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Callie Simon is technical advisor for adolescent and youth sexual and reproductive health (AYSRH) at Pathfinder International. Based in Washington DC, Ms. Simon provides technical assistance to Pathfinder’s AYSRH programs globally, in addition to supporting Pathfinder’s AYSRH advocacy efforts domestically and abroad.
Claire Cole is technical documentation advisor at Pathfinder International. Based in Boston, MA, she supports Pathfinder’s global offices in implementation analysis to advance technical practice.
Today’s generation of young people is the largest in history. Through the sheer size of their numbers and where they live— predominantly in resource-limited countries—young people represent the future and present of development. Yet, essential sexual and reproductive (SRH) health services that have the power to help a young person shape the direction of his or her life (and health) are often out of reach. Young people are unable to access the high-quality services they need because of community and provider stigma, lack of confidentiality and privacy, and health-system limitations like cost, operating hours, location of services, and shortages of trained providers.
Thankfully, in recent decades this issue has increased in prominence among our global health professional community. The concept of youth-friendly services (YFS) is more readily discussed as a core part of global health services—as evidenced at the 2011International Conference on Family Planning in Dakar, as well as the 2012 International AIDS Conference just last month in Washington, D.C.
Unfortunately though, when we think of the size of the global population of young people, we have to recognize how insufficient current coverage of YFS is to meet the challenge posed to us. Boutique YFS programs and small-scale pilots are never going to enable us to ensure these populations have the health services they need. Scalable YFS strategies are essential to fulfilling the rights of the nearly 3 billion people under the age of 25 who need these services now, and who will continue to need them in the years to come. But getting to this goal will require multi-dimensional thinking on our part. What does multi-dimensional thinking mean in this context? It means recognizing that geographic expansion to more and more clinics is not going to be a sufficient answer to the challenges posed by larger upstream factors that create barriers to sustainable, institutionally-supported YFS. We need solutions like pre-service training, which has the power to produce providers readily able to respond to young clients’ needs from the start of their medical careers, and policies that support young people’s right to quality SRH —regardless of marital status or sexual orientation. We need to capitalize on opportunities to take existing YFS to scale, and push wherever possible to introduce YFS into current large-scale programming.
In Pathfinder’s experience in Ethiopia over the past eight years, we’ve learned a substantial amount about what it looks like to do this. We found ways to mainstream adolescent and youth sexual and reproductive health by introducing YFS into large-scale reproductive health and family planning programs. When funding gaps looked to be signaling the end to our first large-scale YFS effort, we found ways to work YFS into our next large-scale collaboration with the FMOH—in this case via the Integrated Family Health Program (IFHP). Working in regions that comprise more than 80 percent of the country’s population, the potential for geographic scale was a given. But institutional scale—that is, ensuring that YFS was part of the national reproductive health strategy, that there were national training curricula, guidelines, and standards for YFS, and that YFS was a part of regional MOH work planning and monitoring structures—was equally important. Working at these two angles in tandem, we were able to support the FMOH in navigating the myriad challenges that are inevitably part of scaling a critical but often neglected and stigmatized service like YFS.
But more is needed. We need collective action, partnerships, and learning to ensure YFS is brought to scale more regularly across our global health landscape. Across agencies, we need to share our lessons, our challenges, and our failures from implementation as we strive toward this goal. With the increased attention being given to YFS, there’s good cause for optimism that this learning-oriented dialogue around YFS will only continue to grow. Our recent technical brief, Bringing Youth Friendly Services to Scale in Ethiopia, captures many of the key lessons and take-aways from our experience scaling YFS through IFHP. We look forward to continuing this important dialogue with the greater YFS community in the future.
IFHP is a five-year (2008-2013) USAID-funded project that collaborates with the government of Ethiopia to promote an integrated model to strengthen family planning, reproductive health, and maternal and child health services for rural and hard-to-reach populations. The project works in six regions: Oromiya; Tigray; Southern Nations, Nationalities, and Peoples (SNNPR); Amhara; and parts of BenishangulGumuz and Somali. The project is led by Pathfinder International and John Snow, Inc. in partnership with the Consortium of Reproductive Health Associations (COHRA) and 11 other local implementing partners.
Victoria Pascoe is a project associate at JSI where she works on issues relating to family planning and reproductive health. She is interested in sexual health and education and teaches a school-based health curriculum on puberty and adolescent development to 6th graders in Massachusetts.
The somewhat wary yet energetically charged group of 12-year-olds responds with a resounding “pituitary gland!” The chorus dies down a bit and predictably becomes interspersed with giggles as we progress to body parts and reproductive anatomy in this “parroting” game we use to break the ice. When I ask if they know what the pituitary gland does I’m met by blank stares. I explain that it is a small gland at the base of the brain; it releases hormones that trigger changes that occur during adolescence. For this brief overview of puberty, that’s as far as we delve into the role of the brain in the complex reaction of physical, cognitive and social changes that adolescents experience.
However, advances in neuroimaging technology over the past decade have shown that hormone production is just the tip of the iceberg in what is the complex and dynamic adolescent brain. Research* suggests that the prefrontal cortex — which is responsible for functions like impulse control, planning and decision-making, and risk assessment — continues to develop and mature throughout adolescence. These insights into the neurobiology of the adolescent brain are improving our understanding, shifting our conversations and informing how we relate to adolescents. This new knowledge is important for us to have about a stage of life that can be confusing for teens, who are weathering these changes, and also for their parents, who often struggle to understand and relate to them during this time.
Many resources have been produced to help parents and educators understand the implications of the new findings. Less has been said, however, about how this information translates in the health care setting. How can this information better inform the work of health care providers working with teens? To address this need, JSI Research & Training Institute, Inc. (JSI) developed “Inside the Adolescent Brain: New Perspectives for Family Planning Providers,” an online course on the neurobiology of adolescent brain development to improve reproductive health care for adolescent patients.
Family planning providers sometimes feel mystified, discouraged, or frustrated in their work with young clients, and communication barriers threaten the open and honest dialogue that is essential to minimizing risky behaviors. This course guides providers though the interplay between sexual and neurological development, adolescent risk-taking behaviors and decision-making, and effective approaches for counseling and educating adolescent clients. For providers to successfully interact with teen clients, it is crucial that they reorient their expectations of adolescents, create a safe environment for care, and use adolescent-specific counseling and communication techniques.
JSI’s online course prepares family planning practitioners to support adolescents and effectively provide them with the health information they need to navigate this often tumultuous period. Facilitating improved communication and strengthening relationships in this way will not only result in improved health outcomes but also will foster positive experiences in the health care setting, for both practitioners and teens alike.
* For more information on this research, refer to The National Campaign to Prevent Teen and Unplanned Pregnancy’s Report – The Adolescent Brain: A Work In Progress
This course was funded by Office of Population Affairs/Office of Family Planning, U.S. Department of Health and Human Services and Centers for Disease Control and Prevention.)
The course is available for FREE on JSI’s eLearning Management Platform here
This is the third post in our series, Adolescent Girls, Microbicides, and HIV Prevention Trials. Ms. Doreen Bangapi, community recruitment officer; Ms. Anna Kaale, study coordinator; and Dr. Sylvia Kaaya, local principal investigator, are with Muhimbili University of Healthand Allied Sciences (MUHAS) and work with FHI 360 on the study.
A unique aspect of the trial titled “Adolescents, Women and Microbicide Trials: Assessing the Opportunities and Challenges of Participation,” is the involvement of a youth interactive group (YIG) in various aspects of the research process. The YIG, which is composed of Tanzanian youth ages 20 to 26, was formed as a strategy for involving the community in this study. Community involvement before and throughout HIV prevention trials is essential for a successful trial. Youth are a particularly important group of stakeholders given that this study focuses on adolescent participation in trials. Thus far, YIG members have participated in a research literacy workshop and a study initiation meeting, and they have attended regular meetings where their feedback on various research issues has been solicited. For example, YIG members have provided suggestions and strategies for recruiting study participants, finding high-risk youth to participate, retaining participants in the study, and making our study clinic more youth-friendly and informative.
YIG members have been particularly helpful in the recruitment of study participants. They have helped develop and distribute brochures about the study and they have participated in peer education sessions with potential participants—explaining the study and answering their questions. In a focus group discussion, YIG members told us that challenges to recruitment included participants’ reluctance to admit sexual activity and sexual matters with adults as well as the need for parental support (and perhaps consent) for study participation. Members also said that recruitment was difficult because many youth in the Dar es Salaam area are highly mobile. One YIG member noted, “You find today a young woman is here but some few days later you find she has shifted to another place.”
YIG members felt there were numerous benefits to adolescents and young women participating in the study. Benefits included learning more about sexual health and their risk of HIV/STIs, gaining more opportunities to talk with parents and guardians about HIV and other health issues (particularly for 15-year-olds, who require parental consent to participate), knowing their HIV status, and learning more about the process of evaluating new health products such as microbicides. In addition, YIG members said that study participants might become valuable sources of sexual and reproductive health information within their own peer networks.
Regarding the benefits of their own participation in the research, one YIG participant said, “First of all, I like being part of the YIG of the study because I discover new experiences about reproductive health among girls…and second, I get to know how people know about HIV/AIDS.”
Leonard Bufumbo is a research associate with FHI in Uganda. He worked on an operations research project focusing on voluntary counseling and testing with youth. The project was funded by USAID in 2000–2002 and implemented by Sociology Department of Makerere University, Kampala, Uganda.
As part of a youth assessment in Uganda, I led a team of data collectors in an effort to understand the sexual and reproductive health needs of youth. Our study consisted of focus group discussions with young people, interviews with government stakeholders, and assessments of health facilities that young people reported as being “youth-friendly.” Observations from this assessment confirmed that youth in Uganda face a number of challenges. Rates of teen pregnancy are high, use of family planning is low, and adolescents face many difficulties in accessing care.
After this trip, this is what I think. Youth have not yet been understood. The health workers think they understand them, but they don’t. That’s the biggest challenge! When young people present a complaint to a provider, the complaint often does not reflect what they truly need. When youth seek services, they often seek help with psychosocial issues that have more to do with relationships, both sexual and non-sexual, than they do with clinical issues. Sometimes, youth will even go to the clinic, not report anything at all, and just hang idly around. The youth do this because they believe it will provide them an entry point to services. These same youth will continue to try and access services, and sometimes they have to bring up the same problem at every visit to a clinic. Can you imagine? While this trend demonstrates positive health-seeking behavior among youth, it clearly shows that youth are not receiving the treatment that they really need. Furthermore, the service statistics reflect the issues youth initially report, NOT the real issues faced by youth.
In addition to the communication barriers, it seems clinic staff may simply not have enough time to deal with youth issues. Staff workload and staff shortages seem to take a toll on providers. Remember, these clinics are not only serving youth; there are many other members of the population that cannot be ignored.
Currently, there is an ‘impunity gap’ between national youth policies, guidelines, and strategies and the actual care provided at public health facilities. It is truly alarming! Something needs to be done structurally, behaviorally, and professionally to lessen this gap.
One way to immediately address this issue may be through peer networks. Peer educators can have great influences on peer members. Peer networks should focus on using positive deviance to sustainably change behavior; I believe this can be done without compromising the structure of the peer network.
While most of us enjoy working with youth because they are fun, we cannot forget that they are also vulnerable. There is still much that needs to be done to ensure that the reproductive health needs of young people are met.