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Well-planned collaboration between implementors of information, education, and communication (IEC) projects and clinic service providers is essential to the success of any efforts to improve young people's reproductive and sexual health. Youth reached by IEC programs deserve access to services so that those who are sexually active can protect themselves from pregnancy and sexually transmitted diseases (STDs). Too often, IEC programs successfully increase youth's motivation to seek services but service providers are left out of the process and are unprepared to meet adolescents' needs.

Reproductive and sexual health IEC efforts can be effective in changing knowledge, attitudes, and practices. Well-designed IEC activities that utilize such media as radio or television advertising, newspaper or magazine promotions, or theatrical performances can provide large numbers of young people with accurate health information. Further, the positive potential of these activities greatly increases when young people are referred by the campaigns to health centers. Early, ongoing collaboration with health center personnel can ensure that clinic referral sites are ready and able to provide reproductive and sexual health services to young people and that they will provide messages that are consistent and mutually reinforcing with those of the IEC campaign. The most successful collaborations can achieve measurable changes in both behaviors and social norms within a community.

Making the Connection between IEC and Services

Although IEC efforts aimed at youth vary widely in their target audience, strategy, scope, and intended outcomes, research points to several components essential for success, including:

• Identification of campaign goals
• Assessment of community needs
• Research on the needs and assets of the target audience
• Identification of measurable, achievable objectives
• Meaningful involvement of youth
• Involvement of parents, community leaders, and service providers
• Wide dissemination of messages
• Provision of training and support for involved youth.

Further, an advisory council of members from various community sectors may strengthen the IEC effort, particularly if the project encounters opposition. Finally, a simple process or outcome evaluation may provide valuable data to inform future efforts.

Strategic program planners will implement IEC activities which the community- especially, health care providers- can sustain and augment. In particular, effective IEC efforts to improve adolescent reproductive and sexual health will include referral to health care sites that offer, or have access to, a full range of services- including contraceptive counseling and services, pregnancy testing and prenatal care, and HIV and sexually transmitted disease (STD) counseling, testing, and treatment- in environments which make young people feel comfortable and to which they are likely to return.

Health Services that Are Friendly to Youth

IEC program planners should identify health care collaborators that either are already prepared to serve youth or are willing to make changes that will make young people feel welcome and comfortable. Youth-friendly services should offer:

• Confidentiality
• Privacy
• Trustworthy staff whose attitudes are nonjudgmental and respectful toward youth
• Convenient hours of operation
• Convenient location(s)
• Inexpensive or free services
• Youthful waiting room decor
• Casual dress among staff.

By carefully identifying health services providers and by involving them in the development of the IEC program, program planners help guarantee that young people will receive the reproductive and sexual health information and services they need. Three innovative examples of such partnerships follow.

Reaching Low-Income Urban Youth in Lagos

Residents of Isale Eko community on Lagos Island, Nigeria, are mostly low-income traders. Most local youth are born to unmarried mothers. Most live with their grandmothers, who are frequently the primary guardians and often struggle to care for these youth. Most youth are neither employed nor in school. With unlimited free time, many of the young males are involved in drug use and illegal activities. Most youth are sexually experienced by age 14. Many believe they are invulnerable to AIDS, although syphilis and gonorrhea are pervasive and are usually treated with drugs from local healers or medicine peddlers. By age 18, most young women have two or three children and/or have resorted to unsafe abortion. Although they may be in relationships with local young men, most young women derive their livelihood from sex with "sugar daddies."

Planned Parenthood Federation of Nigeria (PPFN) recognized a need to expand youth services in Lagos and selected the Isale Eko region because of pervasive sexual activity among youth and staff familiarity with local youth concerns. Visits from PPFN to the Lagos Island Local Government Area (LILGA) authorities led to the formation of a 9-member Project Advisory Committee (PAC) composed of representatives from the community, PPFN, and from the local government's medical, youth, and education departments, as well as a male and a female young person. The PAC conducted assessments in the community. Informal discussions with youth identified education, employment, and STDs as major concerns.

Young PAC members suggested the IEC effort take place through mass rallies- involving singing, dancing, and passing out handbills- to be led by peer educators and immediately followed by one-on-one discussions and the provision of condoms and contraceptive foaming tablets to interested youth. The PAC identified all community associations for youth and trained young representatives from each as peer educators. Health professionals helped develop educational messages. Rallies, launched in January, 1998, occurred in the neighborhood on the last Friday of each month. Peer educators attracted the attention of passersby, met youth and their parents, offered counseling on reproductive health issues, provided condoms and foaming tablets, and referred the youth who needed more in-depth services to two PPFN clinics. The peer educators then reassembled and repeated the process elsewhere in the neighborhood.

Close PPFN and LILGA involvement with the PAC and its messages for youth assured that clinics could meet increased youth demand for services. PPFN also instituted positive program policies: youth needed neither parental consent nor medical examinations for non-prescriptive contraceptive services, clinics provided all services in privacy, and staff emphasized confidentiality. The two referral clinics adopted many other "youth friendly" characteristics, including appealing decor, casual dress among staff, short waiting times, videos and television monitors in the waiting rooms, flexible hours, and low-cost or free services. Clinics reported contraceptive continuation rates as high as 80 percent at the first two to three visits. After these visits, youthful clients gained the self-confidence to purchase contraceptives on their own. Because the campaign appealed to youth and parents, some parents brought youth to the clinics for services, and staff used these opportunities to counsel both youth and parents.

Between the first and third quarters of 1998, the numbers of young clients receiving counseling, condoms, and clinic referral tripled.

Strategies for success included:

• Commitment of the campaign staff, regular meetings, local government involvement, sustained motivation of peer educators, and support from parents and grandparents of peer educators.
• Meaningful involvement of all stakeholders in the PAC, including youth, PPFN staff, and local governmental medical, youth, and education department representatives.
• Extensive planning and preparation for the collaboration.

The project also experienced some challenges. Although peer educators had a clear system for providing service referral, they were unable to determine whether referred individuals actually visited clinics. The project learned that better tracking of clinic clients would ascertain the exact number of referrals resulting from IEC efforts.

ASHE* and Jamaica AIDS Support Tackle STDs Among Kingston Youth

ASHE Caribbean Performing Arts Ensemble began in 1992 in Kingston, Jamaica in response to the increasing number of people living with, or dying from, AIDS. The founder of ASHE, Joseph Robinson, saw that Kingston youth faced exceptional challenges to their health and development: severely restricted economic and educational opportunities, high poverty levels, frequent community and family violence, and early onset of sexual activity, especially in young males. Further, as STD rates rose, young people's access to STD prevention education and services was practically nonexistent. Youth increasingly reported multiple sexual partners and transactional sex. Harsh circumstances left many youth with few life options or decision making skills.

ASHE began as a performing arts group providing sexual health information in a lively, realistic, and entertaining manner to youth in schools as well as in youth and community centers. The first production, Vibes in a World of Sexuality, was a humorous musical revue giving positive, accurate information to youth about self-knowledge, respect, empowerment, values, trust, and communication with parents and teachers as well as the integral role these attributes play in sexual decision making. ASHE staff- with backgrounds as teachers, counselors, and performing artists- worked with youth to develop the scripts, songs, and dances to help teens, parents, and teachers discuss sexuality and HIV/AIDS.

ASHE also emphasized the growth, development, and well-being of its young performers- ranging in age from eight to 25 and mostly from low-income families- as the embodiment of the important messages they delivered. Performers, trained as peer educators, met with young audience members after shows to discuss messages, answer questions, and offer referrals for additional reproductive and sexual health information or services from Jamaica AIDS Support (JAS). Co-founded by Mr. Robinson to support and care for people with HIV/AIDS and to educate and unite high risk groups, JAS was particularly concerned about the increasing number of AIDS cases among people ages 10 to 19 years. JAS became the first organization in Jamaica to target the gay, lesbian, and bisexual community. Mr. Robinson drew on his experience with and links to JAS to guide ASHE's performance messages and to ensure that JAS would be a reliable referral source.

Surveys conducted before and after 20 ASHE performances indicated a 20 percent increase in knowledge among audience members. From November 1992 to May 1993, more than 16,000 youth, teachers, parents, and opinion leaders in Jamaica and nine other countries were exposed to ASHE's messages. Over 6,000 condoms were distributed at community performances. Further,

JAS staff noted that each ASHE performance in Kingston generated five to 10 contacts from young people desiring STD/HIV information and services, HIV pre- and post-test counseling, individual counseling or group support. While ASHE performances did not explicitly address homosexuality, messages focused on self-acceptance and on preventing high risk behavior, and those who called JAS frequently were grappling with their sexual orientation.

While the majority of its clients were under age 25, JAS did not consider itself to be "youth-serving." Even though no specific policies or services identified youth as a special population, JAS was innately youth-friendly. Its atmosphere was informal, staff dressed casually, and JAS operated during evenings and weekends and accommodated drop-ins. Staff offered age-appropriate counseling, and none of the services, including STD/HIV testing or access to condoms, required parental notification or consent.

Strategies for success included:

• Charismatic, visionary leadership committed to adolescent reproductive and sexual health allowed ASHE and JAS to address controversial issues. Youth whose sexual behavior put them at risk of negative outcomes increasingly requested information and services after ASHE performances.
• Ongoing, longstanding, close, professional and personal links between ASHE and JAS strengthened the overall project, ensuring that performances provided information aligned with and backed up by services offered by JAS.
• The origin and identity of ASHE and JAS as non-political, inclusive, humanitarian organizations enabled them to gain broad community acceptance around controversial subjects.

The biggest obstacle experienced by both ASHE and JAS was difficulty in securing long-term funding. This has restricted the ability of both ASHE and JAS to expand their programs.

Improving Reproductive Health of Kenyan Youth through Radio

Concerned about the absence of programs to foster youth development and address high rates of unintended pregnancies, STDs, and abortions, the Family Planning Association of Kenya (FPAK) partnered with the National Council of Population and Development, the Johns Hopkins University, and Kenya's private family planning sector to determine the reproductive health needs and preferred solutions of Kenyan youth. In 1992, the partners conducted an assessment of adolescents' needs and of the problems and prospects faced by youth-serving organizations (YSOs). Results- showing a lack of socio-political support for youth programs as well as poor and inadequate quality of and access to reproductive health information- lead to the launching of the Kenyan Youth Initiative Project (KYIP).

KYIP established a Campaign Technical Committee with members from YSOs, radio broadcasting professionals, and youth groups to set objectives for increasing 1) reproductive health knowledge and 2) utilization of existing services. Research identified radio programming as the best channel for providing reproductive health information to Kenyan youth. The Committee planned the Youth Variety Show, a one-hour, Saturday morning radio program which featured a popular "dee-jay" and included music, dramas, speakers, life-based role modeling, and teen panel discussions on adolescent reproductive and sexual health issues. The interactive show encouraged on-air phone-in response, especially by rural youth beyond Nairobi, provided answers to questions submitted by phone or letters, and referred listeners to FPAK clinics.

Meeting quarterly, the committee chose topics that related to current events and identified health professionals to address these topics, while KBC radio staff wrote the scripts. More than 95 shows aired during a three-year period. Phone calls and letters from listeners, KBC's listening youth survey, and client-use data from the referral centers permitted program monitoring. Staff identified four major accomplishments: more open public discussion of reproductive health, increased demand for information, improved youth and adult awareness of reproductive health issues, and increased use of referral centers which provided condoms and counseling.

FPAK participated in the KYIP Technical Committee to help shape radio messages and to inform its own preparations for an increased youth clientele at the clinics. Trained staff made service changes to improve youth's comfort and willingness to return for services. Clinic staff assured adolescents' confidentiality and provided all information, counseling, and contraceptive services free. Clinics made contraception available without parental consent and counseled all clients about contraceptive use. Clinics served both genders, and one offered specific hours for males to discuss substance abuse and sexual orientation.

The numbers of youth attending clinics increased considerably as a result of the radio program. One site received an estimated twenty calls to its hotline after every show. Another began playing reproductive health videos to educate large groups in the waiting room. Several clinics found that increased demand- particularly for prescription contraceptives and STD treatment- exceeded their service capacity. Indeed, few anticipated the enormously increased demand for services resulting from the Youth Variety Show. Therefore, clinics were occasionally unable to provide adequate services.

Strategies for success included:

• Research-based planning involving youth and other concerned community members.
• Team work and coordination between mass media staff, health providers, youth, and health experts.
• Strong backing from many sectors.

Challenges encountered in this joint effort were mostly related to funding shortages. The Youth Variety Show ceased production twice due to lack of funding, and clinics were sometimes unable to meet increased demands for services.

Tips for Successful Collaboration

Although little research is available concerning the components of successful collaboration between IEC projects and service providers, by working together, IEC project planners and clinic service providers can successfully improve young people's reproductive and sexual health. The case studies presented here offer some important principles for successful collaborative efforts:

• Identify collaborators early.
• Gain early support from stakeholders- including the public and private sectors- in planning and implementing the project.
• Conduct research to identify the most effective medium and messages and most needed services.
• Ensure that reproductive and sexual health messages conveyed by IEC programs and services offered by health care providers are consistent and mutually reinforcing.
• Develop realistic budgets.
• Hold regular meetings between IEC and health services staff throughout the project.
• Plan and prepare for increased demand for services - better to be over prepared than overwhelmed.

*Ashe, a West African word, means the inner strength and the God within every person.

Cristina S. Herdman
Manager, International Clearinghouse and New Media
Advocates for Youth
Washington, DC 20036

Oladimeji Oladepo, Ph.D.
ARHEC, Sub-Department of Health Promotion and Education
College of Medicine, University of Ibadan
Ibadan, Nigeria

April 1999 © Advocates for Youth