TOWARDS EFFECTIVE COMMUNITY INVOLVEMENT IN SEXUAL AND REPRODUCTIVE HEALTH EDUCATIONAL PROGRAMMES FOR YOUTH IN EGYPT
By
MERVAT ESHAK
MA HEALTH MANAGEMENT, PLANNING AND POLICY
August, 2008
Nuffield Centre for International Health and Development Leeds Institute of Health Sciences DECLARATION
“This dissertation has been submitted in partial fulfilment of the requirements for award of (add the name of the relevant degree). The examiners cannot, however, be held responsible for the views expressed, nor the factual accuracy of the contents”.
Signed ......
Programme Director
The University of Leeds Declaration of Academic Integrity
I declare that in the attached submission I have not presented anyone else’s work as my own. Where I have taken advantage of the work of others, I have given full acknowledgement. I am aware of and I understand the University rules on cheating and plagiarism as published in the Taught Student’s Handbook, and also any more detailed rules specified at School or module level.
I also declare that the document submitted electronically to the Nathan Bodington Building is the same document as the hard copies submitted to the Department
Signed: Mervat Eshak Date: 22 August 2008
FORMAT
TYPE OF STUDY Programme review √ and/or plan
Research proposal
In-depth study
OUTPUT Action plan Draft article
Research proposal Recommendations √
Dissemination √ action plan Preliminary pages
DEDICATION
To dearest Basem my husband who encourages me all the time…. he is always the secret of my success. To my beloved sons Peter and Andrew who supported me and dealt with my absence amazingly
Dedications i Preliminary pages
ACKNOWLEDGEMENTS First and foremost, to my Lord for granting me strength, grace and many blessings. Indeed, I felt God’s hands supporting me … I am genuinely thankful. Though I wish to sincerely thank all who have contributed in completion of this study; yet I will acknowledge few on behalf of all. My sincere gratitude to my supervisor and mentor Dr. Nancy Gerein for her guidance and genuine support to me. Her thoughtful comments guided me to deliver this piece of work. She inspired me with real, honest understanding especially when I was feeling down. My special thanks to my Programme Director, Dr. Ricky Kalliecharan for his encouragement throughout the course. Thanks to my personal tutor, Philippa Bird for her support. I really appreciate the efforts done by Leeds University, Institute of Health Science’s teaching and administrative staff as well. My true gratefulness to Ford IFP programme, my sponsoring agency which gave me the opportunity to pursue this Master’s degree. Sincere appreciations and praises to my mother and my mother-in-law; I could not do it without their love, kind support and prayers. A profound thank you to my brother Magdy and my sister-in-law Elham as they were there, looking after my children. I am indeed indebted to my friends and my colleges in Egypt who supported me by their prayers, telephones and emails and restored my confidence. They were always there for me. Indeed, I am really grateful to my colleague Sonia for being the true friend I gained this year. We studied, travelled, cried and laughed together. I will always cherish those memories. My special thanks go to all my friends here in UK; they have been shown abundant care since I came and throughout the year. Thanks to my colleagues in the Institute of Health Science MA HMPP, MPH and HM, I learned a lot from their invaluable experiences. Finally, to my family members and my friends in all the world who supported me, encouraged me and shared with me their precious experiences, I thank you deeply from my heart. Indeed, I hope that this piece of work will be an added value to CDS, the place I work in and I learned a lot from.
Acknowledgements ii Preliminary pages
TABLE OF CONTENT
DEDICATION ------i
ACKNOWLEDGEMENTS------ii
LIST OF DIAGRAMS AND TABLES------viii
KEY TO ABBREVIATIONS ------ix
EXECUTIVE SUMMARY------1
CHAPTER 1: INTRODUCTION ------2
1.1 Why sexual and reproductive health (SRH)?------2
1.2 SRH problems overview:------2
1.3 Egypt overview: ------2
1.4 Egypt and ASRH problems------3
1.5 Aim:------4
1.6 Objectives:------4
1.7 Methodology:------4
1.8 Author’s role ------5
1.9 Outputs:------5
1.10 Stakeholders: ------5
1.11 Outline of dissertation: ------5
1.12 Dissertation limitations ------6
1.13 Conclusion ------6
CHAPTER 2: ASRHEPS; ARRAY OF PROGRAMMES AND DIVERSITY OF ACTORS------7
2.1 Why ASRHEPs? ------7
2.2 Types of ASRHEPs in developing countries ------7
2.2.1 Curriculum-based programmes ------8
2.2.2 Community-based programmes ------8
2.2.3 Health facility-based programmes------9
2.2.4 Workplace programmes------9
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2.2.5 Mass media programmes ------9
2.3 Methodology for conducting ASRHEPs ------10
2.4 ASRHEPs in Egypt ------10
2.5 Community involvement, definitions and concepts ------11
2.5.1 What is community?------11
2.5.2 What are communities?------11
2.5.3 What is community involvement/ participation? ------11
2.5.4 What is community empowerment? ------12
2.5.5 What is social capital?------13
2.5.6 What are gatekeepers, stakeholders and positive deviants? ------13
2.5.7 Health and community participation ------14
2.6 Community involvement in ASRHEPs ------14
2.6.1 Key actors------14
2.6.2 Meaningful community participation in ASRHEPs------15
2.7 Conclusion: ------15
CHAPTER 3: PROBLEM ANALYSIS, PROGRAMMES AND INTERVENTIONS TO ADDRESS ------16
3.1 Problem in-brief: ------16
3.2 Problem tree ------16
3.3 Actors’ involvement; significance, problem analysis and positive experiences:------18
3.3.1 Youth the indispensable actor: ------18
3.3.1.1 Youth involvement, challenges and problems ------18
3.3.1.2 Experiences: programmes and interventions ------20
3.3.1.3 Youth roles: ------22
3.3.2 Parents ------23
3.3.2.1 Parents involvement, challenges and problems------23
3.3.2.2 Experiences: programmes, interventions and roles ------23
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3.3.3 Religious leaders ------24
3.3.3.1 RLs involvement, Challenges and problems ------24
3.3.3.2 Experiences: programmes, interventions and roles ------24
3.3.4 Community Leaders ------25
3.3.4.1 CLs involvement, Challenges and problems ------25
3.3.4.2 Experiences: programmes, interventions and roles ------26
3.4 Conclusion: ------27
CHAPTER 4: TOWARDS EFFECTIVE COMMUNITY PARTICIPATION IN ASRHEPS IN EGYPT ------28
4.1 Interventions to foster meaningful community participation------28
4.1.1 All actors------28
4.1.1.1 Starting: ------28
4.1.1.2 NA:------28
4.1.1.3 Planning:------29
4.1.1.4 Implementation (process) ------29
4.1.1.5 M&E ------29
4.1.1.6 Ensuring gender equity------29
4.1.1.7 Gaining more support ------29
4.1.1.8 Enabling supportive environment------30
4.1.1.9 Increasing social capital------30
4.1.1.10 Ensuring sustainability and Scaling-up ------30
4.1.1.11 Advocating for policy change------30
4.1.2 Parents: ------30
4.1.3 RLs------30
4.1.4 CLs------30
4.2 Diversity of ASRHEPs. Which match the Egyptian context? ------31
4.2.1 Comprehensive SRH services:------32
4.2.2 Youth-Friendly clinics: ------32
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4.2.3 School-based programme: ------32
4.2.4 PE programmes:------33
4.2.5 Life-skills programmes:------33
4.2.6 Mixing ASRHEP with Literacy classes:------33
4.2.7 Mixing ASRHEP with sports: ------33
4.2.8 Religious-based programmes:------33
4.2.9 Mixing ASRHEP with economic livelihoods programmes:------34
4.2.10 Specific programmes for vulnerable groups: ------34
4.3 Conclusion------36
5.1 Conclusions: ------37
5.2 Recommendations------38
5.2.1 For policy makers:------38
5.2.2 For implementing agencies: (International organisations and consulting agencies including CDS): ------39
5.2.3 For Media:------39
5.2.4 For LNGOs and YAs:------40
5.2.5 For donor agencies: ------40
5.2.6 For religious entities: ------41
5.2.7 For researchers: ------41
5.3 Dissemination------41
5.4 Reflective Conclusion------41
REFERENCES ------43
APPENDICES ------52
Appendix 1: Map of Egypt:------52
Appendix 2: Relevant Economic and Health Indictors for Egypt: ------53
Appendix 3: Graph shows Current and Expected Practice of Female Genital Cutting before Age 18, by Mother’s Education, Egypt 2005------55
Appendix 4: Graph shows Beliefs about Female Circumcision in Egypt, 2005------56
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Appendix 5: Table shows mode of transmission of AIDS cases from 1986- December 2002------57
Appendix 6: Table shows Results of study in Greeter Cairo reveals the prevalence of STIs------58
Appendix 7: Graph shows Married Women Aged 15 to 19, 2005------59
Appendix 8: Graph shows Young Women Giving Birth by Age 18------60
Appendix 9: Details about primary data collection:------61
Appendix 10: The Cairo Declaration of Religious Leaders in the Arab States in Response to the HIV/AIDS Epidemic ------62
Appendix 11: Themes of training curriculum targeting the PEs in CDS programme:------64
Appendix 12: Diversity of interventions that facilitate different community players’ engagement and create enabling environment for this engagement------66
Appendix 13: Types of ASRHEPs------73
Appendix 14: community involvement in ASRHEP in Egypt------74
Appendix 15: Dissemination action plan------76
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LIST OF DIAGRAMS AND TABLES
Diagram 1 Typology of community participation------12 Diagram 2 Process of community empowerment dynamic continuum------13 Diagram 3 Main stakeholders in ASRHEPs------14 Diagram 4 Problem tree------17 Diagram 5 Community engagement process------31 Diagram 6 Mobilising for a continuum of enhancing ASRH------38
Table 1 ASRHEPs’ options appraisal------35
List of diagrams and tables viii Preliminary pages
KEY TO ABBREVIATIONS
ASRH: Adolescent sexual and reproductive health ASRHEPY: Adolescent sexual and reproductive health educational programmes CDS: Centre for Development Services CHPs: Community health promoters Cls: Community leaders FBOs: Faith-based organisations FGM: Female genital mutilation FHI: Family Health International FP: Family planning FSWs: Female sex workers GBV: Gender-based violence ICPD: International Conference on Population and Development INGOs: International governmental organisations IUDs: Injecting Drug Users LNGOs: Local non-governmental organisations MDGs: Millennium Development Goals M&E: Monitoring and evaluation MISA: Ministry of Social Insurance and Affair MOE: Ministry of Education MOHP: Ministry of Health and Population MOY: Ministry of Youth MSM: men having sex with men NA: Needs assessment NCCM: National Council for Children and Mothers NYT: National Youth Taskforce OJT: On-the-job training PE: Peer education PEs: Peer educators PLA: Participatory learning and action PLWH: People living with HIV RLs: Religious leaders SRH: Sexual and reproductive health STIs: Sexually Transmitted Infections TOT: Training of trainers UN: United Nations UNICEF: United Nations Children's Fund VCT: Voluntary Counselling and Testing WHO: World Health Organization YAs: Youth associations YFCs: Youth-Friendly Clinics
Key to abbreviations ix Main document
EXECUTIVE SUMMARY Youth constitute one third of the Egyptian population. This gives them the power and responsibility not only for their health but for Egyptian future as well. Egypt was the place of the International Conference on Population and Development (ICPD) in 1994 and while there have been considerable improvements in youth reproductive health; gaps exist in adolescent sexual and reproductive health (ASRH) programmes as well as in policies. Many ASRH problems face Egyptian youth; nevertheless the “culture of silence” exists within community as “inter-generational” dialogue regarding ASRH issues is rarely opened. Therefore, enhancement of community perception of and participation in adolescent sexual and reproductive health educational programmes (ASRHEPs) are the keys for change. The aim of this dissertation is to identify factors that could contribute towards active and meaningful community participation in ASRHEPs in Egypt through exploring different experiences from Egypt and developing countries. This is a review study; secondary information is collected through literature review; augmented by some primary data which were collected via a field visit to a project to enhance ASRH in Egypt. The analysis of community involvement aspect in ASRHEPs revealed that the behaviours of youth are affected by the community cultural norms in addition to the expectations and attitudes of key community actors such as parents, religious leaders, community leaders, community health promoters, teachers, political leaders and health care providers. Community participation in such programmes refers to engagement of the community as well as youth themselves in different roles within all the programmes phases. Empowerment of the community through tailored capacity building is a fundamental factor as it enhances community self-esteem and self-efficacy and hence improves its engagement. Furthermore, building on community’s existing social capital, strengthening it and creating new ones are contributing factors for success of such programmes. Within the array of educational programmes that provide ASRH, mixing ASRHEPs with literacy classes; life-skills; peer education; religious-based programmes and specific programmes for street children are appraised by author to be the most feasible for youth participation within the Egyptian context. However, to ensure holistic approach; different interventions could be done not only to avert community resistance, or tackle it but also to foster community engagement. Key recommendations for ASRHEPs’ planners and implementers resulting from this study are: multi-sectorial approaches should be taken to identify and engage the key strategic stakeholders, gate-keepers and youth themselves into ASRHEPs from the needs assessment phase; through planning, implementing, monitoring and evaluation; then advocacy for such programmes. Inter-agency collaboration must be adopted between policy makers, donor agencies, religious organisations, non-governmental organisations, youth associations and communities with all their layers to create more enabling environment to support and sustain healthy youth behaviours. Rigorous research to explore more innovative and culturally sensitive tools and approaches for community engagement within ASRHEPs are invaluable. As it is deeply rooted problem; a worthy journey must be travelled to achieve active and meaningful Egyptian community participation in ASRHEPs.
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CHAPTER 1: INTRODUCTION
1.1 Why sexual and reproductive health (SRH)? The influence of youth decisions about their SRH is not limited to their lives but also affects global community health as well. ICPD, which took place in Cairo at 1994 was the first time that the international public health community admitted the challenges faced by youth with respect to their SRH and acknowledged it as a priority that must be addressed (Advocates for Youth, 2005).The Millennium Development Goals (MDGs) in 2000 consequently flagged the need to have comprehensive programmes that tackle ASRH because of its immense influence on the capacity of countries to meet the MDGs (WHO and GFHR, 2007).
1.2 SRH problems overview: In many developing countries, the majority consider SRH a taboo subject. Parents are uncomfortable about teaching their unmarried adolescent children about sex, as they consider it a tool for encouraging their children to engage in pre-marital sex (Hardee et al., 2004). Besides, the majority of sources of information available to youth are unreliable ones. Youth rarely approach clinics, as they are commonly unwelcome by service providers (Simasiku et al., 2000).
The modernisation of life, the media, materialism, broken families and peer pressure are considered main factors behind premarital sex and early sexual activities between youth, as they increase not only the desire but opportunity for sexual activity (PRB, 2000). Sexually transmitted infections (STIs) and HIV/AIDS prevalence is escalating in some developing countries, especially in sexually active youth before marriage (Hardee et al., 2004).
Moreover, early marriage as well as early pregnancy and childbearing are contributing factors in rising maternal and child mortality rate. Lack of use of contraception methods including condoms and emergency contraception is a prominent problem within poorer and less educated people.
Gender-based violence (GBV) such as incest, sexual harassment, rape, sex trafficking, female genital mutilation (FGM) and rape as a weapon of war are devastating problems which also contribute to risks like HIV infection, unintended pregnancies, unsafe abortion and psychological trauma (PRP, 2000, 2008).
1.3 Egypt overview: Topographically, Egypt is divided by the River Nile into Delta, Nile valley (Upper and Lower Egypt), two huge deserts and Sinai (EIP, 2008) [Appendix 1: Egypt map]. That reflects on the characteristics and social norms of communities as Upper Egypt norms differ from Delta or Sinai Bedouin’s norms. Rural, urban and urban slum areas have also different characteristics. The total population is 74,357 million (CAPMAS, 2008). According to USAID 2005, the population aged 10-24 constitutes 31.3% of total population. The majority of population are Moslems and 15-20% are Christians. [Appendix 2: Relevant economic and health indictors].
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1.4 Egypt and ASRH problems FGM is a major SRH problem facing female youth with its detrimental physical, psychological and human rights effects (WHO, 2008). More than 97% of women aged 15-49, both Muslims and Christians, had undergone FGM (DeJong et al., 2005). [Appendix 3& 4: Graphs discuss the relation between the education of mother and daughter’s FGM and different beliefs around FGM].
Regarding HIV/AIDS, Egypt is categorised under the low prevalence countries. The number of people living with HIV (PLWH) according to Egyptian Ministry of Health and Population (MOHP), were 1,155 in 2007 while UNAIDS estimates for 2005 were about 5,300 (USAID, 2008). Indeed, the challenge is keeping that low prevalence (UNFPA, 2003). The stigma regarding PLWH is very high. [Appendix 5: Mode of transmission of AIDS cases].
Egypt has a high prevalence of Hepatitis C, which has a similar mode of transmission to HIV. Moreover, the most vulnerable group for both viruses are similar such as the million street children who are highly vulnerable to sexual exploitation; injecting drug users (IDUs); female sex workers (FSWs) and men having sex with men (MSM) (UNICEF, no date a). Regarding the STIs, they are very prevalent within married women in remote rural areas (more than 30% have STIs) (UNICEF, 2008). [Appendix 6: Prevalence of STIs].
Early marriage exists but is less than before. According to PRP (2008), 12% of women aged 15-19 in the year 2005 were married. Consanguinity and polygamy still exist. Families exert pressure on female youth to marry then to have children. Virginity before marriage is a premium however hymen repair operations are under-researched (DeJong et al., 2005). [Appendix 7& 8: Graphs comparing Egypt and some Arab countries regarding: early marriage and childbearing].
Furthermore, unconventional urfi (secret) marriages have become common practice among youth with little guidance from schools and universities. This evolved as a means to obtain marriage certificates in the atmosphere of unemployment. In a survey conducted in 1996 in four universities, 26% of young males and 3% of young females stated that they had sexual intercourse at least once. Unmarried youth seldom go to family planning (FP) services for fear of stigma (DeJong et al., 2005).
However, a significance decrease in maternal mortality rate had been encountered in the last 15 years from 174/100,000 in 1993 (DeJong et al., 2005), to 130/100,000 in 2005 (WHOSIS, 2008). Gynaecological morbidity is high within higher parity especially in young age. Abortion is legal only to save a woman’s life, so “self-induced abortion among young women” is high (DeJong et al., 2005).
The “culture of silence” is predominant in the discussion of ASRH, hence data on unwanted pregnancy and abortion, GBV and HIV are considerably limited (PRP, 2008). There are many scattered efforts to conduct ASRHEPs; however they lack the active and meaningful community engagement.
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1.5 Aim: The aim of this paper is to improve the SRH of Egyptian youth through exploring potential community participation approaches that address challenges facing ASRHEPs in developing countries.
The author attempts to identify the factors to build on towards effective community participation in ASRHEPs in Egypt.
1.6 Objectives: 1. To describe the extent and significance of ASRH issues in Egypt and developing countries, and community perceptions about it. 2. To explore the different educational programmes tackling ASRH in developing countries, the diversity of key actors in those ASRHEPs and the meanings of their active involvement. 3. To identify and critically analyse problems of poor community participation in and perception of ASRHEPs and explore experiences of positive community contributions, as well as community resistance, in ASRHEPs, highlighting the socio-cultural, economic, political, educational and religious influencing factors. 4. To appraise different ASRHEPs and interventions that could be used in Egypt in dealing with community resistance and encouraging active community participation. 5. To propose feasible recommendations supported with proper and realistic dissemination methods.
1.7 Methodology: This is a review study relying mainly on secondary data. University of Leeds library search was done for peer-reviewed journals and electronic resources were explored, through Global Health, PubMed, ScienceDirect and MEDLINE databases using the following key words “community participation”; “community involvement”; “community-based programmes”; “peer education”, “sexual and reproductive health”; HIV/AIDS”, “educational programmes”; “youth”, “young people” “Egypt”, “Arab world” and “developing countries”.
About 510 articles were filtered according to their relevance to research questions, authors’ reputation and published articles within last ten years, to the most pertinent 18 articles. The author used the bibliography of those articles for hand-searching, so 39 articles were identified. In addition, articles from reputable organisations like the World Health Organization (WHO), its Reproductive Health Library and United Nations Children's Fund (UNICEF) were used. Articles from organisations specialised in SRH like Family Health International (FHI) and UNAIDS were obtained. The author also used search engines like Google scholar and gateways like ELDIS and HINARI.
Abstracts were read; articles were skimmed and relevant ones were read thoroughly. To keep up-to-date, the author subscribed to WHO Bulletin; AIDS Alliance; CEDPA; Global Health council; Interagency Youth Working Group; and Population council email alerts.
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The author attended the Global Health Council May 2008 conference entitled “Community Health. Delivering. Serving. Engaging. Leading.” in the USA. Several lectures dealt with community involvement in ASRH and AIDS topics. Abstracts booklet, CDs and discussions were used as resources.
Supplementary primary information was obtained through a field visit to a project titled “SRH awareness for youth” currently implemented in Egypt. [Appendix 9: Details about primary data collection]. Telephone conversations, email correspondence and personal communication were used. Personal experience of the author as she shared in conducting SRH trainings for youth is presented as well.
1.8 Author’s role The author has experience as a trainer and researcher in health development field in Egypt and Arab world for more than 12 years. She has shared in designing and implementing some formal and informal programmes on SRH, as well as several programmes for youth and care givers on a diversity of other themes. This assisted her in analysing the data of the review not only from an academic perspective but also from a field experience perspective.
1.9 Outputs: Expected outputs include: Assessment of community participation dimension in ASRHEPs implemented in developing countries. Feasible recommendations for planners and implementers of ASRHEPs in Egypt to strengthen active and meaningful community participation. A plan of action for disseminating recommendations to appropriate stakeholders.
1.10 Stakeholders: Stakeholders in this study are those who play a role in planning, implementing, funding and evaluating ASRHEPs carried out in Egypt and Arab countries. These include, but are not limited to, policy makers, donors, implementing agencies, local non-governmental Organisations (LNGOs) and youth associations (YAs) staff and media.
The study will be presented to Centre for Development Services (CDS) where the author works as it is currently implementing a project for enhancing SRH of youth in Cairo/Egypt and launching another one to improve SRH of FSWs in Syria.
1.11 Outline of dissertation: Chapter One: provides an overview of the importance of ASRH and its implication for youth health in particular and their countries’ development in general. It covers problems encountered by youth with respect to their SRH and presents community perception about this issue, focusing on the Egyptian ASRH problems. That is in addition to the aim,
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objectives, outputs, methodology, author’s role, stakeholders and limitations of the study. Chapter Two: presents an overview of different types and methodologies of ASRHEPs in developing countries and identifies the key actors of these programmes. Furthermore, it identifies diversity of concepts and terms of the community involvement. Chapter Three: explores and critically analyses community involvement in and perception about ASRHEPs. It explores active community contribution experiences as well as challenges facing implementation of the programmes in developing countries and diversity of factors lying behind them. Chapter Four: describes different interventions and relevant lessons could be used in Egypt in tackling community resistance to ASRHEPs. It discusses and appraises those ASRHEPs that create an enabling environment for active and meaningful youth participation, highlighting criteria of selection of the programmes that match the Egyptian context. Chapter Five: highlights the overall conclusion of review and recommendations for possible solutions to achieve effective community participation in ASRHEPs in Egypt.
1.12 Dissertation limitations Little published literature about ASRHEPs in Egypt and the Arab world was found, making the author broadened her search to developing countries to choose the experiences applicable to Arab culture.
The most problematic issue is the lack of process documentation. Besides, negative findings and unsuccessful programmes are not documented, although their results are necessary to learn from.
While the author’s focal point is the SRH in general, most of the literatures focus on HIV/AIDS. In addition, most of reviewed programmes focused on enhancement of knowledge rather than impact on behaviour which is more difficult to evaluate.
1.13 Conclusion In summary, this study will focus on assessing the options for active and meaningful community participation in ASRHEPs in developing countries. It is expected that its findings and recommendations would be usable in guiding MOHP, donors and implementing agencies in enhancing Egyptian ASRH. What are the types and methodologies of ASRHEPs? Who are those main actors in such programmes? What are the different meanings of active engagement? That what will be explored in chapter two.
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CHAPTER 2: ASRHEPS; ARRAY OF PROGRAMMES AND DIVERSITY OF ACTORS As the proverb says “It is easier to straighten a tree when it is still young than when it is old.”
This chapter explores the types and methodologies of ASRHEPS in developing countries, which are considered a fundamental solution to address ASRH problems and the “culture of silence”. This is an initial step to determine how those types and methodologies could affect and be affected by community participation. Definitions and concepts about community involvement are presented, followed by identifying key ASRHEPs’ actors.
This study focuses on the programmes targeting ages 10-24 years which are defined by the WHO (2003a) as “young people” or youth.
2.1 Why ASRHEPs? ‘‘Young people are the key in the fight against AIDS. By giving them the support they need, we can empower them to protect themselves against the virus. By giving them honest and straightforward information, we can break the circle of silence across all society. By creating effective campaigns for education and prevention, we can turn young people’s enthusiasm, drive and dreams for the future into powerful tools for tackling the epidemic.’’ (Kofi Annan, 2002, cited in UNAIDS, 2003 p3)
Many adults consider youth a burden, although they are the engines of change in any country. Educating youth not only protects but also makes them role models for their peers and resources for their societies (UNAIDS, 2003).
Denial about AIDS and other sexual problems exists on the individual and the community levels.Considering “AIDS is an issue for ‘others’ ” has to be tackled in a comprehensive manner on all levels (UNAIDS, 2004). ASRHEPs are considered salient solutions. Schools, universities, LNGOs and YAs are the usual theatres to conduct ASRHEPS through governmental and international governmental organisations (INGOs) contributions (Hardee et al., 2004).
Though a universal governmental commitment worldwide to meet the MDGs has been reached (primary education completion, gender disparity elimination and HIV reduction among youth are crucial aspects within that commitment), yet programmes links between those three goals are few (UNAIDS and GCWA, 2006).
2.2 Types of ASRHEPs in developing countries There are different terminologies concerning SRH education. “Sex” education refers to programmes concerned with pregnancy or HIV/STIs prevention; however “sexuality” education comprises other SRH themes as well (FHI, 2005a). This dissertation will deal with “sexuality” ones.
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ASRHEPs could be categorised according to target group, curriculum, way or place of implementation. The following section briefly describes varieties of programmes, with more attention given to the first two which are considered to be likely most appropriate for authors’ stakeholder organisations.
2.2.1 Curriculum-based programmes Curriculum-based ASRHEPs can play a pivotal role to provide youth with the required knowledge and skills enabling them to behave in consonance with values and sound behaviours regarding their SRH (Senderowitz and Kirby, 2006).
They could be implemented as a part of the school curriculum; hence titled school-based programmes (Tiendrebéogo et al., 2003). To ensure maximum benefit of programmes, the schools environments should be youth-friendly and teachers should be recruited and trained in a way to guarantee effectiveness of the programmes (UNAIDS and GCWA, 2006).The Kenyan Ministry of Education mandated one HIV/AIDS lesson/ week in 11,000 primary schools. Teachers were trained, and resistance to teach sensitive issues was tackled. Programme evaluation revealed that within 6,700 boys and 6,300 girls ages 11 - 17, the virginity age significantly rose for both. Use of condoms for girls increased as well (Youthlens, 2007).
Some curriculum-based programmes are implemented as out-of-school activities such as in YAs, juvenile detention centres, and community centres as youth attend those places regularly (FHI, 2005a).
Tailoring curricula to harmonize with the culture, social norms, and policies is crucial (Senderowitz and Kirby 2006). Furthermore, curricula can be designed to match religious perspectives, hence religious-based ASRH curricula (FHI, 2008).
Those programmes could be designed to reinforce youth self-esteem and dealing with peer pressure (Tiendrebéogo et al., 2003). From this perspective, notion of the life-skills ASRHEPs has emerged.
“Life-skills" “….. refers to a large group of psycho-social and interpersonal skills which can help people make informed decisions, communicate effectively, and develop coping and self-management skills that may help them lead a healthy and productive life”(UNICEF, no date b, p1).
It is advised that stakeholders such as governmental, LNGOs’ educators and youth themselves assist in designing and reviewing such curricula. Moreover, advocating for and achieving supportive policies create an enabling environment for such programmes (Senderowitz and Kirby, 2006).
2.2.2 Community-based programmes There is a paradigm shift among health promotion programmes from traditional health education methodologies into community-based ones (Campbell and Mzaidume, 2001). Community-based ASRHEPs hinge on involving the
Chapter Two 8 Main document grassroots level and local authorities in programmes. LNGOs play a pivotal role in such programmes as they are considered the community representative (Kanesathasan, 2008).
The programmes could be multifaceted, encompassing youth education; counselling and youth-friendly clinics (YCFs) (Lou et al., 2004). Although programmes could be conducted by the health care providers, engaging community members in the educational aspect leads to more sustainability. Fostering enabling environment is crucial in success of such programmes (Muebesa, 2008).
Overlaps could be encountered between some programmes as community-based programmes could be implemented through a curriculum-based approach, in a literacy class for instance.
Details and countries’ experiences will be discussed in Chapter 3
2.2.3 Health facility-based programmes Using health facilities such as FP clinics as venues for ASRHEPs are not considered relevant to unmarried youth, particularly females in most developing countries. Comprehensive SRH services offer services, counselling and education; however, their services are not tailored to youth needs. Therefore, the need emerged to establish specialized YFCs which provide education and services such as appropriate contraception with informed choice; SRH information; STIs diagnosis and management and counselling as well (FHI, 2007).
Training of staff on how to deal with youth respectfully and ensuring absolute confidentiality, is crucial to attract youth, meet their needs and retain them (AYA/Pathfinder, 2003). Caribbean youth considered their YFC ideal because they experienced trustful communication with the empathetic knowledgeable counsellors (Senderowitz, 1998).
2.2.4 Workplace programmes The notion here is integration of SRH education activities into existing community structures such as work places. Successful workplace programmes rely on involving youth in programmes implementation which enhances their knowledge and skills. However, some programmes still use the traditional way of learning in which the employers or health agencies conduct education (Israel, 1998).
An evaluation to a factory-based programme for single adolescent workers in Thailand revealed an increase in workers’ awareness of their vulnerability to HIV/AIDS and ways of protecting themselves (Senderowitz, 1997).
2.2.5 Mass media programmes “Broadcast media have tremendous reach and influence, particularly with young people, …. who are the key to any successful fight against HIV/AIDS.” (Kofi Anan, cited in UNAIDS, 2004 p3).
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Media programmes assist raising youth listeners and viewers’ awareness and educating them with accurate knowledge. An Indian survey revealed that 70% of the involved people gained their information about AIDS from TV programmes (UNAIDS, 2004).
In an evaluation of a Ugandan media SRH programme, comprising radio shows, two newspapers and “complementary school-based activities”, it revealed positive behavioural changes such as “more balanced attitudes toward condoms”, increase communication between parents and children regarding SRH issues and enhanced sense of gender equity among girls (Adamchak et al., 2007).
Moreover, media has a pivotal role in challenging stigma and impeding discrimination. Muppet show can portray how PLWA can live a normal life. It can promote the HIV/AIDS services offered and encourage new policy formation as it drives leaders to take actions (UNAIDS, 2004; UNICEF, 2006).
Media is considered complementary for all the above ASRHEPs as it can break the silence and initiate dialogue.
2.3 Methodology for conducting ASRHEPs Participatory activities (vs. the use of traditional teaching methodologies) encourage youth to analyse their own situations and consequently explore their needs and resources. This approach helps youth develop confidence, enhance their self-esteem and take a comprehensive action as a group. In a comparison between participatory and traditional SRH interventions presented in Maclean’s meta-review (2006), the impact was more positive in the first, as it initiates community empowerment. Mathur et al. (2004) noted that the participatory approach adopted in Nepal ASRHEP, facilitated achieving outcomes such as delaying age of marriage and enhancing male awareness of females RH needs.
2.4 ASRHEPs in Egypt Despite the vulnerability of Egyptian youth to many SRH problems, explicit sex education is rare. ICPD was a milestone in SRH education in Egypt and the Middle East; though SRH research and advocacy was launched a long time before that conference. Joint work between NGOs, women’s groups and research organisations was the catalyst agent in raising those sensitive topics into public domain and influencing government attention. Several sporadic initiatives on micro-scale level have taken place; however ASRH needs remain inadequately tackled (DeJong et al., 2005). According to UNAIDS (2008), HIV/AIDS prevention programmes and services in Middle East region are poor, even among high risk youth.
Schools offer one to two sessions about HIV/AIDS, the physiology and anatomy of genital system within the science curricula (Hardee et al., 2004). Anecdotally, those sessions are mostly skipped by teachers as they are embarrassed and not equipped to teach these information, so it cannot be considered ASRHEP. Examples of Egyptian experiences will be discussed in chapter 3.
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2.5 Community involvement, definitions and concepts 2.5.1 What is community? Community as a word is derived from the Latin word “communitas” meaning shared by all (Wikipedia, 2008). Mahoney et al., 2007 defined “Community” as a group of people who are related in some way. It is not only based on the geographic distribution, as those who live in the same area might not share the same characters and views.
2.5.2 What are communities? Communities are defined by shared characteristics, interests, or geographical area. Communities could be socially complex covering diverse economic, political and social aspects that can change by time, space and generation (Maclean, 2006). In other words, communities are defined as correlated groups which act as a reconciling constitution to connect people and offer a sense of belonging (Mahoney et al., 2007).
2.5.3 What is community involvement/ participation? Involvement and participation are used interchangeably in many contexts. “Participation” refers to the idea of power sharing as it encompasses factors facilitating decision-making as well as those influencing partaking resources and knowledge (Mahoney et al., 2007).
As defined by WHO (1999), “participation” has two elucidations: “Participation as a means” in which participation is a process of community collaboration with externally established projects.That collaboration plays an effective role in the projects’ success. “Participation as an end”, in which participation itself is considered a goal as it reflects the community empowerment. Communities will acquire new skills, experiences and knowledge, making them responsible for their development. Hence, participation is the key for change.
Moreover, the stage of involvement of community determines their influence or power for decision-making [Diagram 1: describes typology of community participation]. Social and power dynamics among community members have a critical influence on who has the ability to participate or not, i.e. economic factors and gender norms may potentially exclude the poorer, marginalised and women from real participation (Maclean, 2006).
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Diagram 1: Typology of Community Participation Collective Co-learning action Toward ownership Cooperation and sustainability Consultation
Compliance
Co-option
Away from ownership and sustainability Source: Maclean, 2006
“Community mobilization,” a related term, is used to describe a process at the higher end of this continuum, as a group of people realises shared need and initiates an action. Another means to envision community involvement is cyclical rather than linear, as the quantity and quality of community participation in any project fluctuates over time, depending on diversity of factors such as context, timing and status (FHI/YouthNet, 2006).
2.5.4 What is community empowerment? Laverak and Wallerstein (2001 p182) also describe community empowerment as a process and an outcome. “….community empowerment as a process along a continuum …. offers most insight to the ways in which people are enabled through the programme to make their potential and progress from individual action to collective social and political change. Community empowerment as an outcome is limited to long time-frame and contingent action”. They argue that even the heterogeneous ones can share needs and form small mutual groups which in turn can unite to create community organisations. Through the partnership of the community organisations, social and political action could be initiated [Diagram 2: Process of community empowerment dynamic continuum as envisioned by Laverak and Wallerstein, 2001].
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Diagram 2 Process of community empowerment dynamic continuum
individual Small Small mutual individual individual individual mutual group group
individual individual Community organisation Social and Partnership political Action
individual Small Small individual individual mutual individual mutual group group
individual individual Community organisation Source: Author, 2008
Community empowerment encompasses a move towards more equality in social power (Laverack and Labonte, 2000), meaning who owns authority, power, knowledge, resources and influence.
2.5.5 What is social capital? Wakefield and Poland’s (2005) define social capital as: “.. a resource that accrues to individuals and groups, who can leverage it to achieve particular goals that may or may not be beneficial to society as a whole”
Kreuter 2003 (cited in Campbell and Foulis, 2004 p8) defines it as: “Those specific processes among people and organisations, working collaboratively and in an atmosphere of trust, that lead to accomplishment of goals of mutual social benefit”. . 2.5.6 What are gatekeepers, stakeholders and positive deviants? Alliance and Frontiers (2006 p31) differentiate between the two terms gatekeepers and stakeholders as follows: “Gatekeepers are people who control access to certain individuals, groups of people, places or information. For example, school teachers and parents are gatekeepers to children; brothel owners are gatekeepers to FSWs”.
“Stakeholders are people who have an interest (or stake) in the outcome of community mobilisation. A primary stakeholder is a person or organisation that a community mobilisation process aims primarily to benefit (e.g. a young person in a youth prevention process). A secondary stakeholder is someone who may not benefit directly but who will be affected or involved in some way (e.g. a teacher in a youth prevention process)”.
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Regarding positive deviants
“In every community there are certain individuals (the "Positive Deviants") whose special practices/ strategies/ behaviours enable them to find better solutions to prevalent community problems than their neighbours who have access to the same resources.” (Positive Deviance Initiative, no date p1).
2.5.7 Health and community participation With reference to Campbell and Foulis (2004), there are three categories of participation in international health promotion literature. The first is grassroots participation in the conduct of formal health services. The second is participation in community-based health promotion projects aimed to positively change behaviours. The third is high level of community involvement in LNGOs and hence strengthening community social capital.
2.6 Community involvement in ASRHEPs 2.6.1 Key actors Youth, parents, teachers, political leaders, RLs, CLs, CHPs and health care providers are the key stakeholders of such programmes [Diagram 3: Main stakeholders of ASRHEPs].
Youth are the core and main actors of those programmes, still ensuring positive adult roles and commitment facilitates youth access to older people for support and advice. Such support sensitises and gives community consent in formal and informal ways to tackle sensitive SRH issues and create an enabling environment as well (Maclean, 2006). Coalition between those actors is crucial for achieving such environment.
Diagram 3:Main stakeholders in ASRHEPs Community leaders
Religious Leaders Community Community Parents Peer Policy Health Educators makers Educators Youth
Families Counsellors Teachers Health care providers
Political Leaders
Funding agencies
Source: Author, 2008
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While acknowledging the existence of all these main actors, however, this dissertation will focus on four key actors: youth, parents, CLs and RLs.
2.6.2 Meaningful community participation in ASRHEPs Community participation and health education are integral dimensions to protect and promote health as stated in Alma Ata declaration (WHO, 1978). Community participation in ASRHEPs could be either meaningful or compelling for programme as SRH messages may appear to oppose established cultural and religious values and beliefs (FHI, 2005b). Among different actors who play a role in such programmes, various factors influence their perception and involvement.
Adapted from Campbell, Mzaidume, 2001, the author argues that positive influential community participation relies on several interlinked factors: First, empowerment of community, as participation gives them the health-related knowledge increasing their self-efficacy and enhancing their engagement. Second, developing health-enabling communities, which provide an environment promoting positive influences on community empowerment. Third is the mobilization of existing sources of social capital or promoting the initiation and progress of new sources.
2.7 Conclusion: This chapter has identified and categorised ASRHEPs into main categories. Different terminologies and concepts about community participation are discussed. The diversity of community actors in such programmes is explored. However, what are the main problems of community participation in and perception of ASRHEPs? What are the factors behind those problems? How is that tackled in developing countries’ experienceses? That what will be explored in the next chapter.
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CHAPTER 3: PROBLEM ANALYSIS, PROGRAMMES AND INTERVENTIONS TO ADDRESS This chapter presents an analysis of the problems of poor community participation in and perception of ASRHEPs in addition to experiences of positive community contributions in such programmes. It starts by brief analysis of the problems followed by detailed analysis for challenges and problems facing each actor’s involvement with a focus on the Egyptian context. Significance and approaches of meaningful engagement of each actor’s are discussed through exploring positive experiences from developing countries as well as Egyptian experiences.
3.1 Problem in-brief: Youth are an integral part of their community. Parents, families, RLs and community members all play a fundamental role in shaping youth’s knowledge, attitudes and behaviours regarding SRH issues. In Egypt, women consider their reproductive and sexual roles as the main essence of their womanhood, so they internalise any pain related to these roles. Men have internal concerns about their potency and fertility considering them the very essence of their manhood as well. However, a “culture of silence” exists, as intergenerational dialogue on SRH issues is seldom held openly .This evolved from the belief that talking openly may encourage premarital sex (Khattab et al., 1999 p2-3). Communities want to achieve sound ASRH behaviours; however they are poorly engaged in ASRHEPs and perceive them shameful (“Ieb”). Adults mostly do not allow youth to attend such programmes, or allow them cautiously. Youth and their gatekeepers have many concerns about the conducted ASRHEPs as a diversity of norms, religious, socio-cultural, economic, educational and political factors; precipitate and fuel their worries.
3.2 Problem tree [Diagram 4: Problem tree].
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Diagram 4: Poor Community Participation in and perception of ASRHEPs in Egypt
COMMUNITY RELIGOUS HEALTH HELATH CARE PARENTS POLITICAL LEADERS LEADERS promoters PROVIDERS TEACHERS YOUTH LEADERS
Absence of Improper Shortage in Lack of legislation of Gender training motivation sexuality roles programmes education in Threat from schools youth empowerment Reactions from Lack of Lack of Deficiency in Deficient families & proper time culture skills friends knowledge sensitive curriculum Lack of youth Poor engagement Negative Lack of in policy Lack of Incentives role of training developmen inter- media curriculum t generationa l dialogue Scarcity of skilled Little interest trainers/ from religious professionals organisations Few interested NGOs Insufficient funds
Socio- Religious Financial cultural Educational Political constraints constraints constraints constraints constraints Source : Author, 2008
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The intersections between different factors indicate the level of interrelation between root causes as well as different actors.
3.3Actors’ involvement; significance, problem analysis and positive experiences: 3.3.1 Youth the indispensable actor: FHI (1998) believes that involving youth in ASRHEPs in a meaningful way is crucial for the effectiveness of such projects; however challenging for projects’ managers. It argued that evaluation of this strategy encountered critical lack and no research findings discussing which youth involvement approach may result in which benefit and what is the quality and quantity of that benefit.
Ten years later, has evaluation of ASRHEPs been conducted? What are the results? That is what will be explored below:
3.3.1.1 Youth involvement, challenges and problems Youth are the main persons who can realize their real needs; consequently, they can identify the appropriate communication channels and proper messages. They can be an outreach connection to their community and effectively publicize ASRHEPs. Youth involvement from the early phases of project such as needs assessment (NA) till its end strengthens their sense of ownership, self-efficacy and empowerment (Purdy, 1998). According to WHO (2006) evidence of impact of youth participation on ASRHEPs is not very strong, some studies revealing good, others revealing weak, yet most concur that youth participation is the means for an effective programme.
Youth are a diverse community. They have different perspectives, priorities and needs (Maclean, 2006).This can be attributed to an assortment of factors influencing their involvement:
a) Gender norms: “The years of transition from childhood to adulthood are usually defined by expanding opportunities, growing self-awareness, and increased knowledge about the world. For girls in rural Egypt, the opposite can be true. As girls reach adolescence, their world becomes increasingly confined to the home, their opportunities limited to household chores, and their future prospects restricted to early marriage” (Brady et al., 2007 p1).
According to Egyptian Labour Market Panel Survey of 2006 cited in Brady et al. 2007 p1; 26% of Egyptian girls aged 13–19 in Upper Egypt had not enrolled in schools or dropped out of school after 1-2 years. Anecdotally, female youth (more than 12 years) in some extremely conservative villages of Qena governorate do not go outside their homes except once at marriage and the second time to be buried.
Parents and extended families play a crucial role in shaping youth female’s social lives. Brothers and cousins, whose voices are respected in their families, do not only monitor females’ physical mobility but limit them and consequently
Chapter three 18 Main document constrain any opportunities for their involvement in leisure and social activities (Brady et al., 2007).
Besides, females resist engaging in ASRHEPs as they do not feel comfortable dealing with male peers within such programmes. “I can’t talk in front of male peers about those sensitive issues. It is forbidden to do that (“Ieb”). What will people say about me?!!! (Female participant in CDS programme/ Egypt, 2008).
Further, boys’ access to SRH information is better and the social acceptability to boys’ premarital activity is relatively higher than girls as for them it is not accepted at all. All these factors in addition to early marriage and early childbearing hamper female youth participation in ASRHEPs.
b) Socio-cultural factors: The potential for breaching confidentiality and privacy about SRH issues is a hindering factor regarding youth involvement in such programmes. Besides, the sensitivity of SRH topics makes participatory methodology, tools and discussions are difficult to apply (Mathur et al., 2004).
Regarding vulnerable youth such as street children, orphans, FSWs and IDUs, they are more exposed to SRH hazards however, they can not engage in regular ASRHEPs as the curricula and environment are not suitable for that.
c) Economic: Hardee et al., 2004 points out that one half of youth males and one-sixth of youth females work, and some work more than one job. Lack of time, searching for jobs and shortage of incentives are compelling factors for youth involvement in ASRHEP. Their participation in voluntary programmes is considered a luxury they cannot afford (WHO, 2006). Peer educators (PEs) in an ASRHEP started in hundreds and became fifty at evaluation time because of low salary and remuneration. Even when a programme offers incentives, they prefer to have permanent jobs (FHI, 2007). Although volunteerism is not a new concept in Egypt, not all youth are acquainted with or contribute.
“Volunteerism and civic participation are integral values of the Egyptian people that are deeply embedded in the country's history, traditions and culture. However, promoting enhanced youth participation and volunteerism entails overcoming certain negative social and cultural stereotypes that limit the role of youth in society and sometimes work to jeopardize the key role that youth can play in the development process” (UN Volunteers, 2008 p1).
d) Educational: Illiterate youth have less opportunity to be involved in ASRHEPs as they work and have no time to share in YAs and LNGOs social activities (WHO, 2006).
Training youth on peer education (PE) methodologies and on-the-job training (OJT) are another educational concerns as that requires experts to build capacity of youth and create a powerful team capable to share in all project phases
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(Mathur et al., 2004). This expertise may not be available in some areas or hard to fund.
e) Political In 2004, a review of national progress in the implementation of the ICPD Programme of Action, only 61% of countries had advanced policies or legislation on ASRH needs and rights. Many of the ratified laws have not been implemented, so youth do not gain fruit of the legislations (FCI, 2008).
According to UNICEF (no date c), interests of Egyptian youth have not been taken into consideration for long time. The problem falls in deficiency of the wide range of data required to identify not only the needs but also youth resources and potentials. Besides, there is a clear lack of capacity of institutions dealing with youth such as schools and YAs. Lack of policy and enabling environment to integrate SRH in schools curricula are crucial issues as well.
f) Religious: Will be discussed in RLs section.
3.3.1.2 Experiences: programmes and interventions a) Gender issues: Creating safe spaces for females’ interventions is vital for their involvement. “Ishrak” is a project that mixed ASRHEP with sports activities, an exceptional challenge in Upper Egypt. Within the restrictive gender norms, sports are not socially accepted as a female domain (“Eib”). However, the project succeeded in sensitising community and engaging female youth by guarantying girls’ protection from male harassment through ensuring safe environment to play and learn (Barber and Weichold, 2007).
In Zambia, participatory sex census was a technique for girls to express their ideas through using slips of papers to answer questions and responses remained anonymous (Simasiku et al., 2000).
b) Socio-cultural factors: Specific programmes for vulnerable groups: Tailored programmes are conducted to address vulnerable youth and ensure their involvement. Castle et al., no date cited in Maclean, 2006 p21 points out that a project addressed FSWs in Brazil achieved positive change towards alcohol and drug use and decreased “violent client reaction towards condom negotiation”. CDS/Egypt (1999) conducted a project for street children in which PEs were chosen to assist their peers in combating snuffing glue and practising sex with each other. Those “champions” revealed vivid capabilities to address these topics with peers. Moreover, they produced a booklet made of pictures to help them in conveying messages (Mossaad, personal communication, 4, June, 2008).
Life-skills programmes: Capacity building of youth on SRH knowledge, life-skills enables them to take better SRH choices. In South Africa, it was proved that life-skills programme did not increase youth sexual activity but helped decrease number of sexual partners
Chapter three 20 Main document and increase youth’s intentions for condom use and abstinence (Population Council/ Horizon, 2003).
Sports as a tool for SRH education, makes use of sports popularity to attract youth. Lesotho, a country with HIV prevalence 23%, conducted a series of one-day sports activities, through which HIV education, testing and counselling were provided. Making it more comprehensive, programme offered anti-retro-viral treatment through linking HIV positive individual to the nearest clinic. Over 6000 youth males and females engaged in those activities (Fleming, 2008).
Keeping confidentiality and privacy as key theme to train providers and educators on; as well as tailoring programmes’ participatory tools to suit SRH were crucial in Nepal programme’s success (Mathur et al., 2004).
c) Economic factors: In Nepal’s ASRHEP, one of the objectives was acquiring skills, enabling youth participation in livelihood projects, as they considered one of SRH problems causes is economic in origin. Programmes assisted youth to share in credit groups in rural areas and equip urban youth by skills needed to obtain jobs available in market (Mathur et al., 2004).
Regarding incentives for PEs, anecdotally, although surrounded by controversy, incentives must be considered, because of family responsibilities and financial constraints.
Motivation and initiation of voluntary spirit is crucial to encourage youth participation. To link between volunteerism and MDGs in the Egyptian youth minds, the UN Volunteers programme with the Ministry of Youth (MOY) organised the International Volunteer Day (2005). Currently, 43 national UN Volunteers are engaged in the “Free Village project” to abandon FGM which builds on cumulative efforts from1950 till now. Involving youth and other key actors in campaigns contribute to its success (UN Volunteers, 2005, 2008). Some Upper Egypt villages have been declared “FGM free” (DeJong et al., 2005).
d) Educational factors: Literacy classes To achieve MDGs, Nepal conducted a programme mixing life-skills/ASRHEP with literacy programmes. More than 500 girls who participated at phase one of programme were selected to be trained as PEs for 1537 female peers. In five months the advocacy reached 20,000 people within their communities (Kayastha, 2008).
e) Political factors: Recently, a National Youth Taskforce (NYT) was established in Egypt under auspices of MOY which considered recognition from policy makers to the role of youth; however it still needs endorsement to be more effective as stated by USAID (2005).
f) Religious factors: Will be discussed in RLs section.
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3.3.1.3 Youth roles: Youth as researchers: Simasiku et al. (2000) documented a Zambian experience using participatory learning and action tools (PLA) in assessing ASRH needs. Participatory research tools were adapted to suit work with and by youth as using picture stories to facilitate their insights. Furthermore, involved youth chose their future leaders who were trained to be PEs and counsellors for that programme, helping tackle problems from youth perspectives.
Youth as planners and designers: youth are aware of what their peers need, which way they like to obtain the messages through, the barriers of SRH provision and the timings and places of the interventions as well (Maclean, 2006).
Youth as PEs: is considered an effective approach in ASRHEPs. Training PEs on peer-to-peer techniques, supervising and offering them OJT are keys for success (Pathfinder, 2005). Sustainability was a fundamental result of the PE approach in Colombia.Youth felt sense of responsibility so they continued implementation after the project fund was over (Perez and Dabis, 2003).
In Cameroon, 28 PEs were recruited and trained on SRH topics, social marketing techniques for condom distribution and communication skills. Mass media campaign and YFCs were other interventions of the programme. Evaluation revealed that all target reported learning new SRH knowledge. The half declared that they changed their behaviour as a result of such intervention (Rossem and Meeker, 2000). Indian community called PEs “the lasting resource”. They generated confidence among adolescent girls in negotiating and using contraception hence increase in FP methods use (Pathfinder, 2006).
Freedom, an Egyptian faith-based organisation (FBO) trained ex-drug users (recovered IDUs) to be PEs for current IDUs. Within 3 years, Freedom reached more than 900 IDUs on the streets, in addition to 625 users visited the outreach centre.
“I consider the Freedom outreach workers as more than family, they are everything to me,” (Recovered IDU, USAID 2006 p.1). Involving recovered IDUs is along the invitation of escalating their engagements in decisions affecting their lives “Nothing about us without us” (Alliance, 2008 b). This is considered building a new social capital.
Prior to coming to Leeds, the author shared in planning and launching CDS project to enhance SRH of youth through three LNGOs; one serves a slum area, the second serves orphans and the third serves street children (2007-current). Capacity building of thirty champions to be PEs was done through training on peer to peer techniques, life-skills and SRH topics [Appendix 11: Themes of training curriculum].
Youth as evaluators: In the African Regional Forum, youth were engaged as presenters so they prepared the presentation, participated in panels and actively engaged in discussions. They were the key resource persons, as their feedback assisted organizers in making modifications to facilitate for maximum interaction with all attendees (WHO, 2006).
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Youth as advocates: “Empowering young people to make changes in their communities can create life-long advocates” (FCI, 2008 p26).
FHI (2007) stated that PEs in Egypt were responsible for advocacy and community mobilisation interventions as conferences, meetings and cultural events organisation. To ensure sustainability PEs carried out meetings with CLs to get local funds.
3.3.2 Parents 3.3.2.1 Parents involvement, challenges and problems Parents play a pivotal role in shaping lives of their children. Effective and meaningful involvement of parents is indispensable to create a supportive environment for ASRHEPs (FHI/YouthNet, 2006).
“Why now, it is not the proper time. Just before marriage they can know everything about sexuality” (Father of a young man in CDS programme/Egypt, 2008).
Egyptian parents are considered conservative. Some parents neither engage in ASRHEPs nor allow their children, especially daughters, in contrast to parents in Bangladesh (Rob et al., 2003) and Nepal (Mathure et al., 2004), who supported the introduction of ASRH education in school curricula and encouraged offering FP services to unmarried youth. Egyptian parents focus on their children’s studies and think that attending such programmes is a waste of time and might encourage pre-marital sex. Evaluation of an ASRHEP revealed that some parents did not permit their daughters’ attendance as it was held in YFCs. Visiting such places might affect unmarried females’ reputation as it is shown related to virginity issue. Furthermore, fundamentalists do not allow their daughters and even sons to attend as they might listen to religiously unacceptable topics (FHI, 2007). Peer pressure from relatives especially mothers-in-law and neighbours hinders parents’ engagement.
Social norms, taboos and lack of information attribute to “culture of silence” and missing “Intergenerational dialogue” (Diop and Diagne, 2008).
“I want my daughter to know the basics about SRH but for me I do not have the scientific information plus I am embarrassed to discuss that with her, I think it is role of Mosque, church or school, but not me” (Mother of a teenage female, Cairo/Egypt, 2008).
3.3.2.2 Experiences: programmes, interventions and roles Parents can participate in ASRHEPs’ planning, implementation and advocacy. In a programme conducted in Mozambique, parents were trained to be community activists as they became PEs for other parents and adults. This was an effective strategy to tackle parents’ resistance (Hainsworth 2002, cited in Maclean 2006 p28).
Parental support, respect and acknowledgment of youth needs, rights, and capacities could be ensured through sensitising activities to parents and
Chapter three 23 Main document gatekeepers about ASRH significance as done in Senegal; monthly sessions were conducted between youth and adult PEs. Sessions were held to parents discussing ASRH followed by an “Intergenerational Dialogue Session” to address same topic in presence of parents and youth. Media played a great rule in sensitizing parents as well. Project evaluation revealed that youth could discuss sexuality issues easier with their parents and condom use increased among both male and female youth (Diop and Diagne, 2008).
Drama is effective in presenting SRH ideas. The discussion follows it; is an important tool for tackling taboos and facilitating behaviour change (Alliance, 2008 a). In Nigeria and Vietnam it assisted in creating a room for discussion about YFCs (Ipas, 2003).
Merging SRH education with different programmes discussed above such as life- skills, livelihood programmes and literacy classes encourage parents to engage their children into such comprehensive programmes. Anecdotally, launching programmes addressing both hepatitis C and AIDS can encourage parents to participate and allow their children participation. Engaging doctors in teaching scientific SRH issues is crucial as they are considered the resourceful persons in their communities (FHI, 2007). Moreover, involving mothers-in-law, brothers and cousins is crucial for female engagement.
3.3.3 Religious leaders 3.3.3.1 RLs involvement, Challenges and problems “Religion has traditionally been a pervasive social force in Egypt” (FHI/IMPACT, 2007 p3).
RLs are respected leaders in developing countries communities. Because of their “social legitimacy”, they have the capacity to influence the attitude and behaviour of communities. They differ in their opinion about ASRHEPs, while some agree and even participate; others believe that programmes encourage promiscuity so they hamper other community actors’ participation (FCI, 2008).
“We have to teach SRH on individual level to the needy person, that one who has shown pre-mature sex activity but not for all” (Religious leader in Giza, 2008).
Some ASRH topics initiate conflicts with some RLs such as FGM, masturbation. Before marriage, abstinence is the only solution. Condom use is not accepted in both Muslim and Christian context.
Moreover, RLs contribute in shaping national policies and legislations regarding ASRH (FHI/IMPACT, 2007).
3.3.3.2 Experiences: programmes, interventions and roles RLs have a tremendous role in creating an enabling environment for ASRHEPs and abandoning discrimination for vulnerable groups and PLWA. They can play a pivotal role in developing the implementation guidelines and revising sensitive or controversial SRH materials as well as conveying SRH issues to youth and
Chapter three 24 Main document stakeholders and hence the idea of Religious-based ASRHEPs (FHI/YouthNet, 2006).
In Mozambique, 463 RLs were trained on HIV prevention topics and they reached 21,000 youth and adults and taught them about abstinence and faithfulness behaviours. Project’s evaluation showed reduction in number of sexual partners among youth who are never married; however little change in youth abstinence behaviour (Chambers et al., 2008).
In Georgia, RLs responded with suspicion to CARE’s ASRHEP then blamed it by “contributing to the depravity of youth.” Hence, project staff quickly addressed potential allies, including Orthodox priests, other stakeholders through establishing an advisory committee, holding regular meetings and introducing new interventions before launching. That assisted to predict and avoid conflicts (FHI/YouthNet, 2006).
In Bangladesh, Imams objected an ASRHEP considering it “anti-religious”. That resulted in temporary suspension of activities to propose respect to RLs. Individual meeting with RLs, CLs, political and governmental officials were done to address conflict. Tailored advocacy packages and workshops to explain project benefits were carried out with assistance from National RLs and Ministry of Health officials. Eventually, Imams shared in programme activities and that enabled it to resume (FHI/YouthNet, 2006)
In Egypt, FHI/IMPACT trained Muslim and Christian RLs in HIV/AIDS prevention programme. Each sheikh or priest designed an annual plan of activities to fight HIV/AIDS in his district. OJT was offered by the project staff. These interventions reduced widespread misconception that “HIV/AIDS is a punishment for one’s sins” (FHI/IMPACT, 2007). Other programme engaged RLs in identifying verses from Quran and Bible to assist formulating ASRH messages. Female RLs were fundamental actors in approaching women in this programme. Increase in SRH knowledge was revealed within 37% of community. Case study of a sheikh who started as a staunch opponent then became a positive deviant, was highlighted. Staff used peer pressure from RLs to each other in case of opposition (Hussein et al., 2008).
On the regional level, 80 Arab RLs signed the Cairo Declaration (2004), to respond to HIV/AIDS (FHI/IMPACT, 2007). [Appendix 10: The Declaration].
3.3.4 Community Leaders 3.3.4.1 CLs involvement, Challenges and problems CLs are the gatekeepers of community; they have crucial influence on its members as they can challenge norms which hamper youth engagement or create room for emerging more supportive norms. Better understanding of ASRH needs, rights and perspectives enable CLs to offer effective support and enhance “intergenerational dialogue” (Maclean, 2006).
In Egypt, some CLs are resistant to new notions, holding on norms, old ideas and traditions, so they undermine ASRHEPs. In FHI YFCs, female participants were afraid of rumours affecting their reputations as they felt that CLs might think that clinics could be places where females and males meet. Some CLs were against
Chapter three 25 Main document programme because it opened discussions of topics such as FGM and FP.They thought that these programmes have hidden agenda, which introduced those “weird ideas” (FHI, 2007). “People told me it is an invasion from USA and Israel which want to introduce their western culture to us” (Male participant in CDS programme/ Egypt, 2008).
Lack of information or misconception usually results in opposition from CLs, however some never support ASRHEPs, regardless information they obtained (FCI, 2008). Some CLs feel threatened from youth empowerment as youth gain skills, knowledge and expertise through programmes. So they discourage youth initiatives, considering them inappropriate and leading to community conflicts (Mathur al., 2004). Besides, some CLs think that they protect youth from promiscuity. SRH interventions are challenges for the deeply rooted socio- cultural norms including gender roles (Michau et al., 2008).
One of the critical factors influencing Egyptian community is the media as it does not exert much efforts in raising people’s awareness regarding SRH topics nor advocate for services or programmes for youth (FHI, 2007).
3.3.4.2 Experiences: programmes, interventions and roles Involving all is a great burden on staff, so strategic selection of CLs and introducing them at the proper time is crucial. In Nepal, they defined the primary accessing to community and program design as significant points for recruiting stakeholders. Strategic participation implies engaging marginalised people such as women, poor, ethnic or social class groups (FHI/YouthNet, 2006).
In Thailand, CLs were engaged from the launch of a project to reduce HIV/AIDS stigma.Quality planning, leadership and community resource mobilisation were important roles as most of the projects face tight financial constraints. Hence time and efforts of core group members as they shared knowledge, skills, expertise, influence, and connections had contributed to project success. They participated in implementation of the project as PEs for adults. Monitoring, evaluation (M&E), developing sustainability and sharing experience were other roles of CLs (Apinundecha et al., 2007).
“Snowballing” is other advantage of CLs’ engagement hence they are able to identify other influential stakeholders in the next phase or to solve a problem (Alliance and Frontiers, 2006).
In Burkina Faso, to conduct community-driven ASRH NA, the programme developed local village’ committee from 10 community members from each village. Village assembly (encompassed the 20 targeted villages), shared conclusions and experiences from whole community as a participatory action plan. The process created a sense of ownership within community. Moreover by the end of the project, 69 percent of community members reported their participation in at least one project activity. More than 75% viewed youth as key actors in the programme (FHI/YouthNet, 2006).
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Community events such as street fairs and national workshops facilitate raising CLs’ awareness. Regular meeting and gathering actors’ feedback helped prompt identifying of problems and facilitate tackling them in Tanzania (Obasi et al., 2006).
Anecdotally, accessibility of the venue of intervention plays a role as some leaders in tribal areas insist that interventions must held in their territories. Mobile seminars could help to access remote areas (Mathur et al., 2004).
3.4 Conclusion: Developing countries’ experiences reveal that many factors contribute to actors’ involvement in ASRHEPs. Identifying gatekeepers, stakeholders and positive deviants is a crucial to launch such programmes. Community actors cannot be dealt with as separate entities, as they affect and are affected by each other. If programme staff recruits, engages and build capacity of actors effectively in the proper time and in the appropriate roles, attitude shifts can be encountered which reflect positively on the programmes as a whole. What lessons can be further learnt from the presented experiences? Which criteria we can choose programmes according to? Which interventions match with Egyptian context? This leads to chapter Four.
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CHAPTER 4: TOWARDS EFFECTIVE COMMUNITY PARTICIPATION IN ASRHEPS IN EGYPT
Based on the previous chapters, this one presents different programmes and interventions that could be used in Egypt in dealing with community resistance and encouraging active community participation with focus on youth engagement. It is divided into 2 main parts; first is common interventions that facilitating key actors’ engagement as a whole; as well as specific interventions for each actor. Second is an appraisal of the diversity of ASRHEPs with respect to youth involvement as they are the main target and the fundamental actor of such programmes. Criteria of selection that match Egyptian context are highlighted.
4.1 Interventions to foster meaningful community participation This section presents diverse interventions that facilitate different community actors’ engagement and create an enabling environment through all programmes’ phases. As without their involvement, youth participation is hard to achieve. Such interventions which are considered feasible based on the author’s experience (but not appraised in detail) are presented to show how a comprehensive approach might appear [Appendix 12: Table presents community actors’ interventions, targets, criteria and concerns in details].
As key actors are from same community and influenced by same factors, so some interventions can assist participation of all actors; however; specific approaches can be adopted to facilitate involvement of each particular actor.
4.1.1 All actors 4.1.1.1 Starting: In proposal and budget writing, it is crucial to include community mobilisation activities and to tentatively identify gatekeepers and potential stakeholders for target beneficiaries whether students, out-of-school or orphans, etc. Exploring the goal and objectives of the programmes to actors from the very beginning in a transparent way could clarify images and prohibit rumours of the western hidden agendas.
4.1.1.2 NA: NA is an opportunity to recruit key stakeholders and gatekeepers ensuring that all layers of community have an opportunity to engage in the programme which encompasses: men and women; rich and poor; different social classes; different age groups; diversity of tribes, marginalised and disempowered people. It is not necessary that every subgroup be represented in each activity; the most important is involvement of key groups at strategic interventions. However, caution must be paid in dialogue facilitation as women and youth may not prefer to talk in front of men especially in Upper Egypt, rural and slum areas. Participatory NA assists in identifying positive deviants. Stakeholder analysis is pivotal to predict and avert community resistance to programme.
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4.1.1.3 Planning:
Selected stakeholder’s engagement in designing action plan and recruiting beneficiaries is crucial. Community resources such as facilities and human resources of LNGOs, YAs and FBOs; could be considered in planning. Curricula tailoring and piloting are pivotal to harmonise with the youth needs, social norms and religious beliefs. Besides, addressing Hepatitis C prevention could be a convenient gate for tackling HIV/AIDS.
4.1.1.4 Implementation (process) Tailored capacity building of stakeholders is crucial, on scientific ASRH issues and enabling skills such as communication skills, persuasion and team work. Volunteerism, motivation and trust building are important skills acting on attitude and behaviour. Introducing participatory methodology facilitates discussions and hence community capability to understand ASRH and its implications. Drama is an effective tool in portraying negative impact of harmful social norms as early marriage and FGM. It creates space for reflection and positive change of attitude. Moreover, community events including street fairs, national workshops and intergenerational sessions are helpful to initiate dialogue. Engaging youth in all project stage as researchers, planners, PEs, evaluators and advocates requires discussions with adults to sensitise them. Ensuring financial and non-financial incentives for PEs e.g. recognition through special events, T-shirts, mobile phones, pens and notebooks, helps retain them and avoids high turnover.Training them on citizenship and volunteerism promotes voluntary spirit.
4.1.1.5 M&E Providing support, supervision and OJT for PEs throughout their work is important to ensure that right knowledge, skills and attitudes transferred to their peers. Regular meeting with stakeholders and getting feedback help prompt problems’ identification, allow emerging of community solutions based on their norms and resources and encourage snowballing.
4.1.1.6 Ensuring gender equity “Gender-based-approaches: SRH issues should not be discussed in a mixed programme in rural and slum area to avoid rumours. Safe space for female education and activities facilitates girls’ attendance as it protects them from sexual harassment especially in slum areas.
4.1.1.7 Gaining more support Collaboration with National Council for Children and Mothers (NCCM), a powerful agency addressing women’s issues and headed by the first lady can help with advocacy. Moreover, media could promote for ASRHEPs through TV and radio in powerful daily social programmes such as “Elbiet Beitak/ Feel at Home”. Recruiting football players and actors for TV shows as well as using international events can lend a hand in raising community awareness.
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4.1.1.8 Enabling supportive environment It is vital to ensure geographic accessibility to all targets including holding mobile seminars to access remote and marginalised areas. Attention must be paid to difference between urban, rural and Bedouin cultures, in respect to vocabulary and way of teaching.
4.1.1.9 Increasing social capital Creation of taskforces facilitates distribution of work and addresses more than one goal concurrently. It fosters creation of social capital as community stakeholders together with staff became responsible for the programme. However, it is time consuming and takes effort to ensure ample representation by the diverse groups and to allow youth skills, talent and leadership to prosper.
4.1.1.10 Ensuring sustainability and Scaling-up Holding workshops to exchange experiences between different initiatives, areas and stakeholders is important to create much room for learning. Programme’s scaling up requires collaboration of all parties based on the previous lessons learnt. Building on the human resources and social capital of communities along with the support of advocacy groups and the facilitation roles of local government are fundamental.
4.1.1.11 Advocating for policy change People are catalysts for change and if communities advocate for policy changes such as school-based SRH education, that should help on the long run.
4.1.2 Parents: Identify common ground with parents, building on it and exploiting peer- pressure among parents are effective tools in gaining more involvement especially in rural and slum areas. Using mothers-in-law as positive deviants can provide support for youth as they are a significant source of information. When engaged in programmes, mothers-in-law in rural and slum areas offer many resources, such as their houses, as venues for seminars.
4.1.3 RLs Exploring importance of ASRH, its implications on community, significance of their roles and the goals of ASRHEPs facilitate engaging RLs into programmes. Reinforcing existing initiatives for engaging RLs to produce faith-based SRH educational curricula consistent with religious values and norms from Muslim and Christian perspectives is vital. Recruiting both male and female RLs could tackle sensitive SRH issues and taboos. Further, Friday prayers for Muslim; Liturgy, Sunday schools and specific meetings for Christians could be the means via which education can be provided. Using the Arab RLs declaration along with peer- pressure among RLs could help gaining more meaningful involvement. Creating advisory committees which comprise RLs, CLs and parents could assist avoiding conflicts.
4.1.4 CLs Recruiting strategic CLs such as the Mayor (El-Omda) in villages and Sheikh El- Hai in slum areas and involving them in strategic programmes stages facilitate
Chapter four 30 Main document community participation. Engaging Local Political people has an advocacy long term effect.
(Diagram 5: presents community engagement process and identifies key interventions areas).
Advocating together Diagram 5: Community engagement process Scaling up together Capacity building occurs at each stage to enable communities to carry out each of Ensuring these activities. sustainability
Enabling supportive Planning environment together
Assessing Ensuring together gender Starting equity together
Evaluating Acting together together Monitoring together Increasing Gaining Social Capital more support Source : adapted from Alliance, 2006
Adapted from Alliance 2006, actors involvement in such programmes is as a means towards programme success and sustainability and an end by itself pro increasing community exist social capital as well as initiating new ones. [Appendix 14: Community involvement as a means and as an end in details].
4.2 Diversity of ASRHEPs. Which match the Egyptian context? This section appraises different discussed ASRHEPs regarding youth, the core and main actor of programmes. The criteria for appraising presented below are adapted from (Green, 2007 p.265-266; Walley et al., 2001 p.58-62):
Effectiveness: examines the ability of option to improve youth engagement into the programme as well as retaining them. Acceptability: assesses the cultural acceptability of option by youth and their gatekeepers. Affordability: examines the financial ability of youth to be engaged in such option. Social and economic equity: examines the accessibility of option to various layers of targeted youth from both social and economic points of view. Gender equity: measures the accessibility and acceptability of option to females youth in comparison to males ones. Sustainability: evaluates how youth engagement and adoption of SRH issue will persist after the programme is over.
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Organisational feasibility: assesses the ease of option implementation successfully considering administrative and legal organisation of the implementing and stakeholder agencies. Capacity for equipment and availability of trained resources are considered from the main factors of such feasibility. Political feasibility: weighs up how much the current policy can augment option’s implementation.
Below is a brief discussion about different kinds of ASRHEPs [Appendix 13: Diagram of ASRHEPs’ categorisation] and how much each one fulfils selected criteria according to Egyptian context:
4.2.1 Comprehensive SRH services: Although such multi-faceted programmes provide not only the education but the service and counselling as well, however they are not effective in attracting youth as they are not well culturally accepted by the Egyptian community especially for unmarried youth and particularly for females. Mainstreaming those services, equipping them and training human resources need time, funds and introducing them to the 10-years national plan. Subsidiary policy has to be adopted to ensure affordability and equitable accessibility by youth.
4.2.2 Youth-Friendly clinics: They offer specifically tailored SRH for youth in ways respecting their dignity and confidentiality. Furthermore, YFCs offer service, education as well as counselling. Yet, they again are not culturally acceptable for unmarried youth especially for females as they can precipitate rumours. Offering contraception methods for non-married people is not acceptable by the Egyptian community from the religious point of view. Although YFCs may be the best for youth but for Egypt, a long journey is required slowly but surely to sensitize the community for such interventions, as well as lots of funds. Physicians and other health care providers have the same community social norms hence training them on how to be not biased to their personal opinions in dealing with ASRH will not be an easy task. They must be trained to deliver proper knowledge and services for youth. Confidentiality, respect of others and social marketing are important skills for them to acquire as well.
4.2.3 School-based programme: It is one of the significant options as it provides SRH as mandatory education which can guarantee social and economic equity for all school students; as well as gender equity. However, policies in Egypt are not with this type of programmes. It is not acceptable from RLs at the macro-level. Implementing this programme necessitates developing curricula, arranging administrative as well as organisational regulations and capacity building of teachers. Motivation of teachers to speak about sensitive SRH topics is another concern. All this needs time, efforts and funds. Sensitising community to accept this intervention is needed as well. Dropped out of school youth (mostly females) would not benefit from such programmes.
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4.2.4 PE programmes: It is an effective method for conveying sound SRH messages as youth are the main engines and beneficiaries at the same time. The acceptability among youth is high; however sensitising approaches for community are needed. Capacity building of youth requires funds and experts; nevertheless community assets and new networks of social capital will be created; hence sustainability is high. The programme ensures considerable equity as PEs can be selected from different social and economic community layers as well as from males and females.
4.2.5 Life-skills programmes: It provides empowerment for youth by not only SRH knowledge but also skills which enable them to positively change their behaviours and ensure sustainability. As it encompasses diversity of attractive skills, it is effective in encouraging youth engagement and facilitating acceptance from parents and community gatekeepers. Life-skills curricula should be tailored to match the Egyptian context and that needs time and funds as well. LNGOs and YAs could be theatres for such programmes which ensure sort of accessibility, social and economic equity. However, human and organisational capacity building is needed. Searching for funding agencies concerned with SRH issue is required.
4.2.6 Mixing ASRHEP with Literacy classes: This is a step towards achieving MDGs, as it combines both literacy and SRH education. Literacy classes are encouraged by the Egyptian government so they are distributed in many venues all over the country and offered free of charge. It is accessible to most of illiterate youth which are considered a vulnerable group. Moreover, there are special classes for females which ensure gender equity and acceptability. However, that requires permissions from literacy class implementing agencies, training of educators and sensitisation activity to parents and community.
4.2.7 Mixing ASRHEP with sports: Sports, especially football, is very popular in Egypt. It can be implemented by incorporating ASRHEP with YAs activities. Sport effectively encourages male youth participation. Although for females it is not accepted culturally except by implementing special programmes as “Ishraq” and identifying safe places that ensure privacy for activities, necessitating more funding. And even with all those precautions, activities to sensitise families and community are required. Permission from YAs and even the MOY has to be taken as well.
4.2.8 Religious-based programmes: Those programmes are very effective in reaching Egyptian youth as religious values are the main acceptable source of knowledge. As it can be conveyed through Friday prayers in Mosques and Sunday schools and specialised youth meetings in churches, it is accessible to different community layers and ensures social, economic and gender equity as well. Recruiting and training males and females RLs require time, efforts and funds to initiate the programme. Little funds are needed to sustain programme as most of the services in religious places are voluntary in nature.
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4.2.9 Mixing ASRHEP with economic livelihoods programmes: As unemployment is a major problem facing Egyptian youth, launching economic livelihood programmes and incorporating ASRHEP in them is an effective way to attract youth as it lessens financial constraints. Such programmes ensure economic equity and specific programmes targeting females ensure gender equity as well. However, such programmes require much expertise and funding, they are not easy to sustain and they target particular community classes.
4.2.10 Specific programmes for vulnerable groups: Specialised programmes are effective in addressing specific targets. It has moderate organisational and technical feasibility as curricula have to be tailored to match each beneficiary’s problems and context. Capacity building of staff and teaching them about the background of each category and their specific problems are needed. Permissions must be taken to launch these programmes with orphans and military services. However, programmes address FSWs and street children face other problems which are how to recruit, convince and retain them. Funds are required to cover such programmes and sustain it. However, Egyptian government and donors currently pledge considerable funds for street children which could be used efficiently in such programmes.
Table1 appraises the above options regarding the selected criteria. The ratings of high, moderate and low are based on the author’s experience and the above discussions on interventions for youth and for all actors. Though some criteria might weigh more than others (such as the organisational feasibility), that has been taken into consideration by the author in the process of feasibility scoring.
From the above discussions and table1; life-skills, mixing with literacy classes, religious-based, PE programmes and specific programmes for street children are shown to have the highest feasibility from the author perspective.
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Table 1: ASRHEPs’ options appraisal Effectiveness Acceptability Affordabil Social and Gender Sustainability Organisational / Feasibility ity economic equity political scoring Equity feasibility Comprehensive SRH services, low low moderate moderate low high Low low counselling and education
Youth-Friendly Clinics low low moderate moderate low high low low
School-based programmes high moderate high moderate moderate high Low moderate
PE programmes high moderate high high high high high high Life-skills programmes high high high high high high moderate high ASRHEPs +Literacy classes high high high moderate high high moderate high ASRHEPs + Sports high high/males low moderate high low low moderate Low/ females Religious-based programmes high high high high high high moderate high ASRHEPs + Economic high high moderate moderate Low low low low livelihoods programmes
Specific programmes for High/ moderate moderate high moderate high moderate Moderate vulnerable groups moderate /high
Source: Author, 2008.
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4.3 Conclusion While many ASRHEPs could be offered for youth, still not all of them are feasible in the Egyptian context. Building on the evidences from previous chapters and author experiences; life-skills, mixing ASRHEPs with literacy classes, PE, religious-based SRH programmes and specific programmes for street children are appraised by author to be the most feasible ones. However without other actors’ involvement, youth participation hardly exists; hence interventions enhancing active and meaningful actors’ participation are fundamental to ASRHEPs’ success. The following chapter summarises dissertation’s conclusions and recommendations.
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CHAPTER 5: CONCLUSIONS, RECOMMENDATIONS, DISSEMINATION AND CRITICAL REFLECTION
5.1 Conclusions: “The Millennium Development Goals, particularly the eradication of poverty and hunger, cannot be achieved if questions of population and reproductive health are not squarely addressed. And that means stronger efforts to promote women’s rights, and greater investment in education and health, including reproductive health and family planning” (Kofi Annan, 2002 cited in FCI, 2005 p2).
This dissertation has tried to pave way for one of the crucial topics in ASRHEPs field which is community participation. Main risks to adolescents’ health are shown to be more behavioural than medical. Cultural taboos are the major barriers to informed discussions about SRH topics. Therefore, community involvement is a salient aspect for success of such programmes. In reviewing other developing countries’ experiences, it revealed that multifaceted approach must be adopted in addition to more inter-agency collaboration. Different stakeholders, gatekeepers and positive deviants should be identified. Efforts should be exerted to mobilize parents; religious; community and political leaders; LNGOs and YAs’ staff and CHPs. Youth are the target and at the same time the engines of change, therefore, they must be involved from the start and “intergenerational dialogue” should be encouraged. This dialogue is the first milestone to create an enabling environment to support youth healthy behaviours. Sensitisation activities, regular meetings and rigorous monitoring to all actors should be implemented to overcome community reluctance or resistance. Selective main actors involvement must be from the NA, through planning, implementation, till evaluation and advocacy phases. This increases the sense of community ownership as it creates, fosters and at the same time builds on the social capital in community, hence assists sustainability of such programmes.
Attention must be paid to under-served youth such as street children, and other vulnerable groups through implementing tailored programmes addressing them. Positive policy changes support sustaining an enabling environment for such programmes.
The author reiterates that to enhance this field rigorous research; process documentation for successful and unsuccessful experiences and programmes evaluation must be done. Exchange of experience as well as lessons learned and best practices should be carried out as well. [Diagram 6: describes mobilising for a continuum of enhancing ASRH].
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Diagram 6 :Mobilising for a continuum of enhancing ASRH
Laws and Policies
ASRHEPs
The community Gender norms; social norms, The community values; religious beliefs; economic; educational; The individual political factors The (or group of similar individual individuals) Knowledge, attitudes, behaviours, skills
SRHEPY Effectiveness; acceptability affordability; social and economic equity; gender equity; sustainability; organisational Laws and policies and political feasibility Local, national and international laws, policies and procedures
Source : adapted from Alliance, 2006
5.2 Recommendations This section provides recommendations for different stakeholders. The recommendations are not only confined to how to engage community in ASRHEPs but extend to those of policies, services and supporting atmosphere that facilitate this active, meaningful and sustainable community engagement. Inter-agency collaboration between the following stakeholders is crucial as no actor can work without others’ endorsement.
5.2.1 For policy makers: Short-term: Concerned Ministries or their directorates at governmental level should collaborate and provide needed permissions and technical support to community driven ASRHEPs. Protocols could be signed to give the required legitimacy. For literacy classes-based ASRHEPs: Ministry of Education (MOE) and Ministry of Social Insurance and Affair (MISA) are concerned For life-skills programmes, PE programmes and street children programmes: MISA and MOY are concerned. For Religious-based ASRHEPs: Ministry of Al-Awqaf (Islamic Council) and the Christian Youth Bishopric are concerned. Government should allocate more resources to ensure meeting ASRH needs. Policy maker should endorse the role of NYT in developing policies regarding ASRH.
Long-term Laws, policies and legislations to guarantee girls’ human rights, including their SRH rights must to be developed and endorsed such as developing a policy to absolutely abandon FGM. There is a need to place SRH in the10-years national developmental plan.
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MOHP has to strengthen the capacity of health care providers for SRH issues, sensitising them to youth needs and enabling their participation in education in the appraised programmes.
5.2.2 For implementing agencies: (International organisations and consulting agencies including CDS): Short-term: Implementing agencies should incorporate community involvement activities within their proposals and budgets for ASRHEPs. They should choose the suitable intervention whether life-skills, PE, literacy classes, religious-based or street children programmes according to governorate and target group context. They must consider community social norms and religious values in designing activities.
Designing and developing tailored life-skills curricula to different target youth groups, community actors and providers, is crucial. Mainstreaming concepts of gender equity and positive gender norms around SRH in all programs concerned with youth in both curricula content and trainings methodology need to be undertaken.
They should involve strategic key stakeholders in all the programme phases and engage youth in identifying their needs, designing, implementing and evaluating their ASRHEPs. Educating different stakeholders such as parents, teachers, RLs, CLs, CHPs, policymakers as well as providers about the significance of meeting ASRH needs is a must. Participatory methodologies in teaching and training activities should be incorporated. Creating task forces and advisory committees, and drawing on positive deviants within each category such as parents, RLs and youth to influence others are recommended.
Implementing agencies must adopt measures to ensure confidentiality within ASRHEPs, recruit appropriate and motivated PEs, invest in their building capacity and provide them with meaningful supervision and OJT. Incentives are recommended to retain them.
Agencies should engage communities in programme process’s documentation, comprise their perspective of what happened and rational behind that and hold seminars for best practise’ exchange of experiences.
Long-term: Implementing agencies have to design and carry out large-scale ASRHEPs and ensure both accessibility to all targeted youth and gender equity as well. They should draw on appropriate methodologies, activities and messages that match age, sex, culture, religion and sexual experience of targeted beneficiaries.
5.2.3 For Media: Media should provide a supportive environment through raising the significance of ASRHEPs and initiating discussions to tackle sensitive ASRH areas. It is recommended to recruit famous actors such as Mahmoud Kabil (UNICEF Regional Goodwill Ambassador) and football players for discussions to facilitate
Chapter five 39 Main document dialogues. Famous family programmes such as (Elbiet Beitak/ Feel at Home) should be one of the theatres. Media should involve youth popular RLs with such as “Amr Khaled” for Moslems and Bishop Mousa for Christians; to tackle debated issues and encourage intergenerational dialogue.
5.2.4 For LNGOs and YAs: Short-term: LNGOs and YAs such as clubs and centres are recommended to integrate life- skills, peer education through their existing programmes or initiate literacy classes-ASRHEPs. They must create innovative approaches and tools to encourage community participation and partnerships at all levels, identify community gatekeepers, engage them in planning, keep them informed about activities and gain their support to programmes. There is a need to involve Mayor (El-Omda) in villages, (Sheikh El-Hai) in slum areas, local political people and local parities representatives as well. Community events such as community conferences and walks should be held. They should adopt culturally appropriate approaches and identify means to ensure a safe enabling environment for youth participation
Long-term: LNGOs and YAs should lend a hand in advocacy for policy supporting ASRH needs. They should learn from successful programmes’ experiences, share lessons learned and disseminate best practices .Coordination should be maximised between different agencies concerned with ASRH such as coordination with NCCM.
5.2.5 For donor agencies: Short-term: Donor agencies should pledge more contributions for the appraised ASRHEPs. They should invest in capacity building of stakeholders especially PEs and RLs.
They should embrace community involvement aspect in strategies for such programmes, sensitise planners and programme designers to set precise indicators for community involvement outcomes within the programme and post- programme impact.
Long-term: They have to support process documentation to compile experiences about: how community had been engaged, barriers and how barriers were tackled. Formative research encompassing success stories, case studies, lesson learnt and best practices of community involvement in ASRHEPs should be funded as well.
Identifying inter-organizational partnership potentials and support evidence- based programmes and researches facilitating informed programmes are recommended.
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5.2.6 For religious entities: Mosques and churches should implement religious-based ASRHEPs. Males and females RLs should deliver SRH messages to youth and their gatekeepers and encourage “intergenerational dialogue” through their regular and specialised meetings with respective congregations such as Friday prayers for Muslims, Sunday schools for Christians. Capacity building of RLs should be done first and faith-based curricula have to be developed.
5.2.7 For researchers: Researchers are encouraged to conduct formative researches to identify tools of community involvement and overcoming resistance. They are recommended to document the unsuccessful experiences and root causes for them as well as the successful ones and best practices.
5.3 Dissemination An action plan to disseminate study findings to the identified stakeholders in Egypt and beyond will be followed. Different methods and forums will be used which include informal, formal meetings and published articles with some NGOs’ staff; donor agencies, implementing agencies and concerned Ministries. Presentations will be delivered to CDS staff to assist in the current programmes to enhance SRH of youth in Cairo and FSWs in Syria. Through CDS, a national conference will be held, concerned stakeholders will be invited and study recommendations will be discussed. The study will be posted on NearEast/CDS website as well. Arabic translated executive summary and particular parts will be prepared to be published in series in “Sehatek Beldonya” (Your health worth the whole world) Journal which the author is its editor-in-chief. A proposal on life-skills ASRHEPs will be designed, written down and searched for funding. A brief dissemination plan of action is attached as Appendix 15.
5.4 Reflective Conclusion The author is among those girls who were raised in the Egyptian conservative community and experienced the scarcity of information about SRH which have not been enhanced much even after her graduation from Faculty of Medicine, Cairo University. Furthermore, her experience while working in several projects concerned with youth in Egypt and Arab world triggered her to engage in this hotly debated ASRH area. Experiences with FGM violated girls in Sudan, gangs in Yemen, sexually abused children in Oman and street children in Egypt, all motivated her to explore this field in more academic way to identify the causes and some remedies from developing countries’ experiences. Significance and relevance of the topic crafted the beginning to formulate the aim and objectives for the study. Problem analysis and identifying concepts lent a hand to the author to figure out the root causes behind the poor community participation in ASRHEPs. Her visit to Egypt during dissertation writing and meeting with a number of stakeholders in a programme currently held in Egypt to enhance the ASRH in Cairo slum areas, facilitated crystallising the topic in the Egyptian context. Moreover, literature searching and critical reading assisted her in realisation and analysis of approaches which facilitate meaningful community involvement.
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However, the author was faced in the literature review by the use of jargon such as “engage community” but without clarification of how this engagement occurred. Combining little primary data within huge secondary data was not an easy task. Time and word limitations were barriers as well. However, the supervisory meetings provided a great influence on her way of thinking, developing evidence-based argument and academic writing. Indeed, this dissertation was a real opportunity to practice what she has learned at the Leeds Health Science Institute. The author intends to have a good reflection on her dissertation and the bibliography she collected for deeper search for her work as she thinks that this is not the end but a major step on the road.
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References 51 Appendices
APPENDICES Appendix 1: Map of Egypt:
Source: World Atlas, no date a, b.
Appendix 1 52 Appendices
Appendix 2: Relevant Economic and Health Indictors for Egypt:
Indicator Figure Source
Total population, all ages 2008 74,357 million (CAMPAS, 2008) Population ages 10–24 (%),2003- 2005 31.3 (USAID, 2005) Adolescent fertility rate (%), 2003 48 (WHOSIS, 2008)
Teen pregnancy rate per 1000, 2003- 47 (USAID, 2005) 2005 Adult literacy rate (%), 2005 71.4 (WHOSIS, 2008)
Human Development Index rank 2003- 120 (USAID, 2005) 2005 Gross national income in purchasing $3,810 (USAID, 2005) power parity (GNI PPP) per person, 2003- 2005 Gross national income per capita (PPP 4940 (WHOSIS, 2008) international $), 2006
Net primary school enrolment ratio male 96 (WHOSIS, 2008) (%), 2005
Net primary school enrolment ratio 91 (WHOSIS, 2008) female (%), 2005
Population annual growth rate (%), 2006 1.8 (WHOSIS, 2008)
Population in urban areas (%), 2006 43 (WHOSIS, 2008)
Population living below the poverty line 3.1 (WHOSIS, 2008) (% living on < US$1 per day), 2000
Total fertility rate (per woman), 2006 3 (WHOSIS, 2008)
Contraceptive prevalence (%), 2005 59.2 (WHOSIS, 2008)
Married young women 15–24 44 (USAID, 2005) using contraception (%), 2003-2005 Median age at first marriage (F),2003- 19 (USAID, 2005) 2005 Median age at first birth, 2003-2005 22.1 (USAID, 2005) Women who have undergone FGM(%), 97 (USAID, 2005) 2003-2005 General government expenditure on 38 (WHOSIS, 2008) health as percentage of total expenditure on health, 2005
Number of environment and public health 9531 (WHOSIS, 2008) workers, 2004
Per capita government expenditure on 106 (WHOSIS, 2008) health (PPP int. $), 2005 Per capita government expenditure on 30 (WHOSIS, 2008) health at average exchange rate (US$), 2005 Appendix 2 53 Appendices
Births attended by skilled health 89.1 (WHOSIS, 2008) personnel (%) highest educational level of mother, 2005
Births attended by skilled health 54.3 (WHOSIS, 2008) personnel (%) lowest educational level of mother, 2005
Deaths due to HIV/AIDS (per 100 000 <10.0 (WHOSIS, 2008) population per year), 2005
Life expectancy at birth (years) both 68 (WHOSIS, 2008) sexes, 2006
Life expectancy at birth (years) female , 70 (WHOSIS, 2008) 2006
Life expectancy at birth (years) male, 66 (WHOSIS, 2008) 2006
Maternal mortality ratio (per 100 000 live 130 (WHOSIS, 2008) births), 2005
Infant death rate 38 per 1,000 , 2003- 38 (USAID, 2005) 2005 Prevalence of HIV among adults aged <100.0 (WHOSIS, 2008) >=15 years (per 100 000 population), 2005
Highlighted are the specific indictors for youth.
Appendix 2 54 Appendices
Appendix 3: Graph shows Current and Expected Practice of Female Genital Cutting before Age 18, by Mother’s Education, Egypt 2005
50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% r r r r y s y s y s y s e e e e d d d d d d d d t h t h t h t h a n a n a n a n t t t t u u u u e e e e e e e e o o o o r t r t r t r t c c c c l l l l n n n n M M M M i i i i A A A A
No Some Primary & Secondary education primary some school &
Source: Adapted from Egypt Demographic and Health Survey, 2005: table 16.3. Cited in PRP, 2008 p53 .
Appendix 3 55 Appendices
Appendix 4: Graph shows Beliefs about Female Circumcision in Egypt, 2005
Percent of ever-married women ages 15–49 who agree with various statements about FGM
70% 60% 50% 40% 30% 20% 10% 0% Huband prefers Prevents Can Lead To Makes Adultry girl's death childbirth difficult
Source: Adapted from Egypt Demographic and Health Survey, 2005: table 16.7 Cited in PRP, 2008 p53.
Appendix 4 56 Appendices
Appendix 5: Table shows mode of transmission of AIDS cases from 1986- December 2002
Mode of Transmission Cumulative Table Percent Heterosexual 162 44.02 Homosexual 85 23.10 Blood/Blood 51 13.86 Products Injecting Drug 15 4.08 Users Mother to 2 0.54 Child Multiple 10 2.72 Unknown 43 11.58 Total 368 100
Source: Ministry of Health and Population, National AIDS control Programme (NACP), 2003 cited in UNFPA, 2003.
Appendix 5 57 Appendices
Appendix 6: Table shows Results of study in Greeter Cairo reveals the prevalence of STIs
Target Percentage infected by STIs females attending 4% antenatal clinic females in family planning 8.3% clinics drug users 5.3% Men having Sex with Men 3.8% (MSM) Female Sex workers 36.5% (FSWs).
Target Percentage Married men reported that their spouse 11.1% suffered from discharge, burning, or ulcers on genitalia Married women reported that their spouse 12.5% suffered from discharge, burning, or ulcers on genitalia
Source: FHI/IMPACT, 2007.
Appendix 6 58 Appendices
Appendix 7: Graph shows Married Women Aged 15 to 19, 2005
12%
10%
8%
6%
4%
2%
0% Egypt Tunisia Kuwait Palastine UAE
Source: Adapted from United Nations, World Fertility Report 2003: tables II.9 and II.11; Pan Arab Project for Family Health Survey (Tunisia 2001 and Palestine 2006); Gulf Family Health Surveys (UAE 1995 and Kuwait 1996); and Demographic and Health Surveys (Jordan 2002 and Egypt 2005). Cited in PRP, 2008 p9.
Appendix 7 59 Appendices
Appendix 8: Graph shows Young Women Giving Birth by Age 18
25%
20%
15%
10%
5%
0% Lebanon Jordan Egypt Morroco Turkey Algeria Yemen
Source: Adapted from Donna Clifton, Toshiko Kaneda, and Lori Ashford, Family Planning Worldwide 2008. Cited in PRP, 2008 p11.
Appendix 8 60 Appendices
Appendix 9: Details about primary data collection: The dissertation is based on the secondary date; however some primary data was collected to augment shaping the Egyptian context. The primary data was collected through:
A field visit was done to a programme titled “SRH awareness for Youth” currently implemented by CDS in Egypt aiming to enhance the SRH of youth in three areas of greater Cairo (2007- current). Through which the author conducted: A focus group discussion with 17 CHPs as representatives for the recruited 45 CHPs from the 3 LNGOs serving the programme (one serves a slum area, the second serves orphans and the third serves street children). An in-depth interview with the CDS programme coordinator. An in-depth interview with one of the programme trainers.
An in-depth interview with a Christian religious leader in Giza governorate. Personal communications with the programme coordinator for a project to enhance SRH of Garbage collectors’ youth. Personal communications with a trainer in Freedom project to enhance SRH of IDUs.
Source: Author, 2008.
Appendix 9 61 Appendices
Appendix 10: The Cairo Declaration of Religious Leaders in the Arab States in Response to the HIV/AIDS Epidemic
We, the Muslim and Christian leaders, working in the field of HIV/AIDS in the Arab world, meeting in Cairo, Egypt from the 28-30 Shawal 1425 H, 11-13 December 2004 AD, in an initiative of the United Nations Development Programme’s (UNDP) HIV/AIDS Regional Programme in the Arab States (HARPAS), under the auspices of the General Secretariat of the League of Arab States, and in collaboration with UNAIDS and FHI/Impact, have agreed upon the following:
First: General Principles Due to our realization of the value of every human being, and our awareness of God’s glorification of all human beings - notwithstanding their situation, background or medical condition- we, as religious leaders, face the imminent danger of the HIV/AIDS epidemic and have a great responsibility and duty that demands urgent action.
It is our duty to promote virtue and religious values and enhance people’s relationship with their Creator, seeking God through prayers and petitions that He may protect us from this imminent danger and preserve our homeland from it, and that He may grant His grace and favor upon those affected by this disease. We stand in solidarity with those who are infected with this disease, and we encourage them to pray and receive God’s help and grace.
Illness is one of God’s tests; anyone may be afflicted by it according to God’s sovereign choice. Patients are our brothers and sisters, and we stand by them seeking God’s healing for each one of them.
Second: On Prevention The family is the foundation for building and defending society. It is therefore necessary to encourage starting families in accordance with heavenly decrees, and we should remove all obstacles in the way, while emphasizing the prohibition of adultery by all heavenly decrees.
We emphasize the need to break the silence, doing so from the pulpits of our mosques, churches, educational institutions, and all the venues in which we may be called to speak. We need to address the ways to deal with the HIV/AIDS epidemic based upon our genuine spiritual principles and our creativity, and armed with scientific knowledge, aiming at the innovation of new approaches to deal with this dangerous challenge.
Appendix 10 62 Appendices
We reiterate that abstinence and faithfulness are the two cornerstones of our preventive strategies but we understand the medical call for the use of different preventive means to reduce the harm to oneself and others.
We view as impious anything that may cause infection through intention or negligence - as a result of not using all possible preventive means available, in accordance with heavenly laws. We emphasize the importance of reaching out to vulnerable groups which are more at risk of being infected by HIV/AIDS and/or spreading it, including commercial sex workers and their clients, injecting drug users, men having sex with men, and those who are involved in harmful practices. We emphasize the importance of diverse approaches and means to reach out to those groups, and although we do not approve of such behaviours, we call on them to repent and ask that treatment and rehabilitation programs be developed. These programs should be based on our culture and spiritual values.
We call upon the media to abide by ethical codes regarding the material they present.
We advocate the rights of women to reduce their vulnerability to HIV/AIDS. Third: On Treatment and Care
People living with HIV/AIDS and their families deserve care, support, treatment, and education, whether or not they are responsible for their illness. We call for our religious institutions, in cooperation with other institutions, to provide spiritual, psychological, and economic guidance and support to those in need. We also encourage them not to lose faith in God's mercy, and aspire to a rewarding and productive life, embracing fate with courage and faith.
We reject and emphasize the necessity to abolish all forms of discrimination, isolation, marginalization, and stigmatization of people living with HIV/AIDS, we insist on defending their basic freedoms and human rights.
Fourth: Addressing other leaders As religious leaders we need to reach out to our governments, civil society institutions, NGOs, and the private sector, to seek closer cooperation and greater action in the response to this epidemic.
We also emphasize the importance of mobilizing other religious leaders’ role against the imminent danger of HIV/AIDS in society, particularly in the media and in educational and popular campaigns.
The need to formulate policies and laws that prevent the further spread of the disease particularly mandatory health check ups before marriage.
Promote the setting up of guidance and awareness raising centres and facilitate the establishment of charitable organizations to provide care, and support for people living with HIV/AIDS. Source: FHI/Impact, 2007. Appendix 10 63 Appendices
Appendix 11: Themes of training curriculum targeting the PEs in CDS programme:
The aim of the curriculum is to enhance knowledge, skills and attitude of PEs: The curriculum is based on three pillars: SRH education, life skills and peer to peer techniques
1. SRH education Anatomy of male and female genital system Physiology of reproduction Reproductive rights Sex education Puberty : physiological, physical and psychological changes FGM Masturbation Unconventional marriage “ URFI” HIV/AIDS STIs Hepatitis C Addiction FP
2. Life skills : adapted from WHO curriculum “ skills for health”( WHO, 2003 b) Interpersonal Communication Skills Active listening Expressing feelings Negotiation Skills Conflict management Assertiveness skills Refusal skills Empathy: active listening, express understanding and accepting others Leadership Teamwork Advocacy Influencing skills and persuasion Motivation skills Networking and Decision-making and taking Problem solving skills Critical thinking skills Building self-esteem/confidence Creating self-awareness skills Setting goals Monitoring and evaluation skills Skills for managing stress Time management Positive thinking
Appendix 11 64 Appendices
3. Peer-to-peer techniques Participatory presentation techniques: - Debates - Simulations - Story telling - Exercises - Drama - Educational games - Brain storming/ card storming/ ball storming - Case studies - Group work Creative thinking - What is creative thinking - How to enhance your creative thinking ability Audio-visual aids - How to produce an audio-visual aid from the local resources - Drawings - Posters - Puppets - Puzzles Interviews
Source: CDS, 2007.
Appendix 11 65 Appendices
Appendix 12: Diversity of interventions that facilitate different community players’ engagement and create enabling environment for this engagement
Stage/ Theme Target Intervention criteria Concerns / Feasibility Starting /Needs All players Identifying gatekeepers Effectiveness Are the selection criteria unified or it must be assessment Deciding selection criteria tailored to match the community context? How much is it feasible to identify gatekeepers, stakeholders and key players? Including activities for Efficiency To what extent do the funding agencies accept community mobilisation in the including activities for community mobilisation proposal and the budget in the budgeting? All players Social and How much are the entire community layers Identifying key stakeholders economic equity involved in programmes? How much is the Marginalised representation of females within the Gender equity community players? Females How is the quality of this representation? Can the women talk and share in decision in the presence of men? All players Identifying positive deviants Effectiveness How difficult could be picking the positive Families Acceptability deviants? Is it easy to identify and recruit mothers-in-law and sisters-in-law as positive deviants? How in their impact? Community Encouraging snowballing effect Effectiveness How much do the community leaders nominate leaders others for problem solving and trouble shooting? Planning All players Community engagement in NA Effectiveness Is it difficult to engage community in the very Relevance start of the programme? How much are their Sustainability impact on identifying the real youth needs and resources as well?
Appendix 12 66 Appendices
Stage/ Theme Target Intervention criteria Concerns / Feasibility Planning cont. Community Using community resources Efficiency How much is it difficult to use community leaders resources? Do the players facilitate community resources mobilisation? All players Tailoring curricula and Relevance To which extent do curricula content match teaching methodology Acceptability with Egyptian youth SRH problems? Are the tailored curricula acceptable by audience and by community? Effectiveness How much attention paid to the difference between different cultures? urban/rural /slum & Religious Upper Egypt/Delta/Bedouin & males/females & leaders Literate/illiterate How difficult was Engaging the religious leaders in tailoring the curricula? Implementation All players Tailored capacity building of Effectiveness Is it an easy task to tailor the curricula and stakeholders training according to the players’ need? How Introducing participatory much effort and time does it necessitate? Does methodology the participatory methodology have a positive Sustainability impact on players? To what extent does the capacity building of players impose an impact on the sustainability of the programme?
Physicians Recruiting physicians as Acceptability Is it easy to recruit physicians in a community- educators based programme? Physicians Recruiting physicians as Organisational In which approaches the collaboration can be educators feasibility made? Implementation All players Community participation in Effectiveness Is the community capable to share in (cont.) implementation process Acceptability implementation activities? Who can do what
Appendix 12 67 Appendices
Stage/ Theme Target Intervention criteria Concerns / Feasibility Relevance best? To what extent do the community events play a role in community mobilization? Parents Youth participation Acceptability Do the adults will accept the youth to have a Youth say? Can the youth talk freely in presence of adults?
Religious Recruiting religious leaders to Acceptability How much is the acceptance or rejection from leaders tackle sensitive SRH issues and Relevance religious leaders? How to overcome resistance? taboos Effectiveness
Appendix 12 68 Appendices
Stage/ Theme Target Intervention criteria Concerns / Feasibility All players Community events Effectiveness How do the community accept the events? How Implementation Acceptability much is the culture sensitivity of the events? (cont.) Drama as a tool Acceptability To what extent the community accept the events such as drama as a tool to address the SRH problems? Parents Ensuring geographic Social and To what extent do geographic distribution of Enabling supportive Youth accessibility economic equity SRH classes and mobile seminars serve all the environment community layers in an equitable manner? Does Mobile seminars Accessibility it serve different tribes(if applicable) To what extent to SRH classes are physically accessible to target?
All players Regular meeting, getting feed Sustainability How regular are the monitoring meetings? Monitoring and back Effectiveness What is their impact? evaluation Educators Providing support, supervision Quality What are the ways to offer support to educators? on-the-job support and Sustainability Is it easy to provide OJT? How much time and technical assistance for efficiency money it will take? Do the educators accept educators throughout their technical assistance? work Implementing Collaboration with different Efficiency To what extent do the private sector and Gaining more agencies agencies pharmaceutical companies play a role in support NGOs and bridging the gap in SRH programmes? youth Accessibility How it works on accessing partners such as associations Sustainability NGOs, Youth clubs, association and NCW? To what extent was the collaboration with the different agencies, what is its impact? Media Media support Effectiveness How much is it difficult to access the media and have its support?
Appendix 12 69 Appendices
Stage/ Theme Target Intervention criteria Concerns / Feasibility Does the media involvement help addressing the SRH issue in right way or it fuel the problems? Political Engaging the Local Political Political How difficult is recruiting local political people parties people and local parities feasibility and local parties? What is the impact from their engagement? Interventions to All players Promote voluntary spirit Sustainability Is it possible in the atmosphere of decrease turnover unemployment and low incomes to initiate voluntary spirit? Youth Incentives Sustainability What types of incentive do they prefer? Is it Health Efficiency right way or it does affect the voluntary spirit? educators All players Creation of taskforces Sustainability Do taskforces collaborate or compete? How Increasing and Effectiveness much effective are their roles? How is their building on social effect on community social capital? capital Religious / Creation of advisory Effectiveness Does advisory committee play a positive role? Community committees Acceptability Does it have sometimes a negative impact? leaders How to overcome that?
Appendix 12 70 Appendices
Stage/ Theme Target Intervention criteria Concerns / Feasibility Parents Exploiting peer- pressure Acceptability To what extent does the peer- pressure have a Religious Effectiveness positive influence on each player involvement? Community sustainability Is it an easy task to get this lobbying? leaders youth
Different Exchanging experiences Sustainability How much is the influence of partner NGOs Ensuring agencies and other organisations after the fund is over? sustainability Does the exchange in experiences have an impact on the sustainability of programmes?
All players Gender-based-approaches Gender equity Is it easy to mainstream, gender-based Ensuring gender Female youth Acceptability approach within the curriculum and within equity Accessibility the methodology of training? Does the community accept such changes in norms? Safe space for female education How much was it difficult to have a safe place and activities for female educations? Is it accessible? Is it acceptable by family and community members? All players Collaboration between all Sustainability To what extent the community can participate in Scaling-up parities the scaling up of such programmes?
All layers Advocacy for policies Sustainability How much does the community advocate for Policy change concerned with school-based Effectiveness policy change such as policies for school-based SRH education programmes? Religious Using the Arab religious Effectiveness How can the declaration be reinforced? How it
Appendix 12 71 Appendices
Stage/ Theme Target Intervention criteria Concerns / Feasibility leaders Leaders declaration among Relevance can be used to gain more policy change? All players religious leaders
Source: Author, 2008.
Appendix 12 72 Appendices
Appendix 13: Types of ASRHEPs
TYPES
OF
COMMUNITY- CURRICULUM- HEALTH WORK PLACE MASS BASED BASED FACILTY PROGRAMMES MEDIA PROGRAMMES PROGRAMMES PROGRAMMES PROGRAMMES
MIXING MIXING WITH MIXING WITH OUT-OF-SCHOOL COMPREHENSIV WITH Vulnerable groups PEER SCHOOL-BASED E YOUTH – LITERACY ECONOMIC PROGRAMMES EDUCATION SRH AERVICES, FRIENDLY CLASSES SPORTS LIVELIHOOD EDUCATION AND CLINICS
RELIGIOUS CLASSE
S LIFE SKILLS Source: Author, 2008.
Appendix 13 73 Appendices
Appendix 14: community involvement in ASRHEP in Egypt
Community involvement in ASRHEP in Egypt is as a means towards:
“Creating demand for SRH activities”, since communities become more aware and responsive of their youth SRH needs “Enhancing youth access to ASRHEP and services”, as communities will allow their children to access them. Moreover, they will pick the access problems in the existing programmes and start new accessible one as well. “Scaling up SRH activities”: they can search for other donors to fund future programmes “Increasing the effectiveness and efficiency of SRH programmes activities”, as communities have been involved in the planning and design so the programmes are much tailored to youth specific needs “Mobilising additional resources to the programme”, since the community is now working with other organisations so it contributes by its members’ time and resources. Moreover, the community now learned how to search and get resources from outside of the community. “Reaching the most vulnerable”, the community is the most capable entity not to identify its most vulnerable and marginalised people but to work with them as well “Addressing the underlying causes of SRH problems”, as this requires a rigorous understanding of community’s norms and culture. “Increasing community ownership and sustainability”, as the community participates in NA and implementation which builds a high sense of responsibility that assists the adoption of the idea and continuity of the project after the fund is over.
Community mobilisation is an end by itself pro: “Rights fulfilment” – sound SRH is one of the indispensable youth right, it is not just a “good thing to do”; to develop it by the community is a right as well. “Applying political pressure” – communities can advocate to change or introduce new policies to have more legitimacy for their interventions as well as translating supporting policy into action “Strengthening civil society/good governance” – mobilised communities contributes to civil society, which plays a vital role alongside government and the private sector. As the three entities work in collaboration towards better SRH for youth, this is called ‘good governance’ “Empowerment and equity” – community mobilisation facilitates better distribution of knowledge and resources within communities (e.g. empowering youth to have more proper choices regarding their SRH) “Increasing community developmental capacity” – community engagement should lead to new SRH resources such as curricula ,
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skills, knowledge and leadership (as a result of the capacity building of its members on different skills such as writing proposals , NA, management, M&E and TOT ).Members can transfer those skills in tackling any other community problem. “Increasing social capital”– community participation effectively enhances the social capital as it increases the trust among community members hence they are capable to work in a much better effective approaches as well as initiating new social capitals through new networks such as peer educators, advisory committees and taskforces. “Reducing SRH problems including HIV/AIDS and STIs incidence” – As the communities gained high levels of social capital , the incidence of SRH problems including HIV/AIDS and STIs incidence are reduced as youth are now have the abilities and access to better SRH choices.
Source: Adapted from Alliance 2006.
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Appendix 15: Dissemination action plan
Activity Time-Frame Who is Resources Objective Outcome Responsib required le A copy of the dissertation will October 2008 Author Time , Adoption of CDS to the Applied recommended tools be delivered to CDS copying ideas of community in the project to enhance machine and engagement in SRH of youth in Greater funding ASRHEP Cairo , Egypt and for sex workers in Syria Dissertation will be posted on October 2008- Author & Professional Accessing World wide PDF Formatted dissertation the world wide web: NearEast March 2008 NearEast/ relations and audience to the posted on world wide web /CDS, for public access. CDS staff technical Dissertation assistance Dissertation executive October 2008- Author Time , Distributed dissertation data Summary and will be printed March 2009 stationary, and copies will be sent to Ford funding and Dissemination of Foundation, Pathfinder, Tear professional dissertation Fund and other key & personal recommendations organisations concerned with relations SRH for youth Adoption of the A national conference will be October 2008- Author & Time , notion of interagency Held National conference held to discuss community September CDS staff funding and collaboration regarding Attended MOHP, MOE and involvement in ASRHEP and 2009 professional ASRHEP MOY concerned staff, its implication on the & personal NGOs, youth associations Egyptian and Arab youth. relations implementing and funding agencies, religious MOHP, MOY and MOE organisations and media
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Activity Time-Frame Who is Resources Objective Outcome Responsib required le concerned staff, NGOs, youth associations, implementing and funding agencies, religious organisations and media will be invited Participation in different October 2008- Author Time Dissemination of Attended national SRH forums regarding SRH of September dissertation forums by author youth 2009 recommendations A paper for October 2008- Author Time , Dissemination of Published abstract in presentation at Global health March 2009 computer dissertation conference booklet Conference 2009 will be and funding recommendations developed and submitted for conference attendance The Dissertation’s October 2008- Author & Time , Dissemination of Published parts of the executive summary and some September Journal’s computer dissertation ideas to dissertation in the journal parts will be translated to 2009 staff and personal Public Arabic , simplified and & published in Sehatak Beldonia professional Breaking the “culture of Inter-generational dialogue Journal relations silence” launched
A proposal on “Life skills” October 2008- Author & Time, Practical application to Applied recommendation ASRHEP will be designed , September CDS staff computer, the dissertation regarding the active and written down and searched for 2010 professional recommendations meaningful community funding relations and participation in a “ life
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Activity Time-Frame Who is Resources Objective Outcome Responsib required le ( relevant recommendations funding skills” ASRHEP will be incorporated in this project) A programme on “peer October 2008- Author & Time, Practical application to Applied recommendation education” ASRHEP will be September Orthodox personal the dissertation regarding the active and designed and implemented in 2010 church relations and recommendations meaningful community the Orthodox church as a pilot religious funding (religious leaders , parents project using the dissertation leaders & and youth) participation in recommendation servants a“ peer education” ASRHEP Source: Author, 2008
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