A visiting health education team has set up a stage and loudspeakers, and the whole village has come to watch. A dozen adolescents are sitting up front. They take turns before the microphone as a moderator quizzes them about reproductive anatomy and disease prevention, teasing them gently when they become embarrassed, and the crowd laughs.
One young-looking teenager, blushing but confident in her answers, has a lively interaction with the trainer. Then she quietly leaves the group and goes behind the stage to nurse her infant son.
Phetsone, 16, in many ways typifies the 15-24 target group that the educators, from the INGO Health Unlimited, aim to reach in this rural area where sexual activity and childbearing often start at an early age. Briefly married to a boy her own age, Phetsone is now divorced and lives with her family. She tells a visitor that she wants to marry again, if she finds a good man.
The educational activity is part of the Reproductive Health Initiative for Youth in Asia (RHIYA), which operates in seven countries with support from the European Union and UNFPA, the United Nations Population Fund.
Reproductive health for poor, rural youth
In three of this countryâ€™s poorest provinces, RHIYA collaborates with the Lao Youth Union and local health authorities to provide information, counselling and services to youth, who make up a third of the rural population. Here, teen marriage and large families are normal while skilled childbirth assistance is rare, contributing to high maternal death rates. Young people, especially those who do not speak Lao, have limited knowledge about or access to reproductive health services.
Phontong houses 63 families of the Katang minority, who raise cattle and water buffalo. During the dry season, young people leave home to work in coffee plantations in Paksong. The village has one water pump for its 350 inhabitants and no latrines. The school has one teacher for 166 pupils and stops at grade three. The nearest health facility is 18 kilometres down a very rough road.
Phetsone delivered her baby at home, with no midwife and no means of transport had she needed to get to a hospital. She did receive prenatal care, though, from a UNFPA-funded mobile mother-child clinic that now comes to Phontong once every three-months.
To improve reproductive health outreach, the RHIYA project is organising a network of peer educators in 60 southern villages. Behavioural surveys have been conducted. Training materials and participatory methods used to train peer educators in Vientiane are being adapted for rural use. Radio programmes have started broadcasting health messages for young people, and these have been put on cassette for meetings in remote villages.
The youth union has picked candidates who will be sent to the provincial town for a week of training. They will be taught to teach fellow village youth about reproductive health concerns, both in private counselling sessions and group discussions. They will be expected to keep a log of their activities, to organise village activities every two weeks, and to return to town every three-months for follow-up training.
From Phontong, one girlâ€”Tuay Sak, 15â€”and one boyâ€”Thongbai Saysongkhamj, 17â€”have been selected. Asked about the concerns of young people in her village, Tuayâ€™s immediate answer is not about reproductive health: â€œWe need water and electricity.â€
The education team visiting Phontong provides a sampling of what the training will cover: songs and games to build confidence and trust; lessons and quizzes on health, including prevention of HIV/Aids, family planning, pregnancy care and the importance of going to a health centre to give birth; and gender role-reversal skits highlighting the unfairness of women having to do all the childrearing and housework. The village children shriek with delight at a scene where a drunken woman shouts at a cowering man clutching an infant.
Teaching about womenâ€™s rights is a priority, according to Dr Chintana Somkhane of Health Unlimited, a community trainer. â€œGirls in rural areas really donâ€™t know anything about their rights. Women cannot make their own decisions; they have to follow the man.â€
â€œWe have to work hard to reach young people,â€ she says. â€œThey canâ€™t read, canâ€™t write, and many need translators to ask us questions. They are very shy,â€ she adds, â€œand afraid to ask health workers about condoms.â€
Peer educators will have models for demonstrating condom use, and organisers hope that once the programme is established, local authorities will also permit them to distribute condoms and oral contraceptives.
Economic progress in Laos is triggering social changes that are putting growing numbers of young people at risk. Uneven growth has widened disparities between town and country, and between the Lao majority and other ethnic groups. There is a rising flow of youth out of poor villages, including growing numbers of young women going into sex work in the cities and neighbouring countries.
Expanding commerce (logging exports, for instance) and new transport routes across borders are opening the country to new dangers, including HIV infection, which is still comparatively rare. Abuse of alcohol and drugs, particularly methamphetamines, is rising among urban youth, along with traffic accidents. Premarital sex, sexually transmitted infections and illegal abortion also seem to be on the increase, though these topics are not readily discussed here and data are limited.
Vientiane Youth Centre
To address such problems the Vientiane Youth Centre was started in 2001. The centreâ€”managed by the Lao Womenâ€™s Union with support from RHIYA and Oxfam Hong Kongâ€”teaches adolescents about reproductive health issues and life skills, drawing them in with a variety of recreational activities and classes. It is also a training centre for peer educators, aged 15-24, who conduct outreach to other young people in their own neighbourhoods and in a rehabilitation centre for juvenile offenders.
On a Saturday morning, a large classroom resounds with the voices of 50 young teens singing a get-acquainted song as they dance in a large circle. After the warm-up, they break into smaller classes. An energetic trainer, Daravanh, 20, leads a lesson about nutrition, eliciting input from the group and sparking a lively exchange; they then divide into smaller groups for discussion.
Daravanh also uses her communications skills as a peer educator in her community. â€œI like to help friends who donâ€™t have the opportunity to get the knowledge the youth centre can provide, â€œ she says.
After class, there is more singing in the meeting hall downstairs, where the walls display posters about condom use and avoidance of drugs. The adolescents take turns on stage performing break dancing, karaoke, catwalk modelling or role-plays about relationships, all to raucous approval. Everyone is having a lot of fun.
But the centreâ€™s mission is serious. The expectation is that some of these young people will become peer educators. This involves a week of training, followed by a retreat where trainees build self-confidence and hone their interpersonal skills. Once deployed, the educators return to the centre and refresher sessions three times a year.
Lao Xiu-ting, 17, a tall Chinese-Laotian nicknamed Ley, is a volunteer peer educator in a workersâ€™ district not far from the youth centre. Her concern about the dangerous behaviour of many young people she grew up with has brought her to this work, Ley says, and she appears to have a talent for it.
â€œCommunity outreach activities are different from those at the youth centre,â€ Ley notes. â€œI go to places where young people gather and talk to them. I have to gain their confidence; they donâ€™t know me. We have to build relationships. I try to localise the information for them, to meet their needs and win their trust.â€
â€œThe training has given me a lot of skills and taught me to be more confident. At the beginning I felt a bit shy, but I received over it because we are friends. Iâ€™m no different from these young people; I am part of their community. The only difference is that I have more information that I want to share with them.â€
Articulate and determined, she describes some of the situations faced by friends she has counselled. One was a girl whose boyfriend took advantage of her when they were alone in an isolated spot, leaving her deeply ashamed. Ley helped her accept what happened and move on; she now goes out with other boys, but only in larger groups.
Another friend, a boy, confided that he had gotten a sexually transmitted infection from a sex worker. She encouraged him to seek medical care, and to change his behaviour.
In her neighbourhood, Ley says, young people may gather at someoneâ€™s house to take drugs or drink beer. Sometimes they have sex.
In her work she has found that â€œaddicts have heard about Aids; they know Aids means death. But they donâ€™t know any facts.â€
â€œI start out by telling them about the transmission modes of HIV and the difference between being HIV-positive and having full-blown Aids. I also help them identify behaviours that put them at risk, and discuss how they can avoid these.â€
In the grounds of a Buddhist temple in her neighbourhood, Ley applies her training and leadership skills as she guides a mixed group of older teenagers in a wide-ranging discussion that touches on sex, contraception, HIV/Aids, gender violence and the dangers of drug use. It is hard for a visitor to tell what behavioural impact this will have, but it is clear that the group is well-informed and not uncomfortable talking about sexual issues.
The Vientiane Youth Centre has served as a model for developing peer training materials and methods that will be used outside the capital. It also provides Laosâ€™s first example of a â€œyouth-friendlyâ€ reproductive health clinic.
Dr Khamla Phaodavanh is a physician who works at the clinic five days a week. When dealing with adolescents, she notes, â€œwe address them as â€˜younger brotherâ€™ or â€˜sisterâ€™ to put them at easeâ€, and assure them that the services and counselling are confidential.
Most patients are seeking treatment for gonorrhoea or another sexually transmitted infections. â€œAfter treatment, we educate them and recommend they use contraceptive methods, especially condoms.â€ Others come for pregnancy tests. If a young woman is pregnant the doctor refers her to a maternal and child health facility, and â€œwe counsel her to tell her parents.â€
â€œNowhere else in Vientiane offers these services for youth,â€ Dr Phaodavanh says. But the clinic, in its fourth year, is still under-utilized. It averages only seven to ten patients a day; about 60% are female. The womenâ€™s union plans to expand radio publicity about the clinic.
Peer education among sex workers
The RHIYA effort in Laos has one other component: an innovative peer education project aimed at â€œvulnerable youthâ€, especially those in commercial sex work. CARE Laos runs the project, which has reached young people working in 132 bars and 24 nightclubs in Vientiane. Working teams have identified the establishments where sex is sold, convinced managers that they are not a threat to business, and trained dozens of service women and some men to counsel their fellow workers about sexual and reproductive health, including HIV/Aids.
Dr Senkham Boutdara of CARE says the project started with advocacy to persuade local leaders of the need to act. His teamsâ€™ research revealed a sharp rise in the number of sex workers in the capital last year, increasing from an estimated from 1,200 to 2,000. They are typically young women and girls from rural areas who came to the city to find work, he says, and were drawn into the sex trade through some combination of exploitation and the lure of cash. â€œThe tendency is to start in small drink shops, and move on to bars, nightclubs and discos, changing jobs every two or three-months.â€ This mobility adds to the challenge of outreach.
The peer educators often have discussions with the young women in the bars and clubs before clients arrive. Some visit their homes in the daytime. They talk about health and gender issues, and life skills including negotiating safe sex.
In an elegant Vientiane hotel one evening, peer educators are able to use a ballroom for their outreach activity. Tables display graphic photos showing the symptoms of syphilis and other STIs. Three dozen service women, some of them teenagers, and a few men sit and watch the team perform a drama based on real experiences.
The story centres on Phaiboun, a bar girl who uses condoms with her clients, but is pressured by her boyfriend to have unprotected sex. She becomes pregnant, has an abortion at a private clinic, and is hospitalised after haemorrhaging. When the doctor asks the boyfriend to pay for a blood transfusion, he flees, leaving Phaiboun alone.
At the conclusion, one of the actors leads a group discussion about the playâ€™s messages concerning unsafe sex, family planning and abortion. Several women take the microphone and respond to her questions.
At eight-thirty, the session is over. As members of the CARE team pass out condoms, the service women file out of the room. They head upstairs to a room next to the hotelâ€™s nightclub, where each will wait until a client selects her to join him for drinks, most likely followed by a sexual transaction.
The RHIYA/CARE effort has contributed to an observed high awareness of HIV/Aids among sex workers, and reportedly to their regular insistence that clients practise safe sex. Lao Xui-lien, (Leyâ€™s older sister) works as a cashier at another cabaret visited by the CARE team and confirms its impact. â€œThe girls will refuse anyone who wonâ€™t wear a condom,â€ she says, â€œeven if he offers to pay extra. They know that money wonâ€™t do them any good if they get sick.â€