Providing technical assistance: lessons learned from the first three years of the WHO Adolescent and Youth Sexual and Reproductive Health and Rights Technical Assistance Coordination Mechanism.

Young people's sexual and reproductive health (SRH) continues to be a major challenge in low and middle-income countries, with implications for public health now and in the future. Fortunately there is a growing array of evidence-based interventions, and commitments from governments, development partners and donors, to support programmes that aim to improve young people's SRH.However, in some situations, the technical assistance that governments feel that they need to strengthen and implement national policies and strategies, to move from words to action, is not available. The WHO Adolescent and Youth Sexual and Reproductive Health and Rights (AYSRHR) Technical Assistance (TA) Coordination Mechanism was initiated to help fill this technical assistance gap; to respond to TA requests from ministries of health in ways that are timely, efficient, effective and contribute to strengthening capacity.This paper describes the process of developing the Technical Assistance Coordination Mechanism (TA Mechanism) and the outcomes, experiences and lessons learned after three years of working. It triangulates the findings from a preliminary review of the literature and discussions with selected key informants; the outcomes from a series of structured review meetings; and the documented processes and results of the technical assistance provided to countries.The lessons learned focus on three aspects of the TA Mechanism. How it was conceptualized and designed: through listening to people who provide and receive AYSRHR TA and by reviewing and synthesizing past experiences of TA provision. What the TA Mechanism has achieved: a standardized process for TA provision, at different stages for a range of AYSRHR issues in ten countries in three geographic regions. And what worked well and what did not: which common challenges was the TA Mechanism able to address and which ones persisted despite efforts to avoid or resolve them. The paper ends with the implications of the lessons learned for future action.

Findings from a mixed-methods evaluation of a multi-level adolescent and youth reproductive and maternal health intervention in Karnali Province, Nepal.

INTRODUCTION: Adolescent girls and young women (AGYW) in Nepal have disproportionately poor reproductive and maternal health outcomes. In response, Save the Children, the Nepal government, and local partners designed and implemented Healthy Transitions for Nepali Youth, a multi-level integrated intervention. The intervention aimed to improve reproductive, maternal, and newborn health knowledge, attitudes, and behaviors among AGYW, and address gender attitudes and norms in four districts of Karnali Province, Nepal. METHODS: Married and unmarried AGYW aged 15-24 were engaged in a small group, curriculum-based intervention; husbands and families received home visits, using short videos to catalyze discussion; communities were engaged through dialogue-based activities; and the health system was made more adolescent-responsive through quality assessments, training, and supervision. An external organization conducted a quantitative survey with a sample of 786 AGYW intervention participants at baseline and 565 of the same AGYW at endline. Pooled linear regressions were estimated for each indicator to assess the statistical significance of differences between baseline and endline. Focus group discussions and key informant interviews were conducted with AGYW, husbands, families, community leadership, and program implementers. Data analysis was done through STATA 14th version and NVivo. RESULTS: The percentage of AGYW currently using a modern contraceptive method increased significantly, and more AGYW believed that their family was supportive of delaying marriage and motherhood at the endline. Young women's knowledge of danger signs during labor increased, and there was a significant improvement in essential newborn care practices immediately after birth. AGYW reported shifts towards more gender equitable attitudes and behaviors, including related to decision-making about reproductive and maternal health. CONCLUSION: Positive shifts in reproductive, maternal, and newborn health and gender knowledge, attitudes, and behavior were observed among AGYW, their male partners, and families. The results can inform the design of future interventions to effectively reach this critical population. TRAIL REGISTRATION: Not applicable.

Making good on a call to expand method choice for young people - Turning rhetoric into reality for addressing Sustainable Development Goal Three.

BACKGROUND: Investments in the nearly two billion young people, aged 10-24 years, in the world today are necessary to meet global development commitments, specifically the Sustainable Development Goals and Ending Preventable Child and Maternal Deaths. More than 12 million married and unmarried adolescents (aged 15-19) will give birth in 2016. Complications of pregnancy and childbirth are the second leading cause of death among 15-19 year-old women and early childbearing can significantly curtail social and economic prospects for young women. Facilitating the ability of sexually active young people to choose and effectively use a satisfactory contraceptive method will ensure they can exercise their right to prevent, delay or space pregnancy. The Global Consensus Statement, "Expanding Contraceptive Choice for Adolescents and Youth to Include Long Acting and Reversible Contraception" provides evidence on the safety and effectiveness of LARCs for young people. Three inter-dependent actions linking advocacy and policy (advocating for policy and guideline revisions); supply (improving quality and accessibility of an expanded method choice) and an enabling environment (social norms and comprehensive reproductive health information) are suggested as vital to achieving full access and full choice for all sexually active young people. Identified approaches include national advocacy addressing policy guidelines and standard operating procedures that guide providers in the provision of age and developmentally appropriate contraceptive services; pre-service and in-service training for health care providers to be able to effectively communicate and counsel young people, including dispelling myths and misconceptions around LARCs; and partnering with young people to design appropriate, contextually-relevant, and effective strategies to increase their self-efficacy and, at the community level, address broader social norms to dispel stigma and discrimination. CONCLUSION: An immediate call to action for collaborative and coordinated global, regional and national efforts that enable full access and full choice for all young people is paramount to achieve their reproductive health intentions and the Sustainable Development Goal targets.

Invest in adolescents and young people: it pays.

This year's Women Deliver conference made a strong call for investing in the health and development of adolescents and young people. It highlighted the unique problems faced by adolescent girls and young women-some of the most vulnerable and neglected individuals in the world-and stressed the importance of addressing their needs and rights, not only for their individual benefit, but also to achieve global goals such as reducing maternal mortality and HIV infection.In response to an invitation from the editors of Reproductive Health, we-the sixteen coauthors of this commentary-put together key themes that reverberated throughout the conference, on the health and development needs of adolescents and young people, and promising solutions to meet them.1. Investing in adolescents and young people is crucial for ensuring health, creating prosperity and fulfilling human rights.2. Gender inequality contributes to many health and social problems. Adolescent girls and boys, and their families and communities, should be challenged and supported to change inequitable gender norms.- Child marriage utterly disempowers girls. It is one of the most devastating manifestations of gender discrimination.- Negative social and cultural attitudes towards menstruation constrain the lives of millions of girls. This may well establish the foundation for lifelong discomfort felt by girls about their bodies and reticence in seeking help when problems arise.3. Adolescents need comprehensive, accurate and developmentally appropriate sexuality education. This will provide the bedrock for attitude formation and decision making.4. Adolescent-centered health services can prevent sexual and reproductive health problems and detect and treat them if and when they occur.5. National governments have the authority and the responsibility to address social and cultural barriers to the provision of sexual and reproductive health education and services for adolescents and young people.6. Adolescents should be involved more meaningfully in national and local actions intended to meet their needs and respond to their problems.7. The time to act is now. We know more now than ever before about the health and development needs of adolescents and young people, as well as the solutions to meeting those needs.

Fostering gender equality and reproductive and sexual health among adolescents: results from a quasi-experimental study in Northern Uganda.

OBJECTIVE: To assess the impact of the Gender Roles, Equality and Transformations (GREAT) intervention: a narrative-based, resource-light, life-stage tailored intervention package designed to promote gender-equitable attitudes and behaviours, and improve sexual and reproductive health (SRH) and gender-based violence (GBV) outcomes among adolescents and their communities. DESIGN: Repeated cross-sectional evaluation study, using propensity score matching combined with difference-in-difference estimation. SETTING: Two postconflict communities in Lira and Amuru districts in Northern Uganda. PARTICIPANTS: Male and female unmarried adolescents (10-14 years, 15-19 years), married adolescents (15-19 years) and adults (over the age of 19 years) were selected using a stratified, two-stage cluster sample of primary and secondary schools and households (baseline: n=2464, endline: n=2449). PRIMARY OUTCOME MEASURES: Inequitable gender attitudes and behaviours; GBV; and SRH knowledge and behaviours. RESULTS: Statistically significant intervention effects were seen across all three outcomes-gender equity, GBV and SRH-among older and newly married adolescents and adults. Among older adolescents, intervention effects include shifts on: inequitable gender attitudes scale score: -4.2 points ((95% CI -7.1 to -1.4), p<0.05); Inequitable household roles scale score: -11.8 ((95% CI -15.6to -7.9), p<0.05); Inequitable attitudes towards GBV scale: -1.9 ((95% CI -5.0 to -0.2), p<0.05); per cent of boys who sexually assaulted a girl in past 3 months: -7.7 ((95% CI -13.1 to -2.3), p<0.05); inequitable SRH attitudes scale: -10.1 ((95% CI -12.9 to -7.3), p<0.05). Among married adolescents, intervention effects include shifts on: Inequitable household roles scale score: -6.5 ((95% CI -10.8 to -2.2), p<0.05); inequitable attitudes towards GBV scale: -4.7 ((95% CI -9.8 to -0.3), p<0.05); per cent who reacted violently to their partner: -15.7 ((95% CI -27.1 to -4.4), p<0.05); inequitable SRH attitudes scale: -12.9 ((95% CI -17.3 to -8.5), p<0.05). CONCLUSION: The GREAT intervention model demonstrates the promise of a resource-light, life-stage tailored programme that employs culturally appropriate, participatory and narrative-based techniques to advance gender equity and adolescent health. This type of programming contributes towards reductions in GBV and improved adolescent SRH outcomes.

Increasing Contraceptive Use Among Young Married Couples in Bihar, India: Evidence From a Decade of Implementation of the PRACHAR Project.

BACKGROUND: Evidence on effective behavior change programming for sexual and reproductive health among married youth aged 15-24 in developing countries is lacking. To address this gap, we examined monitoring, evaluation, and special study data from the Promoting Change in Reproductive Behavior of Adolescents (PRACHAR) Project, which was implemented between 2001 and 2012 in Bihar, India, over 3 phases using 2 different implementation models (NGO- and government-led). METHODS: We conducted a synthesis of evidence from multiple PRACHAR studies to identify key findings on intervention effectiveness, scalability, and sustained effects on behaviors. Data were triangulated from quantitative population-based quasi-experimental evaluations from each project phase; the project's performance monitoring database; and qualitative studies with beneficiaries. RESULTS: PRACHAR's original comprehensive NGO-led model, which included behavior change elements and multiple overlapping communication channels (including home visits and small-group meetings), increased contraceptive use among young married couples, and these outcomes were sustained 4-8 years after project interventions ended. Several program elements were critical to the effectiveness of PRACHAR, including use of a socioecological intervention model with emphasis on behavior change efforts; use of a gender-synchronized approach that engages both male and female partners; and intensity of interventions calibrated to different moments in the life cycle of adolescents and youth. While the hybrid government-NGO model of PRACHAR implementation reached greater scale than the original NGO-led model, comparison of results suggests trade-offs in effectiveness of interventions and sustained impacts. CONCLUSIONS: A decade of learning from the PRACHAR Project in Bihar, India, finds that comprehensive programming with gender-synchronized interventions tailored to specific life stages and aimed at different levels of the socioecological model can effectively increase contraceptive use among married young people in a conservative context. Shifting from a more intensive NGO-led model to less intensive government implementation enhances scalability but may have diminished impact on reach and long-lasting effectiveness.

Scale-up of adolescent contraceptive services: lessons from a 5-country comparative analysis.

BACKGROUND: Poor sexual and reproductive health outcomes among adolescents aged 10-19 years are indicative of the barriers this group faces in accessing health services and highlights a gap in the availability of appropriate services, including adolescent-friendly contraceptive services (AFCS). The HIV Investment Framework identifies contraceptive services as an entry point for HIV counseling, testing, and treatment, and as a component of HIV prevention. To effectively meet the needs of adolescents, greater understanding of effective scale-up strategies for adolescent-friendly services is needed. METHODS: The authors conducted a retrospective analysis of AFCS scale-up experiences in Ethiopia, Ghana, Mozambique, Tanzania, and Vietnam using the ExpandNet/World Health Organization framework for systematic scale-up. The authors analyzed the type of scale (expansion or institutionalization), dissemination and advocacy, organizational process, costs and resource mobilization, and monitoring and evaluation. RESULTS: The analysis showed that all programs simultaneously pursued expansion and institutionalization, contributing to sustainable scale-up. Advocacy complemented by intensive capacity building at all levels of the health system contributed to adoption of AFCS in national and district work plans and budgets as well strengthening collection of age-disaggregated data. DISCUSSION: To achieve scale-up of AFCS, the authors identified the importance of institutionalization and expansion in tandem for synergy and reinforcement, empowering adolescents to be agents of change and hold government accountable to its commitments, and strengthening health systems to sustain AFCS. CONCLUSIONS: This article contributes to a growing body of evidence around scale-up of AFCS, which can inform the implementation and sustainable scale-up of HIV and other services for adolescents.