Tamizaje de la actividad antiplasmodial de los extractos

PROGRAMMES

School-based SRH is considered an important strategy in reducing risky sexual behaviour among adolescents (421). The school-based approach plays an important role in promoting comprehensive sexual health among young people (422). Numerous systematic reviews and meta- analyses have highlighted the value of school-based health services. Data from high income countries suggests that school-based health services remains popular among young people and provides vital mental and SRH services but also address health disparities in clinic attendance (377). A systematic review of eight cluster-RCTs enrolling more than 500000 participants in five trials were conducted in SSA (Malawi, South Africa, Tanzania, Zimbabwe, and Kenya), Latin America (Chile), and in Europe (England and Scotland). The studies evaluated the impact that school-based programme had on the prevalence of HIV and other STIs. The review concluded that schools remained an appropriate place to provide health education that included contraceptive choices and condoms (421). Sani et al. reviewed 21634 relevant citations evaluating school-based SRH education. From the 51 papers finally reviewed, the authors concluded that school-based health care had the potential to promote condom use among young people in SSA (422).

Adolescents need access to effective SRH interventions, but face barriers accessing them through traditional health systems. Data from rural Kwa-Zulu Natal found overwhelming community support for school-based SRH clinic services particularly in areas with high reported HIV prevalence and teenage pregnancy rates among adolescents (423). A series of after-school SRH education programmes and school health services was conducted in 18 schools and among 1576 participants in the Western Cape Province. Low rates of attendance were reported with lower rates described among those who had been victim of IPV or sexual violence, or had perpetrated IPV. Those attending were motivated by wanting to access information, and the life coaching offered but those unable to attend were hampered by the lack of available safe transport and by domestic responsibilities. There is an obvious need to reduce these structural barriers to attendance (424). Scaling-up the provision and access to HCT is a priority as the South African youth are at particular risk of acquiring HIV. Focus group discussions conducted in rural schools in the Vulindlela sub- district of uMgungundlovu in KwaZulu-Natal found that the stigma and discrimination associated with HIV testing, exacerbated by concerns of a potential positive result remained the most

63 significant obstacles to uptake of voluntary HIV testing services. Their fears were compounded by the perceived backlash of peers, partners, family and the community (425). Systematic review of the evidence base for HIV prevention strategies among the youth yielded the key recommendations of addressing HIV social risk factors (such as gender, poverty and alcohol); targeting the structural and institutional context of their understanding; working towards changing social norms and normalising the HIV testing; and engaging schools in new ways that promote participatory learning (399). Although HIV prevalence has declined among young people in many high-burden countries, 20 countries in SSA accounted for nearly 70% of the world’s new HIV infections among young people in 2009 (426).

Adolescents encounter difficulties dealing with their sexuality and the impacts of peer pressure such that they have a high propensity for engaging in early and risky sexual practices making them susceptible to early infection with diseases such as HIV (427, 428). Young people need to be empowered to make constructive decisions about their SRH and need to make informed decisions about engaging in sexual relationships once they feel emotionally and sexually mature (429, 430). However, the broader context of the adolescent in South Africa has to be taken into consideration. Many adolescent children face the daily reality of dysfunctional homes, poor role models, inadequate life-skills, violence, crime, poverty and hunger (431). Despite efforts at ‘normalizing’ the disease, discussions around sex and sexual behaviour often remains taboo between parents and children resulting in adolescents developing many misconceptions about sexual health and risk, increasing the probability of them acquiring STIs (432). Apart from high rates of HIV and unwanted pregnancy, poor sexuality education reinforces the environment for gender-based violence to occur, thereby harming young people in general but particularly the educational attainment of women (430, 433).

There are have been several more positive perspectives approached in school-based health care specifically in South Africa. Lawrence et al. evaluated a mobile school-based HCT service based on the WHO youth-friendly health service model that operated in two secondary schools in Cape Town. They concluded that HCT in this setting made the service more accessible but stressed an acceptable and equitable distribution of services (434). Data from HCT testing conducted in rural KwaZulu-Natal confirmed the high prevalence of HIV among female learners and further

64 underlies the vital need for school-based HIV testing services as an entry point for HIV prevention and treatment services (435). In Cape Town, the ‘Listen Up’ programme was introduced as a structured, curriculum-based, peer-led educational system to learners entering high school on topics varying from HIV knowledge transmission to sexual attitudes. The study findings reinforced the role of peer-education in facilitating adolescents' self-efficacy in sexual relations and in improving HIV transmission knowledge, thus potentially contributing to reduced HIV transmission among adolescents (436). PREPARE, a multi-dimensional school-based programme was introduced as part of a RCT in 42 South African high schools, targeting IPV in particular. Those among the intervention arm reported lower rates of victimisation, suggesting safer relationships with a potential decreased risk of HIV acquisition (437). Exploring a strategy as diverse as VMMC in a school-based programme enjoyed a level of success. Studies that engaged learners on VMMC in 42 schools in Vulindlela found the programme was embraced as feasible, acceptable and safe in the school-based setting (333). Drawing from the outcomes of 70 consultative meetings held with the community and key-stakeholders in rural Kwa-Zulu Natal, the SRH service provision pilot was deemed acceptable and feasible for scale-up. Their additional comment was that school-based services needed to be tailored to suit the health needs of the adolescents (423).

There remains a desperate need for a comprehensive approach towards sexual health interventions and programmes that are culturally and socially sensitive and relevant. It may be the case that the educator may be unfamiliar with the cultural backgrounds of the learners. Hence the need for a working relationship between the family/community and the school to facilitate the development of a curriculum that is responsive to the needs of the child (438). From the evidence presented globally and in South Africa, school-based health services appear to be an acceptable, accessible and safe option for delivery of health care to adolescents. The school environment appears to be conducive to peer led and curriculum based learning that embraces the participation of the learners as opposed to the more traditional delivery mechanisms of health service at PHC facilities.

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