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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.

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Presentation on theme: "The Youth for Youth (Y4Y) Program in Western Kenya Testing a Comprehensive Adolescent Education and Services Model to Reduce HIV/STDs and Teen Pregnancies."— Presentation transcript:

1 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 Y4Y K-MET/ UCLA

2 Acknowledgements UCLA Globalization Research UCLA Globalization Research Center – Africa (sponsors) Center – Africa (sponsors) Edmond Keller, Director Edmond Keller, Director Charisma Acey Charisma Acey UCLA Y4Y Development Team UCLA Y4Y Development Team Paula Tavrow, PI Paula Tavrow, PI Edith Mukudi, Co-PI Edith Mukudi, Co-PI Rebecca Morris Rebecca Morris Tarik Benbahmed Tarik Benbahmed Karen Michail Karen Michail Adesuwa Ogiamien Adesuwa Ogiamien Kyle Pusateri Kyle Pusateri JC Walsh JC Walsh Kenya Y4Y Management Team Kenya Y4Y Management Team Kitche Magak, K-MET Kitche Magak, K-MET Albert Obbuyi Albert Obbuyi Vidalyne Omollo Vidalyne Omollo All photos by Rebecca Morris Webuye division, Bungoma district, Kenya

3 Adolescents worldwide: Key facts Nearly one-sixth of the worlds population is between years old Nearly one-sixth of the worlds population is between years old About 84% of the worlds adolescents live in developing countries About 84% of the worlds adolescents live in developing countries Nearly one-half of new HIV infections are occurring among young people Nearly one-half of new HIV infections are occurring among young people Source: Youthnet (2003 )

4 New HIV infections in 2003

5 Problem of HIV/AIDS in Africa 29 million Africans estimated to be HIV+; half under 25 years old 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 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 One in seven children in some African countries have lost one or both parents to AIDS Source: UNAIDS (2003)

6 Risk factors for African youth -1 Personal Lack of knowledge; belief in low personal risk Lack of knowledge; belief in low personal risk Low self-efficacy, especially of girls Low self-efficacy, especially of girls Low self-esteem Low self-esteem Belief in low personal risk Belief in low personal risk Male desire to be masculine or virile Male desire to be masculine or virile Belief that abstinence can be injurious to boys health Belief that abstinence can be injurious to boys health Misconceptions or dislike of condom Misconceptions or dislike of condom

7 Risk factors for African youth -2 Interpersonal Peer pressure for early sexual activity Peer pressure for early sexual activity Belief that condoms signify mistrust, promiscuity Belief that condoms signify mistrust, promiscuity High incidence of coerced sex High incidence of coerced sex Youths often barter sex for goods or services Youths often barter sex for goods or services Multiple sex partners Multiple sex partnersStructural Barriers to youths acquisition of correct information about reproductive health Barriers to youths acquisition of correct information about reproductive health Barriers to youths use of reproductive health services 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+ Due to poverty and lack of life skills, youths are vulnerable to older sexual partners, who may be HIV+

8 Location of project: Kenya Population: 31.3 million GDP per capita: $995 Literacy rate: 84% Fertility rate: 4.3 births/ woman Roads paved: 12% Estd HIV prevalence: % (~1.5 million have died of AIDS) Estd HIV prevalence (15-24 yrs): Girls: 11-15%; Boys: 4-9% Estd AIDS orphans: 890,000 Kenyan teens reported being pregnant or given birth: 20% Sources: World Bank (2002), UNAIDS (2003), Demographic and Health Survey (1998) Bungoma District

9 <20% Philippines8.1% Rwanda14.2% Peru18.4% % Kazakstan20.5% Brazil (NE)22.5% Bolivia22.9% Guatemala25.0% Domin. Rep.26.9% Colombia29.6% Haiti29.0% Zimbabwe29.7% % Paraguay30.1% Senegal35.4% % Namibia42.4% U.S. 46.0% Kenya46.1% Tanzania49.9% % Burkina Faso54.1% Ghana59.0% % Zambia60.5% Niger60.9% Uganda61.6% Central Afr. Rep.62.0% Mali66.0% Côte dIvoire68.1% Cameroon68.5% Adolescent sexual activity Percent of adolescents who report ever had sex (10-19) Sources: Demographic and Health Surveys ( ) ; US data from Advocates for Youth (2003)

10 <10% Malawi7.9% Niger8.4% Rwanda7.5% Zambia3.5% Guatemala6.1% Paraguay9.2% % Kenya12.5% Madagascar13.7% Senegal15.8% Tanzania16.5% Uganda16.9% Bolivia14.8% Domin. Rep.14.2% Haiti14.3% % Peru22.7% Columbia25.6% Brazil (NE)22.5% Zimbabwe20.5% Namibia22.5% Mali25.6% Ghana22.4% C. African Republic20.4% Burk. Faso21.3% 40% + Cameroon52.7% U.S. 75.0% % Nigeria30.7% Côte dIvoire34.9% Kazakstan39.0% Percent of sexually active year olds using any contraceptive method at last sex Adolescent contraceptive use Sources: Demographic and Health Surveys ( ); US data from Advocates for Youth (2003)

11 Why Kenyan youth are not getting reproductive health education & services Parents traditionally do not talk about sex with children Parents traditionally do not talk about sex with children Teachers uncomfortable with sex education: pick what to teach Teachers uncomfortable with sex education: pick what to teach Governments latest AIDS curriculum excludes condoms Governments latest AIDS curriculum excludes condoms Most churches and elders oppose contraceptives education for youth: believe leads to sexual immorality Most churches and elders oppose contraceptives education for youth: believe leads to sexual immorality Catholic churches preach HIV virus can pass through condoms Catholic churches preach HIV virus can pass through condoms Many health providers reluctant to give youth contraceptives: believe encourages promiscuity Many health providers reluctant to give youth contraceptives: believe encourages promiscuity

12 Challenges in designing programs to reach rural Kenyan youth Less than 40% of youth enter secondary school Less than 40% of youth enter secondary school About 90% of rural primary schools and 50% of secondary schools lack electricity About 90% of rural primary schools and 50% of secondary schools lack electricity Less than 10% of schools have a library Less than 10% of schools have a library Less than 1% of youth have access to internet Less than 1% of youth have access to internet Health facilities often inaccessible to youth (distance, hours, costs) Health facilities often inaccessible to youth (distance, hours, costs)

13 Lessons learned from other adolescent programs Education Train peers to convey sexuality information Train peers to convey sexuality information Use structured, comprehensive curriculum Use structured, comprehensive curriculum Develop relevant life skills Develop relevant life skills Spend enough time and be interactive Spend enough time and be interactive Train older youth to educate younger youth Train older youth to educate younger youth Include out-of-school youth Include out-of-school youthServices Combine education with services Combine education with services Use peers to deliver services Use peers to deliver services Actively ensure services are youth-friendly Actively ensure services are youth-friendly Build on what exists and what youths want Build on what exists and what youths want Be affordable and replicable Be affordable and replicable

14 Goals of Youth for Youth (Y4Y) To test whether a comprehensive adolescent reproductive health education and services model in rural Africa can: To test whether a comprehensive adolescent reproductive health education and services model in rural Africa can: Increase youths knowledge about reproductive health Reduce unwanted pregnancies and unsafe sex Increase youths use of health clinics Be sustained and replicated in-country

15 Main components of Y4Y 1. Extra-curricular education Peer sexuality education and skills-building in secondary schools Peer sexuality education and skills-building in secondary schools Peer sexuality education and skills-building among church-affiliated out-of-school youth Peer sexuality education and skills-building among church-affiliated out-of-school youth Mentor education and skills-building in primary schools Mentor education and skills-building in primary schools 2. Adolescent-focused service delivery Development of a network of youth-friendly health clinics Development of a network of youth-friendly health clinics Teen peer providers in health clinics Teen peer providers in health clinics 3. Ongoing monitoring Youth satisfaction with health services Youth satisfaction with health services Regular meetings of peer educators (PALS) Regular meetings of peer educators (PALS) Y4Y K-MET/ UCLA

16 Conceptual framework of Y4Y Church PALS* Peer educato r Youth- friendly health facility PAL Peer prov ider s) Secondary School Peer HIV/AIDS and reproductive health education PALS* (Peer educators ) PALS* (Mentor s) Peer provider health facility Primary school Features of PALS-led education: week struc- tured curriculum 2. Magic Bag of puppets, games, books PALS: Peer Advocates for Life Skills

17 What is unique about Y4Y 1. Secondary schools as hub for sustainability 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 Time mapping: everything within 30 minutes Nothing required for implementation except Magic Bags, pens, exercise books and umbrellas 3. PALS curriculum: 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 Youth-friendliness assured New monitoring cards: referral plus exit interview Y4Y K-MET/ UCLA

18 Does Y4Y achieve significant improvements in reproductive health knowledge among youth? Does Y4Y achieve significant improvements in reproductive health knowledge among youth? Does Y4Y reduce high-risk sexual behaviors among youth? Does Y4Y reduce high-risk sexual behaviors among youth? Does Y4Y increase youths use of reproductive health services? Does Y4Y increase youths 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: Is Y4Y a logistically feasible and potentially replicable model for achieving comprehensive peer-led reproductive health education and services for youth in: Secondary schools? Secondary schools? Primary schools? Primary schools? Churches? Churches? Research questions

19 Design: quasi-experimental pretest posttest with a comparison group Design: quasi-experimental pretest posttest with a comparison group Two neighboring divisions from Bungoma district selected: Two neighboring divisions from Bungoma district selected: Webuye division: intervention Webuye division: intervention Kimilili division: comparison Kimilili division: comparison Data collection (pre- and post-) Data collection (pre- and post-) Self-administered questionnaires Self-administered questionnaires - Knowledge, practices, self-efficacy School records School records Clinic records Clinic records Research methodology

20 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

21 Bungoma district Western Province, Kenya Bungoma district Western Province, Kenya 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 Sources: World Bank (2002), Demographic and Health Survey (1998), Moi University data Bungoma District

22 Webuye town: Street scene

23 Webuye town: market day

24 Webuye sub-district hospital

25 Pan Paper Factory, Webuye Pan Paper Factory, Webuye

26 Transport in Bungoma district Matatu (minibus) Boda-bodas (bicycle taxis)

27 Y4Y program timeline Pre-implementation (June-Dec. 2003) Pre-implementation (June-Dec. 2003) Baseline assessment (Jan. 2004) Baseline assessment (Jan. 2004) Implementation (Jan.-Nov. 2004) Implementation (Jan.-Nov. 2004) Evaluation (Dec Feb. 2005) Evaluation (Dec Feb. 2005)

28 Phase 1: Program development at UCLA Phase 1: Program development at UCLA Literature review and dialogue Literature review and dialogue PALS curriculum designed PALS curriculum designed Selection of other curriculums Selection of other curriculums Baseline questionnaire, sample design Baseline questionnaire, sample design Phase 2: In-country preparation Phase 2: In-country preparation Hiring of Kenyan staff and office-set-up Hiring of Kenyan staff and office-set-up Focus group discussions Focus group discussions Time mapping of target schools, churches and health centers Time mapping of target schools, churches and health centers Community mobilization and planning meetings Community mobilization and planning meetings Pilot-testing of questionnaires and curriculum Pilot-testing of questionnaires and curriculum Youth-friendly training of providers Youth-friendly training of providers Pre-implementation (May – Dec. 2003)

29 From focus groups: Misconceptions about AIDS, FP A friend of mine said: if you dont want to get AIDS, just play sex without thinking about it. (Male, yrs.) If a youth wants to prevent getting an STI, he should eat well-cleaned and well-cooked foods. (Male, yrs.) The best way to avoid pregnancy is to swallow aspirin. (Female, yrs.) To avoid pregnancy you take yellow medicine with milk before sex. (Female, yrs.) From focus group discussions, Webuye division, Kenya 8/03

30 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, yrs.) Teens understand my problems better than older people do. (Female, 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, yrs.) From focus group discussions, Webuye division, Kenya 8/03

31 Headquarters of local NGO (K-MET) & Y4Y Bungoma staff 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)

32 Y4Y office in Bungoma town Bungoma Y4Y office in Wing B of Bungoma District Education Office Interior of Y4Y office

33 PALS curriculum: Content 1: Dreams & Goals 2: Gender Roles 3: Puberty & Relationships 4: Human Sexuality 5: 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

34 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

35 Pilot testing of PALS curriculum Bungoma Pilot testing of the PALS curriculum, using posters and puppets Interior of Y4Y office

36 Participating institutions in first year (2004): 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 Y4Y program statistics

37 Schools participating in Y4Y - 1 Primary school, Webuye division, Bungoma district Interior of a primary school, Webuye division, Bungoma

38 Schools participating in Y4Y - 2 Pan Paper High School, Webuye division, Bungoma Interior of secondary school, Webuye Divison, Bungoma

39 Youth-friendly services training of health providers Content of 4-day course: Characteristics of youth- friendly services Characteristics of youth- friendly services Service provider values Service provider values Adolescent development Adolescent development Youth sexual and reproductive health Youth sexual and reproductive health Communication with youth Communication with youth Creating youth-friendly services Creating youth-friendly services Nurses in Webuye division, Bungoma district

40 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 wont answer, I am told to go away. We dont like it when services are crowded. We youths are impatient…we dont want to wait 1-2 hours to talk to someone. Its 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

41 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 Lugulu Mission Hospital Webuye Health Centre Webuye Health Centre Webuye Sub-District Hospital Webuye Sub-District Hospital Bokoli Health Centre Bokoli Health Centre Annetta Annex (Webuye town) Annetta Annex (Webuye town) Pan Paper Clinic 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: _______ Where did you go? ________________Date: _______ Your age? ______ years Your sex (gender)? _____ Your age? ______ years Your sex (gender)? _____ What services did you receive? (Tick all that apply.) What services did you receive? (Tick all that apply.) Counseling Family planning VCT Counseling Family planning VCT STI treatment Other __________________ STI treatment Other __________________ Did you feel free to ask any questions you had? Yes Somewhat No Did you feel free to ask any questions you had? Yes Somewhat No Did you get the information or supplies you wanted? Did you get the information or supplies you wanted? Yes Somewhat No Yes Somewhat No Was any provider harsh or made you feel ashamed? Was any provider harsh or made you feel ashamed? Yes Somewhat No Yes Somewhat No Did a PAL provide counseling services to you? Did a PAL provide counseling services to you? Yes No Yes No About how long did you have to wait? _______ minutes About how long did you have to wait? _______ minutes What did you pay for services, if anything? ___ KSh What did you pay for services, if anything? ___ KSh Would you recommend this place to other youths? Would you recommend this place to other youths? Yes Maybe No Yes Maybe No

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

43 The need is great… Bungoma Mural on primary school wall concerning sexual harassment, Webuye division, Bungoma district Interior of Y4Y office

44 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? 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 November 30, 2003 in BBC interview


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