ADVOCATES FOR YOUTH

Issues at a Glance

Improving Youth's Access to Contraception in Latin America

Also available in [PDF] format and in Spanish [HTML] [PDF].

Most Latin American youth face significant obstacles to sexual and reproductive health services. These barriers interfere, in particular, with their obtaining and using effective, modern contraception and/or barrier protection against sexually transmitted infections (STIs). This document summarizes these barriers and ways to create youth-friendly services. Finally, it describes organizations in Peru, Ecuador, and Nicaragua working to design and implement effective strategies to improve youth's access to family planning.

Latin American Youth Face Obstacles to Getting Family Planning Methods.

Research identifies major barriers to young people's accessing contraception. These barriers relate primarily to specific aspects of sexual and reproductive health services: characteristics of the facilities, the design of services, and the way providers treat youth.

Facilities

Facilities are not always located in areas accessible to young people. Surveys reveal that, in order to avoid running into family members or acquaintances, many youth prefer to receive care in facilities away from their own neighborhoods. However, youth may have a difficult time traveling long distances or reaching places that lack public transportation.

Other facility-related barriers include the lack of privacy due to lack of space devoted exclusively to the care of youth, of appointment hours exclusively for youth, and of a youthful and informal atmosphere that will help young people feel comfortable and welcome.

Program Design

Research with youth identifies several undesirable features of services' design, including high cost, crowded waiting rooms, refusal to serve walk-in clients, and inadequate supplies of a wide variety of contraceptive methods. These obstacles may prevent young people from making a first visit and/or discourage them from returning for subsequent visits. Second, young people will not seek services if they are unaware of the importance of reproductive health care or do not know where to obtain such care. If youth are obliged to visit a different facility for each type of service, or if youth's needs and expectations have been ignored in the design of services, they may discontinue care.

Providers' Attitudes

According to research with youth, the most important barrier to care relates to provider attitudes that contraceptive services are inappropriate for young people. Providers with this attitude frequently fail to take seriously youth's need for services and may even try to dissuade young people from having sexual relations. Providers' attitudes often reflect the tremendous difficulty that societies and cultures have in accepting the sexuality of adolescents and in viewing sexuality as a natural and positive part of the full development of every person. Such hostile attitudes may result in young people's giving up—not on having sexual intercourse—but on using contraception.

Providers Can Make Their Sexual and Reproductive Health Services Youth-Friendly.

Providers can take a number of steps to encourage youth to seek sexual and reproductive health services and to enable them to use contraception and to avoid unintended pregnancy and sexually transmitted infections, including HIV. These steps will break down many of the barriers youth face.

Facilities

• Locate clinics where public transportation is available and close to places where young people gather, such as schools, markets, amusement parks, community and employment centers, and sports facilities.
• To address one of youth's chief concerns about seeking sexual and reproductive health care—assuring their privacy—create a separate space for services for youth, or, if that is not possible, set aside certain appointment times exclusively for them during non-school and non-work hours—afternoons, evenings, and on weekends.
• Within the space and times set aside for youth, create an atmosphere as little like a conventional clinic's as possible. Strive for a welcoming, youthful, and informal style.

Program Design

• Offer free services (or as low-cost as possible) to youth.
• Keep waiting times to a minimum.
• Permit walk-in appointments.
• Consider postponing the pelvic exam and blood tests as long as this would not jeopardize the health of the adolescent.
• Maintain an adequate supply and a wide selection of contraceptive methods.
• Offer as many services as possible in a single location. When necessary, refer clients to youth-friendly facilities where they can quickly obtain the services they need.
• Welcome young men and encourage them to participate in counseling sessions when they accompany their partners to the facility.
• Recruit and train male staff to meet the sexual health needs of young men.
• Provide information in the language and appropriate to the cultural background of the client. Provide information that is responsive to the needs and concerns of adolescents.
• Involve young people in program design and implementation. This is important because youth can identify their peers' needs and propose appropriate ways of meeting those needs. Train youth, as peer educators, to transmit sexual health messages effectively to their peers.
• Reach out with educational activities to make young people aware of the importance of sexual and reproductive health care, inform them of the services available to them, and assure them of the confidentiality of those services.

Providers' Attitudes

• Treat young people respectfully. Avoid judging their behavior. Work to develop solid, mutually trusting relationships with them.
• Provide good counseling services, encouraging counselors to spend as much time as necessary with each adolescent in order to address all of her/his concerns.
• Provide all staff with ongoing training regarding the physical and psychosocial development of adolescents and their needs and interests.

Legal Barriers Often Hinder Youth's Access to Services.

In addition to barriers elated to service delivery, youth also face barriers in the form of laws and policies that prohibit or limit confidential services for youth. These laws and policies often fail to recognize both the needs of today's youth and also the ability of youth to make responsible decisions regarding their reproductive and sexual health. To bring down these barriers, concerned organizations should join together to work for legal and policy reform. As a fundamental aspect of such efforts, campaigns should raise public awareness about the sexual and reproductive health issues that young people face. At the same time, campaigns must sensitize policy makers about the consequences of their decisions on young people's lives.

Case Studies in Sexual and Reproductive Health Services for Youth

1. "Futuro" Youth Center—INPPARES

In 1986, the Peruvian Institute for Responsible Parenthood (Instituto Peruano de Paternidad Responsible—INPPARES) opened the "Futuro" Youth Center (CJF) in Lima to promote the overall development of adolescents, with emphasis on sexual and reproductive health care. INPPARES now provides services for young people in five additional Peruvian cities—Tarapoto, Huancayo, Ica, Tacna, and Huacho.

CJF offers medical-clinical and educational services to youth ages 10 to 25. However, almost 80 percent of clients are ages 15 to 22. Most are middle- and low-income women from the city of Lima; many of them seek counseling prior to their first sexual relationship. In Lima and the 10 provincial centers, CJF has provided counseling services for 13,224 young people, workshops for 3,530, video-forums for 6,592, informative talks for 11,362, and medical services for 7,799. In the first half of the year 2000, INPPARES's services and educational activities reached 21,105 youth nationwide.

CJF is youth-friendly, its facilities designed exclusively to provide comprehensive services for youth. A valuable aspect of CJF's approach is active youth participation. At present, nearly 200 youth volunteers work in:

• Prevention training for students, parents, and professionals who work with young people
• Developing educational materials, such as CD-ROMs, videos, and brochures
• Providing television and radio interviews and writing articles on adolescent issues for the popular press
• Providing peer counseling on sexual and reproductive health for individuals and groups—in person, by phone, and via E-mail
• Coordinating activities between institutions and sharing information with other national and international organizations
• Conducting research, with professional supervision, on the sexual and reproductive health needs of adolescents
• Generating and participating in projects to improve the quality of life for youth
• Organizing outreach and cultural activities for youth
• Participating in evaluating CJF's services.

CJF works to assure positive interactions between center staff and youth. To that end, INPPARES developed a training manual for working with young people, Manual de Trabajo con Jóvenes 1999-2004. In addition, CJF holds meetings every two weeks to monitor staff's work and offer further training.

INPPARES regularly evaluates the work carried out at CJF. Every two years, it applies a self-evaluation module, developed by International Planned Parenthood Federation. INPPARES also conducts regular internal and external studies, including interviewing youth volunteers.

The challenges facing CJF include obtaining the financial resources to promote its services through mass media campaigns in order to increase the clientele base and maximize use of its facilities, increasing the use of modern technology to disseminate information to young people, responding to the need to prevent violence towards women, and providing education and access to emergency contraception.

2. Reproductive Health Awareness—CEMOPLAF

Between March 1998 and August 1999, the Medical Center for Family Guidance and Planning (Centro Médico de Orientación y Planificación Familiar—CEMOPLAF) in Ecuador carried out a program of counseling, education and clinical services targeted exclusively to the adolescent population. This project occurred in coordination with the Institute for Reproductive Health (IRH) of Georgetown University in the United States and utilized an approach, developed by IRH, known as Reproductive Health Awareness (RHA).

CEMOPLAF offered services to male and female youth, ages 10 through 19. The youth resided in Ibarra, Latacunga, and Quito (urban areas) and Cajabamba (rural area) and came from middle- and lower-middle socioeconomic strata. Through questionnaires and interviews, CEMOPLAF developed an understanding of the sexual and reproductive health needs and practices of youth. This study enabled CEMOPLAF to design a youth-friendly strategy of care, including the following components:

• Allotting space in each clinic exclusively to the care of young people including, in some cases, special waiting rooms for youth
• Adapting the hours of service to accommodate school and work schedules
• Reducing fees for services to adolescents
• Providing information, education, and communication (IEC) activities aimed at youth, teachers, parents, and the community that include promotional and educational materials (posters, pamphlets, brochures, etc.), talks and/or presentations in schools and other institutions, home visits, and health fairs
• Involving youth actively in the various phases and activities of the program
• Training staff intensively in the RHA approach and in interpersonal communication and counseling skills, with emphasis on the importance of confidentiality.

CEMOPLAF evaluated the program in several ways: 1) interviews with adolescent clients, before and six months after receipt of services; 2) review of videotaped interactions between providers and users; 3) monthly review of service statistics; and 4) a comparative study of four experimental clinics—one that applied a peer education model and three that did not. CEMOPLAF found that the RHA program did not attract a significant number of new clients. A major barrier to attracting new clients may have been a cultural understanding of medical attention as being curative rather than preventive. Fear and embarrassment about physical examinations may have posed another barrier to new clients.

Evaluation found a considerable increase in the demand for services on the part of continuing clients (youth who were already coming to the clinic for sexual and reproductive health services). CEMOPLAF credits this increase to notable improvements in the quality of treatment and information services. These improvements made adolescents feel more comfortable expressing their concerns about sexuality and encouraged them to take a more active part in their own health care.

Based on the lessons learned in the RHA program, CEMOPLAF continues working to address the sexual and reproductive health needs of youth. At present, it is carrying out a community program for adolescents ages 10 to 19. Through a network of specially trained volunteer youth health promoters, the program provides guidance and makes condoms and birth control pills available at affordable prices.

3. PROSIM (MOH-GTZ)

In November 1996,the German Technical Cooperation Agency (GTZ) assisted the Division of Comprehensive Care for Women, Children, and Adolescents within the Ministry of Health (MOH) in Nicaragua in launching an ambitious project called "Comprehensive Health Promotion for Women" (Promoción de la Salud Integral de la Mujer—PROSIM). The first phase of the project targeted 10 rural municipalities in the northern portions of León and Chinandega as well as District VI and Tipitapa in the city of Managua. The second phase will expand the project across Nicaragua by the end of 2005.

PROSIM's objective is to improve the sexual and reproductive health of low-income women ages 10 to 49, primarily by significantly improving the quality of services and by working to educe domestic violence. In keeping with the comprehensive approach of this project, PROSIM considers it essential to address the sexual and reproductive health needs of particular segments of the population, including adult and adolescent men, prisoners, sex workers and their clients, truckers, and other groups at risk. In particular, the PROSIM Program of Comprehensive Care for Adolescents is designed to serve youth ages 10 to 24. Working through MOH health units, nongovernmental organizations, and communities, the program provides young people with access to information and to free, confidential sexual and reproductive health services.

In addition, to actively involve young people in health promotion, PROSIM creates clubs for youth and for pregnant teens. The clubs carry out activities in places exclusively designated for that purpose. In the youth clubs, adolescents receive training from adult and youth facilitators using the educational program, Cómo Planear mi Vida. They also receive support to organize and carry out recreational, educational, cultural, and outreach activities. The clubs for pregnant teens offer training in prenatal, childbirth, and postpartum health promotion; guidance regarding young women's sexual and reproductive future; and opportunities to develop craft skills. Through their participation in these clubs, some young women become breast-feeding consultants.

PROSIM sponsors intensive training for health care providers in supplying comprehensive, high-quality care for adolescents. As a result, these trained providers enjoy wider acceptance among young people, making it possible to ensure solid, effective technical teams in each locale and helping to encourage adolescents to remain members of the clubs and become increasingly involved in program activities. Further, young people's participation in evaluation activities—both as survey respondents and participants in focus groups—is important. In the future, PROSIM intends to share the results of each study with youth in order to give them the opportunity to discuss the findings.

Bibliography

Alan Guttmacher Institute. Population Reports: Meeting the Needs of Young Adults. 1995;23(3):34-35.

Barnett B, Katz K. Adolescent Reproductive Health: Navigating between Needs and Services. Research Triangle Park, NC: Family Health International, 2000.

Barett B, Schueller J. Meeting the Needs of Young Clients: A Guide to Providing Reproductive Health Services to Adolescents. Research Triangle Park, NC: Family Health International, 2000.

Brindis C, Davis L. Improving Contraceptive Access for Teens. [Communities Responding to the Challenge of Adolescent Pregnancy Prevention, v. IV]. Washington, DC: Advocates for Youth, 1998. [PDF: English] [PDF: Español]

Catino J. Meeting the Cairo Challenge: Progress in Sexual and Reproductive Health: Implementing the ICPD Program of Action. New York, NY: Family Care International, 1999.

Finger WR. Encouraging youth-friendly clinics. Network 2000;(20):32-33.

Senderowitz J. Making Reproductive Health Services Youth Friendly. [Research, Program, and Policy Series]. Washington, DC: FOCUS on Young Adults, 1999.

Written by Cecilia Moya
August 2001 © Advocates for Youth