CommunicaTEEN

In low- and middle-income countries, 21 million girls ages 15 to 19 experience pregnancies each year. The WHO recognizes early pregnancy as a significant public health concern. Teenage mothers aged 10 to 19 are at risk of serious health complications. Early pregnancy increases the risk of death in childbirth. Moreover, the babies of adolescents face a higher risk of low birth weight and neonatal health issues. In these countries a reported 55% of unwanted pregnancies in teenagers are aborted, often under unsafe conditions. Unintended pregnancies contribute to gender inequalities by limiting girls' access to education and employment opportunities.

Like most of the world's migrant populations, it is very difficult to obtain recent and transparent data on the situation of Burmese women and girls in Thailand. Furthermore, the circumstances of this group constantly evolve, particularly following the February 1st 2021 military coup in Myanmar. Nevertheless, existing literature indicates migrant girls and women are more likely to experience early pregnancies and suffer severe consequences than their Thai counterparts, especially when they lack access to education, health literacy, legal status, health insurance, live in poverty, face exploitation, language barriers, discrimination, and gender-based violence, among other challenges. The UNFPA acknowledges constraints in the monitoring of maternal health in Thailand, with a specific focus on the heightened vulnerability observed along the Myanmar border.

The WHO outlines key objectives for interventions aimed at reducing early pregnancies, including reducing marriage before the age of 18, minimizing coerced sex among adolescents, increasing contraception use, and fostering understanding and support for reducing pregnancies before the age of 20. CommunicaTEEN focuses on the latter two objectives. Our research, including interviews and focus groups underscores two main issues: the low utilization of contraception among Burmese teenagers in Thailand and the initiation of sexual activity without prior access to information about the risks of unprotected sex.

The low use of contraception among Burmese teenagers in Thailand appears to stem from challenges in access, a lack of skills in negotiating safe sexual practices, and inadequate awareness of contraception's importance. Certain prevailing beliefs, such as the idea that condoms should only be used when engaging with sex workers, further hinder contraception use.

The early initiation of sexual activity without prior access to information can be attributed to early exposure to sexuality, including the prevalence of sex in Thailand and the easy accessibility of pornography on smartphones. It is also linked to a lack of literacy in sexual and reproductive health (SRH). Just as existing scientific literature has demonstrated concerning Burmese migrants in Thailand, interviews with migrants confirm that sexuality remains a taboo subject, leading to a significant deficiency in SRH literacy. 

CommunicaTEEN's approach assumes that low literacy in SRH is a result of insufficient educational resources in public health and school programs coupled with a lack of support during the early stages of adolescents' sexual lives. Communication about sexuality seems to be impeded by feelings of shame, guilt, and the adults' own limited SRH literacy.

link-youtube.com/watch?v=8l5VNfbGwvc

CommunicaTEEN leverages the Theory of Planned Behavior (TPB) as its foundation to address the unique needs of the Burmese migrant community. This comprehensive approach takes into account psychosocial factors and community input to improve the SRH of this underserved population.

The central idea of the TPB model is that behavioral intentions are shaped by an individual's attitudes, subjective norms, and perceived behavioral control regarding the behavior in question. CommunicaTEEN acts intentionally to influence these core concepts.

The goal of CommunicaTEEN is to reduce unintended pregnancies among Burmese girls and women between the ages of 10 and 19, beginning in Phang Nga, Thailand.

Objective 1- Promote contraceptive use among teenagers.

The first steps to achieve Objective 1 is raising awareness about the importance of contraceptives and changing people's attitudes toward contraceptive use.The first action focuses on reinforcing adolescent’s positive attitudes toward contraceptive methods through a course that covers existing methods and the risks of unprotected intercourse. Additionally, the Kahoot mobile app will be utilized, encouraging interactive sessions.

The second step is to facilitate access to contraceptives and to bolster participants' perceived control over contraceptive use. The project will distribute contraceptives to adolescents, community leaders, and adolescent promoters. During the initial session, practical training on condom use will be provided, along with information on where to obtain contraceptives.

The third step is to train teenagers to negotiate sexual practices, focusing on the perceived subjective norms. This will be done through a roleplay game that encourages participants to discuss dilemmas related to sexuality during a second course on consent.

Objective 2 - Provide access to information about the risks of unprotected sexual activity before exposure. 

The first step to achieve Objective 2 is to enhance sexual education for teenagers. This involves incorporating SRH into migrant schools, with teachers regularly addressing sexuality-related topics. To support educators, we will produce an explanatory video covering a range of topics from the reproductive system to consent. Two teenagers from each class and community will be appointed as health promoters, providing a direct channel for teenagers to communicate their needs. The project includes sessions for parents, teachers, and community leaders on contraceptive methods and the risks of unprotected sex, influencing their attitudes and improving overall SRH education. Adults will be encouraged to discuss certain topics with teenagers between sessions, helping them practice communicating with their children. Finally, large events will be organized, bringing together teenagers and adults, fostering open communication, and reinforcing support for teenagers' sexual health. 

The second step is to provide a framework for early exposure to sexuality. This involves a class for teenagers focused on consent, violence, and the risks of adhering to gender stereotypes. The session redefines "good sexuality" as safe, protected, and consensual, deconstructing perceptions that hinder open communication. To address perceived subjective norms, ethical issues related to peer pressure will be incorporated into roleplays. Moreover, the second session of the course for adults will address gender stereotypes and pornography, aiming to change social norms.

As of 2019, Thailand’s official documentation states there are 3,600,000 registered Non-Thai citizens in the country. Of those, about 2 million are from Myanmar. It is widely agreed that there are between 2 and 4 million additional unregistered migrant workers and dependents, again mostly from Myanmar. In the Phang Nga province, there are around 22,000 registered migrants, and closer to 60-80,000 total. This province receives little notice nationally as it is not technically a “border province,” though 16-22% of its residents are migrants. 

CommunicaTEEN will focus first on supporting young migrant women and girls in 4 migrant communities and 2 learning centers in Phang Nga. The communities are diverse, including 2 fishing villages, a tourism hub, and an agricultural community. The two learning centers have more than 800 total students, with over 120 girls ages 10-19. The 4 communities have many more adolescents that attend other learning centers or are out-of-school.  

There are around 6,000 youth in migrant learning centers in Southern Thailand, 1,200 of them in Phang Nga. There is no way to give an exact count of those out of school, but the IOM Thailand Migration Report 2019 states “it is estimated that more than 200,000 migrant children remain out of school and are not receiving any form of education.” This number has only increased following the 2021 military coup. FED’s Unified Learning Center has doubled in size, with attendance currently at 680 students as compared to 320 in 2019-2020. As the conflict in Myanmar continues, we see more and more migrant children brought to the relative safety of Thailand.

Even if students are in schools, the content of the education Burmese-speaking children receive is also substandard. The Myanmar national primary school curriculum has no mention of basic anatomy and physiology, much less SRH. According to the Myanmar Department of Health and Sport, in 2016, less than 17% of youth aged 15-24 had knowledge of HIV prevention (UNAIDS data). Due to Covid-19 and the coup, schools in Myanmar have been closed for more than 3 1/2 years as of October 2023

SRH education, discussion, and improved access to services are crucial to empowering Myanmar’s next generation. There are no active programs now in this region, leaving youth almost completely without access to reliable information. 

Additionally, youth in isolated agricultural communities have poor access to contraceptives. Youth in crowded fishing villages face intense scrutiny if they try to purchase contraceptives locally. Youth in the heavy tourist traffic area are frequently exposed to sex and sexuality and are unprepared by their traditional culture.  

Our solution works to encourage use of contraceptives, boundary-setting, and negotiation skills through education and informed open discussion about SRH in migrant communities and schools.

FED is the only local organization providing SRH education for the 60-80,000 Burmese migrants in the Phang Nga province of Thailand. It was the first NGO registered to support Burmese in Thailand in 2007, and >80% of the staff are Myanmar citizens. 

FED has provided health education and direct case support for migrants’ health issues for nearly 20 years, while developing a network of Community Health Volunteers.

The team assembled for this project consists of 2 Burmese teachers, one Thai, a French MPH, and an American as Team Lead. Older Health Program Field Staff are acting in an advisory role.

Key team members include 2 young Burmese who were forced to leave Myanmar and a French MPH. Khine Mar Htet(25) was in her second year of medical school in Yangon and acted as a medic during anti-coup protests. She now teaches Biology and English to migrant children. Shein Nay Zin(25), has been working and living at our school since 2022. This young man is looking for ways to become more involved in community outreach. These motivated young people face the same issues as those targeted by the intervention. Eléonore Sparwald(25), a recent graduate in the social psychology of health, is a volunteer through a French civil service program, continuing her work to understand and support migrants across different contexts. She brings both academic rigor and innovative approaches to FED’s grassroots programming. 

Bob Forrester(35) is acting as the Team Lead. A ‘Returned’ Peace Corps Volunteer, he has worked at FED for 5 years, with an all-Burmese team for more than 3 of those. He is fluent in spoken and written Thai, and is studying Burmese. His most recent project supported Myanmar living with HIV. Through this and other community health projects, he has spent thousands of hours with Burmese migrants, sitting on floors, traveling to meetings, and cooking and eating with migrants. Through his position in senior management he is able to influence organizational decisions.

This project was developed through structured focus group discussions and individual interviews, as well as several informal group discussions and consultations with active community health educators.

Structured discussions and interviews raised dozens of issues affecting young women and girls, ranging from negative views of those who buy or use condoms, to gender-based-violence, to unsafe abortion techniques used by migrants. Two common themes ran through the conversations though, shame and lack of awareness/education. Teachers claimed children needed to have proper information, however were unwilling or unprepared to provide it. Community leaders were more open to providing education, but felt they needed external support to convince parents to agree. Adolescent girls, especially those out-of-school, were reluctant to discuss SRH at all. 

The informal discussions helped identify resources and brainstorm potential solutions. Female community leaders with prior training in SRH were very willing to participate in activities for girls, young women, and their parents. Leaders and health educators offered venues, suggested ideal timing for activities, and stated their own priorities regarding education.

Inspired by this grant opportunity, we have begun trialing sessions with FED teachers, community leaders, and students to address the stated issues. The approach, involving open discussion of SRH between age groups, is new to the area. Female teachers/community leaders, parents and adolescent girls were brought together for education sessions that concluded with activities promoting open discussion. By building on shared understanding and creation of a safe environment, we were able to successfully hold discussions about contraceptives, safe sex practices, unwanted pregnancy, and early marriage. 

The completed sessions proved that time-constraints would be an obstacle to the project success. To allow full participation by both adolescents and adults, encouraging questions and discussion, and provide comprehensive SRH education, we believe we will need to allow for 2 or more sessions per group, followed by a final large session focusing on discussion between groups.

CommunicaTEEN utilizes TPB as its foundation. This psychosocial model, introduced by Ajzen in 1985, has demonstrated its effectiveness in promoting contraceptive use worldwide and within migrant populations. The TPB model emphasizes the psychosocial dimension and the autonomy of individuals. It departs from the traditional top-down and hierarchical approach between healthcare professionals and patients However, it has rarely been applied to the context of the Burmese migrant community in Thailand. In this regard, CommunicaTEEN stands as a pioneering initiative.

In the next year, we aim to create and share one good quality video covering the same content we will provide in our educational sessions for youth. Different segments of the video can be shown to youth in migrant learning centers or communities to lessen the time burden on teachers, parents, and community health volunteers. Upon completion, We will use the existing network of migrant communities and learning centers to show this video to 1500 students and 500 out-of-school youth.

Using the video as a tool, we will have performed educational sessions with adolescent girls in at least 2 learning centers and 4 migrant communities of Phang Nga, reaching at least 100 girls directly.

We will also have provided educational sessions to 50 female teachers and community leaders from the same area, before bringing adults and adolescents together in group discussion sessions. 

The first year will be used to create and refine session content while networking with more migrant communities throughout Phuket and Ranong provinces. The target for expansion will be the identification of 15 communities in which to perform the intervention.

Impact is tied to the effect on SDG 3.7, directly improving access to sexual and reproductive health-care services, including for family planning and information and education.

While is it notoriously difficult to collect population level data from migrants, our impact can be measured by the reported attitudes concerning program topics, and distribution levels of contraceptives. 

In five years time, we aim to have arranged yearly interventions in 25-30 communities, for both women and girls and men and boys. This will require creating and refining sessions appropriate for men and boys, as well as outreach to identify adult participants.

In order to prevent unwanted pregnancies among young Myanmar migrant women and girls in Thailand there are two things to do. First, promote contraceptive use among adolescents. Second, improve access to information on the risks of sex before sexual debut. 

Young people need correct information before they start taking risks, and they need to have resources available to protect themselves if they still choose to take chances. Initially, education and access to contraceptives make it possible for youth to make the right choices. After that, it takes an attitude change to encourage people to choose correctly in reality. 

To change attitudes, our sessions help participants to realize how much power they have over their own bodies. We do this by helping them to identify common beliefs about sexuality, giving them the power to disagree or agree. We give participants comprehensive information about SRH while focusing on individual goals, this encourages them to approve of contraceptive use. We allow participants to practice contraceptive use and negotiation with their partners through practical activities and roleplays. 

The way we cement this attitude change is by bringing together adolescents and adults to openly and honestly discuss SRH issues. At the moment, there is little to no SRH information provided by trusted adults to young women and girls. The dialogue between groups not only helps youth feel less embarrassment and shame about sexuality, it reinforces the educational content when adolescents see their elders publicly support the project’s information and attitude.

4 full-time staff - All have other responsibilities at the organization, but are involved part-time with this solution

1 full-time volunteer 

FED as an organization has worked to ensure the Right to Health for Myanmar people in Thailand for 19 years. The Team Lead has been working to improve Sexual and Reproductive Health for migrants for over 6 years.

The current solution has been under development since the Solve challenge opened.

The team puts diversity, equity, and inclusion at the at the heart of all activities. FED and this team work to empower and include the most vulnerable in every way possible. 

The majority of our organization's staff come directly from our target group, with Thai and Western staff acting primarily in support roles.

Programs are purposefully designed to equitably include different genders, ages, sexualities, educational levels, ethnicities, and physical abilities. Community interviews and surveys are taken before projects are designed, and feedback sessions are held after activities. 

All programs promote inclusion in their activities. FED's schools accept students of all ethnicities(including Rohingya children fleeing the genocide in 2017 and "Nepali" Myanmar citizens) and sexualities. The Health program has PLHIV staff, and supports MSM and migrants with a variety of physical and mental disabilities to access their Right to Health. The Migrant Development team represents and frequently provides case work for migrants with severe drug and alcohol addictions.

The new solution will be held to the same standards, striving to provide equity and representation to the greatest extent possible.

FED provides value to 3 groups, migrants themselves, their Thai employers, and international donors such as UN bodies and national aid programs. We currently collect revenue from migrants and international organizations.  

One revenue stream for FED is fee-for-service. FED operates two schools for more than 800 migrant children. These fees are kept to 1.5 times the daily minimum wage in Thailand per month. There are discounts for households with multiple children attending the centers. 

International donors frequently reduce project costs and improve reach by sub-granting to local NGOs with facilities and administration already in place. FED is currently the only NGO in the Phang Nga province with multiple active programs supporting migrants. FED’s Phang Nga offices are located within 3 hours drive of the provincial capitals of Krabi, Phuket, Surat Thani, and Ranong. There are more than 250,000 Myanmar migrants in these provinces and FED has developed a network of nearly 100 migrant community leaders in the area. This positioning, as well as FED’s cross border ties, has made FED a preferential partner of several UN bodies, primarily the ILO and IOM, but also UNICEF and UN Women.

As the number and percent of international migrants across the world increases (from 214 in 2010, 3.2%, to 281 million in 2020, 3.6%), greater numbers of both philanthropic and corporate donors are focusing on the issues faced by this group. FED has traditionally taken advantage of philanthropic giving, and will continue to do so. In reaction to the growing number of migrants, there has been an increase in research focused on the group. FED has been able to take advantage of this new opportunity to perform implementation science research supported by ViiV Healthcare. To expand our capability to perform such research, FED is hosting Dr. Sai Kyi Zin Soe, a former professor at the University of Sydney who is providing a 4 month course to FED students to learn about the research project cycle along with blinding procedures, data collection practices, research biases, and data entry and management.

The 3rd group benefitting from FED’s actions are the Thai employers. FED provides workplace health and safety training to their employers for free, provides childcare services for their employees’ children, gives Thai language lessons and continuing education to young employees, and assists with providing legal documentation to employers on the behalf of workers. There is potential for sponsorship from nearby employers, especially hotels and restaurants, however efforts to recruit these sponsors were delayed by the pandemic. 

As mentioned in the FED Business Model, FED primarily uses fee-for-service revenue in the form of student fees and donations/grants to maintain current activities and grow. 

FED has a track-record of sustained donors, with Dana Asia managing a yearly donation of 100,000 USD to its education program for 10+ years, repeated grants from the Japanese ODA, 9 years of support from the US-based Freedom Fund, more than 15 years of funding from the Inspirasia Foundation, and 6 years from ViiV Healthcare. 

To supplement these donations and create more unrestricted funding, FED has begun regular local event fundraising and is expanding its volunteering and ambassador programs to increase private, repeat donations. 

Once videos have been produced and sessions have been refined, project costs drop substantially. Each educational session for 20-30 attendees can be performed for $100 plus travel and staff time. This can be lowered if venues or food is donated by the community or school.