Adolescent and Youth Sexual and Reproductive Health

CHARTING

DIRECTIONS FOR

A SECOND

GENERATION OF

PROGRAMMING

A report on a workshop of the UNFPA in collaboration with the

Adolescent and Youth Sexual and Reproductive Health

CHARTING DIRECTIONS FOR A SECOND GENERATION OF PROGRAMMING

A report on a workshop of the UNFPA in collaboration with the Population Council

1–3 May 2002, New York ii

The Population Council is an international, nonprofit, nongovernmental institution that seeks to improve the well-being and reproductive health of current and future generations around the world and to help achieve a humane, equitable, and sustainable balance between people and resources. The Council conducts biomedical, social science, and public health research and helps build research capacities in developing countries. Established in 1952, the Council is governed by an international board of trustees. Its New York headquarters supports a global network of regional and country offices.

Population Council One Dag Hammarskjold Plaza New York, New York 10017 USA 212/339-0500; fax 212/755-6052 e-mail: [email protected] http://www.popcouncil.org

UNFPA, the United Nations Population Fund, is the world’s largest international source of funding for population and reproductive health programs. UNFPA works with govern- ments and nongovernmental organizations in over 140 countries, at their request, and with the support of the international community. UNFPA supports programs that help women, men, and young people plan their families and avoid unwanted pregnancies; undergo pregnancy and childbirth safely; avoid sexually transmitted diseases, including HIV/AIDS; and combat violence against women. Together, these elements promote repro- ductive health—a state of complete physical, mental, and social well-being in all matters related to the reproductive system. Reproductive health is recognized as a human right, part of the right to health.

© 2003 The Population Council, Inc. Contents

Acknowledgments v

Executive Summary 1

Introduction 5

Goals and Agenda of the Meeting 6

Opening Session 6

Session 2 A Strategic Approach to Adolescent and Youth Programming: Learning from the Past and Building for the Future 8

Session 3 Evidence-Based Planning Concepts and Tools for Improved Programming 13

Session 4 Adolescent Refugees and Internally Displaced Persons in Emergency Situations 15

Session 5 The Strategic Value of Education 17

Session 6 Meeting the Distinctive Needs of Adolescent Girls and Boys 21

Session 7 Safe Livelihoods for Older Adolescents 25

Session 8 Working with Married Adolescent Girls 30

Session 9 Preventing HIV/AIDS Among Adolescent Girls and Boys 34

v

Acknowledgments “Adolescent and Youth Sexual and Reproductive Emily Arnold served as meeting rappor- Health: Charting Directions for a Second teur and wrote the original draft of this report. Generation of Programming” was convened at The workshop organizers thank each speak- the Population Council’s headquarters 1–3 May er—Linda Martin, Thoraya Obaid, Mari 2002. The workshop was organized by UNFPA in Simonen, Judith Bruce, Barbara Mensch, Ann collaboration with the Population Council. The McCauley, Susan Adamchak, Nicola Jones, workshop organizers are grateful for the dedi- Laura Laski, Carey Meyers, Stan Bernstein, cation and tireless efforts of the following indi- Patricia Guzman, Hally Mahler, Rachel Jones, viduals: At UNFPA, Laura Laski, Maria Jose Allison Pillsbury, Akello Betty Openy, Pamela Alcala, Lili Koster, Malak Khatib, and the entire DeLargy, Cynthia Lloyd, Lkhagvasurengiin adolescent cluster had the vision for this work- Oyun, Noor Mohammad, Delia Barcelona, shop and the wherewithal to bring it to fruition. Martha Brady, Seydou Doumbia, Gary Barker, At the Population Council, Judith Bruce, Carey Alphonsus Ekah, Cecilia Correa, Ziad El-Rifai, Meyers, and Rachel Goldberg collaborated Sajeda Amin, Anjali Widge, Lopita Huq, closely with UNFPA colleagues on developing Christine Norton, Jose Garcia Nuñez, Wariara the workshop agenda and logistics. The actual Mbugua, Shanti Conly, George Brown, workshop would not have been possible with- Mercedes Borrero, France Donnay, G. out Erica Chong’s behind-the-scenes wizardry. Ogbaselassie, Geeta Sodhi, Nicole Haberland, Anna Stumpf’s technical support was also Shelley Clark, Angela Stewart-Buchanan, invaluable. A special thank you goes to the Julitta Onabanjo, and Kunio Waki—for review- Office Services staff, as well as that of the ing text attributed to him or her. Office of Publications, at the Population Council.

Executive Summary 1

Executive Summary The United Nations Population Fund (UNFPA), in and Chapters 4b, 5, 6, and 9 in the back- collaboration with the Population Council, con- ground paper.) vened a three-day workshop that took place • Adolescents are a diverse group, and their 1–3 May 2002 at the Population Council’s head- diversity must be considered when planning quarters in New York. The workshop provided programs. The first generation of adolescent an opportunity to review research and pro- programming tended to homogenize the grams in the area of adolescent reproductive adolescent or youth experience. The work- health and development (the “first generation”) shop repeatedly emphasized the importance and to think critically about key lessons learned of diversifying the information base and from this work as we move forward into the designing strategies tailored to the distinc- “second generation” of work with this impor- tive needs of adolescents based on their: tant population. – Age This report summarizes the presentations and discussions from that workshop. For the – Gender purposes of this executive summary, we are – Marital status gathering key points into two clusters: those – Schooling status that underscore principles of program plan- – Residence ning, design, and evaluation, and those that – Living arrangements (with one, highlight neglected subjects or subgroups on two, or no parents) the adolescent agenda. Where possible, refer- – Migration status ence is made to the sections of the report as The research reported on at the work- well as the background paper* where the shop suggested that there are often dra- reader may find more detailed descriptions. matic contrasts in the needs, vulnerabili- ties, and capacities of adolescents. For Program Planning, Design, example, a strategy such as youth cen- and Evaluation ters—which have not always been safe • Facts, not assumptions, are the proper spaces for girls and have tended to be basis for planning effective programs. selective of older boys’ participation— A review of the first generation of program- may be suitable for reaching out-of- ming revealed that key target groups were school boys ages 15–19 but may miss or often missed, and some less vulnerable even be inimical to the needs of out-of- subgroups (older adolescents who were in school girls ages 10–14. school, for example) were reached instead A gender-differentiated strategy with interventions, because unfounded is essential to program planning and assumptions were made about the lives and is timely as we evaluate the effective- needs of adolescents. This phenomenon can ness of the four most popular first-gen- be prevented in the future if the necessary eration programs: youth centers, youth- background research and analysis are friendly services, family-life education, done. (See Sessions 2 and 3 of this report and peer-education programs.

* Copies of the background paper, “Adolescent and youth sexual and reproductive health: Charting directions for a second generation of programming—Background document” (New York: Population Council, 2003), may be obtained by contacting Erica Chong at [email protected]. 2 Adolescent and Youth Sexual and Reproductive Health

• Boys and girls have very different experi- ming for adolescents is still so new, a diag- ences, particularly during puberty. In many nostic phase wherein information is gath- places, girls’ mobility, schooling, and self- ered about and from key stakeholders is esteem become starkly differentiated from essential. It is almost impossible to monitor those of their brothers, and girls’ lives or evaluate a program competently when it become constrained. Where girls have few is finished if there has not been a regular places to gather away from their families process of observation and documentation. outside of school—if school is even an (See Session 3 of this report and Chapter 2 option—boys have more mobility and in the background paper.) gathering places although the activities undertaken in those spaces and their peer • Program plans should take into account the relations may be far from safe. Under- role that new social and economic options standing the separate experiences of boys might play in assisting adolescent boys and and girls and taking them into account girls in achieving good sexual and reproduc- when planning programs is necessary for tive health. Whereas the first generation of the development of sound programs. (See interventions focused heavily on health, Session 4 of this report and Chapters 2, 3, information provision, and occasionally the and 4a in the background paper.) provision of health technologies, informa- tion and technology are not always effective • To assure acceptability and sustainability, in giving adolescents—especially girls— local stakeholders and community leaders the tools to forge better life paths. Because must be involved in program planning. the health, social, and economic aspects of When relevant data are available on a tar- adolescents’ lives are closely integrated, get population, it is useful to review this participants repeatedly affirmed the impor- information with local stakeholders. In tance of working across sectors and at the some instances, they will actually be sur- community level. To do this competently, prised by the information. The process of participants acknowledged the importance questioning the assumptions of stakehold- of working outside the health sector and ers is valuable in and of itself. Further- forming partnerships with organizations more, their input in interpreting informa- that have expertise in community mobiliza- tion and developing plans fosters a sense tion, livelihoods development, or other of community ownership of a project and types of interventions that build skills. (See may spark interest in doing original Sessions 2 and 7 of this report.) research to further understand the situa- tion of adolescents in a community. (See New Program Content and Session 2 of this report.) Neglected Subgroups • Monitoring and evaluation should not be The conventional wisdom of the first generation afterthoughts—research, observation, and of adolescent programming had the strength of documentation are processes that should be building on what was already known about built into programs from the beginning. Data reaching adolescents—yet most of what was collection and interpretation during the plan- known was learned in Western settings. Thus, ning phase will help inform later monitoring key subgroups were often neglected, and con- and evaluation phases and are an essential tent outside the normal purview of health inter- part of program design. Because program- ventions often was not explored. Executive Summary 3

• In many countries—particularly throughout research—especially strategies that West Africa and South Asia—the majority of include adolescents themselves—is of sexually active adolescent girls are married. great value and that special attention The first generation of adolescent programs should be given to gender dimensions. The focused primarily on unmarried adolescents programs described outlined ways of who often were in school. The entry points including adolescents at each stage—plan- they employed for reaching this popula- ning, implementation, and even evalua- tion—family-life education programs in tion—resulting in increased credibility and schools, youth centers, peer education the creation of peer leaders. (See Session approaches, and youth-friendly clinics— 4 of this report.) focused on contraception and occasionally • In many countries, particularly in sub- STI prevention, and were largely out of the Saharan Africa, adolescent girls are poten- reach of married adolescent girls. There tially doubly affected by HIV because they was much discussion about a variety of are vulnerable to infection and often act as interventions that could target married ado- caregivers. Adolescents, especially girls, lescents, including how to redirect antena- are often vulnerable to HIV infection tal pregnancy care and after-care programs because of their lack of social status and to make sure that married adolescents, their economic vulnerability. In some their partners, and other gatekeepers in instances, adolescents are responsible for their lives were included. Parallel interven- providing care to HIV-positive kin, a role tions will be necessary to reduce the pro- that may turn them into de facto heads of portion of girls married while adolescents household. This situation may increase through community-based strategies for their own susceptibility to infection if they changing the norms around early marriage. begin seeking income from unsafe sources In some settings, deferring marriage is (e.g., sex work) or engage in exchanging especially urgent as some married adoles- sex for food or school fees. cents are differentially vulnerable to HIV In some settings in sub-Saharan Africa infection (see below). (See Sessions 8 and 9 there is emerging evidence that early mar- of this report, and Chapter 10 in the back- riage brings increased vulnerability to HIV ground paper.) infection. A married adolescent may have frequent sexual relations with her husband • Refugees and internally displaced who is often older and sexually experi- populations often include a significant pro- enced. She is also often subject to pres- portion of adolescents. Workshop partici- sure to bear a child soon after marriage. pants portrayed the experience of dis- (See Session 9 of this report and Chapter placed adolescents as adding a layer of 10 in the background paper.) complexity to program planning. Adolescent refugee groups are detrimentally affected • Investments in education are linked to a by the lack of community infrastructure, myriad of positive long-term effects, yet limited opportunities to attend school, limit- access to high-quality education—especially ed or no health care, increased vulnerabili- for girls—continues to pose a barrier to ty to physical and sexual abuse, and the progress. Workshop participants discussed absence of positive role models. how the challenge of getting girls into school Participants agreed that diagnostic can be overcome through any number of 4 Adolescent and Youth Sexual and Reproductive Health

incentives (e.g., subsidies to parents, build- • Boys have distinctive needs with regard to ing dormitories, building village schools). reproductive health information and The discussion returned several times access to services. Boys generally know to the importance of gender training for less than their female peers about repro- teachers, as there is increasing evidence ductive health, yet they have a hard time that in some places teachers are not only acknowledging their need for information. insensitive to gender issues but may actu- At the same time, boys are more likely to ally harass girls themselves. (See Session be sexually active. Improving boys’ access 5 of this report and Chapters 4a and 4b in to positive mentors, as well as their com- the background paper.) fort at youth-friendly health services (which boys often consider girls’ spaces), • Effective sexuality and reproductive health were discussed as possible areas for education requires participation and sup- intervention. (See Session 6 of this report port of stakeholders at all levels (e.g., and Chapters 6 and 7 in the background national, local, teacher, parent, and stu- paper.) dent). Evidence from a UNFPA-supported project in Mongolia illustrated the results • Livelihood programs may serve the dual of strong community support and sense of purpose of offering adolescents opportuni- ownership in a comprehensive and gender- ties to attain a better standard of living, sensitive sexuality education curriculum. become self-motivated, and achieve mobili- (See Session 5 of this report.) ty while reducing risky behavior that often • Boys’ special needs must not be overlooked results from social and economic vulnera- when planning programs for adolescents. bility. The livelihoods approach recognizes While boys enjoy greater mobility relative to the fluid links between the economic and their female peers, they may congregate in noneconomic aspects of adolescent lives, unsafe spaces and engage in risky activi- and the association of livelihoods with edu- ties. Boy-dominated spaces may also cation and reproductive health. Many par- expose boys to social content or gender ticipants emphasized the importance of norms that do not promote respect for girls looking at livelihoods as a gradient of skills and women. Programming for adolescent and acknowledging the relationship, partic- boys can address their specific needs, as ularly for adolescents, between social, pro- well as foster long-term change by working ductive, and reproductive issues. Mention to alter gender norms through addressing was again made of the value of working the male sense of entitlement, questioning with partners outside of the health sector practices of violence against sexual part- who have a track record and expertise in ners, and attempting to eliminate homopho- financial literacy, savings, employment/ bia, which leads some boys to exaggerate vocational training, and micro-finance. their masculinity in negative ways (e.g., In some settings, the workplace (includ- machismo, use of force in sexual relation- ing training areas) may offer an appropri- ships, and unwillingness to participate in ate and attractive venue for sexual and nurturing, childcare, and domestic activi- reproductive health programming. (See ties). (See Session 6 of this report and Session 7 of this report and Chapter 8 in Chapters 6 and 7 in the background paper.) the background paper.) Introduction Thoraya Obaid 5

Introduction therefore lack the means by which to prevent Thoraya Obaid, Executive Director, UNFPA unwanted outcomes that can have a detrimen- tal impact on their futures. Adolescence is recognized as the stage of life Investing in young people is a top priority in which individuals establish their own identi- of the United Nations Population Fund (UNFPA), ties and prepare to become adults. For many which is guided by the goals of the young people across the world, however, the International Conference on Population and notion of adolescence as a time of self-devel- Development (ICPD) and its five-year review of opment under safe and healthy conditions progress (ICPD+5). The ICPD Programme of could not be further from their reach. Millions live in poverty or other difficult circumstances, Action gave special attention to the conditions with little access to knowledge and resources. of adolescents, including the health of pregnant adolescents, HIV prevention, gender equality in Both girls and boys face many challenges the areas of reproductive health and rights, and and pressures. For boys, adolescence can be a their impact on poverty reduction and develop- time for expanded participation in community ment trends in general. These goals highlight and public life. Girls, however, may experience the stake young people have in the develop- intensifying restrictions, with their freedom of ment process and the general relationship mobility severely limited. In addition, pres- between health and development. sures derived from traditional gender roles restrict girls’ future prospects to roles as Recognizing the crucial challenges adoles- wives and mothers, giving them little say cents face today, UNFPA and the Population about their own aspirations and hopes. Boys Council joined forces to examine the latest also face multiple and parallel societal and trends and evidence on program approaches peer pressures, as they may be encouraged that address adolescent sexual and reproduc- to be risk-takers and to demonstrate their tive health. While many challenges remain, the manhood through aggressive behavior, thereby evidence is demonstrating that investing in putting themselves and others in unsafe young people is the best intervention now and situations. for the long term. In short, investing in young Today, adolescents, and adolescent girls people is important for a host of ethical, in particular, are the age group among whom human rights, gender, and economic reasons. HIV infection is most rapidly spreading. Every Simply stated it makes good sense. This report year millions of young girls face unwanted and summarizes the presentations and open dis- early pregnancy, unsafe abortion, and sexually cussions from a three-day meeting entitled transmitted infections (STIs). Obstetric fistu- “Adolescent and Youth Sexual and lae—a largely ignored condition that results Reproductive Health: Charting Directions for a from internal ruptures in girls who are simply Second Generation of Programming” that took too young to be bearing children—are yet place in New York 1–3 May 2002. another horrific reproductive health outcome Lessons learned from the experiences of that affects adolescent girls. The world over, UNFPA and its partners are critical for a sec- the majority of adolescents, married and ond generation of programming in adolescent unmarried, in school and out of school, lack reproductive health. Because the world is dif- access to sexual and reproductive health ferent for girls than it is for boys, program information, education, and services, and approaches must account for this. Programs 6 Adolescent and Youth Sexual and Reproductive Health

that work with governments, nongovernmental • the importance of tailoring programs organizations (NGOs), and others using a mul- to the diversity of adolescents; tisectoral approach and that differentiate the • the strategic value of education in needs of adolescent girls and boys must also supporting adolescent social devel- provide more attention to married adolescents opment and reproductive health; (who are treated as adults when they are still • creating safe and supportive spaces girls and boys). Addressing these issues for girls; requires change at multiple levels, including service delivery, funding priorities, community • creating safe and supportive spaces resources and environments, and adult behav- for boys; ior and attitudes. • the challenges in developing safe While there is a long way to go in develop- and appropriate livelihood programs; ing effective program approaches to meet ado- • the emerging challenges of prevent- lescent and youth priorities, UNFPA is ready to ing HIV/AIDS; and address the challenge of the second generation. • the neglected social and health needs of married adolescent girls Goals and Agenda (and their partners). of the Meeting Each theme emphasized the importance of UNFPA invited key staff to attend the workshop, building on development and rights-based which was organized by UNFPA in collaboration agendas, developing and drawing on data and with the Population Council, to map new direc- systematically evaluating field experiences, tions for a second generation of adolescent employing multisectoral approaches where programming. The objectives were twofold: appropriate, explicitly addressing diversity and gender-related inequalities, and finding partner • to provide state-of-the-art research organizations with complementary skills. findings and evidence-based guidance This report is organized around the sum- for adolescent programming strate- maries of each session. Subsequent sections gies, building on a review of the first are divided into two parts: a summary of the generation of adolescent sexual and presentations and a summary of the discus- reproductive health programs; and sions that followed the presentations. • to provide input for future program- The workshop was followed by an inter- ming in adolescent sexual and repro- nal session at UNFPA headquarters to discuss ductive health. the implications of the meeting for UNFPA Each of the nine sessions was structured programming and to generate initial recom- around the latest research and program find- mendations (available on request). ings on adolescent sexual and reproductive health. Presentations were made by experts Opening Session from UNFPA, the Population Council, and oth- ers. The themes of the sessions were: The opening session was chaired by Mari Simonen, Director of the Technical Support • lessons garnered from the first Division at UNFPA. Linda Martin, President of generation of programs; the Population Council, opened the workshop by • data analysis and evaluation welcoming the participants and noting the approaches; Council’s pleasure in collaborating with UNFPA. Opening Session 7

She expressed her admiration for UNFPA and Because adolescents are an increasingly the leadership role it has played and will contin- high-priority focus of UNFPA, it is essential to ue to play in shaping the experience of the one review past experience. Ms. Simonen envi- billion young people who are beginning their sioned a future agenda that, while continuing reproductive and productive lives. Acknowl- the commitment to reproductive health infor- edging the limited resources available for this mation and services, is expanded to include work, she highlighted the importance of evalu- an adolescent social and economic develop- ating previous efforts and identifying the most ment agenda. She underscored the high value cost-effective approaches. She concluded by that UNFPA has placed on understanding the observing that UNFPA is uniquely positioned to distinctive needs of girls and boys, incorporat- make an extraordinary contribution, given its ing gender concerns into mainstream pro- ability to reach across multiple development gramming, and including young people them- sectors, and bring about large-scale change. selves in programming decisions. Thoraya Obaid, Executive Director of Ms. Simonen framed the challenges of UNFPA, then offered opening remarks on behalf the workshop—from UNFPA’s perspective— of UNFPA. She noted that the workshop came as follows: at a timely moment—it took place one week •What can UNFPA learn from its expe- before the United Nations Special Session on riences? How can it develop a knowl- Children, which reviewed progress in imple- edge base that is useable and acces- menting the UN Convention on the Rights of the sible to program developers? Child (CRC). (The CRC protects children up through age 18 so that the vast majority of ado- • How can adolescent programs lescents fall under its protection.) strengthen their monitoring and eval- Dr. Obaid offered statistics on the vulner- uation? What are the key issues to ability of adolescents. Each year, 10–11 million consider at different stages of pro- teenage marriages take place in less-devel- gramming, such as during planning, oped countries (excluding China) and 15 mil- implementation, and the monitoring lion adolescent girls get pregnant; in addition, and evaluation stages? approximately 7,000 adolescents are infected •What are the key populations adoles- by HIV every day. Adolescent programs can cent programs should consider? break the cycle of poverty and encourage Addressing the diversity of adoles- youth empowerment and involvement in civil cents is a challenge, given differ- life. Dr. Obaid asserted that by offering adoles- ences in rural/urban residential sta- cents appropriate social support and access to tus, marital status, gender, age, and sexual and reproductive health programs, war-affected or refugee status. UNFPA can unleash their potential, particularly that of young girls. Young people must become • How can adolescent programs consid- agents of their own empowerment. er sustainability in the design stage? Ms. Simonen reviewed the goals of the • How can UNFPA advocate for workshop. She noted that UNFPA has been the adolescent health, social, and engaged in adolescent programs for the past economic agenda in other forums? three decades, supporting family-life educa- Linking adolescent concerns to larg- tion, sexuality education in schools, peer edu- er development agendas should cation, multipurpose youth centers, youth- remain a key goal. friendly services, and youth participation. 8 Adolescent and Youth Sexual and Reproductive Health

Session 2—A Strategic Approach teenagers at all. The clientele tended to be to Adolescent and Youth older—the average ages of attendees were Programming: Learning from the 18 years in Ghana, 21 in Zimbabwe, and 24 in Past and Building for the Future Kenya (in Ghana and Zimbabwe over 40 per- cent of those using reproductive health serv- This session, chaired by Elizabeth Lule, ices were over age 24). Centers in Kenya and Population Advisor at the World Bank, exam- Zimbabwe were also much more likely to ined the lessons learned from the predomi- attract males than females. While staff volun- nant approaches to adolescent sexual and teers were often knowledgeable about repro- reproductive health during the first genera- ductive health issues, their attitudes prevent- tion of programs, and introduced alternative ed them from providing nonjudgmental infor- intervention models that thus far comprise mation about sexuality and protection from the second generation. STIs and pregnancy. Staff were also only vari- ably observant of the need to protect the con- The First Generation: Lessons fidentiality of their young clients. Learned from Predominant Ann McCauley of the Population Council Approaches to Adolescent Sexual summarized the lessons learned from several and Reproductive Health decades of experience of family-life education Barbara Mensch of the Population Council programs, noting that UNFPA has a long histo- reviewed the experience of youth centers, ry of supporting these programs. She framed drawing on data from three research studies her remarks by explaining that the local con- conducted in Ghana, Kenya, and Zimbabwe text often plays a significant role in determin- with the Planned Parenthood Association of ing the relative success or weakness of such Ghana, the Family Planning Association of programs; she therefore urged the audience Kenya, and the Zimbabwe National Family to look carefully at each situation and not to Planning Council. Typically, youth multipurpose generalize. (Dr. McCauley based her conclu- centers have been structured around recre- sions on current Horizons program school- ational activities, libraries, and career coun- based programs in Mexico, South Africa, and seling. These activities are complemented by Thailand and on the extensive literature on the provision of reproductive health informa- these types of programs.) tion and services. The strength of family-life education is its Dr. Mensch reported that use of reproduc- broad acceptance within the community, par- tive health information and services attached ticularly where the community has been to the youth centers was low—in some set- engaged before the introduction of family-life tings, only two or three young people might be education and involved in creating the curricu- seen in a day. In many cases, the hours and lum. However, this same acceptability strategy the days of operation were not convenient. has a weakness; the content generated can be She also noted that the high-profile associa- overly general and diluted. Many programs tion of family planning efforts and adolescent lack a precise focus on sexual and reproduc- programs effectively stigmatized the centers tive health and give little, if any, attention to (in some cases, signs saying “Family Planning issues such as male dominance of females Association” were prominently displayed). and sexual decisionmaking, and child–parent Users of the youth centers were not the negotiations regarding marriage. These power youngest adolescents, and often were not dimensions must be dealt with if young people Session 2 Strategic Approach to Adolescent and Youth Programming 9

are to adopt voluntary, informed, and safe sex- similar characteristics. This approach has had ual and reproductive behaviors and values. some success with “hard-to-reach” youth. While these interventions were initiated with, Research has revealed that friends are the pri- and were most suited to, in-school youth, their mary source of sexual and reproductive health benefits can be multiplied if messages are information for young people, and that peer spread beyond the school, such as through education can create changes in environment, youth scouts, youth clubs, and so forth. affect attitudes, provide information, and In some settings, family-life education increase acceptance of programs. has become politicized, which has resulted in Peer educators require selective recruit- programs covering a very limited agenda. For ment, training, supervision, and ongoing sup- example, some programs emphasize total port. Peer educators “age out,” however— abstinence as a protection strategy for young they naturally have a high turnover and typi- people, even in settings where a substantial cally a short term of service—which can be proportion are sexually active and potentially addressed by careful selection, use of contrac- without protection. Family-life education pri- tual arrangements, good support, consistent marily reaches only those in school, and has reinforcement, and compensation and other rarely been successful in reaching young peo- rewards. In addition, peer educators can han- ple who are married, out of school, older, or in dle only a limited number of queries and are difficult living circumstances (e.g., migrants not equipped to handle issues of negotiation and orphans). Recent improvements to family- and self-esteem and other more difficult— life education programs have resulted in life and, sadly, common—situations such as sexu- skills programs that go beyond providing infor- al coercion and sexual abuse by adults. mation to teaching young people negotiation, Discussions with peer educators may open the planning, and refusal skills through role plays door on these difficult subjects, but a cadre of and practice. Although family-life education is better-trained, perhaps older, counselors are a good first step and has gained wide policy needed to deal with them. Peer educators may support, it is not a sufficient program not be able to provide intensive and sustained approach on its own. It is, however, a valuable efforts to promote behavior change in large part of an overall strategy to reach young peo- groups, but they can be part of a good initiat- ple, because such programs increase knowl- ing strategy. edge and communication about reproductive Dr. Adamchak stated that peer education health issues among adults, such as teachers should not be a stand-alone activity, rather it and administrators, as well as among youth. should be packaged with complementary ele- Susan Adamchak of the Population Council ments to build a comprehensive approach to made a presentation on peer education and adolescent programming. While peer education youth-friendly services, in which she pointed to has a clear and positive impact on the peer strengths that could be exploited in the next promoters themselves, it may not be the most generation of programs. She based her com- efficient way to reach young people. ments on a report prepared by the Frontiers It is unclear whether school- or peer- program in the context of HIV prevention and based programming is more effective. While the Population Council’s experience in this community-based peer programs do change area. Peer-education programs employ trained behavior, the greatest effects are often seen peers similar in age, background, and often among in-school youth. As yet it has been diffi- gender to effect change in populations with cult to determine whether the impact is the 10 Adolescent and Youth Sexual and Reproductive Health

result of peer programs or other activities. to young people, who are not only on the move Similarly, there may be differential effects by but may want to be served outside of their gender, age, and marital status, but few stud- communities. Dr. Adamchak emphasized the ies have reported on these distinctions. need for future youth-friendly service pro- There is some evidence of success of peer grams to combine a number of strategies— programs with hard-to-reach populations such including outreach and community awareness as street children, sex workers, and out-of- in addition to clinics—and the possibility of school young people. Such programs may also reaching young people in nonclinical venues prove effective in reaching young married where they congregate. women, although this population is likely to start When considering the accessibility of accessing health facilities as they begin child- services for young people, time is perhaps of bearing, and as such will have a point of contact greater importance than geography. Most pub- with health providers then. Further evaluation of lic clinics operate on fixed schedules that are peer-education programs is required to better not compatible with the hours or days when understand their effectiveness. schools are not in session, or when young peo- Dr. Adamchak went on to discuss youth- ple are not working. friendly services, that is, developing service procedures within the context of existing fami- The Second Generation of Adolescent ly planning and reproductive health programs, and Youth Programming so that young people seeking specific services Judith Bruce of the Population Council out- (mostly contraceptive, but sometimes STI lined the three main tasks of moving forward services) feel welcomed. Such services have to a second generation of programming. been available through both private- and pub- lic-sector partners, and have not been limited • Advocates of adolescent sexual and to the clinical setting—some function within reproductive health programs must schools and youth outreach programs. make a stronger case to other sec- While many young people clearly are in tors for investing in adolescents. need of better information and services, thus • Programs must be responsive to the far youth-friendly services have not reached internal diversity* of adolescents. this population. Such services, centered in tra- Without such attention to important ditionally “adult” clinical circumstances, are segments of the adolescent world, often viewed as inappropriate sources of care programs will be unable to attract by young people. In a parallel manner, committed participation by young people providers, whose central experiences are with themselves or yield sustainable results. adults, may be uncomfortable about the legali- ty and moral responsibility of serving young • Because adolescents are not simply people. “younger adults” or “older children” Also, because existing reproductive the success and effectiveness of health and family planning clinics have been interventions for adolescents must geographically based on the needs of adults, be defined in the context of their they are not always geographically accessible transition to adulthood, and the

* Paying attention to diversity involves considering age, sex, marital status, education level, urban/rural residence, number of parents who live at home, and so forth. Session 2 Strategic Approach to Adolescent and Youth Programming 11

knowledge, capacities, and opportu- diagnostic phase and some budget flexibility nities that they need and will benefit so that lessons learned in the first analytic from—as measured by their self- phases and pilot demonstrations can be used perception, informed decisionmak- to change program design over time. ing, strengthened personal assets, Key partners in adolescent programs positive peer and mentoring relation- include young people, their parents, and non- ships, social mobility, power in nego- governmental and governmental agencies with tiation, and acquisition of skills. talents and interests outside the health sector. Ms. Bruce proposed that program plan- Participation of adolescents as peer coun- ners build the case for investments in adoles- selors, while desirable, must be examined criti- cents on the UN Convention on the Rights of cally—young people may not be able to be the Child, which offers both protections and drawn in en masse as volunteers, and they rights to children up to the age 18—including often age out of programs. Involving adoles- the right to information they need to manage cents in the design of programs and in the their health and lives. While programs should early phases of implementation is perhaps eas- be based on development-oriented, rights- ier to accomplish than giving them responsibili- affirming principles, a rights-based framework ty for “managing” programs and finding the does not obviate the need for close analysis resources to sustain them. Obviously, it is best and provision of evidence of success. if parents and other gatekeepers can be made Emphasizing diversity as a theme, Ms. into program allies; however, in cases where Bruce not only highlighted the stark differ- they cannot, programs must be prepared to act ences among adolescents of different ages, on their behalf in order to protect young peo- genders, and schooling and marital status, ple, especially girls. Finally, the other sectors among other factors, but also suggested that are clearly important partners, as many pro- program content must be diversified. grams will have content that falls outside of She queried the impact of the first gener- the comfortable, better-known health arena. ation of programming (e.g., family-life educa- Forming strategic alliances with partners in tion, youth centers, peer education, and other social and economic development fields youth-friendly services) in combination with (some perhaps who have limited experience more standard interventions, on significant working with young people but who are willing subsets of adolescents, including those 10–14 to learn) may be the best way to diversify pro- years old, boys and girls, those in and out of gram content. school, and those who are unmarried Finally, many of the sexual and reproduc- and married. tive health outcomes we are seeking for ado- Programs that are based on clear lescents may not become visible within three evidence and that include evaluation increase to five years; benchmarks such as delayed our ability to make the case for investment in marriage, avoidance of infection with HIV, adolescents. The first generation of programs spacing of children, better marital or partner was introduced quickly, but was not well-eval- communication, and so forth can indeed be uated. Better program evaluation enables achieved, but most likely will take place five or planners to engage other sectors and design even ten years later. Socio-cultural and gender programs with more refined and achievable transformations are required. Sustained objectives. The evidence-based approach is behavioral changes take place over time. Thus best served by a process that has an authentic we must define benchmarks that are attain- 12 Adolescent and Youth Sexual and Reproductive Health

able within relatively short time frames and a more rigorous use of data to fine-tune ado- that represent goods in and of themselves, but lescent programs and policies would likely fos- also lead logically to desirable health and ter better results. Without substantial new demographic changes. Such benchmarks expenditures, existing data could be used to include (and are mentioned in documents such identify the most vulnerable adolescents, as the CRC) increased knowledge, self- important gender differences among adoles- esteem, social mobility, retention in school, cents, and how these differences may affect and positive peer relationships. their knowledge, behaviors, and, ultimately, Nicola Jones of UNFPA shared some their health. Much, though certainly not all, of insights into how the adolescent agenda fits this data is “free” and readily available. into UNFPA’s strategic directions. She Overall, the costs of mounting programs not referred to a recently completed exercise based on evidence outweigh the additional that indicates how UNFPA can best pursue expenditures necessary to conduct a sound the objectives laid out in the ICPD agenda. diagnostic phase. The review included an analysis of how sexu- Data are also vital to advocacy. In order al and reproductive health is best achieved, to conduct a compelling dialogue with policy- revealing the interdependence of social, eco- makers and the media and to influence public nomic, and health factors. Poor reproductive opinion, UNFPA must collect information health knowledge and behaviors in young about and from young people. Also vital to people can lock them, particularly girls, into a the success of the next generation of pro- cycle of poverty. The best and perhaps the grams is the expansion of partnerships with last opportunity for programs to effectively other sectors, as addressing adolescent intervene in this cycle is during adolescence. social issues requires change at multiple lev- UNFPA is re-examining the meaning of els and the involvement of the education, adolescence across societies. There is a fair sports, military, and employment sectors, amount of diversity between cultures regard- among others. UNFPA’s current emphasis on ing how the transition to adulthood is viewed youth participation should be expanded to and the “tasks” of transition that are include other aspects of development, partic- assigned to boys and girls. Ms. Jones empha- ularly in the area of livelihoods and the cre- sized that, in the past, there had been no ation of safe spaces for girls. investigation of what adolescent lives look like in different domains and a resulting Summary of Discussions homogenization of their identities. UNFPA will Most of the discussion revolved around the adopt a more culturally sensitive and evi- comments made about youth centers, family- dence-based approach and likely substantial- life education, peer education, and youth- ly increase the investment it makes in quali- friendly services. tative and quantitative data collection. It will It was generally accepted that youth cen- use its standing and extensive array of pro- ters were often underutilized because of incon- grams to place adolescence high on national venient hours, the stigma of a close associa- and international agendas and to bring NGOs tion with family planning, and the attitudes of and youth organizations to the table. staff toward young people in general but often, Laura Laski of the UNFPA Adolescent especially, toward young unmarried girls. Some Cluster discussed the potential of evidence- in the audience felt successful youth centers based programming at UNFPA. She stated that were possible. It was suggested that centers Session 3 Evidence-Based Planning Concepts and Tools 13

diversify their program content to include more Session 3—Evidence-Based activities that girls like or that some centers be Planning Concepts and Tools for reserved for girls alone to encourage more use Improved Programming and less stigma. One participant said, “I don’t want to hear the sentence that youth centers This session, chaired by France Donnay of the don’t work,” to which one of the presenters Reproductive Health Branch,Technical Support responded, “And I don’t want to hear that Division, UNFPA, examined ways in which data youth centers do work. Perhaps we can all can be used for program planning, monitoring, agree that for each strategy we need to speci- and advocacy. It reviewed data sources and fy for whom they work and for whom they data gaps, and, in some instances, proposed don’t work; that is really the issue.” ways of filling them. The audience generally agreed with the Carey Meyers of the Population Council assessment given of family-life education and and Stan Bernstein of UNFPA opened the ses- discussed those who were missed by that sion with a discussion of how to use existing approach, which is centered in schools. data—in this case, Demographic and Health Further, the audience lamented how family-life Survey (DHS) data—to get a clear picture of education programs diluted information on adolescent lives. The Population Council has sexual and reproductive health, and therefore compiled and tabulated data on adolescents reduced their utility. At the same time, audi- in 47 countries. For each country, information ence members acknowledged the usefulness of is organized in as many as 14 tables to the family-life education approach in building reveal—often in surprising terms—facts community support for sexual health programs about adolescents with regard to schooling for young people. and work status, living arrangements, sexual There was a fair amount of enthusiasm activity, childbearing, and other reproductive for peer-education programs and their poten- health indicators. Close attention is given to tial—perhaps not fully realized—to address disaggregating data by age, gender, and mari- issues concerning social norms, self-esteem, tal and schooling status. Ms. Meyers pointed and negotiation. Most discussants confirmed out that even the most preliminary cut of data that peer educators required ongoing supervi- for a given country may challenge existing sion, training, and that their period of service assumptions about young people. The DHS was often too short. Questions raised con- data show, for example, that young people in cerned whether peer education as a strategy many countries—particularly older adoles- was equally applicable to different sets of cents—are not in school, that a substantial peers, for example, younger adolescents, proportion of younger adolescents may be liv- girls, and boys; which peers speak to whom; ing with neither parent, and that the majority and whether age-, gender-, and marital and of sexually active adolescent girls in less- schooling status–specific peer-education pro- developed countries (excluding China) are grams should be developed. A suggestion was married. Ms. Meyers and Mr. Bernstein made that innovative evaluation methodolo- argued that investing money (often not a gies such as network analysis should be large amount) and time at the outset of a pro- employed to assess the efficacy of peer edu- ject to develop a specific problem-based cation for different groups, and with respect strategy will save money in the long term and to different subjects, such as its impact on in many cases may obviate the need for pri- prevention of HIV infection. mary data collection. 14 Adolescent and Youth Sexual and Reproductive Health

Key aspects of young people that pro- In many instances, monitoring a project gram planners should examine include gender, requires little more than common sense. For age, urban/rural status, living arrangements example, routine record-keeping that collects (i.e., living with both parents, with one parent, information on the gender, marital and school- or with no parent), and schooling, work, and ing status, and living arrangements of pro- marital status. In addition to variations in gram beneficiaries can increase the program’s these key aspects, young people’s lives are reach and effectiveness. also likely to vary in terms of personal Rita Badiani of UNFPA Mozambique and resources, such as social networks, access to Pathfinder International gave an example of schooling, and the potential protection of par- how to use relatively limited resources to do ents. Data sources can include national cen- better intervention targeting. The program she suses, UNICEF’s Multiple Indicator Cluster described consisted of three interconnected Surveys, existing situation analyses, Living approaches to young people—school-based, Standards Measurement Surveys, other pro- community-based, and clinic-based approach- ject-level research, and DHS (in particular es—that involved out-of-school peer educa- “Facts about adolescents from the tors, parents, young people, teachers, coun- Demographic and Health Survey,” published by selors, and also employed community radio the Population Council). programs. Initially, the program made use of Mr. Bernstein emphasized the need to qualitative and quantitative data to assess include strong monitoring and evaluation com- efficacy, drawing on a survey of students to ponents, most easily generated for programs determine where they had accurate knowl- that have built their strategies on data. He edge and where they did not. suggested designing projects that target the The initial cut did not disaggregate by actual documented needs of particular popula- gender, which Ms. Badiani recognized as a tions and allow for flexibility. In this, he hear- drawback. She expressed a desire to learn kened back to the first session’s question, “Do more about girl-to-girl and boy-to-boy commu- youth centers work?” and concluded that they nication because she suspects that peer edu- neither work nor do not work. Rather, the cation without a gender component might fall question must be completed: “Do youth cen- short of the mark. ters work for out-of-school boys ages 15–19? An interesting adjunct study focused on Do they work for in-school girls ages 10–14?” out-of-school young people, examining their Through specification alone, many pro- understanding of sexuality, sexual and repro- grams would be able to develop a simple moni- ductive health decisionmaking, and use of toring plan and determine whether they are leisure time. Ms. Badiani looks forward to accomplishing their objectives. Without such taking another look at the data and the pro- specificity, however, it is possible that what is gram procedures to determine who is making achieved—even if it is vaguely measurable— use of program services and whether the will not be able to be attributed to the program, program has been reaching the most vulnera- and program managers will not know whether a ble populations. There is great demand for particular strategy worked for a specific audi- services, which is one measure of success. ence. Specificity of problem statement allows After a relatively short period of program the program to identify mismatches, such as experimentation and planning on a small finding and observing older boys rather than the scale, the program will be extended to three younger girls the program intended to reach. provinces in the country. Session 4 Adolescent Refugees and Internally Displaced Persons 15

Summary of Discussions The Health of Adolescent Refugees Project Most of the discussions reaffirmed the prin- ciples laid out by the presenters but gave Hally Mahler of Family Health International special attention to programs that are not described the Health of Adolescent Refugees collecting evidence and credible documenta- Project, a two-year intervention to improve the tion. As one participant said, “Programs that general and reproductive health of adolescent are not documented miss the opportunity to refugees, supported by UNFPA and the United share lessons learned with others in a Nations Refugee Agency in Egypt, Uganda, and meaningful way.” Another participant Zambia. Refugee adolescents face multiple observed that information collection is not challenges, including lack of services, necessarily a lengthy process and actually increased vulnerability to sexual violence, lan- allows a program to maintain its relevance guage and cultural barriers, and lack of posi- and flexibility so that it can quickly identify tive role models. groups that, despite good planning, are not The project established Girl Guide units in being served. refugee sites that offer a reproductive and Examples were shared of programs that general health curriculum through Girl Guides, have been evaluated at such a general level who serve as peer educators and employ a (e.g., the program is well-used) that the pro- “learning by doing” methodology. A particular- gram planners as well as their sponsors were ly innovative feature of this project is the way unclear about which parts of their efforts in which links are established to existing clini- needed strengthening and/or replication and cal services. Girl Guides peer educators act as scaling up. “consultants” to adult health providers, advis- Special attention in the discussion was ing them on how to make the mix and inter- given to youth participation. Existing data personal dimensions of health services more should be supplemented by interviews with adolescent-friendly. Health providers work young people in focus groups selected by age, with Girl Guide groups, teaching sections on gender, marital status, and so forth. Such reproductive health, serving as technical back- information can only enhance programs and up to the peer educators, and gaining expo- help to avoid miscalculated strategies and sure to young people and their health needs. mismatches. The project evaluation emphasized a vari- ety of informational and social objectives. The Session 4—Adolescent Refugees assessment revealed that participant refugee and Internally Displaced Persons girls (both Girl Guides and the girls they reach) in Emergency Situations retained accurate information, and the Girl Guides themselves increased their self-confi- This session, chaired by Mercedes Borrero, dence, developed a sense of group identity, Assistant Representative, UNFPA Colombia, enjoyed a sense of fun away from the stress of reviewed evidence-based examples from everyday life, and, most importantly, developed Egypt, Kosovo, Sierra Leone, Tanzania, a relationship with a mentoring, caring adult Uganda, and Zambia of sexual and reproduc- female. In effect, the project created a tive health programs developed for adoles- “space” for refugee girls heretofore lacking. cent refugees and internally displaced per- Future programming attention will be sons in emergency situations. given to ensuring that as many materials as 16 Adolescent and Youth Sexual and Reproductive Health

possible are available in local languages and females (17 percent) than males (8 percent)— that they are adapted for use with illiterate pointing to the need for distinct strategies for adolescent boys and girls. While girls will reaching boys and girls. It was also clear that remain a primary focus of the project, a strat- information and behavior were not necessarily egy for boys will be developed, as they also linked, as those with HIV/AIDS knowledge did need information on sexual and reproductive not necessarily practice safe behaviors. health and positive adult male role models. Ms. Jones and colleagues affirmed the value of including adolescents in early stages Reproductive Health Knowledge, of study design, involving them in generating Attitudes, and Practices Survey of questions at every stage, and finding new and Refugee Adolescents in the Kigoma better ways to monitor gender balance Region of Tanzania: Findings and throughout the process. Lessons Learned * Rachel Jones of the International Rescue Promoting the Protection and Committee reported findings from a cross-sec- Capacity of Adolescent Refugees in † tional knowledge, attitudes, and practices sur- Kosovo, Sierra Leone, and Uganda vey conducted among refugee adolescents in Allison Pillsbury of the Women’s Commission the Kigoma region of Tanzania, funded by the for Refugee Women and Children described Women’s Commission for Refugee Women and participatory adolescent research projects Children. The survey was carried out by 100 undertaken in Kosovo, Sierra Leone, and community health workers, many of whom were Uganda that work with adolescents in a holistic refugees themselves, who received two days of manner, ensuring that the many dimensions of training to administer the interview in village adolescent life are represented. An initial settings. A sample of 1,500 adolescents was review of programs and policies relating to interviewed through random selection of 25 per- war-affected adolescents was conducted cent of the village, and within those villages 7 across five sectors of adolescent life: educa- percent of the households participated. The tion, livelihoods, health, psychosocial dimen- team interviewed one boy and one girl in each sions, and protection. That research, published household. The youngest adolescents (ages in “Untapped potential: Adolescents affected 10–13) were least well-represented (and most by armed conflict,” a report published by the difficult to find and interview), and the sample commission, found that adolescents in war- contained more male than female adolescents. affected areas are more likely to be recruited The mean age of respondents was 16 years. into armed conflict, suffer sexual violence and There were significant differences related health problems, be exposed to between adolescent boys and girls regarding HIV/AIDS and STIs as a result of coercion or knowledge of and education in reproductive economic disadvantage, be required to work health, family planning, and HIV. Only 13 per- for pay and therefore run the risk of exploita- cent of unmarried adolescents surveyed had tion, and miss out on educational opportunities. heard of reproductive health or family plan- The commission trained a diverse group ning, but awareness was greater among of war-affected adolescents to serve as

* Rachel Jones credits Sandra Krause, Naomi Nyitambe, Millicent Obaso, Margaret Mukabana, and Michelle Thompson as collaborators. † Allison Pillsbury credits Jane Lowicki of the Women’s Commission for Refugee Women and Children as a collaborator. Session 5 Strategic Value of Education 17

researchers under the guidance of adult Gulu Youth for Action, a youth group research advisors and in collaboration with founded by Ms. Openy and other researchers youth coordination groups. The research following their participation in the Women’s sought to answer the question, “What are Commission project, faces challenges in imple- the main problems for adolescents in our menting its program plans, which include fully country today, and what are some solu- involving girls in programming, getting parents tions?” Their work underscored the impor- to allow their girls to participate, and finding tance of giving attention to gender and the sufficient personnel and funding resources. diversity of adolescent needs. It also made clear that solutions to problems in one sec- Summary of Discussions tor could not be attained without work in the The discussion was brief as time was short other sectors. but there was great enthusiasm for the sys- Training refugee adolescents in research is tematic and participatory way in which the time-intensive and requires ongoing advocacy research and action programs described were with program planners and funders to ensure carried out. The issue that received the most their commitment to follow up the research attention was the need for agencies to be with appropriate implementation plans. Funding comfortable with research, willing to fund for research and project implementation ideally research, or willing, by their program cycles, should be received and planned in tandem to to allow for a diagnostic phase on which to assure implementation of research findings. base implementation plans. Discussion also Ms. Pillsbury acknowledged that data collection included comments on the need for improved efforts are most fruitful when they can report indicators to monitor and evaluate gender bal- specific information about the needs of differ- ance in adolescent initiatives. ent age and gender groups. Session 5—The Strategic Precious Resources: Adolescents in Value of Education the Reconstruction of Sierra Leone Akello Betty Openy, an adolescent researcher Importance of Investment in Early and activist, described the project carried out and High-Quality Schooling of Girls by the commission in the Gulu district of This session, chaired by Shanti Conly, Senior northern Uganda. She and her peers inter- Technical Advisor for Youth Reproductive viewed over 2,000 adolescents and adults in Health, USAID, focused on the broadest policy northern Uganda and generated several sug- arguments for increased investment in school- gestions, such as including information on sex- ing; the influence, direct or indirect, of school- ual and reproductive health and HIV in the ing experience on reproductive health; the school curriculum, improving access to infor- features of successful in-school and out-of- mation and emergency support through formal school programs; and family-life education and nonformal education, and increasing both in and out of the school setting. social and psychosocial services for adoles- Cynthia Lloyd of the Population Council cents. Empowering girls through education opened the session by highlighting new per- and skills training was seen as a key strategy spectives on schooling for girls based on to assist them in avoiding sexual abuse and recent Council research. Lloyd looked at four exploitation based on their economic vulnera- factors associated with promoting the school- bility as refugees. ing of girls: the social and economic benefits 18 Adolescent and Youth Sexual and Reproductive Health

of investing in girls, the decision to enroll, the school, there is some concern about the quali- decision to drop out, and policies to promote ty of instruction in schools with these policies. girls’ schooling. Factors such as nutritional status, distance to There are tangible social and economic school, school fees, and domestic responsibil- benefits to investing in girls. Summarizing ities have been cited in research on delayed the work of T. Paul Schultz, the highest eco- enrollment. nomic rate of returns to investments in basic Examples of research on factors affect- schooling comes from investing in those who ing dropout were drawn from research in have the least schooling (girls), rather than Egypt and Kenya. Data from Egypt found that raising the level of education of those who dropout rates for girls in preparatory school have more (boys). Schultz’s work also indi- were six times greater for those attending cates that differential social externalities are double-shift schools than for those attending potentially affected by investments in girls’ single-shift schools. In Kenya, girls were sig- education, such as improved child survival, nificantly less likely to drop out when teach- better child health, greater children’s school- ers took their academic abilities seriously (as ing, and lower fertility. Lloyd then examined measured by teachers’ viewing math skills as the decision to enroll in three key domains: important for girls). The Kenya data also led proximity to schools (especially in places the Council to question conventional wisdom where there are concerns about girls being about the effect of pregnancy on school away from home), parental concerns about dropout rates. Among girls who left school, school quality, and the timing of school entry. only 1 percent said that pregnancy was the Looking at data from Pakistan on the role of cause. Furthermore, girls attending schools proximity, in cases where a school was pres- with a more gender-neutral atmosphere were ent in the village, girls were more likely to less likely to engage in premarital sex. Taken attend (35 percent not in school versus 52 together, the evidence from Kenya raises percent in school). The importance of school interesting questions about cause and effect: quality (which was measured by a teacher’s Do schools that foster a protective environ- residence within the village) was also found ment for girls encourage a delay in sex, mak- to have a significant impact on schooling for ing pregnancy an unlikely cause of school girls (40 percent of girls attended school dropout? Further research should be done to when the teacher resided outside of the vil- investigate the relationship of gender treat- lage versus 75 percent who attended when ment and pregnancy to school dropout. Dr. the teacher resided within the village). In Lloyd recommended several policy strategies Pakistan, teachers who are women have to promote schooling for girls: more difficulty traveling, therefore those who • subsidies to parents to encourage resided within the village were more likely to them to send their girls to school provide high-quality instruction. are likely to increase enrollment The US literature demonstrates that rates, provided legislators also young people learn better and achieve more ensure a high quality of education in years of schooling when they begin their edu- the schools themselves; cation early, and classes consisting of young people in one age group are easier to teach. • infrastructural investments; and Although flexible policies on school starting • gender training for teachers. age do allow more young people to attend Session 5 Strategic Value of Education 19

Sexual and Reproductive Health number of hours in which to provide sexuality Education: The Experience of education and “pulled topics” from the curricu- UNFPA in Mongolia lum. Only 4.5 hours per year were allotted by Lkhagvasurengiin Oyun, a health educator on the government to teach sexual education, a far leave from the National Health Development from adequate amount of time, while experts Center at the Ministry of Health in Mongolia, recommend more hours. In addition to the low spoke on the experience of creating sexual and number of mandated hours, the Ministry of reproductive health education programs in Education gave school instructors the choice to schools in Mongolia.* Dr. Oyun shared three teach the following topics: sexual harassment, strengths and two challenges of the UNFPA- child abuse, decisionmaking (including sexual supported program in Mongolia. Among its decisionmaking), domestic violence, human sex- strengths, the program is implemented nation- ual response, and the responsibilities of each ally by the government, which has mandated partner in a relationship. Although teachers that sexual education be taught to every received training on these topics, they were not enrolled child in grades 3–10 in all schools. It mandated to teach them in their classrooms. In took a great deal of advocacy work on the part response to the positive response by students, of UNFPA and early program leaders within the teachers, and parents, however, the govern- Ministry of Health (with support from col- ment is expected to increase the number of leagues within Margaret Sanger Center hours of required sexuality instruction after a International) to achieve this policy. Meetings planned review in 2003. were held with the ministers of Education, Health, and Finance to gain their support and Life Skills for Out-of-School Girls plan the curriculum. Second, UNFPA encour- Noor Mohammad of UNFPA Bangladesh made aged investment in local capacity building as a presentation on life-skills training for out-of- well as a locally developed curriculum. school married girls. Life-skills training Technical advice was provided by Margaret enables individuals to develop positive skills in Sanger Center International. The curriculum order to deal effectively with the demands and developed considered age-specific develop- challenges of everyday life. mental issues. For example, students learned According to the DHS fact sheets on about their bodies from early ages, and by Bangladesh, 88 percent of adolescents live in grades 9–10 they received instruction on sexu- rural areas, and 70 percent of girls ages 15–19 al relationships, self-respect, and communica- do not go to school. The literacy and education tion, including safer sex and condom use. levels for this group are among the lowest in The overarching goal of the program was the Asian region, and reflect tremendous gen- comprehensive sexuality education. In keeping der disparities. Overall, 50 percent of adoles- with this goal, the curriculum addressed gender cents ages 10–19 are illiterate. The mean age inequality as well as other sexuality-related of marriage for girls is 18 years while for boys topics, another strength of the program. During it is 27, reflecting an average spousal age dif- its implementation, however, the program ference of 9 years. Alarming new trends in encountered two major challenges: a limited adolescent health include an increase in pre-

* The Mongolian sexual and reproductive health education project supported by UNFPA was featured in the most recent issue (no. 12) of Quality/Calidad/Qualité published by the Population Council. The introduction to the issue was co-authored by Delia Barcelona and Laura Laski of UNFPA. To obtain a copy, e-mail Michelle Skaer at [email protected]. 20 Adolescent and Youth Sexual and Reproductive Health

marital sex, a rise in the proportion of teenage so they formed partnerships with local gate- mothers, and an increasing number of adoles- keepers to overcome this barrier. The commu- cent girls in the labor market. The life-skills nity was sensitized to the rights of these girls training project was aimed at out-of-school and their capacities, and special efforts were married adolescent girls, one of the most vul- made to reach husbands, parents, teachers, nerable populations in Bangladesh. and community and religious leaders. By influ- The project had two objectives: to encing the environment in addition to influenc- increase awareness and understanding of ing the girls themselves, it has been possible adolescent girls’ reproductive health needs to build more support for the reproductive among themselves and those around them; health of married adolescent girls. and to develop and disseminate knowledge, The numbers of community members who create innovative approaches, and increase support the project are increasing. Further- institutional capacity to implement program more, UNFPA anticipates that the adolescent interventions appropriate to adolescent girls. groups—two groups in each upazilla (the sub- The project was implemented in partner- district level) consisting of at least 30 mem- ship with the Department of Youth bers in each—will become change agents for Development under the Ministry of Youth and the society. Sports. Working at the grassroots level with local youth centers, the program developed Summary of Discussions local capacity in adolescent reproductive The discussions emphasized that investments health by providing training to peer leaders in girls’ education effect other important within the centers. These peer leaders, in changes in addition to benefits for girls, turn, reached out to married adolescent girls, including improved child survival, better forming support groups and teaching them child health, greater investments in children’s about adolescent reproductive health. schooling and the next generation, and Through the support groups, the project intro- lower fertility. duced married adolescents to health service Participants observed that any number of providers to facilitate accessibility to health incentives seemed to work, ranging from sub- services. The Department of Youth sidies to parents for girls’ schooling to infra- Development also sponsored skills training at structural investments, such as building dormi- the youth centers; married adolescent girls tories for girls that would ensure a separate received priority for this training and also and safe space for them. The discussion opportunities to participate in loan schemes. returned several times to the importance of After acquiring a particular set of skills (e.g., gender training for teachers, as there is sewing, poultry raising, block-batik) girls increasing evidence that in some places teach- could apply for loans of up to Tk25,000 ers are not only insensitive to gender issues (approximately US$500) to undertake an but may actually harass girls themselves. income-generating project. The discussion of the project for out-of- The idea that married adolescent girls school married adolescent girls touched on should have access to new opportunities did two subjects important to the workshop over- not meet with immediate acceptance. Thus, all. The first was the importance of developing advocacy was an important ingredient at all strong community support for out-of-school levels. Project workers found that it was diffi- initiatives in general and especially with cult to gain access to married adolescent girls, regard to socially isolated groups such as Session 6 Meeting the Distinctive Needs of Adolescent Girls and Boys 21

married adolescents. The process used to parallel efforts to offer boys different views of increase the schooling opportunities for mar- what it means to be a man and without under- ried adolescents, in this case, paralleled a taking policy and program initiatives that finding discussed later in the workshop encourage young men to function as support- regarding the importance of understanding ive partners and peers. that married adolescent girls are more isolat- ed and often far more disadvantaged than Increasing Girls’ Mobility and their unmarried counterparts. Social Empowerment As schools often are not supportive of Martha Brady of the Population Council pre- girls, participants discussed steps that could be sented information on an intervention taken to make schools safer and more sup- research project aimed at creating safe portive. Participants from the Population spaces for adolescent girls that is being pilot- Council mentioned that they are working with ed in upper Egypt. This initiative is emblematic the Ministry of Education in Kenya to design of a broader “Safe Spaces” effort that the and evaluate a teacher-training program that Council and partner organizations are foster- will make both male and female teachers more ing. The Safe Spaces concept emphasizes the aware of girls’ needs and the often negatively need to create spaces for girls where they: gendered environment of schools. • can find a supportive peer network The second generation of adolescent pro- (girls’ peer networks often shrink at gramming must focus on building programs puberty and in general are much that consider the distinctive needs of boys and smaller than those of boys); girls, incorporating gender issues into life- skills education and encouraging behavior • can find adult female mentors, apart change. Clearly, providing information alone to from teachers and mothers, who can adolescents—as valuable as it is—does not provide them with a sense of con- automatically change their choices. nectedness and serve as positive role models; Session 6—Meeting the • are given the opportunity to acquire Distinctive Needs of new and valued skills (including func- Adolescent Girls and Boys tional literacy), participate in team sports and have leadership roles, This two-part session, chaired by George acquire rudimentary economic Brown, Associate Director of Health Equity at knowledge, and find support for the Rockefeller Foundation, discussed the future livelihood efforts; and challenges of creating safe, supportive spaces • can freely discuss sensitive subjects for boys and girls. Girls often have, relative to such as harmful traditional practices, boys, few or no spaces of their own. Boys, on male/female relationships, and sexu- the other hand, may have their own spaces, al and reproductive health. but these spaces might not be safe in the sense that they expose boys to social content The Egyptian project—called Ishraq or gender norms that do not promote respect (which means “enlightenment”)—has been and equality. In chairing the session, Dr. mounted in partnership with the Egyptian min- Brown observed that we can’t improve girls’ istries of Education and Youth and Sports and social, economic, and health choices, including NGO partners Save the Children, the Centre their reproductive health outcomes, without for Development and Population Activities, and 22 Adolescent and Youth Sexual and Reproductive Health

CARITAS. The project is being carried out in the project will track its effectiveness. Of Minya, a traditional governorate in Upper interest will be improvements in girls’ safe Egypt where girls’ schooling opportunities are mobility, time use (reductions in their unfair limited and early marriage is endemic. workload at home), attitudes toward mar- Ishraq is aimed at out-of-school girls riage, relationships with family members and ages 13–15. It offers them opportunities to peers, sense of self-efficacy and self-expres- “learn, play, and grow,” with the longer-term sion, and the evolving attitudes of parents and objective of enhancing their ability to partici- boys toward girls’ exercise of rights and pate in key decisions regarding their future capacities. The project is oversubscribed— productive and reproductive lives. In the diag- that is, more girls would like to participate nostic phase of the project, existing quantita- than can be accommodated—which indicates tive data, a new survey, and some qualitative a high level of community acceptance. data were compiled to paint a picture of girls’ However, the project promoters have learned time use, workloads, social activities, and that there are many issues that require con- aspirations and expectations, as well as the tinued attention and monitoring. For example, perspectives of their parents, boys, and other some parents need to be persuaded of the gatekeepers regarding activities appropriate utility of the project, and they need to be to adolescent girls. Of particular importance assured that the safety and dignity of their was documentation of girls’ social networks daughters will be protected. In addition, early and mobility patterns. For example, data were engagement is a problem; project staff have collected on acceptable places for girls to go, been working with parents and future hus- how girls move within the community, circum- bands to convince them to permit engaged stances that hinder the mobility of married girls to continue participating in the project. and unmarried girls, and existing community Creating a space for girls means paying norms regarding girls’ opportunities. close attention to the social, familial, and The intervention offers girls—in cohorts logistical factors that can impede girls’ partici- of up to 50 in three villages—training in liter- pation, for example, choosing an appropriate acy and numeracy, opportunities to engage in time of day for project activities, ensuring safe sports and other physical activities, cultural and secure transportation to and from home in awareness, opportunities for community serv- order to protect girls’ reputations, and engag- ice, and training in basic economic and prob- ing gatekeepers and parents early to win lem-solving skills. Keeping girls engaged approval and community acceptance. Key requires ongoing relationships with parents strategies have remained flexible and have and community gatekeepers. In addition, the been designed to enhance girls’ participation. attitudes and behaviors of brothers are being Seydou Doumbia, Country Director for the examined to determine why public harass- Population Council in Mali, reported on the ment of girls is so prevalent so that future findings of a collaborative study undertaken by interventions can be designed for boys who, the Ministry of Youth and Sports and UNFPA to while protective of their own sisters, often learn more about the lives of adolescent girls create discomfort for girls (i.e, other boys’ in Bamako and the implementation of the min- sisters) in public places. istry’s national youth policy. In Mali, as in Using a research and evaluation strategy many other countries, girls are not formally that employs a baseline process documenta- barred from participating in sports activities, tion, monitoring evaluation, and a post-test, although levels of girls’ and boys’ sports par- Session 6 Meeting the Distinctive Needs of Adolescent Girls and Boys 23

ticipation differ widely. With UNFPA support Based on the findings of the study, the and technical assistance from the Population Ministry of Youth and Sports is developing a Council, the ministry diagnosed obstacles to strategy to enhance girls’ participation in girls’ participation. The study was also ministry-sponsored activities. Special efforts designed to generate a base of information on are being made to address the location of attitudes regarding gender, suitable age for program activities, recruit females to lead marriage, disparities in educational experience activities, and reconsider the scheduling of and attainment, work, social networks, mobili- events to accommodate girls. ty, sports participation, and reproductive health knowledge. Engaging Boys: Knowing Their Needs, The study found that both boys and girls Changing Their Norms, and must seek parental permission to go out, but Supporting Safe and Positive Sexual that boys got permission much more easily and Reproductive Health Behavior than did girls. Further, girls’ mobility tended to Gary Barker of Instituto Promundo in Brazil be closely linked to domestic responsibilities— made a presentation on how to reduce the that is, they were able to go places when their dichotomy between boys’ and girls’ worlds. He families wanted them to, but, for example, they suggested it was possible, at least in the did not frequent youth centers. Approximately Brazilian context, to bring them together while 40 percent of girls reported being harassed addressing gender issues and sexual and often (harassment was defined on a continuum reproductive health concerns. Adolescent boys of behaviors including being yelled at or heck- should be targeted with sexual and reproduc- led by boys and men while in the streets). tive health programming for the following rea- When boys were queried about their behavior, sons: boys have their own needs; they are they stated that they harassed girls because often open and eager to discuss their sexual they thought it was “funny.” Boys also said relationships; and, crucially, because gender they heckled girls because girls should not be roles are rehearsed during adolescence, work- in the street, they were wearing provocative ing with boys is also good for girls. clothing, or they liked to be teased. Boys are much more likely to be found The finding from this study that affirmed outside the home than are girls, making it the need for creating spaces for girls was easy to engage them in programs. Adolescent boys had a much higher level of social affilia- boys are a diverse group; for programming tion than girls. Only 27 percent of girls purposes it is important to consider whether belonged to a group versus 62 percent of they are married, unmarried, in school, out of boys. Only 31 percent of girls (versus 88 per- school, and whether their sex partners are cent of boys) had been involved in a sports female or other young men (between 1 and activity in the preceding week. Both boys and 16 percent of young men in various contexts girls reported working for pay, with boys around the world admit they have had sexual employed mainly in small trade and girls work- experiences with other men). Despite the ing to provide childcare in the household or internal heterogeneity of boys’ sexual worlds, involved in small trade or food production. they share similarities that distinguish them Interestingly, in Mali girls tend to be remuner- from adolescent girls. In most regions, boys ated for their work more often than boys, engage in sexual activity at a younger age because boys are usually in apprenticeships than girls. They are as or more frequently during this period of their lives. misinformed about issues of sexual and 24 Adolescent and Youth Sexual and Reproductive Health

reproductive health than girls, yet they find it services as essentially designed for and rele- difficult to admit their lack of knowledge. vant to females. In Argentina, sex education HIV/AIDS prevention campaigns can increase and family-life education are not provided condom use among boys, but this use is incon- through the schools, so most adolescents dis- sistent, owing to lack of communication with cuss sexual matters with peers who may or partners and gender scripts that have tended may not have accurate information. to stigmatize condom use for both males and Perceptions of acceptable sexual behaviors females. Adolescent fathers (a phenomenon for adolescent boys and girls in Argentina that is rare worldwide but common in the vary dramatically. Males are expected to dom- Western hemisphere) may face social pressure inate females and be the sexual decisionmak- to leave school and find work. In addition, ers, while females are expected to be pas- young men, like young women, are ill-prepared sive, which is considered a measure of their for parenthood, and boys who are fathers need femininity. The active expression of virility special support and skills. Finally, connecting through sexual intercourse is thought to be a boys to health services is a challenge as boys key component of masculinity, and young men tend to view reproductive health as a female are under substantial pressure to initiate sex- concern and clinics as “female spaces.” ual behaviors early. Adolescent girls, on the While programming for adolescent boys other hand, are encouraged to preserve their can address specific needs, long-term change virginity until marriage. Getting clear informa- will require altering gender norms—including tion from girls and boys can prove quite diffi- the male sense of entitlement, the acceptance cult as adolescent boys tend to exaggerate of violence against sexual partners, and the number of their sexual partners, while homophobia, which leads some boys to exag- girls often understate their sexual experience. gerate their masculinity in negative ways Opening the door for exchange of infor- (e.g., machismo, use of force in sexual rela- mation is encumbered by fear and ignorance. tionships, and unwillingness to participate in So that they can appear masculine, boys may nurturing, childcare, and domestic activities). be reluctant to ask questions regarding their Socially, boys are often lonely and isolat- sexuality. Program methods that allow for ed. Efforts to reach them are usually welcomed “anonymous” questions to be submitted may and can enable them to function as allies in be helpful in this regard. In spite of these pursuit of girls’ and women’s reproductive challenges, Ms. Correa observed that young health, as well as primary agents of their own. people in Argentina could be engaged, were enthusiastic, and were probably the best Youth Perspectives on the Gender- sources of information for each other—that Specific Needs of Adolescents * is, peer-education programs for girls reached Cecilia Correa of the Foundation for the Study girls and programs for boys reached boys with and Investigation of Women in Argentina was accurate information in places that allowed for the final presenter and offered what she had discussion of underlying fears about sex roles learned from young people themselves about and power issues—and that peer-education their sexual and reproductive health. programs were vital. Mass media can also Much of what she said affirmed Dr. play a role by frankly confronting the underly- Barker’s perception of young males’ view of ing construction of male/female imagery.

* Cecilia Correa credits Laura Pagani and Claudio Vera as collaborators. Session 7 Safe Livelihoods for Older Adolescents 25

Summary of Discussions ment in programs that initially separate boys The discussions centered on the best ways to and girls and then bring them together at create spaces for adolescent girls that protect some key moment? Do program models or them over both the short and long term. settings exist that allow for the integration of Clearly, in highly traditional settings where boys and girls, yet still offer girls a chance to marriageability is key to girls’ survival, and express themselves in light of the power early marriage is common, any activity direct- issues that affect them? Do such programs ed at adolescent girls must protect their repu- allow boys to openly discuss the burden of tra- tations and preserve their marriageability. As ditional masculinity/virility constructs? such, interventions must have gatekeepers’ Learning more about what constitutes an and parents’ approval at the beginning appropriate, safe space for boys and girls, stages; after activities are underway, there either separately or together, is an area for may be periods when parents and gatekeep- future research. ers with conservative attitudes toward girls must be managed. For example, in the Session 7—Safe Livelihoods for Egyptian example given, program managers Older Adolescents had to have the trust of the community so that they could negotiate for the continued partici- This session, chaired by Christine Norton, pation of engaged girls in the education and Senior Adviser, Adolescent Development and sports program. Participation, UNICEF, began with observations There was much discussion of whether by Ms. Norton about the importance of liveli- youth centers—often maligned as expensive hoods in fulfilling, respecting, and protecting interventions that exclude females—can be adolescent rights to health and development. more accommodating of girls. In the Egyptian Livelihood programs generally give adoles- case, working closely with the Ministry of Youth cents the opportunity to have greater control and Sports and the Ministry of Education, over their futures while allowing them to spaces in the village that had been male-domi- attain an adequate standard of living, become nated were redefined as girls’ spaces for cer- self-motivated, and achieve mobility with the tain times of the week, and female staff and result that risky behavior is reduced. She chal- mentors were assigned to them. lenged planners of second-generation pro- There was general consensus that ado- gramming for adolescents to consider the lescent boys need attention and relevant infor- necessity of shifting the focus on work from a mation on sexual and reproductive health, and vocational to a livelihood approach in order to that the cost issues around condoms are not encourage policymakers and programmers to only social but also material—the cost of con- view work, other than hazardous work, as an doms is a barrier for otherwise motivated opportunity and not as a burden and to ensure boys (and girls) to protect themselves. that both education and work were offered as Discussion of programming for boys empha- parts of an integrated program aimed at the sized that they need positive role models (i.e., total development of adolescent girls and male mentors) and support from peers to boys. Ms. Norton also discussed the challenge encourage changed behavior without loss of posed by HIV/AIDS and the attempts by pro- self-esteem. grammers to “add on” livelihood components A lively discussion centered on when and as a means of dealing with risk reduction how to mix the sexes. Should there be invest- among young girls in particular. She pointed 26 Adolescent and Youth Sexual and Reproductive Health

out that in order to ensure the effectiveness reduce uncertainty and risk regarding income- and efficiency of programs as part of overall generation activities. Finally, belonging to a HIV/AIDS prevention efforts, program plan- credit union or a girls’ or boys’ club can ners should make certain that livelihood pro- increase control over resources. grams were evidence-based and well-targeted. The livelihood approach recognizes the fluid links between the economic and noneco- nomic aspects of adolescent lives, and the What Is the Livelihood Approach association of livelihoods with education and and Why Is It Important for reproductive health. In designing livelihood Adolescent Girls? programs, it is essential to collect and weigh Sajeda Amin of the Population Council opened information from a number of areas. What are the session with an overview of adolescent young people doing currently; how do they use livelihoods. Dr. Amin emphasized that in many their time? What are their aspirations? Is settings adolescents spend the majority of wage or nonwage employment desirable or their time in some kind of productive work. available for everyone? What are the opportu- Although adolescent girls work longer hours nity structures that affect the ability to work, than boys, they are less likely to be remuner- such as physical safety, transportation, and ated for the work they do (in some settings, the means to obtain the entry-level require- there is a similar contrast in savings—girls ments for work? are more likely to save, but have fewer safe When discussing the needs of boys and places to keep their earnings and assets). girls, and girls in particular, one must review Dr. Amin proposed a view of livelihoods impediments to access (e.g., there is a fear, consistent with her own research that oppor- expressed by girls and/or their parents, of let- tunities to work for income produce substan- ting girls travel because their safety and repu- tial noneconomic benefits, including delayed tations may be compromised). How do social marriage, improved health behaviors, structures affect girls’ access and mobility? improved bargaining power with sexual mari- What is the role of schooling? On the one tal partners, and enhanced social mobility and hand, some schooling may be necessary if self-esteem. girls are to work; on the other, if girls must Yet the word “livelihood” brings to mind attend school for seven or eight hours a day, economic outcomes only, which generally are they will be less able to engage in livelihood at the top of the list of adolescent and activities than girls in settings in which school parental concerns. However, positive economic is organized around the economic cycle of the outcomes can also mean increased human community (e.g., in agrarian communities) or capital, increased income-earning potential, lasts only three or four hours a day. reduced uncertainty regarding income flow, Dr. Amin emphasized that in many cases and increased control over resources. adolescents do engage in domestic work, Programs can influence each of these through schooling, and income generation. These activ- separate or linked interventions. Life-skills ities are not incompatible, and sometimes are training can increase human capital. Specific mutually reinforcing. Planning livelihood pro- economic activities that are well-designed and grams also requires careful consideration of supported may increase the potential to earn the diversity of the adolescent population. income. The availability of savings and credit Because no one formula will reach everyone, it opportunities in a collective setting may is critical to consider gender, age, marital sta- Session 7 Safe Livelihoods for Older Adolescents 27

tus, urban/rural residence, and ethnicity in nomic independence. The Council decided to designing a livelihood approach. In addition, work in partnership with the Self Employed the capabilities in different adolescent popula- Women’s Association (SEWA)* because of its tions must be assessed, including vocational experience in the informal sector, its goal of and technical skills, life skills, basic literacy economic empowerment, and its openness to and numeracy skills, and entrepreneurial or working with young people. Project objectives management skills. are to improve the economic and social well- Building these skills, either de novo or being of unmarried and married adolescent incrementally, requires tremendous flexibility girls; their understanding of work roles and in program design. Recognizing adolescent how participation in livelihood activities affects capacity may require a different approach self-confidence and negotiating skills; and the than recognizing adult capacity. Dr. Amin gave ability of girls to influence decisions related to special attention, for instance, to the role that marriage, childbearing, and future livelihood apprenticeships may have in traditional eco- opportunities. The project is also trying to iden- nomic structures. A young worker may not be tify effective approaches for expanding safe, compensated monetarily, but may gain impor- appropriate livelihood opportunities for adoles- tant skills and access to a market that would cent girls; enhancing the understanding of sav- otherwise be unavailable. ings, livelihood training, and group participation The program inputs necessary to support as strategies for expanding livelihood opportuni- young people can include credit, employment ties; and supporting SEWA’s research capacity. opportunities, access to productive assets A pilot project is taking place over a peri- (e.g., financial assistance to purchase a od of three years in two districts of Gujarat sewing machine), access to social assets, State. Approximately 450–900 girls will be involvement in networks (e.g., participation in covered, and groups of adolescent girls ages a credit union), and introduction to banks. In 13–19 will be formed in three phases. SEWA addition, programs may need to become more introduced the project to the community youth-friendly, and barriers to employment through village-level meetings, meetings with may need to be removed. parents, and meetings with adolescent girls. Project staff decided that only less-educated Kishori Mandal Group, SEWA Project girls from families of lower socioeconomic sta- Anjali Widge of the Population Council, India, tus should participate in the groups. The proj- made a presentation on a livelihoods project ect uses a flexible model, so that girl members in India that focuses on building livelihood can identify the types of activities they will skills and opportunities for adolescent girls. carry out. Taking an evidence-based approach, Council In general, girls participating in the proj- researchers conducted a preliminary review of ect are involved in such routine activities as adolescent livelihood programs in India before reading and contributing to Akashganga, a designing the project and identifying a partner. monthly newsletter developed by and for ado- Existing research demonstrated that adoles- lescent girls; reading Anusuya, a SEWA maga- cent Indian girls were generally socially and zine for adult women members; and participat- economically disadvantaged and continued to ing in leadership development training and lit- have limited choices because of a lack of eco- eracy training for those girls not in school.

* SEWA is a union that has almost a quarter of a million women members working in the informal sector. 28 Adolescent and Youth Sexual and Reproductive Health

Project activities also include a basic training training. The community has been involved in package of general knowledge and awareness the project from the earliest stages. Groups training, and general and adolescent health- of 20–25 adolescent girls are organized by related training; forestry and nursery training; NGO staff and meet weekly. Peer educators savings workshops; visits to places of interest provide skills training and lead group activi- and learning; milk cooperative training; and ties and discussions. The girls and NGO work- water management training. ers identify livelihood projects, select mem- The project has worked to establish a bers for credit and training, and participate in loan and scholarship fund to provide girls with a savings scheme, which begins on the first access to more formal vocational training such day of membership for each girl. The evalua- as training in computers or fashion design. In tion component of the project uses qualitative addition to their service activities, project staff and quantitative research methods. Results of intend to document the process of the pilot a baseline survey indicated that early mar- project with the goal of understanding riage was generally prevalent within the proj- whether it works, how it works, and whether ect area (mean age at marriage was 16–18 it can be replicated in other contexts. Staff years in certain areas); dowry demands were also intend to conduct an evaluation in order high and rising; the gender gap in education to understand the process of girls’ participa- at young ages was disappearing as a result of tion in the groups and the impact of the pro- incentives for girls’ schooling, yet girls gram on their lives. The research design dropped out of school early because of mar- makes use of quantitative and qualitative riage and subsequent childbirth; and girls had methodologies to describe the influence liveli- limited mobility and social networks. The proj- hood activities have on major life decisions ect has encountered challenges. For example, regarding education, work, sexuality, mar- there are limited markets for goods because riage, and childbearing. all of the project districts have extremely poor subsistence economies. Similarly, the limited Kishori Abhijan Adolescent mobility of adolescent girls and women has Girls Adventure created time and place constraints for pro- Lopita Huq of the Bangladesh Institute of gram activities (i.e., they must take place dur- Development Studies (BIDS) presented find- ing daylight in the village). The program has ings on a three-year intervention research had similar administrative constraints owing project taking place in rural Bangladesh with to the limited mobility of female teachers, adolescent girls. Several partners are which makes it difficult to get qualified teach- involved in the program including BIDS (the ers to the villages. Negotiating space within premiere social science research institute in villages and challenging traditional values Bangladesh), BRAC (Bangladesh’s largest (e.g., incorporating the topic of sexual abuse NGO working in 60,000 villages on children’s into the curriculum) have also made program- education, women’s credit, and health), the ming difficult. Dr. Huq pointed out that Centre for Mass Education in Science (CMES, because adolescents mature and their lives a relatively small local NGO specializing in change, it is difficult to isolate the impact of adolescent programming), the Ministry of the program from the impact of schooling Women’s Affairs, the Population Council, and and general developmental changes that UNICEF. Kishori Abhijan is a pilot project adolescents experience during this stage in working to combine life-skills and livelihood their lives. Session 7 Safe Livelihoods for Older Adolescents 29

The Workplace as a Venue for tant to target sexual and reproductive health Providing Sexual and Reproductive training programs to employment sites for Health Education young people. Jose Garcia Nuñez of UNFPA gave the final Summary of Discussions presentation, discussing a study of the sexual and reproductive health needs of young people There was great interest in the livelihoods dis- that took place at youth training and employ- cussion—centering first on the usefulness of ment programs in five Latin American coun- an expanded definition. Many participants tries (Bolivia, Colombia, Ecuador, Peru, and emphasized the importance of looking at liveli- Venezuela). Economic participation among hoods as a gradient of skills and the relation- young people in this age group is growing ship, particularly for adolescents, between quickly. So, too, are training and employment social, productive, and reproductive issues. programs. Because offering sexual and repro- Participants seemed especially interested ductive health information and services at the in the notion that some livelihood programs are, program sites could allow adolescents conve- in effect, expanded life-skills programs (i.e., nient access to them, a study was conducted because life-skills programs are already famil- in order to propose appropriate strategies for iar, adding a livelihoods component may meet doing so. Research methodology included with little resistance). Participants remarked on review of documents, interviews of govern- the extent to which programs had a clear eco- ment authorities, a survey of young people in nomic content and sought to offer either eco- the five countries, and eight focus groups in nomic skills or employment opportunities. They each country. The results were varied. One also recognized the importance of working with important finding was that young people’s partners outside of the health sector who had visions of the future were uncertain, however, an understanding of social and economic devel- adolescent girls had a clearer vision than opment processes as well as a track record, if boys. Traditional gender roles prevailed among possible, in specialized areas of micro-finance, adolescent boys and girls despite new oppor- savings, and employment training. tunities for employment through training. Some participants recognized the need to Communication between adults and young bring programs to where young people are people on issues of sexual and reproductive and to directly involve organizations already health was limited. The survey also showed working with them in programming. The work- that while knowledge of family planning meth- place, including training areas, may therefore ods (particularly the pill and the intrauterine offer an attractive scenario for sexual and device) was high, use of these methods was reproductive health programs. low as was the ability to acquire contraceptive Evaluating adolescent programs with methods. Dr. Nuñez shared a number of rec- livelihood content was seen as a special chal- ommendations and challenges regarding lenge. Although such activities may well be reaching adolescents in employment and train- designed to have noneconomic benefits, some ing programs. Approximately 44 percent of effort must be made to evaluate the pro- adolescents do not achieve secondary educa- grams’ contributions to livelihoods. tion. Employment facilities offer a practical Participants emphasized the importance and acceptable venue for influencing young of context-specific interventions, which means people’s acceptance of information on sexual considering the age and gender of the groups and reproductive health, therefore it is impor- whose livelihood capabilities or opportunities 30 Adolescent and Youth Sexual and Reproductive Health

are being expanded as well as their economic (excluding China) will be married as adoles- situation. In communities that have a strong cents. This number varies by country and and long tradition of community-based micro- region, for example, in Nigeria, the proportion finance and savings schemes, incorporating of women ages 25–29 who were married adolescent livelihood approaches may be more before age 18 is 55 percent; in Bangladesh, successful than in settings with less such the proportion is 79 percent. Moreover, in experience and more in-depth poverty. most countries, most sexually active girls are On the other hand, drawing on the experi- married. In 37 of the 45 countries for which ence in India, there may be many vocational DHS data are available 60 percent or more of training opportunities that adolescent livelihood sexually active adolescent girls are married. programs could link adolescents to, thereby While marriage offers social respectabili- building a social pathway between the opportu- ty, it does not ensure the safety of adolescent nity and, in this case, young women. In Uttar girls, who are unconditionally sexually avail- Pradesh, for example, a seven-week engage- able to their husbands and under pressure to ment on a broad reproductive health agenda bear children regardless of their own desires was carried out before selectively referring or needs. Choosing husbands is usually the job girls to vocational training opportunities avail- of a girl’s parents. In terms of their ability to able through NGOs and government structures. choose their husbands, the youngest brides The project also had to underwrite some of the have the least choice. For example, among social costs of girls’ participation, such as adolescent girls ages 14–15 in Egypt, only 14 transportation that protected their reputations percent chose their husbands, whereas among and safety as they traveled to work. 18–19-year-olds, 26 percent chose their hus- bands. In addition, spousal differentials in age (e.g., men’s mean age at marriage is 7.5 years Session 8—Working with Married Adolescent Girls older than that of their wives in Mali and 4.7 years older in India) exacerbate gender differ- This session, chaired by G. Ogbaselassie of ences within marriage. the UNFPA Country Support Team, Harare, Marriage itself can be a lonely and fright- Zimbabwe, examined the scope and situation ening experience for girls. Newly married of married adolescent girls, their heightened adolescent girls are often isolated and vulner- vulnerability relative to their unmarried peers, able. They are far from their familiar social and a program that has had success reaching and familial networks, often have limited young married girls. mobility, and are in a junior position in their new households. Married Adolescent Girls: Married adolescent girls face distinct and The Neglected Majority severe health risks because of the limited Nicole Haberland, Program Associate from the power they have in their sexual/marital part- Population Council’s Gender, Family, and nerships. In general they have higher levels of Development program, provided an introduc- sexual activity than their unmarried sexually tion to the issue of married adolescent girls. active peers, have little ability to leave an abu- First, the number of girls married as adoles- sive sexual/marital partner, and generally per- cents is large. A Population Council analysis of ceive themselves to be at low risk for STIs and DHS data indicated that about half of all girls HIV/AIDS. Their ability to negotiate condom currently ages 10–19 in developing countries use and to seek out health information or care Session 8 Working with Married Adolescent Girls 31

is also affected by their low status. Finally, age age at marriage through policy advise- once girls are married they are under pressure ment and programs that encourage later mar- to prove their fertility, frequently having their riage. Examples include state-level efforts first child within 14–24 months after marriage. such as in Haryana, India, where the govern- Given the danger these conditions pose to ment is providing financial incentives to delay the reproductive health of married adolescent girls’ age at marriage. girls, it is critical to implement evidence-based The second approach is to provide sexual approaches to target this vulnerable popula- and reproductive health information and serv- tion. Diagnostic research on the transition to ices, social support, and social and economic marriage and motherhood is extremely useful opportunities to engaged and married adoles- in understanding the local context and inform- cent girls—including those who are pregnant ing appropriate and effective programs for and those who are already mothers. For exam- married adolescent girls. For example, the ple, programs that involve men are a natural First Time Parents Project in India found that link. However, such programs should involve many young women return to their natal home husbands in a way that supports and empow- to deliver their first child, and that there is a ers young women—husbands’ involvement desire among some young women and their should never be mandatory and should only partners to delay their first birth. Both of occur with the expressed consent of women. these pieces of information had important Safe motherhood programs might also be prof- implications for the project, suggesting places itably reconfigured to better respond to the to reach pregnant married adolescents and needs of young, first-time mothers. highlighting opportunities for interventions. In general, married adolescent girls can Working with Married Adolescents: be reached at a number of points, with each A UNFPA Collaborative Experience requiring different program content Geeta Sodhi of KIDAVRI India provided insight emphases. For example, the following people based on her experiences with the reproduc- could be targeted in the marriage-to-parent- tive and sexual health program of Swaasthya, hood continuum: an NGO based in an urban resettlement colony • engaged adolescent girls or couples; in Delhi, India. The community-based program • newly married adolescent girls (with includes clinical services; information, educa- or without their husbands); tion, and communication services; social sup- • married adolescent girls pregnant port mechanisms; community-based social for the first time (with or without marketing strategies; skill-building programs; their husbands); and projects that provide access to economic • new young mothers and their hus- resources in the form of micro-credit for mar- bands; and ried (and, more recently, unmarried) women. To inform the development of activities • family members of married adoles- for adolescent girls, Swaasthya undertook a cent girls (including mothers, moth- needs assessment that revealed that adoles- ers-in-law, co-wives, and other cent girls were vulnerable to negative out- senior female family members). comes of sexual activity, namely pregnancy, Ms. Haberland described two primary infections, and sexual coercion and exploita- programming approaches for working with tion. A lack of information, skills, and social this population. The first is to delay girls’ aver- support contributed to their vulnerability. 32 Adolescent and Youth Sexual and Reproductive Health

Based on the findings, a set of evidence- include a strong preparatory phase to com- based interventions targeted to adolescent plete the needs assessment, advocacy activi- girls was introduced to Swaasthya’s ongoing ties with gatekeepers, and identification of community-based program. Adolescent girls pre-existing resources. now participate in girl groups; receive infor- mation and engage in discussions on topics Learning About Married such as health, rights, and adolescent con- Adolescents in Senegal cerns; build skills in decisionmaking, problem- Carey Meyers presented results from a solving, communication, negotiation, relation- Population Council study of married adoles- ships, and boundaries; and learn about sexu- cent girls in Senegal. Findings from the 1997 ality and how to prevent sexual abuse. Senegal DHS reflect the special needs of this While none of the interventions was con- population of adolescent girls. Over half of ceived or designed specifically for married Senegalese women ages 20–24 are married adolescent girls, they are among the benefi- by age 20, and 91 percent of adolescent girls ciaries of Swaasthya’s adolescent program ages 15–19 who are sexually active are mar- and among the beneficiaries of its programs ried. In addition, 54 percent of 15–19-year- for women. Married girls are accessing clini- old girls have ever had a child and 64 percent cal services for antenatal care, treatment for of 15–19-year-olds who have ever been mar- reproductive tract infections, fertility regula- ried have been pregnant at least once. With tion, and general health care. They are partici- these data in mind, and with the hope of pating in peer group discussions on health, developing appropriate strategies for a pilot legal rights, and social issues. They are also intervention for this population, the Council accessing micro-credit programs to prepare sought to learn more about the lives of mar- for delivery and motherhood. Finally, married ried adolescent girls, and how they differed girls are getting support for dealing with from those of unmarried girls. (Data on domestic violence and are accessing home- unmarried girls had been collected previously based social marketing outlets for condoms for another Council project.) Using qualitative and sanitary napkins. methods, researchers conducted 187 in- An evaluation of the scope of married depth interviews and recruited 64 partici- girls’ participation in the program and the pants for focus groups among 13–19-year-old effects of the interventions on them has yet to married girls in St. Louis and Louga, semiur- be conducted. However, anecdotal evidence ban centers in Senegal. The Council also suggests noteworthy positive influences. interviewed husbands (in 39 in-depth inter- Perhaps one of the most striking effects of views and 23 focus groups) in order to cap- the program is the effect it has had on moth- ture their perspectives on the situation of ers-in-law, who have started to support their married adolescent girls. daughters-in-law by, for example, encouraging The findings revealed stark differences in them to access services and supporting their the experiences of married and unmarried participation in group activities. The positive girls. Most respondents did not know the age support of mothers-in-law even extends to of their spouse; those who did reported siz- gender violence. Mothers-in-law have begun able age differences. Overall, 46 percent of reporting abuse of their daughters-in-law by married girls had one or more children, nearly their sons to paralegal workers. Important 70 percent had no direct source of income, strategies that have guided the program about 20 percent engaged in small trade, and Session 8 Working with Married Adolescent Girls 33

only 6 percent were allowed to stay in school. peer educators; involving husbands, mothers, The vast majority of married adolescent girls and mothers-in-law; making youth-friendly did not choose their husbands, rather, their services more friendly, particularly in the area parents did. Most were informed of the mar- of safe motherhood programming; and provid- riage at the last moment, some not until the ing married adolescent girls with access to day of the event. After marriage, the lives of livelihood interventions. adolescent girls underwent great change. They were no longer free to choose friends, attend Summary of Discussions school, or go out unless they received permis- There are different proportions of married sion from one of the female members of the versus unmarried sexually active girls in dif- household or were in the company of their ferent regions. For example, in Latin America, husbands. Girls expressed the opinion that married adolescents are less of a priority they were more mature because they were compared to those who are unmarried, where- married. While they appreciated the affection as in West Africa the opposite is true. The pro- of their husbands and reported that they file and situation of adolescent girls in various enjoyed sex, they disliked the subservient role regions, countries, and within countries must they played in the marriage and the curtail- be carefully considered so that program plan- ment of their freedom. In terms of reproduc- ners are clear on whom programs are reach- tive health, most girls wanted to delay child- ing and how. Participants discussed different bearing for 2–3 years, and some reported dys- program approaches for reaching married menorrhea and suspected infections. The girls girls. Swaasthya, for example, has not target- described their husbands as their primary ed married girls explicitly but feels it is meet- source of reproductive health information, ing their needs. Key participants noted that if a with their mothers-in-law as secondary separate program is not initiated, sensitizing sources. Girls cited shame, distance, provider staff and adjusting program content to consid- attitudes, and inability to pay as reasons for er the special needs of married adolescents not seeking clinical services. In terms of their and first-time mothers is critical. economic situation, the majority of the girls A participant noted that adolescents reported that their husbands were their only experience higher levels of morbidity and mor- source of income. After a great deal of prob- tality during pregnancy and labor in the form ing, married adolescent girls suggested partic- of severe anemia, pregnancy-induced hyper- ipating in small trade or earning money as tension (including eclampsia), and obstructed domestic workers as ways to secure a person- labor due to cephalo-pelvic disproportion. As al income. such, adolescents should receive special ante- Ms. Meyers summarized the study’s find- natal care and should be delivered in a health ings stating that married adolescent girls dif- facility staffed by personnel trained in mid- fer from their unmarried counterparts with wifery. Adolescents should also be provided respect to school, mobility, friends, access to with counseling services during pregnancy or information, levels of sexual activity, and child- after delivery on the use of family planning bearing. Married adolescent girls require pro- methods, with emphasis on dual protection. grammatic attention because of their isolation There was debate regarding appropriate and early and often unplanned pregnancies. HIV prevention messages for married girls. Is Strategies to reach this vulnerable population it ethical to recommend remaining faithful to might include developing a cadre of married her husband as a woman’s sole method of 34 Adolescent and Youth Sexual and Reproductive Health

protection? Most participants thought not. among married and unmarried adolescent Similarly, the issue of voluntary counseling and girls in sub-Saharan Africa. After observing testing before marriage was raised. the rising HIV/AIDS prevalence rates among Participants commented that where the preva- adolescent girls ages 15–19 and noting that a lence of HIV/AIDS is high, encouraging cou- high proportion of sexual activity among ado- ples to participate in voluntary counseling and lescent girls occurs within marriage, Dr. Clark testing before marriage is important because explored the relationship between early mar- it enables individuals to learn their HIV status, riage and HIV/AIDS. Despite the common can encourage behavior change, and can help belief that sex within marriage is safer than create a solid base for a safe and satisfying sex before marriage, empirical evidence sug- married life. It is true that in the era of gests that it is necessary to question this HIV/AIDS and high levels of other STIs, the assumption and look objectively at whether consistent use of condoms should be promot- early marriage is contributing to rising rates ed for dual protection and spacing of pregnan- of HIV infection among adolescent girls. cies. However, is recommending condom use What are the relative risks of HIV for sex- within marriage a feasible strategy? There ually active married and unmarried girls? was disagreement among participants, There are surprisingly few published studies although all agreed that current messages do that compare sexually active adolescents. not take into account the special situation of Those that exist often contain biased results married girls. Others noted that it is crucial due to their sampling techniques and inclusion that husbands should also be sensitized and criteria. Focusing exclusively on sexually educated to contribute to the reduction of active girls (and omitting virgins presumed to HIV/AIDS and gender-based violence. be at minimal risk), Dr. Clark compared sexual- ly active unmarried and married adolescent Session 9—Preventing girls by analyzing DHS data from Burkina Faso, HIV/AIDS Among Adolescent Kenya, and Zambia. She started with an ana- Girls and Boys lytical framework, positing that early marriage was associated with certain sociodemographic This session, chaired by Adjoa Amana of the characteristics that led, in turn, to specific UNFPA Country Support Team, Ethiopia, sexual behaviors and HIV risk factors directly explored largely un- or underexamined evi- affecting HIV status. dence on HIV risk among subpopulations of Marital status is correlated with a series adolescents (boys versus girls and unmarried of sociodemographic characteristics, including girls versus married girls), and the program- age differences, pregnancy intentions, knowl- ming implications for the relative risks. It also edge about HIV, economic opportunities, addressed a large-scale HIV-prevention inter- mobility, access to health care, and social vention and how it has considered the varying norms about male and female sexual promis- needs of different groups of adolescents. cuity. Specifically, the characteristics of mar- ried girls that would serve to protect them Relative Risks of HIV Among included their being less likely to engage in Married and Unmarried Adolescent sex for money or gifts and to have partners Girls in Sub-Saharan Africa (i.e., their husbands) who were less likely to Shelley Clark of the University of Chicago pre- have more than one partner. In contrast, char- sented her findings on the relative risks of HIV acteristics that would serve to protect unmar- Session 9 Preventing HIV/AIDS 35

ried girls included a smaller age difference Clark found that 70–85 percent of unprotect- between their partners and them and their ed sexual activity among adolescent girls in being less likely to want to get pregnant. all three countries occurs within marriage. Unmarried girls were also more likely to know Arguably, unmarried and married adolescents a way to avoid AIDS, to have completed prima- are having sex with very different popula- ry school, to live in an urban setting, and to tions of men, but given that husbands tend to know of a source for condoms. be older than unmarried male partners, it is Dr. Clark then examined the association unclear whether HIV prevalence rates would between marital status and several proximate be higher among the partners of married or determinants of HIV infection, such as absti- unmarried girls in this age group. The study nence, frequency of intercourse, number of results strongly suggest that early marriage partners, HIV prevalence among partners, is an important factor in the HIV/AIDS risk condom use, and the biological rate of trans- equation, and that married and unmarried mission. Exploring the link between marriage adolescent girls have very different risk pro- and HIV risk factors while controlling for files for HIV/AIDS. It is therefore important sociodemographic characteristics revealed to develop appropriate messages for married important findings on the effects of early mar- adolescent girls, who still need to be consid- riage. Marriage appeared to increase adoles- ered in HIV/AIDS prevention strategies. cent girls’ risk of infection with HIV by signifi- cantly decreasing their use of condoms at last The loveLife Program: Experiences sex and increasing the likelihood of their hav- and Challenges in a “Brand” ing had sex in the last week. Yet, marriage Approach to HIV Prevention, also promoted some protective behaviors: South Africa Married adolescent girls were less likely to Angela Stewart-Buchanan of loveLife described have had multiple partners. Examining the now world-famous loveLife program, based changes in behaviors in response to concerns in South Africa. She described the HIV/AIDS about HIV/AIDS uncovered further differ- scenario in South Africa, where over 5 million ences. Married girls were less likely to have people are HIV-positive. She emphasized that made any changes in behaviors in response to the importance of moving beyond information concerns about HIV/AIDS. They were also sig- to behavior change is evident in the country, nificantly less likely to stop having sex, start where 98 percent of the adult population are using condoms, or reduce their number of aware of HIV, but only 10 percent use con- partners. Married adolescent girls, in fact, doms. HIV, tragically, is infecting younger and were more likely to have only one partner and younger people, and young women are becom- to ask that partner to be faithful. ing infected at a much higher rate than young Weighing the overall impact of the diver- men, with some of the highest rates of infec- gent HIV risk factors and protective strate- tion emerging among girls ages 15–20 and gies of married and unmarried sexually active young men ages 20–25. Twelve million South adolescents is difficult. Yet, a simple analysis Africans are under the age of 15, and they are of the patterns of unprotected heterosexual becoming sexually active just as the HIV epi- activity (the major mode of transmission in demic is peaking. Chances are that half of them sub-Saharan Africa) points toward early mar- will become HIV-positive. A number of factors riage as an important factor. Using reported contribute to why young South Africans are data on frequency of sex and condom use, Dr. having early and unprotected sex. Sex is often 36 Adolescent and Youth Sexual and Reproductive Health

coerced—39 percent of girls reported forced ics that work with government clinics to sex. Young boys experience pressure from make them more accessible to young people; peers to exert their manliness. In addition, in franchises, with 106 community-based orga- such a poor country there is much transaction- nizations that have adopted the loveLife mes- al sex, that is, the exchange of sex for goods, saging approach; outreach through two radio money, and favors. There are also high levels of broadcast units and a mobile sexual health violence against women, often in the context of education center and clinic housed in a rail- intimate relationships, which both increase and road car that travels throughout the country exploit girls’ and women’s low self-esteem. on the national rail network; the loveLife loveLife’s target population is 12–17- games, which are the largest inter-school year-old adolescents, whom the program tries sports development program in South Africa; to reach before they become sexually active. partnering with schools; and the More than an information program, loveLife is groundBREAKER program, which takes unem- a lifestyle “brand” for young South Africans ployed 18–25-year-olds off the streets and that makes use of traditional marketing tech- involves them in a supervised program of niques to promote healthy living and positive community mobilization linked to all loveLife sexuality. Its goal is to halve the rate of new programs. HIV infections, STIs, and pregnancies among loveLife’s media activities are what first 15–20-year-olds within a five-year period (i.e., brought it to public attention both in South by the end of 2005). Africa and the wider world. Advertisement loveLife uses a three-point strategy that placement is intensive and includes television, includes high-powered multimedia communica- radio, taxis, billboards, and water tanks. tion, outreach and delivery services, and Advertisements are broadcast on the radio in research. The starting point in combating HIV 11 languages and printed in newspapers and is to get people in South Africa talking more magazines. Mindful of the role of adult lead- openly about the AIDS epidemic and sexual ers’ influence on young people, the program’s behavior in general. The program endeavors to messages encourage parents to talk about sex teach adolescents how to assert the impor- with their children (“Love them enough to talk tance of setting and observing sexual limits about sex”) and have benefited from public and delaying first intercourse. For those who support from leaders such as Archbishop are sexually active, it urges delaying the next Desmond Tutu and Nelson Mandela. sexual encounter, reducing the number of sex- loveLife has carried out some evaluation ual partners, and increasing condom use. of its programs, through self-reported behav- loveLife seeks to be a positive part of ior change research among its target audience young people’s lives, and not simply an infor- of 12–17-year-olds, and has identified seg- mation campaign, such that they will internal- ments of the youth audience it reaches most ize its messages and integrate its approach effectively (e.g., by age, gender, and schooling into their everyday lives. The service-delivery and marital status). Among 62 percent of program includes free help lines, which young people who report having heard of receive more than 50,000 calls per month; loveLife, 78 percent reported that it made multipurpose recreational youth centers that them more aware of the risks of unprotected combine clinical services, computer training, sex, and 65 percent reported the program had sports and recreation (including basketball), made them delay or abstain from sex. Most and personal motivation; youth-friendly clin- encouraging is change among sexually active Session 9 Preventing HIV/AIDS 37

young people—78 percent say their interac- is a continuing debate about whether program tion with loveLife is responsible for their using staff could recommend the use of condoms condoms consistently during sex. Obviously within marriage and under what circum- self-reported behavior should be interpreted stances. Much concern was expressed about with caution, but even if the findings were actions that are ethical and feasible in situa- halved, it still suggests that fundamental tions where the partner of a married adoles- change is occurring. cent girl is HIV-positive or has had—or cur- Though expensive, the program is power- rently has—outside partners. ful, and in the context of saving lives, it can Also discussed were the best ways that be viewed as being cost-effective. The current antenatal, pregnancy care, and after-care pro- annual budget is R200 million (approximately grams could give differential attention to mar- US$23 million). In order to mount a program ried adolescent girls and ways programs could of this range and vision, many partnerships draw in partners and other family members. are required, including those with the govern- There was much enthusiasm for the ment, private foundations, and corporations loveLife program, particularly as it has reached (who donate resources and money). national scale. One participant noted that with- in South Africa, if present trends among girls Summary of Discussions currently 10–14 years old continue, within There was animated discussion about the fea- some communities as many as half might be sibility of workshop participants advocating for infected with HIV by age 19. It was thus later marriage—based both on rights/demo- emphasized that such energetic programs need graphic factors and increasing evidence that to give special attention to reaching younger marriage does not provide a safe haven from adolescents, particularly girls, with information poor reproductive health, including HIV. Much and protective strategies. attention was given to the need to understand The discussion also centered around more about possibilities for negotiation within youth centers and how loveLife continues to marriage, especially for the youngest married attract substantial numbers of both boys and women under pressure to become pregnant. girls to youth centers first by offering such There was also great concern about strategies activities as basketball and netball and access that would be safe and feasible for married or to computers, music, and entertainment and unmarried adolescent girls and how best to then giving them the opportunity to enroll in intervene with them and their partners. There sexual health courses. One Dag Hammarskjold Plaza New York, New York 10017 USA