بررسی زمینه های اجتماعی و فرهنگی بهداشت جنسی برای جوانان در مغولستان: پیامدها برای ارتقای سلامت

Recent political, economic, and cultural changes in Mongolia make its large proportion of young people vulnerable to HIV infection. While there had been only two clinical cases of HIV in Mongolia by the year 2000, the incidence of sexually transmitted infections (STIs) is on the rise, especially among people aged 15–24. Little is known about the social and cultural context in which the sexual knowledge, attitudes, and behaviour of Mongolian young people are created and negotiated. This context must be better understood in order to promote safer sex practices. This study employed qualitative research methods to explore and describe the social and cultural context in which sexual behaviour is negotiated among secondary school students in Ulaanbaatar, Mongolia. Students and teachers from two schools in Ulaanbaatar and health professionals were selected by purposeful sampling to participate in six semi-structured focus group interviews in autumn 2000. Thematic content analysis was conducted on the focus group transcripts. Seven themes were extracted including embarrassment, lack of knowledge, concepts of sex, perceptions of condoms, gender roles, peer norms, and the influence of drinking on sexual activity. Results presented are the first description of the social and cultural context of sexual health and highlight the combined impact of these themes on safer sex practices in Mongolia. These findings are not generalizable, but their agreement with the Mongolian and the international literature indicates that they may be transferable. Implications for STI and HIV/AIDS prevention efforts and further research in Mongolia are discussed.

Mongolia has been in political, economic, and cultural transition since 1990 when the Soviet Union collapsed and withdrew its political and economic support. While Mongolia had reported only two clinical cases of HIV by 2000, lessons from HIV/AIDS epidemics in other areas indicate that these changes make Mongolia vulnerable to an HIV epidemic. The sense of urgency is heightened because half of Mongolia's population is under the age of 20 (Patel & Amarsanaa, 2000). Young people are the most vulnerable age group to sexually transmitted infections (STIs) and HIV: approximately half of STIs worldwide occur among young people aged 15–24 (Rivers, & Aggleton (1999a) and Rivers, & Aggleton (1999b)). The increasing STI rates in Mongolia confirm that the conditions favouring the rapid spread of HIV are present and that young people are vulnerable. Between 1993 and 1995 syphilis rates doubled from 18/100,000 to 32/10,000 and gonorrhoea rose from 51/100,000 to 142/100,000 (Kipp, Sodnompil, Tuya, Erdenchimeg, & Nymadawa, 2002). Syphilis rates among Mongolians aged 15–24 rose 1.5–3.0-fold higher than any other group between 1993 and 1995 (Purevdawa et al., 1997). These data have prompted the Mongolian Ministry of Health to make reproductive health among young people an urgent priority, resulting in new policies, curricula, and programmes.

Six focus groups with secondary school students aged 15–17, health teachers, and health professionals generated seven main themes that describe part of the social and cultural context of sexual health in Mongolia: embarrassment, lack of knowledge, concepts of sex, perceptions of condoms, gender roles, peer norms, and the role of drinking in sexual activity. This exploratory study raised some important questions that require more qualitative and quantitative research and have important implications for health-promotion programmes among youth in Mongolia. The embarrassment felt when discussing sexual matters and the lack of knowledge about sexual matters appears to be a major barrier for youth, parents, teachers, and institutions. While embarrassment is an indication that the discussion of sex is taboo, it may also be due, in part, to a systematic lack of knowledge. To minimize the embarrassment of discussing sexual matters, more sexual health knowledge must be transferred to youth, parents, and teachers. First, health-promotion interventions should transfer knowledge through youth's peers—the most common communication conduit. Lear (1995) found that discussing safer sex with friends is actually a strong predictor of safer sex. Thus, a school-based peer education programme is recommended for urban Mongolia. Furthermore, government and non-government organizations must work with school administrations and the Ministry of Education in Mongolia to broadly implement the new sexual health curriculum at the secondary education level and introduce the topic of health, including sexual health, at the post-secondary level for new teachers. The gendered division of sexual health knowledge, sexual behaviour, and condom negotiation in Mongolia elucidated here has not been described in the international literature. Considering the power imbalance men have over women regarding sexual matters in most countries worldwide, there is an emerging call for health-promotion interventions to focus on behaviour change among men (UNAIDS, 2000; Rivers & Aggleton, 1999b). The results of this study have important implications for sexual health interventions among men in Mongolia and abroad. First, young men require access to reliable and anonymous sexual health information. Second, the myths upon which their sexual attitudes are based (especially towards condoms), must be dispelled by credible adult male figures. Third, the notion that selecting only “healthy girls” to have sex with is an effective means of STI protection must be addressed. This belief reinforces the need for young women to keep a clean reputation by remaining uniformed and passive about sexual matters and prevents the uptake of condom use among young men. The impact of Adolescent Cabinets on the attitudes and reputations of secondary school students must be explored further, especially among young women. The impact of Adolescent Cabinets on other school-based sexual health programmes must be evaluated. For example, having Adolescent Cabinets for young women only reinforces the idea that contraception is a woman's responsibility. Also, any relationships or trust created between students and teachers may be disrupted by the exams. This service ought to be redirected to provide confidential counselling, reproductive health services, and contraceptives for both women and men (UNFPA, 2000). The present study indicates that sexual activity often occurs when young people are under the influence of alcohol. The impact that alcohol has on sexual activity is heightened by Mongolia's cultural acceptance of heavy drinking, especially among men. Alcohol's impact on sexual risk taking and lack of condom use has been well-documented (see Leigh & Morrison, 1991; MacDonald, MacDonald, Fong, & Zanna, 2000). Any health-promotion intervention among young people should address drinking, sexual activity, and sexual-decision-making skills together. To date, this approach has not been taken in Mongolia (personal notes). Immediate quantitative research should be conducted in Mongolia to determine the prevalence of drinking and sexual activity among youth, including consumption of alcohol at first sexual encounter and sexual coercion. “Cultural” or “traditional values” were directly or indirectly referred to in several of the themes elucidated in the present study. For example, the teacher participants suggested that the discussion of sex is taboo because of “traditions and cultural attitudes”. Also, the male students’ concepts of “normal” and “abnormal” sex may indicate a connection with traditional medicine. Immediate research is required to explore and thus understand the relationship between the attitudes and values elucidated here and the sexual values and concepts that may be found within Mongolian Traditional Medicine and Tibetan Buddhism. Perhaps within this relationship we may also learn why the discussion of sex is taboo and understand the gender roles related to sexual behaviour. By investigating the traditional values behind sexual attitudes and behaviour among youth in Mongolia, barriers and opportunities for health-promotion interventions and STI treatment can be revealed. There are limitations to the generalizability of the findings presented here. First, this study's exploratory design using focus groups cannot be generalized to a larger population because the participants of any focus group cannot be ‘representative’ of anyone except themselves (Kingry et al., 1990). Second, selecting schools and participants based on their support or interest in health promotion, enthusiasm, and communication skills presents a source of bias. Discussions presented here may be more liberal than if we had conducted focus groups among randomly selected students or teachers. For example, unlike Oyungerel et al.'s (1999) focus groups that found most Mongolian's feel that contraception is a female's responsibility, about half of the students in the present study thought that contraceptive responsibility should be shared among men and women. Third, this study does not represent the views of rural Mongolian students who may face more structural challenges (e.g., poorer health services, less access to contraceptives). Despite these limitations, this study presents a fascinating glimpse at the social and cultural context among youth in a country that has not been studied extensively by Western social scientists. Considerable agreement with the Mongolian and the international literature suggests that these data may be transferable to other locations. Specifically, the impact of gender roles, peer norms, and alcohol consumption on young people's safer sex practices has important implications for health-promotion interventions in Mongolia and abroad. Much more qualitative and quantitative research is required to understand the social and cultural context of sexual health, especially on Mongolian traditional values and their impact on sexual behaviour among youth.