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.

ASRHR in Ethiopia: reviewing progress over the last 20 years and looking ahead to the next 10 years.

Over the last two decades, improvements in Ethiopia's socio-economic context, the prioritization of health and development in the national agenda, and ambitious national health and development policies and programmes have contributed to improvements in the living standards and well-being of the population as a whole including adolescents. Improvements have occurred in a number of health outcomes, for example reduction in levels of harmful practices i.e., in child marriage and female genital mutilation/cutting (FGM/C), reduction in adolescent childbearing, increase in positive health behaviours, for example adolescent contraceptive use, and maternal health care service use. However, this progress has been uneven. As we look to the next 10 years, Ethiopia must build on the progress made, and move ahead understanding and overcoming challenges and making full use of opportunities by (i) recommitting to strong political support for ASRHR policies and programmes and to sustaining this support in the next stage of policy and strategy development (ii) strengthening investment in and financing of interventions to meet the SRH needs of adolescents (iii) ensuring laws and policies are appropriately communicated, applied and monitored (iv) ensuring strategies are evidence-based and extend the availability of age-disaggregated data on SRHR, and that implementation of these strategies is managed well (v) enabling meaningful youth engagement by institutionalizing adolescent participation as an essential element of all programmes intended to benefit adolescents, and (vi) consolidating gains in the area of SRH while strategically broadening other areas without diluting the ASRHR focus.

Updated research gaps on ending child marriage and supporting married girls for 2020-2030.

Over the past 25 years, tremendous progress has been made in increasing the evidence on child marriage and putting it to good use to reduce the prevalence of child marriage and provide support to married girls. However, there is still much to be done to achieve the Sustainable Development Goal target 5.3 of ending child marriage by 2030, and to meet the needs of the 12 million girls who are still married before age 18 each year. To guide and stimulate future efforts, the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction, the World Health Organization, the UNICEF-UNFPA Global Programme to End Child Marriage, and Girls Not Brides: The Global Partnership to End Child Marriage convened an expert group meeting in 2019 to: (1) review the progress made in building the evidence base on child marriage since the publication of research priorities in this area in 2015, (2) identify an updated set of research priorities for the next ten years, and (3) discuss how best to support research coordination, translation, and uptake. This article provides a summary of the progress made in this area since 2015 and lists an updated set of research gaps and their rationale in four key areas: (1) prevalence, trends, determinants, and correlates of child marriage; (2) consequences of child marriage; (3) intervention effectiveness studies to prevent child marriage and support married girls; and (4) implementation research studies to prevent child marriage and support married girls. It also highlights a number of calls-to-action around research coordination and knowledge translation to support the emerging and evolving needs of the field.

RéSUMé: Au cours des 25 dernières années, d'énormes progrès ont été réalisés pour mettre à jour les données concernant le mariage des enfants et les mettre à profit pour réduire la prévalence du mariage des enfants et apporter un soutien aux filles mariées. Cependant, il reste encore beaucoup à faire pour atteindre la cible 5.3 de l'Objectif de Développement Durable consistant à mettre fin au mariage des enfants d'ici 2030 et pour répondre aux besoins des 12 millions de filles qui sont encore mariées avant l'âge de 18 ans chaque année. Guider et stimuler les efforts futurs, tel est le Programme Spécial de Recherche de la Banque Mondiale PNUD-FNUAP-UNICEF-OMS, du Développement et la Formation à la Recherche en Reproduction Humaine, de l'Organisation Mondiale de la Santé, du Programme Mondial UNICEF-FNUAP pour mettre fin au mariage des enfants et «  Des filles pas des Mariées  ¼ : le Partenariat Mondial pour mettre fin au mariage des enfants a convoqué une réunion de groupe d'experts en 2019 pour : 1. passer en revue les progrès accomplis dans la constitution de la base de données factuelles sur le mariage des enfants depuis la publication des priorités de la recherche dans ce domaine en 2015, 2. identifier un ensemble actualisé de priorités de recherche pour les dix prochaines années, et 3. discuter de la meilleure façon de soutenir la coordination, la traduction et la compréhension de la recherche. Cet article résume les progrès réalisés dans ce domaine depuis 2015 et répertorie sous forme de mise à jour un ensemble de lacunes dans la recherche et leur justification dans quatre domaines clés: 1) prévalence, tendances, déterminants et corrélatifs du mariage des enfants; 2) conséquences du mariage des enfants; 3) études ayant trait à l'efficacité des interventions pour prévenir le mariage des enfants et soutenir les filles mariées; et 4) études de recherche sur la mise en œuvre pour prévenir le mariage des enfants et soutenir les filles mariées. Il met également en évidence un certain nombre d'appels à l'action autour de la coordination de la recherche et de l'application des connaissances pour répondre aux besoins émergents et à l'évolution de ce domaine.

RESUMEN: En los últimos 25 años se ha avanzado enormemente y existe ahora más evidencia sobre el matrimonio infantil, y sobre como se debe poner la evidencia en práctica para reducir la prevalencia del matrimonio infantil y proporcionar apoyo a las niñas casadas. Sin embargo, aún queda mucho por hacer para alcanzar la meta 5.3 de los Objetivos de Desarrollo Sostenible de poner fin al matrimonio infantil para 2030, y para satisfacer las necesidades de los 12 millones de niñas que cada año se casan antes de los 18 años. Para orientar y estimular los esfuerzos futuros, el Programa Especial de Investigación, Desarrollo y Formación de Investigadores en Reproducción Humana del PNUD-FNUAP-UNICEF-OMS-Banco Mundial, la Organización Mundial de la Salud, el Programa Mundial para la Eliminación del Matrimonio Infantil de UNICEF-FNUAP y Girls Not Brides: La Alianza Mundial para Acabar con el Matrimonio Infantil convocó una reunión de un grupo de expertos en 2019 para: 1. Revisar los progresos realizados en la construcción de la base de evidencias sobre el matrimonio infantil desde la publicación de las prioridades de investigación en este ámbito en 2015, 2. Identificar un conjunto actualizado de prioridades de investigación para los próximos diez años, y 3. Debatir la mejor manera de apoyar la coordinación, la traducción y la aceptación de la investigación.Este artículo ofrece un resumen de los progresos realizados en este ámbito desde 2015 y enumera un conjunto actualizado de lagunas de investigación y su justificación en cuatro áreas clave: 1) prevalencia, tendencias, determinantes y correlaciones del matrimonio infantil; 2) consecuencias del matrimonio infantil; 3) estudios de eficacia de las intervenciones para prevenir el matrimonio infantil y apoyar a las niñas casadas; y 4) estudios de implementación para prevenir el matrimonio infantil y apoyar a las niñas casadas. También destaca una serie de llamados a la acción en torno a la coordinación de la investigación y la traducción de conocimientos para apoyar las necesidades emergentes y en evolución del campo.

The state of adolescent menstrual health in low- and middle-income countries and suggestions for future action and research.

In recognition of the opportunity created by the increasing attention to menstrual health at global, regional, and national levels, the World Health Organization's Department of Sexual and Reproductive Health and Research and the UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction convened a global research collaborative meeting on menstrual health in adolescents in August 2018. Experts considered nine domains of menstrual health (awareness and understanding; stigma, norms, and socio-cultural practices; menstrual products; water and sanitation; disposal; empathy and support; clinical care; integration with other programmes; and financing) and answered the following five questions: (1) What is the current situation? (2) What are the factors contributing to this situation? (3) What should the status of this domain of adolescent menstrual health be in 10 years? (4) What actions are needed to achieve these goals? (5) What research is needed to achieve these goals? This commentary summarizes the consensus reached in relation to these questions during the expert consultation. In doing so, it describes the state of adolescent menstrual health in low- and middle-income countries and sets out suggestions for action and research that could contribute to meeting the holistic menstrual health needs of adolescent girls and others who menstruate worldwide.

Trends in adolescent first births in sub-Saharan Africa: a tale of increasing inequity?

BACKGROUND: Single aggregate figures for adolescent pregnancy may fail to demonstrate particular population groups where rates are very high, or where progress has been slow. In addition, most indicators fail to separate younger from older adolescents. As there is some evidence that the disadvantages faced by adolescent mothers are greatest for those at the younger end of the spectrum, this is an important omission. This paper provides information on levels and trends of adolescent first births in 22 countries (at national and regional level) disaggregated by age (< 16 years, 16/17 years and 18/19 years), socio-economic status and place of residence. It highlights differences and similarities between countries in the characteristics of women who experience first birth during adolescence, as well as providing information on trends to identify groups where progress in reducing adolescent first births is poor. METHODOLOGY: In this descriptive and trend analysis study we used data from 22 low- and middle-income countries from sub-Saharan Africa that have at least three Demographic and Health Surveys (DHS) since 1990, with the most recent carried out after 2005. Adolescent first births from the most recent survey are analysed by age, wealth, and residence by country and region for women aged 20-24 years at time of survey. We also calculated annual percentage rates of change (using both short- and longer-term data) for adolescent first births disaggregated by age, family wealth and residence and examined changes in concentration indices (CI). FINDINGS: Overall percentages of adolescent first births vary considerably between countries for all disaggregated age groups. The burden of first birth among adolescents is significant, including in the youngest age group: in some countries over 20% of women gave birth before 16 years of age (e.g. Mali and Niger). Adolescent first births are more common among women who are poorer, and live in rural areas; early adolescent first births before 16 years of age are particularly concentrated in these disadvantaged groups. Progress in reducing adolescent first births has also been particularly poor amongst these vulnerable groups, leading to increasing inequity. CONCLUSIONS: Findings from this study show that adolescent births are concentrated among vulnerable groups where progress is often poorest. Strategies and programmes need to be developed to reduce adolescent pregnancies in marginalised young women in low- and middle-income countries.

Building an enabling environment and responding to resistance to sexuality education programmes: experience from Jharkhand, India.

BACKGROUND: Despite the substantial need for sexuality education and evidence on its effectiveness, implementing organisations continue to grapple with numerous challenges, especially related to community support and resistance. This article aims to analyse the experience of Udaan, a programme that has achieved remarkable success in Jharkhand, India, to answer the following questions: (1) What strategies did Udaan use to create a supportive environment? and (2) What processes did Udaan use to respond to resistance during its implementation? METHODS: We reviewed programme documents and publications, synthesized key themes, identified questions of interest, and conducted interviews with key informants from the Centre for Catalyzing Change's leadership. RESULTS: Community support for Udaan was built by ensuring that the curriculum was responsive to the context, capitalizing on an enabling policy environment, institutionalizing Udaan through government-led implementation, prioritizing careful selection and training of teachers, emphasizing monitoring and evaluation, and engaging with community gatekeepers. Udaan effectively responded to resistance by organizing a formal curriculum review, orienting editors of local newspapers on the programme; responding to questions and concerns; and proactively creating positive visibility. CONCLUSION: The lessons from Udaan provide insight into approaches that can be used to design and sustain sexuality education programmes in complex settings.

Adolescent health programming in India: a rapid review.

BACKGROUND: Recognizing the potential of the country's large youth population and the importance of protecting and supporting its health and well-being, the Government of India committed to strengthening its programmes and systems for adolescents, initially through the Adolescent Reproductive and Sexual Health Strategy (ARSH) launched in 2005 and, subsequently, through the National Adolescent Health Programme (Rashtriya Kishore Swaasthya Karyakram or RKSK) launched in 2014. In 2016, in response to a request from the Government of India, the World Health Organisation undertook a rapid programme review of ARSH and RKSK at the national level and in four states (Haryana, Madhya Pradesh, Maharashtra and Uttarakhand) to identify and document lessons learnt in relation to four domains of the programmes (governance, implementation, monitoring and linkages) that could be used to enhance current and future adolescent health programming in India. METHODOLOGY AND FINDINGS: A rapid programme review methodology was utilised to gain an overview of the successes and challenges of the two adolescent health programmes. A desk review of policy statements, Program Implementation Plans (PIPs) (Program Implementation Plan (PIP) is an annual process of planning, approval and allocation of budgets of various programmes under the National Health Mission (NHM). It is also used for monitoring of physical and financial progress made against the approved activities and budget. ), reports and data provided by the four State governments was conducted alongside 70 semi-structured interviews with health, education and NGO officials at national, state, district and block levels. Data showed that the ARSH Strategy put adolescent health on the agenda for the first time in India, though insufficient human and financial resources were mobilised to ensure maximum impact. Further, the Strategy's focus on clinical service provision in a limited number of health facilities with a complementary focus on promoting community support and adolescent demand for them meant that services were not as easily accessible to adolescents in their communities, and in addition many were not even aware of them. Under RKSK, significant investment has been made in adequate management structures, as well as in community engagement and clinical service delivery at all levels of the health system. Monitoring the quality of service delivery remains a challenge in all four of the states, as does training of counsellors, nodal officers and other implementing partners. Additionally, further thought and action are required to ensure that peer educators are properly trained, supported and retained for the programme. CONCLUSIONS: India's RKSK clearly integrated learning from the earlier ARSH Strategy. The findings of this review present an opportunity for the government and its partners to ensure that future investment in adolescent health programming continues to be framed around lessons learnt across India.

The feasibility and acceptability of collaborative learning in improving health worker performance on adolescent health: findings from implementation research in Moldova.

BACKGROUND: Collaborative learning has been shown to be effective in improving health worker performance, but relatively little is known about the feasibility or acceptability of collaborative learning in youth-friendly health services (YFHS). This paper describes the characteristics, feasibility and acceptability of a collaborative learning approach implemented in YFHS in Moldova as part of a national scaling up process. METHODS: We gathered and analysed data on the number, location, themes, and participants of sessions, as well as benefits and challenges of collaborative learning, using two information sources: 1) formal reports on collaborative learning sessions, and 2) two questionnaires conducted with participants and moderators. RESULTS: Collaborative learning sessions have been implemented in 30 out of 35 YFHS in Moldova. In 2016, 464 collaborative learning sessions were conducted. Sessions were conducted one to three times per month, had a mean of 15 participants and an average duration of two - three hours. 74.3% of participants (n = 6942) were from rural areas and 55.1% were health professionals. The most common topics in 2016 were adolescent health and YFHS (159 of 464 sessions), sexual and reproductive health (103 sessions), and violence (76 sessions). Reported benefits for participants of collaborative learning fell into three categories: 1) improved knowledge on adolescent health / development and use of evidence-based resources; 2) strengthened teamwork and cooperation; and 3) empowerment to provide high quality, youth-friendly care. Moderators identified benefits for the quality, youth-friendliness, and positioning of YFHS as centres of excellence on adolescent health. Challenges included the time and resources required to start and maintain the program, developing a constructive multi-disciplinary learning culture, and ensuring the involvement of stakeholders from outside YFHS. CONCLUSION: This study confirms that collaborative learning within YFHS is feasible and acceptable, and offers benefits to both participants and YFHS. Collaborative learning may be a valuable strategy to improve the quality and youth-friendliness of services. It may also be relevant to key challenges in scaling up YFHS such as increasing utilisation and achieving long-term sustainability. Further research is required to confirm our results in other settings and to examine the effects of collaborative learning at the outcome and impact level.

Correction to: the revised international technical guidance on sexuality education - a powerful tool at an important crossroads for sexuality education.

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How can collective action between government sectors to prevent child marriage be operationalized? Evidence from a post-hoc evaluation of an intervention in Jamui, Bihar and Sawai Madhopur, Rajasthan in India.

BACKGROUND: Although the need for multi-faceted and multi-sectoral approaches to address the multidimensional issue of child marriage is well-acknowledged, there is a dearth of documented experience on the process of implementing and managing such programmes. METHODS: WHO evaluated a district-level, government-led multi-sectoral intervention to address child marriage in Jamui, Bihar and Sawai Madhopur, Rajasthan, implemented by MAMTA Health Institute for Mother and Child (MAMTA). We evaluated the intervention's design, implementation, monitoring, and outputs and identified key challenges and successes. RESULTS: Through actions at the state and district levels, the intervention succeeded in creating a cascade effect to stimulate more concerted action at block and village levels, with tangible intersectoral convergence occurring at the village level. The success factors we identified included an experienced partner NGO that was committed to supporting this effort, context-specific design and implementation, and a flexible and responsive approach. However, despite contributing to informal coordination between various stakeholders, the intervention did not succeed in developing a sustained joint-working mechanism at the district level. Shared ownership for prioritization of child marriage across national- and state-level sectors was not established, due in part to lack of directives transcending ministerial/departmental boundaries. Nevertheless, due to its efforts at the district-level, the intervention was able to enlist leadership from the District Magistrates and Child Marriage Prohibition Officers, in line with their duties outlined in the 2006 Prohibition of Child Marriage Act. The challenges we identified included lack of clear directives and institutional support for collaboration, obstacles to monitoring, administrative challenges, differing perspectives on strategy among district leaders, community resistance, and intervention over-commitment. CONCLUSIONS: The findings of this evaluation reveal the potential of multi-sectoral approaches to prevent and respond to child marriage and provide insight into obstacles that affect multi-sectoral coordination. We point to actions that MAMTA could take to strengthen collaboration on this and other initiatives. We also recommend further documentation and evaluation of projects and programmes in this area.

The revised international technical guidance on sexuality education - a powerful tool at an important crossroads for sexuality education.

In January 2018, UNESCO, together with UNAIDS, UNFPA, UNICEF, UN Women, and the WHO, completed the substantial technical and political process of updating the International Technical Guidance on Sexuality Education, thereby unifying a UN position on rationale, evidence, and guidance on designing and delivering comprehensive sexuality education (CSE). The revised Guidance builds on the original Guidance, with improvements and updates based on new evidence and good practice documented from across the globe. User-surveys and structured consultations with representatives from a wide range of fields and interest-groups informed and guided the revision process. The revised Guidance presents one, commonly agreed definition of CSE; enhances and expands its key concepts, topics and learning objectives; places a strengthened focus on gender and human rights; provides guidance on building support and planning the implementation of CSE programmes; and reflects the contribution of CSE to the realization of multiple Sustainable Development Goals (SDGs). With its unified voice, progressive position, and attention to key implementation challenges, the revised Guidance is a responsive, timely, and critically needed tool to advance towards a tipping point for the large-scale application of quality CSE.

38.8 million additional modern contraceptive users: this, in fact, is "a never-before opportunity to strengthen investment and action on adolescent contraception".

BACKGROUND: We thank Bijlmakers et al. for their interest in our article, "A never-before opportunity to strengthen investment and action on adolescent contraception, and what we must do to make full use of it", and are grateful for the opportunity to respond to their four key assertions. RESPONSE: First, we fully agree that sexual rights are controversial, which we discussed in depth in our original article. However, we reaffirm that there is global consensus on adolescent contraception as evidenced in part by recent data emerging from FP2020 on 38.8 million additional modern contraceptive users, the Global Goods and commitments emanating from the 2017 FP2020 summit, and their translated actions at the country level. Additionally, we clarify WHO's working definitions of sex, sexual health, and sexuality, and introduce WHO's newly released Operational Framework on Sexual Health and its Linkages to Reproductive Health. We welcome and agree with Bijlmakers et al.'s second point, which elaborates on the barrier of restrictive laws and policies. To address this barrier, we describe examples of resources that can help programmes understand the political/social context that drives these laws and policies at national and subnational levels, and identify programmatic gaps and best practices to address them within specific political/social contexts. We also welcome and agree with Bijlmakers et al.'s third point, which reiterates that discomfort around adolescent sexuality is a major barrier for sexuality education. In response, we point to four relevant reviews of CSE policies and their implementation, our original article's description of three programmes that have successfully addressed inadequate teacher skills, and our ongoing work on documenting strategies to build an enabling environment for CSE and deal with resistance. Lastly, we wholeheartedly agree that the harmful policies noted by Bijlmakers et al. are damaging to international efforts to improve adolescent SRH and rights. We argue, though, that these policies alone will not undermine efforts by countless other stakeholders around the world who are working in defence and promotion of adolescents' SRH and rights. CONCLUSION: Despite the many valid obstacles noted by Bijlmakers et al., we truly believe that this is "a never-before opportunity to strengthen investment and action on adolescent contraception".

Trends in adolescent first births in five countries in Latin America and the Caribbean: disaggregated data from demographic and health surveys.

BACKGROUND: Adolescents in the Latin American and Caribbean region continue to experience poor reproductive health outcomes, including high rates of first birth before the age of 20 years. Aggregate national level data fails to identify groups where progress is particularly poor. This paper explores how trends in adolescent births have changed over time in five countries (Bolivia, Colombia, Dominican Republic, Haiti, and Peru) using data disaggregated by adolescent age group, wealth and urban / rural residence. METHODS: The study draws on Demographic and Health Survey data from five countries where three surveys are available since 1990, with the most recent after 2006. It examines trends in adolescent births by wealth status and urban/rural residence. RESULTS: There has been little progress in reducing adolescent first births over the last two decades in these countries. Adolescent first births continue to be more common among the poorest and rural residents, and births among the youngest age-group (< 16 years) are particularly concentrated among these populations. CONCLUSION: Adolescent first births continue to be a major issue in these five countries, including amongst the youngest group (< 16 years), although the contexts in which it is occurring are changing over time. Efforts are needed to expand sexual education and services for adolescents and young people, as well as introduce and enforce legislation to provide effective protection from abuse or exploitation. Greater disaggregation of adolescent fertility data is needed if we are to measure progress towards the attainment of the Sustainable Development Goals to "leave no-one behind".

Assessment of country policies affecting reproductive health for adolescents in the Philippines.

BACKGROUND: Adolescents in the Philippines face many legal, social and political barriers to access sexual and reproductive health (SRH) services, putting them at higher risk of unplanned pregnancy, abortion, sexually transmitted infections and HIV, and other health and development problems. OBJECTIVE: This study aims to evaluate whether current normative documents on SRH in the Philippines are in concurrence with adolescents' human rights principles using the World Health Organization (WHO) Guidance and Recommendations on ensuring human rights in the provision of contraceptive information and services. METHODS: The review focused on policies and normative guidance documents which included the national reproductive health law, its implementing rules and regulations, and the Supreme Court decisions on the law, and documents cited in the government's Adolescent and Youth Health Programme. Also included were documents identified through keyword searches in an online database of the health department. We assessed these documents on their agreement or non-agreement with WHO recommendations, and the presence or absence of adolescent-specific content. RESULTS: Of nine WHO summary recommendations, Philippine normative documents are in agreement with four, namely on acceptability, participation, accountability, and quality, and have adolescent-specific provisions in three. Philippine normative documents are partly in agreement with the remaining five WHO summary recommendations-nondiscrimination, availability, accessibility, informed decision-making, and privacy. Of twenty-four WHO sub-recommendations, Philippine normative documents are in agreement with fifteen, not in agreement with five, and partly in agreement with four. Two possible factors may explain the many documents with conflicting contents: devolution of the Philippine health system, and the deep social and policy divide on sexual and reproductive health. CONCLUSION: Many Philippine-governmental norms and standards are in agreement with adolescents' human rights to contraceptive information and services as recommended by the WHO. However, a significant number are restrictive, reflecting the strong influence of conservative religious beliefs. RECOMMENDATIONS: We recommend: 1) further elaboration of the laws and policies that are fully in agreement with WHO recommendations; 2) a more liberal interpretation of the law to ensure the provision, delivery and access to reproductive health care services, and to promote, protect and fulfill women's reproductive health and rights; and 3) popularization of ethical and human rights norms.

Help and Care Seeking for Sexually Transmitted Infections Among Youth in Low- and Middle-Income Countries.

BACKGROUND: The ability to seek help or medical care for sexually transmitted infections (STIs) is vital for sexually active youth; yet, their needs are often unmet. METHODS: We conducted a qualitative systematic review of studies to assess youth and provider views about the behaviors of young people in help seeking and care seeking for STI services in low- and middle-income countries. We searched peer-reviewed literature for studies published between 2001 and 2014 with a study population of youth (age, 10-24 years) and/or health service providers. Eighteen studies were identified for inclusion from 18 countries. Thematic analyses identified key themes across the studies. RESULTS: The majority of studies included discussion of youth not seeking treatment, resorting to self-treatment, or waiting to access care, suggesting that many youth still do not seek timely care for STIs. Youth desired more information on sexual health and cited barriers related to fear or taboos in obtaining help or information, especially from providers or parents. Many did not recognize symptoms or waited until symptoms worsened. However, many youth were able to identify a number of sources for STI related care including public and private clinics, pharmacies, alternative healers, and nongovernmental organizations. Youth's help seeking and care seeking preferences were frequently influenced by desires for confidentiality, friendliness, and cost. CONCLUSIONS: Youth in low- and middle-income countries experience significant barriers in help seeking for STIs and often do not seek or postpone medical care. Improving uptake may require efforts to address clinic systems, provider attitudes, confidentiality, and cultural norms related to youth sexuality.

Mapping the knowledge and understanding of menarche, menstrual hygiene and menstrual health among adolescent girls in low- and middle-income countries.

BACKGROUND: Menstruation is a natural physiological process that requires proper management. Unlike other normal bodily processes, menstruation is linked with religious and cultural meanings that can affect the perceptions of young girls as well as the ways in which the adults in the communities around them respond to their needs. OBJECTIVES: This review aims to answer the following questions: (1) how knowledgeable are adolescent girls in low- and middle-income countries about menstruation and how prepared are they for reaching menarche, (2) who are their sources of information regarding menstruation, (3) how well do the adults around them respond to their information needs, (4) what negative health and social effects do adolescents experience as a result of menstruation, and (5) how do adolescents respond when they experience these negative effects and what practices do they develop as a result? METHODS: Using a structured search strategy, articles that investigate young girls' preparedness for menarche, knowledge of menstruation and practices surrounding menstrual hygiene in LMIC were identified. A total of 81 studies published in peer-reviewed journals between the years 2000 and 2015 that describe the experiences of adolescent girls from 25 different countries were included. RESULTS: Adolescent girls in LMIC are often uninformed and unprepared for menarche. Information is primarily obtained from mothers and other female family members who are not necessarily well equipped to fill gaps in girls' knowledge. Exclusion and shame lead to misconceptions and unhygienic practices during menstruation. Rather than seek medical consultation, girls tend to miss school, self-medicate and refrain from social interaction. Also problematic is that relatives and teachers are often not prepared to respond to the needs of girls. CONCLUSION: LMIC must recognize that lack of preparation, knowledge and poor practices surrounding menstruation are key impediments not only to girls' education, but also to self-confidence and personal development. In addition to investment in private latrines with clean water for girls in both schools and communities, countries must consider how to improve the provision of knowledge and understanding and how to better respond to the needs of adolescent girls.

The health status of adolescents in Ecuador and the country's response to the need for differentiated healthcare for adolescents.

BACKGROUND: Adolescents face a range of health problems but many barriers block their access to health services, and in particular to sexual and reproductive health services. The objective of this study was to assess the health needs of adolescents in Ecuador and to draw lessons from the ways the country has responded to their need for differentiated care. METHODS: We conducted a literature review and consulted key stakeholders. RESULTS: Adolescents in Ecuador today have a wide range of health care needs, in particular related to sexual and reproductive health. A major concern is the high rates of adolescent pregnancy. A national programme was established in 2007 to offer differentiated health care for adolescents-an effort that featured specially trained staff, enclaved facilities, respect for adolescents' privacy and confidentiality, a friendly atmosphere, and a dedication to establishing trust. It resulted in rapid increases in visits by young persons both for preventive and curative services. In 2011, the government initiated a model for "integrated family and community health care" which led to a disruption of the central support for capacity building and follow-up of adolescent friendly services. CONCLUSION: The Ecuadorian experience has demonstrated the need for institutionalised differentiated care for adolescents who are facing a wide range of health issues.

How do national contraception laws and policies address the contraceptive needs of adolescents in Paraguay?

BACKGROUND: The main objective is to examine how the Paraguayan laws, policies and regulations (hereafter referred to as normative guidance) specifically address adolescents and their contraceptive information and service needs using a human rights analytic framework. It must be noted that this paper examines the adolescent content of national laws, policies and regulations on contraception, not how they were applied. METHODS: The recommendations on "Ensuring human rights in the provision of contraceptive information and services" from the World Health Organization (WHO) were used as an analytic framework to assess current Paraguayan laws, policies and regulations. Three questions were explored: 1) whether the Paraguayan normative guidance relating to each WHO recommendation was present and specifically addressed adolescents 2) whether the normative guidance for each WHO recommendation was present but did not specifically address adolescents, or 3) whether Paraguayan normative guidance relating to each WHO recommendation was absent. This assessment led to the development of an analytic table which was used by the co-authors to generate conclusions and recommendations. RESULTS: The analysis found specific normative guidance for adolescents relating to six out of nine WHO summary recommendations and nine out of the 24 sub-recommendations. The guidance included strategies to overcome contraceptive service barriers and to improve access for displaced populations. Further, it supported gender-sensitive counselling, quality assurance processes, competency-based training, and monitoring and evaluation of programmes. CONCLUSIONS: Paraguay's contraception laws and policies are grounded in human rights principles. However, there are a number of aspects that need to be addressed in order to improve the quality of contraceptive provision and access for adolescents. Our recommendations include improving accessibility of contraceptive information and services, ensuring acceptability, quality, and accountability of contraceptive information and services, and promoting community and adolescent participation in contraceptive programmes and service delivery.

A never-before opportunity to strengthen investment and action on adolescent contraception, and what we must do to make full use of it.

BACKGROUND: Increasingly, the health and rights of adolescents are being recognized and prioritized on the global agenda. This presents us with a "never-before" opportunity to address adolescent contraception. This is timely, as there are enormous numbers of adolescents who are currently unable to obtain and use contraceptives. From research evidence and programmatic experience, it is clear that we need to do things differently to meet their needs/fulfil their rights. MAIN BODY: In this commentary, we call for action in several key areas to address adolescents' persistent inability to obtain and use contraceptives. We must move away from one-size-fits-all approaches, from a 'condoms-only' mind set, from separate services for adolescents, from ignoring the appeal of pharmacies and shops, and from one-off-training to make health workers adolescent friendly. Our efforts to expand access to quality contraceptive services to adolescents must be combined with efforts to build their desire and ability to use them, and to do so consistently. In order for these changes to be made, action must be taken on several levels. This includes the formulation of sound national policies and strategies, robust programme implementation with monitoring, regular programmatic reviews, and implementation research. Further, high-quality collection, analysis, and dissemination of data must underlie all of our efforts. As we move ahead, we must also recognize and draw lessons from positive examples of large scale and sustained programmes in countries that have led the way in increasing contraceptive use by adolescents. CONCLUSION: This unprecedented moment in history gives us a real opportunity to bring about transformational change, particularly when there is so much at stake.