Science and Success in Developing Countries: Holistic Programs That Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections

Full Study Report [HTML] [PDF]
Executive Summary [HTML] [PDF]

The reproductive and sexual health choices made by the world's 1.5 billion young people will largely determine the quality of life on this planet for decades to come. Yet, educators, community leaders, and parents are often unsure about what works to improve reproductive and sexual health outcomes among youth. Until recently, program planners and community leaders in developing countries have had little help in identifying effective programs. In part, this has been due to a lack of focus and funding for evaluation and, in particular, evaluation regarding behavioral outcomes. Moreover, there has long been a shortage of peer-reviewed evaluations, since many nonprofit and nongovernmental organizations (NGOs) self-publish their findings. Fortunately, planners in developing countries now have access to an expanding body of published evaluations that identify effective programs. In fact, many of the most recently published, peer-reviewed evaluations are of highly effective programs designed and implemented in developing countries.

Youth in developing countries face significant threats to their health and well-being. These threats include the HIV and AIDS pandemic, high rates of sexually transmitted infections (STIs), and unintended pregnancies that may result in maternal morbidity and/or mortality. Policy makers and program planners should look to the body of published evaluation and research to identify programs that have proven effective with youth in similar circumstances. To that end, this paper compiles descriptions of 10 rigorously evaluated programs that have been effective in reducing behavioral risks for pregnancy and STIs, including HIV, among youth in developing countries.

Advocates for Youth conducted an exhaustive literature review of nearly 200 programs in developing countries. From among them, Advocates selected those programs with evaluations that showed impact on sexual behaviors and/or on sexual health outcomes. Advocates reviewed the evaluations against its criteria for inclusion (see below). As a result, Advocates was able to identify the 10 highly effective programs highlighted in this document. In addition, Advocates previously published a review of 26 highly effective, U.S.-based programs that may also be useful, if culturally adapted, in developing countries. [Science & Success, Second Edition: Sex Education & Other Programs that Work to Prevent Teen Pregnancy, HIV & Sexually Transmitted Infections]

Criteria for Inclusion

Programs included in this document all had evaluations that:

• Were published in peer-reviewed journals (a proxy for the quality of evaluation design and analysis);
• Used an experimental or quasi-experimental design, with treatment and control / comparison conditions;
• Included at least 100 young people in intervention and control / comparison groups.

Further, the evaluations either:

• Included follow-up, collecting data from both groups at three months or later after the intervention; and
• Demonstrated that the program showed two or more positive behavior changes among intervention youth, relative to comparison / controls, including:
  • Delay in the initiation of sexual intercourse
  • Increase in abstinence / reduction in the frequency of sexual intercourse
  • Reduction in the number of sex partners / increase in monogamy
  • Increase in the use or consistency of use of effective methods of contraception
  • Increase in the use or consistency of use of condoms / reduction in the incidence of unprotected sex,

Or

• Showed effectiveness in reducing incidence or rates of pregnancy, STIs, or HIV in intervention youth relative to comparison / controls. [See Table A.]

Outcomes

Of the 10 programs identified as meeting the criteria above, evaluations showed the following: [See Table A.]

• Delayed Sexual Initiation—Six programs demonstrated statistically significant delays in the initiation of sexual intercourse among intervention youth, relative to comparisons.
• Risk Reduction for Sexually Active Youth—Programs also demonstrated statistically significant reductions in other risk-taking behaviors among sexually active intervention youth relative to comparison youth. Specifically,
  • 8 programs demonstrated an increased use of condoms.
  • 6 programs showed a reduced number of sex partners among participants.
  • 5 programs showed an increased use of modern methods of contraception.
  • 3 programs demonstrated increased abstinence among sexually experienced youth.
• Reduced Incidence of Sexually Transmitted Infections—One program demonstrated a statistically significant reduction in STIs among intervention youth, relative to comparison youth.
• Reduced Incidence of Pregnancy—One program demonstrated a statistically significant reduction in the incidence of pregnancy among intervention youth, relative to comparison youth.

Program Strategies

All of the programs described here include comprehensive sex education. That is, each provides information about abstinence and the use of contraception and condoms. Eight programs also provide sexual health services, contraceptive supplies, and/or referral to sexual health services. Seven programs involve community members, including parents, religious leaders, health care providers, or others, in designing and supporting programs for youth. Six programs directly involve youth in program planning and operations. Six programs rely, at least in part, on IEC (information, education, and communication) and/or mass media strategies, including two that are framed within national social marketing programs (Horizon Jeunes and Promoting Sexual Responsibility among Youth).

Setting of Effective Programs

All of the highlighted programs were designed and implemented within developing countries, most in sub-Saharan Africa, one in eastern Asia, and one in Latin America. Within the description of each program, Advocates for Youth includes information about the program's components, the populations with whom evaluation showed the program to be most effective, the evaluation methodology, and its findings. To the best of Advocates' knowledge, there has not been a published evaluation of a replication of any of these programs.

Conclusions

The 10 programs highlighted in this document treat youth holistically—they acknowledge sexual development as normal for youth and offer youth community-wide support for making healthy decisions about sex. Every program actively involves either youth or the community or both. All ten provide youth with comprehensive information about sexual health—including abstinence and contraception and condoms. It is also worth noting that eight of the ten provide some form of health services or referral to services; six include mass media strategies to reinforce sexual health messages and to encourage youth to make healthy decisions about sex.

These programs underscore the reliability of more than two decades of research showing that:

• Education that includes information about both abstinence and contraception is the most effective in delaying the onset of first
  sexual intercourse and in ensuring that young people protect themselves when they become sexually active.[1,2,3,4,5,6,7]
• Neither provision of information nor access to contraception and condoms increases sexual activity among youth.[1,2,3,4,5,6,7]

By demonstrating what committed communities can accomplish in devising culturally appropriate, thoughtful, and realistic programs to improve the health and the future of adolescents, these programs offer effective strategies that can be considered and adapted by other concerned communities.

These programs also underscore the critical importance of funding to support short- and long-term evaluation to determine behavioral and health outcomes of community-driven programs to improve adolescent sexual health. In fact, behavior and health outcomes are critical to identifying effective programs simply because a great deal of research around the world shows that changes in knowledge and attitudes alone do not necessarily result in behavior change.[8]

In a world where adolescents are at high risk for unintended pregnancy—including maternal morbidity and mortality—as well as to infection with HIV and other STIs, reliance on proven, effective programs is essential. The 10 programs highlighted here provide both examples and models for programs in other communities around the world.