UNFPAReproductive Health in Refugee Situations: An Interagency Field Manual
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REPRODUCTIVE HEALTH IN REFUGEE SITUATIONS: AN INTER-AGENCY FIELD MANUAL
CHAPTER EIGHT
Reproductive Health of Young People


Contents:


Growing up is stressful and challenging in the best of times. For those young people living as refugees, the stresses are much greater. Their transition to adulthood is often made more difficult by the absence of the usual role models and the break-down of the social and cultural system in which they live. They may have gone through personal trauma themselves, including armed conflict, violence, insecurity, sexual abuse, harm to or loss of family members, disruption of schooling or employment, of friendships, and of family and community support.

The definitions of children, adolescents and adults may change from culture to culture. Health workers must adapt the definitions they use to suit the specific refugee situation in which they are working. Whether an adolescent has assumed the roles and responsibilities of an adult is also a reflection of the culture and the refugee situation. When working with young people, the cultural, ethical and religious values of the refugee community must be respected.
 

Defining Children and Young People

Children
Convention on the Rights of the Child

0-18 years

Adolescents
UNFPA, WHO, UNICEF

10-19 years

Youth
UNFPA, WHO, UNICEF

15-24 years

Young People
UNFPA, WHO, UNICEF

 

10-24 years
 


RH Services for Young People Should:

  • be "user-friendly"

  • have competent staff who are friendly, welcoming, and non-judgmental

  • promote trust and confidentiality

  • be free or low cost

  • be easily accessible

  • have flexible hours

  • be located in attractive facilities

  • offer same-gender providers


Young people have special needs in all circumstances; and each age group within this population has different problems and requirements. In refugee situations, where it is difficult enough to set up basic reproductive health (RH) services for the entire community, health providers will also have to consider and address the special needs of young people. But young people are tremendously flexible, resourceful and energetic. They can help each other through peer counselling and peer education, and they can provide care to others and assist health providers as volunteers.

 

Reproductive health in refugee situations
Photos
An inter-agency field manual

Foreword

Preface

Acknowledgments
 

Chapters


1. Fundamental Principles

2. Minimum Initial Service Package (MISP)

3. Safe Motherhood

4. Sexual and Gender-based violence

5. Sexually Transmitted Diseases, including HIV/AIDS

6. Family Planning

7. Other Reproductive Health concerns

8. Young People

9. Surveillance and Monitoring
 

Appendices


a1. Information, Education, Communication

a2. Legal Considerations

a3. Glossary of Terms

a4. Reference Addresses


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©1999 United Nations High Commissioner for Refugees

This document is issued for general distribution. All rights are reserved. Reproductions and translations are authorised, except for commercial purposes, provided the source is acknowledged.


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Young People in Refugee Situations

Young people often have an easier time adapting to a new situation than their parents do. They learn how to "work the system" quickly. In trying to understand their special circumstances and meet their needs, it is helpful to remember the following:

  • Adolescence is a time for learning about close relationships.
    In normal situations, much of this information is gained from peers and from role models in the young person's family and community. These people may not be available in refugee settings. As respected adults in the lives of young people, male and female service providers may become important role models and should be aware of their potential influence.
     

  • Young people often lack a well-developed future orientation. This can be reinforced by refugee or displaced status.
    Projects that provide these young people with a reason to look to the future may also help them consider the consequences of unsafe sexual activity and the need to take responsibility for their actions.
     

  • The behaviour of young people in refugee or displaced situations may not be subjected to the same kind of scrutiny as it would be under normal circumstances.
    The separation from one's homeland, one's elders and one's traditional culture may create a situation in which risky behaviour is less socially controlled. Thus there is a greater risk of early teen pregnancy, sexually transmitted diseases (STDs), drug abuse, violence, etc.
     

  • Young people are not a homogeneous group.
    Young women and young men face very different problems and opportunities. Young women are much more vulnerable to common RH problems and they invariably bear most of the consequences. Also, young people aged 10 to 14 years have different needs than those aged 16 to18 or 20 to 24. And different cultures have different expectations for youth in these different age groups. For example, in some cultures, marriage is acceptable/ expected for a 14- year-old girl; in many other cultures, it is not.
     

  • In many countries with high STD/ HIV prevalence, the most vulnerable group is young women.
    The AIDS epidemic is exacerbating the health risks that young women face. Their lack of power over their sexual and reproductive lives compounds the risks of unwanted pregnancy, unsafe abortion and STD/ HIV infection, all of which are likely to occur more frequently in refugee situations.

     

Reproductive Health Needs of Adolescents

The background characteristics of young people, including their religion, cultural upbringing, place of origin (rural or urban), and level of education will, to some extent, define their needs. However, basic RH needs include:

  • information on sexuality and reproductive health

  • access to family planning services

  • prenatal and post-abortion care

  • safe delivery

  • treatment of unsafe abortions

  • diagnosis and treatment of sexually transmitted diseases

  • protection from sexual abuse

  • culturally appropriate psychosocial counselling and/ or mental health services

  • negotiating skills


Principles in Working with Young People

The primary principle in working effectively with young people is to promote their participation. Although this principle applies to the provision of RH services in adult populations, it is particularly important for young people. As a group, young people often have a "culture" of their own, with particular norms and values. They may not respond to services designed for adults. They are at a stage in life where they need to develop a sense of control over their bodies and their health. At the same time, since they are young and relatively inexperienced, they need guidance that is both sensitive and reassuring. The best way to encourage young people to participate is to develop a partnership between them and the providers with proper regard for parental guidance and responsibilities. Services will be more accepted if they are tailored to the needs as identified by young people, themselves.

Other principles to remember:

  • Service providers must understand the cultural sensitivities surrounding the provision of information and services to young people.
    To the extent possible, community leaders and parents should be involved in developing programmes targeted at young people. Service providers with deep cultural knowledge (especially if the provider is part of that culture) are more likely to provide services acceptable to the community than those considered "outsiders".
     

  • Programmes should identify and encourage peer leadership and communication.
    Peers are usually perceived as safe and trustworthy sources of information.
     

  • It is essential to have links between health and community services.
    Links between health and community services are necessary to ensure that young people get the appropriate treatment for problems which might be revealed through one service but require additional assistance from another service (e. g., sexual violence or unsafe abortion).
     

  • Young people need privacy.
    The problems that bring them to a service provider often make them feel ashamed, embarrassed or confused. Though space may be at a premium in a refugee camp, it is important for providers to try to create the most private space possible in which to talk to young people.
     

  • Confidentiality must be guaranteed.
    Service providers need to maintain confidentiality in their dealings with young people and be honest with them about their health problems.
     

  • In most cultures, the gender of the service provider is important.
    A young person should be referred to a provider of the same sex.

     

In the absence of information specific to the young people, providers must assume that many of the common problems cited above may be worse in the refugee situation. The disruption of health and education services and general state of disorder imply a lack of protection and supervision, increased sexual violence, and a greater need to exchange sex for food, shelter, safe passage and protection. It is important to obtain information about a young person's history of STDs and pregnancy status, unsafe abortion, rape and other forms of sexual abuse. Health care providers should also be aware of a young person's knowledge about and access to any form of contraception, and his/ her beliefs, attitudes, perceptions and values.

More specifically, it is important to gather information about:

  • cultural norms related to sexual relationships and rites of passage into adulthood (including harmful traditional practices, such as female genital mutilation)

  • current norms/ practices/ perceptions/ attitudes related to sex

  • typical patterns of adult authority over adolescent behaviour within the camp

  • services available to young people (and applicable restrictions) and the degree to which the refugee community understands this availability

  • perceptions of camp staff/ service providers related to providing RH services to young people

  • n young people's perceptions of their RH needs

This information can be gathered through camp records, interviews and focus group discussions and possibly through simple survey techniques. (Some further guidance is found in Appendix One on IEC.)


Responding to the RH Needs of Young People

Young people need basic information about sexuality and reproduction. They also need to learn how to protect their reproductive health. In many refugee settlements, formal education ends after primary school. Therefore, information about reproductive health must be communicated in creative ways. Any organised activity for youth -- sports, video showings, handicraft "clubs" -- may provide an opportunity for disseminating important health information to participants.

It has been proven that sex education leads to safe behaviour and does not encourage earlier or increased sexual activity. (See UNAIDS document in Further Reading.) Therefore, young people should be informed about STD/ HIV/ AIDS and early pregnancy, and appropriate advice and supplies should be made available to them. Young people need to develop certain skills to be able to make informed, responsible decisions about their sexual behaviour. They need to be able to resist pressure, be assertive, negotiate, and resolve conflicts. They also need to know about contraceptives, such as condoms, and feel confident enough to use them. Peer counselling and peer education can be very effective in strengthening these skills and attitudes.

Young girls who do not attend school and who are destined to marry immediately after the start of menstruation may be particularly difficult to reach. However, their society may allow a community worker to visit the girls at home and discuss health matters relating to preparations for parenthood.

Rape may be the reason an adolescent first approaches health services. Many victims of rape and sexual abuse are girls, but boys are also vulnerable to sexual violence. Young people who have been sexually abused need immediate health services and access to a safe environment.

In refugee situations, adolescent girls and boys may be forced into selling sex simply to survive. Refugee-community members should be involved in identifying ways to protect girls and women from sexual violence and coercion. One possible protective measure is to ensure that women administer the distribution of food and shelter. (See Chapter Four -- Sexual Violence.)

If an adolescent is pregnant, it is vital to provide her with good antenatal care, since young women, especially those under 15 years of age, are prone to complications of pregnancy and delivery. Many young pregnant women will resort to unsafe abortion. They will need special care if complications from an unsafe abortion develop. Information about family planning must be readily displayed and available to help keep unwanted pregnancies to a minimum. (See Chapter Six -Family Planning).

Adolescent boys engaging in homosexual intercourse should be taught how to prevent STD/ HIV. However, IEC messages related to STDs should not label this behaviour in a way that may stigmatise the boys (e. g., as homosexual), but should refer to the behaviour as "men having sex with men" or "same-gender sex".

Psychological trauma resulting from refugee experiences may make young people reluctant to seek services related to their sexual health. But they do need to know that these services are available to them, that they will receive care and support if they want it, and that they will not be judged or punished in any way. Information about the services could be displayed in places where young people gather or provided through other activities or social services.

Psychosocial support and counselling should be provided by trained counsellors whenever needed, but particularly in cases of sexual abuse and unwanted pregnancy.


Community-Based Programmes

Ideally, a person with experience in RH services for young people should participate in the needs assessment and planning of the programmes. Young people from all age groups should be identified, as quickly as possible, to help design the programmes and eventually to take a leadership role.

When an assessment of current needs and available resources has been made, the group of service providers and young people who are assembled to develop the programme can consider the project objectives and develop the corresponding activities. Planners should define simple mechanisms for collecting information that can later be used to measure the project's impact. That information will also guide any modifications made to the programme. Young people should be involved in evaluating and modifying the programme.

RH services for young people are more effective and acceptable when they are linked to other activities or settings, for example recreation or work. Youth centres, developed in some refugee settlements, offer a place for young people to learn, play and receive health services. In other refugee settings, young people have access to health services during special hours, usually after school or after work. Young people need their own physical spaces for social interaction. These may be the best venues for providing health services.


Monitoring and Supervision

RH programmes should be monitored to ensure young people have access to health services and health care providers are caring for young people without stigmatising them.

To be sure young people are attending health services and being targetted with health information, many RH indicators should be measured by age and sex break down. See Chapter Nine for select indicators for young people.


Further Readings

"A Picture of Health: A Review and Annotated Bibliography of the Health of Young People in Developing Countries", WHO, Geneva, 1995.

"Action for Adolescent Health: Towards a Common Agenda", recommendations from WHO, UNFPA, and UNICEF, 1997.

"Coming of Age: From Facts to Action for Adolescent Sexual and Reproductive Health", WHO/ FRH/ ADH/ 97.18, Geneva, 1997.

"Counselling Skills Training in Adolescent Sexuality and Reproductive Health: A Facilitator's Guide", WHO, Geneva, 1993.

"Refugee Children: Guidelines for Protection and Care", UNHCR, Geneva, 1994.

"Technical Report of the WHO/ UNFPA/ UNICEF Study Group on Programming for Adolescent Health", WHO, Geneva, 1997.

"The Impact of HIV and Sexual Health Education on the Sexual Behaviour of Young People: A Review Update", UNAIDS, Geneva, 1998.

"Working with Young People in Sexual Health and HIV/ AIDS: A Resource Pack", AHRTAG, London, 1996.
 


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REPRODUCTIVE HEALTH IN REFUGEE SITUATIONS: AN INTER-AGENCY FIELD MANUAL