|Sexually Transmitted Diseases (STD) Prevention: New Challenges, New Approaches (AIDSCAP/FHI - USAID, 1996, 47 p.)|
by Donna Kabatesi
I was treated for an STD, but it reappeared. Another doctor said it was pelvic inflammatory disease. Can you tell me what that means?
I was tested and found to be suffering from syphilis. I have had several injections since. Does this mean that there is no cure for my disease?
Young people benefit when they have access to STD education and counseling that respects their integrity and autonomy. (Schytte/UNICEF/4909)
Every week, young people from all over Uganda send or call in questions like these about sexually transmitted diseases (STDs) to my radio show, Capital Doctor. Their voices often reveal their anxiety, and I do my best to help them deal with the complex medical and personal concerns they raise.
Youth in Uganda and throughout the world seldom have access to reliable information about STDs. In many cultures, shame, fear and denial cloud discussion of the issue, and adults to whom young people might naturally turn - parents, teachers, school nurses, community leaders - find it difficult to speak openly about STDs. In poor countries, educational and medical resources for prevention and treatment of STDs are particularly scarce.
But even when facts and figures on STDs are available to young people, their needs are often still unmet. The questions from my listeners illustrate how young people remain confused about their diagnoses and treatment even after they've turned to providers for help.
As I've come to realize from talking about STDs to young people over the air, at schools and in clinical settings, reaching and helping youth require more than random information and a prescription for the pharmacist to fill.
STDs and Ugandan Youth
In Uganda, STDs are a serious health problem. While reliable information is scarce, one 1991 survey done by the Ministry of Health showed that approximately 20 percent of hospital outpatient visits were attributable to STDs. About half of the hundreds of calls and letters I receive at Capital Doctor are about STDs, the majority of them from young people between the ages of 17 and 25.
One reason why there are so few data on national STD prevalence is that many STDs are not treated within the formal health sector. Ugandans who suspect STD infection often ask drug store proprietors, traditional healers or family and friends for advice on diagnosis and care. Young people in particular seek primary STD diagnosis and treatment recommendations from the latter. If they turn to the formal health care system at all, it may be months after they've already consulted these informal sources.
Such delays are caused at least in part by cultural values that inhibit discussion of sexuality and sexually related health problems. Young people may be too embarrassed to seek clinical treatment, fearing stigmatization. Girls in particular regard anything related to sexual behavior as taboo.
High costs for treatment also discourage some young people. Even at clinics where STD treatment is free, unauthorized charges keep some away. A young person might spend 50,000 shillings (U.S.$50) - the equivalent of half a term's school fees-for basic treatment at a private clinic. It's little wonder that many youth turn to self-diagnosis and self-treatment, with the help of friends or family.
What motivates most young people to finally seek professional advice and treatment is what they've learned about the dangers of leaving STDs untreated. Some of the most compelling reasons include suspicion that a symptom signals HIV infection, or fear of infertility, chronic pain or even death from the STD. Because young people frequently postpone treatment, such complications are a very real threat.
One 18-year-old girl I treated waited four months to come to the clinic, despite severe pain, for which she had self-medicated with antibiotics and painkillers. She had pelvic inflammatory disease (PID), complicated by a tubo-ovarian abscess. Because of the delay, her fallopian tubes are badly damaged; she is likely to suffer from chronic PID, and will probably never be able to conceive.
Many young people receive confusing and conflicting diagnoses that leave them more bewildered than when they started.
Unfortunately, when youth finally approach the formal STD care system, they often encounter an obstacle course. Many STD clinics are overburdened, and providers have little time to talk or counsel patients. Often, young people feel they have to endure a judgmental and alienating clinic atmosphere. Care providers, believing they can influence risk-taking behaviors, may berate young men for their sexual activities, which discourages them from using formal health care systems in the future. It's hardly surprising that an impersonal newspaper column or radio program attracts young people as an alternative source of reliable STD advice.
The frustration can deepen during and after the examination. Too often, young people find that their questions are given short shrift, or ignored altogether. Many receive confusing and conflicting diagnoses that leave them more bewildered than when they started. The diagnostic process can sometimes be incomplete or inaccurate, as seen by a widespread tendency at STD clinics to diagnose most outbreaks of genital ulcers as syphilis. Excerpts from letters sent to the health advice column of New Vision, a Kampala daily, are revealing.
I am 19 years old, and for six years I'd get vaginal itching and a creamy discharge. When I went to doctors, first they said it was gonorrhea, and I was treated with injections. A laboratory assistant said it was syphilis, and I was given tablets, but the cure was temporary. I also used various creams and traditional herbs, but the itching is back.
I am suffering from a chronic STD. I have been treated with various medical injections and capsules, but I only end up with temporary relief, not a complete cure. I got the disease when I was 17 years old. Now I have many problems, pain in my testes, backache, itching. I am in a dilemma.
Although radio talk programs and newspaper health columns are valuable and popular sources of STD information for young Ugandans, they cannot substitute for comprehensive, cooperative, community-based STD education and treatment networks that include the schools, mass media, the national health care system and youth organizations such as religious groups and the Scouts. Such multisectoral networks could offer both education and consistent messages reinforcing behavior change, in addition to attractive and affordable treatment options for young people.
As part of this effort, health care practitioners must be trained to provide accurate diagnosis and treatment, as well as counseling appropriate for young people. Sensitivity and tact are particularly important when providers counsel youth. Information alone-without consideration for the confidentiality, integrity and autonomy of young people-will not lessen the anxieties that keep so many from seeking care in the first place.
In a Ugandan classroom, boys learn how to prevent becoming infected with HIV. (Schytte/UNICEF/4909)
Thoughtful youth educators also know that it helps to use a broad-based approach to STD education and counseling that takes other anxieties of young people into account. Most teenagers take personal appearance and social behavior very seriously and often compare themselves critically with their peers. Worrying about attractiveness and what is normal is all part of the package of concerns that young people have about sexuality, and youth respond well to STD educators who can also address such issues. Young callers to Capital Radio want reassurance that acne is part of growing up, that the size of their breasts isn't unusual, that a penis that points in the wrong direction doesn't imply sterility. When I'm able to answer such questions, it's more likely that the young people who ask them will return for help if STD symptoms ever appear.
One pioneer in youth-oriented STD care is the Naguru Youth Health and Information Center in Kampala, a pilot project that provides comprehensive adolescent health services with the active participation and leadership of young people. The Family Planning Association of Uganda, the Ugandan YWCA and various religious organizations are also developing STD services for young people.
To curb the spread of STDs among young people, Uganda must tap the full range of society's educational, medical, social and human resources-schools and teachers, parents and employers, doctors and traditional healers, religious leaders and sports stars, radio shows and mass advertising campaigns. Individual STD education and treatment projects for youth make valiant and valuable contributions, but comprehensive national efforts are what will ultimately make the difference for young Ugandans and for millions of young people around the world.
Donna Kabatesi, M.D., is currently a Fogarty Scholar at the School of Public Health, University of California at Berkeley. In Uganda, she works in the STD control unit at the Ministry of Health. In addition to co-hosting Capital Doctor, Dr. Kabatesi is an advisor and contributor to Straight Talk, a UNICEF-funded tabloid offering Ugandan youth information about STDs and HIV.