Adolescent and Youth Sexual and Reproductive Health Programs
More than 1.75 billion individuals in the world today are young people (aged 10-24 years) (WHO, 2008). Adolescents (aged 10 to 19 years) have specific health and development needs, and many face challenges that threaten their well being, including poverty, a lack of access to health information and services, and unsafe environments. Considering that youth aged 15 to 24 accounted for an estimated 45% of new HIV infections worldwide in 2007 and about 16 million girls aged 15 to 19 give birth every year (WHO, 2010), adolescents' and youths' sexual and reproductive health (AYSRH) needs --particularly girls -- deserve considerable attention and resources.
In the past decade, more programs have targeted AYSRH because:
- Existing human rights treaties, including the Convention on the Rights of the Child and the Convention on the Elimination of All Forms of Discrimination against Women, make it right, in principle.
- It is an effective way to consolidate and sustain global gains achieved in early and middle childhood since 1990 (e.g. reducing the under-five mortality rate, reducing gender gaps in primary school enrolment).
- Investing in adolescents can accelerate the fight against poverty, inequality and gender discrimination.
- Preconception care and contraceptive use can prevent unintended pregnancies, unsafe abortions and sexually-transmitted infections in adolescent girls and young women (Dean, Lassi, Imam and Bhutta, 2014).
- Young people need to be empowered and equipped with the skills and capacities to address pressing global challenges (e.g. climate change and environmental degredation, burgeoning urbanization and migration, frequent humanitarian crises).
- Although adolescents are commonly referred to as the "next" or "future generation", they require protection and care, services, opportunities, support, and recognition now (UNICEF, 2011).
AYSRH programs may assume a variety of forms and may appear in a variety of settings. Among the more common program types are:
AYSRH programs focus on achieving one or more of four major goals:
1. Creating an enabling and supportive environment for young people
2. Improving their knowledge, attitudes, skills, and behaviors
3. Increasing young people's use of services and
4. Increasing young people's participation in programs.
- Sexual-reproductive health or life-skills education programs in schools;
- Mass media-based behavior change and social marketing interventions;
- Programs to make reproductive health services more "youth- friendly";
- Community-based non-formal education programs;
- Community mobilization campaigns;
- Workplace-based reproductive health education programs;
- Youth clubs/organizations;
- Livelihood programs to generate economic opportunities for youth; and
- Advocacy campaigns to influence political and cultural leaders (and adults in general).
It is worth noting some differences in terminology. WHO defines adolescents as 10-19 years old, youth are 15-24 years old, and young people are 10-24 years old. Most currently available data is for 15-24 year olds, or "youth". Most of the indicators presented here are for adolescents and/or youth, which cumulatively captures the entire age range of young people.
Methodological Challenges of Evaluating AYSRH Programs
As they do in other areas of RH, program officials and evaluators face a number of formidable methodological challenges in assessing the performance of AYSRH programs. Together, these challenges make the evaluation of AYSRH programs among the more difficult types of RH programs. Specific methodological challenges include the following:
- A myriad of factors heavily influence adolescent behaviors.
Adolescent behaviors are influenced in important ways by a sizeable number of factors operating at the individual, family, school, community, and societal levels. Granted, these same factors influence adults, but because adolescents have not fully developed-- socially, psychologically, and physically -- they are perhaps more susceptible to "contextual" or "environmental" influences than are adults. This susceptibility requires that programs address a number of determinants or "antecedents" of adolescent behaviors simultaneously. Evaluators must measure and "control for" a sizeable number of factors in order to tease out the effects of specific AYSRH interventions. Furthermore, evaluators often find themselves beyond the bounds of their own disciplinary training in dealing with the range of factors (e.g., relationships with family, school, and community; selfesteem; self-efficacy).
- The intended effects of AYSRH interventions are long-term for some interventions, further complicating evaluation.
The appropriate time-reference for measuring the impact of an AYSRH program is tricky. For some outcomes, (e.g., delayed age of sexual initiation), the desired result/ behavior is a short-term phenomenon an evaluator can accurately measure within the typical time-frames of most program evaluations (usually two to three years or less). For other outcomes, however, evaluators require longer periods of observation. Further complicating matters is that, in some cases, program effects may be short-term or transitory in nature. For example, an evaluation of school-based AYSRH education programs in Jamaica found significant effects on knowledge, attitudes and behaviors when measured nine months after program implementation, but these effects had largely disappeared when measured again after 21 months (Eggleston et al., 2000). Thus, strong impact evaluations of AYSRH programs require evaluators to measure impact at several points in time after program implementation.
- Measuring the quality of AYSRH programs requires an understanding of cultural constructs in the local setting.
Assessing the quality of AYSRH programs from the "client's perspective" requires the evaluator to elicit subjective interpretations, perspectives, and meanings from youth and others in the community. As a result, a combination of qualitative and quantitative data are generally required for the meaningful evaluation of AYSRH programs.
- AYSRH programs are often quite complex, multicomponent initiatives.
Because AYSRH programs must simultaneously address multiple "risk" and "protective" factors, a sizeable and growing number of programs have complex designs and multiple components. For example, many programs have life-skills education, peer promotion, community mobilization, and access to RH services components. Measuring the impact of each of the separate components is especially difficult, and as a result, program evaluations often focus on the net or combined impact of the full "package" of interventions.
- AYSRH programs produce effects at more than one level.
Although AYSRH programs primarily focus on influencing adolescent behaviors and RH outcomes, programs often attempt to bring about change at more than one level. For example, some programs mobilize community support for and involvement in initiatives and activities for youth. Failure to garner such community involvement could greatly diminish the effectiveness of the program in changing the attitudes and behaviors of adolescents at the individual level. Without measuring change (or lack thereof) at the community level, the evaluator could not accurately interpret the lack of change at the individual level.
- Sensitivities to AYSRH programs and to issues of adolescent sexuality complicate measurement in many settings.
Many societies regard the intended outcomes of AYSRH programs as personal and private. Some societies even prohibit discussions about sexual behavior and personal relationships. Program officials and evaluators may face parental and community resistance to asking adolescents questions about these topics. Because of the social sensitivities surrounding adolescent sexual behaviors, evaluators face more rigid informed/parental consent procedures for AYSRH programs than for other types of RH programs.
- AYSRH indicators overlap with other areas of RH.
Some indicators described elsewhere in this database are relevant to AYSRH programs. For example, most or all of the cross-cutting indicators can apply to AYSRH programs as well as to other types of RH programs. However, the nuances involved in AYSRH programs necessitate several specific indicators even in these generic areas. It should be noted that evaluators should collect and report outcome indicators for adolescent programs by gender.
- There is not a universal definition of "youth".
Unlike the various stages of pregnancy and infancy which have precise timelines and age ranges, the period of youth can vary by organization, project, and individual. WHO defines adolescence as 10-19 years, youth as 15-24 years, and young people as 10-24 year old. The USAID Youth in Development Policy (2012) considers those age 10-29 as youth. However programs decide to define the age range for youth, it should be noted and tracked consistently.
WHO. 10 facts on adolescent health. September, 2008. Available at: http://www.who.int/features/factfiles/adolescent_health/en/index.html
WHO. Young people: health risks and solutions. Fact sheet No 345. August, 2010.
UNICEF. The State of the World's Children 2011: Adolescence - An Age of Opportunity. NY, NY. February, 2011.
Dean SV, Lassi ZS, Imam AM, and Bhutta ZA. 2014. "Preconception care: promoting reproductive planning." Reproductive Health 11(Suppl 3):S2.
Eggleston E, Jackson J, Rountree W, and Pan Z. 2000. "Evaluation of Sexuality Education Program for Young Adolescents in Jamaica." Pan American Journal of Public Health 7, 2: 102-112.