Youth: Vulnerable but resilient; Better understanding of the sexual and reproductive health needs of youth produces new initiatives and allies.

SOWETO, South Africa -- On a clear August afternoon, about 400 high school students filled the large courtyard at the Mafori Mphahlele High School in Soweto, South Africa, waiting for the AIDS awareness program to begin. Marie, 16, Nomomde, 17, Mbali, 16, and Margaret, 17, laughed together in the afternoon sun, placing on their school uniform skirts and sweaters stickers reading "Safe Sex Saves Lives" and "Protect the Ones You Love." Marie had made earrings out of several stickers. Boys also were spreading stickers over their own uniforms and bodies.

The long afternoon program at Mphahlele High School included guest speakers, student skits, condom demonstrations, music, an appearance by the "Trust" condom man, poems and songs written by students, and a candle lighting for all those living with AIDS. Students remained patient during the program, which stretched well beyond the end of school. The most remarkable moment of the afternoon came when 18-year-old Michelle spoke.

"I did not have a positive mind when I was in school," she told the students. "I was sexually active. I only thought about boyfriends." She paused, then turned to the audience, her hand in the air. "Are you living for sex?" Michelle asked the students. Many of them yelled back, "No!" "Because in the fun, there's pregnancy, sexually transmitted infections, AIDS. Do you ever stop to think about that? We have dreams. I thought I might be a dancer or a musician, but all we think about is sex. I wish I was in your footsteps now. I got pregnant. The guy ran away. He couldn't take the responsibility."

Michelle, poised and alone before the 400 students, continued. "After the birth, I wanted to breastfeed the baby, but they called a doctor and a counselor in. They told me I was HIV-positive and couldn't breastfeed her. I didn't know what to do. I was going to die." She paused, looking out directly at the students. "So what we need to do is to change our behavior. When you drink, you lose yourself a bit. Whatever people say you might do, you do. Respect your parents. Be thankful they're giving us advice. Sex is a gift for married people, not for young people like us. Parents and teachers, we need you to guide us."

VULNERABLE AND RESILIENT

The students at Mphahlele High School, like their peers around the world, are both vulnerable and resilient. Meanwhile, new allies for young people are increasingly becoming available, complementing the support youth may get from parents, teachers, peers, and traditional community resources. New initiatives for youth are addressing the dangers youth face, many of which are tied to behaviors related to sexuality (see page 20).

In the last 10 years, a broader understanding of the sexual and reproductive health needs of youth has emerged. Studies have found that the age of first sexual activity is dropping in many countries and the age of marriage is rising, resulting in more possible years of sexual activity with multiple partners.(1) The different cultural norms for boys and girls are getting more attention, highlighting gender violence and generating new opportunities for both girls and boys. As gender norms change, for example, girls may have more ability to negotiate when they want to have sex, and boys may incorporate more nurturing and less risky behaviors. (2) Early studies showed that youth had limited access to services and information about reproductive health. For example, providers were not willing to provide unmarried youth with services at family planning clinics, including the provision of condoms. (3)

"There is a lot more consciousness about the needs of adolescents," says Dr. Nancy Williamson of FHI, who is director of YouthNet, a new $85 million, five-year program to improve adolescent reproductive health, funded in part by the U.S. Agency for International Development (USAID). "Slowly, over the last decade, barriers are falling. There is more sex education in schools, for example. Policies are changing so that more providers will actually serve unmarried youth, and we are beginning to learn more about which types of services are most effective."

WHAT SERVICES WORK?

Reaching youth requires techniques different than those used to reach older adults. Most youth do not seek reproductive health services on their own. In order to encourage them to seek services, programs need to increase adolescents' awareness of reproductive health issues.

The World Health Organization, the United Nations Population Fund, the FOCUS on Young Adult Project funded by USAID, and other groups have identified several keys to effective design of youth programs: (4)

* Identify the target group; analyze assets and needs

* Involve youth

* Work with the community, including parents

* Build on and link existing interventions

* Use materials designed by and for youth

* Make accessible needed services, as identified by youth.

EVALUATE INTERVENTIONS

Programs are attempting to incorporate these components into projects ranging from outreach services and youth-friendly clinics to school-based education, media campaigns, and hotlines. In the process, various organizations have identified the approaches they have found to work best. For example, analyzing its work with youth service delivery projects in eight countries from 1995 to 2000, U.S.-based John Snow, Inc. identified 22 lessons it learned. Having a "champion" for youth within a clinical setting, for example, can help maintain a youth-friendly environment. Peer-education approaches are valuable. Help is needed to address community resistance to youth interventions. Starting a separate project or intervention is not necessary to serve youth effectively. (5)

Evaluations of specific types of programs offer some helpful data for program planners:

* Multipurpose youth centers most often attract boys, older youth, or young adults, and a low proportion of youth center attendees come for reproductive health information. Youth centers run by family planning organizations "are often stigmatized by the community and youth themselves," a recent Population Council study found. "Many youth, especially girls, do not want to be associated with family planning organizations because it suggests sexual activity or because young people brand [the centers] as places for those with sexually transmitted infections." (6)

* Scouting projects can successfully reach both in-school and out-of-school youth although extra time is needed to train the leaders, who are not used to addressing reproductive health issues. One project concluded that youth respond better to reproductive health programs that are integrated with scouting activities than those offered independently. (7)

* Hotlines and radio call-in programs can be efficient ways to reach many youth. "They provide youth with convenient, confidential, interactive, and compassionate access to information, counseling, and referrals," according to a report of these projects by FOCUS on Young Adults. Evaluating and monitoring these programs is challenging because confidentiality is important. Sustaining them may also be difficult, although a hotline in the Philippines received support from a telephone company after donor support ended. (8)

* Combining mass media, school-based, and community-based approaches can be effective, as demonstrated by Arte y Parte/PROMES in Paraguay, which targeted youth ages 15 to 19 years through in-school workshops, street drama, an hour-long weekly radio program, and peer educators. An evaluation found that the project reached 44 percent of youth in major cities but was riot as successful in reaching lowincome and out-of-school youth. Mass-media efforts are especially effective when targeted to specific demographic groups of youth and when combined with access to more interactive resources. (9)

* Confidentiality. Peer educators in Kenya were found to be judgmental about premarital sex, and only 42 percent of youth interviewed trusted peer educators to keep information confidential. "Special attention needs to be paid to addressing staff attitudes and quality of care" with lay staff, the study concluded. (10)

Little research is available on the role of male youth in reproductive health and HIV/AIDS programming. A recent study by the Panos Institute found that young men, ages 15 to 24 years, have more sexual partners than any other group and do not widely use condoms. "Most HI V/AIDS programs either target young people in general or just young women," says Thomas Scalway, author of the study report. "Young men are the most likely sector of the population to be involved in activities associated with HI V/AIDS risk, yet remain largely ignored in awareness and prevention programs." (11)

Also, experts agree that little careful evaluation and research has been done on involving youth, cost effectiveness, sustainability, and impact. A review of youth programs supported by the Gates Foundation found that two-thirds used the strategy of, making clinical health services youthfriendly, mainly targeting unmarried youth, even though numerous studies have pointed out the difficulty of getting large numbers of youth to use these facilities, and none of the grantees have documented success with this approach. (12) Another review of programs found that "constraints on financial and human resources, coupled with the great size of the youth population, highlight the need to find less costly ways to reach young people." (13)

EXPANDING PROJECTS

As projects for youth expand, lessons learned from previous efforts influence program development. But funding sources, the situation of each country, personalities, and other factors also help shape program decisions. In South Africa, for example, many projects are competing for resources, attention, and access to adolescents.

The Society for Family Health (SFH), a social marketing and educational outreach organization working since the early 1990s, has begun to focus more of its efforts on youth at locations such as Mphahlele High School and others in Soweto, as well as in its television and film productions. The South Africa Department of Health has operated a large anti-AIDS campaign called "Beyond Awareness Consortium," which included the highly visible "Soul City" project, a conglomerate of groups working with educational ventures throughout the country. The newest and largest major initiative, loveLife, began in 1999, with a well-financed, multimedia project and public health campaigns to promote a healthy lifestyle among youth (see page 19).

"South Africa is much more complicated than other African countries," says Rob Giger, who worked with condom social marketing campaigns in Zaire, Guinea, and the Ivory Coast before coming to Johannesburg in 1999 to head the SFH program. "There is an infrastructure here, which is hopeful, and AIDS is a high visibility subject, which is good. But it is bad when organizations are competing. In the Ivory Coast, we covered 75 percent of the country. Here, it's much more difficult." With multiple sources, types, and prices of condoms, consumers have to make more choices, and providers must compete for consumer loyalty.

The government has supported a widespread free distribution of condoms. "The danger in this is that people will expect the government to solve your problem and give you the condom free," says Giger. People have to take responsibility, reducing the number of partners as well as using condoms. People need to say, 'I've got a. role to play.'"

REFERENCES

(1.) McCauley AP, Salter C, Kiragu K, et al. Meeting the needs of young adults. Popul Reports 1995:J(41):3-9.

(2.) Finger WR. Some cultures tolerate risky male behaviors. Network 2000;20(3):21-23; 1-23; Barnett B. Gender norms affect adolescents. Network 1997;17(3):10-13.

(3.) Abdool Karim Q, Preston-Whyte E, Abdool Karim SS. Teenagers seeking condoms at family planning services: part I. A user's perspective. S Afr Med J 1992;82:356-59.

(4.) WHO/UNFPA/UNICEF. Action for Adolescent Health: Towards a Common Agenda: Recommendations from a Joint WHO/UNFPA/UNICEF Study Group. Geneva: World Health Organization, 1997; Senderowitz J. Reproductive Health Outreach Programs for Young Adults.

Washington: FOCUS on Young Adults, 1997; Senderowitz J. Thematic evaluation on adolescent reproductive health -- global report submitted to UNFPA. Unpublished paper. Geneva: United Nations Population Fund, 1996; Johnson S, Finger WR, Rivera R, et al. Reproductive Health of Young Adults: Contraception, Pregnancy and Sexually Transmitted Diseases. Research Triangle Park, NC: Family Health International, 1997.

(5.) Newton N. Applying Best Practices to Youth Reproductive Health: Lessons Learned from SEATS' Experience. Arlington, VA: John Snow, Inc., 2000.

(6.) Overview of youth center assessments in Kenya, Zimbabwe and Ghana. Unpublished paper. Population Council, 2000.

(7.) Kahuthia G, Radeny S. Project highlights: using scouting as a vehicle for reaching out-of-school youth. Program for Appropriate Technology in Health, 2001. Available from: http://www.pathfind.org/Project%20Highlights/Scouts%20Kenya.htm.

(8.) Moch L, Stevens C. In focus: reaching adolescents through hotlines and radio call-in programs. FOCUS on Young Adults, 1999.

Available from: http://www.pathfind.org/IN%20FOCUS/PDF/dec99.pdf.

(9.) Aguilar P, Booking SM. Project highlights: combining mass media, school, and community-based approaches. FOCUS on Young Adults, n.d. Available from: http://www.pathfind.org/Project%20Highlights/para guay.htm.

(10.) Operations Research Technical Assistance, Africa Project II. Programme Briefs: Adolescents: Population Council, n.d.

(11.) Scalway T. Young Men and HIV: Culture, Poverty and Risk. London: Panos Institute, 2001.

(12.) Shepard B, Nunez JG, Helfenbein S. Youth program strategies in the Bill and Melinda Gates Foundation's Global Health Program: a strategic assessment. Unpublished paper. Gates Foundation, 2001.

(13.) Hughes J, McCauley AP. Improving the fit: adolescents needs and future programs for sexual and reproductive health in developing counties. Stud Fam Plann 1998;29(2):233-45.

RELATED ARTICLE: CAMPAIGN ENCOURAGES YOUTH TO TALK ABOUT SEX AND SEXUALITY

A large billboard looms above the vegetable stands beside the sprawling taxi and bus stops at the edge of Soweto, South Africa, where tens of thousands of people catch their ride daily to nearby Johannesburg. Drawings of two people and the words "His and Hers" loom in large pink print against a vibrant purple background amidst the dusty roads and empty sky. "loveLife: Talk about it," reads the catch line at the bottom. Is the message reaching the right people? And what does it mean? Does "loveLife" refer to loving one's life or is it meant to emphasize one's love life with a sexual partner?

"This message is about a state of mind, about a hope for the future," says Jonathan Stadler of the Research Health Research Unit, University of Witwatersrand, and research director for loveLife. Sitting in his office in Baragwanath Hospital, across from the Soweto taxi stand, Stadler describes how the loveLife campaign is trying to "create a new culture. It's a motivational program to encourage people to stand up and talk about life with each other." The campaign includes billboards, community mobilization efforts, a hotline, and other elements.

The loveLife campaign seeks to build awareness of reproductive health and life skills issues. In addition, it launched a multipronged service delivery component in 2000. It has developed eight youth service delivery centers (called Y-centers), worked to make existing clinics more youth friendly, funded peer education and outreach activities through the Planned Parenthood Association of South Africa (PPASA), and sponsored the loveLife games (an annual sports competition).

One of the Y-centers is at Orange Farm, a low-income rural black township about 45 minutes from Soweto. Khanyisile Khumalo, a PPASA nurse, works out of this Y-center, which is just beginning and has one other employee plus peer educators. Khumalo shares information through talks at schools and offers clinical services at the Y-center in the afternoon. "We also offer life skills workshops, where we discuss sexuality, pregnancy, sexually transmitted infections, sexual abuse, and life skills," she says. "I'm optimistic. The more information you give youth, the more you address myths they have. We use motivational programs to empower them about how to relate to their partners." The center is also beginning to offer activities that it hopes will attract girls as well as boys, such as drama, jazz. dance, aerobics, and net ball, a version of basketball played by girls and women in South Africa.

How well, the loveLife project can achieve its ambitious goals remains to be seen. A survey of 1,000 people found that more than half of every 10 respondents had heard about loveLife. (Participants included 600 youth ages 12 to 17 years and 400 individuals over age 25.) About onethird of those surveyed had heard of the project through the television show S'canto, which follows the journeys of young people who travel the country talking to other youth about sex and sexuality. Campaign billboards were also recognized by many. More than 90 percent of those who were aware of loveLife identified it as a symbol of hope and communication about sex, sexuality, and HIV/AIDS. (1)

Another study of youth centers in South Africa found that awareness of loveLife centers is high, compared to other youth centers, probably because loveLife centers are new, large, and colorful. Visitors to the loveLife centers were balanced by gender, and focused on recreational activities. "Providing recreational facilities for young people may go a long way in satisfying a program's developmental objectives," according to study researchers. "However, linkages between providing recreation and positive health outcomes are not clear-cut." (2)

Some are skeptical of the loveLife project, saying that it is very costly without having a clear sense of direction. "The project does not have a model, it has an approach," says Warren Parker, director of Center for AIDS Development, Research and Evaluation, a research organization based in Johannesburg that has analyzed national AIDS awareness and condom distribution programs in South Africa. "loveLife is a public relations engine on top of an idea. Its high-cost mass media activities place very little emphasis on condom promotion. We need more work on more specific issues such as addressing condom stockouts and increasing consistent access for youth, particularly in rural areas."

REFERENCES

(1.) Stadler J. Looking at loveLife the First Year: Summaries of Monitoring and Evaluation, September 1999 - September 2000. Bertsham, South Africa: Reproductive Health Research Unit, Baragwanatah Hospital, n.d.

(2.) Erulkar AS, Beksinska M, Cebekhulu Q. An Assessment of Youth Centres in South Africa. New York: Population Council, 2001.

YOUTH IN DANGER

Soweto is the black township on the southwestern side of Johannesburg where youth-led, often violent protests against the apartheid government of South Africa dominated life in the 1970s and 1980s, closing many schools. Today, Soweto -- with some four million people -- has returned to a more normal life, including fully functioning schools.

But the Soweto youth in post-apartheid South Africa face a new kind of danger. It is a type of danger facing many of the 1.5 billion young people in developing countries, about one of every four people. Youth are even more vulnerable than adults to HIV and other sexually transmitted infections (STIs). About one-third of the world's 34 million HTV-infected people are between ages 10 and 24 years, with girls disproportionately affected by HIV infection for both biological anti cultural reasons. (1) In addition, in developing countries, some 13 million births occur each year to women ages 15 to 19 years, many of whom are unmarried. Nearly always, the young unmarried mothers drop out of school to raise the baby, without help from the father. (2) The World Health Organization (WHO) estimates that between 1 million and 4.4 million abortions are performed each year among women ages 10 to 24 years, with most of them performed illegally under hazardous conditions. (3)

REFERENCES

(1.) Young People and Sexually Transmitted Diseases, Fact Sheet No. 186. Geneva: World Health Organization, 1997; Report on the Global HIV//AIDS Epidemic. Geneva: Joint United Nations Programme on HIV/AIDS, 2000.

(2.) Barnett B, Eggleston E, Jackson J, et al. Case Study of the Women's Centre of Jamaica Foundation: Program for Adolescent Mothers. Research Triangle Park, NC: Family Health International, 1996.

(3.) Young People and Sexually Transmitted Diseases: WHO Fact Sheet No. 186. Geneva: World Health Organization, 1997.