PRB

(May 2003) The successes are real, but they’re small compared to the task: reaching the half-million adolescents¹ who form some 20 percent of this island’s 2.5 million population and enabling them to adopt healthier sexual lifestyles.

Early sexual activity, combined with a lack of relevant information, services, and skills to avoid risky situations, place adolescents (most often classified as young people ages 10 to 19) at risk of unintended pregnancies, sexually transmitted infections (STIs), including HIV, and other threats to their sexual and reproductive health.

Several studies over the past decade in Jamaica have identified a number of risk factors for these young people, including multiple partners, sexual abuse, and a lack of reproductive health information.²

Facing Some Troublesome Issues

Research shows that the country’s adolescents begin sexual activity at early ages. Studies conducted since the mid-1990s put the mean age of initiating sexual activity at around 13 years for boys and 15 years for girls.³ Forty percent of Jamaican women have been pregnant at least once before age 20, and more than 80 percent of adolescent pregnancies are unplanned.⁴

Early sexual activity also increases the risks of exposure to HIV and other STIs. The Ministry of Health’s Jamaica AIDS Report 2002 notes that close to one out of 60 AIDS cases between 1982 and the end of 2001 were ages 10 to 19. During 2001, there were 69 new cases for the 15 to 24 age group, 7.4 percent of the total. Also, adolescent females ages 10 to 14 and 15 to 19 had two and three times the risk of HIV infection, respectively, than boys of the same age group.⁵

“This is as a result of social factors, whereby young girls are having sexual relations with HIV-infected older men,” notes the report.

Irregular use of condoms heightens the risks for boys. The Adolescent Condom Survey 2001 shows that 41 percent of sexually active boys ages 15 to 19 are at higher risk of contracting STIs, because they had more than one partner in the previous year and did not consistently use condoms. The survey also found that while some 86 percent of adolescents knew about HIV/AIDS, only 11 percent of young men ages 15 to 19 perceived themselves to be at personal risk.

According to the survey, the most recent island-wide study of contraceptive use among sexually active adolescents, 74 percent of youths ages 15 to 19 and close to 10 percent of those ages 10 to 14 reported being sexually active. Contraceptive use was relatively low for boys ages 15 to 19 at the first sexual encounter (31 percent, compared with 59 percent for girls), but usage increased to 68 percent at the last sexual encounter.

While older adolescents generally had some knowledge of how to prevent STIs, younger ones were less aware. Some 88 percent of teens ages 15 to 19 cited condoms as a way to prevent infection, compared with 57 percent of those 10 to 14.

In addressing reproductive health challenges among youth, the government and nongovernmental organizations (NGOs) have communicated positive messages; trained health care providers, peers, and other important pillars of the community; and have taken steps to improve the policy environment.

Improving the Policy Environment

Decentralization within Jamaica’s health system has recently limited the role of the National Family Planning Board (NFPB), the agency mandated to prepare, promote, and carry out family planning and population-related programs in the country. Nevertheless, the NFPB is sourcing and supplying contraceptives to the public health system; linking with other agencies on policy and training; and providing information, mainly through its daily call-in, walk-in counseling service, its automated hotline, as well as limited outreach on request.

“One of our broad strategic objectives is to expand access to reproductive health information and services to adolescents,” explains Olivia McDonald, executive director of the NFPB. “We are more or less responsible for the lead initiative in trying to get a policy in place for access to contraception to people under 16 years.”

The legal age of consent in Jamaica is 16 years, making it illegal to supply contraceptive services to younger teenagers, even when they are admittedly sexually active. In addition, many providers balk at providing services to nonpregnant teens less than 18 years, the legal age of majority.

A new draft policy sent to Parliament for consideration and approval offers guidelines that would enable providers to counsel and prescribe medical contraceptives for sexually active girls under 16 years who cannot be persuaded to become abstinent or to involve an adult caregiver and who are deemed mature enough to understand the implications of sexual activity. Surgical contraception, such as Norplant or sterilization, would still require the consent of a parent or guardian.

The Access to Contraceptives guidelines also recommend that nurses, doctors, and other providers uncomfortable with making such decisions — whether on moral or legal grounds — refer these cases to other health care workers.

A draft national youth policy, developed by the National Centre for Youth Development, overlaps with the Access to Contraceptives guidelines but does not address adolescent reproductive health. The development of an adolescent reproductive health policy has been discussed but, so far, not pursued.

Enhancing Services for Young People

Government initiatives aimed at improving young people’s reproductive health are spearheaded by Youth.now, the national adolescent reproductive health project that is supported by the U.S. Agency for International Development (USAID). Underway since early 2000, Youth.now works in conjunction with state and nongovernmental organizations, including the health ministry, the NFPB, and the National Centre for Youth Development.

The project is working in nine of Jamaica’s 14 parishes — the island’s major administrative units. At various sites, the project is testing approaches that may encourage adolescents to use public sector health centers for counseling as well as clinical needs, including contraception and STI treatment.

The environment is ripe for change, according to Pauline Russell-Brown, chief of party at Youth.now. “People see the benefits of enabling young people to lead healthy sexual lives … and we are seeing success; there’s enthusiasm at the community level in those parishes where we’re working.”

Youth.now is testing and evaluating five approaches to delivering youth-friendly reproductive health services, through NGOs⁶ or public-sector facilities. These facilities have been phased in over the past two years and support the following approaches:

• A wellness center model, offering fitness facilities to attract young men as well as family planning and other services;
• A stand-alone public health center that does regular outreach to nearby schools and communities;
• A joint venture with the NGO Children First to provide reproductive health services to youth along with skills training, community advocacy, and tutoring;
• A program with the YMCA in the capital Kingston to provide more than 100 street boys with reproductive counseling and education as well as condoms — as part of a wider plan to support peer leadership and parenting education; and
• Programs linking schools and health centers at two locations in the southwestern parish of St. Elizabeth and another with an NGO partner in Kingston. The guidance counselor, the school nurse, or the peer educator discusses services available at the health centers as well as reproductive issues broadly.

Traditionally, young people have shunned health centers that dispense reproductive health services, despite their generally convenient locations. In a recent study they identified a number of problems at the centers.⁷ They referred to dirty clinics; a lack of privacy, especially for counseling about STIs; and unfriendly attitudes toward youth, especially sexually active youth. They also disliked the traditional system of serving clients by handing out numbers on a first-come, first-serve basis, rather than by appointment. On a scale of 1 to 10, the health centers received the lowest rating of 1.

“Private doctors are thought to provide the best service but are the least available due to cost,” the survey found.

Some teens have the perception that providers more willingly serve boys than girls, reflecting the social judgment that boys and young men should “sow their wild oats,” while girls and young women should be proper in their behavior. In a 1996 study, providers said they would give condoms to the boys and counsel abstinence to girls.⁸ Traditionally, it is only after girls become pregnant that they are seen as justifiable clients at the health centers.

For condom purchases, adolescents favor small shops for reasons of privacy and confidentiality. More than 55 percent of young men bought condoms at a pharmacy or shop, while many others got theirs from friends, according to the Adolescent Condom Survey.

“They’re not going to clinics even though they’re free there,” says McDonald of the NFPB. “I suspect in the clinics, they don’t just leave them on tables for youth to pick up, and the youngsters are not going in there to ask for them.” She recommends a focus on social marketing for condoms, targeting adolescents at the community level.

Youth.now’s Russell-Brown says many adults don’t acknowledge that few young people will simply approach a provider with a reproductive health problem. “They will come with a question about a skin problem or some other issue. But a skilled provider can, in fact, in the conversation — it’s not a counseling session yet — discover issues related to reproductive health.”

At present, teen mothers are the main adolescent users of the public-sector facilities. The Women’s Centre Foundation of Jamaica, which is funded by the government and various international agencies, is the preferred site for teens seeking contraceptive services after the births of their babies. The foundation helps girls under age 18 to continue their education during pregnancy and to return to school whenever possible. It provides other support to the girls, their parents, their babies, and the “baby fathers.”

Training Service Providers

Training has been a major plank of the effort to strengthen reproductive health care for adolescents. Core groups of some 20 individuals including clinical providers, parents and people working with groups of parents, pastors, peers, and men have undergone intensive training, with a major focus on coming to terms with their own sexuality so as to be able to cope with issues raised by teens. Subsequently, those trained have been reaching out to their own constituencies and many have been listed in a locally available directory of trainers. Russell-Brown says that the project has seen a “tremendous increase” in requests for training assistance over time.

At the health centers, staff — from the doctors and nurses to the janitors and caretakers who often play a gatekeeping role — are being trained to create a youth-friendly environment, based on the issues identified by young people. In an effort to further protect adolescents’ privacy, dental nurses and dental auxiliaries, who see school-children routinely and who are sometimes trusted with confidences, are also being trained in reproductive counseling.

This year, a second youth-friendly service site has opened in Lucea, in the western parish of Hanover, where much of the staff throughout the parish has already received some training. The first such site opened in southeastern Jamaica early in 2001. Elsewhere, in the parishes of Clarendon and St. Elizabeth, medical officers of health — the chief health executives — have asked Youth.now to develop some basic orientation and training for all staff so that all the facilities in the parishes can offer some services.

So, is the plan to certify clinics as youth friendly? Russell-Brown says that Youth.now has worked with partners to develop youth-friendly service standards and criteria that could be useful management tools. She says that any decision on certification is in the hands of the Ministry of Health’s Quality Assurance division, however. Her bigger interest is in ensuring an improvement in attitudes among providers, within the communities, and among young people themselves.

Responding to Information Needs

Communication to adolescents has been another major plank in the strategy to help adolescents adopt healthier lifestyles. Youth.now’s partner, Dunlop Corbin Communications, has been running a media campaign with separate messages for different age groups. The message to those 10 to 12 years old is one of abstinence. For the group ages 13 to 15, the message has been to abstain, but if not, to use a condom. Youth ages 16 to 19 are urged to use condoms. And all the ads, on a range of media, have urged young people to seek help by calling the “Friend’s Hotline,” run by the Jamaica Foundation for Children.

To test the effectiveness of the campaign, a follow-up survey was conducted in September 2002.⁹ The survey found 82 percent recall among adolescents (90 percent among adults), with 49 percent of the adolescents saying that the messages would affect their thoughts and behaviors. The message of abstinence resonated strongest with young women and with youth ages 10 to 12. The message of safe sex with the use of a condom was best received among young men, especially in the oldest group.

Whether the messages will be reflected in behavioral statistics in the next round of surveys is moot. Only about 15 percent of girls ages 15 to 19 and 5 percent of boys consider abstinence as a contraceptive method appropriate for youth. The condom and the pill are the preferred methods.¹⁰

Nonetheless McDonald stresses that information and communication are key to improving adolescents’ reproductive health. She wants the focus to be on parents, providers, and students in school, most of whom are exposed to the ministry’s Health & Family Life Education program. Critics say this program is not specific enough, starts too late (in terms of age), and is taught by teachers uncomfortable with the subject.

In another effort to provide information to adolescents, the Family Planning Board has piloted a half-hour television magazine program, using teen moderators and popular music. About 13 episodes of “Teen Scene” have been produced, with funding from the national budget. The limited production budget, however, restricts the half-hour program to air on Saturday afternoons during the summer and Christmas holidays. Condom use, emergency contraception, and sexual behavior are among the topics explored on the program.

Other educational materials under development include a series of fact sheets that Youth.now is developing for use in public education and by its advocates in the parishes. They encapsulate and simplify some of the vast amount of information on reproductive health gathered in Jamaica over the years.

“We can never fill the need for information,” McDonald emphasized.

Measuring Success

The existing research is impressive in its reach and persistence. Yet there are critics. Marjan de Bruin, the acting director of the Caribbean Institute of Media & Communication (CARIMAC) at the University of the West Indies questions whether the existing research reflects the multiple dimensions of high-risk sexual behavior. De Bruin contends that most of the research focuses on sexual intercourse itself and does not connect risky sexual behavior to its cultural context and to its social, economic, and political meanings.¹¹

With so many interlinking issues and initiatives, one challenge has to be how to judge what is succeeding or most likely to succeed, particularly given competing demands in Jamaica’s long-stagnant economy.

Despite the challenges ahead, Russell-Brown still sees positives. She is clearly pleased with the outcome of recent evaluations from the Balaclava Health Centre in rural St. Elizabeth, the first Youth Friendly Site, initiated in March 2001.

“What we have noticed in the last year is that the number of adolescent users of the health services generally — not just for family planning — more than doubled,” she says. “For family planning, it went up by almost 60 percent. And the first thing the staff mentioned is that in fact their attitudes have changed.” With regard to the adolescent clients, some staff have said, ” ‘ee’re treating them differently; we feel different towards them. And they’re feeling more comfortable to come in and talk — about anything, not just reproductive health issues’,” according to Russell-Brown.

But just how will her project measure success?

“Success for us is going to mean that we begin to see some decline in new cases of STIs, because it’s scary. What we know is that the rate of infection is growing fastest in the adolescent age group … issues the project can’t address in the short term.”

She adds: “Success for us would be to continue to see an increase in the number of young people who are using facilities, whatever they’re going in for; to see in the 2007 Contraceptive Prevalence Survey an increase in the number of young people who tell us that their first pregnancy — they had planned it.”¹²

Suzanne Francis Brown is a freelance writer and communications consultant, based in Kingston, Jamaica.

References

1. Statistical Institute of Jamaica, “Total Population by Age Group”
   (STATIN 2001), accessed online at www.statinja.com/stats.html, on April 17, 2003. The figures indicate that the 10 to 14 age group was 267,500 and the 15 to 19 age group numbered 243,700 in 2000. (Note: The 2001 Demographic Report put the 10 to 19 population at 497,909.)
2. Hope Enterprises, Report of the National Knowledge, Attitudes, Behaviour & Practices Survey Year 2000 (Kingston, Jamaica: Hope Enterprises, 2001). The survey notes that 54 percent of the male respondents ages 15 to 19 had multiple partners in the previous 12 months, as did 16.5 percent of the young women. The Adolescent Condom Survey 2001 found 4.7 percent males ages 15 to 19 and 11.7 percent females had been forced at first sex; and 14.5 percent males and 28.5 percent females have ever had forced sex. Knowledge of sexual and reproduction, as measured in the Advanced Training & Research in Fertility Management Unit baseline study (2001) in the parish of St. Elizabeth found that more than 85 percent of teens knew about contraception, but few used it at first sex. Studies have also looked at parental presence in the home, church and club attendance, as well as developmental supports such as self-awareness, communication skills, and caring support systems.
3. Hope Enterprises, Report of the Adolescent Condom Survey Jamaica, 2001 (Kingston, Jamaica: Hope Enterprises, August 2001). This survey was commissioned by the United States Agency for International Development’s Commercial Market Strategies project. The study found that the mean age at first sexual experience for adolescents ages 15 to 19 was reported as 13.2 years for males and 15.2 years for females. Some social context should be noted — boys may feel that they gain social credit from reporting early sexual activity, and girls by reporting later sexual activity.
4. Elizabeth Eggleston, Jean Jackson, and Karen Hardee, “Sexual Attitudes and Behavior Among Young Adolescents in Jamaica,” Family Planning Perspectives 25, no. 2 (June 1999), accessed online at www.guttmacher.org/pubs/journals/2507899.html, on April 17, 2003.
5. Jamaica Ministry of Health, National HIV/STD Prevention & Control Program, Facts and Figures: Jamaica AIDS Report, 2001, accessed online at www.jamaicanap.org/aids2002.htm, on April 17, 2003.
6. National Centre for Youth Development, Adolescent and Youth-Serving Organisations in Jamaica: Results from the Youth Programmatic Inventory Survey of the National Centre for Youth Development (Kingston, Jamaica: National Centre for Youth Development, 2002). An inventory of 141 organizations that serve youth found that youth constituted 24 percent of clients; that two-thirds of services for youth are for young women, most over 15 years. The survey found that 23 percent of those focusing on health for youth were NGOs.
7. Cate Lane et al., Nine-Tenths of Reality (Kingston: Youth.now, May 2002).
8. Carmen McFarlane et al., The Quality of Jamaica Public Sector and NGO Family Planning Services: Perspectives of Providers and Clients (Research Triangle Park, NC: Family Health International, 1996).
9. Hope Enterprises, Youth.now Advertising Recall Survey (Kingston, Jamaica: Hope Enterprises, September 2002).
10. Hope Enterprises, A Report of the Adolescent Condom Survey Jamaica, 2001.
11. Marjan de Bruin, Teenagers at Risk (Kingston: Youth.now, 2002).
12. C.P. McFarlane et al., Reproductive Health Survey 1997, Jamaica: Final Report (Atlanta: Centers for Disease Control and Prevention, 1999). Some 13 percent of mothers ages 15 to 19 who gave birth in the previous five years said the birth was planned.