Tape #429 - Girl Power

them short. Our next speaker after Pat will be Kathleen Curts. Dr. Curts is a nutritionist and she is director of health and social analysis division at the international center for research on women. She is responsible for conducting and administering research on adolescence and women’s nutrition and reproductive health in developing countries. She’s worked in the field of international health for over 15 years and currently she’s working on projects that address adolescent sexuality and fertility in India and on that need of family planning in Zimbabwe, Zimbabwe and the health in multinational status preschool girl child, I can’t even read, for USAID child Zimbabwe programs to correct gender disparities. Our third speaker is Dr. Vaughn Rickard. He is a clinical psychologist and an associate professor of Obstetrics and Gynecology within the division of pediatric and adolescent gynecology at the university of Texas in Galveston Texas. He’s authored and co-authored over 60 articles, reviews, and book chapters most in the area of adolescent health and currently Dr. Rickard is working full time as a research investigating sexual violence, mental health, and substance use in female adolescents. So I think we have a broad group of expertise here this afternoon to talk about a number of the issues for this, our target population. I will spend a little bit of time talking about what are some of the issues in the United States and how I representing what’s happening in the Department of Health and Human Services in the Federal Government here has been looking at some of these issues and beginning to work on them and then the others will follow me. Certainly the early adolescence. is a time of transition for young women. Some of the problems are unique to more of the industrialized and some to more the agrarian economies. But there are certainly some issues which are universal to girls as they enter the early stages of womanhood. Their body changes, their psychological changes, social role and responsibility changes. Obviously, these changes are both true for boys and girls, traditionally, boys have often gotten more attention, have gotten more resources and have been considered at a higher risk of getting into trouble during this period. Whether it’s been accessed to education, to help services, to better nutrition, to choices of when and to whom they marry, girls have been left behind in many of cases. Not all countries have the same specific issues they may vary from the culture an date traditions of the society but they all have a common theme of girls of getting less, or having less attention paid to their unique needs. What I would like to do is to talk briefly about some of the things that are going on here in the States. Recently in The least several years we have had several books have come out focusing on the differences and the experiences of early adolescents for boys and girls. They pointed to the decreased in the sense of self worth and powerfulness and capability and feeling of capacity the girls of 9 to 14 have faced. At 9 they begin to lose the sense of self worth while boys during the period of age 9 to 14, tend to increase their sense of self worth. We don’t understand what’s all involved, but we are trying in the States to see if we can capitalize where they are at nine to prevent the consequences that seems to happen to these young people during these early years. What I would like to do is to cover just a little bit of some statistics of what we know about young girls in this country and then talk about one program that is occurring here. Again, most people have thought boys being the one to have more problems but, as it’s shown here since 1975, girls have been equally or more likely than boys to smoke and now adolescent boys and girls are drinking equally. It used to be that the boys were much more likely to drink. Among adolescents, men are more likely girls to use illicit drugs but this not true among adolescents where both girls and boys have equal risks. Among adults over 30, the ratio of men to women who use illicit drugs is higher for men, but it’s 1.5 to 1 men to women whereas for 12 to 18 year olds the ratio between boys and girls is the same. And today’s daughters are 15 times more likely than there mothers to have begun using illicit drugs by the time they are 15. So certainly the young women in this country are doing more having more risky behaviors in relationship to substance abuse than they did in the past. Another area is violent crimes. Between 1985 to 94, the arrest for young women for violent crimes have risen over 100% over 125% compared to 67% for boys. And again, these violent crimes frequently involve substance abuse so this is a major problem in this country. Just a little background from sexual activity , even though in the United States our birth rate is finally going down. We’re still one of the highest, we are the highest certainly in the industrialized countries and nearly twice as high as Great Britain. In the US, 4 out of 10 girls will become pregnant at least once before the age of 20. In terms of mental health, 1 of 20 girls has attempted suicide this is more than double the rate for boys in this country although Dr. Ricard will speak of this issue on an international where the statistics are somewhat different. And 10% of girls compared to 7% of boys have reported considering suicide in the last year. These are some of the sort of startling statistics that we are dealing with and concerned about, however there are some things that have been improving in this country. Basically, girls from 15 to 19 years old having sex is declining our birth rate of our young women has also decreased and condom use during first intercourse is increasing from what it was previously. I’m going a little quickly since I’m trying get through this as fast as possible so we can have as much time for discussion. On my last slide, here is, that east we know in some areas such as math achievement girls are doing as well as boys. However it is not true in Science. There are many more organizations and youth groups that are serving the needs of young girls and are beginning to become aware of these problems and there is recent research that shows girls are using a wide range of strategies for exploring their identities and articulating their opinions and developing and preserving their sense of self and this is what we want to capitalize. On t of the main plusses where this is happening actually is a program the Federal Government started, our Secretary of Health, Donna Shelayla two years ago really has always decided that it was really time to focus on this 9 to 14 year old girl. She felt that this is the populations where we could make a difference and where not enough was being done. And as a result, she initiated a campaign called girl power whose role was to raise the awareness the unique pressures facing girl and the emphasizing the needs for girls to build skills and self confidence in academics, sports, and other activities. The first part of this campaign was really a public awareness both to the adults in the States and to the young girls themselves. We’re now beginning to enter into the second part of this which is really an attempt to do some skill building for these young people because all of the data now is suggesting that you can’t just prop them up and telling them that they are good, you really have to give them skills and things to do and that is really where we are focusing. There are a number of different specific projects but one that we really would like to focus on today is called Girl Neighborhood Power and Dr. Pat Maloof will actually speak to you about this particular program because she is actually in charge of it, and knows much more about it than I do. So I would really like to turn the podium over to Dr. Maloof who will then go on to speak to some other issues that are more on an international level.

Good afternoon. I’m going to start with an overview of Girl Neighborhood Power of Building Bright Futures for Success as the whole title is and there’re actually two major components. One is national component which we, the national healthy mothers healthy babies coalition has and this is really to do a variety of activities. One is to build a national consortium we’re trying to develop at least 2500 partners to join into this to develop a youth advisor network, we are at the moment sending out a call for best practices and strategies on working with youth and particularly girls in the 9 to 14 age group. WE are also going to be doing a bright future for success journal we provide technical assistance to the force funded sights and that’s the second component that I’ll get to in a minute. And also what we are going to be doing a national promotional campaign so the first component is the National component. The second component are community partners that have a cooperative agreement with the maternal child health bureau but are also funded by the office on women’s health and ICHD and national institute of childhood development and there were two others, all Federal agencies that came together again to address this very important issue. And the partners are, actually I have a handout that I can give you later if you don’t have to worry about taking notes on this. But the partners are in York, PA , one is in the city of Madison in Madison, WI, one is a girls insight in Rapid City, SD, and the fourth one then is a girls insight in Memphis TN. Now, to be a community based partner, they are also funded for five years through a cooperative agreement, and they have certain requirements. One is they had to have a minimum of four sights, one of the programs actually has 6 sights and then they had to have a number of other components. These components include before and after school activities, well two are required, one community service, and one journaling. Journaling, we are working whit the sights to interpret broadly so that girls who may have difficulties with English, for example, would not feel excluded. So community service and journaling are required. Community service is turning out to be, at least here, in this country at the time a particularly important component because it’s helping kids feel connected to their community and their surroundings. There was recently an adolescent health study that talked about this whole notion of connectedness of children to their families and to their community. So the community service and journaling are required and each sight chooses two of the four that are left before or after school activities, career development, health education, and mentoring. And actually when it comes to health education, we are working really hard with them to make sure that girls are enrolled in whatever programs they may be eligible for and they are linked with a health care provider. The neat thing about this program is that it’s really community based. Although these are requirements, the community itself decides, what are our resources, what are our assess, what do our kids need and who are we going to bring together as partners and how are we going to go about this. I have some statistics on the various sights but I won’t go into those too much. Let me just say that the goals and objectives of the program generally are to communicate messages and information that lead to responsible decision making and the avoidance of risks and consequences associated with risk behaviors and some of these were given to you already and I have a few others that I might go over quickly. It’s also meant as a way to support and help guide parents, as well as peers and communities that are responsible for ensuring the well being of girls. Other goals and objectives include to support positive inter personal skills that build confidence and increase self awareness and create a sense of belonging among girls, their families, and communities. And then also to work at a broad range of interest in academics, arts, sports, music, volunteerism, and other positive endeavors as a way to encourage healthy self image. The question comes up, why girls 9 to 14, because of the time, I think I’ll skip those overheads, but one of the major reasons is that we really find that the younger girls have a very much more positive outlook and healthy lifestyle as far as their attitudes towards drugs, or towards drinking, they’re much more physically active and then as the girls get older, these kinds of things start to change. So, again, as Janelle mentioned, it’s an opportunity to try to capitalize on some of those positive healthy behaviors that girls still have while they’re young and hopefully that they don’t lose them as they grow older. The attributes really of the program is that it addresses this critical nature of the unique needs, interests, and challenges of the 9 to 14 year olds in relationships to families and communities and as we work with the communities, we’re really finding that developmentally, we as activities are presented that we are looking at two groups within this 9 to 11 and then 12 to 14 because we really do have quite a broad range. The other thing that we are trying to do with this program is to reach under served communities and community is broadly defined in girls in under served communities and one of the sights has girls with disabilities with mild mental retardation. So again in this case, while they have unique needs and some of them at nine may not be developmentally nine, you may be finding a much younger age group there. And the also takes a comprehensive approach. We’re looking at health prevention, health promotion, self confidence, it’s really a holistic approach to health. There’s an emphasis to build strong partnerships, parents, schools, communities, religious organizations, health care providers, media, businesses, local governments. One of our sights came and presented and said how the mayor had turned out and they said he hadn’t come to anything before and they were really excited about that. They had also brought together six groups of organizations that had never worked together before. And so this was a really good opportunity to bring everyone together and it challenges Americans to organize both at the national level and also in the local neighborhoods. And that’s where the emphasis on technical assistance is provided. I can answer more questions specifically on the program later we have, I have a few things that show some of the activities, but it covers a wide range of things such as, discussion groups, links with health providers, peer leadership programs, there are girls councils. And at one sight, the girls voted on what kind of journal they wanted to do, where they would buy the journal, their blank book, others are doing it in a different way. We have art and dance, we have at one sight, what do you call it, a trainer who’s donating her time to teach the girls how to become more physically fit, there’s working with the media, tutoring, some sights have formal curricula, others do not have as formal a curricula and then there are family activities and all kinds of exercises and sports, and other really neat things. For example, there’s a career fashion show where one of the sights is working with the girls not to think only of what’s seen as traditional women’s jobs but what other things women might be doing and so they come dressed as they would for work and also describe the job that they are doing. Okay, so that’s where things are with the program and I abbreviated it considerably, but certainly I would be happy to answer questions on it. What I want to do is sort of a quick switch, not real quick sort of transitions probably a better way to say it, and we have a, you’ve probably all seen this bumper sticker that says ‘Act locally, but think globally’. So you’ve seen the logo. Now I am going to go global briefly so that it will help to prepare some of the, prepare the way for the speakers who are coming. When we look at girls and there’s this book called the Burden of Girlhood, which is sort of a depressing title, but in actuality when you see the statistics, it is in some ways a very big burden and one of the things you hear a lot about is daughter preference and I put a question mark because, very few cultures really actively or deliberately prefer daughters, but we find that, and this if from the 83 World Fertility Survey, daughter preference was found in only 2 of 38 countries. I hear it’s now up to four so we’re moving right along, but nevertheless, you don’t really see a whole lot of daughter preference, unfortunately. And what we find is that the economic value of girls is under valued. That there is really no economic value given to the work which girls do at home as surrogate mothers and care givers nor are their contributions as far as what they do in the farm community or in their domestic circles really recognized. The decline is son preference frequently has now been associated with demonstrated economic contributions that women make to agriculture and trading economy so the important thing is to make sure that the impact of what girls are contributing is somehow there. These are sort of interesting statistics, depressing, but interesting and I wanted to pull them out because you know in the US we pride ourselves on all these women’s rights and feminism and everything else, but some of these statistics are a little distressing, more than a little distressing. In early grades, girls are ahead or equal to boys on most measures but, by the time they graduate from high school or college they really are falling back and that teachers tend to interact with boys more frequently. They ask them better questions, the give them more precise or helpful feedback and interestingly enough, again you see the gender distinction of white males getting the most attention, and then males of color, followed by white females and females of color. When if boys are praised by their teachers , it’s frequently because of their intellectual achievement or quality of ideas, girls are more likely to be praised for other kinds of things for rules, following rules. We find the same things with parents. Parents may, there is a book that came out talking about how parents will praise their sons about how great they are in sports or with athletics, but they’d praise their daughters on how pretty they are, which is okay, but their daughters have a whole lot more than that too. And this is, I’m just going to skip to this one cause it’s sort of so blatant it’s kind of interesting. In a typical school yard the boys area is 10 times larger than the girls area, I just though I’d throw that in to just change the tone of it. We see though, not only in education, but also in healthcare some major discrepancies that more male children are immunized and treated even in areas if the immunizations are free, then the rates tend to approximate each other more closely. If there’s a fee, even a small one, then the boys show a higher rate of immunization than girls. Girls have a higher rate of death from measles, diarrhea, respiratory infections. Boys tend to be breast fed longer. You find nutritional differences in allocations of foods differences between genders. I want to just look briefly at teenage moms. From the UN in 1989 the adolescent fertility rates for will constitute 10 to 15 percent of total fertility rates. and more than 1/3 of births of the world occurred in women below 19 or older than 34. We’re kind of moving from girls into adolescents and the World Health Organization really defines that time span is girls between the ages of 10 and 19. The average level of fertility among girls globally is not exactly known, but in 1985 estimates for 15 to 19 year olds in various areas range from 4 births per 1,000 to 239 per 1,000 and it’s estimated that 40 % of all 14 year old girls alive today will have been pregnant once by the time they are 20. This is a rather startling statistic that mothers aged 15 to 19 are twice as likely to die in childbirth as mothers in their early twenties and those under the age of 5 are five times as likely to die in childbirth and that babies born to a teen mom are more than twice as likely to die in their first year of life. So there are real risks for early pregnancy. In conclusion, I have just a few points to ponder, more than a few, but there really is not a whole lot, there’s some data that is sort of heavily relied on, but you don’t really see separate data on girls and this is a major limitation in really trying to figure out what’s happening with them. And the next thing that I think is particularly important, and this is from a reference by Soheni, where she says there is a false complacency that exists among developments, planners, and feminists that women’s gains will automatically percolate down to younger females. It’s the same thing with economic development, their trickle down theory is not working and that what we really need to look at are very specific childhood interventions, rather than thinking that addressing only women’s issues will ultimately benefit girls equally as well. Being very realistic or practical about it, moral arguments are not going to be sufficient, we really need to look at ways of showing the impact and the contributions that women and girls make to the whole economic sphere and this goes largely unnoticed. Recent research, because of the fertility statistics I gave you earlier, I wanted to mention recent research indicates that sex education is not linked to earlier or increased sexual activity youth, that 6 out of 19 international studies found that sex education led either to a delay in the onset of sexual activity or a decrease in over all sexual activity and it’s also been found help to foster safer sex practices among youth. Research indicates also that primary education and the result in economic productivity helped to result in lowering birth rates, later marriages, and improved family health and also shows a dramatic decrease in infant mortality. Countries that have a higher female education index also tend to have a lower infant mortality rate and a lower fertility rate. And what we need to do is to look at long and short term strategies to reduce gender disparity in childhood. These need to be actively implemented by government as modeled by the provisions and clauses of the international policies that many of you are already aware of. I wanted to say that adolescence has been noted as one of the major under served groups in comparison or comparing probably almost equally with rural populations and urban poor. So that adolescents are a group as far as services are concerned that have been really that are under served. It has been suggested, as a final note, that it’s too late for the 1990’s but maybe in the 2000’s we might have a decade of the girl designated and give some real emphasis and importance to a critical group. By the way, just to give you some idea of this Girl neighborhood power program that we have there are 11 million girls between the age of 9 to 14 just in the US So thank you and I have hand outs that I can leave in the back later. Thanks.

I want to thank Dr. Maloof for the nice statistics the tact I was taking was more just about in the work the international center on the research on women has done. To go right to some of the lessons we learned about programming and dealing with girls in this age group so that was set up quite nicely. Our organization does work mostly research, but very problematic and operational kind of research in developing countries only so I also appreciate the overviews and the similarities with the US. And I think, I think we’re probably all at agreement that even though the sessions on Girl Power that we want to put an emphasis but perhaps a different emphasis on girls and boys and especially the way they interact and the differences in the way they interact. The international center for research on women does an increasing amount on what I’ll call adolescents, including this youngest group of adolescents. Our research and programmatic emphasis is more on the kinds of things we’ve been talking about the social science and behavioral aspects as opposed to biomedical aspects of their health and puts an emphasis on poor groups in developing countries. There’s probably more I’m drawing on but four recent programs projects we’ve had, I’ll be drawing on. Directly, we had a program on Women and AIDS funded by United States agency for international development that were 18, that were at various points over about seven years eight to 17 studies going on. First, in the first phase to just describe and highlight women’s vulnerability to HIV infection and in the second phase to test some interventions to reduce that vulnerability. And at least at every phases of the program more than half, half or more of the individual research projects had an emphasis on adolescents. Another, a second program is just winding up is sort of a first descriptive phase and going developing proposals for a second phase of interventions if four studies in India. Three in the State of Mahash and one in the state of Tomalnadu. We named that one adolescent sexuality and fertility but it really has a lot of aspects of a lot of things about their health or their reproductive health including health seeking behavior. One of the studies did do a biomedical study of the extent to which married women already have reproductive tract infections and found at fairly high rate. A third program is a little bit older now from the PU foundation, I should say the second one is funded by Rockefeller foundation, the third one from PEW charitable trust we did a needs assessment in the Caribbean of what programs on adolescents of what was being done and what were the gaps what were the programs going on there felt were needs and the fourth is a program on adolescent nutrition which was 11 research projects showing that anemia was a major problem amongst them we set off more to study thinking that the major findings would be on weight and height kind of under nutrition malnutrition generally kind of issues and ended up feeling like anemia was the more major program that you could act on. I mean there’s a lot of malnutrition probably coming from childhood and then being reinforced, but there might not be a whole lot you could do at least about their height because that was, that was fairly set, but you could do something about the anemia. So I guess I just want to go right into some of the things we’ve learned and then fill the use some of the results to feed into some of those lessons. I guess I feel on reproductive health that, I don’t know if this, in your various working situations how much you find of this, but in some of the funding programs and the various foundations and US agencies that fund things overseas, I see a kind of did a lot of vertical programs and one distinction that I, that I try to blur, but is there, is that the motivation for a lot of these efforts on adolescents in developing countries comes from a combination of trying to postpone pregnancy and prevent HIV and since I work on both the health and fertility areas, as well as the nutrition area, nutrition fits more in preparing young girls for when they are going to be pregnant. So I will speak to both of these, but I find it among the US agencies doing this that if they’re working on preventing pregnancy then they don’t really want to work at the same time on preparing young girls to be pregnant. They sort of want to keep those separate, but I see them very much together in reproductive health. Another thing I want to say in the introduction to all this is that more things by example are going to come more from older girls, 15 to 19. But every time we’ve studied that, that older age group we feel that the implications are really for starting earlier which leads to the 9 to 14 age groups. Time and time again we just feel like, I’ll keep pointing that out where, especially where, we need to start earlier than where current problematic emphasis has been. So I guess I’ll start right into some of these lessons and the first ones are really about sexual activity. I was asked to speak on one each of the sexuality and then nutrition so sense a lot of, sense the HIV epidemic has really made us open our eyes and pay attention to sexual activity and neither how to reduce it or make it safer, certainly make it voluntary. Let me start at that end of things. I guess as little, well I don’t know if it was a surprise or not, but one thing I wanted to start out with is a lesson that young girls in our work don’t want to be a sexually active or certainly as early as they are. So why did they become sexually active? A whole range of reasons. We have peer pressure, which we could probably see in any setting, and sometimes it’s not from peers, sometimes it’s pressure on girls from older men. I think that’s true in this country as well as in a lot of developing countries that the pressure for sexual activity is not only from your peer, the peer of an adolescent, but from older men as well, which leads directly to a second reason for this early sexual activity with at least, I guess especially some of the African countries that I’ve worked in there’s an element of economic contribution to, gifts if you will, to a relationship. We’re not talking about prostitution, we’re talking about, you know facial cremes or some money or some help into the family. I’m talking mostly about in poorer families that might be gifts at all levels but it becomes an incentive for the sexual activity when those economic contributions are needed the most, so among the poorer families. A third reason why they become sexually active is a need for love from peers or older people, or confirmation of who they are, attention, whatever you, whatever you want to call it that can turn into sexual activity trying to please a partner or a boyfriend that you want some love or attention from. So that’s probably a classic that could probably go unstated. Another reason, because I said sometimes they don’t want to be sexually active, well the assistance for not being sexually active is the phrase ‘Just say no’ but what we find is that there are probably a set of skills that should go along with the phrase ‘Just say no’ and they don’t tend to go together as often so, particularly from church or religious settings there is an expectation or a statement that a young girl should just say no but it’s kind of confusing how to operationalize that, if you will, and there’s not much help developing those skills from the same groups who would say just say no. So I thing it was eye opening for me hear, especially from girls from the Caribbean that they don’t want to be sexually active but they don’t really know how to get away from some of the pressures to be sexually active. And in more dire circumstances another reason for sexually activity is that it’s violent, that it’s not voluntary that there’s pressure that they absolutely can’t get away from that there’s either rape or relationships within families just they don’t really have any choice because it’s foisted on them. So all of these, even if the sexual activity is taking place at a slightly older age in adolescents, I think particularly this skills building one about how to put off the sexual activity needs to start being addressed at the 9 to 14 year age group. Another lesson we’ve learned from work HIV’s and AIDS, is to broaden the education about HIV’s which is quite widespread a lot of places in the world. It’s been, information about HIV is being included into health education or just a lot of places. But we think it should be broad to include a discussion of sexuality, relationships and gender roles. In some places people, some of our studies in India and Sub-Saharan Africa, people can, young people can if you, if you’re testing knowledge as an evaluation of a education program you’ve run say. You can get a lot of right answers back about HIV infection itself. But if you probe a little bit further, you find, we find, that knowledge has been acquired in a vacuum if you will. They don’t see any relationship with any other sexually transmitted diseases with the sexual activity and the relationship with gender roles is not clear. And the bottom line is adolescents who really might be quite at risk of acquiring HIV and infection and other sexually transmitted diseases do not see themselves at risk and certainly, even if that’s what they say, but secretly they are worried about being at risk there’s just not enough of a connection that would lead them to some sort of action to be able to prevent their vulnerability to HIV. So, again, to broaden the education to include the discussion of sexuality and relationships in general, we think will be useful and to start earlier. Now there’s probably people more on the programming side would tell you that there’s a lot of new onsets about how to start that conversation among a nine year old than a 13 year old than a 15 year old than a 17 year old and we agree with all of those but somehow start earlier so the notion, the notion of relationships and how to handle the relationships and the vulnerability about sexual activity and either how to put off that sexual activity or how to make it safer would all be worth while before, before they’re into that pressure to have (tape ran out)

Side two of tape #429

about working with adolescents is that they’ll open up much more quickly than, than people think they will and we’ve come to the conclusion that they need to talk and don’t have that many people to talk to, particularly adults as I’ve been saying. So then the interviewer, and there’s pros and cons of whether this trusted adult is someone you know very well and then knows your parents and knows a lot of people around you or whether it’s someone who might, might come and go. There’s advantages and disadvantages to someone whose going to disappear after the interview and someone who’s going to stick around for your follow on questions. So the interviewer might, might serve a particular link even more because you’re not going to see this person very often and the case that I’m thinking of there were Medical doctors and medical doctors in training so could answer the adolescents health questions quite a ways and then refer them to the appropriate health center, or say come into the clinic and I’ll treat you whenever you can get around to coming into the clinic. So the trusted adults really been an important lesson too. Another one is involving to involve adolescents in the design of programs intended for them. In our field this has become a bit of a, this has become a montral almost that we’ve, I think because probably of the failure of being able to reach young people particularly those out of school. But even if you’re going to schools to reach adolescents they’ll turn off fairly quickly to certain kinds of programs and so it’s really fought and there have been successes along the way of programs that have involved the youths themselves in developing the programs that are, that are intended for them. Coming more, being a researcher myself I guess I’d like to see things tested out how much more do you get if you, if you involve adolescents and you know, which part of it, is it just the design or is it the implementation and should they do the evaluation as well I mean how much involvement and where, where do you get the most because we all know that being participatory makes for a better program but also makes it take a lot longer to, to get to the development stage so what are the particular elements of this participation so we’re actually embarking on a research study to, to test that you know at different levels of the involvement of the adolescent where do you get you know, the best utilization of them. I think another one of our lessons is that Dr. Maloof also mentioned and it’s really important to bring home, when you’re trying to get a program started is to be really clear that, and we’re very grateful, and I can’t take any credit for these but that the WHO’s commissioned a number of studies, the 19 she was talking about, which showed that sex education does not increase sexual activity. And to the contrary, I think that in 10 of those 19 studies that it actually increases safe behavior. In India there’s a lot of information not given to young, young girls and boys and they’re not told about, they’re often not told about menstruation until menarche occurs same with sexual activity on the basis they don’t need to know this before it actually occurs because there’s some fear if they know about it, then, then something more risky will happen. So it’s really nice to have that lesson. And then just going a little bit broader in conclusion that if we could increase adolescent access to education and adult women’s access to economic resource, we’d reduce some of the pressures that lead women into earlier sexual activity than they prefer. And then I guess the final point in the preparation for the adulthood, particularly the pregnancy, is that the nutrition fits in critically at this point. We found in our studies that anemia among young girls is nearing the most, that are experienced during pregnancy which is a surprise cause we associate anemia during pregnancy, with pregnancy. And there’s some evidence to suggest that for all the treatment we do during pregnancy that you might get the best outcomes the anemones related to birth outcomes a bit to prematurity but the strongest relationship is between pre-pregnancy anemia and some of these outcomes which speaks to reducing the amount of anemia before the pregnancy begins. So again, 9 to 14 is a great time to improve the iron status of young girls. Thanks.

Basically what I’d like to do for you today is three common mental health disorders among women in agriculture particularly in children. Depression, substance use, and family violence and to also talk about issues and recommendations that I have about role mental health service delivery. Why is it important to look at women in agricultural communities? Well in the United States, at least 1/3 of children resolve in, reside in rural areas and many are poor. And more importantly in developing countries, children may count to up to 50% of that countries population, so it’s critical to look at this issue and of look at these children. Well we can’t really talk about mental health as many of you already know, unless we talk a little bit about adolescent development. And again, just in review, when we look at children, that is ages 5 and above, we have the pre-operational and children 9 to 14 are in the concrete operational stage and as they move past 14 move into formal operations that is abstracts thinking, understanding what’s going to happen in the future so what I do today is going to impact me tomorrow. We also need to look at psycho social development. And in the school age children, we have Ericksons notion that industry versus inferiority. Now even though I’m a clinical psychologist, I had to go back and figure out what this meant, and essentially what he’s talking about here is a notion of industry that school age kids learn to put together a product. So even if we’re talking about poor, rural kids from Africa, who may or may not be in school, the point here is to learn to do something and to learn and a process of doing it with people, because if you don’t learn that sense and value that sense it leads to not feeling very good about yourself. As school age children move into adolescence, we have a notion of identity, both in terms of identity of a person as well as their sexual identity and intimacy versus isolation. Intimacy developing relationships with friends, as well as developing romantic relationships as well. So the whole point of development is that it does interrelate with culture. I think, however, looking at the broad scheme is that the issues of development remain the same whether you’re talking about agriculture girls in Nairobi, or if whether you’re talking about in Arkansas, that the issues are sort of the same thing. The expression of those issues probably differ. But the point here is when you look across the research, whether it’s in this country, whether it’s in Spain, whether it’s in China, or other countries, that mental health behaviors then to co-occur and cluster together. And in developing countries, the expression of these and what’s accepted and what not accepted is very much complicated by ethnic diversity. In agricultural communities in Africa and in other portions of the globe, whether it’s not a dominate culture but various ethnic cultures, you have a notion of customary which is sort of accepted within that culture versus statutory what’s really against the rule of the government or the nation. And those complicate how things are expressed and so how children sort of deal with these developmental issues leading to mental health problems. So if we’re going to look at mental health problems of children, we really need to know what the common mental disorders of rural adolescents or rural adults are. Well they are alcohol abuse, depression, family violence and suicide. Therefore, this kind of takes into account of what we need to look at in terms of what are the rural mental health disorders of children and adolescents. Essentially, the prevalence of psychiatric disorders across rural children is somewhere between 2 and 11 percent with conduct disorders representing the largest part. Conduct orders being basically anti-social, you know, not minding their parents, and a little bit more exacerbated than that in terms of leading to a psychiatric condition. And 10 to 15 % of adolescents, where ever you pick, probably have some of psychiatric condition whether it be Spain, or whether if be Africa, or whether it be China. Now emotional disorders are far more prevalent, particularly depression and depression is far more common across cultures in the female population, just generally. Suicide ideation and the attempts are also very common. The WHO estimates there are 100 thousand completed successful suicides each year, between, adolescents between the ages of 15 and 24 which roughly translates into 4 million suicide attempts that are going on around the globe. Interestingly enough, from an international perspective, there doesn’t seem to be any difference between the number of attempts by females and males. What we do know is that males are far more successful at completing the attempt than females. In terms of looking at substance use in rural areas, the early studies were reported much lower rates between people who live in rural areas when comparing them to metropolitan areas. But more recently, at least in this country, the rates are very comparable. But most interestingly, there are greater quantities among rural individuals when they do consume on per occasion when you compare how much people in metropolitan areas consume and there generally is a higher daily frequency of use among the rural populations. Now when we look at female rural alcohol use, there are very few data available but generally there are lower rates reported. And the reason that there are lower rates reported because it vary according to the prohibitions against young females drinking. For example, in some third world countries they do not want their young females to during because it will affect reproduction, and reproductive health in terms of the babies, and therefore, there are large prohibitions to not drink and so that when you look at young girls in agricultural communities, there is a lot of guilt and a lot of anxiety when they do consume actually perpetuating and developing the relationship, as I mentioned before, between substance use and depression or depressive symptom mentology. Rates of use, again, across industrial countries are very comparable. Basically in China, for example, there was a really nice study that looked at males and female, and you don’t really see a whole lot of difference. What you do see though is that the in starting use is different. That is males start a little bit sooner than girls, but girls catch up which is the bad news. In terms of other substance use among rural females, illicit drug use is far less common across cultures, in terms of cultural areas when you compare to more metropolitan areas. For example, in Africa, cannabis is far more use for ritualistic or medical purpose, and so the rates of use is very, very low in that particular culture. But the predictors of substance use, whether we’re talking about cigarette smoking, whether we’re talking about alcohol, which are the big ones with young girls, are similar. That is if you smoke, you probably have drunk or are drinking. If your parents are heavy drinkers, you are probably at risk to being a heavy drinker. and if your peers are drinking, you too probably are drinking and smoking. What’s interesting is the notion of socioeconomic status. There was a really nice study that was done, it was a longitudinal done on Nairobi youths. And essentially what they found in this, in this population is that among females of 15 years to 16 years of age, who were enrolled in private school, their rates of smoking were ten times higher than the same girls who are going to governmental schools and so it’s sort of leads to this notion that we’ve seen in the States that with increased comfort, family comfort in terms of money and status, also goes with an increased risk for substance use. Depression, as I mentioned before, they’re far more likely to be female. With the developmental issues, as you know Pat mentioned, as Janelle mentioned, and as Kathleen mentioned, it is a very big issue. It’s highly related to substance use, so when you see low self esteem and you see depressive symptomotolgy, you need to be thinking about alcohol in girls in agricultural communities or in non agricultural communities. Suicide ideation also goes hand in hand with depression obviously. Obviously physical abuse, poor communication particularly with a parent and chronic illness among females who are residing in rural areas, seem to be greatly related and strongly related to severity of the suicidal ideation. We need to talk about women and violence. And I don’t want to spend a lot of time on this, but particularly when you have patriarchal systems, that is where the male is valued either very directly or very subliminally this kind of a culture isolates women because they have no implement sources of income, typically they have little education and they few marketable economic skills. Well, what does this do? Well it does a great deal and impacts a great deal on the female child because she sees what her mother is doing, she sees what her older sister is doing, and so she has to sort of accept this deprivation and this dependence because in these kinds of society, these girls are eating less, they’re not getting the same amount of food. And so it becomes a way of life it leads to early, early marriage because of dairy expenses or because of reimbursement of having a young wife, because as Janelle pointed out to me today in the Washington Post you know, if you marry off your youngest daughter you’re going to get more economic return as a father. So this obviously, directly leads into family violence and so when we look at the prevalence of child maltreatment among rural groups, we essentially see the same prevalence of occurrence that is somewhere between, you know, at 1 and 5 children are abused. Now physical abuse are far, are much more commonly equated that is there’s not greater proportion of males to female children that are physically abused than are males. But sexual abuse is far more common across cultures and across rural and urban distinction in girls. And so the consequences of child maltreatment particularly abuse and neglect is that there are far higher emotional and behavior risk particularly among females with depressive symptomatology and you know among males you know hitting and physical aggression. However, the biggest risk, particularly for rural females who are, are physically abused, is that increases ten fold their risk for domestic violence. That is, entering a relationship as an adolescent as they’re experimenting with getting to know how to inter-relate and relate with other opposite gender and then as an adult women being in the hands of violence from her partner or spouse. So when we look at how we have prevented these or what’s going on with child mental health services, basically they follow the development of adult psychiatric services and adults come in and say, you know I don’t feel very good I need some help. Well, the good news is particularly in developing countries there’s been a resurgence or, resurgence is the wrong word, but a significant growth in the types of child mental health services that are available particularly in the last twenty years but we really even need to go two more steps to develop more mental health because 80 to 85% of the total population of third world nations resides within rural areas and so you can’t take the child out of the entire context of the family and then of the larger community and society. but we have to be sensitive about mental health issues and agricultural communities because generally agricultural communities are characterized by a high regard for autonomy and self reliance, not wanting to go outside the community. And so there’s at least, in this country, there’s a particular resistance by rural folks to have not wanting public health, or not wanting governmental handouts and things like that. Generally across cultures in agricultural communities, there is a tremendous stigma with having a mental health problem and more importantly, going and getting treatment for it. And so rural family and rural children are less likely to access care because of stigma. And there are cultural expectations about what is and what is not a mental health problem that need to be dealt with. So when we look at mental health services in agricultural areas, basically they suffer from the same neglect and service barriers that you find in urban centers, inadequate personnel, limited facilities, fragmented or poorly coordinated services particularly when it comes to children. When you put on top of that the notion of rural you have the additional service barriers of the geographic distance, the isolation. Rural areas have different sets of demographic characteristics which may set them apart very much from a rural area, as little, as far away as a thousand miles, but even as short as a hundred miles. And then you have different cultural characteristics that interplay, and as I mentioned before stigma is something you really need to be aware of. So when we provide services to rural areas or when we’re thinking about what we should do to improve the mental health of young female children who reside in rural areas, we need to think about, it’s going to cost more, it’s farther to get to. Typically you have things that are coming from urban areas being exported out to rural areas so there’s transportation costs, there’s communication costs. Typically within the rural areas there’s an inadequate array of support services, they may have very basic medical health coverage for targeted specific illnesses, and they are over burden as well and when you are asking them to coordinate the mental health component of this, it just falls apart. It’s hard to recruit and retain people who have, in fact, been child trained. Because you just can’t send and adult person out there who’s trained to deal with people who hear things or see things and expect them to deal with, you know, a nine year old child who suffers from sexual abuse. There tends to be an over reliance on governmental funds and with the escalating demands for services, this gets to be very much a catch 22. So what can we do to improve the mental health of children, particularly female children who reside in rural areas. Well unfortunately it can’t be addressed with one solution. So what works in the United States may not work in Spain, and may not work in Africa, and may not work in China, and may not work in the Middle East. We need to look at innovative approaches and gear these appropriately. We need to use families as therapists, as role models, as caregivers. We need to capitalize on the self reliance that the agricultural family has and to increase their abilities to self help other families. We need to increase the training for the traditional care providers within the community and improve our ability to recruit and retain providers who provide services In looking over the literature, there are a couple of model programs and it’s not that these are any better or any worse than other programs, they are just programs I happen to find illustrate a particular point. One is the national mental program in Tanzania which was under taken by the World Health Organization and its subsidiary in the Scandinavians country and the Cascade Passages program which is out of Brazil. Essentially the healthcare system in Tanzania, and the reason I picked this is it’s more and organization with administrative kind of issue. What they had done prior to over hauling their mental health service delivery for rural kids, is they had decentralized and make very much accessible their primary health care facilities. So kids were, rural kids were getting in to be seen, rural mothers were getting in to be seen, rural families were getting to be seen, for real basic care. I mean, we’re not talking about specialty care, but their mental health services were very poorly staffed, it was almost all out patient, if they had some kind of institution, it was basic custodial, these were the chronic types of people to do. So what they did, which I think was very innovative, is they targeted five area, five mental health areas that they were going to service. Only five. And so what they did is they did acute and emergency problems, epilepsy, chronic psychosis, common emotional illnesses and mental retardation. I think what’s particularly interesting here is that epilepsy was a mental health program. Now you have to understand, that this is Tanzania. I worked in Arkansas for 11 years as a clinical psychologist dealing with children and one of the biggest issues among the rural people were families taking their kids off of epilepsy medication because they thought God had done this to them. The certain superstitions that abound by certain medical diseases, are transcended by culture. And so it’s very interesting that I think we need to think more broadly than mental health and just depression particularly for kids. Mental retardation is obviously a big one because these kids particularly female children are a much greater risk for victimization both emotional, physical as well as sexual. What they did before they started any program delivery, is they decided they needed to improve the education about mental health to that community. They recognize that it was a sensitive topic, they needed to enlist public support, and so they did a coordinated strategy in order to make it okay to get help and I think that this is particularly important. Very much in contrast in Brazil, they started the cascade passage and program, and excuse me if I didn’t pronounce that correctly, but essentially this program was for adolescent females 12 to 18 years of age who are prostitutes. It was specifically designed as a grass roots effort to basically to take these girls off the street and reduce the rate of victimization. And so essentially what they did is they got community based people to provide dance instruction and so under this guise, they provided education, they provided health services, they tried to improve their social skills and their skills building, and essentially provided them a safe environment and so maybe less likely to get an STD, less likely to be hit or abused during their course of day to day interaction with their clients. Ultimately, this program across time, has essentially changed. It still services girls who are engaged in prostitution, but basically the goals are not to prevent prostitution, as much as it is to develop competency. And so what’s nice about this program is grass roots efforts that starts with one specific focus in mind often change across time and become very much community based and self sufficient. Finally in conclusion, I thing it’s extraordinarily interesting that in 1993 a group of bankers and looked at, how can we invest in health. And basically they noted a strong relationship between economic development in health and they were also overwhelmed in huge and striking differences in health status among countries. Which allowed them to look at the recommendations that is one, countries really need to invest in their economics because it directly relates to their health, they need to invest in education because you get a two fold increase. You get better economy, you get better health and what we need to do is if we educate in our females, we can really improve the economy because they’re not contributing because they haven’t been allowed to. And finally we need to promote the rights and status of women, if in fact we’re going to improve the lot of both mental health as well as physical health of those constituents. Thanks.

Not exactly how much time we have, we may have 10 minutes or 20 minutes somewhere in there. What we’d like to do is to sort of open it up now if there are anybody who has any questions, specifically to address to anybody here. One of the, to me fascinating things was that is Kathleen is you were talking about issues and lessons learned, you’re talking about the international community, sounds awful lot like through the basic same things we’re trying to sort of say about what are the issues in the United States and I think I was sort of naively under the assumption that stories were very different in different countries, but it doesn’t seem as though that’s very true, nearly as much as I would have thought.

Questions-(inaudible)