The SHARP Programme (Sensible, Healthy and Responsible People)
Families, within extended family networks, have always guided teenagers to adulthood throughout Africa. However, the migrant labour system and apartheid in South Africa and the socialisation of production and reproduction in industrial economies have eroded family functions, authority and cohesion. Once stable cultural, support and kinship systems have become fragile, and for some families have disappeared.
The weakening of family life has taken place along side increasing poverty, unemployment, lack of housing and insufficient health, education, security and other social services. The HIV/AIDS pandemic, which developed slowly in South Africa, was seen as health and education problem, to be solved by insufficient but considerable professional and technical resources. Late in the day, AIDS is recognised as a problem for everybody.
Mr Thabo Mbeki, has said “The power to defeat the spread of HIV and AIDS lies in our Partnership … in fact, all of us”.[9] It calls for a cultural response, a conscious change in the way ordinary people relate to each other. Nurses, educators and social workers can provide support. They cannot solve the problem by themselves.
“The tragedy is that young people are being infected in increasing numbers, and yet it is with young people that prevention efforts are most successful” [10] School learners are the most accessible of this group, and they will be most at risk for the longest period.
South Africa has the fastest growing HIV incidence in the world. At the time of the 1998 antenatal survey published in February 1999, there were 3.3 million HIV positive people in SA or 7.6% of the total population. There are 167 000 people with AIDS (including 46 000 children) and 405 000 have died of AIDS to date. Projections are that in five years there will be 5.6 million HIV positive people and 2.1 million people will have died because of the epidemic.[11]
Factors promoting the spread of HIV at secondary schools
There is a high level of sexual activity among learners. Nationally, two thirds of thirteen year-olds in SA are estimated to have already experienced their sexual debut. The evaluation tentatively estimated that in grades 10 - 12, about 75% of learners were sexually active, about 30% of learners have more than one current partner and learners had an average of 3 partners and 9 sexual encounters in the past year[12]. Other factors promoting the spread of HIV at secondary schools in poor communities appear to be:
· The high incidence of sexually transmitted diseases (STDs) in the general population: about 4 million cases annually. “The risk of contracting HIV during a single episode of hetero-sexual vaginal intercourse is less than 1% if no other STD is present. This risk increases 8-10 times in the presence of a genital sore and 4-5 times if there is a discharge.”[13] STD incidence is highest in women in the 15-19 age group and in men in the 20-24 age group.[14] In 1998, HIV prevalence increased most (by 65%) in the 15-19 age group of pregnant women, from 12 to 21% (in all age groups it increased by an average of 33%)
· “One typical pattern involves girls being inducted into semi-coercive sexual relationships by older men, including well-heeled fast living gangsters (genza). Such girls and their families are often economically dependent on the boyfriend and the girls are therefore willing to engage in unprotected sex and to bear children at a young age. It is not clear how widespread this practice is in the community, but it is apparently frequently alluded to, for example by boys complaining that they cannot find suitable girlfriends”[15]
· Traditional restraints that limited sexual activity among youth have withered and family cohesion has weakened but the traditional reticence of parents and other adults to discuss sexuality with teenagers has in many cases persisted. However, locally, “there were no correlations between family intactness on the one hand and knowledge, attitudes, condom-use or risk behaviour on the other”[16] and “the perceived quality of advice learners received from … family, clinics and church ministers being seen as extremely good sources of advice, closely followed by radio and TV programmes, and with friends, traditional healers and initiation school a long way behind”[17]
·
“Implementation of the
programme [sexuality education by guidance teachers] did not happen as envisaged”[18] “ … the role of these
teachers has been gradually undermined over the last number of years… with
restructuring and redeployment of teachers there is an acute shortage of teachers at many
schools… Even under ‘ideal’ conditions, guidance is experienced as
difficult to do properly.” [19]
· Clinic based sexual health care is often not ideal for learners. Clinics may be out-of-the-way, crowded with long waiting times, not private or unsympathetic to sexually active teenagers. Tracing of sexual contacts with non-HIV STD carriers who attend school may be difficult from the clinic.
· HIV/AIDS is a dread disease that is difficult to acknowledge. Other STDs, however are more readily acknowledged and treated.
· Teenage pregnancy is a major problem in its own right – the Population Reference Bureau estimates the fertility rate of teenage girls in South Africa is 0.55 – meaning on average, 55 babies are born to 100 girls during their teenager years. Other estimates are lower, but teenage pregnancy is widely acknowledged as a problem in poor communities. “… the great majority of learners at both types of schools rejected the idea of schoolgirl and schoolboy pregnancy, knew that family planning was a means of preventing it, and believed that visiting a family planning clinic was a good idea. However, a substantial minority nevertheless became pregnant or expressed no great desire to avoid pregnancy. There were also knowledge deficits with regard to the long-term effects of the family planning injection and morning-after contraception.”[20]
· The effects of teenage pregnancy will be made worse by the AIDS pandemic, which will impose a burden on grandmothers[21] to take care of AIDS orphans (200 000 at present in SA) so that they will be less able to help teenage mothers. Similarly, health and education facilities will be strained by HIV/AIDS and will be less able to support indigent teenager mothers, who themselves may be AIDS orphans.
“Sapler should seek to understand why a substantial minority of learners want to become pregnant despite rejecting pregnancy in the abstract, and should develop ways of engaging with such learners.”[22]
Community workers’ strength is their knowledge, understanding and good standing with their neighbours. They know their perspectives, concerns, etiquette and culture. Because they work for low rates of pay, they are able to do simple tasks cost effectively and are able to spend the time, during successive encounters if necessary, to come to good understanding with individuals and groups so that informed consensus and confidence spreads in the community.
Community workers should always play major role in health promotion efforts such as responsible teenage sexuality and family planning. Unfortunately, conservative thinking in the medical and health fields regarding the maintenance of standards often unnecessarily restricts what community workers are allowed to do and imposes excessive training requirements. NGOs all too often have a core of officials surrounded by volunteers who are given partial responsibility, part time work and derisory payment.
This proposal is both an opportunity to prove the capacity of community workers in health promotion and strengthen the influence of guidance counsellors in schools. “Pioneers should encourage learners to think about sexuality education as an on-going engagement with lifestyle issues rather than a set body of knowledge that can be mastered once and for all.”[23] “Sapler should conduct an informal survey among pioneers and selected other stakeholders on pioneers’ most urgent training needs and find ways of responding to these.
Particular attention should be given to group work, outcomes-based education and referral techniques.”[24] “Sapler should continue to develop the role of guidance teachers as mentors to pioneers, particularly concentrating on using guidance teachers as sounding boards and points of referral rather than merely formal supervisors.” [25]
Refer to Appendix 1 for a discussion of twinning schools and clinics and school health visits.
Current trends indicate approximately 2000 new infections are currently happening in South Africa each day[26] - most being within the economically and sexually active age group. This is estimated to result in between 1,5 - and 3 million children being either infected or affected by the pandemic within the next 10 years [27].
HIV incidence among youth will fall when responsible teenage sexual behaviour is the norm. “..there is still a pervasive lack of linkage for all learners between knowledge and attitudes on the one hand and behaviour on the other. Along with other organisations in the field of safe sexuality education, this is likely to remain a major challenge for Sapler.”[28]
“However, when learners from Sapler schools only are considered, the pattern is somewhat different. Although the most significant correlations are still between knowledge and attitudes on the one hand and between the two behavioural measures (condoms and risk taking) on the other, in addition attitudes also correlate significantly (albeit fairly weakly) with condom use and risk behaviour.
This could
tentatively be interpreted as an indication that the work of the Sapler pioneers may be
beginning to forge a link for learners between attitudes and behaviour.”[29]
For school-going youth, this engagement with sexually responsible norms is most effectively provided during school-time by pioneers supported by partnerships between schools and the community through NGOs. “An important area of concern is the fairly limited time pioneers are able to spend with learners and it is suggested that becoming an official part of the education department’s sexuality education strategy may address this.”[30]
References:
[9] Deputy President Thabo Mbeki, “Declaration to Launch the Partnership Against AIDS”, October 9, 1998 Back
[10] Dr Peter Piot, Executive Director, UNAIDS quoted in SAfAIDS News Vol 7 No 1 March 1999 Back
[11] Peter Doyle, MD Metropolitan Life, quoted in The Sunday Independent May 9 1999 Back
[12] Dr Martin Terre Blanche, Institute of Social and Health Research, UNISA, “Independent evaluation of the SAPLER peer counselling programme December 1999. Section B.3.5 Promiscuity Back
[13] Training manual for the management of a person with a sexually transmitted disease for health care providers Dept of Health August 1998 p22 Back
[15] ibid. Section A.3.8 Socio-economic and gender issues Back
[16] ibid. Appendix B1 Family intactness Back
[17] ibid Section B.3.8 Discussing sexual issues and seeking advice Back
[18] Department of Education, North West Province, “Business Plan: HIV/AIDS Life Skills Education; Secondary Schools; December 1999” p5. Back
[19] ibid. Dr Martin Terre Blanche, Institute of Social and Health Research, UNISA, “Independent evaluation of the SAPLER peer counselling programme December 1999Section A.3.4 Role of guidance teachers Back
[20] ibid. Section B.3.7. Pregnancy and contraception Back
[21] In Zimbabwe, some 45% of those caring for orphans are grandparents. A study of households headed by children or adolescents showed that while the overwhelming majority had lost both parents, most did have surviving relatives. In 88% of those cases, however, the relatives reported they did not want to care for the orphans – UNAIDS, reported in SAfAIDS News, March 1999 Vol. 7 No1 p9. Refer also to www.safaids.org Back
[22] Dr Martin Terre Blanche, Institute of Social and Health Research, UNISA, “Independent evaluation of the SAPLER peer counselling programme December 1999. Section B.3.7 Pregnancy and contraception Back
[23] ibid Section A 2.18 Learning more Recommendation Back
[24] . Section A.3.5 Pioneers skills Back
[25] ibid. Section A.3.4 Role of guidance teachers Back
[26] Peter Doyle, MD Metropolitan Life, quoted in The Sunday Independent May 9 1999 . Back
[28] Dr Martin Terre Blanche, Institute of Social and Health Research, UNISA, “Independent evaluation of the SAPLER peer counselling programme December 1999 Section B.3 Impact of the programme on learner’s knowledge, attitudes and behaviours Back
[30] ibid. Executive summary Back