Transcript USAID & ADOLESCENT REPRODUCTIVE HEALTH

PROGRAMMING FOR YOUTH
IN HIV & REPRODUCTIVE HEALTH
Shanti Conly
USAID/GH
ANE/EE PHN SOTA
October 2002
SESSION OVERVIEW
 Transition to Adulthood: RH/HIV Issues
 “State of the Science” re:
Contextual factors influencing youth behaviors
Effective interventions—”What Works”
A Framework for Youth Programming
 USAID/W Support for Youth Programs/YouthNet
 Approaches adopted by ANE & EE Missions
I. THE TRANSITION TO
ADULTHOOD: RH/HIV ISSUES
Adulthood
Childhood
Age Range: 10-24 years
Pre-Teens thru Young Adults
Preferred Terms: Youth, Young People
KEY MARKER EVENTS VARY IN
TIMING AND SEQUENCE
23
24
22
21
20
19
18
17
16
15
14
13
12
11
10
•First Pregnancy
and Childbirth
•Leaving Home
•Marriage
•Starting Work
•Sexual Initiation
•Alcohol/Drug Use
•Leaving School
•Puberty
YOUTH IN GLOBAL PERSPECTIVE
 1.7 billion youth aged 10-24 globally
 30 percent of total population in
developing regions
YOUTH ARE DIVERSE
 Younger/Older
 Boys/Girls
 Married/Unmarried
 Sexually Active/Not
 In/Out of School
 Parents/Not
 Rural/urban
 Economic status
 At-risk/Vulnerable
Programs Need to
“Segment for Success”
THE SOCIAL CONTEXT
 Gap between puberty and marriage growing
with rising education and age at marriage
 Premarital sexual activity increasing; doublestandard in social norms for boys vs. girls
 Lack of empowerment of young women;
coercive and unwanted sex common
 Political sensitivity around teen sexual activity
 Openness/flexibility: a formative period,
potential to influence life-long behaviors
KEY YOUTH RH/HIV ISSUES
 Poor knowledge of RH and HIV
 Low use of contraception/condoms
 Unintended pregnancy, unsafe abortion
 HIV and STIs
 Early childbearing and maternal deaths
 Poor nutrition, anemia
 Injecting drug use/other substance abuse
EE: HIV AMONG YOUTH INJECTING
DRUG USERS
RUSSIA
Number of Reported New HIV Infections
Reported Number of New HIV Infections Among Adolescents
(Aged 10-19) Who Inject Drugs, 1995-2000
12,000
10,000
9,612
8,000
6,000
4,000
3,008
2,000
0
260
501
1995
1996
1997
333
0
1998
1999
2000
EE: SEXUAL ACTIVITY &
CONTRACEPTIVE USE, YOUNG WOMEN
% Reporting Sexual Activity in Past 4 Weeks
% Of Sexually Active Reporting Contraceptive Use
100
Age 15-19
90
Age 20-24
80
70
Percent
60
74%
66%
85%
54%
50
63%
73%
70%
73%
87%
40
72%
79%
30
80%
20
10
0
In Union
Source: CDC.
Not in
Union
Moldova
In Union
Not in
Union
Romania
In Union
Not in
Union
Ukraine
In Union
Not in
Union
Moldova
In Union
Not in
Union
Romania
In Union
Not in
Union
Ukraine
EE: CONTRACEPTIVE METHOD CHOICE
AMONG YOUNG WOMEN
Percent of Sexually Active Young Adults Using
Contraceptive Methods
Pill
Condom
Other Modern
Traditional
100
Age 15-19
90
Age 20-24
80
70
60
50
40
30
20
10
0
In Union
Not in
Union
Moldova
Source: CDC
Intrauterine Device
In Union
Not in
Union
Romania
In Union
Not in
Union
Ukraine
In Union
Not in
Union
Moldova
In Union
Not in
Union
Romania
In Union
Not in
Union
Ukraine
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Age 15-19
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R
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160
ss
i
ss
i
U
an
ia
ol
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va
Fertility Rate Per 1,000 Women
R
u
R
u
Source: CDC
R
om
M
Per 1,000 Women
EE: HIGH RATES OF INDUCED ABORTION
Induced Abortion Rate Per 1,000 Women
180
Age 20-24
140
120
100
80
60
40
20
0
ANE: DIFFERENCES IN MARRIAGE RATES
Age 15-19 Taiwan
Percent Ever Married
Philippines
Male
Thailand
Female
Indonesia
Nepal
Age 20-24 Taiwan
Philippines
Thailand
Indonesia
Nepal
Source: EWC
0
20
40
60
80
es
h
a
in
es
19
97
19
98
00
1
l2
Vi
et
na
m
Ph
i li
pp
ep
a
19
97
Condom
N
ne
si
a
99
9
19
98
/1
Injections
In
do
a
20
00
20
00
Age 15-19
In
di
ia
19
99
/
19
97
Intrauterine Device
Ca
m
bo
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es
h
Vi
et
na
m
19
98
00
1
l2
in
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ep
a
Ph
i li
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N
19
97
Values less
than 5%
not shown
ne
si
a
99
9
19
98
/1
20
00
Pill
Ba
ng
la
d
Source: DHS Surveys.
In
do
In
di
20
00
50
ia
19
99
/
Percent of Married Young Adults Using
Contraceptive Methods
60
Ca
m
bo
d
Ba
ng
la
d
ANE: CONTRACEPTIVE USE AMONG
YOUNG MARRIED WOMEN
Any Traditional
Age 20-24
40
30
20
10
0
ANE: PREMARITAL SEXUAL ACTIVITY
Premarital Sex Among Youth Sexually Active Before Age 20
Taiwan
Hong Kong
Philippines
Thailand
Indonesia
Male
Female
Nepal
0
20
Source: EWC
Note: For Nepal, among age 20-22
40
60
Percent
80
100
ANE: KNOWLEDGE AND
ATTITUDES ABOUT CONDOMS
Single, sexually active male Filipinos 15-24 (1994):
 30% used contraception at last sex—but only 9%
used condoms
 Over 95% know about condoms, but only 58%
knew condoms can prevent HIV/AIDS
 Negative attitudes to condoms widespread:
 Reduces pleasure (58%)
 Too expensive (34%)
 Too embarrassing to buy (47%)
 Against religion (32%)
YOUTH AND HIV/AIDS
Half of all new infections in young people age 15–24;
over 2 million new infections every year
YOUNG WOMEN ARE EPICENTER
OF GENERALIZED
HIV Prevalence
by Age and Sex EPIDEMICS
Kisumu, Kenya, 1998
HIV PREVALENCE BY AGE & SEX, KISUMU, KENYA, 1998
50
HIV Prevalence (%)
Males
Females
40
30
20
10
0
15-19
20-24
25-29
30-39
40-49
YOUTH ALSO IMPORTANT IN
CONCENTRATED EPIDEMICS
High-risk populations include many youth:
 Young sex workers and trafficked girls
 Young injecting drug users
 Young men who have sex with men
 Young men who visit sex workers
 Street children/orphans
 Refugee youth
YOUNG SEX WORKERS AND
HIV, MYANMAR
The majority of female sex workers are aged 15-24, Myanmar, 2000
Percentage of All Sex Workers
40
30
35
28
20
22
10
14
0
aged 15 - 19
43% HIV+
aged 20 - 24
41% HIV+
aged 25 - 29
47% HIV+
aged 30 - 34
21% HIV+
Source: Sentinel surveillance data for March-April 2000, AIDS Prevention and Control Project, Department of Health, Myanmar.
THAILAND: THE IMPORTANCE OF
CHANGING SOCIAL NORMS
Thai Males 15-24 Ever Having Had Sex with A Sex Worker
SOURCE
DATE
SEX WITH SEX WORKER
Propakkham
1985
35%
Van Landingham
1993
30%
Nelson
1996
57% (1991), 44% (1993),
24% (1995)
Podhisita
1995
6%
Podhisita
1995
10%
Office of Population
Experts
1996
13%
Saisorn
2000
6.5%
McCauley, adapted from Simon Baker, 2002
II. THE STATE OF THE
SCIENCE: “WHAT WORKS”
CONTEXTUAL INFLUENCES ON
YOUTH BEHAVIORS
 Multiple, contextual “risk” and “protective” factors
influence youth behaviors
 These influences operate at the individual, family,
school, peer and community levels
 Contextual factors not easily amenable to
programmatic intervention?
 Thai program to protect girls from sex work: girls
identified by family “risk factors”
FINDINGS FROM PROGRAM
EVALUATIONS: WHAT WORKS?
 Caveats regarding evidence base
 No evidence that education or services for
youth increase sexual activity
 Programs more effective in influencing
knowledge and attitudes than behaviors
SCHOOL-BASED PROGRAMS
 Most interventions  knowledge & attitudes
 ~50% had impact on behaviors in short-term;
long-term impact less certain
 Programs have broad reach; despite challenges in
implementation, acceptable in many contexts
 Need more info on key elements of effective
school programs in developing countries
KEY ELEMENTS OF EFFECTIVE SEX
EDUCATION (U.S. Research)
 Clear focus on specific behavioral goals
 Accurate info about risks/ways to avoid risk
 Teaching methods reflect behavior change theory,
help youth personalize information
 Goals, materials, appropriate to age, culture and
sexual experience
 Attention to social and peer pressures
 Opportunities to practice communication,
negotiation and refusal skills
 Adequate duration/Minimum # of hours
MASS MEDIA PROGRAMS
 Mass media has broad reach, influential with
youth
 Consistently affects knowledge, attitudes, norms
 Less evidence of direct influence on sexual and
contraceptive behaviors
 Links to more personalized activities needed for
behavior change?
 Links to social marketing promising for
increasing access to, use of, condoms
PEER EDUCATION PROGRAMS
 Peer education approach appears promising
 Key questions require further investigation
Magnitude of effects on peer contacts vs. peer
promoters
Reach—selection of peer promoters key
Level of training and supervision required
Turnover/Sustainability
WORKPLACE PROGRAMS
 Wide variability in program types–target specific
groups of out-of-school youth, for example:
 Young army recruits in Thailand
 Garment workers in Cambodia
 Young sex workers in India
 Impacts on knowledge, attitudes, skills
 Evidence is thin on behavioral effects, but has
potential where many youth employed
OTHER COMMUNITY-BASED
PROGRAMS
 Wide variety of educational programs for out of
school youth, especially for girls, married youth
 India Better Life Options Program:
Non-formal ed, vocational and life skills training, FLE
 May have potential for improving health practices
and increasing use of health services
 Need better outcome information
HEALTH-FACILITY PROGRAMS
 “Youth friendly” Clinical Services”— Trained
convenient hours, location, etc.
staff,
 On their own do not appear to attract youth for
preventive services
 Need outreach and community mobilization to
obtain support for providing youth RH services
 Not a promising strategy for primary prevention
YOUTH CENTERS
Do not increase the use of RH services by
adolescents
Most use is for recreational rather than
counseling/clinical purposes
Much use by males out of target ages
Does not appear promising/cost-effective
SUMMARY: A FRAMEWORK FOR
YOUTH PROGRAMMING
Multi-component programs are needed to address
multiple contextual influences & varying needs:
 Improve policies, change social norms and build
community support
 Reach youth early with clear, consistent
messages, accurate info & life skills
 Improve access to condoms and other services,
especially thru non-clinical channels
PROMOTING HEALTHY BEHAVIORS:
THE THREE-LEGGED STOOL
Healthy Youth
Behaviors
Supportive
Policies and
Community
Norms
Expanded
Access to
Quality Services
Improved
Knowledge,
Attitudes, Skills
III. USAID/W SUPPORT FOR
YOUTH RH/HIV PROGRAMS
YOUTH A PRIORITY FOR
GLOBAL HEALTH BUREAU
 Youth are central to USAID HIV/AIDS Goals
 High prevalence countries: Reduce HIV by 50% in 15-24
year olds
 Low prevalence countries: Keep HIV below 1%
 Youth important in Population & Reproductive Health
 High unmet need– both unmarried & married youth
 Early Childbearing: Health, social, demographic impacts
MULTIPLE GH MECHANISMS
SUPPORT YOUTH RH PROGRAMS
 Dedicated GH Activity provides technical
leadership on youth RH/HIV (YOUTHNET)
 Mainstreaming through other Agreements
(POLICY, PCS, IMPACT, AIDSMARK)
YOUTHNET…VALUE ADDED?
YOUTHLENS
KEY YOUTHNET ROLES
 Global Technical Leadership
Advance evidence base, develop tools, build capacity
 Short-term Technical Assistance
Provide specialized youth expertise to Missions
 Focus Countries?
Help scale up youth programs for national impact
NEED FOR STRATEGIC
PARTNERSHIPS