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Knowledge is power: access and improved knowledge, attitude, and practices towards family planning / Savoir est pouvoir: Pour l’accès et de meilleures connaissances, attitudes et pratiques de planification familiale
Krishna Bose, Senior Technical Advisor, AYSRH, Bill & Melinda Gates Institute for Population and Reproductive Health, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health
Florence SIBOMANA, Vice coordinator, Rwanda Village Community Promoters
Including the following presentations:
Comprehensive Sexuality Education (CSE) in Rwanda: Findings from the Knowledge, Attitudes, Practices & Behavior (KAPB) survey of in-school adolescents aged 10-19. (18.104.22.168)
Therese Karugwiza, Gender, Culture and Human Rights Program Specialist, UNFPA; Peter Wallet, UNESCO; Furaha Siraji, Program Analyst-Youth, UNFPA; Liana Moro, Programme Analyst, Adolescents & Youth, UNFPA; Angelique Tusiime, Deputy Director General, Rwanda Education Board; Joyce Musabe, Independent, Independent; Mark Bryan SCHREINER, REPRESENTATIVE, United Nations Population Fund – UNFPA
UNFPA and UNESCO support Eastern and Southern African countries to scale-up comprehensive sexuality education (CSE) since 2016, the Government of Rwanda has implemented the CSE programme in all primary and secondary schools.In Rwanda, youth aged 15-24 (20.4% of the population) have limited access to sexual and reproductive health and rights (SRHR) information and services. The current Reproductive Health Law requires parental consent for access to modern contraceptives for youth under age 18. Modern contraceptives use of sexually active young women is only 32.8%, and 14% of the women aged 15-49 are married by age 18. In addition, adolescent pregnancy rates increased from 6.3% to 7.3% (2010 to 2015) and childbearing by age 19 slightly increased to 21%. While sexuality issues largely remain a taboo and expectations to abstain from premarital sex are the publically accepted norm, data shows that 1 in 5 women report having sex by age 18, as compared with 12% of men.Furthermore, the unknown status of knowledge gaps in topics within sexuality education provides the rationale for this baseline study.
In December 2017, UNFPA and the Rwanda Education Board conducted a nationwide baseline study for the School Based CSE Programme. The primary objective of the baseline study was to determine and document the Knowledge, Attitudes, Practices, and Behavior (KAPB) of adolescents aged 10-19 years in primary and secondary school in topical and thematic areas related to CSE.
The study utilized a cross-sectional, mixed methods design. An extensive document review was carried out to gather secondary data and map gaps in available information. The quantitative component of the study used a semi-structured questionnaire, administered to in-school male and female adolescents aged 10-19, enrolled in Primary 4 up to Senior 6. Data collection was preceded by a pilot test of the tools in Kicukiro District. At each selected school, data collectors carried out a Simple Random Sampling of respondents. The study included key informant interviews and Focus Group Discussions, which were matched to the survey questionnaire to allow a triangulated analysis.
A total of 2432 respondents (1208 boys; 1224 girls) responded to the questionnaire. The study was conducted in 16 randomly selected Districts across the four Provinces and Kigali City. 215 schools were selected, providing the baseline study a confidence level of 95%. The sample is representative for gender at Primary and Secondary School levels.
Youth reported a gendered division of household responsibilities, with gendered attitudes evident as respondents (50.65% girls; 61.42% boys) reported boys being better than girls in science-related lessons.
Nearly 40% of adolescents reported having been in a romantic relationship at least once: 6.25% girls and 14.77% boys state to have had sexual intercourse, 53.31% of which with a partner their age. On gender based violence (GBV), 55.23% of respondents reported that, sometimes, husbands have grounds for beating their wives. Nearly 3 in 4 girls and 9 in 10 boys reported that girls wearing mini-skirts are the ones attracting rapists.
1 in 3 girls and 1 in 2 boys reported teachers as main source of learning about sexuality issues, while over 10% did not identify any source. For contraception sources of information for girls are school (56.12%), mothers (13.62%) and radio (10.21%), while for boys, school (54.15%), radio (21.96%) and peers (10.92%). Over 60% of girls and boys never discussed sexuality with their fathers, while 36.27% of girls and 64.14% of boys never discussed sexuality with their mothers. Although respondents reported accurate knowledge of biological functionalities, 17.98% of girls and 24.92% of boys did not know of any changes during puberty. Moreover 28.04% of young people have never heard of contraception, with 90.1% of girls and 72.95% of boys reporting to practice abstinence. 29.5% of respondents indicated they would not share meals with HIV+ persons. 61.36% of girls and 46.94% of boys reported not knowing the signs/symptoms of sexually transmitted infections (STIs).
The findings indicate a heavily gendered understanding and perception of CSE concepts, as observed in the reported division of labour and tolerance to GBV, also highlighting the lack of aspects of positive masculinity in the current programme. School teachers were the most reported sources of sexual learning for youth on several aspects regarding sexuality. Nevertheless, interviews revealed that teachers, while willing, were often uncomfortable or lacked the necessary skills to effectively teach CSE. Overall, gaps in sexuality education knowledge, including on contraception, STIs, HIV, GBV, and other aspects of gender were exposed and call for greater investment to contribute to the CSE programme’s objectives.
The study furthermore highlighted the importance of data triangulation to validate responses. For example, as it appears that a mobile app was accepted by youth as a trustworthy form of HIV testing, quantitative findings were considered inconclusive. Similarly, as girls are expected not engage in premarital sex, results on the number of girls engaging in premarital sex are not considered reliable.
Finally, the study allowed for a number of recommendations towards the improvement of the current CSE programme in Rwanda, including the integration of CSE in the country’s key documents, monitoring CSE indicators through national surveys, the adoption of a gender transformative approach and capacity-building of teachers. The baseline data provides a solid set of evidence in which to monitor and report curriculum and teacher effectiveness in transmitting key information, as well as the state of knowledge, attitudes, practices and behaviours among Rwandan students over time.
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The contribution of integrated family planning package to improve living conditions of First Time Young Mothers aged 10-19 in Rubavu district, Rwanda (22.214.171.124)
Felix Hagenimana, Monitoring and Evaluation Officer, Imbuto Foundation; Helene Rutamu Mukamurara, Imbuto Foundation; Rachel Akimana, Imbuto Foundation; Geraldine Umutesi, Deputy Director General , Imbuto Foundation; Sandrine Umutoni, Director General, Imbuto Foundation; Bernard Ngabo Rwabufigiri , University of Rwanda School of Public Health; Furaha Siraji, Program Analyst-Youth, UNFPA; Marie Claire Iryanyawera, Program analyst/ FP-RHCS, UNFPA; Therese Karugwiza, Gender, Culture and Human Rights Program Specialist, UNFPA
Adolescent pregnancy has negative effects on girls’ education, physical, mental, and socio-economic wellbeing, as it frequently leads to school dropout, discrimination and stigma from families and communities. 95% of births to adolescent mothers occur in developing countries. About one in five young women in developing countries become pregnant before age 18, an equivalent of 7.3 million births every year.In Rwanda, the teenage pregnancy rate increased slightly from 6% in 2010 to 7.3% in 2015. One in five girls in Rwanda are First Time Young Mothers (FTYMs) at the age of 19. Only 34.2% of these mothers used contraceptive methods after delivery, as per the baseline assessment. Despite Government efforts, in recent years, to expand Adolescent friendly Sexual and Reproductive Health (ASRH) services and access to quality services, including use of Family Planning (FP) tailored to young people’s needs, is limited.As a response, the FTYMs programme was initiated, providing an integrated package of interventions focusing on psycho-social support counselling including HIV testing, Parent Adolescent Communications (PAC), community based outreach campaigns and income generating activities for effective social re-integration. This paper aims to share the best practices and key lessons learned to influence adolescents and youth programming efforts.
Program intervention/activity tested:
From April 2017, the programme introduced new interventions, targeting the most vulnerable FTYMs aged 10-19 and focusing on improving maternal health, wellbeing and newborn care to prevent other subsequent unintended pregnancies. This is implemented through psycho-social support group counseling, PAC forums sessions to restore the relationship between FTYMs and their parents, community-based outreach campaigns to increase awareness and fight social discrimination, stigma and violence, skills-based training for health care providers aimed at increasing the uptake of contraceptives post-partum and HIV testing, improved child care practices among FTYMs, and the promotion of income generating activities for FYTMs.
The FTYMs programme has been implemented by Imbuto Foundation and funded by UNFPA since April 2017, with the selection of 50 of the most vulnerable FTYMs from two health centers (HCs). In November 2017, the programme was expanded to five more HCs across 7 sectors in Rubavu District, as the pilot phase. 175 FTYMS from 7 HCs benefit directly from the programme to-date. Primary data collection for the programme was done using Monitoring and Evaluation tools over the last 10 months. Nurse focal persons also collected and reported data on monthly basis. Descriptive statistics were used to provide basic programme features, using stata version 14.
As the FTYMs programme is targeting adolescent mothers and their children, orientation meetings and training of community health workers and nurses were conducted to support FTYMs to accept their status through psycho-social support group counseling, promoting uptake of contraceptives post-partum, including HIV testing, and promoting improved child care practices. PAC sessions and community based outreach campaigns were conducted monthly on preventing discrimination, stigma and violence among FTYMs in their families and communities. The programme also provided cooperative management skills and formed FTYMs-Income Generating Activities (IGAs) groups at HCs.
During 10 months of interventions, through psycho-social support group counseling, all 175 FTYMs were equipped with ASRH information compared to the previous period where they had not been exposed to ASRH information and services including contraceptives, and 70% of them chose to use FP methods to prevent another unintended pregnancy. Among those who did use modern contraceptive methods, injectables and implants were the most preferred (31% and 68.3%, respectively). 44 FTYMs who were rejected were allowed to return back home after seven PAC sessions that were introduced to initiate a conversation between enrolled FTYMs and their parents, and six outreach campaigns that were conducted to increase awareness among community members.
Apart from FP services, the FTYMs gained other SRH services related to HIV testing. All 175 adolescent mothers consented for HIV counseling and testing and; 1.14% of them were found HIV positive and were adhered to care and treatment at HCs.
Within the same period, the programme interventions trained 175 FTYMs on cooperative management and also formed 7 group-based IGAs, where each group counts 25 members, with each member committing to save at least an average amount of US$0.2 after weekly psycho-social counselling sessions. Overall, 175 FTYMs have saved a total amount of US$7,726 in Umurenge Savings and Credit Cooperatives (Umurenge SACCOs). The median amount of savings in all groups is US$1,146; IQR (interquartile range) [US$950; US$1,187]. From Group-based IGAs interventions, all FTYMs were able to pay health insurance and cover other basic needs for themselves and their children.
Program implications/lessons learned:
Providing an integrated package, including PAC forums, outreach campaigns, psychosocial and economic reintegration, was instrumental in effectively re-integrating FTYMs in their families and communities.
ASRH, a major challenge among adolescents, requires innovative approaches to ensure adolescents are reached and provided the right information and friendly services early, if they are to make informed decisions and avoid negative outcomes. This also includes removing legal barriers, such as parental consent for adolescent girls below adult age, for them to access ASRH services.
Counseling sessions and the provision ASRH information are a key influencer in the adoption of FP methods, as the majority of our beneficiaries used FP methods of their choice participating in counseling sessions and receiving the relevant information. PAC sessions and outreach campaigns are also positive factor in address discrimination, stigmatization and violence against FTYMs in families and community.
The experiences of the pilot programme implementation can be scaled up in the whole District of Rubavu and others Districts using the linkage to existing programmes in the same settings for its sustainability. Clustering with similar identities ensures an easier entry point to targeted populations and address the real needs.
Partnership and collaboration (in the District) are essential for effective programming to FTYMs in order to address negative outcomes due to social, health, economic and education problems, including malnutrition, poverty and long-term negative developmental outcomes that can be perpetuated if they are not effectively responded to.
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Linkage between community and schools to health facilities to improve knowledge on ASRH and family planning utilization among adolescent aged 10-24 years in Nyarugenge and Gicumbi districts, Rwanda. (126.96.36.199)
Amanda Rurangwa, Project Officer, Imbuto Foundation; Sandrine Umutoni, Director General, Imbuto Foundation; Hubert Kagabo, M&E Officer, Imbuto Foundation; Geraldine Umutesi, Deputy Director General , Imbuto Foundation; MIREILLE BATAMULIZA, Imbuto Foundation; Bernard Ngabo Rwabufigiri , University of Rwanda School of Public Health
Rwanda has made substantial progress in increasing access and utilization of reproductive health and family planning services. Although this progress has led to overall improvements in key sexual and reproductive health indicators—including significant decline in unmet need for family planning (from 40% in 1992 to 19% in 2015)—the country continues to face several Adolescent Sexual Reproductive Health (ASRH) challenges including the high rates of teen pregnancy, and low levels of contraceptive use among adolescents. By age 19, roughly one in five Rwandan women has experienced at least one pregnancy. Many adolescents in Rwanda are sexually active— roughly, 40 percent of women have had sexual intercourse by age 20. There is limited knowledge about HIV/AIDS transmission and prevention among youth. Only 62 percent of females aged 15 to 19 years and 60 percent of males of the same age have “comprehensive knowledge” of HIV/AIDS.Against the above background, Imbuto Foundation tested a new approach, pairing in and out-of-school youth to health facilities to improve ASRH-related knowledge, attitudes and practices, and increase the utilization of youth friendly services in Rwanda.Program intervention/activity tested:
Since 2010, Imbuto Foundation has been implementing the “Adolescent Sexual Reproductive Health and Rights” program in two districts: Nyarugenge and Gicumbi, to advocate for the rights of young people aged 10-24 years, regarding access to quality reproductive health information and services in Rwanda. This program features three interrelated components: (1) establishment of youth ASRH clubs to facilitate peer-to-peer learning and communication; (2) pairing of youth clubs with nearby health facilities and training health facility staff on the delivery of youth-friendly ASRH services; and (3) organizing ASRH forums and outreach events for parents and community members.
In May 2016, using qualitative research design, 58 Focus Group Discussions (FGDs) of 8-10 participants each and 56 In-Depth Interviews (IDIs) were conducted at national and district levels as well as in six of the 31 administrative sectors in which the community-level ASRH intervention had been implemented. In each sector, we included sector health center in our sample, and randomly selected one school and one administrative cell (each containing one club), for a total sample size of six health centers, six schools, and six cells.
For each school and out-of-school club, we conducted two FGDs with club members (one with young women and one with young men). At each selected school and in each selected cell, we conducted two FGDs with non-club youth (one with young women and one with young men). In each sector, we conducted two FGDs with parents—one with parents of club members and the other with parents of non-club youth. We conducted IDIs with teacher mentors and presidents of in and out-of-school clubs, health care providers and school staff. Program monitoring data were used to check and enhance the findings. For qualitative data, we used Nvivo software for coding following thematic and contribution analysis approach.
Imbuto established 263 clubs (107 school clubs and 156 out-of-school clubs) in its two intervention districts. On average, ASRH clubs include 30 members. Club members appreciate the intensive ASRH education and dialogue provided by the clubs. Club members participating in FGDs repeatedly expressed their enthusiasm for the education and communication activities of the ASRH clubs.
Greater awareness of and changes in the provision of ASRH services at health centers have influenced youth perceptions, and use of facility-based SRH services. Knowledge of key ASRH topics and use of facility-based ASRH services, have improved substantially among members of both in and out-of-school youth club.
Religious and cultural norms that favor sexual abstinence until marriage are deeply entrenched in Rwanda. However, by acknowledging and validating these beliefs, while promoting safe sex practices, the program helped to temper the view, that contraceptive use is entirely taboo for unmarried adolescents. Clubs have increased understanding of the benefits of family planning for preventing unwanted pregnancy.
Distance, limited availability of nurses, and traditional beliefs regarding abstinence still deter some non-club members from seeking contraceptive services at health centers. They still have pressing ASRH needs that require greater attention. Parents of club members still find it challenging to discuss ASRH issues with youth. While school staffs want to enable their students to make healthy reproductive choices, and have bought into the awareness-building mission of the ASRH clubs, they still struggle to reconcile program objectives with their largely traditional views on adolescent sexual activity and contraceptive use.
Program implications/lessons learned:
The linkage between schools, community, and health care providers has improved exposure to information and knowledge of ASRH topics among club members, and helped to dismantle harmful myths regarding puberty, sex, and reproduction.
However, peer education needs to strongly be supplemented with nurse and mentor-led instruction to improve knowledge of ASRH concepts especially at community level. Integrating income-generating activities into ASRH programming can increase participation in out-of-school clubs. It provides them with an opportunity to earn, save, and become more self-sufficient, which acts as a strong incentive for many to join and stay in the ASRH clubs. Given deeply rooted cultural beliefs discouraging premarital sexual activity and contraceptive use, youth greatly value privacy and respectful treatment in ASRH service delivery, they are particularly sensitive to any indications of judgment when they are discussing their needs with service providers.
Sustained parent outreach is needed to effect meaningful shifts in socio-cultural norms. Parents of club members are deeply concerned about the Sexual Reproductive Health (SRH) challenges that youth face and feel a strong sense of responsibility to guard their children against risks of pregnancy, STIs, and sexual abuse or coercion, and to encourage them to make responsible decisions.
Findings suggest that a significant number of families need to be reached out through Parent Adolescent Communication (PAC) to mobilize parents, gain their support in this process, and sustain the work done in schools and by health care providers.
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Parents’ Knowledge, Attitude, and Practices (KAP) towards Comprehensive Sexuality Education in Secondary Schools in Rwanda (188.8.131.52)
Athanase Rukundo, Director of Program, Health Development Initiative-Rwanda; Kaleeba Ali, University of Rwanda; Amy Shipow, Health Development Initiative-Rwanda; Aflodis Kagaba, Executive Director, Health Development Initiative( HDI)
Over the last decade, countries in the Eastern and Southern Africa (ESA) region have taken major strides toward the development and incorporation of Comprehensive Sexuality Education (CSE) in their school curricula. In Rwanda, CSE has been subsumed in the new Competence Based Curriculum as one of the essential cross cutting components. The aim of the school based CSE is to equip children with knowledge, skills and values in an age appropriate and culturally gender sensitive manner so as to enable them to make responsible choices about their sexual and social relationships, explain and clarify feelings, values and attitudes, as well as to promote and sustain risk reducing behavior (Rwanda Education Board, 2015).Despite a new curriculum that includes the CSE adopted in March 2015, Rwanda has not officially signed ESA commitment made in 2014 on CSE and Sexual and Reproductive Health (SRH) Services for Adolescents and Young People. Furthermore, although the new curriculum was developed and adopted, there could have been more opportunities for meaningful involvement from civil society organizations (CSOs). Thus, HDI sought to contribute to the research on CSE understanding and implementation from a local level.Main question/hypothesis:
Studies in Rwanda on sexuality education predominately focus on views of adolescents and teachers in teacher education institutions (UNESCO, 2015; REB, 2017); however parents’ attitudes and perceptions towards CSE in secondary schools are unknown. Therefore, HDI assessed parents’ knowledge, attitude and practices towards CSE in secondary schools. The objectives were to determine parents’ knowledge and understanding of CSE; seek parents’ opinions on aspects of CSE that were pertinent to their children as well as the appropriate level/age for the onset of sexuality education. The study was likewise conducted to inform HDI and partners in program planning and advocacy on SRH.
In the fall of 2017, a mixed-methods study was implemented in 10 districts and 20 sectors in Rwanda, divided proportionally among urban and rural districts per province. Two enumerators conducted interviews with key informants (n=91). These informants included secondary school teachers and senior education officials (SEOs) in charge of monitoring and supervising CSE implementation. Quantitative data was obtained using a structured questionnaire adapted from Kaiser Family Foundation’s “Sex Education in America: General Public/Parents Survey.” This tool was administered to parents of secondary school children (n=574) from 40 schools (20 private and 20 public) and 91 key informants including teachers. Parents and teachers were purposively selected from 40 schools. Quantitative data was cleaned and coded with SPSS version 16 to perform simple descriptive statistics. Similarly, qualitative data was coded to identify major themes and organize participant responses within such themes.
Findings revealed that almost half of the parents surveyed (47%) did not have sufficient knowledge about adolescent sexual behavior, with fathers less knowledgeable than mothers. No parents were able to identify any sexuality education related policies; almost two-thirds were not aware whether CSE was taught in schools (64%); and nearly half had a superficial understanding of CSE. There was an increasing lack of parental awareness towards CSE in rural areas (83% aware) compared to urban ones (56% aware).
Although 87% parents acknowledged the importance of CSE in schools, 36% of parents felt that it might provoke adolescent sexual activity and the majority (71%) stated they felt uncomfortable to discuss sexuality issues with children. Concerning parent-child discussions about sexuality issues, majority of the parents sampled (77%) reported that they had not discussed sexuality issues with their children at home due to feeling shy, and upholding cultural norms and values.
More than half of the parents believed that all teachers should be responsible for imparting information on sexuality to students. Nonetheless, teachers and SEOs believed that only teachers teaching disciplines in which CSE was integrated should bear this responsibility. Both parents and educators were in agreement that the appropriate level to teach CSE is in either upper primary or secondary school.
Encouragingly, the majority of parents recognized that CSE does not serve as a precursor for promoting sexual activity among students. Although the majority of parents surveyed acknowledged that CSE is important for students, almost half had a superficial understanding of CSE content. Parents also raised concerns that they felt could jeopardize the teaching of CSE including: teachers lacking enough time due to heavy workloads; teachers lacking training; lack of sexuality related teaching materials; insufficient clarity on the scope of teaching content; and cultural and religious beliefs. Going forward, it is evident that CSOs have an integral role in promoting positive masculinity as parents predominately responded that it was the role of mothers to have sexuality conversations at home.
Consequently, HDI recommended that the Ministries of Education and Health, the Rwandan Education Board, and other CSOs should design a comprehensive teaching manual on CSE, develop awareness and sensitization strategies focusing on parents, and better monitor the implementation of CSE across different educational settings and age groups. As a first step to engaging CSOs, HDI held a regional conference in December 2017 that convened high level stakeholders across ESA to discuss best practices and lessons learned regarding the implementation of CSE in their respective countries.
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