Youth

PREVENTING SEXUAL RISK BEHAVIORS AMONG YOUNG PEOPLEMore Evidence On What Works : PREVENTING SEXUAL RISK BEHAVIORS AMONG YOUNG PEOPLE More Evidence On What Works Shanti R. Conly Senior Technical Advisor Office of HIV/AIDS USAID GH Mini-University October 2006


OUTLINE OF PRESENTATION : OUTLINE OF PRESENTATION Global trends in youth transitions Key health issues for youth in developing regions Key risk factors and influences on youth behaviors New evidence on effective program approaches Concluding thoughts for policymakers, programmers


TRUE OR FALSE? : TRUE OR FALSE? Adolescence is a healthy time of life


ADOLESCENT AND YOUNG ADULT HEALTH : ADOLESCENT AND YOUNG ADULT HEALTH Health status improving overall, except in areas most affected by HIV In those countries, very high HIV prevalence among youth, especially girls and young women In other countries, pregnancy and childbirth often remain the most significant risks for young women Young men disproportionately affected by accidents, violence, suicide, substance abuse Mental health problems — a substantial, and possibly increasing, share of illness


Slide5 : 1. GLOBAL TRENDS IN THE TRANSITION TO ADULTHOOD 'Youth:' 10-24 years—Pre-Teens thru Young Adults Adolescence is a time of both risk and opportunity A distinct but diverse group requiring special programs Adolescence


Slide6 : 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 Age KEY 'MARKER EVENTS' Puberty Leaving School Initiating Alcohol/Drug Use Starting Work Marriage Leaving Home First Pregnancy Childbirth First Sex Sequence, timing, vary across cultures


CHANGING YOUTH TRANSITIONS : CHANGING YOUTH TRANSITIONS More young people attend school and remain there longer; income gap in enrolment greater than gender gap Smaller proportion of adolescents married than in the past Marriage delays not accompanied by delays in first sex, so first sex increasingly likely to occur before marriage But age at first sex, levels of premarital sexual activity vary greatly across countries In-school youth consistently initiate sex later than out-of-school youth, more likely to use protection NRC/IOM, Growing up Global, 2005


Slide8 : MORE YOUNG PEOPLE ATTEND SCHOOL Girls Boys 40-44 yrs old 20-24 yrs old Africa Latin America Asia Source: NRC/IOM 2005, DHS and AYP data Per cent completed six or more years of schooling


Percent ages15-17 ever having had sex, by enrollment status : Percent ages15-17 ever having had sex, by enrollment status Source: NRC/IOM 2005 YOUTH IN-SCHOOL LESS LIKELY TO HAVE EARLY SEX


MEDIA ACCESS, 15–19 YEAR OLDS : MEDIA ACCESS, 15–19 YEAR OLDS Watch television at least once/week: Source: NRC/IOM 2005, DHS, all women surveys Percent


ACCESS/USE OF MEDIA AMONG YOUTH : ACCESS/USE OF MEDIA AMONG YOUTH FHI/YouthNet, MTV Evaluation, 2006 Percent of Youth Ages 16 to 25 Years


Trends in percent women married by age 18 : Trends in percent women married by age 18 Data source: NRC/IOM 2005, Demographic and Health Surveys, 1990-2001. WIDESPREAD DECLINES IN AGE AT MARRIAGE


MARRIAGE RATES VARY GREATLY : Source: Demographic and Health Surveys MARRIAGE RATES VARY GREATLY


TRENDS IN TIMING OF MARRIAGE AND FIRST SEX : TRENDS IN TIMING OF MARRIAGE AND FIRST SEX NRC/IOM, 2005, based on 41 DHS countries Percent distribution of countries by type of change: comparison of 20-24 yr and 40-44 yr olds


Slide15 : Sources: DHS and AIS 2000 to 2005 PREMARITAL SEX VARIES ACROSS COUNTRIES


FOR MANY YOUTH, SEX IS NOT A CHOICE : FOR MANY YOUTH, SEX IS NOT A CHOICE Adolescent girls are most frequent victims of coercive sex; boys also experience forced sex but at lower rates Globally, between 2% and 20% of young women report forced sex; rates in Africa and Caribbean are highest Of sexually experienced girls, 15% to 30% report forced first sex; larger proportions report pressure by a partner The earlier the initiation, the more likely to be forced; most rapes by family, acquaintances, authority figures S. Jejeebhoy, Sex without Consent, 2006


Slide17 : KEY HEALTH ISSUES FOR YOUNG PEOPLE IN DEVELOPING COUNTRIES


Slide18 : Half of all new HIV infections are in youth ages 15–24; over 2 million new infections every year TRUE OR FALSE?


HIV PREVALENCE IN WOMEN AND MEN AGE 15-24 YEARS, SELECTED AFRICAN COUNTRIES, 2002-2005 : HIV Prevalence (%) HIV PREVALENCE IN WOMEN AND MEN AGE 15-24 YEARS, SELECTED AFRICAN COUNTRIES, 2002-2005 Demographic and Health Surveys; UNAIDS 2006 Report on the Global AIDS Epidemic, Annex 2


CONCENTRATED EPIDEMICS: YOUTH AT RISK : CONCENTRATED EPIDEMICS: YOUTH AT RISK In low prevalence settings, HIV driven by sex work, IDU, MSM behaviors, rates often higher among young men Most at-risk populations have young profile, high proportion andlt; age 25 Some studies show younger members of high-risk groups have higher risk behaviors and rates of HIV Interventions for at-risk youth are key to decreasing HIV transmission in many concentrated epidemics


TRANSITIONS TO PARENTHOOD : TRANSITIONS TO PARENTHOOD Age at first birth rising; pace of change varies 90% of births occur within marriage or union; no change in two decades Mean length of first birth interval is declining everywhere Patterns of childbearing vary substantially by region


MARRIAGE AND CHILDBEARING BEFORE AGE 18 : MARRIAGE AND CHILDBEARING BEFORE AGE 18 Source: NRC/IOM 2005 Percent South America Carib/Cent America Former Soviet East/South Africa West/Middle Africa SC/SE Asia Middle East


First Births to Women Under Age 18 among 20-24 year olds : First Births to Women Under Age 18 among 20-24 year olds Sources: Demographic and Health Surveys and Reproductive Health Surveys, 2001-2005 TIMING OF FIRST BIRTHS ANE LAC AFR


CONTRACEPTIVE USE AMONG YOUNG MARRIED WOMEN : CONTRACEPTIVE USE AMONG YOUNG MARRIED WOMEN DHS and RH Surveys 2002 - 2006 Contraceptive Use (%) Age 15-19 Age 20-24


Slide25 : UNMET NEED FOR CONTRACEPTION Among Girls Aged 15-19 by Marital Status Sources: DHS 1999 - 2005, ORC Macro *Data from Senegal, Nigeria, and Congo include sexually active and not sexually active Women in need of contraception (%)


Slide26 : v CONTEXTUAL INFLUENCES ON RISK BEHAVIORS


Slide27 : CONTEXTUAL RISK AND PROTECTIVE FACTORS PROTECTIVE Parental connectedness School attendance Positive peer role models Higher family income (young women) Risk behaviors are interrelated: youth who engage in one risk behavior are more likely to engage in others RISK ENHANCING Family Conflict Out-of-school status Negative peer role models Higher family income (young men)


OTHER FACTORS CONTRIBUTING TO YOUTH VULNERABILITY : OTHER FACTORS CONTRIBUTING TO YOUTH VULNERABILITY Lack of family protection (street kids, orphans) Early and/or forced initiation of sexual activity Transactional, cross-generational sex Alcohol and drugs (especially for young men) Lack of knowledge and skills, low personal risk perception Poor access to condoms/contraception—services not convenient or confidential, health workers judgmental) Episodic, 'unplanned' sex among unmarried youth


HIV INCIDENCE AND SEXUAL COERCION IN WOMEN <25 : HIV INCIDENCE AND SEXUAL COERCION IN WOMEN andlt;25 Coercive first sex Coercive First Sex Coercion only after first sex Never Coerced Source: Koenig AIDS 2004 Submitted Coercive first sex


Slide30 : HIV AND CROSS GENERATIONAL SEX


ROLE OF CONTEXTUAL FACTORS IN PROGRAMMING FOR YOUTH : ROLE OF CONTEXTUAL FACTORS IN PROGRAMMING FOR YOUTH Contextual factors play a powerful role in youth risk-taking and vulnerability, especially early sexual initiation Multi-faceted programs needed to address varied contextual influences, explicitly target risk factors specific to setting Difficult to reduce vulnerability, but in short-term, analysis of contextual factors can help identify/target at-risk youth


CONTEXTUAL FACTORS HELP IDENTIFY YOUTH AT-RISK : CONTEXTUAL FACTORS HELP IDENTIFY YOUTH AT-RISK Young IDUs in Vietnam Adolescent boys who had discontinued schooling before initiating drug use, had family problems, peers important in influencing use Girls at risk of entering sex work in Thailand Poor 6th grade girls living with a stepparent, not continuing in school Females ages 15-18 with higher HIV prevalence in Zimbabwe Maternal orphans who are not in school Patterns of Drug Use in Hanoi, UNDCP/Vietnam, undated; Kanchanachitra, Thai Journal of Population and Social studies, July 1998 Gregson, AIDS Care, October 2005


Slide33 : NEW EVIDENCE ON EFFECTIVE PROGRAM APPROACHES


TRUE OR FALSE? : TRUE OR FALSE? Sex education increases sexual activity among teens


Slide35 : Reviews evidence for effectiveness of interventions for youth in developing countries Uses standard methodology to weigh evidence, review different interventions in different settings Makes recommendations to policy makers/programmers for investments in interventions for young people WHO SYSTEMATIC REVIEW


SCHOOL-BASED SEX/HIV EDUCATION : SCHOOL-BASED SEX/HIV EDUCATION Schools hold a central and influential place in society Primary schools reach large numbers, sustainable Policy environment for HIV/sex education improving Parents and principals increasingly supportive; highly acceptable with prior community consultation Implementation challenges: teacher training and management capacity for scale-up


SCHOOL-BASED PROGRAMS: WHO FINDINGS : SCHOOL-BASED PROGRAMS: WHO FINDINGS Review looked at 22 programs with/without curricula, certain characteristics, both adult/peer-led Interventions significantly delayed sex, reduced frequency of sex, decreased number of sexual partners, increased use of condoms/contraceptives, reduced unprotected sex Strongest evidence is for programs with curricula, adult-led, that incorporate specific characteristics associated with greater effectiveness A separate, linked review found such programs can also be effective in non-school settings


CHARACTERISTICS OF EFFECTIVE PROGRAMS : CHARACTERISTICS OF EFFECTIVE PROGRAMS Kirby (2005) review: andgt;80 school and community-based sex/HIV education in developed and developing countries Effective programs had 17 common characteristics relating to curriculum development, content, implementation Many characteristics flow from 'logic model'—links activities to changes in risk/protective factors, sexual behaviors Other characteristics include tailoring curriculum to specific youth audiences, interactive teaching methods to help youth personalize information and to develop specific skills Kirby, Impact of Sex and HIV Education Programs,YouthNet 2005


LESSONS FROM PRIMARY SCHOOL ACTION FOR BETTER HEALTH (PSABH), KENYA : LESSONS FROM PRIMARY SCHOOL ACTION FOR BETTER HEALTH (PSABH), KENYA Scale-up of HIV education in upper primary schools; evaluation shows reduced risk behaviors Program integrated into existing education system, draws on expertise of both MOE and MOH Builds on formative research to understand young people’s attitudes to sex, forces/pressures to have sex Accommodation reached on condoms to address resistance from teachers, mixed messages from community Key to scale-up: develop training capacity within MOE to address attrition, maintain pipeline of trained teachers, strengthen training cascade


COMMUNITY OUTREACH THRU YOUTH PEER EDUCATION : COMMUNITY OUTREACH THRU YOUTH PEER EDUCATION Popular model involving huge investments, important for reaching out-of-school youth In the past, questions regarding effectiveness Youth development or health education delivery system? Lack of standardization, systematic approach; supervision High turnover relating to aging out → low sustainability Cost of training, retraining Peer educators reach similar youth; selection critical QA for peer-to-peer interaction, need for more structure (e.g., session plans), repeat contacts


COMMUNITY INTERVENTIONS FOR YOUTH:WHO FINDINGS : COMMUNITY INTERVENTIONS FOR YOUTH: WHO FINDINGS 22 interventions reviewed including those working through existing youth-oriented structures, targeting youth vs. the entire community, using traditional networks, using community-wide events Evidence strongest for interventions delivered through existing youth-oriented organizations; others require further evaluation Best practice: Interventions delivered through existing youth-oriented organizations need to work with community 'gatekeepers' carefully select program leaders mobilize ongoing resources to sustain intervention delivery link to interventions in other areas (e.g., services) ensuring culturally appropriate content, delivery


HEALTH SERVICES PROGRAMS: WHO FINDINGS : HEALTH SERVICES PROGRAMS: WHO FINDINGS 16 studies reviewed in health facilities, the community and other sectors; training service providers/staff; make facilities 'youth-friendly' Majority of studies increased use of health services by young people Evidence weak but sufficient to recommend widespread implementation of interventions to increase young people’s use of health services, if carefully monitored, evaluated Best practice interventions train service providers and other clinic staff, make facilities more accessible and acceptable, and generate demand and support in the community; need to better understand most important/strategic elements of these actions Interventions to increase access to health services need to be linked to interventions in other settings that aim to improve youth knowledge, attitudes and behaviors


ADDITIONAL THOUGHTS: HEALTH SERVICES FOR YOUTH : ADDITIONAL THOUGHTS: HEALTH SERVICES FOR YOUTH ANC, STI Rx, CT essential for sexually-active youth YouthNet research on health services: Clinical services, e.g., stand-alone VCT, attract youth exhibiting high risk behaviors, low risk perception Need for integrated services: youth attending HIV services (PMTCT, VCT) have unmet need for pregnancy prevention Youth often prefer private sector, especially retail outlets, owing to judgmental providers, lack of confidentiality Mixed results in making health facilities 'youth-friendly' to increase preventive services use by unmarried teens


MEDIA PROGRAMS: WHO FINDINGS : MEDIA PROGRAMS: WHO FINDINGS Media are influential source of information and norms for youth, have tremendous potential to reach youth 15 studies included 3 intervention types: radio-only, radio + other supporting media, radio + TV + other media Interventions influenced knowledge, self-efficacy in condom use, interpersonal communication, condom use, awareness of health providers, some social norms Strongest evidence is for approaches involving multiple media channels with mutually reinforcing messages Large-scale media campaigns must be closely coordinated with other interventions to maximize effects, tailored to and pre-tested among young people


MOST AT RISK YOUTH: WHO FINDINGS* : MOST AT RISK YOUTH: WHO FINDINGS* Interventions delivered in mainstream settings often may not reach most-at-risk youth (CSWs, IDUs and MSM) Specially targeted interventions should be widely implemented for these youth, who are at high risk of HIV Both reducing risk behaviors and structural interventions to reduce vulnerability are needed Evidence strongest for interventions that provide both information and services, and include linked facility-based and outreach components More research needed on needs of at-risk youth; strong Mandamp;E disaggregating data by age and sex *Including evidence from studies that did not disaggregate by age


WHO RECOMMENDATIONS FOR EACH INTERVENTION : WHO RECOMMENDATIONS FOR EACH INTERVENTION GO! Take these interventions to scale NOW! Sufficient evidence to recommend widespread implementation on large scale now, with careful monitoring (coverage andamp; quality … andamp; cost) READY Implement widely but continue to evaluate Evidence suggests interventions are effective, but large-scale implementation must be accompanied by further evaluation to clarify impact and mechanisms of action STEADY More research and development still needed Evidence is promising, but further intervention development, pilot testing and evaluation urgently needed before they can move into the 'ready' or the 'do not go' categories DO NO GO Not the way to go …


INTERVENTIONS THAT ARE GO! : INTERVENTIONS THAT ARE GO! * Provided they follow best practice, both in terms of content and process


INTERVENTIONS THAT ARE READY : INTERVENTIONS THAT ARE READY * Including evidence from studies that did not disaggregate by age


PRIORITIES FOR POLICYMAKERS : PRIORITIES FOR POLICYMAKERS Encourage more active collaboration between health and education sectors Provide sex/HIV education to all young people, both in and out of school Increase service availability for the sexually active Recognize safe motherhood as a continuing priority Target programs to the poor, especially girls


PRIORITIES FOR PROGRAMMERS : PRIORITIES FOR PROGRAMMERS Prioritize needs: segment by age/sex, tailor approaches to different country needs and youth populations Behavioral effects of individual interventions modest; develop comprehensive, multi-component programs Build on youth-serving networks for scale and sustainability Context matters: Involve parents, other adult gatekeepers, reinforce protective factors and positive community norms Quality counts: Incorporate best practices, QA mechanisms


KEY SOURCES : KEY SOURCES Growing up Global: Changing Transitions to Adulthood in Developing Countries (NRC/IOM, 2005; Chair, Cynthia Lloyd, Population Council) Preventing HIV/AIDS in Young People: A Systematic Review of The Evidence from Developing Countries (WHO 2006) For resources on youth RH/HIV prevention, Family Health International/YouthNet, www.fhi.org/youthnet


Slide52 : THANK YOU! 'If our children are to live, we must teach them about sex.' Pascoal Mocumbi, former President of Mozambique