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De Eso No Se Habla: An Explorative Study on the Sexual and Reproductive Health Education Of Adolescents in the Monteverde Zone Globalization and Community Health University of South Florida Monteverde Instituto Summer 2006 Group Members Hollie Fuhr ma n n 3 rd year A nthropology Ph.D. student at University of South Florida. Spanish Level: Intermediate. Jennifer Garcia Senior u ndergrad in Anthropology at University of South Florida. Spanish Level: Beginner. Nicole Haykin 2 nd year Anthropology M.A. s tudent at California State University, Northridge. Spanish Level: Intermediate. Rebecca Sameroff Senior undergrad in a dual program in Anthropology and Pubic Health at Northwestern University. Spanish Level: Beginner. Rebecca Todd Senior undergrad uate in the University of South Florida. Spanish Level: Beginner. Introduction The Monteverde Zone was once a relatively remote and isolated location. However, within recent years influential factors including globalization, modernization, and increasing tourism have changed the structure of the community. Temporary residents including students, volunteers, tourists, and migrant workers affect all facets of society, including issues pertaining to sexual and reproductive heal th.
2 Because of these influences community advisors identified sexual and reproductive health as topic of concern. Thus, for the first time, sexual and reproductive health was identified as a research topic in the 2006 field season of Globalization and C ommunity Health in the Monteverde Zone. Through our community advisors, our group was able to narrow this topic to the sexual and reproductive health of adolescents. And, in fact, the statistics from the local EBAIS supported the need to examine the sexu al and reproductive health needs of adolescents in the Monteverde zone. The following charts demonstrate that there is a high incidence of adolescent pregnancy in the Monteverde Zone and a low level of reported contraceptive use. 2005 Monteverde EB AIS Table 1: Adolescent Pregnancy Births from Adolescents >19 Total Births % 2000 14 82 17.07 2005 18 107 16.8 Table 2: Reported Contraceptive Use by Adolescents GO DIU M CONDOM F CONDOM INJECTION NATURAL M STERILIZATION F STERILIZATION 8 0 6 8 8 0 0 0 (Ministerio de Salud 2006) Goals With all of this information and context in mind, we formulated the following three questions as a guide to our research.
3 1. How and where do adolescents in the Monteverde zone receive information regarding the ir sexual and reproductive health? 2. What are the most important issues with regards to the sexual and reproductive health of adolescents in the Monteverde zone? 3. How can the process of educating adolescents about their sexual and reproductive health be impro ved in the Monteverde zone? In order to answer these questions, we decided to recruit sexual and reproductive health educators, parents of adolescents, and adolescents themselves to participate in our exploratory project. By doing so we aimed to identify overlaps, contradictions, and gaps that may exist in the perceptions of these three participant groups with regards to the sexual and reproductive health education of adolescents in the Monteverde zone. Literature Review A ny discussion of sexual and rep roductive health must note the international context of reproductive health specifically the recent recognition of universal reproductive rights and the special reproductive needs of adolescents. Thus, the following section of our report will b riefly exp lore reproductive health and reproductive rights with particular focus on their intersections reproductive health as well as contributing factors in developing countries, particularly in Latin America will be examined through a brief literature review. Reproductive Health and Reproductive Rights In 1994 the United Nations International Conference on Population and Development (ICPD) was held in Cairo, Egypt. O ut of this conference came the ICPDs 1994 Programme of Action (PoA) and an international ly accepted definition of reproductive health.
4 Reproductive health is a state of complete physical, mental and social well being in all matters relating to the reprodu ctive system and to its functions and processes. It implies that people have the capability to reproduce and the freedom to decide if, when and how often to do so. Implicit in this is the right of men and women to be informed and to have access to safe, ef fective, affordable and acceptable methods of family planning of their choice, as well as other methods of their choice for regulation of fertility, which are not against the law, and the right of access to health care services that will enable women to go safely through pregnancy and childbirth. Reproductive health care also includes sexual health, the purpose of which is the enhancement of life and personal relations. (7.2) Drawing upon universal human rights already recognized in national laws and inte rnational human rights documents, the ICPDs 1994 PoA went on to declare universal repro ductive rights. These rights rest on the recognition of the basic right of all couples and individuals to decide freely and responsibly the number, spacing and timing o f their children and to have the information and means to do so, and the right to attain the highest standard of sexual and reproductive health. It also includes the right of all to make decisions concerning reproduction free of discrimination, coercion an d violence as expressed in human rights documents. In the exercise of this right, they should take into account the needs of their living and future children and their responsibilities towards the community. The promotion of the responsible exercise of the se rights for all people should be the fundamental basis for government and community supported policies and programmes in the area of reproductive health, including family planning. As part of their commitment, full attention should be given to the promo tion of mutually respectful and equitable gender relations and particularly to meeting the educational and service needs of adolescents to enable them to deal in a positive and responsible way with their sexuality. (7.3) This declaration of universal hu man rights was a watershed moment in population on population policy and family planning to a new paradigm that is broad, holistic, and rights based. This shift c hallenged stratified reproductive rights, which only attended the reproductive needs of a particular population that was both socially defined and approved, in most instances married white women. This shift also broadened the scope of reproductive health beyond traditional patterns of maternity care, family planning, and government pro or anti natalist positions to encompass reproductive tract infections, abortion, harmful traditional practices, the
5 impact of violence and environmental insults upon the re productive health and fertility of both men and women, and cultural perceptions of reproductive health needs (Anderson 2005 ) Reproductive Rights for Adolescents repro ductive needs and rights of adolescents. The reproductive health needs of adolescents as a group have been largely ignored to date by existing reproductive health services. The response of societies to the reproductive health needs of adolescents should be based on information that helps them attain a level of maturity required to make responsible decisions. In particular, information and services should be made available to adolescents that can help them understand their sexuality and protect them from un wanted pregnancies, sexually transmitted diseases and subsequent risk of infertility. This should be combined with the education of young men to respect determination and to share responsibility with women in matters of sexuality and reproduc tion. This effort is uniquely important for the health of young women and determination and, in many countries, for efforts to slow the momentum of population growth. Motherhood at a very young age entails a risk of mater nal death much greater than average, and the children of young mothers have higher levels of morbidity and mortality. Early child bearing continues to be an impediment to improvements in the educational, economic and social status of women in all parts of the world. Overall for young women, early marriage and early motherhood can severely curtail educational and employment opportunities and are likely to have a long term, 94 PoA also points out risk factors, particularly in developing countries, which can contribute to poor sexual and reproductive health among adolescents. Poor educational and economic opportunities as well as sexual exploitation are identified as importan t factors in high levels of adolescent pregnancy. Furthermore, the document acknowledges the vulnerability of adolescents, particularly young women, to engage in early sexual activity which put them at higher risk for contracting and transmitting sexually transmitted illnesses and emphasizes the need to create participatory programs that secure the full involvement of adolescents in the program development process. Madreselva
6 Madreselva is a non governmental organization in Costa Rica that aims to pr ovide services and implement public policies that will improve sexual and reproductive health of Costa 1994 PoA, Madreselva recognizes the special sexual and re productive health needs of adolescents. In fact, one of its main goals is to implement a sexual education program in the Costa Rican education system that examines sexuality from the position of diversity and plurality in terms of sexual orientation. In addition, Madreselva is currently offering services and working to implement policies that will reduce the number of undesired pregnancies in Costa Rica, particularly among adolescents. As mentioned previously, the rate of teenage pregnancy in the Monteve rde zone is disconcerting at 16.8%. The Sexual and Reproductive Health of Adolescents in Developing Countries Adolescents are typically identified as persons somewhere between 10 and 20 years of age. They comprise approximately 20% of the world population (Blanc 1998:106). In developing nations, adolescents account for approximately 30% of the population (Hughes 1998:236). These numbers indicate that adolescents are not only a large portion of the world population, but also that it is important to focus o n adolescents because they play a large role in shaping the future. In addressing the sexual and reproductive health issues of adolescents it is important to first understand their social contexts. In Latin America and the Caribbean in general, cultura l roles heavily influence accessibility and availability of information on sexual and reproductive health. Early sexual initiation in Latin America reflects a variety of social issues, particularly for women (Remez 1989:144). It is often related to negat ive attitudes towards female sexuality. This includes the lack of alternative roles and opportunities for women, which is a problem
7 particularly in rural communities. Early sexual initiation can also be an indicator of inadequate sexual education. While in the past many Latin American women were married at a very young age, modernization, increasing educational possibilities and job opportunities have meant that many young women are getting married later in life. Studies in Costa Rica have shown that p remarital sex is quite common (Rosero Bixby 1991:25 29). Approximately 38% of unmarried women have had sex by the age of 20. The highest occurrence of premarital sex occurs between the ages of 17 and 19. In Costa Rica, it is believed that increased educa tion, higher socio economic status, and modernity are conducive to such behavior. However, there are some limitations to this study. The first and most obvious is how to define sex. No definition was offered for the purpose of this study. The second li mitation is the willingness of participants to admit their sexual encounters. The third limitation is related to the role of engagement. It is common in Latin American society to view premarital sex as acceptable as long as the couple is engaged, regardl ess of the length of engagement. The same rule applies for consensual unions. Other factors are of importance to the incidence of premarital sex, both at the micro and macro levels. At the micro level is the individual personality which includes their v alues, beliefs, and opinions. At the macro level is the social environment they have been exposed to. This includes societal values and cultural marriage norms. Another issue of concern in Latin America is that of adolescent pregnancy. In South Ameri ca, the average annual rate of premarital conceptions ranges from 25% in parts of Ecuador to 63% in Santiago, Chile. This supports the common conception that marriage is often to legitimize a birth (Remez 1989:145). Adolescent pregnancy is an important i ssue around the world and in particular Latin America because of it s many potential negative outcomes. These
8 include high risk pregnancies which can result in miscarriage or maternal death, unsafe abortion complications from undesired pregnancy, in additi on to social, educational, and economic disadvantages (Blank 1998:107). While individual personality and social environment play a role in the above factors, there is also a general lack of available and accurate information regarding sexual and reprod uctive health. While most parents would prefer to be the main source of information, they are often confused, ill informed, or embarrassed to speak about the subject with their children (Hughes 1998:234). Additionally, existing research indicates that the re is a poor fit between adolescents and current programs (Hughes 1998:234). It is important to realize that improving these programs is only a partial solution to solving the sexual and reproductive health problems of adolescents, particularly in Latin A merica. In general, the most common sources of information other than parents are schools, the media, and local clinics (Hughes 1998:236). However, many adolescents avoid the clinic for fear of being chastised or revealed to their families. Often a firs t visit to the clinic is because o f infection or pregnancy Social taboos are a huge barrier for adolescents to overcome. One of the most common is the reluctance of females to request condoms out of fear of being labeled as promiscuous (Hughes 1998:234 235). Also important to point out is that adolescents do not always have control in terms of their sexual education and health. Factors such as poverty and coercion can influence availability and access for adolescents (Hughes 1998:235). Methodology Th is explorative study of the sexual and reproductive health education of adolescents employed both qualitative and quantitative methods. These methods included surveys, one focus group, three interviews, and ar chival research As mentioned previously, t he above methods
9 were execut ed amongst three distinct participant groups: (1) adolescents a ged 14 to 20; (2) parents of adolescents aged 13 to 20; and (3) sexual and reproductive health educators in the Monteverde zone. Preliminary lectures and meetings with local community members were held to discover what issues appeared to be a prominent concern of the community. Initial surveys were distributed at a community health assessment in Caitas, a small town located within the Monteverde Zone. The first s ection of the survey assessed socio demographic information (See Appendix ) and was given to all adults that attended the health assessment. The second section of the survey (See Appendix ) was given to adults with adolescents between the ages of 14 and 20. The purpose of this second section adolescents acquire information on sexual and reproductive health. Additionally, it asked how often they spoke with their children about the subject and what they believed to be the most important issues on the matter within the region. This sur vey was later distributed amongst residents of the Monteverde zone with the help of the Monteverde Institute and its community contacts. There were 30 participants surveye d in total. The focus group consisted of four girls and was held on a weekday afternoon at Casa Club in Caitas. The adolescent girls were also recruited through the Monteverde Institute as well as through recruitment fliers (See Appendix) that were sen t home with participants at the health fair and students living in home stays. The girls were asked open ended questions to assess what issues are important to adolescents in terms of sexual and reproductive health and then were asked to rank them in order of importance. The semi structured interviews were held with community leaders from the Monteverde Clinic and a Colegio in the Monteverde zone which will remain anonymous. The first interview
10 with a nurse from the clinic took place in her home. The se cond group of interviews with a teacher and guidance counselor from the school took place on the campus itself. Confidentiality of all participants has been of strict importance. Permission was received from all participants prior to their involvement as well as any tape recording (See Appendix ) Additionally, no names were used and no photographs were taken of any participants. A coding system was used to identify and organize surveys. All data was cross referenced between parents, educators, and adolescents to gain insight on where adolescents receive information on reproductive and sexual health. Major themes were identified and examined. All of the survey data was recorded and analyzed in SPSS. Results Where and How do Adolescents Receive Inf ormation About their Sexual and Reproductive Health? Parents of Adolescents From our survey results the parents indicated ten possible avenues where they believed their children were receiving information regarding sexual and reproductive healt h. Graph 1 below illustrates that the parents perceived their adolescents to be receiving information primarily from school, family, and the clnica with church, work, and books receiving the least amount of responses.
11 Graph 1: Where Parents Perceive Adolescents Receive Information Regarding their Sexual and Reproductive Health Sexual and Reproductive Health Educators Colegio The sexual health curricul um at the Colegio which is created and mandated by the National Ministry of Education and must be accepted by the Catholic Church, is primarily taught in 7 th and 8 th grades. There is a significant decrease in the time allotment for the 9 th grade due to the preparation requirements of the National Test. During the 9 th year, when adolescents a re between the ages of 13 and 15, the science curriculum devoted to sexual heath and reproduction is reduced to one 40 minute class per week for a two month time period. In 10 th grade, this is further reduced to one week. While there is a formal curricu lum that includes such topics ranging from anatomy and preference, teaching in a dynamic manner which utilizes educational tools such as group research projects, w orkshops, and role playing, particularly for the latter three grades where there is very little time devoted to the subject
12 C l nica A nother source of sexual health information for adolescents comes from the health clinic. Here youths are assessed on th eir first visit using the Tamizaje Questionnaire. This helps health professionals to engage the needs and services that they should offer. The clinic also holds a monthly meeting, Reunion de Adolescents, which serves as a co ed forum for adolescents betw een the ages of 14 and 19 The topics are decided upon by the attending students and range from drugs, to contraceptives, to STIs and beyond. The Reunion usually hosts between 15 and 20 students, primarily from the Colegio with a significantly higher per centage of female students regularly attending due to the cultural constructs of machismo and patriarchy. Adolescents things are that ac nt a granddaughter As you can see from these quotes, from some of the members of our focus group, the adolescents were very open and poignant in their assessment of their sexual education. The y mentioned school, the health clinic, their families, and the streets as some of the greatest sources of their sexual and reproductive health knowledge. As the impact of tourism steadily increases and the breadth of globalization penetrates the Monteverd e Zone, the adolescents mentioned the pervasiveness of media in the forms of music, magazines, and television as strong influential factors.
13 The adolescents tend to view the formal sexual and reproductive health instruction they receive in the public sc hools as a technical, general, and somewhat superficial education. The students also mentioned their families as being contributors to their sexual heath knowledge. However, they seemed to feel a reluctance to openly discuss this topic with their families alluding to feelings of embarrassment and a lack of knowledge on the subject. They also mentioned that there are stereotypes and taboos such as teenage pregnancy that their families did not want to encourage with open discussion. The information that t he adolescents learned on the streets and from one another remained the most si gnificant. Here it is critical to point out a contradiction between where parents perceive their adolescents receive information regarding their sexual and reproductive health and where adolescents said they receive sexual and reproductive health information. While parents considered the family to be a significant source of information, the adolescents found this source of information to be problematic and instead discussed the importance of information from friends, which ranked low in parental responses as well as from the streets, which the parents did not even mention as a source of information. What Are the Most Important Issues with R egards to The Sexual and Reproductive Health of A dolescents in the Mont everde Z one? Parents of Adolescents In the survey parents were asked to identify what they perceived to be the most important issues regarding the sexual and reproductive health of adolescents in the Monteverde zone. A s illustrated below, teen pregnancy, contraceptive methods, and STIs/HIV/AIDS were most frequently mentioned, and education, sexuality, and premarital sex were least frequently mentioned.
14 exual and Reproductive Health Sexual and Reproductive Health Educators Colegio Educators at the Colegio identified a variety of themes they felt to be important to adolescents in the Monteverde region. They saw a need to change adolescent co ncepts of sexuality. According to these educators, many adolescents believe that sexuality is simply the act of coitus. Students are having quick relationships and frequent sexual encount ers with one or many partners. The educators stressed that students need to be aware that having a boyfriend or girlfriend does not mean that you have to have sex with them immediately or even at all. The above issue was also linked to a growing problem with materialism. In recent years, t he educators have witnessed an i ncreasin g trend towards materialism which is affecting who students date and why they date them. Adolescent g irls have been known to exchange sex for mo ney or other goods particularly with taxi drivers or men who have cars. The car is seen as a symbol o f wealth as well as freedom to travel. Taxi drivers can exchange their transportation services for sexual encounters and are more likely to have cash readily available.
15 In addition, the educators discussed the need for open dialogue amongst parents and c hildren, students and teachers, and even amongst friends. Opening this dialogue may first require that the parents be educated about these issues. In fact, many of the adolescents have asked the educators to organize a special workshop for parents. The educators also pointed out that through education and open dialogue that false information and myths can be dispelled and replaced with accurate information. Finally, the educators mentioned many of the same issues as the adolescents which will be discus sed later. These include contraceptive methods, sexually transmitted infections, social and family problems, and teenage pregnancy. Cl nica One of the primary concerns of the clinic with regard to adolescents is the need to educate about contraceptive s. Once again, adolescents should be aware of the different methods (natural and artificial), how they function, when to use them, their effectiveness, and their potential side effects. A nurse at the clinic said that many adolescents have said to her, Another important issue raised at the clinic was that of fidelity and abstinence. Given the small size and relatively remote location of Monteverde, many res idents falsely believe that tourism have affected the community in many ways. First of all, there are many temporary visitors to the community, including tourists, st udents, and people from other cities who come to work for a short period before returning home. Second, in order to accommodate these temporary inhabitants, many local children are going to school just long enough to learn English so that they can work in the tourism industry. They are moving out of their homes early and
16 living with many other young people. Often this leads to increased usage of drugs and/or alcohol. If these adolescents become pregnant, they are typically not the ones raising their chi Finally, the lack of recreational outlets in the region was mentioned as a source of potential problems for adolescents. Because of this, many adolescents spend much of their time on the streets at night. Adolescents In the focus group held in Canitas, four adolescent girls were asked to identify and rank in order of importance the most important issues for adolescents in the MV Zone regarding sexual and reproductive hea lth. At the top of the list was the need to emphasize contraceptive meth ods, m ore specifically, how to use them, their efficacy, and side effects. In particular, the girls mentioned the need to know the correct use about condoms. Second on the list was to need to learn more about sexually transmitted infections. Specifically, to be made aware of the various types, their causes and consequences, in addition to how to treat and cure them. The girls pointed out that they often hear about HIV and AIDS but it is important to educate adolescen ts that this is not the only sexually transmitted illness Third, the girls believed there to be a need to have workshops and courses in schools, colleges, and in communities that cover all subjects pertaining to sexu ality and reproduction. Fourth, it was po inted out that social problems are of increasing importance to adolescents in the Monteverde region. This includes themes such as drugs, prostitution, and family problems.
17 Fifth, adolescent pregnancy is an import ant theme of concern amongst adolescents in the region. This is of course, related to availability and proper execution of contraceptive methods. avoided. Teen age pregnancy happens because of lack of contraceptive methods and because of th on the list for adolescents, whereas the parents ranked this as number one. Finally, the girls mentioned the need to discuss appropriate methods of personal hygiene. Methodologically, it is important to note that this listing and ranking activity took place at the beginning of the focus group. As the discussion progressed, the major issues of importance shifted to t hemes of sexuality and how education can address the more cognitive, emotional, and relational aspects of sexual health. This will be discussed more in depth later. How Can the Process of Educating Adolescents about their Sexual and Reproductive Health b e Improved in the Monteverde Zone? Our third research question explored how adolescent awareness and education about sexual and reproductive health could be improved. We again gathered information from the perspectives of parents of adolescents, educator s from the public school and the clinic and, of course, the adolescents themselves. All groups had ideas of how to improve sexual education as a preventative measure against important issues mentioned earlier. Parents of Adolescents Parents of adolescent sexual and reproductive health information could be improved. Over half of the adults surveyed imp ortance of beginning to discuss these issues at an early age and described the closeness of
18 familial relationships as a major benefit to learning about sexual health in the household. Trust between family members came up in many responses as a source of t improvements related to education and the availability of accurate information, often mentioning schools as the proper source of this knowledge. answers that suggested a general increase in communication about sexual and reproductive matters would benefit adolescents. Parents talked about the importance of breaking social and cultural taboos as an important outcome of open communication in the community. Another popular suggestion similarly called for an increase in more formal types of communication such as lectures, workshops and charlas, where adolescents coul d have access to professionals, gain knowledge through creative methods or exchange experiences and information. Graph 3: Parents Perceptions about How the Process of Educating Adolescents about their Sexual and Reproductive Health can be Improved
19 Sexual and Reproductive Health Educators Colegio In an interview with educators from the Colegio, our conversation about for raising sexual awareness and c onsciousness in adolescents and discussing sexuality in the Educators suggested more dynamic types of education to supplement the official curriculum provided by the National Ministry of Education and described their experiences usin g additional activities, such as role playing, that they found very successful in the school. However, the need for more time dedicated to sexual and reproductive health education came up many times as a severe limitation to their ability to incorporate these creative activities. This limitation weighs heavily on the curriculum of students in the 9 th grade particularly due to the national examinations that Jennifer mentioned earlier. part of everyday life as a necessity for improving the sexual health of their students. Educators felt that most adolescents think about sexuality as limited to the act of sex, which leads to dangerous behaviors. Helping adolescents understand that there can be sexuality without sex and relationships that are not sexual relationships is seen as important. They suggested dynamic, participatory workshops as a tool for accomplishing this goal. Educators also spoke of the benefits of creating a more integr ated curriculum that involve other community groups that are influential in shaping the knowledge available to teens. Parents, the clinic and the church were specifically mentioned. Clnica Educators at the clinic echoed many of these concerns and sugge stions. One educator from the clinic explained how adolescents could benefit from having a specialist in
20 schools specifically responsible for teaching sexual and reproductive health and easily accessible to adolescents. The need for a more dynamic learni ng process was also reiterated. Importance of spreading prevention awareness was stressed, esp making teens aware that they must pay attention to sexual histories. Increased recreational activities, brought up in our parent surveys, was also mentioned as there is little in this area for adolescents to do. Adolescents In our adolescent focus group, our conversation about improvements to education also rested largely on the need for expanding beyond just contraceptives and STIs and changes to teaching metho dology. While the group agreed sexual and reproductive education must be emphasized in school, they stressed that it must not be taught like an ordinary scholastic subject Sexuality was kind of curriculum that addressed sexuality as more of a life skill. The girls had a great deal to say about this problem and agreed that classic methods, such as memorizing information about contraceptive methods from a book, were far too superficial f or such a complex issue. On e girl noted that with current edu cation methods the information does not sink in: Adolescents also discussed the ways in which they believed parents af fected the educational options in schools. Some parents worry that educating about sexual and reproductive health might motivate adolescents to become sexually active stereotypes and taboos were also mentioned here.
21 This potential conflict between the i nterests of some parents and educators over this matter was reminiscent of our conversation with public schools educators about the benefits of an integrated program that would actively involve parents and constructively address differing opinions. The gr oup discussion about how education could address the issue of adolescent pregnancy was especially interesting. Throughout our data collection, adolescent pregnancy came up most frequently as a community concern, so we were not surprised that it was also a topic in our focus group. The adolescents, however, discussed this issue from a completely new angle, addressing the stigmatization and discrimination experienced by pregnant teenagers. The girls explained how education that promotes tolerance would re duce the psychological burden on pregnant teenagers, specifically mentioning pressures they may feel to consider abortions. At the end of the focus group, the discussion about improving education and awareness was summarized as the need to start education early with correct information and with an emphasis on maintaining an open mind. This mentality would break the existing taboos and stereotypes that make open discussion about sexuality inappropriate and fuel discrimination. What is the Significance of S exuali dad ? Parents of Adolescents Although sexuality has not been a significant topic in our presentation thus far, it was repeatedly referred to, addressed, and, even, debated by parents, sexual and reproductive health educators, and adolescents. Only t hree parents that were surveyed considered sexuality in terms of sexual orientation, respect for body, and sexual health to be an important issue for adolescents. And, although, neither the sexual and reproductive health educators nor the adolescents dire ctly
22 identified sexuality as an important issue it was a ubiquitous issue, always lingering just below the surface. Sexual and Reproductive Health Educators Colegio According to both of the instructors we interviewed from the Colegio de Santa Elena, s exuality is defined through human relationships. They integrated this concept with our daily live and interactions. However, as discussed previously by Nicole, both teachers strongly felt that adolescents did not perceive sexuality the same way, and, ins tead confused sexuality and, thus, intimate human relationships with the actual act of sex. Clnica Although the sexual and reproductive health educator at the clinica did not ant to be open about program refers to PAIA, the adolescent reunion group that meets monthly at the clinica Thus, here we can see again that sexuality is a sig nificant issue, but one that is not readily identifiable. Adolescents It was the adolescents themselves that were most informative about sexuality and its significance. Throughout the focus group the adolescents preferred to use sexualidad instead of sal ud sexual y reproductiva When asked to explain the meaning or significance of sexualidad the following discussion occurred: A: chool but it is more than that. B: Well it is the action but not only the action A: con vivencia between genders. B: cognize it we are all tog ether. D: a game.
23 C: r of a book or as a topic of a class then, no, but if we see it as a broad thing that is part of life then si lo sera (it will be) As you can see, there was some disagreement amongst the girls. The teenager identified sexualidad differently than the other three teenagers. Her interpretation limits sexualidad to sex for the purpose of reproducing while the other three girls reach a consensus that sexualidad is a part of daily life and human relationships. The phrase con viviencia is particularly indicative of how the teenagers conceptualize sexualidad in their own lives. Con viviencia is not a phrase that can be translated and easily captured in English. It refers to shared lives and experiences amongst family, friends, and partn ers. Recommendations Based on the information we collected, the following is a list of recommendations for improving the sexual and reproductive health of adolescents in the Monteverde zone as well as how the process of educating adolescents about their sexual and reproductive health can be improved in the Monteverde zone. Encourage communication and open dialogue Open communication and dialogue was emphasized by all of our participant groups. In particular the idea of developing workshops where parents and adolescents can practice their communication skills through role playing was mentioned. Create an integrated s exual and reproductive health e ducation p rogram The sexual and reproductive health educators we interviewed suggested that an integrated sexu al and reproductive health education program could best serve the needs of adolescents. Specifically, this program would involve adolescents, parents, educators, health professionals, church leaders, and possibly the Monteverde Institute.
24 Utilize dynamic and creative teaching methods Examples of dynamic and creative teaching method were often given as a source for improving adolescent sexual and reproductive health education. These include w orkshops, role playing, charlas, research projects, drama, magazi nes, and movies. Emphasize the emotional social, and psychological aspects of sexual and repro ductive health previously, sexualidad was not directly referred to in response t o our questions and investigations; nonetheless, it was significant and sexual and reproductive health education programs for adolescents must engage this topic along with the physical and biological components of sexual and reproductive health. S ugges tio n s for Future Research Further investigate the important issues identified here as well as the possibilities of implementing any of the articulated suggestions Explore how these issues relate to the sexual and reproductive health o f adolescent boys in Mont everde Further explore the concept of sexualidad Further explore the influence of globalization and its many forms, such as materialism drugs, and prostitution, on the sexual and reproductive health of ado lescents in the Monteverde Zone Study Limitations Over the course of our project we encountered various limitations to the collection, analysis and quality of our data. Time was one of our most limiting factors and affected our
25 research in two ways. First, our limited time for data collection affected t he number of parents, adolescents and educators we were able to reach. Many of our requests for interviews with educators were turned down because of conflicting schedules, which may have been sorted out if we had been able contact them further in advance These issues were greatly intensified by a less obvious issue of timing. Our data collection period coincided with local school vacations so many teens were away on vacation and schools could not be used as sources of networking recruitment. Accessing adolescents and school teachers was therefore surprisingly difficult. We were able get educators from one local public colegio to meet with us and, while these teachers gave us their opinions about other local schools (the Creative Learning Center and the Quaker school), we were only able to explore the perspective of educators with a limited scope. Timing also significantly affected our recruitment of adolescents. We had originally hoped for two female focus groups, and then aimed for one male and one fe male group when getting teens began to be problem. The actual focus group consisted of only 4 adolescent girls from 2 public colegios. While the discussion was very rich and provided the richest qualitative data, the small number of participants inherent ly limited the diversity of opinions and experiences we were able to incorporate in our study. Had we anticipated only reaching educators from the public colegios, we may have also tried to specifically recruit students from those colegios to get a more r epresentative data on a smaller population of adolescents (i.e. public school teens). With respect to analysis, more time to completely translate the content of our interviews and focus group would have added to the richness of our qualitative data. The language barrier inherently imposed many limitations on our research had a large impact on our investigation, affecting both data collection and analysis. We anticipated the impact of this limitation and prepared strategies for accomplishing our research goals. As is the
26 case with most exploratory research, our strategies changed significantly as we gained experience. For our earliest interview with a health clinic nurse, we read our questions in Spanish and used a translator to relay back each answer an d translate our probe questions. This method was successful in its inclusion of every group member in the discussion, but the frequent breaks for literal translation interrupted the flow of conversation and created a more formal atmosphere that did not se em compatible with our topic of conversation. Later interviews with educators were conducted in Spanish with a translator present for clarification when needed and assistance translating our unscripted questions. The most successful part of this strategy was our follow up meetings with the translator directly after our interviews during which we would reconstruct the discussion by compiling our notes with those of the translator. In a later interview with a clinic educator we also used a tape recorder, w hich was later translated. Both these strategies were used very successfully in our adolescent focus group. Here the translator also served as the focus group mediator. We hung large pieces of paper on the wall to serve as a place for the discussion med iator to take notes as the girls talked. We also incorporated two writing activities into the discussion to ensure participation from each adolescent. These strategies provided primary written records of the discussion that could easily be translated lat er. Meeting with the mediator to review the notes, followed by pulling significant comments from the audio recordings gave us a rich collection of information. Lastly, both time and language limited our abilities to network for access to educators, paren ts of adolescents, and adolescents themselves. We relied almost completely on the Monteverde Institute in our recruitment of all three samples. Our surveys came primary from the health fair, which is run through the Institute, and a from the home stay fa milies of students from the Institute. Recruitment for our focus group was also done completely through the Institute,
27 although other leads were followed unsuccessfully. This may have had an impact on how representative our sample was of the study popula tions. Acknowledgements We would like to acknowledge the following people. Thank you for all of your support. You made our research project possible! All of the parents, adolescents, and educators who participated in our study The communities of Montever de, Cerro Plano, Santa Elena, Canitas and La Cruz for allowing us to live and work with them Jenny Pe a our program coordinator Dr. Nancy Romero Daza and Dr. David Himmelgreen, our program directors Scott Mitchel and Federico Cintrn, our graduate assista nts Patricia Jimnez, our community advisor The Monteverde Institute The University of South Florida
28 References Cited Ministerio de Salud 2005 C aja Costarricense de Seguro Social: EBAIS 9. Calderon, C., Freidus, A., Gillin, K., Schwar, J., & Weiner, C. 2003 Sexually Transmitted Diseases and Avenues for Education: Community Perspectives from Monteverde, Costa Rica, June 21 August 3. Field Methods for Community Health Report, 34 47. Monteverde: University of South Florida, Program in Applied Anthropology and Public Health. Hughes, Jane & Ann P. McCauley 1998 Health in Developing Countries. Studies in Family Planning 29(2):233 245. Remez, Lisa 1989 Adolescent Fertility in Latin America and the Caribbean: Examining the Problem and the Solutions. International Family Planning Perspectives 15(4):144 148 Rosero Bixby, Luis 1989 Premarital Sex in Costa Rica: Incidence, Trends and Determinants. International Family Planning P erspectives 17(1):25 29. Blanc, Ann K. & Ann A. Way 1998 Sexual Behavior and Contraceptive Knowledge and Use among Adolescents in Developing Countries. Studies in Family Planning: Adolescent Reproductive Behavior in the Developing World 29(2):106 116.
30 Interview Questions: School Teachers Preguntas De la Entrevista: Profesores De la Escuela 1. How long have you been here in the Monteverde area? How long have you been working here at the public school? C unto tiempo usted ha estado viviendo e n la zona de Monteverde? Cunto tiempo usted estado trabajando usted aqu en la escuela pblica? 2. We are interested in what is going on in regards to reproductive and sexual health education within the schools in the Monteverde zone. Could you tell us wh at you know about the sexual education that is offered here at your school? a. What is the curriculum? b. Any talk of contraception? c. Who teaches the class? d. What age/ grade are the students receiving the education? Estamos interesados sobre lo que pasa con respe cto a la educacin de salud sexual y reproductiva en las escuelas de la zona de Monteverde. Nos podra contar lo que usted sabe acerca de la educacin sexual que se ofrece aqu en su escuela? e. Como es el plan de estudios? f. Hay charlas sobre metodos antico nceptivos? g. Quin ensea la clase? h. A qu edad los estudiantes reciben educacin sobre salud sexual y reproductiva? 3. Who makes decisions regarding the content of the curriculum of sexual and reproductive health? Quien o quienes deciden sobre el contenido del curriculum que se imparte sobre salud sexual y reproductive? 4. In your opinion, how does this education compare to that of the other schools in the Monteverde zone? En su opinion, cmo es la educacin sobre salud sexual y reproductiva en su institutio n comparado con la de otras escuelas en la zona de Monteverde? 5. What is your opinion on the education that is currently being provided? What would you change, if anything? Cul es su opinin acerca de educacin que se proporciona actualmente? Qu cam biara usted?
31 6. In your opinion, what are the most significant issues regarding sexual and reproductive health among adolescents in the Monteverde zone? En su opinin, cules son los asuntos ms significativos con respecto a la salud sexual y reproductiva entre adolescentes en la zona de Monteverde? 7. Do you think that those issues should all be addressed and taught in schools or should they be addressed elsewhere? Piensa usted que esos asuntos deben ser enseados en las escuelas o deben ser atendidos en otra parte? 8. In your opinion, what is the best way to educate adolescents on sexual and reproductive health? En su opinin, cul es la mejor manera de educar a los adolescentes acerca de salud sexual y reproductiva?
32 Reproductive & Sexual Health 2006 Estamos estudiantes trabajando con el Instituto Monteverde y estamos interesadas en como aprenden los adolescentes sobre los temas de salud sexual y reproductiva? Los resultados de esta cuestionario nos ayudaran a aprendir mas sobre la educacion y las tem as mas importantes de la salud sexual y reproductiva de adolescentes en Monteverde. Muchas gracias por su colaboracion! 1. Por favor, diganos el sexo y edad de sus hijos/hijas: SEXO EDAD 2. A cul escuela asisten sus hijos/hijas? [ ] es cuela de los amigos [ ] el centro creativo [ ] escuela pblica. Especifique cual: _____________ [ ] otra: ______________________ 3. Dnde reciben sus hijos/hijas la informacin sobre salud sexual y reproductiva? Por favor, marque todos los que aplica n: [ ] escuela [ ] trabajo [ ] otra: ___________ [ ] iglesia [ ] televisin [ ] otra: ___________ [ ] amigos [ ] revistas [ ] otra: ___________ [ ] familia [ ] la clnica [ ] internet/computadora 5. Qu tan frecuen tamente habla usted con su nio/nia sobre la salud sexual y reproductiva? [ ] Nunca [ ] Casi Nunca [ ] Una vez [ ] A veces [ ] Frecuentamente
33 7. En su opinin, cules son los temas ms importantes en la Zona de Monteverde con respecto a la salud sexu al y reproductiva para los adolescents de hoy? 1. Por qu? 2. Por qu? 3. Por qu? 8. En su opinin, cual es la mejor manera de educar a los adolescentes sobre la salud sexual y reproductiva? A. _______________________ Por q u? B. _______________________ Por qu? C. _______________________ Por qu?
34 Focus Group Buenos tardes, gracias por venir a nuestra reunion. Mi nombre es Federico, y mi companeras son Hollie, Rebecca, Becky, etc y trabajamos con el Instituto M onteverde. Hoy vamos a hablar sobre la educacion y temas importantes de la salud sexual y reproductiva de adolescentes en monteverde. Los resultados de esta discusion nos ayudaran a aprendir como la comunidad puede mejorar la educacion sobre estostemas. Queremos enfatizar que las opiniones de todas y cada una de ustedes son muy valiosas, por eso es muy importante que todas participen y expresen sus opiniones y puntos de vista. Nuestro papel aqui es el de facilitar la discusion, no el de juzgar, no hay r espuestas buenas o malas, ademas, todo lo que se discuta en esste salon es totalmente confidencial, nadie va a saber sus nombres, por lo tanto pueden sentirse libres de expresar sus opiniones con toda franqueza. Antes de empezar quiero decirles como va a funcionar esta discusion: Como dije antes, cada persona tiene derecho a expresar su opinion sin ser juzgada por nadie. Si hay algun descuerdo o si gente tiene diferentes opiniones acerca de algo es importante que las personas hablen una a la vez y que se presenten las opiniones en una forma cordial y amable. Muchas gracias por su colaboracion! Focus Group Questions: 1. Por favor, se introduzcan y diganos que le gustan hacer para disvertirse. 2. Piensenlo y escribanlo su opinion sobre de tres temas mas import antes con respecto de salud sexual y reproductiva por adolescentes? a. Gather answers, discuss and probe to come up with top choices of the 3. Hablan los padres a los hijos sobre la salud sexual y reproductiva? 4. Cuanto ensena a la escuela sobre la salud sexual y reproductiva? 5. Donde mas pueden aprender adolescentes learn la salud sexual y reproductiva? 6. En su opinion, como podemos mejorar la educacion de salud sexual y reproductiva por los adolescentes? 7. Despues de nuestros charla, hay otr as temas que consideran importante con respecto la salud sexual y reproductiva? a. Probe por que?
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