Abstract
Sexual health is a signficant dimension of health among children and youth in Tanzania. Local discourses highlight concerns regarding HIV/AIDS and sexual violence. The aim of this study was to examine the experiences and participation of children and youth in sexual health-related discussions, decisions, and actions in Njombe; a Tanzanian rural community. A focused ethnography, with a participatory approach, was conducted over a 3.5 month period, using participant observation, group interviews, and analysis of key texts, as well as key informant advisors. Twenty-eight participants, 8–16 years of age, were recruited from a community Youth Peer Health Educator program and an HIV youth group. Four principal themes were identified: (a) knowledge and understanding of sexual health, (b) children/youth value sexual health education and discussion, (c) supports and barriers for participation in sexual health education, and (d) children/youth value participation in their own care and promotion of their health. Results demonstrated that these children/youth have the capacities, interests, and values to actively participate in matters affecting their health and sexual health. Specific barriers and supports to sexual health education were identified. The study demonstrated how young people’s agency is socially mediated and can persist even when confronting significant barriers.
Background
The aim of this study was to examine the experiences and participation of children and youth (children/youth) in sexual health-related discussions, decisions, and actions in Njombe, a Tanzanian rural community. There is a growing body of research on the health-related experiences and participation of children/youth throughout the international literature (Carnevale, 2016; Greene and Hogan, 2005), and little has focused on Tanzanian settings. The international literature recognizes children/youth as bearers of ‘participation rights’; highlighting that they should be active participants in matters that affect them (Carnevale and Manjavidze, 2015; UNCRC, 1989).
Sexual health is a signficant dimension of health and wellbeing among children/youth in Tanzania. A national survey indicated that 9% of females and 10% of males, aged 15–24, reported having had sexual intercourse for the first time before the age of 15 (THMIS, 2013). 1 Moreover, 50% of females and 43% of males reported having had sex by the age of 18 (THMIS, 2013).
Dominant discourses on sexual health commonly focus on HIV/AIDS. In 2014, approximately 25.8 million people were living with HIV in Sub-Saharan Africa (SSA), accounting for 66% of the global total of new HIV infections; 190,000 were children (UNAIDS, 2015). In Tanzania, surveys have reported a general 5.1% HIV prevalence (THMIS, 2013). HIV/AIDS is responsible for 9.3% of under five deaths in the country (Feinstein and Mwahombela, 2010). The Njombe region is recognized as having one of the highest HIV prevalence rates for people aged 15–49 years of age (13.30%), which is increasing among young people (THMIS, 2013). A national survey indicated that 50% of females and 80% of males who have had sex, 13–17 years of age, reported that they have never had an HIV test (URT, 2011). Furthermore, the use of condoms during the last sexual engagement under the age of 18 was of 58% for females and 59% for males (URT, 2011).
International policy recommends that HIV-infected children be fully informed about their health status and that they participate in treatment-related decision-making (WHO, 2011). The WHO Guidelines (2011) on children reported that those who were informed of their HIV status had a greater rate of antiretroviral therapy adherence, reduced risk of death, and less psychological distress than their peers who were not informed about their status (WHO, 2011). Tanzanian National Guidelines for the Management of HIV and AIDS recommend that disclosure occurs by 10 years of age and that they should be active participants in their own care (NACP, 2012).
A national survey also demonstrated that 30% of females and 13% of males between 13 and 24 years of age experienced at least one incident of sexual violence before the age of 18 (URT, 2011). Only 20% of females and 10% of males sought sexual health services prior to the age of 18 (URT, 2011). Among those who sought services, only 12.5% of females and <5% of males received services for their experiences of sexual violence; many reported that they would have liked additonal sexual health services (URT, 2011).
Given these signicant concerns about sexual health among children/youth in Tanzania, research is needed to advance knowledge on the experiences of these young people and how these can be improved. This research should examine ways in which children/youth can actively participate in promoting their own sexual health. The research question examined in this study was: How do children and youth in Njombe, Tanzania participate in discussions, decisions, and actions regarding their sexual health?
Methodology
Focused ethnography was used as the methodology for this study, which is well-suited for examining how experiences are affected by the surrounding sociocultural context (Cruz and Higginbottom, 2013; Montreuil and Carnevale, 2018; Polit and Beck, 2008). Moreover, given the history of colonization in Tanzania and the vulnerabilities of children living in rural Njombe (TNBS, 2012), a participatory approach was used (Jagosh et al., 2012; Montreuil and Carnevale, 2018). For example, community key informants helped developed the focus, methods, and analysis of the study.
The study was conducted from September to December 2016, while a co-author (AS) completed a master’s global health nursing placement. During this time, the student-researcher lived in Njombe—immersed in the everyday life of the community—conducting data collection and analysis. In the initial two to three weeks, she consulted with key informants to discuss effective and respectful ways to speak with children/youth about sexual health. Toward the end of the study, a presentation of preliminary results was made to the community to share this knowledge with the community and seek feedback.
Njombe region is located in the southern highlands of Tanzania. The region has one of the highest prevalence rates of HIV in the country (THMIS, 2013). TANWAT hospital in Njombe, has been developing HIV/AIDS care and education programming, investing in specialized professional training and peer education programs such as the HIV youth group and the Youth Peer Health Educator (YPHE) program. The YPHE program was designed to help empower youth in making healthy decisions and to address knowledge gaps regarding HIV transmission, as there is no formalized HIV education programming in local schools. To date, more than 500 primary school students have been trained as YPHE in 50 schools. Also, an HIV youth group was developed to provide support, counseling, and education to youth who were told about their HIV status.
This study collected data from (1) the HIV youth group and (2) the YPHE program in four Primary Schools in Njombe.
Sampling
Key informants
Consultations were conducted with key informants in the community, that is, local community and cultural experts. Key informants oriented the student-researcher to (a) local views and understandings of children/youth participation in sexual health-related discussions, decisions, and actions; (b) suitable data collection sites and methods; and (c) relevant key texts. Four key informants provided advisory input throughout the study.
Participants (children/youth)
Children/youth were eligible to participate in the study if they were (a) between 6 and 17 years of age, (b) living in Njombe (Tanzania), and (c) participant in either the YPHE program or the HIV youth group. Children/youth were excluded from the study if key informants had concerns that participating in the project could present a risk for the participant. Children/youth attending the HIV youth group were invited to participate if staff considered them eligible participants. Children/youth in the YPHE program were approached at the four Njombe primary schools if they were considered eligible participants by key informants and teacher mentors from each school. If children/youth were interested in participating in the project, their parents/guardians were provided consent forms (sent home with child/youth to be signed) and verbal assent was obtained from the child/youth when signed consent forms were received. Twenty-eight participants were recruited from the HIV youth group (18 participants, 8–16 years of age) and the YPHE program (10 participants, 12–14 years of age).
Data collection
Data were collected by the student-researcher through participant observation, interviews, and analysis of key texts. Community members were employed to translate data from Kiswahili to English when required, and all consent forms were translated from English to Kiswahili.
Participant observation
Participant observation (PO) was used because it can help minimize the power differential between children/youth and adults (Carnevale et al., 2008) and provide insight into the daily activities of children/youth in their own settings. The student-researcher became familiarized with the two recruitment sites (HIV youth group and YPHE program) by spending time with health-care workers and volunteers, as well as with children/youth in both settings.
The student-researcher observed interactions between health-care providers and participants, as well as among participants, recording field notes on how children/youth participated in discussions, decisions, and actions regarding their sexual health. Particular attention was paid to how participants’ voices were recognized or not. Seven PO sessions of child/youth meetings were conducted (19 total hours); five with the YPHE participants and two with the HIV youth group. PO included informal interviews with participants to further examine their experiences.
Recognizing the challenges involved in conducting PO with cultural and language differences, specific strategies were used (a) although the student-researcher did not understand most verbal exchanges between participants and heath-care providers, nonverbal communication was noted; (b) the student-researcher asked ad hoc questions with participants and health-care providers to clarify what had been observed; and (c) PO was complemented by other data sources (see below).
Group interviews
Group interviews can help explore children/youth’s sexual health experiences as they can help mitigate power differentials between children/youth and adults (Polit and Beck, 2008). Group interviews were conducted in settings that were familiar and accessible for participants (e.g. local schools). Participants were told that confidentiality would be ensured by the student-researcher and moderators. Although confidentiality was also requested from all group participants, they were told that this could not be ensured.
Three group interviews were conducted with 5–13 particpants in each group. A total of 23 children/youth particpated. Interviews were approximately 1.5–2 hours in duration. Interview questions were open-ended and were continuously adapted through consultations with key informants. Questions were presented in Kiswahili. Two moderators were present during the group interviews, one to translate the group discussion and the other to record field notes on the discussion. Moderators, fluent in English, were recruited from the local community. They were provided training on interviewing and recording of field notes. During group interviews, the student-researcher and one moderator recorded field notes to document verbal and non-verbal communication. Moderators and participants were interviewed afterward to confirm the student-researcher’s understanding of the discussion.
Group interviews began with broad questions, moving on to more specific questions. Questions were adapted to local language practices through consultations with key informants.
Through consultation with key informants, group interviews incorporated some group activities, for example, games, small group discussions, role-playing, anonymous questions, debate questions, and scenario questions, all of which contained an embedded moral concern and that touched on child/youth participation and decision-making regarding their sexual health.
Group interviews were audio-recorded and transcribed. HIV youth group discussions were not audio-recorded to respect the private nature of those discussions. Field notes were transcribed immediately after the interviews.
Analysis of key texts
Key texts were also collected, that is, written materials that reflected local standards of practice as well as the social, cultural, and historical context of the community (Polit and Beck, 2008). These included a national document outlining the legal rights of children in Tanzania, the child abuse policy at TANWAT, the program report from a local adolescent sexual health program, and a secondary school moral ethics textbook. Texts were analyzed in terms of guiding questions.
Data analysis
Data analysis involved four phases: domain analysis, taxonomic analysis, componential analysis, and thematic analysis (Polit and Beck, 2008). Thematic analysis was used to identify prominent categories, themes, and patterns from the data. This involved data coding as well as generation of thematic categories. Multiple investigators on the project team participated in data analysis.
Ethical considerations
The project received research ethics approval from the investigators’ university in Montreal, Canada (McGill University). All participants and parents provided informed and ongoing assent/consent.
Results
A vast body of data were collected. Given space limitations, only the results that are most significantly related to the aims of the study are presented. The following four principal themes were identified: (a) knowledge and understanding of sexual health, (b) children/youth value sexual health education and discussion, (c) supports and barriers for participation in sexual health education, and (d) children/youth value participation in their own care and promotion of their health. These principal themes and corresponding subthemes are described below. Some verbatim quotations are presented (in quotation marks) to illustrate how participants discussed the themes.
Knowledge and understanding of sexual health
Data revealed how knowledge and understanding of sexual health was fostered among children/youth. This included an examination of (a) conceptions of ‘sexual health’, (b) sexual health information resources, (c) accuracy of sexual health information, and (e) gender differences in how children/youth participate.
Conceptions of ‘sexual health’
Two factors were identified as significant in determining whether someone is sexually healthy. First, it is important for individuals to be informed, aware of and to ‘know their sexual health status’. When someone does not know one’s sexual health status, the person should seek health-care services. Second, sexual health was defined as being free of sexually transmitted infections or other reproductive health problems. Sexual health means to ‘have no infection or other things that can affect one’s sexual health’.
Sexual health information resources
YPHE participants described various ways that children/youth can access to sexual health information. It was not clear whether this information is always reliable or accurate. When discussing how YPHE gain information, they referred to television, magazines, hospitals, radio and newspapers. The YPHE also indicated that they had ‘previously experienced discussions on sexual health related topics in the YPHE training’, which they were required to attend to become a YPHE. Furthermore, the YPHE had ‘previously read information around sexual health in the YPHE training book’, which appeared to be a valued resource as many YPHE referred to their training books throughout their education sessions. Participants viewed the YPHE training as ‘very good', as the training taught them how to ‘prevent HIV’, ‘improve one’s health’, ‘strengthen one’s body’, ‘prevent diseases’, ‘improve one’s thinking capacity’, and taught them about taking ‘leadership’ roles in their schools.
Accuracy of sexual health information
YPHE participants and their peers demonstrated a significant level of knowledge and information regarding sexual health topics, including HIV/AIDS, sexually transmitted and blood-borne infections (STBBI), puberty, and ‘how to avoid (sexual) temptations’. The accuracy of the YPHE’s sexual health knowledge was evident when a YPHE participant discussed symptoms of STBBIs and wrote a list of symptoms on the board, including, ‘vaginal/penile discharge and foul smell from genitals, pain during urination, herpes lesions’. One student said, ‘HIV/AIDS is transmitted through various ways such as unsafe sex, sharing sharp instruments and blood transfusions’. YPHE participants also seemed to have knowledge regarding sexual health-related topics that were not discussed in the education sessions, for example, various forms of sex (i.e. vaginal, oral, anal) and how HIV/AIDS can be transmitted by these activities. Accurate replies from children and youth, however, did not necessarily convey understanding. Some statements seemed like a repetition of information that they acquired from lessons or books.
Although many children/youth seemed to have a strong level of sexual health knowledge, some seemed to hold misinformation or misconceptions. This related to HIV/AIDS transmission and prevention as well as condom use effectiveness (e.g. uncertainty regarding the effectiveness of condoms in protecting against HIV). The main misconception that arose during YPHE education sessions related to a belief that condoms are not effective in the prevention of HIV transmission. Key informants highlighted potential sources of misconceptions around condom effectiveness, for example, religious views on reproduction and the sanctity of marriage and perpetrators of sexual abuse seeking unprotected sex with children/youth (URT, 2011).
Gender differences in how children/youth participate
During YPHE group discussions on sexual/reproductive health, male participants were more verbally active than their female counterparts. In all four primary school sites, the male students dominated the sexual health discussions and appeared comfortable with their engagement in the conversation. Female participants had minimal verbal participation in discussions, appearing more comfortable with listening and nonverbal engagement.
Key informants highlighted that gender differences may be related to several factors. Female youths (1) are aware of the inferior social status of women, (2) fear being perceived as promiscuous if they show interest in sexual health, (3) feel intimidated by aggressive approaches taken by males, (4) do not feel comfortable speaking about sexual health in front of males, (5) do not feel comfortable discussing sexual topics while adults are in the room (specifically male adults), and (6) feel it is a male’s responsibility to worry about condoms (male condoms) in sexual activity.
Male youths discussed gender discrepancies in participation in sexual health-related discussions. Some believed that the low level of female participation in the YPHE sexual health education session was due to low self-confidence. Some males stated ‘they (females) themselves have created this system’ and believe it is the responsibility of females themselves to participate in discussions around sexual health and that they are responsible for the existing gender discrepancies.
Children and youth value sexual health education and discussion
Children/youth participants demonstrated that they value participation in sexual health education and discussion. Participants showed that they value (a) learning from adults, (b) learning from peers, (c) educating peers, and (d) opportunities for sexual health-related discussion.
Value learning from adults
Participants valued sexual health information from knowledgeable adults (e.g. physician, nurse, mother, father, guardian, aunt, uncle, teacher, sexual health counselor). A male HIV youth group participant said, ‘if I am suffering with something and I am not feeling well for long, I am going to ask the doctor’. Another male HIV youth group participant stated he would speak to his doctor about ‘the source of the disease I am suffering for, and know the medicine that is going to help me’.
Value learning from peers
Participants value learning about sexual/reproductive health from their peers through open discussion. For example, in a YPHE role-play activity a female participant said, ‘Next we need to discuss about sexual health and first and foremost we need to sit down and then we can discuss very well about this, we need to look for other people and then we can talk about this’, and then a male participant responded ‘we need to look for our friends I think it will be better’.
Value educating peers
Participants also valued teaching their peers about sexual health. They used role-playing and group discussions, among other strategies, to teach peers about HIV/AIDS, STBBIs, adolescence/puberty, and ‘avoiding temptations’. The YPHE program is an example of how children/youth in Njombe value educating their peers about sexual health. Each YPHE, in all four primary school sites, chose to volunteer and commit time and energy to partake in YPHE training and to take on a leadership role at school; to promote sexual health education among fellow peers. However, several factors can affect the level of child/youth participation (discussed below). Some YPHE participants showed significant initiative in conducting class discussions on sexual health, when opportunities are not already structured within school timetables. This was done by seeking permission from the head teacher and using free-time in school schedules, striving to sustain the YPHE program that they consider valuable.
Value opportunities for sexual health-related discussion
It was clearly apparent that YPHE participants and their peers valued opportunities to discuss sexual health related topics. This was demonstrated through their openness and interest in partaking in the YPHE education sessions, actively participating in the education sessions by asking thoughtful questions and contributing comments that enriched conversations with their peers. At all four primary school sites, there were more students interested in participating in the PO sessions than the project could accommodate.
Supports and barriers for participation in sexual health education
The study identified community supports and barriers for child/youth participation in sexual health education. The latter included general barriers to discussion and learning about sexual health; ways in which adults can create barriers; and local conceptions of sexual activity as morally wrong.
Community supports to discussion and learning about sexual health
Participants viewed some community programs and environments as supportive in promoting their learning and participation in discussions about sexual health (e.g. HIV youth group), while also providing leadership opportunities for them. The YPHE Program was viewed as a place to learn and openly ask questions regarding sexual health. Within these environments, adults play a major role in impacting whether the environment is experienced as supportive or unsupportive for children/youth accessing these spaces. Teacher mentors and principals played an active role in supporting children/youth participation in activities related to their sexual health, especially education. Some teacher mentors actively supported children/youth learning about sexual health by encouraging their verbal participation in discussions about sexual health, as well as intervening to correct the exchange of inaccurate information.
Trust had an important supportive impact. It was essential for participants to have some (adult) community members that they could trust and confide in regarding their sexual health. Some participants did not feel that they could discuss their sexual health with their parents or other adults and consequently felt isolated and unsupported.
Barriers to discussion and learning about sexual health
There were some barriers to sexual health discussion and education in the primary school settings. YPHE participants highlighted that it is very difficult to ensure that time is scheduled in their school timetable for YPHE education sessions. Also, some YPHE participants felt limited in their ability to conduct class discussions because of the lack of teacher mentors, for example, ‘our teacher mentor retired’. Moreover, there was a significant reduction in YPHE related activates in the school when ‘the chairperson who was leading us completed standard seven’ (i.e. graduated from the school), demonstrating the important role that YPHE leaders play in the sustainability of YPHE program activities.
Adults can create barriers
Adults (e.g. parents, teachers) can sometimes create barriers for children/youth in their participation in sexual health learning activities. For example, children/youth provided examples of being excluded from appointments with physicians; some parents and teachers disallowed child/youth attendance in YPHE training; ‘shaming practices’ were sometimes used in primary schools; little time was provided in school timetables for school-based sexual health programs such as the YPHE program.
Some parents did not allow their children to attend YPHE training because they thought the children went there to ‘learn how to wear condoms’. As an example of ‘shaming practices’, when some primary school students were identified as engaging in sexual activity they were punished by ‘being told to stand in front of (all) students and teachers and talk about what they have done’. Some adults seemed to use punishment and shaming of children/youth to deter them from sexual activity. It was unclear whether shaming was used to protect children/youth from risks associated with sexual activity or whether this was based in sociocultural moral objections, or both. Lastly, YPHE have few opportunities and little time to conduct class discussions and teach peers about sexual health because there is no time allotted by principals/teachers in the school timetable.
Conceptions of sexual activity as morally wrong
Some YPHE participants expressed a firm moral stance regarding their peers’ sexual activities, viewing them as morally wrong; ‘For us it was something which we were not happy with, so after they were punished’. This view of sexual activity as morally wrong was also exemplified through follow-up actions that some YPHE participants took when they were informed of such instances at their school. They sometimes spoke to their peers about their engaging in sexual activity, as well as teacher mentors, as a way of encouraging them to stop. Some YPHE participants said that some punishment or shaming practices in the school toward children/youth engaging in sexual activity can be a good deterrent strategy.
Children and youth value participation in their own health care and health promotion
Children and youth also demonstrated that they value participating in their own health care and in the promotion of their health. These themes are less developed, as this was a secondary focus of the study.
Children and youth value participation in their own care
Participants disclosed that they valued being included in their health care. For example, they appreciated being informed if there was a problem with their health; to have the opportunity to ask questions regarding their health and to be included when receiving medical test results. Participants described that the level of involvement was dependent on the children/youths’ age, understanding, and some contextual particularities. For example, their participation in communication about medical information depended on whether their parents were present. A YPHE participant stated, ‘If you went there with your parents or any other relative, your doctor will give the results to your parent or your relative, but if you went there alone you will get the results directly from the doctor’.
Children and youth value promotion of their health
Participants demonstrated that they valued actively promoting their own health. Many of the other themes reported here demonstrate how they promoted their own health education and participated in and advocated for their own health care, for example, doing physical exercise, eating a balanced diet, knowing about their own health status.
Discussion
This study examined the experiences and participation of children/youth in sexual health-related discussions, decisions and actions in Njombe, a Tanzanian rural community. We investigated how (a) community programs can promote improvements in sexual health-related knowledge and actions in children/youth and (b) how children/youth participated in their own health care and health promotion. Four principal themes were identified; two focused primarily on participation in sexual health education (i.e. knowledge and understanding of sexual health; children/youth value sexual health education and discussion) and two focused on participation in health care and health promotion (i.e. supports and barriers for participation in sexual health education; children/youth value participation in their own care and promotion of their health).
The results highlight that these children/youth have the capacities, interests, and values to actively participate in discussions, decisions and actions regarding their health in general and sexual health in particular. Their capacities, interests, and values were not limited to solely promoting their own self-interests. They demonstrated concern and commitment to promoting the interests of other children/youth in their community. Peer health education was a particularly striking demonstration of how young people have the capacity to understand and use health promotion information.
These results corroborate research in other settings that demonstrate how children/youth can act as moral agents, concerned and engaged toward the promotion of good for themselves and others (Carnevale et al., 2015; Montreuil and Carnevale, 2015). The results of this study provide a particularly important contribution to our understanding of moral agency in children/youth by demonstrating how young people’s agency can persist even when confronting significant barriers. Indeed, this study demonstrates how (a) child/youth agency is socially mediated, as the actions of others can promote or impede the expression of their agency, and (b) community programs can provide effective assistance to support their agency.
Results highlighted several specific barriers and supports that can help inform the development and implementation of community initiatives to promote sexual health among children/youth. Significant barriers that children/youth had to navigate included: little or no scheduled time in school devoted to sexual health promotion; resistance from adults (e.g. parents and teachers) toward sexual health education, fearing this would condone sexual activity; and widely held views toward sexual activity as morally wrong that perpetuated taboos toward open discussions of sexual health. On the other hand, children/youth drew on numerous community supports, which helped them confront these barriers. These supports included community programs that provided a safe space for learning and discussion; peer educators; and teacher mentors and principals who actively encouraged children/youth to participate in community programs and openly discuss their questions or concerns about sexual health.
These results highlight that although children/youth have significant agential capacities to promote their own sexual health, their agency is socially mediated. Community supports as well as barriers have a significant impact on how children/youth can enact their agency.
This study has also highlighted some considerations for future implementation of community support programs that promote child/youth sexual health in contexts similar to the study setting. Programs should consider (a) creating group environments that are more ‘girl/young-woman-friendly’, that can optimally promote their participation in discussions, decisions and actions related to their sexual health; (b) creating opportunities for children/youth in the community to learn accurate information regarding sexual health (specifically HIV/AIDS transmission and prevention as well as condom use effectiveness), to help address possible misconceptions and further promote their sexual health; (c) allocating time in school timetables for school-based sexual health programs; and (d) providing support for teacher mentors and opportunities for peer-to-peer training that could facilitate the sustainability of such programs.
Despite this study’s many strengths, it was not without limitations. The most significant limitation of the study was language and cultural differences between those of the community and the student-researcher. Although various interpretation and translation supports were provided by community partners, language and cultural differences may have limited our understanding of the full scope and depth of discussions and activities that were observed and analyzed.
Conclusions
This study of children/youth in Njombe, Tanzania, demonstrated that they have the capacities, interests, and values to actively participate in discussions, decisions and actions regarding their own—and their peers’—health and sexual health. Specific barriers and supports to peer sexual health education were identified. The study demonstrated how young people’s agency is socially mediated and can persist even when confronting significant barriers.
Footnotes
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by McGill Nurses for Highlands Hope and McGill Global Health Programs as well as an Insight Grant from the Social Sciences & Humanities Research Council of Canada (Grant Number 239025)