Embras y Varones Adelante (EVA)

‘Girls & Boys Get Ahead’

A School-based Sexual Health and Skills Training Program

For Dominican Children ages 8-11 in Batey Communities

Executive Summary

Rates of HIV infection are estimated at more than 5% in batey communities in the Dominican Republic. To prevent further spread of the infection and to address the needs of at-risk youth, the sexual health intervention Embras y Varones Adelante (EVA) will target children ages 8-11 living in three bateyes in the southwest region of the country. The intervention will include a sexual health and social skills training curriculum, which includes information about HIV/STI transmission, the impact of adolescent pregnancy and other risks associated with early sexual debut. To ensure the success and sustainability of the program, teachers will undergo extensive training prior to the start of the intervention and will receive on-going professional support for the duration of the program. Successful implementation also requires parental and community involvement. Therefore, participatory methods will be emphasized at all phases of the planning, implementation and evaluation processes.

It is the program team’s contention that by intervening at the primary level, children living in batey communities will be equipped with the information and life skills, such as effective communication techniques and self-esteem, needed to make healthy choices about their sexuality before risky sexual behavior takes root in their lives.

Problem Statement

According to a 2004 study by the World Bank, the Dominican Republic has 120,000 persons living with AIDS—approximately 9 times the total number of reported cases—with heterosexual intercourse documented as the primary mode of transmission in 81% of cases among 15-44 year olds. Young people between the ages of 15 and 24 constitute 18% of total cases, implying infection occurs in early adolescence.[1] HIV prevalence in the country is highest (5% of adults) among low-income groups that include many Haitian immigrants living in rural communities commonly referred to as bateyes (shantytowns on sugar cane plantations). In bateyes, HIV prevalence among 15-49 year olds is estimated at 4.9%, with prevalence slightly higher in women (5.2%) than in men (4.7%).[2] Factors, such as early sexual debut, high birth rates among adolescent girls and young women, unequal gender socialization, female economic dependence on men, seasonal migration patterns and poverty contribute to the spread of HIV and put young people in these communities at greater risk of this and other sexually transmitted infections (STIs).[3]

To combat the spread of HIV among youth, in 2002 the Ministry of Education began implementing a sexual health education program, Programa Afectivo Sexual, in secondary schools. According to the Ministry of Education, the program, which includes a learning manual designed by a team of sexologists, psychologists and HIV/AIDS/STI experts, is currently being implemented in 55 percent of public secondary schools with 253,361 students attending twice weekly classes under the Program. In addition, 54% of secondary school teachers have been trained on HIV/AIDS/STI prevention.[4]

Although this program is an important component of the country’s national HIV prevention strategy, there are two primary reasons why it is not sufficient to combat the spread of HIV among vulnerable rural populations—specifically young people living in bateyes. Firstly, lacking citizenship documentation many children living in bateyes are not allowed to continue school beyond the primary level, which means they cannot participate in a secondary school program.[5] Secondly, evidence suggests that sexual health interventions targeting elementary school children can have a greater positive impact on the health-risk behaviors of children than interventions delivered at the secondary level.[6]

Therefore, the sexual health intervention Embras y Varones Adelante will target children ages 8-11 living in three bateyes in the southwest region of the Dominican Republic. The intervention will include a sexual health and social skills training curriculum which includes information about HIV/STI transmission, the impact of adolescent pregnancy and other risks associated with early sexual debut. By intervening at the primary level, children will be equipped with the information and life skills, such as effective communication techniques and self-esteem, needed to make healthy choices about their sexuality before risky sexual behavior takes root in their lives.

The Goal of EVA : To increase the age at which young people make their sexual debut in bateyes in the Dominican Repub lic —therein reducing the spread of HIV/STDs.

The Aim of EVA : To increase 8 - 11 year olds’ motivation to delay sexual debut, avoid pregnancy and HIV/STDs (purpose) through a school-based sexual health and social skills training curriculum and after-school component (methods) .

Objectives:

· To create a culturally appropriate sexual health and social skills training curriculum

· To train teachers to effectively implement the curriculum

· To engage boys and girls in participatory and cooperative learning activities

· To develop strong community links

Planning Methodology

This project is being planned and will be implemented and evaluated using the PRECEDE/PROCEED model as a framework. Accordingly, the EVA intervention is based on a diagnosis of the social, behavioral, environmental, educational and organizational factors which influence the spread of HIV and other STIs in batey communities. The project proposal includes a systematic evaluation plan, which will help determine the extent of both the short and long-term impact of the program. Lastly, EVA’s success is predicated on active community involvement. Therefore, community participation is considered essential at every phase of the intervention and program activities will be constructed in partnership with community members, school administrators, teachers, parents and students. The initial implementation of the program will be coordinated by the CARA Network (CARA)—a donor-driven international NGO, which funds education-related development projects for marginalized populations.

Epidemiological Determinants of HIV

In accordance with Phase III of PRECEDE, CARA’s project team has identified the epidemiological determinants of HIV/STIs and adolescent pregnancy in batey communities. Youth living in bateyes face high susceptibility to HIV/STIs and adolescent pregnancy for myriad reasons. Firstly, the marginalized status of women and girls contributes to high rates of both HIV/STI transmission and adolescent pregnancy. Dysfunctional gender norms lead to relationships between males and females characterized by poor communication among partners on sexual needs and concerns, sexual violence, and women’s socio-economic dependence on men—all of which limit a woman or girl’s ability to negotiate safe sex.[7]

High poverty rates also influence women and girls’ decisions to have sex in exchange for food, school fees or other basic needs. According to the Caribbean Task Force on HIV/AIDS, there is “peer pressure on young girls to have early sex and [there is also] a hidden story of coercive sex, rape, incest, domestic violence and predatory ‘sugar daddies’ that young girls must cope with.”[8] Indeed, a study of migratory patterns of Haitian women found that “women born in the bateyes were more likely than Haitian women to give a history of exchange of sex for money/goods, and were also more likely to identify themselves as prostitutes.” The authors’ of the study concluded that “it is possible that being a ‘daughter of the batey’, born and raised in an environment where the exchange of sex for money is common, might predispose to such activity.”[9]

Other prevailing social norms contribute to increased risk. For example, it is acceptable and even encouraged for men to have multiple sexual partners—regardless of the age of either the male or female, and some of the traditional religious and moral codes which encouraged monogamy and early marriage, no longer exist, which increases the time during which premarital sex can occur.[10] Early sexual debut in the bateyes also brings with it increased risk of HIV/STI infection and/or adolescent pregnancy. For example, the median age for sexual debut is 16.1 for women without a formal education versus 24.8 years for women with post-secondary education.

Finally, seasonal migration patterns lead to greater risk of HIV/STI infection and adolescent pregnancy. During the 5-6 month sugarcane harvest, batey communities accommodate an increase of approximately 30,000 young Haitian men who typically cross the border without their families and/or sexual partners to cut cane. In a study of migratory patterns, Brewer, et al. found that “the social disruption inherent in a migratory cycle fueled by poverty, and the resulting strategies for economic survival, are also of primary importance in the transmission of HIV within the bateyes.” [11] This trend is consistent with studies in Africa, which also linked seasonal migration to increased HIV seroprevalence due to “the social disruption caused by the migration of young men without their partners, skewed sex ratios, and the exchange of sex for subsistence goods by impoverished women as the keys to this link.”[12]

Justification of Activities

Given the epidemiological context, Embras y Varones Adelante (EVA) seeks to address the special needs of young people in batey communities through a school-based sexual health and social skills training curriculum and after-school program for children ages 8-11. EVA is based in part on the social development model (SDM), which hypothesizes that communities can promote healthy behaviors by communicating healthy beliefs and clear standards for behavior to young people.[13] SDM finds that young people will try to live according to those standards if they form a bond, have strong relationships or “attachments to the family, school and community” or feel invested in positive activities, such as school involvement.[14]

Targeting Younger Children at School

The project team chose to use school as the place to implement the intervention for several reasons. Firstly, “primary school programs offer a potentially efficacious and cost-effective way to provide HIV/AIDS prevention for nearly all young people, especially in resource-poor countries.”[15] As previously mentioned, many children living in batey communities do not attend secondary school, which makes an intervention at that level insufficient.

Secondly, evidence suggests that intervening prior to the initiation of sexual activity is more effective at decreasing risky sexual behavior than waiting until children are sexually active—i.e. it is easier to deter children from having sex if they have never started. Indeed, evaluations of two teacher-led HIV prevention programs in Uganda and Namibia, only reported positive outcomes for students who were not sexually active at pretest.[16] An evaluation of a sexual education program for Jamaican youth found 64% of 12-year-old boys reported baseline sexual experience, which “[suggested] that sex education should be introduced well before [children] enter their adolescent years.” Lastly, an evaluation of an intervention in the United States among low-income middle school students, found that students with a ‘safer’ pre-test score (i.e. children who had not yet made their sexual debut) were more likely to show positive outcomes regarding knowledge, self-efficacy regarding sexual matters, behavior-intention, and self-reported behaviors. Siegel, et al. concluded that this “observation speaks to the need for development and testing of school-based sexual risk reduction interventions among younger students, such as those in the elementary grades.”[17]

Thirdly, research indicates that increasing children’s attachment to school is one of the most important protective factors for positive youth development.[18] A recent World Bank study of nine Caribbean countries found that “school attendance and connectedness are the single most important protective factors identified in reducing risky behaviors. Among youth who feel connected to school, the study [found] that the probability of sexual activity falls by 30% for boys and 60% for girls, of engaging in violent activity by 60% for boys and 55% for girls, and of drug use by 50% for boys and 30% for girls.[19]

A study by Hawkins, et al. (1999) found that a school-based intervention had “enduring positive effects on the academic development and health-risk behaviors” of elementary-aged children. The intervention, which featured in-service training for teachers, child skill development activities and optional parent training classes, was given to the intervention group beginning in grade 1 and continuing through grade 6. Researchers compared their results with children from a late intervention group who received the intervention in grades 5 & 6 only and also with children in a control group who received none of the program components—including interaction with the specially trained teachers.

Results of the study found that at age 18, children from the full intervention group reported significantly stronger commitment (P = .03) and attachment to school (P = .006) than the kids in the late intervention or control groups. Children from the intervention group also reported fewer incidents of sexual intercourse—only 72.1% had sex by the age of 18 versus 83% in the control group (P = .02), multiple sex partners—49.7% versus 61.5% in the control group (P = .04), or pregnancy—only 17.1% had been pregnant or gotten someone pregnant versus 26.4% in the control group (P = .06)—though the finding on pregnancy was just shy of statistical significance.[20] Additional analysis of the data found that children from poor families who participated in the full intervention were significantly more attached to school than poor children from the control group (P = .001).[21]

The Curriculum—A Multi-faceted Approach

EVA’s curriculum will address sexual beliefs, attitudes and skill development of the target population. Specific emphasis will be placed on impacting participant attitudes regarding the perceived negative consequences of pregnancy, motivation to avoid pregnancy, HIV and other STIs, the perceived responsibility of men for pregnancy and perceiving more personal and social costs of having sex.

This focus was chosen based on a systematic review of the risk and protective factors affecting adolescent sexual behavior, pregnancy, childbearing and sexually transmitted infections, including HIV. After reviewing more than 400 studies, Kirby, et al. found that factors involving sexual beliefs, values and attitudes, skills and behaviors of teens about having sex, using condoms and avoiding pregnancy and HIV/STIs are “most amenable to change by organizations accustomed to addressing reproductive health.” Therefore, “efforts aimed at bolstering teens’ motivation to avoid pregnancy and STD can reduce the chances that teens will take part in risky behaviors. Research demonstrates that some sex and STD/HIV education programs can improve these sexuality-related beliefs and attitudes and can thereby delay first sex, reduce the frequency of sex, lower the number of sexual partners and/or increase condom and other contraceptive use.[22]