A “ Youth M ulti-function Centre ” in the Free State : An alternative to clinic-based HIV / AIDS prevention and care

The youth are especially vulnerable to the HIV/AIDS epi­ demic in South Africa. In the Free State (second highest incidence o f H IV /A ID S am ong the prov inces), the Welkom-Goldfields area may for various reasons be sin­ gled out as a high risk area for HIV/AIDS which should receive priority attention in attempts to combat the dis­ ease. It is suggested that a Youth Multi-function Centre would place youth reproductive health care in the broader development and life skills arena where it could be thought to rightfully belong. The objectives of the paper are to depict the rationale for a Youth Multi-function Cen­ tre, to broadly conceptualise a Youth Multi-function Cen­ tre, and to report on the process and methodology fol­ lowed in an attempt to actually establish such a centre in Thabong/Welkom. Abstrak In die loop van die MIV/VIGS epidemie in Suid Afrika is die jeug besonder kwesbaar. In die Vrystaat (tweede hoogste MIV/VIGS insidensie onder die provinsies) kan die Welkom Goudveld area vir ‘n verskeidenheid redes as ‘n hoë-risiko area uitgesonder word en behoort hierdie area in die stryd teen die epidemie prioriteit te geniet. Dit w ord aan die hand gedoen dat jeu g reproduktiew e gesondheid deur ‘n Jeug M ulti-funksie Sentrum in die breër arena van ontw ikkeling en lew ensvaardighede geplaas sal word daar waar dit na regte behoort. Die oogmerke van die artikel is om die rasionaal vir ‘n Jeug M u lti-fu n k sie S en trum te v e rd u id e lik en ‘n breë konseptualisering van ‘n Jeug Multi-funksie Sentrum uit te voer, asook om verslag te doen van die proses en die metodologie om so ‘n sentrum in Thabong/Welkom te vestig.


Introduction
More than half o f the w orld's population is under 25 years of age, and most o f the w orld's youth -more than 80 percentlive in developing countries.Around the world a significant num ber o f adolescents are sexually active at an early age, with an increasing proportion of this activity occurring out side marriage.In South Africa, HIV/AIDS has affected young men and women more directly than any other age cohort (Na tional Youth Commission 1997).Antenatal clinic attendance statistics for South Africa for the period 1995 to 1999 indi cate the highest prevalence o f HIV amongst women 20 to 24 years and 25 to 29 years of age (1999 = >25 percent) (Williams et al. 2000:307).For the period 1997 to 1998 the highest rate of increase has been observed in women younger than 2 0 years (65,4 percent) (Adler & Qulo 1999:304).
In 1998 a group of researchers, primary health care (PHC) practitioners and non-governmental organisation (NGO) staff in the Free State formed a study group, the Youth M ulti-function Centre (YM C) Taskgroup, based at the Centre for Health Systems Research & Development (University o f the Free State), to examine youth reproductive health care and the role played by PHC clinics in combating HIV/AIDS among young people in the province.The YMC Taskgroup came to the re alisation that public PHC services, for various reasons, are relatively ineffectual (in the sense o f not reaching the youth) in rendering effective reproductive health services (education and care) to young people, and adolescents in particular.
The concept o f a youth multi-function centre with an effec tive reproductive health service emanates in main from three observations: (i) the youth are particularly susceptible to HIV/ AIDS; (ii) socio-cultural and socio-economic factors predis pose the majority o f the youth in South Africa to HIV/AIDS; and (iii) public health policy in South Africa fails to effec tively single out the youth as far as HIV/AIDS prevention and care are concerned.The YMC Taskgroup believes that a youth multi-funtion centre could go far in reaching the youth with appropriate reproductive information and care amidst

Youth' s special vulnerability to HIV/AIDS
T h e J o in t U n ite d N a tio n s P ro g ra m m e on H IV /A ID S (UNAIDS) chose to carry out its 1998 World AIDS Cam paign for, and with, young people -and did so for three rea sons: "One is the special vulnerability o f young people to the epidemic.O f all those infected after infancy, at least h a lf are young people under 25.A nother reason is that young people aged 10-24 account fo r more than 30% o f all people in the developing world where the epidemic is concentrated... M ost important, working with young people m akes sense because they are a fo rce fo r change.They are still at the stage o f experim entation and can learn more easily than adults to make their behaviour safe or to adopt safe practices from the start" (UNAIDS 1998).
Young women have both a biological and a socio-economic vulnerability to HIV infection.According to Taylor (1999:54), the efficiency o f transmission from men to women is thought to be seven times greater than from women to men in South Africa.Specifically, younger women are at even greater bio logical risk -their physiologically immature cervix and scant vaginal secretions put up less o f a barrier to HIV.Tearing and bleeding during intercourse, whether from "rough" sex or rape, multiplies the risk o f HIV infection.Also, sexually transm it ted diseases (STDs) in women more often go unrecognised because sores or other signs are absent or hard to see.In fact, between half and four fifths of STD cases in women are un recognised (Avert 1999:2).
Young wom en's greater socio-economic vulnerability to HIV/ AIDS stems from them often lacking economic resources of their own or being fearful of abandonment or violence on the part of their male partners.Also they have less control over how and when to have sex, and hence, over their risk o f be coming infected with HIV.M ale dom ination characterises value systems and behaviour patterns in much of South A f rica.Girls are also socialised to leave initiative and decision making in sex to men.Males are expected to dominate and there is often tolerance for male predatory and violent sexual behaviour.Male infidelity is allowed or even tacitly expected, while women are blamed or thrown out.In developing com munities young women often heavily rely on "sugar daddies" and sporadic or permanent prostitution.
A breakdown in tradition and formal culture is taking place in South Africa.According to Craig & Richter-Strydom (in Kunene 1995:49), because of a breakdown in traditional family lifestyles, African teenagers are nowadays very rarely edu cated in reproductive matters within their family contexts.
Traditional mores and structures such as rituals of initiation into adulthood until recently existed as systems o f education on sexuality in many cultures.Today, however, many of these practices have disappeared in the wake o f modernity, leaving nothing in their place to educate adolescents about their sexu ality.
Another major issue regarding adults in relation to youth re productive health, is that parents often believe that sex edu cation leads to earlier or increased sexual activity among ado lescents.A World Health Organisation (W HO) review o f pro grammes around the world, recently updated by UNAIDS (1998), revealed the contrary.The review showed that: ■ Life skills needed for responsible and safe behaviour can be learned ■ Good-quality educational programmes help delay first intercourse and protect sexually-active young people ■ Sex education encourages safer sexual behaviour ■ Even where there had been little impact on condom use, programmes have led to a delay in the age o f first sex The reproductive health needs and problems o f young people in Southern Africa are embedded in the socio-cultural, eco nomic and political settings in which they grow up.Recogni tion o f young people as a unique group can help minimise the problems and meet their total needs.Problems relating to re productive health impact negatively on young people's devel opment and welfare.These problems pose a daunting chal lenge to such service providers as nurses, community lead ers, teachers, parents and young people themselves.

Reproductive health policy failing to single out the youth
There are many ways of defining reproductive health.Differ ent definitions and priorities are being proposed by HIV/AIDS activists, w om en's health advocates and family planning or ganisations.Generally, good reproductive health should in clude freedom from risk of sexual diseases, the right to regu late one's own fertility with full knowledge of contraceptive choices, and the ability to control sexuality without being dis criminated against because o f age, marital status, income, or similar considerations (International Conference on Popula tion and Development 1994).Achieving such goals will re quire any facility to wisely use scarce resources, which may include ways to integrate different reproductive services.For example, STD/HIV/AIDS, family planning programmes and other reproductive health projects may share certain services, such as maintaining a central file of patient records.Im por tant is that the client needs and culture o f each community be considered."To look at reproductive health means looking at all aspects o f people's lives" (Hardee in Keller 1995:22).The Beyond Awareness Campaign has indicated that it is possible to apply an integrated HIV/AIDS strategy at national, pro vincial, regional or local level: "Every situation requires ac tive research, clear goals and objectives and includes consid eration o f resources that will support activities.Each level of strategy and intervention requires a related strategy for com munication and evaluation" (Parker et al. 1998: 15).
While the high-tech orientated health system of the past is supposedly shifting towards a person orientated PHC care system, progress in fully integrating the vertical and frag mented family planning services of the past into PHC, is slow.Progress is being ham pered by the arduous task o f develop ing a solid district health system with community participa tion as prerequisite.Inequity in access to effective MCWH (Mother, child and women health) exists particularly in pre viously disadvantaged rural areas, as well as in many highdensity urban and peri-urban areas and informal settlements (U nited Nations Population Fund 1998:49).A ccording to CASE (in H S T Update 1999:5) alm ost all young white (95 percent) and Indian (93 percent) persons are able to access health care within 30 minutes, whilst only 61 percent and 84 percent o f respectively African and coloured young people can do so.
Although it appears as though the necessary structures fo r STD treatment and comprehensive reproductive health care have already been implemented in South Africa, the practi cal limitations hampering their proper functioning, are still numerous (National STD/HIV/AIDS Review 1997:7).One o f these hampering factors is the lack o f properly trained coun sellors.Kunene (1995:49) established that health workers are to act as counsellors to adolescents, but that no proper m oni toring mechanism exists fo r the supervision o f counsellors to ensure that adequate services are rendered.Some counsel lors receive very limited training with no follow -up supervi sion whatsoever.
Obstructive, judgm ental and m oralising attitudes am ongst health workers also influence the health-seeking behaviour of teenagers (Fuglesang 1997(Fuglesang :1245-54)-54).Some health work ers refuse adolescents contraceptives fearing that this could encourage pre-marital sexual relationships (Kunene 1995:49).In a study amongst teenagers in Northern Province, teenag ers voiced discontent with health workers' judgm ental atti tudes regarding adolescent sexuality (Wood et al. 1997).This study noted that one o f the most problematic aspects o f clinic attendance for teenagers was that nurses would not provide condoms before asking questions about their sexual relations and lecturing them on being too young to have sex.
The South African Demographic and Health Survey of 1998 has shown that South African women experience first sexual intercourse at a median age o f eighteen years, while at an even younger age for rural women.By the age of nineteen years 35 percent o f all teenagers have been pregnant or have had a child (South African Demographic and Health Survey 1999:27).
Studies have also shown that the health seeking behaviour of adolescents in relation to STDs differ substantially from that o f adults (Fortenberry 1997; W HO Press Release.1998:1).Teenagers, and especially teenage women, tend to delay health seeking for STDs longer than adults.In fact, the tendency to delay seeking of health care partially explains the high rates o f STDs among adolescents.However, it is acknowledged that the so-called "procrastination" interval may often be ascribed to factors that are not always in young people's control, par ticularly lack o f access to ("youth-appropriate") health serv ices.
It is therefore proposed that the reproductive health needs of adults and youths cannot be optimally fulfilled underneath the same roof.At least in high incidence, urban settings unique reproductive health facilities catering exclusively and appro priately for the youth are a necessity.
M otivating for a Youth M ulti function Centre in Thabong/ Welkom W hy a Youth M u lti-fu n c tio n Centre?
[T]he H IV/AID S pandem ic has helped us to realise the ef fe c ts o f using a disease profile in crafting health care re sponses.Within the South African context, the 'single dis ease approach ' will not be particularly helpful in addressing the health needs o f the youth.Instead a broad based strategy reflecting a partnership between all relevant sectors would be a logical approach in addressing youth health, irrespec tive o f prevailing diseases."Avert (1999a:2) expounds the idea of a youth multi-function service: "The kind o f services that are fo u n d m ost acceptable and appropriate by young people are those that offer a range o f integrated services, are accessible at evenings and weekends, are close to public trans port, have an appropriate image and atmosphere, and have approachable, non-judgmental and reassuring staff." PPASA (Planned Parenthood Association of South Africa), who cur rently follows a health model in the provision o f youth serv ices, also expounds the idea o f a more comprehensive model for the future: "There is only so much a health model can do, and we need to move fu rth er particularly i f we are to reach the ones who are most vulnerable -those who are out o f school ... Bv getting youth who are not in school to come along to the centre fo r recreational activities or to learn a new skill, they can then be pulled in fo r health services and education on reproductive hea lth "{Strachan 1999:8).
According to M cN air & Brown (1996:347), an adolescent health service, under youth friendly circumstances, could go a long way in providing an effective, as well as exciting, new alternative to conventional health services.For many teenag ers requiring confidential management o f sexual health m at ters, the conventional system o f health care provision and counselling is inappropriate.With obstacles such as time con straints, high patient loads and the complexity of patient prob lems already blocking the way towards ideal levels o f service provision, health care personnel are obviously not favourably equipped to deal with the very sensitive needs and questions teenagers might come up with.Kunene (1995:50) (1999) conducted an assessm ent of quality of care for STDs in the Kopano district which showed that STD control in the W elkom/Thabong area is lacking in a great many respects.
After KwaZulu-Natal (32,5 percent), the Free State (27,9 per cent) currently has the highest HIV prevalence for women attending antenatal clinics of the nine provinces in South Africa (Department of Health 2000: 14).Within the Free State, Region C in 1997 had the highest HIV prevalence amongst antenatal clinic attendants of the six health regions in the province (Region C -26,6 percent; Region E -25,8 percent; Region D -17,7 percent; Region A -17,6 percent; Region F -17,5 percent) (Department of Health 1998: 12-14).Only three regions in KwaZulu-Natal (Empangeni, Ulundi/Vryheid and Durban) had higher prevalence rates than the Tshepano Region.O f all the health regions in South Africa, Tshepano had the fifth highest HIV infection rate am ongst pregnant women making use of public health care.These statistics are all the more worrying considering that antenatal surveys might underestimate the overall HIV prevalence rate in a target popu lation as confirmed in recent studies in Uganda (Gray et al. 1998: 98-103).

Methodology
The project, which is ongoing, has thus far comprised four major activities: (i) literature study, (ii) study visits to exist ing youth centres, (iii) consultation w ith stakeholders in Thabong/W elkom, and (iv) establishment of structures to en sure the continuance o f the initiative.The literature study, stu d y v isits to e x is tin g y o u th c e n tre s , and a firs t conceptualisation of the envisaged Centre have been published by the Centre for Health Systems Research & Development in a research report: Combating HIV/AIDS amongst youth in South Africa: A Youth M ulti-function Centre fo r Thabong Welkom in the Free State province, which is being used in a concerted effort to raise funds for the establishment of the Centre.This document has also been used as a basic working document during a protracted series of consultation sessions with the youth, civil society, and local government organs in the target community, as well as the provincial governm ent1.

Conceptualising the Youth M ulti-function Centre
The research, study visits and consultation process have lead to the following conceptualisation of the Thabong/W elkom Youth M ulti-function Centre: " Id e n tity" of the Youth M u lti-fu n ctio n C entre All interest groups consulted felt that the Centre should be non-partisan in terms o f its political, ethnic, religious and gender characteristics.This was seen to be crucial if the Cen tre were to be perceived as a place where youth (from any background) are welcome.The Centre should also not have a "governm ent" or "local authority" identity or be seen as an institution driven by any particular organisation.
A very im portant consideration is that the Centre should also not be one-sidedly or negatively labeled as a "clinic" or a "health centre" .This aspect was em phasised over and again by consulted organisations.It was felt that should the Centre be characterised by concepts such as health, HIV/AIDS or sexuality education, its intended purpose w ould never be achieved.The "multi-function" image of the Centre should characterise its nature, image and marketing.Thus, the origi nal m otivation for the Centre, namely to curb the rapid spread of STDs and HIV amongst the youth, is never to be em pha sised in the way the Centre is established and marketed to the youth.Even within the Centre, the "health room ", should be "tucked away" to the extent that other activities are seen to be more characteristic o f the Centre's nature and purpose.
The Centre should be seen as an independent and locally "owned" establishment encom passing the participation o f a variety of role players in its establishment, functioning and management, and forem ost amongst these the youth and or ganised youth formations.Active youth involvement in the establishment and m anagem ent o f the Centre (not as a form o f tokenism to legitimise it) is an im portant prerequisite and real and sustained involvement should be fostered.This im plies that mechanisms should be put in place for the youth to identify their own needs and preferred strategies for meeting them.Youth program m es should also endeavour to draw out and nurture youth leadership.
Range of activities a t the Youth M u lti fu n ction Centre The " health room " w ithin the Youth M u lti fu n ction Centre Poor accessibility to reproductive health services is one o f the most serious barriers preventing youths from making use of the health care services available to them.Since it is clear that there are a very complex assortment of factors that pre vent youths from seeking reproductive health care, a m ulti faceted approach should be followed.In this regard the Youth M ulti-function Centre provides a num ber of possibilities that might be able to deal with all, or at least with most, o f these shortcomings.Some o f these possibilities are to: > Extend opening hours to include evenings and w eek ends V Discourage/prohibit adults from making use o f the services provided by the Centre 'r Employ health care providers who are youthful and/or have a record of achieving success with the youth > Ensure the possibility o f personal attention (one-onone consultation) to youths visiting the Centre > Provide specialised training to staff members in how to handle the unique reproductive problems o f youths V Promote the fact that the Centre has a preventative as well as a curative function and that youths are free to make use o f both The literature also suggests that successful youth health serv ices have to be both preventative and curative.W hen dealing with sexual matters and prevention strategies, emphasis should fall on harm reduction rather than on a punitive approach.However, if the harm has already been done, health care pro viders should be qualified and able to assist in the curing of ailments.Health care facilities should therefore be able to present a dual service o f prevention and medication/methods to youths at any time.
Given that HIV/AIDS in South Africa is closely linked to the high prevalence o f tuberculosis and STDs, these diseases have to form part o f the scope o f preventative and curative treat ments at a youth reproductive health service.It is especially im portant to treat tuberculosis and STDs early in order to reduce the duration o f the infectious period.U nder aged c h ild re n 's p arents have access to their clinic records Confidentiality in reproductive mat ters will be ensured, even from par ents Adolescents will feel more secure in obtaining information and methods.

Comparison in summary
The growing health needs of young people are to be prioritised and addressed as a m atter of urgency, as it seems that insuffi cient, or perhaps more accurately, misdirected attention is paid to prim ary prevention intervention strategies for youths (Atwood & Donnelly 1993: 219).It has become very clear that something new, that would enable youths to make re sponsible decisions regarding their sexual behaviour, has to be conceived.This will have to be a facility that can ensure unprejudiced, professional and efficient care, in order that the youths who attend it could feel confident, comfortable and safe.Please send your com m ents and suggestions to Christo Heunis -e-m ail h e u n is j@ o p v.u o v s .ac .za /fax 0 5 1 -4 4 8 0 3 7 0 / tel 0 5 1 4 4 8 0 3 7 0 .

Figure 1 :
Figure1: Age prevalence of women attending antenatal clinics found that only 26 percent female and 23 percent male youths in the Western Province made use o f an integrated (adult) health centre, showing the degree of under-utilisation and/or avoid ance of such services.W hy the Free S ta te and Thabong/W elkom ?The population of the Free State province numbers 2,6 mil lion (Development Bank Southern Africa 2000:63), with Re gion C (Tshepano or Welkom region) housing more than a quarter (27 percent -some 750 000 people) o f the provincial population (Centre for Health Systems Research & Develop ment 1996:15).Thabong/W elkom is situated in the Free State Goldfields area, the mining and industrial hub of the prov ince, and also the focal point of m igrant mine workers from other provinces and Lesotho and other Southern African coun tries.According to the National Syphilis Survey of Women A ttend ing Antenatal Clinics of the Public Health Sector in 1998, the Free State had the highest syphilis prevalence among preg nant women o f all nine the provinces (18,4 percent com pared to a national average of 11 percent).The correspond ing figure for Region C in the Free State was 18,2 percent (Department of Health: 1998: 17-19).Recently M ullick et al.
l T h e s tak e h o ld e r g ro u p s co n su lted c an b e g ro u p e d in to six categories: Youth organisations/structures: > A frica n N atio n al C o n g re ss (A N C ) Y outh L eague > A z an ia n Y outh o rg a n isatio n r F rien d s fo r L ife > N ational C o m m unity T h eatre for E ducation and D e v elo pm ent N etw ork r T h a b o n g A rt a n d C u ltu re A sso c ia tio n > T h a b o n g Y outh D e v elo p m en t O rg a n isatio n (T ity C o u n cil (S tan d in g C o m m itte e ) Provincial government departments/divisions: > D e p artm e n t o f H e alth (R e g io n C ) > H IV /A ID S /S T D P ro g ram m e furtherance of the project that have been established and have been engaged in the refinement o f the proposed model and the drawing up of a funding proposal for the establishm ent and first three years o f operation o f the Centre.These structures include a widely representative Steer ing Group, a Board of Trustees and its Executive Committee.

Source: W illiams
et al. 2000:307.20 years and older.Programmes can therefore also be classi fied as for: > Pre-teens (younger than 10 years) >■ Young teenagers (10-14 years) > Teenagers/young people (15 to 19 or 15 to 24 years) > Young people/young adults(25-35 years) With regard to the health room 's preventative function, fam ily planning/STD/HIV/AIDS information, education and com munication (IEC) cam paigns and program mes should take place at and from the Centre.The health room will provide a continuous consultation service to youths.The underlying philosophy of the IEC service will be that every person is entitled to information about the range of contraceptive choices available and should have the ability and skills to control sexu ality without fear of being discrim inated against because of age, gender, marital status, etc.The health room should pro vide around-the-clock access to barrier m ethods (free of charge).The following care functions may also form part of its ambit of services: STD/HIV/AIDS control and treatment, tuberculosis control and treatm ent, tuberculosis, STD and HIV-testing, and contact tracing.However the training should not be focused on to the extent that the Youth M ulti-function Centre becomes a training centre.General life-skills devel opment, recreation and reproductive health services should be seen as equally important.As far as possible "training should pay its own way", i.e. by following the example of an organisation like the Joint Enrichm ent Project in Johannes burg who secures contracts from Local Authorities for projects such as the refurbishing o f community halls.Training could take the form of short-term certificate courses with a substantial practical component.Trainees should also be exposed to other services in the Youth Multi-function Cen tre, including general lifeskills development and reproduc tive health counselling and services.If possible trainees will earn limited stipends during training, but a fixed percentage of the profits should go back to the Centre."Non-profitable" training should also take place where funding and other re sources can be secured.The process of fairly and objectively selecting trainees should be stipulated in the Centre's consti tution.
cific age categories for specific purposes.As far as reproduc tive health is concerned, it may be appropriate to have spe cific programmes for pre-teens (younger than ten years) and early teens (10 to 15 years).Within the main target group, (16-35 years) programmes may be directed towards schoolgoing and out-of-school youth, while it should be noted that in our country the school-going youth often include people

Table 1
Comparing the advantages of a Youth Multi-function Centre over current services A place of opportunity for youthsYouths can make contacts, get information, en gage in c e rtific a te sk ills-d e v e lo p m e n t p ro grammes.
Table 1 reflects a comparison of the Youth M ulti function Centre to the existing situation pertaining to (pub lic) youth reproductive health care: The Thabong/W elkom Youth M ulti-function Centre is a dream shared by many peo ple and a variety o f interest groups and organisations.Should such a Centre realise, it could serve as a pilot and a model for other communities in the Free State, and further afield.