Evaluation of a Peer-Based Sexual Health Education Program in Quito, Ecuador

Emily Nagler

April 24, 2018

Ecuador is a socially conservative and predominantly Catholic nation, with the second-highest teenage pregnancy rate in Latin America and a climbing rate of sexually transmitted infections (STIs). Abortion is criminalized, which contributes to high rates of clandestine abortions that cause female morbidity and mortality. Because of this, President Lenin Moreno mandated in May 2017 that sexual health education in public schools be medically accurate and without ideological influence, though he has yet to enforce this policy. The Ecuadorian government has made many strides to improve health in recent years; however, it continues to fall short in promoting sexual and reproductive health. Non-governmental organizations (NGOs), such as El Centro Médico de Orientación y Planificación Familiar/The Family Planning and Counseling Clinic (CEMOPLAF), work to fill these gaps by improving access to reproductive healthcare and education. The CEMOPLAF Adolescenteprogram educates adolescents and trains Youth Health Promoters (Promotores) to share sexual health information and distribute contraceptives to their peers. CEMOPLAF also works to promote the discussion of adolescent sexual health through their online resource, Mucha Nota. 

In the present study, we surveyed and interviewed Promotores in four different CEMOPLAF centers throughout the city of Quito, Ecuador to determine their attitudes towards this program. Participants revealed that the program is beneficial to adolescents who cannot come to a center themselves and are unwilling to speak to adults about sexual health. From our observations, we recommend that CEMOPLAF should continue expanding to more schools and leading interactive workshops with Promotores. Furthermore, we suggest the addition of an interactive forum to Mucha Nota and implementation of a pre- and post-program test to evaluate the knowledge gained by Promotores. Future research should analyze teenage pregnancy and STI rates by neighborhood in Quito to quantify the benefits of CEMOPLAF Adolescente.

Background

Sexual and Reproductive Health in Ecuador

Although the Ecuadorian Constitution proclaimed sexual and reproductive health a human right to all in 1998, gender inequality and stigma against sexuality persist. In 2008, the president of Ecuador, Lenin Moreno, amended the Constitution to recognize life from the moment of conception, reaffirming the criminalization of abortion. About 65% of Ecuadorians support decriminalizing abortion, although 75% of citizens self-identify as Catholic, a faith that is traditionally anti-abortion.1Despite these reported attitudes, promotion of family planning remains controversial and contentious. 

Partially due to limited access to contraceptives, teenage pregnancy rates in Ecuador are the second highest in all of Latin America, where 29,000 teenage girls gave birth in 2014.1This lack of readily available contraceptives mainly impacts young, poor and indigenous women. Due to legal restictions, abortions are often performed in unsafe, clandestine conditions. Complications from these underground abortions are the leading cause of female morbidity in Ecuador, and a significant cause of maternal mortality.2Lack of access to contraceptives and safe abortion is particularly detrimental to the health of women facing sexual violence, which is highly prevalent: of women over 15 years old, 38% have experienced physical and/or sexual violence from an intimate partner at least once in their lifetimes.3

In effort to rectify poor sexual health outcomes in Ecuador, President Lenin Moreno mandated in May 2017 that sexual health education in public schools be medically accurate and without ideological influence. This policy has not yet been implemented, and does not coincide with any current governmental plans to improve sexual and reproductive health throughout the country. To redress this inaction, non-governmental organizations (NGOs) must take on a larger role to provide comprehensive sexual health education.

CEMOPLAF History

CEMOPLAF (El Centro Médico de Orientación y Planificación Familiar/The Family Planning and Counseling Clinic) was established in Quito, Ecuador in 1978. Today there are 26 CEMOPLAF centers in 11 provinces of Ecuador, staffed by 342 people.4The NGO’s main objectives are to raise awareness about sexual health issues and provide health services to marginalized populations, particularly mothers, youth, and families in underserved rural and urban areas. Currently, 25% of CEMOPLAF services are provided to youth under 19 years old and 51% of services are provided to adults under 25 years old.4CEMOPLAF services include low-cost basic healthcare screenings, gynecological services, psychological services, and more. Women comprise 90% of clients, while family planning and gynecology comprise 57% of provided services.4

In 1995, CEMOPLAF launched the CEMOPLAF Adolescente program for local teens. In this program, professional educators work with adolescents to improve knowledge of sexual health and lower STI and teen pregnancy rates. This program also trains Youth Health Promoters (Promotores), ages 10-19, to share sexual health information with their peers, thereby improving access to information among adolescents. Some Promotores are trained to distribute contraceptive methods to adolescents, including male condoms and the emergency contraceptive pill. This program operates in 18 CEMOPLAF centers, with 480 Promotores trained thus far. In 2017, CEMOPLAF launched Mucha Nota: a website, Facebook page, and YouTube channel that provide sexual health information for adolescents and parents online.

Statement of Purpose & Hypothesis

The purpose of this study is to determine how CEMOPLAF Adolescente can better meet the needs of adolescents in the city of Quito. It aims to explore which strategies would make peer-based sexual health education efforts more likely to succeed, or whether professional-led programs are more beneficial. We hypothesize that Promotores trust the staff and enjoy their time at CEMOPLAF, but that many face pushback from skeptical peers and family members. We thus predict that adolescents prefer peer-based to professional-led education.

Methodology

This project received ethical approval from the Institutional Review Board at Duke University in Durham, North Carolina. The research participants are 33 Promotores ages 13-22, who voluntarily visit CEMOPLAF once a week for workshops and trainings. They live in four different neighborhoods in Quito and attend workshops at four different CEMOPLAF centers: Comité del Pueblo, Cuero y Caicedo (17 out of the 33 participants), El Inca, and Chillogallo. Those who had been in the program for less than a month were excluded, as were friends or partners who attended workshops inconsistently. CEMOPLAF Adolescente staff helped determine which students attended workshops frequently enough (once a week for more than a month or at least twice a month for more than two months) to qualify for the study. Of the Promotores surveyed, 7 self-identified as male and 25 as female.

Those who qualified for the study and gave verbal consent to participate were asked to fill out a 21-question survey. Some volunteered to participate in 5-10 minute interviews guided by 13 main questions. Due to the overlap in responses to these tools, the findings are reported together. 

Since Promotores are not required to come to CEMOPLAF, attendance varies day-to-day within each center. Over the course of two weeks, they were asked to complete this survey when they arrived at CEMOPLAF before engaging in any activities. Before completing the survey, participants were read the consent script, were offered the chance to ask questions, and received a contact card. If they agreed to the interview, participants were taken to a quieter area of the room or separate room to discuss the adolescent program for 5-10 minutes. After administering 33 surveys and 9 interviews, trends among all responses were analyzed. The interviews were translated from Spanish to English for our purposes. 

Results

Before CEMOPLAF

Before coming to CEMOPLAF, 65.6% of participants had never spoken with a counselor, health professional, or teacher about sexual health. The rest had spoken with siblings, other Promotores, professionals, or CEMOPLAF staff who had led workshops in their high schools. They had discussed sexuality, bodily changes that occur during adolescence, and how to protect themselves against STIs, HIV/AIDS, and/or unplanned pregnancy. As shown in Figure 1, 71.9% of participants heard about CEMOPLAF at their high school (many through CEMOPLAF’s presentations), 12.5% from family members (mainly parents and siblings), 12.5% from friends, and 3.1% on the Internet.

When asked about why they first decided to come to CEMOPLAF, 41.2% of participants said they had a sexual-health-related concern, 32.4% at a friend’s suggestion, 20.6% due to non-parental family member’s suggestion, and 5.9% prompted by parental suggestion. Seven students provided alternative reasons for coming, including: CEMOPLAF had come to their high school and the program seemed interesting, they believed it was important to learn about sexual health, and they wanted to know more about these topics.

Figure 1: Where did you hear about CEMOPLAF?

Typical Promotor Involvement

Interviewees emphasized that many Promotores had friends, partners, or siblings already in the program that encouraged or inspired them to join and that many others were interested after attending CEMOPLAF talks in their schools. During a typical month, Promotores came to CEMOPLAF anywhere from once a week to once a month, depending on their availability. Once school ended for summer vacation, many choose to spend time at the centers beyond scheduled workshop days, some coming up to 4 days per week for several weeks. Through workshops, they learned about topics such as STIs, how to put on a male and female condom, proper use of other contraceptive options (such as injections, implants, the patch, IUDs, the emergency contraceptive pill, and the 21 and 28-day pills), how to react to a friend who says she wants an abortion, Ecuador’s specific abortion policies, and the importance of pap smears, self-esteem, communication, and related information. They also learned to how to share information with others, such as classmates, friends, and family members, focusing on helping those who are unable to come into CEMOPLAF themselves. Some learned how to “counsel” friends who need contraceptives, and are trained to give out condoms, emergency contraceptive pills, or referrals for injections, along with all necessary information about the contraceptive method. 

Curriculum Gaps, Likes and Dislikes

Since the participants had been attending workshops for different amounts of time, ranging from several weeks to over five years, individual levels of sexual health knowledge varied. Some students (4) reported that they did not have questions about any topics, while others wanted to learn more about abortion (1), pregnancy (2), STIs (5), sexuality (1), menstruation (1), contraceptive methods (4), and sexual/gender identity (1).

Participants enjoyed the structure, topics, and social aspect of the program, as well as  how the teachers explained complex topics, the dynamic activities and interactive demonstrations, and the conversations in which they could participate and ask questions. Their favorite topics were contraceptive methods and how to avoid STIs and teenage pregnancy. They also appreciated that the program allowed them to meet other types of people and teens from other centers, who they would not know otherwise, to discuss their issues with people of similar ages. They enjoyed CEMOPLAF social events, especially the annual 3-day national retreat with Promotores from around the country. 

Fifteen Promotores responded that they liked “everything” in the program. Others mentioned that they did not like “when we mess up or make mistakes during a workshop or chat,” “that there are not enough boys in the program,” “when there are just lectures and we do not get to interact as much,” “the short time” spent in the centers, “when we don’t do anything,” and “when the workshops are confusing and hard to understand.” 

Adolescents’ Sentiments on Communicating About Sexuality

Twenty-three participants said the only external resource they use for information on sexual health is Mucha Nota (Figure 2). Others ask friends (1), family (6), learn in school (6), or use magazines/books (1). Every participant would invite a friend to CEMOPLAF, and the majority felt neutral, a little comfortable, or very comfortable sharing the information they learn with peers and family (Figure 3). One Promotor reported: “My friends think it’s a little funny, but my family likes [that I go to CEMOPLAF] since my mom and aunt don’t have a lot of time to explain things about sexual health to me.” 

Figure 2: Where do you go for sexual health information?

All participants felt that their communities benefit from CEMOPLAF Adolescente. Their families and friends were generally supportive of their participation, though some had initially been hesitant to let them join the program. Participants speak most frequently about sexual health with friends and siblings, and speak more frequently with their mothers than fathers. Teachers and guidance counselors serve as a resource for a few of the respondents, but always infrequently (Figure 4). 

Figure 3: How comfortable do you feel sharing sexual health information with friends and family?


Many interviewees expressed that it was difficult to discuss sexual health with their parents, many of whom are “traditional” and do not want to discuss it. It was evident that many teens felt uncomfortable bringing up these topics with their older, socially conservative and Catholic parents as well as their cousins, siblings, or friends who typically do not have the knowledge to provide useful advice. Adolescents often lacked the trust to speak with teachers, felt their guidance counselors only want to discuss mental health, and thought their doctors only want to discuss disease prevention. Therefore, they often turned to online resources, where Mucha Nota, the center’s website, is valuable. Though many expressed a strong desire to communicate better with their parents and family members, they did not know how to improve communication.

Figure 4: How frequently do you speak to different people about sexual health topics?

Promotores’ Suggestions

Twenty-two Promotores offered suggestions to improve the program, including that the program should expand to more schools, help more teens, become better known, and continue incentivizing schools and students to participate in the program. Others wanted to meet with Promotores from other centers more frequently, have longer workshops, spend more time at CEMOPLAF (more than once per week), review the advanced activities, and create a mascot or logo for CEMOPLAF Adolescente.

Some offered suggestions to improve CEMOPLAF’s online presence. They agreed that Mucha Nota does a great job serving its purpose: it a comprehensive resource that is especially valuable to adolescents who are too embarrassed to ask adults about sexual health or who cannot come into CEMOPLAF. Some suggested that it should become more interactive, serving as a forum where adolescents could post their questions, professionals could respond, and everyone who visited the page could see the answers and post concerns and follow-up questions.

Discussion

Recommendations for CEMOPLAF Adolescente

Based on this data and our observations of CEMOPLAF Adolescente, we have developed several recommendations for the program. CEMOPLAF should encourage more adolescents to join the program, especially by leading workshops in more schools. They should focus on expanding the program into schools that are farther from CEMOPLAF centers. Since school presentations appeared to be the most effective way of recruiting adolescents, expanding the range of schools will spread awareness of the services CEMOPLAF offers and recruit more Promotores.

CEMOPLAF Adolescente should improve options for students who cannot visit every week. This includes expanding Mucha Nota to create an interactive forum, so that students can participate in conversations about sexual health without being in-person at a center. This would reduce the workload of CEMOPLAF doctors and counselors: since all users would be able to view all question threads, CEMOPLAF staff would have to respond to fewer personal questions through the existing “chat” mechanism. CEMOPLAF Adolescente should ensure that workshops remain productive, interactive, and interesting for students at various knowledge levels. Workshops should emphasize strategies to improve communication with parents, teachers, family members, doctors, and guidance counselors.

CEMOPLAF Adolescente should also implement a pre- and post-assessment to ensure that Promotores retain the most important parts of the curriculum. Every Promotor would take this assessment upon entering the program to evaluate existing knowledge and avoid re-learning information. Before being allowed to counsel peers and distribute contraceptive methods, Promotores would retake this test to ensure they were adequately prepared to teach.

Limitations

Although we read the consent script to each Promotor and they all expressed verbal understanding of its contents before beginning the survey, some factors may have impacted their responses. Due to the confined setting, we were unable to separate some Promotores while filling out their responses, so they likely heard others’ ideas. Although we were present and ready to answer questions, some preferred to ask the CEMOPLAF Adolescente staff for help with the survey, which may have influenced responses.

We hoped that our role as foreign interns would encourage the Promotores to be more honest when critiquing the program than they would be with regular staff members. However, it is possible that the Promotores did not want to give us honest and extensive critiques since they knew we would be discussing their responses in the United States (where much of the program’s funding comes from). We also could not guarantee that every response remained fully anonymous since some Promotores filled out the survey alone (when no one else had visited the center that day), so they knew we could look at the survey immediately after and identify that it was theirs. To address this issue,  we assured them we would wait to review the surveys in aggregate. Additionally, since we used a convenience sample of only 33 eligible Promotores who volunteered, this data is not generalizable to all adolescent populations in Ecuador receiving CEMOPLAF services.

Implications and Future Research

Although this data is specific to the CEMOPLAF Adolescente program, it has relevant implications for other sexual health education initiatives. This study supports prior observations that adolescents prefer to discuss sexual health with their peers, and that many are more likely to consult friends, siblings, or the Internet than they are to consult books, parents, teachers, or guidance counselors. Sexual health education programs for adolescents should include peer-based initiatives, such as CEMOPLAF’s Promotores program, which allows adolescents to discuss issues with people of similar ages, meet new people, and create social spaces in which sexuality is not stigmatized. In areas where contraceptives are inaccessible or expensive, these programs improve access for adolescents who lack other means to acquire them. Peer-based initiatives also encourage referrals to reproductive healthcare clinics for adolescents who may otherwise be too embarrassed or afraid to visit on their own.

Future studies should evaluate and quantify the impacts of the CEMOPLAF Adolescente program and the benefits of Promotores within their communities. They should compare rates of STIs and teen pregnancies in neighborhoods in Ecuador that do and do not have CEMOPLAF centers, and more specifically compare neighborhoods that do and do not have CEMOPLAF Adolescente and/or Promotores. In addition, obtaining the perspectives of adolescents’ parents would improve centers’ understanding of what parents want their children to gain from sexual health education programs. Such studies would provide a stronger basis to increase funding for CEMOPLAF and promote their expansion into more communities in Ecuador.

References

  1. Guidi, R. (2015). As Pope Francis visits Ecuador, women there say they’re losing ground[online]. Public Radio International. Available at: https://www.pri.org/stories/2015-07-04/pope-francis-visits-ecuador-women-there-say-theyre-losing-ground
  2. Human Rights Watch (2013). Rape Victims as Criminals. Illegal Abortion after Rape in Ecuador[online]. Human Rights Watch. Available at:  https://www.hrw.org/report/2013/08/23/rape-victims-criminals/illegal-abortion-after-rape-ecuador
  3. UN Women (2016). Ecuador: Prevalence Data on Different Forms of Violence against Women[online]. UN Women Global Database on Violence against Women. Available at: http://evaw-global-database.unwomen.org/en/countries/americas/ecuador#1
  4. CEMOPLAF (2017). Sexual and Reproductive Health NGO- CEMOPLAF. 

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