Programming for Adolescent Reproductive Health
Involving Young People
Involving Young People: Essay Competition
Involving Young People: Africa Youth Forum
"Youth-friendly" Health Services
Advocacy, Law and Policy
Knowledge and Responsibility: Population Education
Learning What Works: Methods and Manners
The Impact of Population Education
The Importance of a Comprehensive Approach
Improving the Quality of Basic Education
Did You Know:
International Consensus On Children's Rights
The Health Risks of FGM
Combatting FGM Nationally and Globally
Stopping the Spread of Aids
Dispelling Myths in the Philippines
Male Involvement--Male Needs
Family Planning at Health Clinics
Training Youth to Train Youth and Stay in School
Youth Speak Out: UNFPA's First International Essay Contest
By Women, for Women: Comprehensive Services for Palestinian Refugees
"Youth-friendly Health Services"
Giving Chilean Youth a Forum to Discuss Their Sexuality
Advocacy in the Arab States
In-school Population Education for Russian Teens
Spreading the Word: Population Education in the Americas
Sex Education Promotes Responsible Behaviour
Senegal: Education beyond the Classroom
Educating Young Mothers: Jamaica Women's Centre
Love is on the Air: Radio Soaps in Tanzania Teach While They Entertain
Combining Forces: "PEARL" Programme Uganda
NGO Involvement in Egypt
Whenever adolescent reproductive health is discussed, a series of critical issues emerges. Should adolescents be allowed to have access to reproductive health information and services? Will formal education about reproductive health and sexuality lead to promiscuity? What forms of education are needed, and who should provide it? Should newly married couples be encouraged to postpone the first pregnancy?
While respecting social and cultural diversity, the position of the United Nations Population Fund (UNFPA) on reproductive health is unequivocal. Reproductive health is a right for everyone, including young people. When young people have access to private and confidential services, they are better able to protect themselves against sexually transmitted diseases (STDs), avoid unwanted pregnancy, care for their reproductive health and take advantage of educational and other opportunities that will affect their lifelong well-being. Some people fear that access to information and services will lead to greater sexual activity among youth, but numerous studies have found that this simply is not the case. Young people need comprehensive information and access to services. They have the right to privacy, confidentiality and respect.
When considering the programme requirements of adolescents, it is important to recognize and address the diversity of needs. Young married couples, sexually and nonsexually active teenagers, young mothers, abused adolescents, girls who have suffered female genital mutilation (FGM), as well as children in especially difficult circumstances like refugees, street children, commercial sex workers, handicapped, poor and uneducated adolescents and adolescents with an STD or HIV/AIDS all have very different needs. These diverse needs must be approached and addressed in very different ways. A comprehensive and socio-culturally appropriate approach to information and education activities and services should be provided. Knowledge as well as contraceptives and youth-friendly health services are needed to encourage healthy and responsible behaviour.
It is important to understand adolescent sexual and reproductive health in the context of the individual's overall life situation. Sexual and reproductive health is part of physical and emotional well-being. A holistic approach is essential if adolescent sexual and reproductive health needs are to be addressed successfully.
Adolescents are faced with a number of critical issues unique to their age group, such as changes in the body brought on by puberty, and the implications of teen pregnancy. In light of the importance of these matters, UNFPA approaches adolescent reproductive health in a number of ways within the parameters of its three programme areas: reproductive health; population and development strategies; and advocacy.
On the local and global scales, the Fund integrates young people's opinions into its activities from design to implementation and evaluation. Over the past three decades, UNFPA has funded the development and inclusion of population education in school curricula and programmes to reach out-ofschool youth in over 100 countries. The Fund promotes the formulation and adoption of laws and policies to support adolescent reproductive health worldwide. Clearly, there is much that UNFPA--together with young people, their families, parents, teachers, religious leaders, communities, governments, the media, as well as grassroots and other organizations--can do to expand young people's life options, so that they can develop their full potential and contribute effectively to their communities.
As we move into the next millennium, some 17.5 per cent of the estimated world population of 6.09 billion in the year 2000 will be aged 15 through 24. Today, births to teenage women account for a little over 10 per cent of all births worldwide. While the global birth rate for women under age 20 is declining, the number of adolescents worldwide is increasing, so that the total number of births to young women is growing. Moreover, fertility rates are declining more rapidly among women of other age groups, which means that births to adolescents account for an increasing proportion of overall births in many countries.
Actions taken during adolescence can affect a person's life opportunities, behavioural patterns and health. For physical, sociocultural, economic and psychological reasons, young people are typically poorly informed about how to protect themselves sexually and are thus particularly susceptible to unwanted pregnancies and sexually transmitted diseases, including HIV/AIDS.
More than half of the world's population is under age 25.
The number of people aged 10-19 was 1.1 billion in 1995.
The United Nations estimates this number to increase to 1.25 billion in the year 2010 and to 1.3 billion by 2020--a 22 per cent increase from 1995.
17 per cent of married women aged 15-19 use contraception in less developed countries.
15 million adolescent women give birth each year, mainly in developing countries.
Infant mortality rate to adolescent mothers is 1.5 times higher than to mothers aged 20-29.
Up to 4.4 million abortions to adolescent women in developing countries take place each year.
1 in 20 adolescents contracts an STD each year.
Half of all cases of HIV infection are in people under age 25.
20 per cent of adolescents are illiterate in less developed countries.
Sources: UN, "The Sex and Age Distribution of the World Population" 1994; Population Reference Bureau/Centre for Population Options, "The World's Youth 1994: A Special Focus on Reproductive Health ".
In some societies, premarital pregnancy and childbearing is culturally accepted--and even condoned--as a way for a young woman to prove her fertility. In other places, a large proportion of teenage pregnancies is unwanted, as evidenced by the fact that the abortion ratio for teenagers is high. It has been estimated that between 1 and 4.4 million adolescent women have abortions in developing countries each year.
Young single women frequently seek abortions in unsafe conditions. This is partly because they are more reluctant than adults to admit to their pregnancy at an early stage. Even where abortion is legal, unmarried adolescents often avoid seeking help from the official health care system since they do not want anyone to know they are pregnant. There is widespread misinformation among adolescents about self-induced abortions; these can be fatal.
Teenage mothers face a higher-than-average risk of maternal death than mothers in their twenties, and their children have higher levels of morbidity and mortality. Early marriage and childbearing also impede young women's educational and employment activities. This, in turn, impacts negatively overall on a country's development as a whole.
High levels of adolescent pregnancy, childbearing and unsafe abortions reflect--and result in--a lack of educational and economic opportunities. Young women and girls, particularly those who are poor, face considerable pressure to engage in sexual activity and are especially vulnerable to sexual abuse, violence and prostitution.
"Early childbearing increases the likelihood that an adolescent mother and her children end up on the streets: an estimated 100 million children around the world live and work on city streets, sometimes as prostitutes. Studies have found that approximately 800,000 girls under age 20 work as prostitutes in Thailand, 500,000 in Brazil, and 400,000 in India. " --Population Reference Bureau, 1994.
Adolescence is a time of gradual yet dramatic transition: socially, physically and psychologically. It is a "preparation period", during which the child develops into an adult. This definition is new in many societies, where the transition from child to adult was traditionally rapid, often marked by a special event with a symbolic or educational aspect.
In the past, adolescents were largely neglected in both health and family planning programmes. This is partly explained by the fact that in many societies adolescents are not considered sexual beings until marriage. Another factor in this systemic neglect is the unfounded fear that providing information and services would encourage premarital sexual activity. As a result, unmarried adolescents have been denied access to services by law or policy. And yet, young people's reproductive health needs require urgent consideration, as indicated by recent global trends.
In many countries, young people are spending more time pursuing an education, marrying later and reaching the onset of puberty at an earlier age. According to a 1995 study by the International Planned Parenthood Federation (IPPF), the majority of young people become sexually active in their teens. These trends coincide with increasing urbanization, poverty, exposure to conflicting ideas about sexual values and behaviour, and breakdown of traditional channels of information about sexuality and reproduction. As a result, adolescents are increasingly engaged in premarital sexual activity, often without the intent to reproduce, without the knowledge or means to do so safely and sometimes without the young person's free consent.
"In developed and in developing countries, adolescents initiated sexual activity at about the same age. However, pregnancy rates are 5 to 20 times higher in developing countries, because sexual and contraceptive education and services are usually absent. "
--Evert Ketting, "Planned Parenthood Challenges. Empowering Youth. " IPPF, 1995.
In addition to the new realities of the modern world, harmful traditional practices, as well as societal values and structures often directly worsen the adolescent's sexual and reproductive health, and restrict access to empowering opportunities. As a result, young people are exposed to serious risks that threaten to compromise their health, and future social and economic situation.
The health risks include too-early and unwanted pregnancy and childbirth, unsafe abortion, female genital mutilation (FGM.), and transmission of STDs, including HIV/AIDS. These risks can lead to disease, infertility and death. Social risks include rejection and lower education which generally lead to decreased life opportunities and greater likelihood of poverty.
From a national perspective, these risks are costly. There are expenditures directly associated with both child-bearing and disease, and indirect costs incurred when the full potential of the individual is not realized. Moreover, early child-bearing generally leads to higher lifetime fertility for the individual woman and to a reduction in the time-span between generations.
The rights of children (to the age of 18) are outlined in the United Nations Convention on the Rights of the Child and were reaffirmed at the World Conference on Human Rights in 1993. The 1994 International Conference on Population and Development (ICPD) Programme of Action speaks specifically of the right of adolescents to reproductive health education, information and care. In addition, the ICPD Programme of Action and the 1995 Fourth World Conference on Women (FWCW) Platform for Action deal specifically with the special needs and the rights of the girl child.
The ICPD agreed in Cairo in 1994 to "substantially reduce all adolescent pregnancies". This was further strengthened at the 1995 Fourth World Conference on Women in Beijing, which took the position that "In all actions concerning children, the best interests of the child shall be a primary consideration." Furthermore, the World Programme of Action for Youth for the Year 2000 and beyond, adopted by the General Assembly in 1995, singled out UNFPA for mention in continuing to meet the health needs, including reproductive health, of adolescents.
International support for adolescent reproductive health and adolescent rights has been reinforced by a number of initiatives supported by the United Nations. In 1989, the World Health Organization (WHO), UNFPA, and the United Nations Children's Fund (UNICEF) published a joint strategy for action for adolescent reproductive health and have since supported a number of related regional and country programmes.
Although many governments support these rights, enforceable laws are not always in place to ensure that they are guaranteed. As a result, the status of adolescent sexual and reproductive health in many countries needs to be improved.
ICPD Programme of Action. Paragraph 7.44:
"The objectives are:
(a) To address adolescent sexual and reproductive health issues, including unwanted pregnancy, unsafe abortion and sexually transmitted diseases, including HIV/AIDS, through the promotion of responsible and healthy reproductive and sexual behaviour, including voluntary abstinence, and the provision of appropriate services and counselling specifically suitable for that age group;
(b) To substantially reduce all adolescent pregnancies. "
ICPD Programme of Action. Paragraph 7.41:
"... In particular, information and services should be made available to adolescents to help them understand their sexuality and protect them from unwanted pregnancies, sexually transmitted diseases and subsequent risk of infertility. This should be combined with the education of young men to respect women's self-determination and to share responsibility with women in matters of sexuality and reproduction.... "
U.N. Convention on the Rights of the Child, Article 27: "States should recognize the right of every child to a standard of living adequate for the child's physical, mental, spiritual, moral and social development... "
World Conference on Human Rights, Vienna Declaration and Programme of Action, Part III, Chapter II, Paragraph D: "Exploitation and abuse of children should be actively combatted, including byaddressing their root causes...." and "... The World Conference urges States to repeal existing laws and regulations and remove customs and practices which discriminate against and cause harm to the girl child".
ICPD, Paragraph 7.46: "Countries, with the support of the international community, should protect and promote the rights of adolescents to reproductive health education, information and care and greatly reduce the number of adolescent pregnancies".
FWCW Platform for Action, Paragraph 97: "The human rights of women include their right to have control over and decide freely and responsibly on matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence. "
Although certain risks are associated with all sexual activity, this is particularly so for adolescents. Young people need education and economic opportunities. They also need information and services to protect their reproductive health and help them avoid abortion.
To the young mother, pregnancy can be a health risk. A young woman is usually not ready for childbirth until she is at least 18 years old. Yet approximately 15 million young women ages 15 to 19 give birth every year, accounting for more than 10 per cent of all babies born worldwide. Pregnancy is much more dangerous for teens--four times riskier than for 25 to 29 year olds. For girls ages 10 to 14, maternal mortality rates may be five times higher than for women in their early twenties, and their children are also more likely to fall sick or die in infancy.
Pregnant adolescents are at higher risk than 20 to 34-year-olds of encountering the four main causes of maternal mortality: haemorrhage; hypertensive diseases of pregnancy; infection; and abortion. These risks can be substantially decreased by measures such as access to essential obstetric care and by preventing unsafe abortion.
Biological and socio-economic factors, including physical immaturity, poverty, lack of education and lack of access to appropriate medical care, increase an adolescent's risk of pregnancy-related complications. Adequate pre-natal care and nutrition are of particular importance for young mothers.
Very often, young pregnant women face severe social problems. Many girls find themselves mothers on their own without responsible fathers for their child. Women who become mothers during their teens generally end up with less education and fewer job opportunities. This, in turn, exposes them to greater risk of poverty. In a minority of cases, this may also work the other way around: getting pregnant and being supported by a man can be a survival mechanism for a poor, uneducated woman.
The infant of a teen mother faces greater risks than a child born to a mother in her twenties. The child is more likely to be hurt during delivery or to have low birth weight In addition, when pregnancy has adversely impacted the mother's life opportunities, the child is more likely to suffer from poor nutrition, as well as late physical and cognitive development. These setbacks can lead to the child having learning problems when compared to peers.
The practice of female genital mutilation has a life long effect on the sexual and reproductive health of girls (see box). The related health risks include haemorrhage, shock, infection, chronic pelvic inflammatory disease, psychological problems, sexual dysfunction, infertility, obstructed labour and death. By removing the organs that give a woman sexual pleasure, FGM often limits a woman's sexuality to one area: reproduction. The practice is a deeply-rooted tradition in many societies and must be challenged in a multi-disciplinary approach that changes public opinion.
FGM is a violation of the basic human right to bodily integrity and it involves serious health risks. The body of the girl is mutilated in an irreversible manner at an age where the girl herself is not able to make an independent decision as to whether she wants to go through this procedure. These are the main reasons why FGM should be actively abolished. Besides the serious health risks connected to the procedure itself, FGM increases vulnerability to STDs and HIV. Transmission can occur during the mutilation if the same instrument is used on several girls. Afterwards, the wounds and the increased likelihood of tearing of the skin during sexual intercourse constitute major risks for STDs and HIV transmission.
FGM is practised in as many as 28 African countries and known or suspected to be practised in a number of developed countries by immigrants from Africa. WHO has estimated that between 85 and 1 15 million women living in the world today have been subjected to FGM and that 2 million girls under go the procedure each year.
Thanks to a recent UNFPA pilot project in eastern Uganda, the Reproductive, Educative and Community Health Programme (REACH), the number of girls and women undergoing "cutting" in the targeted district declined by 36 per cent between 1994 and 1996. REACH actively educates policy makers, health professionals, parents and adolescents on the need to abolish the practice. The programme stresses that a community's cultural values are different from its practices, and that the latter can change without compromising the former. It promotes ceremonies marking adolescents' passage to adulthood which preserve the feasting and dancing that often accompany female genital mutilation, but replace the circumcision procedure with symbolic gift-giving.
On the global level, UNFPA joined with UNICEF and WHO to adopt a joint plan to bring about a major decline in female genital mutilation in 10 years and to completely eliminate the practice within three generations. The three agencies will emphasize a multi-disciplinary approach and teamwork at the local and global levels. They will bring together governments, political and religious institutions, international organizations and funding agencies in their effort to eliminate the harmful traditional practice. Emphasizing changing public opinion, the three agencies will target audiences including the general public, medical professionals, decision makers, governments, political, religious and village leaders, traditional healers and birth attendants.
Sexually transmitted diseases, including HIV/AIDS, pose serious threats for all sexually active people, but they constitute a particular risk to adolescents due to physical, psychological and social factors.
Often, young adults do not understand how to protect themselves against sexually transmitted diseases. Because most societies frown on premarital sex, young people may be embarrassed to seek help and may be turned away if they do.
UNFPA currently supports HIV/AIDS prevention activities for youth and adolescents in 95 countries.
Increasing attention is being given to specifically addressing the reproductive health needs of young people. In the majority of the countries reporting support for HIV/AIDS prevention, UNFPA projects target adolescents either through population education activities in schools or through community based information and education activities. During 1996, several countries initiated projects involving reproductive health counselling directed to adolescents on unwanted pregnancies and the prevention of STDs, including HIV (Dominican Republic, Mali, Namibia, Nicaragua, Panama, South Africa and Uganda). An important means of reaching out to adolescents is through prevention programmes targeting scouts (Burundi, Botswana, Kenya, Mongolia, Madagascar and Senegal), youth groups (Morocco and Egypt) and holiday camps (Romania and Syria).
Evidence suggests that adolescent women constitute the sex and age group most susceptible to STDs including HIV infection. Young women are physiologically more vulnerable to STDs and also more vulnerable to coercion.
Social reasons for increased risk of STDs including HIV and unwanted pregnancy exist on different levels. Some relate directly to the situations in which adolescents are put at risk such as unequal relationships because of the low status of women, young people and the poor. Examples of this are manifold and include sexual abuse, incest and situations where the woman is not able to determine when and how to have sexual intercourse. Sexually transmitted diseases are also transmitted because of to the failure or inability to negotiate contraceptive use, promiscuous behaviour by partners, relationships involving money for sexual favours ("Sugar Daddies" or "Sugar Mommies") and full-time prostitution.
From 75 to 85 out of every 100 HIV infections are transmitted through unprotected sexual intercourse, but the virus also spreads through mother-child transmission, blood transfusion and drug use. The latter constitutes a particular danger for young people. Tobacco, alcohol and other drugs are readily available to most young people. In the modern world, these substances constitute a real danger to adolescent health in both the short and long term. Their use has been linked to high rates of STD and HIV transmission.
The Second Young Adult Fertility and Sexuality Study, implemented by the University of the Philippines Population Institute with financial assistance from UNFPA, was a nationwide study involving some 11,000 youths.
The study found that young Filipinos generally are aware of HIV/AIDS, and that most understand how HIV is transmitted and how it can be avoided. But many do not know that an infected person can remain asymptomatic for years, and there are still some who believe--mistakenly--that AIDS can be cured.
The survey revealed that although about 10 per cent of the young men interviewed had engaged in casual or commercial sex, only a small proportion used condoms.
These findings illustrate the need for education to address mistaken attitudes and help these young people realize their greatest potential.
Although the use of condoms is known to guard against the transmission of STDs, young people's psychological development often leads to risky sexual behaviour. Having unprotected sex might also be a result of adolescents being less capable of thinking through the consequences than adults. Young people have less developed "future orientations". The embarrassment of obtaining condoms may be more important than the fear of pregnancy or a future disease. Moreover, the adolescent is likely to believe in what is called the "personal myth," i.e., that "bad things will not happen to me".
Another developmental aspect that may influence the use of contraception involves the fact that adolescents are usually still influenced by the values of their parents and other adults. When a young person knows that these adults disapprove of adolescent sexual activity, then he or she may be less likely to obtain contraception beforehand since that would be admitting to the intention to do something perceived as wrong.
Another indirect social cause is the failure of societies to recognize and address all these problems in a way that will meet the needs and respect the rights of adolescents. Unmarried adolescents have often been denied access to sexual and reproductive health services including access to contraceptives. In many places, the expectation of young married couples to prove fertility has prevented them from practising family planning.
Healthy adolescent development can be undermined by factors in the social environment. These include poverty and unemployment, gender and ethnic discrimination, and the impact of social changes on familial and cultural support systems. While programming for adolescent health cannot directly focus on the inequities present in many countries, these conditions represent real constraints to improving the health and welfare of youth. The attitudes and behaviours that health programmes seek to influence often arise from other socioeconomic influences. For this reason, adolescent reproductive health programming must be integrated with all aspects of social development.
Young men and young women both require comprehensive education and services; the different needs of each group must be a factor in programme design and implementation. Gender differences and developmental stages must be addressed in programming.
Recently, male involvement and responsibility have been increasingly incorporated into sexual and reproductive health policies and programmes.
In adolescent programming, it should be natural to stress the equal and individual responsibility for safe and healthy sexual behaviour; the need for the man to respect the reproductive choices of the woman; and the shared responsibility in case of pregnancy and childbirth.
However, men are sometimes raised with very different ideas and expectations. In this regard, special attention also has to be paid to male adolescent needs and attitudes.
Young girls hospitalized for abortion complications will have a particular need for information about contraceptive use and the dangers of unsafe abortion. Pregnant adolescents have special nutritional needs and are in special need of maternity and postnatal care. Adolescents wishing to delay first sexual intercourse might be in special need of improved self-esteem and negotiating and communication skills. When dealing with street children there is a particular need to view their health risks in light of their circumstances.
The case of adolescents in refugee situations illustrates the importance of taking into consideration the special conditions of the life situation of the target group. Adolescent refugees who have lost their natural role models, i.e., peers and relatives, may be more likely to look to service providers as role models; service providers should be aware of their potential influence. The same loss may lead to an increase in risky behaviour since there is less risk in being condemned. A larger prevalence of sexual violence may also result in this situation.
Source: UNHCR: The Interagency Field Manual for Reproductive Health in Refugee Situations, 1995
In light of the complexity of issues facing adolescent reproductive health programming, it is crucial that young people be involved in all aspects of programming. They should be the subjects and not the objects of programmes. They must be involved in baseline studies of adolescent need, as well as in the planning, implementation and evaluation stages of a programme.
In Jamaica and Antigua, where family planning is offered to all individuals at health clinics, a UNFPA evaluation team found that setting aside special days or space for family planning services discouraged adolescents to make use of the services, because this system exposed what services adolescents came to the clinic to obtain.
Involving adolescents in programme planning enables programme personnel and management to understand the adolescent way of thinking, behaving and responding in the particular cultural setting.
Since 1994, UNFPA has supported the Botswana YWCA's Education Centre for Adolescent Women (ECAW), which helps teen mothers finish school, and its Peer Approach to Counselling by Teens (PACT) programme.
ECAW is a one-year study programme designed to help young mothers continue their education. It provides an integrated programme of education, counselling, and day care to prepare young women for the certification necessary to enter secondary or vocational schools.
PACT is a preventive programme that helps teens counsel each other. In each participating school, ten students and one teacher attend a one-week workshop as well as weekly meetings to help them address teenage troubles. Counsellors are trained in a variety of topics, ranging from human sexuality to problem-solving. They urge their peers to stay in school, delay having sex, and, if they are already sexually active, to get and use contraceptives to prevent unplanned pregnancy and STDs. A recent evaluation showed that PACT is ready to be introduced to schools nationwide.
To give greater voice to youth, and to assist the Fund in its work with young people, UNFPA organized an essay contest last year under the theme "Promoting Responsible Reproductive Health Behaviour: The Youth Perspective". The response was overwhelming. Thousands of young people from 112 countries sent in entries that were serious and direct. Worldwide, youth are requesting unrestricted access to education, information and services of reproductive health.
The essays made clear that young people want information on reproductive health and sexuality education, preferably from their parents. They want this information early and in a form appropriate to their psychological and physical development.
Young people want to have at their disposal --and this does not mean they will automatically use those services--family planning information and supplies to avoid early and unwanted pregnancy, and abortion, and to protect themselves from sexually transmitted diseases, including HIV/AIDS.
Another key theme that emerges from these entries is an abhorrence of sex discrimination. The writers accurately point out that sex discrimination begins at the moment of birth in many cultures, where the family rejoices over the birth of a boy, but not if the baby is a girl. They also want everyone, particularly girls, to have access to basic education. They firmly condemn all forms of sexual abuse and exploitation, particularly that of young women.
The essay contest was held as part of the momentum for the World Youth Forum, held in Vienna in November 1996. More than 300 representatives of young people' s nongovernmental organizations (NGOs) attended the Forum. Its focus was on how nongovernmental organizations can best work with the United Nations to implement the World Programme of Action for Youth. In conjunction with UNFPA, many youth and youth-related NGOs also helped organize the essay contest. Other large organizations such as national chapters of the World Young Women's Christian Association, the World Association of Girl Guides and Girl Scouts and the World Organization of the Scout Movement participated. Medical students and young Rotarians also helped organize the contest. In addition, there were numerous entries from religious groups, arranged through the Geneva-based World Council of Churches.
Many countries organized nationwide contests. There were 3,000 entries from South Africa alone. The contest in El Salvador became a community event, with participation of not only the young people, but also their parents and teachers.
More than 500 delegates from throughout subSaharan Africa attended the historic African Forum on Adolescent Reproductive Health, convened in Ethiopia in January 1997 by the Fund's Africa Division. The Forum brought together a diverse group of people, indicating the importance with which adolescent reproductive health is regarded in the region. Those attending included youth activists and health promoters, top government officials, experienced front-line health care providers, religious leaders, researchers and academicians, legal experts, traditional artists, donors and journalists. Forty-one African countries were represented, as well as 12 North American, Caribbean, European and Asian nations.
Young people comprised one third of the delegates. They brought their own ideas and perspectives about the issues and enlivened each day with their dynamism and commitment. The exchange of ideas continued beyond the working groups and workshops into the evening hours and again in the early morning, before the plenaries began. People of all ages shared their thinking and discovered common ground on which to form and strengthen coalitions.
"On the one hand, society places a protective veil over the realm of sex, preventing young people from getting the knowledge they need; on the other, young people's senses are excited ... how can teenage pregnancy be prevented under such conditions? I believe that the fundamental solution is to provide sex education to young people."
--Zhou Quan, 18, China
"The media must play a role in this raising of awareness ... They must try to learn young people's opinions, particularly with regard to subjects relating to population and development, in order that in the future, every person is able to enjoy all his rights and freedoms ... without discrimination.."
--Moshera Saad El-Deen Mahmoud Zidan, 19, Egypt
"People must be educated not to disapprove when a woman carries out activities which only men can allegedly perform ... and also not to disapprove of men who help out at home or in some other activities which until now have only been done by women."
--Carolina Leonor Ruiz Herrera, 18, Guatemala
"History demonstrates that the imposition of extremely strict taboos on sexual relations yields no effective results. On the contrary, various benighted interpretations of the sex act emerge which have a pernicious effect on young people."
--Elmira Gilmudinova, 17, Kazakhstan
"Man, like a bird, needs the combined force of his two wings--one male and one female--to fly, otherwise his flight will be skewed. As long as I'm prevented from realizing my fullest potential, you won't be able to realize yours because you'll be working alone for two. Encourage me to study and acquire knowledge so that all my sisters and I won't be unemployed as a result of ignorance and illiteracy."
--Mwimpe Kamanga Julie-Jamal, 19, Zaire
Discussion produced a rich variety of conclusions and recommendations for strengthening health policies and services to better meet the critical needs of adolescents. Recommendations included making reproductive health services"adolescent- friendly" to encourage the patronage of young people; providing services to disadvantaged adolescents such as those who are imprisoned, disabled or orphaned; and formulating comprehensive national policies to meet the reproductive health needs of all teenagers.
Sexual and reproductive health services should include preventive services such as the provision of contraceptives, counselling and testing services for pregnancy and STDs. They should also provide intervention and treatment in case of disease, delivery services and pre- and post-natal care.
Opportunity should be provided for feed-back from young clients. Adolescents, like all individuals, should be empowered to make fully informed contraceptive choices. This implies an understanding of contraceptive options: how they work, how to use them and their side-effects. Moreover, the counsellor should address the fears the adolescent may have regarding contraceptive use, on negotiating contraceptive use with the partner and regarding the counselling itself. For example, if postponement of the pelvic examination would increase the likelihood of continued use of both contraception and the counselling service, then this should be considered.
Poverty and an environment inattentive to women's needs are part of life in the Gaza Strip. Female teenagers in Gaza are an especially neglected group. Because tradition holds that these girls are best protected by strict family codes, issues such as incest and rape usually go unmentioned in an attempt to safeguard family honour. In addition, health programmes for women generally focus on maternal health. But now, teenage girls have a place to turn in Gaza.
In 1995, UNFPA supported the establishment of a women's centre at the Al-Bureij refugee camp. It now provides reproductive health services, pre- and postnatal care, family planning, legal assistance and, most recently, exercise programmes so that women can increase their physical fitness. All services are located under one roof, and are provided for women, by women, and based on a comprehensive approach to the well-being of women. Staff members conduct home visits to introduce the Centre and its services and for follow-up. Free transportation is provided for women living in remote areas. The men from the Al-Bureij have been supportive of the programme and have even attended some of the Centre's activities.
The Centre holds weekly seminars, where the women who attend choose topics. These have included the importance of breast-feeding, anaemia, violence in the family, social conservatism, menopause, sexual education (for both women and men), post-partum depression, labour rights, women and divorce, inheritance, and dowries. "We are able to discuss issues that usually we cannot," says camp resident Zaleh Odeh.
Because of its comprehensive approach, individualized care and direct focus on education and counselling, the Women's Health Centre at Al-Bureij has become a beacon of hope for women throughout the West Bank and Gaza Strip. It will soon be replicated in another area with staff trained at Bureij.
Two words cover the requirements for success in terms of adolescent use of services: "accessibility" and "acceptability". In practical terms, this means: - Privacy and anonymity should be assured.
- Time and place: Services should be within an accessible distance, have convenient hours and waiting time should be limited.
- Personnel: Empathic and nonjudgemental personnel should be able to communicate with adolescents, be sensitive to their fears and their relationships in the community. Strangers might be preferable to parents' acquaintances.
- Quality: A wide range of services should be available in one place; safety is a must, and this includes sterile and proper equipment and well-trained personnel. Sufficient time should be available for each client, and comprehensive information given in everyday language and with informational material.
- Cost: Services should be affordable for adolescents.
Studies show that in some places, the majority of adolescents think that using contraceptives can lead to infertility. In addition, many young people use contraceptives incorrectly. For instance, some take birth control pills only after intercourse. It is important that contraceptive counselling be explicit.
Clinical services for adolescents must be equipped to handle the complications of unsafe abortion. In areas where adolescents account for the majority of abortions, an appropriate response might be to establish a clinic for adolescents that would provide a comprehensive range of services (including emergency contraception) and STD prevention and treatment services, including providing advice on alcohol and drug use.
Health care providers in clinics serving adolescents should be able to screen and refer high risk pregnancies. It is not enough to only care for the mother during pregnancy; postnatal services must also be provided. The success of adolescent reproductive health services should be measured by several factors, including decreased pregnancy and birth rates. Other measures of success are increased use of the facilities over the years, as well as increased knowledge about health and safe sex practices. Clients should be satisfied with the counselling they receive.
The non-governmental organization Education for Improving the Quality of Life has created a forum where young people can discuss their feelings and sexuality, and receive the information they need to understand their fertility and make informed choices about sexuality and child-bearing.
The programme (known by its Spanish acronym, JOCAS), organizes group discussions of 20 people or fewer. The dialogues cover a range of previously taboo topics (including the use of condoms and prevention of sexually transmitted diseases). Participants are encouraged to share information, explore prevailing attitudes, discuss their values, and express their doubts, anxieties and questions about sexuality. Facilitators are trained to encourage participation and to respect silences during the two hour dialogues. Questions are noted and answered the following day by nurses, psychologists and clerics.
In Chile, which has one of the highest rates of illegal abortion in Latin America, this project offers a welcome forum for youth to gain the tools they need to understand their fertility and the challenges of responsible parenthood.
The UNFPA-supported programme started in several regions in 1995. It was expanded in 1996 and is now spreading to all parts of the country.
Adolescents often more readily open up to peers than to adults about issues of sexual and reproductive health. This makes young people the obvious choice for a number of roles including:
Facilitators in participatory education and group discussions;
Safe sex promoters;
Peer counsellors and educators; and
It is essential to increase awareness--at all levels of society--of the importance of the issues involved in adolescent reproductive health. Building such an enabling environment is one of the Fund's greatest challenges. Efforts in this regard take the form of political advocacy to develop and enforce laws and policies in support of adolescent sexual and reproductive well-being. Advocacy efforts also include strengthening government ministries and local organizations, fostering strategic alliances and increasing public awareness.
High rates of childbirth, abortions and transmission of STDs and HIV among adolescents cause problems for society and are costly to a nation. Thus, it is in the interest of governments to address the problems of adolescent sexual and reproductive health. Moreover, if the countries have ratified the United Nations Convention on the Elimination of All Forms of Discrimination Against Women and the United Nations Convention on the Rights of the Child they are obligated to modify their laws and programmes accordingly. Countries which adopted the ICPD Programme of Action and the FWCW Platform for Action are expected (although not bound) to bring their own programmes in line with these agreements.
States are increasingly recognizing the needs of young people including adolescents and are developing "youth policies" as part of national population and development policy. Adolescent sexual and reproductive health should be a made part of any such youth policy.
Policies in support of adolescent sexual and reproductive health should include equal rights for women and equal life opportunities; minimum legal age for marriage, access to health care including adequate nutrition, reproductive health services and contraceptive services; and sexual and reproductive health education as part of a wider framework of universal education for all.
In addition to societal structures which can make it difficult for a programme to reach adolescents, the Fund has found that "gatekeepers" such as parents, community leaders, religious leaders, health personnel and educators may oppose adolescent reproductive health programmes for various reasons. For example, despite numerous findings to the contrary, there is widespread belief that providing information and contraceptives will increase sexual activity among adolescents. Religious and traditional leaders might be afraid to lose the status they hold in society when traditional beliefs, values and customs are challenged. Parents might feel that programmes invade the privacy of the family, where they hold responsibility and are in charge. These obstacles can be successfully addressed by building a climate of awareness and trust.
In spite of great diversity in terms of social indicators, Arab countries face several common challenges with respect to the well-being of young people. Harmful traditional practices, including female genital mutilation, are prevalent and the overall status of girls and women is low.
Still, governments throughout the region share a commitment to population and development issues and to implementing the goals and objectives of the ICPD Programme of Action. A national conference on reproductive health was held in Baghdad, Iraq, where the Minister of Health reaffirmed the Government's support for family planning. In Sudan, a workshop was organized to develop a five-year plan for reproductive health activities.
The Fund works closely with governmental and nongovernmental agencies in order to strengthen the adaptation and implementation of guidelines for reproductive health, and to set programme priorities. It provides training and logistical support, all with the aim of strengthening national capacity.
UNFPA emphasizes incorporating adolescent reproductive health components into national policies, in spite of socio-cultural barriers and conservative trends prevailing in some countries. There is an increased awareness among policy makers and community leaders of the importance of this issue, and UNFPA has helped to improve coordination of the initiatives undertaken by governments and NGOs in this area.
With support from UNFPA and other donors, a number of countries of the region launched new programmes on sexual and reproductive health for youth. To further sustain this new trend and as part of its advocacy efforts aiming to promote the reproductive health of youth in the region, UNFPA organized a regional meeting that gathered more than 60 government, youth and NGO representatives. UNFPA enlisted additional allies in this field, and a joint agreement was signed with the Islamic Educational, Scientific and Cultural Organization (ISESCO) in 1996.
Population education devotes considerable attention to family life, sexuality and human ecology. Educators have long realized that traditional methods of instruction do not sufficiently prepare young people to meet realistic and important challenges.
Population education stresses participatory teaching techniques that encourage students to think about the implications of their own behaviour. Children become sensitized; they learn to care what happens to other people and the environment as a result of irresponsible behaviour.
Contrary to popular belief, population education does not increase promiscuity.
Population education emphasizes family life and sexuality education, which encourages responsible and ethical behaviour, including higher levels of abstinence, later start of sexual activity, higher use of contraceptives and fewer sexual partners.
UNFPA is supporting a project in the Russian Federation to address the critical lack of family life education in the school system. With one of the world's highest abortion rates and rapidly spreading STDs, there is urgent need to develop awareness of sexual health issues.
UNFPA supports both the Ministry of Education and the Russian Family Planning Association in their efforts to increase awareness of key officials and strengthen the Ministry of Education. It also focuses on measuring and improving knowledge and attitude about reproductive health among teachers, parents and students, through meetings, surveys and the development of academic materials.
The Fund has worked with ministries of education in over 100 countries to introduce education regarding population, including reproductive health and gender issues.
UNFPA supports including population education in formal and non-formal educational sectors.
The Fund helped achieve the inclusion of population education into curricula as part of educational reforms in countries including Bolivia, Peru and Honduras. In Colombia and Venezuela, UNFPA supported the development of innovative outreach and school associated approaches; in some cases governments have taken over these models and built upon them. In Ecuador, population education activities are being operationalized with the involvement of local populations in school activities in order to reach youngsters as well as their parents.
UNFPA also supports non-traditional forms of education, largely through its assistance to innovative local projects and the work of NGOs. UNFPA created an inter-institutional group to coordinate activities in the Dominican Republic and optimize resource utilization. In Saint Lucia and El Salvador, UNFPA-supported activities involving parents, teachers, the community and the mass media to promote responsible sexual behaviour.
Experience shows that it is possible to introduce some of the most important concepts in the area of reproductive and sexual health to adolescents without arousing controversy. These include respect for others (especially persons of the other sex); self-esteem; the possibility of planning families and understanding that children are ideally born as the result of a conscious decision by loving and responsible parents; the importance of postponing the first pregnancy; and the ability to withstand peer pressure.
UNFPA, through its innovative work in population education, has played an important role in promoting girls' education and improving the quality of basic education. Programme efforts have emphasized review and revision of curricula to include concepts of gender equality and equity, women's empowerment, enhancement of girl's self-esteem, gender roles, and status and rights of women.
A key ingredient in the success of these projects is the involvement and support of parents and the community. Population education is most effective when supported by parents who frankly discuss sex with their children, but such discussions are difficult and most families do not undertake them. Health systems, and health educators in particular, can play an important role in ensuring that support.
UNFPA emphasizes several aspects to enhance population education. Qualitative evaluation is important to assess whether the learning objectives have been met. If they have not, the evaluation/monitoring process enables educators to improve their performance before mistakes are perpetuated or repeated on a large scale. Focusing on a breadth of information may be counterproductive; when content is spread so thinly it can become diluted and children learn little, if anything at all.
In the 1970s, projects tried to teach broad demographic concepts to young children with poor results. Older children were somehow expected to be predisposed to practice family planning later because they learned something about population growth in school. This approach has not been effective.
UNFPA is strengthening the quality of education activities by:
1. Improving qualitative evaluation and research;
2. Focusing the content of population education on key issues (many of which should be selected with personal relevance in mind);
3. Emphasizing attitude formation rather than memorization of facts and figures; and
4. Introducing population education at an early age.
Lessons learned in developing family life education enhance the quality of basic education.
Educational content must be clear and relevant to the individual learner. Otherwise, it may be easily forgotten. Learners must be able to see the implications of population issues for themselves and their future families. Then, they will be able to take actions that reflect their interests and concerns.
The age at which information and services are provided has been proven very significant. While information should at all times be adjusted to the developmental level of the learner, it is at the same time important that it be provided ahead of the developmental stage of the young people, preferably from pre-adolescence. This provides young people with knowledge about the changes they will experience before the changes occur.
If abstinence or postponement of the initiation of sexual activity are among the prograrnme goals, programmes should reach adolescents before sexual activity is likely to start. While it is important that many of the above-mentioned subjects are addressed continuously throughout adolescence, it is equally important that sexuality education is handled in a sensitive way to encourage adolescents to discuss their concerns.
While facts and figures are important, attitudes and values determine children's outlook on life and their future behaviour. Since attitude formation is so important, and since it begins at an early age, it is important to introduce population education at the primary level. This has been done with success in a number of countries, and in some instances parents also participate in pre-school population education activities.
Many external factors contribute to changes of behaviour. It is therefore difficult to attribute causality to any one intervention or factor. The impact of population education on behavioural change is long-term, making it even more difficult to track, because longitudinal studies are expensive and, by definition, take a long time to complete. The impact of population education over the long-term has not been studied.
Several recent developments indicate that population education in schools is having an impact on behaviour. In China, pilot school projects reported that following exposure to population education, students who had agreed to postpone marriage were sticking to their agreement.
Rural health officials in Bangladesh started to notice a sudden and steady influx of young couples coming to health centres to ask for family planning. The timing of this event coincided with the graduation from school of the first cohort of young people who had been exposed to several years of population education in the classroom.
Nineteen studies all disprove the myth that sex education "teaches youth to have sex" and promotes premature sexual behaviour, according to WHO's Global Programme on AIDS. The studies confirmed that:
Sex education led to a delay in the onset of sexual activity or to a decrease in the number of sexual encounters;
Youth who were already sexually active adopted safer practices after receiving sex education;
Programmes advocating both postponement of sexual intercourse as well as condom use when sex occurs were more effective than those that only promoted abstinence;
Sexuality education is most effective if begun before the onset of sexual activity;
Access to counselling and contraceptive services did not encourage earlier or increased sexual activity.
The impact of population education may suffer when there is a conflict between what students learn in school and what they learn from other sources. The information about health, sexuality, and the responsibilities of parenthood that young people acquire from their peers or "in the street", and sometimes even from their families, may conflict with what they get from their teachers in school. This can negate whatever gains in learning might be made through population education efforts.
A comprehensive approach to population education can guard against such counterinfluences. Such an approach ensures that students are reached through a variety of channels with messages that reinforce what they learn in school. It also implies the importance of involving the larger community, including parents, school administrators, the church, the mass media, and other concerned groups, in the development and promotion of population education programmes.
An NGO called GEEP--Groupe pour l' étude sur l'enseignement de la population--is working under the guidance of Senegal's Ministry of Education to increase awareness about population, environment and development. With UNFPA support, GEEP is targeting 50 secondary schools. The programme sensitizes parents and children on family life issues through a variety of non-traditional teaching methods. The group has Environment and Family Life Clubs, and a related summer camp. Exchanges between rural and urban youths are being considered.
Private counselling should give young people the opportunity to ask personal questions on all subjects related to maturing, puberty, sex, reproduction and relationships. Counselling should be confidential, private, accessible and acceptable. The counsellors should be nonjudgemental and have good communication skills.
The advantages of peer counsellors needs to be underscored. They usually understand adolescent life in a manner that cannot be taught to other counsellors. Peer counsellors are only peers for a relatively limited period of time and, therefore new counsellors have to be trained continuously. Such counsellors should have experience as peer educators before being selected and trained for peer counselling. While many adolescents tend to prefer counselling from peers, it should be noted that some may prefer to work with adults.
Education, particularly the education of girls, has a profound influence on reproductive health. Population education contributes to improving the quality of basic education in several ways. It introduces contents with direct relevance to the learners. It emphasizes participatory education, which facilitates learning.
Population education influences gender attitudes, responsible behaviour and the development of self-esteem. When introduced in the early years of basic education, before harmful practices and patterns are established, its chances of success are strengthened.
UNFPA co-sponsored the 1990 World Conference on Education for All in Jomtien, Thailand, and supplied population education material for the conference documents. These documents have become the principal education reference materials for countries around the world as they work to reach the goal of education for all.
Selecting issues to be dealt with in the classroom is an ongoing process. The contents have to be directly related to the project objectives. In the interest of improving the quality of projects, the Fund developed a set of indicators for measuring the impact of population education.
Delivering high quality education, services and counselling to young people is a specialized skill. Counsellors and others require specific training, both in programme and content and communication skills.
In 1978 the Women's Centre in Jamaica, then a single centre in Kingston, initiated low-profile activities to support pregnant young women and to help them to finish their education after delivery. Programme success has gradually led to broad community support, expansion in reach and scope and, in 1985, to actual change of national policy to specifically allow for young mothers to return to school.
Today, the programme, which has been supported by UNFPA since 1986, consists of seven main centres and 11 outreach stations. The programme now offers academic instruction, counselling, skills training, parenting course-work, training in family planning and family life, nursery school services, and outreach counselling, training and education. Because of its continuous expansion, the programme is considered an innovative approach in adolescent reproductive health programming. For example, the programme's success has demonstrated the importance of combining education, information and services in pregnancy prevention: only 1.4 per cent of girls reached by the programme had a second pregnancy before graduation or starting work. The project now serves as model for other programmes.
Because of the diversity among young people, creative and strategic alliances are needed to convey information and services. Multiple settings and innovative approaches are necessary.
Private sector involvement is a relatively new area in the realm of adolescent reproductive rights. Yet in many ways it is the wave of the future. UNFPA has already supported several successful and innovative approaches to working with the private sector in developing information services. In one such partnership with the private sector, popular recording artists in Ghana and Nigeria were enlisted to incorporate population education messages into their music. The project was successful on all sides: the music sold and the message got out
Mass media is a potent force in shaping adolescent expectations and ideas of behaviour. It already reaches most places in the world, communicating messages to adolescents on sexuality, relationships and love. Because of its influence, the media can be an important ally or a potent foe in communicating facts and shaping values concerning adolescent sexuality and reproductive health.
Often, images portrayed in the mass media are unrealistic. The primary focus is usually on the romance of initiating a relationship while important aspects such as declining an unwanted sexual proposition or negotiating contraceptive use are most often neglected. Moreover, these images often enforce stereotyped gender roles.
Mass media can use--and create--popular culture to articulate messages in young people's own terms. That makes it an especially important tool for reaching adolescents. Television, radio and magazines can be used for informational programming and for documentaries, and also to incorporate realistic images and important messages into existing popular programmes or by making special soaps, radio serials or romantic stories.
It is difficult to quantify the impact of an immensely popular drama stimulating conversations throughout the country on a broad range of critical population- and development-related topics. But 19 per cent of married women who don't listen to a certain radio show in Tanzania use family planning, while 64 per cent of the show's married female fans do.
Technically referred to as an "entertainment-education radio soap opera on family planning and HIV/AIDS prevention", the show goes by a more catchy name in Swahili,"Twende Na Wakati", or "Let's Go with the Times". And it seems that Tanzanians are not only listening to the soap, but emulating its values, according to a study done by the University of New Mexico, which found that awareness was being raised throughout the country due to the show's realistic and personal approach to sensitive issues.
The immensely popular show, currently sponsored by UNFPA and Population Communications International, will become self-sustaining in the coming months due to the interest of commercial sponsors. The show's producers plan to help set up a similar project in Namibia. And still more developing countries are interested in creating responsible radio soaps of their own
The Fund works with other development agencies in order to better address the diverse needs of adolescents. UNFPA has successfully collaborated with WHO and UNICEF to develop policy statements on adolescent reproductive health. On the global level, UNFPA has supported WHO's Adolescent Health and Development programme. Collaboration also occurs at the country level.
For instance, in Fiji, UNFPA, UNDP and UNICEF jointly sponsored two activities: a rock music competition, where 23 secondary schools performed rock music and dance with HIV/AIDS prevention themes and a month long AIDS Awareness Campaign on the national level. In addition, UNFPA is specifically responsible for monitoring the implementation of the UNAIDS work plan for Fiji and Tuvalu.
The UNFPA-supported Programme for Enhancing Adolescent Reproductive Life (PEARL) in Uganda has been developed through a participatory process involving all social partners. Government departments, NGOs, community groups, the donor community, young people, district authorities and other social partners come together to enhance young people's reproductive health. The approach is broad; it includes advocacy and awareness building along with information and service provision. The project seeks to build a supportive environment and empower adolescents.
All societal levels influencing adolescent reproductive health are involved in implementation. Political and community support is promoted. Parents, children and teens are encouraged to improve and increase inter-personal communication. Education, skills training and recreational opportunities are increased; reproductive health services are provided and personnel trained. Positive cultural practices are being investigated and negative issues like sexual abuse addressed. Coordination and information flow among all these levels are integrated into the project.
Messages are disseminated through the mass media, seminars, workshops, community meetings, village-level discussions, peer educators, talks at schools and churches, competitions, existing health services and recreational facilities.
First implemented in four of the country's 39 districts, PEARL, is being expanded to 20 districts, reaching more than half the country's population.
UNFPA aims to tailor programmes to be carried out in close collaboration with national and local NGOs that have an internal understanding of the community and are already accepted locally. Obvious choices for effective NGO partnerships are organizations which focus on young people, women, human rights, parents and teachers, and national family planning agencies. On the global level, the Fund benefits from input provided by its NGO Advisory Committee.
The activities of local NGOs are sometimes restricted due to limited capacities. In these eases, the Fund helps expand those capacities or facilitates correspondence with other organizations. Sometimes, NGO efforts are hampered by governmental reluctance to provide funds for organizations working in what may be considered a controversial field. When this happens, UNFPA and other agencies encourage governments to overcome their reluctance through advocacy and awareness building.
A UNFPA-supported programme in Egypt seeks to combine youth involvement and institutional capacity building of local NGOs. The programme supports local NGOs develop the capacity to carry out reproductive health education programmes by formulating and implementing reproductive health training programmes for youth leaders. These youth leaders are trained to educate other young adults about reproductive health, as well as gender and empowerment issues. The project involves both youth and youth-serving NGOs.
Developing alliances with social gatekeepers is an ongoing process. Part of this process involves providing information and education to the gatekeepers themselves, who are usually adults. Such messages should address the problems and changes of adolescence in this age of conflicting influences. Correct and specific information should be provided on the health risks young people face. It is important to definitively dispel the prevailing myth that providing reproductive and sexual health information to adolescents promotes sexual activities.
Programme designers need to respect and work with these influential adults. Their concerns--and the reasons for them--should be understood and evaluated. In order to fully succeed, programmes require community acceptance. In some places programmes start out on a very small scale to gain acceptance before expanding.
In working with gatekeepers, programme designers should consider the degree to which consensus can be built around the overall goals of adolescent health and development, rather than focus too rigidly on the means, which tend to be more controversial. If service provision cannot be accepted on the large scale, it may be better, over the long term, to start a small-scale information and services programme. If information and services cannot be combined at all, resources may be better spent on advocacy and awareness building.
Programme adaptation should not compromise the intended programme beyond an acceptable degree. When such initial adaptation is incorporated into programme design, the longer-term goals should not be forgotten. Efforts to change the inhibiting structure should be carried out in parallel with the adapted programme.
There are tremendous challenges ahead in the area of adolescent well-being. But lessons can be drawn from past efforts, which will enhance our future work. UNFPA' s work with adolescents highlighted certain components.
Baseline studies are an important starting point. They identify target groups and assess needs. Adolescents must be involved in designing, implementing and evaluating programmes. There should be creativity and mix in programme design. Whenever possible, NGOs should be involved in programme implementation. Education, information and communication strategies should be comprehensive and always combined with services. Clinical services, including contraceptives, should be accessible and acceptable.
Programmes must be designed with sociocultural sensitivity and keeping gatekeepers in mind. To maximize impact, programmes should collaborate with related efforts (horizontal networking). Vertical networking between policy makers, service providers and clients is needed to create a supportive environment and create awareness. Finally, because the well-being of adolescents affects the international community equally, the results of programme evaluation should be shared. Successful programming promotes sustainability, necessary for real and lasting improvement in the well-being of young people.
Young people have choices to make. It is not enough to wish the situation facing our young people were less complex. Adults have the obligation--on the institutional and personal levels--to equip youth with the tools they require to protect and maximize their future opportunities.
Adolescent reproductive health is inextricably linked with factors relating to poverty and environmental degradation. Concrete and concerted action is today an ethical and practical requirement. Based on the premise that each individual is of prime importance, we must chart a course designed to maximize opportunities and utilize potential. This is the formula for the future.