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Chapter 7 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS 7.1. General Design and Methodology This report represents the findings from the population-based Survey on Knowledge, Attitude, and Practice in Sexual and Reproductive Health (SRH) among representative number of 1800 Armenian young people above the age of 12 years old and adults over 24, which was completed with the Case Studies among 150 young people on Impact of Sex Education on Sexual Behavior and Health. The investigation was designed and implemented in 2001-2002, by the Armenian “For Family and Health” Association (AFHA), as part of the joined with the Ministry of Health (MOH) and the Center on Perinathology, Obstetrics an Gynecology (CPOG) project on “Improvement of the Sexual and Reproductive Health of Women, Men, and Young People”. The United Nations Population Fund (UNFPA), Armenia Office has kindly provided financial and technical assistance for project implementation. The general goal of this study was obtaining baseline information on SRH related knowledge, attitude, and practice among young people and adults over 24 years of age in the project target areas and development of the rational approach towards adolescent’s health protection. The project has targeted 30 communities in city of Yerevan and the region Ararat (15 urban and 15 rural). In order to assess needs and demands for provision of sex education for young people and improved access to sexual health care services we conducted the questionnaire based survey-interviews among 900 young people between the ages of 13-24 years old (including students, institutionalized children and those who dropped out from educational institutions), and 900 adults above the age of 24 (including parents/guardians, health providers, as well as teachers/educators and administrators of public and boarding schools, orphanages, colleges, universities). Determination of the sample size for the survey was based on official data concerning the size of the target population, as well as the confidence, precision desire, and variables of the study. The sample of eligible respondents was selected from the total population of males and females above 12 years of age using the method of Random Cluster Sampling with a multistage sampling design. Each eligible respondent had exactly the same chance to be selected for the survey-interview. To reveal the impact of sex education on sexual behavior and reproductive health of young people we conducted in-depth interview of 150 respondents between the ages of 13-24 years old, including young people, which: a) participated in the training courses on sexuality and sexual and reproductive health, b) received relevant information from previously trained peer educators and c) never had an access to accurate information about these issues. The case studies were carried out in the selected urban and rural communities of the project target area. Three main focus groups of young people were investigated and there were 50 participants in each group. The participants of the first focus group were randomly selected from the list of 292 peer educators 13-24 years of age, which have been trained on sexuality, and sexual and reproductive health, after participation at the relevant training courses, provided by the AFHA at least 6 months before this study. Among them were students of public schools, colleges and universities/institutes as well as one young man, who had completed his education. The participants of the second focus group were young people, which received information on sexuality, and sexual and reproductive health from the previously trained peer educators. These respondents were living in the same communities as peer-educators involved in the first focus group. The participants of the third focus group didn’t have an access to accurate information on sexuality, and sexual and reproductive health and lived in the communities where sex education was never introduced. Information obtained was evaluated using standard statistical package “Epi-Info”. The elementary statistics were used for data evaluation, including cross-tabulations, Chi-square, and classical F-Nova tests. The demographic and socio-economic profile of the respondents, the level of awareness, knowledge and personal beliefs about sexuality, puberty, conception, fertility regulation and STI/HIV/AIDS, and access to information and medical services on sexuality and sexual health have been assessed, together with common pattern of sexual, marital, and reproductive behavior and the attitudes towards provision of sex education to children and adolescents. The AFHA research team composed of the Project Supervisor Dr. Mary Khachikian, the Project Manager Dr. Jasmen Hurutiunian, and the Consultant on Sexual and Reproductive Health Dr. Harut Tanielian performed data evaluation and developed recommendations on plan of action on introduction of sex education as a separate subject in the curriculum of the public schools and creation of the “youth-friendly” SRH services within the network of existing outpatient public health facilities. As an outcome of this study the governmental authorities, non-governmental organizations and international agencies have been provided with baseline information on sexual and reproductive health knowledge, attitude, and practice of adolescents and adults living in the city of Yerevan, and urban and rural areas of Ararat Region, together with the feasible and culture-appropriate recommendations on plan of action towards protection of the adolescent’s health.
7.2. Summary of Main Findings General characteristics of target population: The majority of target population (97%) consider themselves as Christians by culture. Most of the teachers and health providers of the targeted educational institutions and public health facilities are of female gender. Mainly mothers and female guardians take care of children and have time available for interview. Men, more often than women refuse to participate in the survey. Although the majority of young people is studying at educational institution, significant proportion of them (41%) is looking for an appropriate job for income generation. The most common types of current occupational activities of young people are trade, agriculture, and miscellaneous physical work. Living together with parents in the same house is common in Armenia (97%). The housing conditions, especially in rural areas, are not satisfactory in most of the cases (91%). There are certain difficulties with water supply, power systems, and sanitation.
Awareness, knowledge, and personal beliefs about sexuality and SRH related issues Almost 10% of young people associate the word “sex” with prostitution, or relationships outside the marriage, or behaviour of “street” people, or pornography, or striptease etc. About 22% of young people and 10% of adults have no idea about possibility of teenage pregnancy. The most frequently reported by young people known methods of contraception are condom (88%) and withdrawal method (25%), while level of awareness about hormonal contraceptive pills (12%) and IUDs (4%) is very low. For adults over 24 years of age the most frequently reported known methods are condom (93%), withdrawal method (72%), and intrauterine device (67%). Only 38% of adults over 24 years of age consider hormonal contraceptive pills as reliable method of fertility regulation. Only 19% of young people heard about Gonorrhea, 5% - about Chlamydeous infection, and 4% - about Ureoplasmosis. The awareness on Chlamydeous infection (35%) and Ureoplasmosis (25%) among the adults over 24 is also low. Those young people, who have been provided in the past by training course on sexuality, and sexual and reproductive health have better knowledge about modern methods of contraception, and STIs, including Syphilis, Gonorrhea, and Chlamydeous infections, as compared to those who had no access to reliable information. However, most of young people (95%), regardless access to sex education, know that HIV/AIDS is a sexually transmitted infection/disease, and that condom use is an effective mean for STIs/HIV/AIDS protection (85%). Access to information and medical services on sexuality and SRH issues In most of the targeted Armenian families (82%) parents or guardians rarely or never talk openly with their children about these issues due to the cultural constrains, lack of communication skills and insufficient knowledge on related issues. Most of the students (71%) never talk with their teachers about sexuality, sexual and reproductive health, or experience difficulties during communication about these issues (47%). The access to sexual and reproductive health related medical counseling and care is also limited (20%). Most of the medical services (61%) provided to young people are not “youth-friendly”. Sexual, marital, and reproductive behavior The majority of young people born between 1977 and 1988 (70% females, 92% males) experience first feeling of love before reaching 24 years of age, in fact, more than one half (51%) of young males and 19% of young females report about the start of sexual relationships by that time. Meanwhile, the great majority of the Armenian females (83%) and males (94%) born between 1930 and 1988 have their first sexual experience before the age of 24 years old. About 25% of girls have their first sexual relationship in their adolescent ages, between 13-19, and 23% of girls get married in the same period of their life-spin. In fact, only 7% of boys marry between the ages 13-19. By the age of 24 the majority (80%) of females and more than one half (51%) of males start their family formation. Girls, who were born between 1977 and 1988, have their first sexual experience at the average age of 19, which is about 2 years less than the average 21 for females born in 1976-1952, and about 4 years less than the average 23 for those born earlier. In fact, boys who were born between 1977 and 1988, have their first sexual experience at the average age of 15, which is about 5 years less than the average 20 for males born in 1976-1952, and about 7 years less than the average 22 for those born earlier. Girls are still getting married within one year after the first intercourse, while boys are getting married about 4-5 years later. Traditionally, the first child for Armenians is mainly wanted child and termination of the first pregnancy is an exception. There are about 2 children per family in the average (Median=2, Mean= 2.3 ±0.83). Most of the couples, which are married or are living in consensual union, have at least one child, however 6% of them are childless. Young men, who had no access to accurate information on sexuality and sexual health, started their sexual activity about 1 year earlier, as compared to those who had been trained on SRH issues or had received related information from trained peer-educators. It was found also that only 41% of sexually active young females below 25 years of age have ever used means of family planning, however this indicator increases with the age (65% among females above 24 years old). The majority (72%) of sexually active young men and those above 24 years of age (73%) or their partners have ever used condoms or other means of contraception. Young people rarely use hormonal contraceptive pills, intrauterine devices (IUDs) and other modern methods. The first most popular method ever used by adults above 24 years of age is male condom (61% of females and 73 % of males), and the second most popular method is IUD (17% of females and 13% of males). Only 5% of females ever used of hormonal contraceptive pills, and only 4% of males reported ever use of hormonal contraceptive pills by their partners. About 12% of sexually active young women below 24 years of age and 41% of older women are current contraceptive users. Young men below 24 years of age are better contraceptive users than older men (56% versus 42%). About 6% of young females and partners of 3% of young males have ever experienced induced abortion. The number of abortions increases with age. The frequency of abortion use is much higher among adults over 24 years of age. The majority of adult females above 24 years of age (72%) have had at least one abortion during their lifetime. The average number of abortions during lifetime is 3 (Median=3). Attitudes towards provision of sex education to children and adolescents The majority (67%) of young people and (74%) adults over 24 years of age have an opinion that parents and teachers are responsible for sex education of children and adolescents. About 70% of all respondents have an opinion that mothers have to take care of sex education of their daughters, and fathers - of their sons. Most of the respondents (88%), regardless their age and access to information on SRH related issues, stress the needs and demands for introduction of sex education into the curriculum of public school. By opinion of 75% of young people and 76% of adults over 24 years of age this will not have negative influence on sexual behavior of adolescents. The general opinion, expressed by 95% of respondents is that teachers of Biology or of any other subject, who have appropriate knowledge and communication skills in Youth sexuality and SRH, are eligible for teaching this subject at school. The majority of target population (87%) prefer introduction of sex education as a separate subject in the school curriculum, rather than integrated with other subjects. Opinions on whether boys and girls have to participate at sex education lessons together are controversial. More than one half (51%) of young respondents preferred joined for both genders sex education, while 50% of adults over 24 years of age preferred separated education. There is also another opinion that boys and girls have to participate at these lessons together, with an exception of some lessons that should be provided separately. Young people prefer provision of sex education in schools starting from the average age of 14 years (Median =14), while adults over 24 years of age recommend to start from the age of 13 (Median =13). The majority of young people and those who are over 24 years of age consider important to introduce to 13-14 years old adolescents the following topics: personal hygiene, puberty, menstruation, wet-dreams, sexual intercourse, pregnancy and childbirth, fertilization and conception, abortion, HIV/AIDS and other STIs. The majority of young people (90%) are willing to participate personally at sex education courses. Most of the adults over 24 years of age (93%) are interested in possibility of participation at sex education courses for their own children or children who are under their care.
7.3. Conclusions The main conclusions that have been drawn from this study are described below: General characteristics of target population: 1. Taking care of children and their education is predominance of women. 2. Young people live together with parents and are growing up in inappropriate housing conditions with the poor standards of living. Significant proportion of them has willingness to generate an income and support the family. Awareness, knowledge, and personal beliefs about sexuality and SRH issues 1. Generally speaking, the awareness and knowledge among young people, as well as adults above 24 years of age about some important issues related to pubertal changes, human sexuality, sexual relations, pregnancy and childbearing, family planning, abortion, HIV/AIDS and other STIs is not sufficient. Existing information on these issues is often inadequate and misleading. 2. Those young people, who have been provided in the past by training course on sexuality, and sexual and reproductive health have better knowledge about modern methods of contraception, and STIs, including Syphilis, Gonorrhea, and Chlamydeous infections, as compared to those who had no access to reliable information. 3. Most of young people, however, regardless access to sex education, know that HIV/AIDS is a sexually transmitted infection/disease, and that condom use is an effective mean for STIs/HIV/AIDS protection. Access to information and medical services on sexuality and SRH issues 1. In most of the Armenian families parents or guardians rarely or never talk to their children openly about these issues due to the cultural constrains, lack of communication skills and insufficient knowledge on related issues. 2. The school does not provide young people with information on sexuality, and sexual and reproductive health. Most of the students never talk to their teachers about sexuality, sexual and reproductive health. Teachers experience difficulties in provision of sex education due to the lack of knowledge and communication constraints. 3. The access for young people to sexual and reproductive health related medical counseling and care is also limited due to unavailability of “youth-friendly” services, as well as because of cultural and financial constraints. Sexual, marital, and reproductive behavior 1. The average age at the first sexual intercourse has declined in recent generation of males and females. It is lower among rural and less educated people. 2. The access to reliable and accurate information on SRH related issues does not contribute to earlier start of the sexual activity among young people and helps to develop responsible sexual behavior. 3. Cultural traditions and moral norms still have significant influence on public attitudes towards gender related sexual, and reproductive rights. There is the national tradition for females to keep their virginity until marriage, while premarital sexual relationships in males are quite common and acceptable. 4. Expectation that a woman should be a virgin before marriage increases the chance of early marriage. Significant proportion of girls have their first sexual relationship in their adolescent ages, between the ages of 13-19, and get married in the same period of their life-spin. 5. The urbanization and education are important determinants of sexual, marital, and reproductive behavior of target population. The average ages at first sexual intercourse, first marriage and first birth are significantly lower in rural people than in urban. Women and men, who have university level education, start their family formation about 3-4 year later, as compared to those with lower educational status. 6. The majority of young females and more than one half of males start their family formation before the age of 25. The national behavior of having first child without postponing within one year after the marriage is still common and results in high teenage fertility rate. Traditionally, the first child for Armenians is mainly wanted child. Termination of the first pregnancy is not common. In the average there are about 2 children per family. 7. Most of sexually active young women do not use contraceptive methods. Young men are better contraceptive users than older man of reproductive age. The first most popular methods of family planning ever used are male condoms, and the second most popular method is IUD. The hormonal contraceptive pills, intrauterine devices and other modern methods are rarely used. 8. About 6% of young females have experienced induced abortion and its number increases with women’s age. The majority of adult females above 24 years of age are having at least one abortion during their lifetime and the average number is 3. Attitudes towards provision of sex education to children and adolescents 1. The general public opinion is in favor of provision of sex education to children and adolescents, and introduction of the subject of sex education as a separate subject into the school curriculum, starting from the age 13-14 years of age. Most of them have no fears that sex education will have negative influence on sexual behavior of adolescents. 2. The general opinion is that teachers of Biology or of any other subject, who have an appropriate knowledge and communication skills in Youth sexuality and SRH are eligible for teaching this subject at school.
3.4. Recommendations Below are recommendations that could be used for planning effective information, education and service delivery campaigns, and projects. Public information and education 1. There is a priority need for ongoing public information and education campaign to address the issues of pubertal changes, human sexuality, gender related reproductive rights, sexual relations, pregnancy and childbearing, family planning, abortion, and prevention of STIs/ HIV/AIDS. An effective IEC strategy needs to be developed and introduced. Information should be provided as close as possible to the community. Adolescents, youth, and adults of reproductive age should be targeted in this campaign, with particular emphasis on vulnerable groups within the population. The public at large can be reached with specific information with the help of mass media, printed materials, and telephone “hot lines”. 2. The sex education should be introduced as a separate subject into the public school curricula, starting as the pilot projects from local levels, and going up the scale to the regional and national levels. Government should develop and adopt culture-appropriate policy on Sex Education, in collaboration with national experts and NGOs having experience in this field. The appropriate name of this subject should be chosen; the age-appropriate school programme should be developed, together with teacher’s guide and textbooks for children. The most preferable age for starting of sex education in school is at the age of 13 years old. In general, boys and girls have to study together, however, the possibility of providing selected lessons separately should also be considered. Schoolteachers and nurses have to be carefully selected and trained in order to improve their professional knowledge and communication skills on SRH issues. 3. The special emphasis should be provided on training and on-going support of peer-educators at each level (schools, colleges, universities, institutes, orphanages, institutions of specialized care, etc.), including of so-called “street children”. Parents have to be provided with appropriate information and printed materials on related issues. 4. There is a need for ongoing advocacy and awareness raising campaign among men about shared responsibility of both parents in taking care of children and their education. Professional education 1. The quality of SRH education of medical university/colleges graduates and postgraduate students should be considerably improved. The special graduate and postgraduate training programs should be introduced in the pedagogical colleges and universities. 2. Counseling, clinical and communication skills training courses on FP/SRH should be provided for physicians, nurses and midwifes. 3. Training of journalists and reporters from mass media on FP/SRH issues may help to further disseminate responsible educational campaigns within the public at large. Improvement of access of young people to the SRH services 1. The governmental public health expenditures should be increased in order to provide all adolescents with free access to counseling and the primary medical care on issues related to SRH. There is a need to upgrade existing primary health care public facilities in order to provide young people with elementary SRH counseling, first aid and referral. 2. The services should be established as close as possible to adolescent’s homes or at school in order to reduce the barriers of distance and lack of transport. They have to be advertised and provided by the trained professionals, with respect and dignity, in privacy, and confidential manner in order to make it “youth-friendly”. The both genders should have an access to these services. 3. The challenge for reproductive health programs is to promote contraception together with safe abortion services. There is a need for a long-term supply of safe, effective, and affordable options for contraception, as well as essential drugs and supplies. The condoms should be available for young people in order to prevent unwanted teenage pregnancies and the spread of HIV/AIDS and other STIs. |