Sexually active young adults are seldom well-informed about their
contraceptive choices or the risks they face in acquiring a sexually transmitted disease
(STD). They are often reluctant to go to clinics for services and may even be refused
services or treated rudely if they do. Inconvenient hours or location and unaffordable
costs may also discourage them from seeking help.
Yet compared with older men and women, adolescents are more likely to change partners
often or have partners who have multiple partners. In many countries, adolescents have
high rates of unwanted pregnancies and STDs.1 In the United
States, women from 15 to 19 years old have the highest incidence of chlamydia and
gonorrhea of any age group,2 while in Kenya, one study among
205 adolescent school students, ages 13 to 15, found that one in every three had
gonorrhea.3 Worldwide, young people under age 25 account for
one-half of all HIV infections.4
The age of puberty is falling worldwide, partly due to better nutrition,5
while the age at marriage in many countries is rising.6 These
trends suggest that the opportunity for sexual activity prior to marriage is increasing.
Finding effective ways to serve youth is difficult, yet crucial. Experience shows that
planning youth services may call for creative steps. For example, health professionals
should involve parents, teachers, community leaders and youth themselves in developing
strategies to serve young adults. Community workshops to explore attitudes about teenage
sexuality and to discuss approaches for tailoring services to meet young people's needs
may be useful.
Convenient ways for young adults to obtain latex condoms should be considered,
including vending machines or distribution by peer educators. In educating young adults
about pregnancy and STDs, role playing or theatrical skits have been used successfully.
Even the physical appearance of a clinic may play a role, since an appealing environment
and adequate privacy may help to attract young clients.
Sex education
Contraceptive use among adolescents is generally low. Unmarried young women, who face
social disapproval of their sexual activity, are unlikely to get and use contraceptives.
Among sexually active unmarried teenage women in Zimbabwe, for example, about two of every
five become pregnant before marriage.7
Youth generally do not know what contraceptive choices are available, or how to obtain
them. In Senegal, a survey of 1,973 single and married women ages 15 to 24 and 936 single
men ages 15 to 19 showed that the most prominent reasons given for not using contraception
were that they did not know about contraceptive options or did not expect to have sex.
About 80 percent of survey respondents incorrectly believed that oral contraceptives cause
infertility.8 Similarly, in Mauritius, misperceptions were the
most common reasons given by teenagers for not using condoms, including the mistaken
belief that condoms were intended for married couples only.9
FHI researchers Karen Katz and Elizabeth Tolley, working with the Comité d'Etude sur
les Femmes, la Famille et l'Environnement en Afrique (CEFFEVA) in Dakar, Senegal,
identified lack of contraceptive services and health information as the two main factors
contributing to unintended pregnancies among adolescents in the West African country.
Better reproductive health services for young adults, they concluded, should include an
expansion of sex education programs in schools.
Since community approval of sex education is vital, they suggested bringing parents and
providers into the process. A workshop with family planning providers to explore community
attitudes and build support is planned.
Parents may fear that sex education will hasten or encourage sexual activity, despite
research that shows education may delay activity.10 In Zaire,
a survey by the Population Council found that 75 percent of the 500 parents interviewed
believed that teaching female teenagers about contraception would promote promiscuous
sexual behavior.11 However, a World Health Organization
review of 19 studies found that offering sex education in school often delayed or
decreased sexual activity and led to more contraceptive use.12
For young adults who are already sexually active, better education helps prevent STDs
and unwanted pregnancies. In addition to informing youth about family planning choices,
young adults should be taught to assess their risk of STD infection and to understand the
relationship between various contraceptives and infection. Sexually active youth should be
offered condoms or other barrier contraceptive methods to protect against STDs and
counseled about how to negotiate risk reduction in a relationship.
Those who are at high risk should be urged to use condoms with every sexual encounter,
and those who are infected with STDs must be treated and counseled about the importance of
informing partners about their infection. Learning how to use a condom is difficult for
people of all ages, but may be especially challenging for youth, who are less experienced
with relationships and may be more embarrassed about discussing condom use with a partner.
Embarrassment
Many young adults are simply too embarrassed to seek family planning or STD treatment
and prevention services. "Adolescents are reluctant to go to clinics because of
cultural and social barriers and, even if they go, they are not well received, because
providers don't want to give them what they need," says Christine Nare, president of
CEFFEVA in Senegal. "From a social and cultural perspective, if a woman is not
married, people believe that she should not have sexual intercourse. If an unmarried young
woman goes to a clinic to look for methods, it suggests that she is having sex. This is
something girls generally do not want people to know, and they do not want people to see
them going to a clinic."
Once at a clinic, young adults may be refused condoms, other contraceptives or even
counseling. Some providers openly disapprove of a young client's sexual activity, and
confidentiality may be lacking. In the Senegal project, 12 teenagers were hired to visit
clinics to obtain contraceptive information while pretending to be regular clients. Of
those who requested a contraceptive method, none of them received contraception.13 In some countries, although not Senegal, it is illegal for
family planning providers to serve adolescents, or illegal to do so without parental
consent.
Because of these barriers, nonjudg-mental, specialty clinics that serve only youth may
be necessary. Motivational media campaigns using clear, simple messages and positive
images can inform youth where to get health services, as well as increase awareness about
the risks of being sexually active and how to take preventive measures. Involvement of
other young people as educators, coordinators or program developers may be effective.
In Haiti, the Youth Project of the Fondation de la Santé Reproductive et l'Education
Familiale (FOSREF) operates a clinic specifically for young adults, targeting 15- to
24-year-olds. The youth clinic was established after a survey of teenagers attending
FOSREF's clinics showed that young clients typically sought help only during an emergency,
such as a need for emergency contraception after unprotected intercourse or treatment for
an STD.
"If they didn't have a big fear [about their health], they wouldn't have
come," says Dr. Fritz Moise, FOSREF director. "In Haiti, all school children
wear school uniforms, and they knew that people would recognize them as students and know
that their presence at the clinic meant they were having a sexual relationship. The big
fear was that their parents might find out."
Research showing that Haitian youth had the highest risk of STDs and the highest rates
of maternal mortality helped gain community support, says Dr. Moise, who convened a
workshop of parents, school representatives, church officials and others. "Those
people were afraid and surprised to know that young people were the most vulnerable to
STDs and that clandestine abortion was the leading cause of death," he recalls.
"The parents asked us to please do something." Schools invited Dr. Moise and
colleagues to conduct focus groups with their students, and FOSREF gained support from the
ministries of education and health in Haiti to provide family planning and STD prevention
services specifically for teenagers.
"I believe the way we started with the parents, churches and school teachers --
everyone recognized the problem and saw how big it was," says Dr. Moise. "We
confirmed that there was a need. I think all young people's programs should start that
way."
Access to condoms
Access to contraceptives, especially to condoms, is often a problem among sexually
active young adults. In Portland, OR, on the west coast of the United States, Project
ACTION made condoms available to teenagers through vending machines. Vending machines were
selected as the way to improve access based on focus group research, which showed that
adolescents were most often discouraged from buying condoms because of embarrassment, cost
or inconvenient access to them.
About 240 vending machines were installed in night clubs, clothing stores, restaurants,
college buildings and recreation centers - places frequented by young adults. The price
per condom was kept low at U.S. 25 cents, about the cost of a telephone call. A private
business has since purchased the vending machines and continues selling condoms at U.S. 25
cents.
Finding ways to involve businesses in STD prevention is part of a larger strategy, says
Julie Convisser, campaign director for Project ACTION, sponsored by Population Services
International, which coordinates condom campaigns in many countries. "The single
reason our program succeeded is because we focused first and foremost on building
community mobilization across society," she says. "Many people think health is
separate from business, politics and ethnic or racial issues when, in fact, it is integral
to it."
Before the vending machine project began, Project ACTION spent six months building
community support, with frequent visits to business, religious and ethnic leaders, as well
as to government agencies and non-government organizations that work with health or youth.
With strong community backing, "safe sex" messages to young adults were
frequently broadcast by local television and radio stations as public service
announcements.
Based on interviews with more than 2,200 teenagers before and after the two-year
Project ACTION campaign, condom use with casual partners increased substantially and the
number of teenagers reporting sexual activity declined somewhat, from 82 percent to 75
percent at the project's conclusion.14
Another way to reach youth is with clinics that are conveniently located or have been
designed to serve adolescents. In the Central African Republic city of Bangui, the Projet
d'Appui aux Jeunes pour une Sexualité Responsable (PAJESR) operates an office in the same
compound that houses a high school and is located near another large high school. Many
teenagers congregate at the compound after school, and typically about a dozen of them
visit the office daily.
"At first it was difficult to get youth there, and the ones who did show up were
mainly boys," says Gaby Supe, program coordinator. "We did a lot of public
relations and have managed to increase the ratio of girls to more than one-third."
The project has trained young people to work as peer educators and as puppeteers with a
theater marionette group that performs for adolescents. Video messages about contraception
and STDs have been made by the project and are shown locally.
In Haiti, Dr. Moise and colleagues are using similar strategies. The clinic that
targets adolescents is at a location where many youths pass on their way to school. A
large room near the entrance serves as both waiting room and gathering place for
teenagers, who can watch educational videos and television, or listen to music, without
using the clinic's services. In addition to films about STDs and teenage pregnancy,
general entertainment films are shown.
Unlike Haitian clinics for older adults, where clients must register upon arrival,
young adults do not sign in at the youth clinic. "The way the youth clinic is
organized, the young people come in and see television, young people talking, and
posters," says Dr. Moise. "It is only when they cross a small corridor and go
for something else that they see a nurse auxiliary. We do not even ask for their names
until the teens leave the clinic. We know that some just come here to see what it is
like."
Because of STD risks, condoms are made available to every teenager, even for young
adults who are using another method. "We are always talking about condoms," Dr.
Moise says, "even if they say they're monogamous." Dr. Moise's research on
Haitian adolescents shows that young people, on average, change partners two to three
times every year.
Confronting denial
In a United States farm community that has an unusually high prevalence of HIV
infections, an AIDS prevention project encourages adolescents to confront their own denial
about sexual risks. The project in Belle Glade, FL, called the Health Education AIDS
Research Team (HEART), uses theatrical skits, games and other community events to help
teenagers understand HIV risks.
One popular skit involves a teenage party in which some of the "guests" are
STD symptoms, who pretend to be casual acquaintances and slip into the party uninvited.
The skit is intended to show how STDs can slip into a person's body uninvited or
unnoticed.
"It is hard for some people to see themselves as being at risk," says
Henrietta Johnson, a field supervisor for HEART, which is funded by the American
Foundation for AIDS Research with technical assistance from FHI. "It is not so much
what you see in your partner, but the information you do not have, and you do not know
about, that could put you at risk." In one game played by teenagers, everyone who
knows one individual gathers around the person, illustrating that person's many
relationships with other people. The game helps adolescents understand how any couple's
relationship can easily follow a history of sexual relationships with many other people.
Other games and role playing deal with issues of trust and fear about asking a partner to
wear a condom.
HEART conducted surveys of more than 500 teenagers before the project began in 1992,
then again in 1994. The proportion of adolescents who reported having sexual intercourse
decreased from 56 to 43 percent, and the proportion of teenage girls reporting no sexual
partner during the previous month increased from 10 percent to 33 percent. Sexually active
teenagers reporting they had ever used condoms or had used a condom at their last sexual
encounter also increased.15
Other promising approaches for young adults include the Youth to Youth Project in
Burkina Faso, which promotes reproductive health information and services to young people
nationwide. Several reproductive health clinics have been established to serve adolescents
with a range of reproductive health services, including STD screening and treatment,
contraceptives and gynecological services.
Youth to Youth bases its services and campaign strategy on survey data collected on the
sexual attitudes and behavior of 1,877 young adults. Teaching materials are designed by
youth, youth are trained as educators, and information about the program is channeled
through youth peer networks.16
In Ethiopia, several AIDS prevention programs have managed to increase youth attendance
at STD clinics. The Family Guidance Association of Ethiopia (FGAE), with technical and
financial assistance from FHI's AIDSCAP Project and the Ministry of Health, has trained
youth volunteers to give youth-to-youth educational sessions. Peer educators distribute
free condoms to out-of-school teenagers and provide them with booklets and discussion
groups about AIDS. Many experts feel that youth involvement may be the single most
important feature of any successful public health campaign targeted at teenagers.
-- Sarah Keller
References
- Meeting the needs of young people. Population Reports
1995;J(41).
- U.S. Centers for Disease Control and Prevention,
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U.S. Centers for Disease Control and Prevention, 1996.
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Tract Infections: Global Impact and Priorities for Women's Reproductive Health. (New
York: Plenum Press, 1992) 281.
- Population Reference Bureau and Center for Population
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- Nare C, Katz K, Tolley E. Measuring access to family
planning education and services for young adults in Dakar, Senegal. Unpublished.
- Schenshul S, Oodit G, Schensul J, et al. Young Women,
Work and AIDS-related Risk Behavior in Mauritius. Washington: International Center for
Research on Women, 1993.
- Mauldon J, Luker K. The effects of contraceptive
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- Population Council, Association Zairoise Pour Le
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- Baldo M, Aggleton P, Slutkin G. Does Sex Education
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- Nare.
- Blair J. PSI/Project ACTION: Impact on teen risk
reduction. Unpublished paper. Population Services International, 1995.
- Fox LJ, Bailey P, James D, et al. Reaching
Adolescents at HIV Risk in Belle Glade, Florida: Results of the 1992 and 1994 Household
Surveys. Poster, XIth International Conference on AIDS, July 7-12, 1996, Vancouver,
BC.
- Family Health International, Johns Hopkins Program for
International Education in Reproductive Health, Program for International Training in
Health. Proceedings: Regional Conference on Increasing Access and Improving the Quality
of Family Planning and Selected Reproductive Health Services in Francophone Sub-Saharan
Africa. Ougadougou, Burkina Faso, March 12-17, 1995. Durham: Family Health
International, 1995.
For more information, visit Family Health International's Website at www.fhi.org
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