FHI - FAQs: Youth-friendly Services

Recognize and share with the adolescent client that sexual interest and desire during adolescence is normal and natural.
Discuss the client's personal values and those of his or her family regarding sexual activity, taking into account his or her age, gender, marital status, social norms, and expectations.
Encourage the adolescent to have discussions with family or significant others in his or her life, if appropriate.
Ask the adolescent to discuss how far he or she is willing to go with respect to intimate sexual contact with his or her partner.
Ask the adolescent to identify the pros and cons of becoming sexually active (including health and social risks) and the potential effect of sexual activity in general, and sexual intercourse in particular on themselves, their partners, their family, and others.
Discuss and provide information on "how to say no" to unwanted or unprotected sexual activity. Suggest and explore possible responses to pressure from partners and peers. One way to do this might be through role-playing "real life" situations so that the adolescent develops the language and skills needed to negotiate with a partner or peers.
Help the adolescent set realistic life goals, and discuss how an unplanned pregnancy might disrupt the accomplishment of those goals.
Provide complete information about preventing pregnancy and STIs, including AIDS, and information about where to obtain additional information and services, should the adolescent choose to become sexually active.

Q: What do counselors need to know about the physical development of young clients to reach, serve and counsel them more effectively?

Providers need to understand puberty and the accompanying body changes experienced by both boys and girls.
Girls begin menstruating and boys reach puberty at earlier ages than in previous decades. That, in many cases, means an increase in the time between the onset of puberty and marriage and a greater period of possible sexual activity and risk for pregnancy and STIs.
Among younger female adolescents, physiological immaturity may put them at greater risk for complications during pregnancy.

Q: What do counselors need to know about the psychosocial development of young clients to reach, serve and counsel them more effectively?

Adolescents are very concerned about being "normal," and they may have a great deal of anxiety about the changes their bodies are going through.
Adolescents respond to and integrate information differently on the basis of age, stage of development, and level of maturity. For example, many adolescents may have difficulty grasping complex concepts or complicated medical terms, so information needs to be repeated several times or explained in different ways, using simple language and a variety of media.
Younger adolescents may be at greater risk of sexually transmitted infections (STIs), including HIV, because of an inability to negotiate within relationships that are often with older adolescents or with adults.
Lifestyles of many adolescents may not be conducive to the kind of routine or privacy necessary for consistent contraceptive use. Therefore, consideration needs to be given to the method that best fits the individual's lifestyle, or the provider needs to work with the adolescent to figure out how best to accommodate the method within the adolescent's lifestyle.
Many adolescents have engaged or are currently engaging in sex against their will, have been or are being abused, or are coerced into having sex in return for favors such as payment of school fees.
Not all adolescent sexual relationships are heterosexual.

Q: How is counseling young people different from counseling adults?

Youth may be less informed about their bodies, reproductive capacity, contraceptive methods, their risk for pregnancy and STIs and HIV/AIDS, and these issues may have to be brought up by the counselor.
Adolescents may have dangerous misconceptions or false beliefs because of inadequate or poor sources of information.
Many societies tend to be less accepting and less tolerant of sexual activity among adolescents in general and those who are unmarried in particular. As a result, it may be more difficult for adolescents to admit to being sexually active and share important information, particularly if they perceive bias on the part of the provider.
Adolescents may seek or accept greater guidance from a professional whom they hold in high regard.
Adolescents are less likely to be in stable relationships.
Adolescents generally require more counseling time to ensure that they understand information and instructions and have an opportunity to address other issues they may bring to the counseling setting.
Adolescents may present a wider range of concerns � such as those related to their relationships with partners, peers and family members � as opposed to purely medical concerns or those related to contraception. They may also have questions or may need assistance with issues related to relationships with family members, school and employment. As a result, the counselor should be aware of available resources and be able to refer the adolescent.

Q: What are the most important points to cover when counseling adolescents about sexual behavior?

Help them understand the physical and emotional changes that occur with growth and development.
Stress the importance of clarifying one's personal values and having skills to ensure that unwanted sex does not occur.
Dispel local and customary myths and practices that may be harmful or put the adolescent at greater risk for pregnancy or STIs.
Ask questions that help assess risk, including inquiries about STIs and possibly abusive relationships.

Ask questions that help assess risk, including:

Whether the adolescent is engaged or has been involved in sex with a partner.
His or her level of knowledge about preventing pregnancy and STIs and his or her perception of risk.
Whether the adolescent practices safe sex every time he or she engages in sex.
If the adolescent has had multiple partners.
If the adolescent has engaged in same-sex sexual relationships; and if the partner or partners of the adolescent is engaging or has engaged in same-sex sexual relationships.
Inquiries about STIs and possibly abusive relationships.
Ensure that an adolescent understands his or her own risk for contracting, and how to protect against, STI/HIV infection and unplanned pregnancy.
Stress the importance of communication and mutual respect in sexual relationships.
Inform the adolescent of the location of other youth-friendly services and resources.
Adolescents may not be forthcoming with information, particularly about their sexual experiences, and it may take extra effort to establish a relationship conducive to getting the necessary information from them.

Q: How can adolescents be assisted and supported to communicate their concerns more often and more effectively?

Youth can participate through their schools, community-based organizations, and youth centers in artistic and cultural activities such as poster contests, dramas, songs and music, poetry, and puppetry, debates, or discussion groups, newsletters, or Internet sites.
Individual and group forums can address issues of peer pressure and gender disparities and can assist young people in developing the coping and language skills necessary to deal with situations as they arise.
Leadership skills-building activities can be designed, in part, to increase youth participation.
Country-wide or regional meetings or conferences can be held, in which youth are full participants and are invited to share their experiences, insights, advice, and proposals with policy makers.
Youth can receive training in conducting research and in documenting and disseminating their findings and program experiences.
Adolescents can be recruited to share their experiences as recipients of and participants in programs and services.
They can be guided to develop relationships with adults who are willing to serve as mentors and advocates and with whom they can openly discuss issues and concerns.
They can participate in programs and activities that facilitate parent or extended family member/ child discussion of issues related to reproductive health.

Q: What kind of people transmit information well to adolescents?

Those who are:

Nonjudgmental, open and empathetic to their situation;
Trustworthy, who will not violate their confidence;
Able to relate to their issues and concerns and who are knowledgeable, well informed and resourceful;
Understanding of how adolescents communicate and what is important to them;
Advocates for youth on issues that matter to them;
Involved with youth and the decisions affecting them;
Comfortable discussing sexuality and other issues with youth; and
Interactive and are not dogmatic in their presentation of information.

Q: What interventions have been shown to be effective in increasing condom use among young adults?

The experience in Jamaica provides insight into some effective strategies used to increase condom use. The 1997 Jamaica Reproductive Health Survey and other data indicated that 60 percent of sexually experienced young men ages 15 to 24 and 40 percent of sexually experienced male adolescents ages 10 to 14 reported using condoms for their last or most recent sexual intercourse.

Four interventions/circumstances were found to have contributed to increased condom use among adolescent males in Jamaica:

Perceived peer acceptance. Interventions that promote peer endorsement, peer promotion, and condom skills training by peer facilitators will significantly increase condom use because adolescent males are far more likely to accept and use condoms if they believe that their peers are using condoms.
Communication campaigns. Effective communication campaigns should a) address issues of STIs and pregnancy prevention; b) promote messages that desensitize condom inhibitions, popularize condom usage, and establish social acceptance (using a condom is the "cool" thing to do); and c) create a healthy, positive image of condoms and condom users.
Youth-friendly access and wide availability. By making condoms available through outlets such as health clinics, pharmacies, and retail stores for free or at affordable prices for youth. Youth-friendly access includes: a) establishing a variety and large number of outlets, with emphasis on nontraditional retail points that are more anonymous and have convenient opening hours; b) sensitizing "providers" to be more accommodating and encouraging to adolescents who wish to use and purchase condoms; and c) creating a nonthreatening environment for access to condoms.
Skills training. training in correct condom use should include instructional leaflets, "older" youth as demonstrators or instructors, and a relaxed and open group environment.

Q: How can youth-friendly providers address the fact that contraceptive use is low among adolescents?

The reasons for low contraceptive use among adolescents are varied and often complex. They include psychological, social, and lifestyle factors. Adolescents have provided the following insights as to why they are poor contraceptors:

Negative attitudes on the part of providers often pose a barrier to service use and continuation of contraception.
Adolescents often don't plan and may not expect to have sex.
They think they are not vulnerable to pregnancy: "It can't happen to me."
They fear rejection by their partner.
Ambivalence about becoming pregnant and cultural expectations about marriage and motherhood or fatherhood may discourage contraceptive use.
They fear being or becoming infertile because of contraceptive use or find it difficult to cope with pressure to "prove" their fertility.
They receive inadequate information about reproduction, contraception, or pregnancy risk.
They don't know where to get contraceptives.
They want to hide sexual relations or contraceptives from their parents or other family members.
Costs of contraceptives may be beyond their ability to pay.
They are embarrassed to buy condoms and other contraceptives.
They believe that contraceptives, especially condoms, impede sexual pleasure.
They lack the skill and expertise to negotiate condom or contraceptive use with partners.
They fear the side effects of contraceptives.
They fear physical examination, especially the pelvic exam, often required to get contraceptives.
They worry that their partners will think they have other sexual partners if they use contraception.

Many of these barriers require special care on the part of the provider to identify the myths and misinformation the adolescent client may have, to provide the correct information, and to counsel the adolescent in a way that helps the client choose a contraceptive method compatible with his or her lifestyle.

Q: How can a provider facilitate more consistent contraceptive use among adolescents?

A primary factor influencing effective contraceptive use is the interaction between the provider and the adolescent. Negative provider attitudes present one of the greatest barriers to service use by adolescents. It may, in fact, inhibit an adolescent's ability to seek or obtain services.

Facilities are often understaffed and overwhelmed, and providers may lack sufficient time to explain methods and respond to the needs and questions of adolescents to the extent required. A physical setting that is not conducive to privacy and confidentiality can also make it difficult for adolescents to focus on new and often complicated information. Ambivalence on the part of the adolescent about getting pregnant can lead to inconsistent use of contraceptives. The availability of a provider to respond quickly to questions or concerns and method problems may decrease method discontinuation.

If information is reinforced by various staff members who use a variety of mechanisms, including counseling sessions, Information, Education and Communication (IEC) materials, and peer educators as counselors, and so forth, method discontinuation may decrease.

If information sharing is an engaging process, giving adolescents an opportunity to repeat the information to ensure they understand what has been discussed, they may be more likely to continue to use the method.

Adolescent lifestyles sometimes make correct and consistent use of contraceptives difficult. Providers should explore ways to make consistent and correct use easier and explain what to do in the event that the contraceptive is not used correctly or consistently. Common side effects of contraceptives and what to do about them should be fully explained to the client. Adolescents may be better able to tolerate side effects if they know what to expect.

The adolescent's motivation to use contraceptives has a lot to do with how well he or she uses them. Because contraceptive use occurs within the context of relationships, providers should assess and provide opportunities to discuss the nature of the clients' relationship(s), desires to get pregnant, and other personal factors that may affect the adolescent's motivation. Youth need to know where to get affordable contraceptives in a safe and confidential place on a consistent basis.

Q: How can adolescents be effectively reached?

This question deals with where to find adolescents as well as strategies for reaching them with information and services.

With respect to locating adolescents, places where they naturally congregate, such as schools, workplaces, concerts, sports clubs, dance halls, and other locations that provide social or recreational services for adolescents, provide excellent opportunities to reach users and nonusers with reproductive health services and information.

In terms of providing information and services, a holistic approach that recognizes and responds to the multiple service and information needs of adolescents has been found to be effective. This approach sees reproductive health as a part of an adolescent's total life, not in isolation from other realities or needs.

Involving youth directly in program development and implementation, as well as in the design of reproductive health messages, has been found effective in expanding the scope and reach of information and services.

Strategies that involve adolescents in roles such as educators, counselors, and community-based distribution (CBD) agents build on peer-to-peer relationships and increase adolescents' access to information and services.

Q: What are the kinds of staff attitudes or behaviors that affect service delivery to adolescents?

Staff attitudes can be a major determinant of whether or not an adolescent understands and makes use of the information provided, returns for services, or refers peers. In this respect, "staff" refers not only to those providing clinical services but also to anyone providing any reproductive health information and services, including community workers, pharmacists, shopkeepers, and others with whom the adolescent comes in contact. Among the most important characteristics of youth-friendly staff are:

Being respectful, nonjudgmental and objective;
Showing a genuine interest in what the adolescent is saying by listening and responding to questions or problems; and
Maintaining privacy and confidentiality.

Q: What kind of support, referral services, or networks should be available to adolescents?

If resources permit, or if coordination of services is possible, supports that provide a range of services to meet the varied needs of adolescents' including education, employment, and counseling such as referrals for services that are not provided on site benefit adolescents the most.
Services and networks that are known to be friendly to adolescents are very important.
Referral networks that include organizations known to be youth-friendly.
Services that are easily accessible (i.e., via public transportation, telephone, Internet or other technologies) and available during hours when adolescents prefer to visit.
Hotlines or radio and television call-in shows are popular ways of providing confidential or anonymous information and referrals to youth-friendly service delivery sites.
Reproductive health facilities in the developing world serve fewer adolescents than people in their 20's and older. While there are usually health services in place to provide married women under 20 with the prenatal and maternity care they need, consideration is rarely given to their age-related, physical, or emotional needs. Also, contraceptive services are often discouraged until after a young married woman has had a first or even a second birth. Health providers are especially reluctant to serve young unmarried people. This reluctance often reflects social attitudes and cultural perceptions that adolescent sexual activity is inappropriate. Yet, as more unmarried young women become pregnant, some new efforts to meet their special need for prenatal and maternity care are being tested and evaluated.

Q: What are the experiences of youth-friendly hospital-based services designed for pregnant teenagers, teenagers giving birth, and teenagers in the postpartum period?

Because the health needs of pregnant adolescents and young women can be easily and immediately identified, special programs for this group have been developed earlier than health programs to serve young women who are not pregnant. Some evaluations of these efforts illustrate positive outcomes:

In Mexico, a hospital-based program implemented by the Asociaci�n Mexicana de Educaci�n Sexual (AMES), offered family planning information and counseling at both prenatal and postpartum sessions for women under 20 who were delivering a baby at a public hospital. Education and services were also offered through a special adolescent clinic located in the hospital. After an evaluation found that counseling and education sessions were not effective during the immediate postpartum period, this approach was changed. A second evaluation of the project showed that young adults who had attended a prenatal educational session received more prenatal check-ups, and were more likely to space their subsequent births than young women who had not attended that session (86 percent vs. 64 percent).^1,6
Another Mexican hospital-based program, the Educational Program for Adolescent Mothers (PREA), was conducted by the Centro de Orientaci�n para Adolescentes (CORA�Adolescent Guidance Center). Participants attended postpartum and one or more subsequent sessions in which family planning was discussed. Evaluation showed that PREA participants breastfed their infants longer and had a higher rate of contraceptive use than a control group.⁵
In Chile, multidisciplinary teams have been working to improve birth outcomes and postpartum practices among high-risk young women in government hospitals and clinics. Medical records reveal several positive results: reduced rates of infant mortality, higher rates of continued breastfeeding, and reduced rates of second pregnancy.⁴
A Brazilian hospital-based program offered adolescents who were in the postpartum or postabortion period special out-patient services. These included counseling, education, and contraceptive services. Evaluation showed that 50 percent of the young women who received services or educational talks returned to the out-patient clinic for follow-up. Furthermore, in one participating hospital the ratio of abortions to births declined from 18 to 13 percent after five years of project operation.⁹
In the United States, a comprehensive program for pregnant women under the age of 18 was offered in a university medical school. The program used nurses, social workers, a nutritionist, obstetricians, and a psychiatrist. Caseload management was carried out by nurse-midwives. Evaluators concluded that this approach resulted in a significantly lower incidence of low-birth-weight babies, even among a socio-economic population of adolescents who were considered to be at high risk.⁷

Q: Have specialized nutrition programs for pregnant adolescents improved birth outcomes?

Some specialized nutritional services have also resulted in improved outcomes for young women:

A survey in Nigeria found that pregnant adolescents who had received antimalarial drugs and iron and folic acid supplements during the second half of pregnancy had a reduced incidence of cephalopelvic disproportion.²
In the United States, a group of pregnant adolescents who had received calorie, protein, vitamin, and mineral supplements gave birth to infants with a significantly higher mean weight than a group that had received no supplements; larger beneficial effects were observed among girls under 16.⁸

Q: What is the experience of youth-friendly services designed to help non-pregnant teenagers delay childbearing and improve their reproductive health?

There are mixed conclusions from US studies that have assessed the impact of specialized youth services to improve contraceptive use and help young women delay pregnancy.

In a US study, six family planning clinics introduced a special protocol that addressed adolescents' psychological and social concerns. Elements of the service included: one-to-one counseling; delaying the pelvic exam (which many teenagers often fear); special staff training; trained teenage counselors; involvement of male partners; encouragement of parental involvement; additional time for discussion; more frequent follow-up visits; and other refinements. The intervention resulted in higher rates of contraceptive continuation and lower pregnancy rates (within one year) among clients in the experimental group than in the control group.¹⁰
A US study looked at the effect of an ambitious effort to expand family planning services directed at teenagers in the area near the clinic. Among the added strategies were expanded afternoon and evening hours, walk-in hours, decreased waiting time, and outreach efforts directed at teenagers and their parents. The study showed disappointing results. The project was found to have no measurable impact on the reproductive behavior, attitudes, or knowledge of the target population. These findings suggest that while the clients who come to a clinic may be well served, improving and increasing the availability of services will not necessarily increase the demand for services or affect the reproductive health of the larger population living nearby.³

Q: What are some common obstacles to implementing effective youth-friendly services?

Restrictive or unclear public policies.
Provider attitudes. Many providers (including community-based distribution agents and pharmacy employees) are often unaccepting of adolescent sexual behavior and disapprove of family planning services for young people.
Ambivalent and moralistic community attitudes. These can often be partially addressed by means of public education activities.
No tradition of adolescents routinely using services and adolescent discomfort with using clinical services. Both these problems can be addressed by making clinic services friendlier and by taking outreach services to adolescents in the kinds of places they spend time at in their everyday lives.
Lack of evaluation data about specific elements of service provision. Answers are particularly needed to the following questions:
- What elements of a clinic service (e.g., atmosphere, assurance of privacy, drop-in scheduling, hours, costs) are most important for young adults?
- What services (and service providers) are most vital to attract young people and to meet young adults' reproductive health needs?
- For young adult women coming for prenatal, postnatal, and postabortion care, what are the most effective ways to encourage teenagers to adopt and use a contraceptive method following delivery or pregnancy termination? What timing, format, and frequency of contraceptive information services are most effective in leading to adoption of contraceptive methods?
- How can young adults be encouraged to go to clinics for STD screening and treatment?

References

Corona E, Gribble JN, Ehrenfeld N, et al. A Study to Evaluate the Quality of Care in a Comprehensive Model of Service Delivery to Adolescent Mothers in a Mexico City Hospital. Asociaci�n Mexicana de Educaci�n Sexual (AMES), 1988.
Harrison KA, Fleming AF, Briggs ND, et al. Growth During Pregnancy in Nigerian Teenage Primigravidae. British Journal of Obstetrics and Gynecology 5(suppl.): 32-39 (1985).
Hughes ME., Furstenberg FF, Teitler JD. The Impact of an Increase in Family Planning Services on the Teenage Population of Philadelphia. Family Planning Perspectives 27(2): (1995).
Maddaleno M. Promoting Comprehensive Health Services for Adolescents in East Metropolitan Santiago de Chile. Final Report. Departments of Pediatrics and Psychiatry, University of Chile, 1994.
Martin A, Schenkel P, Vernon R, et al. A Sustainable Educational Program for Postpartum Adolescent Mothers, Mexico. Paper presented at the 19^th annual NCIH International Health Conference. Arlington, Virginia, June 14-17, 1992.
Pathfinder International, Evaluation Unit. Adolescent Project Evaluation. (Draft). 1995.
Piechnik S, Corbett MA. Reducing Low Birth Weight among Socioeconomically High-Risk Adolescent Pregnancies. Journal of Nurse-Midwifery 30(2): (1985).
Rosso P, Lederman SA. Nutrition in the Pregnant Adolescent. In: Winick M, ed. Adolescent Nutrition. New York: John Wiley & Sons, 1982.
Shepard BL, Garc�a-N�nez J, Miller JT, et al. [Pathfinder International] Adolescent Program Approaches in Latin America and the Caribbean: An Overview of Implementation and Evaluation Issues. Discussion Draft prepared for the International Conference on Adolescent Fertility in Latin America and the Caribbean. Oaxaca, Mexico, Nov. 1989.
Winter L, Breckenmaker LC. Tailoring Family Planning Services to the Special Needs of Adolescents. Family Planning Perspectives 23(1): (1991).

Reprinted with permission from Pathfinder International's "FOCUS on Young Adults" Project, 2002.

FAQs: Youth-friendly Services

Q: What are the best strategies for counseling adolescents about delaying sexual intercourse?