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THEME PAPER
Strategies to Operationalize
Innovative Programmes
to Address Adolescent Concerns
Prof. Jay Satia
International Council on Management of
Population Programmes (ICOMP)
Kuala Lumpur, Malaysia
IUNFR4
South Asia Conference on the Adolescent
21-23 July, 1998
New Delhi - India
Section 2 of the paper reviewing current approaches, strategies and programmes draws heavily upon the country
papers prepared for the Conference. Unfortunately, the Pakistan country paper was not ready at the time this paper
was written and, therefore, it docs not include information from Pakistan. The framework for ASRII programmes
is based on the documented case studies of ICOMP which were reported in its two publications: Innovations Vol. 2
( 1995) and Population Manager Vol. 4 ( 1996). Thanks arc also due to Malicca Ratne and Hina Pradhan for their
comments on an earlier draft of the paper
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Theme Paper: Sfrafe^ic to Operafionalize Innovafivc Programmes to Address Adolescent Concerns
TABLE OF CONTENTS
Page
1.
INTRODUCTION
2
i
REVIEW OF CURRENT APPROACHES, STRATEGIES
AND PROGRAMMES
3
2.1
2.2
2.3
2.4
3.
ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH
PROGRAMMES: WHAT IS NEEDED?
3.1
3.2
3.3
3.4
3.5
3.6
3.7
4.
A Societal Vision for ASRH
Creating an Enabling Environment for ASRH Programming
A Framework for ASRH Programming
In-school Programmes
Reaching Out of School Adolescents
Peer Group Networks and Youth Centres
Special Services
OPERATIONALIZING ASRII PROGRAMMES
4.1
4.2
5.
Developmental Programmes
Health Programmes
NGO’s SRH Programmes
Post-ICPD Response
Issues in Operationalization
Strategies for Operationalization
CONCLUSION
REFERENCES
3
4
6
6
7
8
9
10
12
13
14
16
16
17
18
20
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
1.
INTRODUCTION
The country papers from the South Asian Region, prepared for this seminar, vividly
describe the adolescent needs and their sexual and reproductive health (SRH) problems.
The age of menarche has been declining and girls continue to remain ill prepared for
this event or understand its significance for reproduction. The age of marriage,
although still low in most countries, is gradually increasing thus the period between
menarche and marriage is widening which, coupled with the exposure to modernisation
influences, places new demands on adolescent sexual behaviour. Despite the increase
in age of marriage, the proportion of births to adolescents is high, except for Sri Lanka.
Contraceptive use among married adolescents remains low. The recourse to abortions
for unwanted pregnancies by unmarried adolescents is high. A large proportion of
adolescent girls suffer from anaemia as well as acute and chronic malnutrition, which
not only enhances the risk of teenage pregnancy both to mother and child but also
adversely affects full development of their human potential. Although varying in
intensity, there is concern about prevalence of STDs and IIIV/AIDS in this age group.
There is evidence of considerable violence, both physical and sexual, against
adolescents, albeit inadequately documented. In addition, there are special problems trafficking and prostitution, dowry, forced marriages, substance abuse etc.
Overarching these problems is the low status of girls, including in their adolescent
years.
Most countries view the adolescent sexual and reproductive health (ASRH) concerns in
the context of their overall socio-economic development. Thus, there are concerns for
their education, socialisation and livelihood. In studies elsewhere in the Asian region,
these are also highlighted as major concerns of adolescents. Once again, except for Sri
Lanka, more than half of all adolescents drop out of school by the age ot 15 yeais. The
girls often feel isolated, as opportunities to socialise, except within immediate family
circles, are limited although they contribute to household or other economic activities.
Special programmes for income generation for adolescents are few except for vocational
education and as a part of such income generation activities lor women.
Socio-cultural factors are an important determinant of ASRH behaviour and
modernisation influences impinge on tradition. Therefore, traditional responses to these
problems would not suffice.
Despite the recognition of importance of overall
developmental perspective and the seriousness of ASRH problems, the piogrammatic
responses have been meagre. There are no comprehensive national programmes.
Many NGOs have implemented innovative ASRH activities but both their coverage and
scope is limited. Generally developmental programmes of non-formal education (NFE).
credit, nutrition and health care serve adolescents but often do not pay special attention
to their needs or make their services adolescent-friendly. Post ICPD. ASRH has
become an area of concern, as reflected in the formulation of overall RH programmes
such as Reproductive and Child Health Programme (RCH) in India and Essential
Service Package in the Health and Population Sector Strategy in Bangladesh.
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
In this paper, we briefly review the current approaches, strategies and programmes to
address ASRH concerns (section 2), suggest what is needed (section 3); and develop an
operationalization framework to bridge the gap between what is needed and the current
status (section 4).
2.
REVIEW OF CURRENT APPROACHES, STRATEGIES & PROGRAMMES
Adolescent health concerns are of more recent origin and most programmes are in their
infancy. The current approaches and strategies could be classified under four headings:
(1) developmental programmes including education and income generation for women,
(2) various health programmes such as population education/family life education
(FLE), family planning (FP), maternal and child health (MCH), nutrition, and
HIV/AIDS; (3) innovative SRH programmes of NGOs; and (4) post-ICPD response of
the countries. Given the wide diversity and richness of initiatives as well as lack of
information on their coverage and effectiveness, the review is stylistic in nature.
2.1
Developmental Programmes
Adolescent girls are the most vulnerable as women generally have low status. In order
to ensure gender equity, equality and empowerment of women, most countries have
established legal frameworks and institutional structures, implemented special formal
and non-formal education, and vocational education and income generation schemes.
To encourage girls’ education at secondary level, a special scholarship scheme has been
introduced in Bangladesh. Both Bangladesh and India have made girls schooling free.
Non-formal education has been a major approach to address low enrolments in the
formal education system. The non-formal and literacy education in Nepal aims at
providing educational opportunities to children of 8 - 14 years of age group who have
missed primary school. The graduates of these NFE programmes are encouraged to
enter regular schools. Similarly, BRAG, an NGO in Bangladesh, operates 34,000
schools having an enrollment of 1.2 million children for NFE where 70% participants
are girls. In Maldives, NFE emphasizes educational needs of the large over-age school
population through an accelerated educational programme. Bhutan government has
used NFE strategy to expand access to functional literacy and 70% of attendees at NFE
centres are women.
Most of the NFE in Sri Lanka is directed towards skill
development. However, a large number of literacy classes are also conducted.
Both government and a large number of NGOs operate vocational skills development
and micro-credit systems. However, very few of them have special focus on adolescent
girls. While generally they have achieved success, albeit to a varying degree in the
countries, the participation rate of adolescents and the benefit derived by them are not
clear.
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
All governments also have programmes for youth development, which mainly focus on
their socialization and involvement in community development activities. In Maldives,
the Maldives Youth Centre conducts education and training, sports and recreation and
social and cultural programmes. The Bhutan Youth Development Association aims to
channel energies of adolescents/youths through promotion of sports activities,
organizing social services and supporting youth guidance centres. Department of Youth
Affairs, Government of India also mobilizes youth through its centres called “Nehru
Yuva Kendras”. In Sri Lanka, the National Youth Services Council trains youth
leaders in youth clubs and other such networks. It has incorporated RH education and
counselling services in its programmes.
There are very few integrated programmes. One such example is UNFPA supported
Haryana Integrated Women’s Empowerment and Development Scheme in India
(UNFPA 1998). The adolescent girls’ component includes life skills development and
imparts practical competencies including basic literacy and maths, health, sanitation and
nutrition, and RH and reproductive rights.
There has been steady increase in education levels of adolescent girls, the female
participation in organized sectors of economic activity has been increasing and generally
the legal and institutional frameworks have become more favourable for gender equity
and equality. However, much more needs to be done.
It is also worth noting that there have been no special programmes for adolescent boys.
If gender equity and equality are to be internalized, it is important that such values are
imparted to and internalized by them.
2.2
■ Health Programmes
Most countries, largely with UNFPA assistance, have been implementing population
education for more than a decade. Earlier population education largely covered
population and development, population growth, and family planning. The main aim
was to institutionalize it at all levels of school education. These programmes had some
impact. More recently, their scope has been broadened to include emerging concerns
including family life education (FLE), HIV/AIDS and drug abuse,
although
considerable effort will be required for its effective integration into curriculum, material
development and teachers training. In Sri Lanka, as a successor to Population
Education/FLE, a programme on RH education is being introduced. It incorporates
both social and medical aspects, and will sensitize parents and test peer education on a
pilot basis. Building on earlier population education efforts, Nepal has recently
implemented a project in 20 of its 75 districts which aims to create awareness of
benefits of late marriage, delay first pregnancy, use of FP methods, birth spacing and
MCH care. In Bangladesh, some NGOs are implementing innovative FLE models.
Adolescents in all the countries of the region have expressed a need for FLE.
4
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
Malnutrition as well as anemia not only limit development of full human potential but
also increase the risks associated with teenage pregnancies. It is not clear how many
countries have programmes to address this issue. However, it is worthy to note that the
Integrated Child Development Scheme (ICDS) in India has extended its activities to
adolescent girls in the age group 11-18 years. This programme operates through Girls’
Clubs and provides health and nutrition supplementation. It is an extension of such a
programme for pre-school children and pregnant mothers. However, innovative and
cost-effective ways to address this problem are yet to emerge.
Until recently family planning programmes in the region were guided mainly by
demographic considerations of reducing fertility to decrease population growth rate.
Consequently, they did not pay special attention to contraceptive education and service
needs of married, let alone unmarried, adolescents. As fertility rates have begun to
decline, the realization has grown that population momentum would be a leading cause
of future population growth. Therefore, some attention is now given to delaying the
age of marriage and of the first birth. Since social norms generally do not favour
delaying the birth after marriage, emphasis is being placed on delaying the age of
marriage. Most countries have laws on minimum legal age of marriage although in
rural areas these may not be strictly enforced. Consequently, the extent of unmet need
for contraception, unwanted pregnancies and abortions among adolescents seem high.
Many factors determine the age of marriage and alternative social and economic options
need to be made available through multi-pronged strategies.
Although the pregnancy-related risks associated with teenage pregnancy are higher,
MCH programmes in the region do not pay special attention to them. Despite some
IEC activities, communities also do not seem to be aware of these higher risks.
Most national AIDS programmes have carried out a variety of IEC activities. Although
adolescents are at higher risk, these are not specifically directed at them. This has
The
resulted in either lack of or only a superficial knowledge of HIV/AIDS.
knowledge about STDs is even lower, as the country papers have documented, Most
societies seem to have underestimated pre-marital sex, especially among boys, The
evidence is growing that a significant proportion of young boys may have visited
commercial sex workers and generally indulged in unsafe sex. There is a need to evolve
methods and IEC materials to reach young persons. Special efforts also need to be
made to encourage use of condoms to ensure safe sex.
Many NGOs and most governments have shelters for women and some legal framework
to address violence against women.
Recently laws related to rape have been
strengthened in most countries. Despite many women’s NGOs having taken up this
issue, both the documentation of and responses to violence remain grossly inadequate.
Similarly, there are sporadic attempts to address problems of adolescents who face
difficult circumstances such as refugees and migrants. Away from the traditional social
support systems, they are particularly vulnerable to exploitation.
5
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
2.3
NGOs’ SRH Programmes
Generally NGOs have been more at the forefront than governments in addressing ASRH
concerns. A large number of NGO programmes in India are described in the country
paper for India. For instance, the Better Life Option Programmes of CEDPA fosters
self esteem among adolescent girls through increased access to NFE, FLE and RH
education and services, and skills and vocational training. The Family Planning
Association of India (FPAI) provides health counselling and information services for
adolescents. Several organizations are working towards ways to respond to and prevent
sexual abuse. Some NGOs work with legal ramifications of abuses such as dowry,
divorce, child custody and rape. Yet a few others have programmes to rehabilitate
commercial sex workers and many organizations have been working with street
children. Many NGOs are also working on programmes to prevent HIV/AIDS. In
addition, NGOs have carried out advocacy activities.
In Nepal, FPAN has implemented FLE programmes and a few NGOs are actively
involved in AIDS awareness programmes. The projects and programmes of NGOs in
RH include FP MCH, prevention education of HIV/A1DS and STDs, condom
promotion and diagnosis and treatment of RTIs. Since 1994, NGOs have been
particularly active in the needs assessment, research and advocacy for ASRH. Some
are active in advocating against violence and girls trafficking.
Sri Lanka has relied on pioneering FP NGOs such as the Family Planning Association
of Sri Lanka (FPASL) to cater to the reproductive health needs of adolescents including
in-school RH education. Pre-marital counselling in SRH is addressed in the education
programmes of NGOs.
The government and NGOs work closely to facilitate
implementation of laws against sexual abuse and violence.
NGOs have played an important role in the family planning programme in Bangladesh.
Several NGOs provide FLE and operate youth clubs. Jatiyo Tarun Shangh (JTS)
operates a large number of youth clubs that are active in population work. Recently
some of them have begun adding other ASRH activities.
Thus the review shows that NGOs have developed innovative ways to address specific
RH concerns. They have generally worked on a few specific aspects of RH, rather than
addressing comprehensive concerns of adolescents.
Many also do not have
comprehensive ASRH programmes to cover specific geographic areas. They would
have to develop and pilot test such approaches which can lay the foundation for future
programmes to improve ASRH.
2.4
Post-ICPD Response
Post-ICPD, most countries have either planned or begun implementing adolescent
health as a part of overall reproductive health. In Bangladesh, ASRH is included under
6
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
the overall essential service package in the Health and Population Sector Strategy. It
will address nutritional deficiency, early and unwanted pregnancy, maternal services,
complications of unsafe abortions, RTI/STDs, addiction to substance abuse, accident,
violence and sexual abuses. Behaviour change communication and IEC, training to
service providers, involvement of private and NGO sectors and inter-sectoral
coordination are the major strategies. Similarly the RCH service package in India aims
to enhance RH knowledge of adolescents and improve self health-care as well as health
care seeking behaviour of adolescents and enhance awareness of communities to their
SRH needs. Nepal’s RH strategy encompasses inter-divisional within MOH and inter
sectoral coordination, which will deliver RH education services at family, community,
and health service levels. It will improve gender perspectives and empowerment of
women.
Counselling, sex education, contraceptive education and services and
STD/HIV/A1DS prevention would be specially targetted at adolescents. In Bhutan, the
programme would focus on improving quality of RH care and include various RH
services for adolescents. The RH education will also be emphasized in schools and
NFE activities, In Maldives, attempts will be made to make services friendly to
adolescents, MOH and Ministry of Education will coordinate SRH education in
schools. Sri Lanka had undertaken various SRH activities and a policy is being
finalized. Preventive strategies have been started through youth counselling centres and
vocational training centres. Post-ICPD, the governments have also encouraged greater
involvement of NGOs and other civil society organizations. They are participating in a
task force to formulate national policies. Both India and Bangladesh have formalized
mechanisms for enhanced NGO involvement.
These activities are of recent origin and theretore, it is difficult to predict their impact.
Although some actions are based on previously tested government or NGO experiences,
many are new. However, post-ICPD most governments have established a framework
in which ASRH education and services can take place.
3.
ADOLESCENT SEXUAL AND REPRODUCTIVE HEALTH PROGRAMMES:
WHAT IS NEEDED?
The review shows that the ASRH programmes are generally small scale except for
family life education in schools or AIDS awareness campaigns. Although post-ICPD
many countries are incorporating ASRH activities in their overall RH programmes,
there is a need to recognise that adolescents constitute a separate group which cannot be
treated in the same manner as adults, and even among adolescents, needs differ
depending on the socio-economic status and sexual behaviour. Often even married
adolescents are not able to access the family planning services because of either social
or economic barriers. Adolescents would generally like to be informed by their peers,
would like services which are friendly, and ensure privacy and confidentiality. They
are often not at places where adults may go for services. So the channels to reach them
would need to differ. Therefore, special ASRH programmes would be needed.
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Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
3.1 A Societal Vision for ASRH
However, before ASRH programmes can be launched, there is a need to create social
acceptability for them. ASRH is a sensitive issue in most communities. Therefore,
social acceptability needs to be created by analysing problems, carrying out advocacy
through communication and addressing those problems which are widely recognised as
those requiring action. All the stakeholders need to have commitment to ASRH. For
instance, if in-school ASRH education activities are to be implemented, the stakeholders
- Ministry of Education, district education officers, school principals, teachers and
parents - need to be sensitised and their commitment sought. Failure to get social
acceptability can also cause difficulty as it is easy to spread rumours about the nature
and intent of these programmes through media or otherwise.
In many South Asian countries, NGOs have begun to advocate for ASRH (see box 1).
In Sri Lanka, for instance, NGOs,
Box 1. Advocacy for ASRH in'Nepal
human rights groups and government
officials engaged in probation and
childcare services have been in the Various NGOs, particularly the Family
forefront in advocating preventive Planning Association of Nepal, are
workshops/seminars . for,
strategies and legal reforms.
The organizing
mass media has also played a useful parliamentarians, the media, women leaders
role in bringing to focus incidents of
exploitation and violence against
children to create a public opinion to
“===
enforce social control on these issues.
Although the recognition of the
need for ASRH programmes is
growing, continuing advocacy is
necessary. First, many believe that
ASRH may encourage an early onset
of sexual activities among adolescents.
......... ................ =-.............................
Therefore, one needs to demonstrate
that ASRH programmes will actually
lead to more responsible sexual behaviour among adolescents and that the harmful
effects on their health will decline. Second, sensitising policy makers and generating
their commitment should be a priority. Third, there is a need to demonstrate that
ASRH programmes can be implemented in diverse cultural settings.
.
■
;
■
“xrr5 ann * sZi tz™’
S'XSi.z.zs:
8
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
However, to develop a common societal vision,
Box 2
one must move beyond advocacy and
Commitment to Common Vision:
sensitisation to a broader participatory process
Four Stages
(box 2).
Sensitisation of key stakeholders
requires identification of and discussions on
Sensitisation
problems with them. Advocacy efforts require
__ ' •
s
intensive communication and dialogue with
Advocacy
various stakeholders.
The participation of
stakeholders in programme formulation would
Participation in programming....
increase their support to the programme.
S
Commitment to a common vision would go
Common vision
beyond these stages and provide appropriate
roles to key stakeholders in programme implementation.
A participatory process implemented by the Government of Uganda and UNFPA in the
development and implementation of Programme for Enhancing Adolescent
Reproductive Life (PEARL) illustrates how a common societal vision can be created.
The guiding principle was the approach that focused on the tasks, was inclusive and
participatory. The task focus implied that instead of discussing conflicting positions
about sexuality and reproductive health of adolescents, groups and representatives of ’
social and religious institutions should identify a problem to solve or an issue to
address. Inclusiveness means making room for all social partners including the youths
themselves as part of the process. The participatory process implies that each group can
contribute according to their strengths and mandate and complement each other in
addressing ASRH concerns (Farah and Nalwadda 1996). The PEARL programme has
been implemented on a pilot basis in four of Uganda’s 39 districts. Its objectives are to
(a) promote district and community support among leaders, positive cultural practices,
and responsible sexual behaviour among adolescents; (b) increase interpersonal
communication between parents, children and adolescents; (c) provide accessible,
acceptable and affordable RH services to adolescents; (d) develop skills of adolescents;
and (e) strengthen management capacity with a view to ensure programme
sustainability.
3.2. Creating an Enabling Environment for ASRH Programming
Currently governments do not have an explicit policy regarding the reproductive rights
of adolescents and ASRH programmes, although most governments have included these
activities as part of their broader approach to RH. The views regarding the desirability
of an explicit policy differ among the ASRH advocates. Some feel that it may be better
to let the programmes develop and demonstrate what can be done and the policy will
follow. They fear that a premature policy discussion could actually place barriers to
ASRH programmes. Others feel that a conducive policy environment can accelerate
implementation of ASRH programmes. Clearly the situation will differ from country to
country.
9
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
3.3. A Framework for ASRH Programming
Programming for ASRH activities suffer from two serious lacunas. First, the research
base on understanding the ASRH behaviour and its causes is weak. As Jejeebhoy
(1996) remarks, “ Unfortunately for programme planners, the paucity of reliable
information is less conducive to recommendations for adolescents programmes than to
research recommendations”. Second, the knowledge base on effectiveness of ASRH
programmes is inadequate. As Hughes and McCauley (1998) remark, “First, there is
broad and strong consensus on many elements of what constitutes ‘best practice’ based
on practice, not science. Second, the research knowledge base about programme
effectiveness is quite weak.”
Reflecting the current state of art, many authors have described the best practices for
ASRH (Amana, Population Manager Vol. 4). These usually address key elements of
programming such as (a) needs assessment, (b) addressing holistic needs of adolescents,
(c) creating a common vision, (d) programme strategies (peer education, linkages with
other agencies, segmenting the groups according to their needs, comprehensive range of
services), (e) implementation processes including adolescent friendly education and
services, and monitoring and evaluation, (f) appropriate IEC strategies and materials,
(g) importance to gender concerns, and (h) building capacity for sustainability.
A study group jointly convened by WHO, UNFPA and UNICEF (1997) also proposed
a framework for country programming for adolescent health.
According to the
framework, the programmes need to (a) promote development to meet needs; (b) build
competencies; and (c) prevent and respond to health problems. Its major interventions
are to create a safe and supportive environment, provide information and counselling,
build skills and improve health services. It recommends use of all settings where
adolescents may be found and all actors who may come in contact with them. Four
major challenges identified are to (a) building political commitment, (b) identifying
priorities for action, (c) maintaining implementation and (d) monitoring and evaluation.
>
The process of ASRH programming is important. The youth must be at the centre stage
and should be involved in programme planning, implementation and evaluation. The
programme design should begin with the identification of target segments - which age
groups, who and where. Then it is necessary to carry out a situation analysis through
surveys, focus group discussions, narrative research and/or other methodologies. This
exercise is necessary both to ensure that the real needs of target segments are addressed
and to serve as a basis for dialogue with the stakeholders which should follow in order
to determine the problems to be addressed as well as to generate commitment to address
them. The interventions should be based on an understanding of why the behaviour that
is sought to be changed persists. It is known that knowledge alone is often not
sufficient to cause change. Therefore, key determinants of behaviour need to be
addressed through programme interventions. Once the range of interventions and
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Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
activities have been identified, implementation arrangements would need to be worked out.
Ultimately the programmes should not only cause the desired behaviour change but also
empower the youth and the community to ensure programme sustainability.
Comprehensive ASRH Programmes
Although the ASRH programmes would have to be appropriate to their cultural context and
need to continuously learn and adapt as the knowledge base strengthens, a contour of such
programmes emerges (figure 1) through an analysis of documented innovations
(Innovations Vol. 2 1994. Population Manager Vol. 4 1996). A comprehensive ASRH
programme would have three components:
Sexual and reproductive health education for in-school and out of school adolescents
through parents, teachers and mass media;
Youth centres supporting a peer group network, telephone counselling and personal
2.
counselling; and
A referral network for promotion and provision of special services, although some
3.
services may be incorporated in the above components.
These components would have to be supplemented to address special programmes such as
those for violence against women and trafficking for prostitution or street children.
The life styles of adolescents have great influence on their sexual and reproductive
behaviours. The promotion of values, opportunities for employment and education as well
as the provision of social events (sports, outdoor activity etc.) can further strengthen a
comprehensive ASRH programme. Since ASRH is a sensitive issue, the cultural context
must be given adequate attention during the process of programme design and
implementation.
Figure 1. Comprehensive Youth Reproductive Health Programmes
CULTURE
EMPLOYMENT
LIFE STYLE
VALUES
PROFESSIONALS
/ HOT LINE x
PEER-GROUP
YOUTH CENTER
1N/OUT OF SCHOOL
SRHE
EDUCATION
COUNSELLORS
STAFF, MECIA
ARENT
LACHER
SPORTS SOCIAL EVENTS
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
3.4. In-school programmes
Our review had shown that
population education and its
successor
family
life
education programmes are
being offered in almost all the
countries.
However, their
coverage and impact are not
clear. An innovative example
of ASRH education in schools
in Sri Lanka is shown in box
3.
Teachers and parents play an
important role in in-school
programme, Although some
also
educate
programmes
the activities to
parents,
interaction
(he
improve
and
parents
between
adolescents; to inurture and
of
support
the
process
J
maturation have not been
emphasised. A programme in
Indonesia organises families
into small groups, which meet
to
discuss
periodically
problems/issues.
adolescent
these
group
Through
facilitated
by
meetings,
trained cadres, families are
exposed to ways of addressing
adolescent
problems
and
needs.
Box 3
In-school Programme
Family Planning Association of Sri Lanka
This innovative programme was started in 1992. Its
objective is to provide youth with information on
growing up process, reproductive system, sexuality,
STDs including HIV/AIDS, and create opportunities for
counselling
On the basis of a request from the school, a three-hour
multi-media presentation is organised by a team of a
former teacher and an organiser. It includes lectures,
films, question-answer sessions, pre-test and post test.
To ensure follow up as well as to institutionalise the
programme, teachers, who volunteered, are trained to
provide in-school sexual and reproductive health
education as a regular part of curriculum.
z
The major lesson is that commitment within the
Ministry of Education and among school principles was
created through a process of dialogues and advocacy. .
Linkages were established with selected youth
organisations and other NGOs. Initially the publicity
about the programme was kept to a minimum so as not
to risk adverse public opinion.
More than 200,000 students were covered in the
programme by 1994. Now in collaboration with the
government, the programme is extended to 18 districts.
Although the programme initially used special teams,
there is debate as to whether such education should be
included in regular curriculum and taught through
teachers. The former is more costly but the latter may
dilute the emphasis and quality of education.
Generally the content
of such education includes (a)
personal: human physiology,
It is estimated to cost US $0.84 per student or US $
primary health care, changes
300,000 per year if extended to whole of Sri Lanka.
at
puberty,
child/parent
(Basnayake and Andersson 1995)
conflict, nutrition, hygiene,
self esteem and problems and
options of adolescents; (b) societal: relationships, responsibilities, family planning, love
12
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
life styles, parenthood; and (c) social problems: smoking/alcoholism, prostitution, STDs
and H1V/AIDS, drug abuse and child abuse.
The Bangladesh Rural Advancement Committee (BRAC) in Bangladesh has pilot tested
a FLE curriculum in its NFE schools as well as in selected government schools. It is
currently being evaluated. Once refined, BRAC plans to make it more widely available
in (he country and assist in upscaling it in the schools.
Most such programmes emphasise provision of information. However, theories of
social influence suggest that this may not lead to behaviour change. They suggest that
adolescents need to acquire “life skills” such as planning ahead, decision making,
problem solving, negotiating and forming positive relationships if their behaviour is to
change.
Some groups have now embraced the centrality of skills building for
adolescents in their programmes (Hughes and McCauley 1998, Population Manager
Vol. 4 1996).
3.5. Reaching Out of School Adolescents
Unfortunately, in most of the South Asian countries (Sri Lanka is an exception), many
adolescents are out of school by the age of 15, particularly in rural areas. They need to
be reached through special means. These have included youth guidance centres in Sri
Lanka, vocational training centres in India, Sri Lanka and Bhutan, youth clubs in India,
Bangladesh (box 4) and Maldives or work place programmes such as in export
processing zones in Sri Lanka. Unfortunately the data on the scope, coverage or
effectiveness of such activities are not available. One innovative mechanisms used by
many NGOs has been a camp approach (box 5).
Box 4
Youth Clubs in Bangladesh
A UNFPA supported project on involvement of youth in population and family
welfare activities through the Department of Youth Development of the Ministry
of Youth and Sports in Bangladesh, aims to train the youths in the training centers
on family welfare education, and develop leadership qualities and appropriate
skills in population education activities for the organizers of the local level
voluntary youth clubs. After the training, the organizers mobilize the members
and the community for population activities.
(Department of Youth Development 1996)
■
13
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
Box 5
Camps for adolescents
’
•
;
Action 1" and Research in Comrnunity Health
The Society for Education, Action
(SEARCH) in India, as an extension of its community-based health programmes,
started giving lectures on sexuality and sex education to adolescents in nearby
schools. A similar programme was organized for parents and teachers. Because
of high demand, “Family Life Education and Personality Development” camps
are being organized regularly. The five and a half-day residential camps
(separate for boys and girls) focus noLonly on sexuality education but also on
personality and skills development..(such as repairs at home,, and use of
telephone). To address the cause of sexual exploitation of girls, gender issues
are addressed. In addition, each participant receives a medical examination.
The cost per trainee is estimated to be about US $ 15.
(Mavlankar et aL 1998)
3.6
Peer group networks and youth centres
Adolescents get information or seem to learn about SRH issues through their peers and
many would prefer peers to the parents or teachers for such knowledge. Therefore,
many programmes rely on peer educators. Typically, in such a programme, peer
educators are trained and supported by a counsellor in their activities.
Box 6
Peer Educator Networks
The Lucknow Centre of the Sex Education, Counselling, Research, Training and
Therapy (SECRT) Programme of the Family Planning Association of India has
trained peer educators through a three-day workshop. The , training covers
information on sexuality, preparing for marriage and planned parenthood, sexual
behaviour development, drugs, STD and HIV/AIDS, and counselling and
leadership skills. The peer educators (called ‘young inspirers.’) carry out a variety
of outreach activities as well as counsel their peers at school and in their
residential neighbourhood.
. •
(Chakraborty et. al. 1995)
A project supported by UNFPA to improve? health care for adolescent girls living
in urban slums of Jabalpur, in Madhya Pradesh, India uses a cadre of adolescent
girls as. health guides to provide, continuing education, about ARII arid..information
on where to obtain services for adolescent-girls’ The project objectives were to
reach adolescent girls who have RH problems with medical care and appropriate
treatment, to improve maternal care, to increase the use of family planning and to
provide'a range of quality RH services and information to them. The service
delivery network was also expanded by training providers about-the-special needs
of adolescents.
(UNFPA 1998)
14
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
In many countries, youth centers (box 7) have been opened with objectives of not only
ASRH activities but also training for leadership and voluntarism. They usually support
a peer educator network and counselling services, but also include a whole range of
outreach activities such as talks, dialogues etc., youth Camps, education sessions for
youths in factories, talks and poster competitions. They may also include other services
for adolescents such as legal advice, career guidance, and referral services.
Box 7
The Rural Women Social Education Center (RUWSEC), India.
RUWSEC is a community-based NGO that focuses on the rights of women
in their households,, including reproductive rights and their overall well
being. Its ASRH programme comprises of (a) separate in-school workshops
for girls and boys of class VIII; (b) health festivals or “Melas” for
adolescent girls; (c) educational programmes for young women factory
workers; and (d) youth center for adolescent boys.
RUWSEC recognized that adolescent boys (11-18 years of age) had
remained in the periphery of its programmes. The issues of career and
employment, in addition to all the other concerns that they share with
adolescent girls, are their major concerns. Failure in examinations and
unemployment push potentially productive male youth to anti-social
behaviour out of frustration. So RUWSEC set up a youth center in a large
village, which provides facilities for recreation, education and assistance
with school examinations and choice of career. Sex education and health
care counseling are also provided. The Center conducts weekly half-day
workshops on gender sensitisation, gender relations within marriage,
sexuality and responsible safe sexual behaviour.
(Subramanian 1998)
Telephone counselling in urban areas or those with good access to phone services has
proved useful in many settings.
For instance, the Foundation for Adolescent
Development in Philippines operates a programme called ‘DIAL-A-FRIEND’. Most of
the telephone counsellors are volunteers and are selected based on their age, education,
personality characteristics and counselling skills. The counsellors also have to undergo
practical training. Continuing education to counsellors is provided through case
conferencing to share experiences and case consultations with professional counsellors.
15
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
3.7. Special services
Some adolescents may require special services
(box 8) requiring professional assistance
... ' Special Services
—
(contraceptive
services,
professional
counselling, legal aid etc.).
It may not be
•- Professional counseling and
possible to offer such services in a programme
therapy
and perhaps the best way to organise it is
® CxOntracentive anui otner ’r>TT
ix h through an informal or a formal referral
network. The professionals need to be provided
training in addressing special problems of
adolescents in friendly and non-judgemental
: ^noretebillMion
manner. Some programmes have incorporated
Kspecial services for key ASRH issues. For
programmes
instance, some NGOs in Africa have included
programmes for unmarried teenage mothers
_
including facilities for adoption, continuation of
their education, and assistance in income generating activities (Population Manager Vol.
4).
i
■
I
■
The health centres need to become adolescent friendly if they are to meet their needs.
This would not only require community support and participation of adolescents but
also a review of policies, procedures, staff and physical environment.
Special services are also required to meet the needs of adolescents in difficult
circumstances such as refugees or migrants, particularly, in the age group 14-19,
where they are must vulnerable to exploitation. Such programmes would have to
incorporate an integrated package of services aimed at making them socially and
economically self-reliant and responsible.
4.
OPERATIONALIZING ASRH PROGRAMMES
Above, we have discussed a framework for a comprehensive ASRH programmes.
However, it may neither be feasible nor desirable to implement such a comprehensive
programme at the outset. Instead it may be useful to use an incremental approach
building on what already exists and utilising all opportunities for ASRH activities.
Based on a review of programme experiences. Hughes and McCauley (1998) suggest
following programming principles for ASRH programmes:
•
•
Recognise and address the fact that the programme needs of young people differ
according to their sexual experience and other key characteristics.
Start with what young people want, and what they are already doing to obtain sexual
and reproductive health information and services.
16
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
•
•
•
•
Include building skills (both generic and specific to SRH) as a core intervention.
Engage adults in creating a safer and more supportive environment in which young
people can develop and manage their lives, including their sexual and reproductive
health.
Use a greater variety of settings and providers - private and public, clinical and
non-clinical - to provide SRH information and services.
Make the most of what exists. Build upon and link existing programmes and
services in new and flexible ways so that they reach many more young people.
4.1. Issues in Operationalization
Several issues would need to be addressed for effective operationalization of ASRH
programmes: involvement of adolescents, paucity ot resources, inadequate
organisational framework, need for cultural harmonisation and gaps in the knowledge
base.
Involvement of adolescents. It is widely recognised that adolescents themselves should
be involved in planning, implementation and evaluation if ASRH programmes are to be
effective. However, most programmes tend to be developed by experts who are
generally adults. Although many NGOs consulted adolescents to identify their concerns
or in evaluating their programmes, it is not clear how many government programmes
had explicitly involved them in formulation of programmes or envisage their active
involvement as peer educators.
Paucity of resources. Adolescents constitute a large group, comprising nearly a fifth of
the population. If comprehensive ASRH programmes are to be implemented then their
resource requirements are likely to be large. Therefore, programmes need to ensure
their cost effectiveness through use of existing facilities and human resources,
harnessing the energy of adolescents, and reorienting some of the existing programmes
to serve adolescents better. In addition, where contraceptive prevalence is high, some
of the IEC resources in the FP programme could be diverted to the ASRH programmes.
Inadequate organisational framework. A multi-sectoral and multi-disciplinary approach
is necessary to implement ASRH programmes. For instance, typically Ministry of
Education, Ministry of Information, Ministry of Youth and Sports and Ministries of
Health and Population would have to work together. Similarly, a coalition would need
to be formed of government, NGOs, youth organisations, women’s NGOs and training
and research institutions to address ASRH issues. Such a coalition does not seem to
exist in any country. However, multi-sectoral approaches used in population field can
be utilised to build such a coalition.
Need for cultural harmonisation.
Recognising that ASRH issues are culturally
sensitive, the approaches used should be harmonised with the culture. For instance,
successful reduction in FGM practices in Uganda through REACH programme
17
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
separated basic cultural value of girls’ initiation from FGM and succeeded in involving
religious leaders as well as community elders leading to significant and rapid reduction
in the incidence of FGM.
Gaps in the knowledge base. The researches in the ASRH area are rapidly growing.
However, many issues still require careful study. As one is dealing with sensitive
issues, innovative research methodologies need to be used.
However, ASRH
programmes themselves should encourage continuous learning from their own
experiences through careful periodic review, reflection and evaluation. There is also a
need to share experiences both more rapidly and widely.
4.2. Strategies for Operationalization
Our review of the current status of ASRH programmes had indicated the need to place
ASRH programmes in a developmental perspective. Therefore, existing developmental
programmes - particularly education, income generation and employment - should have
specific components for adolescents. Many health programmes also have hitherto
neglected adolescent needs. Therefore, these programmes need to be enabled and
motivated to meet those needs. Many innovations in ASRH programmes have taken
place. These need to be upscaled. However, comprehensive adolescent programme
designs have not yet emerged and these need to be pilot tested before they can be
upscaled. Finally, research needs to be encouraged to build a reliable database on
adolescent needs, concerns and behaviour.
Therefore, operationalization strategy should have five components: (i) incorporating
adolescent concerns in the relevant development programmes, (ii) orienting existing
health programmes to be adolescent-friendly, (iii) upscaling ASRH innovations; (iv)
pilot testing models of comprehensive ASRH programmes in specific geographic areas;
and (v) encouraging research in ASRH.
Incorporating adolescent concerns in existing developmental programmes
As discussed earlier, the developmental programmes of NFE and credit include
adolescents but often do not have special component to meet their needs. Such
programmes, to meet these special needs, may need to link up with other programmes.
For instance, NFE programmes have established linkages with formal school
programmes so that adolescents can either join schools or are able to complete
schooling through self-study. Similarly, credit programmes may need to link up with
vocational training and/or entrepreneurship development programmes so that
adolescents are able to access an integrated package of services.
Many programmes of youth development such as sports and youth clubs do not often
incorporate ASRH education and referrals for services. Although the current coverage
18
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
of such programmes may be limited, the participants could be provided not only ASRH
education but also be trained to be peer educators in their community.
Reorienting health programmes to be adolescent-friendly
There are many barriers to the use of existing services by adolescents they may be ill
informed they do not have resources to access services, they are shy or worried bout
being ‘found out’, providers may scold them or be judgmental.
In short, the
programmes may not be adolescent-friendly. The health services are delivered by health
workers and health centers. Typically they do not consider adolescents as target
groups The task here is to orient them to be more ‘adolescent-friendly’ and reach
them This would require training providers, flexible hours, assurance of privacy and
confidentiality, and development of a referral network. The monitoring system would
have to include indicators related to services provided to adolescents.
Upscaling ASRH innovations
The previous two strategies, that of reorienting existing programmes, would not suffice
as adolescents are as a group distinct from adults, the size of adolescent group is large,
and they have many and varying ASRH needs. Therefore, it would be necessary to
upscale proven ASRH innovations. These innovations have largely been implemented
by NGOs, and given the current cultural and policy environment, the governments may
want NGOs to upscale them. In some countries, governments may also be able to
provide financial support as well as set standards for quality and content.
own
The upscaling process could
could be
be in
.n several
severa. ways: (a) an NGO may upscale its pLE
innovation through expanding coverage. 1------, after the pilot test is completed, to cover its NFE schools^(b) ol^er NGOs
programme,
outreach activities; (c)
may implement tested models such as youth camps or
expand in-school FLE
Government and NGOs may collaborate for instance to
tests at
programmes; and (d) the mass media activities could be expanded after their
small scale.
; is not autonomous.
An organizational framework is needed, as the upscaling process
Government ministries and NGOs may wish to form a coalition to catalyze the
upscaling process.
Pilot testing comprehensive programmes as models
Most of the innovative programmes have implemented piecemeal approaches and have
not taken a comprehensive health approach.
Different components of ASRH
Programme interventions interact and would have a synergistic impact. As a result^
they can neither be evaluated nor provide a generic design for comprehensive ASRH
19
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
programming. It would be useful to implement pilot demonstration projects in several
countries to learn how they respond to diverse cultural settings. Although the generic
design of these programmes may be similar to that outlined in Section 3.4, each pilot
project would have to adapt itself to local conditions. Each pilot project would also
have to follow the process of programme development comprising needs assessment,
stakeholder dialogue, agreement on ASRH problems/issues to be addressed, design of
the content for interventions, implementation arrangements, and monitoring and
evaluation procedures to be followed. Thus situation analysis will be part of the pilot
lest programmes which can use operations research methodologies. It should be
emphasized that adolescents should be involved in all the phases of pilot testing.
Encouraging Research in ASRH
It was mentioned earlier that there are many gaps both in terms of understanding ASRH
behaviour as well as in development of cost-effective interventions. Therefore, ASRH
researches need to span community-based, behavioural, biomedical and programme
intervention/action research.
An illustrative list of research needs arising out of
Jejeebhoy’s (1996) review of researches, is as follows:
•
•
•
•
•
RH needs and decision making authority among girls.
Pre-marital sexual behaviour awareness and attitudes among boys and girls.
Levels, patterns and context of abortion behaviour among unmarried and married
girls.
Community-based studies on RH morbidity in obstetric, gynecological and RTIs.
Access to health care and barriers in its use.
The above research needs to be an input into policies and programming for ASRH. In
addition, intervention research is needed in various components of ASRH as well as
sharing of experiences through careful documentation. Given its sensitivity, researchers
would need to both innovate new methodologies as well as acquire skills in using
existing methodologies for ASRH research.
5.
CONCLUSION
To date, programmatic responses to adolescent needs and their SRH concerns have been
limited. However, there is growing recognition of the need for ASRH programmes and
post-ICPD most countries have incorporated ASRH activities as part of broader
reproductive health programmes.
The paper argues that adolescents constitute a group separate from adults and,
therefore, special ASRH programmes will be needed. These would require developing
a societal vision for ASRH and a framework for programming. Comprehensive ASRH
programmes would comprise of in-school and out-of-school SRH education; youth
20
Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
centers supporting peer groups network, telephone and personal counselling, and a
referral network for promotion and provision of special services.
,
Several issues need be addressed for effective operationalization of ASRH programmes:
involvement of adolescents, paucity of resources, inadequate organizational framework,
need for cultural harmonization and gaps in the knowledge base. The strategies for
operationalization should be situated in a developmental framework and would include
(i) incorporating adolescent concerns in the relevant development programmes; (ii)
orienting existing health programmes to be adolescent-friendly; (iii) upscaling ASRH
interventions; (iv) pilot testing models of comprehensive ASRH programmes; (v)
encouraging research in ASRH. Addressing ASRH problems is the key to improving
sexual and reproductive health status in the Region and the world.
♦ ♦ ♦
21
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Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
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Theme Paper: Strategies to Operationalize Innovative Programmes to Address Adolescent Concerns
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