Challenging Dogma


...Using social sciences to improve the practice of public health

Wednesday, April 25, 2007

Japan and Tanzania: The Case For Peer Based Sex Education Programs- Nicole Daley

In recent years, Japanese conservatives have begun attempting to use the sex education program (SEP) to prevent the loss of “traditional values”. In place of true sex education, lawmakers and educators are misframing HIV/AIDS as a Human Rights issue and leaving the majority of the teenage population bereft of consistent accurate details about preventing STD infections(1). The fragmented SEP that is being implemented is primarily based on the Health Belief Model and tries to make Japanese kids aware of their susceptibility to STDs, however implemented on that model alone, it is failing to work(2). Japanese law makers should consider using elements of The Theory of Reasoned Action, self-efficacy, and the advertising model to deal with the issue. Since teenagers are in a phase of life in which they are defining themselves and looking more to peers for their needs, developing these theories into a youth run peer education program would be the most effective method(3). Japan’s current school-based sex education program (SEP) is ineffective because it fails to acknowledge the risky behavior it is seeking to change. Therefore, it should seek to incorporate social science elements from the Tanzanian youth run and youth focused sexual behavior modification campaign ISHI to help Japanese children protect themselves.

The Average Japanese Student experience with Sex
The Japanese SEP currently has two faces, a clinical focus and a human rights advocacy focus. Some children are taught in elementary school about the reproductive system and the clinical words for penis and vagina(4). These lessons are taught periodically as isolated classes rather than a comprehensive curriculum. Likewise, the Human Rights curriculum incorporates HIV/AIDS and stigma into one or two classes depending on the school. In junior and senior high school classes the curriculum has been altered in recent years to entirely remove terminology about genitalia and sexual intercourse. Teachers have been forced to reverse back to elementary school lessons about fertility and pregnancy. When discussing prevention of AIDS and STDs, the guidelines advise teachers to stress “avoiding sexual contact”(2). Teachers are allowed to talk about condoms but are forbidden to teach students how to use them(2).

A 200 survey found that 45% of female high school seniors in Tokyo had lost their virginity and of those, only 21% said they regularly use condoms(2) . HIV/AIDS is an issue that is lurking in the background due to the low incidence and prevalence rates. In contrast, teenagers are contracting STDs at alarming rates. A surveillance study done in Hokkaido from 1998-2001 found in 2001 among women and men aged 15-19, there was a 227 and 245 incidence rate of gonococcal infection respectively (5). In light of these disturbing statistics, misframing sexual issues as destigmatizing HIV/AIDS allows teenagers to disassociate their risks and not analyze their behavior. HIV/AIDS remains someone else’s problem that we have to help them with and not an analysis of how they contracted HIV and how that same behavior relates to STDs.

Young Japanese girls, in particular, are at high-risk for infection due to several trends among teenagers. The first marginal but persistent trend is enjo kosai (teenage prostitution) which started in the early 80’s (6). Many high school girls arrange to meet once or repeatedly with older men in a fee-for-sex arrangement(7). Often times girls will seek out these arrangements while in a relationship with a boy their age. The other main stream trend is short transient relationships(12). For high school students, most relationships are very short-lived ranging from a few weeks to a few months. While the relationships may appear monogamous and thus deemed okay, this serial dating is high risk sexual behavior. One Japanese study of 248 males found that the average number of sexual partners in the last year was 5.8. This number was highest for the teenage population and then decreased with age(8).

Educators incorrectly frame the issue.
Similar to its United States counterpart, the Japanese SEP is currently under attack by conservative factions in government and society. However, the Japanese Diet in an effort to avoid the controversy has placed the onus on the prefectural government to implement programs as they see fit. The lack of government commitment to the issue has led to a wide disparity in the implementation of programs, including one teacher being reprimanded for using pictures of genitalia in his sex education lesson(2). This creates a climate of fear surrounding SEPs and decreases teachers’ willingness to discuss the issue. Parents think the schools should be teaching sex education and the schools think parents should be teaching it(4). All of this has left teenagers in Japan uneducated and sexually active in a society with increasing rates of STDs and HIV/AIDS.

Framing HIV/AIDS as a Human Rights concerns does not take into account issues of susceptibility which is an inherent precursor to all behavior change. While the use of the Health Belief model as the only basis for a behavioral modification program is flawed, there is an intrinsic need for teenagers to feel at risk for acquiring HIV/AIDS and other STDs. The average Human Rights curriculum focuses one or two lessons on the issue of AIDS and attempts to destigmatize young people’s perceptions of those living with the virus. However, focusing on HIV/AIDS ignores the issue of STDs and allows the issue to remain someone else’s problem. The current human rights classes are not getting at the real issue that AIDS is a part of the family of STDs and as long as one engages in unprotected sex, he or she is putting him or herself at risk for contracting AIDS and a host of other STDs. As long as Japanese teenagers continue to feel that this problem primarily affects foreign female sex workers working in Japan, they will continue to practice unsafe sex.

Societal Norm vs. Cultural Norm: Students left in the gap
The current SEP does not take into account the societal norms and cultural norms that informs the students’ choices and decisions to have unprotected sex. In Japan, virtually every video store has an X-rated section with the soft porn openly displayed and the hard core porn in a back room that requires an ID for access. Several prominent newspapers feature soft porn ad sections that display naked women as well as the telephone number and addresses for snack bars and strip clubs. The societal norms do not match up with what is being taught in school. Japanese students are living in a context that has normalized sex and the human body. Therefore, it is fruitless to have a conversation about sex without using pictures of genitalia when they see it in the manga cartoon storylines they read. Requiring health educators to teach sex education without the required terminology, when material on sexual contact is so ubiquitous in Japanese society, will not encourage students to contemplate their behavior and transition towards using protection. To help teenagers make positive sexual behavioral changes, Japan needs a program that will address teenagers’ social norms to help them make a personal decision in that context.

Cultural Norms also affect Japanese students’ ability to make difficult choices that will positively affect themselves and counter the beliefs of their peers. Japanese people are a very group oriented culture(9). “The nail that sticks out must be hammered back in.” is a Japanese proverb that reflects the extent to which the group is the basis for society. Japanese teenagers are having casual, unprotected sex through on-line communities(10). The term "sextomo" (sex friend) or “mail tomo” (email/text message friend) has been coined to express this network of sexual and social relationships orchestrated through their cellular phones and the internet. To ask a Japanese teenager to upset the balance of the group by introducing condoms, is asking for him or her to go against what is culturally engrained and socially acceptable. Any program that attempts to increase condom use among this population needs to take this aspect of their culture into account and create a SEP that would frame condom use as group behavior modification.

Tanzania as a Teacher
Japan remains mildly xenophobic of foreigners who are not from Western countries, however there is a lot that can be learned from the Tanzanian Youth developed and implemented ISHI campaign. An entire transplantation of the ISHI model into a Japanese SEP is not possible, however, there are certain social science based elements that can be modified and applied due to certain similarities in the cultures regarding sex. Like Japan, Tanzanian culture is very conservative when it comes to teaching young people about sex. With the introduction of western culture, the elders of the tribes no longer give traditional sex education lessons to pubescent girls and boys. The children of Tanzania were living in a vacuum of knowledge around the issue of safe sex. In addition, the relationship between teachers and students is exceedingly hierarchical and thus not conducive to conversations about sex(16). The ISHI campaign has effectively applied the social science theories of planned action, self-efficacy in conjunction with the advertising model, into their design to circumvent these barriers and start saving their young people. Japan can learn a thing or two.

ISHI focuses on self-efficacy and on making it feasible for young Tanzanians to take control of their sexual lives. ISHI is the Swahili command to live. This youth dependent program has infiltrated all levels of media in order to get its message out. Its message “Usione Soo!/Don’t be shy, talk to your partner” is on billboards, TV, and radio. It is the focus of rallies as well as songs sung by famous rappers and singers in the country such as XPlastaz(12). They distributed t-shirts with the Abstinence Be Faithful Condom use message in Swahili, however, the emphasis is not on the A but on the C. In order to help young Tanzanians overcome the embarrassment barrier over condom use, the program gives out condoms to everyone who attends their social events (13). This allows teenagers to get over the initial reservations about obtaining condoms in a non stigmatized way, and when coupled with the small peer group discussions, it helps transition the kids into using condoms(13). Japan is a very media and name brand conscious society, so implementing a media campaign to start changing the cultural norm has the potential to have a strong impact. Taking a social science approach imbedded in a media campaign, with small group peer interactions, makes the goal of using a condom or abstinence more attainable.

The ISHI campaign truly incorporates the Social Cognitive Theory unto its advertising model. It encourages kids to talk to their partners, which makes it seem a fun and trendy thing for teenagers to do. Wide spread media campaigns are effective in spreading a message and changing the cultural context in which small groups engage the topic. Without making Usione Soo the popular song of the day and imbedding the message in youth sporting events, the mentors would be asking the kids in the small group activities to do a marginalized activity. By using the advertising model, the organizers have presented a problem and given a “product” that, if used, will have “cool” results. It is increasingly harder to introduce an individual intervention if the societal context is not concurrently shifting to embrace the positive behavior change.

Peer Lead Sex Education over School Based Sex Education
A peer educator is best prepared to handle risky sexual behavior among teenagers, because they can empathize best with the emotions students face in attempting to go against the grain. They can also be a role model to their peers which can increase self-efficacy. Within peer lead discussions, Japanese youths would gain a deeper sense of efficacy by interacting with young adults who are doing what they are being encouraged to do. It is a well established fact within Japan among teenagers that teachers are uncomfortable with the subject matter(3). Also, the dichotomous relationship between the student and the teacher in Japan restricts kids from engaging in true dialogue about their sexual practices and safe sex tips. The teenage years are a time when kids are defining their adult status in relation to their environment and their friends’ opinions are one of the preeminent sources of influence(1). Therefore, it is important for students to have peer facilitated discussions in which they receive proper sex education facts. A social science based peer education program will help the kids gain access to needed benefits more so than a school based education program.

Dr. Iwamuro conducts an independently run SEP that is implemented through schools, shows us qualitatively that the current Health Belief based model is not a deterrent to risky sexual behavior. In an Asahi newspaper article that highlighted a high school student’s reaction to a STD video presentation, one boy commented that “many kids were looking down or listening to music because it [the picture presentation of STDs] was so disgusting” (3). Using a campaign that highlights the benefits of protecting oneself will go much further than trying to provide momentary shock value. Rather, using a funky trendy campaign geared at teenagers has the potential to sweep through Japan like Louis Vutton, the Disney Princesses, digital pets, and sticker picture fads(15).

Implications
Every country has been where Japan is in terms of its low prevalence and incidence of HIV/AIDS. The question is what will they do to prevent those numbers from swelling? There will be some additional barriers to implementing ISHI methods in Japan. Political commitment is crucial to the process and currently there is no cohesive government consensus on the issue in Japan. PEPFAR is the financial backer to ISHI, however the Tanzanian government has fully backed the program which is lending weight to its campaign around the country(13). In the coming months Japan needs to seriously address its rising STD problems and ticking HIV/AIDS time and allow peer based campaigns to grow and meet the needs of its youth in a comprehensive fashion. The implications of continuing their Health Belief model and Human Rights approach may lead to serious consequences in the near future.

While ISHI has not achieved broad societal acceptance in Tanzania, its in your face message is reaching its intended target population, young people, and helping to create major social and behavioral changes. Japan should look to its “senpai” (mentor) in this matter and act accordingly to decrease the incidence of STDs among its youth.

References
1. Nonoyama M., Tsurugi Y., Shirai Chika., Ishikawa Y., Horiguchi M. Influences of sex-related information for STD prevention; Journal of Adolescent Health 2005; 36;442-445
2. Shriek Seaway, Area; Information overload: Sex end: To teach or not to Teach?; http://www.asahi.com/english/lifestyle/TKY200501150158.html
3. Wikipedia. The free encyclopedia. Maslow’s Hierarchy of Needs. http://en.wikipedia.org/wiki/Maslow's_hierarchy_of_needs
4. Women 2000, Japan NGO Alternative Report. The Girl-Child. Japan: Japan NGO Report Preparatory Committee,1999
5. Takahashi S. Incidence of Sexually Transmitted Diseases in Hokkaido, Japan, 1998-2001. Journal of Infect Chemother 2004;10;163-167
6. Wikipedia. The free encyclopedia. Enjo Kosai http://en.wikipedia.org/wiki/Enjo_k%C5%8Dsai
7. TIME Asia. She is only a little school girl. Why did she sleep with him. Money? Fun? Boredom? Gucci? Because, like, whatever. http://www.time.com/time/asia/features/sex/sexenjo.html
8. Koroku M. Questionnaire survey on sexual behavior of Japanese males infected with sexually transmitted diseases. Hinyokika Kiyo 2002;48(6);333-336
9. Nakane C. Japanese Society. Japan: University of California Press, 1970
10. Efforts Failing to Keep Roppongi Girls Clean, Japan Today http://www.japantoday.com/jp/kuchikomi/192
11. Be a Professional Lover to Earn Money, Japan Today http://www.japantoday.com/jp/shukan/352
12. Japan Network Newsletter. Summer 2005 http://www.japanetwork.org/jnnewsl/summer_2005.pdf
13. USAID Global Site. Tanzania’s Youth Counseling Youth about HIV and AIDS http://tanzania.usaid.gov/article.php?id=0125_EN
14. Tanzania-Hip Hop Warriors news.minnesota.publicradio.org/features/2005/11/27_newsroom_aidsmusic2/
15. Facklar M. International Business: Japan, Home of the Cute and Inbred Dog. The New York Times http://query.nytimes.com/gst/fullpage.html?res=9A07E6DE1F31F93BA15751C1A9609C8B63
16. Student Partnership Worldwide : Case Study, Aid Project, Tanzania, Africa
www.findagap.com/gap-year-organisations/volunteer-abroad-spw-case-study.aspx

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