Providing reproductive health services to adolescents, especially services that acknowledge sexual activity among those who are unmarried, is often controversial. For adolescents living as refugees, the provision of any type of reproductive health services may be viewed as a luxury in comparison to immediate needs such as shelter, food, water, emergency health care, and physical security. Yet, the refugee situation itself creates an instability in the sexual and reproductive development of teenagers, which can have severe, even life-threatening, consequences.
The removal of adolescents from their homeland culture, and the uncertainties of their present lives, can cause confusion about sexual behaviour. This confusion may lead to activities that place the adolescent at serious risk for sexually transmitted diseases (STDs), unintended pregnancy, unsafe abortion, sexual and gender violence, or pregnancy-related morbidity and mortality. The precarious economic situation of most refugees also increases the chances that adolescents will engage in prostitution as a way of feeding themselves or their families. Adolescents, who typically lack experience and knowledge about how to gain access to family planning services in their home communities, may find access to these services even more limited in a refugee setting, where reproductive health programmes (if they exist at all) are often devoted to the care of pregnant women, or women with young children.
This paper presents two case studies of adolescent refugees now living in Thailand. One study explores the need for services to prevent sexually transmitted diseases, including AIDS, among young men. The second examines the need for pregnancy care, family planning services, and sexuality education among two groups of young women. Both case studies illustrate the fact that the reproductive health needs of adolescents are diverse. The second case study also suggests that the cultural norms of the refugees' homeland can influence their current sexual behaviour. The key conclusion of the report is therefore that it is essential to conduct an initial assessment of adolescents' reproductive health needs on which to base the design of programmes and the delivery of services.
During the past decade, thousands of students, almost all male, have fled Burma (Myanmar) across the Thai border. Many of these young men eventually moved to Bangkok to live without the benefit of legal status or access to official government services. The boredom and the loneliness of living without family and friends often leads to drug abuse and sexual activity with prostitutes, placing these young men at high risk for contracting STDs.
To help these young men survive in their new country, the United Nations High Commissioner for Refugees (UNHCR) offers a variety of social and educational services at the Centre for non-Indochinese, and young male refugees from Burma comprise more than three-quarters of the clients enrolled in this programme. Drug use is a major problem among these young men with more than 10% of them having drug problems and nearly 25% of those with drug problems being heroin addicts. The common sharing of needles among the drug users puts them at risk for AIDS, whilst a second risk factor among this population is sexual activity with prostitutes. Little is known about their use of condoms to prevent STDs, but it is likely that condom use is low.
Given the risk behaviours of this group, staff at the Centre for non-Indochinese have developed several strategies for the delivery of AIDS-prevention messages. One is the provision of AIDS education at the English language school, which is conducted in a separate building but affiliated with the Centre. Many teachers at this school are themselves Burmese refugees who are in the process of repatriation to other countries. This work provides a connection to the larger community that can potentially lower risk factors for HIV infection and drug use.
In addition to education, the Centre provides legal assistance to the refugees who have been suspected of breaking the law and sent to detention centres, and also offers the opportunity for medical services and information, education, and communication (IEC) activities on reproductive health, including AIDS. In summary, the primary reproductive health need of these young, unmarried male refugees is STD/HIV prevention. The Centre has therefore sought opportunities to provide information and services to reduce high-risk behaviour (drug abuse and unprotected sex with prostitutes) through their clinic and through their educational, mental health and legal activities.
This UNHCR camp, located a 90-minute drive from Bangkok, has housed as many as 20,000 Vietnamese and Laotian refugees at one time. In February of 1995, when site visits were made, its residents numbered about 3,000 as the camp prepared to close in June 1995. Two distinct cultural groups have inhabited the camp over its 20-year history: i) the Hmong from Laos, and ii) the lowland Laotians and Vietnamese. The differing characteristics of these two groups had striking implications for the types of reproductive health care needed by adolescents. Service delivery for the two groups was often separate and was usually provided by different NGOs.
The Hmong were characterised as more traditionally patriarchal and less educated than their Vietnamese peers. Polygamy was practised and girls married early in their teens and bore children soon afterwards. Fertility was higher among this group and women were usually unwilling to make family planning decisions without the permission of their husbands. Family planning counselling and services were thus typically provided as part of prenatal and postpartum care and husbands were usually present. The reproductive health needs of adolescents focused primarily on safe pregnancy care. Most women did not practice family planning until after they had achieved their desired family size.
Because of the longevity of the camp, many of the Hmong teenagers had been born in camps and knew little of life outside and much of the 'clan culture' of the Hmong had been maintained inside the camp. Domestic violence was tolerated among this culture, and service providers expressed concern about the difficulty of dealing with this problem. Physical abuse noted by the health workers could be referred to social workers for further investigation.
During the site visit, a discussion was held with a group of Vietnamese and Laotian teenagers ranging from 17 to 20 years of age. The discussion revealed that the adolescents in the Vietnamese group were more likely to be unmarried than the Hmong group. Often they were unaccompanied minors or minors whose parents were either left behind in the country of origin or who had moved on to a new settlement country. Most of the adolescents' reproductive health needs appeared to be educational. Without a parent close by, there were no traditional sources of sex education. Young people often relied on peers or some of the more trusted service providers for their information on pregnancy and STD prevention. There was some acknowledgment of romantic relationships among the boys and girls in this group, but they seemed relatively inexperienced. The most pressing problems discussed were those having to do with money and resettlement. Mostly, the young people were bored, lonely and unhappy, and they wanted to pursue their new lives, wherever that was going to be. The service providers acknowledged that among this group there were some difficulties with unintended pregnancies, STD/AIDS and drug abuse, but these did not seem to be overwhelming problems. (Providers had heard of a higher incidence of illicit abortion in other refugee situations.) STD diagnosis and treatment was generally the responsibility of the International Organization for Migration as part of the testing required for repatriation. Some IEC activities occurred in the refugee camp; these were mostly in the form of posters and signs. These posters motivated adolescents to seek out additional information.
Recommendations for the development of youth-distinct reproductive health care programmes were identified for these three groups of adolescents in the two programmes studied in Thailand. The health needs of these groups and the implications for programme design are discussed briefly below. 'Burmese male refugees needed prevention and treatment programmes as they were at high risk for STD and AIDS because of their drug use and sex with prostitutes.
'Young Hmong women began married life at an early age and began childbearing soon afterwards. They needed prenatal care and access to family planning services.
'Unaccompanied Vietnamese and lowland Laotian adolescents needed information about sex, pregnancy prevention, and STD prevention.
Needs assessment
The differences among these three groups illustrate that programmes for adolescent refugees must take into account cultural norms and current behaviour. A needs assessment is therefore an important part of designing reproductive health programmes for adolescent refugees. The following criteria are suggested for conducting an assessment to determine reproductive health priorities for adolescent refugees.
'The assessment should be conducted with the cooperation of members of the refugee population, especially the potential clients (in this case, adolescents).
'The assessment should be conducted at the level at which services will be delivered.
'A person with some experience in adolescent reproductive health programmes and refugee situations should facilitate the assessment.
nService providers from various NGOs that work with adolescents should be represented. In this way opportunities for collaboration among these groups can be identified.
nService providers should identify adolescents who are 'natural leaders' and capable of participating in this process. These youth could eventually play a role in developing the programme and communicating its benefits to other refugees.
As part of the needs assessment, information should be gathered regarding:
ncultural norms related to sexual relationships and rites of passage into adulthood;
ncurrent adolescent norms/practices/perceptions/attitudes related to sexuality;
ntypical patterns of adult authority over adolescent behaviour within the refugee programme;
n description of services available to adolescents (and those which are restricted) and adolescents' and adults' awareness of availability of services in the camp;
nperceptions of camp service providers about services for adolescents;
nadolescentsn perceptions of their own reproductive health needs.
This information can be gathered through records, interviews and focus group discussion and, possibly, through simple survey techniques. The resources needed for these types of data collection will depend on the record-keeping systems in place and the availability of computers for analysis. Once an assessment of available services and current needs has been conducted, service providers and adolescents can consider programme objectives, outline programme goals, and develop strategies to meet those goals.
A needs assessment does not necessarily require that a separate or specific programme for adolescents be established. The assessment can, however, help determine how the unique needs of adolescents can be met within existing programmes. If possible, some type of ongoing review of the programme should be developed and implemented so that modifications may be made as needed.
The case studies highlighted in this article illustrate the diversity of reproductive health needs among adolescent refugees. An important finding during the site visits was the presence of several 'natural leaders' among all groups, former Burmese students teaching at the English school in Bangkok, Vietnamese students who worked for the UNHCR in Panat Nikhom, and teenage Hmong girls who were responsible for the care of children from several families within the compound. These young individuals were potential collaborators in the development of reproductive health services in refugee situations and could play an important role in conducting needs assessments, gathering information, and implementing and evaluating reproductive health programmes. Programmes designed to meet the needs of adolescent refugees can be strengthened by the involvement of adolescents at all phases of development.
Cindy Waszak is a Senior Research Associate and Beverly Tucker is the Associate Director of Family Health International, Research Triangle Park, North Carolina, NC 27705.
This paper is based on visits made to several refugee programmes in early 1995 to document the needs of adolescents and identify strategies for meeting these needs.
October 1996