Photo credit: Adwoa Atta-Krah/EDC

Vision

An enhanced focus on adolescents and youth is vital to the U.S. Agency for International Development's (USAID's) ability to achieve its global health goals of an AIDS Free Generation¹ and Ending Preventable Child and Maternal Deaths (EPCMD).² HIV- and pregnancy-related complications remain major causes of death among youth worldwide,³ and adolescent mortality rates have remained virtually unchanged over the past 50 years.⁴ USAID's Youth in Development Policy's (2012) goal is: to improve the capacities and enable the aspirations of youth so that they can contribute to and benefit from more stable, democratic, and prosperous communities and nations. The Policy defines youth as individuals between the ages of 10–29 years and acknowledges that a range of investments and programs are needed from all development sectors, including those that ensure the health and wellbeing of youth.  

The Office of Population and Reproductive Health (PRH) is committed to a greater focus on adolescents aged 10–19 and promotes healthy sexual and reproductive health behaviors among young women and their partners that achieve the following outcomes:

• Delayed first pregnancy to at least age 18 years
• Birth to pregnancy intervals of at least 24 months

Evidence

The World Health Organization's Health for the World's Adolescents: A Second Chance in the Second Decade⁵compiles global evidence of the urgency of including youth in health programming, noting:

• Adolescence is a period of rapid human development.
• Biological maturity precedes psychosocial maturity, thus policy and programming must respond to this period of exploration and experimentation.
• Individual development and the external environment both influence the trajectory of adolescence.
• Adolescence as a life stage not only has an immediate effect on youth, but also affects the life course and spans generations.

High levels of early marriage, gender-based violence (GBV), childbearing and unmet need for contraception among adolescents persist in many EPCMD priority countries.⁶ Efforts to delay the age at first birth, improve birth spacing, and address GBV will not only improve health outcomes among adolescents, but also will contribute to the ability of countries to achieve their demographic dividend by reducing overall fertility and slowing population growth and will enable girls to remain in school, improve workforce participation, and ensure opportunities for civic engagement and participation. In many sub-Saharan African and South Asian countries, future population growth can be slowed as much as 20 percent by delaying marriage and childbearing by 5 years.7

Priorities: Populations

The PRH Youth Technical Team identifies three significant youth population segments where family planning and reproductive health programming efforts should be targeted and intensified as relevant to country context. These include (but are not limited to):

• First time mothers (both married and unmarried): The majority of early pregnancies in developing countries occur within marriage and are intended and/or expected, although pregnancies and childbearing outside of marriage also occur, both intended and unintended. Many young women quickly become pregnant again after a birth. Programs that work to end early marriage, delay childbearing, and change harmful gender norms should devote additional efforts to ensure young women are able to space their next pregnancy by at least 24 months.
• Sexually active, unmarried adolescents aged 15–19:  Adolescents need access to information and services to prevent unintended pregnancies, as well as community support to engage in healthy and safe behaviors. Gender transformative programming that promotes gender equality is pivotal. Depending on country context, programs may want to consider specialized approaches for marginalized and vulnerable adolescents, such as orphans and vulnerable children, street children, girls at risk of GBV, and harmful traditional practices such as early marriage, youth affected by humanitarian crises, and trafficked youth.  
• Very young adolescents aged 10–14: It is essential to reach adolescents before they are sexually active with information about puberty, fertility awareness, contraception, relationships and gender dynamics, and opportunities to develop communication, decision-making, and negotiation skills. These programs enable adolescents to delay sexual initiation, prevent GBV, or to engage in safer sexual practices, including contraceptive use.

Projects may also wish to consider interventions to reach these emerging groups of adolescents and youth:

• Urban adolescents: Countries are rapidly urbanizing, and much urban migration is by adolescents in search of education or employment. Depending on where these young people land, they may be displaced from the safety and support of their families and communities, may have less access to information and services, and may be vulnerable to GBV, coerced and/or transactional sex, early pregnancy, and sexually transmitted infections, including HIV.
• Adolescents living with HIV: Many HIVpositive children are surviving into adolescence and beyond. Adolescents living with HIV need sexual and reproductive health information, skills, and services, so they can safely disclose to partners, prevent unintended pregnancy, or ensure a safe pregnancy.

Priorities: Programming Approaches

The PRH Youth Technical Team recommends four programming emphasis areas to achieve the identified adolescent outcomes. Variables that will contribute to improved design and implementation of quality health communication and services will include marital status, education level, and place of residence well as an improved understanding of the factors that motivate adolescents to make changes in their behavior.   

Programming emphasis areas are intended to create an enabling environment and expand adolescent access to quality information and services; further, they are linked to the PRH Technical Focus Areas (Method Choice, Social and Behavior Change Communication [SBCC], Family Planning Workforce, Total Market Approach, and Supply Systems). While the following do not address the full range of best and promising practices in adolescent health, PRH Youth Technical Team believes that USAID is best positioned to invest in the following areas:

• Ensure adolescents have ready access to a wide range of contraceptive methods, including long acting and reversible contraceptives, emergency contraception, fertility awareness-based methods,⁸ and condoms (Technical Focus Area: Method Choice, Total Market Approach, Family Planning Workforce)
• Adolescent friendly contraceptive and reproductive health service delivery approaches that meet the needs of priority populations (e.g., married adolescents and unmarried, sexually active adolescents) as part of clinic-based and mobile services, social franchises, social marketing, community-based distribution, and drug shops.  
• Contraceptive service and referral integration where adolescents naturally access health services, such as HIV (e.g., for orphans and vulnerable children [OVCs] and adolescents living with HIV); treatment for sexually transmitted infections (STIs); antenatal clinics (ANC) and maternal and child health (MCH) (e.g., for married adolescents); voluntary medical male circumcision and even dental services (for adolescents who may be reluctant to seek other health services).
• Partnerships and referral systems with schools and workforce programs, sports and recreation activities, and adolescent "safe spaces."
• Provider biases and concerns in the provision of contraception to both married and unmarried adolescents addressed through the development and implementation of quality standards of care for adolescents, criteria and guidelines for adolescent friendly services, as well as pre- and in-service training in quality standards of care for adolescents for all health care workers, employing a whole of clinic approach.
• Supportive policies that address legal and/or socio-economic-cultural and gender-related barriers to adolescent access to contraception and reproductive health services, and engage the community, traditional and religious leaders as well as parents, spouses, in-laws, and the extended family to support adolescent health, reduce stigma around adolescent sexual activity and/or contraceptive use, and address gender norms around fertility.
• Emphasize the provision of adolescent friendly postpartum family planning, ANC and MCH services, as well as post abortion care, especially for young and first time parents to encourage early uptake of contraception (Technical Focus Area: Method Choice, Total Market Approach, SBCC)
• Community-to-facility contraceptive linkages for adolescents, especially for first time parents, are strengthened.
• Adolescent friendly and gender-sensitive approaches are applied in all health services that are provided to young people, regardless of marital status or parity.
• Performance-based incentives that encourage delivery of high quality services to adolescents as well as task shifting to increase the number of providers who are interested in serving adolescents.
• The health and social benefits of contraceptive use for healthy timing and spacing of pregnancy for young women and their children are well understood among couples, first time parents, extended family, and the community, to include the community health system as well as key influencers, such as traditional and religious leaders.
• Create an enabling environment that supports the delivery of adequate, developmentally appropriate, and gender equitable information about sexuality, fertility, relationships, gender, STIs, HIV, and contraception to adolescents and addresses perceptual barriers to contraceptive and condom use (Technical Focus Area: SBCC)
• Supportive policies are in place and enforced
• Multichannel and segmented SBCC programs address key knowledge and attitudinal gaps includingmyths, misinformation and concerns among adolescent boys and girls about menstruation, puberty, fertility, STIs, HIV, contraceptive methods, and gender norms.
• Messengers/role models that are trusted adolescents are engaged, and SBCC programs also target gatekeepers and key influencers of adolescents decision-making and outcomes, such as husbands and families for married adolescents; and parents, partners, peers, teachers, traditional, and religious leaders for unmarried adolescents.
• Mobile technology and social media are utilized to provide information, create virtual support networks, and link adolescents to health services, including mobile phones for reproductive health platforms (m4RH) and e-Vouchers for reproductive health and contraceptive services.
• Adolescent specific concerns are included in community based education, outreach, and demand creation efforts.
• Peer education or sexuality education programs ensure fidelity to evaluated best practices.
• Design, support and/or leverage existing programs for adolescents that work across two or more sectors and that integrate health information and services to promote synergies, address common risk and protective factors and to expand reach of family planning and reproductive health programs. (Technical Focus Area: Total Market Approach, SBCC)
• Support efforts to enable girls to transition to and remain in secondary school and build support for girls' education through community-based health platforms such as community councils, traditional leader structures, parent teacher organizations, village savings and loan groups, OVC programs, and other community bodies. (See High Impact Practices brief
• Support policies and programs that prevent all forms of GBV, including early/child marriage and mitigate its effect on the wellbeing of adolescent boys and girls.
• Promote workforce development programs that integrate "life skills" as part of "soft skills" training, to include health information and links to health services.
• Support the integration of environmental and reproductive health programs for adolescents and youth.
• Ensure linkages between schools, school health programs, and health services are strengthened.
• Develop programs that not only reduce risk, but also strengthen protective factors, assets and resilience, and implement approaches that include mentors, supportive role models, and positive gender norms among boys and girls.
• Strengthen adolescent leadership, agency, and engagement in reproductive health programs.

Tracking Success

One of the most fundamental needs to measure success is the availability of age disaggregated data that is, at a minimum, disaggregated by 5-year age bands (e.g., 10–14, 15–19). All health programs should establish adolescent appropriate indicators. Basic indicators can include one or more of the following, depending on the goal and objectives of your program9:

• Age at first marriage:  Percentage of women who were first married by exact age 15, 18, 20, 22, and 25, according to current age.  
• Current marital status:  Percent distribution of women by current marital status, according to age (e.g., percent of women 15–19 who are married).
• Teenage pregnancy and motherhood by background characteristics: Percentage of women 15–19 who are mothers or pregnant with their first child by selected background characteristics (note: In some countries, this data is only collected from married women, which may overlook childbearing among unmarried adolescents).
• Birth intervals by background characteristics: Percent distribution of non-first births among adolescent women age 15–19 in the 5 years preceding the survey by number of months since previous birth, according to selected background characteristics.
• Current use of contraception:  Percent distribution of all women, of currently married women and of sexually active unmarried women by contraceptive method currently used, according to age (e.g., 15–19) .
• Age at first sexual intercourse:  Percentage of women who had first sexual intercourse by exact age 15, 18, 20, 22, and 25 and median age at first intercourse, according to current age.
• Recent sexual activity:  Percent distribution of women by sexual activity in the 4 weeks preceding the survey and the duration of abstinence by whether or not postpartum, according to selected background characteristics (including age and marital status).

Annex. Technical Support

PRH supports a full-time youth advisor, Cate Lane, who can be reached at clane@usaid.gov.  A Youth Technical Team of PRH staff with strong interest and experience in youth programming across a range of programmatic areas includes:

Michal Avni (gender): mavni@usaid.gov
Jane Ebot (research): jebot@usaid.gov
Andrea Ferrand (SBCC): aferrand@usaid.gov
Temitayo Ifafore (workforce development): tifafore@usaid.gov
Joan Kraft (gender): jkraft@usaid.gov
Shegufta Sikder (research): ssikder@usaid.gov
Reena Shukla (HIV, OVC, GBV, service delivery): rshukla@usaid.gov
Shelly Snyder (policy): ssnyder@usaid.gov
Linda Sussman (research): lsussman@usaid.gov
Nandita Thatte (research): nthatte@usaid.gov
Amy Uccello (community-based service delivery, HIV): auccello@usaid.gov

Several global mechanisms have a focus on youth and can be utilized to program for youth at the country level:

1. www.pepfar.gov/documents/organization/201386.pdf [PDF, 2.9MB]

2. Pregnancies that under occur under age 15 and closely spaced pregnancies among adolescents contribute to maternal and infant mortality

3. apps.who.int/adolescent/second-decade/

4. www.thelancet.com/series/adolescent-health-2012

5. apps.who.int/adolescent/second-decade/

6. dhsprogram.com/pubs/pdf/CR34/CR34.pdf [PDF, 1.7MB]

7. www.prb.org/Publications/Reports/2012/demographic-dividend.aspx

8. In the presence of irregular vaginal bleeding (which is common among adolescents), FAM methods may be unreliable. Barrier methods should be used until bleeding patterns are compatible with proper method use. See: www.ncbi.nlm.nih.gov/books/NBK138643/

9. The USAID-funded FOCUS on Young Adults project developed a tool for monitoring and evaluating adolescent reproductive health programs: http://www2.pathfinder.org/pf/pubs/focus/guidesandtools/PDF/Part%20I.pdf [PDF, 3.5MB]