Adolescent Pregnancy in CumbayÃ¡, Ecuador : A Gender Sensitive Situation Analysis Elizabeth Poulsen email@example.com Master of Sustainable Development Practice Field Practicum Report Spring 2014 Supervisory Committee: Dr. Richard Rheingans, Chair Dr. Robert Lawrence, Member
TABLE OF CONTENTS FIGURES & TABLES ................................ ................................ ................................ ................................ ... 2 ABSTRACT ................................ ................................ ................................ ................................ ............... 3 RESUMEN ................................ ................................ ................................ ................................ ................ 4 ACKNOWLEDGEMENTS ................................ ................................ ................................ ............................ 5 ACRONYMS USED ................................ ................................ ................................ ................................ .... 6 INTRODUCTION ................................ ................................ ................................ ................................ ....... 7 BACKGROUND AND CONTEXT ................................ ................................ ................................ .................. 8 Ecuador ................................ ................................ ................................ ................................ ............... 8 Adolescent Pregnancy in Ecuador ................................ ................................ ................................ ........ 9 Adolescent Sexual and Reproductive Health and Rights (ASRHR) ................................ ....................... 11 Tumbaco Valley Zone (TV Z) ................................ ................................ ................................ ................ 13 Host Organization: Ministry of Public Health of the Tumbaco Valley Zone (MoPH TVZ) ...................... 14 PRACTICUM TIMELINE ................................ ................................ ................................ ........................... 16 LITERATURE REVIEW ................................ ................................ ................................ .............................. 17 RESEARCH APPROACH AND CONCEPTUAL FRAMEWORK ................................ ................................ ....... 20 RESEARCH FOCUS A ND METHODS ................................ ................................ ................................ ......... 22 Focus Groups ................................ ................................ ................................ ................................ ..... 22 Surveys ................................ ................................ ................................ ................................ .............. 24 RESULTS ................................ ................................ ................................ ................................ ................ 26 Population Characteristics: Pregnancy Rates, Sexual Activity, and Condom and Contraceptive Use .... 26 ................................ ................................ ................................ ....................... 28 ................................ ................................ ................................ ................................ 32 ................................ ................................ ................................ ......................... 36 CONCLUSION AND RECOMMENDATIONS ................................ ................................ .............................. 43 ADDITIONAL PRACTICUM ACTIVITIES ................................ ................................ ................................ ..... 46 Curriculum Development ................................ ................................ ................................ ................... 46 Monitoring and E valuation Framework ................................ ................................ .............................. 46 REFERENCES ................................ ................................ ................................ ................................ .......... 47 APPENDIX A: SURVEY RESULTS ................................ ................................ ................................ .............. 51 APPENDIX B: FOCUS GROUP DISCUSSION GUIDE ................................ ................................ ................... 63 APPENDIX C: SURVEY INSTRUMENT ................................ ................................ ................................ ....... 65
2 FIGURES Figure 1: Ecuador ................................ ................................ ................................ ................................ ..... 8 Figure 2: Age specific Fertility Rates (number of live births per 1,000 women) 1950 2010: Adolescents a ged 15 19 ................................ ................................ ................................ ................................ ............ 10 Figure 3: Adolescent Births as Percent of Total Births: 1950 2010 ................................ .......................... 10 11 Figure 5: The Tumbaco Valley Zone ................................ ................................ ................................ ....... 13 Figure 6: The "AdministraciÃ³n Zonal " of the Tumbaco Valley Zone ................................ ......................... 14 Figure 7: One of the buildings of the Colegio Nacional de CumbayÃ¡ ................................ ....................... 15 Figure 8: Practicum Timeline ................................ ................................ ................................ ................. 16 framework ................................ ................................ ................................ ................................ ............ 20 ................................ ...... 21 TABLES Table 1: Self Ident ified Ethnicity of TVZ Residents ................................ ................................ .................. 13 Table 2: Highest Level of Education Completed by TVZ Residents ................................ .......................... 13 Table 3: Percentage of adole scent girls that ................................ ................................ ........................... 14 Table 4: Focus group participants ................................ ................................ ................................ .......... 23 Table 5: Age of survey respondents ................................ ................................ ................................ ....... 25 Table 6: Grade level of survey respondents ................................ ................................ ........................... 25 Table 7: Grade level equivalencies: Ecuador and U.S. ................................ ................................ ............ 25 Table 8: Gender of survey respondents ................................ ................................ ................................ . 25
3 ABSTRACT Ecuador has the third highest rate of adolescent pregnancy in South America. In 2010, just under 20 % of 15 19 year old girls in the country had given birth at least once. The Ecuadorian government has created a national strategy known as ENIPLA/PEA to reduce adolescent pregnancy rates. ENIPLA/PEA calls for conducting situation analyses , to better understand the specific factors that contribute to teen pregnancy in different geographical regions. This study attempts to shed light on the underlying factors that contribute to teen pregnancy among the student population in a public secondary school in the semi urban town of CumbayÃ¡, which is part of the Metropolitan District of Quito. The study was conducted in partnership with a local, decentralized branch of the Ministry of Public Health, which is one of the four government ministries that is responsible for carrying out the ENIPLA/PEA strategy. Sex disaggregated focus groups (n=32) and self administered questionnaires (n=338) were conducted with students aged 14 18 to gather information about knowledge, attitudes, beliefs, and behaviors relating to sexual activity and contraceptive use . It found that barriers to contraceptive use may include embarrassment to obtain contraceptives, gender related social stigma for having contraceptives, perception that contraceptives have negative side effects, and a host of misinformation about the proper use of contraceptives and their effecti veness. Additionally, factors that may contribute to sexual activity include social pressure, and drug use, curiosity, and a desire to connect with another person.
4 RESUMEN En Ecuador, la ta sa de embarazos en adolescentes es la tercera mÃ¡s alta del mundo. En el aÃ±o 2010, un poco menos de 20% de chicas de 15 19 aÃ±os de edad habÃan dado la luz al menos una vez. El gobierno nacional de Ecuador ha creado una estrategia llamado ENIPLA/PEA para red ucir la tasa de embarazos en adolescentes en el paÃs. Un parte de ENIPLA /PEA es realizar anÃ¡lisis situaciona l, para mejor entender los factores subyacentes que contribuyen al embarazo en adolescentes en distintas regiones geogrÃ¡ficas. Este estudio intenta aclarar los factores subyacentes que contribuyen al embarazo en adolescentes en la poblaciÃ³n estudiantil de una escuela secundaria p Ãºblica en la parroquia de CumbayÃ¡, del Distrito Metropolitano de Quito. El estudio se realizÃ³ en colaboraciÃ³n con la oficina del Ministerio de Salud P Ãºblica de la AdministraciÃ³n Zonal de Tumbaco. El Ministerio de Salud PÃºblica es uno de los cuatro ministerios gubernamentales que estÃ¡ encargado de realizar ENIPLA /PEA. Se realizÃ³ grupos focales desagregados por sexo (n=32) y cue stionarios auto administrados (n=338) con estudiantes de 14 18 aÃ±os de edad para recolectar informaciÃ³n acerca de conocimiento, actitudes, creencias, y comportamientos relacionados a la actividad sexual y el uso de mÃ©todos anticonceptivos. Se descubriÃ³ que barreras al uso de mÃ©todos anticonceptivos pueden incluir vergÃ¼enza al conseguir ciertos mÃ©todos anticonceptivos, estigma social relacionado al gÃ©nero por tener mÃ©todos anticonceptivos, percepciÃ³n que los mÃ©todos tienen efectos negativos, y varios creenci as acerca del uso correcto de anticonceptivos y su eficacia. AdemÃ¡s, los factores que pueden contribuir a la actividad sexual incluyen presiÃ³n social, la falta de confianza en sÃ misma para rechazar relaciones sexuales, el uso de alcohol y drogas, y el des eo de conectar con otra persona.
5 ACKNOWLEDGEMENTS Richard Rheingans, PhD | University of Florida College of Liberal Arts and Sciences, Center for African Studies | Academic Committee Chair Robert Lawrence, MD | University of Florida College of Medicine , Department of Pediatrics | Academic Committee Member Stacey Geryak, RN BSN | University of Florida College of Medicine | Research Co coordinator Francisco Viteri, MD | Director of Public Health Programming, Tumbaco Valley Zone Regional Government Adminis tration | In Country Supervisor Katherine Tafur | Public Health Program Manager, Tumbaco Valley Zone Regional Government Administration | Research Assistant Glenn Galloway | University of Florida College of Liberal Arts and Sciences, Master of Development Practice Program | Program Director MDP Program Coordinators and classmates
6 ACRONYMS USED ASRHR Adolescent Sexual and Reproductive Health and Rights CNC ENIPLA/PEA Colegio Nacional de CumbayÃ¡ Estrategia Nacional Intersectorial de PlanificaciÃ³n Familiar y PrevenciÃ³n del Embarazo en Adolescentes (National Inter sectoral Strategy for Family Planning and Adolescent Pregnancy Prevention) FGDs GNI Focus Group Discussions Gross National Income HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome MDP M o PH TVZ Ministry of Public Health of the Tumbaco Valley Zone STI TVZ USFQ Sexually Transmitted Infection Tumbaco Valley Zone Universidad San Francisco de Quito
7 INTRODUCTION opulation under the age of 25, we must harness the positive claim their right to education and health including sexual and reproductive health they increase their oppor tunities to become a powerful force for economic development and Secretary Hillary Clinton, Statement on World Population Day, July 11, 2011 (YHRC, 2011) Prompted by high adolescent pregnancy rates, STI rate s, sexual abuse and assault, and other sexual and reproductive health issues around the world, Adolescent Sexual and Reproductive Health and Rights (ASRHR) have come to the forefront of many de velopment initiatives over the last few decades. Sexuality educ ation programs address ASRHR issues by dialoguing directly with adolescents about the issues and resources that are most relevant in their specific context. In Ecuador, the country with the third highest teen pregnancy rate in South America, the government has made ASRHR a national priority issue. Four government ministries, including the Ministry of Public Health, are co responsible for implementing a national strategy to address issues relating to ASRHR in the country. This report outlines the rese arch a nd other activities that were carried out during my MDP field practicum in summer of 2014, during which I partnered with a local branch of the Ecuadorian Ministry of Pub lic Health in the town of Tumbaco, Ecuador (p art of the Metropolitan District of Quito ) , as well as a medical student from the University of Florida . The main focus of our work was a study carried out in a public second ary school in the nearby town CumbayÃ¡, in which we aimed to elucidate the underlying causes of teen pregnancy in the student p opulation by talking directly with students in focus groups, and by carrying out self administered written surveys with over 300 students in four grades. The results of this study will be used by both the Ministry of Public Health in Tumbaco and the scho ol administration in CumbayÃ¡ to design a sexuality education curriculum that will be implemented in the CumbayÃ¡ school and possibly in other areas of the greater Tumbaco Valley Zone. This paper begins by providing contextual information about the location of the field practicum and background on ASRHR worldwide. The results of the study are then outlined, first describing general sexual health possible underlying factors t hat may contribute to teen pregnancy rates in the student population : opportunity, availability, and motivation . Following the conclusion and recommendations is a brief description of some additional deliverables developed during the practicum, including a preliminary sex education curriculum, and a project monitoring and evaluation framework.
8 BACKGROUND AND CONTEXT Ecuador Ecuador is a small country (slightly smaller than the U.S. state of Nevada) in South America; its population in 2010 was over 14 mi llion (INEC, 2010) . The country is characterized by four distinct zones: the coastal lowlands , the Andean highlands, the Amazon , and the Galapagos Islands. Ninety five percent of the ion identifies as Catholic (INEC, 2010) . Seventy two percent of Ecuadorians identify as mestizo (mixed Amerindian and white ), while 7% identify as Montubio, 7% as Afroecuadorian, 7% Amerindian, and 6% as white (INEC, 2010) . Despite a banking crisis in 1999/2000, Ecuador is currently experiencing a period of strong economic growth, with an average annual growth rate of around 5% each year since 2010 (World Bank Group, 2014) . This has led to an incr ease in per capita GNI, which is currently just over $10,000 (PPP), up from $7,130 in 2005 (World Bank Group, 2014) . According to Solano (2012), oil accounts for over a third of government revenues in Ecuador, and it is partial ly because of the high prices of this commodity that the Ecuadorian government has been able to double public spending in the last decade. At over 10% of its gross national product, Ecuador dedicates the greatest share of its economy to public investment o ut of all Latin American and Caribbean nations, with 7.3% dedicated to health, and 4.4% dedicated to education (Solano, 2012) . However, bec coefficie nt of 48.5 is the 23 rd highest in the world), a large percentage of the population still lives in poverty (World Bank Group, 2014) . Although only 8% of the population earns less than $2/day (PPP), about 26% of the population wa (World Bank Group, 2014) . However, both of these figures are markedly lower than they were a decade ago, when 19% of the population lived on $2/day and 42% were u nder the national poverty line. Life expectancy, at 76.6 years, is fairly high, and although mean years of schooling is currently low (7.6), this is expected to increase to 12.3 in the near future (United Nations Development Prog ramme, 2014) . Figure 1 : Ecuador (Source: www.worldofmaps.net)
9 Adolescent Pregnancy in Ecuador Although adolescent fertility rates in Ecuador have decreased dramatically since the 1950s, they have remained steady since 1990 at over 80 births per 1,000 women age 15 19 , and are much higher than rates fo un d in other regions (see Figure 2 ). Additionally, as seen in Figure 3 , adolescent births as a percentage of total births in Ecuador has increased over the last 50 years, so that now, nearly one in five b irths in the country is to an adolescent. Although adolescent pregnancy is not universally regarded as a problem (Stern, 2012) , there are several reasons why many regard such a high rate as cause for concern. Firstly, there are health risks associated with adolescent pregnancy: it is correlated with a higher risk of medical complications for the mother, as well as higher morbidity and mortality rates for her child (United Nations, 2013) . Worldwide, th e second leading cause of death for 15 19 year old girls is complications during pregnancy and childbirth (World Health Organization, 2014) . Many adolescent pregnancies worldwide are unplanned and unwanted, which leads about 3 million girls aged 15 19 to undergo unsafe abortions each year (World Health Organization, 2014) . Additionally, a dolescent motherhood may result in lifelong negative social and economic consequences for both the mother and her (Hindin & Noah, 2011) . Lastly , adolescent fertility contributes to world population growth, which is currently projected to reach around 11 billion by the end of this century (United Nations Population Division, 2012) . This figure is above most estimates of global carrying capacity (United Nations Population Division, 2001) , meaning that extreme issues such as food insecurity, conflict, and climate change are likely to increase dramatically before this 11 billion mark.
10 Figure 2 : Age specific Fertility Rates (number of live births per 1,000 women) 1950 201 0: Adolescents aged 15 19 Figure 3 : Adolescent Births as Percent of Total Births: 1950 2010 It is important to note that although the term is often used interchangeably with pregnancy rates are act ually higher than fertility rates, as the latter term do es not take into account pregnancies that were terminated due to miscarria ge or abortion. For this reason , the actual teen pregnancy rate in Ecuador is slightly higher than the rates dep icted in these graphs. Due to the difficulty in collecting accurate data on abortion and miscarriage rates among teens, the exact teen pregnancy rate in Ecuador will not be referenced in this paper fertility rates will be used 48.9 (World) 23.6 (MDR) 52.7 (LDR) 72.5 (South America) 132.3 (Ecuador) 83.5 (Ecuador) 0 20 40 60 80 100 120 140 Births per 1,000 women aged 15 19 Year World More developed regions (MDR) Less developed regions (LDR) South America Ecuador 10.9 (World) 6.5 (MDR) 11.4 (LDR) 17.9 (South America) 13.7 (Ecuador) 17.7 (Ecuador) 0% 5% 10% 15% 20% Percent of births in 15 19 age group (out of total births) Year World More developed regions (MDR) Less developed regions (LDR) South America Ecuador Source: United Nationa World Population Prospects: The 2012 Revision (http://esa.un.org/unpd/wpp/Excel Data/fertility.htm) Cal c ulated as "number of births to women in a particular age group, divided by the number of women in that age group." Regional trends are shown for comparison, and are defined by the UNDP as follows merica and the Caribbean plus Melanesia, Micronesia, and Polynesia. So urce: United Nations World Population Prospects: The 2012 Revision (http://esa.un.org/unpd/wpp)
11 instead. It should also be no ted that the graphs only display data for births to girls aged 15 19; data on births to girls younger than 15 were not available in the UNDP databases. Adolescent Sexual and Reproductive Health and Rights (ASRHR) As Eager (2004) articulates, there has bee n a relatively recent global paradigm shift regarding family planning initiatives: prior to the 1990s, family planning initiatives often emphasized population control , whereas now, human rights and health are instead usually the primary focus of such initi atives. According to the UNFPA (2014), sexual and reproductive rights include deciding the number, spacing, and timing of children; the right to voluntarily marry and establish a family; and the right to the highest attainable standard of health , among o ther rights. Several g overnments of South American countries have chosen to use this rights based approach to respond to high teen fertility rates in the region. In 2007, the Ministries of Health of Chile, Bolivia, Peru, Ecuador, Colombia, and Venezuela r atified the Andean Plan for Adolescent Pregnancy Prevention , which places reproductive rights as the central pillar of their strategy to reduce teen fertility rates . The Andean P lan outlines the following objectives: develop a situational analysis of adole scent pregnancies in the Andean sub region; implement healthcare services accessible by adolescents; media, health providers, and civil society regarding th e importance of developing policies and actions for adolescent pregnancy prevention (PlanEA, 2010) . Ecuad or has incorporated the Andean P lan into its national adolescent pregnancy prevention strategy , called ENIPLA/PEA ( See fi gure 4 ). This acronym stands for sectoral Strateg y for Ado l e scent Pregnancy Prevention. ENIPLA /PEA emphasizes a rights based appro ach to reproductive health, aim ing to provide access to information, education, and services related to sexual and reproductive health care. As seen in Figure 4 , ENIPLA is jointly coordinated by the Ministry of Public Figure 4 : (Source: Ministerio Coordinador de Desarrollo Social)
12 Health, the Ministry of Coordination of Social Development, the Ministry of Economic and Social Inclusion , and the Ministry of Education. Additionally, there reproductive health: Health i s a right guaranteed by the State social, cultural, educational, and environmental policies; and the permanent, timely, and non exclusive access to programs, actions, and services promoting and providing in tegral healthcare, sexual health, and reproductive health . The State shall promote access to the necessary means so that these decisions take place in safe (Article 66, Section 9) ive life and to decide when and how many children to have (Article 66, Section 10) educational institutions provide education in citizenship, sexuality, and the environment, using a rights based app roach (Article 347, Section 4) and [will guarantee] the integral healthcare and the life of women, especially during pregnancy, childbirth, (Article 363, Sect ion 6) (Asamblea Constituyente, 2008) Although these articles do not specifically refer to adolescents, nor do they in themselves guarantee that such rights will actually be provided , the rhetorical backing of the importance o f sexual adolescent pregnancy rates.
13 Tumbaco Valley Zone (TVZ) The Tumbaco Valley Zone (TVZ) , located in the Andean highland zone, is one of the eig ht administrative divisions of the Metropolitan District of Quito (see Figure 5 ). It is comprised of eight parishes (similar to townships) : Checa, CumbayÃ¡, Pifo, Puembo, El Quinche, Tababela, Tumbaco, and Yaruqu Ã . The TVZ covers a pproximately 250 square miles (MDMQ, 2014) , and has approximately 119,000 inhabitants (INEC, 2010) . This study that will be discussed in this report took place in a secondary school in CumbayÃ¡: the westernmost parish (town) in the Tumbaco Valley Zone. Table 1 : Self Identified Ethnicity of TVZ Residents Mestizo White Indigenous Mulatto African American Other TVZ 82% 12% 4% 2% 1% <1% CumbayÃ¡ 72% 22% 3% 2% <1% <1% Table 2 : Highest Level of Education Completed by TVZ Residents No Formal Education Primary School Secondary School University TVZ ( all residents ) 6% 41% 37% 9% TVZ ( residents age 20 24) 2% 35% 39% 14% CumbayÃ¡ ( all residents ) 3% 28% 35% 2 3% CumbayÃ¡ ( residents age 20 24) 1% 20% 31% 38% Approximately 96% of residents of the TVZ reported that they speak only Spanish, while 1.4% reported that they speak Spanish and an indigenous language, .4% reported that they speak only an indigenous lan guage, and .3% reported that they speak a foreign language (INEC, 2010) . The most commonly spoken indigenous languages in the TVZ are Quichua, Shuar/Chicha, and Kichwa (INEC, 2010) . The most common o ccupational field reported among TVZ residents in the 2010 Home and Demographic Census was unskilled labor (domestic and janitorial work, street vendors, transportation workers, and other unskilled workers), with approximately 23% of the population working in this field. About 18% of the population reported working in agriculture, livestock, forestry, and/or fishing, while 13% reported working in manufacturing, physical labor, or artisan work, and 11% percent of residents reported working as installations o r machine operators (INEC, 2010) . Tumbaco Valley Zone Figure 5 : The Tumbaco Valley Zone (Source: Google Maps ; label by author )
14 Table 3 : Percentage of adolescent girls that have given birth at least once As seen in Table 3, adolescent birth rate s in the Tumbaco Valley Zone and in CumbayÃ¡ are slightly lower t h an national averages. However, they are still much higher than global rates. This study attempts to elucidate the complex factors that contribute to the high teen pregnancy rate in the Tumbaco Valley Zone. Although Cumbay Ã¡ does not have th e highest teen birth rates in the region, it was chosen as the location for the study because of ease of access to the school and because of the enthusiasm of the school administrators both in allowing the administration of the study and in planning to res pond to the study results through future sex education interventions in the school. Host Organization: Ministry of Public Health of the Tumbaco Valley Zone (M o PH TVZ) The administrative offices of the Ministry of Public Health for the Tumbaco Valley Z one (MoPH TVZ) are part is housed in a building in the town of Tumbaco (see Figure 7 ) . Most government ministries have a presence in this building, and are administered by between 1 4 staff members pe r ministry. The director of MoPH TVZ programming is Dr. Francisco Viteri , a medical doctor who is also a faculty member at the nearby Universidad San Francisco de Quito (USFQ) . It is through this second post that Dr. Viteri met and has coordinated with Dr. David Wood, a former faculty member at the University of Florida, on various health related initiatives over the past 10 years. This MDP practicum was the first time that a representative from the University of Florida collaborated on a project directly w ith the AdministraciÃ³n Zonal; previous collaborative efforts took place through USFQ. There are eight health related programs administered by the MoPH TVZ, one of which is the Adolescent Sexual and Reproductive Health and Rights (ASRHR) program. There ar e currently four permanent staff members (including Dr. Viteri) that administer these programs, one of which was hired in June of this year specifically to focus on administer ing the ASRHR program. Last year, there were also two contracted staff members wh o worked o n the ASRHR program, who travelled to secondary schools Age 10 14 15 19 10 19 Ecuador 5.9 % 16.8 % 10.6% Tumbaco Valley Zone 0.5% 14 .6 % 9.3% CumbayÃ¡ 0.6% 8.5% 5.5% Source: VII Censo de PoblaciÃ³n y VI de Vivienda 2010 (http://www.ecuadorencifras.gob.ec/sistema integrado de consultas redatam/) Figure 6 : The "AdministraciÃ³n Zonal" of the Tumbaco Valley Zone
15 in the TVZ to teach sex education classes. Due to administrative changes following governmental elections in 2013, the MoPH TVZ was not able to contract personnel for the ASRHR program in 20 14 as was planned. Although the MoPH TVZ had previously concentr ated the efforts of the ASRHR program on rural areas within the TVZ, the MoPH TVZ identified a secondary school in CumbayÃ¡, a semi urban area , as the target area for ASRHR interventions in 201 4. This was because of the accessibility of the school (a 10 minute drive from the AdministraciÃ³n Zonal building), the large number of students that attended this school (around 1,500), and the interest and openness of the school administrators to ASRHR in terventions. The CumbayÃ¡ , CNC ) is a co ed public secondary school (equivalent to a combined middle and high school in the U.S.) . Due to its proximity to Quito, there are many more female students t h an male ; school adm inistrators told us this is because many male teens from CumbayÃ¡ study in private schools in Quito, while female teens are more likely to study in local (free) public schools like CNC. Figure 7 : One of the buildings of the Colegio Na cional de CumbayÃ¡
16 PRACTICUM TIMELINE Figure 8 : Practicum Ti meline Review of literature Jan April 2104: at UF May 5 17: In Ecuador Develop research instruments May 20 31 Data collection Focus Groups: June 4 12 June 11: Stacey arrives Surveys: June 18 19 Data analysis June 20 July 14 Presentation of results July 15
17 LITERATURE REVIEW Before designing the research instruments for this study, a thorough literature review was conducted to gather information from other researchers who had previously conducted similar studies. A systematic review of adolescent f ertility in low and middle income countries conducted by McQueston, Silverman, and Glassman (2012) found that proximate causes of pregnancy, such as lack of contraceptive usage or early age of sexual debut, were not as significant as distal causes, like h uman rights abuses, gender inequality, child marriage, and socioeconomic marginalization. This supports the rationale for comprehensive sexuality education programs, which not only provide medical information about pregnancy, STIs, and contraceptives, but also address topics such as sexual rights, abuse, gender issues, goals for the future, decision making skills, self esteem, and communication skills, among other topics. A 2007 study by the World Health Organization found that between 55 72% of pregnancies among unmarried adolescents between 15 19 years old in Bolivia, Colombia, and Peru (three countries near Ecuador) were unplanned or unwanted. Another study by Chedr aui, Van Ardenne, Wendite, Quintero, & Hidalgo (2007) of 357 adolescent girls who gave birt h in Guayaquil, Ecuador found that 63% of study participants did not plan to become pregnant. Goi colea, Wulff, Ohman , & San Sebastian, in a 2009 study in the rural Amazonian province of Orellana, Ecuador, found correlations between adolescent pregnancy and a history of sexual abuse, early sexual debut, parental absence, and poverty. d early union (marriage or cohabitation) between a female child and an adult , which the authors identify as th e most prevalent form of child adolescent sexual abuse in the region. A study evaluating teen pregnancy interventions in Ecuador and Nicaragua by Tebbets & Redwine (2013) found that peers exert a significant influence on making arou nd sexual and reproductive health issues. The 2007 study by Chedraui et al also found that among the girls who had just given birth in Guayaquil, 90% of them know what oral contraceptives were, while only 85% knew what condoms were, 67% knew about injectab le methods on contracept ives, and only 63% knew about i ntrauterine d evices (IUDs) . Additionally, the most important sources of information about sexual health for the girls in this study was television, high school, and family/relatives. Chedraui et al . (2 007) recommend that adolescent pregnancy interventions focus on the perceived negative aspects of condom use, such as that they reduce pleasure, they are artificial, unromantic, and that they interrupt sexual activity.
18 Grey literature (an unpublished Minis try of Public Health project proposal) describes Ecuadorian culture as viewing non reproductive pleasure necessary of repression (Secretaria de Salud del Municipio del Distrit o Metropolitano de Quito) . This proposal document asserts that t his view has negatively impacted many past adolescent pregnancy prevention interventions in the country , for example leading to an over emphasis on abstinence, while neglecting the opportuni ty to help adolescents con struct their own identities and equip them with the means and resources to freely make their own responsible decisions. This document also emphasizes the importance of in ter generational dialogue, which it asserts would help adoles cents to make informed, autonomous decision s about their sexua l lives. The document states that such intergenerational dialogue in Ecuador punitive views of adolescent sexuality (p. 3). Furthe rmore, the proposal document points to a need to improve reproductive healthcare services in Ecuador, which, while generally more accessible in the urban area of Quito, are still largely unavailable in other areas of the country, including less urbanized a reas of the Quito metropolitan district (such as the Tumbaco Valley Zone). Lastly, th e proposal states that Ecuadorian adolescents have historically had few opportunities for political participation, cultural expression, education, work, and recreation, an d have experience d high levels of social, gender based, and sexual violence; all of these factors likely contribute to the high pregnancy rates in the country. At least one project investigating the causes of teen pregnancy in Tumbaco has already been cond , produced by the Ministry of Public Health. In the interviews on this DVD, adolescents from Tumbaco identified the following factors contributing to high risk sexual activity: misinforma tion (from educational and healthcare institutions as well as families), curiosity, peer pressure, lack of communication with parents, pressure on male adolescents to engage in sexual activity, and lack of plans or hope for the future. However, it appears that the interviews were only conducted for advocacy purposes ( rather than project planning), and that a systematic way. Two large scale systematic reviews, by McQueston et al . (2013) and Kirby, Laris, & Rollert (200 5), provide information about strengths and weaknesses of past adolescent pregnancy prevention programs in developing countries. McQueston et al . (2013) advocate a rights based approach to teen pregnancy prevention, emphasizing issues such as human rights abuses, gender inequality, and the right to accurate education. Kirby et al . (2005) also emphasize the need to tailor interventions to the needs of the young people they are targeting; they suggest conducting focus groups or interviews with youth to learn more about why youth engage in sexual activity and the barriers to contraceptive use . In delivering
19 an educational program, Kirby et al . (2005) recommend focusing narrowly and explicitly on specific behaviors such as abstaining from sex or using condoms, g iving clear messages about these behaviors, and addressing how to avoid situations that might lead to risky sexual decision making. Additionally, this study emphasize d the need to target psychosocial risk and protective factors affecting sexual behaviors, including knowledge, perceived risks, attitudes, perceived norms, and self efficacy. Teaching methods should actively involve youth, and help them to personalize information they receive (Kirby et al, 2005). This study also found that successful programs t ended to focus more heavily on abstinence in interventions targeting younger, less sexually experienced youth, shifting the focus to condoms and other contraceptives for older, more experienced adolescents. Lastly, Kirby et al . (2005) also found that succe , generally and more specifically in terms of resisting unwanted or unprotected sex and insisting on condom use. Tebbets & Redwine (2013) advocate a Youth Peer Provi der program, which has already been carried out in several locations in Ecuador, but does not appear to be con nected with the ENIPLA program, and does not appear to have been carried out in the Quito area. This program trained youth under age 20 on reprodu ctive healthcare topics, and provided them with condoms, oral contraceptive pills, emergency contraception, and injectable contraceptives, all free of charge. The Peer Providers could then distribute both the contraceptives and relevant information to othe r youth in their community. They received minimal monetary compensation, as well as jackets, hats, or other program attire. Tebbets & Redwine found this program to be extremely effective, resulting in much higher contraceptive usage rates among program par ticipants, as well as increased self esteem, stronger communication and decision making skills, close relationships with friends and family, more interest in school, and increased understanding of responsibility in relationships.
20 RESEARCH APPROACH AND C ONCEPTUAL FRAMEWORK Figure 9 : "Bubbles" Behavior Change Framework (PSI, 2004) behavior change framework (see Figure 9 ) was created by Populatio n Services International in 2004 initiatives, many of which center on adolescent pregnancy in developing countries . Many behavior change theories are reflected in the framework ; as such, the language in the framework reflects commonly used terms in behavior change theories found in academic literature. This study used the Bubbles framework , as well as ideas from the literature review, as a starting point for designing the resea utilized . Although a traditional grounded approach would only create a framework after data collection, with the elements in the framework reflecting ideas and concepts arising from the data (thus resulting in a completely original framework), the framework used for this study instead incorporated elements both from the Bubbles framework and from ideas and concepts repeatedly mentioned by students in Cumbay Ã¡. As seen in Figure 10 , t central to the Bubbles framework, remain in this conceptual framework.
21 Figure 10 : Final Conceptual Framewor rk) In the above framework, d ecreased sexual activity and increased contraceptive use are the two desired behaviors, and are found at the center of the diagram . Note that a typical Bubbles framework would only contain one desired behavior, but because th e determinants (factors that possibly influence the health outcomes) of the desired behaviors in this case are likely to be very similar, the two behaviors are depicted together . Each green rectangle depicts a behavioral determinant . The yellow bubbles in the framework each demarcate a domain, or a group of similar behavioral determinants. domain contains desired behavior; usually these are structural or institutional fact ors that are not controllable by the individual . The contains factors relating to the skills or proficiencies that influence whether an individual is capable th at influence whether or not a person wants to perform a certain behavior.
22 RESEARCH FOCUS AND METHODS As previously highlighted, both sub regional and national adolescent pregnancy strategies call for a situation analysis as a primary component of a tee n pregnancy prevention plan ; this recommendation was also echoed by some papers discussed in the literature review. Although interviews inquiring about the underlying causes of teen pregnancy had previously been conducted with some teens in the Tumbaco are J Ã³ the results were largely anecdotal; no systematic research had yet taken place. As such, the primary research question for this study was: the Colegio A mixed methods approach was used in order to collect both qualitative and quantitative information from the students in Cumbay Ã¡ ; first, focus group discussions (FGDs) were held, followed by self administered written quest ionnaires . Both methods a ttempted to measure the degree of influence of each of the behavioral determinants depicted in the green rectangles in the conceptual framework. Focus Groups Design The quest ions asked in the focus groups reflected the researc intention of assessing the presence (or non presence) and degree of influence of the factors outlined the preliminary conceptual framework , with flexibility for new concepts to naturally arise from the conversations . All of the questions were reviewe d and edited by staff at the AdministraciÃ³n Zonal and school administrators in CumbayÃ¡. This helped to e nsure that the questions were culturally appropriate, that they addressed the main factors that were hypothesized to influence teen pregnancy rates in t he region, and that the language used in the questions would be easily understood by the FGD participants. Participants were not asked to share personal experiences during the focus group sessions; rather, they were asked to speak in general terms about tr ends or phenomena that they perceived in their student population. The discussion guide that was used during the focus group sessions can be found in Appendix 1.
23 Implementation Table 4 : Focus group participants Gender of partici pants Number of participants Age range Male 10 15 16 Female 6 15 Female 4 15 16 Male 12 14 17 Four focus group discussions (FGDs) , with a total of 32 participants, were held in a p rivate conference room in the Cu mbayÃ¡ school, with prior approval fro m the school administration and the A meeting was held a few days before the FGD sessions with parents of the participants to explain the purpose of the focus groups and of the ASRHR program in general. All of the students were in gr , th grade in the American school system. Participants were randomly selected by choosing every fifth name on class enrollment records. It is worth noting that although girls greatly outnumber boys in this school , the number of male participants in the FGDs is much greater than female, simply because of misco mmunication with the students w e invited an equal number of male and female participants. About half of the focus group participants in each session had receiv ed some form of sex education, either from the school director or medical students from a local university , while the other half had not. All four sessions were co moderated by myself and a female staff member of the AdministraciÃ³n Zonal (Katherine Tafur , 25 years old ). Katherine does not live in CumbayÃ¡ and was not personally known by any of the participants; this helped to ensure confidentiality and candidness during the sessions. Stacey Geryak, a medical student from the University of Florida who co coo rdinated the latter half of this study, observed the last focus group session. After the FGDs were concluded (approximately one hour each), students were given the opportunity to write down an anonymous question relating to sexuality , which was then answer ed by myself or Katherine. Although this was originally intended simply as an educational opportunity for the participants, this actually provided us with further information about gaps in knowledge relating to sexuality . All FGD participants were provided lunch at the conclusion of the session. All sessions were audio recorded , and all of the participants were read an informed consent script that had been previously approved by the IRB board at the University of Florida, as well as the IRB board of the Uni versidad de San Francisco de Quito .
24 Analysis The contents of the FGDs were transcribed within one week of the discussions. The transcripts were later printed out and color coded by gender . Codes were assigned to each of the potential behavioral determina nts depicted in the conceptual framework, and were written in the margins of the transcripts, which were then cut into sections and re organized according to their code. This ensured that all conversations relating to a potential behavioral determinant wou ld be analyzed together, and differences or similarities (especially between genders) could be easi ly spotted. Surveys Design The surveys were also designed to address the factors outlined in the conceptual framework , including the new elements that ar ose from the FGDs; particular attention was paid to knowledge, attitudes, and behaviors relating to sexual activity and contraceptive use . Additionally, through personal correspondence with the authors of two published articles related to adolesc ent sexual health in Latin America (Antrop, Walker, Gutierrez, & Bertozzi, 2006; PSI Research & Metrics, 2011) , I was able to obtain two blank survey inst r uments in Spanish that had been used for similar research activities. I also used several activities which contains an extensive sexuality education unit, again in Spanish. Additional survey questions reflected topics brought up by the focus group participants. The survey questions were divided int o three sections: knowledge, attitudes/beliefs, and behaviors. Thirty five point scale. Five additional questions were open answer in format. This section included questions about reproductive rights, correct condom usage, STI prevention, and effectiveness of various agree/disagree statements to be answered on a five point Like rt scale, and included statements about comfort level when obtaining or suggesting the use of contraceptives, social expectations of men and women regarding sexuality, and social implications of asking a sexual partner to use a condom, among other topics. contraceptive use, and drug and alcohol use. The survey addressed all of the behavioral determinants depicted in the conceptual framework. The survey was reviewed and edited by staff at the AdministraciÃ³n Zonal and members of the CumbayÃ¡ school administration. Unfortunately, there was not
25 time to pre test the surveys, as the school year was ending the administration of the surveys took place on the last two days of the school year. A copy of the survey instrument can be found in Appendix 2. Implementation The surveys were carried out one week after the focus group discussions. All surveys were anonymous and all participants were read an informed consent script that was approve d by the IRB board of the Universidad de San Francisco de Quito. Students were instructed to remain quiet and to respect the privacy of their classmates during the administration of the survey. After the surveys were administered, the data was manually ent ered into Epi Info 7. The age, grade level , and gender of survey respondents is as follows: Table 5 : Age of survey respondents Age 14 15 16 17 18 Number of respondents 39 93 98 67 38 Table 6 : Grade level o f survey respondents Grade level 10 4 5 6 Number of respondents 90 121 62 64 Table 7 : Grade level equivalencies: Ecuador and U.S. Table 8 : Gender of survey respondents Analysis Preliminary analysis of the survey results was conducted in Epi Info 7, with some graphs and charts created in Microsoft Excel. Further analysis was carried out in STATA /SE, version 13 . Ecuadorian grade level U.S. grade level equivalent 10 9 4 10 5 11 6 12 Gender Female Male Number of respondents 211 125
26 R ESULTS Population Characteristics: Pregnancy Rates , Sexual Activity, and Condom and Contraceptive Use which penile va ginal penetration occurred. Although there are many other way for example taking into account non penetrative activity, same sex sexual activity, and/or frequency of activity, this simplified version of the term was used sin ce the focus of the survey and the intervention is pregnancy prevention. A definition was provided on the written survey every time that . It is worth noting that similar studies that attempt to monitor sexual activity of ten use a time bound definition; for example, a survey would not only ask if a respondent had ever been sexually active, but would also ask if the respondent had been sexually active in the last three (or six) months. In some cases, studies would only cons ider respondents to be sexually active if they had engaged in sexual activity within the time period specified in the letter question . Unfortunately, I was unaware of this definition at the time of the survey design, and so all participants in this study w ho stated that they had ever engaged in sexual activity are considered to be sexually active, even though this is not usually the standard definition. Some of the data presented in this report is disaggregated by grade level rather than by age, since one i mportant intended outcome of this situation analysis wa s to determine the grade level at which to start the educational intervention. Since age varies widely within grade levels (more so than in the United States), disaggregating by age alone would not pro vide this information. Table 5 provides a general correlation of the Ecuadorian secondary school system to the U.S. system. About 2% of female respondents reported ever having been pregnant, and 1% of male respondent reported ever having provoked a pregnan cy. When reading these figures, one should take into account that these are simply the self reported pregnancy rates actual rates could be higher or lower for a variety of reasons: respondent s might not have wish ed to share this information, respondent s mi ght not have known they were pregnant (female) or had provoked a pregnancy (male), etc. teen birth rates found by the government census in the CumbayÃ¡ p arish and the TVZ (8.5% and 14.6 %, respectively) this may be due to the factors just listed, and/or because of the fact that girls who become pregnant may drop out of school and thus were not present in the study population, even though they are still residents of CumbayÃ¡.
27 Overall, about 35 % of respondents reported being sexually active (ever having engaged in sexual activity). The only statistically significant difference between the sexes in terms of sexual activity is between 14 year old boys and girls: aro und 37% of 14 year old male students and 6% of 14 year old female students in the CNC are sexually active. At all other ages, there is no statistically significant difference between the sexes. It is unclear why boys seem to start sexual activity earlier t han girls, although one must keep in mind the possibility of non honesty in reporting. Additionally, about 24% of students in grade 10 (equivalent of U.S. 9 th grade) reported being sexually active, as did 35% of those in 4 th grade (U.S. 10 th grade). This is significant because p ast sexuality education interventions in the CNC had been delivered to students in grade level 4 . School administrators explained that this grade was chosen as the target group for interventions because they believed that students b egan to engage in sexual activity when they were in this grade. In fact, the school administration was hesitant to allow the 10 th graders to participate in the study, both because they believed that they were too young to be exposed to the questions in the study, and because they thought they would not be able to provide meanin gful information for the study because they believed that so few of the 10 th graders were sexual ly active. After seeing that 24% of them were already sexually active, they said that t hey would begin sex education interventions in earlier grades. Around 20% of sexually active respondents report ed when they engage in sexual activity co ndom . (Note that gender disa ggregated data is not depicted in the data in the appendix for this variable because answers by gender were not significantly different .) However , when respondents were asked if they used a condom the last time they had sex, aro und half of the respondents said no. In the analysis presented use rather than the first, since it is likely to be a more realistic measure of condom use patterns in this po pulation. There was no statistically significant difference between male and female respondents for this variable. Around 44% of sexually active female respondents did not use a condom or any other type of contraception the last time that they engaged in sexual activity. Thirteen percent did not use a condom but did use another contraceptive method, 28% used a condom but no other type of contraceptive, and 16% used both a condom and a contraceptive method.
28 As previously explained, contraceptive use. chance to perform a desired behavior; usually these are structural or institutional factors that are not controllable by the individual. The in this study were availability, product attributes, quality of care, a nd social norms (with an emphasis on gender norms). Availability commun ity , as well as the availability of accurate knowledge about sexual and reproductive h ealth and rights . Participants in all four of the focus groups stated that pharmacies and health centers in their community are regularly stocked with contraceptives. One participant stated that the school bookstore also used to sell condoms, but that they When asked if students thought that it would be a good idea to locate a condom dispenser in the school, many students said that it would run out of condoms immediately, either because students would take the condoms and play with them (infl ating them like balloons, for example) or because they would be used for sexual activity. One male participant stated ( perhaps Female participants in one group stated that students that used the sch ool facilities at night would use the condoms, because some of them had been previously known to have had engaged in sexual activity near the soccer field adjacent to the school. One participant suggested having the school nurse supply condoms to students who ask for them; this way, students would not see who was obtaining condoms. Some participants stated that condoms had been distributed during some of the previous sex education interventions in the school, and played with the condoms. Several participants stated that condoms are more widely used than other birth control methods because they are the most widely available contraceptive method, and because alternative methods can be difficult to obtain. Some f emale participants said that they did not personally know any girls their age that used a contraceptive method other than condoms. Students expressed interest in the possibility of an adolescent only reproductive healthcare center in their community that would provide information about contraceptives as well as contraceptive methods. Although the students were not aware of this at the time of the FGDs, the MPH TVZ is in the
29 process of coordinating with other local organizations to implement an adolescent only reproductive healthcare center in Tumbaco, about five kilometers away from the school . In the questionnaire, around 35% of students reported that buying condoms makes them feel very embarrassed, and 18% said that they would never buy or obtain condom s or other contraceptive methods because it would make them very embarrassed. Over 65% of sexually active respondents said that they obta in condoms when they need them, suggesting that around 30% do not obtain condoms when they need them. These answers sug gest that embarrassment of obtaining condoms (which are provided in public places such as grocery stores and neighborhood health clinics) is a barrier to their use. Product Attributes refer to characteristics of contraceptive methods . When asked why some of their sexually that many male teens think (or say) that using a condom will decrease physical sensation during sexual activity, although one femal . two of the groups stated that this point had been directly addressed in previous sex education interventions in the school , with the instructors emphasizing that condoms did n ot decrease physical sensation . One male participant mentioned the possibility that a male teenager might not want to use a condom because he might be afraid that it might not fit him, especially if he has a small penis, and this would cause him embarrassm ent. When asked for ideas about why a teenage girl might prefer to rely on male condoms as the only form of contraception , one female participant suggested it might be because male condoms are easier to use than female condoms. Another female participant s tated that some girls might not use the pill because they will forget to take it, and they might not get the injection if they are afraid of needles. A male participant suggested that girls might be more likely to use the pill rather than other non condom contraceptives, because it is the most widely known method. Around 30% of survey respondents Male respondent were about 70 % mor e likely to agree with the statement than female respondents.
30 Quality of Care quality of healthcare service received when teens try to obtain contraceptive s, and second, the quality of the educational interventions that adolescents receive in their school. In the FGDs, o pinions varied on whether or not health center or pharmacy workers in CumbayÃ¡ would have a judgmental attitude toward adolescents attempting to obtain contraceptives. I t was generally agreed that pharmacy personnel were more likely to be judgme ntal than health center workers, which is significant as there are many more pharmacies than health centers in CumbayÃ¡ ( and the rest of the TVZ ) . Some p articipants stated that healthcare workers might ask adolescents lots of questions about why they needed contraceptives, which would make some adolescents feel embarrassed, although participants stated that they did not personally know anyone that that had happened to. Female parti cipants in one group stated that as part of a previous sex education looks from the female pharmacy staff. One female participant sta ted that a barrier to girls using non condom contraceptive methods was embarrassment of obtaining such methods. When asked what advantages an adolescent only healthcare center might have over a regular health center, some participants stated that the qual ity of care in an adolescent only healthcare center would be better because the healthcare staff woul because they would be working only with adolescents and not with adults or children . Some participants even suggested that such a center be staffed with adolescent healthcare workers (their peers, in other words) , so that teen patients would feel even more comfortable. In terms of the quality of previous sex education interventions, most participants who had received interve ntions felt positively about them It appeared that each class section (each grade had four class sections) had a different facilitator for the interventions, and that the facilitators did not coordin ate with each other ; therefore, the conten t, structure , and length of the interventions varied. Some facilitators, for example, had a structured curriculum of twelve classes, while another simply asked students what they wanted to talk about. Nonetheless, all participants stated that they felt satisfied with the instructors, and many also stated that they would not want their regular school teachers to be facilitators because they might be patronizing or uncomfortable with the topic. One participant who rec eived an intervention from local medical school students stated that
31 (male and female) who received sex education from the school director also said they were very happy with him as an instructor , and that they would not prefer another person to be their instructor . Social Nor m s Conversations about s ocial norms in this study generally centered on for teenagers to attempt to obtain contraceptives, to carry condoms with them, and to be sexually active . In most cases, the perceived norm was different for adolescent females and adolescent males . Many focus group participants stated that although contraceptives were widely available in their community, adolescents might feel too embarrassed to try to obtain contraceptives because people might see them and m ight talk about them behind their backs, or even make judgmental comments in front of them. Opinions differed on whether adolescent females or males would be more likely to try to obtain contraceptives ; s ome female participants stated that boys would be le ss likely to try to obtain contraceptives, because their peers would talk ab out them more behind their back, while many male participants stated that adolescent girls and boys would be equally as likely (or unlikely) to try to obtain contraceptives because of fear of societal judgment. Much interesting conversation emerged on the topic of social norms around carrying condoms. While it was generally agreed upon that it is normal for male adolescents to carry condoms, many participants although they emphasiz ed that it should be normal and acceptable for girls to carry condoms stated that adolescent girls faced much higher levels of societal judgment for carrying condoms as compared to adolescent boys . Male participants stated that while they personally would be supportive of a girl carrying condoms , other people might perceive her or a was likely be a source of gossip in their school. Female participants reiterated the likel ihood of such judgment al attitudes , and stated that they were most likely to come from male peers ; female peers were more likely to perceive a teen girl carrying condoms as normal, smart , and responsible . Participants of both genders emphasized that such
32 machismo in their society. Some female participants hinted that they personally had condoms in their backpacks at the time of the FGD . The discussion about carrying condoms seemed to be closely tied to perceptions ar ound whether it was normal or acceptable for adolescent girls to be sexually active. One female participant stated: worst always and this is something that society i tself has made us believe. So, for example, if at a party a guy is with four girls, kissing and doing whatever, to his friends and to whatever other guy he is going to el macho, el hombre ]. In contrast, if a girl is having a conversation with three or four guys that are friends of hers or if she is laughing with someone, then the girl pardon the word is a slut, is a whore, This same participant stated that male teens might even fabricate stories about bein g sexually active in order to impress their friends. She also emphasized that some teen boys are not sexist. One group of male participants stated that sexual activity among (male and female) adolescents was viewed as normal by students in their school, an l activity in their school was around 14 or 15 years old. In the survey, around 12% of respondents said they felt that using condoms was a sign of lack of er, and male respondents were more than twice as likely to agree with this statement than female respondents. proficiencies that influence whether an individual is capable of performing a certain behavior. Knowledge events (PSI Research Division, 2004) . To assess knowledge about pregnancy prevention and other Alt machismo negative connotation), a more
33 sexual he alth related topics, s tudents in the focus groups were first asked about what topics had been taught in sex education interventions that they had previously received. While some students had not received any interventions, other had learned about contrace ptive methods, masturbation, drug use, HIV/AIDS and other STIs, sexual orientations, reproductive rights, self esteem, sexual abuse, sexism, and teen pregnancy, although not all of these topics were covered with all of the class sections. When asked to wri te down anonymous questions relating to sexuality at the end of the focus group sessions, a variety of questions emerged , indicating some possible topics to address in future interventions participants). Although some s tudents initially stated that they thought that teen pregnancy occurred because of a lack of knowledge about pregnancy prevention, most participants concluded that teens in CumbayÃ¡ had plenty of knowledge about how to prevent pregnancy (partially because o f previous educational interventions, but also from other sources) and so there must be other, more important underlying causes of adolescent pregnancy. However, results from the survey indicate that many students do not know the following facts: a person can have an STI without symptoms, a girl can get pregnant the first time she engages in sexual activity, adolescents do not need parental permission to obtain contraceptive methods from clinics or pharmacies, vaginal douching does not prevent pregnancy, pu tting one condom on over the other does not provide extra protection against pregnancy and STIs, a girl can get pregnant if she engages in sexual activity during her period, a man will not incur physical or psychological co ndoms do not have microscopic holes that permit HIV to travel control pills do not cause cancer. Some statistically significant differences emerged bet ween boys; and see Appendix A for more information. Self Efficacy Self or successfully (PSI Research Division, 2004) . Because personal information and experiences were not
34 asked about during the focus group sessions, self efficacy could not be measured during the FGDs. In the survey, only around 30% of responde nts said that they felt capable of going to a healthcare professional to ask for information about contraceptive methods. Around 60% said they would feel capable of speaking openly with their partner about their feelings and thoughts relating to sexual act ivity (suggesting that around 30% do not feel capable discussing the topic, although it is possible that this 30% is not yet sexually active). Around 75% said that they would feel capable of turning down sex if they as likely to agree with this than boys. Additionally, girls were 3.5 times more likely to say that they could avoid engaging in sexual activity even if they really like the person they are dating (82% of girls agreed with this as opposed to 57% of boys), a nd girls were also available (77% compared to 55%). Social Support/Pressure Social support and social pressure can be seen as opposite ends of a continuu m, wherein teens may be more likely to achieve desired health outcomes if they have more social support, and less likely to achieve them if they perceive social pressure. Focus group participants talked about three sources of social support and social pres sure: friends/peers, romantic/sexual partners, and parents/family. Focus group participants stated that peer support and pressure regarding sexual activity is different for adolescent girls as compared to adolescent boys. While some participants stated t hat girls and boys are equally as likely to pressure their friends to be sexually active, most participants concluded that boys were more likely to pressure other boys to be sexually active, while girls were more likely to support other girls in their deci sion to remain sexually abstinent. Male (and some female) participants stated that teen b oys, for example, might pressure non sexually active male peers by saying that they talking about them behind their back, and/or calling them gay or s marico n es ]. masculine the more girls he is with Female participants stated that some girls also pressure other girls to be sexually ac tive , but that girls were more likely to support, rather than ong to
35 When asked why social pressure might be different for teen girl s and teen boys, male respondents stated that teen girls and that girls have more conversations about their personal/romantic lives with each o ther. In contrast, p eers of teen boys might react to such , (and are encouraged) to talk about sexual (rather than romantic) experiences with each other. Wh en Although participants did not state this outright, it seems likely that practicing abstinence would be more sexual) lives. participants wrote questions asking why peer pressure is so powerful/influential for adolescents. Although related, pressure/support from romantic partners seemed to be a bit different than that from other peers. When FGD participants were asked whether adolescents experienced press ure from romantic partners to engage in sexual activity, most assumed that the moderator was talking about pressure from male partners, even though the moderator did not specify the gender of the partner that they were asking about. Most participants agree d that although teen girls might sometimes pressure their male partners to have sex, it was more likely that teen boys would pressure their female partners. Many focus groups talked about a widely known phenomenon called prueba de amor ], in which teen boys pressure their female partners to have sex with them in order to . d that teen boys did not actually for a teen boy to pressure a girl to have sex, so that he could then be respected by his friends. However, one male pa Many (male and female) FGD participants stated that a major underlying cause of teen pregnancy was te pressure to h ave sex. S ome stated that t his inability stems esteem , and others stated that it simply does not occur to some girls that they can say no. Some partici pants also mentioned that apart from pressure to simply engage in sexual activity, some male partners also pressured their female partners to not use condoms when they had sex, because they did not like the physical sensation of condoms .
36 FGD participants also talked about the importance of communication and support from parents of teens regarding sexual abstinence and use of contraceptives, stating that teens whose parents talked openly with them about sexuality were less likely to become pregnant or provo ke pregnancy. Some participants also mentioned that feeling supported and taken seriously by teachers and other adults when talking about sexuality was also important. Most participants stated that many parents do not ever talk to their teenage kids about sexuality or pregnancy, although some do talk openly about contraceptives, dating, and other topics. Some female participants even stated that their parents or other family members have yelled at them or hit them for saying that they have a boyfriend or ev en a male friend. P , pretend to be one way (sexually inactive) around their family, when in reality they are dating and sexually active . It was i risk taking on the part of the adolescent, and that such an adolescent might be more likely to practice abstinence or use contraceptives if their parents were more supportive of their dating choices . Some participants also stated that many parents would be open to participating in workshops about adolescent sexuality, and that such workshops would be a good idea. In the survey, just under 50% of respondents said they if they wanted to use contraceptive me thods, their parents would support their decision. Additionally, fewer than 20% said that their peers lose respect from their friends if the y beco me sexually active, suggesting that peer pressure to remain abstinent is probably not a very strong deterrent to sexual activity. wants to perform a certain behavior. Attitude In the Bubbles vior is seen as morally During the FGDs, many participants expressed that certain behaviors, while n ot always waiting to have sex until or married) ; using contraceptives ; communicating openly with partners about sexual activity and contraceptive use ; resisting pressure from peers and partners to have sex ; and , above all , being
37 Interestingly, there was no mentio n of religion in any of the FGD sessions , even though the major ity Ecuadorians (and residents of the TVZ) self identify as Catholic (INEC, 2010) . Language relating to morality was similarly absent from the discussions. Intention d behavior (PSI Research Division, 2004) . In the survey, only slightly more than half of sexually active respondents said that they proposed using a condom the last time they engaged in sexual activity, and only 64% said that t hey are going to use a condom the next time they have sex. Locus of Control In the Bubbles individual believes that they have direct control over their ability to perform a desired behavior, or whether this ability instead lies with other people, fate, luck, or chance. In the FGDs, many participants alluded to an additional possible locus of control: hormones (or uncontrollable desire). Statements such r ; they lose their minds ; -; F lesh is weak ; illustrate that some adolescents might think that they literally are not able to control wh ether or not they engage in sexual activity As previously discussed, many participants also stated that some adolescents (usually girls) felt that their partner held all or mos t of the decision making power regarding whether or not to have sex or to use contraceptives. Some FGD participants also mentioned the possibility that some teenage girls might become pregnant as the result of rape: a situation in which the locus of contro l clearly is outside of the individual. Participants stated that they themselves did not know of anyone that had become pregnant as a result of rape , although they acknowledged that they probably would not know if they did because such an occurrence would probably not be admitted openly . Some participants stated that they had seen stories on television where girls had been drugged with Scopolamine a nd date raped, although they had not heard of cases of this happening in their community. The BUBBLES framewo demographics , usually portrayed as being part of the framework . However, mentions of
38 substance use was associated with a loss of control over decision making abilities ; students connected drug and alcohol use with increased levels of sexual activity and decrease usage of condoms . Focus group participants stated that drug and alcohol consumption was very common at informal house parties ( ) and local discotecas , which some teenagers supposedly attended several times a month. Participants stated that the most commonly consumed drug was marijuana (which many said was s old by students during school hours), and some said that ecstasy and cocaine use was also common. Participants said that teens normally started going to parties when they were between 12 and 15 at their children were attending parties or using drugs or alcohol (although some parents were aware and gave their kids permission to attend) . Some participants stated that it was common for adolescents to engage in sexual activity during parties, when th , sometimes supposedly not remembering the next day what they did the night before. Interestingly, the survey results indicate that although around 61% of teens in this populati on have drank alcohol at least once, the majority of those who have drank have only tried alcohol once or a few times. Additionally, over 80% of those who are sexually active reported that they were never under the influence of drugs or alcohol when they e ngaged in sexual activity. Drug use among the student population seems to be relatively low, with 12% having tried marijuana once or a few times, and less than 3% using the substance more than that. Outcome Expectation ther or not a promoted behavior or product (abstinence and contraceptives in this case) is believed to be effective in preventing the health outcome (teen pregnancy) . One FGD participant expressed doubt about the rel iability of condoms, stating that they very safe because they can break, and therefore abstinence is the most reliable method for preventing pregnancy. Some participants stated that some adolescents might not use condoms because they are perceived to be so unreliable that as far as preg One participant stated that c ondom unreliability might be a reason why adolescent girls might prefer to use contraceptive methods such as the pill or implant. However, two
39 partic ipants stated the opposite: that adolescents might not perceive other non condom methods of contraception to be necessary because they perceive condoms to be reliable. Participants stated that non condom forms of contraception were generally perceived to b e reliable. Around 80% of survey respondents said that they believe that condoms help to prevent the transmission of STIs, while around 70% said they thought that condoms were effective in preventing pregnancy and the transmission of HIV. This suggests th at around 30% of respondents do not believe that condoms are very effective, even though the failure rate of condoms (if they are used correctly) is around only 2%. Subjective Norm eived pressures to comply with what an individual believes other in the social group believ It is worth emphasizing that subjective norms can be simply perceived rather than actually stated. A common theme in the FGDs was tha t many adolescents who engaged in sexual activity did not communicate with their partner before engaging in such activity. Participants stated that this was re, it is possible that an adolescent might simply guess or assume what their partner is thinking. As previously discussed, adolescents (especially boys) may be less likely to practice abstinence if they influenced by what they perceive that their partner believes about sex and contraceptive use, even if this belief is not expressed directly by their partner. One male participant even stated that adolescent gir with infidelity, adolescents might not wish to use condoms with their partners, either to prove that they are not being unfaithful, or to indirectly (although maybe unsuccessfully) pressure their partner to be faithful. Finla s would also be important in determining subjective norms regarding abstinence and contraceptive use. However, just as teenage romantic partners might be reluctant to talk to each other about sexuality, focus group participants stated that many parents are also reluctant to talk about sexuality with their
40 teenage children. This therefore might leave many adolescents to guess at what their parents might feel about sexual activity and contraceptive use. However, participants did emphasize that this treatment of some teens do talk to their partners at length about sexual activity and contraceptive use, and some parents also discuss sexuality and pregnancy prevention with their adolescent children. Around 56% of survey respondents said that they did not believe that it is important to talk around 15% said that if they ask their partner to use condoms, their partner will think that they are Threat seriousness of a health problem, and susceptibility, or problem will negatively harm him/her. Most focus group participants stated that they felt that teen pregnancy was common in their school and was a serious problem, citing consequences such as having to d rop out of school, family problems, social problems, abortion, health problems, and abandoning their child. However, one female participant stated that she did not think that teen pregnancy should be seen as a problem, and that if a teen girl chose to have a child, she should not be outcast by society. Interestingly, many respondents (male and female) repeatedly variations on e ven though gender wa s not specified in the question; the respondents seemed unaware that the y had specified only one gender in their answers (admittedly, the moderators did not catch this nuance at the time, either) . When later asked if pregnant adolescent girls and their male partners equally divided the responsibilities of taking care of a child, many respondents said that some teen boys would abandon their partner, leaving the girl to take care of the child by herself . Although the physical threats of te en pregnancy are clearly exclusive to females, these comments suggest that other consequences of teen pregnancy in CumbayÃ¡ also lie more heavily with girls . Some participants said that some teen girls might not perceive pregnancy as being a very serious problem because they can get an abortion if they do not wish to have a child. However, all participants
41 emphasized that they themselves knew that abortions could pose health (and sometimes emotional) risks to a teen girl, especially since abortions are ill egal in Ecuador and are therefore performed in less than optimal conditions. Several female participants stated that they personally knew of girls who had gotten abortions. Many participants stated that despite the potential serious consequences of teen p regnancy, some adolescents actually want to have children. Most participants stated that this was because such teens do not fully think through the consequences of teen pregnancy they might think that having a or an effective way of keeping a romantic partner. One participant stated children later in life. Many participants stated that a major underlying factor in teen pregnanc y is that adolescents about the future or th It is unclear whether this is because these adolescents think that teen pregnancy is not a seriou themselves are likely to provoke pregnancy or become pregnant (susceptibility), or a combination of both. Participants stated that many (although not all) adolescents engage in sexual activity with much forethought, and without discussing it in depth with their partner. One participant stated that her mother had taken her to a place where teen mothers lived with their children, and after the participant had talked to the girls there about how diffic ult it was to raise a child, she understood that teen pregnancy was a severe problem Around 60% of survey respondents said that having a child now would make it difficult for them to finish their studies in secondary school or to accomplish their goals for their future . This seems surprisingly low, suggesting that perhaps many respondents have not thought critically about the possible consequences of having a child during adolescence. Around 20% s aid that they do not think it is necessary to use a condom with a partner that they know well, or if another contraceptive method is trust that they are telling the truth, although boys were about twice as likely to say this than girls. The most commonly reported negative consequence of teen pregnancy among respondents was a negative impact on studies (36%), followed by difficulty in achieving future goals (16%) for the teen mother (7%).
42 Curiosity Although it is not traditionally part of the BUBBLES framework, curiosity emerged as a theme in the FGDs as an explanation for why adolescents (male and female) might choose to engage in sexual activity, and also why adolescents (male and female) might choose not to use a condom during sexual activity. Many comments about curiosity included state ments about a desire to experience physical pleasure, and curiosity about what such pleasure would feel like. Interpersonal Connection Interpersonal connection is also not typically a variable in the BUBBLES framework, but it also emerged repeatedly as a theme during the FGDs. Some participants stated that teenage girls might therefore seek such connection with a romantic partner through sexual activity or even pregnancy . One female participant stated that she knew a girl who became pregnant on purpose in order to gain attention from her emotionally negligent mother. As discussed previously, many participants stated that teen girls (and some boys) may see h aving a child as an effective means of forcing a connection /tie ( ) with their romantic partner, who otherwise may be tempted to break up with them ( the participants acknowledged that such a tactic was unlikely to be successful). Many participants also stated that female adolescents are more likely than males Only around 7% of survey respondents said that more than twice as likely as girls to believe this.
43 C ONC LUSION AND RECOMMENDATIONS When the preliminary results of this study were presented to the school administrators, many of the findings were in line with what they had expected, while some findings were surprising to them . Perhaps the most significant finding in terms of planning the educat ional intervention was that students in the school were engaging in sexual activity at a younger age than school administrators had assumed. When they learned that nearly 20% of students in the 10 th grade (equivalent of US 9 th grade) had already been sexua lly active, the administrators immediately came to the conclusion that the intervention should begin in the 10 th grade instead of 4 th grade (US 10 th grade), or even earlier. Additionally, while they knew that rates of condom use and contraceptives was rela tively low (as evidenced by the prevalence of adolescent pregnancy among the student population), they were surprised to learn that a full 50% of sexually active students had not used a condom the last time that they engaged in sexual activity, and that mo st of those students were also not using any other type of contraceptive method. The school administration did not directly state that they would consider providing condoms in the school, but given that they had previously provided condoms through the nur study found that access to condoms was a major barrier to condom use, the administration may again consider providing condoms on school grounds. A full 47% of female survey respondents (and 33% of male respondents) stated that buy ing condoms makes them feel very embarrassed, while 20% of girls (and 14% of boys) stated that they would never buy or obtain condoms or other contraceptives because it would make them too embarrassed. As Chedraui (2007) suggests, it will also be important to continue to directly address the fear that using condoms will decrease physical pleasure, given that several students mentioned this during the focus groups. Thirty six percent of male respondents stated that they believed this to be true, and 19% of s tudents who did not use a condom the last time they engaged in sexual activity stated that their primary reason for not using a condom was that it decreases physical pleasure. Any future educational intervention should also directly address harmful gendere d social norms, especially the stigma facing adolescent girls for carrying condoms and other contraceptives, and peer pressure on adolescent boys to be sexually active. Additionally, it may be important for an intervention to address the question of whethe 18% of male respondents stated that they believed that this was true. Lastly, around 35% of all a condom. Addressing this gender expectation by encouraging female adolescents to obtain and suggest using condoms could result in higher rates of condom use.
44 The survey results also indicated that this population needs additional accurate information ab out pregnancy, STIs, and contraceptives. For example, only 82% of respondents knew that a girl can get pregnant the first time that she has sex and only 41% knew that a person can have an STI without having symptoms. Additionally, a significant percentage of respondents either agreed with or said they condoms , as nearly 20% of respondents stated that they did not believe that condoms are an effective way to prevent pregnancy. While the school administrators and parents were aware of and concerned about rumors of high rates of alcohol and drug consumption amon g the student population, they were surprised to see the relatively high rates of alcohol consumption (with around 20% of respondents saying they drink once a month or more), although it seemed like relatively few (16%) of sexually active respondents had e ngaged in sexual activity while under the influence of alcohol or drugs, especially considering how prominent this theme was in the focus group discussions. It could be that more than 16% of respondents had engaged in sexual activity after consuming alcoho l and/or drugs, but did not consider much. Or, it could also be that stories of inebriation and sexual activity are more likely to circulate among the stud ent population due to their shock factor, even though such occurrences make up a small percentage of sexual activity among students in the school. Nevertheless, a sexuality education curriculum should probably include at least some information about alcoho l and drug use. Interestingly, only around 60% of respondents (male and female) stated that they thought that if they had a child now, it would make it difficult for them to finish their studies in secondary school or achieve their goals for the future. S ince it seems likely that respondents are underestimating the impact that having a child in adolescence would have on their future, an intervention might want to include information and activities related to goals for the future. In fact, many comprehensiv e sexuality education programs do include a module on future goals.
45 Unfortunately, since the eight parishes within the Tumbaco Valley Zone are quite different from each other, it may be unwise to simply cut and paste the implications drawn from the inform ation uncovered in this study and attempt to apply them to other areas of the TVZ. It may instead be desirable to replicate this study in other schools and parishes in order to be able to design truly context specific health and educational interventions t hat directly respond to issues of sexual and reproductive health in each area. Additionally, it is important to remember that due to the intimate nature of the questions in the survey, it is likely that not all of the respondents answered completely honest ly. Therefore, the insights gained from this study are not only spatially limited, but are also somewhat limited in credibility. Nevertheless, the study still reveals many significant findings that will hopefully be taken into account when designing the se xuality education program in CumbayÃ¡.
46 ADDITIONAL PRACTICUM ACTIVITIES Curriculum Development After concluding the study, I was able to gather and deliver to the CumbayÃ¡ school administrators a variety of sex education curricula and lesson plans in Spani sh, which cover several topics that could be part of this educational intervention. These topics include sexual and reproductive rights, gender roles, self esteem, puberty and anatomy, STIs, HIV/AIDS, pregnancy, abstinence, contraceptive methods, violence, goals for the future, and drug and alcohol use. I have personally used many of the materials that I provided , during my tenure as a sex education teacher in Guatemala (about two years), and found the materials to be accurate, engaging, and easy to use. Mo nitoring and Evaluation Framework Additionally, I developed a draft version of a monitoring and evaluation framework that could be used for the project, including indicators for each educational module, and matching questions from the survey that would ad dress each indicator. Unfortunately, I did not have time to hand over the framework to the Ministry of Public Health staff nor the CumbayÃ¡ school administrators, so this activity ended up being simply an exercise for my own benefit.
4 7 REFERENCES Antrop, P., Walker, D., Gutierrez, J., & Bertozzi, S. (2006). Estrategias novedosas de prevencion de embarazo e ITS/VIH/SIDA entre adolescentes escolarizados mexicanos. Salud Publica Mexico, 48 , 308 316. Asamblea Constituyente. (2008). Constitucion de Ecuador . Retrieved February 2, 2014, from http://www.asambleanacional.gov.ec/documentos/constitucion_de_bolsillo.pdf Berglas, N., Brindis, C., & Cohen, J. (2003). Adolescent Pregnancy and Childbearing in California. California State Library, California Research Bureau. Sacramento: California State Library. Retrieved June 1, 2014, from https://www.library.ca.gov/crb/03/07/03 007.pdf Central Intelligence Agency. (2014). Ecuador . Retrieved November 6, 2014, from CIA World Factbook: https://www.cia.gov/libr ary/publications/the world factbook/geos/ec.html Chedraui, P., Van Ardenne, R., Wendite, J., Quintero, J. C., & Hidalgo, L. (2007). Knowledge and practice of family planning and HIV prevention behavior among just delivered adolescents in Ecuador: the probl em of adolescent pregnancies. Archives of Gynecology and Obstetrics, 276 , 139 144. Eager, P. (2004). Global Population Policy: From Population Control to Reproductive Rights. Ashgate Publishing Ltd. Finlay, K. A. (1999). The Importance of Subjective Norms on Intentions to Perform Health Behaviors. Journal of Applied Social Psychology, 29 (11), 2381 2393. Goicolea, I., Wulff, M., Ohman, A., & San Sebastian, M. (2009). Risk factors for pregnancy among adolescent girls in Ecuador's Amazon basin: A case control study. Revista Panamericana de Salud Publica (Pan American Journal of Public Health), 26 (3), 221 228. Hindin, M., & Noah, A. (2011). A Meta analysis of Women's Fertility and Women's Empowerment in Sub Saharan Africa. International Center for Research on Wo men (ICRW), Washington, DC. INEC. (2010). Informacion Censal . (Gobierno Nacional de la Republica del Ecuador) Retrieved December 10, 2014, from Ecuador: ama la vida: http://www.ecuadorencifras.gob.ec/informacion censal cantonal/ INEC. (2010). Resultados de l Censo 2010 . (Gobierno Nacional de la Republica del Ecuador) Retrieved December 7, 2014, from Ecuador: ama la vida: http://www.ecuadorencifras.gob.ec/resultados/ INEC. (2010). VII Censo de Poblacion y VI de Vivienda 2010. Instituto Nacional de Estadisti cas y Censos . Quito, Pichincha, Ecuador: Gobierno Nacional de la Republica de Ecuador. IPPF. (1996). IPPF Charter on Sexual and Reproductive Rights. International Planned Parenthood Federation. London: IPPF. Retrieved November 27, 2014, from http://www.ipp f.org/resource/IPPF Charter Sexual and Reproductive Rights Kirby, D., Laris, B. A., & Rollert, L. (2005). Impact of Sex and HIV Education Programs on Sexual Behaviors of Youth in Developing and Developed Countries. Family Health International, Research Tri angle Park. Retrieved April 2014, from https://www.iywg.org/sites/iywg/files/youth_research_wp_2.pdf
48 McMahon, S., Caruso, B., Obure, A., Okumu, F., & Rheingans, R. (2011, December). Anal cleansing practices and faecal contamination: a preliminary investiga tion of behaviours and conditions in schools in rural Nyanza Province, Kenya. Tropical Medicine and International Health, 16 (12), 1536 1540. McMahon, S., Winch, P., Caruso, B., Obure, A., Ogutu, E., & Ochari, I. R. (2011). 'The girls with her period is the one to hang her head' Relfections on menstrual management among schoolgirls in rural Kenya. BMC International Health and Human Rights, 11 (7). Retrieved June 1, 2014, from http://www.biomedcentral.com/1472 698X/11/7 McQuestion, K., Silverman, R., & Glassma n, A. (2012). Adolescent fertility in low and middle income countries: Effects and solutions. Center for Global Development. Washington, DC: CGD. Retrieved December 9, 2014, from http://www.cgdev.org/content/publications/detail/1426175 MDMQ. (2014). Adini straciÃ³n Zonal Tumbaco . (Municipio del Distrito Metropolitano de Quito) Retrieved September 21, 2014, from Quito AlcaldÃa: http://www.quito.gob.ec/administracion zonales/administracion zonal tumbaco#Ã¡rea de intervenciÃ³n Peace Corps Guatemala. (2010, April) . Habilidades para la Vida (Life Skills curriculum). Guatemala. PlanEA. (2010, March). Plan Andino para la Prevencion del Embarazo en Adolescentes . Retrieved April 20, 2014, from Lineas de Accion: http://planandinopea.org/?q=node/27 Population Services Int ernational. (2014, May 5). Estudio Sobre Salud Sexual y Reproductiva en JÃ³venes de 15 a 24 aÃ±os en Chetumal, Quintana Roo. Mexico. PSI Research & Metrics. (2011). Programa de PromociÃ³n de la Salud Sexual y Reproductiva. Estudio TRaC Evaluando Comportamient os de Riesgo, Factores Asociados e Impacto del Programa entre JÃ³venes de 15 24 aÃ±os en Chetumal, Quintana Roo. MÃ©xico: Population Services International. Retrieved December 9, 2014, from http://www.psi.org/resources/publications PSI Research Division. (200 4). PSI Behavior Change Framework "Bubbles". Washington, DC: Population Services International. Retrieved from http://www.psi.org/resources/research metrics/publications/concept papers/psi behavior change framework Secretaria de Salud del Municipio del Dis trito Metropolitano de Quito. (n.d.). Salud sexual y reproductiva en adolescentes. Quito, Pichincha, Ecuador. Solano, G. (2012, January 25). Public spending fuels Ecuadorian leader's popularity. Associated Press . Soper, M., & Tristan, M. (2004). Exploring teen pregnancy and sexual education with adolescente, and mothers of adolescents, in Guadalupe, Costa Rica: A rapid health assessment using qualitative methods. San Jose: International Health Central American Institute Foundation. Retrieved June 1, 2014, f rom http://www.ihcai.org/soperfinalreport.pdf Stern, C. (2012). El "problema" del embarazo en la adolescencia: contribuciones a un debate. Mexico, DF: El Colegio de Mexico.
49 Tebbets, C., & Redwine, D. (2013). Beyond the clinic walls: Empowering young people through youth peer provider programmes in Ecuador and Nicaragua. Reproductive Health Matters, 21 (41), 143 153. Torres, P., Walker, D., Gutierrez, J. P., & Bertozzi, S. (2006, July August). Estrategias novedosas de prevenciÃ³n de embarazo e ITS?VIH?SIDA ent re adolescentes escolarizados mexicanos. Salud PÃºblica de MÃ©xico, 48 (4), 308 316. Retrieved March 2014 UNFPA. (2014). Human Rights: Supporting the Constellation of Reproductive Rights . Retrieved September 23, 2014, from Population Issues: http://www.unfpa. org/rights/rights.htm United Nations. (2013). Adolescent Fertility since the International Conference on Population and Development (IPCD) in Cairo. Department of Economic and Social Affairs. United Nations. Retrieved September 21, 2014, from http://www.un .org/en/development/desa/population/publications/pdf/fertility/Report_Adoles cent Fertility since ICPD.pdf United Nations Development Programme. (2014). Human Development Index and its components . Retrieved November 6, 2014, from United Nations Development Program: https://data.undp.org/dataset United Nations Population Division. (2001). World Population Monitoring 2001. Department of Economic and Social Affairs. New York: United Nations. Retrieved September 23, 2014, from http://www.un.org/en/development/de sa/population/publications/pdf/environment/populatio n monitoring.pdf United Nations Population Division. (2010, August). Population Facts. Department of Economic and Social Affairs. Retrieved September 23, 2014, from Population Division United Nations Popu lation Division. (2012). World Population Prospects: The 2012 Revision . Retrieved November 14, 2014, from United Nations, Department of Economic and Social Affairs: http://esa.un.org/unpd/wpp/Excel Data/fertility.htm WHO. (2007). Adolescent pregnancy -Un met needs and undone deeds. Issues in Adolescent Health and Development . Geneva, Switzerland: World Health Organization. Retrieved December 9, 2014, from http://whqlibdoc.who.int/publications/2007/9789241595650_eng.pdf World Bank Group. (2014). World Devel opment Indicators . Retrieved November 6, 2014, from World Databank: http://databank.worldbank.org World Health Organization. (2014, September). Adolescent Pregnancy (Fact sheet No. 364) . Retrieved September 21, 2014, from Media Centre: http://www.who.int/m ediacentre/factsheets/fs364/en/ Worldofmaps.net. (2014). Map of Ecuador . Retrieved December 8, 2014, from Worldofmaps.net: http://www.worldofmaps.net/south america/map ecuador/map region ecuador.htm YHRC. (2011, August). Promoting the Sexual and Reproducti ve Rights and Health of Adoelscents and Youth. Youth Health and Rights Coalition. Retrieved DEcember 9, 2014, from
50 http://www.pathfinder.org/publications tools/pdfs/Promoting the sexual and reproductive rights and health of Adolescents and Youth.pdf Young, M., Magelgaard, K., & Hardee, K. (2009). Projecting Population, Projecting Climate Change: Population in IPCC Scenarios. Working Paper, Popuation Action International. Retrieved September 24, 2014, from http://populationaction.org/wp content/uploads/2012/ 01/Projecting_Population_Projecting_Climate_Change_Population_in_IP CC_Scenarios.pdf
51 APPENDIX A: SURVEY RESULTS Population Characteristics: Pregnancy, sexual activity, and condom/contraceptive use Respondents who report ever having provoked a pregna ncy/been pregnant Age Male Female 14 n=39 0 0 15 n=93 0 0 16 n=98 1% (.1 7%) 1% (.01 7%) 17 n=67 2 % (.2 10) 5% (1 13%) 18 n=38 0 8% (3 22%) Total n=337 1 % (.1 2%) 2% (1 5%) Respondents who report ever having been sexually active (by age) Age Male Female Total Odds Ratio p value 14 n=39 37% (18 61%) 6% (.01 32%) 22% (11 38%) .10 .043* 15 n=93 28% (15 46%) 22% (13 36%) 24% (15 35%) .72 .530 16 n=98 32% (18 50%) 31% (21 44%) 32% (23 42%) .95 .914 17 n=67 54% (34 72%) 43% (28 60%) 48% (36 60%) .65 .408 18 n=38 56% (23 84%) 65% (45 81%) 63% (46 77%) 1.51 .600 Total n=337 38% (30 47%) 34% (27 41%) 35% (30 41%) .82 .407
52 Respondents who report ever having been sexually active (by grade level) Grade level Male Female Total 10 n=90 35% (22 51%) 14% (6 28%) 24% (16 35%) 4 n=121 33% (20 50%) 35% (25 47%) 35% (26 44%) 5 n=62 41% (22 63%) 22% (11 39%) 29% (19 42%) 6 n=64 53% (29 75%) 61% (45 74%) 58% (45 70%) Age Never Almost Neve r Sometimes Almost Always Always 14 n=8 0 0 13% (1 58%) 50% (18 82%) 38% (11 74%) 15 n=19 11% (3 35%) 0 5% (1 31%) 21% (8 46%) 63% (39 82%) 16 n=28 4% ( 1 22%) 11 % (3 29%) 14% (5 33%) 18% (7 37%) 54% (35 71%) 17 n=28 18% (7 37%) 11% (3 29%) 25% (12 45% ) 18% (7 37%) 29% (15 48%) 18 n=23 22% (9 44%) 9% (2 30%) 22% (9 44%) 22% (9 44%) 26% (12 48%) Total n=106 12% (7 20%) 8% (4 14%) 18 % (12 26 % ) 22 % (15 30%) 41 % (32 51%) square = 20.03 b = .25 P = .219
53 Age No Yes 14 n=7 57% (21 87%) 43% (13 79%) 15 n=19 37% (18 61%) 63% (39 82%) 16 n=29 35% (19 54%) 66% (46 81%) 17 n=30 57% (38 73%) 43% (27 62%) 18 n=23 70% (48 85%) 30% (15 52%) Total n=108 50% (41 60%) 50% (40 59%) Reported condom and contraceptive use at last intercourse amo ng sexually active female respondents Age No condom or other contraceptive method Only non condom contraceptive method Only condom Condom and other contraceptive method 14 n=1 100% 0 0 0 15 n=10 30% (9 65%) 0 40% (15 72%) 30% (9 65%) 16 n=18 33% (15 5 8%) 6% (1 33%) 56% (32 77%) 6% (1 33%) 17 n=16 50% (26 74%) 19% (6 46%) 6% (1 36%) 25% (9 52%) 18 n=18 50% (27 73%) 22% (8 48%) 17% (5 42%) 11% (3 37%) Total n=63 44% (32 56%) 13% (6 23%) 28% (18 41%) 16% (8 27%) Respondents who reporte d that they used a condom the last time they engaged in sexual activity Male n=44 Female n=65 Odds Ratio p value 59% (44 74%) 43% (31 55%) .52 .103
54 Access Perce nt that answered "agree" Odds Ratio p value Total Male Female Buying condoms makes me feel very embarrassed 35% (30 40%) 41% (33 50%) 31% (25 37%) 0.63 .053 I would never buy or obtain condoms or other contraceptive methods because it would make me v ery embarrassed 18% (14 22%) 14% (8 21%) 20% (15 26%) 1.5 .191 I obtain condoms when I need them [responses only from sexually active respondents] 67% (57 75% 74% (58 85%) 62% (49 73%) .58 .207 Product Attributes Percent that answered "agree" Odds Rat io p value Total Male Female It feels very different to engage in sexual activity without a condom as compared to with a condom 29% (24 34%) 36% (27 45%) 25% (19 31%) 0.59 .034* Social Norms Percent that answered "agree" Odds Ratio p value Total Male Female In my group of friends, carrying condoms is looked down upon 17% (13 21%) 17% (10 23%) 17% (12 22%) 1 .995 The majority of my friends use condoms when they engage in sexual activity 39% (34 45%) 42% (33 51%) 38% (31 44%) 0.84 .451 Contrac eptive methods are only used by girls who have more than one sexual partner 11% (8 15%) 10% (5 16%) 12% (7 16%) 1.11 .768 Condoms are only used by "ladies' men"/"womanizers" (hombres mujeriegos) 11% (8 14%) 10% (5 16%) 11% (6 15%) 1.03 .936 Condoms are o nly used with people that aren't trusted 12% (8 15%) 13% (7 19%) 11% (6 15%) 0.81 .54 0 Contraceptive methods are only for men or women who are married. 6% (4 10%) 8% (3 13%) 5% (2 8%) 0.64 .329
55 Using a condom during sexual activity is a sign of lack of t 12% (9 16%) 18% (11 25%) 9% (5 13%) 0.44 .016* It is looked down upon by society to ask the person that you are going to have sex with to use a condom. 20% (17 25%) 19% (12 26%) 22% (16 27%) 1.19 .543 Women (not men) are the ones wh o should take measures to prevent pregnancy 28% (23 33%) 23% (15 30%) 31% (25 37%) 1.53 .104 condom 36% (31 42%) 37% (28 46%) 36% (29 43%) 0.95 .831 Before condom 34% (30 40%) 35% (26 43%) 34% (28 41%) 0.98 .942 Masculinity/Femininity A man is not a real man until he has had sex 6% (4 9%) 7% (3 12%) 5% (2 8%) 0.71 .458 Men who cry are weak 9% (7 13%) 10% (5 16%) 9% (5 12%) 0.8 .57 0 child 8% (6 12%) 9% (4 14%) 8% (4 11%) 0.84 .665 A woman should tolerate violence to keep the family together 11% (8 14%) 8% (3 1 3%) 5% (2 8%) 0.63 .31 0 Women should not work they should dedicate themselves to their home and children. 11% (8 15%) 15% (8 21%) 9% (5 13%) 0.58 .121
56 Knowledge Percent that answered "agree" Odds Ratio p value Total Male Fema le Once a woman has had her first menstrual period, she can get pregnant if she engages in sexual activity with a man. 79% (74 83%) 77% (69 84%) 80% (75 86%) 1.25 .414 A girl can get pregnant the first time she engages in sexual activity. 81% (77 85%) 84% (78 91%) 79% (74 85%) 0.7 .246 A person can have an STI without symptoms. 42% (36 47%) 42% (33 51%) 41% (35 48%) 0.99 .952 A person can have HIV without knowing it. 73% (68 78%) 73% (65 81%) 73% (67 79%) 0.99 .96 0 A person can have a negative result on an HIV test even if they have the virus. 30% (22 39%) 28% (22 34%) 0.89 .643 Odds Ratio p value Percent that answered " false " Total Male Female Adolescents need parental permission to obtain contraceptive methods in clinics or in health ce nters. 46% (41 51%) 50% (41 59%) 43% (37 50%) 0.77 .25 0 Vaginal douching (washing the vagina immediately after sexual activity) can prevent pregnancy. 58% (52 63%) 59% (51 68%) 57% (50 64%) 0.9 .641 Putting one condom on over another provides more protec tion against pregnancy and STIs. 47% (42 53%) 44% (35 53%) 49% (42 56%) 1.2 .432 A condom can be re used if it is washed. 95% (92 97%) 94% (90 98%) 96% (93 98%) 1.34 .571 A girl cannot get pregnant if she engages in sexual activity during her period. 43% (38 49%) 41% (32 50%) 44% (38 51%) 1.15 .549 have physical or psychological problems. 67% (62 72%) 69% (61 77%) 66% (60 73%) 0.87 .564 A girl canno relations few times. 73% (68 78%) 79% (72 86%) 70% (64 76%) 0.61 .065
57 A girl can always know exactly when the time is 23% (19 28%) 18% (11 25%) 26% (20 32%) 1.6 .097 A gi 33% (29 39%) 39% (30 48%) 30% (24 37%) 0.67 .102 Birth control pills can cause cancer. 21% (17 26%) 29% (21 37%) 17% (12 22%) 0.49 . 009* When a man is aroused and has an erection, he ejaculation) because if not, it could harm him. 20% (16 25%) 34% (26 43 %) 12% (8 17 %) .26 .000* Only men can physically experience an orgasm. 51% (46 57%) 62% (53 70%) 45% (38 52%) 0.51 .004* Condoms make the transmission of STIs impossible. 25% (21 30%) 27% (19 35%) 24% (18 29%) 0.81 .431 Homosexuality is a mental illness. 59% (54 64%) 50% (41 59%) 65% (58 71%) 1.82 .009* Homosexuality can be cured 40% (35 45%) 31% (23 39%) 45% (38 52%) 1 .8 .014* There is no difference between HIV and AIDS 48% (43 53%) 46% (38 55%) 49% (42 56%) 1.11 .639 There is a vaccine for HIV. 43% (38 49%) 55% (46 64%) 36% (30 43%) 0.47 .001* There is a cure for HIV. 59% (53 64%) 68% (59 76%) 53% (47 60%) 0.54 .011 * The majority of cases of HIV infection occur between homosexuals. 41% (36 46%) 36% (27 46%) 44% (37 51%) 1.39 .16 0 Condoms have microscopic holes that permit HIV to travel through them. 40% (35 46%) 43% (34 52%) 39% (32 46%) 0.87 .533 Masturbation can cause psychological problems. 24% (19 28%) 26% (18 34%) 22% (17 28%) 0.82 .463 When sexual assault occurs, generally the assailant is a stranger. 46% (41 52%) 41% (33 50%) 49% (42 56%) 1.36 .183
58 Self Efficacy Percent that answered "agree" Odds Ratio p value Total Male Female I feel capable of going to a healthcare professional to ask for information about contraceptive methods. 29% (25 34%) 33% (25 42 %) 27% (22 34 %) .77 .288 I would feel capable of speaking openly with my partner about my feelin gs and thoughts about sexual activity. 62% (57 67%) 58% (49 67%) 65% (58 71%) 1.32 .228 I feel capable of rejecting (saying no to) sexual 75% (70 79%) 66% (58 76%) 80% (75 86%) 2.06 .005* I can avoid engaging in sexual activity even if I really like my partner or person that I am going out with. 73% (68 77%) 57% (48 66%) 82% (77 88%) 3.47 .000* I feel capable of rejecting (saying no to) sexual 69% (64 74%) 55% (46 64%) 77% (72 83%) 2.81 .000* Social Support Percent that answered "agree" Odds Ratio p value Total Male Female Boys my age that engage in sexual activity stop being respected by their friends. 15% (11 19%) 13% (7 19%) 16% (11 21%) 1.3 .42 0 Girls my age that engage in sexual activity stop being respected by their friends. 20% (16 25%) 20% (13 27%) 20% (14 25%) 0.98 .954 If I wanted to use contraceptive methods, my parents would support my decision. 48% (43 53%) 54% (45 62%) 44% (38 51%) 0.69 .108
59 tors Intention Percent that answered " yes " Odds Ratio p value Total Male Female Did you propose using a condom the last time you engaged in sexual activity? 54% (44 63%) 53% (38 69%) 54% (41 67%) 1.01 .961 I am going to use a condom the next time I have sex 64% (59 69%) 65% (56 73%) 63% (56 70%) .91 .697 Locus of Control (Alcohol and Drug Use) Total Male Female Odds Ratio p value In the sexual activity that I have engaged in, I was under the influence of drugs and/or alcohol Never 84% (76 90%) 83% (69 92%) 85% (74 92%) Almost Never 7% (4 14%) 7% (2 20%) 7% (3 17%) Sometimes 7% (4 14%) 7% (2 20%) 7% (3 17%) Always 1% (.1 6%) 2% (.01 16%) 0 How often do you drink alcohol? Never 37% (33 44%) 40% (31 49%) 38% (31 45% Once or a few times 43% (37 48%) 38% (30 48%) 45% (38 52%) Once a month 12% (9 17%) 13% (8 21%) 12% (8 17%) Once every two weeks 2% (1 5%) 4% (2 10%) 1% (.4 4%) Once a week or more 4% (2 6%) 4% (2 10%) 3% (2 7%)
60 Total have drank at least once 61% (56 67%) 60% (51 69%) 62% (55 69%) 1.09 .706 How often do you consume more than seven drinks in a week? Nev er 69% (64 74%) 70% (60 77%) 69% (63 75%) Once or a few times 17% (13 21%) 14% (9 22%) 18% (14 24%) Once every two or three months 6% (4 9%) 4% (2 10%) 6% (4 11%) Once a month 6% (4 9%) 8% (4 14%) 4% (2 8%) Every two weeks or more 2% (1 5%) 4% (2 10%) 1% (1 4%) How often do you have more than three drinks in less than two hours? Never 79% (74 83%) 80% (71 86%) 78% (72 83%) Once or a few times 9% (6 13%) 9% (5 16%) 9% (6 14%) Once every two or three months 7% (4 10%) 4% (2 10%) 8% (5 12%) Once a month or once every two weeks 3% (2 6%) 4% (1 9%) 3% (1 6%) Once a week or more 3% (1 5%) 4% (1 9%) 2% (1 5%) How o ften do you consume marijuana? Never 86% (81 89%) 77% (69 84%) 90% (85 94%) Once or a few times 12% (9 16%) 18% (12 26%) 9% (6 13%) Once every two or three months 1% (.4 3%) 3% (1 8%) .5% (.01 3%) Once a month or once every two weeks .3% (.1 2%) 1% (.01 6%) 0
61 Once a week or more 1% (.3 3%) 2% (.4 7%) 1% (.01 3%) Outcome Expectation Percent that answered "agree" Odds Ratio p value Total Male Female Condoms help to p revent the transmission of STIs. 79% (74 83%) 77% (68 83%) 80% (74 85%) 1.21 .479 Using condoms is a very effective way to prevent the transmission of HIV 72% (67 77%) 77% (69 83%) 70% (63 76%) .69 .159 Using condoms is an effective way to prevent pregna ncy. 71% (66 76%) 71% (62 79%) 71% (65 77%) 1.00 .988 Subjective Norms Percent that answered "agree" Odds Ratio p value Total Male Female it moment 56% (51 62%) 55% (46 63%) 57% (51 64%) 1.11 .638 If I ask my girlfriend/boyfriend to use condoms, s/he will think I have another partner 15% (12 20%) 15% (10 23%) 15% (11 21%) .97 .922 If I ask my girlfriend/boyfriend to use condoms, e her/him seriously 17% (13 21%) 16% (11 24%) 17% (12 23%) 1.04 .879 Threat Total Male Female Odds Ratio p value If I had a child now, it would make it difficult for me to finish my studies in secondary school 63% (58 68%) 63% (54 71%) 64% (57 70%) 1. 04 .849 If I had a child now, it would be difficult for me to accomplish my goals for my future 59% (53 64%) 56% (47 65%) 60% (53 67%) 1.20 .431 I can stop using condoms with a partner that I know well 21% (17 26%) 20% (14 28%) 22% (17 28%) 1.15 .625 If trust in their word 18% (15 23%) 26% (19 35%) 14% (10 19%) .46 .006*
62 condom in a sexual relation with that person if another form of contraception is be ing used 20% (16 25%) 24% (17 32%) 18% (13 24%) .71 .215 What do you think are some of the consequences of teen pregnancy? Can negatively impact studies 36% (33 43%) 33% (25 42%) 41% (34 47%) 1.40 .151 Makes it more diffic ult to achieve future goals 16% (12 20%) 16% (11 24%) 15% (11 21%) .96 .887 12% (9 15%) 10% (6 16%) 13% (9 18%) 1.36 .402 Can cause economic problems /might have to look for work 7% (5 10%) 6% (3 12%) 7% (5 12%) 1.18 .710 Can cause family problems 7% (5 11%) 4% (2 9%) 9% (6 14%) 2.47 .078 Can pose health risks to [teen] mother 7% (5 10%) 3% (1 8%) 9% (6 14%) 3.1 1 .042* Can pose health risks for baby/child 6% (4 9%) 2% (1 7%) 8% (5 12%) 3.51 .049* Societal discrimination/criticism 5% (3 8%) 2% (1 7%) 7% (4 11%) 3.06 .081 Interpersonal connection Percent that answered "agree" Odds Ra tio p value Total Male Female To demonstrate love for someone, it is necessary to engage in sexual activity 7% (5 11%) 11% (7 19%) 5% (3 9%) .39 .027*
63 APPENDIX B: FOCUS GROUP DISCUSSION GUIDE I came up with the questions for this guide, and toget her with the Ministry of Public Health staff, of the focus group sessions. Pregunta central de los grupos focales: Â¿Por quÃ© existe altos niveles de embarazo en adolescencia en la comunidad? 1. Â¿Ustedes creen que el embarazo en adolescencia es un problema en esta comunidad? Â¿Hay muchos madres y padres adolescentes en la comunidad? Â¿Piensan que los y las adolescentes de su comunidad vean al embarazo como un gran cambio (en positivo) o trastorno (en negativo) a la vida? Â¿O piensan que la vida puede seguir normal despuÃ©s de un embarazo? Â¿Piensan que algunos adolescentes desean tener un hijo? (si dicen que si) Â¿por quÃ©? 2. Â¿Ustedes piensan que el embarazo en l a adolescencia puede ser peligroso? Â¿CuÃ¡les son algunos riesgos a la salud de una chica adolescente que se embaraza? 3. Â¿CuÃ¡les mÃ©todos de anticoncepciÃ³n piensan que los y las adolescentes preferirÃan utilizar (condones, pÃldora, mÃ©todos inyectables, T de cob re, etc.)? Â¿Por quÃ©? Â¿CuÃ¡les piensan que son buenas y cuales piensan que no son tan buenas? Â¿CuÃ¡les protegen contra las ITS? 4. Â¿Ustedes piensan que los jÃ³venes en su comunidad tienen miedo o vergÃ¼enza de ir al centro de salud, o a la tienda, o a una farmacia para pedir mÃ©todos de anticoncepciÃ³n? Â¿Por quÃ© si o porque no? Â¿Alguna vez han escuchado que el personal de una farmacia o tienda o centro de salud le tratÃ³ mal a un adolescente por pedir mÃ©todos de anticoncepciÃ³n, o se le negÃ³ darle un mÃ©todo? Â¿QuÃ© les a yudarÃa a no tener miedo o vergÃ¼enza ir a pedir anticoncepciÃ³n? 5. Â¿CÃ³mo es que los adolescentes de esta comunidad normalmente consiguen mÃ©todos de anticoncepciÃ³n? Â¿Donde piensan que serian los lugares mÃ¡s convenientes para que los y las adolescentes tengan acceso a anticoncepciÃ³n? 6. Â¿Piensan que los padres y madres de los y las adolescentes de su comunidad hablan del embarazo y/o de los mÃ©todos de anticoncepciÃ³n con sus hijos/as? Â¿Por quÃ© si o por quÃ© no? Â¿Ustedes piensan que es importante que los padres hable n con sus hijos/as adolescentes acerca de la sexualidad y prevenciÃ³n de embarazo? 7. Â¿QuÃ© piensan ustedes que son las razones por las cuales algunos/as adolescentes de su comunidad tienen relaciones sexuales? Ejemplos de respuestas (Solo aportar ideas si los y las adolescentes no pueden pensar en ideas): Curiosidad, Amor, Placer, PresiÃ³n de la pareja (hombre), PresiÃ³n de la pareja (mujer), PresiÃ³n de los amigos, Quieren tener hijo, RelaciÃ³n no consensual (violaciÃ³n) con la pareja, RelaciÃ³n no consensual (viola ciÃ³n) por otra persona, etc. 8. Â¿Por quÃ© piensan que un o una adolescente que planifica tener relaciones sexuales no use condÃ³n u otro mÃ©todo anticonceptivo en esa relaciÃ³n? Ejemplos de respuestas: Piensa que no va a provocar un embarazo/quedar embarazada, Ti enen miedo de buscar/conseguir en mÃ©todo, Su pareja no quiere, Piensa que el condÃ³n disminuye la sensaciÃ³n, etc. 9. De quienes y/o de donde piensan que a los adolescentes de esta comunidad les gustarÃa recibir informaciÃ³n acerca de la sexualidad, el embarazo, y el VIH/SIDA? Ejemplos: padres, promotores de salud, maestros, libros/folletos, compaÃ±eros/amigos, medios electrÃ³nicos, medios audiovisuales 10. Â¿CuÃ¡les ideas o estereotipos existen acerca de chicas y chicos adolescentes que usan condones u otros mÃ©todos an ticonceptivos? Â¿Ustedes creen que los y las adolescentes de su comunidad
64 condones no toman en serio a sus parejas? Â¿Los jÃ³venes piensan que tener relaciones s exuales sin condÃ³n es una seÃ±al de falta de confianza en la pareja? Â¿Piensan que los chicos no permiten que las chicas usen mÃ©todos anticonceptivos, porque es un seÃ±al que las chicas pueden estar con otros hombres? 11. y las adolescentes tengan sexo? Â¿A quÃ© edad se inician las relaciones sexuales? Â¿La edad de inicio de las relaciones sexuales es diferente para chicos y chicas? Â¿Un o una adolescente que tiene relaciones sexuales es respetado/a por su grupo de amigos/as? Â¿ Por quÃ© si o no? 12. Â¿Es comÃºn que los y las adolescentes presionen a sus parejas a tener relaciones sexuales? Â¿Por quÃ© piensan que pasa eso? Â¿Es comÃºn que las chicas tienen parejas que son mayores que ellas? Â¿QuÃ© se podrÃa hacer para ayudar a las personas que no quieren tener sexo, cÃ³mo hacer que respeten tu decisiÃ³n de no tener sexo, como defenderse de tu pareja? 13. Â¿Los y las adolescentes en esta comunidad toman alcohol? Â¿Usan drogas? Â¿Cuales drogas usan? Â¿Ustedes piensan que el embarazo en la adolescencia pue de ser conectada al uso de drogas y alcohol? Â¿CÃ³mo? 14. Â¿QuÃ© informaciÃ³n han recibido ustedes en la escuela acerca de la sexualidad y la prevenciÃ³n de embarazos? Â¿Fue Ãºtil esta informaciÃ³n? Â¿QuÃ© informaciÃ³n faltaba?
65 APPENDIX C : SURVEY INSTRUMENT