Author's Abstract: COPYRIGHT 2000 Washington State University Press This two-phase study explores, within socio-cultural dimensions, information sources for, and knowledge about, health or health-related problems among Kenyan adolescents. Respondents rely more on health clinics than on any other source for information on sexually transmitted diseases (STDs), their most commonly cited health problems; however, those with high knowledge of contraceptives are significantly more likely than those with low knowledge to report that the mass media are information sources. The implications of those results for controlling and preventing teenage pregnancy and STDs in sub-Saharan Africa are presented. Full Text: COPYRIGHT 2000 Washington State University Press The transmission of sexually transmitted diseases and their health consequences in sub-Saharan Africa indicate no sign of abating. For example, it has been estimated that if current HIV/AIDS infection trends continue, by 2010, life expectancy will be less than 40 years in eight African countries: Botswana, Ethiopia, Malawi, Namibia, Rwanda, Swaziland, Zambia and Zimbabwe (U.S. Department of State, 1999). (Kenya's estimate is 43.7 years.). Consequently, within nine months, at least two major international conferences sought to bring increasing attention to the scourge. The first was in September 12-16, 1999, when the Eleventh International Conference on AIDS and STDs in Africa was held in Lusaka, Zambia. Its theme, "Setting Priorities for HIV/AIDS in Africa," cast those diseases in paradoxical terms: Despite communication and health programs implemented over a decade in attempts to reduce their incidence in sub-Saharan Africa, the region faces a much higher incidence of the disease than at the start of this decade. In May 15-20, 2000, the World Health Organization held its annual conference in Geneva, this time pledging "to give new directions and a new energy to an expanded, revitalized response to the HIV/AIDS pandemic" (Brundtland, 2000). Health agencies in the region must, therefore, revisit their priorities and search for more effective strategies to halt the devastating scourge of a variety of diseases, the most devastating of which are HIV/AIDS. It was in tandem with those concerns that this study was undertaken to examine socio-cultural factors that underlie sexual practices and sexually transmitted diseases in sub-Saharan Africa. It also explores sources from which teenagers in Kenya get information on health or health-related problems and on contraceptives that they can use to prevent sexually transmitted diseases (STDs) and pregnancy. This study is guided by four overarching realities: (a) the endemic nature of STDs, particularly heterosexually transmitted HIV/AIDS in Africa (Quinn, 1996); (b) the high rate of HIV/AIDS on the continent, as a consequence of the high rate of STDs (Green, 1994; "Improved STD Treatment," 1995; Rushing, 1995; U.S. Department of State, 1999); (c) the importance of controlling STDs in the fight against AIDS in developing countries (Grosskurth, Plummer, & Mabey, 1993; Rushing, 1995; Williams, 1992); and (d) the 60% rate of new HIV infections among 15- to 24-year-olds worldwide. A study conducted at Nairobi's Kenyatta National Hospital found, for example, that 23% of 15- to 19-year-old women who visited an antenatal clinic had STDs (Aggarwal & Matu, 1992). Similarly, U.S. women between the ages 15 and 19 have the highest incidence of gonorrhea and males of a similar age group the second-highest of any age group in the United States (Division of STD Prevention, 1999). Why Kenya and Its Adolescents? We focus on Kenya for three reasons. First, it is one of the world's youngest countries; 52% of its 30 million people are younger than 15. People between the ages of 10 and 19 comprise about 25% of its population and are the fastest-growing segment in the country (Center for the Study, 1995). Those patterns justify the focus of this study on teenagers. Second, the country's adolescent fertility rates are among the world's highest. Njau and Radeny (1995) note that Kenya's "high teenage sexual activity is reflected in the incidence of pregnancy, abortion, and STDs" (p. 2). One in five women aged 15 to 19 years has begun childbearing, either given birth or being pregnant with her first child. Seventeen percent had one child, and another 8.6% were pregnant, according to the Kenya Demographic and Health Surveys of 1989 and 1990. Illinigumugabo, Njau, & Rog (1994) reported in their study of four rural districts in Kenya that 81% of girls aged 15 to 19 years had at least one pregnancy, 14% two pregnancies, and 3.2% three. Third, Kenya is strategically positioned as the port of call en route to the trans-Africa highway. This makes it a reservoir of, and a conduit for, the spread of HIV/ AIDS, particularly by long-distance truckers who cross the region from Mombasa (Kenya) on the East Coast through Lusaka (Zambia) in the central region to Beira (Mozambique), and to former Zaire in the West Central region. This "truck town hypothesis" asserts that the geographic distribution of HIV/AIDS follows the major routes of truckers who patronize prostitutes, spreading the HIV virus (Smallman-Raynor & Cliff, 1991). Socio-Cultural Dimensions of STDs Rushton and Bogaert (1989) provide socio-biological explanations for AIDS in Africa, asserting that race "Mongoloid," "Caucasoid," or "Negroid" is the explanatory variable in its prevalence and incidence. They conclude that because Africans practice less sexual restraint and provide minimal offspring care, they are more likely to have sexual coitus with numerous partners, a behavior that places them at risk for AIDS. Hunt (1996) describes Rushton and Bogaert's thesis as specious, arguing for the consideration of socio-structural factors: migratory patterns, ethnicity, and economic system. Zwi and Cabral (1991) argue that social situations place Africans at high risk for AIDS. Africa's traditional societies vary greatly, and indicate cultural differences in attitudes or reactions toward sexual behaviors. In the traditional societies of the Akan of Ghana, the Ganda of Uganda, and those of the Ibos of Nigeria, teenage pregnancies are infrequent because sexual activities among unmarried teenagers are discouraged. However, among the Tswana of Botswana, the Zulus of South Africa and Swaziland, and the Swazis of Swaziland, the phenomenon is more common and usually results in early marriage and the subjugation of women to men, since single-parenthood is abhorred. Similarly, MacDonald (1996) provided three factors that explained the incidence and prevalence of HIV/ AIDS in Botswana: (a) that it is culturally accept for men to have more than one sexual partner and for married men to have concubines; (b) that young women feel they are powerless in making decisions in condom use; and (c) that, culturally, young women should prove their fertility before marriage by becoming pregnant. Other cultural factors in the spread of HIV/AIDS are wife-sharing, polygamy, and widow inheritance, the latter of which provides moral dignity to sexual activity that is acceptable only to married people (Ouma, 1996). The ever-increasing urbanization and exposure to international media and to Western education threaten the primacy of some of the traditional attitudes toward teenage pregnancy in Africa. Among West Africans, for example, changes resulting from European influences have resulted in the widening of sexual networks in that individuals have more partners, and an overlapping of networks in that those partners are not local residents, as males patronize bars, night clubs and hotels (Caldwell, Orubuloye, & Caldwell, 1991). For the African, urbanization threatens traditional norms and institutions that regulate sex (Mann, Tarantola, & Netter, 1992). In many of Africa's urban centers, evolving uniform points of view and attitudes supplant traditional and ethnic-based value orientations. The situation in Kenya illustrates the strong influence of those emerging factors on attitudes toward teenage pregnancy, which is increasingly prevalent. In Kenya, about 4.1% of teenagers initiate coitus at ages younger than 10 (Lema, 1990), although a mean age of 13.5 years for sexual initiation has been reported in some districts. In general, about 26% of single women aged 15 to 19 years report having had sexual intercourse (Kenya Demographic, 1993; Kiruhi & Simalane, 1993; Njau, 1993). Not all teenage pregnancies are pre-marital pregnancies, but many pregnant teenagers are unmarried. Pre-marital pregnancies among Kenyan teenagers are explained by "an interplay of individual and social factors within the context of the communities in which the teenagers live" (Njau & Radeny, 1995, p. 4). Early sexual activity in the absence of appropriate knowledge and the use of contraceptive devices are major contributors to teenage pregnancy. Even when contraceptive awareness is shown to be as high as 76%, contraceptive use is reported to be as low as 4% (Kenya Demographic, 1989). Only about 18% of sexually experienced adolescent girls use contraceptives (Okumu & Chege, 1994), while in the capital city of Nairobi, the proportion of users is as low as 5% (Njau & Radeny, 1995). That low use reflects a combination of factors that include disapproval, unavailability, lack of information, and the inconsistent nature of teenagers' sexual behavior, among others (Njau, 1993; Njau & Radney, 1995). In the United States, public-information campaigns that include the mass media are major sources of information for a variety of health problems and awareness about strategies for combating them (Allen et al., 1992; Austin, 1995; Brashers, Haas, & Neidig, 1998; Wallack, 1990). In sub-Saharan Africa, however, the mass media are supplemented by the interpersonal media (Njau, 1993; Njau & Radney, 1995; Obunga, 1989) as sources for health messages. A, study of 10- to 19-year-old Zimbabweans indicated that television and radio were their top sources of information on STDs, whereas clinics were their preferred source (Kasule et al., 1997). Similarly, Zimbabwean high-school students mentioned the mass media as both the first and the most informative sources on AIDS, their preferred sources, in order, were physicians, the mass media, health workers, and teachers (Ndlovu & Sihlangu, 1992). Those results suggest a difference in the reported importance between the use of the mass media and of interpersonal communications as sources of information on STDs. Research Questions Trends in the prevalence and incidence of HIV/ AIDS in sub-Saharan Africa in general, and in Kenya in particular, led us to pose four questions: 1. What major health or health-related problems do Kenyan youths report? 2. What social factors explain some of those problems? 3. How important are the mass media as sources of information for controlling and preventing those problems? 4. What are the implications of the results of this study for controlling and preventing some of those health or health-related problems, e.g., teenage pregnancy? Method This study employs a two-pronged method. The first is interviewer-assisted questionnaires, that is, interview schedules (Phase I). The second method is focus-group discussions among teenagers (Phase II). Phase I Sample. A systematic sample of Kenyan youths aged 15 to 19 years (N = 351) was selected from residents in three residential areas in Kenya's second-largest city, Mombasa. Those areas were Mombasa Municipal Estate, National Housing Corporation Estate, and Kizingo Estate. They were selected for two reasons: (a) their high proportion of (residential) teenagers; and (b) their economic, social, and ethnic diversifies. Households were selected from area sketch maps (that is, clusters) developed specifically for this study by the Nairobi-based staff of the United Nations Fund for Population Assistance (UNFPA) in preparation for its Regional Population Information, Education, and Communication Training Program. Interviewer-assisted questionnaires. A 43-item, English-language questionnaire was developed by 25 participants in a six-week UNFPA course in Audience Research and Segmentation for Population Information, Education, Communication, which was organized by the UNFPA in Nairobi, Kenya. It was pretested among Kenyan teenagers. It had open-ended and structured questions on respondents' knowledge and practices regarding the use of contraceptives, their perceptions of the causes of pregnancy, their beliefs about adolescent reproductive health, their sources of information on health-related issues, and their demographic profiles. Items included the following: (a) "What do you consider the major health problems affecting people of your age group (15 to 19 years) in Mombasa?"; (b) "What methods can teenagers use to prevent pregnancy?" (c) "How can an unwanted pregnancy be prevented?" (d) "Identify from the following [nine-item] list all the contraceptive methods you know"; and (e) "What counseling services for contraceptive use or pregnancy are available to teenagers in Mombasa?" Procedures. Participants of the UNFPA training course individually administered the questionnaires to 15- to 19-year-olds. Using maps of the three selected housing estates (Mombasa Municipal, National Housing and Kizingo), and guided by local resident research assistants who were recruited for this study, the UNFPA participants selected households through systematic random sampling. Within selected households, the first available youth (15 to 19 years of age) was interviewed. Interviews were held in secluded areas of homes to avoid the social influence of family members. All interviews were conducted during the day. Respondents cooperated fully; there were no refusals. Overall, 351 interviews were completed with both in-school and out-of-school youths. Even though the demographic profile of the sample did not seem to represent (or mirror) the population of Kenyan youths, the difference could be attributed to the peculiar nature of Mombasa, the most heterogenous city in Kenya. There were more girls (62%) than were boys (38%). Phase II Focus-group meetings. In addition to the survey instrument (Phase I), six focus-group meetings (FGMs) were organized on two major themes that provided additional answers to our research questions. The themes were family life education (under which adolescents' health-related problems were discussed) and strategies for controlling and preventing HIV and STDs. They were held in the three residential areas from which respondents were selected for Phase I of this study. To prepare for the focus-group meetings, we pretested their protocols in three seven-student groups. All participants were provided introductory materials on teenage pregnancy and STDs prior to the meeting. This, according to Morgan (1988), would stimulate their thinking and discussion of the subject of their meeting. The selection of the eight participants in each FGM was purposively done to match, as much as possible, the demographic profile of participants with that of survey respondents (Table 1). Respondents of the interview schedules did not participate in the FGMs. Each discussion lasted about one hour, and was facilitated by a resource person in the UNFPA training program.
Table 1Demographic Characteristics of 15- to 19-year-old SurveyRespondents (Phase I) & Focus-Group Participants (Phase II) Phase 1 Phase 2 Survey Focus-Group Respondents Participants (N=351) (N=48) Characteristics n (%) n (%) Gender Female 218 (62) 26 (54)Male 133 (38) 22 (46) Religion Protestant 221 (63) 18 (37)Catholic 60 (17) 15 (31)Moslem 36 (10) 9 (19)None 1 (0.3) 2 (4)Others 33 (9) 4 (8) Highest Education None 10 (3) 1 (2)Some Primary School 7 (2) 7 (15)Completed Primary School 171 (49) 23 (48)Some Secondary School 97 (28) 10 (21)Completed Secondary School 19 (5) 5 (10)Other 10 (3) 2 (4)No Response 37 (10) -- --
Results Phase I: Interview responses Demographic profiles. Overall, there were 351 teenagers, of which 38% (n = 133) were male and 62% (n = 218) were female. Their highest educational levels ranged from "none" to "completed secondary." More primary-school than secondary-school graduates participated in both the survey and the focus-group sessions. Research Question 1: What are major teenage health-related problems? HIV/AIDS and STDs were ranked by 126 respondents (21.8% of total mention) as the most serious health problems, followed by malaria (20.1%), dysentery (13.2%), and hygiene (9.2%). Teenage pregnancy and abortion were fifth (5.5%). (Because of multiple responses for each health concern, the frequencies in Table 2 total more than 351.)
Table 2Respondents' (N = 351) Most Frequently CitedHealth or Health-Related Problems Frequency of Mention Percent ofHealth Problem (N=578) Mention HIV/AIDS, STDs 126 21.8Malaria 117 20.2Dysentery 76 13.2Hygiene 53 9.2Pregnancy, abortion 32 5.5Drag use 25 4.3Menstrual irregularities 9 1.6Others 140 24.2
Research Question 2: What reported social factors explain teenage pregnancy? A majority (70%) of respondents reported that teenage pregnancy was a national problem. Even though teenage pregnancy was ranked fifth in importance, about 79% (n = 277) of the respondents had heard of it and 84% (n = 295) knew of girls aged 15 to 19 years who had gotten pregnant. When respondents were asked what they thought pregnant teenagers did on discovering they were pregnant, 61% (n = 214) said they had an abortion, while the rest said they gave birth. These results indicate that teenage pregnancies, STDs and HIV/AIDS were perceived as common health issues by the Kenyan youths interviewed in this study. Even though it is outside the scope of this present study to investigate the equivalency of teenage pregnancy to the current prevalence of AIDS in Kenya, a plausible assumption can be drawn regarding some association between the prevalence of teenage pregnancy and high-risk sexual behaviors. The factor that most frequently explained the reported prevalence of teenage pregnancy was religion (24.2% of total mention). The latter's dominance could be explained by the depths of Christianity in Kenya. (More than 75% of Kenyans are Christians, of whom 30% are Catholics.) The Catholic Church and conservative Protestant churches preach openly against the use of contraceptive pills and devices. Also, many religious groups in Kenya are avowedly against offering "sex education" in class rooms. In fact, so far-reaching are their influences that schools and colleges in Kenya are forced to substitute "family life education" for "sex education" as the official label for courses that address human reproductive health. The lack of parental guidance (21.8% of total mention); exposure to radio, television, newspapers, and magazines (20.2%); and the lack of contraceptives (13.2%), in that order, were major explanatory factors. The others were low-level education (9.2%) and peer pressure (5.5%). Research Question 3: To what extent are mass media the sources of information on contraceptives? Institutional sources such as hospitals, clinics, and the Ministry of Health were cited most frequently (28.2% of total mention). This is in contrast to findings among U.S. mid- to late-adolescents who rely on the mass media (e.g., radio; television; posters and billboards; and magazines such as Seventeen, Teen, and Sports Illustrated) for health-related messages (Austin, 1995). In the present study, the mass media were the second most important source (19%) of information on contraceptives. The other sources were teachers and schools (16.9%), parents (10.8%), and guidance and counseling (8.8%). The importance of the media as sources of contraceptive information is more clearly evidenced in the relationship between knowledge levels and exposure to health-information sources. ("High," that is, when a respondent reports three or more methods of contraception, and "low," that is, when knowledge of two or fewer methods is indicated.) When respondents' knowledge levels high or low are cross-tabulated with media use, results indicate that those with high levels of knowledge about contraceptives tend to cite the media significantly more often than their counterparts with low levels of knowledge ([c.sup.2] [1, N = 82] = 28.0, p [is less than] .001, as reported in Table 5). High knowledge levels are also significantly associated with the school ([c.sup.2] [1, N = 73] = 4.94, p [is less than] .05) and the home ([c.sup.2] [1, N = 47] = 9.38, p [is less than] .01) as information sources. But high knowledge levels are not associated with counseling, friends, and neighbors as information sources.
Table 5Respondents' Most Frequently Cited Sources ofInformation on Health or Health-Related Problems, byLevel of Knowledge About Contraceptives Knowledge Level High Low Source of Information n (%) n (%) [chi square] p< Hospitals, clinics, Ministry of Health 54 (44.3) 68 (55.7) 1.6 nsMass media 65 (79.3) 17 (20.7) 28.0 .001Teacher, school 46 (63.0) 27 (37.0) 4.94 .05Parents, home 35 (72.3) 13 (27.7) 9.38 .01Guidance, counseling 2 (5.3) 36 (94.7) 30.4 .001Friends 19 (67.9) 9 (32.1) 3.56 nsNeighbors 13 (61.9) 8 (38.1) 1.18 nsOthers 19 (90.5) 2 (9.5) 13.8 .001
When media were classified as high and low information sources, it was found that a majority of those who used the mass media as a high information source also were majority users of hospitals, clinics, the Ministry of Health, teachers and schools, parents and home, guidance and counseling, friends, neighbors and others. The z-test for differences between proportions was performed on the percentages listed under "mass media" and "other sources" (Table 6). Because those proportions represent the number of respondents categorized in each high/low cell of those two variables, the high/low data are independent of each other and are appropriate for making comparisons of the use of each of the two information sources. A comparison of the z-test scores (z = Po - P/square root of Po [1 - P]/n]) reveals an interesting pattern. Significant differences are found between the use of the mass media as an information source and the uses of other sources of information, when subjects were classified by their use of all sources listed in the first column. One may then conclude that a significant larger percentage of individuals tended to use the mass media as sources of information about contraceptives, except in one case: information sources categorized as "others." That pattern was, however, reversed when respondents had a low level of knowledge about STDs.
Table 6Proportions of the use of the mass media versus other informationsources by knowledge levels about contraceptives Knowledge Level High Low Media Use Source of Information % (n) % (n) Hospitals, clinics, Ministry of Health 79.3 65 20.7 17Teacher, school 79.3 65 20.7 17Parents, home 79.3 65 20.7 17Guidance, counseling 79.3 65 20.7 17Friends 79.3 65 20.7 17Neighbors 79.3 65 20.7 17Others 79.3 65 20.7 17 Knowledge Level High Low Other Sources Source of Information % (n) % (n) Hospitals, clinics, Ministry of Health 44.3 54 55.7 68Teacher, school 63.0 46 37.0 27Parents, home 72.3 34 27.7 13Guidance, counseling 5.3 2 94.7 36Friends 67.9 19 32.1 9Neighbors 61.9 13 38.1 9Others 90.5 19 9.5 2 Knowledge Level High Low Media Use Source of Information Total n Z-score(a) Z-score(a) Hospitals, clinics, Ministry of Health 204 -4.61 -1.7Teacher, school 155 1.02 .75Parents, home 129 0.8 .81Guidance, counseling 120 -9.9 9.47Friends 110 -1.3 -1.29Neighbors 104 -7.6 -1.36Others 103 1.24 2.07 (a) All z-scores significant at p < .01.
Therefore, it appears the mass media have two contradictory effects on respondents: (a) as contributing to the incidence of teenage pregnancy (Table 3), and increasing the odds of contracting STDs; and (b) as channels for acquiring contraceptive information.
Table 3Respondents' (N = 351) Most Frequently CitedCauses of Teen-age Pregnancy Frequency of Mention Percent ofCause (N=578) Mention Religion 140 24.2Lack of parental guidance 126 21.8Mass media exposure 117 20.2Lack of contraceptives 76 13.2Low level of education 53 9.2Peer pressure 32 5.5Split families 25 4.3Early marriage 9 1.6
Contraceptive methods. Respondents indicated awareness of various kinds of contraceptives. Birth-control pills (19.8% of total mention) and condoms (19.6%) were the most commonly mentioned methods, followed by the loop and IUD (10.0%). The least-known methods were foam and jelly (7.7%); coitus interruptus, that is withdrawal or rhythm method, (5.2%); and tubal ligation (3.8%). The diaphragm (9.4%) and "injectables" (9.3%) were also fairly well-known by respondents. Research Question 4: What are the implications of results for controlling and preventing health-related problems, e.g., teenage pregnancy? The reported incidence of pregnancy among the teenagers, their familiarity with the problem, and their acquaintanceship with teenagers who had become pregnant suggest that a considerable number of youths tend to engage in sexual activities. Therefore, indirectly, they tend to both expose and make themselves vulnerable to the risks associated with contracting STDs and HIV/AIDS, all of which were perceived as major health problems by a majority of respondents. When respondents were asked to suggest what could be done about the problem, counseling was most frequently cited (31.9% of the time), followed by the use of contraceptives (13.3%). Other methods were abstinence (10.2%), education (9.7%), and parental guidance (8.8%). Phase II: Focus-group responses Complementing the survey research results were those of six focus-group meetings (FGMs): two male groups, two female groups, and two mixed groups. The results of those meetings confirmed, for the most part, survey results. Health-related problems. The discussions started by asking participants to identify some of the major health or health-related problems of Kenya's youths. In order of frequency of mention, they mentioned teenage pregnancy, unprotected sex, drug abuse, and alcoholism, three of which were apparent in survey results. "I can say some of them [the youths] do not protect themselves," one participant said, matter-of-factly. "You find that they go with one man this day and another man another day. This is why I feel that the youths are responsible for spreading STDs." On the prevalence of teenage pregnancy as a health problem participants agreed that there were many instances of such pregnancies in their community. One female said, "We have young girls who give birth in school which I think is not nice ... to have children while in school. They are not expected to have babies at that time." On the use of contraceptives to prevent pregnancy, another female remarked: "The dilemma is on whether to use or not use ... Some girls are not sure whether to use contraceptives or not ... they are not sure on how to use them." Controlling and Preventing HIV and STDs. When participants were asked to discuss preventive measures against HIV/AIDS and STDs, they indicated that youths should be taught about the dangers of all three. One female said, "They should be taught by parents, teachers, and elders." Condoms were cited as another solution toward controlling or preventing the spread of STDs among youths. This suggestion was opposed by some participants, one of whom admitted, "Some young people do not have enough knowledge about condom use. They may try to use them and end up contracting the infection." Another commented, "Condoms are unreliable. They break if used improperly." One participant noted that youths may not be able to afford condoms. Another, however, claimed that early maturity was a factor that contributed to premature sex, with its consequent pregnancies and diseases. He said: "Nowadays, we young people, we mature early, especially girls are growing very fast. All their sexual organs are working fast." On the use of contraceptives, a female participant said, "Girls should seek advice from older people." Another suggested, "Girls should seek counseling and avoid `such things.'" Another female argued," ... instead of using these contraceptives of which we do not know the correct way of using them, it is better for us to avoid sex ... sex brings us problems ... pregnancy and STDs." One male, however, disagreed with the females. He argued, "It is hard to restrain people from using contraceptives because some people are really fond of indulging in sex." In response to the preceding remark, one male participant asked him how the problem of AIDS could be solved if youths were fond of sex. He replied, "By providing more information, people would be taught more about AIDS." Implications for Intervention Programs This study provides preliminary data that suggest several implications for controlling and preventing STDs in Kenya, in particular and in the sub-Saharan region in general. First, the use of formal institutions such as health clinics, Ministries of Health, and schools for family-life and reproductive-health education should be complemented by vigorous uses of the mass media. This implication is particularly borne out by the finding that institutional and mass media sources are the most often reported sources of health information. As noted in a preceding paragraph, whereas Zimbabwean teenagers reported that television, school, and radio in that order were the primary sources of information on STDs, their preferred choice for such information was the clinic (Kasule et al., 1997). However, it is important that the mass media include the traditional media, commonly labelled "oramedia." The latter are instruments such as drums, horns and gongs and theatrical settings such as plays, theaters, and the marketplace. They encompass the nature of African societies and reflect the dominant mores of African communication systems, the essence of interpersonal and inter-group exchanges, and the normative principles that guide those communications. That communication mix will fill a void in AIDS- or STD-prevention strategies. Studies have shown that Kenyan adolescents are concerned about developing a consistent set of behaviors for coping with practices injurious to their health (Balmer et al., 1997). And, studies have also shown that AIDS-awareness campaigns enhance adolescents' knowledge and practice of safe sex (Campbell & Mbizvo, 1994; Kasule et al., 1997; Wilson, Greenspan, & Wilson, 1989). Second, because religion and socio-cultural practices exercise major influences on the perceived susceptibility of teenagers to the major health problems they confront and on how to address them, control and prevention programs must be culturally relevant. As Kiefer and Hulley (1990) note, "Every epidemic must be seen in the particular social context in which it took hold, in order to understand both its propagation and society's response to it" (p. 9). Thus, it is suggested that programs targeting youths co-opt relevant socio-cultural practices (and religious mores) into their themes. Coital relations have deep cultural roots; therefore, campaigns aimed at affecting them must embody culturally-appropriate messages and methods. Religion, parental guidance, and the mass media, all cultural forces, were cited as the three most important factors in managing teenage pregnancy. In certain parts of southern and central Africa, for example, males have a cultural preference for "dry sex": having a dry, tight vagina during intercourse (Civic & Wilson, 1996; Kalipeni, 1996). In Rwanda, there is a preference for the reciprocal flow of fertility fluids during intercourse (Taylor, 1990); that is symbolic of the exchange of beer and milk during social interactions. Both those cultural preferences pose challenges for campaigns aimed at promoting the use of condoms (Kelipeni, 1996). Third, as in the developed nations, HIV/AIDS are a part of a larger set of the health problems of Kenyan teenagers. For example, while Latinos comprise 6.4% of the U.S. population, they account for about 15% of the HIV/AIDS cases (Handsfield & Jaffe, 1990). U.S. minority populations' sexual behaviors, which place them at risk for contracting AIDS, tend to be rooted in the teenagers' belief that they are invincible; that they are immune to the consequences of high-risk sexual behaviors (DiClemente, Brown, Beausoleil, & Lodico, 1993). Teenagers in this study recognized the seriousness of the AIDS pandemic. Ironically, they appeared not to attach commensurate weight to taking measures to protecting themselves. Such a conclusion is reinforced by findings from a study of 216 adolescents in Nairobi. Those between the ages of 12 and 18 had a slight knowledge of contraceptives; did not have access to condoms; denied that there was such a thing as AIDS, arguing that it was a scare campaign perpetuated to prevent them from enjoying sex; and, among females, generally did not go to family planning clinics because they believe they would be turned away (Balmer et al., 1997). Finally, these results and AIDS pandemic portend serious consequences for social development, and the implications of national development for HIV/AIDS prevention among youths. As Ainsworth and Over (1994) wrote, "AIDS is fundamentally a development problem, not just a health problem" (p. 584). And, as WHO's 53rd World Health Organization Assembly (held in 2000) and the Lusaka, Zambia, international conference (held in 1999) noted, the HIV/AIDS pandemic is partly rooted in economics, that is, in poverty. Macrotrends in Africa, all poverty-related, have profound implications for health programs there in that poverty at the local level is translated into personal risk for HIV infection and is a critical barrier to sustained health promotion efforts (Klepp, Masatu, Setel, & Lie, 1999). Therefore, strategic attempts to fight HIV/AIDS translate into a fight against poverty pari passu. Health practitioners on the continent, therefore, must act to strengthen the links between HIV/AIDS control and prevention and the continent's national-development agendas. Such links are particularly important in Kenya, where 52% of the population is younger than 15, and where 27% is between 15 years and 29 years. Because the effects of STDs are apparent beyond the health sector, the health and resourcefulness of African teenagers can be at risk if health promotion and STD-prevention programs do not get the necessary policy-level support. Concluding Remarks This study suggests that the reported sexual practices of teenagers portend tragic consequences for youths at risk. Therefore, strategic communication responses to the effects of STDs and HIV/AIDS among those youths must include all-encompassing media campaigns targeting not only the young, but also the elderly. The latter, as family members and mentors, influence, through their "model" behaviors, the youths' lifestyles and social practices. Alcalay (1983) and Solomon (1989) note the importance of communicating with such eclectic audiences or relevant multiple markets because not taking into account the social context of change will diminish community support for an individual's behavior change process. But more than that, the social context tends to serve as conduits for facilitating information about health issues. Solomon (1989) writes, "The awareness, understanding, and involvement of secondary but influential target markets that might not be the ultimate consumers of a campaign are quite critical to its success" (p. 98). The results of this study also suggest that education and communication campaigns need to be implemented through institutional and mass media channels. Because coital relations are quintessentially talked about, learned and practiced in cultural contexts, information, education and communication campaigns for safe sex must be designed and implemented to conform with relevant socio-cultural norms. McAlister (1981) argues that even though the mass media can be effective in informing and persuading publics, a supportive social environment is vital to an enduring change. Such a supportive environment is critical for strategic communications to chip away at enduring cultural stereotypes commonly associated with, say, condom use and "dry sex." The vital roles of the modern and traditional media in such efforts must be supplemented by interpersonal channels such as peers, family members and teachers. The results of this study support the view that both information and social-change campaigns use integrated approaches that do not merely rely on radio and printed materials, that do not merely emphasize the need for a reduced number of sexual partners, and that do not merely advocate widespread use of condoms or other forms of contraceptives. Therefore, future research in this area can address the use of multiple research methods and analyses of communication content to assess the effectiveness of AIDS information and education campaigns in various settings.
Table 4Respondents' (N = 351) Most FrequentlyCited Sources of Information on Health orHealth-Related Problems Frequency of Mention Percent ofCause (N=432) Mention Hospitals, clinics, Ministry of Health 122 28.2Mass media 82 19Teacher, school 73 16.9Parents, home 47 10.8Guidance, counseling 38 8.8Friends 28 6.5Neighbors 21 4.9Others 21 4.9Table 7Respondents' (N = 351) Most Frequently Cited Contraceptives Frequency of Percent ofContraceptive Mention (N=1025) Mention The pill 203 19.8Condom 201 19.6Loop, IUD 103 10.0Diaphragm 96 9.4"Injectables" 95 9.3Vasectomy 81 7.9Foam, jelly 79 7.7Withdrawal or rhythm method 53 5.2Tubal ligation 39 3.8Others 75 7.3Table 8Respondents' (N = 351) Most Frequently CitedStrategies Against Teen-age Pregnancy Frequency of Percent ofStrategy Mention (N=442) Mention Offer counseling 141 31.9Use contraceptive 59 13.3Practice abstinence 45 10.2Offer education 43 9.7Provide parental guidance 39 8.8Use legal measures 4 1.0Others 111 25.1
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LINCOLN JAMES--WASHINGTON STATE UNIVERSITY |
