Table 9. Types of Reproductive Health Programs for Young Adults
Audience/Activities	Extent of Program	Special Issues	Research Findings
Family Life Education
Intended audience: Young people, mostly in school. Activities: Varying educational programs. Most taught in schools; some outreach. Curricula may cover: Consequences of population growth, Encouragement of sexual abstinence, Reproductive health and physiology, Planning and decision-making skills, Gender equality, and Contraceptive methods (158, 221, 424).	Most widespread reproductive health program for youth. School FLE Programs: 1950s—pilot programs, Europe 1960s—national programs, Europe 1960s—pilot population education programs, developing countries 1980s—family life information added to population education, developing countries 1984—UNFPA supporting projects in 52 countries 1994—47 of 50 US states recommend sexuality education in schools but only 17 require it (17, 74, 424, 445). 1995—UNFPA supporting programs in 79 countries (447). Outreach FLE Programs: Scattered efforts by NGOs in a few developed an developing countries. Some programs by Boy Scouts and Girl Guides. Some efforts to add FLE material to adult literacy or vocational education in developing countries (53, 95, 424, 429, 447, 503).	Programs designed locally to suit local standards. Thus programs often focus on population growth, decision-making skills, or general health and nutrition and skip human reproductive physiology and contraception (94, 577). Integrating material into other subjects may arouse less controversy than separate courses but may dilute content. Some teachers resist because they feel curricula are too crowded, are uncomfortable with the subject, or fear parents criticism (143, 200, 344, 469, 482). FLE receives more attention in classes if covered on standardized examinations (320, 344, 425). Curricula must vary to suit age, gender, and experience of audiences (443). Outreach programs may need to be tailored to serve young people with special needs such as homeless youth, commercial sex workers, young parents (96). Specific evaluation needs: Which program elements contribute most to reaching goals? How much participation or exposure needed to change knowledge, attitudes, behavior? Costs. Quality of training and materials. Intermediate steps to behavior change.	Most FLE programs increase knowledge of course content (260, 378, 379) and positive attitudes toward course materials (97, 260, 379). Behavioral effects of FLE are programmatically important but modest. For example: Some programs have delayed sexual initiation (180, 181, 258, 333). Some programs have increased contraceptive use (181, 258, 333, 378). Training in negotiation skills may delay sexual initiation and may encourage contraceptive use (264). Teachers can be effective sex educators when properly consulted, trained, and supported (482).
Clinics
Intended audience: Young people who want reproductive health services including counseling, maternal health care, family planning, and STD services. Activities: Reproductive health counseling and services like those for adults.	Hospital/family planning clinics: 1960s—Free access for youth in Northern Europe. 1970s—Some clinics for youth opened in Latin America. 1995—Limited access for youth outside Europe (53, 345, 355, 399, 511). Outreach Clinics: Some health facilities have experimented with small, freestanding clinics especially for young adults. Conveniently located and with specially trained staff, they usually offer fewer services but refer to larger health centers (53, 429).	Access to health or family planning clinics often limited by: Legal restrictions, Unsympathetic staff, Cost to client, Lack of confidentiality, Potential clients lacking awareness of services, Inconvenient hours or location (2, 22, 110, 197, 371, 393). Some adult opposition to confidential care for young people (197, 371, 393), but many young people will not use services that are not confidential (565). Age-specific service statistics can identify: Service use, Health needs of young people, Health outcomes (7, 161, 433, 504).	Clinic personnel need special training to treat young clients in a supportive, nonjudgmental way (110, 393) and to help them choose appropriate contraceptive methods and STD protection. Outreach clinics can attract young people and win community support when part of broader social services (95, 96, 503).
AIDS Prevention
Intended audience: Young people in school and out of school. Activities: Various educational programs may cover: AIDS prevention, HIV transmission, symptoms, Attitudes towards people with AIDS, and Practicing negotiation skills. Outreach programs reach: Factories, Night club districts, Beach resorts, Truck stops, and Homeless persons (1, 80, 86, 186, 354, 364, 372). If a young person wants an AIDS test or treatment, most programs refer them to health clinics.	School programs: AIDS education often part of FLE 1980s—First programs in Europe and US add AIDS information to school FLE programs. 1994—All 50 US states require AIDS education in schools (17, 132). Outreach programs: 1980s—First programs 1995—Programs run by NGOs and government health departments; mostly small programs addressing high-risk youth.	To convince young people that they are at risk for HIV infection, programs have: Invited people with AIDS to meet students, Helped students assess their own risk (129, 161, 512, 574). Programs integrated into FLE require: Age-appropriate information and activities, Connection to condom distribution, if appropriate, and Training for teachers and peer educators. Some programs stress only abstinence or attempt to frighten young people.	Most AIDS education programs increase knowledge. Learning negotiation skills enhances ability to delay sex or to use condoms (132, 262). INteractive teaching methods are better than lectures at increasing condom use and confidence in using condoms and at reducing number of sexual partners (514, 528). Some US programs have: Delayed initial intercourse Increased condom use, and Reduced number of sexual partners (262).
Condom Distribution Programs
Intended audience: Sexually active young people. Activities: Provide condoms. Many programs also counsel on condom use and AIDS prevention—often informal, individual instruction by distributors.	1980s—Peer-counselors in Latin America and Caribbean. 1988—Condoms distributed to out-of-school youth in parts of Europe. 1990s—Pilot in-school distribution programs in US, Canada 1995—50 US school districts have approved in-school programs to distribute condoms through multiple sources including nurses, teachers, counselors, and/or vending machines (142, 194, 195, 261, 309, 426, 438). Programs in Africa and Latin America specifically address young people in and out of school (170). Few large-scale effots.	Controversial, especially when in schools (426). In-school distribution accepted only where pregnancy and STD rates are high. Distribution programs often fail to promote service. Programs must ensure that young people: Can afford condoms; Know how to use them; Know where to get them; Can talk to their partners about condom use (359, 426); Understand the importance of consistent and correct condom use (359, 426). Special evaluation issues: Impact on knowledge, attitudes, and behavior hard to assess because contact between program and client is slight. School programs can better evaluate condom use than outreach programs because they can survey students.	School programs may distribute more condoms when: Condoms are free or inexpensive, Parental consent is not required, There are multiple delivery points, and At least some delivery points are confidential (257).
School Clinics
Intended audience: Students. Activities: Provide various health services including treatment of injuries, primary care, and physical examinations (318). Three-quarters of the 607 US school clinics offer family planning counseling, pregnancy testing, or gynecological exams. One-third serving secondary-school students provide condoms and/or prescriptions for oral contraceptives (318). Some clinics provide reproductive health counseling and classroom presentations (318).	School clinics are few. Most are in US: about 60% are in schools; 40%, new schools. About 60% are in urban areas (317). 1970—First Us clinic 1980s—First school clinics open in Latin America and Caribbean. 1984—31 clnics in US 1994—607 clinics in US (317, 318). In US schools with clinics, 58% of students used some clinic service in 1993 (318).	Some community/parental opposition, especially if parents are not notified when their child is seen at a clinic. Speical evaluation needs: Knowledge, attitudes, and behavior of clinic clients compared with that of students who do not use clinics. whether school clinics merely substitute for other services that students formerly used.	Compared with 6 schools without clinics, in 6 US schools with clinics: Pregnancy rates were not clearly lower, but large annual fluctuations made measurement difficult (263). Students did not start sex earlier. Students did not have sex more often. Students not more likely to have used a contraceptive at last intercourse just because their school distributed contraceptives. A strong AIDS prevention and condom promotion campaign at one school did increase condom use (266). In one US study clinic-users from one school were more likely to use contraceptives than students from a school with no clinic (167). One urban US clinic found that: Classroom presentations and clinic services serve different needs; both are valuable. Pregnancy rates fell after several years of program operation (563).
Communication Through Entertainment Media
Intended audience: All young adults. Activities: Mass-media formats nclude music and drama videos, popular songs, radio and television soap operas and spots (109, 251, 357, 414, 423 442 480, 523). Community formats include drama contests and performances, school events, radio call-in shows, telephone hot-lines (12, 67, 104, 109, 236, 251, 270, 271, 285, 367, 268, 384, 287, 414, 470, 523).	1970s—Televised informational sexual education programs in Sweden 1980s—First projects use entertainment media to educate young adults. 1988—Songs promoting sexual responsibility hit "top 10" in Latin America. 1990s—Increasing but still limited use of entertainment media (165, 252, 253).	Young people get much of their information about sex from the mass media. Information is often wrong, however, or glamorizes unsafe behavior. Recent counter-efforts use popular performers and entertaining formats to encourage responsible behavior. Need links to service providers for full impact. Special evaluation needs: How much exposure necessary to achieve program goal? Best ways to link media message and services?	Hotlines and call-in radio shows are popular because young adults appreciate confidential sources of accurate information (104, 270, 271, 285, 367, 268, 384, 387, 415). Combining several media reinforces the message (67, 251, 252, 414, 423, 523). Enter-educate soap operas and dramas attract young people, offer models of responsible behavior, and help young people consider decisions about personal relationships and sexual behavior (381, 454, 470, 480). Popular performers' endorsements of sexual responsibility foster positive attitudes (109, 251, 252, 253, 414). may have high total costs but low unit costs because mass media reach vast audiences. High-quality media presentations encouraging sexual responsibility can attract corporate sponsorship and donations of air time (414, 415).
Peer Education
Intended audience: Young people contacted by programs. Activities: Young people counsel, inform, make referrals, and in some cases distribute contraceptive methods such as pills or condoms to their peers (200, 309, 313, 323). Peer educators have worked at clinics, schools, factories, military bases, bars, sports events, adult education classes, universities, in the streets, and with street gangs (107, 200, 226, 309, 313, 323, 408, 418).	1970s—Peer educators first used in US drug and alcohol prevention programs. 1980s—Peer educators first used in reproductive health programs in Mexico, US (132, 233). 1990s—First use in Africa. Limited use by many NGOs; always part of broader program.	Extensive education, training, and supervision required, and turnover may be rapid (309, 323). Advantages over adult educators: Know how to talk to young adults and motivate them, Can reach young people whenever and wherever topic comes up, Themselves benefit from participation; gives them sense of belonging and support and builds leadership skills (226). Special evaluation issues: Peer educators are usually evaluated by observing their interaction with other young adults. Indicators include: Numbers of young people reached, Numbers of young people who ask questions or numbers of questions asked, Changes in audiences' knowledge, Number of contraceptives distributed (413, 479).	In a US study peer and adult educators were equally able to increase knowledge and improve attitudes about AIDS, but young people asked peer educators more questions (413). In a Mexican study youth outreach workers reached more unmarried young men while youth centers reached more unmarried young women. Married young people used adult outreach services. Outreach workers cost less per person reached than youth centers (479). Peer educators are often volunteers or receive low salaries, buth they need extensiver—thus costly—training and supervision (191).