The Gender Agenda

We had an interesting discussion after the speakers had finished presenting at the session, 4A, ‘Gender Norms: Correlates and Consequences.’

In response to the presentation on, ‘Sexual Harassment as a Reproductive Health Challenge for Female Nigerian Undergraduates,’ someone in the audience said that oftentimes females invite harassment by the way they dress. It was noteworthy that the session moderator, Bene Madunagu stated in no uncertain terms that nobody could possibly dictate how an individual chooses to dress and that cannot be used as an excuse to harass a female. She also mentioned that if that were the case, swimming pools would be rather unsafe places! The entire audience (will not comment on the gender distribution there!) applauded in consent!!

Commenting on Rajib Acharya’s presentation, ‘Adverse Health Outcomes of Physical and Sexual Violence Within Marriage: Experiences of Young Women in Maharashtra, India,’ someone in the audience said that it was counterintuitive to think of sexual experience within marriage as nonconsensual. Once again, the session chair, Margaret Greene emphasized that willingness for sex is as important within marriage as outside. She also explained that young married females are particularly vulnerable particularly in settings like India where gender power imbalances make violent behaviors from husbands acceptable and prevent negotiation among partners.

It is clear that as we work towards taking the agenda of reproductive and sexual health of youth forward, we need to examine our own attitudes and behaviors!

Jaya, MBBS, DrPH ’06, MPH ’01, received a dissertation grant from the Bill and Melinda Gates Institute for Population and Reproductive Health and now works with the Public Health Foundation of India

Pt. 2: Youth Perspectives

A group of vibrant, energetic young adolescents participated in the Conference. After running and playing in the halls, they were attentive and focused in the sessions – quite a feat for these 10 and 11 year olds. And to our pleasant surprise, they received awards for their artistic endeavors during the plenary. Their smiles and enthusiastic thank you’s helped remind us of how wonderful it is to be young… and young-at-heart.

Daniel, from Ondo State, and Emmanuel, Taiwo and Tobi, from Ogun State, were accompanied by Paschal Gozie Ezea from SOS Children’s Villages Nigeria and Ruth Ogo, John Omolaye and Michael Fasoro from UNFPA/Youth Action Initiative.

Photo: From L to R, Daniel, Emmanuel, Tobi, Ruth, Taiwo

Angela Bayer, MHS, PhD ‘08, recently completed her PhD in Population, Family and Reproductive Health at JHSPH.

Pt. 1: Youth Perspectives

A few youth participants from Nigeria were excited to share their perspectives on the Conference with us!! Obe Olajide and Kolapo Abidemi are both students of Dentistry in the Community Dental Health program at the University of Lagos. When asked about the lessons they’d learned at the conference, they responded…

Obe: “I’ve learned that communication is key. In Nigeria, sexuality can’t be spoken about in so many places... not with adults, not at church, hardly anywhere. But young people need the right information at the right time and from the right person. So we need to improve communication about sexuality. Adolescents shouldn’t fall victim to things like STIs, pregnancy and HIV because of lack of good information.”

Kolapo: “The conference was quite interesting. I learned that adolescent sex education is important. I really liked making art with condoms. Often, people see condoms and say ‘AAAHHH’… they feel ashamed, for example, if they see them in the market. I got to decorate a condom and now it looks nice. And now people will ask, they’ll want to know what’s there. I can explain it and they’ll feel more comfortable. It’s beautiful… I like it.”

Photo: Obe and Kolapo with friends (from L to R, Hussaini G Mohammed from Media Trust LTD Abuja, Obe, Ayodeji Adeyemo from UNFPA Abuja, Kolapo)

Angela Bayer, MHS, PhD ‘08, recently completed her PhD in Population, Family and Reproductive Health at JHSPH.

Media Training in Reproductive Health

The media was an integral component of the just concluded Youth Deliver the Future Conference held in Abuja Nigeria from the 27 - 29, 2008. It was a theatre of interaction between journalists, researchers, policy makers and general participants. The conference which had more than 650 registered participants from about 32 countries across the globe kicked off with a pre-conference training for journalists. Then there was the conference Newsletter developed by a team from the 11 journalists trained at an intensive 2-day training organized by Population Reference Bureau (PRB) in collaboration with Development Communications Network, Lagos. It had as trainers Erin Sines of the PRB, Akin Jimoh, Development Communications Network, and Josephine Kamara, Internews Network. There were a number of resource persons drawn from the conference participants. The Conference had a wide flavour of media presence drawn from Kenya, Uganda, Nigeria and some others representing different foreign media.

Nnenna Ike

Pt. 4: In Their Own Words: 4 Young People at the Abuja Conference

Haben Fecadu, 22
International Program Coordinator, Advocates for Youth
Washington D.C., USA

I came for the advocacy perspective. It is great to come here and learn all the empirical evidence that we can use in our advocacy. A lot of the presentations have to do with reproductive health and focus on young people. There are so many. At one panel I went to a woman presented on a slum in Nairobi, Kenya. They are doing work and including young people. It was backed up with empirical evidence, and it worked well. It really did involve young people doing work. It was a program for girls, and alumni would go and replicate what they learned. It was youth empowerment and it addressed the needs of females there. They formed groups and worked with schools to delay marriage. That was great, the fact they actually had positive results. This is something you can cite when you actually incorporate young people [who] were doing some of the work themselves.

[Researchers] are obviously trying to understand young people. You can’t really complain when they are making a huge effort in conferences like this and valuing our opinion and trying to make things as youth friendly as possible.

Interview by Brian W. Simpson, editor of Johns Hopkins Public Health magazine.

Pt. 3: In Their Own Words: 4 Young People at the Abuja Conference

Svenn Grant, 29
UNFPA Youth Ambassador
Youth Coalition for Sexual and Reproductive Rights
Trinidad

Research always informs our work as advocates. Any time someone does a piece of research, it gives us a means to justify our position for access to sex and reproductive health services for young people. We ensure young people are stakeholders and are represented in any kind of final document or statement that is made. We not only want to be served. We have to be a part of the creation of the policy, the implementation of the policy and the evaluation of the policy.

I look at things through an advocacy lens. There is still a role for young people to play in making things happen and being vigilant with the respect to their rights and achieving full recognition of their human rights and sexual and reproductive health rights in particular. African young people are very interested in advocacy and lobbying and start to work together. To have young people thinking about research and advocacy as well, that can be a plus.

I think the content of research that comes here can open people’s eyes. There is research on vulnerable groups and sex workers. They may not be here, but this paper says they have been touched in some way, that some program works and needs to be scaled up. And their stories are here and that makes them really valuable. We need to create a legacy.

Interview by Brian W. Simpson, editor of Johns Hopkins Public Health magazine.

Pt. 2: In Their Own Words: 4 Young People at the Abuja Conference

Ayodeji Adeyemo, 23
Action Group on Adolescent Health
Student, University of Ibadan
Nigeria

My organization is an action and advocacy group for sexual and reproductive health rights of young persons;. I just felt there is a need to make a difference in sexual and reproductive health. In Africa, a lot of young persons are being plagued by sexual health challenges like unattended pregnancies and unsafe abortions. In many parts of Nigeria, there are still gender inequities, which is the neglect of the girl child and making her less empowered. Sexually transmitted infections are still prevalent among youth.

I grew Osogbo, Osua state. It is a semi-urban area. The challenge is around youth who just finished secondary school. It is really those who didn’t get admitted in to university. They come down with unintended pregnancies and abortions. As a young kid, I always knew I would go to university. I speak for those who are not as empowered as I am. This conference has brought research so close to everyone. I know that I can easily conduct research on sexual and reproductive health challenges that could benefit a lot of other youths. I love challenges, but my worry is you only get your voice to be heard when you have facts and figures. As an average Nigerian, you always think research is big do for the professors. Coming to a conference like this is a lifetime investment because I realize I can conduct my own research on issues that are plaguing youths that are not being paid attention to.

Interview by Brian W. Simpson, editor of Johns Hopkins Public Health magazine.

Pt. 1: In Their Own Words: 4 Young People at the Abuja Conference

Vanessa Geffrard, 21
Advocates for Youth; International Youth Leadership Council
College Park, Maryland, USA

Being on the International Youth Leadership Council, I’m involved in issues like maternal mortality, AIDS, adolescent reproductive rights. Our overall goal is having young people to teach other young people and move and influence people.

Researchers underestimate us. Just keeping us away from the information and not telling us what is out there is inhibiting us. The more you share with us, the more we are able to grow and make better and wiser decisions. I always believe one is a product of one’s environment. If you don’t educate young people, if you don’t give them the facts and resources, then they are prone to make bad decisions.

I also believe that a lot of great historical moments and movements have been done by young people as result of getting motivated and getting educated and starting their own revolutions. I feel a lot of us are complacent. That is not our fault. We are just not given the issues and topics that we should be passionate about. Older people are giving us what we should know and should and shouldn’t do. I believe that inhibits us from thinking outside the box, from starting our own clubs and organizations and really getting involved in issues that really affect us. So if older people don’t empower us and include us in decision-making that affect our lives as young people, we won’t be equipped with resources to lead ourselves and be better advocates for ourselves.

Interview by Brian W. Simpson, editor of Johns Hopkins Public Health magazine.

Photos from the Closing Plenary

Photo Credit: David Colwell (c) 2008

Abuja Call to Action

Abuja Call to Action: Increase Investments for Youth Health and Development

The Call to Action was read by Honorable Saudatu Sani at the closing on Tuesday, April 29. We invite comments until 5/16.

From 27-29 April 2008, in Abuja, Nigeria, 550 participants from 37 countries from throughout the world discussed new research and program findings at a notable International Conference, “Investing in Young People’s Health and Development: Research that Improves Policies and Programs.”* The conference leadership of all ages – drawn from academia, government, civil society, and parliamentarians – call on governments and donors to increase investments for youth health and development as an essential step to ensure the promise that young people hold for the future. We:

· Recall the emphasis on youth at the 1994 International Conference on Population and Development and the challenge of meeting the Millennium Development Goals;

· Recognize that youth aged 10 to 24 make up about one of every three people in many countries and represent society’s hope for the future;

· Celebrate the potential and resourcefulness present in all young people as they transit to adulthood;

· Acknowledge the rapid social transitions and challenges surrounding youth that hold positive and negative implications, including urbanization, technology, and globalization;

· Note that while many youth are healthy, the transition to adulthood involves many health-threatening problems, such as road traffic accidents, tobacco use, and problems related to sexual and reproductive health;

· Emphasize that adolescent girls are among the most vulnerable of all groups for HIV infection due to gender-based biological, social, cultural, and economic reasons, including sexual coercion;

· Underscore the risks of very early pregnancy (e.g., maternal mortality) to both married and unmarried girls;

· Recognize a lack of attention and resources focused on young adolescents (ages 10-14), young married youth, and marginalized groups such as street children, sex workers, displaced youth, teenage orphans, injection drug users, trafficked youths and domestic servants;

· Recognize the importance of meaningful youth participation in all program elements.

The conference focused on sexual and reproductive health issues, including the promotion of positive reproductive health outcomes, and on social and economic development of youth, recognizing:

· A wide consensus exists on positively redirecting the high energy, protective and risk factors for youth involving social and community norms and policies, yet more research is needed on how to reinforce their resourcefulness and protective factors (such as family, education, and religion) and mitigate risk factors such as inequitable gender norms, sexual coercion and violence, and very early pregnancies;

· Even so, some interventions have a strong positive evidence base and need to be widely implemented now, including:
· curriculum-based sexuality, family life, and HIV education with appropriate information for
different age groups and certain criteria
· gender-sensitive youth-friendly services that include community outreach
· information campaigns that involve more than one type of media
· policies that increase access to contraception, including emergency contraception expanded
opportunities for girls’ education

· Other promising interventions require more evaluation, programmatic scale-up, and broader policy support, including:
· curriculum-based peer education interventions
· working with communities to reduce sexual coercion
· projects that work with parents
· social support systems for young married women

Therefore, this conference calls on donors and governments, working with civil society and the international health and development community, to invest new and substantial funds and other resources to:

· Scale up youth projects found to be effective, working through sustainable institutions.

· Support research to:
· identify elements needed to scale up effective interventions with sustainability
· analyze promising interventions to assess whether they should be scaled up

· Encourage multiple ministries often involved with youth to consider a formal collaboration with clear responsibilities, funding, and youth involvement.

· Support closer linkages between research, programs, and policy development, utilizing findings from operations research and policy implementation.

· Pay attention to those groups who are particularly exposed to debilitating vulnerabilities.

· Address negative gender norms through improved laws, policies, and the implementation of these policies.

· Track the progress of youth programs at the country level including financial
investment, number and type of youth services, and social and health status of youth.

With this greater investment, the participants and sponsors of this conference, in turn, make a commitment to at least re-double our efforts to reinforce the great potential of youth, to enable their healthy transition to adulthood. Youth carry the hopes of us all that each future generation will be better off than the one before.

* The Gates Institute of the Johns Hopkins Bloomberg School of Public Health sponsored the meeting with multiple partners, including the University of Ibadan’s Center for Population and Reproductive Health and the Obafemi Awolowo University’s Department of Community Health. “Youth” and “young people” refer to ages 10 to 24.

Leading the Way to Better Health in Nigeria

Mairo Mandara doesn’t have a lot of patience for endless talk about sexual and reproductive health issues. The senior country advisor for The David and Lucile Packard Foundation prefers action.

“If I have my way, we would not produce any more policy in Nigeria for next 10 to 20 years because we have some of the most fantastic policies in the world,” Mandara says. They just need to be implemented, she says.

A native Nigerian who is well-versed in the political and reproductive health challenges in Nigeria, Mandara knows that the federal Ministry of Health creates health policies, but it’s up to Nigeria’s 36 autonomous states to implement them. Governors in each of the states wield most of the political power, and health infrastructure and spending has traditionally not been a top priority.

“You have to be strategic and know what buttons [to push], what buttons are the real buttons and use your political connections, who you know, for the good, for what you want to do,” she says.

In August 2007, Mandara, MD, and her colleagues tried a new tack. They got a meeting with the newly elected governor of Bauchi state. Knowing he was committed to improving health and that he had inherited a government full of people he did not know, Mandara got a meeting with him. They told him they knew he wanted to accomplish great things but that he would need to refine his agenda and persuade his cabinet and political leaders in the state to follow his vision. Mandara suggested she could help arrange leadership training for him and his cabinet.

The governor agreed and devoted three days to the training, bringing along his cabinet ministers. “He was there and so everybody was there,” Mandara says. “We got him to articulate his own ideas of what he wanted to do. He wanted to improve education, health, youth development and small scale industry.”

After two days of leadership training by internationally respected consultants, the governor and his team were ready to take on a practical challenge: maternal mortality. She brought in experts to convey its prevalence and what caused it. “We were talking about leadership but the context was the maternal mortality issue,” she says.

At the end of the training, the governor was persuaded to make several health commitments. First, he agreed that maternal services should be free. The action was put into law. He also planned to develop a primary health care agency. “It was done 2 months ago, then a law was also passed” preserving the arrangement for the future (since laws are more difficult to change than executive decrees). Another victory: the state allocates more than 10 percent of its budget to health (far surpassing other states that mark only about 5 percent for health and the federal government, which allocates about 8 percent for health.) “All this was done within six months,” Mandara says.

The governor is now an advocate for the leadership training and for health, Mandara says. Four other governors have contacted her for similar training, and Mandara is seeking additional funding.

“We in the health sector need to engage with the strategic people that translate our ideas into action. These are the people that control budgets. It’s only by their understanding the gravity of the issues that our ideas can be turned into reality.”

Brian W. Simpson is editor of Johns Hopkins Public Health magazine.

Images from the Conference

Photo Credit: David Colwell (c) 2008

A Sparks-Filled Q&A: Youth and Nigerian Policy Makers

As three Nigerian parliamentarians met with young people in a sparks-filled Q&A session during the Abuja conference, one issue quickly rose to the top of the agenda. Reveling in the opportunity to share their opinions on adolescent health and good governance, the young people wanted to clarify their role as future leaders.

They want to be leaders today; they do not want to wait.

The problem with being labeled “future leaders” means the mantle of leadership always remains in the future, said S. Urias Goll, a project officer for Mano River Union Youth Parliament in Liberia. “Young people should participate. Let them be present leaders. Let us not see young people as future leaders.”

The comment drew raucous applause from the adolescents packed into the meeting room. The parliamentarians embraced young people’s desire to affect politics and called on them to become more involved.

The Honorable Saudatu Sani, a member of the Nigerian Parliament, said, “We as a parliament have allocated money [for youth programs]—more than 400 million [Naira] this year; I’m telling you want I did with my hand. It is now for you to find out what are they are doing with that money.” Sani noted that Nigeria’s legislative branch allocates the money, while the ministries spend the money. “As young people, you must take a stand. … The Nigerian budget is on the Internet, go and get it. Then find out what happens to youth programs in Nigeria. Let’s work on the present and the future.”

Government needs to involve young persons in creating programs that affect them, said the Honorable Senator Olorunnibe Mamora. “It is better for youth to come together and articulate their own positions on issues,” he said. “For every bill, we have public meetings. How many people show up? There is a need for outreach to the constituency. There has to be engagement.”

Asked tough questions from young people (and a few elder researchers) in the crowd, the Honorable Senator Daisy Danjuma in turn challenged them to become more politically involved to improve the government’s implementation of programs. “We have some basic problems in our society. Policies are made—fine policies, fine plans—but implementation of policies is the problem in Nigeria,” she said. “The reason is accountability in Nigeria. You can only sustain development by rule of law. If I do something and get away with it, then how do we progress? We have to be accountable. We know what is right, but you youths have to help too.”

In a spirited exchange with a Nigerian journalist, Senator Danjuma decried the corruption in the media, the journalists who are mere “envelope collectors” filing stories that are paid for by sources. “I happen to have worked in television. I know what the media is supposed to do—educate and enlighten the public. The media should expose what’s wrong in the society. Your role is most critical to society. What you do in the media is the only thing can change society. Please report right and expose those who do not do jobs well.”

Some in the audience hooted and shouted, “They will lock you up!”

"You have to pay a price if you want things to work,” Senator Danjuma responded.

Senator Mamora encouraged youth and all Nigerians to become better informed. “A friend once said that one of the easiest ways to hide something from Nigerians is to put it in book form,” he said. “We have a very poor reading culture. That is why it is very easy to be misled. You can always get the right information if you have that habit of reading.”

In closing, youth leader Tope Folaranmi acknowledged the communications gap between policy makers and youth and sought to emphasize what they agreed on. “We agree the future is now. We have to have confidence to believe one another to move forward. We concluded there is a desperate need for mentorship. I want to challenge young people as President Kennedy did. Young people, don’t ask what Nigeria can do for you. Ask what you can do for this nation.”

Brian W. Simpson, editor of Johns Hopkins Public Health magazine

Nigeria’s Forgotten Young People

The many sexual and reproductive health problems in developing countries have been well documented, but less known is the plight of adolescents living on military bases. Young people who live on such military “cantonments” are especially vulnerable for risk for promiscuity and sexual abuse. They are surrounded by poorly paid soldiers who move frequently and often spread sexually transmitted infections (STIs).

Ololade Dosunmu, MD, an MPH student at Johns Hopkins Bloomberg School of Public Health, shared findings at the Abuja conference from her study of the Ikeja Military Cantonment. Dosunmu and her colleagues interviewed more than 250 adolescents at the Ikeja Military Cantonment. The second largest such base in West Africa, Ikeja is located outside of Lagos, Nigeria.

Dosunmu found a high level of promiscuity, poor hygiene and sanitation, and a lack of health services infrastructure.

“We found 67 percent of respondents admitted to being sex active,” said Dosunmu. “We also found the median age of first intercourse was 14.” While 72 percent of the youths surveyed knew of at least one method of contraception, use of condoms during sexual intercourse was only 56 percent. About 35 percent admit having an STI that was confirmed and treated in the hospital, but 48 percent had suspected they had an STI but did nothing or treated it by themselves. “Sadly, sexual abuse was reported by 35 percent of the respondents with most of the victims being females,” Dosunmu. “A majority of whom knew their abusers. Five percent of the participants reported being raped (10 cases involved females and 2 cases involved males). “I think even one case of rape is too much,” said Dosunmu.

The study showed that adolescents in the military cantonment is a vulnerable population that is often unintentionally left out of the country’s reproductive health services. “The adolescents have little or no guardianship, and many of them spend their time having unprotected sex for pleasure or money,” Dosunmu said, urging that more attention be paid to this population by targeted reproductive health services and an increased preventive health program.

Brian W. Simpson, editor of Johns Hopkins Public Health magazine.

Impacts of Life Planning Skills Training on Changing Disadvantaged Young Adolescents’ Gender Awareness in China

Guangxi Zhuang Autonomous Region is one of five underdeveloped ethnic minority autonomous regions in China and heavily hit by the emerging HIV/AIDS epidemic, In 2006, the Guangxi Women’s Federation and PATH launched the Spring Bud Healthy Development project to integrate participatory life-planning skills (LPS) training into existing curricula in primary and middle schools, including a focus on gender equity and healthy behaviors. The intervention spanned the period of April 2006 to July 2007. I am happy to be the person that responsible for the field implementation of this project.

In this reference, I am presenting the results of the impact evaluation of this school-based life planning skills training among disadvantaged young in-school adolescents. The main research questions include: Can the life planning skills curriculum introduced improve young adolescents’ self confidence, their pro-equal gender norms and their knowledge of reproductive? A quasi-experiment study design with both baseline and end-line survey was adopted among students of Grade 4 and Grade 7 in three project counties. Students in another three non-project counties, matched with demographic and socioeconomic profiles, have been selected as control groups. Pre-tested self-administered anonymous questionnaires were utilized as instruments to collect data. The sample sizes ranged from 700 to 800 for both grades in the two waves of survey. Cluster sampling using class as the cluster unit was employed to select participants in both interventional and control groups.

The main findings for my study include students received life planning skills training showed significant improvements in their self confidence and their knowledge of pubertal development. However, gender awareness among Grade 7 students has not significantly changed, as it did with Grade 4 students. Such absence of project impact suggests that, by the mid-teen, stereotypes of gender discrimination are more resist to change. The development status of adolescents has to be taken into consideration for future similar projects.

Jianhua Yang is a graduated PhD student (2006) of the Gates Institutes and now working in China on HIV prevention and behavioral change communication field.

Smile!

In the Republic of Georgia, youth lack access to confidential, youth-friendly reproductive health services and information due to conservative Orthodox beliefs. The highest abortion rates in the world and increasing incidence of HIV/AIDS have brought leaders to see the need for improved reproductive health services.

Part of the larger USAID-funded Health Women of Georgia project, youth-friendly pharmacies were created by Save the Children to respond specifically to the needs of young people. These pharmacies staff specially trained pharmacists who provide reproductive health information in a sensitive, welcoming way that meets youth’s needs and also offer youth friendly corners with take-home materials.

A recent evaluation of the youth friendly versus other pharmacies using youth mystery shoppers found that the shoppers preferred the youth friendly pharmacies… especially since the pharmacists there were certain to do what youth in the Imereti Region feel is most important when they are searching for reproductive health information and services… SMILE!

Angela Bayer, MHS, PhD ‘08, recently completed her PhD in Population, Family and Reproductive Health at JHSPH.

Adolescents Can Know Best

There are numerous and diverse factors that influence the sexuality of adolescents in developing countries. Much research has been carried out on the issue, but little of this research has provided adolescents with the opportunity to describe sexuality as they see it and to share their perspectives on the factors that they think impact their sexuality – independent of pre-determined frameworks or pre-conceived notions. During my study, I went directly to adolescent experts in Lima, Peru to talk with them about the factors and pathways driving adolescent sexuality, based on the premise that adolescents can know best. The young experts provided important new factors and new insights on previously recognized factors, such as personal values and will, achievements and aspirations, family relationships, the close environment of peers, teachers, community and the media, and partner relationship, as well as wisdom on the relationship between and importance of the factors.

Adolescent experts also created possible decision-making pathways to having sex – which included the causes and consequences of having sex, personal will, the close environment, negative household influences and partner opinions. Coupled with the other results, these findings affirm the value of integrating adolescent voices into research and set the stage for future research and programs. This will be important information for the 5.8 million adolescents in Peru, and hopefully for adolescents in Latin American and other regions as well.
(The photo shown affirms the creativity, ingenuity and great perspectives of adolescents. It was taken by a 12-year old female as part of a photovoice project on items that affect adolescent sexuality.)


Angela Bayer, MHS, PhD ‘08, recently completed her PhD in Population, Family and Reproductive Health at JHSPH.

A Student's Perspective

This is one of the best conferences I have attended, but off course I am not an objective observer since adolescent health is my specialty. It is like being at the United Nations but the difference here is most people agree on what needs to be done. There are so many fields and countries represented that learning about people's work in itself is very educative. The sessions are superb, dealing with a wide variety of adolescent health issues. You feel like every minute is fully utilized. Today, I presented findings from my research and it is nice to see so many people interested in your work.

Esther Kaggwa, Doctoral candidate, Bloomberg School of Public Health. She also received a grant from the Gates Institute to conduct doctoral research among students in Uganda.

Orphans and HIV Risk in Tanzania

Globally, more than 16 million children have been orphaned by AIDS. Without continuous antiretroviral treatment, that number will increase to 25 million by 2010.

For young people, losing one or both parents significantly increases the likelihood of earlier sexual debut and their risk for HIV, as previous studies have shown.

Why do orphans engage in high risk sexual activity? What are the potential risk and protective factors? Does risk differ because of orphan status? Researchers Kristin Mmari, Robert Wm. Blum, Annie Michealis, Kaglemo Kiro and Mark Urassa sought to answer these and other questions in a study among HIV among orphans and non-orphans in Tanzania.

The researchers used in-depth interviews and focus groups among adolescents ages 14 to 18 in Kisesa Ward (a sub-district in Tanazania), said Blum, PhD, MD, MPH, the William H. Gates Sr. Chair and Professor of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health. Fifty-two adolescents (including orphans and non-orphans) participated and discussed their personal experiences and sexual life histories.

Among the 52 adolescents interviewed,13 reported having either exchanged sex for money or having had unprotected sex. (In Tanzania, Unicef reports the mean age for sexual debut is 16 years.) “I was fifteen years old the first time I tried sex,” an adolescent girl told interviewers. “The man came to me and he said he would give me money, 5000 shillings (about $5) [for sex]. … I did it because I needed clothes.” Indeed, if males have money, there is an expectation they would give money to girl with whom they have had sex.

“Lack of information was another issue that we heard repeatedly,” Blum said. “Adults are providing less information today.” He related one participant’s comments that the tradition of the “night fire” when parents talked with children and imparted ethical lessons has disappeared. “We’ve forgotten our culture,” said one adolescent.

Study participants agreed that female orphans are at highest risk for HIV. Risk factors include not being enrolled in school and the fact that caregivers are not providing young people with needed resources and moral guidance.

“The study is a starting point for examining risk and protective factors among orphans,” Blum said. “The findings suggest that HIV interventions for orphans may be most effective by targeting females and parents/caregivers of orphans.”

Blum presented the study findings April 28 to attendees of the conference

Brian W. Simpson, editor of Johns Hopkins Public Health magazine.

Dancing in Abuja, Nigeria

Photo Credit: David Colwell (c) 2008

New “Enlightenment” for Girls in Upper Egypt

In poverty-wracked Upper Egypt, rural girls are the most disadvantaged group. As their mothers before them, girls there suffer perpetuating cycles of poverty, deprivation and isolation, according to Nihal Elwan of the International Population Council.

The region is extremely conservative. Most girls are illiterate and face the risk of harassment if they leave their homes without a parent or brother. Female genital mutilation is almost universal. Girls traditionally work at home until they are moved from their father’s home to their husband’s home—without having any say in who their new spouse will be, Elwan told an audience of 200 attendees of the Abuja conference on April 28.

The Ishraq (“Enlightenment”) program was initiated in 2001 to create safe public spaces for girls and increase their mobility, skills and knowledge. Ishraq targeted out-of-school girls aged 13-15. Eighty-four percent had never attended school; 53 percent had already been circumcised (and 95 percent anticipated being circumcised); 52 percent had no information on menstruation prior to menarche; and only 56 percent could name the district in which they live.

Ishraq began in four villages (with two villages for control) in the Minya Governorate, one of the poorest regions in Upper Egypt. The villages differed religiously, ethnically and geographically. The intervention lasted 30 months and included two classes per village and four classes per week for 3 hours each. Classes included literacy, life skills and sports.

At the end of the program, 92 percent of those who took the literacy exam passed it and 66 percent reentered the education system.

Ishraq is going to be a nationwide program and is going to be transferred to Egypt’s National Council of Youth.

Brian W. Simpson, editor of Johns Hopkins Public Health magazine.

Menstruation and School Attendance

Menstruation and School Attendance in Sub-Saharan Africa

There are numerous barriers to girls’ completing their education in sub-Saharan Africa, including school fees, a preference for educating sons, safety concerns due to a school’s distance from home, and social pressures for girls to drop out of school and get married once they reach reproductive age. But the effect of girls’ periods on school attendance has long been neglected by researchers. The limited existing literature and my research from Tanzania suggest that pubescent girls’ attendance and participation are hindered by “girl-unfriendly” educational environments: schools lack adequate, safe, and private latrines and water supplies; schools continue to be dominated by male teachers and administrations; there are no private spaces for girls with menstrual discomfort to rest; and girls lack effective menstrual management materials (such as sanitary pads) and practical information on managing menses. In sub-Saharan Africa, only 57 percent of all girls are enrolled in primary school, with a significant drop-off to only 17 percent enrolled in secondary school. Many girls are reaching puberty around the end of primary school. For some ethnic backgrounds, menarche is still a signal to families and communities that a girl should drop out of school and prepare for marriage. However, for many girls, it is the gender discriminatory school institution that is hindering academic success. Much could be done to make schools more “girl-friendly,” thereby contributing to girls’ chances of successful academic achievement and future life careers. Priorities include safe, private and adequate numbers of sanitation facilities, affordable sanitary materials for all girls in need, environmentally sustainable disposal mechanisms and basic puberty information.

Marni Sommer, DrPH, MSN/MPH ’00, researched girls’ experiences of menstruation and schooling in urban and rural Kilimanjaro, in northern Tanzania.

Time is of the Essence

The following is excerpted from Ayo Atsenuwa’s keynote address to the conference.

We have inherited a legacy. There wasn’t much recognition of a state between childhood and adulthood. You were either a child who was not to be seen and certainly not to be heard [and] who was not recognized as a full human being. And next, you were an adult.

If we are going to make progress [in adolescent health], we need to recognize that time is of the essence and every skill that we have, we need to deploy. The exigency of the future of development compels us to take action. All around the world, the health situation of young people give us reason to worry.

How far should research go? How much research is required? We need to research into any and every area. An intellectual society ought not to fear research. Some fear research will unearth things they will be uncomfortable with. I think we need to emphasize that research only unearths what exists, what is the reality.

Ayo Atsenuwa is executive director of the Legal Research and Resource Development Centre in Nigeria.

Social Change and Adolescence

The following is excerpted from Robert Wm. Blum’s keynote address.

The origins of adolescence began at time of great change. In 1904, G. Stanley Hall coined the term “adolescence” because of the dramatic changes in the U.S. The industrial revolution led to higher values on education, a shift from farm to factory …

Social change is the norm today in much of the world: education, gender roles, global economy, instantaneous communication with the world, immigration and migration at a massive scale, democratization of political structures … This is the social context of many young people growing up in countries around the world.

Our new understanding of adolescence brings with it a new perspective of youth that views them not as the problem but as the possibility—the opportunity. Adolescence is a time of possibility and a time of opportunity.

To tap the potential as well to address the problems of youth, we need to view adolescence as nested in a wide set of social contexts, and we need to understand how they influence both health and morbidity.

Robert Wm. Blum, PhD, MD, MPH, is the William H. Gates Sr. Chair and Professor of Population, Family and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health.

Quotes from the Conference Opening

“The current global youth [population] bulge provides an unprecedented opportunity. [This is] the largest pool of children and youth in recorded history. It also provides an opportunity to capture the demographic bonus or dividend. Youth can be a positive force for change. Youth can be a positive change for the future if the right investments are made early.”
— Elizabeth Lule, World Bank

“This conference is uniquely desgined to assemble researchers and policy makers together to freely interact and share knowledge that will promote and better prepare our youths for the new world that we all desire now and in future.”
— Oladosu Ojengbede, Centre for Population and Reproductive Health, College of Medicien, University of Ibadan

“Twenty years ago most research was focused on the why, making the case for attention to adolescents. … This conference provides abundant attention to WHAT needs to be done for adolescents.”
— Jane Ferguson, World Health Organization

“This meeting will be very useful to learn state of art in this field; we need to make sure we have evidence to convince policymakers to invest early in adolescence. We need to know how to target those young people out of reach especially married adolescents and unmarried girls. We need better evidence of how to design health services deliery models. We need to improve our standards of how to deliver young-friendly reproductive health services.”
— Laura Laski, UNFPA

“Our hope for this conference is that we will all come out with evidence-based findings that will better inform policy planning design and implementation for improving young people’s health.”
— Abdullahi Maiwada, USAID Nigeria

“The slogan of this conference, “Youth Deliver the Future,” is an apt one. Without the proper development of young people thre will be no future development anywhere.”
— Hajia Turai Umar Yar’Adua, First Lady of the Federal Republic of Nigeria; her opening remarks given by the Minister of Health and Labour, Dr. Hassan Muhammad Lawal

Protect the Health of Young Mothers

The following comments are excerpted from Susan Rich and Mairo Mandara's opening plenary statement on Sunday, April 27.

We must also ensure that our youth are able to grow into the healthy and productive adults our world needs tomorrow. Young people today are faced with a myriad of health problems, some of which have been with us for a long time – unintended pregnancies, unsafe abortions and sexually transmitted diseases. Some are new, like HIV/AIDS. All these conditions have grave consequences, but, more importantly, all are preventable.

For example, we know that an unwanted pregnancy can abbreviate a girl’s education and diminish her future economic potential. We also know that about a third of all maternal deaths can be linked to unwanted pregnancies. Further, methods to prevent the occurrence of unwanted pregnancies are available to us. We must find ways to inform youth and offer services that protect the health of young girls and young mothers before they conceive a pregnancy that may threaten their lives but also the lives of their babies.

Child spacing and family planning can prevent about a third of all maternal deaths. Family life education can help young people delay childbearing and allow them to complete their education. In doing so, access to information and services can determine whether young people will enjoy economic independence or face a life of struggle. If we ensure the right conditions for our youth to become healthy adults, we will set them on the path toward economic security, for their lifetimes and those of future generations.

Susan Rich is a senior program officer for reproductive health with the Bill & Melinda Gates Foundation. Mairo Mandara is an program advisor to the David and Lucile Packard Foundation.

Amy Tsui: Tomorrow’s Future, Today’s Youth

Tomorrow’s Future, Today’s Youth

How do you help the world’s 1.77 billion young people ages 10 to 24 secure their health and well being? More than 500 experts and students from 33 countries are gathering in Abuja, Nigeria in late April to exchange research and programmatic solutions to this and other pressing developmental questions. Sponsored by the Bill and Melinda Gates Institute for Population and Reproductive Health, in partnership with Nigeria’s University of Ibadan and Obafemi Awolowo University and more than 40 other international and national organizations, “Investing in Young People’s Health and Development: Research that Improves Policies and Programs” serves as a forum for researchers and practitioners to share evidence and ideas for meeting the health and developmental needs of young people in low-resource settings.

Youth will deliver our global future. What’s needed is well-researched, peer-reviewed evidence about what influences their welfare in the short and long term. This conference benefits from a unique commitment of researchers, educators, policymakers, practitioners and donors. All of us are working to ensure that science, practice and the youth themselves work hand-in-hand to secure the best possible future.

Amy Tsui, PhD, is director of the Bill and Melinda Gates Institute for Population and Reproductive Health at the Johns Hopkins Bloomberg School of Public Health in Baltimore, Maryland, USA.