Lessons Learned From SEATS’ Experience
By Nancy Newton, M.A., M.P.H.
January 2000
The goal of the Family Planning Service Expansion and Technical
Support (SEATS II) Project is to expand the development of, access
to, and use of high-quality, sustainable family planning and reproduc￾tive health services in currently underserved populations. It built and
followed on the SEATS I Project (1989-1995).
John Snow, Inc. (JSI), an international public health management
consulting firm, headed a group of organizations implementing the
SEATS II Project. These included the American College of Nurse￾Midwives (ACNM), American Manufacturers’ Export Group, AVSC
International, Initiatives, Inc., the Program for Appropriate Technol￾ogy in Health (PATH), World Education, and United States Agency
for International Development (USAID) Missions and other partner
organizations in each country where SEATS was active.
This publication was made possible through support provided by the
Office of Population, USAID, under the terms of Contract No. CCP￾C-00-94-00004-10, and by JSI. The contents and opinions expressed
herein are those of the author and do not necessarily reflect the
views of USAID, JSI, or its partner agencies.
Lessons Learned From SEATS’ Experience
By Nancy Newton, M.A., M.P.H.
January 2000
SEATS’
lessons learned from
Experience
i
Acknowledgements
Many people have contributed valuable ideas, expertise, insight, and
long hours to the SEATS’ experiences in improving youth reproductive
health. We especially want to thank current and former SEATS staff and
consultants, including Joy Awori, Laurie Cappa, Anna Chirwa, Shalote
Chipamaunga, Enilda Gorishti, Alix Grubel, Joan Haffey, Nancy Harris,
Diane Hedgecock, Janne Hicks, Maggie Huff-Rousselle, Meba Kagone,
Barbara Kennedy, Asta-Maria Kenney, Deb Kreutzer, Priya Mammen,
Mary Lee Mantz, Irene Moyo, Lisa Mueller, David O’Brien, Melinda
Ojermark, Leslie Patykewich, Elaine Rossi, William Sambisa, Mbaye
Seye, Cathy Thompson, Frank Webb, Dan Wendo, Willow Gerber, and
Tim Williams. Many of these contributors also reviewed this document;
their comments are most appreciated.
Kate Bond and Lisa Weiss of the FOCUS on Young Adults Program
were important collaborators in Cambodia, Zambia, and Zimbabwe.
Tijuana James Traore, formerly of Planned Parenthood Federation of
America, also contributed. Thanks also go to Drew Banks for docu￾ment design and layout and Sue Carrington, Carrington & Company
Communications, Inc., for editorial assistance.
We also acknowledge the support of USAID Missions in Albania,
Burkina Faso, Cambodia, Eritrea, Russia, Senegal, Zambia, and Zimbabwe.
Above all, we appreciate the time, dedication, and commitment
of colleagues and counterparts in SEATS’ partner organizations: Asso￾ciation Burkinabé pour le Bien-Etre Familial (ABBEF), the Albania Family
Planning Association (AFPA); Association Sénégalaise de Bien-Etre
Familial (ASBEF); Department of Health Services, Primorsky Krai
Administration, Russia; Gweru [Zimbabwe] City Department of Health;
Lusaka [Zambia] District Health Management Team (LDHMT); the
officials of the Mayoral districts in Dakar and Louga, Senegal; the
Ministry of Health (MOH) of Albania; National Union of Eritrean Youth
and Students (NUEYS); the National Family Planning Program, Senegal
(PNPF); Novosibirsk Oblast Department of Public Health, Russia;
Reproductive Health Association of Cambodia (RHAC); and Zambia Nurses
Association (ZNA).

SEATS’
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Experience
iii
List of Acronyms
ABBEF Association Burkinabé pour le Bien-Etre Familial
AFPA Albania Family Planning Association
AGI Alan Guttmacher Institute
AIDS Acquired immune deficiency syndrome
ASBEF Association Sénégalaise de Bien-Etre Familial
CA Cooperating agency
CERPOD Centre for Applied Research on Population
and Development
CQI Continuous quality improvement
CSO Central Statistical Office [Zimbabwe]
CSW Commercial sex worker
EC Emergency contraception
EHP Eritrea Health and Population Project
EQUIPE Expanded Quality to Improve Program Effectiveness
FGD Focus group discussion
FGM Female genital mutilation
FLE Family life education
FOCUS FOCUS on Young Adults Program
HIV Human immunodeficiency virus
ICPD International Conference on Population and Development
IEC Information, education, and communication
IPPF International Planned Parenthood Federation
IUD Intrauterine device
JHU/CCP Johns Hopkins University/Center for Communication
Programs
JSI John Snow, Inc.
LAM Lactational amenorrhea method
SEATS’
lessons learned from
Experience
iv
MASO Midlands AIDS Support Organization [Zimbabwe]
MI Macro International
MIS Management information system
MOH Ministry of Health
NGO Nongovernmental organization
NHC Neighborhood Health Committee [Zambia]
NUEYS National Union of Eritrean Youth and Students
OC Oral contraceptive
PLA Participatory learning and action
PNPF National Family Planning Program [Senegal]
PRB Population Reference Bureau
PSI Population Services International
PTA Parent-teacher association
PVO Private voluntary organization
RHAC Reproductive Health Association of Cambodia
SEATS Family Planning Service Expansion and Technical
Support Project
STD Sexually transmitted disease
STI Sexually transmitted infection
UNAIDS United Nations Joint Programme on HIV/AIDS
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
VCR Video cassette recorder
WHO World Health Organization
YAC Youth Advisory Committee
ZNA Zambia Nurses Association
ZNFPC Zimbabwe National Family Planning Council
SEATS’
lessons learned from
Experience
v
Table of Contents
ACKNOWLEDGMENTS ............................................................................ i
LIST OF ACRONYMS .............................................................................. iii
FOREWORD ............................................................................................ vii
EXECUTIVE SUMMARY........................................................................... ix
INTRODUCTION ......................................................................................1
Barriers to Information, Counseling, Skills, and Services......................3
The SEATS Project and the Unmet Reproductive
Health Needs of Young People ...............................................................4
INNOVATIONS IN PROGRAMMING FOR YOUNG PEOPLE’S
REPRODUCTIVE HEALTH: AN OVERVIEW OF SEATS’ EXPERIENCE ......5
COUNTRY PROGRAMS, SUBPROJECTS, AND ACTIVITIES ........... 11
Summary of Achievements .................................................................... 11
Burkina Faso: “Youth for Youth” Replicated by Ministry of Health...12
Eritrea: Youth Leadership Takes the Lead in Promoting
Reproductive Health ...............................................................................15
Senegal: Multiple Strategies to Improve Youth Reproductive Health....19
Zambia: “A Window of Hope” in the World of HIV/AIDS............... 24
Zimbabwe: Gweru, A City That Supports Its Youth ........................... 34
Albania: Ensuring Young People’s Reproductive Rights .................... 43
Russia: The Client-Centered Approach Addresses Young
People’s Needs ....................................................................................... 45
Cambodia: Expanding the Reach of Peer Educators ......................... 49
LESSONS LEARNED............................................................................... 53
REFERENCES CITED ............................................................................... 59

SEATS’
lessons learned from
Experience
vii
Foreword
The purpose of the Family Planning Service Expansion and Technical
Support (SEATS) Project (1995–2000) was to expand the development
of, access to, and use of quality family planning and reproductive
health services in currently underserved populations and ensure that
unmet demand for these services was addressed through the provision
of appropriate financial, technical, and human resources. In order to
fulfill this mandate, SEATS combined the strengths of a broad-based,
flexible program capable of addressing all aspects of service delivery
with five Special Initiatives designed to tap into underutilized resources
to meet the needs of important pockets of the underserved. Quality,
sustainability, and monitoring and evaluation were cross-cutting techni￾cal themes of all activities.
The five Special Initiatives included:
ª Midwifery Association Partnerships for Sustainability (MAPS):
Empowering midwives, through their professional associa￾tions, to develop and sustain community-based reproductive
health care services.
ª Youth: Meeting people’s needs early in their reproductive
life cycle.
ª Urban: Using a data-driven approach with multisectoral
urban partnerships to create more effective and sustainable
services in African cities.
ª Integration of family planning/reproductive health into
nongovernmental organization/private voluntary organiza￾tion (NGO/PVO) programs: Working with well-established
community programs to improve both access to and quality
of reproductive health services.
ª Women’s Literacy: Reaching women already striving to
improve their lives with reproductive health information
and services.
Special Initiative activities were often implemented in conjunction with
or through SEATS’ 30 subprojects in Africa, Asia, the Near East, and
Eastern Europe. This paper summarizes SEATS’ experience with sub￾projects and activities of the Youth Initiative, many of which combined
the resources of the Urban Initiative and MAPS.

SEATS’
lessons learned from
Experience
ix
Executive Summary
The sexual and reproductive health needs of young people are com￾plex, diverse, and demanding of urgent attention. Young people not
only need, but also have the right to, reproductive health information
and services, a principle endorsed by the global community at the
International Conference on Population and Development (ICPD) in
Cairo in 1994 and the Fourth International Conference on Women in
Beijing in 1995. Meeting these needs was a focus of SEATS’ sub￾projects and activities in eight countries: Albania, Burkina Faso, Cam￾bodia, Eritrea, Russia, Senegal, Zambia, and Zimbabwe.
SEATS’ youth-oriented subprojects and activities shared several fea￾tures. Many reflect agreed-upon best practices, and others represent
novel approaches to promoting, protecting, and improving young
people’s sexual and reproductive health. Characteristics of subprojects
included:
ª The use of multiple interventions in multiple settings to
address young people’s reproductive health problems.
ª Clinical services for youth, including contraception, sexually
transmitted disease (STD) screening and treatment, antenatal
and delivery care.
ª Focus on urban youth.
ª Collaboration among local, national, and international institutions.
ª Youth involvement in program design, implementation,
management, and evaluation.
ª Outreach, including peer education.
ª Incorporation of youth reproductive health programming into
ongoing program activities.
ª Community mobilization and advocacy.
ª Attention to quality and sustainability.
Among the lessons that SEATS learned as it carried out its broad,
flexible mandate to improve health services for youth while simulta￾neously applying a range of documented best practices and testing
new approaches are:
ª Addressing the special needs of young people does not
require starting with a separate project or intervention
targeting youth.
SEATS’
lessons learned from
Experience
x
ª The willingness to pioneer new ventures in reproductive
health services for young people is not exclusive to the
private sector.
ª Basic human rights—clients’ rights and reproductive rights—
are a compelling rationale for offering reproductive health
education and services to young people.
ª Young people and service providers demand integrated
reproductive health interventions.
ª Integrated reproductive health services that include STD
prevention and screening can attract young men.
ª Health centers can be reconfigured to attract youth seeking
information and counseling as well as services.
ª A “champion” for youth within a clinical setting can help
maintain a youth-friendly environment.
ª The costs associated with referral services are a barrier to
access.
ª Young people also prefer contraceptive method choices.
ª Programs require support, advice, and assistance in address￾ing community resistance and opposition to youth reproduc￾tive health interventions.
ª Identifying a sustainable and appropriate package of com￾pensation and incentives for peer educators is complicated.
ª Peer educators can be very resourceful fundraisers.
ª Adult-friendly programming may be as important as youth￾friendly services.
ª Standard family planning and reproductive health monitoring
indicators do not capture the results of youth projects.
ª Evidence of sexual activity among girls 12 and younger points
to the need to develop appropriate interventions targeting
this age group.
ª The sensitivity surrounding reproductive health services for
young people is not an insurmountable barrier to demonstrat￾ing their feasibility.
The staff of SEATS and its many counterparts and collaborators are
proud to have contributed to making young people’s right to appropri￾ate information and confidential, private reproductive health services a
reality in the eight countries.
SEATS’
lessons learned from
Experience
1
The SEATS I Project operated between 1989 and 1995. The SEATS II Project ran from 1995 to
2000. “SEATS” is used throughout the document to refer to both projects, although only
activities in Burkina Faso occurred during the SEATS I project. 1
Introduction
The reproductive health needs of adolescents
as a group have been largely ignored to date
by existing reproductive health services.
(UNFPA 1994)
Since 1989, the Family Planning Service
Expansion and Technical Support Projects
(SEATS I and II), managed by John Snow, Inc.
(JSI), provided financial and technical support
to expand the development of, access to, and
use of quality family planning and reproduc￾tive health services in currently underserved
populations.1
 The problems associated with
early, unwanted, and unprotected sexual
activity among today's generation of 1.6
billion young people between the ages of 10
and 24 justify the designation of youth as an
underserved population.
The transition from childhood to adulthood is a period of great possi￾bilities as well as a time of great risk. Although rates of childbearing
among women under 20 are declining in many countries, approxi￾mately 15 million young women ages 15 to 19 give birth every year.
Pregnancy and childbearing among adolescent women frequently lead
to school dropout, reducing opportunities for both further education
and future income. Maternal mortality is estimated to be twice as high
for women ages 15 to 19 than for women ages 20 to 24. Infant and
early childhood mortality is also higher when the mother is under age
20. Many pregnancies are unwanted. In some countries, complications
from unsafe abortions are a leading cause of death among teenage
women. Young people under age 25 account for one half of all human
immunodeficiency virus (HIV) infections, and the highest rates of
sexually transmitted diseases (STDs) occur among 20 to 24 year olds,
followed by youth ages 15 to 19. There is growing evidence that many
young women and girls experience rape, incest, and other forms of
sexual violence, with severe repercussions including an increased
likelihood of drug abuse and prostitution. Millions of girls are subjected
to female genital mutilation (FGM) each year (PRB 1996).
photo by Marty Lueders
Young people under age 25 account for one half of all HIV infections,
and have the highest rates of STDs.
How Old Is a Youth?
The World Health Organization
(WHO) considers adolescence as
the period between 10 and 19
years. The United Nations defines
youth as 15 to 24 years. In SEATS I
and II, each country used a locally
established definition of “youth,
young people, or young adults.”
For example, in Cambodia, the
subproject aimed to reach young
people 12 to 25; in Eritrea, the
target population was youth 14 to
35; and in Zambia, the goal was to
provide improved reproductive
health information and services for
young people 10 to 24.
SEATS’
lessons learned from
Experience
2
These global data mask the enormous differences in young adult
sexual and reproductive behaviors from one country to another, and
from one setting to another within countries. For example, the propor￾tion of women who have their first child by age 18 ranges from less
than 10 percent in Rwanda to more than 50 percent in Zimbabwe, 38
percent of young men and women aged 20 to 24 report they were
sexually active by age 18; in Ghana, 43 percent of males and 66
percent of females say they had intercourse before they were 18.
Young women who live in urban areas and those who have completed
seven or more years of school are more likely than their counterparts
in rural areas and with less education to delay childbearing until they
are at least 18 (AGI 1998). In addition, the social and cultural context of
young people's sexual activity—and the risks and consequences associ￾ated with it—differ greatly for males and for females in almost all societ￾ies (Weiss et al. 1996).
Focusing on the very real problems resulting from early, unprotected,
and unwanted sexual activity also obscures the many valuable assets
young people bring to their families, communities, and countries:
tremendous energy, new ideas, and society’s potential for develop￾ment and growth. The attention to problems can also mislead one into
thinking that most young people are sexually active. In fact, in the
developing world the majority of young women aged 15 to 19 are not
sexually active, and when they are, most sexual activity takes place
within marriage (McCauley and Salter 1995).
Clearly, the sexual and reproductive health needs of young people are
complex, diverse, and demanding of urgent attention. Young people
not only need, but also have the right to, reproductive health informa￾tion and services, a principle endorsed by the global community at the
International Conference on Population and Development (ICPD) in
Cairo in 1994 and the Fourth International Conference on Women in
Beijing in 1995. Experts on adolescent health, many health program
practitioners, and youth themselves agree that all young people need
access to the reproductive health information, counseling, and related
skills (both life skills and those specific to reproduction and sexuality)
that will help them lead healthy lives. Young people who are sexually
active require these interventions as well as access to a broad scope of
reproductive health services, including a range of contraceptives,
screening and treatment for STDs, pregnancy testing, and other clinical
services such as antenatal, postpartum, and postabortion care (Hughes
and McCauley 1998; WHO/UNFPA/UNICEF 1997).
SEATS’
lessons learned from
Experience
3
Barriers to Information, Counseling, Skills, and Services
Despite global calls for action, the barriers to young people’s access to
information, counseling, skills, and services are many. Adult discomfort
with young people’s sexuality is almost universal. Many policymakers,
program planners, and parents mistakenly believe that information and
education about sexuality and reproduction encourage sexual activity
among unmarried teens. Numerous studies show that young people
are poorly informed about basic sexual and reproductive health
matters; yet, parents, teachers, and health care providers are often
unprepared to discuss sexuality with youth. While programs such as
family life education (FLE) in schools and mass media campaigns
directed at young people can improve knowledge, they rarely include
skills development components that help young people learn to
protect themselves and form positive relationships. Sometimes youth
disregard available information because the content is perceived as
irrelevant or the source as unreliable or outdated (Hughes and
McCauley 1998; McCauley and Salter 1995).
For sexually active young people, particularly those who are not
married, obtaining reproductive health services is even more difficult
than gaining accurate, culturally relevant, age-specific information.
Although well over half the young women and men in most developing
countries report that they have heard of at least one modern contra￾ceptive method, many do not know where to get these methods or
how to use them. Few clinics are designed, prepared, or even willing to
provide services to young people. Although legal barriers sometimes
limit young people's access to services, more often than not, practices
such as providers' judgmental attitudes, inconvenient clinic hours, and
lack of confidentiality deter young people from seeking services. Costs
and geographic distances also limit access. Since family planning
services have traditionally served women, young men are even less
likely than young women to feel welcomed at many clinics. Conse￾quently, many young people, both married and unmarried, are left with
an unmet need for contraception and other reproductive health
services (AGI 1998; PRB 1996).
Social norms, especially those for gender roles, and other environmen￾tal factors contribute to these barriers as well as to the conditions
underlying poor reproductive health among young people. The same
conditions that limit countries’ abilities to offer adequate health ser￾vices to the entire population obviously affect their ability to serve
young people. In most societies, women, and especially young
women,have little power to negotiate sexual activity. Childbearing may
be a young woman’s only way to avoid social outcast or to gain social
status. Poverty leads growing numbers of young people to engage in
sex in exchange for money, food, or gifts (Kilbourne-Brook 1998).
SEATS’
lessons learned from
Experience
4
The SEATS Project and the Unmet Reproductive
Health Needs of Young People
The starting point of all SEATS’ efforts is people's reproductive health needs:
ª Access to sustainable, quality reproductive health services
that meet the needs of women and men throughout their
lives and that emphasize health promotion and prevention,
but also include therapeutic care.
ª Knowledge and the skills required to make good use of that
knowledge when making decisions that affect reproductive
health.
ª An enabling socioeconomic and legislative environment that
supports access to family planning and reproductive health
services and encourages healthy behavior.
Meeting these three needs was at the center of SEATS’ activities to
improve young people’s reproductive health. The attention that each
need received in a subproject varied according to the specific socio￾economic and cultural context. In basing its approach on these three
needs, SEATS recognized that health services alone are insufficient—
and often, inappropriate—to improve the reproductive health and
enhance the personal development of young people. At the same
time, SEATS and its many courageous collaborators did not shy away
from the controversy and sensitivity that often surround the delivery of
reproductive health services for young people; all its youth-oriented
subprojects and interventions included a range of clinical services.
This report presents a review of SEATS’ experience in programming for
young people, including early experiences under the SEATS I project.
Overviews of subprojects in Albania, Burkina Faso, Cambodia, Eritrea,
Russia, Senegal, Zambia, and Zimbabwe (grouped by geographical
region) highlight program approaches and innovations—the new
techniques and approaches designed to improve access to and use of
quality reproductive health information and services for youth. Sub￾projects in Zambia and Zimbabwe were fortunate to have access to
resources for pre- and post-intervention evaluations; these are reported
with more depth. The final section outlines lessons learned.
SEATS’
lessons learned from
Experience
Innovations in Programming
for Young People's Reproductive
Health: An Overview of
SEATS’ Experience
The evidence, particularly from developing countries, upon which to
base firm conclusions about the most effective interventions for young
adult reproductive health is extremely limited. Numerous expert
reviews of program experience to date highlight the dearth of research
and call for greatly increased attention to program evaluation. Never￾theless, there is a broad consensus about best practices based largely
on experience, expert opinion, process evaluations, and qualitative
research (McCauley and Salter 1995; Hughes and McCauley 1998;
Senderowitz 1997a; Senderowitz 1997b; PRB 1996; WHO/UNFPA/
UNICEF 1997).
Although many of the “recom￾mended approaches” or “key ele￾ments” arising from the expert
reviews evolved after SEATS sub￾projects were designed, interventions
were remarkably consistent with the
state of the art and with the ap￾proaches recommended by the
WHO/UNFPA/UNICEF Study Group
on Adolescent Health and Develop￾ment in particular (see box). The
affinity of subprojects with the
WHO/UNFPA/UNICEF framework
can be attributed to both SEATS’
approach to meeting reproductive
health needs and a key innovation
that all subprojects shared: the use of
multiple interventions in multiple
settings to address young people’s reproductive health problems.
Rather than relying on a single predominant strategy, e.g., peer coun￾seling, mass media outreach, school-based education, or facility-based
services (McCauley and Salter 1995; Senderowitz 1997a; Senderowitz
1997b; Israel and Nagano 1997; Birdthistle and Vince-Whitman 1997),
5
ª Put youth at the center
ª Address multiple health
problems
ª Build on and link existing
interventions
in various settings
ª Combine interventions
ª Respect cultural diversity
ª Strengthen programme
management
ª Encourage positive adult
attitudes and behaviors
 FRAMEWORK FOR PROGRAMMING FOR ADOLESCENT HEALTH
SOURCE: Adapted from “Framework for country programming for adolescent health" in WHO/UNFPA/UNICEF.
1997. Action for adolescent health: Towards a common agenda: Recommendations from a joint WHO/UNFPA/
UNICEF study group. Geneva: WHO
ª Create safe and
supportive environments
ª Provide information
ª Build skills
ª Provide counseling
ª Improve health services
ª Home
ª School
ª Health center
ª Work place
ª Street
ª Community organization
ª Residential center
ª Media/entertainment
ª Political and legislative
systems
 Keys to Success Settings Major Interventions
SEATS’
lessons learned from
Experience
6
each subproject drew upon many approaches and many existing
institutions to overcome barriers and increase access to youth-friendly
information, counseling, skills building, and services. The lessons
learned from a study of the youth programs of 10 family planning
associations in sub-Saharan Africa also guided the design of subprojects
(IPPF/AR and JSI/SEATS 1997).
SEATS subprojects shared other features. Many reflect agreed-upon
best practices, and others represent novel approaches to promoting,
protecting, and improving young people’s sexual and reproductive health.
ª Clinical services for youth. SEATS’ mandate to focus on
quality family planning and reproductive health services
meant that SEATS did not ask if services for youth were
politically or culturally possible; rather, it asked what was
needed to improve young people’s access to and use of
services. Several subprojects specified the creation of
“youth-friendly” (see box, page 7) clinical settings as objec￾tives. Others took steps to modify services to ensure they
were acceptable to young people, although they did not use
the term “youth-friendly.” These efforts to expand access to
clinical services were a first for each of SEATS’ counterpart
institutions.
ª Focus on urban youth. Most subprojects and activities took
place in cities and towns, usually national and provincial
capitals. Young people ages 10 to 24 make up a growing
proportion of the population in urban areas—sometimes as
much as 35 percent (Sambisa et al. 1999). A number of
trends put the reproductive health of urban youth at great
risk. Secondary school enrollment is higher for urban youth
than rural youth. Although the advantages of higher educa￾tion are indisputable, the interaction with schoolmates,
greater freedom from parental supervision, and the declining
influence of traditional cultural values and institutions that
discourage nonmarital sexual activity may all contribute to a
greater likelihood of sexual relationships before marriage
among urban youth. Urban youth also marry later than rural
youth. These patterns, combined with the universal tendency
for earlier onset of puberty, lengthen the period when young
people in cities and towns are at risk for unprotected sexual
activity and unwanted pregnancy (AGI 1998; Singh 1998).
SEATS’
lessons learned from
Experience
7
ª Collaboration among existing institutions. Subprojects
turned to health care service delivery systems, youth organi￾zations and recreation centers, schools, local governments,
neighborhood advisory bodies, and other on-the-ground
institutions to build and strengthen capacities to meet young
adult reproductive health needs. In addition to support from
the United States Agency for International Development
(USAID), many subprojects benefitted from the inputs of
other international donors such as the United Nations Popu￾lation Fund (UNFPA) and the United Nations Children's Fund
(UNICEF) as well as USAID cooperating agencies (CAs) such
as MotherCare, FOCUS on Young Adults (FOCUS), and
Johns Hopkins University/Center for Communication Pro￾grams (JHU/CCP).
ª Base in public- and private￾sector institutions. The
sensitivities involved in
delivering reproductive
health care to young people
often mean that nongovern￾mental organizations
(NGOs) are more willing
than public-sector institutions
to offer services (Senderowitz
1997a; McCauley and Salter
1995). Contrary to this trend,
public-sector institutions were
the base for many SEATS
subprojects; collaboration
between the public and private
sectors marked all of them.
ª Integration of reproductive
health interventions. The
specific nature of the repro￾ductive health issues facing
youth in the subproject
communities, coupled with a
growing “post-Cairo” con￾sciousness and the expressed
needs of youth, led all sub￾projects to address preg￾nancy and STD prevention as
well as other reproductive
health issues such as FGM and
pregnancy care and delivery.
WHAT ARE YOUTH-FRIENDLY SERVICES?
Health Facility Characteristics
ª Separate space and special
times set aside
ª Convenient hours
ª Convenient location
ª Adequate space and sufficient privacy
ª Comfortable surroundings
Other Possible Characteristics
ª Education material available on
site and to take away
ª Group discussions available
ª Delay of pelvic examination and blood
tests possible
ª Alternative ways to access information,
counseling, and services
SOURCE: Senderowitz, J. 1999. Making reproductive
health services youth-friendly. Washington, DC:
FOCUS on Young Adults program.
 Provider Characteristics
ª Specially trained staff
ª Respect for young people
ª Privacy and confidentiality honored
ª Adequate time for client and provider
interaction
ª Peer counselors available
Program Design Characteristics
ª Youth involvement in design and
continuing feedback
ª Drop-in clients welcomed and appoint￾ments arranged rapidly
ª No overcrowding; short waiting times
ª Affordable fees
ª Publicity and recruitment that inform
and reassure youth
ª Boys and men welcome and served
ª Wide range of services available
ª Necessary referrals available
SEATS’
lessons learned from
Experience 8
ª Youth involvement. Many international organizations at￾tribute the success of their youth programs to the meaningful
involvement of youth in all aspects of programming
(Senderowitz 1998). Creating and maintaining mechanisms
for youth participation in program design, implementation,
management, and evaluation was one of the ways that SEATS
subprojects demonstrated their faith in young people’s
capabilities and talents.
ª Outreach. Many SEATS youth subprojects were the first in
their countries to introduce trained peer educators or coun￾selors to reach young people in their communities with more
than HIV and acquired immune deficiency syndrome (AIDS)
prevention information. In other subprojects, health providers
went beyond the clinic walls to reach parents, teachers,
school students, and others.
ª Incorporation of youth reproductive health programming
into ongoing reproductive health programming. Initially,
SEATS II envisioned programming for youth sexual and
reproductive health as a separate special initiative. As SEATS
began its discussions with USAID missions and counterpart
agencies, the need for models that take into account and
address the specific needs of youth as an integral component
of a comprehensive approach to reproductive health became
apparent. Rather than addressing youth separately, SEATS’
programming evolved into full integration of youth-oriented
reproductive health programming into existing institutions—
either through youth-targeted subprojects or general quality
improvement interventions.
ª Community mobilization. All SEATS subprojects faced the
challenge of gaining the acceptance, involvement, and support
of parents and community leaders for youth reproductive
health initiatives, particularly for clinical services. Subprojects
employed a range of strategies—from including community
members in advisory committees, to sharing research results
and engaging parents, leaders, and youth in defining sub￾project objectives—aimed at creating a supportive environ￾ment for sustaining and advancing subproject achievements.
ª Attention to quality and sustainability. Quality of care and
sustainability were cross-cutting technical themes of all SEATS II
subprojects, not only those focused on young people. In addition
to attention to 
“youth-friendly
” information, education, and
services, SEATS II’s Quality Initiative introduced innovative quality
assurance approaches such as continuous quality improvement
SEATS’
lessons learned from
Experience
9
(CQI) to bring together multiple sites and multiple stakeholders in
defining, assessing, and ensuring quality of care. Sustainability was
addressed through attention to management capacity, leveraging
of existing resources, and the use of nonclinical, community￾based interventions, which have a lower cost than clinic-based
interventions and are often easier for youth to access.
ª Flexible, multisectoral approaches. SEATS’ broad mandate,
multidisciplinary capability, and wide range of skills allowed
youth-oriented subprojects to creatively combine the applica￾tion of known best practices with the involvement of new,
sometimes unconventional, resources.
ª Consistency with USAID strategies and national public
health priorities. Because all subprojects included integrated
reproductive health interventions, they contributed to
achievement of several of the strategic objectives of USAID’s
Global Population, Health, and Nutrition Center as well
as the strategic objectives of the USAID missions in the
countries where they took place. All subprojects reflected
their host governments’ reproductive health policies and
programs, many of which had been recently reformulated
to designate young people as a specific audience.
photo by Willow Gerber
In most societies, women, and especially young
women, have little power to negotiate sexual activity.

SEATS’
lessons learned from
Experience
11
2Unless otherwise cited, data reported in this document come from unpublished SEATS subproject
reports, memoranda, interviews with staff, and SEATS Database Management System.
Country Programs,
Subprojects, and Activities
Summary of Achievements
SEATS’ youth-oriented subprojects and activities reflected the
specific situation and needs in each country. Some subprojects
addressed youth needs through general improvements in the quality
of care and did not track clients by age. Hence, overall results cannot
be quantified. Principal achievements in each country are listed
below.2
Burkina Faso: 125 peer educators trained; 77,304 youth reached;
reproductive health services offered in two youth clinics;
clinical services to 7,459 youth; program model replicated in
Burkina Faso and other Sahelian countries
Eritrea: 72 peer educators trained; 85,945 youth reached;
313,000 condoms distributed; reproductive health services
offered in three youth centers
Senegal: 22 peer educators trained; reproductive health services
offered at multipurpose youth center; youth-oriented educa￾tion and services incorporated into public– and private–
sector programs
Zambia: 20 peer educators trained; 18,217 youth reached; 18
service providers trained in youth-friendly services; reproduc￾tive health services offered in seven city clinics; 4,400 new
contraceptive users; 7,494 visits for other reproductive health
services; services rated highly by young people; provider and
community attitudes changed from negative to positive;
youth-friendly services incorporated into other service sites
nationwide
Zimbabwe: 40 peer educators trained; 8,141 youth reached; 43
providers trained in youth-friendly services; reproductive
health services offered in seven city clinics and multipurpose
youth center; services rated highly by youth; 500 adults
reached through advocacy and community mobilization;
improvements in young people's attitudes toward condom
use and increases in reported use of condoms; city govern￾ment committed to sustaining services
SEATS’
lessons learned from
Experience
12
Albania: Trained providers offered youth-friendly services and
counseling; range of contraceptive options for young people
expanded; information, education, and communication (IEC)
materials developed
Russia: Trained providers offered youth-friendly services and
counseling; outreach and education for youth established;
range of contraceptive options for young people expanded;
providers committed to youth reproductive rights
Cambodia: 47 peer educators trained; 2,000 youth reached;
additional donor funding obtained to expand to three
other cities
Burkina Faso: “Youth for Youth” Replicated by
Ministry of Health
SEATS began to incorporate services for young people into its program
portfolio under SEATS I (1989 to 1995). The subproject “Youth for
Youth: Family Planning Services and Family Life Education for Youth,”
implemented by the Association Burkinabé pour le Bien-Etre Familial
(ABBEF), set the pace for subsequent SEATS’ programming for youth: it
used multiple approaches to reach youth including clinical service
delivery.
A First for Francophone Africa
In the early 1990s in sub-Saharan Africa, the idea of young people
providing health information to other youth—peer education and
counseling—was just beginning to gain adherents, and few countries
were willing to get involved in the delivery of reproductive health
services to adolescents. Burkina Faso was. The data on adolescent
sexual activity and reproductive health pointed to the need for better
information and services for young people. The overwhelming majority
(92 percent) of women 20 to 24 years were sexually active by age 20.
Although most sexual activity took place within marriage, only 2
percent of the sexually active women aged 15 to 19 who did not want
a child soon were using a modern contraceptive. Ever-use of modern
contraception was higher among unmarried women aged 15 to 19 (31
percent) than among married women of the same age (14 percent).
Only half of the ever-married young women in urban areas knew
where to obtain a modern method (AGI 1998).
SEATS’
lessons learned from
Experience
13
Although the evidence of need was compelling,
it was not the only factor contributing to the
uncommon willingness to embark upon an
innovative approach to delivering reproductive
health information and services to youth.
Equally important was the policy environment,
marked by a public commitment to improving
reproductive health, an openness to innovation,
and substantial attention to building support
from community, religious, and government
leaders. Consequently, the pioneering pilot
project “Youth for Youth” took no one by
surprise, nor was it subject to overt opposition.
Begun in 1992 in the two major urban centers
of Burkina Faso, Ouagadougou and Bobo
Dioulasso, the four-year subproject aimed to
develop a model for the provision of IEC, FLE,
and clinical services
in family planning to in-school and unemployed
youth aged 14 to 20. Input and advice from
community leaders, parent-teacher associations
(PTAs), government institutions (particularly the
Ministry of Health [MOH], the Ministry of
Education, and the Ministry of Social Affairs),
and youth shaped the subproject design and
secured enthusiastic endorsement of the
activities. A specially established Youth Center
in each city, staffed by a trained midwife and
two social workers, along with a visiting physi￾cian, offered reproductive health services and
counseling. Centers also had libraries stocked
with information on reproductive health and
showed films on family life and sexuality-related
topics daily. The 125 trained male and female
peer counselors came from every district in the
two cities. They visited homes, community
settings, and schools to hold group education
sessions, show films, perform dramas, and
provide one-on-one counseling. ABBEF staff and
the peer counselors produced and broadcast
almost 50 radio shows. Initially, the peer coun￾selors did not distribute condoms; midway
through the subproject, they began to sell them
at a modest price, keeping a small portion of
the profit as an incentive.
Burkina Faso:
Subproject Overview
Dates: January 1992 to September 1995
Target population: Youth 14 to 20 in two cities
SEATS’ counterpart: Association Burkinabé pour le Bien-Etre
Familial (ABBEF)
ü Advocacy and community mobilization: meetings with
parents and leaders
ü 125 peer counselors (high school students and unem￾ployed youth) trained
ü IEC materials developed: leaflets, posters, t-shirts, radio
talk shows
ü 77,304 youth reached
ü Clinical services to 7,459 youth: contraception, STD
screening, gynecology in two Youth Centers
ü Management information system (MIS) to track client
visits, referrals, outreach
ü Program model replicated in other cities
ü Youth Unit established within MOH
ü Subproject cited as model for other Sahelian countries
ü Collaboration with MOH
SEATS’
lessons learned from
Experience
14
The peer counselors’ performance far exceeded expectations: they
reached 77,304 youth, compared with a target of 20,500. Most (about
80 percent) of the youth reached were not in school. The counselors,
particularly those from the informal sector (the unemployed), gained
status and recognition in their communities. The peer counselor
component also faced the challenges common to many peer outreach
programs that rely on volunteers: a high turnover rate, the need for
frequent refresher training, unsystematic data collection, and limited
geographic coverage due to lack of transportation (Senderowitz
1997b).
The Youth Centers were popular sources of information. After 18
months of operation, 12,000 young people had visited the centers, and
many students residing in the surrounding neighborhoods came to
learn about and discuss reproductive health topics with Center staff.
Many also came for reproductive health care: 1,329 clients (mainly
young men) sought diagnosis and treatment for STDs, 1,771 young
women consulted for gynecological problems, and 4,359 (mainly
young women) came for contraceptive services. Subproject staff
believed that the inconvenient locations of the Centers for many youth,
the failure to open on weekends, and the shyness of young women
were barriers to greater use of clinical services. They proposed explor￾ing the incorporation of recreational and vocational activities and the
expansion of the operating schedule beyond regular business hours to
make the Youth Centers more attractive to young people. The lack of
laboratory services for STD diagnosis at the Youth Centers further
inhibited appropriate service delivery. The young people referred to
other facilities could not pay the associated costs of transportation and
services; they also feared ridicule, scolding, or violation of confidential￾ity by service providers at these other facilities.
A Model for Replication
“Youth for Youth” convinced the MOH of the political and cultural
feasibility of this model of delivering reproductive health information
and services to young people. Immediately following the end of the
subproject, the MOH, with support from UNFPA and the Dutch
government, began to train additional peer counselors in Ouaga￾dougou, Bobo Dioulasso, and other urban areas; it is now starting to
open more Youth Centers. The MOH also established a Youth Unit
within the Family Health Division.
The subproject also had an impact beyond the borders of Burkina
Faso. In a 1995 seminar in Bamako, Mali, to review and disseminate the
findings of quantitative and qualitative research on adolescent repro￾ductive health in the Sahel, representatives from public- and private-
SEATS’
lessons learned from
Experience
15
sector organizations in Burkina Faso, the Gambia, Mali, Niger, and
Senegal learned of the ABBEF subproject. Together, they recom￾mended that countries “draw on the Burkinabe experience as a model
of accessibility of contraceptive methods” for young people (CERPOD
1997). ABBEF is now well-positioned to explore and refine new models
to reach young people.
Eritrea: Youth Leadership Takes the Lead in
Promoting Reproductive Health
During Eritrea’s lengthy struggle for independence,
the National Union of Eritrean Youth and
Students (NUEYS) was one of the main and
most effective grassroots organizations sup￾porting the quest for freedom. Following
independence in 1991, NUEYS defined new
priorities, programs, and policies to engage the
country's youth in action-oriented contribu￾tions to the task of national reconstruction.
Encouraging healthy lifestyles among young
people, with a special focus on the dangers of
unwanted and early pregnancies, HIV/AIDS,
STDs, and other social problems such as early
marriage and FGM, became one of the NGO’s
principal objectives.
Developing the Capacities of
a Youth Organization
In 1996, SEATS II and NUEYS decided to work
together to strengthen NUEYS’ capacity to
promote, develop, and implement young adult
reproductive health programs. NUEYS was—
and continues to be—well-positioned to take a
lead in addressing young people’s reproductive
health. Its role in the war for independence
earned it visibility and respect from the Gov￾ernment of Eritrea and community members.
Its nationwide presence—a membership of
100,000 of both genders (80 percent are in the
age range 18 to 24) and offices in all 10 zones
of the country—and its multisectoral programs
in sports, recreation, environment, health, and
job training—allow it to reach a large portion of
Eritrean youth. The values guiding NUEYS’ actions,
including youth involvement in program design and
Eritrea: Subproject Overview
Dates: November 1996 to July 1998
Target population: Youth 14 to 35 in three cities and in the
National Service Camp
SEATS’ counterpart: National Union of Eritrean Youth and
Students (NUEYS)
ü 72 peer counselors trained in three urban sites
ü IEC materials developed: leaflets, posters, story writing,
video
ü 85,945 youth reached; 313,000 condoms distributed
ü Clinical services in Youth Center in Asmara and clinic in
Sawa Camp with referrals to MOH facilities
ü MIS to track client visits, referrals, outreach
ü Organizational capacity strengthened: training of trainers;
training in management, quality, sustainability
ü Other donor funding obtained for national expansion and
purchase of printing press
ü Advocacy and outreach for eradication of FGM
ü Collaboration with MOH, Ministry of Defense, UNFPA,
MotherCare, BASICS, Population Services International
SEATS’
lessons learned from
Experience
16
management and a commitment to gender equity, are particularly
important for young people’s reproductive health. The designation of
young people as a specific target group for increased access to and
use of reproductive health information and services complemented the
ongoing MOH/USAID Eritrea Health and Population Project (EHP),
which focused on strengthening the delivery of integrated primary
health care. Activities took place in three of NUEYS’ urban youth
centers in Asmara, the capital, Mendefera, and Agordat—sites corre￾sponding to the EHP emphasis zones—and the National Service Camp
at Sawa, where twice a year, more than 20,000 young men and
women come together for mandatory national service. During sub￾project development, discussions among SEATS II, NUEYS, UNFPA,
and the MOH resulted in substantial additional support from UNFPA to
NUEYS, allowing the youth reproductive health program to take on a
national scope.
Capacity-building actions took many forms. NUEYS gained trainers that
can continue to train peer educators and advocates for change of
harmful traditional practices, and its management has skills in NGO
sustainability. SEATS also helped NUEYS obtain grant funds from two
other donors to purchase a printing press. At the time the subproject
began, the only other operating printing press in the nation was owned
by a religious institution, which refused to allow the production of
materials promoting condom use. Owning the printing press allowed
NUEYS to provide at-cost printing services for its own programs and
for other NGOs.
In each of the three urban sites, about 20 trained peer counselors, all
NUEYS members, conducted IEC outreach activities in the schools and
communities, and made referrals for services and counseling. The
NUEYS recreational facility in Asmara was refurbished, and a trained
nurse provided counseling, nonclinical family planning services (oral
contraceptives [OCs] and condoms), and referrals to MOH health facilities.
Reaching a Captive Audience
Program planners often suggest that a “captive audience” is the easiest
one to reach; activities at the Sawa Camp gave NUEYS the opportunity
to test this saying. Twice a year, more than 20,000 young men and
women gather at the camp for mandatory national service. Two health
providers at the camp health center received training in family planning
and offered nonclinical services to trainees and referrals to the MOH
hospital in the nearby town of Agordat (also a subproject site). Every
six months, camp staff conducted reproductive health education
sessions during a two-week period. In the mornings, the health
providers and other NUEYS staff made presentations in the three
Eritrean languages.
SEATS’
lessons learned from
Experience
17
In the evenings, after the sand storms and rains had subsided, they
showed films and videos such as the MOH/SEATS coproduction on
the consequences of unwanted pregnancy, Could They Have Been
Saved? Debates and question-and-answer sessions followed the films.
Sometimes, trainees presented their own poems on AIDS and other
reproductive health themes. Trainees received copies of the subproject
leaflets on contraception and STDs in national languages along with
condoms. Over time, IEC activities extended into surrounding villages,
where many trained youth remain to perform their national service.
NUEYS also took on a challenge that other Eritrean organizations were
unwilling to address: the almost universal practice of FGM. It formed
an FGM technical advisory group, and members received training in
“communication for change,” vowing to engage in individual and
collective actions to combat the practice.
By the end of the subproject in mid-1998, NUEYS had reached almost
86,000 young people with information on reproductive health and
distributed more than 300,000 condoms. Although the massive size of
the groups at Sawa camp ruled out one-on-one counseling, the IEC
sessions did serve as an open forum for bringing up reproductive
health concerns. Trainees asked about issues such as masturbation, the
“safe period,” contraception and promiscuity, and legalization of
abortion, and the printed materials reflecting the Eritrean cultural
context were very popular. NUEYS also succeeded in institutionalizing
reproductive health IEC into Sawa camp: the camp military command￾ers and NUEYS agreed to a regular schedule for IEC activities.
photo by Susan Rae Ross, USAID/Entrea
SEATS’
lessons learned from
Experience
18
NUEYS’ combined recreation and health center at Asmara, with its
associated peer counselors, reached only a fraction (less than 5 per￾cent) of the total 86,000 youth benefitting from the subproject.3
Nevertheless, the number of young people seeking services at the
Asmara Center increased steadily over the subproject—from fewer than
100 per quarter to more than 550 per quarter by subproject’s end.
NUEYS staff believe that offering reproductive health services along￾side a recreational program made the reproductive health component
more attractive. The majority of the Center’s clients were young men
seeking STD prevention or treatment, but requests for contraception
by young women also increased. Although the demand for services
offered by MOH facilities was low (as evidenced by the low number of
referrals), the establishment of the links between NUEYS and the MOH
was an important achievement. The lack of overt opposition to the
Center’s activities was another indicator of its potential. Before this
subproject, open discussion of sexual and reproductive health matters
was discouraged. Nevertheless, the conservative nature of Eritrean
society made it difficult for NUEYS to carry out its plans to develop
community advisory committees.
Off to the Front
When armed conflict between Eritrea and Ethiopia broke out in 1998,
many of NUEYS’ members and constituents were called to the front,
affecting all of NUEYS’ activities, including its reproductive health
program. Even under these difficult circumstances, NUEYS members in
Agordat (in the war zone) requested peer counselor training, and
NUEYS responded. The opportunity to further improve the status of
women, an important result of Eritrea’s war for independence, was one
possible ray of hope in the renewed conflict.
NUEYS’ commitment to promoting young people’s reproductive
health as a means to personal and national development remains, and
it is determined to continue with peer counselor programs linked to
MOH health services along with actions to eradicate FGM. In fact,
NUEYS renewed its reproductive health services in mid-1999, and the
numbers of young people served were similar to those reached before
the war. NUEYS also produced a feature-length video on HIV/AIDS.
Equally important, NUEYS, an organization managed by young people
serving young people, now has the experience and capacities to carry
out such programs, the confidence and support of donor agencies, the
established working relationship with the MOH, and the implicit
endorsement of the public to move forward.
3
Peer counselors in Mendefera and Agordat did not receive training until the last quarter of the
subproject, so data on their performance are not available.
photo by Marty Lueders
By the end of the subproject in mid-1998,
NUEYS had reached almost 86,000 young
people with information on reproductive health
and distributed more than 300,000 condoms.
SEATS’
lessons learned from
Experience
19
Senegal: Multiple Strategies to Improve
Youth Reproductive Health
SEATS II’s large, multifaceted program portfo￾lio in Senegal focused on groups and sectors
not previously targeted by the National
Family Planning Program (PNPF)—youth,
factory employees, municipal governments,
and private midwives. Although only one
subproject specified youth as its target
population, SEATS II’s Urban Initiative and
quality improvement activities, introduced in
1997 and 1998 respectively, identified youth
as a priority audience for improved reproduc￾tive health services.
Dakar, the nation’s capital and the largest
metropolis in the Sahel region, has lower
rates of adolescent marriages (71 percent of
women are single by age 20), of adolescent
premarital sex (22 percent of women report
sexual relations by age 20), and of adolescent
childbearing (12 percent give birth before
age 20) than other cities in the region. But
married adolescents begin childbearing soon
after marriage, and less than 20 percent aged
15 to 24 say they have discussed with their
spouses the number of children they want.
Many fewer use a modern contraceptive—7
percent of married women 20 to 24 report
ever use (CERPOD 1997). Fifty-five percent
of all urban women 15 to 19 do not know
where to obtain a modern method of contra￾ception, and only 5 percent of all women in
this same age group can name the fertile
days in the menstrual cycle (AGI 1998).
Inspiration From Burkina Faso
Inspired by ABBEF’s experience with “Youth to Youth” in Burkina Faso,
the Association Sénégalaise pour le Bien-Etre Familial (ASBEF) asked
SEATS II to assist in strengthening and expanding its youth IEC and
counseling activities to include an effective strategy for making quality
family planning services more widely available to young adults.
Senegal: Subproject Overview
Dates: November 1995 to September 1997
Target population: Young adults in a peri-urban community
SEATS' counterpart: Association Sénégalaise pour le Bien-Etre
Familial (ASBEF)
ü Community input through Advisory Committee
ü 22 peer educators (young men and women) trained
ü IEC materials developed
ü Young Adult Community Center with capacity to provide
reproductive health services and recreational activities
ü Clinical services: contraception, STD screening, gynecology,
psychological counseling in Youth Center
ü Reproductive health education in classrooms
ü MIS to track client visits, referrals, outreach
ü End-of-project qualitative evaluation
ü Collaboration with MOH
SEATS’
lessons learned from
Experience
20
The center of the subproject was the Pikine/Guédiawaye Juvenile
Protection Center, which provides primary, secondary, and vocational
education to 300 young people in its custody (for a variety of legal
infractions, including infanticide and having had an induced abortion)
and some 1,000 other unemployed youth who are completing their
education. Building on ASBEF's experience in integrating reproductive
health instruction into the Center’s classes, the subproject aimed to
transform the Center into a comprehensive resource for young adult
reproductive health, serving students at the Center and the 150,000
young people residing in Pikine and adjacent Guédiawaye, peri-urban
communities of Dakar.
An Advisory Committee, composed of young people, teachers at the
Center, parents, and ASBEF and MOH representatives, played a critical
role in gaining and maintaining parent and teacher commitment to
activities. At first, its large size made decision making cumbersome, but
over time the involvement of many stakeholders yielded beneficial
results.
A reproductive health center, staffed by a midwife, with regular visits
from a physician and a psychologist, was created within the Center.
Following training, 22 peer educators, recruited from among Center
students, offered information to their counterparts in the Center
programs and in the surrounding communities, distributed condoms
and vaginal foaming tablets, and made referrals to clinical services in
the Center. Seven trained teachers served as peer educator supervi￾sors, and two were coordinators. Reproductive health education in the
classrooms improved, after 13 additional teachers received training in
the use of participatory, interactive teaching methodologies. Parents on
the Advisory Committee facilitated conferences and meetings with
other parents from the community.
Challenges to Community Outreach
and Quality Services
Although activities enjoyed parental support and the Government of
Senegal increased its financial support to the Center, end-of-project
focus group discussions (FGDs) with peer educators revealed that they
faced challenges in carrying out their community-based work. Young
people were reluctant to seek individual information or counseling
publicly, although youth participated in group activities such as drama
and sports events organized around reproductive health themes. Many
claimed they did not need “family planning,” as they were “chaste.”
Although a few youth secretly requested condoms, knocking on a peer
educator’s window at night, the educators believed that young people
preferred sources of information and services outside the neighborhood,
SEATS’
lessons learned from
Experience
21
4Married women, even if under the age of 20, were considered adults, not “youth.”
such as pharmacies, where privacy and confidentiality were more
likely. In contrast, the married women students at the Center and in the
surrounding areas appreciated the peer educators’ services. In fact,
about one half of the clients reached by the subproject were married/
adult4
 women and men (Thiam 1999).
Local residents doubted the chastity of peer educators engaged in
distributing contraceptives. “The fact that you are explaining these
things to us means you must use contraceptives yourself. Hence, you
cannot swear that you have not had sexual relations.” Although a few
young women peer educators were willing to reveal that they used
contraceptives in order to gain their audiences’ confidence, many,
especially in the beginning of the subproject, feared the label “un￾chaste.” Home visits were particularly difficult for the young women
educators. Male heads of household often accused them of being
“perverts” seeking to seduce their children and occasionally reported
them to the young women’s parents, who in turn questioned their
daughters’ virginity. This type of censure made many peer educators
prefer to work outside their own neighborhoods. Some peer educators
became known as “Mr. Condom,” causing them shame and leading
them to suggest that they be allowed to distribute a wide range of
essential drugs to “avoid all suspicion” (Thiam 1999).
The peer educators responded to these criticisms by taking a cautious,
step-by-step approach to introducing issues in reproductive health.
They began by talking about AIDS, a universally acceptable theme. The
key message was “chastity.” Once they gained confidence, they would
introduce contraceptive methods as a means to prevent STDs and
HIV/AIDS (Thiam 1999). Holding separate sessions for young men and
young women resulted in greater parental support, as this approach
was consistent with traditional religious and sociocultural norms.
Other barriers reduced the effectiveness of the peer educators and the
subproject activities. Despite ASBEF’s interest in young adult reproduc￾tive health, it failed to take into account the fact that programmatic
approaches that work well for married adults may not adequately meet
the special needs of young people. Its lack of staff with expertise in
youth programming impeded its ability to provide appropriate monitor￾ing and support to the Center and the peer educators. By the time the
MIS was in place, peer educators had been trained; introducing new
data collection procedures into their ongoing activities was difficult. A
stock-out of contraceptive commodities early in the subproject left
Center staff and the peer educators demoralized when they could not
offer the services wanted by clients. The peer educators’ other commit￾ments limited the time they could give to the subproject, and the lack
of transportation and compensation reduced their motivation. When
SEATS’
lessons learned from
Experience
5
The experiences of the Urban Initiative and those of quality improvement activities are further
analyzed in Meeting the growing demand for quality reproductive health services in urban Africa:
Partnerships with municipal governments. Lessons learned from SEATS’ Urban Initiative (Rossi
1999) and Mainstreaming quality improvement in family planning and reproductive health
services delivery: Context and case studies (JSI/SEATS in press), available on the SEATS website
www.seats.jsi.com
trained peer educators graduated from the Center, they abandoned
their peer education responsibilities. New educators were not trained to
replace them.
Costs were another obstacle the peer educators and
their clients faced. The Center service providers often
referred clients to other clinics for specialized services.
Clients demanded that the educator accompany them,
or they asked the educator or Center to pay their bus
fare. This placed the educators in a difficult position,
as they wished to help, but did not have the means to
do so.
Despite the shortcomings, the work in Pikine/
Guédiawaye did establish Senegal’s first comprehen￾sive youth reproductive health education and services
project. The Advisory Committee continues to work
with the Center staff and teachers, exploring new
activities such as income generation to strengthen
the program.
Urban and Quality Initiatives
Generate Local Solutions
In contrast to the ASBEF subproject, which began with
youth as a specific target audience, the process￾oriented interventions of SEATS II’s Urban Initiative
and quality improvement actions created awareness of
the need to expand and improve reproductive health
services for youth.5
Empowering municipal governments, which had
recently gained control over social service and health
budgets, to advocate for, design, develop, and take
responsibility for appropriate reproductive health care
services for their constituents, was the essence of the
Urban Initiative in Senegal. Meetings, workshops, and
roundtable discussions brought together municipal
officials, urban leaders, NGO and donor agency
representatives, and young people in new coalitions
in the municipalities of Dakar and Louga. Analysis of
local data on reproductive health led many of the 11
participating mayoral districts to identify access to
information and services by young adults as a priority
action. More than 250 youth peer educators received
training in basic reproductive health messages, and
22
Senegal: Urban Initiative and Youth
Intervention dates: September 1997 to March 1999
SEATS’ counterparts: Mayoral districts in Dakar and
Louga
ü Baseline data collection and dissemination
ü Coalition building among municipalities, donors,
NGOs
ü Development of data-based action plans, including
interventions for youth reproductive health
ü Community mobilization
ü Peer educators
ü Clinical services
Senegal: Quality Initiative and Youth
Intervention dates: May 1998 to June 1999
SEATS’ counterparts: PNPF, ASBEF, Santé Familiale
ü Site-based quality teams of managers, providers,
community members
ü Baseline data collection on client perspectives and
site-specific problems
ü Action planning to address priority problems,
including youth reproductive health
ü Community outreach and mobilization
ü Ongoing assessment and changes
ü Collaboration with Management Sciences for
Health, AVSC International
SEATS’
lessons learned from
Experience
23
supervisors supported them while they provided information and
referrals. Each municipality funded at least 20 percent of these actions,
and several successfully obtained additional outside funding. At least
100,000 youth received information and referrals; some clinics re￾ported up to 50 percent increases in visits for STD symptoms and
family planning.
The Urban Initiative showed that powerful advocates for young adult
reproductive health can be created by building new and stronger
relationships among elected officials and health-sector authorities, local
NGOs, and communities.
SEATS II’s quality improvement activities adapted and combined the
components of the USAID Maximizing Access and Quality initiative
and techniques from CQI into an approach called EQUIPE (Expanded
Quality to Improve Program Effectiveness). EQUIPE’s clinic-based
quality teams emphasized collaboration among service delivery sites,
referral sites, and the communities they serve. Service providers and
communities worked together to identify and make quality improve￾ments and to measure the outcomes of the changes. Eight public and
private-sector sites in Dakar formed a network to learn from each other
and reinforce the testing of innovations and application of best practices.
At least three sites undertook actions addressing youth reproductive
health. For example, providers from one site collaborated with the
local high school’s family life education program, offering classroom
presentations and discussions. Another clinic initiated regularly sched￾uled “youth teas,” where young people from the community gathered
to view films and videos and hold group discussions. Offering educa￾tion on reproductive health did not trouble providers at this site, but
they were unwilling to make condoms available at the teas, despite
requests from young people. At a third site, providers and managers
engaged in in-house dialogue designed to increase awareness of the
need for special approaches to youth and to foster willingness to
provide services to this population.
photo by Marty Leuders
SEATS’
lessons learned from
Experience
24
EQUIPE’s consultative feedback mechanisms and focus
on quality, rather than specifically on youth, allowed
service delivery sites to design and implement improve￾ments that reflect community concerns, resource
availability, and provider comfort with youth sexuality.
The Urban Initiative and the quality improvement
approaches led to locally generated solutions to youth
reproductive health issues. Although perhaps not far￾reaching, these approaches allowed communities to
take ownership of the problems—an important contri￾bution toward creating a supportive environment in
the context of the social conservatism surrounding
youth sexuality and Islam’s teachings on family plan￾ning.
Zambia: “A Window of Hope”
in the World of HIV/AIDS
The devastating impact of the AIDS epidemic and high
rates of unsafe abortion among young women were
among the reasons the City Council of Lusaka devel￾oped a 1996 action plan to provide improved repro￾ductive health information and services to youth in all
its health facilities. Ongoing health reforms, focused on
reorienting health services to decentralized, integrated
programs, shaped the management context. A USAID
Mission that placed priority on integrated health
actions for adolescents facilitated immediate support
for follow-up to the plan.
The Lusaka District Health Management Team
(LDHMT) initiated youth-oriented reproductive health
actions in 1996, with support from CARE International
and UNICEF. In 1997, SEATS II, together with the
FOCUS project, was asked to assist seven more city
clinics to integrate outreach and services that ad￾dressed youth needs, building on the trust and confi￾dence generated through experience with the existing
SEATS subproject “Expanding Family Planning Services
in Lusaka Urban District.” Two of the seven clinics—
Bauleni and Matero Reference—served as model
demonstration sites for documenting and evaluating a
comprehensive approach to improved reproductive
health services for youth in peri-urban communities.
Zambia: Subproject Overview
Dates: October 1997 to April 1999
Target population: Youth 10 to 24 in the catchment
areas of seven urban clinics
SEATS’ counterpart: Lusaka District Health Management
Team (LDHMT)
ü Participatory appraisal of adolescent reproductive
health
ü Community mobilization: Neighborhood Health
Committee actions, school Anti-AIDS clubs, PTAs,
businesses
ü End-of-project qualitative evaluation and client exit
interviews
ü 20 trained peer educators (male and female) and
“Youth Corners” in two model clinics
ü IEC: films, videos, theater, print
ü Resource generation for sustainability
ü Youth-friendly services in seven clinics; 18 service
providers trained
ü 18,000 youth reached; 42,000 condoms and
14,500 foam distributed
ü 4,400 new contraceptive users; 7,494 visits for
other reproductive health services
ü Provider and community attitudes changed from
negative to positive
ü Collaboration with CARE, UNICEF, FOCUS,
USAID bilateral Family Planning Services and
Zambia Integrated Health Package, Family Life
Movement of Zambia, Planned Parenthood of
Zambia, JHU/CCP, PSI, MotherCare
SEATS’
lessons learned from
Experience
25
A participatory appraisal of adolescent reproductive health, Participa￾tory Learning and Action (PLA), in the communities surrounding the
two model clinics, launched the subproject. The appraisal was adapted
from the experiences of CARE and its counterparts. Unlike more
conventional formative research methods, in which information is
collected from the community and analyzed by outside experts, PLA
engages the community in gathering and assessing data. Derived from
participatory rural appraisal methodologies, the PLA in these two
communities generated an understanding of stakeholder perspectives
on youth reproductive health and simultaneously created a forum for
community mobilization in support of the subproject. Neighborhood
Health Committees (NHCs), composed of local residents and designed
to provide a link between health providers and the community, helped
organize and recruit participants for the PLA. Through FGDs, other
qualitative methodologies (ranking and scoring, mapping, and transect
walks), and meetings to disseminate and discuss the findings, service
providers, youth, and community members helped define the scope of
activities and built a foundation for ongoing collaboration (Shah 1999;
Sambisa and Chibbamulilo 1998).
Risky Behaviors and Barriers to Services
The PLA findings confirmed that young people in these two communi￾ties, like their peers throughout Zambia, engage in numerous behav￾iors that put their reproductive health at risk (Sambisa and Chibba￾mulilo 1998; Koster-Oyekan 1998; Pillai et al. 1999). Parents and
youth stated that girls initiated sexual activity at age 10 to 12, and boys
somewhat later at 12 to 14. Parents attributed early sexual activity to
sex videos and films; observing immoral behavior among adults; lack
of parental role models and guidance; peer pressure; alcohol and drug
abuse; and condom promotion. “When youths are given condoms,
they go on [a] rampage, thinking that there is nothing wrong with sex.”
Young women reported that sex in exchange for money or other forms
of payment was common. Parents and young people agreed that the
appropriate age for initiating sexual activity was much older—around
20. The potential adverse consequences of sexual activity were well￾known: STDs, AIDS, unwanted pregnancy and the stigma of illegiti￾mate children, and unsafe abortion. Knowledge of condoms and pills
was high, but reported use was low. Youth perceived condoms as
inappropriate for steady relationships. “When you have been in love
with your girl friend for a long time, she becomes like your wife; so you
stop using a condom,” said one youth. The PLA participants tended to
believe that pills caused infertility or birth defects (Sambisa and
Chibbamulilo 1998).
Lusaka Youth Speak
about Condoms
“Boys accuse us of being promiscu￾ous when we want to use condoms.”
“Girls think we are promiscuous
when they see us with condoms.”
“Skin-to-skin is better.”
“Boys are clever. They may wear
condoms, and then secretly prick
the tip, so that they can then
refuse to take responsibility after
pregnancy. Hence, it is better not
to use them.”
SOURCE: Sambisa and
Chibbamulilo 1998.
SEATS’
lessons learned from
Experience
26
 “We did not know how you
felt . . . if we have been serving
[youth] as badly as you have just
described, we vow to change our
attitudes so as to serve you better.”
Lusaka Health Provider
Young people said that friends were their most prominent source of
reproductive health information, followed by radio and television, and
schools, through science lessons and print materials. The youth viewed
aunties, grandparents, and parents—the people who gave their parents
information in the past—as outdated, inaccurate, and unreliable sources
of information (Sambisa and Chibbamulilo 1998).
Youth and parents reported that young people used local clinics only
as a last resort in cases of suspected STDs. According to the young
people, clinics did not offer privacy, the lines were long, the fees were
unaffordable, providers were rude and “too inquisitive,” and discussing
sexual matters with providers of the opposite gender was embarrass￾ing. Parents and youth believed that clients could only receive STD
treatment when accompanied by their partner, although providers
stated this was not the case. Young people preferred traditional healers
and private health practitioners, where services were faster and more
private, and did not involve “scolding sessions” by nurses (Sambisa and
Chibbamulilo 1998).
The PLA identified additional barriers to reproductive health informa￾tion and services for youth. NHC members echoed parents’ sentiments
when they said that contraceptive use by young people was immoral
and should be targeted to married people only. Both clinics already
had youth-friendly clubs with peer educators, although youth did not
mention them as sources of information and support, and the NHCs
were unaware of the clubs. The members of the youth-friendly clubs
reported that they faced numerous obstacles to engaging neighbor￾hood youth in their endeavors: limited knowledge and skills in STD/
HIV/AIDS education and counseling; community disapproval of
reproductive health education and services for young people; and lack
of financial and material resources to support recreational, skills build￾ing, and educational activities (Sambisa and Chibbamulilo 1998).
Planning and Acting Together
On the last day of the PLA exercise, participants from the two commu￾nities came together to discuss the findings and the subproject plans to
initiate youth-friendly services. These dialogues between providers,
NHC members, parents, and youth were an opportunity to clarify
misconceptions about contraception and generated many suggestions
for activities, including more publicity about the youth-friendly clubs;
the introduction of entertainment, games, and vocational skill building
to attract youth; and sensitization and increased involvement of par￾ents and the NHCs. These frank discussions were a turning point in the
subproject, initiating a process of creating a supportive environment
SEATS’
lessons learned from
Experience
27
for the provision of youth reproductive health information and ser￾vices, one of the subproject’s key objectives. “Thank you very much for
this exercise. Our minds are now opened up,” said one NHC chairperson.
The community input reinforced the decision to strengthen and ex￾pand the youth-friendly clubs through training and support for peer
educators and the creation of Youth Corners in the clinics—private
spaces located away from the busy outpatient departments. Ten peer
educators (five male and five female) from each of the two model sites,
selected with input from the community, participated in an initial one￾week training. Over the next year and a half they attended two re￾fresher training workshops. These follow-up courses allowed the peer
educators to exchange experiences, review data collection tools, and
gain additional information and skills on topics such as self-image and
decision making. The peer educators received an allowance to support
their transportation and related costs. High-energy exchange visits
between the peer educators from the two sites offered further oppor￾tunities for brainstorming about novel approaches to reaching out into
their communities.
The Youth Corners offered both a gathering place and private room for
counseling. Billboards throughout the city and signs at the clinic gates
informed the community that “youth-friendly services are provided
here,” and on the clinic doors a poster directed youth to the Youth
Corners. Each clinic designated a trained nurse midwife to act as the
peer educator supervisor.
Although only two clinics had Youth Corners and peer educators,
all seven clinics took steps to make services more youth-friendly and
mobilize the community in support of the improved services. Two
or three providers from each of the seven clinics, along with their
respective supervisors, received training in comprehensive youth￾friendly reproductive health services, including antenatal, delivery,
and postpartum care; family planning; STD services; and counseling.
They in turn oriented the other providers at their clinics about youth￾friendly services. Some clinics established lunch-time and weekend
hours, and services were free. Clinics offered a full range of contracep￾tive methods, including emergency contraception.
Clinic staff did not always welcome the changes required to make
clinics youth-friendly. For example, the peer educator supervisor at one
clinic reported that some clinic staff resented shifting their lunch hour
and “giving up their kitchen,” where the Youth Corner was set up.
SEATS’
lessons learned from
Experience
28
These staff also claimed that the supervisor was neglecting her duties
when she joined the peer educators in the communities, and they did
not agree with the provision of free services to youth who did not have
“medical schemes” [insurance].
Subproject staff also shared the results of the earlier
PLA exercise with the NHC of the other five clinics.
NHC members were encouraged to view the staff of
the youth-friendly clinics as modern-day “grandpar￾ents” and “aunties,” with responsibility for providing
education on sexuality and reproduction (Chirwa
1998). The NHCs formulated action plans for further
engaging community and parental support for the
youth-friendly services and the peer educators. NHC
members reached out to churches, PTAs, and busi￾nesses, informing them of the subproject and encour￾aging them to share information about it. Church
elders made announcements in their Sunday services,
taverns and markets placed posters about the clinics,
and community clubs invited NHC members and clinic
staff to talk about the initiative. Midway through the
subproject, each clinic formed a quality team, which
took on responsibility for monitoring and supporting
the community mobilization actions in the overall
context of improving the quality of care.
Peer Educators as Entrepreneurs
The peer educators at Bauleni took on the issue of
sustainability whole-heartedly, demonstrating their
entrepreneurial abilities. Together they obtained a
vacant building and converted it into a reproductive
health performing arts center, where they showed
films and videos, and gave theater performances for a
small fee. They also rented out the vacant rooms and
sold soft drinks at the clinic. Their net income after one
year was approximately K300,000 (US$150).
The peer educators, NHCs, and the community also
played an active role in generating resources to sup￾port the youth-friendly services. With support from the
NHCs, peer educators earned money doing commu￾nity chores such as weeding fields and cutting hedges.
Each clinic sold the youth-published newspaper Trend
Setters at a locally determined price to earn funds to
Selection Criteria for Peer Educators
Subproject staff, community members, and youth defined
the selection criteria for the peer educators:
ü Serve as credible role model for the social compe￾tencies they will advocate (e.g., safe sex)
ü Are accepted by peers and able to establish good
relations within a group
ü Are admired and respected for their social skills
ü Are committed to family planning and reproductive
health issues
ü Can communicate clearly and persuasively
with peers
ü Can read and write English
ü Have completed at least nine years of education
ü Have good interpersonal skills including
listening skills
ü Are interested in self-enhancement, have self￾confidence, and have potential for leadership
ü Have time and energy to devote to work without
a salary
ü Can work irregular hours
ü Have been selected by community
ü Are capable of being nonjudgmental and
confidential
ü Are between 17 and 26 years old
SEATS’
lessons learned from
Experience
29
purchase more papers, develop IEC materials, and/or pay for transpor￾tation to meetings with other peer educators. Several NHCs held fund￾raising events such as “braais” (bar-b-ques) and requested donations
from businesses to generate financial support for the peer educators
and clinics.
Alliances with local schools were formed through collaboration with
the Anti-AIDS Clubs of 10 primary and secondary schools in the
catchment area of the seven clinics. Each Club sent two members to a
two-day workshop that introduced the youth-friendly health services
and reviewed facts and feelings about unprotected sexual activity.
Clubs regularly invited the peer educators and clinic staff to give talks
in the schools, and schools received updated information on reproduc￾tive health to share with staff and students.
The Coordinating Committee for the existing subproject, which in￾cluded clinic and SEATS staff along with representatives of the LDHMT,
CARE, and the Family Life Movement, expanded to include youth
leaders. At first, some Committee members were uncomfortable
sharing authority with young people. Over time, they recognized that
many of the issues affecting the delivery of services were common to
adults and youth, and welcomed the younger members.
Reaching Youth in the Community
The peer educators were responsible for
collecting data on clinic services provided
to youth as well as on their own activities.
They compiled and submitted monthly
reports, based on daily activity reporting
formats developed specifically for the
subproject. The MIS included data on
clinic-based cases for antenatal care, STD
screening and treatment, family planning,
and referrals for abortion complications as
well as on peer educator activities: com￾modities distributed, individuals counseled,
group sessions conducted, and referrals
made.
SEATS’
lessons learned from
Experience
30
The peer educators were extremely active, reaching
18,217 young people with individual counseling and
group educational activities. Of these, they referred
4,100 for services at “our” youth-friendly clinics.
Although only 19 percent of the contacts represented
individual counseling sessions, the group activities
were for the most part appropriately small—with about
12 participants. The peer educators made efforts to
reach all young people in their communities. Prison
authorities in Matero welcomed the peer educators
when they came to give education to young inmates
there.
The peer educators reached many more young
women than young men—12,372 young women
versus 5,845 young men. They distributed 42,814
condoms and 14,587 foaming tablets (see box). The
data on foaming tablet distribution give further
evidence of the peer educators’ effective outreach to
young women. Spermicides represented 25 percent
of the contraceptive commodities distributed by peer
educators, and most (58 percent) of these were
distributed in individual counseling sessions, suggesting
that recipients requested this method (rather than
obtaining it as “sample” in a group session).
The end-of-project evaluation also provided evidence
of the peer educators’ effectiveness. Peer educators’
ranking as a source of information on reproductive
health rose from no mention at the baseline PLA to a
major source, along with mass media. Youth also cited
peer educators and the youth-friendly clinics as among
the most reliable sources of information (LDHMT
1999). After observing the progress made by the two
model clinics, a third clinic included a funding request
for a peer education program into its annual work plan
submitted to the LDHMT. The request was approved,
and the peer educators were trained and on the job by
June 1999.
In addition to the peer educators’ remarkable performance, there was
very little turnover among them. Of the original 20 trained, four
dropped out, but they were replaced. Subproject staff attributed the
peer educators’ success to many factors: having their own space in
their “own” clinics; their responsibility for data collection; their partici￾pation in project management; refresher training; community support;
and their active role in fund raising.
Lusaka Youth Speak on
Peer Educators
“When I suspect that I have an STI, I go to the peer
educator who also refers me to the clinic where nurses
give proper medication.”
“In the past we were so nervous to go to the clinic after
contracting STIs. We feared being shouted at by the
health worker and we were denied proper treatment. .
.But nowadays, we go to the peer educators in confi￾dence, who discuss problems and fears and give us the
information we need about sex. In cases of STIs, they
write referral letters to the clinic.”
SOURCE: LDHMT 1999.
SEATS’
lessons learned from
Experience
31
By the end of the subproject, allowances and other forms of incentives
for peer educators had become a point of contention. Although the
subproject paid a modest transportation allowance to the peer educa￾tors, the LDHMT recommended it be discontinued because other
youth projects did not provide monetary payments to their peer
educators. On the other hand, the peer educators and often their
families, their supervisors, and the NHCs, believed that larger allow￾ances were essential. “If the issue of transport and lunch allowance is
not looked into, the peer education program is dead,” said one peer
educator. These conflicting viewpoints raised key questions about the
role of incentives and the meaning of volunteer service in peer educa￾tion programs (LDHMT 1999).
Increased Access to and Use of Youth-Friendly
Information and Services
Youth did use the youth-friendly clinics for
a variety of reproductive health concerns.
During the subproject’s 18 months, 3,268
young people aged 10 to 19 (1,631 males
and 1,637 females) came for sexually
transmitted infection (STI) screening and
treatment; 4,126 young women (12 to 19
years) came for antenatal care, and 100 (12
to 24 years) for treatment of abortion
complications. The seven clinics had 4,415
new youth acceptors in the age range 12
to 24 years. The method mix (excluding
those who received commodities from the
peer educators) was diverse and included
injectables, OCs, condoms, emergency
contraception (EC), and lactational amen￾orrhea method (LAM) (see figure). A few
young people selected dual methods.
Exit interviews with youth clients found that they were generally
satisfied with services they received. Three out of four considered the
nurses friendly or very friendly, and even more said they were polite
and resolved the clients’ problems. Although pleased with the services
offered and the treatment they received, young people were slightly
less satisfied with opening hours and privacy. Lack of medications was
clients’ greatest complaint. In almost all respects, youth rated the peer
educators in the Youth Corners higher than the nurses in the main
clinic. For example, all who saw a peer educator, compared to 77
SEATS’
lessons learned from
Experience
32
percent of those who saw a nurse, reported that the provider took time
to listen to their concerns. Similarly, only 3 percent stated they did not
feel comfortable talking to the peer educator, while 13 percent said
they felt uneasy with the nurse (JSI/SEATS 1999).
Interviews with providers trained in youth-friendly services, conducted
at the end of the subproject, found a generally positive attitude toward
youth sexual and reproductive health needs and services, compared
with the discomfort and reluctance to provide services revealed in the
baseline PLA. Providers said they would support the use of contracep￾tion among youth of either sex as early as there is a need. They stated
there were no age restrictions in providing any contraceptive method,
with the exception of voluntary surgical contraception. Contrary to
prevailing sociocultural norms, which do not support communication
about sexuality between parents and children, the nurses believed that
parents should feel free to share information on reproductive health
with their children. Unfortunately, many trained providers had been
transferred to other sites, and the untrained providers were much less
supportive of youth-friendly services and the peer educators (LDHMT
1999; JSI/SEATS 1999).
In addition to the need for a “critical mass” of providers trained in
youth-friendly services, another important factor in the success of
youth-friendly services was the ongoing presence of a “youth cham￾pion” within a clinic. At one model site, where the enthusiastic and
supportive peer educator supervisor remained the same throughout
the subproject, progress in establishing youth-friendly services was
much faster than at the other site. This “youth champion” even advo￾cated for an increased allowance for the peer educators, reflecting her
acknowledgment of their hard work. At the other site, personnel
changes resulted in much slower start-up, inconsistent support, higher
absenteeism among the peer educators, and poorer record keeping.
By the end of the subproject, peer educators at both sites reported
adequate satisfaction with their supervision (LDHMT 1999).
A Supportive Community
Community enthusiasm for this new program was high. NHC members
were aware and supportive of the peer educators and youth-friendly
services (see box). The commitment to meaningful community involve￾ment, dedicated staff, and active outreach transformed an environment
of staunch opposition to reproductive health services for young people
into one of support.
Neighborhood Health
Committees Support Peer Committees Support Peer
Educators and
Youth-friendly Services
“. . . youth-friendly services should
be supported because they educate
and motivate youth to talk and
discuss freely on matters related to
sexuality among themselves.”
“This is where our children seek
help on sexual and reproductive
health issues and problems
affecting them. They find it easy to
express themselves fully as they are
attended to by their fellow youths
called peer educators.”
SOURCE: LDHMT 1999.
SEATS’
lessons learned from
Experience
Zambia Nurses Association Expands
Youth-friendly Services Nationwide
Nurses and midwives are usually the primary providers in many health
services in Zambia and are often the only clinicians with whom adoles￾cents have contact. With support from the SEATS Special Initiative,
Midwifery Association Partnerships for Sustainability (MAPS), the Zambia
Nurses Association (ZNA) carried out a subproject to strengthen the
ability of the association and its members to provide quality sustainable
reproductive health services to youth throughout Zambia. One of the first
activities was training the providers from the seven SEATS-supported
clinics in Lusaka in youth-friendly services. ZNA also adapted the national
reproductive health training curriculum to produce its own modules on
youth reproductive health. Trained ZNA facilitators used the modules in
conducting continuing education updates for more than 500 members
attending ZNA branch meetings.
In early 1999, the ZNA held a series of “youth meetings,” where peer
educators and the producers of Trend Setters exchanged views with ZNA
members in order to encourage the nurses and midwives to become more
involved in offering youth-friendly information and services at their places
of employment throughout Zambia. Follow-up visits in mid-1999 found
that 85 percent of the facilities visited had begun actions such as establish￾ing Youth Corners to make the services more youth-friendly. For example,
ZNA members working at the University of Zambia health clinic helped
recruit 10 peer educators from among various student clubs and were
about to start delivery of youth-friendly services in a university residence.
At the Kapiri Mposhi District Hospital, 161 youth had already made use
of the new youth-friendly services, and hospital management contributed
funding for furniture for the youth corner. Visits by young people to all
service sites staffed by trained ZNA members rose to 4,540 in April 1999.
With its ability to reach nurses and midwives in both the public and
private sectors, the ZNA has the potential to make youth-friendly health
services a nationwide reality.
33
Nevertheless, all involved—peer educators, service providers, NHC
members, and SEATS staff—believed much, much more needed to be
done. They agreed that it was unrealistic to expect 20 peer educators
to reach a substantial portion of the young people in their catchment
areas. Indeed, the end-of-project evaluation found many youth still
lacked specific knowledge about health-promoting behaviors, such as
how to use and dispose of condoms. Misconceptions about the safety
and effectiveness of condoms and contraceptive methods continued.
Some parents opposed youth-friendly services (LDHMT 1999).
SEATS’
lessons learned from
Experience
34
City Youth Committee Identifies
Reproductive Health Concerns
The intersectoral Youth Committee of Gweru City
identified a range of reproductive health concerns facing
young people:
Lack of knowledge of human sexuality and reproductive
health due to:
ü Poor communication between parents and children
ü Parents’ lack of knowledge and discomfort in
discussing sexuality
ü Decline in traditional modes of sexuality educa￾tion, previously provided by aunts and uncles
ü Limited availability of appropriate literature and
counseling on human sexuality and reproductive health
ü Shortage of trained teachers or other community
educators
Reproductive health services inaccessible to youth due
to:
ü Negative staff attitudes
ü Lack of training
ü Inappropriate policies
ü Lack of meaningful entertainment, recreational,
and vocational training facilities
ü Unprotected sexual activity resulting in unwanted
pregnancy, STD, school drop-out, illegal abortion,
and other social problems
ü Unemployment and poverty among youth contrib￾uting to the problems associated with youth
Subproject staff suggested measures to advance
community ownership and management of the pro￾gram: sustainability measures and peer educator
incentives could be defined by the community; train￾ing workshops could include community members as
presenters; and education of parents could be
strengthened to better prepare them to cope with their
children’s sexuality and issues such as early initiation of
sexual activity and coercive sex. NHC members
recommended training more peer educators; establish￾ing Youth Corners and services outside the clinics;
expanding community awareness activities; strengthen￾ing linkages with other community organizations; and
improving educational and recreational activities for all
young people. Together these actions could expand
the “window of hope” in the world of HIV/AIDS that
this subproject represented.
Zimbabwe: Gweru, A City that Zimbabwe: Gweru, A City that
Supports Its Youth
The achievements of Zimbabwe’s national family
planning program are notable and contribute—along
with universal education—to the somewhat more
positive reproductive health data on young people,
when compared to data on their peers in other sub￾Saharan African countries. For example, Zimbawean
young women aged 15 to 19 are more knowledgeable
about modern contraception (90 percent know of
modern methods) and more likely to use modern
contraception (33 percent of unmarried, sexually
active women in this age group use a modern method)
than their counterparts in most other countries in
the region. Rates of premarital sex by age 18 have
remained steady between generations, whereas they
have risen in other countries (AGI 1998). Childbearing
among teens in Zimbabwe has declined over the last
25 years, reflecting efforts to keep girls and women in
school through more advanced levels to improve their
socioeconomic status (CSO and MI 1994).
SEATS’
lessons learned from
Experience
35
But much of the data substantiate Gweru City
Council’s concern for the reproductive health
of the city’s 45,000 young people aged 10 to
24. Forty-seven percent of Zimbabwean
women aged 20 to 24 have had a child by
age 20, and 50 percent of adolescent births
are unplanned (AGI 1998). An estimated 26
percent of the adult population 15 to 49 is
living with HIV/AIDS. Rates of HIV infection
among antenatal clinic attendees are even
higher: in 1995, 28 percent of women 15 to
17 years of age in the capital city, and 49
percent of women 20 to 24 in a southern
province, tested positive for HIV (UNAIDS
and WHO 1998).
The Gweru City Youth Committee, com￾posed of representatives from central minis￾tries, local government, and NGOs, advises
on citywide youth programming. In 1997, the
Committee identified numerous reproductive
health concerns facing youth (see box) and
recommended that action be taken to
improve the reproductive health of youth 12
to 24 through increased access to quality
information and services in the context of the
existing SEATS II subproject “Gweru Family
Planning Service Delivery: Support for
Quality Improvement and Training” with the
Gweru City Health Department. The sub￾project design called for community mobili￾zation, peer education, and youth-friendly
reproductive health services in seven City
clinics and in the renovated multipurpose
Ndhlovu Youth Center. The FOCUS project
joined SEATS II in providing financial support
and technical assistance.
Zimbabwe: Subproject Overview
Dates: November 1997 to June 30, 1999
Target population: Youth 10 to 24 in Gweru City
SEATS’ counterpart: Gweru City Department of Health
ü Baseline and postproject surveys data
ü Community mobilization: City Youth Committee, commu￾nity leader and parent sensitization and advocacy work￾shops, multisectoral involvement
ü Youth advisory committee (YAC); YAC members on Gweru
Youth Committee
ü Multipurpose youth center with health, recreational, and
vocational services
ü 40 trained peer educators; peer educator contact monitor￾ing system
ü 43 providers trained and provided youth-friendly services in
seven City clinics
ü 8,141 youth reached; 4,845 condoms and spermicides
distributed
ü Peer educators reached more at-risk youth over time
ü Youth Corners in seven clinics and in Youth Center
ü IEC at all sites and in peer education
ü Youth rated services and peer educators as friendly in exit
interviews
ü Improvements in attitudes toward condoms
ü Collaboration with FOCUS, Zimbabwe National Family
Planning Council (ZNFPC), Midlands AIDS Support
Organization (MASO), Zimbabwe Republic Police, Ministry
of Education, Ministry of Sport, Recreation, and Culture,
UNICEF
SEATS’
lessons learned from
Experience
36
Beliefs, Behaviors, and Risk
A baseline survey gathered information from a systematic cluster
sample of 250 unmarried youth aged 12 to 24. In addition to the usual
questions on reproductive health knowledge, attitudes, and behaviors,
the survey also explored young people's use of time, their social
interactions in the community, the value they attributed to male-female
relationships, and the context of sexual activity (Sambisa et al. 1999).
Thirty-nine percent of the respondents were currently in school, and 61
percent were out of school, although 85 percent of these indicated
they had completed secondary education. Respondents reported that
they spent an average of six hours the previous day engaged in social
and recreational activities including playing, gossiping, watching TV,
listening to the radio, and family gatherings. Sixty percent did not
participate in organized sports, religious, or service activities. Thirty￾four percent of the sample had had sexual intercourse in the past (24
percent of young women and 44 percent of young men). The mean age of
the first sexual experience was 17.
Knowledge of the “facts” was quite high: almost all respondents,
regardless of age, gender, or sexual experience, could cite modern
contraceptives, name STDs, and state basic physiological changes that
occur at puberty. Practical knowledge information—that could be
applied to actions to protect one’s sexual health—was much lower. For
example, only 10 percent of young women knew when in the men￾strual cycle a woman was likely to conceive, and 37 percent of males
and 14 percent of females could describe the steps involved in the
correct use of condoms (Sambisa et al. 1999).
Attitudes toward the condom and its use were somewhat positive,
although often contradictory. Although 71 percent agreed that a girl
who carries a condom is responsible, 36 percent thought that a
woman would lose a man's respect if she requested him to use a
condom. Less than half (29 percent) agreed with the statement “Con￾dom use is not necessary when a relationship moves from casual to
serious”; yet when asked if condoms should be used in steady boy-girl
relationships, 82 percent said they should not. About three-fourths
believed that condom use prevented HIV/AIDS (Sambisa et al. 1999).
Knowledge of the facts about contraception, STDs, and HIV/AIDS and
relatively positive attitudes toward condoms appeared to have little
impact on these youth’s perception of their risk of HIV/AIDS. Eighty￾one percent assessed their risk to be low to nonexistent. Young
women were much more likely than young men to see themselves as
SEATS’
lessons learned from
Experience
37
at risk. Among those who had had sexual intercourse, the difference
was sevenfold; 43 percent of young women perceived themselves to
have moderate to high risk, while only 6 percent of the young men did
(Sambisa et al. 1999).
Although many young people indicated they did not see themselves at
risk of HIV/AIDS, those who were sexually active nevertheless did take
steps to protect themselves from STDs and pregnancy. Among the 24
percent of respondents who indicated that they had been sexually
active in the last 30 days, 83 percent reported that they and their
partners used a method to protect themselves against STD or preg￾nancy at every sexual encounter. Two-thirds of the respondents
thought it was easy for unmarried young men and women to obtain
contraceptives, and 27 percent though it was difficult. The reasons for
difficulty in obtaining contraceptives include disapproval of the elders,
difficulty in finding contraceptives, and shyness (Sambisa et al. 1999).Young
people in Gweru discussed reproductive health and other matters
related to their well-being with their friends and their teachers, but
only rarely with family members, health professionals, counselors, or
religious figures (Sambisa et al. 1999).
Together, the findings revealed a somewhat puzzling portrait of
young people's risk of unprotected and unwanted sexual activity,
while reconfirming the appropriateness of peer education, increased
access to services, and outreach to youth through a multipurpose
youth center.
Multipurpose Services for Youth
The Ndhlovu Youth Center was transformed into a multipurpose
center offering health, recreational, and vocational services to attract
both male and female youth of a range of ages and with differing
interests. New clinical equipment was added, along with a trampoline,
ping-pong tables, a marimba, chess sets, handball goal posts, and a
TV and video cassette recorder (VCR). The City Department of Health
seconded a full-time nurse to provide health and counseling services,
with referrals to other clinics. The City Department of Social Work
provided a full-time counselor to offer additional counseling support
for issues such as education and employment. The counselor and
nurse organized workshops, seminars, and informal talks on communi￾cation, decision making, goal setting, risk reduction, and other repro￾ductive health-related topics. By the subproject’s end, the City
of Gweru had extended the Center's opening hours to include
Saturdays.
SEATS’
lessons learned from
Experience
38
The Youth Center nurse, instructors from other City
youth centers, and 43 providers from the City’s seven
clinics received training in youth-friendly reproductive
health services. Each clinic established a Youth Corner,
similar to those in Lusaka, Zambia. Peer educators
staffed these private areas, which were stocked with
IEC materials. The subproject coordinator and the
City nursing officer supervised the clinical services,
monitored the use of the Youth Corners, and sup￾ported the youth-friendly trained nurses. The 797
youth who used the clinics came mainly for STI ser￾vices and antenatal care (see figure). Many youth also
came to get condoms. The majority of the youth
visiting the Youth Corners sought information; about
two-thirds were not in school, indicating the appeal of
these services to this group of young people.
Several months after the subproject ended, trained youth interviewers
conducted exit interviews with all youth between 12 and 24 who
sought services for themselves at four City Health clinics over a two￾day period. Most (75 percent) clients were female; half were aged 21
to 24 years; and one in three had a child. The majority (76 percent)
were out of school. About half came for reproductive-health related￾reasons (antenatal care, STD treatment, family planning, and/or coun￾seling and information). Young men used the Youth Corners much
more than young women: 23 percent of males, and 9 percent of
female respondents consulted with a peer educator in a Youth Corner
(Moyo 1999).
Overall, respondents expressed satisfaction with the
quality of the services they received. Almost all (98
percent) who saw a nurse reported that the provider was
polite and took time to listen to their concerns. More than
90 percent agreed that services had adequate privacy,
convenient opening hours, skilled providers, and confi￾dentiality of information. Among the most-liked factors
about the clinic, respondents cited the friendliness of the
nurses, the availability of informational materials, and the
peer educators. Eight-seven percent said the nurse was
friendly or very friendly, although the proportion rating
the nurse as very friendly varied greatly among the four
clinics. “Nurses take time and understand our problems.
They have good manners; they are patient, welcoming,
and show respect.” The most frequently mentioned
problems were dissatisfaction with a medication dis￾pensed and cost of drugs (Moyo 1999).
photo by Lisa Mueller
SEATS’
lessons learned from
Experience
39
In almost all respects, those who visited a Youth Corner rated its
services more favorably than the services of the main clinic. Those who
saw the peer educator rated the peer educators as friendly or very
friendly. However, most respondents were not aware of the Youth
Corners nor had they met the peer educators. Ten percent of respon￾dents had met a peer educator in the community to discuss a repro￾ductive health issue. Within the clinics, nurses made few referrals to
the Youth Corners, believing that only clients with reproductive health
concerns should be sent to this service (Moyo 1999).
Expanding Into the Community
Before activities began, and throughout the course of the subproject,
small workshops and seminars sensitized political, civic, and religious
leaders and parents to youth reproductive health concerns and the
subproject. Almost 500 adults participated in 41 meetings and work￾shops. Their initial skepticism gave way to eagerness to see the sub￾project succeed and promises of support. Curious and concerned
parents began to visit the youth consultation rooms. They often came
away positively impressed, saying reproductive health information was
vital for their children's well-being, especially in this age of AIDS.
The training workshop for the peer educators propelled the subproject
into high gear and generated much enthusiasm. Forty peer educators,
provided with specific terms of reference and recruited from church
and church-related organizations such as the Young Women's Christian
Association; drama, art, and music groups; and the Ndhlovu and other
youth centers, received training in a one-week workshop. The work￾shop used role play, games, and video to introduce reproductive
anatomy and physiology, contraception, STDs/HIV/AIDS, hygiene,
alcohol and drug abuse, communication skills, counseling skills, self￾esteem, assertiveness and decision making, and record keeping and
report writing to the participants. Staff from many community agen￾cies, including the Midlands AIDS Support Organization (MASO),
Zimbabwe National Family Planning Council (ZNFPC), Zimbabwe
Republic Police, and City Health Department, provided technical
assistance and trainers for the workshop.
Equipped with a t-shirt, tote bag, condoms, and IEC materials, the
highly motivated peer educators focused on reaching out-of-school
youth. Supervised by instructors from city youth centers, they attended
monthly meetings, where they reviewed activities, clarified doubts,
and received an allowance to offset transportation expenses. Peer
educators used an innovative, low-cost methodology to monitor their
activities (Mueller et al. 1999). Over a nine-month period, the peer
educators reached 8,141 young people, distributed 4,845 condoms
SEATS’
lessons learned from
Experience
40
6
At the time of publication, analysis of endline survey results was very preliminary. A full report is
forthcoming and will be available on the SEATS’ website: www.seats.jsi.com
Table 1. Percent of Peer Educator Contacts
Reporting Reproductive Health Behaviors
and spermicides, and held 2,430 individual counseling and 833 group
education sessions in the community and at major events such as the
Musicians Against AIDS concert. The main topics discussed by peer
educators were STDs and HIV/AIDS, sexuality, drugs and alcohol, and
pregnancy. Slightly more of their contacts were young women (54
percent) than young men (46 percent). Out-of-school youth repre￾sented 54.5 percent of the contacts. Most contacts were between 17
and 20 years old (Mueller et al. 1999).
The monitoring system also showed that the peer educators’ contact
networks expanded as they reached more young people outside their
circle of friends and family over time. For example, in the first quarter
of 1999, the peer educators were not well-acquainted with 34 percent
of their contacts; in the second quarter, this percentage increased to
50 percent. Their networks also grew to include greater numbers of
youth more likely to be at risk of unprotected and unwanted sexual
activity. Contacts who lived with their parents and who participated in
some kind of organization decreased from the first to second quarter
of 1999 (Mueller et al. 1999).
The behaviors reported by peer educator contacts also changed over
time (see Table 1). Contacts reporting sexual intercourse decreased,
while those who visited a clinic in the previous six months increased as
did those reporting use of a family planning method at last sexual
intercourse (Mueller et al. 1999).
Visits from outsiders bolstered the morale of peer educators and
subproject staff. A delegation from the provincial medical directorate
of a neighboring province was very impressed with the work of the
peer educators. Members of the City Councils of Harare and Chitung￾wiza, Zimbabwe's capital and third city, respectively, also came to learn
from the subproject. The mayor and others from Birmingham, Alabama,
Gweru's sister city, had the opportunity to discuss with the peer educa￾tors the problems facing Zimbabwean youth.
Outcomes: A Preliminary Picture
An endline survey gathered information from a sample of 606 never￾married youth aged 12 to 24.6
 Compared to the baseline survey
sample, the endline survey sample had: more males (58 percent versus
50 percent); more in-school youth (52 percent versus 38 percent);
and more recently employed youth (22 percent versus 16 percent)
(Moyo et al. 1999).
SEATS’
lessons learned from
Experience
41
No more than one in five respondents had made use of any of the
services developed and offered by the subproject: 20 percent had
been to a clinic for a reproductive health matter, although not all had
made their visit within the last six months; 9 percent had been to a
Youth Corner at a clinic, and 12 percent reported they had met with a
peer educator in the community and discussed an issue of concern
(Moyo et al. 1999).
Young people’s knowledge of the facts remained high at endline,
although knowledge of specific contraceptives decreased slightly for all
methods except safe period (period abstinence) and withdrawal. There
were some increases in practical knowledge, although the changes varied
by gender, topic, and age (see Table 2) (Moyo et al. 1999).
Table 2. Percent of Respondents With Basic Reproductive
Health Knowledge by Selected Background Characteristics
Pe ercent who knew: Be aselin Endlin
When during cycle a woman becomes pregnant
T0 otal 182
Ma ales n3 / 3
F0 emales 112
1 04 2-14 years 1
18 5-17 years 152
11 8-20 years 173
2 45 1-24 years 3
Can girl get pregnant if she has sex standing up
T9 otal 555
M9 ales 556
F8 emales 534
10 2-14 years 362
11 5-17 years 635
19 0-20 years 686
25 1-24 years 676
Girl can get pregnant if boy withdraws before ejaculation
T2 otal 202
M8 ales 342
F 64 emales 1
13 2-14 years 101
19 5-17 years 291
16 8-20 years 152
21 1-24 years 322
Visits from outsiders bolstered the morale of
peer educators and subproject staff.
SEATS’
lessons learned from
Experience
42
Percent who agreed with statement Be aseline Endlin
A girl who carries condoms in her purse is responsible
Total 75 1 4
Males 66 0 4
Females 83 2 4
12-14 years 50 8 5
15-17 years 74 6 4
18-20 years 70 3 4
21-24 years 70 5 5
Using condoms is difficult because it looks like I planned to have sex
Total 42 4 4
Males 31 8 4
Females 53 0 4
12-14 years 42 5 3
15-17 years 52 3 4
10-20 years 35 6 4
21-24 years 41 2 4
Using condoms reduces sexual pleasure
Total 37 0 1
Males 20 7 3
Females 36 4
12-14 years 31 2 1
15-17 years 32 1 1
18-20 years 33 1 2
21-24 years 27 7 2
When a relationship moves from casual to serious, it is no longer necessary to use a condom
Total 27 9 1
Males 30 1 2
Females 23 7 1
12-14 years 37 8 1
15-17 years 36 0 1
10-20 years 25 6 1
21-24 years 37 5 2
A woman would lose a man's respect if she requested him to use a condom
Total 37 6 3
Males 34 8 4
Females 36 4 2
12-14 years 27 1 2
15-17 years 51 0 3
18-20 years 35 6 4
21-24 years 37 5 4
Table 3. Percent of Respondents Agreeing With Condom Use
Statements by Selected Background Characteristics
SEATS’
lessons learned from
Experience
43
Attitudes toward the condom and condom use tended to be more
favorable at endline, although young women’s attitudes showed more
consistent positive changes over baseline. In addition, younger adoles￾cents seemed to be more approving of condom use than older youth
(see Table 3) (Moyo et al. 1999).
Friends and teachers continued to be the people with whom young
people most frequently discussed matters related to reproductive
health. A few youth mentioned peer educators as the most frequent
discussant for topics related to sexuality—sexual urges, whether it is
possible to have fun in a relationship without having sex, and body
changes during puberty. Compared to the baseline, youth reported
discussing certain topics more often: body changes during puberty,
relationships with the opposite sex, how to use condoms, and where
to get condoms. Unwanted pregnancies or abortion was a topic much
less frequently discussed (Moyo et al. 1999).
Parents were also asked about their awareness and opinions of the
Gweru youth program. Only 6 percent said they knew of the city
program. Of these, 37 percent had participated in a meeting, and all
had positive views of the program (Moyo et al. 1999).
Although the activities of the subproject did not directly reach large
portions of the population of Gweru, together they helped create a
climate of support for young people and their reproductive health. The
Gweru City Council committed to sustaining youth-friendly services in
its clinics. After several months on the job, two peer educators de￾scribed their experiences at a meeting of the staff of several SEATS II
subprojects in Zimbabwe. As they confidently told about young
people's hunger for information on sexuality, the popularity of the
youth consultation rooms, and their own need for more knowledge,
skills, and resources in order to address the many concerns their peers
bring to them, the Mayor of Gweru's wide smile revealed his pride in
these youth and their work.
Albania: Ensuring Young People's Reproductive Rights
When SEATS II began working in Albania in 1996, family planning had
been legal for less than four years. Sexually active women of all ages
relied heavily on abortion as a family planning method. FGDs, con￾ducted by the MOH and the Albania Family Planning Association
(AFPA) with support from SEATS II, revealed that most women were
unfamiliar with the concept of family planning and had little knowledge
of modern contraceptive methods. This was not the case with univer￾sity students. These young, unmarried women aged 18 to 24 had very
 photo by Enilda Gorishti
SEATS’
lessons learned from
Experience
44
positive perceptions of family planning—“a basic
human right”—and were aware of OCs, injections, and
condoms, although they shared with the older and
married women concerns about contraceptive safety
(Gorishti and Haffey 1997).
These young women also reported that many of their
peers were not as knowledgeable as they were. They
said that all youth, especially girls, needed more
sexuality information, because they often initiated
sexual activity without an understanding of the pos￾sible negative consequences. Their peers were said to
have little concern about STDs and HIV/AIDS, as the
youth they knew felt less vulnerable to these health
threats. “Pregnancy is the primary thing, even when
they speak of the condom. AIDS for them is not
dangerous because they think it is difficult to get
[infected]” (Gorishti and Haffey 1997).
Despite young people’s need for information and
services, and the availability of services in the local
maternity hospital, the young women said the intimi￾dating nature of the facility and the negative staff
attitudes created formidable barriers to access. “Even if
we have a disease, we don't go there” (Gorishti and
Haffey 1997).
As part of its overall response to the needs of all Albanian women of
reproductive age, SEATS II worked with the MOH and AFPA to im￾prove the availability of and access to quality reproductive health
services in the public and private sectors. The establishment of youth￾friendly reproductive health services outside the maternity hospital
setting was particularly important. Service providers working in MOH
and AFPA facilities received training in interpersonal communication
and counseling, which included issues specific to young people. A
variety of print materials—the medium preferred by both young and old
in this literate society because it permits the reader to refer to it in
private and when needed—on family planning, contraception, and
other reproductive health topics was produced. Many of these materi￾als were distributed in collaboration with PSI and reached young
people through condom social marketing outlets. SEATS II did not track
individuals reached and clients served by age, so determining to what
extent young people benefitted from these improvements was impos￾sible. Nevertheless, staff reported that young people were voracious
readers of the print materials and increasingly made use of reproduc￾tive health services.
Albania: Subproject Overview
Dates: January 1996 to
December 1999
SEATS’ counterparts: MOH and Albania Family
Planning Association (AFPA)
ü Qualitative research revealed youth concerns
ü Trained providers offer youth-friendly reproductive
health counseling and services
ü Increased range of
contraceptive options for young people
ü IEC materials developed
ü Collaboration with Aksion Plus (PSI), Marie
Stopes International, Albanian Youth Forum,
Student Organization for Sex Education, National
AIDS Control Program
SEATS’
lessons learned from
Experience
45
Recognizing the need to reach even greater numbers of youth, a
consortium of youth-serving agencies approached SEATS II in late 1997
and requested technical assistance and support to improve outreach
efforts. Consortium members, including the Student Organization for
Sex Education, the AFPA Youth Group, the Albanian Youth Forum, and
Aksion Plus, agreed to work together to train and supervise peer
educators, produce and distribute youth-oriented materials, and
coordinate referrals to services. The National AIDS Control Program
was asked to join the effort. Unfortunately, the current security situa￾tion in Albania limited SEATS’ ability to provide technical assistance to
this youth initiative that could further contribute to making Albanian
young people's conviction of their reproductive rights a reality.
Russia: The Client-Centered
Approach Addresses Young
People's Needs People's Needs
The first time health administrators and
service providers in Primorsky Krai, in
Russia’s Far East with Vladivostok as its
capital, and Novosibirsk Oblast, in Western
Siberia in the geographical center of
Russia, heard about the client-centered
approach to reproductive health services,
they were skeptical about its relevance and
value. They expressed doubt about clients’
desire for information, their concern for
privacy and physical comfort, and their
ability to play an active role in reproductive
health decision making. Nevertheless, data
from other countries raised interest in
finding out more about client perspectives,
and the health officials and providers
endorsed a small qualitative study to
explore clients’ preferences, expectations,
and levels of satisfaction with existing
reproductive health services. In each site,
findings from FGDs with specific client
groups—women, postpartum women,
husbands of postpartum women, and
sexually active young women between the
ages of 15 and 20—were used to inform
policy decisions, design or modify training
curricula, and reconfigure service delivery.
Russia: Subproject Overview
Dates: January 1996 to December 1997
SEATS’ counterparts: Department of Health Services, Primorsky
Krai Administration, and Novosibirsk Oblast Department of Public
Health
ü Qualitative research revealed youth concerns
ü Facility-specific action plans to apply client-centered approach
to information and services for youth. Interventions included:
• Outreach to schools and parents
• Clinic and center renovations/design modifications to
increase youth comfort
• Private counseling rooms and IEC/meeting rooms
• Condom promotion/STD prevention
• Clinical services for youth
• Exit interviews with youth clients
ü Increased range of contraceptive options for young people
ü Provider commitment to youth reproductive rights
ü Decrease in abortions among women under 18
ü Collaboration with MotherCare, AVSC International,
JHPIEGO Corporation, JHU/CCP, Centers for Disease
SEATS’
lessons learned from
Experience
46
Service providers attitudes and qualifications had the greatest influ￾ence on young women’s opinions about the quality of services at the
women’s consultations—outpatient clinics providing gynecological,
infertility, and limited contraceptive services. Young women generally
viewed physicians as attentive, thorough, and sincere, in contrast to
their negative perceptions of nurses, midwives, and administrative staff.
“They [the latter] consider all the girls they see as potentially hopeless.”
“. . .She shouted at me: ‘So young, and already almost a whore’. . . . I
refused to go there again.” Adult participants in the other FGDs often
reflected similar sentiments about young people, calling them irrespon￾sible and accusing them of becoming sexually active without the
maturity to make decisions about contraception. Ironically, the young
women were the only FGD participants to report making preventive
visits to the consultations to seek protection from unwanted preg￾nancy. They also held the most positive attitudes toward hormonal
contraception and condoms, and no other group brought up the
importance of protection from both unwanted pregnancy and STDs
(JSI/SEATS et al. 1998).
The young women also expressed the strongest desire for more knowl￾edge about reproductive health. “There will never be enough. I know
almost nothing about myself. You learn and learn.” They requested
more and better sex education in schools. “They told us that you will
find out all about [pregnancy] from your parents and from the newspa￾pers but we cannot teach that in school.” All FGD participants high￾lighted the need to begin sex education at an early age and the special
role of the family in this process. At the same time, most admitted that
open communication and mutual understanding between parents and
their children about sex-related issues were more the exception than
the rule (JSI/SEATS et al. 1998).
photo by Joan Haffey
SEATS’
lessons learned from
Experience
47
Acting to Promote Youth Reproductive Rights
Findings such as these, coupled with training in clinical and counseling
skills for reproductive health, were fundamental to creating awareness
of the special concerns of youth and shaped the action plans of each
of the 12 pilot clinics and health facilities participating in the joint
SEATS/MotherCare subproject to expand access to, availability, and
use of high-quality, sustainable modern contraception and reproduc￾tive health services in Primorsky Krai and Novosibirsk Oblast. The
subproject was part of the USAID/Russia Women’s Reproductive
Health Project, which aimed to decrease Russia’s high rates of maternal
mortality and morbidity by increasing use of modern contraception as
an alternative to repeat abortion. The emphasis placed on youth varied
from facility to facility, although Novosibirsk Oblast included a youth￾specific objective in its oblastwide family planning program. Most sites
focused on outreach and support for parents and school teachers, and
several also paid special attention to improving services for youth. The
cases below exemplify the variety of changes health services made to
address youth needs.
The women’s consultation in Kuybyshev, a city in Novosibirsk Oblast,
began to attract women, men, and youth from the town, the region,
and even neighboring oblasts. The renovated cellar of the building with
its pharmacy, an IEC/meeting area, and a private counseling corner
were evidence of the attention given to client comfort and conve￾nience. The new outreach program to secondary school teachers and
parents was very popular. School classes visited the IEC room to learn
about sexuality and contraception, and staff reported that often one
class waited on the clinic lawn while a second class received educa￾tion inside. Mothers brought their daughters to the center for a range
of services. Officials from the neighboring city of Barabinsk asked the
center to assist in serving youth from that city.
In Berdsk, also in Novosibirsk, the adolescent health center Unona
(“you know”) undertook a range of efforts in cooperation with the
Department of Education and with the strong support of municipal
authorities. The “School for Family Life Training” for grades 7 through
10 operated in all 13 city schools. Classes from kindergarten onward
received health education, including sex education, with age-appropri￾ate materials and content. A “School for Young Mothers” offered
counseling on breastfeeding and LAM. The center’s youth program
actively promoted condom use and STD prevention, purchasing
condoms locally and supplying them free of charge to young people. A
survey of 338 adolescent users of the center identified clients’ knowl￾edge and attitudes about contraception, STDs, and center services
(Chernyakina 1997).
The Client-Centered
Approach
The client-centered approach refers
to the organization and delivery of
reproductive health services that
take into account (a) knowing and
meeting the needs and expecta￾tions of clients and ensuring client
satisfaction and (b) ensuring the
high performance of programs and
service providers according to up￾to-date clinical standards.
SOURCE: JSI/SEATS et al. 1998.
SEATS’
lessons learned from
Experience
48
The center’s branch counseling room, managed by the
deputy mayor in charge of health care and next to the
city’s marriage registration office, became a mandatory
stopping point for all couples about to be married. In
this city, the number of abortions among women
under 18 decreased almost 25 percent during the first
year of the subproject (see box).
Centers in Primorsky Krai also took steps to make
services more youth-friendly. In the new Ussuriysk
Family Planning Center, house plants, large and color￾ful posters on the walls, and a donated TV and VCR
made the center more comfortable to young people. A
gynecologist specializing in adolescents worked part￾time there. The local Youth Affairs Committee in
Lesozavodsk supported the renovation of its Youth
Center, including a music room, a computer room, and
a family planning clinic, staffed by trained providers
from the Women’s Consultation. In addition to youth￾friendly service improvements, reproductive health
education was introduced into 20 high schools in the
krai.
Providers at all sites endorsed the value of the client-centered ap￾proach in their all work, and work with youth in particular (see box).
The participatory techniques used in their training sessions were
successfully applied to IEC efforts. “We changed to your methods. . .
We divided them into small groups and had discussion, video, partici￾pation. . . we had a completely different result. . . some young couples
came forward for more information or to have counseling or to receive
a contraceptive method.”
Although the subproject FLE, counseling, and services for young
people generally enjoyed a great deal of support from local political
authorities, religious opposition—fueled by the “right to life movement”
originating in the United States—to family planning in general and
youth services in particular was on the increase. For example, a conser￾vative member of the Novosibirsk Municipal Council denounced a
youth reproductive health center, claiming it was “seducing children.”
In this case, he publicly retracted his opposition after he visited the
center. For the most part, providers and managers were perplexed and
unprepared to address constructively the criticisms and negative
messages surrounding youth reproductive health. Without support and
assistance in dealing with the growing opposition, the ability of these
and other centers to continue to serve this vulnerable population will
be greatly diminished.
Russian Providers Speak About Youth Rights
“The attitudes of health personnel have changed. . .[the]
client-friendly approach means interesting discussions
with young people about their problems, and doing this
professionally, candidly, tactfully, and truthfully.”
“The client can enjoy her RIGHTS at last! . . .to improve
the quality of services, to create a comfortable environ￾ment, and to ensure confidentiality are particularly
important for counseling adolescents. . . that is, to
provide for the clients’ rights.”
SOURCES: Chernyakina 1997; Makiyan 1997.
SEATS’
lessons learned from
Experience
49
Cambodia: Expanding the Reach
of Peer Educators
The Reproductive Health Association of
Cambodia (RHAC) was established as a
national NGO in 1996 just two years after the
Government of Cambodia initiated the Na￾tional Birth Spacing Program. A year later,
RHAC staff, volunteers, and other stakehold￾ers in reproductive health held a strategic
planning workshop in which they identified
youth as a priority for future RHAC programs.
Data from RHAC projects reinforced the
staff’s observations about the need to reach
this population with appropriate information
and services. Traditional social norms con￾demn sexual activity before marriage; yet
young, unmarried women were known to
seek abortion from unqualified providers.
Unmet need for contraception among mar￾ried women was high and likely to be much
higher among the unmarried. The commercial
sex industry was growing, particularly in towns
and cities, as national reconstruction efforts
attracted many migrant workers and day
laborers. Many commercial sex workers
(CSWs) were young women. It is estimated
that 90 percent of the approximately 120,000
HIV-positive individuals in Cambodia are be￾tween the ages of 15 and 35.
Because of the newness of reproductive
health information and services in general,
accompanied by the sensitivities surrounding
young adult reproductive health, RHAC
decided to test the applicability of peer
education in the Cambodian context through
a pilot project in Sihanoukville, the largest port
in Cambodia. RHAC’s HIV/AIDS prevention
programs there led to the selection of this city;
almost 6 percent of all clients and 52 percent
of the CSWs visiting the RHAC clinic were
HIV-positive. SEATS II provided financial
support for the in-country costs of the pilot
phase, but the technical expertise came
largely from within RHAC.
Cambodia: Subproject Overview
Dates: January 1997 to September 1998
Target population: Youth 12 to 25 in one city (pilot phase) with
expansion to three other cities
SEATS’ counterpart: Reproductive Health Association of
Cambodia (RHAC)
ü Advisory Committee: local government, schools, and
youth
ü 47 peer counselors (high school students), 7 teachers
trained
ü 2,000 youth reached
ü Links and referrals to reproductive health services estab￾lished
ü $700,000 additional donor funding to expand program
ü Expansion to additional cities includes:
• IEC materials development
• Clinical services: Youth Centers in existing clinics
• MIS to track client visits, referrals, outreach
• Baseline and postintervention surveys
ü Collaboration with Department of Health, Department of
Education, Youth, and Sports, UNFPA, FOCUS
SEATS’
lessons learned from
Experience
50
Before the subproject began, RHAC formed an informal Advisory
Group, composed of RHAC staff, officials from the municipal Depart￾ment of Health, representatives from the Department of Education,
Youth, and Sports, and young people. The Advisory Group worked
closely with RHAC throughout the pilot phase, helping to ensure
community acceptance and support. For example, the Advisory Group
recommended appropriate topics for the peer educator training
curriculum and outreach activities. The two government departments
subsequently approved the curriculum with only minor changes.
A workshop to train 23 students (12 young women and 11 young men)
from Sihanoukville High School as peer educators and eight teachers
launched activities in July 1997. An additional 24 peer educators from
the high school in Khan Prey Nop, a district of Sihanoukville, received
training over the next 15 months, and 12 of the original group received
refresher training. RHAC staff and the teachers supported the peer
educators as they conducted group education sessions in schools and
in communities and reached more than 2,000 youth with verbal and
print information on unwanted pregnancy and its prevention, contra￾ceptive methods, STD and HIV transmission and prevention, reproduc￾tive rights, and safe motherhood. “Quiz shows” organized by the peer
educators brought together as many as 1,000 youth who participated
in games and other activities to raise reproductive health awareness.
The peer educators referred youth in need of services or contraception
to RHAC clinics or community-based distribution agents, as RHAC was
reluctant to allow the peer educators to distribute condoms or other
contraceptive commodities.
Expansion to Other Cities
The positive response by government, youth, and teachers to the pilot
phase and the requests to expand activities satisfied RHAC that peer
education was feasible in Cambodian cities. RHAC received recogni￾tion as a national leader in adolescent reproductive health. RHAC also
recognized that it needed additional technical expertise in young
people’s reproductive health programming. With specific technical
skills, RHAC believed it could avoid some problems it encountered in
the pilot phase. Attrition among the peer educators was high, the peer
educators’ communication skills were weak, and their training focused
more on content (the facts) than process (effectively delivering the
facts). Out-of-school youth proved hard to reach. Although the peer
educators were linked to RHAC clinics, the service providers did not
receive any orientation in youth-friendly service delivery. The lack of a
formal supervisory system and limited monitoring and evaluation
hindered RHAC’s ability to describe subproject outcomes.
“Quiz shows” organized by the peer educators
brought together as many as 1,000 youth
who participated in games and other activities
to raise reproductive health awareness.
RHAC
SEATS’
lessons learned from
Experience
51
Building on the experiences and lessons learned from the pilot project,
in late 1998 RHAC received a three-year, $700,000 grant from the
European Union through UNFPA to expand peer education to Phnom
Penh, the capital, Battambang, and Kampong Cham. SEATS II, in
collaboration with other CAs such as FOCUS, provided technical
expertise in a range of areas, including the establishment of Youth
Centers within RHAC clinics; improvements in peer educator recruit￾ment, training, and supervision; development of IEC materials; imple￾mentation of an MIS; and baseline and postimplementation surveys.
By mid-1999, 281 trained peer educators were active, reaching 6,150
young people. Four RHAC clinics were providing clinical services to
young people, including 1,145 contraceptive clients and 1,705 STD
clients. More than 6,000 youth visited the RHAC libraries to obtain
information on reproductive health.
The efforts of RHAC, complemented by those of the Government of
Cambodia and six other national NGOs working to improve youth
reproductive health, stand to make an important contribution toward
RHAC’s goal of improved quality of life for all Cambodians.
RHAC
By mid-1999, 281 trained peer educators were active, reaching 6,150 young people.

SEATS’
lessons learned from
Experience
53
Lessons Learned
The observations drawn directly from SEATS’ experience with youth
reproductive health offer some new knowledge and insight on pro￾gram design and management. Because SEATS’ youth-oriented sub￾projects and activities began with the premise that drawing upon
lessons learned from its own and others’ efforts is the most likely
pathway to success, the discussion below tries not to repeat what has
already been established by others (e.g., youth involvement is essen￾tial). Instead, it focuses on what worked and what did not work as
SEATS carried out its broad, flexible mandate to improve health ser￾vices for youth while simultaneously applying a range of documented
best practices and testing new approaches.
ª Comprehensive, multiple-intervention approaches can
meet the needs of many audiences. Field realities—from lack
of data to political expediency—often did not permit sub￾projects to pinpoint a specific target group with regard to
age, marital status, gender, and sexual activity, a program
practice suggested by some experts (Hughes and McCauley
1998). SEATS found that multifaceted subprojects combining
primary prevention with primary care and parental and
community involvement were able to reach many subgroups
of young people with unmet needs as well as adults. For
example, other programs in Africa have found that peer
educators are more effective in reaching males and in-school
youth than females and out-of-school youth (Herdman 1999).
SEATS subprojects in Zambia and Zimbabwe were able to
reach all four of these groups.
ª Addressing the special needs of young people does not
require starting with a separate project or intervention
targeting youth. SEATS II’s Urban Initiative and the applica￾tion of client-centered approaches to quality improvement
demonstrated that a focus on quality of care can lead pro￾grams to recognize the benefits of ensuring access to safe,
comprehensive, and high-quality services to all individuals at
any stage in the life cycle. These approaches did not have a
mandate to start with youth. Instead, they encouraged stake￾holders to identify priority groups and actions for improving
access and quality, based on available data. Almost always,
youth emerged as an underserved group with special needs,
SEATS’
lessons learned from
Experience
54
and appropriate interventions followed. In Zambia and
Zimbabwe, existing subprojects were expanded to integrate
interventions that addressed the special needs of young
people.
ª Flexible, multisectoral, process-oriented interventions
incorporate many of the documented “best practices” for
improving youth reproductive health. Approaches such as
CQI, EQUIPE, the Urban Initiative, and PLA brought together
multiple stakeholders (e.g., providers, youth, parents, and
local leaders) from multiple sectors (e.g., health, education,
recreation) and involved them in defining, assessing, and
ensuring quality of care and creating support for youth
reproductive health efforts. These flexible and participatory
models allowed subprojects to adjust to realities and newly
recognized needs as they arose. They were also well-suited
to settings where decentralization policies require local
entities to take responsibility for the provision of integrated
health care.
ª The willingness to pioneer new ventures in reproductive
health services for young people is not exclusive to the
private sector. The predominance of NGOs in the delivery
of reproductive health services to young people has led
some to conclude that governments are unwilling to offer
services to this population. The experiences in Russia,
Senegal, Zambia, and Zimbabwe demonstrated that local
governments are eager to take on the challenge and test
innovative approaches.
ª Data can be very persuasive in motivating parents and the
community to support youth reproductive health initiatives.
Sharing the findings of formative research or existing data
with parents, politicians, local leaders, and service providers
allowed these “gatekeepers” to appreciate the urgency and
magnitude of reproductive health problems among their com￾munities’ youth and was critical to overcoming initial opposition.
ª Basic human rights—clients’ rights and reproductive rights—
are a compelling rationale for offering reproductive health
education and services to young people. Providers, clients,
and young people in Albania and Russia often came to share
the conviction that access to quality reproductive health
services was the right of people of all ages. In these coun￾tries, the concept of rights clearly served as the basis for
ensuring that efforts to improve and expand services incorpo-
SEATS’
lessons learned from
Experience
55
rated the special needs and concerns of youth. In Cambodia,
reproductive rights were a specific theme of peer educators’
outreach activities.
ª Young people and service providers demand integrated
reproductive health interventions. Youth and service provid￾ers in SEATS subprojects wanted a comprehensive package
of interventions to prevent and address the adverse risks
associated with early, unwanted, and unprotected sexual
activity.
ª Integrated reproductive health services that include STD
prevention and screening can attract young men. In most
countries, the availability of STD prevention and treatment
was the magnet that drew young men into the program—not
an interest in family planning or other reproductive health
issues. Once young men were “in the door” (or in a commu￾nity educational setting), they had the opportunity to learn
more about other reproductive health issues.
ª Health centers can be reconfigured to attract youth seeking
information and counseling as well as services. Before
SEATS’ interventions, few youth cited health care providers
or clinics as a source of information on reproductive health,
and clinics were considered the resource of last resort for
curative services. When clinical settings have trained provid￾ers, a welcoming environment, educational materials and
resources, and reassuring promotion, youth will visit them for
information as well as services. In fact, in some countries,
such as Burkina Faso and Eritrea, more youth came to facili￾ties to learn about reproductive health than they did to seek
services. Despite the willingness to make changes to better
accomodate youth, modifying clinic operations to include
evening and weekend opening hours proved to be difficult in
many countries.
ª Offering reproductive health information and services in
nonclinical settings such as Youth Centers can also attract
youth who may have otherwise avoided a health facility. In
Eritrea, Senegal, and Zimbabwe, reproductive health services
were linked with recreational and educational activities
offered in multipurpose centers, making it easier for young
people to unobtrusively or casually seek assistance. In most
other countries, youth, their parents, and project staff urged
programs to consider adding nonhealth components.
SEATS’
lessons learned from
Experience
56
ª A “champion” for youth within a clinical setting can help
maintain a youth-friendly environment. In Zambia, the
presence of an enthusiastic, outspoken advocate for youth
helped overcome other providers’ antagonism to some of the
changes required to make the service youth-friendly.
ª The costs associated with referral services are a barrier to
access. Although all SEATS’ counterparts took care to ensure
free or affordable commodities and services at the sites
directly involved in the subproject, the costs of services at
referral sites and/or the costs of transportation to reach the
referral site prevented many young people from obtaining
complete and adequate care.
ª Young people also prefer contraceptive method choices. An
axiom of quality of care is the provision of a range of contra￾ceptive methods. Yet, services for young people often focus
heavily or exclusively on nonprescriptive methods (barrier
methods and sometimes OCs). The subprojects that were
able to offer a wide variety of methods on-site demonstrated
that young people appreciate choice as much as older
women and men.
ª Programs require support, advice, and assistance in ad￾dressing community resistance and opposition to youth
reproductive health interventions. From the inability of
NUEYS in Eritrea to create a community advisory board to
the peer educators in Senegal who were uncomfortable
working in their own neighborhoods to the confusion of
service providers in Russia over attacks by “right-to-life”
groups, subproject staff were often unprepared to deal with
criticism and condemnation of subproject activities.
ª In most settings, peer education is a culturally and politi￾cally feasible approach to reaching young men and women,
in-school and out-of-school youth with information,
condoms, and spermicides. Only in Senegal did the peer
educators report that they encountered hostilities in the
community, and it is possible that this might have been
overcome with more intensive community mobilization and
greater support for the peer educators. In Cambodia, staff
were unwilling to allow the peer educators to distribute com￾modities. Although peer educators are accepted, data on their
effectiveness in changing knowledge, attitudes, and behaviors
and in reaching younger youth (10- to 14-year-olds) are lacking.
SEATS’
lessons learned from
Experience
57
ª Identifying a sustainable and appropriate package of com￾pensation and incentives for peer educators is complicated.
Unemployment was often a key factor contributing to young
people’s decisions to become peer educators, and once they
found paying jobs, they left the subprojects. Peer educators
were often unhappy with the limited allowances they re￾ceived. On the other hand, offering wages was neither
feasible nor acceptable, and in Zambia, local government
authorities urged the subproject to discontinue the allow￾ances. Providing refresher trainings, offering visits to other
program sites, delegating responsibility for data collection
and compilation, and encouraging the peer educators to
raise their own funds were some of the solutions that came out
of Zambia.
ª Peer educators can be very resourceful fundraisers. The
success of the Zambian peer educators in raising money to
support their activities is evidence of young people’s talents
and energy. Need was not the only factor driving these
youth. Their supervisor’s trust in their abilities and willingness
to let them take the lead were important motivators.
ª Adult-friendly programming may be as important as youth￾friendly services. The key to parental and community sup￾port in many subprojects was a welcoming attitude toward
parental input and involvement in the activities. Inviting
parents to visit subproject sites helped overcome their suspi￾cion and gain their approval.
ª Young people can be effective agents for eradication of
harmful “traditional” practices. In many countries, youth
were more at ease than adults in challenging reproductive
health practices shaped by cultural traditions and gender
norms such as FGM.
ª Standard family planning and reproductive health monitor￾ing indicators do not capture the results of youth projects.
SEATS’ youth reproductive health subprojects aimed to reach
young people who were not sexually active as well as those
who were. Measures such as couples years of protection,
contraceptive prevalence, and numbers of clients for different
clinical services do not provide information on health-protect￾ing attitudes and behaviors such as self-efficacy, abstinence,
or the delay of sexual activity. Other indicators such as
percentage of youth who feel they could seek reproductive
health information and services if they need them and
SEATS’
lessons learned from
Experience
58 7
The forthcoming FOCUS publication A guide to monitoring and evaluating adolescent reproductive
health programs (Adamchak et al. in press) provides useful guidance on measuring the results of youth
reproductive health programs.
percentage of families who support their children's access to
information and services may provide a better picture of the
outcomes of activities aimed at promoting young people's
reproductive health.7
ª Evidence of sexual activity among girls 12 and younger
points to the need to develop appropriate interventions
targeting this age group. Although Zambia was the only
country where subproject data found that very young girls
were engaging in sexual intercourse, this age group is largely
overlooked by current reproductive health programming.
ª The sensitivity surrounding reproductive health services for
young people is not an insurmountable barrier to demon￾strating their feasibility. In settings where there is great
hesitancy to initiate any programming for young adult repro￾ductive health, moving forward with implementation breaks
down many barriers and sets the stage for more efficient
programming of evaluation and other resources. Changing
social norms and the perception of those norms, particularly
those surrounding sexual relationships and activity, can take
much longer than a subproject life span. Nevertheless, by
initiating open dialogue about youth reproductive health
among parents, health providers, community members, and
youth, subprojects can set in motion a process of lasting change.
In March 1999, delegates from 177 nations at the Hague Forum on
ICPD+5 approved a report reviewing progress in implementing the
Programme of Action of ICPD. The report reiterated the needs to
improve young people's access to appropriate information and ser￾vices and to increase political commitment to adolescents’ right to
reproductive health. But it also pointed out that adolescent reproduc￾tive health issues are now on the public agenda and praised those
countries where young people now have the right to confidentiality
and privacy in service delivery (UNFPA 1999). The staff of SEATS II and
its many counterparts and collaborators are proud to have contributed
to making this right a reality.
SEATS’
lessons learned from
Experience
59
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62
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Family Planning Service Expansion
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