PART D: HEALTHY LIVING

Ministry of Community Development Mother and Child Health National Peer Education Training Manual for Adolescents PART D: HEALTHY LIVING Trainer s Manual 2013 0

Table of Contents Acronyms... 2 About the National Peer Education Training Manual for Adolescents:... 3 How to Use this Manual with Youth in the Community... 4 PART D:5 HEALTHY LIVING... 5 Session D1: Introduction to Holistic Health... 6 Session D2: Alcohol and Drug Abuse... 15 Session D3: Sexual and Reproductive Health and Hygiene... 19 Session D4: Human Sexuality... 24 Session D5: Sexual Identity and Sexual Diversity... 34 Session D6: Relationships... 39 Session D7: Pregnancy and Abortion... 42 Session D8: Family Planning and Contraception... 49 Session D9: Safe and Unsafe Sexual Behaviour... 57 Session D10: Sexually Transmitted Infections and Safer Sex... 59 Annex 1: Illustrative Agenda for a four-day training covering all sessions in Part D... 64 Annex 2: Reading materials... 65 Annex 3: Definitions and Concepts (Glossary)... 66 1

Acronyms ADH AIDS ART ARV BBT BCC CRC FAMs FGM/C FP HIV HSV IUDs IEC KEBI LGBTI M&E MC MCDMCH MCP MOH MSM MTCT NGOs OIs PE PLA PLHIV PMTCT PPAZ RRA SDM SMART SRH UNAIDS UNESCO UNFPA USP VCT WHO YFHCs ZISSP Adolescent Health Acquired Immune Deficiency Syndrome Anti-Retroviral Therapy Anti-Retroviral Basal Body Temperature Behaviour Change Communication Convention on the Rights of the Child Fertility Awareness-based Methods Female Genital Mutilation/Cutting Family Planning Human Immunodeficiency Virus Herpes Simplex Virus Intrauterine Devices Information, Education and Communication Keep Expenses Below Income Lesbian, Gay, Bisexual, Transgender and Inter-Sex Monitoring and Evaluation Male circumcision Ministry of Community Development Mother and Child Health Multiple and Concurrent Partners Ministry of Health Men who have sex with men Mother-to-Child Transmission Non-Governmental Organisations Opportunistic Infections Peer Education Participatory Learning and Action People Living With HIV Prevention of Mother-to-Child Transmission Planned Parenthood Association of Zambia Rapid Rural Appraisal Standard Days Method Specific, Measurable, Achievable, Realistic and Time-bound Sexual and Reproductive Health Joint United Nations Programme on HIV/AIDS United Nations Educational, Scientific and Cultural Organisation United Nations Population Fund Unique Selling Point Voluntary Counselling and Testing World Health Organisation Youth Friendly Health Centres Zambia Integrated Systems Strengthening Programme 2

About the National Peer Education Training Manual for Adolescents: Background: The National Peer Education Training Manual for Adolescents is an important document for people working with young people and organisations serving youth and covers various issues affecting the development of adolescents in Zambia. The manual was developed through a process of harmonisation of existing training materials to develop a national peer education training manual that could help in- and out-of-school young people to health-related knowledge, attitudes, and life skills and their access to health services. The National Peer Education Training Manual for Adolescents is a resource document for facilitators of training for peer educators. A summarised version of the same manual is available for participants of this peer education training. Goal: To set a national standard to the content and process of peer education training for adolescents in Zambia. The training plans to equip young people with knowledge, skills and values that aid to make responsible choices and decisions about their sexual health and social relationships as well as their future destiny. Objectives: a) To increase knowledge and understanding of the changing physiological and sociocultural environment; b) To explain and clarify feelings, values and attitudes in the changing environment; c) To develop and strengthen various types of skills; d) To promote and sustain risk-reducing behaviour; e) To encourage career and value development, and f) To promote negotiation and decision-making power of the young people of Zambia. Training Materials: The Facilitator s Manual, divided into five parts, should be used by the facilitators as a resource guide when they train peer educators. The trainer s manual contains comprehensive information in all the subject matters that are relevant to adolescents. The manual provides step-by-step instructions on how to run each session and how to lead exercises and activities. The participant s manual contains hand-outs for each of the sessions. Peer educators should receive the entire facilitators and the entire participant s manuals. Youth in the community can receive individual hand-outs (copied from the participant s manual) for each session. Please see the next page for information about stationery and other training materials. 3

How to Use this Manual with Youth in the Community FACILITATOR: Trained peer educators TARGET AUDIENCE: Youth who present to Youth-Friendly Centres and/or youth that are members of clubs, school groups, etc. The training content is divided into five separate parts. The parts should be used together: Part A: Introduction and course list. This part also has 11 sessions used in training peer educators themselves. Part B: Environment around a young person (8 sessions) Part C: Life skills (11 sessions) Part D: Healthy Living (10 sessions) Part E: HIV and AIDS (10 sessions) The full course list can be found in Part A. SESSIONS: The peer educators may disseminate content of this manual in a more informal way and over a much longer period than ten days depending on their target audience mix. For example, a new session could be covered at each weekly meeting of a youth group. Please note that peer educators can create their own agendas and are encouraged to combine sessions from each part into their activity. The peer educators/facilitators can use, skip, add or modify the content based on the contexts or needs and capacities of the participants of the training. If you wanted to run a training that covers all of Part D, an illustrative agenda can be found in Annex 1. STATIONERY AND OTHER TRAINING MATERIALS: For every session, the following materials are recommended: 1. Copies of hand-outs from the participants manuals (one for each participant) 2. Flip charts and markers (for group work and for recording key discussion points) 3. Blackboard and chalk (if flip charts are not available, or to provide another surface for writing key summary points) 4. Pieces of paper and pens for participants (to take notes) 5. If there are any materials specific to a particular section (e.g., condoms in the how to use a condom session), then these are listed at the start of the section. 4

PART D: HEALTHY LIVING 5

Session D1: Introduction to Holistic Health Session Outcome: At the end of this session participants should be able to recall and state the different aspects of holistic health. Time: 2 hours Part 1: Discussion about holistic health Buzz group activity: Ask each participant to turn to their neighbor and discuss one thing they could do to improve one area of their own health. Encourage the participants to not only think about their physical health, but also their mental, social, cultural, intellectual and spiritual health. Ask for the pairs to share examples with the larger group. Explain the following key points: Health is defined as a dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity. (World Health Organisation) Health is one of the most important things in a person s life. When a person is healthy he or she is able to do the things that make life enjoyable. Health is more than being free from illness and disease. physically, socially/culturally, spiritually and mentally. It is being well Holistic health is a general wellness approach that addresses the body, mind and spirit or the physical, emotional/mental and spiritual aspects including social/cultural, intellectual surroundings of an individual. Lead a discussion with the following questions: Can you be healthy with limited financial resources? What can you do to improve your health in every aspect? Which is more important physical, mental, spiritual, cultural or social health? How can we help each other to become healthier? 6

Part 2: Physical health Ask participants: What is physical health? Can you give examples of how you know if you are physically healthy? Key points: Physical health refers to as a state of well-being when your body is functioning as it is designed to function. All internal and external body parts, organs, tissues and cells are functioning properly. A person is physically fit to perform their daily activities without restrictions. Examples of physical health: If you are physically healthy then the different parts of your body are working properly. our ears can normally hear our eyes have normal vision, our legs can walk, jump, run your breathing is normal you are able to digest your food properly There are four categories of things that affect physical health. 1. Lifestyle 2. Human biology 3. Environment 4. Healthcare services. You cannot always control the things that affect your physical body. But, you can do your best to prevent injury and help your body to function well. Part 2: Mental health Ask participants: What is mental health? What are common mental health issues in adolescents? Key points: Mental health is defined as a state of well-being in which every individual realises his/her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her/his community (World Health Organisation). Mental health in adolescents is related to how they think and deal with emotions during this stage of growth. 7

Mental health issues in adolescents: Emotions can bring discomfort for everyone, but this is especially true for adolescents, who are still learning to identify and manage their emotional responses. The early teen years are marked by rapid changes; physical, cognitive, and emotional. Emotional extremes are common during the teen years and may be reflected in mood swings, emotional outbursts, sadness, or behaviours intended to distract from uncomfortable feelings (such as sleeping or listening to loud music). Issues that can affect the mental health of adolescents include: Stress Changing relationships with peers New demands at school Family tensions Safety issues in their communities The most common mental health disorders in adolescence are: depression, characterised by prolonged periods of feeling hopeless and sad anxiety disorders, which include extreme feelings of anxiety and fear alcohol and other drug abuse, including use of prescription drugs like for non-medical reasons. Most mental health disorders are treatable. Treatment often includes and often works best when multiple approaches are used. These can include cognitive-behavioural therapy, family therapy, medication, and supportive education for parents and other caring adults in how to provide stability and hope as the family navigates its way through the episode of emotional disturbance. Part 3: Stress Ask participants: What is stress? Key points: Stress is a body s reaction to a challenge, which could be anything from outright physical danger to asking someone for a date or trying out for a sports team. Stress is your mind and body s response or reaction to a real or imagined threat, event or change (i.e. Fight or Flight Response ). The threats, events or changes are commonly called stressors. Stressors can be internal (thoughts, beliefs, attitudes) or external (loss, tragedy, change.). Stress is caused by major life changes and environmental events (time pressure, competition, noise, disappointments, financial problems, etc.) 8

Positive and Negative Stress: Stress is an everyday fact of life Good and bad things create stress. Getting into a fight with a friend is stressful, but so is a passionate kiss and contemplating what might follow. Excessive or Chronic stress can be harmful. It has been linked to numerous health problems/illnesses including; cardiovascular disease, cancer, gastrointestinal problems, mental health concerns, etc. Positive Stress: Enables concentration, increases performance and motivation, energizes. Negative Stress: Reduces effectiveness, results in loss of motivation and can lead to physical, mental/emotional and behavioural problems. Ask participants: How can we cope with stress? The ways in which teens cope with these stressors can have significant short- and long-term consequences on their physical and emotional health. Difficulties in handling stress can lead to mental health problems, such as depression and anxiety disorders Tips for Managing Stress: 1. Identify your Stressors. 2. Know how you react. 3. Learn tools and techniques to deal with stress (See Table 11). 4. Integrate stress management into your daily life. Table 1: Tools and techniques to deal with Stress Boost your self-image: Take deep breaths, accompanied by thinking or saying aloud, I can handle this. Lower unrealistic expectations. Accept yourself as you are; identify your unique strengths and build on them. Give up on the idea of perfection, both in yourself and in others. Take time to release stress: Schedule breaks and enjoyable activities. Take care of your physical health: Exercise and eat regular meals Get proper sleep Break the habit of relying on caffeine or energy drinks to get through the day Perform progressive muscle relaxation, which involves repeatedly tensing and relaxing large muscles of the body. Seek support: Talk about problems with others. Set small goals. Break tasks into smaller, manageable chunks. Focus on what you can control (your reactions, your actions) and let go of what you cannot (other people s opinions and expectations). Visualise and practice feared situations. Work through worstcase scenarios until they seem amusing or absurd. 9

Part 4: Spiritual Health Ask participants: 1. What is spiritual health? 2. What are examples of problems people might have related to spiritual health? 3. Why is spiritual health important? Key points: Spiritual health means the act of having direction and meaning in life. It involves the development of positive morals, values and ethics. When people become spiritually healthy, they demonstrate love and sense of caring for self and others. Spirituality centres on the connection to a reality greater than oneself and can include the sacred experience of religious awe and reverence. Spirituality involves deep feelings and beliefs, including a person s sense of purpose, connection to others, and understanding of the meaning of life. Spiritual development is shaped both within and outside of religious traditions, beliefs, and practices. Spiritual health is not only about religion or belief but also one s connection to one inner self. Examples of problems with spiritual health: Someone who is sad can feel out of touch with their true self and disconnected from the Universe. A person can feel spiritually lost and unbalanced, which may cause us to be moody and discontent with life, and perhaps grow emotionally distant from our loved ones. Nourishing our spiritual self is as important as food, water and exercise. When we feel spiritually connected and fulfilled, everything in our life (including physical and emotional pain) are easier to deal with. We feel lighter and happier. There's no denying it - when we feel connected and balanced spiritually we feel better physically and emotionally. Some people claim to experience complete healing from certain health conditions through a variety of spiritual methods, but this doesn't happen all that often. However, even if complete healing is not attainable, our physical health (and over all sense of well-being) can be greatly enhanced by enriching our spiritual health. 10

Part 5: Social cultural health Ask participants: What is social-cultural health? What can improve someone s socialcultural health? Key points: Social-cultural health refers to how one interacts with friends and other community members. It is an indication where an individual stands among members of a community and with people close to a person. Values such as friendship and intimacy are crucial for a person as an individual. On the contrary, loneliness and rejection in the social arena have negative implication for health. Social-cultural health can be improved through: Recognition Making friends Gaining respect Being loved Being considered as a trust-worthy person in a group If you are socially healthy, you are happy and cheerful and can get along with others. For example, you are able to have friends, have fun and accept other people, even if you have different points of view. Part 6: Maintaining good health Ask participants: Which is most important: physical, mental, spiritual or social health? Each area of health is important and they affect each other. For example, if you have an argument with your spouse or friend it means all is not well with your social health. As a result of the argument you may get angry or feel hurt which affects your mental health. As a result of this you may not sleep, which will affect your physical health. Ask participants: What needs must be met in order to maintain good general health? The most basic needs are: Survival needs - basic needs for food, water and shelter. Security needs - the needs to feel safe and protected and also to feel loved and appreciated by family, friends and the wider society. Self-esteem needs - the needs to believe in yourself and be proud of who you are and what you can do. Self-actualisation needs the need to reach your full potential as a person. 11

Your ability to meet these needs will be related to individual, social and economic issues. Individually you will be affected by your abilities and background. Socially you will be affected by your family and the opportunities available to you. Economically you will be affected by your wealth or lack of it. Ask participants: What can a person do to promote and maintain good health? Rest: The body and mind need rest to repair worn out tissues. Sleep is an important way of resting. Adults need about eight hours of sleep each day, whereas children need 12-14 hours. Exercise: Strengthens the heart, muscles and joints and improves the circulation of the blood. Helps to reduce stress and therefore promotes mental health. Everybody should be encouraged to exercise every day at an appropriate level for their age and fitness. Exercises can range from stretches, to housework, to walking, to running or playing a game of football. Nutrition: Eating a healthy, nutritious and balanced diet is central to healthy living. Traditional foods that are widely available in Zambia are cheap and can provide a healthy and balanced diet. Avoiding drugs and alcohol: Drugs and alcohol are potentially damaging to a person s physical, social and mental health. Drugs should only be taken as advised by a medical practitioner. Alcohol intake should be limited to safe levels. Treatment of infections: It is important to treat infections promptly in order to maintain good health. This is particularly important for people living with HIV. Hygiene: Personal hygiene. Handling and storing food carefully. Keeping your home and environment clean Preventing the spread of germs that cause diseases. All of the above are important, but especially so for people living with HIV. 12

Part 7: Small group work: Disability and health Instructions: 1. Divide participants into four groups. 2. Ask each group to discuss a different need of disabled youth in line with the holistic health approach. Each group should address one component: Physical health Mental health Spiritual health Social health 3. Ask each group to present their work in the plenary. Part 8: Personal reflection on health Read the questions called How Healthy Am I? out loud one by one. (You can add to or change the statements as needed to be relevant to your participants.) After you read each statement aloud, let the participants rank themselves as either: Almost always Very often Sometimes Almost never How healthy am I? 1. I avoid drinking alcohol. 2. I practice monthly self-examination for cancer (women breasts/ men testicles). 3. I have no difficulty in falling asleep. 4. I am generally healthy and free of symptoms of illness. 5. I have close friends or relatives whom I can talk to about personal matters and call on for help. 6. I avoid fried or fatty foods. 7. I eat a fresh fruit or vegetable every day. 8. I taste my food before salting. 9. I engage in exercise every day. 10. I enjoy physical activity. After participants answer all the statements, lead a general discussion in which participants identify areas in which they are healthy and areas where they need to improve. 13

Session D1: Summary 1. Clarify holistic health. 2. Physical, mental, spiritual and social health are important and they complement each other. 3. The importance of rest, exercise and nutrition is very significant to promote and maintain holistic health. 14

Session D2: Alcohol and Drug Abuse Session outcome: At the end of this session you should be able to understand and explore the effects of alcohol and drug abuse in sexual and health-seeking behaviours. Time: 1 hour Materials: If possible, use a copy of the magazine Alcohol and You: Tilemekeze Umoyo to use during this discussion. Part 1: Role play Instruction: Ask two volunteer participants to role play the scenario below. Two friends are drinking: one is drinking softies whilst the other is drinking beer. The friend who is drinking beer gets more and more drunk until he eventually passes out. Through the drama demonstrate some of the effects of drugs listed on the information pages. (As an alternative you could act this out with someone smoking dagga.) Ask participants to discuss the following questions. The discussion can be held in a small group or a big group. What are alcohol and/or drug abuse? What are the effects of taking alcohol and alcohol abuse? What drugs do young people use in your community? What drugs do adults use? Key points A drug is any chemical you take that affects the way your body works. Alcohol, caffeine, aspirin and nicotine are all drugs. Drugs and alcohol are potentially damaging to a person s physical, social and mental health. Drugs should only be taken as advised by a medical practitioner and alcohol intake should be limited to safe levels. Alcohol is among the most widely used recreational stuffs. Alcohol is the most common mood-altering drug in Zambia. 15

Types of drugs: Depressant refers to any drug or chemical that decreases the activity of any bodily function. The term most often is used to refer to drugs that reduce the activity of the central nervous system. The sedative effects of these agents tend to reduce pain, relieve anxiety, and induce sleep. They include alcohol and tranquilisers. Stimulant refers to a group of drugs that excite the central nervous system, increase alertness, and alleviate fatigue. Caffeine is perhaps the most socially acceptable and commonly used stimulant. Other stimulants include cocaine and amphetamines, which create intense feelings of joy (well-being). Amphetamines, commonly known as pep pills or diet pills, also decrease appetite. Hallucinogens refer to drugs that change a person's perception in reality. People using these drugs often see images, hear things, or feel sensations that are not there. Marijuana and heroin are two examples. Legal drugs and illegal drugs Legal drugs are those that have been approved for sale either by prescription or in shops. If used improperly, people can become physically dependent on some prescription drugs, such as morphine and valium. Illegal drugs are drugs which people may not manufacture, sale, purchase for sale, or possess. These include drugs such as Marijuana (dagga), Cocaine, and Heroin. Which drugs are commonly used in Zambia? Drugs commonly used in Zambia include alcohol, medicines, tobacco, and dagga (also known as marijuana or cannabis). Cocaine and heroin use exists but by a much smaller group of people. Part 2: Alcohol and drug use in youth Every day young people use drugs, alcohol and other mind altering substances that damage their health and compromise their well-being. Ask participants: Why do some youth choose to take drugs or alcohol? Why do other youth choose to avoid drugs or alcohol? What alternatives are there to drug and alcohol use for young people? Why youth do drugs/alcohol Why youth don t do drugs/alcohol Peer pressure Against religious beliefs Hold onto a relationship Against personal beliefs Because they are bored, lonely or angry No need for them To fit in Don t like the effects Satisfy curiosity Don t want to break the law Like the taste or the feeling Witnessed addiction Trying to forget problems or reality Parents say no Because their families use them Risk of losing control 16

Part 3: Alcohol and drug abuse Drug abuse or substance abuse refers to a maladaptive pattern of use of a substance that is not considered dependent. That is the habitual consumption of drugs by people who are addicted to them, or using drugs for a different purpose than that for which they were designed. Even medicines can harm if used excessively or improperly. When we are sick, medicines drugs may be given in prescribed doses to cure our illness. A drug like Coartem, for example, would be quite helpful in treating malaria. If however, someone deliberately used high doses of malaria medicines for other proposes that would be regarded as an abuse of that drug. When an individual consumes alcohol in excess and has difficulty functioning without alcohol, that person is alcoholic. Some people become addicted to drugs. Addiction occurs when the normal functions of the body are altered in such a way that the body requires the continued presence of the drug to function. Addiction can be psychological or physical depending on the drug. The person who is addicted cannot function normally without the drugs of addiction. Many people cannot function without the stimulant caffeine found in coffee, tea and an assortment of softies. Some cannot socialise without alcohol or dagga. Without the drugs, the addict feels poorly, is anxious and restless and may even neglect him or herself. If you drink a lot of alcohol over a period of time it can seriously damage your body and mind. Alcohol acts as a depressant on the body. It slows our reflexes, constricts blood vessels and influences the way we see and interpret events around us. Drinking too much can make men impotent (they can t keep an erection). For a pregnant woman, drinking can damage her unborn child. Health problems associated with alcoholism include permanent loss of memory, liver and heart damage black-outs and shaky balance. Alcoholics/druggists have frequent mood swings, and may have outbursts of violence or depression while drinking. Young people s normal growth and development is often stopped. Drug abuse and addictive behaviour interferes with the establishment of healthy relationships. Drug use impairs judgment in critical areas. Accidents, missed opportunities unintended pregnancies and academic failure are more likely when you can t think straight. Drug addiction and alcoholism also diverts needed financial resources from more constructive endeavours. 17

Preventing drug and alcohol abuse: Knowledge A healthy self-image A strong system of values Assertiveness Healthy activities Part 4: Alcohol and drugs and HIV Ask participants: How are drug and alcohol use related to HIV infection? Key points When you are under the influence of a drug you can make unsafe sexual choices and put yourself at risk of STIs and HIV infections, or transmitting the diseases and the virus. Alcohol consumption is considered a risk factor for STI and HIV infection. This is especially true if a person abuses alcohol or drug. Alcohol consumption impairs judgment and reasonable thinking. Those who intend to use condoms may lose their resolve after drinking alcohol. Condom negotiation with a partner who is drunk is very difficult. Alcohol is also related to gender-based violence. Session D2: Summary Clarify alcohol and drug abuse as a risk factor for STIs and HIV infection. 1. Getting drunk can lead to risky behaviours such as having sex without a condom, and having sex with someone whose HIV status is unknown to you. 2. Getting drunk can reduce your ability to think clearly and to use condoms during sexual intercourse. 3. Drinking alcohol in large quantities can destroy brain and other organs. 4. Binge drinking can also affect your economic capacity 18

Session D3: Sexual and Reproductive Health and Hygiene Session Outcome: At the end of this session participants should be able to understand, explain and maintain personal hygiene. Time: Materials: 2 hours Pad and tampon to show girls during genital hygiene discussion General instruction: Girls and boys should be separated for these personal hygiene lessons. Cover the common issues of personal hygiene with the entire group and then split the group to deal with issues relating to girls or boys only (e. g., Nocturnal Emissions and Toxic Shock Syndrome). Part 1: Discussion on sexual and reproductive health. Ask participants: What is meant by sexual and reproductive health? What are ways that boys and girls should care for their reproductive health before and after puberty? Key Points: Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. Sexual health: Sexual health implies that people have the required information and support to have a responsible satisfying and safer sex live. It also linked to the capability to reproduce and the right to freedom to decide with whom to have sex, when and how often to do it. Reproductive health refers to the disease, disorders and conditions that affect the functioning of the male and female reproductive system during all stages of life. Men and women of all ages must care for their reproductive health to assure optimum attainment of their physical, social and mental well-being. Examples: impotence, infertility, erectile dysfunction, birth defects. Sexual and reproductive health (SRH) is a broad concept encompassing health and wellbeing in matters related to sexual relations, pregnancies and child birth. It deals with the most intimate and private aspects of people s sexual lives, some might be difficult even in discussion in the public. 19

Part 2: Understanding hygiene Ask participants the following questions: 1. How can we improve our general hygiene? 2. How does good hygiene help us to maintain good health? 3. Why is hygiene especially important for people living with HIV? 4. What are the issues for disabled youth that hamper to keep personal hygiene? Key Points: Hygiene is the science of health that deals in personal and environmental cleanliness in order to reduce diseases and promote health. Hygiene is important in preventing the spread of germs that cause diseases, avoiding bad odour and also feeling and look good all the time. Many common diseases (for example cholera) can be prevented through following the basic rules of hygiene. Always wash your hands with soap and water after using the latrine/toilet and after handling anything dirty or unhygienic. Use running water: either a tap or pour from a jug. Maintain your personal hygiene. Handle and store food carefully. Keep your home and surroundings clean. Part 3: Personal hygiene in adolescents Personal hygiene involves cleanliness, especially important when one reaches puberty. Adolescents should pay more attention to the maintenance of hygiene which includes: bodily or genital hygiene following growth of pubic and ancillary hair increased perspiration and body odor due to increased level of sex hormones on-set of menstruation and vaginal discharge. Ask participants: What challenges do young people face in terms of hygiene, and how can they overcome the challenges? As part of the discussion, the facilitator can ask volunteers (two males and females) to share their personal hygiene experience to the group. A. Oral Hygiene: Oral hygiene is important at all ages. In adolescence, in addition to cavity prevention there are new challenges such as maintaining fresh breath, an attractive smile and dealing with braces. A clean mouth requires daily removal of plaque and food particles from between the teeth and under the gum line. When teeth and gums are not cleaned regularly, the bacteria in the mouth increase. Young people with braces should pay special attention to cleaning their teeth because food particles around the wires can cause decay. 20

B. Hair: The hormonal changes that occur during puberty can cause hair to become oily. Glands are more active during puberty. The glands on the hair follicles deposit oil on each hair. This oil makes the hair shiny but it also attaches dirt to the hair. Oily hair needs to be washed more frequently than dry or normal hair. If hair is very oily it should be washed every day. Choose a shampoo to suit hair type. Rinse out well with clean water. Cut pubic and ancillary hair when deemed necessary. C. Body Odour Sweating is a vital and normal process. When people sweat or perspire, the moisture combines with bacteria to create an odour. The apocrine glands, located primarily under the arms and in the genital area become active at the onset of puberty. When these glands are stimulated, they produce perspiration. When the sweat comes in contact with bacteria on the skin the result is body odour. This odour is often unpleasant and increases with physical activity, stress, excitement, nervousness and warmth. Body odour can be effectively managed by daily showers or baths; changing one s clothes daily especially pants for girls; use of a deodorant or anti-perspirant. Make sure that clothes, socks, panties and beddings are washed regularly. D. Healthy Skin There are different forms of skin problems caused by uncleanliness. Skin irritation caused by lack of hygiene and bacteria can be treated if one regularly wash the body and if necessary seek for medical attention. The other skin issue that affects teens is acne. Acne affects about 80% of adolescents. It is not caused by uncleanliness and food probably only plays a minor role. Increased hormone levels stimulate the oil glands in the skin. These glands produce a sub stance that can block the pores and the result is blackheads and pimples. Blackheads and pimples should never be picked at or squeezed as this can result in permanent scarring. Almost all cases of acne can be treated successfully. The treatment for acne is: Gently wash involved areas with a non-oiled soap and a face cloth, twice a day. Avoid moisturisers. Over-the-counter medications that contain benzoyl peroxide can be used in mild cases. See a dermatologist if acne is severe and does not respond to normal treatment. 21

Part 4: Genital hygiene in males and females At this point, the facilitator may want to split the group by gender, with males and female participants separate. Key points for male genital hygiene: All boys need to wash the penis, scrotum and groin area daily. They must dry the area carefully to prevent jock itch (red, itchy scales on skin). Boys who are uncircumcised need to pull the foreskin back to clean the head of the penis. Related topic: Session E7: Male circumcision Key points for female genital hygiene: All girls need to wash their external genital area daily. During menstruation, girls need to wash regularly. They need to use pads or tampons if possible and affordable during their period. Pads are made of absorbent material to soak up the blood so that you don't have an embarrassing leak. When it is difficult to get pads, girls can use clean clothes. Pads nowadays come in all sizes and thicknesses so that there will be one which is most comfortable for you. Pads have a sticky strip, which will stick to your pants and stop them from sliding around. Some of them have 'wings' which stick to the side of your pants for extra protection. Remember to change pads about every 4 hours and be careful about washing your hands afterwards. Pads should never be put down the toilet as they could block the pipes. Look for a sanitary disposal unit in school and public toilets or wrap the pad in toilet paper or a paper bag and put it into the bin. If you have just started your periods and you are not regular yet, you may want to carry a pad with you in your back-pack. Some girls wear a panty liner when they know it is nearly time. You don't have to wear panty liners or pads when you are not having a period. Tampons are made of thick cotton that has been squashed so that it is small enough to fit inside the vagina. 22

They are useful to wear when playing sport or swimming. They are small to carry about. Because they are inside your body, they are less likely to have an odour (smell) even on hot days. They have a string on the end so that you can get them out easily. You can't 'lose' a tampon inside you. Read the directions on the packet and you shouldn't have any problems, but many young women find tampons tricky to put in when they first try using them. It is really important to change tampons very regularly during the day and it is a good idea to wear pads instead overnight because wearing a tampon for a long time can cause a serious infection called toxic shock syndrome. This is rare but very serious. Symptoms include headaches, being sick, rashes, muscle pains, high fever and diarrhoea. Anyone can use tampons but it may be a good idea to start off with pads until you get to understand your periods, like how heavy or light they are, how long they last and what they feel like. Session D3: Summary 1. Sexual health is important to everybody to have the required information and support to have a responsible satisfying and safer sex life. 2. Reproductive health encompasses the functioning of the male and female reproductive system during all stages of life. 3. Sexual and reproductive health is a broad concept encompassing health and well-being in matters related to sexual and reproductive matters. 4. Early recognition of signs and symptoms of sexually transmitted infections and prompt treatment will ensure a healthy sexual and reproductive life. 5. Hygiene and personal hygiene are important in preventing the spread of germs that cause diseases, avoiding bad odour and also feeling and look good all the time. 6. Many common diseases can be prevented through following the basic rules of hygiene. Personal hygiene involves cleanliness, which is especially important when one reaches puberty. 7. Adolescents should pay more attention to the maintenance of hygiene, which includes healthy skin, body hygiene and genital hygiene following growth of pubic and ancillary hair, increased perspiration, body odour due to increased level of sex hormone, onset of menstruation and vaginal discharge. 23

Session D4: Human Sexuality Session outcome: At the end of this session participants should be able to reflect on both their positive and negative experiences of sexuality and encouraged to end the negative cycle of sexuality experience for others and encourage positive messages. Time: Materials: 2 hours Pictures of female reproductive organs Pictures of male reproductive organs Part 1: Group work: How we learn about human sexuality The facilitator should start the session by explaining that people get information about sexuality at different times in their lives and from different people. The age at which individuals receive their first information on sex varies. People obtain information from various sources; for example, friends, parents, brothers or sisters, aunts, grandparents, etc. The facilitator can share his/her own story as an example to help participants understand what you are talking about. Group work instructions: 1. Divide participants into 3 or more groups. 2. Ask the participants to think back to the first time they received information on sexuality. They could have received this information from parents, friends, teachers, alangazies (traditional counsellors) and others. 3. Ask participants share information with their group members, with a focus on the following: a) What age were you when you first received information on sexuality? b) Who gave you the information? c) What message did you get from the information? 4. The group should write down the information on a flipchart. 5. Remind participants to only talk about their own experiences, unless they have explicit permission from their group members to talk about other people s experiences. 6. Give adequate time for group work. 7. When groups have finished discussions, each group can present back their flip chart to the larger group. 24

Key points: There is a diverse range in terms of when people start to hear about issues related to sex. Some messages give a positive image of sex, while others give a negative image. Most messages that we hear as we grow up focus on the negative consequences, and there is very little positive information that we hear about our sexuality. Point out that even within this group we can find a diversity of ages, sources and types of information. It is the same in the communities that we work in. People receive different kinds of information, from different sources and at different ages. It is important to keep this notion in mind when we work with others. Even in a small group, people will be at different levels of knowledge. If young people don t get the correct information at a young age, they may begin to experiment out of curiosity, or get the wrong information from less dependable sources. There is a need to be open about sex and to enable children and young people to receive accurate information to make informed choices in their lives. Note to facilitator: Be aware at this stage of strong messages that come out of the discussion, as you may need to elaborate more on some issues. Part 2: Understanding human sexuality Write the word SEX in the middle of the flipchart or on the ground, and make a circle around it. Have the participants stand around the circle. Ask participants to say what comes to their minds when they see the word SEX. Say that there is no right or wrong, or good or bad contributions all contributions are welcome. Keep good eye contact with the group and encourage contributions. Do not force participation, but offer it and assist participants who might need more time to think. Write the words that the participants say inside the circle on the flipchart or the ground. You can help participants think of more words by asking the following questions: 1. What are the most important parts of the body with regard to sexuality? (e.g., words for sexual organs such as breasts, vagina, penis, etc.) 2. What are positive and negative words that describe how people feel about sex or how people feel during sex? 3. What can sex lead to? Include both positive and negative consequences. 4. What different sexual identities are there? 25

Key points: Human sexuality is a central aspect of being human throughout life. Human sexuality encompasses: Sex Gender identities and roles Sexual orientation Eroticism Pleasure Intimacy Reproduction (producing offspring) A surge of sexual interest occurs around puberty and continues through adolescence. Factors that facilitate the surge include: bodily changes and an awareness of them, rises in levels of sex hormones, increased cultural emphasis on sex rehearsal for adult gender roles. Healthy sexual development involves more than sexual behaviour. It is the combination of physical sexual maturation known as puberty, age-appropriate sexual behaviours, and the formation of a positive sexual identity and a sense of sexual well-being. During adolescence, teens strive to become comfortable with their changing bodies and to make healthy and safe decisions about what sexual activities, if any, they wish to engage in. Expressions of sexual behaviour differ among youth, and whether they engage in sexual activity depends on personal readiness, family standards, exposure to sexual abuse, peer pressure, religious values, internalised moral guidelines, and opportunity. Motivations may include biological and hormonal urges, curiosity, and a desire for social acceptance. There is an added pressure today, especially with girls, to appear sexy in all contexts throughout their lives school, leisure time, the workplace, with friends, in the community, and even while participating in sports or exercises. Decisions to engage in, or limit, sexual activity in ways that are consistent with personal principles and protective of health reflect an adolescent s maturity and self-acceptance. 26

Part 2: Why do people have sex? Hang up a blank flip chart. Ask participants: Why do people have sex? You can also use different questions to get the discussion moving, such as: Why do young people have sex? Can benefits be a reason for having sex? Do people always have a choice when they have sex? List all the contributions on the flip chart and review the key points below. Key points: The reasons why people have sex are different and varied. The reasons may change with time as well, depending on how old people are and the circumstances people face at different stages in life. It is important to be aware that people practice sex for different reasons depending on their circumstances and situations. Draw a circle on the flipchart/whiteboard/on the ground. Divide it into three equal parts, and write one word on each part: Physical, Psychological and Social. Explain the following points: Many things control sex and the decisions we make regarding it in different circumstances. Our decisions can be classified in three categories: 1. Physical (puberty, physical disability, present physical state etc.) 2. Psychological (self-esteem, stress, pressure, etc.) 3. Social (how we are brought up, what people say, what is socially accepted etc.) We can t say exactly how big a space each sector should have since they all interact with each other. Society will influence how we feel on a psychological level, how we feel on a psychological level will influence our physical health (psychosomatic symptoms) and our physical health will influence our mental health. All these issues are linked together. For example, social norms about what we think is beautiful will influence what other people find beautiful. Ask participants: Which of the three aspects carries more weight in controlling the decisions they themselves make regarding sex? Ask for a response to the question from 2 to 3 participants who feel free to share their personal views with the rest of the group. Point the diversity in the answers that each participant gave. The point is to make participants aware that people are not the same, and we should not impose our own preferences and beliefs on others. 27

Part 3: Sexual organs Ask participants: What are the most important parts of the body when it comes to having sex? Key points: The biggest sex organ is the brain. Everything starts from the brain. It is in the brain that conscious decisions are made and arousal starts before the sexual organ starts responding. Sex is also the ability to enjoy the whole body. People need to know when and where they would like to be touched. We can never know what the other person likes until we communicate with that person. Sex is also about communicating our needs and wants to the other person. People need to be encouraged to communicate more. As individuals, we like different kinds of things but the gender norms in our society often do not allow us to express our sexuality and sexual desires in an open way. Based on the fact that we are different and express our sexuality in different ways, we need to be non-judgmental in order to reach out to people in an effective way. Female and male sexual organs. We are all made from the same parts. Female and male sexual organs only start to develop after week 13 of the foetus life in the uterus. Refer to Session B2: Reproductive Organs. Exploring the female sexual anatomy: Distribute the picture hand-out with the female sexual organ to all participants. Using the hand-outs, talk about each part of the female sexual organ and the role it plays in terms of pleasure. Focus on issues relating to: o Masturbation and pleasure o the whole clitoris, including the parts on the inside o the vaginal corona (or the hymen ) and all the myths about it o female genital mutilations and all issues related to it. Exploring the male sexual anatomy: Distribute the picture hand-out with the male sexual organ to all participants. Explain the role of each male sex organ part in terms of pleasure. Include in the presentation the issues of: o masturbation, o erection and loss of erection, erectile dysfunction o size and shape o semen and sperm production o male circumcision Allow participants to ask questions during the presentation. 28

Session D4: Summary Clarify the concept of human sexuality and its development. 1. Human sexuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. 2. Adolescent s maturity and self-acceptance on sex means decisions to engage in, or limit sexual activity in ways that are consistent with personal principles and protective of health. 29

External (What is visible from the outside): Female Reproductive Organs Even though these parts are on the outside, if a girl or woman wants to examine them she may want to use a mirror. Labia There are two pairs of labia or lips, the outer lips and the inner lips. They help to protect the opening to the urethra and the vagina. The outer labia may have some pubic hair on them. Pubic Hair Above the labia is the pubic hair, which may be in a small area or may cover a large area on the lower abdomen. This hair develops during the teenage years and serves a protective function. Clitoris A small bump at the top of external genitals where the labia meet in the middle. It enlarges during sexual excitement and its function is for sexual pleasure. It is covered by a hood or fold of skin to protect it. Rectum - The rectum is the last part of the intestines and it is from where solid body wastes leave our body. The actual opening to the outside is called the anus. Although it is not a part of the sex organs, it is included here because infections can happen here from leakage from the vagina or from having anal intercourse. 30