Key Element

Issues/Obstacles

Program Examples

1. Adult professionals have traditionally planned and conducted programs for youth, and resist changing;
2. Working with young people as partners run counter to cultural patterns in many countries;
3. Dependence on young people to assume key tasks carries some risks – including high turnover, less than reliable participation, the need for supervision, an incentive and reward structure, and extra training;
4. There have been few models that actively involve youth.

• Focus on Young Adults. "Review of Selected Reproductive Health Programs in Ethiopia."

• Transgrud, R. May 1997. "Adolescent Sexual and Reproductive Health in Eastern and Southern Africa." USAID/REDSOE.

1. Ambivalent and moralistic attitudes challenge whether community becomes involved.

• Maddaleno. 1994. "Promoting Comprehensive Health Services for Adolescents in East Metropolitan Santiago of Chile." University of Chile.

1. Parents are not the traditional informants about sex;
2. Parents may feel embarrassed;
3. Parents, themselves, lack the knowledge, information.

• Banda, E.E.. 1993. "Evaluation of Malawi/90/P02: Integration of the Parent Education Project as a Community Based Training Programme."

1. Typically, operational policies governing how providers should serve adolescents are not clearly spelled out;
2. Need additional training in getting providers to comply with protocols and standards.

• Paxman. 1996. "Evaluation of Interregional Project INT/92/P08, Reproductive Health and Sexuality in Adolescents." WHO.

• Corona, Romero et al. 1995. "Adolescent Reproductive Health Thematic Evaluation." UNFPA.

1. Gender of provider;
2. Age of provider;
3. Knowledge, reliability, and communications skills of provider.

• Theman. 1996. "Adolescent Sexual and Reproductive Resource Materials: A Needs Assessment in English-Speaking Africa." FCI.

1. Adolescents do not go for fear of bad treatment by providers;
2. Many hard to reach adolescents – like those out of school – do not receive any information about service sites;
3. Adolescents worry about lack of privacy/confidentiality;
4. Most adolescents feel services are only for married people;
5. There is a challenge to reach adolescents before their sexual debut.

• Paxman, J.M. 1993. "Clothing the Emperor – Seeing and Meeting the Reproductive Health Needs of Youth." (Lessons from Pathfinder’s Adolescent Fertility Programs).

• Barker, G. and Fontes, M. 1996. "Review and Analysis of International Experience with Programs Targeted on At-Risk Youth." Unpublished Report for the Government of Columbia. The World Bank.

1. be open in the afternoons, evening, and weekends;
2. offer many RH services, including STI treatment;
3. be easily accessible, affordable, confidential, private, and staffed with sensitive service providers;
4. be designed "not to look like a clinic;"
5. be comfortable and useful for young men;
6. Adolescents lack encouragement/education to know when to use clinics.

• Corona, E.; Canessa, P. and Benbow-Ross, C. 1995. "Adolescent Reproductive Health Thematic Evaluation." (Country Case Study Report – Chile). UNFPA.

• Dryfoos, J.G. 1988. "Putting Boys in the Picture: A Review of Programs to Promote Sexual Responsibility Among Young Males." ETR Associates.

1. There is a lack of specialized provider training to serve the adolescent client;
2. There has been little assessment of how effectively counselors assist young people to achieve their objectives;
3. There is controversy as to whether to use nondirective or directive counseling;
4. There is controversy as to use peer versus adult counselors;
5. Counselors should be trained to handle sexual abuse and violence.

1. Contraceptive appropriateness for adolescents is constantly changing;
2. Hormonal methods are safe for adolescents – yet daily compliance and where to store pills is a challenge for many youth;
3. Injectables and implants do not require daily compliance – yet they are typically associated with increased side effects;
4. IUD’s are generally not recommended for women without children;
5. Barrier methods are good choices for adolescents – but require negotiation which young women may not be empowered to undertake successfully;
6. Counseling is needed to clearly inform adolescents about their choices;
7. Medical and cultural barriers can prevent some providers from informing adolescents of all methods.

• Blumenthal and McIntosh. 1995. "Pocket Guide for Family Planning Service Providers."

1. FP clinics are hesitant to provide STI services;
2. A syndromic approach, (which groups clinical findings and patient symptoms for diagnosis), combined with patient risk assessment is the most effective way to diagnose and treat STD infection in resource-poor settings;
3. Partner referral management should be a part of STI treatment;
4. Service offerings should include risk-reduction education/ counseling;
5. Young adults are reluctant to seek formal health sector for treating STDs.

• Kabatesi, D. 1996. "Young People and STDs: A Prescription for Change." AIDSCaptions 3 (1): FHI.

• IPPF/WHR. 1995. "Responding to the Challenge: Presenting Unwanted Teenage Pregnancy in Latin America and the Caribbean."

1. There are inconclusive studies on the effectiveness of combining preventive care with prenatal, postnatal and postabortion care;
2. There is little evidence on adolescent breastfeeding, and interventions with adolescents;
3. Health facilities rarely provide nutritional supplements, such as iron, to patients;
4. Too little is known about determining the optimal doses and most effective means of administration for nutritional supplementation programs;
5. WHO advocates that for an integrated approach, antecedents, and not just symptoms, need to be addressed. However, many adolescents who are generally healthy need good preventive services to remain that way.

• Vadies and Clark. 1988. "Comprehensive Adolescent Fertility Project in Jamaica." Bulletin 22 (3): PAHO.

1. Costs for services must be affordable to adolescents;
2. The translation of affordability into a specific fee varies according to the location and target group.

• MSI. 1995. " A Cross-Cultural Study of Adolescents’ Access to Family Planning and Reproductive Health Education and Services." Final Report to the World Bank.

Key Element

Issues/Obstacles

Program Examples

1. It is a challenge to move school administrators and teachers away from daily routines to adopt new practices.

1. Local schools rely on the presence of national policies and guidelines from ministries of education and health;
2. Education leaders, if informed, can be promoters for reproductive health programs.

• Ministry of Education, the Legislative Assembly, and the Commission for the Family in El Salvador – FOCUS, 1997.

1. Leadership often exists in just a few individuals, but needs to be developed and used across levels and sectors.

1. Schools offer few opportunities to segment audiences to deliver targeted messages;
2. Important methods for gathering information:

1. Needs assessment;
2. Resource Mapping;
3. Evaluation Design and Monitoring.

• OPS/PAHO. 1997. "Education es salud en las escuelas para prevenir el SIDA y las ETS: Usa propuesta para resonables por el desarrolla de programas de estudios."

• Reproductive Health Programs for Young Adults: School Based Programs. 1997. pp. 48-50.

1. Change cannot happen in schools without a critical mass of supporters;
2. Teachers, health workers, parents, and others may have strong personal views that oppose YARH programs;
3. Youth, Families, and Community members need to be involved in program planning.

• WHO/ADH 1993. "The Narrative Research Method: Studying Behavior Patterns of Young People by Young People."

• CARE International in Zambia/Focus. 1998. "The Use of PLA Methodology in Partnership for Adolescent Sexual and Reproductive Health Programs (PALS): A Field Guide."

1. Top administrative leaders and managers are critical to the implementation of YARH programs in schools;
2. Roles and Responsibilities need to be clearly defined;
3. Multidisciplinary and mult-agency management structures need to be created.

1. Political, economic, and social issues in the country or community can either set a supportive climate or present controversy.

1. Local ownership is required for innovative programs to become rooted in individual schools.

• CARE International in Zambia/Focus. 1998. " The Use of PLA Methodology in Partnership for Adolescent Sexual and Reproductive Health Programs (PALS): A Field Guide."

• EDC. 1996. "Rapid Assessment and Action Planning Tool (RAAPT) Development and Pilot Testing: Progress to the World Health Organization."

1. Implementation of any new program in schools takes time, minimally three to five years;
2. Policy makers, planners, and evaluators attempt to measure changes too early in the experimental learning phase.

• WHO. 1996. "The Status of School Health," Prepared for WHO/HQ HEP Unit by Education Development Center, Inc.

1. Team training is one way to create critical mass – training just one person from a school will be ineffective.

• EDC, Marx, E.; Northrop, D. 1995. "Educating for Health: A Guide for Implementing a Comprehensive Approach to School Health Education."

Key Element

Issues/Obstacles

Program Examples

1. A common mistake in planning outreach programs is promising more than a project can deliver;
2. Clearly stating both process and behavioral objectives before project begins is key to measuring success.

• AIDSCAP. 1996. "Descriptive Analysis of AIDSCAP/HAITI BCC Projects: Some Lessons from the Field."

1. Groups of adolescents are very different, and are attracted to different approaches and messages;
2. When resources are scarce, it is important to identify young people who are most vulnerable and disadvantaged.

• IPPF/WHR. 1995. "Working with Youth: A Report of IPPF’s Youth Task Force and Youth Consultation Meeting."

• UNICEF Manila. 1995. "Reaching Vulnerable Youth: Youth Health and Development Promotion in the Philippines."

1. It is important to conduct a needs assessment of the targeted group in order to plan relevant project activities.

• Brandrup-Lukanow, et al. 1992. "Adolescent Sexual and Reproductive health." Report of the Workshop, CIE, Paris.

1. Adult professionals have traditionally planned and conducted programs for youth, and resist changing;
2. Working with young people as partners run counter to cultural patterns in many countries;
3. Dependence on young people to assume key tasks carries some risks – including high turnover, less than reliable participation, the need for supervision, an incentive and reward structure, and extra training;
4. There have been few models that actively involve youth.

• WHO/UNFPA/UNICEF. 1995. "Programming for Adolescent Health." Discussion paper prepared for the WHO/UNFPA/UNICEF Study Group on Programming for Adolescent Health.

• Advocates for Youth. 1996. "The West African Youth Initiative." Presented at the National Council on International Health Annual Conference, June.

1. Community, as a whole, needs to be engaged to address harmful gender-related practices that are barriers to improving young adult reproductive health (forced sex, child marriage, female genital mutilation, nutrition and education biases);
2. Communities need to made aware of the positive benefits of the activities that challenge traditional beliefs;
3. It is important to seek expert advice of the "gatekeepers" before implementing an outreach project.

• Chege, I., Avarand, J., Ngay, A. 1993. "Final Evaluation Report of the Communication Resources for the Under 18’s on STDs and HIV (CRUSH) Project."

• *WHO/UMATI, Tanzania.

1. One way to gain parental support is to convince them of the consequences of not dealing with adolescent reproductive health (IPPF, 1994);
2. If parents are informed, they can play a direct role in communicating with their children.

• *WHO/UMATI, Tanzania.

• Banda. 1993. "Evaluation of Malawi/90/P02: Integration of the Parent Education Project as a Community Based Training Programme."

1. A barrier to good evaluation is a perception that the answers are obvious and no inquiry is needed;
2. A critical need in the collection of data on program participants by relevant age groups;
3. It is important to include an evaluation feasibility study prior to a project’s implementation and evaluation;
4. Youth should play an active role in evaluating their programs.

• Merritt and Raffaelli. 1993. "Creating a Model HIV Prevention Program for Youth." The Child, Youth, and Family Services Quarterly 16 (2).

• "Peer Educators Recording and Reporting Forms"

1. Some believe that all staff involved in adolescent projects, including administrators, should receive training;
2. The amount of training given to peer promoters depends on what tasks and in what types of programs they will be expected to perform;
3. Training cannot be a one-time action;
4. Training content depends on what level of information peers are expected to understand and use;
5. Educators and counselors should receive different types of training;
6. Many counselors depend on their own judgement in serving young people – which result in a wide variety of advice and guidance given to young clients.

• CEDPA/USAID in Ghana: Pilot Project Monthly Progress Report. "Training/Sensitization Workshop Report."

1. Peers should be respectful, nonjudgmental, and confidential, and credible role models for the social competencies they will advocate;
2. Many young people prefer to receive reproductive health information from peers rather than from adults;
3. Turnover is a common problem in peer programs, but it can be partially addressed by careful selection, the use of contractual agreements, and rewards.

• Marques. 1993. "Gente Joven/Young People: A Dialogue on Sexuality with Adolescents in Mexico." Population Council 5.

• SEATS/Zambia: Peer Educator Selection Criteria (Lusaka Urban Youth Friendly Health Program)

1. Provision of Information and Education – adolescents often have difficulty talking with adults about sensitive matters and prefer peers who are similar in age, background, and interests;
2. Provision of counseling – providing information is not sufficient, peer promoters also need to be trained in counseling and imparting skills for behavioral change;
3. Distribution of Methods/Referral – peer promoters are less effective at distributing contraceptives. However, it is essential to have them refer to services (as young people often do not like to go to health facilities for services).

• Paxman, JM. 1993. "Clothing the Emperor – Seeing and Meeting the Reproductive Health Needs of Youth." Lessons from Pathfinder’s Adolescent Fertility Programs.

• Lusaka Youth Reproductive Health Program. "Terms of Reference – Peer Educator Counselor." SEATS Zambia.

1. Defined Responsibilities – when peers’ obligations are not clearly defined, projects may fall short of objectives;
2. Supervision and Support – Supervisors need to provide reinforcements of efforts, (through rewards);
3. Turnover – the tenures of peer promoters tend to be relatively short;
4. Benefits to the Peer Promoters – majority have been found to make changes in their own life and behavior;
5. Use of Quality Materials and Participatory Approaches – participatory approaches are important in teaching young people skills related to protecting their reproductive health.

• Perry C.L. and Sieving, R. 1991. "Peer Involvement in Global AIDS Prevention Among Adolescents." Unpublished Review commissioned by the Global Programme on AIDS. WHO.

• Piper, C. 1992. "A Health Programme for Adolescent Girls in Bangladesh – A Beginning." The Health Exchange. International Health Exchange.

Key Element

Issues/Obstacles

Program Examples

1. Social marketing programs need to target many different audiences so that they reach others in the community who shape social norms.

1. Parents – Philippines Foundation for Adolescent Development; Silayan-go. 1994. "Population Reports: Meeting the Needs of Young Adults". JHU/CCP.
2. Peers – Nigeria’s MUDAFEM IEC Campaign. 1995. "Reaching Young People Worldwide: Lessons Learned from Communication Projects, 1986-1995, Working Paper 2." JHU/CCP.
3. Schools – WHO/GPA school program in FHI/AIDSCAP. December 1993. WHO. 1992. "Approaches to Adolescent Health and Development: A Compendium of Projects and Programs." p.11. AIDSCaptions
4. Communities – PSI. 1996. "Final Report of Project Action: PSI’s Social Marketing Demonstration HIV/AIDS Prevention Project for Youth at Highest Risk in Portland, Oregon." July 1992-1994.
5. Policy makers – CDC. 1996. "The Prevention Marketing Initiative: Applying Prevention Marketing."
6. Health Services – Koontz and Conly. 1994. "Youth at Risk: Meeting the Sexual Health Needs of Adolescents." Population Action International.

1. Because YARH is controversial, it is important to get the key stakeholders ( public policy makers, business, civic, and religious leaders)to agree to and promote the program as soon as possible.

1. Adult professionals have traditionally planned and conducted programs for youth, and resist changing;
2. Working with young people as partners run counter to cultural patterns in many countries;
3. Dependence on young people to assume key tasks carries some risks – including high turnover, less than reliable participation, the need for supervision, an incentive and reward structure, and extra training;
4. There have been few models that actively involve youth.

1. Images and themes from the media often conflict with messages that promote safe sex and sexual responsibility.

*Advocates for Youth Media Project in US.

1. Messages should target behavior change objective; be culturally relevant; be believable; and be doable by targeted audience.

Jamaica, "Keep on Keeping It On" Campaign in Smith et al (1993) "A World Against AIDS: Communication for Behavior Change." Academy for Educational Development.

1. Networks should be built between relevant policy makers, media professionals, health service providers, counselors, peer promoters, etc.

Nigeria’s MUDAFEM IEC Campaign; JHU/CCP. 1995. "Reaching Young People Worldwide: Lessons Learned from Communication Projects, 1986-1995." Working Paper 2.

1. A barrier to good evaluation is a perception that the answers are obvious and no inquiry is needed;
2. Data on program participants by relevant age groups is needed;
3. It is important to include an evaluation feasibility study prior to a project’s implementation and evaluation.