Taking Account of Gender

The interplay of sex (biological) and gender (social) fac­tors results in different disease burdens for boys and girls. They are subject to differing norms and inequities in access to resources and power, resulting in different life opportunities. For example, norms that promote virginity in girls before marriage reduce their ability to practice safe sex, through lack of access to information and resources such as condoms, whereas norms that encourage boys in sexual experimentation also increase their expo­sure to infections.

Inequities in power may result in girls being subject to sexual violence, poorer nutrition, and lower participation in physical activity and sports, while boys may face more exposure to violence, such as bully­ing, or the dangers associated with risky activities such as drink-driving (WHO, 1999). In health facilities, young women may face judgmental providers, poor counseling, and breaches of confidentiality, whereas young men may be treated more sympathetically (Tangmunkongvorakul et al, 2005).

These factors should inform the content and target group of an intervention, since they affect male and female adolescents’ ability to participate in activities and use services. Adolescence is a formative period for learning gender roles and expected behaviors regarding the opposite sex, and programs should foster open discus­sions about sexual relationships and gender roles in ways that help both boys and girls to promote and protect their health.

There has been a tendency in programs to focus on girls, who bear heavier consequences of risky sexual beha­viors (WHO, 2004). Interventions should try to find ways to overcome the disadvantages that gender inequities present to adolescents, but, at a more fundamental level, they should also attempt to change the norms and power differentials in relationships that create the disadvantages.

Media campaigns have been used in attempts to change social attitudes. For example, in Malawi radio broadcasts, backed up by weekly contests and a comic book, dealt with the issue of young women becoming sexually involved with older men, ‘sugar daddies’ and teachers. It gave a voice to girls who had resisted pressure for sex from older men, and created role models for other girls, as well as providing opportunities to act as volunteers and peer educators.

Including Disadvantaged Adolescents. Adolescents from the poorest families have the highest health burden, and inequalities of opportunity are fre­quently transmitted across generations. These adolescents may replicate their parents’ poor life-histories unless spe­cially targeted interventions can reach them (World Bank, 2006). Unfortunately, the most vulnerable adolescents can­not be reached through school programs: orphans, homeless and unemployed adolescents, sex workers, adolescents who are disabled, from ethnic minorities, in prison, or stigma­tized by having HIV/AIDS, a drug habit, or a child out of wedlock.

These groups require carefully targeted programs through diverse, specialized providers. Such programs may be more expensive to run than mainstream programs, and it can be difficult to convince policy makers that these vul­nerable groups deserve attention.

For adolescents who have made poor health choices, or not benefited from preventive health programs, it is important to provide services that help them minimize the adverse consequences of, and recover from, their mis­takes, in effect, giving them ‘a second chance’ to become healthy and productive adults.

Providing treatment for sexually transmitted infections, emergency contraception and legal abortion services, harm reduction programs for drug users, and schooling and health care for unmarried mothers are examples of cost-effective approaches that have long-term benefits for the adolescents affected and for society as a whole, in terms of reduced expenditures on curative care, prevalence of infectious disease, and other effects on welfare and security.

Using Theory. Theories can help the program designer understand what they need to know before designing an intervention, can help to choose program strategies that are likely to be effective, and can identify what should be monitored and how the intervention should be evaluated. Theories have been developed that are applicable at each of the etiolog­ical levels listed earlier in the article. The theories then need to be translated into practice.

For example, a school- based AIDS prevention intervention in South Africa aimed to delay the initiation of intercourse, using theory about the determinants of sexual activity and the various behaviors that affect this outcome. The determinants included knowledge, social influence, self-efficacy, and barriers to change, such as exposure to violence, and behaviors such as avoiding risky situations, saying ‘no’ to intercourse, and negotiation of alternative sexual prac­tices (Aaro, 2006). These determinants and behaviors then need to be operationalized and measured before and after the intervention, in order to evaluate their effectiveness.