Penelope Campbell August 2006 ‘Baseline Assessment Informs Establishment of a Mobile Unit providing HIV/AIDS/STI information, skills-based counseling & services to vulnerable adolescents in Jamaica Penelope Campbell August 2006

The “Bashy” Bus

Delivering Adolescent SRH Services

In a non-threatening environment

Overview Jamaica's 2.6 m population experiencing a generalized epidemic Est. prevalence of 1.5% Est. 22,000 persons living with HIV 9,682 reported AIDS Cases (June 2005) 58% male, 42% female Average rate of 372 per 100,000 Over 800 per 100,000 in some parishes (urban and tourist) Predominantly heterosexual transmission (71%)

The Bashy Bus Route S u m m a r y o f A I D S C a s e s b y P a r i s n J a m a i c a 1 9 8 2 - 2 4 (R a t e p e r 1 , P o p . ) The Bashy Bus Route N W E S H a n o v e r T r e l a w n y S t . A n n S t . M a r y W e s t m o r e l a n d P o r t l a n d S t . E l i z a b e t h S t . C a t h e r i n e M a n c h e s t e r C l a r e n d o n S t . T h o m a s AIDS/100,000 Pop. 100 . - 150 150 - 200 . 200 - . 300 300 . - 400 500 - 830

The Challenge Children and adolescents 40% of population Early sex initiation (boys 13 yrs.; girls 15 yrs.) High rate of forced sex (20%) High rate of transactional sex (20%) High rates of multiple sex partners (48% men, 16% women) Adolescent girls 3 times more likely than boys to become HIV infected 50% report sex partner to be 5-10 years older “Sex on the Bus”: risky sex practices between young people and transport operators widespread

“Turning a Negative into a Positive” An alternative “bus service” (along major transport & high prevalence routes) delivering the following services for vulnerable adolescents : SRH education: avoiding STIs, unwanted pregnancies Life skills counselling: relationships, drug abuse Getting help to restart school after pregnancy Access to condoms & other contraceptives VCT (rapid testing ) for HIV

“Bashy Bus Kru” – SRH education

Interactive Skits & Cultural Presentations

VCT (rapid) & Clinical Services HIV/STIs

Skills-based Counseling, Condom Access

Programme Objectives By December 2009, 20,000 vulnerable adolescents will have: Increased knowledge about HIV/AIDS and SRH issues Improved risk assessment & sexual decision making skills Increased access to HIV/AIDS/STI services Improved sexual health behaviours & practices Penelope Campbell

Research Objectives Determine adolescents’ interest and preferences in the services and design of the Bus. Build a baseline profile of the targeted adolescents re. their SRH knowledge, attitudes and behaviours Prepare a performance framework for monitoring & evaluation (process & impact)

96 adolescents participated in FGDs Research Design 451 adolescents surveyed (structured interviews) 211 boys (47%) and 240 girls (53%) 96 adolescents participated in FGDs 4 intervention & 3 control communities Findings disaggregated by age, gender & location

Research Findings 74% live with mother; only 33% with father 77% enrolled in school 74% live with mother; only 33% with father 1 in 5 live with neither parent (visiting relationship) 20% rely on neither parent for financial support 78% know where nearest health centre located BUT 59% did not have positive impression Girls & younger adolescents were especially reluctant Boys felt proud accessing services (machismo)

Perceived vs. Real Needs High interest in range of services proposed (70%) – especially 15+ age group … but few (19%) actually sought any of services proposed in past 12 months ‘Real’ needs however were high: 1 in 2 reported having sex: boys (62%) girls (38%) Early sex initiation common: 14.9 yrs for girls & 11.8 yrs for boys 84% “ready for sex”(47% never had sex before) Only 27% had comp. HIV/AIDS knowledge Early interventions with in-school sexually inactive adolescents that fosters age and positive attitudes and behaviours, including to delay sex, should help prevent some of the problems associated with early sexual activity including early pregnancies and disrupted schooling.

Sexually active adolescents: 20% females & 66% males did not use condom at first sex 37% females & 30% males did not use condom at last sex with their main sex partner 1 in 10 reported forced sex (93% did not feel need to ‘get help’ afterwards) 1 in 4 reported multiple sex partners 1 in 5 had sex partner - 5 years or older Ave. age sex partners of girls was 21 yrs compared to 16 yrs for boys 1 in 10 girls are teen mothers (94% unintended; 18% under 16)

Taking services to adolescents Over 80% interested in mobility of service: Bus will allow them to express themselves freely and in privacy ‘Bus workers not from area’, do not know parents However, 30% did not want Bus to visit ‘their corner’ because: Don’t want it to look like ‘dem have AIDS’ People/peers will know ‘their business’ The Bus may be better deployed in central, more ‘neutral’ locations

Adolescents’ expectations of service Top 3 priorities: Building healthy relationships (including with their parents) Condoms & contraceptives HIV testing Most important youth-friendly qualities: RESPECT (90%) Clarity of information (90%) Confidentiality (80%) Participation (80%)

Preferences and Interests Music & Entertainment (skits) Simple IEC materials visual that ‘do not look too educational’ or ‘boring’ Condoms (‘good’, brand) & contraceptives Personal testimonials and… Sanitary pads (girls) Timing: Sundays - because ‘boring’ Weekends - evenings Weekdays - afternoons

Deterring Factors Too many “old, grumpy, grumpy people” Judgmental people; staff with ‘attitude’ Magazines showing ‘nastiness’ like oral sex Any association with homosexuals Should not look overtly educational Negative promotion of safer sex No explicit references to ill health, HIV or AIDS Sex is not bad; it is the negative consequences of unsafe sex which they wish to avoid

Recommendations Establish regular schedule Tailor services to adolescents (gender, age, location) Ensure RESPECT Provide ENTERTAINMENT Visit “neutral” locations rather than corners that young people own Work with non-adolescents (e.g. parents, older men, ‘influentials’) Build capacity of local SRH services to better serve adolescents (as referral sources)

Performance Framework Process: # of visitors per Bus Stop (1st time & repeat) Approval rating (exit interviews) % of follow up visits & referrals fulfilled Outcome (2 years): % with comprehensive HIV knowledge % that knows nearest health centre; % with favourable impression; % uses family planning services there Impact (4 years): Condom use at last sex (regular & non-regular) Age of sexual debut; % insist ‘no condom, no sex’; % with multiple sex partners; % unplanned pregnancy Disaggregated by age, sex & location

Expected Impact (4 yrs.) Increase mean age of sexually debut from 11.8 and 14.8 years for boys and girls respectively to 14 years for boys and 16 years for girls Increase condom use at last sex with a regular partner from 70% to 75% and from 63% to 68% respectively Increase condom use at last sex with non regular partner from 69% to 79% and 50% to 60% respectively

Expected Impact (4 yrs.) Decrease proportion with multiple sex partners in the last 12 months from 82% to 62% for boys and 65% to 45% for girls Increase from 63% to 73% the girls with older sex partners (5+ yrs older) that insist on ‘no condom no sex’ Decrease proportion of girls that became pregnant while in school from 53% to 43%

Acknowledgements Rohan Bell & Angela Stultz, Research Analysis & Associates, Jamaica Claudette Richardson-Pious, staff & young people, Children First, Jamaica Global Fund HIV/AIDS Project, National HIV/AIDS Programme, Ministry of Health, Jamaica

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