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Health Provider A PUBLICATION OF THE NATIONAL FAMILY PLANNING BOARD

Assessing risk in your AverAge teenAger

VOLUME 2 NUMBER 3

Reducing Adolescents’ FeRtility RAtes And incidence oF sti by the PRomotion oF Abstinence.

HOW TEENAGERS SEE YOU:

a g u i d e t o p r ov i d i n g e f f e c t i v e s e r v i c e s t o m i n o r s

Credits newsletter co-ordinator Harriett M. Clarke Communications Officer (Writer) CONSULTING EDITORS Dr. Olivia McDonald Executive Director Dianne Thomas Director Outreach Prorgrammes Kevin Bell Director Policy Formulation, Monitoring & Evaluation

Editorial

T

his Newsletter seeks to equip the average health provider with the necessary tools to address adolescent issues by highlighting how adolescents see health care providers and the health centre institutions.

In the article “How teenagers see you: a provider’s guide to providing effective services to minors,” there is statistical evidence that reports a hesitancy on the part of teenagers to approach health providers about their reproductive concerns. Although parents and teachers were reported as the persons who teenagers were more willing to approach for their reproductive health issues, it would also benefit the adolescent if the health providers within the health centers were approached to bring substantially more credible information to this target group.

As health providers we must be careful of our attitudes displayed toward the clientele as these can sometimes complicate the effective and efficient service given to our adolescent clients in our health institutions. The risky behaviours of our

adolescents as highlighted in the article “Assessing risk in your average teenager” has to be addressed in a sensitive and professional environment for there to be significant behaviour modification in our teenagers.

Adolescent sexuality is a sensitive area, one in which the average health provider must try to balance between personal views and perceptions and the health care policy that requires some amount of detachment in dealing fairly with our teens for them to benefit when visiting the clinics.

The article on “Assessing Risk in your Average Teenager” will help the health provider to identify those teens with vulnerabilities which may enhance their risk to early sexual initiation and the consequences of teen pregnancies and sexually transmitted infections.

Addressing adolescent sexuality may lead to further reduction in the fertility rate in our adolescent population while equipping them to prevent sexually transmitted infections.

This is addressed in the article “Reducing Adolescents’ Fertility Rates and Incidence of STI by the Promotion of Abstinence.”

Services to adolescents need to be responsive to the special needs of adolescents and provided in a manner that does not stigmatise sexually active adolescents and be offered in a respectful and confidential way.

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AssEssING RIsk r OU Y iN

av e r a g e T e e n a g e r

the reproductive health needs of the teenagers.

The levels of achievements among these programmes vary and have to some extent acted as behaviour change agents. However, the role of the health care provider is crucial as they are strategically placed and their presence is a constant in these institutions long after these proisky sexual behaviours in adolescents grammes have done their time. are of major concern to health sectors and to educational ministries alike be- Why assess risk in teens? cause these risky behaviours are sometimes linked to unintended pregnancies and sexually The mean age of sexual initiation in 2008 transmitted infections among this age group. By among females ages 15-17 years was 14.4. Acthe end of 2008 (based on the Reproductive cording to the RHS for boys in that age group it Health Survey-RHS 2008) it was calculated that was 13.3. The start of sexual activity for adolescents constitute 19.6% of Jamaica’s popteenagers heightens their risk of exposure and ulation, with 17.2% being in the reproductive contraction of sexually transmitted infections. age group 15-19 years. These numbers make the adolescent population a significant group to tarVulnerable to unwanted and unplanned pregget reproductive health policies and pronancies, the 2008 Reproductive Health Survey grammes. The initiatives undertaken will affect revealed that 18.8 % of females aged 15-19 the future of the reproductive health of these years stated that their current or most recent teens and the population in general. pregnancy was planned. Within this age group, 66.2 % stated their pregnancy was mistimed and There are several programmes in existence 14.6% reported it unwanted. aimed at targeting the teens to abstain or to be aware of their sexuality and to use contraceptive The current adolescent fertility rate among femethods. males 15-19 year olds according to the RHS indicates an 8.8% decrease from the year 2002 The Sex Ed Day put on by the Ministry of which was 79 female teenagers per 1000 women Health under the coordinated efforts of the Javersus 72 per 1000 in the year 2008. maica Youth Advocacy Network along with other programmes from the National Family This decrease is a nominal one and can be rePlanning Board such as Teen Seen, the Marge versed if adequate measures are not put in place Roper Rap sessions and Youth Forums targeting to further reduce these numbers. both males and females have all sought to meet Written and Prepared by Harriett M. Clarke, Communication Officer (Writer) national Family Planning Board

Introduction

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AssEssING RIsk in your average teenager (cont’d...)

Such is the risk also reflected in the data for sexually transmitted infections in 2008. Of the 27,000 persons living with HIV/AIDS in Jamaica women age 15+ with HIV accounted for 7600 of that number.

“The Summary of AIDS cases within the 15-19 age cohort from January 1986-December 2007 (Ministry of Health National HIV/STI programme Jamaica HIV/AIDS Epidemic Update January to December 2007 Facts and Figures) indicated that 30 males and 118 females were infected with the AIDS virus.”

The numbers as they related to females are a cause for concern indicating that policy and programmes are needed urgently to rectify the situation existing among the females.

the stage of trying to “find themselves” and will encounter peer pressures which influence them to become sexually active because of a need to fit in. Not knowing what they want in general also affects the relationships they pursue.

• Inconsistent condom use among teens is a reality of their lack of preparedness to engage in sexual activity. The RHS indicated that they did not expect to have sex when they did.

• 1 in 20 adolescents lack access to condoms some of them giving reasons that they are afraid to approach health providers who believe that teens are not to engage in sexual activity.

But why are teens more susceptible to How do risk assessment and the percontracting Sexually Transmitted Infect- ception of risk affect teens? ions/HIV/AIDS? • Their bodies have just started to mature during puberty – the period or phase from childhood to adulthood. Physiologically teens are more susceptible to contracting sexually transmitted infections because their bodies are just emerging from childhood and sexually transmitted infections are considered far more dangerous to youthful tissues.

•

Teens are more reckless in their behaviours especially towards sex because of the changes in their hormones due to an onset in puberty. This increases the opportunity for multiple sex partners. They are also at

Risk Assessment looks at what could go wrong –both before and during the activity – and then deciding on ways to prevent – or minimizethese potential problems. It is critical to note that person’s perception of risk is important in assessing it in teens and that being aware of persons perceptions involving risk should assist the formulation of effective programmes and policies which would impact upon them positively.

• More than half (55.9%) of women who have ever had sexual intercourse considered themselves to be at no risk of HIV transmission, followed by “little risk” (27.6%).

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AssEssING RIsk in your average teenager (cont’d...)

• Slightly more than half (53.6%) of young • Prevente and manage sexually transmitted men declared they had no risk at all while infections (STIs) to prevents the sexual 31.5% felt they had a little risk. spread of HIV. • Young men were more likely to mention the • Increase contraceptive choices and access lack of condom use as a reason for their risk to lead to fewer unsafe abortions in teens. compared to women in the same age groups • Introduce contraceptives to teens who have (82.5%–75.3% versus 64.2%–63.4%) just had a child • Reduce violence against women to Health providers should be on the lookout for decreases maternal and child morbidity and teens who are socially, emotionally and environmortality, and unwanted pregnancy, and to mentally vulnerable affirm the value of women in society t t

t

Social Vulnerability – Financial need, lack of support systems, peer pressure.

Values and attitudes are lacking in teens as there is a growing deterioration within societies reflected in teen behaviours Absence of strong parental or guardian support is lacking in households which are either managed by a single parent, usually a female figure or by older siblings forced to take over the running of households in the absence of working parents.

Some health interventions that can be practiced in health centres to reduce teen vulnerability to unwanted pregnancies and STIs. reproductive health interventions for teens • Focus on reducing unwanted pregnancies and the contraction of HIV and other sexually transmitted infections. This will improve the chances of girls continuing in school and expanding their life options.

• Provide life coping skills including RH education for boys and girls.

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References • Family Health Manual, Dr. Eva LewisBell and Shelia Campbell- Forrester (etal), Ministry of Health, Kingston, 2007 • The Ministry of Health, National HIV/STI programme – Jamaica HIV/AIDS Epidemic Update January to December 2007 • Reproductive Health Survey Jamaica 2008 – Young Adults Report, The National Family Planning Board, February 2010

Reducing Adolescents’ Fertility rates and incidence of STI by the Promotion of abstinence.

Prepared by Harriett M. Clarke-Communication Officer (Writer)

The Age-Specific Fertility Rate (ASFR) for fe- of early sex; encouraging teenagers to abstain males aged 15-19 years was 112 births per 1,000 longer before indulging in sexual intercourse. females in 1997 and decreased by 29.4 percent In encouraging teens to delay sex a health to 79 births in 2002. provider must be able to highlight for the averBy 2008, the ASFR had decreased to 72 births age teen the consequences of early sex and proper 1,000 females an 8.8 percent decline from mote abstinence as a viable alternative for a the year 2002. These are favourable indicators teen’s protection. This could be achieved by but it is still important that the health provider counselling them about the consequences of put strategies in place to maintain these numbers early sex and encourage them to abstain. In and to reduce it even further by understanding telling them to abstain focus on the advantages the importance of promoting delayed sexual ini- of abstaining and encourage them to get involved in community, school and church activtiation through the practice of abstinence. ities for them to refocus their energies and In order to reduce the group’s risk of pregnan- avoid early sexual activities. cies and sexually transmitted infections, health providers need to recognise: 1. The importance of addressing the issue of early sexual initiation in teens 2. The advantages of promoting primary and secondary abstinence for these age groups and; 3. The consequences of early sex.

In addressing the issues concerning early sexual initiation the health provider will have to examine the mean age of sexual initiation for the average teenager. The mean age of sexual initiation for boys aged 15-17 is 13.3 and for girls in the same age group - 14.4 years.

Health providers in promoting the delay of initiation of sexual intercourse should elaborate on the benefits of abstinence and the consequences

The Consequences of early Sex Unplanned pregnancies Contraceptive information needs to be extended to sexually active adolescents if maximising access to family planning for all persons in the reproductive age group is to be achieved. This should be pursued in order to successfully meet the reproductive health needs for all persons within the reproductive age groups (ages 15-49).

The percentage of planned pregnancies remained constant throughout the ten year period from 1993-2002 (21.3 percent in 1993, 23.2 percent in 1997 and 22.9 percent in 2002.) However, the 2008 Reproductive Health Survey indicated that 18.8 percent of females aged 15-19 years stated that their current or most recent pregnancy was mistimed and 14.6 5

reducing adolescents’ Fertility rates and incidence of STI by the Promotion of abstinence. (cont’d)... percent reported that their pregnancy was unwanted. Adolescent pregnancy has certain negative health and social outcomes which should be highlighted to assist adolescents in postponing or avoiding pregnancy.

Sexually Transmitted Infections

preferred solution is to have our teenagers remaining abstinent until adulthood at 18 years of age where they are deemed physically and emotional ready to take on the consequences of sexual intercourse. Therefore, it is prudent to have contraceptive information, resources and counsel available to them promoting contraceptive methods such as the pill, the injection, emergency contraceptives and the condom which are the preferred methods for adolescents as these do not subject them to clinical procedures such as pelvic examinations that may discourage them from requesting COCs.

Teenagers are occasionally sexually active.

Their risky lifestyles of indiscriminate sex with multiple partners in an effort to assert their independence and to be accepted by their peers make them particularly vulnerable to contracting sexually transmitted infections including the Human Papilloma Virus, HIV/AIDS, Gonor- However, the health provider should never forrhoea, Herpes and Syphilis which may continue get that it is their duty to promote abstinence or affecting them for the rest of their reproductive the delay of sexual initiation among teenagers for reinforcement. lives.

The Knowledge Attitudes and Behaviour Survey, Jamaica 2008 indicated that the percentage of males aged 15-19 who were not sexually active increased by 6 percent (from 27.6 in 2004 to 33.8 in 2008).Whereas for females of the same age group who never had sexual relations there was a 10 percent decrease from 50.5 percent in 2004 to 40.4 According to the reproductive life stages, the percent in 2008.

The Ministry of Health’s National HIV/STI programme Jamaica HIV/AIDS Epidemic Update during the period January to June 2008 indicated that from 1982 to June 2008 within the reported number of AIDS cases totalling 12,893 for persons ages 4-94, 152 were ages 15-19. Of these, 31 were males and 121 females.

Table a:

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Percentage of Young People aged 15-19 who Have never had Sexual relations

reducing adolescents’ Fertility rates and incidence of STI by the Promotion of abstinence. (cont’d)...

Quite often young adults do not plan to have sex. Figure 1 below indicates that of the young adults 15-24 years, 47 percent of the females indicated that they did not expect to have sex while 28.7 percent of the males indicated that they did not expect to have sex when they did.

This could be attributed to the nature of their unpredictable lifestyles which often results in unprotected sex. The Emergency Contraceptive

should be one of the contraceptive methods that the teen is aware of in order to prevent an unwanted pregnancy.

Figure 1.

Young adults reasons for non-use of Contraceptives (Percentage)

Source: 2008 RHS Young Adults Report

Health care providers should inform teens that sexual abstinence is the most effective means of protection against both pregnancy and HIV infection.

In helping teens to abstain the following advice should be given. Encourage young adults to follow these steps in making decisions about sexual activity.

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reducing adolescents’ Fertility rates and incidence of STI by the Promotion of abstinence. (cont’d)... advising teens how to abstain

“I’ve decided to wait until I’ve achieved my academic goals”. o Turn the tables: “You say that if I love you I 1. Be clear about why you want to wait o List your reasons. Talk them over with would, but if you really love me, you wouldsomeone who supports you. n’t insist”. o Check your list from time- to- time to remind yourself.

2. Have a Plan o Know what situations might make it hard to stick with your choice o Decide ahead of time what you’ll do to avoid or deal with them, such as leaving a scene when being pressured to have sex.

3. Be Impressed With Yourself o It can be hard to go against the crowd and make your own choices. o Give yourself credit. You deserve it.

4. Notice the pressures o Pay special attention to messages in music, videos, and movies telling you to have sex.

5. Get Support o Hang out with friends who know about and respect your decisions o Avoid people who might pressure you. o If pressured, threaten to tell someone in authority (a relative, the police).

6. Practise Communication Skills o Learn to say “No!” emphatically or “No, no, no” repeatedly. o Give a reason such as “I’m not ready” or 8

References • 2008 HIV/AIDS Knowledge Attitudes and Behaviour Survey, Jamaica, Hope Enterprise Ltd. MOH, June 2008 • Information Package for Guidance Counsellors on Abstinence, the National Family Planning Board,2009 • The Ministry of Health, National HIV/STI programme Jamaica HIV/AIDS Epidemic Update- January to June 2008,MOH,2008 • Reproductive Health Survey Jamaica Young Adults Report, the National Family Planning Board, February 2010

HOW teenAgeRS See YOu:

a guide to providing effective services to minors.

Written and Prepared by Harriett M. Clarke-Communication Officer (Writer)

Introduction In examining the preferred person (source) for sex information the Reproductive Health Survey (RHS) 2008 indicated that when ranked against parents and caregivers, teenagers least preferred a health care provider to advise or counsel them.

The preferred source for obtaining sex information (education) for a female teenager 15-17 yrs. was a parent or relative (41.1%), 32% preferred a teacher while 8.1% and 4.7% stated peers and health workers respectively. For boys, the same was true with varying percentages for the 15-17 age groups.

It is determined that negative attitudes and the behaviours of health providers as well as poor interpersonal relations and communication can contribute to adolescents’ low use of health facilities. In making an institution adolescent friendly it should appeal to persons of all ages and degrees of sensitivity, given the fact that adolescents are particularly sensitive about matters concerning sex and need to be handled with respect. Such an institution could then be deemed adolescent friendly. Health professionals are required to observe strict confidentiality at all times towards all persons. This is a matter crucial to teenagers who can only be encouraged to seek help with matters concerning their sexual and reproductive health if there is an element of trust in the health care system and its workers.

Thirty-two point nine percent (32.9 %) preferred parents or relatives, 13.7 % preferred peers, 3.3% preferred this information to come from a counsellor and 2.1 % preferred their source to Teenagers also look for a lack of judgment on be a health worker. the part of any person they confide in something The fact that the statistics state that the health the health care policy recognises and as such provider is the least preferred person that stipulates a provision for non-judgmental health teenagers go to for advice concerning their re- information to facilitate informed choices. productive health is cause for concern. Health centres need to examine how adolescent Some major barriers to good relations include friendly they are in terms of how comfortable ignorance, intolerance, language, lack of shared teenagers are made to feel when visiting and re- experiences, and understanding (perceived or lating to staff and whether they would be en- real) and differences in class or status. As good couraged to revisit the institution seeking relations are built on trust, health providers need assistance from these practitioners. This should to reassure teen customers/clients/ patients that help to improve access to quality information everything possible will be done to assist them. and services to improve the health of all Ja- A health provider should pay attention to how maicans and reduce the disease burden in our the adolescent is greeted; demonstrating politeness and tolerance in relating to them will go a country.

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HOW teenAgeRS See YOu: a guide to providing effective services to minors. (cont’d)... far way with our teenagers. They should also be informed about their rights with respect to healthcare services. They should be provided with the relevant information about available health services.

fessional is also required to exercise discretion in determining whether or not contraceptives should be introduced to this teen or whether primary or secondary abstinence should be discussed.

When delivering health care, the health provider should display professionalism in deportment and mannerism, a willingness and commitment to ensuring customer satisfaction and endeavor to contribute to the overall enhancement of the teen’s care and well being

One of the objectives of the policy guidelines is to provide health care to individuals 10-19 years of age, requiring that the health professional has an ethical obligation to: • Show respect at all times and in all circumstances to adolescents, including preservation of their dignity (especially in the case of girls); • Observe strict confidentiality unless there are clear and compelling reasons to the contrary; and in such cases health professionals should always inform the adolescent that they intend to disclose the information and the consequences of such disclosure; and • Provide non-judgmental health information and services that adolescents need to allow them free choice of treatment.

Relating to a teen about sex may go against the values and perception of a professional health provider. However, because there are teens who will visit the health centres for counsel the legal ramifications as they pertain to the policy guidelines for health providers must always remain foremost in the minds of our health care providers when dealing with the client. These are in relation to the administering of counsel and/or contraceptives to teenagers under and over the age of consent.

The policy guidelines require the registration of individuals requesting services by any health care provider or clerk at a health facility, whether or not the person is accompanied by an adult, has a referral or visits on their own volition. It is required that the clerk direct such a person to a health provider.

On matters of counselling, the health provider should encourage teens to delay initiation of sexual intercourse while explaining the benefits of abstinence to the individual. The health pro10

The policy in making allowance for a health care provider to show respect at all times encourages the institutionalisation of an adolescent friendly atmosphere in health centres. The policy was designed to address the weaknesses in our health care system in terms of interpersonal relationships between the health care provider and clients, particularly adolescent clients.

HOW teenAgeRS See YOu: a guide to providing effective services to minors. (cont’d)...

Consequently, teens will be more likely to reach out to health care providers for more information pertaining to their sexual and reproductive health and if followed it is hoped that the numbers preferring a more knowledgeable person, who is the health provider, from whom they can garner sexual and reproductive health information, will increase.

Health providers should be equipped and ready for any teenager who walks through their doors and should always be prepared to answer the questions relating to their reproductive health.

Being prepared means equipping oneself with information relating to a teen’s development both physiologically and psychologically.

Questions that teenagers may ask include: • When is the right time for sex?-Health providers should gauge their answer in terms of the individual they are addressing.

However, it is the duty of the health provider to promote abstinence to teens above anything else to maintain age appropriateness in light of life stages and the best contraceptive methods for each. Scenarios can also be developed to assist teens in deciding whether they are ready for sex and an outlined of some of the negative consequences of teen sex such as unwanted should always be outlined.

• Questions on STIs- At this point it may be critical to introduce the concept of Abstinence or Condom use. It is imperative that teens are reminded that at this stage that ab-

stinence should be pursued. Along policy guidelines it is the duty of the health professional to first promote the delay of initiation of sexual intercourse with full explanation of benefits of abstinence for the individual. Emphasis should be placed on abstinence as the main way to prevent unwanted, pregnancy and sexually transmitted infections, two issues critical to teens’ reproductive health because of their vulnerability. It should be emphasized that both have negative long term effects on adolescent reproductive health and should be avoided at all cost.

Condoms are popular contraceptive methods used by teens. The RHS 2008 indicated that within the 15-19 age groups, 81.6% of the females ages 15-17 years used a condom at their first sexual intercourse and 71.8% of males of the same age group used condoms at their first sexual encounter.

75.8% males aged 15-17 used a condom during their most recent sexual intercourse in the last 12 months. Valid information on other contraceptive methods such as the pill or the emergency contraceptive pill (ECP) can be placed in strategic places for teens to access as this provides them with an option to protect themselves against unwanted pregnancies if for whatever reason abstinence is not the first choice for them.

• How can you get pregnant? Health care providers could reinforce the process of how a male impregnates a female. Teens may need to know that a girl can get pregnant the first time she engage in sexual intercourse whether she has seen her first 11

HOW teenAgeRS See YOu: a guide to providing effective services to minors. (cont’d)... period or not. Teens may also need to know that having sex during a period cannot protect you from getting pregnant. The withdrawal method is not a safe method of contraception, and standing while having sex does not prevent one from becoming impregnated. Teens need to know that the best way to safeguard themselves against an unwanted pregnancy is by using a contraceptive method such as the emergency contraceptive pill. Emphasis should also be placed on when the ECP is to be taken, within what time frame and they should be made aware that the ECP is not to be used as a regular contraceptive method. Information related to other contraceptive methods should be shared with the teenaged client.

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References • Interpersonal Relations: An Experiential Learning Programme for enhanced customer service in Jamaica’s Health care facilities,JA-STYLE,MOH,2006 • Providing Youth Friendly Services: Using standards and Criteria to Assess and Improve Service Delivery to Adolescents: A Work Book,Youth.now,USAID,2000 • Reproductive Health Survey Jamaica2008 - Young Adults Report, the National Family Planning Board, February 2010 • There is a Young Person Just Waiting to talk to You: Instructional Kit for Health Professionals & Counsellors, policy guidelines on providing information and counseling on contraceptives to persons under 16 years, National Family Planning Board,2003 • Reproductive Health Policy Guidelines for Health Professionals, Circular no.182/26, November 2003

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