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.
Click to select preferred language, if other than English:
French | Spanish.
