What Does Not Work in Adolescent Sexual and Reproductive Health: A Review of Evidence on Interventions Commonly Accepted as Best Practices.

Abstract

The 1994 International Conference on Population and Development (ICPD) was a landmark event for adolescent sexual and reproductive health (ASRH). Thanks to the efforts of advocates from around the world, the pressing need to address the sexual and reproductive health (SRH) of young people including adolescents was acknowledged in the ICPD’s Programme of Action.1 We submit that in 1994, while there was some awareness and understanding of the SRH needs and concerns of (mostly unmarried) adolescents in low- and middle-income countries (e.g., high rates of early and unintended pregnancy, early childbearing, unsafe abortion, and sexually transmitted infections), there was limited understanding of effective ways of responding to these needs and problems.2 The knowledge available at that time suggested that adolescents and young people lacked understanding of sexuality, reproduction, and sexual and reproductive health; that they were not getting the information and education they needed at home, at school, or elsewhere in their communities; and that they were neither able nor willing to obtain health services because they were not “youth friendly.” The social environment was not conducive to acknowledging adolescent sexuality or their right to healthy sexual development. Laws and policies around providing information and services to unmarried adolescents were generally restrictive, and even where supportive laws and policies existed, these were contradicted by others or not enforced. There was little evidence based on research or practical experience on effective ways of providing young people with information, education, and health services, or equipping them with skills to protect them from risks. Further, there was limited understanding of approaches to address deeply held community norms and biases against premarital sexual activity among adolescents. Moreover, existing reproductive health programs were primarily targeted to adult women. Married adolescents fell into this category, as marriage usually conferred adult status and thus the right to access services. Yet while it was acceptable for married adolescents to access these services when compared with their unmarried peers, the quality of the services they received was wanting, as they were not sensitive to the age-specific and developmental needs of young women who might want to delay their first pregnancy or who were pregnant for the first time. Much has happened over the last 20 years. Interventions that acknowledge the rights of adolescents and respond to their needs have been designed and piloted; policies and strategies formulated; projects and programs implemented; and research studies and evaluations conducted. Although there are still many gaps in our knowledge and understanding, we have a much better picture of the needs and problems of adolescents in low- and middle-income countries.3,4 We also have a better understanding of what works—and what does not—in responding to their needs and problems. A number of recent publications have pointed to interventions and intervention-delivery mechanisms that have been shown to improve adolescent sexual and reproductive health.5-7 They also argue that some of the interventions and intervention-delivery mechanisms have been shown to be ineffective. Despite this evidence, ineffective interventions and ineffective ways of delivering them continue to be widespread, and interventions that have been shown to be effective are often delivered ineffectively. As a result, human and financial resources are invested without any positive outcomes, and questions are raised about the value of investing in ASRH policies and programs, especially at scale. Although there are gaps in our understanding of adolescent needs and problems in low- and middle-income countries, a growing body of evidence points to interventions that work and ones that do not.