Should condoms be available in secondary schools? Discourse and policy dilemma for safeguarding adolescent reproductive and sexual health in Rwanda

Introduction As a response to challenges associated with adolescent reproductive and sexual health, policy makers in Rwanda have instituted preventive measures against risky sexual behaviours among adolescents. There is an ongoing debate on whether condoms should be made available in secondary schools to minimise risks related to unprotected sex in the context of a growing number of unintended pregnancies among school girls. This paper aims to examine the proposal of condom provision in Rwandan secondary schools through the analysis of policy narratives and the claims-making process. Methods A narrative policy analysis was used to understand the claims and counter claims surrounding the debate on the provision of condoms in secondary schools. Documents that were consulted include: the national reproductive health policy, the girls' education policy, the national behaviour change and communication policy for the health sector, the Rwanda national policy on condoms, the adolescent sexual reproductive health and rights policy and the Rwanda family planning policy. Results Social and cultural norms in the Rwandan context consider adolescent sexual practices as immoral and thus reject the idea of providing condoms in secondary schools. However, some stakeholders promoting reproductive health suggest that ignoring that some adolescents are sexually active will prevent them from accessing appropriate reproductive and sexual health protective programmes. Consequently, adolescents will be exposed to risky sexual behaviours, a situation which may be counter productive to the overarching goal of safeguarding adolescent sexual health which might impact their long-term education goals. Conclusion Making condoms available in secondary schools evokes different meanings among the debaters, underscoring the complex nature of the condom provision debate in Rwanda. This paper calls for a revision of policies related to adolescent reproductive and sexual health in order to answer to the issues of risky sexual behaviours among secondary school students.


Introduction
Adolescent sexual and reproductive health is an issue of immense concern globally and is part of the overall objective to achieve universal access to efficient healthcare services. Social, cultural, religious, and economic factors have an important impact on the progress of sexual and reproductive health among adolescents [1,2]. Unsafe sexual activity-i.e, sexual activity that exposes either of the partners to negative outcomes such as diseases or unintended pregnancy, human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) and other sexually transmitted infections (STIs) are major risks for high mortality and morbidity. The rates of such infections are especially high in lowand middle-income countries (LMICs), hence calling for combined effort to reduce them [2]. The World Health Organization (WHO) reports that two million youth between 10 and 19 years are infected with HIV around the world [3]. Moreover, the adolescent birth rate for adolescent girls aged 15-19 was 44 per 1000 in 2015 [4].
Teenage pregnancy presents risks to both the baby and mother, with increased pregnancy complications to the mother as well as high risk of disease and death to both the baby and mother.
Teenage pregnancy may lead to unsafe abortion, especially in countries where abortion is illegal and or practiced in no-safe conditions due to poor hygiene and inadequate equipment [5].
Teenage pregnancy has also been cited as a major cause of school dropout among young girls [6].
In Rwanda, the most recent Demographic and Health Survey (DHS) (2015) indicated that 7% of teenage girls between 15 and 19 years have either already experienced child bearing or were pregnant [7].
The same document showed that the proportion of childbearing teenagers, which was 11% in 1992 showed a decrease of 4% in reproductive health to adolescents. In schools, MINEDUC has emphasized reproductive health education programs in the education curricula and encouraged parents to discuss reproductive health with their children while keeping in mind social and cultural values [9]. Likewise, MINIYOUTH has put the emphasis on the provision of youth-friendly reproductive and sexual health programs such as Dushishoze Centres for youth friendly sexual and reproductive health dialogue and services in rural areas.
Despite the introductions of such initiatives, the alarming number of pregnancies among school girls across the country indicates that students are sexually active [8]. A behaviour surveillance conducted in 2009 on youth (aged 15-24) indicated that these youth were sexually active [10] and a survey conducted in three rural schools of Rwanda indicated that 44% of students reported to be sexually active and among them, only 36% used condoms regularly [11].
The Rwanda National Policy on Condoms (RNPC), established in 2005, stated that accessible condoms would help to prevent sexually transmitted diseases (STDs) (particularly HIV/AIDS) and unwanted pregnancies [12]. Yet, 13 years after the adoption of the policy, students are not provided with condoms in secondary schools. Rwanda's DHS (2010) states that only 13.3% of women and 10.7% of men aged 15 to 19 used condoms during their last sexual intercourse [10]. In order to explore the discourse surrounding the proposal of condom provision in high schools, this

Methods
A Narrative Policy Analysis (NPA) was used to understand the claims and counter claims surrounding the debate on the provision of condoms among secondary school students. This approach was used due to its nature that helps to understand complex policy debates where there is uncertainty, complexity and confusion surrounding an issue [13,14]. Using tools from literary criticism, the method helps to understand the relationship between different narratives surrounding the issues and to seek a meta-narrative which suggests a reframing of the situation from which progress can be made by more conventional analysis. As a method for analysing For ease of access of claims-making by the actors in the debate, this paper was restricted to stories in the electronic media. Different narratives were selected from electronic media (private and public) that reported on the proposal of condom provision in secondary school. Hannigan (2006) notes the importance of media in raising up problems to be part of political process [21]. Media helps the public to get awareness of information about complex issues that need attention from people in different categories. Studies that fulfilled the following a priori eligibility criteria were included: if the electronic material (1) was from an original source; (2) reported an issue specifically related to the condom provision policy discussion (3) reported on any one or more of the following issues: teenage pregnancy, adolescent health, reproductive health, pre-marital sex, sex education, (4) presented information on HIV/AIDS risk to teenagers. Thirty electronic materials were retrieved including 21 private and nine public articles. All the articles were reviewed in-depth and only ten articles that contained adequate information for the purpose of this paper were used.
After selection of the electronic materials on condom provision, the narrative policy analysis stepwise procedure proposed by Roe (1994) was used [22]. Initially, dominant stories (those stories that are repeatedly told) by proponents and opponents in the debates were identified. Next, non-stories (stories that do not have a beginning, middle or an end) and counter-stories (stories that run counter to the dominant policy narratives) were identified. Stories were then contrasted and combined to form a new story in the form of a metanarrative (alternative to consensus) in the thirds step.
Finally, the metanarrative and how it recasts the condom provision policy problem was examined. The ethics approval was not required because only data available in the public domain were analyzed.

Results
Characteristics of the search materials: Apart from the five policy documents, about 30 electronic materials were retrieved and all of them were reviewed in-depth. Twelve materials/articles/news reports fulfilled our a priori inclusion criteria for this narrative policy analysis. Ten of these studies provided adequate information based on our search terms and inclusion criteria. Twenty materials were excluded for various reasons (e.g. duplication, irrelevant information on condom distribution). Table 1  To buttress the stance above, another teacher shared a similar opinion: "We should educate these young people about condom use and avail them because either way, they engage in sexual intercourse, so the earlier we teach them the better.I don't think this will necessarily push them into early sex because emphasis will be put on the essence of sexuality so that the students understand It is important to acknowledge that different socio-economic factors play a big role in youth initiation to sexual activity and these may be different in developed and developing countries [30]. urged to frame a policy that would be seen as a solution for the issues raised by the two coalitions [22]. More data is needed on adolescent sexual reproductive health from schools and stakeholders institutions in order to better explore the issues surrounding risky sexual behaviours among adolescents, analyse the existing initiatives that have been put in place and explore how they could be strengthened in order to promote healthy sexual and reproductive behaviours among secondary school students. The GoR will need to play a key role in putting together concerned groups to get a compromise on this issue to make adolescent reproductive and sexual health a success.