PROBLEMS AND PROGRAMS BEYOND THE HEALTH SECTOR
A recurring theme of the meeting was that promotion of reproductive health should not be considered a responsibility of the health sector alone. Communication and education about reproductive health, sexuality, and family life are typically shared concerns of several public-and private-sector organizations (as well as the family and other social and religious institutions). Sexual coercion needs to be addressed in strategies for promotion of reproductive health, in part because such coercion is in itself a health problem, under many definitions of reproductive health, and in part because it makes more difficult the solution of other problems of unintended pregnancy and somatic and mental illness. Health ministries and private-sector providers of health care often have important roles in communication and in providing services for victims of sexual coercion and violence; still, the discussion of these issues often ranged quite broadly beyond the work of the health sector.
Sexual Coercion and Reproductive Health
Lori Heise argued that sexual coercion and the larger issue of imbalances of power between men and women must be considered as an integral part of any strategy to improve reproductive health. As one example, AIDS prevention efforts designed to encourage women to insist on condom use may be misdirected if women are subject to physical threats or loss of financial support for doing so. Heise has assembled estimates of the lifetime prevalence of physical abuse of women by their partners from studies conducted in 24 countries, both rich and poor. Almost all of them showed that over 20 percent of women have suffered such abuse (Heise, 1995: Table 1). Although sample designs and definitions vary among studies, in her view such consistent evidence justified the assertion that violence against women is far more common than usually thought. Sketchier information about the prevalence of the rape and sexual abuse of children leads to similar conclusions.
Heise proposed a continuum rather than a dichotomy (rape/nonrape) as the best way to think of sexual coercion: some behaviors are clearly labeled as transgressions (such as a stranger forcing sexual intercourse), others are widely tolerated in a particular society, and other behaviors may be in transition between the two states (Heise et al., 1995: Figure 2). Exactly where custom, criminal law, and common language place this boundary can differ among societies and change over time. The willingness to label behavior as rape differs among societies and changes over time within a society. Changes in public opinion about “date rape” in the United States are a good example of the latter. Heise also cited a study in which Iranian women who had emigrated to the United States used the term rape to describe their own sexual initiation in retrospect, even though the behavior was
not illegal and their compatriots still living in Iran would not use the analogous term for similar experiences.
Sexual coercion and violence against women are associated in numerous ways with other aspects of women's health. Heise cited studies showing that fear of reprisal limits women's ability to control fertility (e.g., Fort, 1989). The spousal consent policies of family planning programs may exacerbate the problems faced by women in abusive relationships. Sexual abuse and coercion have been found to be associated with entry into prostitution and the likelihood of high-risk behaviors. Violence is one of the threats faced by pregnant women; a population-based study in two cities in the United States showed that pregnant women were beaten in nearly one-sixth of pregnancies (McFarlane et al., 1992). These linkages led to Heise's proposal to researchers, health programs, and family planning programs alike to “help untangle the complex web of social forces that encourage violent behavior, . . . design programs that empower women and enlighten men, and . . . identify and refer women to helpful services” (Heise, 1995:50).
Several participants discussed the meaning of culture and the diversity of values in this context. Heise pointed out that excessive squeamishness about ethnocentrism can in practice result in “androcentrism.” She quoted Nahid Toubia: “Why is it only when women want to bring about change in their own benefit that culture and custom become sacred and unchangeable? ” (quoted in Heise et al., 1995:21). Respect for culture and tradition has not prevented the introduction of public health measures aimed at other harmful behaviors. Culture changes all the time, Heise pointed out, and the impetus for recognition of women's human rights is coming from groups of women in both poor and rich countries who find aspects of their own cultures in need of change and could benefit from international support for their efforts.
Huda Zurayk argued that various dimensions must be considered in addition to gender, including differences among societies in the idea of masculinity and differences among religions in ideals of submission to a husband's authority. In Egypt, she said, although women typically “consent” to marriages and sexual relations initiated by others, their experience, the degree to which they could be considered coerced, varies enormously. Alaka Basu placed the discussion in a wider context, asking how free men are in the system of arranged marriages that prevails in South Asia.
Several participants discussed the implications of sexual coercion for programs of different types. Willa Pressman noted the need to include men and older women as audiences for information, education, and communication programs. According to Winikoff, programs to prevent teenage pregnancy should be able to deal with antecedents, protecting children from sexual abuse.
In principle, it would be appropriate to include programs aimed at sexual coercion and violence against women and children in a cost-effectiveness program similar to that used for other health measures. One difficulty comes in
getting good information on the psychosocial consequences of coercion and the benefits of prevention. Some estimates were prepared in background work for the 1993 World Development Report, according to Heise, which showed that gender-based violence is a risk factor comparable to smoking in terms of the number of DALYs lost.
The meeting included presentations and discussions dealing with the potential effects on reproductive health of two types of education program: “life-skills education” and more targeted family life and sexuality education. The meeting did not consider the larger question of the degree to which general education and literacy affect reproductive health.
Life-skills education tries to present a positive approach to young people's health, according to Rhona Birrell Weisen. The life skills forming the core of these programs, which are aimed at diverse health-related behaviors, include problem solving, decision making, self-awareness, empathy, and skills for coping with stress (Birrell Weisen, 1995). In many places the various single-issue health education programs compete with each other for space in the curriculum. Life-skills education as a generic approach is meant to complement the targeted programs, giving young people a foundation in life skills, to which special-purpose programs aimed at salient problems such as AIDS, drug abuse, and teenage pregnancy can be added. Life-skills education typically entails not just the addition of one more subject to standard curricula, but also introduction of new interactive teaching methods, which require teacher training. Birrell Weisen gave as examples a life-skills-based family life and health education program in Caribbean countries that is being assisted by the World Health Organization. A program in Colombia has a very general goal of promoting the health and social development of young people, and another program assisted by the World Health Organization in Thailand is more focused on AIDS.
There was some debate about the effectiveness of targeted versus generic programs in schools. Debra Haffner felt that there is a danger that life-skills education as actually implemented ends up devoting much attention to decision making and assertiveness and avoids difficult issues like sexuality. Douglas Kirby had found in his meta-analysis of evaluations of sexuality education in the United States that the most effective school-based programs were those that concentrated on the single issue of sexuality, although recent comprehensive life-skills programs often had not been evaluated properly. (The WHO Division of Mental Health is developing a set of guidelines for impact evaluations of life-skills education in developing countries.)
Haffner argued that reproductive health programs would be more effective if they explicitly addressed the sexuality concerns of their clients. She described the International Sexuality Education Initiative of the Sexuality Information and
Education Council of the United States (SIECUS) (Shortridge, 1995), which includes a clearinghouse on sexuality education, training, and technical assistance. SIECUS also works with organizations in countries to adapt its Guidelines for Comprehensive Sexuality Education (National Guidelines Task Force, 1991). Projects to adapt the guidelines have been completed in Brazil and the Czech Republic and are under way in Nigeria and Russia. The goal of sexuality education is the promotion of sexual health. Despite great differences in culture and education systems, Haffner noted, professionals in different countries have defined the objectives of sexuality education similarly. Goals include helping young people understand a positive view of sexuality, providing them with information and skills to take care of their sexual health, and helping them acquire skills for making decisions now and in the future (National Guidelines Task Force, 1991).
Most young people around the world are not receiving comprehensive sexuality education. Although many countries have initiated programs in the past decade for HIV and STD prevention, few programs address the more controversial topics, such as contraception, sexual identity and orientation, masturbation, and sexual behaviors. Programs typically begin at adolescence and focus on youth in school settings.
There is growing opposition by conservative religious groups to sexuality education in schools, in Haffner's view. There is a paucity of research on how people make decisions about sexuality. Most research has been motivated by direct concerns with fertility or AIDS epidemiology and is confined to the measurement of contraceptive use, initiation of sexual intercourse, and numbers of sexual partners.
Kirby presented the results of a review of effectiveness of school-based programs, mainly in the United States (Kirby et al., 1994), and discussed their possible implications for reproductive health in other countries. Three main types of school-based programs relevant to reproductive health have been used, sometimes in combination: (1) sexuality education (or specific education about HIV and AIDS), (2) school-based clinics, and (3) condom distribution. Fertility rates have fallen for adolescents, as they have for adults, in the United States. But there are significant differences between adolescents and adults. Adolescents have less information about sexuality and contraception; they have fewer social skills for resisting pressures for unprotected sex; they are more likely than adults to be unmarried and in shorter-term relationships; and they have sexual relations less frequently and thus sexual relations are more often unplanned. Thus, although they share many of the information needs with adults, those needs are more acute for adolescents. The vast majority of Americans are still enrolled in school when they first have sexual intercourse. This proportion is also increasing in many developing countries, as school enrollments increase and age at first sexual intercourse decreases. School-based programs have the advantage of
continuity; topics can be introduced in sequence and spaced over a suitable period (provided students remain in school long enough to complete a sequence).
A consistent finding of the research is that school programs for sexuality education and HIV and AIDS education do not (as many fear) increase sex and pregnancy (Kirby et al., 1994). Some have been shown to increase the likelihood of contraceptive use, and some have delayed the initiation of intercourse (Kirby et al., 1994). The common features of the curricula that Kirby and his colleagues found effective in increasing safe sexual behavior among adolescents in schools in the United States, include:
A theoretical grounding in social learning or social influence theories;
A narrow focus on reducing specific sexual risk-taking behaviors;
Experiential activities to convey information on the risks of unprotected sex and how to avoid those risks and personalize the information;
Instruction on social influences and pressures;
Reinforcement of individual values and group norms against unprotected sex that are age- and experience-appropriate;
Activities to increase relevant skills and confidence in those skills; and
Special training for teachers and staff implementing the curricula.
Earlier generations of school-based programs, which were designed to prevent risky behaviors by providing information alone, by simply promoting abstinence, or by encouraging “values clarification” without the other elements, have proven ineffective.
Participants discussed the political context in which sexuality education must operate. James Shelton claimed that political polarization is not inevitable, since there is much in the effective school-based programs that will appeal to political and cultural conservatives, and an effort should be made to identify shared goals and focus on them. As William Smith pointed out, the biggest obstacle to introduction of school-based programs is often politicians' perceptions of parents ' opposition; parents turn out to want this education for their children. Susan Pick argued that school-based programs in sexuality education in the Americas are facing increasing, organized opposition by religious conservatives.
William Smith presented two alternate pathways through which communications programs could have effects on health status:
Information → Change in individual behavior → Changes in health status
Advocacy → Change in institutional behavior → Changes in health status
There are enough rigorous evaluations of the pathway through individual
behavior, according to Smith, that the relevant question now is not “Does mass communication work?” but “Under what circumstances, and for which health-related behaviors, does mass communication work?” Smith cited evaluations showing that a communications campaign had reduced socioeconomic differentials in immunization rates in Ecuador; he also described a “natural experiment ” in the Gambia when a radio campaign for oral rehydration treatment was interrupted by a coup and the use of oral rehydration went down (evaluations summarized in Academy for Educational Development, 1994). Mass communication influences provider behavior as well as that of the clients of health services, for example, in promoting the idea of oral rehydration as treatment for diarrhea.
Smith identified three important determinants of program effectiveness aimed at promoting behavior change: the perceived consequences of the behavior, the social norms of the relevant reference group, and the self-efficacy of those whose behavior is targeted. Behaviors vary in complexity, programs vary in quality, and people vary in their perceptions. Decisions about communications programs should not be based solely, as they commonly are, on the choice of a particular channel of communication, with the rest of the decisions flowing automatically from that original selection; instead, planners should start by considering the behaviors to be changed and then think of communications strategies to support that change (Smith, 1995). There is a great deal of confidence in participatory methods (such as involvement of community members in the choice and design of programs), although without much evidence of their effectiveness.
Smith contrasted the success of efforts against smoking in the United States with the failure of programs aimed at reducing obesity: the latter have tried to deliver complicated messages about complicated dietary behaviors. Smith challenged the view that interventions like those considered at the meeting could be considered as isolated alternatives, ranked by cost-effectiveness. He preferred a view of reproductive health as “a complex arena of action which should integrate changes in policy—support for long-term structural change like women's empowerment and education, plus support for provision of new and better services, targeted interventions, and yes, mass communication” (Smith, 1995:7).
William Schellstede used a contraceptive social marketing campaign in Bangladesh as an example of careful preparation and targeting of messages (Lissance and Schellstede, 1993; Schellstede and Ciszewski, 1984). Even mass media campaigns can contain messages targeted to particular segments of the audience. Intensive preliminary research in Bangladesh had identified the key constraints to the use of contraceptives, which were addressed in a small number of messages by the subsequent marketing campaign: contraceptive safety, communications with spouse, and economic benefits to the family. The campaign was subsequently evaluated by a nationally representative sample survey (two years after a baseline survey), and statistically significant improvements were found in the attitudes and beliefs that the campaign had targeted, particularly among those who could identify the “tag lines” from the campaign messages.
Schellstede drew several conclusions from this experience in Bangladesh. One concerned the value of mass campaigns reaching a large audience: “The total cost of the effort in Bangladesh (perhaps $3-4 million) may seem high . . . but the per capita cost is surely lower than if it were done piecemeal, one small project at a time” (Schellstede, 1995). Mass communications also allow the standardization of messages: they can be delivered in predictable ways at a predictable cost, unlike face-to-face communication. He discussed some of the trade-offs involved in HIV/AIDS prevention, deciding between campaigns to reach broad audiences and those more narrowly targeted; the broad campaigns, he felt, are often cost-effective. Depending on the nature of the messages, a mix of broad campaigns and more narrowly targeted, intensive efforts may be warranted. Mass media will not solve all problems in health communications, since different messages may not be appropriate for this approach and some audiences might not be reached effectively. But Schellstede argued that the current allocation of funds in health communications is skewed toward small programs, with uncoordinated messages reaching small numbers of people, leaving mass communications underfunded relative to their potential for changing behavior.
Lawrence Kincaid, in his comments, discussed the synergy between mass communication and community-based distribution in the national family planning program in Bangladesh, arguing that together they have brought about a profound change in the culture, manifested in the willingness to discuss contraception, the changes in women's perceptions of their husbands' support for family planning, and other attitudinal data (Kincaid et al., 1993; Rogers and Kincaid, 1981). Such long-term effects are important but difficult to capture in evaluation studies directed at one component of a package. The old-style public service announcements are too restricted in scope, and far more could be done in reproductive health with mixtures of entertainment and information; he cited some good examples of messages about contraception and HIV/AIDS prevention that have been worked into popular television shows effectively. Kincaid also noted that communications campaigns can be used to influence the behavior of providers as well as of consumers of health care.
Participants discussed both the need for cost-effectiveness research on communications programs and some of the hindrances to such research. As Jane Hughes pointed out, it is not so much the aid donors who need to be convinced as the ministries of finance in developing countries, since most of the resources for reproductive health programs are domestic. (For reproductive health programs in developing countries as a whole, the ICPD Programme of Action included an estimate that three quarters of the funding would have to come from domestic sources —ICPD, 1994:Ch. 9). James Shelton pointed out that too little is known yet about the effectiveness of education programs, although early indications are encouraging; that will have to be the focus of research. Beverly Winikoff expressed some doubt about the generalizability of cost-effectiveness findings, since