The assistance of the following reviewers is appreciated: José Barzelatto, Jane Bertrand, Patricia Coffey, Jennifer Daves, Sandra de Castro Buffington, Grace Delano, Efua Dorkenoo, Jacqueline Forrest, Lauren Goodsmith, Fran P. Hosken, Jane Hughes, Douglas Kirby, Cate Lane, Asha Mohamud, Leo Morris, Marjorie Muecke, Katherine Neitzel, Susan Newcomer, Douglas J. Nichols, Joy Ogutu-Ohwayo, Phyllis Tilson Piotrow, Malcolm Potts, Susan Rich, Sharon Rudy, Myrna Seidman, Pramilla Senanayake, Judith Senderowitz, Lindsey Stewart, Nahid Toubia, Marijke Velzeber, Cynthia Waszak, Ann Way, Mary Nell Wegner, Ellen Weiss, Marilyn Wilkinson, and Anne Wilson. Some read portions of the manuscript; others, all.

Suggested citation: McCauley, A. P. and Salter, C. Meeting the Needs Of Young Adults. Population Reports, Series J, No. 41. Baltimore, Johns Hopkins School of Public Health, Population Information Program, October 1995.

This report was made possible by support from G/PHN/POP/CMT, Global, US Agency for International Development, under the terms of Grant No. DPE-A-00-90-00014-00. The opinions expressed herein do not necessarily reflect the views of the US Agency for International Development or the Johns Hopkins University.

Ward Rinehart, Project Director, Population Information Program

Anne W. Compton, Deputy Director, Population Information Program, and Chief, POPLINE computerized bibliographic services

Hugh M. Rigby, Associate Director, Population Information Program, and Chief, Media/Materials Clearinghouse

Jose G. Rimon II, Deputy Director, Center for Communication Programs and Project Director, Population Communication Services, developing family planning communication strategies, projects, training, and materials

Population Reports (USPS 063-150) is published four times a year (September, October, November, December) at 111 Market Place, Suite 310, Baltimore, Maryland 21202-4012, USA, by the Population Information Program of the Johns Hopkins University School of Public Health. Periodicals postage paid at Baltimore, Maryland. Postmaster to send address changes to Population Reports, Population Information Program, Johns Hopkins University School of Public Health, 111 Market Place, Suite 310, Baltimore, Maryland 21202-4012, USA.

Population Reports is designed to provide an accurate and authoritative overview of important developments in the population field. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the US Agency for International Development or the Johns Hopkins University.

This report was made possible by support from G/PHN/POP/CMT, Global, US Agency for International Development, under the terms of Grant No. DPE-A-00-90-00014-00. The opinions expressed herein do not necessarily reflect the views of the US Agency for International Development or the Johns Hopkins University.

One-fifth of world population is between ages 10 and 19. Young people today marry later, and more start sex before marriage. Thus they face more risk of unwanted pregnancy and sexually transmitted diseases (STDs). In developing countries 20% to 60% of young women's pregnancies and births are unintended, most coming sooner than planned. Pregnancy puts young women's health at risk, through childbearing or unsafe abortion. Increasingly, early parenthood means lost education as well, with lifelong loss of earnings. Half of those infected with AIDS-causing HIV are under age 25.

The help that young adults need to avoid these risks varies. Some young people are not yet sexually active. They need support and skills to postpone starting sex. Some suffer from sexual abuse. They need protection and care. Some start sex before marriage, and some change sexual partners several times before they marry. They need help to abstain from sex or use condoms to prevent pregnancy and STDs. Many others are married and need much the same health and family planning services as other married couples.

Family Life Education (FLE) is the only widespread program for young adults. These brief programs, held mostly in schools, may encourage abstinence, teach reproductive health and physiology, build skills in problem-solving, decision-making, and life planning, and, in a few cases, discuss contraception. Many now cover HIV/AIDS as well, while other in-school and outreach programs focus exclusively on AIDS prevention. Impact has been modest. FLE programs can increase knowledge and improve attitudes toward healthy behavior. the vest also have delayed sexualinitiation, reduced frequency of sex, or increased contraceptive use somewhat. A few mass-media campaigns, countering the usual depictions of risk-free sex, have used entertainment to encourage responsible behavior.

For family planning services, STD treatment, and prenatal care, most young adults must go to the same clinics available to older people. Only a few hospitals and nongovernmental organizations have set up special clinics or service hours for young people. Many different outreach programs have been tried, often employing young adults to talk with their peers and sometimes to distribute condoms. In a few US schools, clinics offer some reproductive health services along with other care; a few schools provide condoms.

• Win support by working with parents and local leaders,
• Remove policy barriers and change providers' prejudices,
• Enlist young adults in program design and delivery,
• Tell young adults specifically what they need to do,
• Help them rehearse the interpersonal skills to avoid risks,
• Link information and advice with services,
• Offer role models that make safer behavior attractive, and
• Invest enough—for long enough—to make a difference.

Growing Numbers, Diverse Needs

Young people ages 10 to 19 number more than 1 billion, comprise nearly one-fifth of the world population, and are growing in number. Virtually all of this growth is occurring in developing countries, with sub-Saharan Africa leading the way. Although fertility is now falling in many regions of the developing world, the large numbers of children born in the late 1970s and early 1980s are now reaching early adulthood, and some are already having children themselves. Even if these people have fewer children than their parents did, the number of young adults in developing countries will increase by over 20% over the next 15 years (488) (see Table 1). In some developed countries, in contrast, the number of young adults is expected to decrease. In the world as a whole, the number of young adults is expected to grow to more than 1.2 billion in 2010 (488) (see Table 1).

Another way to look at the place of young adults in the world population is through median age—the age that half of the population is below and half is above. The median for the entire world is 25—that is, half of the world's people are under age 25. For developing countries as a whole the median age is 23, whereas for developed countries it is 35 (497). Some developing countries have very young populations. In Latin America, for example, the median age is 20 in Bolivia, 18.7 in El Salvador, and 18.1 in Guatemala. In Africa median ages are even lower—in Nigeria, 17.5 and in Zambia, 15.1—that is, half of the population is under age 15 (172).

• Progression from appearance of secondary sex characteristics (puberty) to sexual and reproductive maturity;
• Development of adult mental processes and adult identity;
• Transition from total socioeconomic dependence to relative independence (544).

During adolescence many young adults experience critical and defining life events—first marriage, first sexual intercourse, and parenthood. Once these life events were considered inseparable, but this no longer holds true for many young people. Age at puberty is falling while age at marriage is rising. The amount of time young people spend between puberty and first marriage has increased. This means that first sexual experience and childbearing may take place for many in a different personal and social context.

During puberty boys and girls go through some of the greatest physical changes of their lives. Their bodies grow faster than during any other period of life except infancy (66, 201, 471, 537). Secondary sex characteristics develop during a hormonally driven growth spurt. These dramatic physical changes generally occur over a 5-year period but may take as little as 18 months or as long as six years (35, 66, 201, 281). A group of 14-year-olds may include boys and girls who still look like children as well as some whose bodies are those of adult men or women (114).

Like biological development, emotional maturity and cognitive development vary greatly among young people of the same age. Although they are beginning to develop the ability to think abstractly and to plan for the future, most young adults reach sexual maturity before they attain emotional or social maturity or economic independence. Many decision-making models have tried to explain young adults' sexual activity and decision-making. None, however, has succeeded in explaining definitively how to influence behavior (258, 290). The fields of sociology and psychology conventionally have viewed adolescent sexuality within the framework of deviant behavior (290). Thus there has been little focus on what is normal, healthy sexual development and behavior for young people. Recent work points out the need to take into account the context of young adults' sexual activity, as well as the social pressures and psychological costs associated with abstaining from sex or engaging in it, and with using or not using contraceptives if sexually active (51, 59, 402, 416).

Clearly, as they enter puberty, boys' and girls' interest in sex increases. At the same time, they experience strong, often conflicting emotions and social pressures as they move away from childhood dependence toward more independent adulthood. Most are unprepared for the situations they face. Nonetheless, because of the health risks of sexual activity, young people's decisions and experiences during their transition to adulthood can affect the rest of their lives.

In fact, median age at first intercourse among women has increased in many countries, particularly in Asia and Latin America (see Table 2). Continued education and delayed marriage may account for some of the increases in Latin America (450). Even where first intercourse tends to occur at a later age than in the past, however, it increasingly occurs before marriage; even where age at first intercourse is rising, age at marriage is rising faster (101, 166).

Premarital sexual activity. As attention focuses on sexual activity among young adults, it often goes unnoticed that in the developing world the majority of young adults, especially young women, are not sexually active and that most sexual activity of young people takes place within marriage (450) (see Figure 1).

Still, in many parts of the world premarital sexual activity is common among young people (see Tables 3 and 4). Its prevalence varies by gender and socioeconomic class. In all societies larger percentages of boys report being sexually active than do girls of the same age, and boys begin sexual activity earlier. For example, in Young Adult Reproductive Health Surveys in Latin America, average age at first intercourse ranged from 13 to 16 years for boys and from 16 to 18 years for girls (337) (see Table 4). In Africa among Kenyan students surveyed in the late 1980s, 48% of males in primary school and 69% of males in secondary school were sexually active, compared with 17% and 27% of girls in primary and secondary schools (255). In Asia, where fewer studies have been conducted, data for Hong Kong, South Korea, and Thailand show that fewer than 10% of unmarried women under age 24 have experienced intercourse (490). In Thailand, however, more than half of boys report having sex by age 18, often with a prostitute (555).

Young men more often report having multiple sexual partners and having intercourse with casual acquaintances. In contrast, young women usually report that they had their first and subsequent sexual relations with a steady boyfriend or fiance (49, 185, 255, 337, 553). Surveys may not always report young people's behavior accurately, however. Young men may exaggerate, reflecting cultural norms that encourage and approve of sexual experimentation for boys, while young women may underreport their sexual activity because of cultural norms that value virginity for girls. As one young woman noted in a Zimbabwe study, "by writing it down, it's like I have to face my own life" (45).

Sexual activity among unmarried youth is increasing in many regions. Over the last 15 years studies in Africa and Latin America have reported increasing percentages of unmarried young adults who are sexually active (15, 156, 283, 336, 337, 349, 350). At least one researcher points out, however, that casual sexual activity is also more common now among adults, both married and unmarried, as well as among youth (292).

In recent decades age at marriage has risen most rapidly in Asia, the Near East, and North Africa. Changes are less striking in sub-Saharan Africa, where age at marriage remains low, and Latin America, where age at marriage rose earlier. Still, even in sub-Saharan Africa the percentage of women married by age 20 has decreased by at least 10 percentage points in 9 of the 21 countries with survey data (see Table 5).

Young men and marriage. The age at which men marry receives less attention than women's age at marriage; little comparable information is available. Although young women who remain single are becoming increasingly common, single young men have long been more common in most parts of the world (554) because in nearly all societies men marry at older ages than women and tend to be at least several years older than their wives. Thus mean age at marriage for men ranges from early to late 20s. Readiness to marry, often traditionally defined for young women by onset of menses or physical development, may be economically defined for men. Where men are expected to demonstrate an ability to support a wife and family, they may not be considered fit for marriage until their mid to late twenties or until they have completed their schooling or an employment training program (440).

Education and age at marriage. As formal education has become more available in developing countries, it has become a factor in delayed marriage. Women who complete at least primary education tend to marry later (54). For example, in every sub-Saharan country, among women ages 20 to 24, the percentage who completed primary school is much higher among those who married after age 20 than among those who married earlier (see Table 5). In Latin America women in Brazil, El Salvador, Guatemala, Mexico, and Paraguay who delayed marriage until after age 20 were two to three times more likely to have completed seven years of school than those who married earlier (450). The association also is strong in Asia and the Near East.

Education remains out of reach for many, particularly for young women, because many developing countries do not provide schooling for all young people, particularly in rural areas and at the secondary level (485). In Kano State in northern Nigeria, for example, 30,000 girls complete primary school each year, but government secondary schools accommodate only one- tenth of them. Although the rate of enrollment of young women in secondary schools more than tripled in Africa and nearly doubled in Asia between 1960 and 1980, the rate of enrollment of boys remains higher (207, 485). Among both sexes urban adolescents are much more likely than rural adolescents to obtain more than six years of education (450).

In most areas women who attain more formal education are more likely to delay childbearing, as well as marriage, than their peers with little or no schooling. Women who begin childbearing early rarely return to school—schools forbid it or childcare responsibilities prevent it (see Chapter 2.5, Social and Economic Consequences of Early Childbearing). Women who leave school early, whatever the reason, usually marry and begin childbearing within a year (39).

Even among young married women, many births are unintended. Often the marriage was precipitated by an unintended pregnancy. For example, in Chile 35% of married women ages 15 to 20 reported their first births as unintended, and 42% of those pregnancies were premaritally conceived (204). Surveys in six African countries report that between one-fourth and one-half of first births to married women ages 15 to 19 were unintended (119, 120, 122, 124, 126, 127). Unintended pregnancies are not rare even where early marriage and childbearing are the norm. For example, in Pakistan 34% of current pregnancies among ever-married young women were unintended, as were 24% in Egypt (see Table 6). In India among ever-married young women, 16% of current pregnancies and births in the preceding four years were unintended (583).

A young woman's pregnancy is more likely to be unintended if she is unmarried. For example, in Kenya the percentage of current pregnancies among women ages 15 to 19 reported to the DHS as mistimed or unwanted was 7% among married women and 74% among unmarried women. In Peru 51% of current pregnancies among young married women were unintended compared with 69% among unmarried women. Other Latin American surveys indicate that 44% to 76% of first pregnancies among young unmarried women are unintended (338). Among never-married women ages 15 to 24, 59% in Costa Rica and 65% in Brazil reported their first pregnancies as unintended. In Jamaica 76% of all first pregnancies were unintended. Unintended pregnancies often ends in abortion, even where abortions are unsafe (54) (see Chapter 2.4, Unintended Pregnancy and Complications of Unsafe Abortion).

The majority of young women in the developing world still have their first child within marriage. Therefore median age at first birth still closely follows median age at marriage (519) (see Tables 2 and 5). In developed countries and parts of Asia and the Near East, where most women marry after age 20, fertility rates among women ages 15 to 19 are low. In countries where most women still marry young, fertility rates among women ages 15 to 19 remain high—reaching close to or over 200 per 1,000 women in such places as Mali and Niger (see Table 7).

As age at marriage rose during the late 1970s and 1980s, fertility rates among women under age 20 declined in many countries (298, 441, 490). The decline was especially dramatic in much of Asia (298, 490). Another indicator of declining fertility among young women is a drop in the percentage of women who gave birth before age 20. In most countries except those in sub-Saharan Africa, smaller percentages of women ages 20 to 24 at the time of a recent survey were mothers before age 20 than in previous generations (see Table 2). In nearly all countries rural women and less educated women are the most likely to have a child by age 20 (490, 579). Rural/urban differences are greatest among the younger women in this age group because urban women ages 15 to 17 are less likely to be married and more likely to be attending school than their rural counterparts (370, 490).

Even as overall fertility rates are declining, births to young women increasingly occur outside marriage in many regions (54, 185). For example, an analysis of DHS data for Burundi, Ghana, Kenya, Liberia, Mali, Togo, and Zimbabwe showed that the percentage of women who gave birth before marriage had increased in all seven countries (166). Premarital childbearing was more common among literate than nonliterate women in all these countries except Zimbabwe. This increase appears to result not from earlier sexual activity but rather from later marriage, since literate women in most of these countries began sexual intercourse at later ages than nonliterate women but also delayed marriage. Thus these young women spend more time exposed to the risk of premarital pregnancy and are more likely to give birth before marriage (166).

Few unmarried young couples use contraception the first time that they have sexual intercourse. Among women ages 15 to 24 surveyed in Latin America and the Caribbean, the levels of contraceptive use at first intercourse ranged from 4% in Quito to 43% in Jamaica. For men 15 to 24, the percentages using contraception at first intercourse ranged from 14% in Quito and Guayaquil to 31% in Mexico City. Use at first intercourse increases with age (338).

Studies in the US and other countries have found that women delay about one year on average between starting sexual activity and first using modern contraceptives (17, 108, 245). Thus premarital sexual activity often results in unintended pregnancy.In Mexico City nearly two-thirds of women ages 18 to 19 with premarital sexual experience reported that they had been pregnant at least once (337). In a Zimbabwe study 46% of premaritally sexually active women ages 11 to 19 had been pregnant (62). Many unplanned pregnancies occur within a year after first sexual intercourse (108, 562). For example, of 200 16-year-olds delivering at Harare Maternity Hospital, Zimbabwe, over one-half had become pregnant within just three months of starting sexual activity (304).

Why don't more young people use contraception if they are having sex? The most common reason that both young men and women give for not using contraception is that they did not expect to have intercourse. The second most common reason is that they did not know about contraception (255, 337, 338). Other reasons for low levels of contraceptive use, however, may be more subtle and even more difficult to address.

Lack of information. Young people often know little or have incorrect information about fertility and contraception. Young men are more likely than women to mention lack of knowledge and are much more likely to say that it is their partner's responsibility to avoid pregnancy (39, 49, 337). Even when young people can name contraceptives, they often do not know where to get them or how to use them (13, 118). Like many adults, many young people have negative attitudes about contraceptives, have heard false rumors, and have received misleading information about contraception. For example, students in Kenya and Nigeria had heard about contraceptives but incorrectly cited dangerous side effects (39).

Lack of access. Even when young adults know about contraceptives, few use them (13, 14, 294). Often this may be because it is more difficult for young adults to obtain contraceptives than it is for older, married couples. Young adults are generally healthy and are not accustomed to visiting health care providers or clinics. They do not know where to go or what to expect. Many are unable to pay for services or for transportation to clinics. Often laws prohibit or limit providing contraceptives, services, or even information to young people (113, 371). Even where access is not restricted by law, some family planning services have policies or prejudices against serving unmarried people. Rude or judgmental staff deter some young people from seeking contraceptives. For example, in a South African study young field workers posing as clients reported that personnel at some clinics resisted their requests for condoms and often provided no instructions on condom use (5).

Lack of decision-making and lack of power. Even when young people have information about contraceptives and access to services, many contextual factors affect their contraceptive practices. The extent of communication between partners, attitudes about social and sexual roles, and the taboo nature of their sexual activity all influence young adults' sexual decision-making (51, 359). For example, in many cultures sex-related issues are rarely discussed, even between spouses. Young unmarried people may be even less likely to discuss contraception. Many young adults see contracep- tion as something only for married adults who want to space their children (430). Some men and some women themselves may disapprove of contraception because they believe it encourages women to promiscuity (49, 359, 515). Furthermore, social attitudes that condemn girls who plan for sex, combined with perceptions that planning for sex spoils romance, may not stop sexual activity but may inhibit contraceptive use. Such attitudes increase girls' vulnerability to sexually transmitted disease (STDs) and pregnancy (49, 515). Also, young women, especially those involved with older partners, may be too embarrassed to discuss or negotiate contraceptive use. Some young people cannot use contraceptives because sexual intercourse is unwanted and forced (see Chapter 2.2, Sexual Violence and Coercion).

Growth, Change, and Risk

As a group, young people are among the healthiest members of their communities. Having survived infancy and early childhood diseases, they have the lowest mortality rates of any age group in both developed and developing countries (185, 540). The risks related to sexual activity and childbearing are among the most serious health risks that young people face. They can jeopardize not only physical health but also long-term emotional, economic, and social well-being. The reproductive health risks that young people face include:

• Sexually transmitted diseases (STDs) including infection with human immunodeficiency virus (HIV), which results in AIDS;
• Sexual violence and coercion, including rape, sexual abuse, and selling sex;
• Too-early pregnancy and childbearing, with elevated risks of injury, illness, and death for both mother and infant; and
• Unintended pregnancy, often leading to unsafe abortion and its complications.

Young adults are particularly vulnerable to STDs because:

• Most know little about STDs, even if they are sexually active (8, 303). Even when they visit family planning clinics, young people may not receive information about STDs. In the South African study the youth volunteers seeking condoms were counseled about AIDS in only 1 of 48 clinic visits (5).
• Even when they know about STDs, young adults use condoms inconsistently (146, 175) (see Chapter 1.7, Young Adults and Contraceptive Use).
• The earlier people become sexually active, the more likely they are to change sexual partners and thus face a greater risk of exposure to STDs.
• STD pathogens can more easily penetrate the cervical mucus of young women than that of older women. The cervix of a young woman is more susceptible to gonorrheal and chlamydial infection as well as to the sexually transmitted human papilloma virus (HPV), which causes cervical cancer (64, 312, 340, 341).
• Young adults may be even more reluctant than adults to seek treatment for STDs because their sexual activity is frowned upon. Also, young people may not know that they have a disease. They may be too embarrassed to go to a clinic, have no access to a clinic, or be unable to afford services. Many go instead to unqualified traditional healers or obtain antibiotics from pharmacies or drug hawkers without proper diagnosis. Improper and especially incomplete treatment of STDs may mask symptoms without completely curing the disease, making it more likely that STDs will be transmitted to others and that complications such as infertility will occur (185).
• Throughout the developing world millions of adolescents live or work on the street, and many sell sex to make a living, increasing their exposure to STDs (38, 60, 163, 225, 403, 404, 420).
• Young people may be forced into sex or otherwise have little power in sexual relationships to negotiate condom use, particularly if their sexual partner is older (324)—a double risk since older men are more likely to be infected (76). In some areas adult men seeking uninfected short-term sex partners increasingly pursue young women (305, 352, 484).

In pregnant women STDs can affect the infant's health as well as the mother's. STDs contribute to premature births and low birth weight (90, 286). Syphilis and genital herpes infection can cause spontaneous abortion, stillbirth, or perinatal death (117). Gonorrhea and chlamydial infection may spread to a baby's eyes during birth, damaging vision if not treated (184, 419).

Sexual abuse in childhood can lead to high-risk behavior later in life, including early onset of consensual sexual activity (63, 72, 137, 463). For example, in Barbados among a probability sample of 407 men and women, sexual abuse during childhood was the single most important determinant of high-risk sexual activity as a young adult (188). In a recent US study of 535 young mothers, 93% of whom were pregnant by age 17, two-thirds reported having been sexually abused as children. The study found that young women who were sexually abused during childhood began intercourse on average a year earlier than their nonabused peers, were more likely to have used drugs and alcohol, and were less likely to have used contraception (63).

Around the world poverty coerces many young people of both sexes into early sexual activity for money. These young people usually have little bargaining power in their sexual relationships and may be unable to protect themselves from pregnancy and STDs. In Thailand an estimated 800,000 girls under age 20 earn money as prostitutes. In fact, it has become to some an accepted way for young girls to earn money for marriage (225). In parts of Africa some young girls engage in sex with "sugar daddies"—older men who pay school fees or buy clothes and other necessities for them (305, 352, 484).

There are an estimated 40 million street children in Latin America, 25 to 30 million in Asia, and 10 million in Africa, driven from their homes by poverty, abuse, abandonment, or orphaned by AIDS (60, 163). Many street youth are males (38, 404). In Brazil alone some 7 million children and youth live on city streets. Another 10 million work full-time on the streets, many selling sex (60, 225, 403). One Brazilian study found that one-third of women who lived or worked on the street and had had sex said that sex had been forced on them (507). Because street kids are shunned by the community and often have been turned away from public services, these young people tend to be distrustful of the health system and are especially hard to reach with reproductive health services.

Women's Age	Maternal Deaths/1,000 Births	Average Birth Weight	Premature Births (%)	Perinatal Deaths/1,000 Births
12 to 19	3.80	1.9 kg	20	29.6
20 to 30	2.55	2.5 kg	16	18.4
31+	1.07	2.65 kg	11	4.3
Source: Mishra & Dawn 1986 (329)

The life-threatening complications of pregnancy that women under age 20 face are the same risks that all other woman face: hemorrhage, sepsis, pregnancy-induced hypertension including preeclampsia and eclampsia, obstructed labor caused by cephalopelvic disproportion, complications of unsafe abortion, and iron-deficiency anemia. Young women face greater risks than older women of hypertension, cephalopelvic disproportion, iron-deficiency anemia, and unsafe abortion (7, 275, 281, 293, 330, 432, 451). These risks are higher for young women not only because of their age but also because births to younger women often are first births, which are riskier than second, third, or fourth births. Socioeconomic factors, including poverty, malnutrition, lack of education, and lack of access to prenatal care or emergency obstetrical care can further increase a young woman's risk of pregnancy-related complications (19, 212, 428). Among the young, as with older women, risks are greatest for poor women, who are most malnourished and have the least opportunity for prenatal care.

Untreated pregnancy-induced hypertension can cause heart failure or stroke and result in the death of both the mother and infant. Hypertension occurs most often among women having their first child and accounts for a large proportion of maternal deaths in women under age 20 (293, 451).

Cephalopelvic disproportion—meaning that the woman's pelvic opening is too small to allow the infant's head to pass through during delivery—can slow or prevent vaginal delivery. In some cases, if cesarean section cannot be performed, the woman's uterus ruptures, and both mother and infant die. Cephalopelvic disproportion is common in very young women whose pelvic growth is not complete and women of any age who are of small stature because childhood malnutrition stunted their growth (281, 330). The prolonged labor associated with cephalopelvic disproportion increases the risk of fistula—a tear between the vagina and the urinary tract or rectum, which allows urine or feces to leak out through the vagina. In many African countries fistula injuries occur most commonly in women under age 20, and obstructed labor causes most of these injuries (394, 490, 538). Fistula is reparable through surgery. For women who cannot get proper care, however, it often leads to lifelong disability and ostracism.

In many regions iron-deficiency anemia is a factor in almost all maternal deaths. An anemic woman is five times more likely to die of pregnancy-related causes than a woman who is not anemic (510). Anemic women are less able to resist infection and less able to survive hemorrhage or other complications of labor and delivery. Anemia also contributes to premature delivery and low birth weight (47).

Iron-deficiency anemia is particularly common among pregnant women, and young pregnant women are more likely than older women to be anemic, even in developed countries. For example, an analysis of eight US clinical studies found that pregnant women under age 20 were twice as likely to be anemic as older women (432). A US study of pregnant teenagers attending a prenatal clinic found that 70% lacked enough iron (47). Normal menstrual bleeding, a diet lacking absorbable iron, and malaria cause most anemia in pregnant women. To avoid anemia during adolescence, young people need twice as much iron as adults of the same weight (66, 537).

Lack of prenatal care. Adequate prenatal care can reduce pregnancy-related mortality and complications, especially among very young women (19, 161, 314, 353, 432). In developing countries, however, many women get no prenatal care (417), and young women are least likely to get care, even in developed countries (248, 460). When they do so, it is often late in pregnancy (293). Even where available, prenatal care services may not be used because child-bearing is considered normal for young women and thus is seen to require no medical attention.

Higher risks for infants. Pregnancy before age 20 also poses risk to the young woman's infant. Data from Demographic and Health Surveys (DHS) and other studies show that mortality and morbidity rates are higher among infants born to young mothers (468). Young mothers, especially those under age 15, have higher rates of premature labor, spontaneous abortion, stillbirth, and low birth weight infants (161, 314, 329, 353, 394, 428, 432, 434, 464, 493, 538). For the infant who survives, the higher risk of death persists throughout early childhood (32, 56, 113, 314, 329, 432, 464, 468, 490, 493).

Women under age 20 account for more than their share of abortion complication cases and related deaths reported by developing-country hospitals (207, 394, 410, 473). For example, in Latin American studies 14% to almost 40% of women hospitalized for abortion complications during the 1980s were under age 20 (34, 397). In African studies the percentages were even higher, with women under age 20 accounting for as much as 68% of abortion complications treated at selected hospitals (9, 11, 78, 328). Young unmarried women are more likely than older women to seek abortions from untrained providers and to attempt dangerous, late, and often self-induced abortions (54, 147, 220, 394, 538). Also, because of fear, shame, lack of access, or lack of money, young women are more likely to delay seeking medical care if complications arise after abortion (566).

The health risks of unsafe abortion include sepsis (infection) caused by unsanitary instruments or incomplete abortion, hemorrhage, injuries to genital organs (such as cervical laceration and uterine perforation), and toxic reactions to chemicals or drugs used to induce abortion. Severe but nonfatal complications include infertility and vesico-vaginal fistula (241, 282).

• Obtain less education,
• Have fewer job possibilities and lower income,
• Be divorced or separated from her partner (405, 450), and
• Live in poverty.

Many societies, however, condemn unmarried young women who bear children, regarding their emotional or economic suffering as fitting (366). Thus many families prefer to marry off daughters while still young to avoid the risk that a girl will become pregnant before marriage. In societies where divorce is unacceptable, women forced to marry young because of pregnancy may be expected to endure violence or neglect without recourse (359). If a young woman becomes pregnant before marriage, she may be driven from her home or sent away by her parents. When a young woman finds the prospect of social and family sanctions too much to bear, she may run away or attempt suicide (293). Around the world a disproportionate number of suicides are committed by pregnant adolescents (89, 162).

Educational consequences. Young women who begin childbearing early complete less schooling than women who delay childbearing until their 20s (272, 273, 406). In developing countries schoolgirls who become pregnant rarely return to school, whether they are married or not (178). In Kenya alone nearly 10,000 are forced to leave school every year because they are pregnant (154). In Kenya and other countries schools routinely expel young women who become pregnant, while action is rarely taken against male students who cause pregnancy. Many young women risk unsafe abortion to avoid leaving school. Even though some countries are modifying policies of expelling pregnant schoolgirls, most young women cannot return to school after giving birth because they must care for the child (178). Some outreach programs and women's centers around the world help young mothers combine motherhood and school (232, 385, 409). For example, the Jamaican Women's Center Program reported that 64% of its participants returned to school, compared with 15% of nonparticipants (232). Unfortunately, such programs are few.

Economic consequences. Because of social and economic changes going on throughout the developing world, the economic consequences of early parenthood often are more extreme and longer-lasting today than in the past. Increasingly, young women as well as young men find that they need wage- paying jobs, and they need education to get those jobs. Where young women's opportunities for economic advancement are scarce, as in rural areas of many developing countries, early childbearing may not worsen a young woman's already poor economic prospects. Most urban areas, however, offer a young woman some opportunity for a paying job if she has the skills. Thus in cities a woman who has a child before age 20 may suffer the same economic setbacks as her counterpart in developed countries, largely because her education has been cut short (209, 530). In the relationship between poverty and early parenthood, causality appears to run in both directions (582). The poorest women are the most likely to have children while young, and those having children while young also are likely to remain in poverty (23, 43, 179, 273). In the extreme, many young unmarried mothers are forced to sell sex to support themselves and their infants (516).

Most developing countries do little legally to mandate that the father provide financial support for the mother and infant. Even where support is mandated, as in the US, enforcement may be erratic or ineffective. In some societies unmarried young women who give birth receive economic support from the child's father or his family, especially when the father officially acknowledges paternity (373). This support may help keep a young unmarried mother out of poverty, as a Chilean study suggests (79), but support may be irregular or stop after several years (530).

Consequences for boys. Even though early fatherhood may enhance a young man's social status in some societies, boys who become fathers early also may lose opportunities for education or future economic advancement. Those who marry may leave school to support their new families (440). Researchers have only recently begun examining the impact of adolescent fatherhood on young men in developed countries (42, 277, 369, 453). Little information is available from developing countries.

Social costs. Especially where the family fails to provide economic sustenance for the young parents and their child, early childbearing imposes a cost on society. These costs, rarely quantified, include the lost productivity of undereducated and impoverished young people who become parents too soon, especially single mothers (82), as well as government expenditures. In the US, public welfare expenditures for women who first give birth before age 20 amount to $10 billion each year (77). Although social welfare costs may not be so large in most other countries, costs of health care for young mothers and their children can be a considerable part of health and social welfare expenditures.

Overview of Programs
                                   for Young Adults

Reproductive health programs are increasingly aware of young adults' needs, but most efforts so far have been small and isolated. Family planning programs began and continue with a focus on married women, a large group with an obvious need for reproductive health care. In contrast, efforts to meet young people's needs are still struggling to find approaches that are both effective and politically acceptable. In the 1960s development planners started the first school programs to inform students about rapid population growth. Under the name Family Life Education (FLE), those programs have evolved to address life planning. In the 1980s educators began AIDS prevention programs. Reproductive health services for youth, whether in schools or elsewhere, remain small, however, because they are controversial and therefore difficult to establish and fund. Efforts to reduce the risks of sex for young people have been most successful in Northern Europe, where extensive programs reflect community support for addressing young adults' needs.

In the 1960s concern over rapid population growth led to population education programs in the schools. These curricula focused on the relationships among population growth, the nation, and the individual. Students learned that their choices about family size shaped their own futures and the future of the nation as well. Development planners assumed that this information would motivate young people to limit the size of their own families (74). The first national programs, in India, the Philippines, and South Korea in the late 1960s and early 1970s, did not cover sexuality or contraception. Some early programs in the 1970s in Latin America did discuss human reproductive physiology, while those in Africa emphasized economic development and environmental issues (74, 424, 495). Then, as now, each nation designed its own school curricula and decided how the program would be implemented.

Now, most programs, under the broad heading Family Life Education, focus on helping young people plan productive lives. The course materials discuss population growth but also cover topics such as personal health and nutrition, life planning, decision-making, and respect for both women and men (446). Some programs also include discussion of reproductive physiology, sexuality, and contraception. Although some nations such as India and Kenya have uniform programs with curricula designed by ministries of education, others allow regions, school districts, or even individual schools or teachers to choose the topics taught (446). In many places FLE programs are controversial, and, even where the government endorses them, they are not always implemented, often because teachers object to the material or have not been trained (320). Most FLE programs have not been evaluated or even described in detail, and so little is known about their impact.

In the late 1980s many nations and school systems saw FLE in schools as a fast and efficient way to inform the public about AIDS. Existing programs added information about AIDS (495). In some countries, such as Malawi and Peru, new FLE programs were started to cover AIDS (81, 234).

The United Nations Population Fund (UNFPA) and the United Nations Educational, Scientific, and Cultural Organization (UNESCO) have funded most FLE programs in developing countries. In 1995 UNFPA was supporting national or regional school programs in 79 countries worldwide. In some places UNFPA also assists FLE outreach programs run by nongovernmental organizations and youth groups such as the Boy Scouts and Girl Guides (447).

Northern European countries stress sexual responsibility for those who are sexually active and enable them to obtain contraceptive services and supplies. They have not reduced sexual activity among young people (159, 237, 238). Each of these countries has developed its own approach, but all have both educational programs and accessible services. For example, Denmark, Finland, and Sweden have compulsory sexual education in schools, while the government of the Netherlands sponsors outreach efforts such as informational television programs and a magazine sent to all young people (164, 237, 295). This does not mean that the government has replaced parents in educating their children. In the Netherlands 80% of 100,000 young people surveyed said that they had learned about sexuality from their parents (17, 435).

Most northern European countries provide free, convenient medical services to all residents including young adults. Sweden established special youth clinics in the 1970s, but now young people use a combination of neighborhood primary health clinics, condom distribution programs, and special youth services (237, 511). The Netherlands also has a network of youth clinics (237, 374). In Denmark students ages 14 and older go on organized visits to family planning clinics to learn about contraceptive methods. At 16, young people receive their own health insurance cards, enabling them to choose their own doctors and to obtain free and confidential services (164).

This openness with information and services does not, however, mean that young people in these countries begin having sexual intercourse at younger ages than in other countries. Danish youth, for example, receive more information about sexuality and contraception than US youth, yet in both Denmark and the US the average age at first intercourse is about 17 years (17, 164, 525). The experience of northern Europe suggests that an effective national strategy to lower pregnancy rates among young women includes enabling young people to take responsibility for their own reproductive health and giving them accurate information and helpful guidance (159, 238).

Such an approach need not be expensive. European programs have succeeded at least in part by informing young people through school programs and by providing access to the same subsidized services that adults use. Most importantly, social norms support responsible sexual behavior (295). Young people are not ashamed to ask questions and seek services, and many adults are not embarrassed to teach their children how to protect their health if they are sexually active.

Evaluation Findings

Formal evaluations find that most programs for young adults can increase their knowledge about reproductive health and foster positive attitudes towards healthy behavior (see Table 10). To go further and reduce unsafe behavior, programs need not only to provide accurate information but also to tell young people how they can protect themselves, help them identify and resist pressures to be sexually active, and help them rehearse negotiating to avoid sex or at least assure safer sexual behavior. Contrary to some critics' fears, these programs do not increase sexual activity among young people. These findings come mainly from large, well-funded programs in US schools. These programs are not necessarily those with the best chance of success, however. They are often located in schools whose students are most likely to engage in early and frequent sexual intercourse.

The evidence says otherwise, however. According to a review commissioned by the World Health Organization, there is no support for the contention that sex education encourages sexual experimentation or increased activity (181). After analyzing more than 1,000 reports on sex education programs worldwide, the authors concluded that sex education courses did not lead to earlier sexual intercourse, and in some cases they delayed it.

Delay in initial sexual intercourse. School programs can give young people the skills they need to postpone having sex for the first time (36, 181). Among US secondary-school students who took the 15-hour course called "Reducing the Risk," only 29% of the treatment group had initiated intercourse 18 months after completing the course compared with 38% of the comparison group of students who had not taken the course (260) (see Table 10). The course helped students practice saying "no" to unwanted sex (see Program design and methods in Chapter 4.2).

A second US program, "Postponing Sexual Involvement," delayed intercourse among 13- to 14-year-old boys and girls (216) (see Table 10). After the program started in 1983, students were questioned about their needs. Some 84% of girls wanted to know "how to say 'no' without hurting the other person's feelings" (216). The program was adapted to meet this need, and now older teens teach a curriculum that helps young people resist peer pressure and provides information on human sexuality and contraception. Studies of other sexuality information programs, in Mexico and the US, report that graduates do not start sex any earlier than other young people (115, 264, 378).

No increase in sexual intercourse. In Australia, Switzerland, Thailand, and the US, evaluations have found that programs to inform sexually active young adults about contraceptives did not increase coital frequency or number of sexualpartners (181, 196) (see Table 10). Also, providing reproductive health services in or near schools did not increase sexual activity and in fact delayed sexual initiation in some cases (264, 266, 564).

Increase in the use of contraceptives. Most programs have not increased use of contraceptives, but a few have been able to do so. A Swiss study found that regular condom use among young people increased after an AIDS information campaign using school presentations, telephone hotlines, a computer network, and exhibits at village festivals, but only after the first time the young people had intercourse with a new partner. Among young women, regular users of condoms increased from 71% to 77%, and among young men, from 38% to 54% (196). Several FLE programs have found that, if they reached young people before they first had sex, they increased contraceptive use once young adults did start sex. For example, among 1,632 sexually inexperienced youth in Mexico, 82% of girls and 55% of boys who took an FLE course used contraceptives when they began to have sexual intercourse compared with 75% of girls and 32% of boys who did not take the course (379). In this Mexican study and two US studies, however, FLE did not affect contraceptive use among students who were already sexually active when they took the course (215, 260, 378, 379).

• Focused narrowly on reducing sexual risk-taking;
• Were based on a theory of behavior change;
• Were at least 14 hours long or involved intense small-group exercises;
• Used teaching methods that involved the students;
• Provided basic, accurate information about the risks of unprotected intercourse and ways to protect oneself;
• Addressed social pressure to be sexually active;
• Reinforced clear values and presented messages that strengthened individual values and group norms against unprotected sex;
• Modeled and practiced communication and negotiation skills; and
• Trained the individuals who conducted the program.

Based on a theory of behavior change. The four programs with a positive impact on sexual or contraceptive behavior were based on social learning theory, social influence theories, or theories of reasoned action. Social learning theory posits that people learn behavior by observing and imitating others as well as through formal education. Social influence theories suggest that, because behavior is shaped by group and individual norms and attitudes, it is helpful for people to identify social pressures and then to develop individual and group values that support healthy and appropriate behavior. Theories of reasoned action assert that people's intention to adapt new behavior reflects their own beliefs and expectations and perceived social norms.

Rather than teach young people to "just say no," programs based on these theories assume that the decision to have sex may be an individual's choice but is influenced by the social setting. Although young people may seem to be choosing sex, some may in fact have sex because, for example, they are afraid to refuse, crave affection, fear hurting their partners' feelings, or need or want the money or gifts that they receive. Thus the successful US school programs focus on recognizing social influences, changing individual values and group norms, and building social skills (258).

Program content. The four programs all gave students the basic information they needed about sexual health risks and also told them exactly how to protect themselves (258). In a Mexican study as well, students who took FLE courses that presented accurate, specific information about contraceptives and pregnancy prevention were more likely to use contraceptives than those who took courses that avoided these often-controversial subjects. Among students whose courses covered ways of preventing pregnancy, the percentage of sexually active youth who used contraceptives increased from 20% to 70%. Among sexually active students who received information on where to obtain contraceptives, the percentage of students who used contraceptives rose from 42% to 81%. Students whose courses did not cover these topics reported less or no increase in contraceptive use (378). The content of the four US programs that changed behavior also focused on the social pressure on students to be sexually active and on age-appropriate values and skills to help them remain abstinent or to negotiate safer sex.

Program design and methods. The four programs used a variety of methods to involve students and help them practice new responses to situations that might lead to unsafe sex (258). In the "Reducing the Risk" program, students discussed ways that they might be pressured into having intercourse and learned techniques for handling or avoiding such situations. Then, through role-playing exercises they practiced these interpersonal skills (44).

Other programs also have found that involving students actively in learning has greater influence on their behavior than simply lecturing (262, 448). For example, research in Zimbabwe compared a lecture on AIDS with a skills-building session that involved putting a condom on a model and practicing negotiation of condom use. Four months later the young people who took the skills-building course knew more about condoms and their correct use, perceived fewer barriers to action, and had had fewer sexual partners than those who had only heard the lecture (528).

The US programs that led to safer behavior were all at least 14 hours long or involved students in small-group exercises (258). So far, few studies have compared teaching strategies to determine which are most effective at changing behavior.

Emphasis on training. The four US programs with effective curricula provided six hours to three days of training for the teachers and peer educators who taught the courses (258). Here again, there has been little research evaluating training methods and curricula. There are many examples, however, of programs that have failed because teacher training was neglected. In developing-country programs teachers have resisted teaching such courses because they object to the material, feel pressed for time, or feel unprepared to teach the subject (97, 320, 344, 363, 425). Thus, some teacher training courses, such as one in Ethiopia, deal first with improving the attitudes of the teachers who do not want to teach family life material (198).

Unless school FLE programs focus their coverage on specific information and skills, adopt an interactive or skills-building approach to teaching, and train personnel, they are unlikely to change behavior in and of themselves. Increasing knowledge and improving attitudes may be the most reasonable goals for FLE school programs that use only lectures. After all, as Kirby points out, other academic programs that rely on classroom presentations use examination scores, not reports of student behavior outside school, to measure their effectiveness (259). Research has been too limited, however, to assure that all the successful approaches have been identified. The crucial characteristics that distinguish successful programs need to be further identified, refined, adapted to other places and cultures, and tested again. At the same time, program planners and advocates can learn important lessons from others' experience (see sidebar, Lessons Learned: Ten Tips for Serving Young Adults).

Further research is needed into all types of youth programs and in a variety of countries—particularly research that will contribute more to improving program design and implementation. For instance, programs could benefit from learning more about (1) which elements of the program are most important to reaching program goals; (2) how much participation or exposure is needed to increase knowledge, change attitudes, and influence behavior; (3) costs and cost-effectiveness; and (4) efficacy of different training and teaching methods. Of course, evaluation methods and indicators must suit the type and size of program. For example, evaluation of mass-media communication can measure recall, understanding and approval of messages, perception that others approve, intention to act, action, and advocacy with others (575).

Several recent initiatives seek to identify the most effective approaches to encouraging safer behavior among young people in developing countries. A working group on reproductive health services for young adults, representing a number of agencies working in this area, many with support from the United States Agency for International Development (USAID), has developed a manual of indicators to be used in evaluating youth programs (459). In 1996 the World Health Organization will issue a technical paper on accelerating health programs for young adults. The report will identify successful interventions and discuss strategies, including ways of mobilizing resources for expanding small or pilot programs (551). Also in 1996 Pathfinder International, in collaboration with the Futures Group and Tulane University, will begin a 5-year project supported by USAID to promote understanding of the health needs of young people and to identify program strategies that increase the practice of abstinence and other safe sexual behavior.

Winning Support from the
        Community and Young Adults

For reproductive health programs addressed to young adults, two challenges loom especially large. They must persuade the community to support their activities, and they must convince their intended clients that protecting their health is important. Many health programs face these two challenges, but programs for young adults often find these challenges especially difficult and crucial.

Community support can be hard to win. Sex education and services for young adults are almost always controversial. Health professionals who want to meet the reproductive health needs of young adults must begin by helping the community understand and agree on the need for a program and on its goals and approaches. Often that entails persuading adults that young people should be treated in a caring, rather than authoritarian, manner.

In the long run, health and educational programs for young people can accomplish little unless communities acknowledge that young adults need special help and guidance if they are to become sexually responsible adults. Communities do not help young people by ignoring their need to understand sexual relations, by failing to protect them from abuse, or by abandoning them if they become pregnant or ill. Communities need to develop a positive policy toward guiding young people and then join in efforts to meet their various needs.

Young adults themselves want to learn about sex, sexual relationships, and reproductive health. They do not always appreciate the risks that they face, however, and they often do not protect themselves. Thus the second challenge for programs is to provide information and services in ways that persuade and enable young adults to conduct their sexual lives in a healthy manner. To help young people do this, a variety of approaches must be designed, appropriate to youth of differing ages, gender, sexual orientation, and sexual experience. Programs must be able to reach varying clienteles with convincing messages and with services that are useful, accessible, and comfortable to use.

Thus reproductive health education and services for young adults attract public attention and generate public controversy. Religious leaders, politicians, educators, or parents may object to such programs. This opposition sometimes takes health professionals by surprise. Health professionals see such programs as intended to improve and protect health—a goal that they assume everyone shares. Health is not the first concern of many program opponents, however. They often see sexual behavior as a moral issue or as an issue of parental authority. They may argue that only parents or religious leaders should teach young people about sex, and they may consider health or education professionals to be inappropriate sources of information and guidance. Indeed, most adults agree that parents should inform their children about sex and guide their behavior. Also, in places as diverse as Kenya, Mexico, and Zaire, community leaders, too, have been respected sources of sexual education for generations (31, 40, 252, 256, 279). By comparison, organized programs that would share this responsibility are a new idea.

Therefore winning the support of the community—important to any social program—is both vital and challenging for reproductive health programs for young adults. Winning community support requires helping parents and leaders to understand health issues inherent in young adults' sexual behavior, to recognize the need for program action, to agree on solutions, and to work with and trust health professionals to carry them out (572).

Working with community leaders. Programs have won support from community and religious leaders by forming early alliances with sympathetic leaders, by showing that young adults' health needs are important, and by involving community leaders in program design and implementation. In Ethiopia, Kenya, and the Philippines, for example, ongoing programs inform adults in the community about the health needs of youth (200, 351, 449). In Mexico a program enlisted community leaders to serve as outreach workers in poor communities, thus giving these leaders direct contact with young adults' reproductive health concerns (219, 408). In Jamaica community leaders helped design health services and then joined in program activities and monitoring. As a result, the program was accepted in an area where community dissension had undermined previous efforts (503).

Health care professionals are community leaders, too, and deserve special attention. The Johns Hopkins Program for International Education in Reproductive Health (JHPIEGO) has worked with physicians in Latin America and elsewhere to set medical quality-of-care standards and build support for services for young adults (116).

Working with parents. One good way to work with parents is to give them the help and support that they want in guiding their children. Parents and young people often say that they want to talk together about sex, but most fail to do so (88, 174, 199, 229, 230, 249, 279, 343, 348, 444) (see sidebar, Where Do Young People Learn About Sex). Many parents delay talking to their children, perhaps because they feel ill-informed or embarrassed. Some fail to acknowledge that uncertainty is normal in learning to make sexual decisions and alienate their children by demanding rigid obedience. Others present sexuality in a negative way that their children do not find credible (31, 130, 174, 279, 392, 496, 527).

Several programs have helped parents communicate with their adolescent children. One US program made parents more aware of the social pressures on their children to be sexually active. Then parents rehearsed ways to help their children resist these pressures (68). In the Philippines the Foundation for Adolescent Development (FAD) produced a video to show parents that their communication with their children shapes the way that their children communicate with others (449). In a US school program, teachers gave students the assignment to talk to their parents about sexual abstinence and contraception. This approach bypassed parents' reluctance to start such conversations (260). As part of a larger effort to meet the needs of young adults, since 1986 the Zimbabwe National Family Planning Council (ZNFPC) has offered a Parent Education Program to help parents educate their adolescent children about human sexuality and reproductive health (594). In Tanzania community educators offer a manual to help parents discuss sexuality with their children (496).

Young adults endorse informing and helping parents. In research in Ghana and the US, young adults asked for programs to increase parental awareness of the pressures in their children's lives (102, 343).

Programs that value parents' concerns and seek their support can involve them at every stage of the project. Health programs for youth have surveyed parental opinions and attitudes before designing programs, have pre-tested material with parents, have set up advisory groups to elicit parents' advice on an ongoing basis, and have asked parents to evaluate the program (31, 325).

Thus, despite their interest in sex and intimate relationships, young adults can be difficult for programs to reach. Society's confusing messages make young adults wary. They quickly perceive and reject messages about sexual behavior that are hypocritical, and they distrust adults who try to conceal the positive aspects of sexuality. They have begun to learn about sex from experiment and experience rather than by listening to their elders. They are willing to take risks in order to test out their ability to make choices, and they often try or adopt unhealthy behavior such as drinking, smoking, or unsafe sex. Furthermore, they are usually healthy and may not see sex as posing any health problems. Therefore, listening to young adults to understand their points of view and learning how to talk with them are especially crucial to programs and providers that seek to serve these clients.

Determine unmet needs. A first step in attracting young people is working with them to find out what they need. Their unmet needs often differ, even among young adults of similar age and the same gender (see Chapter 1, Growing Numbers, Diverse Needs). For example, many young adults need support in delaying sexual intercourse. Others are only sporadically sexually active and need to know how to protect themselves from unwanted pregnancy and disease. Others are unmarried and having sex regularly, in some cases with members of their own sex, and need comprehensive reproductive health services. Some are sexually abused or forced into sex and need treatment and protection. Many young women are married and need much the same health services that older married women need. Some are having children and need maternal health services to bear children safely and care for them.

One good way to find out young adults' needs is to ask them. Thus surveys, focus-group discussions, and in-depth interviews are standard starting points for designing youth programs, as they should be for all service programs (see sidebar, Do Adults and Youth Have Differing Views?). Still more useful can be involving young adults themselves in the program—for example, developing messages, reviewing program materials, evaluating program impact, working as peer educators or in other jobs, serving on program planning or advisory boards, and working in advocacy campaigns. Their insights help to ensure that the program is appealing. Also, their participation may interest other young people in the program and help to legitimate it in their eyes.

African youth organizations working with the World Health Organization (WHO) have used an innovative narrative method to gather information about young adults' lives and then to plan programs (549). In 11 countries young leaders, meeting in workshops, developed stories about a young man and woman who notice each other, meet, become friendly, and face decisions about their relationship. Through role-playing, the participants determined how these events would take place in their communities. Also, they suggested various paths that the story could take at crucial points. For example, if the girl discovers that she is pregnant, she might tell her mother, seek an abortion, or run away with her boyfriend. Later, some 13,000 young people in the 11 countries reviewed these stories. They chose the paths in the narrative that they thought most typical (548). The young adults involved in this research used the completed narratives to develop messages, training materials, and role-playing exercises (549).

Design communication that speaks to young people. Programs for young adults find themselves pulling against a tide of misinformation and unhealthy attitudes, trying to present balanced, believable messages about what it means to be a sexual human being. Accomplishing this requires offering young adults informationthat they need and want—about how sexuality affects the course of their lives and their relationships with others. Because learning this is a gradual process, programs must make their messages appropriate to the various stages of young adults' lives. A key challenge for programs is audience segmentation—reaching young people who have widely differing needs with the specific messages and services appropriate to each. Here again, programs need to work with young people to design messages that are appealing, meet their information needs, and encourage healthy behavior. Adults and young people may see issues very differently, but, by collaborating, they may be able to create messages and materials that adults find acceptable and young people find relevant.

To reach young people, an appealing message must be combined with an appealing format. Because young people enjoy music, videos, films, dramas, and other entertainment media, these can be good formats for messages about reproductive health. Young adults already rely on the mass media as sources of information about sexual relationships (see sidebar, Where Do Young People Learn About Sex), but much of what they see and hear is incorrect, incomplete, misleading, or misguided and depicts irresponsible behavior as exciting and even rewarding. Now some health programs have begun using the entertainment media and entertaining formats to reach young adults with messages about reproductive health. Some programs use broadcast formats, such as popular songs on radio or music videos on television, which can reach all young adults. Others address the needs of specific groups of young adults with videos, dramas, comics, telephone hotlines, and other media materials (109, 235, 270, 368, 414, 480) (see supplement, "Reaching Young Adults Through Entertainment").

Reach out to young people wherever they are. Even more so than adults, young people may be embarrassed to come to clinics or may not know how to get medical care of any kind. Programs may reach more young people if they set up clinics or employ outreach workers in schools, factories, sports facilities, or on street corners. Street Kids International, for example, uses video vans to reach homeless young people living on the streets in cities such as Colombo, Nairobi, Manila, New York, Rio de Janeiro, and Toronto (107). In Romania a program opened a clinic at a popular beach resort during the summer holiday season (509).

Peer educators can reach young adults wherever they gather. For example, the Christian Health Association of Kenya trains young people as "adulthood teachers," who use discussions, lectures, films, school visits, and club activities to reach young people (313). In Mexico young workers circulate at schools, factories, military bases, bars, or sports events—anywhere that they can talk with other young people (309, 408). Peer workers often provide condoms, a method that does not require a clinic visit.

Many communication media, of course, also can reach young people wherever they are. Soap operas, videos, television spots, billboards at sports events, telephone hotlines, songs, tee shirts, and theater performances all have reached young people with health messages.

Link communication efforts with health services. Programs often succeed in informing young adults about reproductive health, but young people cannot act on this information if they do not know where to get more information or services (see sidebar, Contraceptive Choices for Sexually Active Young Adults). Young people need various resources. Sexually inactive young people may want to know where they can get guidance or protection if they fear unwanted sexual advances. Sexually active young people and pregnant girls need health services. Information about using community health and social resources is a key but often neglected part of FLE programs.

Youth programs can keep a directory of services for referrals, but they serve better when they also reach out to young people with offers of referrals. In Peru Apoyo a Programas de Poblacion (APROPO) has staged street theater performances that bridge the gap between information and services in several ways. Street performers distribute pamphlets and present 15-minute humorous vignettes on contraceptive methods. The actors invite questions from the audience and sometimes direct members of the audience to counseling kiosks, where they can meet privately with a counselor. Performers and counselors also give out clinic addresses and advertise a telephone hotline staffed by counselors who provide information and further referrals (387). The Philippine Multi Media Campaign for Young People promotes and operates a telephone hotline that refers callers to any of 40 agencies offering a wide variety of services (414).

Reduce legal and informal restrictions. The age of consent for medical treatment is as low as 14 years in parts of Canada and New Zealand but as high as 18 years in South Africa. In some places, such as the United Kingdom, the legal age of consent for medical procedures is lower than for voting or entering legal contracts (371). Because of the controversy surrounding advice and treatment for minors, many health departments and school boards take the conservative position of denying services or programs to young people who are legally minors.

Many young adults find it difficult to obtain guarantees of confidentiality. If young people do not have the legal right to choose or consent to reproductive health care, they can be denied confidentiality. Moreover, where sexual intercourse is illegal for minors, some argue that health care providers who offer minors contraceptive advice or methods are condoning illegal acts (2, 22, 197). At the level of program policy rather than law, some parents insist that they should be present or be notified if their children seek reproductive health care. They argue that young people are too immature to understand medical advice or to make health decisions, and they require their parents' guidance.

Requirements of spousal consent, too, can deny confidentiality even to married young people. When women marry young, their husbands, families, or health professionals may not acknowledge their right to make their own decisions about reproductive health.

Many young adults are not willing to use services unless they are confidential, however. Young adults are often shy and uncertain, and they fear ridicule and disapproval. For example, in a US study 30% of sexually active women younger than age 19 said that would not go to a reproductive health clinic because they feared that their parents would find out (565). Many advocates for young people recommend that health professionals encourage young people to talk to their parents but still meet young people's health needs whether or not their parents can be involved (2).

Many young people find it easier to buy supplies such as condoms and spermicides than to go to a clinic or counselor. Thus laws and policy that allow sales of contraceptives to young adults and unmarried people are important. At the same time, other ways to distribute contraceptives should be available, particularly to those who cannot find a place to buy them or who cannot afford them.

Change hostile, judgmental, or reluctant attitudes. Even where law and policy give young adults access to reproductive health information and care, hostile or reluctant individuals may stand in the way. Teachers or health care providers may strongly disapprove of young adults who are sexually active or even those who seek just information about sexuality. They may think that, instead, they should tell young people how to behave. Others may feel uncomfortable discussing reproductive health with young people or offering them services. Authoritarian strictures and embarrassment will not help young people develop a positive attitude towards sexual responsibility, however (346).

To avoid prejudices, clinic managers need to give their staffs clear guidance about how to treat young clients. Providers also need to recognize and reassess their own feelings. In an Italian clinic, for example, some providers scolded young clients and told them to change their behavior (110). In Senegal nurses' aides who screened women at family planning clinic entrances turned away young unmarried women (393). In South Africa clinic staff refused to answer young clients' questions (5). In all three cases clinic managers trained the providers to serve young people politely, in part by helping the providers become aware of their own feelings about sexuality among young adults. In particular, counselors must understand that they will not be effective if they dictate to young people what to do. Instead, they must help them make responsible decisions for themselves.

Teachers may feel even less comfortable discussing reproductive health than health care providers would feel, and they may fear criticism from parents. They usually need extra support and training to teach FLE material. For example, in Kenya many school principals and teachers oppose teaching about contraception. As a result, only about 16% of school FLE courses discuss contraceptives, even though the government supports FLE courses as a way to reduce pregnancy (320).

Programs can address teachers' reluctance and help them face criticism. A Mexican program involved teachers in program design, trained them in presenting the material, met with them regularly as they taught the material, and met with parents periodically to answer questions. As a result, teachers became more convinced of the value of the course and more willing to teach it (482).

Some teachers are not appropriate sexuality educators, however. Focus-group research in an African country, for example, found that some male teachers pressured female students into sexual intercourse (41, 444).

Thus the ultimate task of any program for young people is to help change this situation. Making this change requires advocacy on behalf of young adults—advocacy for a new understanding, throughout the community, of the world in which young people live, the pressures and decisions that they face, the biological and social process of becoming sexually active, and the ways that organized efforts can best help young people. Changing the situation also requires advocacy for more responsible adult behavior—advocacy for an end to the double standard concerning sexual behavior that adults often apply to boys and girls, advocacy for prevention and punishment of sexual abuse, and advocacy for responsible, rather than irresponsible, depiction and discussion of sex and sexuality in the mass media.

Where social attitudes have changed and adults are willing to face the issues, fertility, STD, and abortion rates among young people are low. A study of 37 developed countries found that these rates were lowest in the northern European countries that provide young people with good access to contraceptive information and services (164, 374, 455) (see Chapter 3.3, European Youth Programs and Social Norms).

To change social norms, advocacy to youth also is needed. Programs need to reach out to young people to help them learn a healthy approach to sexuality. FLE programs in some European countries stress responsibility in sexual behavior and encourage young people to postpone sexual intercourse at least until they have developed a longstanding friendship with their partner (93, 295, 297).

Each society must design its own response to the reproductive health needs of young adults. Ignoring the problems will not make them disappear. Indeed, STD rates have risen and pregnancies among young women are more likely to occur outside marriage in many countries despite public concern and condemnation of these trends. Through advocacy, reproductive health programs can help communities start addressing the various needs of young adults.

As a program begins, develops, and becomes established, its role as an advocate changes. At the start, the controversy that often surrounds a new program can offer an early opportunity to encourage new thinking. As the program develops, keeping the community aware of positive changes and success stories helps allay fears. Working with parents, community leaders, and organizations such as churches, schools, and other service groups builds mutual confidence and understanding. Eventually, with effort and persis- tence, a program can become a respected voice in the community, speaking with authority on behalf of young adults.

Sidebars

1. Do Adults and Youth Have Differing Views?
2. Young People Are Different Today—True or False?
3. Are Young People Different Today?
4. It Takes Two: Reaching Out to Boys as They Become Men
5. Where Do Young Adults Learn About Sex?
6. UN Conferences Agree on Responses to Youth Needs
7. Contraceptive Choices for Sexually Active Young Adults
8. Lessons Learned: Ten Tips for Serving Young Adults
9. What Can Be Done?