«Suggested citation: Panday, S., Makiwane, M., Ranchod, C., & Letsoalo, T. (2009). Teenage pregnancy in South Africa - with a speciﬁc focus on ...»
While the study in Nigeria reported increased condom use and decreased self-reported symptoms of STIs, the study in Chile reported an increase in the age of sexual debut among males and increase in contraceptive use among girls. However, the latter study did not improve the use of contraceptives at last sex, neither did it improve the volume of young people attending health facilities during the two year follow up period.
As the primary socialising agents for children, parents are well positioned to inﬂuence the sexual behaviour of their children. Yet parents and adolescents seldom discuss sexuality because of the discomfort related to talking about sex. A number of interventions have been trialed in the US to improve parent-child communication and a limited number of studies have focused on improving parenting involvement and monitoring. While studies report difﬁculty in recruiting parents into multi-session programmes, when they do participate, parents increase their own comfort in talking about sex and in communicating with their children about sexuality in the short-term (Kirby, 2007). In addition, while the available evidence of the impact of such interventions on adolescent sexual behaviour is limited, it does suggest that parent-child programmes can inﬂuence sexual behaviour, particularly condom use (Kirby, 2007).
As discussed earlier, a randomised control trial in rural KwaZulu-Natal to strengthen family relationships and social capital in the community as a protective shield against HIV, showed strong effects among parents and community processes but less so on young people (Bell et al., 2008). The programme was able to increase caregiver comfort in talking about sensitive issues with their children, improve monitoring and control of children’s whereabouts and strengthening support networks among community members to exert informal social control.
However, among youth, the programme effects were limited to improved knowledge on HIV transmission and less stigma towards people infected with HIV. As the intervention focused on pre-adolescents, outcomes in terms of sexual behaviour were not appropriate for the study.
Much more research on programmes for parents and their children is required before ﬁrm conclusions can be reached about their effectiveness and widespread application (Kirby, 2007).
Peer programmes Peer programmes have gained currency over the years as a strategy to intervene with adolescent sexual and reproductive health because it takes advantage of existing networks of communication and interaction, and because peers have been identiﬁed as important determinants in adolescent sexuality and a range of adolescent risk behaviours. Peer programmes, generally recruit and train a core group of young people who, in turn, serve as role models, and sources of information and skills development on adolescent sexuality (Speizer et al., 2003). Peer educators have participated in a number of multi-component programmes – as a complement to teachers in school-based programmes, to distribute condoms outside of health services, to create demand for health services in community-based settings, and in a number of mass media interventions (Speizer et al., 2003). Even though peer education is widely diffused programmatically both locally and internationally, it has not been deﬁned conceptually (Shiner, 1999) and its theoretical underpinnings are yet to be clariﬁed (Turner & Shepherd, 1999). The lack of clarity about the processes and mechanisms that lead to successful programmes as well as standards of practice for peer education means that new modalities are constantly invented with little
evidence for its effectiveness which ultimately impedes evaluation and scale up (Bastien, Flisher, Mathews & Klepp, 2006; Deutsch, Michel & Swartz, 2003).
A review of peer education programmes in sub-Saharan Africa reported a massive increase in the number of programmes since the 1990s but few methodologically sound evaluation studies to support its increasing popularity (Bastien et al., 2006). Although studies report positive outcomes, they are generally focused on knowledge, attitudes and beliefs and number of peer educators that have been trained using relatively small sample sizes. In addition, few studies use robust designs and include biological outcome measures such as STI/HIV and pregnancy. Studies also do not provide an adequate description of the process of setting up the intervention including recruitment of peer educators and content of training. The use of peer education as part of multi-component interventions makes it difﬁcult to attribute effects to the peer education component of the programme.
A review of three peer interventions in Peru, Ghana and Cameroon that were located in the school and community settings, showed consistent positive impact on psychosocial factors such as knowledge, attitudes and self-efﬁcacy and some evidence for effects on sexual activity, contraceptive use and condom use (Speizer et al, 2003). Non-experimental studies are also indicative of declines in unplanned pregnancies, number of sexual partners and increase in condom use among university students. However, given the developmental process that peer educators are undergoing, the largest effects of programmes are often on peer educators themselves and the cost of regularly having to recruit and retrain peer educators may be prohibitive (NRC & IOM, 2005). In fact, a well designed, multi-component adolescent sexual and reproductive health programme in the Mwanza region in Tanzania, showed that rural learners in primary schools lacked the cognitive ability and skills to transfer knowledge to peers (Bastien et al., 2006). The study concluded that the peer component of the programme was not feasible because of the cost of retraining groups of peers as opposed to investing in teacher training. While peers could facilitate some aspects of the training such as ice breakers around sensitive issues and drama performances, careful consideration would have to be given to matching the activities of peer educators to their abilities.
Given the scale of the HIV epidemic among young people in SA, the country has invested in deﬁning standards of practice for, and evaluation of peer education programmes. Termed ‘Rutanang’ – a Sotho word meaning ‘learning from one another’, the process has resulted in a set of guidelines for the development, implementation and evaluation of peer programmes (Deutsch & Swartz, 2002). The guidelines identify four roles for peer
• Educating peers in a structured manner;
• Serving as role models for healthy behaviour;
• Identifying youth who need assistance and making necessary referrals; and
• Serving as advocates to secure resources for themselves and their peers.
The guidelines identify ten elements that are essential for peer education programmes in SA. These include:
(1) planning and needs assessments; (2) mobilising the necessary support from relevant stakeholders; (3) setting up supervisory infrastructure for peer educators; (4) identifying linkages for referral; (5) developing a learning programme that goes beyond awareness raising; (6) setting up infrastructure for selecting, training and
contracting peer educators; (7) managing peer educators and supervisors; (8) providing means of recognising and credentialing peer educators; (9) monitoring and evaluating outcomes; and (10) ensuring the sustainability of programmes.
A recent evaluation study of peer education programmes in SA indicated that a large number of programmes are being implemented using a variety of methodologies to inform programme design (Ward et al., 2007).
While a number of settings are used (schools, universities, youth clubs, social meeting spaces, shebeens and nightclubs) most programmes are school-based or target school-going youth. Even though the majority of programmes target secondary school learners, they are largely focused on abstinence messaging. This often does not match the sexual behaviour of peer educators or of the target audience of the programme. The review concluded that when the Rutanang guidelines are used to guide the development and implementation of programmes, they result in sound interventions. However, the study indicated that beyond curriculum design, most interventions that were included in the review did not use the guidelines for conducting needs assessments, setting up referral systems, or for monitoring and evaluation, probably because they were not a requirement of their funding compacts or that these components of the programme were more technically challenging. Although impact evaluation studies were rare, anecdotal evidence suggests that well developed programmes have the ability to impact on self-esteem, conﬁdence and resistance of peer pressure for both participants and peer educators. There is also some evidence for behaviour change in terms of secondary abstinence, condom use and remaining faithful to one partner. These ﬁndings need to be conﬁrmed through well designed evaluation studies but nevertheless provide support for the use of peer education programmes for adolescent sexual and reproductive health in SA.
In fact, evidence from loveLife, South Africa’s largest public health intervention for HIV and AIDS among young people, suggests that participation in peer education programmes are contributing towards the development of a new generation of leadership from the most marginalised communities. loveLife has trained 1200 young people as peer educators – known as groundbreakers between 2001 and 2005. These peer leaders, together with local volunteers (known as mpintshis), engage in local mobilisation in over 700 communities and 4000 schools. A recent survey among peer leaders indicates that participation in the programme has increased education, employment and civic engagement opportunities among these young people well beyond the national norms for this age group and that a signiﬁcant percentage are taking up leadership roles in community structures (VOSESA, 2008). For example, whereas 45% of groundbreakers were pursuing further studies, only 30% in this age group were doing so nationally. In addition, whereas 75% of young people nationally are not involved in community organisations, 55% of groundBREAKERS continue their community work after graduating from the programme. GroundBREAKERS also report a strong future orientation, positive sense of self and greater conﬁdence in building the networks that are necessary to attain future goals. They also report much more egalitarian views towards men and women’s roles in relationships and the ability to successfully negotiate relationships with partners and peers.
Sexual and reproductive health services Access to family planning services Family planning services are provided to young people with the purpose of making available reproductive health services, providing contraception including condoms and improving their knowledge and skill to use them (Kirby, 2007). While there is evidence from the US that substantive numbers of young people make use of family planning services (up to 40% of 15-19 year olds in the US), the evidence on the impact of such services 87 Teenage pregnancy in South Africa - with a speciﬁc focus on school-going learners on sexual behaviour and pregnancy is limited (Kirby, 2007). Evidence from the Family PACT programme in California showed that providing comprehensive family and reproductive health services to young people at no cost, resulted in a three-fold increase in the use of services by adolescents from 99 739 visits per year to over 300 000 visits per year. No doubt the increased availability and use of contraception by young people through such services averts many unintended pregnancies. However, long-term evaluation studies are required to demonstrate the positive link between family planning services and sexual behaviour.
Young people in SA have beneﬁted from a number of health policies directed at the population at large.
A number of interventions have been instituted within the rubric of family planning services. In particular, contraception has been made available at primary healthcare clinics and other mobile services at no cost since 1974. While vertical family planning services were directed primarily at Black population control during Apartheid, post-1994 signiﬁcant efforts have been made to promote a human rights and integrated approach towards reproductive health care (DOH, 2001). Dramatic increases in the use of contraception are indicative of the success of family planning services, although the quality of care has not always been optimal. As indicated earlier, contraceptive use, particularly condom use, has increased signiﬁcantly since the 1998 SADHS (DOH, MRC & Measure DHS, 2002). In fact, most young people feel conﬁdent about being able to easily access condoms if they need to (Pettifor et al., 2004). Government clinics and hospitals are the principal source of condoms for over 70% of young people (Shisana et al., 2005).
But over half of sexually active young people do not use contraception when they have sex. While a range of socio-cultural factors determine contraceptive use, one of the principal reasons for non-use, is that sex is often not planned (Kirby, 2007) and happens on the spur of the moment (Jewkes et al., 2001). While emergency contraception cannot be used as a regular form of contraception, it can dramatically reduce the chances of pregnancy if used within 72 hours after sex (Kirby, 2007). Fours studies in the US found that providing emergency contraception to young women in advance dramatically increased its use but did not produce the negative effects of increasing sexual activity (Kirby, 2007). Sample sizes were too small to detect effects on pregnancy rates. Although strong recommendations are made for the extensive promotion and ready availability of emergency contraception within the Policy Framework for the Provision and use of Contraception in SA (DOH, 2001), legal regulations (must be bought over the counter from a health professional) and, particularly, the negative and judgemental attitude of health staff (Wood & Jewkes, 2006) prevent young people from using this contraceptive method. Given its safety and efﬁcacy (DOH, 2001), consideration should be given to deregulating emergency contraception in SA in order to increase its availability and usage.
Adolescent friendly services