Support for adolescents through a school health program in Zimbabwe

Sunanda RayDept Community Medicine

University of Zimbabwe College of Health Sciences

• There are a huge number of children in Zimbabwe who have psycho social needs resulting from being orphaned, through living in families with HIV, life- limiting conditions like cancer, chronic illness or disability

• One possible way of addressing these needs is through schools and school health programs

• A recent assessment into the potential for introducing HPV vaccination into school health gave us the opportunity to research knowledge and awareness of school children about health issues in general

• There was significant ignorance about underlying causes of cancer among children

• When asked what cervical cancer is, one girl said “chiruma chinenge chiri mumuviri wemunhu”, (it’s a scary creature that would be in one’s body). Some believed it’s a rat in the womb (derived from a “mole”)

• Some believed cancer was caused by ink from a ball point pen if you write on yourself or from eating paper. The boys said cancer could be prevented by not smoking and not taking alcohol and believed girls could not get cancer because they do not drink alcohol.

• Some girls worried about getting cancer through eating too many chips.

• Some said they were not worried about getting cancer as they were young, they believed it affected older people, ”you cannot worry about something that you are not aware of”.

Stated community concerns about the health of adolescents

• Early marriages and early teenage pregnancy• Orphaned children opt for early marriage

because they lack care or are ill-treated at home by guardians

• Sexual abuse and violence• Menstruation (its onset, unpreparedness of

girls and the embarrassment), menstrual knowledge, hygiene and sanitary wear

• Adolescents living with disability or HIV or from families with HIV struggle with the double burden of caring for themselves and for their families

• Counselling for OVC and the disabled to gain self-esteem, to ensure they are not excluded and stigmatised by other children. Need survival skills for those children.

Menstrual hygiene

• Only 39% of secondary and 34% of primary schools indicated that they provided some menstrual hygiene education for girls.

• Teachers had been trained in how to promote menstrual hygiene in 32% of primary and 32% of secondary schools.

• Thirteen schools (3.6%) had a separate private sanitation section for washing cloth napkins including a basin and water in a bucket with a tap in a lockable cubicle, and 12 of these 13 schools had private disposal incinerator facilities for disposable napkins.

• Good policies in place, but weak compliance, inadequate resources and entrenched gender roles have allowed gender-based violence in schools and homes to flourish

• A study of over 7000 households found that 9% of girls aged 13-17 years [n=495] experienced some form of sexual violence and 6% experienced attempted, forced or pressured sex in the 12 months preceding the survey.

Although only 4% of girls in Zimbabwe have their sexual debut before age 15 years (compared to 32% between ages 16-19 years), high risk behaviours tend to be clustered in this group of adolescent girls who are more likely to

• go on to have multiple partners, • engage in transactional sex, • to become HIV and/or HPV infected • or have unintended pregnancy.

• HIV prevalence reflected this trend and was 4.2% for women and 3.4% for men in the 15-19 age group, increasing to 10.6% for women and 3.8% for men in the age group 20-24 years ( 15% overall for adult population in Zimbabwe)

We know a lot already about the complexities of the context:

the importance of school education for the long-term future of the adolescent population, goes on into adulthood

Staying at school has an impact on delaying sexual debut and other SRH outcomes

School absenteeism and early marriages are closely associated practices observed by some religious groups

Orphan-hood, disability and HIV in families are strongly associated with not going to school so supporting children in these groups has wide benefits (especially in relation to family relationships and household duties)

The evidence and policy context

1. Several national policies and strategies exist stating indicators of adolescent health with advocacy and activities for how to improve these.

2. There are well designed studies in the published literature that contribute evidence on the context of adolescent health, especially in relation to HIV and sexual health.

3. A number of NGOs are providing services directed at adolescent health, often based in communities, but none cover the whole country, in variable degrees of partnership with ministries of health and education.

Children and young people have rights to information and opportunities to learn skills on how to avoid early sexual activity, unintended pregnancy and STIs including HIV should be respected

These are articulated in many international declarations signed by our governments

There is insufficient commitment to the values expressed by the declarations, so for example, many nurses staffing SRH clinics do not believe in the rights of adolescents to information, skills and commodities (contraception and condoms) to protect themselves

• With more than 95% pupil attendance at primary school, schools provide good opportunities for psycho-social support for adolescents, but need resources to provide interventions that are feasible and acceptable for this age-group

• The challenge is how to intervene with these girls at primary school to give them skills to avoid these risks and to prevent dropping out of school as teenagers.

• complexity of creating “agency” among adolescents – the exercise of choice, weighing up benefits and costs in the face of social demands

• The main opposition to SRH education in schools is from parents, which could be overcome with a good communications strategy

• A one-size-fits-all approach to SRH education is inadvisable since concerns are different from place to place and at different ages. Parents could be persuaded that age-appropriate SRH education tailored to their children’s level of understanding could be beneficial in giving them communication skills and confidence in protecting their own health.

“Rethinking children's agency in extreme hardship: Zimbabwean children's draw-and-write about their HIV-affected peers”

C Campbell, L Andersen, A Mutsikiwa, C Madanhire, M Skovdal, C Nyamukapa, S GregsonHealth &Place 2015;31:54–64 ‘draw-and-write’ exercises in which 128 Zimbabwean

children represented their HIV-affected peers.

from Campbell et al 2015

“Most draw-and- writes portrayed AIDS-affected learners as isolated, exhausted, stigmatised and bullied, neglected, hopeless and overwhelmed by the burden of household and caring chores, either in households where their own parents were too ill to care for themselves and their homesteads, or in foster families often depicted as callously viewing orphaned children as a source of free labour “

Revival of School Health PolicyASRH and other health matters can be included as:Taught subjects in the primary school curriculum, in age-

appropriate methods. The curriculum would include communicable and non-communicable diseases, introducing prevention of cancer, chronic disease and improvement of well-being through physical exercise, nutrition, prevention of obesity, avoidance of smoking and immoderate alcohol use.

Topics for inclusion in primary school curriculum using age-appropriate methods: mainstreaming

School health collaborations led by a school nurse or school health committee ( may involve parent or community representatives) to provide the following:

• Annual screenings for nutritional status, visual and hearing impairment, skin infections, scabies and lice infestations.

• Interventions to promote good mental health through school health facility (school nurse) but also through health clubs: identification of depression, anxiety, self-harm, behavioural disorders and referral to appropriate services; group work on promoting well-being and avoidance of substance abuse.

School health interventions

School health Contd.

• Creation of safe places for adolescents to report incidents of violence whether at home, school or in community; partnership with police and organisations training on managing rape and sexual or physical violence; training for teachers.

• Education on relationship between substance abuse, unsafe sex, road accidents; cessation support and treatment; counselling on breaking habits and behaviour change

School health contd.

• Prevention of violence, accidents, injury prevention: especially targeting boys, raise awareness of impact of these on families, cause of disability etc, methods of prevention.

• Access to educational facilities for disabled students, involving students in providing learning aides for students such as reading tapes for the blind.

Pupils in health clubs to

• share information on SRH, HIV, puberty hygiene and other personal hygiene issues, hand-washing to prevent diarrhoeal and other diseases

• provide peer support for children living in families with HIV and/or disability, discuss and advise on avoiding substance misuse, how to respond in cases of physical or sexual violence or harassment, prevention of injuries.

• identify out-of-school adolescents that could be invited to join, and through this be involved in the range of health activities

• The introduction of the HPV vaccination program for 10-12 year old girls as part of a school health program provides opportunities to reach adolescents, adults and communities with information about health and services,

• in particular the opportunity to prevent cervical cancer in adults, but also a range of SRH issues.

• Integrated messages – when women attend for VIAC they receive information on the need for their daughters to receive HPV vaccination.

Community, school and health facility service-delivery components must become more innovative and responsive to the needs of marginalised groups, in school and out-of-school adolescents, those living with HIV or disabilities

Looking for innovation, creative problem solving, negotiation, mediation, empathy.....

Do programs give teachers or school nurses the skills they need to work with young people with the complexity of issues that arise?

• Teachers require comprehensive sexuality education and skills on imparting knowledge to pupils on SRH, including those relevant for young people with disabilities and HIV.

• Training in participatory methods, for example using Aunty Stella cards.