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RHO archives : Topics : Adolescent Reproductive Health

Annotated Bibliography

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HIV and STIs in adolescents

Best, K. Many youth face grim STD risks. Network 20(3):4–5 (Fall 2000).
This article provides an overview of recent research on adolescents and STIs, mostly in developing countries. It describes young people's misperceptions about STIs, including HIV/AIDS, and presents study findings illustrating that even when adolescents have accurate knowledge about STIs, they often continue risky sexual behaviors. Lack of access, inexperience, or embarrassment are significant barriers to young people using condoms. Young people—young women in particular—continue to be more vulnerable to STIs than those who are older. In developing countries, up to 60 percent of new HIV infections are among 15- to 24-year-olds, with generally twice as many new infections in young women than young men. The article describes the high incidence of sexual coercion among young women—experienced by some 95 percent of female street youth in Guatemala—and explains complications that can result from adolescent STI infection.

FOCUS on Young Adults. Youth livelihoods and HIV/AIDS. In Focus (December 2000).
This publication examines poverty's impact on HIV/AIDS-infected and affected youth, and describes the different types of poverty-reduction or livelihood-enhancement programs and strategies currently under way throughout the developing world. In these countries, the link between HIV/AIDS, youth, and poverty is increasingly and painfully apparent. More and more, poverty reduction is gaining recognition as a critical strategy, not only in HIV/AIDS prevention but, equally important, in mitigating its impact, particularly among youth. This paper underscores the importance of linking livelihood initiatives with other reproductive health programs and supportive HIV/AIDS services and policies. Program examples and extensive references are provided.

Mwakagile D., Mmari E., Makwaya C., et al. Sexual behaviour among youths at high risk for HIV-1 infection in Dar es Salaam, Tanzania. Sexually Transmitted Infections 77:255–59 (August 2001).
This study explored sex-specific sexual behavior in youth visiting a sexual and reproductive health youth clinic in Dar es Salaam. A questionnaire was administered to a random sample of youth between 10 and 24 years old attending the clinic, and testing for syphilis and HIV-1 antibodies was also conducted. The study found half of all males reported more than five lifetime partners compared with 14 percent for females. Males reported recent partners to be 2.5 years younger, whereas females reported them to be 5 years older. No contraceptive use was reported by 30 percent of the males and 40 percent of females; 53 percent of females had been pregnant and 14 percent reported having had induced abortions. Six percent of males and 25 percent of females were found to be HIV-1 infected; 14 percent of females with only one lifetime partner were HIV-1 infected, compared with 41 percent with more than five partners.

UNAIDS and WHO. Report on the Global HIV/AIDS Epidemic: December 1998. Available online at www.unaids.org/publications/documents/epidemiology/surveillance/wad1 998/wadrp98e.doc. Accessed February 2000.
At the end of 1998, more than 33.4 million people were living with HIV, including 1.2 million children under the age of 15. Approximately half of new infections occur in young people between the ages of 15 and 24; girls are especially vulnerable. The future of the HIV epidemic lies in the hands and behavior of young people. Young people's behavior will largely depend on the information, skills, and services that the current generation of adults choose to equip them with. In many countries, young people are denied access to education about HIV including safe-behavior skills, condom use, or STI treatment and diagnosis, often because adults believe education and services encourage young people to increase their sexual activity. In fact, good-quality sexuality education can help delay first intercourse and lead to lower rates of teen pregnancy and STIs. This trend was first observed in Switzerland, and has since been observed in the United States, Uganda, and Thailand. This 26-page report describes the epidemic by region and provides compelling narrative.

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Meeting the needs of the youngest adolescents

Baldo M., Aggleton P., and Slutkin G. Does sex education lead to earlier or increased sexual activity in youth?Poster presentation at IXth International Conference on AIDS, Berlin. Global Programme on AIDS/WHO. (1993).
This review of studies on the effect of sex education in schools was carried out in response to policy makers' objection that sex or AIDS education may encourage sexual activity in youth. Most of these studies were restricted to changes in students' knowledge or attitudes. Of 18 studies reviewed, only seven evaluated sexual practices of students exposed to sex education. These seven studies, all from the United States, indicate a clear trend: In no study was there evidence of sex education leading to earlier or increased sexual activity in the participating youth. In four studies, sex education led to a delay in the onset of sexual activity. Two studies showed that access to counseling and contraceptive services did not encourage early sexual activity. Programs that promoted both postponement of sexual initiation as well as protected sex for those choosing to be sexually active were more effective than those promoting abstinence alone. Sex education programs were found to be more effective when provided before young people became sexually active.

Sedlock, L. Reaching the youngest adolescents with reproductive health programs. In Focus (January 2000).
There are numerous benefits and challenges to providing reproductive health information and services to youth aged 10 to 14. Reaching this age group can delay first intercourse, can help them make the transition to adulthood, and can improve their self-esteem. They may be easier to reach than older youth since many still attend school. However, programs working to reach this age group may experience resistance from parents or the community, educators may feel ill-equipped or opposed to providing reproductive health information, and the youngest adolescents may lack the resources or ability to access services. Programs wishing to reach this age group should provide basic, uniform information from numerous sources, encourage skills-building, offer youth-friendly services, tailor efforts to meet the specific needs of the program's population, involve adults, be creative in efforts to reach the target population, and provide programs that are fun.

U.S. Bureau of the Census. World Population Profile: 1998. Report WP/98. , Washington, DC : U.S. Government Printing Office (1999). Available at: www.census.gov/ftp/pub/ipc/www/wp98.html).
World Population Profile: 1998 is the latest published compendium and analysis of data on population, fertility, mortality, contraceptive use, and related demographic topics by the U.S. Census Bureau. The "Special Focus" section of the report provides an update on the worldwide HIV/AIDS pandemic. PDF files of the full report may be downloaded from this site.

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Early and unintended pregnancy

Alan Guttmacher Institute (AGI). Issues in Brief: Risks and Realities of Early Childbearing Worldwide. Available online at www.agi-usa.org/pubs/ib10.html.
Parents, governments, and communities are concerned about early childbearing for many reasons. Early childbearing can limit educational opportunities, restrict skills young people need to succeed in work and life, and reduce the quality of their lives. In addition, sexual relationships at an early age put young people at risk of contracting STIs. This report compiles data about adolescents in 44 developing and 5 developed countries (covering 75 percent of the world's population), and is designed to increase worldwide awareness of the extent to which adolescents are becoming parents and the consequences of pregnancy and childbearing at an early age.

Harrison, A., ed. MotherCare Matters 5(2.3). Arlington, Virginia: John Snow, Inc.  (1995).
This newsletter explores the consequences of early motherhood and includes journal articles discussing a variety of related topics. An analysis of a study titled "The Health Consequences of Teenage Fertility" (published in the May–June 1985 issue of Family Planning Perspectives) concludes that the proportion of women suffering complications did not vary significantly by age. Young maternal age is not a risk factor for obstetrical complications (with the possibility of unsafe abortion and possibly of eclampsia). Nor should young adults be the primary focus of programs aimed at decreasing maternal mortality, as the bulk of both pregnancies and maternal deaths occur among women aged 20 to 35 years. The newsletter also highlights other issues, such as components of successful adolescent reproductive health programs, and other previously published journal articles.

Koontz, S. and Conly, S. Youth at Risk: Meeting the Sexual Health Needs of Adolescents. Population Policy Information Kit, Number 9. Washington, DC : Population Action International. (April 1994).
Sexuality education and contraceptive services for young, unmarried people remain controversial in many societies, but the health problems associated with pregnancy and STIs call for greater openness about adolescent sexuality. Good sexuality education and contraceptive services can give adolescents the information, skills, and ability to protect themselves. They also can encourage young people to delay having sex. This briefing packet contains a question-and-answer overview of current issues in adolescent sexual health; appropriate strategies for addressing the needs of young people; and abstracts of articles from scientific and social science journals on topics such as adolescent pregnancy, childbearing, and sexual health. It also contains several inserts that provide specific information on contraceptive methods, lessons learned from youth programs, and strategies for changing policies. This briefing kit is designed for program managers, policy makers, or individuals faced with the question of whether family planning programs should provide information and services to unmarried adolescents.

Safe Motherhood Inter-Agency Group. Safe Motherhood Fact Sheet: Adolescent Sexuality and Childbearing. Available at: www.safemotherhood.org/init_facts.htm. Accessed September 1999.
Each year, nearly 15 million adolescents give birth. These young girls face increased health risks during pregnancy and childbirth. Girls age 15 to 19 years are twice as likely to die from childbirth as women in their twenties; those under age 15 are five times as likely to die. This fact sheet presents recent data about adolescent sexual behavior, childbearing, and the associated health risks. It concludes with a series of messages aimed at policy makers and program planners to address this public health dilemma.

Save the Children. State of the World’s Mothers. Westport, CT: Save the Children; 2004. Available at: www.savethechildren.org/mothers/report_2004/index.asp.
Recognizing that the quality of children’s lives largely depends on the health and wellbeing of their mothers, this annual report focuses on mothers worldwide. The report brings attention to health dangers of adolescent mothers and their infants, citing that thousands of young mothers die annually. It suggests strategies and solutions on how to address the risks of early motherhood and to keep girls in school or offer better employment opportunities. Further it suggests the improvement and enforcement of laws in regards to the legal age of marriage.

Zabin L, Kiragu K. Health consequences of adolescent sexuality and fertility behavior in sub-Saharan Africa. Studies in Family Planning. 1998;29(2):210–232. Abstract available at: www.popcouncil.org/publications/sfp/sfpabs/sfpabs292.html.
This article reviews the literature on health consequences of adolescent sexual behavior and childbearing in sub-Saharan Africa, and describes the social and cultural context in which they occur. The authors state that in order to address the health consequences of sexual intercourse, sex that occurs early in marriage and premaritally must be considered. The article documents the biological and social context of young women, including the increasingly early age of menarche, the conflict between premarital chastity and sexual encounters, rites of passage into puberty, and the role of schooling. Health consequences such as pregnancy-induced high blood pressure, hemorrhage, obstructed labor, infection, female genital mutilation, and abortion are documented, and implications for interventions are discussed. The authors provide examples of how changes in public attitudes and policies can improve the availability of reproductive health services for adolescents.

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School-based sexuality education

Barnett, B. Education delays sex, protects health. Network 17(3) (Spring 1997). Available online at www.fhi.org/en/fp/fppubs/network/v17-3/nt1734.html.
This article provides an overview of key factors that influence the success of any adolescent reproductive health program. It describes results from a broad array of surveys and also highlights the six key concepts that should be included in a comprehensive sexuality education program identified by Sexuality Information and Education Council of the United States (SIECUS) : (1) human development, which includes reproductive health anatomy and physiology; (2) relationships, including those with family members and friends, as well as relationships in dating and marriage; (3) personal skills, which include values, decision making, communication, and negotiation; (4) sexual behavior, which includes abstinence as well as sexuality throughout the life cycle; (5) sexual health, including contraception, STI and HIV prevention, abortion, and sexual abuse; and (6) society and culture, which includes gender roles as well as sexuality and religion.

Birdthistle, I. and Vince-Whitman, C. Reproductive health programs for young adults: school-based programs. FOCUS on Young Adults. Research, Program, and Policy Series (June 1997). Available at: http://pf.convio.com/pf/pubs/focus/IN%20FOCUS/if%20school%20form.html. This is one in a series of four "key elements" papers commissioned by the FOCUS on Young Adults Program. This paper documents successful approaches to reproductive health programs aimed at young adults and identifies key issues requiring further research. With more children than ever receiving an education, schools are an efficient way to reach school-age youth. In developing countries, more than 70 percent of children complete at least four years of school. The promotion of children's health through schools is being recognized globally as an important means of influencing behavior. This paper provides a literature review and lessons learned from the various types of school-based programs (family life education, sexuality education, population education, and HIV/AIDS education), as well as from school-based peer education and school-based reproductive health services. The paper concludes by presenting recommendations for strengthening school-based programs, including teaching and practice of reproductive health information and life skills early in children's lives, before they face high-risk situations and leave school.

Ecker, N. Culture and sexual scripts out of Africa: a North American trainer's view of taboos, tradition, and trouble and truth. SIECUS Report 22(2):16–21 (December 1993–January 1994).
This article, written by the director of training and education at the Global Institute for Training of Planned Parenthood of Nassau County, New York, draws on the author's many years of experience as a sexologist and international consultant to sexuality training programs in Africa. The article reviews the impact of cultural attitudes, economic conditions, and taboos on the nature of interpersonal and sexual relationships between men and women in Africa. The author emphasizes that these complex influences must be understood and considered in order to develop effective sexuality education programs. The article also provides a helpful list of recommendations for developing school- or community-based sexuality education programs.

Grunseit A. Impact of HIV and Sexual Health Education on the Sexual Behaviour of Young People: A Review Update. Geneva: UNAIDS; 1997. UNAIDS Best Practice Collection.
This report provides a review of the empirical literature on the effects of HIV/AIDS and sexual and health education on adolescent sexual behavior. Commissioned by the UNAIDS Policy, Strategy, and Research Department and the Joint UN Programme on HIV/AIDS, the review updates one from 1993 on the impact of sexuality education and includes 53 studies that evaluated specific interventions. Basic findings of the review include the following key points: (1) education about sexual health or HIV/AIDS does not encourage sexual activity; (2) good-quality programs help delay first intercourse and provide the means to protect adolescents from HIV, STIs, and unwanted pregnancy; (3) adolescents can learn responsible, safe sex behavior; (4) sexual health education should begin before the onset of sexual activity; (5) education should be gender-sensitive; (6) adolescents learn about sexual health from multiple sources; and (7) adolescents are a heterogeneous groupmultiple strategies are needed to reach them. Effective education programs have had a focused curriculum, paid attention to social influences, allowed youth to practice communication and negotiation skills, and are based in social learning theory.

Kirby, D. Sexuality and sex education at home and school. Adolescent Medicine: State of the Art Reviews 10(2):195–209 (June 1999).
This article summarizes the research on both sexuality education at home (parent-adolescent communication about sexuality) and sexuality education at school (especially curriculum-based sexuality and HIV education programs). This review includes a total of 30 curriculum-based studies conducted in the United States and Canada that measured program impact on sexual or contraceptive behaviors. Evaluations of these programs support the conclusion that sexuality and HIV education curricula do not increase sexual intercourse or increase the number of sexual partners. Rather, several of these studies found that their programs delayed the onset of intercourse or the frequency of intercourse or the number of sexual partners. Common characteristics of effective curricula are described.

Sexuality Information and Education Council of the United States (SIECUS). Guidelines for Comprehensive Sexuality Education: Kindergarten–12th Grade. 2nd Edition. New York: SIECUS (1996). Available online at www.siecus.org/pubs/guidelines/guidelines.pdf.
These guidelines provide a model for comprehensive sexuality education in the United States. They were developed by a task force of leading health, education, and sexuality experts, and cover six key concepts: human development, relationships, personal skills, sexual behavior, sexual health, and society/culture. The guidelines contain 36 topics with 778 developmental messages for early childhood (ages 5 to 8), pre-adolescence (ages 9 to 12), early adolescence (ages 12 to 15), and adolescence (ages 15 to 18).

WHO/GPA and UNESCO. School Health Education to Prevent AIDS and Sexually Transmitted Diseases: A Resource Package for Curriculum Planners. Geneva: WHO/GPA and UNESCO (1995).
This is a three-part package of resource materials to facilitate the planning of health education programs aimed at helping school children protect themselves against the risks of HIV infection and sexually transmitted diseases. Developed for curriculum planners, the package explains how to design a culturally relevant prevention program as a key part of a school system. The manuals provide examples of curricula, classroom activities, and learning materials that can be adapted to local or regional school systems. Materials are appropriate for use with students age 12 to 16 years. Information includes a model agenda for meeting with parents, advice on how to select peer leaders, and examples of classroom activities, role plays, and demonstrations. Developing behavioral skills through the use of participatory learning methods is emphasized.

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