How To Prevent Substance Abuse In Girls And Young Women

Transcription

1 Background: The Role of C4D in addressing drug use amongst adolescent girls Draft Background Paper for the 12 TH UNRT on C4D Submitted by the United Nations Office on Drugs and Crime (UNODC) The harmful use of psychoactive substances or simply drugs leads to a number of physical and psychosocial problems in an individual s life. The repeated use of drugs can lead to a dependence syndrome, commonly referred to as addiction. The symptoms include a strong desire to take the drug (craving), difficulties in controlling its use (loss of control), continued use despite harmful consequences, higher priority given to drug use than to other activities and obligations, increased tolerance, and a withdrawal state (physical and/or psychological). The World Health Organization estimates that globally, some 39 deaths per persons are attributable to alcohol and illicit drug use 1. Of these 35 are attributable to alcohol use and four to illicit drug use. The use of alcohol and illicit drugs accounts globally for almost 13 disability-adjusted life years (DALYs) lost per 1000 persons. Approximately 11 DALYs of these are lost due to alcohol use and approximately two DALYs to illicit drug use 2. Globally, the United Nations Office on Drug and Crime (UNODC) estimates that between 149 and 272 million people, or 3.3 per cent to 6.1 per cent of the population aged 15-64, use illicit substances at least once in the last year. About half is estimated to be current drug users, indicating the use in the last month. Global estimates indicate each year almost 200,000 people die from illicit drugs, 2 million from tobacco related and 5 million from alcohol-related health conditions 3. Drug dependence has been recognized scientifically as a chronic, relapsing disease similar to other diseases such as diabetes and hypertension, which require long term treatment, including both medical treatment and psycho-social support. It is increasingly being recognised as a health concern, rather than being a law and order issue. Drug dependence inflicts a heavy toll on users and their families, with the most vulnerable and marginalized groups hit hardest. It is also a challenge for health care and criminal justice systems, especially in low- and middle-income countries. Drug use does not only affect individual users, but also their families, friends, co-workers and communities. Children whose parents take drugs are themselves at greater risk of drug use and other risky behaviors. Drug use is often associated with crime, street violence and other social problems that harm communities. In some regions, the injecting use of especially opiates is contributing to the rapid spread of infectious diseases like HIV and hepatitis. Regarding the use of drugs by women, there are no global estimates available. This should, however not lead to the construct that women do not use drugs. It is rather the lack of comprehensive and consistent sex-disaggregated data across countries and regions which make drug use among women 1 For the purpose of this paper, drugs considered include alcohol, tobacco as well as illicit narcotic and psychotropic substances as defined by the UN Conventions on Drug Control (1961,1971), briefly called illicit drugs. Most common illicit drugs are cannabis, heroin ( and forms of it), cocaine (and forms of it), synthetic drugs (amphetamnines). The paper also mentions prescription drugs such as benzodiazepam and others, which have become a common substance of use in many parts of the world, often together with other substances. 2 ATLAS on substance use (2010) Resources for the prevention and treatment of substance use disorders-who 3 UNODC, World Drug Report

2 invisible. In general, societies are more permissive with men s drug use than with women s. Women s drug use tends to be more stigmatized and their drug use is less likely to be acknowledged than men s. As a result, women s drug use is more hidden and less visible, less studied, less attended to and therefore, in general, much less is known about the prevalence and patterns of women s substance use the cause for it and how to address it in terms of both prevention and treatment. A social taboo against chronic drug use among women may be seen a protective factor, which is reflected in lower long-term female use rates 4 but should also be seen as a cause for nonreporting/under reporting and thus complicating issues. Country-specific information indicates the following information on women s drug use: United States of America: In 2010, the rate of current illicit drug use among persons aged 12 or older as higher 11.2 percent for males and 6.8 percent for females 5. Afghanistan: Cannabis is the most commonly used illicit substance in Afghanistan. Cannabis is less commonly used among women with numbers ranging between 10,000 and 16,000 regular cannabis users (0.2 per cent of the adult female population compared to 8.1 per cent prevalence among the male adult population). The opiate use prevalence among males is estimated to be 3.9 percent of the male adult population (247,000 regular users) compared to 1.3 per cent of the female adult population (76,000 regular users). As for young women, key informants thought that opium, cannabis and heroin were the three main substances used by young drug-using women suggesting that drug use patterns among young women are similar to those among men. The overwhelming proportion of key informants rated cannabis as the main substance used by adolescents. Next to cannabis, opium and heroin are considered to be the two other commonly used substances among adolescent drug users. 6 Australia: Based on 2001 data, the use of illicit substances is more common among men than women (41.3 per cent versus 34.2 per cent), except for the youngest age group. Among 14- to 19-year-olds, 37.4 per cent of males and 37.9 per cent of females report they have ever used an illicit substance. In this same age group, female rates of ever having injected a substance exceed those of males (1.7 per cent versus 1.0 per cent). Illicit substance use is most common among those in the age group years, with 65.2 per cent of males and 59.9 per cent of females reporting they had ever used an illicit substance. Prevalence rates for substance use disorders in the Australian population were 3.1 per cent among males versus 1.3 per cent among females; of those, 46 per cent of women and 25 per cent of men had a concurrent disorder. Brazil: A household survey of substance use in 24 large cities in the state of São Paulo found the male: female ratio of cannabis use to be 3.5:1 and that of cocaine use to be 4:1. For stimulants, the ratio was 0.3:1 and for benzodiazepines, it was 0.6:1. However, the study also found a higher proportion of females than males initiating cocaine use, suggesting a potential increase in cocaine dependency among women. Bhutan: The study Drug Use Situation and Responses in schools and communities - A Rapid 4 UNODC, WDR Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings, - Substance Abuse and Mental Health Services Administration (SAMHSA), Afghan Drug Use Survey

3 Assessment in Phuentsholing found that the onset age for drug use (alcohol, inhalants, pharmaceutical drugs and heroin/brown sugar) among males was 16 years, while for females 19 years. Of all interviewed female drug users, none had started injecting drug use. Chile: Though the rates of lifetime and recent use of illicit substances are higher among men than women, the rates of dependency on cocaine, and on cocaine-base paste, are higher among women. Rates of use of illicit substances have remained stable over the last several years, with a decrease in rates of use of cannabis products and cocaine base paste among adolescents, particularly adolescent women. However, alcohol use has increased more among women than men in this age group. China: Among the overall population, the number of registered drug users has risen rapidly through the 1990s, with the actual number of users believed to be much higher than those registered. The number of women using substances is also increasing and many women substance users are also involved in prostitution to support their habit. Colombia: The national household survey of Colombia (2008) studied the use of ten different substances in the population aged 12 to 64. Substances studies include tobacco, alcohol, tranquilizers, stimulants, cannabis, cocaine, basuko, ecstasy, inhalants and heroin. Of 2.4 million drug users classified as problem users of alcohol, 0.6 million are women. 20 per cent of the alcohol problem users belong to the age range 18 to 24. Regarding illicit drugs, there are some 300,000 dependent users of whom 64,000 are women. 54,000 of the 300,000 dependent users are below 18 and two thirds of all below 35 years. While for almost all substances, prevalence rates are considerably higher for men than for women, there is almost no difference with regard to the initiation of consumption, as follows : tobacco (16 years for men, 17 for women), alcohol (same), tranquilizers (17 years for both sexes), marihuana ( 17 years with 25 per cent having initiated at 15 years), cocaine (16 years for both), basuco (18 years for both), ecstasy (50 per cent of all consumption started between 16 and 20 years with no difference between men and women, inhalants (use mainly related to street children). Germany: It is estimated that about per cent of the substance users who use popularly called hard drugs (illicit drugs other than cannabis) are women, most of whom are poly-substance users with a preference for heroin. However, crack use is increasing among women in their twenties, as well as those in their mid-thirties and older. European Union: In the European Union countries, as in many other regions of the world, national rates of illicit substance use are lower among women than men, while rates of use of licit and illicit medications such as benzodiazepines are higher. However, gender differences in rates of cannabis use among teenagers (15-16 years) are small or non-existent, and girls appear to initiate the use of experimental substances at a younger age than boys. India: Although the majority of substance users in India are male, use of heroin has increased among women in different cities in India. In a rapid assessment survey conducted in 14 cities in India in the period , women substance abusers represented a mean of 7.9 per cent, heroin, alcohol, cannabis and painkillers being the dominant substances of abuse. In a more recent study in 2008, out of 1865 women drug users from all over the country, 113 (6.2%) were below 20 years of age, nearly a third illiterate, many married before the age of 18 years and many of them reported childhoods of poverty. Injecting drug use has been reported from all over the country, with common reasons for injecting being peer pressure and economic difficulties. Sexual abuse, pre-marital sex and sex for money was significantly more commonly reported by female drug users compared to non-drug using female partners of men who use drugs. Being subjected to violence, reproductive health problems, 3

4 and low risk perception to HIV characterized this group. Mental distress was very high, with nearly 40% having made a suicidal attempt in the previous year. 7 Iran (Islamic Republic of): A rapid situational assessment of drug use in 1999 carried out by the United Nations Office on Drugs and Crime and the Islamic Republic of Iran estimated that 6 per cent of the 800,000-1,200,000 substance users were women [14]. It is also believed that substance use among women is increasing rapidly [4]. Common substances of abuse in the Islamic Republic of Iran are opium, opium residue, heroin and cannabis. Only about 5 per cent of women substance users reported injecting drugs mainly women aged between 22 and 30 years and involved in sex work. The interval between first substance use and injecting averages 2.5 years (in contrast to 8 years for men). Only about 5 per cent of those in treatment are women. Nepal: A study on drug use in Nepal carried out by the Government of Nepal in 2007 showed that 7.2 per cent of drug users in Nepal were women. A UNODC supported study Profile, drug use patterns, risk behavior and selected bio-markers of women drug users from seven cities in Nepal (2011) interviewed 393 female drug users, of whom 323 were injecting drug users. 199 of them injected on a daily basis. The mean age of the female injecting drug users was 20 years old with 59.8 per cent of all respondents being in the age range of 18 and 20 years. The median age of first drug use of all females respondents was 17 years. 20 per cent of the 393 respondents had started drug use between 10 and 13 years, 53.9 per cent between 14 and 17 years and 28.2 per cent between 19 and 22 years. Russian Federation: Official statistics indicate that the annual number of women, first registered with a diagnosis of drug addiction during the period , increased 10 times country-wide and 16 times in Moscow. In a study of 80 women admitted to two treatment programmes for heroin addiction, it was found that the time period between starting heroin use and seeking treatment was shorter for women than in a comparison group of men; women were four times more likely than men to have used heroin as their initial substance of abuse and often proceeded to injecting without previous intranasal use. For Australia, Brazil, Chile, Germany, European Union, Iran, Russian Federation: Source: Substance abuse treatment and care for women: Case studies and lessons learned, UNODC 2004 For Colombia:Estudio nacional de consumo de sustancias sicoactivas en Colombia, Ministerio de proteccion Social, UNODC y Direccion Nacional de Estupefacientes For Nepal: Profile,drug use patterns, risk behavior and selected bio-markers of women drug users from seven sites in Nepal, UNODC 2011 (working document) For Bhutan: Drug Use Situation and Responses in schools and communities. A rapid assessment in Phuentsholing, Bhutan. UNODC, 2009 Drug use and its implications for women In most countries of the world, the circumstances of women s lives differ considerably from those of men. This is also reflected in their experience when they try to deal with their substance use problems. Drug use has a very different health impact on women from men. Women experience physical, psychological and social consequences from smoking, drinking and using drugs, many of which are different from or more severe than those experienced by male substance users. For instance, at the 7 Women and Drug Abuse in India, UNODC

5 same levels of use, women are more likely to become dependent on tobacco and more intoxicated from drinking than males and are more vulnerable to alcohol-induced brain damage and other substance-related problems than men. Women with substance use disorders are likelier than men to have co-occurring mood or anxiety disorders 8. Women with substance use problems experience significant barriers to accessing treatment, and are believed to be underrepresented in treatment settings. Cultural taboos and stigma mean their substance use problems are often not acknowledged by themselves, their families or helping professionals who could support them in seeking treatment. Pregnant and parenting women using substances face particular societal condemnation, and pregnant women often delay seeking services with serious implications for the mother and the foetus and later to the child. Women who are parents usually have primary responsibility for childcare, as well as other household responsibilities. However, few treatment services provide childcare, and in some cultures it is very difficult for women to leave their homes and family responsibilities to seek treatment. More often than men, women have been introduced to substances and continue to use substances with their spouses or partners, who may also be physically or sexually abusive. Thus, their choice of drugs mode of use-i.e. whether oral or injecting, decision to initiate, abstain or continue to use remains beyond their control. This, coupled with little emotional support from the family or society, or financial resources to pay for treatment, childcare or transportation, women find it difficult to enter and remain in treatment. Women also have more severe problems at treatment entry than men. Many have experienced trauma and use substances to cope with these experiences. They are more likely to have mental health problems such as anxiety or depression or post-traumatic stress disorder than men. They also have fewer resources in terms of education, employment and finances. At the same time, because more men than women use illicit and other substances of abuse, most treatment programmes have been designed with men in mind and do not take into account gender differences 9. With regard to injecting drug use, both men and women who inject drugs experience a significant burden of HIV disease, infection with other blood borne viruses and also potentially life-threatening conditions such as tuberculosis. However, women who inject drugs face even greater risks. Studies indicate that women who inject drugs are more likely to face violence and greater levels of stigma and are more likely to die earlier 10. Effects of drug use on adolescent girls Adolescence is usually a time of good health for girls, with opportunities for growth and development. But it can also be a time of risk, particularly with regard to sexual activity and substance use. Preventing and dealing with such risks is essential for the health of young people now and for their health in future years. Worldwide there are some 1.2 billion adolescents aged between 10 and 19 years. Around 90 per cent of them live in developing countries, and approximately 600 million are female. The health and development of these girls is very important now, and continues to be important as they mature into adults. The health of adolescents sets the stage for their future health 8 The Formative Years: Pathways to Substance Abuse Among Girls And Young Women Ages 8-22, 2003, The National Center on Addiction and Substance Abuse at Columbia University 9 Substance abuse treatment and care for women: Case studies and lessons learned, UNODC UNAIDS 2010 GLOBAL REPORT 5

6 and well-being, as well as for the health of their children and the development of their societies. Adolescence is normally characterized by low levels of disease and death; it is the period of life when mortality rates are lowest. However, it is also a time of huge physical, social and emotional changes. In many settings, girls are not given the support they need to deal with these changes. The societies in which they live are unable to provide optimal conditions for their healthy development. As a result, girls may miss opportunities to progress successfully through the transition to adulthood, becoming vulnerable to behaviours that put their health at risk. 11 While historically young men have been more likely than young women to drink alcohol, smoke cigarettes, and use illicit substances, local, national, and international data now show that this gender gap in substance use is closing. 12 Recent data shows that in several European countries, alcohol consumption increased among female adolescents between 1993 and 2003 (13) Meanwhile, data from 37 low- and middle-income countries indicate that 14% of girls aged years reported drinking alcohol in the past month compared to 18% of boys. Because of male female differences in body weight and body water content, girls are more vulnerable than boys to the psychoactive effects of alcohol and are therefore more likely to suffer the consequences of its use including violence, unintentional injuries and vulnerability to sexual coercion. Like adolescent boys, many girls take up smoking during adolescence and there is evidence that tobacco advertising is increasingly targeting girls and women. Data from 151 countries indicate that approximately 10% of adolescents (12% among boys and 7% among girls) smoke cigarettes and 10% use tobacco products other than cigarettes (e.g. pipes, water pipes, smokeless tobacco and bidis). Smoking among girls is more common in high-income countries than in lower income countries. 13. In general, there is no global research or literature on influences and pathways to substance use by girls. In 2003, The National Centre on Addiction and Substance Abuse (CASA) at Columbia University, USA published The Formative Years report, a groundbreaking study on the pathways to substance use for girls and young women. This study identified key influences on girls and young women s substance use that can be categorized into four domains: personal attributes, attitudes, and childhood experiences; peer and school influences; family, culture, and community; and societal influences, such as media advertising. The study reveals that girls and young women use substances for reasons different than boys and young men, that the signals and situations of higher risk are different and that girls and young women are more vulnerable to abuse and addiction: they get hooked faster and suffer the consequences sooner than boys and young men. Following are some of the key findings of the assessment of the causes and consequences of substance abuse among girls and young women: 1. Girls who abuse substances are likelier to be depressed and suicidal--increasing the risk for substance abuse. 2. Girls are likelier than boys to diet and to have eating disorders. Such girls are at increased risk for substance abuse. 11 Women and health : today's evidence tomorrow's agenda-who Simons-Morton, B.G., et al., Gender specific trends in alcohol use: Crosscultural comparisons from 1998 to 2006 in 24 countries and regions. International Journal of Public Health, Women and health : today's evidence tomorrow's agenda-who

7 3. Girls are likelier than boys to have been physically or sexually abused. Such girls are at increased risk for substance abuse. 4. Among teens, who move frequently from one home or neighborhood to another, girls are at greater risk than boys of smoking, drinking and using drugs. 5. Girls typically experience puberty at an earlier age than boys. Girls who experience early puberty are at increased risk of using substances earlier, more often and in larger amounts than their later-maturing peers. 6. Substance use can sink into abuse more quickly for girls and young women than for boys and young men, even when using the same amount or less of a particular substance. 7. Girls and women are likelier than males to experience adverse health consequences from smoking, drinking or using drugs. 8. Substance use increases the likelihood that girls will engage in risky sex or be victims of sexual assault. 9. Teenage girls are likelier than women of any other age to smoke, binge drink and use illicit drugs during pregnancy. 10. Girls differ from boys in their ease of obtaining tobacco, alcohol and drugs and in the offers they receive to use these substances. Understanding how substance abuse affects women is important; understanding the unique pathways to addiction that originate in childhood and progress through adulthood is essential if this leading women s health problem has to be addressed. No formula exists for identifying who will engage in substance use or if that use will lead to dependence or addiction. Certain factors increase the risk that a girl or young woman will travel the pathway to substance abuse or move her farther down that pathway; other protective factors help steer her away from the road to addiction. Risk and protective factors for substance use are linked to an individual s personality, family, peers, community and culture. In the past, girls substance use rates and patterns were monitored primarily as a means of highlighting how much greater a problem substance use was for boys than for girls. Today, teenage girls are using some substances of abuse at rates similar to those of boys (particularly tobacco) and even surpassing boys in their misuse of other substances (such as prescription drugs). 14 Prevention of drug use amongst adolescent girls The closing of the gender gap for substance use and the differences between girls and boys in the pathways to substance use and abuse all underscore the need for prevention strategies that are effective for girls and young women. Women with substance use problems already experience significant barriers to accessing treatment, and are underrepresented in treatment settings. Ignoring the growing problem of adolescent girls abusing substances will lead to next generations of women facing the same situation, posing a serious health issue to themselves and societies as well as increasing the burden on the health system. Societies will be losing out on vital human resources. Few programs exist that are designed specifically for girls and research on effective prevention strategies for girls is hard to come by. Although primary care physicians are in a unique position to intervene early in the substance use of their young female patients, physician screening for adolescent substance use is uncommon.even when physicians do screen for substance use, they are unlikely to provide adequate guidance to their young patients. Hence it is vital to replace one-sizefits-all prevention programming with comprehensive approaches tailored to the needs and circumstances of girls and young women. 14 The Formative Years: Pathways to Substance Abuse Among Girls And Young Women Ages 8-22, 2003, The National Center on Addiction and Substance Abuse at Columbia University 7

8 Truly effective substance abuse prevention and treatment for girls and young women requires tailoring programs to address the risks and consequences of smoking, drinking and drug use that are unique to them. The public health community needs to drive home the message that on average, one drink has the impact on women that two drinks have on men. Prevention programs need to recognize, for example, that girls are more likely than boys to be depressed, have eating disorders or be sexually or physically abused, all of which hike the chances for substance abuse. Girls are likelier than boys to use alcohol and drugs to improve their mood, enhance sex and reduce inhibitions. Girls are more likely to be offered drugs by a female acquaintance, a young female relative or a boyfriend, whereas boys are more likely to be offered drugs by a male acquaintance, a young male relative, a parent or stranger. Girls are likelier to receive offers to smoke, drink or use drugs in private settings, whereas boys are likelier to receive these offers in public settings. While few programs are designed around factors that specifically and uniquely influence girls to use or refrain from using substances, research does highlight some factors that may enhance the effectiveness of prevention programs for girls: The Family. Although family supervision and support are important in preventing substance use among both girls and boys, they are especially important for girls. The School. Feeling connected to school may be a stronger predictor of school performance for girls at high-risk than for boys at high-risk. This is especially meaningful when considering that poor school performance in adolescence increases the risk for alcohol and drug abuse in early adulthood. Female Role Models. Programs that provide girls with positive female role models may improve intervention effectiveness for girls. Life Skills. Since relationships and attachments to others are central to girls growth and development, the acquisition of life skills and social skills may be of particular importance to prevention programs for girls. Timing. Prevention programs that begin early, in grades four through eight-- generally before girls begin using substances--have been found to be especially effective for girls. Effective Components of Prevention: Key Findings Program Content and Implementation: Address the personal, social and environmental factors that contribute to substance use. Emphasize the development of behavioral life skills. Strengthen social bonding with people in families, peer groups, schools and other realms who hold strong standards against substance abuse. Address multiple substances. Ensure that interventions are culturally sensitive and appropriate. Intervene early and at critical developmental stages. Intervene in settings that most affect risk and protection for substance abuse, including homes, schools, workplaces and recreational settings. Involve parents, caregivers and families. Utilize interactive methods, such as peer discussion groups. Implement strategies around a clearly defined prevention theory. Program Duration: Offer the program over a sustained period of time. Reinforce interventions over time. For youth at high risk, provide for intense contact (more than four hours a week) and provide more than twenty hours of programming. Source: The Formative Years: Pathways to Substance Abuse Among Girls And Young Women Ages 8-22, 2003, The National Center on Addiction and Substance Abuse at Columbia University 8

9 However, serving girls alone does not, by itself, make a prevention program more effective for girls, especially if the program focuses primarily on feelings and emotions. In a multiple-site study of 48 substance abuse prevention programs across the USA, the Center for Substance Abuse Prevention (CSAP) found that high-risk girls who were participating in programs designed to serve females only did not reduce their rate of substance use relative to girls participating in mixed-gender programs. This may be because the female-only programs tended to emphasize affective activities - or activities focusing on self-esteem, self-awareness and attitudes, beliefs and values associated with substance use and other problem behaviors. 15 The female-only programs also had lesser emphasis on knowledge and information as a prevention activity (21.1% compared to 44.4% of mixed gender programs), where common topics for knowledge-focused sessions in the female adolescent programs included physical and sexual abuse, hygiene and nutrition, pregnancy prevention, and AIDS prevention. It was noted that while programs emphasizing a knowledge focus, affective issues, recreation, or interactive program delivery did not produce stronger prevention outcomes for girls, those that emphasized life-skills programming produced stronger effects that were statistically significant. 16 Integrating communication strategies in drug use prevention programs for adolescent girls Promising prevention strategies are often designed to address different levels of risk factors. (i) Universal prevention efforts, like drug education target all youth without identifying and addressing those particularly at higher levels of risk. (ii) Selective interventions concentrate on those who are particularly vulnerable to drugs because of personal, family, and community risk factors. (iii) Indicated interventions are intensive efforts aimed at youth who are already experimenting with alcohol and other drugs or exhibit other risk-related behavior. Successful prevention strategies also incorporate the cultural, gender, and age-specific needs of participants. Although individual programs differ widely, the Center for Substance Abuse Prevention (CSAP) has identified six basic approaches to prevention which are described in Understanding Substance Abuse Prevention: Toward the 21 st Century: A Primer on Effective Programs: Information dissemination is designed to increase knowledge and alter attitudes about issues related to alcohol, tobacco, and other drug use and abuse; Prevention education teaches participants critical personal and social skills that promote health and well-being among youths and help them avoid substance abuse; Alternative approaches assume that youth who participate in drug-free activities will have important developmental needs met through these activities rather than through drug related activities; Problem identification and referral involves recognizing youths who have already tried drugs or developed substance use problems and referring them to appropriate treatment options. This is particularly important for high-risk youth; Community-based process enhances community resource involvement in substance abuse prevention, for example, by building interagency coalitions and training community members and agencies in substance abuse education and prevention; and 15 The Formative Years: Pathways to Substance Abuse Among Girls And Young Women Ages 8-22, 2003, The National Center on Addiction and Substance Abuse at Columbia University 16 Making prevention effective for boys and girls CSAP National Cross-Site Evaluation of High-Risk Youth Programs,2002 9

10 Environmental approaches attempt to promote policies that reduce risk factors and/or increase protective factors related to substance abuse, such as community laws prohibiting alcohol and tobacco advertising in close proximity to schools. The CSAP-identified key elements are not mutually exclusive; effective strategies include prevention education in schools; mentoring and other supervised activities for after-school hours; special interventions for high-risk youth; strengthening families; and empowering communities. 17 It is in this context that effective Communication for Development or C4D strategies can be woven into drug use prevention and treatment programmes and be used to strengthen responses by relevant stakeholders to address the drug use amongst adolescents. In 1997, through Article 6 of General Assembly Resolution 51/172, the United Nations adopted the following formal definition of Communication for Development: Communication for development stresses the need to support two-way communication systems that enable dialogue and that allow communities to speak out, express their aspirations and concerns and participate in the decisions that relate to their development. Since then, other definitions of C4D have evolved and reflect the increased understanding of the role of C4D in development processes. In 2006, the Rome Consensus from the World Congress on Communication for Development2 defined Communication for Development as: a social process based on dialogue using a broad range of tools and methods. It is also about seeking change at different levels, including listening, building trust, sharing knowledge and skills, building policies, debating and learning for sustained and meaningful change. It is not public relations or corporate communications. United Nations organizations currently identify four main strands within the C4D landscape: (i) behavior change communication; (ii) communication for social change; (iii) advocacy communication; and (iv) strengthening an enabling media and communication environment. They also recognize that there is a significant crossover among these approaches. Behaviour Change Communication (BCC) is an interactive process for developing messages and approaches using a mix of communication channels in order to encourage and sustain positive and appropriate behaviours. It has evolved from information, education and communication (IEC) programmes to promote more tailored messages, greater dialogue and increased ownership together with a focus on aiming for, and achieving health-enhancing results. Since the 1990s, increasingly comprehensive communication strategies including community mobilization, clientcentred counselling and social network interventions have been used to effect behaviour change. Recognizing that individual behaviour is shaped by social, cultural, economic and political contexts, these strategies may incorporate peer education, social marketing, entertainment education, public policy and media advocacy, personal and community empowerment, and public relations. Communication for Social Change (CFSC) emphasizes the notion of dialogue as central to development and the need to facilitate poor people s participation and empowerment. CFSC uses participatory approaches. It stresses the importance of horizontal communication, the role of people as agents of change, and the need for negotiating skills and partnerships. Thinking on CFSC continues 17 Promising Strategies to address substance use - U.S. Department of Justice Office of Justice Programs

11 to evolve, and in some United Nations organizations there is recognition that successful programme initiatives can merge community dialogue processes with mass media approaches and other forms of informational and motivational communication and advocacy. Advocacy communication involves organized actions aimed at influencing the political climate, policy and programme decisions, public perceptions of social norms, funding decisions and community support and empowerment regarding specific issues. It is a means of seeking change in governance, power relations, social relations, attitudes and even institutional functioning. The approach of strengthening an enabling media and communication environment emphasizes on strengthening communication capacities, including professional and institutional infrastructure, to enable all groups to voice opinion and participate in development debates and decision-making processes. 18 Many drug use programs coordinate prevention efforts across settings to communicate consistent messages through school, work, religious institutions, and the media. Research has shown that programs that reach youth through multiple sources can strongly impact community norms. Some carefully structured and targeted media interventions have proven to be very effective in reducing drug abuse. For example, a mass media campaign targeting sensation-seeking youth reduced marijuana abuse by 27 percent among high sensation-seeking youth. 19 The following are examples of initiatives which have incorporated C4D strategies to prevent drug use amongst adolescent girls: Kenya: Integrating HIV/AIDS, drug use and life skills education into the Girl Guide Movement The Kenya Girl Guides Association (KGGA) has been collaborating with Family Health International (FHI) on peer education and behaviour change programmes for adolescents since In 2008, KGGA began a new programme where 32 Girl Guides, whose average age was 13, helped to develop an interactive life skills curriculum and a peer education handbook. The first publication (Discovering the Potential of Girl Guides in Schools: A Life Skills Curriculum for Adult Guide Leaders) is used by an adult Guide leader usually a teacher while conducting life skill education sessions for about 50 Girl Guides per school. Among the girls who complete the sessions, four Girl Guide patrol leaders per school are chosen by their peers to become peer educators. The second (A Curriculum of Peer Education Sessions for Use with Pupils in Primary Schools) is for peer education delivered in schools by Girl Guides for classmates ages The girls selected the 12 session topics; wrote the first draft; and ensured that its interactive format, information, and fun activities would engage the interest of the classmates. Girl Guide patrol leaders in that age range use the manual at their schools to conduct 40-minute peer education sessions (for boys as well as girls) about twice a month, at lunchtime or another convenient period. For each of these sessions, the manual provides scripts for skits and stories, questions and answers, and an "energizer" (or icebreaker) when participants sing and move around. The session topics are: values and school performance, self esteem, common illnesses, understanding feelings of attraction, communication skills, helpful adults, decision-making skills, peer 18 Communication for Development - Strengthening the effectiveness of the United Nations, Promising Strategies to address substance use - U.S. Department of Justice Office of Justice Programs

12 pressure, HIV transmission, reducing stigma and discrimination, preventing rape, and refusing drugs and alcohol. Some parents of peer educators have come to recognize their daughters' great potential and noticed that they became more responsible after taking on that role. One parent testified that she herself had benefited from what her daughters had shared about decision-making, self-esteem, HIV and AIDS, and other topics. Peer educators attest to improved grades and changed lives. Maureen Anita, 14, said that session participants "no longer use drugs and others have stopped engaging in sex. They continue to tell us to teach them more." The highlight of this initiative is that it integrates the enduring values of the Girl Guide movement with the life skill education rather than treating HIV/ AIDS and life skills education as a stand-alone item. Tajikistan and Uzbekistan: The DDRP Sister to Sister projects on drug demand reduction The Sister to Sister Model was developed under the United States Agency for International Development (USAID)-funded Drug Demand Reduction Program (DDRP), which aimed to address social problems among vulnerable populations involved in or at risk of involvement in drug use in Central Asia. Conducted from 2002 to 2007 by a network of international organisations active in HIV prevention and drug demand reduction in the region, DDRP sought to engage all levels of society in reducing demand for heroin and other opiates by educating populations on drug-related issues, promoting healthy lifestyles, providing access to alternative occupational and leisure activities, assisting in solving social problems, and supporting the development of pragmatic DDR strategies at national and local levels. There was a referral system for treatment readiness, drug use treatment and rehabilitation programs for women drug users and those who are not themselves drug users but lived in families where men used drugs. The DDRP Sister to Sister Model addresses issues that have exacerbated female poverty and driven ever-increasing numbers of women in Central Asia toward drug-related crime and sex work. These issues include: Male economic migration to Kazakhstan, Russia and beyond, leaving women with pressing needs for income but few choices for earning income; Increasingly traditional gender roles and expectations, especially in rural areas, again limiting women s ways of earning income; Women s diminished access to education and socialization as well as to employment; Economic and social pressures contributing to low self-esteem, poor life skills and depression Vulnerable women includes women who are poor, divorced, widowed, recently released from prison, or whose husbands are heroin-involved (trafficking, circulation, or use) or have migrated in search of work, leaving their families behind. Young women who have moved to the city unaccompanied are also considered vulnerable. Tajikistan: The DDRP Drug free Public Social Spaces Model The USAID funded Drug Demand Reduction Program (DDRP) implemented five Drug free Public Social Spaces projects, all in Tajikistan. These projects were targeted at disadvantaged communities with a high number of migrants. A Drug free space is a space where children can play with children and where adults and extended kinship networks can gather and interact. The creation of this drug free space serves as a platform for drug use prevention education. Through this phased intervention, a targeted group of adults, parents, migrant families, and mahallas, rather than being treated as frag- 12

13 mented populations needing separate or distinct interventions, are directly involved and collectively empowered to create a community level response to reducing drug demand. The DDRP Drug free Public Social Spaces projects facilitated social contact among recent arrivals and their longer term urban-resident neighbours in a friendly atmosphere that combined social activities with drug demand reduction education. Each of these interventions focused on reducing the economic and emotional vulnerability of individual children, adolescents and parents to criminal activities including drug use. The drug free spaces aimed to create a common drug free social space, which allowed local people to socialize, and combined drug demand reduction education with a variety of skills training and other activities. Communication when providing treatment for adolescent girls who use drugs Few programs exist that specifically cater to the treatment needs of substance-abusing girls and young women. Few studies have evaluated the effectiveness for girls and young women of current smoking cessation and substance abuse treatment programs. Traditionally, substance abuse treatment programs were designed for and primarily served adult males. Prior to the 1970 s, few programs existed for women and until the 1970 s alcohol and drug abuse treatment for women received little attention in the research community. Since then, research on substance abuse treatment for women has expanded and knowledge of women s access and barriers to treatment as well as unique and gender-linked factors that may promote or hinder their treatment success and recovery has grown. The number of programs treating women has increased and growing emphasis has been placed on developing programs that address the needs of female substance abusers. Many experts, however, continue to note the lack of treatment options and inaccessibility of treatment programs to women. Furthermore, research on the effectiveness of substance abuse treatment programs for women remains in short supply. Research specifically addressing the treatment needs of substance-abusing girls and young women as well as the effectiveness of the programs that treat them is in even shorter supply. Treating girls for substance abuse presents challenges that do not apply to the treatment of adult women. Girls go through enormous physical, hormonal and emotional changes that contribute to stress and challenge their coping abilities. Many of the life stresses that lead to substance abuse in girls and young women are intricately connected with other problems such as co-occurring psychiatric disorders, emotional difficulties, dysfunctional family relations, physical or sexual abuse and parental abuse of alcohol or drugs. Each of these issues, when pertinent to the patient, must be addressed in the treatment setting. 20 Even when there are treatment options available, young girls using drugs may feel ashamed, fear stigmatization or the lack of privacy and confidentiality when considering approaching treatment services. They may be afraid to make their problem visible, and thus avoid using services. Thus, there is a need for communication initiatives to: 1) Reach out to the girls and educate them about the treatment and support options available 2) Enable them to comfortably and safely access services 20 The Formative Years: Pathways to Substance Abuse Among Girls And Young Women Ages 8-22, 2003, The National Center on Addiction and Substance Abuse at Columbia University 13

14 3) Educate the community to understand drug use as a health problem that needs treatment and thereby help reduce the stigma surrounding drug use 4) Educate service providers and health care workers An example of an intervention where drug use prevention and treatment was addressed through C4D was the CHARCA Project, implemented in India. The CHARCA (Coordinated HIV/AIDS response through Capacity- Building and Awareness) project was formulated through the coordinated efforts of nine UN agencies and covered six districts of India. The aim was to target men and women between the ages of 13 and 25 years with the objective of firstly, empowering them by increasing their awareness of STI s and HIV and secondly, facilitating a conducive environment for treatment through social support systems. There was also a special emphasis on reducing the vulnerability of women as they are at greater risk of acquiring HIV due to their overall low and marginal status in society. Under this initiative, UNODC worked in the district of Aizawl in Mizoram state of North-East India to reduce STI/HIV/AIDS risks and vulnerabilities including those specifically related to substance abuse and Injecting Drug Use and increase capacities of young women to better protect themselves. The overall strategy in Mizoram was to engage the key stakeholders in the state to prevent the spread of HIV among young women and to mainstream the activities under the project into the ongoing National programmes. This was the first time that a girl/women-centric intervention was developed in the state. Following the development of District Action Plans and a Log frame, two baseline surveys were conducted: on impact parameters and communication planning and on awareness and understanding of myths and misconceptions associated with drugs and HIV/STIs in Mizoram. 289 villages having a Mizo Hmeichhe Insuihkhawm Pawl (MHIP) (the largest women s federation in the State) were selected for the implementation of the project. Women s centres were set up at the MHIP offices in these villages. They functioned on the same lines as drop-in-centres, but at the village level. CHARCA built capacities of trainers (master trainers, key stakeholders, members of MHIP at both district and village levels) on gender and HIV issues and conducted Training of trainers (TOTs) for each district. Training of 900 women counsellors was undertaken. Of these, 300 were selected as peer educators and appointed at centres where young girls could come together, interact and have group discussion and receive counselling on drug use and HIV/AIDS. The project also trained the PE on livelihood skills such as herbal medicine, beauty culture and flower making. As the PE themselves were recovering drug users, ex female sex workers, HIV positive persons or widows, they were able to bring a personal understanding to their work and build strong relationships with the people they interacted with. The PE during their community visit would identify and refer young women, in the age group of years, to the De-addiction cum Rehabilitation Centre in Aizawl. Due to the initiatives undertaken by the PE and the numerous advocacy programmes conducted, the project was also successful in generating support from the churches. For instance, Presbyterian Church was the first church in Aizawl to include the issues of women's vulnerability to HIV and drugs in the Sunday school curriculum. Information, education and communication (IEC) plans were drawn up covering vulnerability of women, HIV/AIDS, drug use, and sex & sexuality, using gender specific IEC material, radio jingles, talk shows and the Young Mizo Association (YMA) newsletter. Materials were developed in the local language on women s vulnerabilities issues, resulting in greater outreach and awareness generation on the theme and identification of critical gaps. Key stakeholders from various ministries as well as health workers, the media, church leaders and community-based organisations were sensitized on the gender dimension and the project strategy. 14

15 Other communication tools employed included: (i) A CHARCA film for awareness generation on women s vulnerability. (ii) Music bands to sensitise young audiences. (iii) Dramas, with the women s vulnerability issue as its main theme. Mass reach out through IEC was one of the main priorities of the CHARCA project. Existing IEC materials were reviewed with respect to key inputs on gender and HIV/AIDS in Aizawl, Mizoram. A Gap analysis on 17 materials revealed that none of the materials had specifically incorporated the CHARCA gender specifics. The materials were not gender sensitive to the Mizo culture. Therefore, a new set of materials were developed for peer educators, taking the findings into considerations and pre-testing of the same. It is heartening to note that the materials are still being used in the region even after the closure of the project. A unique way of creating awareness among the general population was through the Youth Icon Musical Talent contest, organized by LPS, a local cable network in collaboration with UNODC, CHARCA. Given the deep love for music in the region, the idea caught the pulse of the population. Such an event was organized for the first time ever in the history of Mizoram. The event greatly helped Peer Educators to gain greater acceptance from the community and had facilitated in easing their work in the field. The event had also generated a renewed interest in CHARCA with local bodies who came out actively and inquired if UNODC-CHARCA would partner with them in the fight against Drugs and HIV/AIDS in the state. The above examples show that C4D interventions can play a significant role in bringing about addressing drug use amongst adolescent girls. Main challenges in achieving the desired change Limited C4D strategies have been used as part of the planned responses to address drug use among adolescents and subsequently little is known about their effectiveness. Most of the efforts have been directed to prevention of drug use and not for treatment. So evidences on their effectiveness is not enough for replication and scaling up of programme. National drug prevention, treatment and care policies and programmes do not include C4D components Drug prevention, treatment related service programmes do not include C4D as an integral component at the planning/designing stage Indicators for measuring effectiveness of C4D is not included in measuring outcomes of the programmes Capacity for implementing C4D at various levels of staff is poor. Understanding of C4D among the Media personnel and their role in development programmes is limited. Suggestions or recommendations on how to support adolescent girls empowerment, breaking the marginalization and vulnerability using communication Build capacity of development workers, media and policy makers on C4D strategies Include, C4D components in drug prevention treatment programmes right from the inception of all levels of programmes Develop suitable C4D indicators for measuring effectiveness of the programmes right at the inception 15

16 Include, adolescent girls, their parents, guardians, school teachers, other care givers and the media in the planning and implementation process Invest in studies to measure effectiveness of C4D strategies in drug prevention and treatment programmes among adolescent. Discussion Points What are the challenges in bringing female oriented C4D initiatives to address drug use prevention, treatment and care? Need to emphasize on importance of female oriented prevention and treatment services Need to bring in adolescents as a specific group Need greater awareness amongst policy makers/other stakeholders need for communication and advocacy How should such programmes be planned? What needs to be communicated? Assessments and evaluations? What are the cost considerations? How does one make these sustainable? The need for evidence based interventions to be integrated into C4D Programmes Need for Increased recognition of the problem need for increased advocacy amongst policymakers/stakeholders Elaborated by UNODC Regional Office for South Asia with contributions from Ms. Cristina Albertin, Representative, Mr. Debashis Mukherjee, Research Officer and Ms. Madhyama Subramanian, Communications Officer 16