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I. PROGRAM RESOURCES

1. Adolescence Education: Newsletter for Policy Makers, Programme Managers, and Practitioners
2. An Annotated Guide to Technical Resources for Community Involvement in Youth Reproductive Health and HIV Prevention Programs
3. Best Practices in Egypt: Youth Awareness and Action
4. Creating an Enabling Environment for the Advancement of Women and Girls
5. Engaging Communities in Youth Reproductive Health and HIV Projects: A Guide to Participatory Assessments
6. Horizons Report
7. Investing When It Counts: Generating the Evidence Base for Policies and Programmes for Very Young Adolescents
8. The Role of Community Involvement in Improving Youth Reproductive Health and Preventing HIV among Young People: Report of a Technical Consultation
9. Scaling Up HIV Prevention Programs for Youth: The Essential Elements Framework in Action
10. Sex without Consent: Young People in Developing Countries
11. Standards for Peer Education Programmes
12. Tap and Reposition Youth (TRY)
13. Theatre-Based Techniques for Youth Peer Education: A Training Manual

II. RESEARCH SUMMARIES

1. Acceptability as a key determinant of client satisfaction: lessons from an evaluation of adolescent-friendly health services in Mongolia
2. Blood blockages and scolding nurses: barriers to adolescent contraceptive use in South Africa
3. Can a comprehensive voucher programme prompt changes in doctors' knowledge, attitudes and practices related to sexual and reproductive health care for adolescents? A case study from Latin America
4. Child sexual abuse in Henan province, China: associations with sadness, suicidality, and risk behaviors among adolescent girls
5. Confidentiality for adolescents seeking reproductive health care in Lithuania: the perceptions of general practitioners
6. Determinants of condom use among youth in Madagascar
7. The effects of religious affiliation on sexual initiation and condom use in Zambia
8. Emerging changes in reproductive behaviour among married adolescent girls in an urban slum in Dhaka, Bangladesh
9. The epidemiology of HIV-1 infection in northern Tanzania: results from a community-based study
10. Factors associated with teachers' implementation of HIV/AIDS education in secondary schools in Cape Town, South Africa
11. Gender dynamics in the primary sexual relationships of young rural South African women and men
12. Gravidez na adolescencia e exclusao social: analise de disparides intra-urbanas
13. HIV decline associated with behavior change in eastern Zimbabwe
14. HIV prevention in Mexican schools: prospective randomised evaluation of intervention
15. Initiation school amongst the Southern Ndebele people of South Africa: deprecating tradition or appreciating treasure?
16. Knowledge and practice of emergency contraception among female undergraduates in the University of Lagos, Nigeria
17. Marked HIV prevalence declines in higher-educated young people: evidence from population-based surveys (1995-2003) in Zambia
18. Nurse-midwives' attitudes towards adolescent sexual and reproductive health needs in Kenya and Zambia
19. Rationale and design of the MEMA kwa Vijana adolescent sexual and reproductive health intervention in Mwanza Region, Tanzania

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I. PROGRAM RESOURCES

1. Adolescence Education: Newsletter for Policy Makers, Programme Managers, and Practitioners (2005, PDF, 2.18 MB)

This bi-annual adolescent reproductive health newsletter includes information on best practices, regional news, national news, research briefs, and links to Web sites.
Contact: arsh@unescobkk.org

2. An Annotated Guide to Technical Resources for Community Involvement in Youth Reproductive Health and HIV Prevention Programs (2006, PDF, 321 KB)

This compilation of resources – documents, manuals, and toolkits – is intended for program staff and others who are involved with youth RH/HIV prevention and community involvement issues.
Contact: youthnetpubs@fhi.org

3. Best Practices in Egypt: Youth Awareness and Action (2005, PDF, 282 KB)

To find ways to get reproductive health information to youth in Egypt and to raise awareness in the communities, TASHEEN established youth weeks. This brief presents the results of this intervention.
Contact: info@rhycatalyst.org

4. Creating an Enabling Environment for the Advancement of Women and Girls (2006, PDF, 426 KB)

This briefing paper includes reports and recommendations from World Vision's work to empower and advance the status of women and girls. Program highlights include early marriage, education, and sexual violence in armed conflict.
Contact: newsvision@wvi.org

5. Engaging Communities in Youth Reproductive Health and HIV Projects: A Guide to Participatory Assessments (2006, PDF, 2.25 MB)

This manual discusses how to conduct participatory assessments with youth and community members for improved youth reproductive health and HIV prevention, drawing on YouthNet's experience in Namibia, Tanzania, and Ethiopia with youth-led projects using these tools.
Contact: youthnetpubs@fhi.org

6. Horizons Report (2005, PDF, 765 KB)

This issue focuses on operations research regarding issues in HIV prevention and vulnerable populations, including a section on how youth interpret ABC messages.
Contact: horizons@pcdc.org

7. Investing When It Counts: Generating the Evidence Base for Policies and Programmes for Very Young Adolescents (2006, PDF, 1.24 MB)

To address the lack of information on research methods for 10 to14 year-olds, this guide provides strategies to reach and evaluate the needs, vulnerabilities, and inclusion of young adolescents in current programming. Designed with HIV/AIDS in mind, the approaches can be used with other issues affecting young adolescents including female genital cutting, substance abuse, and early and unintended pregnancy.
Contact: pubinfo@popcouncil.org

8. The Role of Community Involvement in Improving Youth Reproductive Health and Preventing HIV among Young People: Report of a Technical Consultation (2006, PDF, 319 KB)

This report of a two-day technical consultation summarizes challenges, lessons learned from promising projects, knowledge and practice gaps, and recommendations for future practice.
Contact: youthnetpubs@fhi.org

9. Scaling Up HIV Prevention Programs for Youth: The Essential Elements Framework in Action (2005, PDF, 2.9 MB)

This report describes the Essential Elements Framework developed by the Margaret Sanger Center International, focusing on HIV prevention programs for young people, including institutional capacity to support the programs. It includes case studies on how the framework was applied in five diverse country settings and recommendations for program staff.
Contact: msci@ppnyc.org

10. Sex without Consent: Young People in Developing Countries (2006)

This 370-page paperback book includes 23 chapters, many of which are based on presentations made at a 2003 global conference. This pioneering volume highlights key factors placing young people at risk and outlines significant distinctive health and social implications they face.
Contact: Limited copies available from youthnetpubs@fhi.org or info_india@popcouncil.org

11. Standards for Peer Education Programmes (2005, PDF, 1.2 MB)

Developed during a consultative meeting with peer educators, trainers, project managers, and technical experts from 22 countries, this tool provides a framework of standards for programs, as well as tips and examples from around the world. It includes a description of 52 recommended standards under five categories: planning, recruitment and retention, training and supervision, management and oversight, and M & E.
Contact: youthnetpubs@fhi.org

12. Tap and Reposition Youth (TRY) (2006, PDF, 953 KB)

This report profiles the Tap and Reposition Youth program in Kenya. Through micro-finance, this program tried to reduce the vulnerabilities of young out-of-school youth to adverse reproductive health outcomes, including HIV/AIDS, by improving their livelihood options.
Contact: pubinfo@popcouncil.org

13. Theatre-Based Techniques for Youth Peer Education: A Training Manual (2005, PDF, 770 KB)

This training manual provides an overview of using theater in youth peer education. It contains four peer theater training workshops, a series of theater games and exercises that can be used in trainings, and information on developing and building a peer theater program.
Contact: youthnetpubs@fhi.org

II. RESEARCH SUMMARIES

1. Acceptability as a key determinant of client satisfaction: lessons from an evaluation of adolescent-friendly health services in Mongolia. Sovd T, Mmari K, Lipovsek V, Manaseki-Holland S. J Adolesc Health 2006;38(5).
To investigate which characteristics of health service quality are most likely to determine client satisfaction with health services among adolescents in Mongolia, data were gathered from 1,301 male and female clients. Exit interviews were used to measure client satisfaction; 82 clinics were visited. All clients between the ages of 10 and 19 years were asked to participate in the client exit interview; those who agreed to participate completed the questionnaire. Bivariate and multivariate analyses were conducted to determine significant associations between service satisfaction and the independent variables. All variables showing a significant bivariate association with service satisfaction (p < or = .05) were retained for logistic regression analyses. The strongest determinant to client satisfaction related to acceptability: adequate facility physical environment, receiving adequate information about the facility, and if the facility was private (i.e., other people didn't know about the services the client received). Additionally, clients who said they received some interruptions, either by other health workers or clients, were significantly less likely to be satisfied with the services. Efforts to improve health service delivery to adolescents need to understand and address the "adolescent-friendly" characteristics that are most salient, and least fulfilled, in each particular context.

2. Blood blockages and scolding nurses: barriers to adolescent contraceptive use in South Africa. Wood K, Jewkes R. Reprod Health Matters 2006;14(27).
One-third of adolescent girls in South Africa become pregnant before the age of 20, despite contraception being free and mostly accessible. This qualitative study was undertaken in Limpopo Province in 1997 on the barriers to adolescent girls accessing clinic services for contraception. Thirty-five in-depth interviews and five group discussions were conducted with girls aged 14-20, and interviews with nursing staff at 14 clinics. Many of the girls described pressure from male partners and family members to have a baby or prove their fertility. Other barriers to sustained contraceptive use included medically inaccurate notions about how conception occurs and fears about the effects of contraception on fertility and menstruation, which were not taken seriously by nurses. Nurses' attempts to stigmatize teenage sexuality, their scolding and harsh treatment of adolescent girls, and their unwillingness to acknowledge adolescents' experiences as contraceptive users, undermined the effective use of contraception by girls. Youth need better information on reproductive physiology and sexual health, and detailed information on contraception. Tools to enhance the accuracy and availability of knowledge in the clinic setting have a role, but need to be introduced along with initiatives to ensure that services are adolescent-friendly and do not stigmatize adolescent sexual activity.

3. Can a comprehensive voucher programme prompt changes in doctors' knowledge, attitudes and practices related to sexual and reproductive health care for adolescents? A case study from Latin America. Meuwissen LE, Gorter AC, Kester AD, Knottnerus JA. Trop Med Int Health 2006;11(6).
This study evaluated whether participation in a competitive voucher program designed to improve access to and quality of sexual and reproductive health care (SRH-care), prompted changes in doctors' knowledge, attitudes, and practices. The voucher program provided free access to SRH-care for adolescents. Doctors received training and guidelines on how to deal with adolescents, a treatment protocol, and financial incentives for each adolescent seen. To evaluate the impact of the intervention on doctors, nearly all participating doctors (n = 37) were interviewed before the intervention and 23 were interviewed after the intervention. The initial interviews disclosed deficiencies in doctors' knowledge, attitudes, and practices relating to adolescent SRH issues. Gender and age of the doctor were not associated with the initial scores. Comparing scores from before and after the intervention revealed significant increases in doctors' knowledge of contraceptives (P = 0.003) and sexually transmittable infections (P < 0.001); barriers to contraceptive use significantly diminished (P < 0.001 and P = 0.003); and some attitudinal changes were observed (OR = 0.046 and P = 0.11). Doctors became more aware of the need to improve their communication skills and were positive about the program. This study confirmed provider-related barriers that adolescents in Nicaragua may face and reinforces the importance of focusing on quality of care and strengthening doctors' training. Participation in the voucher program resulted in increased knowledge, improved practices, and, to a lesser extent, changed attitudes. A competitive voucher program with technical support for the participating doctors can be a promising strategy to prompt change.

4. Child sexual abuse in Henan province, China: associations with sadness, suicidality, and risk behaviors among adolescent girls. Chen J, Dunne MP, Han P. J Adolesc Health 2006;38(5).
To assess the prevalence of child sexual abuse (CSA) and possible effects on mental health and risky behavior among female adolescents living in China, a retrospective survey was conducted among 351 female students in a medical secondary school in the central China province of Henan in June 2004. The anonymous, self-administered questionnaire included items about unwanted sexual experiences before age 16, depression, suicidality, and risky health-related behaviors. Over one in five young women (21.9%) reported at least one type of CSA (any one of 12 forms of nonphysical contact and physical contact CSA) before the age of 16 years, with one in every seven (14.0%) reporting CSA involving physical contact. Risk of CSA was not associated with parents' education level, existence of siblings, or rural/urban residence during childhood. Although some indicators of poor mental health were slightly elevated among girls who had experienced noncontact CSA only, the most significant impact is among victims of contact CSA, including higher rates of depression, overwhelming sadness, suicidal thinking and planning, alcohol drinking, smoking, fighting, and having sexual intercourse. The risk of CSA in this sample of Chinese female adolescents seems similar to that of young women in many Western countries, and the pattern of associated mental health and behavioral problems is entirely consistent with international research.

5. Confidentiality for adolescents seeking reproductive health care in Lithuania: the perceptions of general practitioners. Jaruseviciene L, Levasseur G, Liljestrand J. Reprod Health Matters 2006;14(27).
Confidentiality is a major determinant of the accessibility and acceptability of sexual and reproductive health care for adolescents. Previous research has revealed that Lithuanian adolescents lack confidence in guarantees of confidentiality in primary health care settings. This study aimed to assess the factors that affect general practitioners' decisions regarding whether to respect confidentiality for Lithuanian adolescents under the age of 18. Twenty in-depth interviews were carried out with a purposive sample of general practitioners. The decision about whether to respect confidentiality was found to be influenced by external forces, including the legislative framework and societal attitudes towards adolescent sexuality; institutional features in clinical facilities, such as the presence of a nurse during consultations and the openness of the medical record filing system; and individual factors, including GPs' relationships with adolescents' families and their personal attitudes towards sexual and reproductive health issues. The findings reflect the urgent need for a comprehensive policy to ensure adolescents' right to confidentiality in Lithuanian primary care settings, including legislative reforms, institutional changes in health care settings, professional guidelines and (self-) regulation, and changes in medical training and continuing medical education. Other ways to safeguard confidentiality in adolescent health services, such as establishing youth clinics, should also be explored.

6. Determinants of condom use among youth in Madagascar. Meekers D, Silva M, Klein M. J Biosoc Sci 2006;38(3).
This study sought to identify the key determinants of condom use with regular and casual partners among youth in Madagascar. The data were gathered from a reproductive health survey conducted in October-December 2000 among a representative sample of 2,440 youth aged 15-24 living in Toamasina province. Following theoretical models of behavior change, logistic regression was used to assess the effect of AIDS awareness, personal risk perception, condom access, perceived condom effectiveness, self-efficacy, and social support on condom use. Among sexually experienced youth, only about four in ten males and two in ten females have ever used condoms. Fewer than 15% of youth used a condom in last intercourse with their regular partner. Whether youth will try condoms appears to depend largely on the perceived effectiveness of condoms for family planning, access to a nearby condom source, parental support for condom use, and patterns of risky sexual behavior. Young males' likelihood of using a condom with a regular partner increases significantly if they perceive condoms to be effective for family planning (OR=11.4; p=0.019). For females, it increases with level of self-efficacy (OR=2 1; p=0.042) and having discussed HIV prevention with someone in the last year (OR=2.8; p=0.022). Among males, condom use with casual partners is significantly higher among those who perceive themselves to be at high risk of sexually transmitted infections (OR=2.3; p=0.014), who believe condoms are effective for family planning (OR=2.8; p=0.048), who have good access to condoms (OR=2.9; p=0.002), and who perceive their parents as supportive of condom use (OR=1-7; p=0.048). In conclusion, very few youth in Toamasina are using condoms, highlighting the need to continue and expand adolescent reproductive health interventions. In this low HIV-prevalence setting, it is important for these programs to emphasize that condoms are effective for both pregnancy prevention and STI/HIV prevention.

7. The effects of religious affiliation on sexual initiation and condom use in Zambia. Agha S, Hutchinson P, Kusanthan T. J Adolesc Health 2006;38(5).
To determine whether religious affiliation reduces HIV risk among young women in Zambia, and to examine the effects of religious affiliation on sexual initiation and on condom use during first sexual experience, data were collected and analyzed from a representative probability sample of 5,534 women aged 13-20 years. The instrument included questions on sexual initiation, condom use during first sex, religious affiliation, and socio-demographic characteristics of respondents. Statistical tests were performed at the bivariate and multivariate levels. The results found that affiliation with religious groups that excommunicate members for engaging in premarital sex, and that oppose condom use, has both positive and negative effects on behaviors that carry the risk of HIV infection. Young women affiliated with conservative groups are more likely to delay sexual initiation but less likely to use condoms during first sex. Denominations that are not only strongly opposed to premarital sex and condom use, but are able to exercise control over adolescents through socialization or the threat of social exclusion, are likely to create conflicting behaviors among adolescents that cancel each other in terms of HIV risk. Overall, these findings suggest that affiliation with conservative religious groups is unlikely to reduce the risk of HIV infection. Additional studies are recommended.

8. Emerging changes in reproductive behaviour among married adolescent girls in an urban slum in Dhaka, Bangladesh. Rashid SF. Reprod Health Matters 2006;14(27).
Structural and social inequalities, a harsh political economy, and neglect on the part of the state have made married adolescent girls an extremely vulnerable group in the urban slum environment in Bangladesh. The importance placed on newly married girls' fertility results in high fertility rates and low rates of contraceptive use. Ethnographic fieldwork among married adolescent girls, aged 15-19, was carried out in a Dhaka slum from December 2001-January 2003, including 50 in-depth interviews and eight case studies among 153 married adolescent girls, and observations and discussions with family and community members. Cultural and social expectations led to 128 of the girls giving birth before they were emotionally or physically ready. Twenty-seven had terminated their pregnancies, of whom 11 reported they were forced to do so by family members. Poverty, economic conditions, marital insecurity, politics in the household, absence of dowry, and rivalry among family, co-wives, and in-laws made these young women acquiesce to decisions made by others in order to survive. Young married women's status is changing in urban slum conditions. When their economic productivity takes priority over their reproductive role, the effects on reproductive decision-making within families may be considerable. This paper highlights the vulnerability of young women as they pragmatically make choices within the social and structural constraints in their lives.

9. The epidemiology of HIV-1 infection in northern Tanzania: results from a community-based study. Kapiga SH, Sam NE, Mlay J, Aboud J, Ballard RC, Shao JF, et al. AIDS Care 2006;18(4).
This community-based study aimed to determine the predictors of HIV-1 among women aged 20-44 years (n = 1,418) and their regular male partners (n = 566) from randomly selected households in Moshi, Tanzania. The weighted prevalence of HIV-1 was 10.3% in women and 7% in men. The highest risk of HIV-1 was in subjects whose partners were HIV-1 seropositive in both women (adjusted odds ratio (AOR) = 26.63; 95% confidence interval (CI): 10.74–66.02) and men (AOR = 22.25; 95% CI: 7.06–70.15). Herpes simplex virus type 2 (HSV-2) and Mycoplasma genitalium were also significantly associated with HIV-1. Women with male partners who were at least 12 years older than they had increased risk of HIV-1 (AOR = 1.99; 95% CI: 1.01–7.85). Other predictors of HIV-1 were history of infertility and the number of sex partners in the last three years in women and the age at time of circumcision and history of past sexually transmitted infections (STIs) in male partners. These findings show that HIV-1/STIs were major public health problems among women and their long-term partners in this population. HIV-1 prevention efforts should include promotion of couple's HIV-1 counseling and testing services, control of HSV-2, promotion of safer sexual practices, and strategies to reduce the age difference between women and their partners.

10. Factors associated with teachers' implementation of HIV/AIDS education in secondary schools in Cape Town, South Africa. Mathews C, Boon H, Flisher AJ, Schaalma HP. AIDS Care 2006;18(4).
This study investigated the factors influencing whether high school teachers implemented HIV/AIDS education. The independent variables included constructs derived from expectancy value theories, teachers' generic dispositions, their training experience, characteristics of their interactive context, and the school climate. A postal survey of 579 teachers responsible for AIDS education in all 193 public high schools in Cape Town was conducted. Questionnaires were completed and returned by 324 teachers (56% response rate) from 125 schools. Many teachers (222; 70%) had implemented HIV/AIDS education during 2003, and female teachers were more likely to have implemented it than males (74% vs. 58%). The teacher characteristics associated with teaching about HIV/AIDS were previous training, self-efficacy, student-centeredness, beliefs about controllability and the outcome of HIV/AIDS education, and their sense of responsibility. The existence of a school HIV/AIDS policy, a climate of equity and fairness, and good school-community relations were the school characteristics associated with teaching about HIV/AIDS. These findings demonstrate the value of teacher training and school policy formulation. They also demonstrate the value and importance of interventions that go beyond a sexual health agenda, focusing on broader school development to improve school functioning and school climate.

11. Gender dynamics in the primary sexual relationships of young rural South African women and men. O'Sullivan LF, Harrison A, Morrell R, Monroe-Wise A, Kubeka M. Cult Health Sex 2006;8(2).
A substantial body of South African research describes the importance of gender dynamics within sexual relationships as factors underlying HIV risk, yet we know little about these factors among young adults – a group at exceptionally high risk of infection. The study aimed to explore the ways that young adult men and women interpret and enact gender roles within their established primary partnerships, and how these dynamics influence sexual behavior in relation to HIV risk. Script theory was employed to frame the analysis of the dynamics of gender. Fifty students (25 women and 25 men) at secondary schools in a rural district of KwaZulu/Natal, South Africa completed in-depth interviews about sexual interactions with their primary partner. While many participants indicated that the standards of sexual conduct within relationships reflect dominant gender role norms, the study findings indicate that there are important variations in these roles with some male and female respondents accepting and reinforcing the rights of women to determine the nature of sexual interactions. Efforts aimed at improving acceptance and adoption of alternative scripts for women and men may help to broaden young people's repertoire of HIV prevention options.

12. Gravidez na adolescencia e exclusao social: analise de disparides intra-urbanas. Duarte CM, do Nascimento VB, Akerman M. Rev Panam Salud Publica 2006;19(4).
This study compared adolescent mothers living in four areas with different degrees of social exclusion in the city of Santo André, São Paulo, Brazil, in terms of the mothers' schooling, the birth weight and gestational age of their babies, and the specific fertility rate of each of the four areas in 1998. An ecological cross-sectional study was carried out with 1,314 adolescent girls. The four areas analyzed had earlier been defined in the City of Santo André Social Exclusion/Inclusion Map. Area 1 had the highest exclusion index (worst socio-economic conditions), and Area 4 the lowest exclusion index (best socio-economic conditions). The data relating to the adolescent mothers and their children were collected from the National Live Birth Information System, and the socio-economic data for Santo André were obtained from the State Data Analysis System Foundation, the Brazilian Institute of Geography and Statistics, and the city's Social Exclusion/Inclusion Map. Having little formal education was statistically associated with the poorest areas. Of the infants with a birth weight < 2,500g, 76.8% of them were born in the two poorest areas of the city. The highest fertility rate (35.7 per 1,000 adolescents) was found in Area 1, the area with the worst socio-economic conditions; the lowest fertility rate (12.1 per 1,000) was found in Area 4, the area with the best socio-economic conditions. The proportion of births that were premature did not differ among the four areas (P = 0.81). The results showed that adolescent girls with little schooling and a lower socio-economic level were more likely to give birth. Specific actions should be promoted to prevent pregnancy in this group and to foster the social inclusion of these adolescents and their children, providing them with opportunities to improve their socio-economic situation.

13. HIV decline associated with behavior change in eastern Zimbabwe. Gregson S, Garnett GP, Nyamukapa CA, Hallett TB, Lewis JJ, Mason PR, et al. Science 2006;311(5761).
Few sub-Saharan African countries have witnessed declines in HIV prevalence, and only Uganda has compelling evidence for a decline founded on sexual behavior change. This study reports a decline in HIV prevalence in eastern Zimbabwe between 1998 and 2003 associated with sexual behavior change in four distinct socio-economic strata. HIV prevalence fell most steeply at young ages – by 23% and 49%, respectively, among men aged 17 to 29 years and women aged 15 to 24 years – and in more educated groups. Sexually experienced men and women reported reductions in casual sex of 49% and 22%, respectively, whereas recent cohorts reported delayed sexual debut. Selective AIDS-induced mortality contributed to the decline in HIV prevalence.

14. HIV prevention in Mexican schools: prospective randomised evaluation of intervention. Walker D, Gutierrez JP, Torres P, Bertozzi SM. BMJ 2006;332(7551).
This study assessed effects on condom use and other sexual behavior of an HIV prevention program at school that promotes the use of condoms with and without emergency contraception. The study employed a cluster randomized controlled trial in 40 public high schools in the state of Morelos, Mexico, with 10,954 first-year high school students. Schools were randomized to one of three arms: an HIV prevention course that promoted condom use, the same course with emergency contraception as back-up, or the existing sex education course. Self-administered anonymous questionnaires were completed at baseline, four months, and 16 months. Students at intervention schools received a 30-hour course (over 15 weeks) on HIV prevention and life skills, designed in accordance with guidelines of the joint United Nations Programme on HIV/AIDS. Two extra hours of education on emergency contraception were given to students in the condom promotion with contraception arm. Primary outcome measure was reported condom use. Other outcomes were reported sexual activity; knowledge and attitudes about HIV and emergency contraception; and attitudes and confidence about condom use. The intervention did not affect reported condom use. Knowledge of HIV improved in both intervention arms and knowledge of emergency contraception improved in the condom promotion with contraception arm. Reported sexual behavior was similar in the intervention arms and the control group. The study concluded that a rigorously designed, implemented, and evaluated HIV education course based in public high schools did not reduce risk behavior, so such courses need to be redesigned and evaluated. Addition of emergency contraception did not decrease reported condom use or increase risky sexual behavior but did increase reported use of emergency contraception.

15. Initiation school amongst the Southern Ndebele people of South Africa: deprecating tradition or appreciating treasure? van Rooyen L, Potgieter F, Mtezuka L. Int J Adolesc Youth 2006;13(1/2).
The concept of "initiation school" refers to a type of school that was initially established as a secret rite, which, in a symbolic sense, serves as the teenager's "transit education" or "passport" to adulthood. Currently, in South Africa, many opinions are voiced against initiation, mainly because it prevents children from attending formal school for up to ten weeks to attend the initiation schools, and a rising number of youngsters lose their lives as a direct result of the unprofessional circumcisions that are executed. The matter has become so serious that a new Bill to monitor registration and control of initiation schools was approved in Parliament in 2003. Despite this controversy and the control measures that have been put in place, initiation schools still form the backbone of traditional education. This research aimed to determine what the initiation schools of the Southern Ndebele people of South Africa entail and what value the Southern Ndebele people attach to this type of traditional education. The study revealed that their initiation, when viewed against the work of Arnold van Gennep, consists of three significant phases: the phase of severance, separation, and isolation; the phase of thresholding, restoration, preparation, and entrance; and the phase of inclusion, absorption, and incorporation. The study also revealed that initiation, as it is performed today, is consistent with community values and, to a large extent, serves to contribute to the education of the young people of the Southern Ndebele Tribe in that it supports and assists the parents with the difficult task of disciplining their children and transferring the norms and values of the Southern Ndebele, such as respect for others, the observation of their traditions, caring for and affirmation of their cultural identity, and the stabilization and perpetuation of their cultural temperospatiality.

16. Knowledge and practice of emergency contraception among female undergraduates in the University of Lagos, Nigeria. Ebuehi OM, Ekanem EE, Ebuehi OA. East Afr Med J 2006;83(3).
This study aimed to assess the level of knowledge and practice of emergency contraception among female undergraduates in the University of Lagos, in southwestern Nigeria, and to determine the factors that influence knowledge and practice of emergency contraception among female undergraduates using a cross-sectional descriptive study. The study took place between August 2003 and March 2004, using 480 randomly selected female undergraduate students. The findings revealed that 67.8% of the respondents reported knowing about emergency contraception. More than half (56.1%) were sexually active and of this group, 96.8% had ever practiced contraception with only 33.9% having ever practiced emergency contraception. However, only 37.8% and 36.3% of respondents who had reported knowing about emergency contraception knew the correct time-frame for effective use, and correctly identified emergency contraceptives, respectively. Among those who were aware of, and had used emergency contraception, 34.1% obtained their information from health care providers, while the larger majority obtained it from friends. Knowledge and practice of emergency contraception was found to be directly related to age, level of study, medical education, marital status, sexual activity, previous history of use of contraceptives, and previous history of induced abortion. The study concluded that education efforts that focus on the training of health care providers and young adults on emergency contraception with regards to available methods and correct timing of use would greatly improve women's access to and effective use of this method in Nigeria.

17. Marked HIV prevalence declines in higher-educated young people: evidence from population-based surveys (1995-2003) in Zambia. Michelo C, Sandoy IF, Fylkesnes K. AIDS 2006;20(7).
Higher educational attainment has been associated with a greater risk of HIV infection in sub-Saharan Africa. To investigate change over time in HIV prevalence by educational attainment in the general population, the study collected data with serial population-based HIV surveys conducted in selected urban and rural communities in 1995 (n = 2,989), 1999 (n = 3,506), and 2003 (n = 4,442). Analyses were stratified by residence, sex, and age group. Logistic regression was used to estimate the age-adjusted odds ratio of HIV between low (< or = 4 school years) and higher education (> or = 8 years) for the rural population and between low (< or = 7 school years) and higher education (> or = 11 years) for the urban population. There was a universal shift towards reduced risk of HIV infection in groups with higher education among urban young people [odds ratio (OR), 0.20; 95% confidence interval (CI), 0.05-0.73], both in men (OR, 0.33; 95% CI, 0.15-0.72) and in women. A similar pattern was observed in rural young men (OR, 0.17; 95% CI, 0.05-0.59) but was less prominent and not statistically significant in rural women. In the age group 25-49 years, higher-educated urban men had reduced risk in 2003 (OR, 0.43; 95% CI, 0.26-0.72) but this was less prominent in women. The findings suggested a shift in the association between educational attainment and HIV infection between 1995 and 2003. The most convincing sign was the risk reduction among more-educated younger groups where most infections can be assumed to be recent. The changes in older groups are probably largely influenced by differential mortality rates. The stable risk among groups with lower education might also indicate limitations in past preventive efforts.

18. Nurse-midwives' attitudes towards adolescent sexual and reproductive health needs in Kenya and Zambia. Warenius LU, Faxelid EA, Chishimba PN, Musandu JO, Ong'any AA, Nissen EB. Reprod Health Matters 2006;14(27).
Adolescent sexuality is a highly charged moral issue in Kenya and Zambia, and public health facilities are underutilized by adolescents. Nurse-midwives are the core health care providers of adolescent sexual and reproductive health services. The aim of this study was to investigate attitudes among Kenyan and Zambian nurse-midwives (n=820) toward adolescent sexual and reproductive health problems, in order to improve services for adolescents. Data were collected through a questionnaire. Findings revealed that nurse-midwives disapproved of adolescent sexual activity, including masturbation, contraceptive use, and abortion, but also had a pragmatic attitude to handling these issues. Those with more education and those who had received continuing education on adolescent sexuality and reproduction showed a tendency towards more youth-friendly attitudes. The study suggests that critical thinking around the cultural and moral dimensions of adolescent sexuality should be emphasized in undergraduate training and continuing education, to help nurse-midwives to deal more empathetically with the reality of adolescent sexuality. Those in nursing and other leadership positions could also play an important role in encouraging wider social discussion of these matters. This would create an environment that is more tolerant of adolescent sexuality and that recognizes the beneficial public health effect on adolescents of greater access to youth-friendly sexual and reproductive health services.

19. Rationale and design of the MEMA kwa Vijana adolescent sexual and reproductive health intervention in Mwanza Region, Tanzania. Obasi AI, Cleophas B, Ross DA, Chima KL, Mmassy G, Gavyole A, et al. AIDS Care 2006;18(4).
Large-scale innovative, integrated, and multifaceted adolescent sexual and reproductive health (ASRH) interventions are urgently needed in sub-Saharan Africa. Implementation through schools and health facilities may maximize intervention coverage and sustainability; however, the impact of the use of these structures on intervention content and delivery is not well documented. This paper describes the rationale and design of a large-scale multifaceted ASRH intervention, which was developed and evaluated over three years in rural communities in Mwanza Region, northwestern Tanzania. The intervention included community mobilization, participatory reproductive health education in primary schools, youth-friendly reproductive health services, and community-based condom provision for youth. The study examined the effect of socio-economic, cultural, and infrastructural factors on intervention content and implementation. This paper demonstrates the means by which such interventions can be feasibly and sustainably implemented to a high standard through existing government health and school structures. However, the use of these structures involves compromise on some key aspects of intervention design and requires the development of complementary strategies to access out-of-school youth and the wider community.