoing monitoring
  n   Youth satisfaction with health services                Y4Y
  n   Regular meetings of peer educators (PALS)             K-MET/
Conceptual framework of Y4Y
                    Chur                   Chur
                     ch                    ch
                               PALS*                            Youth-
Features of PALS             educato                           friendly
-led education:                 r
                           Secondary                            health
                            School                              facility
1. 10-week struc-             PALS*
tured curriculum              (Peer
                            educators                            Peer


2. Magic Bag of                                                 health
puppets, games,         Peer HIV/AIDS and
                       reproductive health                      facility
books                       education
                     Primary             Primary
                     school              school

                                                    PALS: Peer Advocates for Life Skills
         What is unique about Y4Y
1. Secondary schools as hub for sustainability
    n   PALS are elected, not selected
    n   PALS have weekly meetings to discuss questions
    n   PALS train new generation each year
    n   Magic Bags stored at schools

2. Nearby primary schools & churches reached
    n   Time mapping: everything within 30 minutes
    n   Nothing required for implementation except Magic Bags,
        pens, exercise books and umbrellas

3. PALS curriculum:                                              K-MET/
    n   Comprehensive reproductive health and skills
    n   New concepts: dream team, gender benders, top-5 list
    n   Fully readable; requires little training
    n   Very interactive: dialogues, games, role plays

4. Peers provide services in clinics
    n   Youth-friendliness assured
    n   New monitoring cards: referral plus exit interview
        Research questions
n   Does Y4Y achieve significant improvements in
    reproductive health knowledge among youth?
n   Does Y4Y reduce high-risk sexual behaviors
    among youth?
n   Does Y4Y increase youth’s use of reproductive
    health services?
n   Is Y4Y a logistically feasible and potentially
    replicable model for achieving comprehensive
    peer-led reproductive health education and
    services for youth in:
        n   Secondary schools?
        n   Primary schools?
        n   Churches?
    Research methodology

n   Design: quasi-experimental pretest
    posttest with a comparison group
n   Two neighboring divisions from
    Bungoma district selected:
         n   Webuye division: intervention
         n   Kimilili division: comparison

n   Data collection (pre- and post-)
    n   Self-administered questionnaires
         - Knowledge, practices, self-efficacy
    n   School records
    n   Clinic records
    Examples of vignettes used in
1. Mary and John have been dating          2. Josephine does not want to play sex
   for 3 months. They have been                until she is married. She really likes
   playing sex for two months, but             a boy at her church named Thomas.
   Mary no longer wants to play sex            After they go out a few times, he tells
   without a condom. She fears to tell         her he wants to play sex. Josephine
   John because he likes skin-to-skin          does not want to break up with
   contact.                                    Thomas, but does not feel
                                               comfortable playing sex.
   1a. GIRLS: If you were Mary, do you
   think you could persuade John to use       2a. GIRLS: If you were Josephine,
   a condom?                                  could you tell Thomas that you would
          □ Yes □ Maybe □ No                  not play sex, even if it meant you would
                                              break up?
                                                     □ Yes      □ Maybe      □ No
   1b. BOYS: If you were John, would
   you think badly about Mary for asking      2b. BOYS: If you were Thomas, would
   you to use a condom?                       you break up with Josephine for not
         □ Yes □ Maybe □ No                   wanting to play sex?
                                                    □ Yes      □ Maybe     □ No
               Bungoma district
            Western Province, Kenya

                                              n   Population: 1 million
                                              n   Less than 20 years old: 60%
                                              n   Number of divisions: 10
                                              n   Main ethnic group: Luhya (Bukusu)
                                              n   Religions: Friends, Anglicans,
                                                  Pentecostal, Catholics
                                              n   Adult literacy: 70%
Bungoma                                       n   Occupations: Farmers 60%,
District                                          Employed 22%, Business 18%
                                              n   Main crops: sugarcane, maize,
                                                  beans, bananas, sweet potatoes
Sources: World Bank (2002), Demographic and
Health Survey (1998), Moi University data
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

n   Pre-implementation
    (June-Dec. 2003)
n   Baseline assessment
    (Jan. 2004)
n   Implementation
    (Jan.-Nov. 2004)
n   Evaluation
    (Dec. 2004-Feb. 2005)
                        (May – Dec. 2003)

n   Phase 1: Program development at UCLA
    n   Literature review and dialogue
    n   PALS curriculum designed
    n   Selection of other curriculums
    n   Baseline questionnaire, sample design

n   Phase 2: In-country preparation
    n   Hiring of Kenyan staff and office-set-up
    n   Focus group discussions
    n   Time mapping of target schools, churches and health
    n   Community mobilization and planning meetings
    n   Pilot-testing of questionnaires and curriculum
    n   Youth-friendly training of providers
     From focus groups:
Misconceptions about AIDS, FP
          n   “A friend of mine said: if you don’t
              want to get AIDS, just play sex
              without thinking about it.”
                  (Male, 15-19 yrs.)
          n   “If a youth wants to prevent getting an
              STI, he should eat well-cleaned and
              well-cooked foods.”
                  (Male, 11-14 yrs.)
          n   “The best way to avoid pregnancy is
              to swallow aspirin.”
                  (Female, 11-14 yrs.)
          n   “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
       n   “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.)
       n   “Teens understand my problems better
           than older people do.”
               (Female, 15-19 yrs.)
       n   “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


   Y4Y office in Wing B of
   Bungoma District Education Office   Interior of Y4Y office
      PALS curriculum: Content
1: Dreams & Goals
2: Gender Roles
3: Puberty & Relationships
4: Human Sexuality
5: Preventing STIs through Safe
6: HIV & AIDS: Facts & Feelings
7: Contraception: Avoiding
     Unwanted Pregnancy
8: Resisting Pressure and Being
9: Saying NO! to Sexual Violence   Some pilot testers of PALS curriculum
10: Protecting Your Future               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


  Pilot testing of the PALS curriculum,   Interior of Y4Y office
  using posters and puppets
           Y4Y program statistics

n   Participating institutions in first year (2004):
    n   Secondary schools = 6
    n   Primary schools = 8
    n   Churches = 10
    n   Health facilities = 6

n   Anticipated # of PALS to be trained: 185
n   Anticipated # of peer providers to be trained: 32
n   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
n   Characteristics of youth-
    friendly services
n   Service provider values
n   Adolescent development
n   Youth sexual and
    reproductive health
n   Communication with youth
n   Creating youth-friendly
                                Nurses in Webuye division,
                                  Bungoma district
What Bungoma youth told providers
        n   “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
        n   “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.”
        n   “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.”
        n   “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

Youths have the right to receive reproductive      Where did you go? ________________Date: _______
    health services. Here are the facilities in    Your age? ______ years   Your sex (gender)? _____
    your division where providers have been
    trained to offer youth-friendly services.
                                                   What services did you receive? (Tick all that apply.)
      n   Lugulu Mission Hospital
                                                    □ Counseling         □ Family planning       □ VCT
      n   Webuye Health Centre
                                                    □ STI treatment      □ Other __________________
      n   Webuye Sub-District Hospital
      n   Bokoli Health Centre
                                                   Did you feel free to ask any questions you had?
      n   Annetta Annex (Webuye town)
                                                                □Yes          □ Somewhat       □ No
      n   Pan Paper Clinic
                                                   Did you get the information or supplies you wanted?
                                                              □ Yes           □ Somewhat       □ No
After you have received services, please take
                                                   Was any provider harsh or made you feel ashamed?
    a moment to fill in the reverse side of this
    card. You can return it to any PAL or to                  □ Yes           □ Somewhat        □ No
    the Youth for Youth (Y4Y) office in the        Did a PAL provide counseling services to you?
    District Education Office, Wing B, in                     □ Yes          □ No
    Bungoma town.                                  About how long did you have to wait? _______ minutes

The answers that you provide are                   What did you pay for services, if anything? ___ KSh
    confidential. Please do not write your
    name anywhere on this card. Your               Would you recommend this place to other youths?
    responses will be used to help improve                   □ Yes  □ Maybe        □ No
    health services here.
        Implementation plan (2004)

n   Baseline questionnaire and record review          (Jan-Feb. 2004)
n   Training of PALS                                  (Jan-Feb. 2004)
n   PALS train secondary schools                     (Feb-April 2004)
n   Training of top PALS as peer providers               (April 2004)
n   PALS train upper primary schools and
    out-of-school youth                              (May-July 2004)
n   Peer providers start counseling in clinics       (May 2004-     )
n   Video taping for replication                  (June-August 2004)
n   Election of new PALS and in-school training      (Sept-Nov 2004)
             The need is great…


                                         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

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