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The training portion of Project ECHO (Extension for Community Healthcare Outcomes) came to an end last month with the second and final session of Bajo Lempa participants being certified as Sexual and Reproductive Health educators by a group of medical professionals from the University of New Mexico. In total, 41 teachers and 17 community health promoters participated in the program.
Over the last two weeks we had the pleasure of hosting Nutritionist, Grace Palm and Gynecologist, Hannah Palm; the two health education consultants from UNM. Since the beginning, these two young doctors have showed nothing but dedication and proved vital in the development of ECHO materials and as facilitators during the video trainings. They came to visit the communities, conduct in-person focus studies and sit in on some of the classes being replicated during their stay.
Two groups of teachers, one group of health promoters and one group of school administrators participated in the focus studies where conversations were constructive, collaborative and full of ideas for the future. The classes they observed were well prepared and well taught and most teachers adapted ECHO’s methodology to fit their own group dynamics.
Jose Acosta, VOICES’ director expressed during the final evaluation with school administrators, “If this proves a successful method to adequately capacitate those who’s role it is to impart such programs, the goal to ultimately implement the ECHO model into the education curriculum can be realized.
Photos of classes being reproduced in schools and communities:
Too often, youth throughout El Salvador make poor decisions regarding their sexual and reproductive health, increasing their risk of an unintended pregnancy or contracting sexually transmitted infections. For many youth, their decision-making process is driven by misinformation, myths, and cultural norms, or they simply lack the empowerment to prioritize their health over other factors. While some in the NGO and government sectors have taken steps to empower youth with information about how to care for their sexual and reproductive health, risky behavior remains the norm. Unfortunately, social, cultural, and religious barriers continue to hamper their efforts.
In the Lower Lempa region of Usulutan, public health promoters and community leaders identify sexual and reproductive health issues as one of their primary public health concerns. Though data specific to the Lower Lempa is unavailable, public health workers estimate that communities in the region are consistent with national averages for rural areas.
A 2005 USAID/CDC report found that the average woman in a rural community has her first sexual encounter at the age of 16, while the average Salvadoran male in a rural community has his at the age of 15. By contrast, the average woman in the United States has her first sexual encounter at the age of 17.4, while the average man has his at the age of 16.9, almost two years later than the average Salvadoran man. By the age of 16, 75.5% of all men in rural Salvadoran communities have had their first sexual encounter, and 60% of their women counterparts have had theirs. The survey also found that for girls who had their first sexual encounter by the age of 15, 34.6% did so with a partner more than 20 years of age. The authors of the report conclude that such an age gap suggests that the reproductive health was likely compromised and that the young women likely had little say in whether or not the sexual activity was initiated.
The same USAID/CDC study found that during their first sexual encounter, only 10.3% of young women in rural areas contracepted. Conversely, 41.7% of young men contracepted during their first sexual encounter. Among unmarried women who failed to contracept, 45.5% state that they did not know they were going to have a sexual encounter and were unprepared, while almost 20% did not know of any means of contraception.
Of unmarried women, 28.5% believed that they could not become pregnant at the time of their first pregnancy. Their reasons varied. Over 25% stated that they did not have intercourse frequently, implying a belief that they had to have sex multiple times to become pregnant. Almost 20% of such women reported that their partners said they could not become pregnant, and they believed them. Over 18% stated that it was their first time, implying a belief that they could not become pregnant during their first sexual encounter. Over 10% believed that they were not old enough to become pregnant. Another 6% of women reported that their partner opposed the use of contraception, suggesting that they were either unable to insist on contraception, or willing to take the risk of pregnancy or contracting an STI. Of married women, 37.7% did not use contraception during their first sexual encounter because they wanted to become pregnant, and 20% did not know of any means of contraception.
The survey also found that 17% of all Salvadoran women have been pregnant by their 17th birthday, and over 46% by the time they turn 20. Of all pregnancies by women between the ages of 15-24, 40% were unintended. Even in El Salvador, which has some of the strictest prohibitions against abortion, some women with unintended pregnancies attempt to terminate their pregnancy. While the number of illegal abortions performed every year is unknown, attempts to self-abort are the second highest cause of maternal mortality in El Salvador. It does not help that Salvadoran law requires doctors to report women who seek treatment for injuries caused during an attempted termination to the police, deterring women from seeking medical care.
Sexual encounters without proper protection also place youth at risk of contracting sexually transmitted infections, such as HIV/AIDS. Between 1984 and 2005, the Salvadoran government reported 15,609 cases of HIV/AIDS. In their 2005 El Salvador Country Report, UNAIDS reports that since 2000, El Salvador has averaged 1544 new cases of HIV/AIDS every year. While over half of El Salvador’s cases of HIV/AIDS are in the capital of San Salvador, cases in rural departamentos such as Usulutan are on the rise. Data on other sexually transmitted infections is unavailable. However, with the number of cases of HIV/AIDS on the rise, it is likely that other STIs such as human papillomavirus, genital warts, syphilis, chlamydia, gonorrhea, and others are increasing as well. Health promoters and community leaders are concerned that their youth are not protecting themselves, and that even a slight increase of infections could quickly spread out of control through the region.
These reports and data highlight the issues and needs that health promoters and community leaders in the Lower Lempa are too familiar with – that youth throughout the region must have greater knowledge concerning their sexual and reproductive health, and be empowered to make healthy decisions. Unfortunately, many barriers to an informed and empowered citizenry exist. Past efforts to implement educational programs in the schools have been met with resistance by the Church and members of the Central Government, as well as some community members. For example, the Ministry of Education recently prepared materials to integrate sexual and reproductive health into the national curriculum. Representatives from the conservative government and the Church edited the materials, however, and cleansed them of any discussions of contraception and to redirect the focus on abstinence. Similarly, though the Ministry of Health receives large quantities of contraceptive materials from the international community, the donations are rarely distributed appropriately. In the Lower Lempa, for example, the government’s family planning agency only provides clinics with approximately 30 condoms per month, which is hardly sufficient. And while women around the country recognize the need for contraception, Salvadoran society continues to follow the Church’s ban on methods other than abstinence and other natural methods. Similarly, El Salvador’s “machismo” culture continues to inform young Salvadoran males that getting women pregnant and having multiple partners are signs of ones’ masculinity.
Despite these barriers, women and men alike are more aware of the issues than the generations before them. When asked, the majority of youth in rural El Salvador want to limit the number of children they have to 3, and are willing to take the steps necessary to control the size of their family. And anecdotal evidence indicates that more women are seeking out long-term contraceptive options such as “the injection” and even hysterectomies. Such options are especially important for women whose partners refuse to use protection or do not want them to use contraception (men often believe that the only reason for their partner to use long-term contraception is because they are cheating on them). In 2005, the Salvadoran Association of Public Health (ASPS, in Spanish) completed two projects in the Lower Lempa that sought to improve awareness and knowledge of HIV/AIDS and reproductive health. The projects, though limited in their scope and duration, were successful and the communities they reached experienced significant declines in unwanted pregnancies and reports of sexually transmitted infections.
In order for Salvadoran youth to have greater control over their sexual and reproductive health, government institutions, NGOs, community leaders, parents, and all others must work together to empower youth with information. They must also work together to change the culture of sexual and reproductive health, so that women are more willing and able to express an informed and empowered decision, and young men respect their decisions. Women must have greater access to a contraceptive method that suits their needs and lifestyle, and their partners must work with them to affectively plan the size of their families. And while respecting long-standing religious and moral values, Salvadorans must be free to take a realistic approach towards preventing unintended pregnancies and sexually transmitted infections. But none of this will happen until society begins talking about the situation and does not back away from open dialogue.
– Montheit R. S., Stupp, P. W. & McCracken, S. D. (2005). “Reproductive, Maternal, and Child Health in Central America, Trends and Challenges Facing Women and Children. El Salvador, Guatemala, Honduras, Nicaragua.” Atlanta, GA: USAID/DRH/CDC. (p. 55).
– Kaiser Family Foundation. “U.S. Teen Sexual Activity Fact Sheet.” 2005
– UNAIDS (2005). “Country Report: El Salvador.” 2005