High rates of unintended pregnancy and sexually transmitted diseases among young adults
reflect an urgent need for better, more effective reproductive health services for youth.
But what makes a program successful?
International health experts agree on several key components that contribute to
successful reproductive health services for youth. Identifying and understanding the group
to be served, involving youth in designing programs, working with community leaders and
parents, and finding better ways to make services accessible are commonly cited as
important considerations. Evaluation should be built into program design, and program
managers should plan for ways to sustain and expand successful services.
"We still have lots of questions, but we can't wait on final answers to act,"
says Dr. Herbert Friedman, recently retired director of the World Health Organization
(WHO) Adolescent Health and Development Programme. "It is an urgent situation for
youth. While we need better evaluations of effectiveness and better measurements of
intervention approaches, we do know enough to act. But we must make a concerted effort to
extend the quality and scope of programming. We are trying to catch up with the growing
interest governments have in serving youth."
WHO is coordinating a review with the United Nations Population Fund (UNFPA) and the
United Nations Children's Fund (UNICEF) of key interventions designed to improve
adolescent health services, focusing on the effectiveness of these efforts.
A crucial consideration in planning any service for young adults is the very nature of
youth themselves. Young adults are typically less informed, experienced or confident about
sexual matters. "They are often more vulnerable than other age groups," explains
Dr. Cynthia Waszak of FHI, whose specialty is adolescent reproductive health. "Also,
providers tend to be more judgmental of youth, and there are more legal and cultural
barriers."
Better ways to make services more accessible, for example, involve the attitude and
training of providers, the logistics of clinic location and service, questions of privacy
and confidentiality, and other issues that will address the unique needs of young adults.
"Young people need advocates. And, providers need special training to serve
youth," says Dr. Waszak.
The group to be served
Successful programs typically identify a specific target group to be served, often
defined by age, school status, marital status and other social factors. This helps in
analyzing the needs of the target group and in developing appropriate strategies to meet
those needs. "It is important to avoid treating adolescents as a homogeneous
group," explains Judith Senderowitz, an independent consultant who has analyzed youth
programs for the U.S.-based FOCUS on Young Adults program, UNFPA and others.
"Focusing on specific characteristics is extremely important -- especially marital
status, school enrollment and geographical location." For example, she says, the
reproductive health needs of urban and rural youth are usually very different, as are the
available resources to serve them.
In a recent evaluation of 70 projects focusing on adolescents, UNFPA found that almost
none of the projects had defined its target population clearly or incorporated a needs
assessment into the program designs.1 "Program planners
were not always clear about the age range they intended to serve," says Senderowitz,
who wrote the UNFPA evaluation. "In some cases, they chose the least costly channel
such as in-school programs, even though the most needy and underserved are out-of-school
youth."
Marital status can be particularly important to consider. Both married and unmarried
youth have common biological and developmental issues regarding reproductive health. Thus,
the need for information about sexuality, contraceptives, pregnancy and other issues are
similar for all youth. Whether married or unmarried, young people face health risks from
pregnancy and sexually transmitted diseases (STDs). But youth who are unmarried often face
more obstacles to services and have different contraceptive needs.
"In designing a program for a particular group, it is essential to use specific
and measurable objectives," says Dr. Waszak of FHI. "Too often, the goals of a
project are not clear. Then, we have no way of judging whether an approach is effective or
not."
Involving youth
Experts agree that providers should involve youth in planning and implementing
reproductive health services, and evaluating programs. However, little research has been
done to clarify exactly how this involvement can be used to achieve successful results.
"Involving youth has gotten to be a fad," says Dr. Ann McCauley, dissemination
advisor for FOCUS. "There is no evidence that it is a more effective way to change
behavior. I believe in the concept and support it, but we need to get a lot smarter about
what is feasible and how best to include youth."
Providers can involve youth in many stages of a project, from the initial needs
assessment and program design to implementation and even training of providers. "It
is important to work with youth in focus groups and workshops to identify the main
problems or constraints that they have had in trying to get reproductive health
information and services," explains Dr. Fritz Moïse, director of the Fondation de
Santé Reproductive et d' Education Familiale (FOSREF) in Haiti, which delivers
reproductive health services and focuses on youth.
In February, Dr. Moïse helped conduct a training program for providers on access to
reproductive health services for youth. Sponsored by FHI in Dakar, Senegal, the workshop
participants included both providers and young adults. The youth participated in role
plays, practice sessions on counseling and general discussions. In the evaluations of the
workshop, several participants mentioned the importance of involving youth. "We
learned a lot from the adolescents. Their participation made the workshop more
fruitful," wrote one participant, a provider. "I liked the young people's
participation a lot. It was good to be able to ask them questions," said another.
Asking young people to talk openly about their problems will help improve services,
offered a third.
Many programs rely on young adults working directly with other youth. Called peer
educators or promoters, these youth have been used effectively in AIDS prevention
projects. The FHI AIDS Control and Prevention (AIDSCAP) Project recently reviewed 21 peer
education projects in Africa, Asia and Latin America. The study found that peer education
is a useful way to provide HIV/AIDS information. "The peer educators speak frankly.
They get right to the point without prejudice," said one Brazilian youth interviewed
in the study. "They understand me easily as well as my problems on this issue,"
is how a Cameroon youth put it. However, the report also found that programs may need to
do more. "Planners need to consider how and if their projects should evolve,"
the report concluded. "If peers are already knowledgeable about STD/HIV infection,
then peer educators should address the skills and attitudes necessary for behavior change
and maintenance."2
Based on that study, AIDSCAP produced a guide for developing peer education projects,
using a practical, hands-on approach. For example, one section titled "Should I use a
peer education approach?" includes a simple worksheet with questions such as: What
are the goals of this project, who is the target audience, how many staff members will be
needed to help train and supervise the required number of peer educators, and does my
budget include supervision expenses?3
FOCUS has identified 11 elements in successful peer programs, including selection and
training, skills building, effective provision of information and referrals, and finding
ways to minimize turnover. When possible, youth should be involved in developing
materials, including design, types of language, and field tests, depending upon local
circumstances.
Community involvement
When designing programs to reach youth, policy-makers and providers need to acknowledge
the importance of culture and tradition when advocating what young people need. Involving
community leaders, parents, teachers and others helps to achieve this difficult balance.
"We need to pay more attention to what works in society in general, not just in
programs for youth," says Dr. Friedman of WHO. "Adolescents tend to believe what
their parents do, but too often interventions tend to pull apart the parents and youth. We
push sex education projects without involving the parents, and they react with horror.
People promoting health need to pay attention to the values of society."
The UNFPA analysis found that most projects did not involve parents, community and
religious groups, and others whose support would be important for project acceptance. Lack
of contact with parents and other invested community groups misses an opportunity both to
educate them about the project and to gain their support, the UNFPA report explains. On
the other hand, trying to please everybody can delay or block new services, cautions
Senderowitz, who adds that "a good strategic approach is to get a few leaders really
supportive of your program, who can then lead the way for other community
involvement." The UNFPA report points to several effective examples, including
projects in Jamaica and Antigua that sought the help of parents and churches in providing
information and guidance to young people.
Sex education programs can be particularly divisive. "Some parents are afraid that
their children are being told things that will encourage them to have sex," says Dr.
Waszak of FHI. "But parents generally just want what's best for their children.
Parents are not necessarily bad people for resisting programs, nor are the kids bad for
wanting information. We've got to be more open and understanding of all points of view,
while pushing ahead with providing youth the services they need." Research has shown
that sex education programs are more effective in changing behaviors when messages reach
youth before they become sexually active (see article on page 14).
Several programs have successfully invested time and resources in involving parents. In
Zimbabwe, the National Family Planning Council offered a program to help parents educate
their children about sexuality and reproductive health. In Tanzania, a parents'
organization developed a manual designed to help parents communicate with their children.
Accessible services
Experts generally agree that a "youth-friendly" environment can help attract
and serve youth who may be embarrassed or intimidated to seek services, or may have
practical obstacles such as lack of transportation and funds.
No program can solve all the problems of accessibility, and solutions may vary, even in
the same country. For example, should a clinic offer separate services for youth? How
youth in a specific target group would respond to this should be taken into account.
"It has proven a good strategy for us to organize focus groups with young people to
help determine the site and location of the clinic centers," says Dr. Moïse of
FOSREF, whose clinics have separate resource centers for youth.
One challenging issue is the attitude of providers, who are often judgmental about
unmarried young women seeking services. Studies in South Africa and Senegal, for example,
tracked the experience of "mystery clients," youth hired to seek services at
clinics. In South Africa, providers resisted requests for condoms and gave no instructions
for use.4 In Senegal, none of the youth who requested a
contraceptive method received it.5
"Providers, who are mostly adults, may have personal or religious views about
sexuality that influence how they assist youth," explains Dr. Jose de Codes of FOCUS,
who for many years trained providers for WHO and other organizations. "Most providers
have difficulty seeing the situation from the point of view of the young person. So
adolescents often hesitate to tell adults that they are sexually active and to talk about
contraception."
The convenience of location, clinic hours, degree of confidentiality, and style of
service can all be important, as can offering referrals to other services. In the recent
Senegal workshop, providers and youth developed plans that included ways to link services
with youth clubs, reorganizing clinic schedules to serve youth better, and training staff
in youth counseling.
Evaluation
To determine if a project is accomplishing its goals, providers must rely on more than
intuition. "Program managers and staff alike are often skeptical of how money and
valuable staff time spent on an evaluation activity can enhance their work," reports
Dr. Catharine McKaig of FOCUS in a summary of evaluation approaches. Also, negative
results might not please donors, jeopardizing future funds. "While these are
legitimate concerns, a simple evaluation can be conducted that can help improve program
operations, increase efficiency and effectively help meet program objectives."6
The most basic evaluation tool is simple observation. Program managers can ask
themselves if the program is going the way they intended. "At a youth center in
Kenya, there were no girls," recalls Senderowitz. "To begin with, they simply
needed to go and ask the girls why they weren't coming. It was a common sense evaluation
tool to use to attract the target group." A group can at least set identifiable and
measurable goals to help monitor if it is meeting those goals.
For a more formal evaluation, a program needs to gather information at the beginning of
a project, called "baseline data," to compare with data collected later. The
comparison can be used to track service delivery, provide information on program
participants and describe delivery systems. Called a "process evaluation," it
can determine whether services are reaching the intended population, are being delivered
as planned and are adequately funded. This approach is often used during a project,
perhaps at a midpoint, to help a project adjust its goals and workplan.
In 1992, for example, CARE International started an AIDS prevention project in Kenya
called CRUSH (Community Resources for Under 18's on STDs and HIV). CRUSH relied primarily
on training peer educators through lectures. A midterm evaluation found that the approach
was not motivating the target group, which itself was too broad and not clearly defined.
The project shifted its approach to improve training for peer educators and to focus on
out-of-school youth, ages 12 to 18.
At its conclusion, the CRUSH project used an "outcome" evaluation, which
seeks to determine how well the project met its goals. This usually involves a sampling
process for a survey to help determine if the project changed people's knowledge,
attitudes or behaviors. Some experts think that in order to measure behavior change,
follow-up surveys need to be done one to three years after the program begins. Such a time
span requires a long-term follow-up of participants and consideration of developmental
changes and behavioral influences other than the intervention. In the Kenya project, the
final evaluation included interviews, a survey of the target population and a control
group, and baseline data for comparison. It found that the target audience had more
knowledge and showed more signs of positive behavior change than did the control group. It
did not compare the rate of STDs among the groups, however.
The EVALUATION Project of the U.S.-based Carolina Population Center recently identified
10 key indicators for an adolescent reproductive health project. These include information
that is not too difficult to obtain, such as the total number of contacts with adolescents
and the existence of government laws and programs favorable to adolescent reproductive
health. It also includes items that would require more ambitious surveys and data
collection. The report includes 41 other indicators to consider.7
Sustaining good programs
Many reproductive health services for young adults begin as small pilot projects that
become models for expanding services. Some successful pilot projects, however, die for
lack of funding or because their innovative approaches are not replicated by established
providers and organizations.
Experts agree that sustaining and expanding good services is important, and should be
considered during planning. One example of a small project that moved to a broader scale
is a project in Mexico City, Centro de Orientación para Adolescentes (CORA). Begun in
1978, CORA has tried many different approaches, using evaluations to modify programs that
were not achieving their goals. It has worked to expand innovative programs into existing
institutions, to broaden the use of limited resources. For example, teenage mothers in
hospitals needed better counseling and related services. CORA did not have the resources
to provide the services on a large scale but served as a catalyst for introducing the
services.
"We developed materials and a training system for those working with teenage
mothers at a major hospital," explains Dr. Anameli Monroy, who started CORA and is
now a consultant to international organizations on youth issues. "We did not have to
sustain the project ourselves because we got it integrated into the hospital. So it was
not expensive, in terms of new staff or resources for CORA. It meant finding an existing
organization that could keep this work going and persuading them to let us do the initial
training."
-- William R. Finger
References
- Senderowitz J. Thematic evaluation on adolescent
reproductive health -- global report submitted to UNFPA. Unpublished report. UNFPA, 1996.
- Flanagan D, Williams C, Mahler H. Peer Education in
Projects Supported by AIDSCAP. (Arlington: Family Health International, 1996) 5,14.
- How to Create an Effective Peer Education Project.
(Arlington: Family Health International, 1996) 9-12.
- Abdool Karim Q, Preston-Whyte E, Abdool Karim SS.
Teenagers seeking condoms at family planning services: part I. A user's perspective. S
Afr Med J 1992;82:356-59.
- Nare C, Katz K, Tolley E. Measuring access to family
planning education and services for young adults in Dakar, Senegal. Unpublished paper.
Family Health International, 1996.
- McKaig C. Evaluation of youth programs: identifying
effective strategies for promoting the health of young people. Passages
1997;15(1):1.
- Stewart L, Eckert E, eds. Indicators for Reproductive
Health Program Evaluation: Final Report of the Subcommittee on Adolescents. Chapel
Hill, NC: The EVALUATION Project, 1995.
For more information, visit Family Health International's Website at www.fhi.org
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