Tell Me Even More: Learning more about perceptions and attitudes to sexuality education by Handmade Communications

Learning more about perceptions and attitudes to sexuality education in eight countries in sub-Saharan Africa.

Tell me even more! Learning more about perceptions and attitudes to sexuality education in eight countries in sub-Saharan Africa. Updated version of the Tell me more! study (2007) ÂŠ Save The Children International Published in 2016

Contents Definitions of terms

Acronyms 3 1. Executive summary

2. Background to this study

3. Methodology

4. Limitations

5. Findings from the primary research

5.1 What young children told us (children 9–12 years old)

5.2 What older children told us (children 13–17 years old)

5.3 What parents and caregivers told us

5.4 What teachers told us

5.5 What traditional, community and religious leaders told us

5.6 What community-based organisations told us

6. Discussion

7. Conclusions and recommendations

References 51

D efinitions of terms Behaviour change – The adoption and maintenance of healthy behaviours. Child – Any person under the age of 18 years old. Comprehensive sexuality education (and information) – Comprehensive sexuality education enables young people to make informed decisions about their sexuality and health. These programmes build life skills and increase responsible behaviours, and because they are based on human rights principles, they help advance human rights, gender equality and the empowerment of young people. Evidence-based and evidence-informed – Evidence usually refers to qualitative and/or quantitative results that have been published in a peer-reviewed journal. The preference for evidence-informed results is in recognition of the fact that several elements may play a role in decision-making, only one of which may be scientific evidence. Other elements may include cultural appropriateness, concerns about equity and human rights, feasibility, opportunity costs and so on. HIV – This term is used to refer to the virus that causes AIDS. The expression HIV and AIDS is not generally used because it can cause confusion. Most people with HIV do not have AIDS. Key populations – are populations that are key to the HIV epidemic and key to the response. The Joint United Nations Programme on HIV/AIDS (UNAIDS) considers gay men and other men who have sex with men, sex workers, transgender people and people who inject drugs as the four main key population groups, but it acknowledges that prisoners and other incarcerated people are also particularly vulnerable to HIV and frequently lack adequate access to services. Countries should define the specific populations that are key to their epidemic and response based on the epidemiological and social context. Living with a disability – includes people who have long-term physical, mental, intellectual or sensory impairments that, in interaction with various barriers, may hinder their full and effective participation in society on an equal basis with others. Living with HIV – A person who is infected with HIV. Parents and caregivers – This term takes into account the fact that not all children are cared for by their biological parents. Caregivers might be extended family members, friends, neighbours, legal guardians or others. People affected by HIV – This term encompasses family members and dependents who may be involved in caregiving or who are otherwise affected by the HIV-positive status of a person living with HIV. Process-oriented approach – This approach supports children to work through key issues of sexuality by promoting dialogue and reflection, and not through the teaching of fear-based messages or the simple provision of factual information.

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Safer sex – The term safer sex reflects the idea that choices can be made and behaviours adopted to reduce or minimise the risk of HIV acquisition and transmission. Safer sex strategies include postponing sexual debut, non-penetrative sex, correct and consistent use of male or female condoms, and reducing the number of sexual partners. Sexual and reproductive health and rights – Sexual and reproductive health and rights are rights related to a person’s sexual and reproductive life. These rights are closely linked with other human rights. Sexuality – This is a broader term than sexual and reproductive health and rights, which it encompasses. Sexuality is a central aspect of being human throughout life, and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors. Transactional sex – This refers to sexual relationships where the giving of gifts or services is an important factor.

Acronyms AIDS

acquired immune deficiency syndrome

CSE

comprehensive sexuality education

CSE&I

comprehensive sexuality education and information

FGDs

focus group discussions

HIV

human immunodeficiency virus

LGBTI

lesbian, gay, transgender, bisexual or intersex

SDG

sustainable development goal

UNESCO United Nations Educational, Scientific and Cultural Organization UNFPA

United Nations Population Fund

UNICEF

United Nations Children’s Fund

WHO

World Health Organization

Definitions of terms

1. Executive summary

n 2007, Save the Children looked at the key issues affecting children in Africa within the context of sexuality and HIV. This included exploring the kinds of strategies children used to protect themselves against HIV, children’s experiences of various forms of sexuality and HIV information and how children viewed their own sexuality, sexual norms and types of behaviour. Now, nine years on, findings of the 2007 seminal report – Tell me more! – have been updated by Save the Children in this new 2016 study – Tell me even more! This update reflects additional primary research undertaken with children and adults in Africa in 2015, as well as global and regional developments in learning, policy and programming in the field of comprehensive sexuality education (CSE) and HIV. As in 2007, this update also engages strongly with children, teachers, parents and caregivers, and community members, and seeks to learn more about their own perspectives. By speaking with children and adults, Tell me even more! set out to identify areas where continued or additional focus is required for improved CSE and HIV research, policy, programming and implementation. The study was approached through two main areas of interrogation. Firstly, a rapid review of literature was undertaken to provide an updated overview of the children’s sector landscape, especially in relation to CSE and HIV. Secondly, primary research was undertaken with children, parents and caregivers, teachers and community and religious leaders in the eight countries where Save the Children’s comprehensive sexuality education and information (CSE&I) programme is operational – Côte d’Ivoire (Yamoussoukro); Ethiopia (Addis Ababa and Adama); Kenya (Nairobi); Nigeria (Lagos); Senegal (Dakar); Swaziland (Siteki and Nhlangano Town); Zambia (Lusaka); and Zimbabwe (Bulawayo). The four main objectives of the 2016 update were to: 1. Investigate perceptions around child sexuality by means of primary research with children, teachers, parents and caregivers, and community members and leaders. 2. Describe what changes, if any, the children who have been exposed to any type of CSE&I initiative or sexuality education have experienced, or have observed in adults. 3. Document any challenges experienced by adults providing sexuality education, and what coping strategies have been useful. 4. Report on key issues and needs of children regarding information on the topic of sexuality education.

TELL ME EVEN MORE

By speaking with children and adults, Tell me even more! set out to identify areas where continued or additional focus is required for improved CSE and HIV research, policy, programming and implementation.

Through focus group discussions (FGDs) and interviews, the following groups were included in the study: children aged 9–12; children aged 13–17; parents and caregivers; teachers and community and religious leaders; and trainers and management from partner organisations. The findings were rich and contribute to our understanding of how children, adults and communities perceive and approach sexuality education in Africa. In many ways, this update serves to emphasise the relevance of the findings of its 2007 predecessor, Tell me more! However, this study also highlights the continued evolution, growth and reach of mobile and digital communications, especially social media; the important role of community and religious leaders; and the need to ensure that families and communities are part of CSE programming. The data collected by this study provides us with several clues as to how these aspects of children’s lives might be mobilised to promote and enhance current CSE policy and programming. This study also revealed that there is a need to target children from a young age with CSE, information and services. Key findings and recommendations are: 1. Teachers are the primary sexuality educators for many children in Africa. This role needs to be further acknowledged and supported in order to strengthen CSE policy, programming and implementation. Teachers do not always appear to be well supported by policies or the school environment to deliver quality curricula in an effective manner. Teachers need and are appreciative of any training and support which can help them deal with their own attitudes, personal conflicts and teaching questions around sexuality. However, they also do not consider it effective for parents to rely completely on teachers to educate children on sexuality, and they advocated for parents to take on a stronger role in this respect. This also brings into focus the need for broader community engagement around CSE in order to reinforce the teaching that children receive in school. 2. Parents and caregivers can and need to play a more central role in providing sexuality education and information to their children. Children made it clear that they would like to receive more information from their parents and caregivers but that poor communication between parent and child was a barrier, often due to a lack of knowledge, confidence or social taboos. Additionally, the role of the fathers and men in CSE was not clear and could be explored further. Parents who had participated in community-based CSE&I programmes were enthusiastic and positive about how they had improved their ability to speak with their children about sexuality. Concerted efforts to support parenting and CSE knowledge and skills should be a priority for policy and programming. 3. School-based sexuality education varies in terms of the quality of the teaching and the quality of the curricula and requires additional support. This includes advocacy for improved national policy, programmes and capacity building, as well

1. Executive summary

All the groups in the study said they wished they had access to more materials.

as scaled-up efforts by non-governmental programmes to support and enhance school-based sexuality education, including fostering a more informed and open environment at the community level. Children and teachers reported how schoolbased curricula and teaching were often haphazard, of varying standards, and lacking in direction. Many of these curricula do not seem to reflect regional and global priorities, approaches and learning, nor do they seem to reflect the realities of children’s lives. Given the key role of schools in CSE and the strong evidence around the continued vulnerability of adolescents, in particular, to HIV, advocacy efforts need to be strengthened at national and sub-national levels in order to develop and roll out strong national CSE policies and programmes, and to develop capacity to deliver these effectively through schools. 4. Young children’s views should be systematically included in sexuality education and information policy and programming, and in service provision. This study indicated that relatively young children, perhaps as young as 6 years of age, are engaging in sexual activity. It is not clear to what extent, if any, adults know how to educate and support these young children in matters of sexuality. The study highlighted that whilst this group does have some access to CSE and other information, this element could be significantly strengthened. There is also a need to take into account if and how to approach siloed issues such as HIV when talking to young children about sexuality. Current theory also considers the teaching of CSE to young children to be a means of preventing negative attitudes and behaviour in relation to sexuality. However, robust CSE guidelines for this age group are still few. Much more needs to be learned around this group of children, and age-appropriate guidelines for policy, programming and implementation need to be developed. 5. Access to printed and online educational materials which are companions to training and education activities are very important to children and adults, and should be well supported and resourced. We should not underestimate the value of educational materials and information which children and adults can take home, read in private or discuss with family and peers. All the groups in the study said they wished they had access to more materials, and many parents reported that they found educational books and leaflets to be a good way of educating themselves and talking to their children. Organisations said they did not have enough materials to give out. Teachers said that up-to-date ‘computer-based’ materials would be more engaging for children. Whilst significant numbers of children do seem to have access to online content, most likely through mobile technology, it may not yet be a good investment in the context of Africa to set up digital CSE programmes only in schools. However, locally adapted sexuality information – which children might access online outside of school – and more print materials are still needed. 6. The media is a powerful influence in children’s lives in Africa. In particular, the impact and potential of the digital media on children in Africa, both positive and negative, needs to be better understood and incorporated into CSE policy,

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Children and adults living with or affected by HIV described how stigma was a central concern in many aspects of their lives.

programming and delivery. This was clearly so, even for children living in resourcepoor environments. Some saw the media as a pernicious force which provides easy access to inappropriate content or teaches negative stereotypes. However, the potential of the media to reach children and other groups with positive CSE and information was also recognised by many study participants and was considered to be a necessary tool in children’s education. More research and development needs to be done to identify approaches which can harness the power of the media for African children, whilst at the same time considering more protective strategies. 7. Community and religious leaders have the potential to play a key role in influencing and bringing about social change in relation to sexuality issues. CSE programmes should work more closely with these leaders to develop approaches which can foster positive attitudes in the community towards teaching children about sexuality. In recent years we have learned about the potential of social change at the community level and the strong influence that various ‘informal’ community and religious leaders have in many communities. Community leaders signalled that work at the community level with other leaders is challenging and needs to be approached with extreme sensitivity and deep local knowledge. The support for CSE from the leaders who took part in this study suggests that more programmes should engage with and target traditional leaders, especially when addressing what are considered to be negative or harmful practices, attitudes or beliefs. 8. The challenges for children living with HIV, especially those linked to stigma, are not well integrated into sexuality education, information and services. More needs to be learned about how to support this group of children in different contexts, and this needs to be translated into policy, programming and capacity building. Children and adults living with or affected by HIV described how stigma was a central concern in many aspects of their lives. There is certainly an ongoing need to continue to address stigma related to HIV by encouraging open conversation with, as well as supplying accurate information to, children and their communities. This is a role that is well suited to local leaders and community organisations which have much influence within their communities. Learning around best practice for stigma reduction should be further explored in collaboration with community leaders and organisations to develop locally appropriate responses and strategies. 9. There is little or no provision for especially vulnerable children in current CSE&I and services. More needs to learned about how to support and educate these vulnerable groups around sexuality in different African contexts. This learning needs to be incorporated into policy, programming and capacity building at all levels. Despite efforts to include a wide range of children’s voices in this study, the voices of especially vulnerable children are not truly captured here. This, in itself, shows how challenging it is to reach these marginalised populations and that more needs to be done to ensure that they can access appropriate CSE, information and services. In particular, children with disabilities have been shown to be especially marginalised

1. Executive summary

For children who are out of school, the relatively limited scale of community programmes means that many outof-school children probably don’t have access to CSE and information.

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when it comes to CSE, with little or no programming guidance available on how to include them in CSE curricula and programming. For children who are out of school, the relatively limited scale of community programmes means that many out-ofschool children probably don’t have access to CSE and information. 10. Common community models of CSE delivery need to be more consistently evaluated and the findings shared and incorporated into policy and programmes. Additionally, much more needs to be learned about especially vulnerable children’s CSE needs through additional research. Because of the recent and stronger emphasis on adolescent sexual and reproductive health and rights in the Africa region in the last few years, we have now started to build a clearer picture of the priorities and strategies required to improve sexuality education and address HIV. However, despite this, there are still many gaps. Not only could data collection be improved generally, but especially vulnerable groups, including children who are out of school, children with disabilities, children living with HIV or disability and children who may be lesbian, gay, bisexual, transgender or intersex (LGBTI) – need to be learned about in different contexts, and appropriate policies, strategies, programmes and curricula developed to support them. Additionally, more could be learned about how boys and men could be better integrated into CSE, as well as how mental health links to CSE&I. Finally, we need clearer guidance and a stronger evidence base around which out-of-school or community-based CSE programmes are working and why. It is suggested therefore that any future research with children and communities might focus more specifically on these key groups and issues, and that further efforts and resources intended for learning and sharing information about successful out-of-school and community-based CSE models be ramped up.

2. Background to this study Tell me more! and the Save the Children CSE&I project

n 2007, Save the Children looked at the key issues affecting children in Africa within the context of sexuality and HIV. This included exploring the kinds of strategies children used to protect themselves against HIV, children’s experiences of various forms of sexuality and HIV information and how children viewed their own sexuality, sexual norms and types of behaviour. The report’s main conclusion was that although many children did access some form of sexuality education or information – which often was primarily designed to prevent them from being infected with HIV or getting pregnant – the approaches used were not always effective, and nor did they respond to the reality of children’s lives and needs. In particular, traditional ‘sex education’ approaches, where moralistic and ‘negative consequence’ messages are given to children to encourage them to avoid sex, were found to be inadequate and not always effective. As a result, Save the Children developed a CSE&I programme which took a much broader, ‘process-oriented’ approach to teaching children, even from a relatively young age, about sexuality. This approach sought to help children work through key issues of sexuality by promoting dialogue and reflection, as opposed to the teaching of negative consequences, or purely factual messaging. It also sought to build upon the strategies that children themselves were using to avoid certain situations. Save the Children worked with and trained partners in eight countries in Africa1 to deliver more comprehensive education and information on sexuality through community-based programmes. This education and information ranged from body changes and body images to feelings, relationships, sexual orientation, gender roles and expectations, making choices, cultural practices and taboos, as well as information on sex, pregnancy, sexually transmitted infections and accessing services. In particular, the programme has sought to help children enter into a dialogue around sexuality in order to gain a positive and more balanced view of their own sexuality, whilst also keeping safe within the context of living in countries where there are high rates of HIV. There has therefore been a strong focus on the participation of children in the research, design and implementation of the Save the Children CSE&I programme.

1 Côte d’Ivoire (Yamoussoukro); Ethiopia (Addis Ababa and Adama); Kenya (Nairobi); Nigeria (Lagos); Senegal (Dakar); Swaziland (Siteki and Nhlangano Town); Zambia (Lusaka); and Zimbabwe (Bulawayo).

2. Background to this study

â&#x20AC;Ś the findings of the 2007 report, Tell me more! have been updated in this new study.

TELL ME EVEN MORE

Tell me even more! Now, nine years on, the findings of the 2007 report, Tell me more! have been updated in this new study â&#x20AC;&#x201C; Tell me even more! This update reflects additional primary research undertaken with children and adults in the eight programme countries, as well as global and regional developments in learning, policy and programming in the field of CSE and HIV. As in 2007, this update also engages strongly with children, teachers, parents and caregivers, and community and religious leaders and organisations, and seeks to learn more about their own perspectives. Tell me even more! sets out to identify areas where continued or additional focus is required for improved CSE and HIV research, policy, programming and implementation.

3. Methodology

he overall goal of this study is to enhance learning around CSE and HIV across the African region, with a particular focus on learning directly from children, parents and caregivers, and other adults in their communities. This specifically includes identifying areas where continued or additional focus is required. This has been approached through two main areas of interrogation. Firstly, a rapid review of literature was undertaken which provided an update on and overview of the children’s sector landscape, especially in relation to CSE and HIV. Secondly, qualitative primary research – FGDs and interviews – was undertaken with children, parents and caregivers, teachers and other community members in the eight countries where Save the Children’s CSE&I programme is operational. The study did not set out to evaluate Save the Children’s CSE&I programme per se, nor did it set out to gauge if children, parents, caregivers and community members had changed knowledge, attitudes or behaviour as a result of any one particular CSE programme. The perspectives and opinions of the children and adults who took part in the primary research are therefore not attributed to any particular intervention or programme, although it is acknowledged that a number of different programmes have undoubtedly had an impact on children and other adult community members.

Four main objectives of the 2016 update: Tell me even more! • Investigate perceptions around child sexuality by means of primary research with children, teachers, caregivers and community members and leaders. • Describe what changes, if any, the children have experienced, or have observed in adults, who have been exposed to any type of CSE&I initiative or sexuality education. • Document any challenges experienced by adults providing sexuality education, and what coping strategies have been useful. • Through primary and secondary research, report on key perceptions, practices and needs of children regarding information on the topic of sexuality education.

3. Methodology

Rapid review of literature The primary purpose of the review of literature was to map key global and regional developments in order to provide an overview of how the children’s sector landscape, including CSE and HIV, has changed since 2007.2 The rapid review of literature looked predominantly at published literature from academic journals, especially systematic reviews, and from global United Nations reports. The review also referenced some limited grey literature and primary documentation. Primary qualitative data collection techniques The following research techniques were used to collect qualitative data: Key-point personal interviews: These are one-on-one interviews consisting of either face-to-face or telephone discussions giving respondents the opportunity to comment on and discuss sensitive issues in detail. This approach was employed for community leaders and partner organisations. FGDs: A group is formed to collectively discuss issues, giving individuals a chance to consider each other’s points of view and to voice agreement or disagreement. The researchers of the current study made use of FGDs to gain insight into the opinions of children, parents and teachers. Scope Countries included in the primary research are: Côte d’Ivoire (Yamoussoukro); Ethiopia (Addis Ababa and Adama); Kenya (Nairobi); Nigeria (Lagos); Senegal (Dakar); Swaziland (Siteki, Nhlangano Town); Zambia (Lusaka); and Zimbabwe (Bulawayo). Stakeholder selection and organisation of focus groups in-country Fieldwork was undertaken between in July 2015 and August 2015. The in-country partner organisations involved in implementing the Save The Children CSE&I programme assisted in recruiting the necessary focus group respondents, obtaining consent from children and parents/caregivers and scheduling the timetable for the research. Partner organisations3 recruited children, parents and caregivers, teachers and community leaders who had been a part of one of their programmes, or who 2 It was not within the scope of this review to examine in any detail how the learning, approaches, trends and movements at the national level in the eight study countries have evolved since 2007. 3 Nigeria: Action Health Incorporated (AHI); Ethiopia: CAFS, Hiwot, Family Planning Ethiopia; Côte d’Ivoire: Renaissance Sante Bouaké; Swaziland: Save the Children; Senegal: Association Sénégalaise pour le Bien-Etre Familial (ASBEF), AMREF Health Africa (West Africa regional office), One World UK (Senegal), Save the Children; Zambia: Sports in Action; Kenya: INERELA, AMREF; and Zimbabwe: PADARE, REPSSI, Million Memory Project.

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were from schools which have close ties to the partners. Despite this, it should be noted that not all of the children or adults who participated in the study had been exposed to Save The Children CSE&I programmes, or for that matter other CSE programmes. Save the Children and researchers worked with partner organisations to ensure that child safeguarding measures were in place for children participating in the study and that all the children and adults gave their informed consent. Stakeholders surveyed

• 123 children were included in the research: 58 children aged between 9 and 12 (27 boys and 31 girls) and 65 children aged between 13 and 17 (31 boys and 34 girls), in seven countries: Nigeria, Ethiopia, Côte d’Ivoire, Kenya, Zimbabwe, Zambia and Swaziland;

• 44 parents and caregivers from six countries: Nigeria, Ethiopia, Côte d’Ivoire, Kenya, Zimbabwe and Zambia;4

• 51 teachers in seven countries: Nigeria, Côte d’Ivoire, Kenya, Senegal, Zimbabwe, Zambia and Swaziland;

• 12 community and religious leaders from Swaziland, Zambia, Zimbabwe, Cote d’Ivoire and Nigeria; and

• 17 trainers and management from partner organisations in all eight countries. Research instruments Age-appropriate discussion guides were designed in collaboration with Save the Children. These consisted of separate guides for children, parents and caregivers, teachers, community leaders and project team members. The research instruments were designed to allow for comparative analysis between children’s and adults’ perceptions of CSE&I in different countries. Discussion guides and interview guides were translated into French for use in Côte d’Ivoire and Senegal.

4 The parents and caregivers who participated in this study were not necessarily the parents or caregivers of the children who participated in the study.

3. Methodology

4. Limitations • The methodology did not adequately accommodate some traditional gender roles and norms. For instance, in Ethiopia it was difficult to recruit girls to the FGDs due to local expectations that girls should stay indoors and undertake household duties. Therefore, the voices of Ethiopian girls do not feature as prominently as desired in the study.

• The study set out to interview religious leaders in all of the countries but it was not able to interview any representatives of faiths other than Christianity, such as Islam. Therefore, the study can only reference Christian religious leaders. It also only interviewed religious leaders in five countries.

• The gender of the adults who participated in the study was not systematically recorded.

• Whilst this study targeted all the stakeholders in all the relevant countries it was not always possible to carry out all the planned interviews owing to particular circumstances in some of the countries: • In Senegal, the school holidays had already started when the data collection took place; therefore it was difficult to mobilise some teachers living in rural areas to attend FGDs. • The school holidays in Senegal also meant that it was not possible to arrange for the younger age group to participate.

• This study also acknowledges that FGDs and interviews took place in a number of different languages, but mainly English, French and Amharic; therefore discussions may have been affected by the translations and interpreters used.

• Many of the parents, caregivers and leaders have already been exposed to various kinds of sexuality information and training and therefore we can expect a bias from this group towards being more open and accepting of CSE. This might not necessarily be so in other groups of adults which have not been exposed to these types of programmes.

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Findings from the 5. primary research 5.1 What young children told us (children 9–12 years old) Young children’s engagement in and perceptions of sexual activity Some young children may be engaging in various forms of sexual activity, reportedly even from ages as young as 6 years of age, but some of them said that this is something children should not do until they are older and/or married. Many children considered it to be the norm that girls will engage in sex at a younger age than boys. Some children also identified reasons why they might engage in sex other than for pleasure, citing peer pressure and financial gain as examples. However, for the most part, these children seemed to have many typical questions related to sexuality and HIV that needed answering. “It is bad to have sex when we are so young.” S wazi child “Why are girls asking for sex if the boys don’t want, when boys ask for sex and girls don’t want.” Swazi child Young children’s knowledge of sexuality and HIV The children were asked whether they had any questions in relation to issues such as body image, relationships, sex, puberty, gender roles and HIV. The children had many questions and fears. From their responses it was clear that whilst all children had heard about HIV, not all of them had a clear understanding of the topic. Children also asked questions which suggest that they are already thinking about different kinds of relationships. Generally, children from this age group showed that they were becoming aware of the many aspects of sexuality and were seeking answers to a whole range of questions. “How is HIV or AIDS transmitted when a boy and girl meet?” Zambian child “I think about my body and how I can get HIV. I think about how I can die. When my sister uses an object and I have to use the same one and if [she] has HIV then I can get it too.” Côte d’Ivoire child “Can somebody have a boyfriend or a girlfriend at this age?” Kenyan child “What happens when a boy and girl sleep together?” Zambian child “Why is it that immediately after becoming a teenager you are exposed to the world of sexual activity? Is it a law or is it compulsory?” Nigerian child

5. Findings from the primary research

Young children’s aspirations and perceptions of gender norms The children were asked about their aspirations. Many had ideas about the kinds of jobs they would like to do, such as becoming scientists, doctors, soldiers, businessmen and teachers, or “HIV capacity leaders”. Children also demonstrated a keen understanding of common respective gender norms and gender roles but they also suggested that these gender roles did not play a very strong role in their lives. For instance, in Swaziland and Côte d’Ivoire, some girls felt that boys did not have the same responsibilities as girls, and that boys had much more freedom – boys could come and go as they pleased, and girls had to stay home and do household chores. In addition, the girls said that boys had opportunities to further their education and have jobs, whereas girls had to stay home and look after the house. However, in other countries such as Zambia, children said girls and boys were treated the same, and in Ethiopia that things were changing. Young children’s access to CSE and other sexual and reproductive health education and services Discussions showed that the majority of children have received some form of sexuality education at school but some indicated that they did not consider this ideal, and would prefer to have these conversations with their parents. Some children felt uncomfortable, shy or embarrassed about discussing sexuality with their teachers. However, children’s sense of comfort with regard to discussing matters of sexuality with their parents also varied. Most children said that they trusted their parents and felt very comfortable engaging with them on issues of sexuality, whilst others indicated that they thought their parents were not knowledgeable enough or did not have detailed information, or, as in Kenya, that they felt uncomfortable about entering into discussions with their parents about sexuality. Whilst children indicated that both teachers and parents/caregivers were potential good sources of sexuality education and information, they also indicated that whom they preferred to get information from depended on the level of information and education of that adult. Also, the fact that children could generally feel uncomfortable discussing matters of sexuality with both teachers and parents/ caregivers suggests that adult–child communication around sexuality could be an important issue. Children also wanted more information to take away and discuss with other peers and adults, for instance flyers or brochures. Children seemed to appreciate having out-of-school services, such as community organisations, which provided education on sexuality or referred children to other community services and clinics where they could discuss sexuality issues and concerns openly. What was clearly revealed was that these children want to access sexuality information services, including clinics, but that they want these services to respond to their needs. It was not clear if the children also wanted to access other services.

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“Some people will think because their friends are doing it and they did not get pregnant, so they want to do it.” Nigerian youth

For instance, in Kenya, a number of children remarked on the lack of privacy when attending clinics as they feared someone would see them and tell their parents, whilst in Ethiopia some children felt uncomfortable about asking questions at a community centre as the members were much older than they were. Children from Côte d’Ivoire referred to the long distances they had to travel to get to community organisations providing services, including clinics, and said that they would like it if there were separate child-friendly areas where they could interact freely and comfortably with their peers. In Swaziland, children were more ambivalent regarding using community centres to access sexuality information and services, saying they preferred this to come from parents and teachers.

5.2 What older children told us (children 13–17 years old) Older children’s engagement in and perceptions of sexual activity The older children who took part in the research study indicated that the majority of their friends were already engaging in sexual activities. When asked about the appropriate age to start engaging in sex, the average age given was 18, with children from Côte d’Ivoire saying one should be “mature and responsible” before engaging in sexual activity. As with the younger group, older children identify very clear reasons why they might engage in sex which go beyond having sex for pleasure. And whilst many children did acknowledge that they had sex “just to know how it feels”, a lack of money or food featured prominently as a reason for having sex: for instance, young girls going with older men in return for these, or even for personal gain, as well as the desire to fit in and gain status amongst peers, or peer pressure. “Some people will think because their friends are doing it and they did not get pregnant, so they want to do it.” Nigerian youth Older children’s aspirations, gender norms and perceptions The issue of gender in relation to this group of children’s aspirations featured prominently in discussions. The children stressed the importance of gender equality and agreed that women could do anything they wanted to do. There were also children who viewed gender roles differently. For instance, a few of the boys mentioned that a man’s role was to be the head of a household. In Senegal, there was an interesting exchange between the boys and girls. A boy from Senegal declared: “The difference is that there is more pressure on men to be successful as we have to take care of the family, whereas even if a woman is not successful her husband can support her and can take care of them.” Female participants responded with uproar to his comment. They were adamant that females were also expected to support their parents and sisters. And despite most boys agreeing with the remark about a man’s role, they admitted that female

5. Findings from the primary research

“I hate discrimination. My parents suggest I stay at home as my brother continues learning. What should I do?” Kenyan youth

emancipation was important for Senegal’s future and women should not be forced to stay at home. This comment was not only interesting because of the protests it elicited from the girls but also because it hints at the pressure of expectations experienced by boys to be ‘men’ and conform to a certain stereotype. Many children said that everyone dreamed of getting married, starting a family and having a good job, but children conveyed an awareness that there were many challenges to attaining their goals and dreams, especially due to lack of money to access higher education, or because of early marriages and pregnancy – which forced girls to drop out of school – or discrimination. “I hate discrimination. My parents suggest I stay at home as my brother continues learning. What should I do?” Kenyan youth The children all agreed that missing out on attending school would result in not being afforded an education. Being uneducated led to inequality, which created a sense of powerlessness, lack of confidence and not attaining one’s dreams. There was much concern that gender and lack of finances could impact on their ability to get a good education. This awareness of the extreme challenges which these children face in their lives should be taken into account when considering children’s wellbeing and behaviour. CSE and other sexuality information and services – older children’s reflections Parents and caregivers as sources of sexuality education and information

Parents and caregivers were considered a source of information from which the youth would like to get answers to their questions. Children believed that parents and caregivers are more sensitive to their children’s needs, and want the best for their children. Therefore, children believed parents and caregivers were the best people to talk to. Whilst older children indicated that some children did speak to their parents and caregivers – mostly their mothers – about sexuality, some of them did not feel comfortable about talking to their parents and correspondingly did not feel that parents were comfortable talking to them. The children gave a number of reasons why sexuality conversations between parents and children could be uncomfortable, including a perceived lack of knowledge about sexuality or a lack of communication skills around sexuality, for instance because sexuality is a taboo subject. Additionally, children said that parents and caregivers often berated children for wanting to find out about sexuality – some children reported that their parents shouted at them when they started a conversation on sexuality matters. One girl explained that parents needed to take more responsibility and not shy away from these topics, with another girl adding that children are curious and love to discover things, but parents believe that if they do not talk to their children about certain things, the children will not embark on a path of sexual discovery.

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Teachers as sources of sexuality education and information

Among this group, school seemed to be the main source of sexuality education. Children indicated that they considered teachers to be knowledgeable and reliable sources of sexuality information, with some indicating that they felt comfortable going to teachers with personal issues. However, many other children said they found it hard to speak with teachers openly regarding personal issues, or did not trust them to keep information confidential or, in the most extreme cases, had conflicting interests because teachers were in relationships or engaging sexually with learners.5 “I also feel it’s good when they tell us in school, ‘cause some, they [community members] lie when they talk about sex.” Swazi youth “I believe that parents and teachers can tell us the truth about the topic. Maybe because of their experiences.” Nigerian youth “For me it’s hard to talk about sexuality with teachers. I can, but it’s difficult for me.” Côte d’Ivoire youth “Some, they are not comfortable because they are engaging in sexual intercourse with a student who they will feel, like, somebody will see me and what will [they] think about them and maybe he embarrassed his/her girlfriend or boyfriend in the class.” Swazi youth

“Most of the teachers talk to us: ‘why do you want to have sex at this age … ?’” Swazi youth

Children shared that in school, lessons about aspects of sexuality varied in terms of approach, with varying negative and positive messages, including HIV (and AIDS), sex, abstinence, sexuality and family planning, but that these curricula are either optional or sometimes integrated into other subjects such as life skills. They highlighted the need for school curricula to address more areas of sexuality, provide more in-depth information, and address more closely the realities and ‘real issues’ of the children’s lives. ‘Negative consequence’ messages were not always well received, although children signalled that this was a common approach used by many teachers. In Swaziland, the children described how this subject became a joke in class, presumably because the teacher was not well trained or supported to provide sexuality education. “Most of the teachers talk to us: ‘Why do you want to have sex at this age … ?’” Swazi youth Community services and organisations as sources of information and services

Many children had accessed community organisations’ sexuality education programmes, valuing their friendliness, confidentiality and support for young people. Children gave positive feedback regarding community organisations providing sexuality education, saying they were sometimes the only places they could find reading material on sexuality. 5 In the case of Swaziland.

5. Findings from the primary research

“How can I cope with menstruation?” Nigerian youth

Quite a few children said that the information they had received from these organisations had given them more confidence to make more informed and responsible decisions about their sexual activity. For example, some children said they felt confident that they had the right to say “no” to getting involved in situations that made them feel uncomfortable. “The NGO [non-governmental organisation] taught me that sex is a part of life and you can either use it in a good way or in a bad way.” Girl from Côte d’Ivoire Older children had mixed feelings with regard to visiting clinics for sexuality information and services. Many children felt comfortable about going to clinics, saying they trusted the nurses and the information they received. Some hospitals they mentioned had a youth unit, staffed by specially trained doctors. However, in Senegal, some said they were reluctant to visit clinics and hospitals. They mentioned that it was difficult to obtain information because nurses and doctors responded to their questions by saying they were too young to be asking such questions; or they were afraid of being seen at the clinics, because their parents might be told they had been there. A number of boys mentioned that some young people preferred buying condoms from a pharmacy to going to a clinic to get them for free. One boy said that he even paid younger children to go in and buy them for him, to ensure greater anonymity than if he bought them himself, or attended a free clinic. Older children’s knowledge of sexuality and HIV information Older children indicated that they want and need more education, information and services on sexuality and HIV. Children pointed out that they wanted to know everything that would enable them to make better decisions. Children were not sure if they could get trustworthy information by talking to their friends, although they did all discuss sexuality with each other. The kinds of questions they asked with regard to sex, sexuality, their bodies, puberty, relationships and HIV confirmed their need for more knowledge around many aspects. “How can I cope with menstruation?” Nigerian youth “What is puberty?” Zambian youth “What is the main cause of HIV and AIDS?” Zambian youth “Does casual sex pose a risk?” Senegalese youth “Can HIV and AIDS be spread through tears and sweat?” Kenyan youth “Can HIV spread through eating or sharing food with an HIV-infected person?” Kenyan youth “If a girl has HIV, what can cure her?” Nigerian youth

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From the kinds of questions being asked by these groups, many of which are very serious in nature, for instance how to tell a girlfriend you have HIV, there is a sense that children do not have adequate information and support on HIV or sexuality, even though the majority of children interviewed said that they had friends who were engaging in sexual activity. Some did know their HIV status, but presumably there were also those who did not.

“I am worried what would my friends say when they find out that I am HIV positive.” E thiopian youth

Older children living with HIV Living with HIV is challenge for many children, and stigma features heavily as one of the main concerns for older children. When older children were asked about how to cope with living with HIV, many of them gave positive or constructive answers, for example: go to a hospital, take your medication, get tested regularly, have a positive mind-set, do not withdraw, abstain from sex, offer psychological support to infected people, and do not discriminate against them. But for children who were aware of their HIV-positive status, the reality seems quite different, with self-stigma and the fear of being stigmatised by others being very apparent. “I am worried what would my friends say when they find out that I am HIV positive.” Ethiopian youth “I am embarrassed because of my status, the way I feel, and I get humiliated.” E thiopian youth Children’s perceptions of the role of social media and the Internet in relation to sexuality and education information Children clearly indicated that they actively seek out information on the Internet and social media, and whilst they were not always sure of the accuracy of the information, they valued the confidentiality compared to teachers or clinics. There was also a sense from the children that television can expose them to a great deal of the information they get about sex and sexuality, but that this information is often not age-appropriate or positive. For example, children are exposed to pornography and unrealistic views of relationships. “The mass media stuff, some of them do watch pornographic movies.” Zambian youth Changes perceived by older children in parents and caregivers who had received training The older children identified several positive ways in which CSE programmes were changing their parents’ views and behaviour. Children from Ethiopia reported that they educated their parents and others in their community by reworking the information they had received, for instance, by dramatising it and presenting it to the parents. The children report that this had had a very positive effect. Some of the young people also mentioned that their parents and siblings had attended

5. Findings from the primary research

The older children identified several positive ways in which CSE programmes were changing their parents’ views and behaviour.

training at local community programmes, which according to them had been very helpful in changing the way parents and children talked about the topic of sexuality. “Before, the parents did not allow most of the kids to come join the club, but now, after we had organised an awareness programme for the parents, they are becoming encouraging and they would allow us to come … . They’re also very proud when they see their child fighting a struggle for these issues, especially when we have events, and young people are on the stage and talking about these things passionately.” Ethiopian youth “Before, my mum would never talk to me about any of these subjects, but after going on the training at ASBEF she has become really open and realises how important it is to provide me with information.” Senegalese youth. Finding information on the Internet or other media was often cited as a preferred source, mainly because of the anonymity involved, but children were not always sure it was accurate. They were also aware that media sources were also ways of accessing pornography and other sexual content. Accessing information online featured prominently among the children and is a reflection of the common reality for many children globally. There is also a sense that sexuality curricula and teaching approaches in schools are often haphazard and tend to focus on negative messages, with teachers not always being well trained or supported to teach sexuality education to older children. Community-based organisations appear to be more open to the idea of children’s sexuality and are often perceived as being friendly and good sources of information. Of note is the fact that children saw these community programmes as being especially useful in reaching their parents and caregivers and helping change their attitudes and knowledge levels around sexuality, both through direct participation in programmes and through their children presenting drama or leaflets to their parents. The value of children accessing leaflets and materials they could take away and read or discuss with peers or parents was made clear. Finally, older children seemed to be aware of many of the potential negative aspects of gender roles, especially for girls, and there was a sense from both girls and boys that social change on this front is possibly being embraced by this generation, with both groups acknowledging that gender roles can be detrimental to a person pursuing their ambitions. However, many socio-cultural norms still seem to prevail, with some girls mentioning a very real worry that they would be forced to marry early and have children, and have to drop out of school as a result.

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5.3 What parents and caregivers told us Many of the parents and caregivers had also been exposed to various kinds of sexuality information and training. In Ethiopia, parents had been involved as volunteers with the partner organisation Family Guidance Association from 2003, although they had not participated in activities recently; parents from Kenya, Côte d’Ivoire and Zambia had attended one or more training sessions offered by Save the Children partner organisations; in Nigeria parents had been involved in a range of activities provided by a number of different community organisations providing sexuality services; and in Zimbabwe activities were limited, although parents had been exposed in some measure to specific training on HIV through door-to-door training or at hospitals. Parents’ and caregivers’ reflections on CSE

“So, I sat her down and I taught her more about HIV and AIDS. How to contract it, how to prevent it, and many other things.”

Parents seemed on the whole to be positive about their experiences and, irrespective of the nature and level of their involvement with various CSE programmes, many parents considered themselves more enlightened and more capable of sharing information with their children as a result. Parents and caregivers also had very few reservations in relation to the need for children to access CSE. This mostly progressive group of parents also explained that many parents believe that sexuality education might “spoil” a child, so the attitude expressed in the FGDs was certainly not the norm. For example, a mother in Nigeria reported how she had bought a book on sex education for her child but had first read it herself to broaden her own knowledge. After her daughter had read the book, she questioned her on her understanding of it and they discussed matters openly. In another story, a mother in Nigeria had read a book her daughter had brought home. She used the opportunity to further educate her daughter: “So, I sat her down and I taught her more about HIV and AIDS. How to contract it, how to prevent it, and many other things.” Notably, parents in Côte d’Ivoire expressed the view that other parents could overcome cultural challenges just as they had done. On the whole, parents felt that children should be given age-appropriate information from as young an age as 8 or 9 years. However, there were also parents who expressed concerns or had reservations regarding teaching children about sexuality. For example, a woman in Zambia said that if children were taught about sexuality it might create a desire in them to experiment. In a more positive example, a grandmother from Côte d’Ivoire looking after her 18-year-old grandson explained she had not known how to talk to the boy until she had received training on a variety of issues, for instance what was meant by ‘wet dreams’. The grandmother could then tell her grandson, “Don’t be ashamed. You are not dirty. It’s natural.”

5. Findings from the primary research

A teacher from Senegal also reported a positive change in parents. “It is more than change … [it’s a] celebration. It was not easy to talk about sexuality to the children … it’s a taboo and victims are taken away. Now we have enough information to see the importance of sexual education.” “So I used to work for [the] Family Guidance Association, and I have an adolescent daughter, and I share my experience with her and we talk about things honestly and very freely. So, I’m changing; I’m now starting to talk about things freely.” Mother from Ethiopia Many women specifically highlighted that they had not received guidance on sexuality from their own mothers but were endeavouring to change and provide this information to their own children. For example, a Nigerian mother said, “Let me give an example concerning my own daughter. The first time she had her period, she came to me and said: ‘Mummy! I have seen that thing!’ Then I told her not to worry. The next day I sat her down and enlightened her about it. My own parents never told [me] about this when I had my first period because we were not close. So I told my daughter that she was now a complete woman.” Another parent from Ethiopia related her first experience of pre-menstrual syndrome. She had felt too ashamed to talk to her mother, and had to learn about it from another source. However, having worked for the Family Guidance Association for eight years, she could talk openly to her daughter about her feelings and prepare her for puberty.

Schools and teachers were regarded as the ideal providers of sexuality information.

Parents and caregivers as sources of sexuality information Parents and caregivers, especially women, saw themselves as important sources of information on sexuality for children, whilst at the same time acknowledging that parents did not play a big role in providing this information, and they did not consider themselves to be the primary information providers. Schools and teachers were regarded as the ideal providers of sexuality information. For example, in some countries, such as Zambia and Ethiopia, parents were reluctant to take on the role of primary providers of information, preferring to support teachers by reiterating or expanding on the information taught in school. “So it’s very unusual for parents to discuss these things with their children, since the schools already give them this information; unless the parents are nurses or doctors.” E thiopian parent. Generally, there was also a perception that women had the traditional role of engaging with children around sexuality issues. In Ethiopia and Kenya, parents said that men feel uncomfortable with this role. Kenyan respondents were of the opinion that both parents were needed to give this education, or at least that a strong support system had to exist between them.

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a significant number of parents and caregivers … used a strategy of ‘building fear of consequences’ by focusing on the dangers of sex.

Whilst some gave positive messages around sexuality, there were a significant number of parents and caregivers who used a strategy of ‘building fear of consequences’ by focusing on the dangers of sex. Parents also said that children received sexuality information from what they considered to be less desirable sources, such as the Internet, social media and television. According to them, television and other media provided information that was not age-appropriate. In response, many parents thought that children’s inevitable exposure to information from ‘the wrong sources’ placed a new urgency on parents to step in and find ways of addressing issues of the Internet and social media. “This world now is one. So if you don’t want to talk with your children, they will get this information and the wrong information: media, TV, Internet and all these things. It will be dangerous.” Nigerian parent In terms of barriers for parents and caregivers providing more information to their children, they mentioned: a lack of technical knowledge – many of them simply lacked the knowledge to answer children’s difficult questions and it was especially hard for parents to know what type of information was age-appropriate; feelings of discomfort – discomfort often stemmed from the cultural taboos associated with speaking about sexuality; time constraints; and disapproval from others. Many had not grown up with parents who taught them anything about sexuality, and they therefore did not know how to relate to their own children. “Some people said I am teaching my children rubbish. Others said my children are too young to be taught about such things.” Nigerian parent “My son can ask this question: ‘Mummy, how do you and daddy do it?’ You know, things like that. So I am afraid of to what extent do I answer such a question.” Nigerian parent Parents’ and caregivers’ views on gender roles and norms Adults highlighted some traditional gender roles, practices and attitudes and how these could affect children and adults. For instance, adult participants pointed out that Swaziland society was polygamous, and men were legally allowed to have more than one wife. Such situations gave rise to questions about a girl’s ability to control safe sex practices and to know the HIV status of her partner. Additionally, adult participants from Senegal and Côte d’Ivoire pointed out that many girls were denied the right to education and were expected to stay at home. It became apparent during the FGDs that the boys in both these countries were afforded the opportunity to go out and work, whereas the girls were required to stay at home, cook, and look after both parents and children.

5. Findings from the primary research

“It’s a good thing for the children, if you give this education they can make better decisions.” Côte d’Ivoire parent

Parents’ and caregivers’ views on HIV Parents and caregivers identified that, with the exception of Kenya and urban Nigeria (Lagos), HIV is still viewed as a big problem, or a problem for rural areas, where it was generally accepted that most people do not have a high level of education. Parents also identified poverty, including food insecurity, as contributing factors to the spread of HIV, as it provoked more HIV-risk related behaviour. Parents saw CSE as beneficial to their children in the light of the HIV epidemic. Parents raising children living with HIV also highlighted the stigma attached to one’s HIV status. “It’s a good thing for the children, if you give this education they can make better decisions.” Côte d’Ivoire parent Parents and caregivers also discussed more specifically some of the ways in which they thought you might transmit HIV or be infected by HIV, which includes issues of hygiene, such as “being too poor to buy your own haircutting tools.” (Nigerian father). Parents identified traditional or cultural practices, alcohol abuse, misinformation and ignorance as additional aspects which contribute to the transmission of HIV. For instance, some parents from Kenya highlighted the fact that the cultural practice of some ethnic groups who ‘inherit’ wives also contributed to the spread of HIV. Another factor mentioned by Kenyan respondents was alcohol abuse, which resulted in a lack of control and in ‘unhealthy’ behaviour. A further factor contributing to the spread of HIV, as expressed by an Ethiopian parent, was that condom usage was still not widely accepted in African countries, and that misconceptions about the use of condoms persisted: “There are misconceptions about using condoms; that it actually transmits diseases.” Ignorance and lack of general and sexual education were also noted by parents in almost all of the FGDs as factors contributing to HIV infection, with parents noting that this was especially so in rural areas. Recommendations made by parents and caregivers Many recommendations focused on how community organisations’ services could be expanded or improved. These included providing a wider range of initiatives and providing more medical equipment to clinics. Parents and caregivers also focused on providing recommendations around how to improve CSE programming. For instance, parents are aware of the effect of media on their children, and although some highlighted this as a threat, many also regarded it as an opportunity to deliver content to children.

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“Once you want to chat video with them, definitely they’ll ask you questions from them, and also you must be available to answer the question as you explain further. And also as you put that video there for HIV-affected people and all those stages of HIV, some of them, they’ll be interested to ask some questions about them and you must be available, at least to explain to them the facts of that information. So, for them, it will be very interesting and can even sink in their mind because they are watching.” Kenyan parent Parents acknowledged that a close relationship between parent and child helped communication, yet this was not always easy for parents to achieve. Parents are often busy earning a living and consequently do not always spend the necessary time with their children. Parents said that a holistic CSE programme should also focus on helping parents understand the importance of a good relationship, and showing them how to achieve this. Finally, parents from Zambia attributed value to their children being engaged in sports activities. The parents perceived this as a positive activity, which keeps children busy and less likely to be in harm’s way.

Teachers linked a number of issues to the spread of HIV, including peer pressure, the media, poverty, transactional sex, lack of information and cultural norms.

5.4 What teachers told us The majority of teachers who participated in the study were responsible for sexuality education in their schools and many had also been involved in training and other CSE activities offered by partner organisations. Teachers’ views on sexuality and HIV Teachers linked a number of issues to the spread of HIV, including peer pressure, the media, poverty, transactional sex, lack of information and cultural norms. In particular, teachers highlighted early sexual debut as a general concern, as well as in the context of HIV. It was reported by some teachers that some children in Kenya, Nigeria and Zimbabwe were actively engaging in sexual intercourse from as early as 6 years of age, while teachers in Zambia, Côte d’Ivoire and Senegal indicated that some children engaged in sexual intercourse from between 10 and 15 years of age. There were many opinions expressed as to the reasons for early sexual debut. In particular, the teachers highlighted poverty, peer pressure, the media, certain television programmes and general curiosity as possible reasons. The teachers also said that younger children often had unprotected sex, may have many sexual partners, or were having “sex for money”. Some teachers also thought that because children often lived with their parents in a one-roomed house, they inevitably saw and heard sexual activity between their parents or other adults sharing the house, which they felt sensitised children to sex at an early age.

5. Findings from the primary research

“Parents do not talk with kids about sexual health, as they presume it is done at school.”

“Influence in some communities where kids as early as 14 years old have their own children – thus other girls in [the] community see it as [a] desirable achievement to also have a child.” Nigerian teacher Teachers also explained some of the reasons behind children lacking information on HIV. For instance, in Senegal and Côte d’Ivoire sexuality is considered a ‘taboo’ topic, which teachers felt was an exacerbating factor for the spread of HIV. One group also felt that many people treated HIV as something which could not be prevented by an individual, as it was caused by external influences such as being ‘cursed’. Teachers’ views on their role as sexuality educators In these discussions, teachers considered their role and the role of parents in sexuality education, with some saying that they thought that parents should take on a stronger role and rely less on teachers to provide their children with sexuality education. Teachers indicated that they thought the best delivery of sexuality education was when parents or caregivers and teachers worked together to reinforce and support one another. In relation to this, some teachers acknowledged that they could do more to counsel and inform parents, such as run more parent information sessions at school. “Parents do not talk with kids about sexual health, as they presume it is done at school.” Teachers signalled that they valued organisations which provided sexuality education and services, not only to children, but also in the form of training to teachers. They gave examples of how they would refer children to these organisations and youth-friendly clinics where required and also noted the importance of ‘official’ support for CSE from various community leaders. The challenges perceived by teachers Teachers highlighted a number of perceived challenges for children and themselves in terms of learning about sexuality and children accessing services. These included the negative influence of television and other media on the general population, the lack of clinics which catered for children, hospitals and medical facilities which were not in close proximity to communities, and some level of uncertainty about how to teach certain issues to children. Teachers’ confidence about teaching sexuality education in schools varied, with some saying they found teaching this topic difficult due to tradition and culture, while teachers from Kenya said that there was not enough time in the school programme to allow for adequate teaching of sexuality education, with teachers often ‘rushing through’ this subject. In Swaziland, teachers indicated that they sometimes felt as if the learners were more knowledgeable about sexuality than they were.

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Teachers were of the opinion that whilst communities’ and parents’ perceptions of sexuality education were changing – in that they had started to see the importance of children learning about sexuality – deep-rooted cultural beliefs and traditional practices in certain communities still presented a challenge. Teachers felt that these challenges could be dealt with effectively through persistence, focusing on continuous training and support, and rolling out CSE programmes to more communities. “The clinics are too busy, they are overwhelmed by the number of patients – and no ‘time to welcome children to explain about sexuality education’. There is also the problem of stigma, if a child is seen by a neighbour as going to the clinic – then something must be ‘wrong’ and stereotyping starts.” Teacher, Senegal. “They do refer youths to clinics, but due to stigma perceptions they will not go during the day, as they can be seen by friends and peers – they thus go at night to get ARVs [antiretrovirals] – but [this] poses [a] danger to youths; [it is] not safe to go at night.” Teacher, Kenya Teachers’ views on sexuality education in their schools

Teachers indicated that in many countries the focus in schools was on teaching about abstinence with strong negative or moralistic overtones.

All the teachers who took part in the study agreed that sexuality education was an important subject which should be taught in schools, especially given their understanding that some children are engaging in sexual activity at a relatively young age. However, the strength of policy direction and curricula varied considerably between countries, with teachers reporting very different levels of support and access to sexuality information and teaching materials, and calling for improved and expanded curricula and support. This included providing more technical and up-to-date materials; developing ‘computer-based’ sexuality teaching resources and materials; giving certificates on completion of community-based training courses so that they would be officially recognised and have their skills more widely accepted by the community. Teachers indicated that in many countries the focus in schools was on teaching about abstinence with strong negative or moralistic overtones, for instance teaching that sex outside of marriage was a sin and could result in getting infected by HIV and other sexually transmitted infections, although there was also some evidence of limited progress. For example, it was reported that schools in Nigeria had expanded their sexuality education focus to include a range of other topics such as selfesteem, assertiveness, decision-making, body image and personal skills. Teachers confirmed that children were hungry for more information than was taught at schools, saying that children used other, and not always reliable, sources of information, such as the home, social media, the church and other religious organisations, books and peers.

5. Findings from the primary research

Now listen more and do not judge so easily.”

Teachers were particularly passionate about the inclusion of age-appropriate sexuality education in the teaching syllabus from pre-school level. They want to ensure that children have access to the correct information and facts from reliable sources at the right time, and to avoid them getting age-inappropriate information from friends or unreliable sources, such as the Internet.

Nigerian teacher Teachers’ views on the value of sexuality programmes provided by other organisations Generally, teachers agreed that the training and support they have received from various organisations has helped them realise the importance of providing sexuality education to children and to consider it a priority. Not only had training boosted their confidence to provide sexuality education to children, but teachers had also become very passionate about the need for sexuality education and had shared information with teachers at other schools, community groups, church organisations and their own families and friends. “Now listen more and do not judge so easily. Children go back to parents and share the sexual education training they received. And teachers also share their knowledge at church, other schools, and community centres – even talk on the radio.” Nigerian teacher

5.5 What traditional, community and religious leaders told us As part of the study, FGDs and interviews were conducted with community and religious leaders in five of the African countries surveyed (Swaziland, Zambia, Zimbabwe, Cote d’Ivoire and Nigeria). The majority of the leaders included in this research study had been involved in some form of sexuality education programme; hence they were possibly more open-minded, and already supported the general idea of providing children with this type of education. Community and religious leaders as influencers Discussions with religious leaders gave a strong sense of the key role these people play in influencing communities. While the religious leaders who were interviewed as part of this study were all from Christian denominations, the project team members confirmed the similar importance of an imam in Muslim communities. For instance, in Senegal, the project team confirmed the need to include the imam in their programme to ensure greater acceptance of the project in the community. In Swaziland, it was reported that the church is regarded as a strong influencer with large numbers of people in the community attending church services. A pastor from Swaziland declared that whatever a pastor in his country said was considered to be right. A pastor from Kenya also referred to his role as a leader: “Because as a pastor I know I hold that position of leadership.”

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“HIV and AIDS is a problem, and it is a problem that as a church we cannot shy away from dealing with.” Kenyan pastor

Community and religious leaders’ perception of sexuality and HIV education “HIV and AIDS is a problem, and it is a problem that as a church we cannot shy away from dealing with.” Kenyan pastor Leaders felt that they had an important role to play in issues which affected their community, such as HIV, and had all seen first-hand the many ways in which HIV affected children, listing issues such as “child-headed households” (Zimbabwe) and the need to instil “good moral values” (Swaziland). The leaders also expressed concern regarding the early sexual debut of children, and supported sexuality education for young children. Leaders said that children engaged in sexual behaviour from an early age, with some of them being forced by parents to engage in transactional sex, for instance for food (Kenya). Early sexual activity was also linked by some leaders to children being exposed to sexually explicit programmes on television (Nigeria). Several religious leaders gave examples of sexuality education their churches or organisations were already providing. Many of the examples used a faith-based approach or materials from other programmes which had a sexuality education component. “But if we tell them, educating them especially at an earlier age, they will be knowing the truth; it will be easier for them to choose what is right and wrong, to make a good decision.” Zimbabwean community leader Leaders also considered the openness of other religious and traditional leaders to embrace sexuality education. Opinions were mixed as to how this might be received. For instance, community leaders in Nigeria said that most cultural and religious leaders supported sexuality education and offered little or no resistance regarding its implementation. However, a pastor in Swaziland said that some religious leaders were still opposed to providing sexuality education to children. In Zimbabwe, those interviewed said that many of the traditional leaders in Zimbabwe, who were older men (grandfathers), were still opposed to sexuality education for younger children. Nevertheless, the Zimbabwean leaders also reported that there was a move in Zimbabwe towards getting community leaders to become more open-minded about such education because children were exposed to information on the Internet and social media, as well as from other sources. Leaders were quite specific about how they thought sexuality education could be effectively approached or improved. This included more programmes to sensitise and educate more community and religious leaders in their countries; the involvement of influential people from outside organisations to work with community leaders, for example: “We invite people like MMP to visit and face those leaders and we tell them and teach them. We bring professional people and are teaching them, and they understand. It takes time.” (Zimbabwe); and

5. Findings from the primary research

bringing leaders and parents/caregivers together through training and information workshops at churches. Leaders in Kenya said that running training sessions in churches on HIV and sexuality had created a positive relationship between church leaders and parents/caregivers and had reduced parents’ resistance to children receiving sexuality education. Additionally, pastors referred to the often-contradictory content of their religious doctrines and sexuality. They recommended that training programmes be developed which would work within or incorporate the various religious doctrines. Leaders also suggested that different community leaders – spiritual, business and political – needed to come together to discuss how they could address HIV (for example, doctors, hospitals and churches). It was argued that including business leaders would promote the sharing of information by professional and other respected people with church members.

On the whole, leaders perceived parents as either unwilling or unable to discuss sexuality with their children.

Community leaders’ perceptions of parents’ role in sexuality education On the whole, leaders perceived parents as either unwilling or unable to discuss sexuality with their children, with one community leader explaining that in Zambia parents feared that by educating children they were creating a desire in them to “taste” what they had been taught, which might lead to early sexual activity. However, leaders also argued for the value of providing training for parents. “Actually it was very beneficial because you see again as I’m saying, I remember there is one time we had the time where we brought the parents and the children together. Through that we were able to open a certain wall that sometimes appears between the children and the parents. The parents are not able to educate their young ones on sexual education. Through that forum, we broke that particular wall. Today you hear of reports of what is happening on the ground; it worked like that … . But the parents, because they are the ones who know, they start, they initiate the discussion.” Kenyan pastor

5.6 What community-based organisations told us Discussions were also held with some of the implementing partner organisations. Discussions focused on what they perceived to be their main achievements and challenges, as well as their recommendations. Programmes and activities led by these organisations include a wide range of activities, such as HIV edutainment; a children’s hotline; children’s clubs; peer support groups; health services provision; child-friendly sexual and reproductive health and HIV services and clinics; training health providers in children’s sexuality service provision; providing extra food and meals to people affected by HIV; training of children, teachers, community members and religious communities and leaders on sexuality; and supporting or presenting radio programmes.

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It is clear that partner organisations are operating in a range of diverse contexts and that they have differing levels of capacities to provide CSE.

It is clear that partner organisations are operating in a range of diverse contexts and that they have differing levels of capacities to provide CSE. However, what emerges is the shared sense that the sexuality information, education and services they provide to children and adults are very important. These partner organisations are filling an important gap in current sexuality education and services programming, as while schools appear to be the main providers, the scope and quality of the information and education provided at schools is often inadequate. Additionally, partner organisations acknowledge and attempt to address the need to involve parents, caregivers, other community members and leaders in sexuality education and service provision, based on an understanding that it is not sufficient to simply target children. In this way, community-based CSE programmes have great potential, as they provide opportunities to influence community members. Some of these programmes appear to reach deeply into the community, and have built strong links with key groups. Partner organisations perceived their main achievements and advantages to include being able to use traditional activities as entry points, such as in Ethiopia where the traditional coffee ceremony is a strategy for providing sexuality education and engaging with communities. Another example is the ability to work in religious contexts to roll out training and information (Côte d’Ivoire). Additionally, some organisations (Ethiopia) said that they made efforts to involve boys and men in order to address the culture of gender inequality. In Kenya, the process-oriented approach was highlighted as an effective way of teaching sexuality. In Nigeria, the positive and far-reaching impact of radio shows was mentioned. Strong collaboration with different ministries and agencies was considered to be a strength in Senegal, whilst in Swaziland the strong links and trusting relationships which have been built up with various communities was mentioned. Partners also highlighted the challenges associated with implementing these programmes. All the partner organisations want to scale up their operations, as they feel that the demand is greater than they can currently supply, but they all have financial and human resource limitations. Many partners also want more, better, contextualised and up-to-date materials. Additionally, in some countries there are restrictions in terms of the kinds of support that can be offered to children (Ethiopia, Nigeria) whilst many highlighted the fact that cultural and religious beliefs in relation to sexuality – including gender norms – still prevent open discussions on sexuality education to children. The need to ensure that clinics and other service providers were more child-friendly was also highlighted by some partners. Finally, in Swaziland, the partner highlighted how religious messaging on sexuality is at odds with traditional practices – religious leaders have a lot of influence in the country, and they focus on abstinence messaging.

5. Findings from the primary research

6. Discussion This section discusses key or especially prominent issues which emerged from the primary research findings with reference to the rapid review of literature. Reaching young children – the shift to gender inequality and empowerment in CSE and its role in prevention In terms of the primary findings from this study, there is certainly a need and an openness to address sexuality education for young children, with several groups highlighting that children might be engaging in sexual activity from relatively young ages, and that early sexual debut was a general concern. Additionally, children and adults said that whilst children might engage in sexual activity to experiment or for pleasure there are also other reasons, such as their perceived gender roles, transactional sex, or even abuse. The importance of gender and power in how children, even quite young children, view and engage in sexuality, as well as how adults and communities perceive sexuality generally was evident from this study. In 2014, the UNFPA (United Nations Population Fund) published its operational guidance on CSE, defining CSE as “a rights-based and gender-focused approach to sexuality education”. This reflects a concerted effort by CSE policy-makers and programmers, at least at the global level, to move CSE programming away from ‘traditional’ CSE approaches, where the focus is on providing information and supporting holistic discussion and reflection, to a more strongly oriented rights-based or ‘empowerment’ approach, which places rights, gender inequality and empowerment at the heart of CSE. Essentially, contemporary, progressive understandings of and approaches to CSE are now understood as seeking to empower young people (Haberland and Rogow, 2015). This shift in approach is reflected globally in development more generally by the new sustainable development goals (SDGs) where power, inequality and human rights, especially in relation to gender, take on a more central role in achieving the SDGs. There is emerging evidence to support an empowerment approach to CSE. For example, Haberland and Rogow’s study (2015) found that sexuality and HIV education programmes that address gender and power in intimate relationships are five times more likely to be effective than programmes that do not. Some 80% of such programmes were also associated with a significantly lower rate of sexually transmitted infections or unintended pregnancy. In contrast, among programmes that do not address gender or power, only 17% have such an association. This emphasis on gender and empowerment also speaks more directly to prevention as well as ‘behaviour change’ strategies. For example, by reaching younger children with CSE, which focuses on gender and empowerment, the need to try and change entrenched negative behaviour and attitudes through CSE later on in a child’s life will be mitigated (Haberland and Rogow, 2015). There are already some CSE programmes being implemented which target children under 12 (UNFPA, 2015). In addition, there are now documented efforts to learn more about empowerment

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There is a small but growing body of evidence which identifies social transformation in relation to children as a process strongly rooted in the community.

among young adolescents, for instance a global early adolescence five-year programme is being implemented to look at these concepts in 10–14-year-olds (UNFPA, 2014). Targeting younger children with empowerment and gender-focused CSE is one strategy which can help prevent certain negative sexual and reproductive health behaviour and outcomes for children later on in life (Haberland and Rogow, 2015). In the context of HIV, it has been noted that investment in children’s early years can yield more cost-effective returns, but so far political and financial commitments at this critical stage in a child’s life have been missing (the Eastern and Southern Africa Regional Inter-Agency Task Team on Children Affected by AIDS and the Coalition for Children Affected by AIDS, 2015). These more recent, evidence-driven theories and approaches have much relevance for children in the study countries and can help inform thinking around the development of CSE for young children, as well as for older children and adults, and incorporate boys more robustly into CSE programming. Moving towards social change – working at the community level and the role of local leaders It could also be argued that by focusing more explicitly on gender and empowerment, CSE should be considered to be part of a bigger social change process, which extends beyond the boundaries of ‘behaviour change’. There is a small but growing body of evidence which identifies social transformation in relation to children as a process strongly rooted in the community, suggesting that the focus of social change must therefore be on actively engaging children and community stakeholders, including informal community systems, in more effective and sustainable community-level processes. For instance, we have learned in recent years that common community-based child protection models, such as externally implemented or supported ‘child rights’ or ‘child protection’ community committees, do not always appear to be sustainable or especially effective at linking with formal child protection structures (Wessells, 2009). It has been found that despite child rights training and support, communities may often revert to more traditional forms of child protection which run contrary to child rights frameworks – for instance beating children as a form of punishment – once the external implementing agency has withdrawn. Action research undertaken in Sierra Leone attempted to identify a more effective community model to protect children. It has so far demonstrated promising results where communities have been supported through deep and prolonged community engagement with local facilitators to identify and prioritise harms to children and then plan how they will address these harms. This research has resulted in community-driven (as opposed to community-based) groups which have addressed a long term concern – ‘pregnancy out of wedlock’ – in several communities through truly inclusive dialogue and negotiation and subsequent active engagement with local family planning and health clinics (Wessells, 2015).

6. Discussion

This learning can provide useful guidance if we transfer it to the context of CSE and the need to foster social change around socio-cultural attitudes to sexuality, which may result in negative health and well-being outcomes for children. The study highlighted how community and religious leaders signalled in interviews that changing the attitudes and beliefs of others is not a simple matter, and that it requires locally led strategies which are sensitive to religious and cultural contexts. The need for a deep knowledge and respect of local traditional values and cultures is required in order to collectively develop appropriate CSE programmes which can address gender and empowerment issues in the community, and effect true social change. Traditional, community and religious leaders, as well as established community-based organisations, are excellent entry points for employing such approaches. Learning suggests that traditional and religious leaders often have more authority and influence in the community than elected leaders, who are part of the formal government structure (Save the Children, 2015). For this reason, developing approaches where traditional, community and religious leaders are more actively engaged in embracing, promoting and leading initiatives which can strengthen HIV and CSE outcomes for children is imperative. This will also entail the development of programmes that can educate, inform and empower traditional, community and religious leaders with appropriate information around children and sexuality (Save the Children, 2015). It should be added here that this must be approached in a highly collaborative manner, which will entail taking time to listen to local leaders and working together with them to build strategies and approaches which are locally informed and appropriate for their respective contexts.

The important role that parents and caregivers should play in their childrenâ&#x20AC;&#x2122;s sexuality education was clearly highlighted by children, parents and teachers.

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Finally, the key role that local organisations play in providing education, information and services to children and adults has been highlighted in this study. These organisations are considered to be important service providers, which are often deeply rooted in their respective communities, with strong links to various groups and leaders. Not only are these organisations well positioned to reach vulnerable and out-of-school children, but they also provide a potential space for adolescents to engage with CSE programmes. They are also potentially in a position to engage deeply in the community to help build understanding, consensus and social change around issues of sexuality. Mobilising parents and caregivers to engage in sexuality education with their children The important role that parents and caregivers should play in their childrenâ&#x20AC;&#x2122;s sexuality education was clearly highlighted by children, parents and teachers. Children indicated that most of them considered their parents to be their preferred source of sexuality information but that there were various barriers, including poor communication, cultural or social taboos, and lack of knowledge, which prevented children and parents from communicating well, if at all, on the subject. Teachers expressed the strong sentiment that parents did not take enough responsibility for

… there is also a sense from current literature that much more still needs to be done to understand exactly why there is opposition to CSE from many community stakeholders.

teaching their own children about sexuality, preferring to leave it to the teachers. Meanwhile, parents who had received training and support on sexuality advocated passionately on how this had helped them address sexuality issues with their children in a more positive way. Whilst the parents and caregivers interviewed seemed very open to the idea of learning about and engaging with their children on issues of sexuality, regional studies such as Young people today: Time to act now (the United Nations Educational, Scientific and Cultural Organization (UNESCO), 2013) conclude that one key barrier to improved CSE in the eastern and southern Africa region is the difficulty of mobilising parent and community support. Adults interviewed for this study also highlighted that there were many challenges to sensitising other parents and the broader community. More generally, there is also a sense from current literature that much more still needs to be done to understand exactly why there is opposition to CSE from many community stakeholders, including parents, teachers and communities, and how this might be addressed (UNFPA, 2015). Like the recommendations by children and adults in this study, suggested approaches include focusing on the importance of the promotion of improved communications between children and caregivers from an early age (World Vision International and the United Nations Children’s Fund (UNICEF), 2015). What was also notable from the study was that adults seemed open to sexuality education for children but there was still reluctance to talk about some aspects of this education, especially sexual pleasure, emerging emotions and why and how children engage in sexual activities. Adults tended to focus on external reasons such as peer pressure, poverty, television and the Internet as the main reasons for children engaging in sexual activity. It appeared that parents in this study did not fully acknowledge the role they can play as parents in helping their children to negotiate these ‘external’ influences, which they seemed quick to blame and generally did not consider in-depth (at least whilst taking part in the FGDs) the effect that home life might have on their children. The dynamic identified between parents and teachers with regard to sexuality education also gives clues as to why sexuality education in schools is often not sufficient. Parents in all the countries surveyed indicated that they relied on teachers to either be the sole sources of information or at least main contributors to their children’s sexuality education. Teachers, on the other hand, reported feeling pressurised by the common negative attitudes of parents and the community towards sexuality education, saying that they need to work together more. Assisting these two groups to have an open discussion, within the context of broader community engagement, might improve the outcomes and impact of children’s sexuality education.

6. Discussion

there was a sense that men and fathers especially could play a stronger role in teaching children about sexuality.

Finally, there was a sense that men and fathers especially could play a stronger role in teaching children about sexuality. When we talk about gender and empowerment within CSE we need to consider how boys and men are supported and trained to teach sexuality and provide information, as well as how they might also be bound by gender norms and roles. Supporting greater participation and engagement from children, families and communities – programmes which address the realities of children The findings from both the 2007 and this 2016 study highlight how, according to children and teachers, school-based curricula need to be updated and revised, as many do not take into account the realities of children’s lives and therefore often have limited relevance for many children. This includes ensuring that children who are living with HIV receive appropriate CSE, support and services. Very broadly, this failure to develop and effectively implement CSE programming that addresses the realities of children’s lives in Africa has contributed to the devastating impact that HIV is having on African adolescents. In 2013, it was reported with great concern that the incidence of AIDS-related deaths for children and adolescents globally aged 10–19 had increased by 50% in 2005–2012 (UNICEF, 2013). UNICEF’s 2015 statistical update on children and AIDS further adds that adolescent deaths from HIV and AIDS have tripled since 2000. The 2015 report goes on to identify HIV prevention amongst adolescents as a pressing global issue, with 60% of new HIV infections among 15–19-year-olds occurring in Africa (UNICEF, 2015a). Additionally, a ten-country review of school curricula in eastern and southern Africa (UNESCO and UNFPA, 2012) concluded that most curricula needed to be improved if they were to offer truly comprehensive sexuality education. The study found that most curricula did not contain enough basic information about male and female condoms and, to differing degrees, had an abstinence-only focus, with a negative and ‘fear-based’ approach to sexuality which did not promote empowerment. The review also found that sexual and reproductive health was generally addressed as a biological issue, without any acknowledgment of the different ways in which puberty can impact on aspects of a child’s life. Gender-related topics were not always adequately taught, or the messaging was confusing or contradictory. Abuse, sexual diversity and other challenging topics were also inadequately or inappropriately discussed, if at all. The report also noted that the everyday realities of children’s lives, including the impact of digital media, were not incorporated into school curricula (UNESCO and UNFPA, 2012). It is now generally recognised that meaningful participation by children and other community stakeholders in the research, development and implementation of effective CSE programming is no longer considered to be ‘nice to have’ but rather is a crucial element of successful adolescent health and well-being. In response to

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Current learning around improving CSE curricula focuses on empowering young people, building agency or teaching advocacy skills.

this, this study sought to gain more insight into children’s worlds by using a research methodology which collected qualitative data directly from children and adults. Taking this approach a step further, it would be interesting to see how children could be more involved in programme revisions and monitoring. Current learning around improving CSE curricula focuses on empowering young people, building agency or teaching advocacy skills (UNFPA and UNESCO, 2012), which includes developing and implementing programmes which build children’s agency and opinions into research, development and programming. In the World Health Organization (WHO) report, Health for the world’s adolescents, which looks at adolescent health more broadly, it is noted that the most effective adolescent health programmes had distinct elements of adolescent participation (WHO, 2014). Meanwhile, global evidence-driven policy now strongly supports engaging adolescents in actions which respond to the realities of their lives in order to help reduce adolescent HIV infections and HIV-related deaths (UNAIDS et al. 2015, #EndAdolescent AIDS brochure). This includes engaging with children and young people living with HIV in all phases of programming (World Vision International and UNICEF, 2015). It is argued that approaches like these provide a critical understanding of how to support empowerment for children, which will lead to a reduction in stigma and discrimination and improve both HIV and protection outcomes (World Vision International and UNICEF, 2015). However, while there is mounting evidence that CSE empowerment approaches are increasingly effective and that these approaches are gaining ground, the reality of implementation of empowerment CSE programmes for children is clearly lagging far behind. This is reflected by the kinds of ‘traditional’ sex education curricula which the children often report in 2016, and previously in the 2007 study. And whilst efforts are made to include children and other stakeholders in the research design and implementation of policy and programmes, the extent to which this is done effectively or at a deep level is not clear. Quality, scope and scale of CSE programmes – what works and what doesn’t work In this study, both children and adults, including teachers, wanted access to more and better, up-to-date information. Additionally, older children gave the impression that there were still many areas of sexuality where they were not clear and wanted answers to quite basic questions. So whilst this study did not set out to evaluate the quality of CSE programmes per se, there is a sense that children have inadequate knowledge of sexuality and HIV and that both school-based and community-based sexuality education curricula and programmes could be improved in terms of quality, scope and scale. Current literature is clear that in terms of the scope and reach of CSE programmes there is still much progress to be made. There is evidence that in the countries where there is the highest HIV burden, which for the most part are in Africa, good,

6. Discussion

scaled-up CSE programmes are few (Haberland and Rogow, 2015). The need for more programmes was also clearly articulated by partners in this study. Additionally, in terms of the quality of CSE programming, evidence suggests that whilst CSE can yield very positive outcomes, these are compromised by programme implementation, which needs to undergo vast improvements in many areas (Haberland et al. 2014). Of particular relevance to this study is the fact that, in a recent review of evidence around adolescent sexual and reproductive health programming in out-of-school contexts, it was noted that despite the existence of evidence around what are effective CSE models, many ineffective practices and models are still widespread (Chandra-Mouli et al. 2015). Some of the most common, ineffective models being implemented were identified as CSE programmes which are built around youth centres; CSE programmes which focus on peer educators; and CSE which is provided through high profile meetings which aim to change peopleâ&#x20AC;&#x2122;s behaviour. Chandra-Mouli notes that this does not mean that these types of programmes do not have positive outcomes for children in other ways, but that in terms of CSE these types of programmes have not yet proven themselves to be significantly effective (Chandra-Mouli et al. 2015).

Studies have also demonstrated that many good CSE practices are compromised by poor implementation.

Studies have also demonstrated that many good CSE practices are compromised by poor implementation. For example, evidence shows that so called â&#x20AC;&#x2DC;youth-friendlyâ&#x20AC;&#x2122; centres and clinics for adolescent health often fall short of their claims and that they are often not accessed by children and young people because of negative experiences or perceptions (Chandra-Mouli et al. 2015). This certainly seems to have been the experience of a significant number of children who took part in this study, as well as being the opinion of some teachers. This recent learning is useful in the context of this study, as children, adults and organisations interviewed all mentioned participating in or implementing programmes, some of which are similar to the potentially less effective out-ofschool models mentioned above. This would suggest that rigorous evaluation is required to understand if, why and how partner programmes and other linked interventions are effective. This would be valuable learning in terms of what particular programmes could be scaled up. Children living with HIV An important issue which came out of this study is that there is a significant number of children who are living with HIV and who are thinking about or are already sexually active. Some children are aware of their status, while some have not been told about their status. We can assume that there are also children who are HIV positive but have never been tested and are therefore unaware of their status. Whilst FGDs did not specifically talk directly with children about their HIV status it

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… children with HIV face numerous challenges at school, many of which are related to the stigma of HIV.

is not clear to what extent, if any, children living with HIV are supported in terms of sexuality education and information. What we did learn was that children with HIV face numerous challenges at school, many of which are related to the stigma of HIV. For instance, adults reported that children are often absent because they are sick or have to go and get their treatment from clinics or hospitals. In Swaziland, where there is still a great stigma attached to being HIV positive, children do not disclose their status to teachers. Therefore, teachers often do not understand that children feel unwell and cannot concentrate. In Zimbabwe, parents of HIV-positive children reported that other adults had refused to help their children get their treatments when asked. Children at school also exhibited a negative attitude towards people living with HIV, possibly because of their fear of being infected. A Zimbabwean parent provided an example of a school that went so far as to separate HIV-positive children from others in the classroom. In terms of current learning around these issues, Towards an AIDS-free generation: Children and AIDS sixth stocktaking report (UNICEF, 2013b) notes that of the many children who were infected vertically at an early age, navigating sexuality is especially complex with serious consequences at stake, with the impact of stigma figuring significantly in these children’s lives. For instance, a parent’s own concern about revealing his or her status will impact on whether a child knows his or her HIV status (UNICEF, 2013b). The common thread of stigma will continue to affect many aspects of the child’s life, including health and sexuality, as he or she grows and develops. It is not clear from the rapid review of literature the extent to which robust policies, guidelines and programmes have been comprehensively developed which can support improved CSE for children with HIV, and how these might be integrated into mainstream CSE curricula. Whilst this group of children are considered important, especially within the context of trying to lower adolescent HIV infection rates and deaths and reach more vulnerable children, there is still limited information, learning or guidance about children living with HIV reflected in key reports, systematic reviews and policy and programming guidelines. The influence of the media The power and pervasiveness of the media in children’s and adults’ lives, whether it be television, the Internet, social media or mobile technology, came through very strongly in this study. Generally, the media is perceived by adults to be a double-edged sword, simultaneously one which has the power to provide enhanced information and learning opportunities to children, whilst at the same time harbouring increased opportunities for children to access or be exposed to inappropriate content and stereotypes. Rightly or wrongly, it was often identified by adults as one of the reasons why children engaged in various types of sexual activity. In spite of this, some teachers requested materials which were ‘computer-based’. Teachers said that

6. Discussion

children were more likely to respond to this type of teaching medium and therefore saw the value in developing digital and online materials. In terms of Africa’s access to digital and social media, by the end of 2014 it was forecast that there would be more than 635 million mobile subscriptions in subSaharan Africa. This was predicted to rise to about 930 million by late 2019, when it was estimated that three in four mobile subscriptions would be Internet-inclusive. The declining prices of both phones and data, along with faster transmission speeds, mean that social media companies like Twitter and Facebook can reach even the remotest rural areas (Guardian newspaper, June 5, 2014). Additionally, whilst controversial, Internet.org, a partnership between social networking services company Facebook and six companies, plans to bring affordable access to the Internet by targeting less developed countries.6 An app has been developed which allows anyone with a simple phone to access the Internet and aspects of Facebook for free.7 Roll-out has already started in several African countries and globally.8

… it seems that there is no hiding from the fact that digital media is becoming a central element of many children’s and adults’ lives.

Faced with this picture in Africa, it seems that there is no hiding from the fact that digital media is becoming a central element of many children’s and adults’ lives. This fast evolving reality needs to be further researched in order to understand what the implications for and impacts on children are, and then actively incorporated into CSE strategies and programming. This will include harnessing the power of media and innovations to enhance CSE teaching, as well as developing approaches which are protective in nature. What wasn’t said … and what can we learn? There were a number of important topics which did not appear to feature in FGDs to any significant extent. In particular, the voices of the most vulnerable children – those living with disabilities, children whose sexuality and gender is outside the ‘norm’ and children who are out of school – were not included in this study. The findings of two recent meta-studies affirm that reaching the most vulnerable and marginalised adolescents is still a challenge, highlighting in particular children with disabilities, key populations and children who are out of school (Haberland and Rogow, 2015; Chandra-Mouli et al. 2015). Being lesbian, gay, transgender, bisexual or intersex (LGBTI) Discussions on relationships or gender identities which are outside the ‘norm’ did not feature in the data collected by this study. The cultural, social, political and legislative environment as regards LGBTI people and rights in the eastern 6 Samsung, Ericsson, MediaTek, Opera Software, Nokia and Qualcomm 7 Reference: Free Basics by Facebook 8 Reference: wikipedia.org/wiki/Internet.org

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and southern Africa region varies from country to country, but generally it is challenging for people to discuss these issues openly for fear of stigmatisation, rejection, persecution or even prosecution. It can only be assumed that this climate also impacted what children and adults did and didn’t discuss in the FGDs in this regard. Whilst this is understandable, it also presents us with a challenge in terms of how to ensure that CSE programming and school curricula can respond to the reality of children’s lives, which inevitably includes some children exploring their sexual identities. This topic is of particular importance in the context of HIV prevention and treatment, as men/boys who have sex with men/boys are considered a key population within the HIV epidemic. Global and regional commitments and targets around HIV prevention and treatment will be hard to achieve without more open dialogue with this group. Children living with a disability “Children and young people who live with a physical, sensory, intellectual or psychosocial disability have been almost entirely overlooked in sexual and reproductive health and HIV/AIDS programmes.” The state of the world’s children 2013: Children with disabilities, UNICEF, 2013a In 2013, the UNICEF report The state of the world’s children 2013: Children with disabilities focused on disability and children. It noted that children with disabilities are among the most vulnerable members of society and that these children’s protection, rights and well-being are often compromised, with children experiencing discrimination, separation from their families, exploitation, abuse and violence. Children with disabilities are also more likely to be out of school. It also highlights how these children are particularly vulnerable to infection by HIV and that they experience many barriers to accessing health services, care and information.

Children with disabilities are considered especially vulnerable to abuse … .

Children with disabilities are considered especially vulnerable to abuse because it is assumed that they are not sexually active, or they may not be able to communicate adequately – because they have been taught to be silent and obedient, or have had no experience of setting limits regarding physical contact. (UNICEF, 2013a). The generally weak evidence base around children and disabilities and their virtual invisibility in relation to CSE programming leads us to assume that the knowledge base around CSE and children with disabilities is extremely limited. The inclusive aspirations of this study were also challenged when it came to including the voices of children with disabilities. More concerted research is required in order to develop CSE programmes which can respond to the everyday realities of children living with disabilities in different African contexts.

6. Discussion

Children who are out of school There are concerns that children who are out of school in the region are not being reached by school-based CSE curricula. Indeed, the groups of children considered especially vulnerable, including children who may have mental health problems or children who have disabilities, are also most likely to be out of school. Current literature tells us that effective programmes which aim to reach children from outside the school are few (Haberland and Rogow, 2015). More attention urgently needs to be given to learning around the best and promising practices to reach out-of-school children, especially the most vulnerable groups of children, with effective CSE. Children’s mental health While children and adults in this study did to some extent discuss how certain situations or experiences made them feel, there was no discussion of mental health issues which might link to sexuality or adolescence. Children, particularly adolescents, are affected by mental health issues, which the WHO has described as an “emerging public health priority” worldwide. About half of mental health problems start by the age of 14, but most go unrecognised and untreated (WHO, 2014).

… the link between children’s mental health and their sexuality in Africa does not appear to be an area with a strong base of evidence or learning.

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A recent review of mental health policy in sub-Saharan Africa concluded that there is still a severe lack of child and adolescent mental health policy and strategy in the region, given the level of need. Additionally, available data on the prevalence of childhood mental disorders in sub-Saharan Africa in 2014 suggested that up to 20% of children and adolescents in the region suffer from a form of mental health problem (Atliloa, 2014). We also know that suicide is the leading cause of death among girls aged 15–19 years globally, followed by maternal mortality, and ranks as the third cause of death for all adolescents (WHO, 2014). Whilst suicide is not always due to mental illness, and can often stem from problems within the family (UNICEF, 2012), these statistics serve to highlight the need to ensure that adolescents get the right information, education and support, including CSE, in efforts to help them navigate adolescence and the changes and upheavals which can accompany this period of life. And whilst it was recommended in the 2015 UNICEF report for the ‘All In’ campaign (UNICEF, 2015d) that mental health be integrated into adolescent health service delivery, the link between children’s mental health and their sexuality in Africa does not appear to be an area with a strong base of evidence or learning. This is despite the fact that issues such as sexuality, intimacy, sexual orientation and relationships are closely linked to our emotional well-being and mental health.

7. Conclusions and recommendations

his study has enhanced our understanding of how children, different groups of adults and communities perceive and approach sexuality education in Africa. In many ways, this report echoes the findings of its 2007 predecessor, Tell me more! For instance, children are still reporting that school curricula are outdated in their approaches and messages and do not correspond to the realities of their lives, although there does seem to be more positive, albeit at times conflicting, feedback regarding the role of teachers as sexuality educators in this more recent study. This positive feedback may be a reflection of the support which some teachers have received as a result of community sexuality education programmes, and possibly also of changes since 2007 in some national policy and programming around school-based sexuality education. It also seems that despite reinforced efforts in the last nine years or so to support CSE and HIV education in and out of school, many of the children who took part in this study still seem to have low levels of practical knowledge on these subjects, both in terms of data collected from children and in terms of what the literature is telling us. Additionally, it would seem that gender and inequality – and the various intersections with social, cultural and religious attitudes, practices and beliefs – still play a strong role in how children can express their sexuality and the roles and aspirations they take on. The 2016 research also showed clearly that, as in 2007, children’s concerns with the confidentiality, privacy and accessibility of various services should be taken seriously, and addressed. On the other hand, this study highlights the continued evolution, growth and reach of mobile and digital communications, especially social media, and the important role of traditional, community and religious leaders. This study also revealed that there is a need to target children from a young age with CSE, information and services, as well as to integrate parents and the broader community more systematically into CSE programming. There does also appear to be an openness amongst many of this study’s participants to embrace new approaches to CSE. We can assume that this can be attributed in part to CSE&I programming which has been rolled out in the study areas by Save The Children since 2009 and which has impacted on many of the children, adults and community members who took part in this study. 1. Teachers are the primary sexuality educators for many children in Africa. This role needs to be further acknowledged and supported in order to strengthen CSE policy, programming and implementation. The study clearly highlighted the important role that teachers play in terms of educating children about sexuality. However, teachers do not always appear to be well supported by policies or the school environment to deliver quality curricula in an effective manner. The study also found that teachers are very much in need

7. Conclusions and recommendations

of more training and support, which can help them deal with their own attitudes, personal conflicts and teaching questions around sexuality. Teachers were clear that they felt parents relied too much on teachers to educate their children on sexuality, and advocated that parents need to be supported to take on a stronger role. Sexuality education that children receive in school is more likely to have a greater impact if it can be supported by parental and broader community engagement, for instance, by community-based CSE&I programmes which target parents and other community members. Sexuality education which children receive in school is more likely to have a greater impact if it can be supported by parental and broader community engagement; for instance, by community-based CSE&I programmes which target parents and other community members. 2. Parents and caregivers can and need to play a more central role in providing sexuality education and information to their children. Children made it clear that they would like to receive more information from their parents and caregivers, but that poor communication between parent and child was a barrier, often due to a lack of knowledge, confidence or social taboos. Parents who had participated in community-based CSE&I programmes were enthusiastic and positive about how they had improved their ability to speak with their children about sexuality. Parents need to be further supported in these skills and knowledge as a priority, as well as being encouraged to reflect on how home life and parenting in general can impact on a childâ&#x20AC;&#x2122;s knowledge, attitudes and behaviour in relation to sexuality. Additionally, the role of fathers and men in sexuality education needs to be further explored and supported, as well as how boys can be better targeted and supported through CSE&I. Organisations which provide training and services to adults, including parents and caregivers, are essential service providers in these respects. Concerted efforts within the community to support parenting and comprehensive sexuality education knowledge and skills for parents and caregivers should be a priority for policy and programming. 3. Many school-based sexuality education curricula do not reflect current learning, best practice, or a skilled teaching workforce and could be further supported through community-based CSE programmes. School-based sexuality education varies in terms of the quality of the teaching and the quality of the curricula and requires additional support. This includes advocacy for improved national policy, programmes and capacity building, as well as scaled-up efforts by non-governmental programmes to support and enhance school-based sexuality education. Central to this is the role that community-based

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programmes can play in fostering a more informed and open environment at the community level, as well as supporting teachers and other educators. 4. Young children’s views should be systematically included in sexuality education and information policy and programming, and in service provision. This study indicated that some relatively young children, perhaps as young as 6 years of age, are engaging in sexual activity and also have many questions which need answering. It is not clear to what extent, if any, adults know how to educate and support these young children in matters of sexuality. The study highlighted that whilst this group does have some access to CSE and other information, this element could be significantly strengthened. There is also a need to take into account if and how to approach siloed issues such as HIV when talking to young children about sexuality. Current theory also considers the teaching of CSE to young children to be a means of preventing the entrenchment of negative attitudes and behaviour in relation to sexuality. However, robust CSE guidelines for this age group are still few. Much more needs to be learned around this group of children, and age-appropriate guidelines for policy, programming and implementation need to be developed. 5. Access to printed and online educational materials which accompany training and education activities are very important to children and adults, and should be well supported and resourced and shared with parents and caregivers. The value of educational and information materials which children and adults can take home, read in private or discuss with family and peers should not be underestimated. All the groups in the study said they wished they had access to more materials, and many parents reported that they found educational books and leaflets to be a good way of educating themselves and talking to their children. Organisations said they did not have enough material to give out. Teachers said that up-to-date ‘computer-based’ materials would be more engaging for children. Additionally, there are significant numbers of children who do seem to have access to online content, most likely through mobile technology. Whilst it may not be realistic or a good investment of resources to install school computers or develop digital materials specifically for school-based CSE, locally adapted sexuality information which children might access online outside of school – and more print materials – are still very relevant and necessary. Materials need to be shared with parents and caregivers so that they can understand in what way the materials are appropriate for their children. 6. The media is a powerful influence in children’s lives in Africa. In particular, the impact and potential of the digital media on children in Africa, both positive and negative, needs to be better understood and incorporated into CSE policy, programming and delivery.

7. Conclusions and recommendations

This study highlighted how pervasive media exposure, including television, the Internet and social media, has become for many children in the region, even those from resource-poor environments. Some children and many adults saw the media as a pernicious force which provides easy access for children to inappropriate content or which reinforces negative stereotypes. There is a clear need to invest more in developing context-specific strategies and programmes which can protect children from direct and indirect harms linked to the media. However, the potential of the media to reach children and other groups with positive CSE and information was also recognised by many study participants. Whilst international and national organisations do already employ different media to reach children and other key audiences around aspects of sexuality and HIV, more research and development needs to be undertaken to identify approaches which can harness the power of the media for African children in the context of sexuality education. 7. Community and religious leaders have the potential to play a key role in influencing and bringing about social change in relation to sexuality issues. CSE programmes should work more closely with these leaders to develop approaches which can foster positive attitudes in the community towards teaching children about sexuality. In recent years we have learned more about social transformation at the community level, including the powerful influence which various â&#x20AC;&#x2DC;informalâ&#x20AC;&#x2122; community and religious leaders have in many communities. We have also learned that initiatives which aim to improve childrenâ&#x20AC;&#x2122;s life skills and knowledge around rights and protection also need to include families and communities, not just the child. The support for CSE from the leaders who took part in this study suggests that more programmes should engage with and target community leaders, especially when addressing what are considered to be negative or harmful practices, attitudes or beliefs. Community leaders who participated in the study signalled that working with other community-level leaders is challenging and needs to be approached with extreme sensitivity and deep local knowledge. Community-based CSE programmes and organisations are often ideally placed to partner with community leaders to develop contextualised approaches to CSE&I. 8. The challenges for children living with HIV, especially those linked to stigma, are not well integrated into sexuality education, information and services. More needs to be learned about how to support this group of children in different contexts and this needs to be translated into policy, programming and capacity building. Children and adults living with or affected by HIV described how stigma was a central concern in many aspects of their lives. There is certainly an ongoing need to continue to address stigma related to HIV by encouraging open conversation with, as well as supplying accurate information to, children and their communities.

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This should include strengthened support for improved and truly child- and youth-friendly sexual and reproductive health services. Community leaders and organisations should play a key role in continued efforts to address stigmatisation and the provision of improved sexual and reproductive health services for children affected by HIV. This is a role that is well suited to local leaders and community organisations which have much influence within their communities. Learning around best practice for stigma reduction should be further explored in collaboration with community leaders and organisations to develop locally appropriate responses and strategies. 9. There is little or no provision for especially vulnerable children in current CSE&I and services. More needs to learned about how to support and educate these vulnerable groups around sexuality education in different African contexts. This learning needs to be incorporated into policy, programming and capacity building at all levels. The voices of especially vulnerable children, including those living with disability, those living on or connected to the street, and children who are out of school, are not often heard. More needs to be done to learn about the specific needs of different groups of especially vulnerable children, and to ensure that these children can access appropriate CSE&I and services. In particular, children with disabilities have been shown to be especially marginalised when it comes to CSE&I programming, with little or no guidance available on how to include them into CSE curricula and programming. Children with disabilities can be more vulnerable to sexual abuse and other rights violations as a result of a lack of access to CSE. The relatively small scale of community-based CSE programming compared to the large numbers of children estimated to be out of school in Africa also means that most out-of-school children probably do not have access to CSE and information beyond what they learn from their families and friends. 10. Common community models of CSE delivery need to be more consistently evaluated and the findings shared and incorporated into policy and programmes. Additionally, much more needs to be learned about especially vulnerable childrenâ&#x20AC;&#x2122;s CSE needs through additional research. Because of the recent and stronger emphasis on adolescent sexual and reproductive health and rights in the Africa region in the last few years, we have now started to build a clearer picture of the priorities and strategies required to improve sexuality education and address HIV. However, despite this, there are still many gaps. Not only could data collection be improved generally, but especially vulnerable groups, including those children who are out of school, children with disabilities, children living with HIV, younger children and children who may be LGBTI â&#x20AC;&#x201C; need

7. Conclusions and recommendations

to be learned about in different contexts, and appropriate policies, strategies, programmes and curricula developed to support them. Additionally, more could be learned about how boys and men could be better integrated into CSE, as well as how mental health links to CSE&I. Finally, we need clearer guidance and a stronger evidence base around which out-of-school or community-based CSE&I programmes are working and why. It is suggested therefore that any future research with children and communities might focus more specifically on these key groups and issues, and that further efforts and resources intended for learning and sharing information about successful out-of-school and community-based CSE models be ramped up.

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Haberland, N. A. (2015). ‘The case for addressing gender and power in sexuality and HIV education: A comprehensive review of evaluation studies’. International Perspectives on Sexual and Reproductive Health, 41(1), 31-42. International Sexuality and HIV Curriculum Working Group (2009). It’s all one curriculum: Guidelines and activities for a unified approach to sexuality, gender, HIV, and human rights education, Vol. 1. N. Haberland and D. Rogow (eds.). Population Council. Regional Psychosocial Support Initiative, UNICEF and Department of Social Development of South Africa (n.d.). Conceptual framework for psychosocial support for orphans and other children made vulnerable by HIV and AIDS, first edition. http://www.dsd.gov.za/Nacca1/index2. php?option=com_docman&task=doc_view&gid=217&Itemid=39 Save the Children Sweden’s Focus Africa HIV/AIDS Group (2007). Tell me more!: Children’s rights and sexuality in the context of HIV/AIDS in Africa. Stockholm: Save the Children Sweden and the Swedish Association for Sexuality Education. Save the Children (2015). Religion and sexuality – a report on faith-based responses to children’s comprehensive sexuality education and information. http://resourcecentre. savethechildren.se/sites/default/files/documents/religion_sexuality.pdf SC CSE&I project outline, mid-term review. Sherr, L., Cluver, L., Tomlinson, M. and Coovadia, H. (2015). ‘Defeating AIDS but missing children’. The Lancet, 386(9998), 1035. Southern African Development Community (2011). Regional conceptual framework for psychosocial support for orphans and other vulnerable children and youth. http://www.sadc.int/files/9913/5293/3501/Regional_Conceptual_Framework-_ psychoscial_support.pdf Temmerman, M., Khosla, R., Bhutta, Z. A. and Bustreo, F. (2015). ‘Towards a new global strategy for women’s, children’s and adolescents’ health’. BMJ 2015, 351:h4414 UNAIDS (2015a). On the fast-track to end HIV and AIDS (2016–2021 strategy). http:// www.unaids.org/sites/default/files/media_asset/20151027_UNAIDS_PCB37_15_18_ EN_rev1.pdf UNAIDS (2015b). Treatment 2015. http://www.unaids.org/en/resources/campaigns/ treatment2015 UNAIDS (2011). A new investment framework for the global HIV response. http:// icssupport.org/wp-content/uploads/2012/02/3-Investment-Framework-SummaryUNAIDS-Issues-Brief.pdf

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UNDP (2012). Understanding and acting on critical enablers and development synergies for strategic investments. http://www.undp.org/content/dam/undp/library/hivaids/ English/UNAIDS_UNDP_Enablers_and_Synergies_ENG.pdf UNESCO (2013). Young people today. Time to act now. Why adolescents and young people need comprehensive sexuality education and sexual and reproductive health services in Eastern and Southern Africa. Summary report. http://www.popline.org/ node/577905#sthash.tUi6RXUH.dpuf UNESCO (2014). Eastern and southern Africa commitment: One year in review – 2013–2014. http://youngpeopletoday.net/wp-content/uploads/2014/12/ ESACommitment-Progress_AnnualReport-DIGITAL.pdf UNESCO and UNFPA (n.d.). ‘Youth and comprehensive sexuality education.’ Fact sheet. http://www.un.org/esa/socdev/documents/youth/fact-sheets/youth-sexualityeducation.pdf UNESCO and UNFPA (2012). Sexuality education: A ten-country review of school curricula in east and southern Africa. UNFPA (2014). Operational guidance for comprehensive sexuality education: A focus on human rights and gender. http://www.unfpa.org/publications/ unfpa-operational-guidance-comprehensive-sexuality-education UNFPA (2015). The evaluation of comprehensive sexuality education programmes: A focus on the gender and empowerment outcomes. http://www.unfpa.org/publications/ evaluation-comprehensive-sexuality-education-programmes UNICEF (2012). Progress for children: A report card on adolescents. Number 10. http:// www.unicef.org/media/files/PFC2012_A_report_card_on_adolescents.pdf UNICEF (2013a). The state of the world’s children 2013: Children with disabilities. http:// www.unicef.org/sowc2013/ UNICEF (2013b). Towards an AIDS-free generation: Children and AIDS sixth stocktaking report. http://www.unaids.org/sites/default/files/media_asset/20131129_stocktaking_ report_children_aids_en_0.pdf UNICEF (2015a). Children and AIDS: 2015 statistical update. http://data.unicef.org/ corecode/uploads/document6/uploaded_pdfs/corecode/2015-Children-Adolescentsand-AIDS-Statistical-Update-Executive-Summary_244.pdf UNICEF (2015b). ‘Social protection programmes contribute to HIV prevention’. Brief. https://transfer.cpc.unc.edu/wp-content/uploads/2015/09/ SocialProtectionHIVBrief_Jan2015.pdf UNICEF (2015c). Synthesis report of the rapid assessment of adolescent and HIV programme context in five countries: Botswana, Cameroon, Jamaica, Swaziland and Zimbabwe. http://www.childrenandaids.org/publication/

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synthesis-report-rapid-assessment-adolescent-and-hiv-programme-context-fivecountries UNICEF (2015d). The state of the world’s children 2015: Reimagine the future. http:// www.unicef.org/publications/index_77998.html UNICEF and EPRI (2015). ‘Social protection programmes contribute to HIV prevention’. HIV-sensitive social protection brief. United Nations (2015). The millennium development goals report. http://www.un.org/ millenniumgoals/2015_MDG_Report/pdf/MDG%202015%20rev%20%28July%201%29. pdf Vogel, J. P., Pileggi-Castro, C., Chandra-Mouli, V., Pileggi, V. N., Souza, J. P., Chou, D. and Say, L. (2015). 'Millennium Development Goal 5 and adolescents: Looking back, moving forward'. Archives of disease in childhood, 100(Suppl 1), S43-S47. doi: 10.1136/archdischild-2013-305514. Wessells, M. (2009). What are we learning about protecting children in the community? An inter-agency review of evidence on community-based child protection mechanisms. London: Save the Children. Wessells, M. G. (2015). 'Bottom-up approaches to strengthening child protection systems: Placing children, families, and communities at the center'. Child Abuse and Neglect, 43, 8-21. WHO (2013). HIV and adolescents: Guidance for HIV testing and counselling and care for adolescents living with HIV: Recommendations for a public health approach and considerations for policy-makers and managers. http://www.youngpeopleandhiv.org/files/ HIV_Testing_guideline.pdf WHO (2014). Health for the world’s adolescents: A second chance in the second decade. Summary. Geneva: WHO. WHO (2015). The global strategy for women’s, children’s and adolescents’ health (2016–2030). http://who.int/life-course/partners/global-strategy/ globalstrategyreport2016-2030-lowres.pdf WHO, UNICEF and UNAIDS (2013). Global update on HIV treatment 2013: Results, impact and opportunities. http://apps.who.int/iris/ bitstream/10665/85326/1/9789241505734_eng.pdf World Vision International and UNICEF (2015). Prevent and protect: Linking the HIV and child protection response to keep children safe, healthy and resilient. http://www. worldvision-institut.de/_downloads/allgemein/CP%20HIV%20Report%20FINAL%20 secure.pdf

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Save the Children International East and Southern Africa Regional Office Pretoria Office 1067 Arcadia Street Hatfield, Pretoria 0028 South Africa Tel: +27 12 342 0222 Fax: +27 12 342 0305 www.savethechildren.net