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.
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, Division of STD Prevention. Sexually Transmitted Disease Surveillance 1995. Atlanta: U.S. Centers for Disease Control and Prevention, 1996.
Maggwa AB, Ngugi EN. Reproductive tract infections in Kenya: Insights for action from research in Germain A, Holmes K, Piot P, et al., eds. Reproductive Tract Infections: Global Impact and Priorities for Women's Reproductive Health. (New York: Plenum Press, 1992) 281.
Population Reference Bureau and Center for Population Options. The World's Youth 1994: A Special Focus on Reproductive Health. Poster. Washington: Population Reference Bureau and Center for Population Options, 1994.
Forrest JD. Timing of reproductive life stages. Obstet Gynecol 1993;82(1):105-11.
Population Reports, 5.
Boohene E, Tsodzai J, Hardee-Cleaveland K, et al. Fertility and contraceptive use among young adults in Harare, Zimbabwe. Stud Fam Plann 1991;22(4):268.
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 education on method use at first intercourse. Fam Plann Perspect 1996 28(1):19-24,41.
Population Council, Association Zairoise Pour Le Bien-Etre Familial. Survey on parents' ability to answer questions about family life. Unpublished.
Baldo M, Aggleton P, Slutkin G. Does Sex Education Lead to Earlier or Increased Sexual Activity in Youth? Poster, IXth International Conference on AIDS, Berlin, 1993.
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.
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