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Ensuring Youth's Right to Participation and Promotion of Youth Leadership in the Development of Sexual and Reproductive Health Policies and Programs

      Abstract

      The purpose of this article was to reflect on the concepts of adolescence and youth, summarize models and frameworks developed to conceptualize youth participation, and assess research that has attempted to evaluate the implementation and impact of youth participation in the field of sexual and reproductive health and rights (SRHR). We searched and critically reviewed relevant published reports and “gray literature” from the period 2000–2013. “Young people” are commonly defined as those between the ages of 10 and 24 years, but what it means to be a young person varies largely across cultures and depends on a range of socioeconomic factors. Several conceptual frameworks have been developed to better understand youth participation, and some frameworks are designed to monitor youth development programs that have youth participation as a key component. Although none of them are SRHR specific, they have the potential to be adapted and applied also for adolescents' SRHR programs. The most monitored and evaluated intervention type is peer education programs, but the effectiveness of the approach is questioned. There are few attempts to systematically evaluate youth participation, and clear indicators and better methodologies still need to be developed. More research and documentation as well as the adoption of innovative practices for involving youth in sexual and reproductive health programs are needed. Participation is a right and should not only be evaluated in terms of effectiveness and impact. Youth participation in program and policy development should still be a priority.

      Keywords

      Implications and Contribution
      Findings from this review highlight the need to further develop indicators and methodologies for the evaluation of youth participation, both in terms of process and outcomes. Participation is a right and involving young people in a meaningful way in program and policy development should continue to be a priority.
      Twenty years from the International Conference on Population and Development (ICPD), youth participation in sexual and reproductive health and rights (SRHR) policies and programs have flourished worldwide, operating at different levels from international advocacy to local interventions. The Programme of Action, adopted after the ICPD in 1994, gave some initial steps in the recognition of young people's participation. Some of these considerations are the encouragement of girl-children's participation in societies' development; the integration and promotion of youth participation in all spheres of society, including political processes and leadership roles; the participation of young people in reproductive health programs; and the need for youth participation in the development of educational projects related to the ICPD Programme of Action [
      UNFPA
      International conference on population and development (ICPD) programme of action.
      ].
      After ICPD+5, there was a proliferation of sexual and reproductive health (SRH) programs for youth, in part because of the flow of resources from international donors after the commitment to investing 20% of the total funding in youth-related programs. Although youth participation is part of international development agendas and recognized as a human right, there is still a need for conceptual clarifications and to address a range of practical challenges for its operationalization as a regular practice in program development and management. One of the major ongoing discussions is related to how to conceptually define “youth” and “participation” [
      • Cook P.
      Understanding the effects of adolescent participation in health programmes.
      ].
      In this article, we reflect on the concepts of adolescence and youth, we highlight the key international agreements related to youth participation and SRHR, and summarize models and frameworks developed to conceptualize youth participation, both from a human rights perspective and a program implementation perspective. Next, we present a critical review of the research that has attempted to evaluate the implementation and impact of youth participation in the field of SRHR, before we finally describe some approaches to move forward on the adoption of youth participation as an essential practice in policy and program development.

      Methods

      A systematic search was performed using the databases PubMed, Education Resources Information Center, Cumulative Index to Nursing and Allied Health Literature, Family and Society Studies Worldwide, Global Health, and Sociological Abstracts. Terms searched included youth participation, youth involvement, meaningful participation, youth programs, consumer participation, social participation, peer group, peer education, leadership, community engagement, reproductive health, sexual health, sexual behavior, process evaluation, youth and community engagement, citizenship, and youth participation for social change.
      Additional publications on youth participation were identified from reports and gray literature, with searches done through Google and Google Scholar, as well as through searches at Internet sites for youth-led or youth-focused organizations; adult-led nongovernmental organizations and programs working on SRH and/or youth; United Nations (UN) official reports; and youth SRH forum minutes and official statements. The timeframe for the search was limited to 2000–2013. The final number of documents selected for review was 57.

      Results

      Definitions of adolescence, youth, and young people

      The concept of youth is relatively new. It gained strength at the international level in the second half of the 20th century, derived mainly from the economic and political need to engage young people as a separate stakeholder group [
      • Angel W.D.
      The international law of youth rights: Source documents and commentary.
      ]. For statistical consistency and comparisons across countries, the UN defines “young people” as those between the ages of 10 and 24 years. Included in this definition is the classification of adolescence, which comprises the ages of 10–19 years old. This operational definition allows the UN system to monitor and document activities regardless of the definitions adopted by Member States in their national youth-related legislation and policies, as well as in any local definition of youth.
      When defining youth, however, it is imperative not to assume that the process of aging is universally the same. Young people are subject to power dynamics that respond to their age, gender, social and economic class, ethnicity, race, sexual orientation, human immunodeficiency virus (HIV) status, and other dimensions that shape their personal identity [
      • Wyn J.
      • White R.
      Rethinking youth.
      ]. The boundaries of childhood, adolescence, youth, and adulthood evolve constantly and may become blurry. As Furlong et al. [
      • Furlong A.
      • Woodman D.
      • Wyn J.
      Changing times, changing perspectives: Reconciling ‘transition’ and ‘cultural’ perspectives on youth and young adulthood.
      ] have pointed out, it is difficult for some sections of the population to identify into which phase a person is transitioning through, especially when the usual benchmarks have been postponed indefinitely or were never present at all. Although age provides a reference for personal transitions from one life stage to another, and having a standardized youth definition is practical from a program's point of view, the process of moving from child to youth and finally adulthood is an experience profoundly ingrained in the cultural, economic, social, and political contexts where people live and grow [
      • Wyn J.
      • White R.
      Rethinking youth.
      ,
      • Furlong A.
      • Woodman D.
      • Wyn J.
      Changing times, changing perspectives: Reconciling ‘transition’ and ‘cultural’ perspectives on youth and young adulthood.
      ].
      In areas of the world with high-income levels, the demarcation of childhood, youth, and adulthood may be less clear-cut. Young people delay marriage, childbearing, and extend their student status while living in a separate household from their parents but are not always economically independent from them or State welfare. At the other end of the development continuum, a large proportion of age-defined young people are affected every day by poverty, unemployment, lack of education, conflict, migration, violence, HIV, and other difficulties that force them to move directly from childhood to adulthood, without the possibility of experiencing their youth as a period of experimentation, preparation, and/or transition [
      • Wyn J.
      • White R.
      Rethinking youth.
      ,

      CSDH. Closing the gap in a generation: Health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health. 2008.

      ].
      These different social and political factors are key determinants of what role young people see for themselves in society and the ways in which young people participate in programs and policies. Interventions and policies need to be sensitive and tailored to the local cultural and social expressions of being young in addition to key SRHR indicators for this population.

      What is youth participation?

      Many international organizations and agencies concur that youth participation should not be regarded solely as a component that will improve the health or development outcomes of a given program or intervention but, rather, as a human right that needs to be monitored and evaluated with the use of specific policy and program indicators [
      • Senderowitz J.
      Youth participation: Aspects and effects.
      ]. Participation can be regarded as a civil and political right (i.e., participation in political elections) and as an economic, cultural, and social right (i.e., the participation in the design and implementation of development agendas, including health, education, housing policies, and poverty reduction strategies such as youth employment). Children's and adolescents' right to participation in all matters related to their own lives has been recognized in the Convention on the Rights of the Child. States party to Convention on the Rights of the Child, with attention to the principles of the best interest of the child [
      UNHCR
      UNHCR guidelines on formal determination of the best interest of the child.
      ] and evolving capacities [
      • Lansdown G.
      The evolving capacities of the child.
      ], must guarantee the conditions that are conducive for the inclusion of their opinions and concerns.
      Some UN documents define participation as seeking information, expressing ideas, taking an active role in different steps of the process of creating a policy or program, being informed and consulted on decisions concerning public interest, analyzing situations and even making personal choices [
      Unicef
      The participation rights of adolescents: A strategic approach.
      ]. Hart [
      • Hart R.A.
      Children's participation: From tokenism to citizenship.
      ] describes participation as the core characteristic of civic life, as a process of“… sharing decisions which affect one's life and the life of the community in which one lives. It is the means by which a democracy is built and it is a standard against which democracies should be measured. Participation is the fundamental right of citizenship” (p5).

      Theoretical frameworks for youth participation

      Various conceptual frameworks have been developed to better understand youth participation [
      • Wong N.T.
      • Zimmerman M.A.
      • Parker E.A.
      A typology of youth participation and empowerment for child and adolescent health promotion.
      ]. Hart's “ladder of participation” has made an important contribution to identifying nonmeaningful ways of participation, such as decoration, manipulation, and tokenism. Hart [
      • Hart R.A.
      Children's participation: From tokenism to citizenship.
      ] also established categories to define true participation where adults and youth share the decision making and power of the program development process. Treseder [
      • Treseder P.
      Empowering children and young people: Training manual promoting involvement in decision making.
      ] established a nonlinear typology, which questions the assumption that the gold standard for youth participation is the youth-driven model at the top of the ladder proposed by Hart, as it might not always be appropriate, practical, or even plausible. Shier [
      • Shier H.
      Pathways to participation: Openings, opportunities and obligations.
      ] further developed Hart's model by establishing a set of questions about organizational readiness to actively involve young people in their organizations and/or programs through three steps: openings, opportunities, and obligations. More recently, Wong et al. [
      • Wong N.T.
      • Zimmerman M.A.
      • Parker E.A.
      A typology of youth participation and empowerment for child and adolescent health promotion.
      ] developed the typology of youth participation and empowerment pyramid where the ultimate aim was to achieve a balance between youth and adult control, through the empowerment of both, by establishing shared power relationships.
      All the previously mentioned models have, as a common intention, the establishment and adoption of processes for shared decision making and power between the holder of the adult role and the young person, through the recognition of young people's contributions, individually and/or collectively. According to Cook [
      • Cook P.
      Understanding the effects of adolescent participation in health programmes.
      ], giving decision-making power to young people and integrating them in all aspects of program development are vital components of meaningful involvement processes, beyond tokenism and decoration.
      A group of experts convened by the World Health Organization in 2002 proposed conceptual categories, explained in the following, for youth participation in programs and policies that can guide its incorporation as a program component, a side effect, an organizational value, an objective, or a program or policy goal [
      • Cook P.
      Understanding the effects of adolescent participation in health programmes.
      ,
      WHO/FCH/CAH
      Report of a meeting on measuring adolescent participation in programmes and the effect of adolescent participation on programme effectiveness.
      ].
      • 1.
        Participation as a way for young people to access services and/or get direct benefits from programs, for example, HIV testing or condoms.
      • 2.
        Participation as a component of the program planning process, including needs assessment, design, implementation, monitoring, and evaluation.
      • 3.
        Participation as a way to lead changes in the implementing institutions and organizations, such as the creation of organizations' youth councils or the inclusion of young people in governing bodies.
      • 4.
        Participation as an approach to improve adolescents' and young people's personal traits and social resources such as self-esteem, confidence, autonomy, greater initiative, teamwork, networks, and social capital, independently of the specific policy or program objectives.
      • 5.
        Participation as a key component to achieve program objectives. It can include direct effects on young people, such as increased knowledge of HIV prevention, and direct effects on institutions that serve this group, such as the increased capacity of the health sector to provide youth-sensitive SRH services.
      • 6.
        Participation as a way to increase policies' and programs' efficiency, by weighting the costs of participatory processes versus its benefits.
      • 7.
        Participation as an environment changing factor that positively impacts the context in which young people live.
      These conceptual categories can guide aspects to monitor and measure youth participation, depending on the level and depth in which it is adopted by organizations.

      Youth participation in sexual and reproductive health and rights programs

      Since ICPD in 1994, and particularly ICPD+5, SRH programs for youth and youth-led organizations have flourished. Nevertheless, there is limited documentation and strong evaluation studies that would provide evidence of its impact. Only a handful of studies have documented and evaluated youth participation as a component of SRH programs, and ultimately, a key component to achieve program outcomes.
      The most monitored and evaluated youth-related SRH intervention type is peer education. Peer education is defined as “a form of teaching and/or sharing information, values and behaviors by members of similar age and/or status groups” [
      • Sciacca J.
      Student peer health education: A powerful yet inexpensive helping strategy.
      ]. It is a way in which a small group of peer representatives from a specific group or population actively attempt to inform and influence the rest of the group [
      • Harden A.
      • Oakley A.
      • Oliver S.
      Peer-delivered health promotion for young people: A systematic review of different study designs.
      ]. The assumption is that peers are a more credible source of information than adults, have more opportunities to reinforce messages through ongoing contact with peers, and may have more access to those at risk or hard to reach. It is also believed that peers have a higher level of trust that allows open discussions of sensitive topics, allowing for information to flow in both directions [
      • Medley A.
      • Kennedy C.
      • O'Reilly K.
      • Sweat M.
      Effectiveness of peer education interventions for HIV prevention in developing countries: A systematic review and meta-analysis.
      ]. These programs are considered to be an alternative to the top-down professional and adult-led health promotion interventions because they promote better communication with young people and ensure youth participation [
      • Harden A.
      • Oakley A.
      • Oliver S.
      Peer-delivered health promotion for young people: A systematic review of different study designs.
      ].
      For this article, we reviewed five published meta-analyses that have assessed SRH peer education programs [
      • Harden A.
      • Oakley A.
      • Oliver S.
      Peer-delivered health promotion for young people: A systematic review of different study designs.
      ,
      • Medley A.
      • Kennedy C.
      • O'Reilly K.
      • Sweat M.
      Effectiveness of peer education interventions for HIV prevention in developing countries: A systematic review and meta-analysis.
      ,
      • Kim C.R.
      • Free C.
      Recent evaluations of the peer-led approach in adolescent sexual health education: A systematic review.
      ,
      • Maticka-Tyndale E.
      • Barnett J.P.
      Peer-led interventions to reduce HIV risk of youth: A review.
      ,
      • Tolli M.
      Effectiveness of peer education interventions for HIV prevention, adolescent pregnancy prevention and sexual health promotion for young people: A systematic review of European studies.
      ]. Together, these meta-analyses evaluated the effectiveness of 137 peer education interventions implemented during the last 25 years.
      The objectives of the interventions included in the meta-analyses were to increase knowledge, change behavior, and reduce risk taking and, ultimately, to impact outcome indicators related to SRH, such as HIV or specific sexually transmitted infections (STI), although one included alcohol and drugs [
      • Harden A.
      • Oakley A.
      • Oliver S.
      Peer-delivered health promotion for young people: A systematic review of different study designs.
      ]. Areas in which significant effects were observed included increase in SRH knowledge, including HIV-related knowledge, condom use, and STI symptoms [
      • Harden A.
      • Oakley A.
      • Oliver S.
      Peer-delivered health promotion for young people: A systematic review of different study designs.
      ,
      • Medley A.
      • Kennedy C.
      • O'Reilly K.
      • Sweat M.
      Effectiveness of peer education interventions for HIV prevention in developing countries: A systematic review and meta-analysis.
      ,
      • Kim C.R.
      • Free C.
      Recent evaluations of the peer-led approach in adolescent sexual health education: A systematic review.
      ,
      • Maticka-Tyndale E.
      • Barnett J.P.
      Peer-led interventions to reduce HIV risk of youth: A review.
      ,
      • Tolli M.
      Effectiveness of peer education interventions for HIV prevention, adolescent pregnancy prevention and sexual health promotion for young people: A systematic review of European studies.
      ]; change in attitudes, including more liberal attitudes about same-sex relationships and increased condom self-efficacy [
      • Kim C.R.
      • Free C.
      Recent evaluations of the peer-led approach in adolescent sexual health education: A systematic review.
      ,
      • Tolli M.
      Effectiveness of peer education interventions for HIV prevention, adolescent pregnancy prevention and sexual health promotion for young people: A systematic review of European studies.
      ]; decrease in positive testing for chlamydia [
      • Kim C.R.
      • Free C.
      Recent evaluations of the peer-led approach in adolescent sexual health education: A systematic review.
      ]; change in behaviors, including delaying intercourse, increasing condom use, reduction in number of sexual partners, and reduction of equipment sharing [
      • Harden A.
      • Oakley A.
      • Oliver S.
      Peer-delivered health promotion for young people: A systematic review of different study designs.
      ,
      • Medley A.
      • Kennedy C.
      • O'Reilly K.
      • Sweat M.
      Effectiveness of peer education interventions for HIV prevention in developing countries: A systematic review and meta-analysis.
      ,
      • Maticka-Tyndale E.
      • Barnett J.P.
      Peer-led interventions to reduce HIV risk of youth: A review.
      ,
      • Tolli M.
      Effectiveness of peer education interventions for HIV prevention, adolescent pregnancy prevention and sexual health promotion for young people: A systematic review of European studies.
      ]. Although these effects were observed, authors were convergent on the fact that the quality of the evaluation methodologies was low and thus the evidence of the effectiveness of peer education is weak. They also questioned the size of the effects, which some, even when statistically significant, were small. According to authors, some studies included in their meta-analyses did not meet the requirements to be considered strong evidence [
      • Harden A.
      • Oakley A.
      • Oliver S.
      Peer-delivered health promotion for young people: A systematic review of different study designs.
      ,
      • Medley A.
      • Kennedy C.
      • O'Reilly K.
      • Sweat M.
      Effectiveness of peer education interventions for HIV prevention in developing countries: A systematic review and meta-analysis.
      ,
      • Kim C.R.
      • Free C.
      Recent evaluations of the peer-led approach in adolescent sexual health education: A systematic review.
      ,
      • Maticka-Tyndale E.
      • Barnett J.P.
      Peer-led interventions to reduce HIV risk of youth: A review.
      ,
      • Tolli M.
      Effectiveness of peer education interventions for HIV prevention, adolescent pregnancy prevention and sexual health promotion for young people: A systematic review of European studies.
      ].
      An area of concern is related to the lack of a thorough reporting on the nature and degree of youth participation in these programs. Few studies reported implementing needs assessments with young people, consulting a subgroup of youth or youth organizations, and/or involving them in the design process of the interventions [
      • Harden A.
      • Oakley A.
      • Oliver S.
      Peer-delivered health promotion for young people: A systematic review of different study designs.
      ,
      • Kim C.R.
      • Free C.
      Recent evaluations of the peer-led approach in adolescent sexual health education: A systematic review.
      ]. Only one study reported a clear process to establish the roles, expectations, and boundaries between youth and adults [
      • Kim C.R.
      • Free C.
      Recent evaluations of the peer-led approach in adolescent sexual health education: A systematic review.
      ]. Authors also uncovered limitations on the processes of selection of peer educators and leaders [
      • Harden A.
      • Oakley A.
      • Oliver S.
      Peer-delivered health promotion for young people: A systematic review of different study designs.
      ,
      • Medley A.
      • Kennedy C.
      • O'Reilly K.
      • Sweat M.
      Effectiveness of peer education interventions for HIV prevention in developing countries: A systematic review and meta-analysis.
      ,
      • Maticka-Tyndale E.
      • Barnett J.P.
      Peer-led interventions to reduce HIV risk of youth: A review.
      ,
      • Tolli M.
      Effectiveness of peer education interventions for HIV prevention, adolescent pregnancy prevention and sexual health promotion for young people: A systematic review of European studies.
      ]. When network analysis is not performed and young people are not given the opportunity to select their peer educators, the peer educators lack legitimacy. Self-selection is also problematic because, according to authors, those who self-select are usually high achievers and already volunteers in other projects, creating feelings of competitiveness among youth and competing demands [
      • Tolli M.
      Effectiveness of peer education interventions for HIV prevention, adolescent pregnancy prevention and sexual health promotion for young people: A systematic review of European studies.
      ]. Last, two studies reported a tendency for more young females to volunteer as peer educators than males [
      • Harden A.
      • Oakley A.
      • Oliver S.
      Peer-delivered health promotion for young people: A systematic review of different study designs.
      ,
      • Kim C.R.
      • Free C.
      Recent evaluations of the peer-led approach in adolescent sexual health education: A systematic review.
      ].
      Attrition from interventions was also high, even in school-based intervention [
      • Kim C.R.
      • Free C.
      Recent evaluations of the peer-led approach in adolescent sexual health education: A systematic review.
      ]. Growing older, competing demands, the need for paid employment, and a lack of incentives were mentioned as some reasons of why attrition may occur [
      • Medley A.
      • Kennedy C.
      • O'Reilly K.
      • Sweat M.
      Effectiveness of peer education interventions for HIV prevention in developing countries: A systematic review and meta-analysis.
      ,
      • Maticka-Tyndale E.
      • Barnett J.P.
      Peer-led interventions to reduce HIV risk of youth: A review.
      ]. Training frequently occurred once only, and youth reported needing refresher courses and supervision. Supervision is different from training and is particularly important when young people face controversial topics, such as sexual diversity and abortion, or when they feel threatened by community members that are against their role as peer educators in SRH topics [
      • Harden A.
      • Oakley A.
      • Oliver S.
      Peer-delivered health promotion for young people: A systematic review of different study designs.
      ,
      • Medley A.
      • Kennedy C.
      • O'Reilly K.
      • Sweat M.
      Effectiveness of peer education interventions for HIV prevention in developing countries: A systematic review and meta-analysis.
      ,
      • Maticka-Tyndale E.
      • Barnett J.P.
      Peer-led interventions to reduce HIV risk of youth: A review.
      ,
      • Tolli M.
      Effectiveness of peer education interventions for HIV prevention, adolescent pregnancy prevention and sexual health promotion for young people: A systematic review of European studies.
      ]. One study reported that students preferred receiving information from teachers [
      • Tolli M.
      Effectiveness of peer education interventions for HIV prevention, adolescent pregnancy prevention and sexual health promotion for young people: A systematic review of European studies.
      ], a finding which indicates that peers and adults may have complementary roles. Adults might be better suited to provide factual information and base their messaging on a deeper knowledge and more experience from the area, whereas peers might be better at hosting conversations on different SRH topics that require a safe youth-oriented space [
      • Maticka-Tyndale E.
      • Barnett J.P.
      Peer-led interventions to reduce HIV risk of youth: A review.
      ]. This shows that the most difficult challenge is to set roles, responsibilities, and effective partnerships between youth and adults when implementing programs.
      Also, although a full review on the impact of programs on peer-educators' SRH outcomes is out of the scope of this article, we recognize it is something lacking in this analysis and, thus, a needed task. Youth peer education is one of the few ways in which youth participation has been put into practice. Instead of allowing youth to engage meaningfully, many interventions deliver adult-driven messages and agendas and relegate youth to less meaningful participation levels, as ladder of participation by Hart [
      • Hart R.A.
      Children's participation: From tokenism to citizenship.
      ] suggests. Although the effectiveness of peer-led education interventions at present is questioned, several components of peer education interventions related to youth participation—such as youth needs assessments, improved recruitment strategies, and better training and mentoring throughout the process—could produce greater impact.
      One of the very few carefully evaluated programs developed with the explicit intention to increase youth participation in community interventions was the Entanebi project in KwaZulu-Natal in South Africa. Its aim was to reduce HIV among youth [
      • Campbell C.
      • Gibbs A.
      • Maimane S.
      • et al.
      Youth participation in the fight against AIDS in South Africa: From policy to practice.
      ]. The study failed to enable youth participation for a range of reasons. Youth participants reported the lack of safe spaces to talk about SRHR topics, mistrust of the community because of the stereotypes adults held of young people, and adults' abuse of youth volunteerism. Also, there were no opportunities to network with organizations that could provide them with resources after the program ended. In reflecting on youth participation in this study, its authors recognized that the adults in this community were themselves marginalized and, hence, adults' power over youth might be one of the few spaces where they can show authority. Thus, there is a need to be aware of the interlinked marginalization of youth and adults and to work with adults as well [
      • Campbell C.
      • Gibbs A.
      • Maimane S.
      • et al.
      Youth participation in the fight against AIDS in South Africa: From policy to practice.
      ].
      Last, another effort documented in the literature to assess youth participation is the work of Tiffany et al. [
      • Tiffany J.S.
      • Exner-Cortens D.
      • Eckenrode J.
      Longitudinal associations between HIV risk reduction and out-of-school time program participation.
      ]. They conducted a longitudinal multilevel study to assess if youth participation had an impact in decreasing HIV-related risks. They used the Tiffany–Eckenrode Program Participation Scale (TEPPS) to assess youth participation and found that, at the individual level, higher levels of youth participation were associated with lower risk taking. At the program level, higher youth participation was related to sustained risk reduction practices over time [
      • Tiffany J.S.
      • Exner-Cortens D.
      • Eckenrode J.
      Longitudinal associations between HIV risk reduction and out-of-school time program participation.
      ].
      Although some efforts have been made in the area of youth participation, the lack of strong evidence of the effect of it in the impact of SRHR interventions, such as peer education programs, is missing.

      Youth-led and youth-focused sexual and reproductive health and rights organizations

      Many youth programs have been housed within nongovernmental organizations working on SRHR more generally. Some have made efforts to establish mechanisms of participation, such as youth representatives in steering committees or youth councils within organizations. For example, the International Planned Parenthood Federation Governing Council passed a resolution in 2001 that strongly urged member associations and regions to have at least 20% of young people as part of their governing structure. As a result of this, International Planned Parenthood Federation developed a self-assessment tool for organizations to move from the rhetoric of youth participation to action, and the majority of its members' associations have reached the 20% goal [

      International Planned Parenthood Federation. International planned parenthood federation governing council. Available at: http://www.ippf.org/Governing-Council. Accessed August 26, 2013.

      ].
      There are also many youth-led organizations and networks that emerged after ICPD+5. For example, the Youth Coalition for Sexual and Reproductive Rights (YC) is a youth-led organization based in Canada, formed by an international volunteer-based membership. The YC has a specific delineated process for applying to membership, and for aging out of the organization, to ensure the transmission of leadership of the organization to younger generations [

      Youth Coalition for Sexual and Reproductive Rights. Youth coalition for sexual and reproductive rights. Available at: http://www.youthcoalition.org. Accessed August 26, 2013.

      ]. The YC has been very successful in advocating for adolescent and youth comprehensive language in UN-level resolutions related to population, HIV, sexuality, gender and sexual diversity, women's rights, and development issues among others [

      Youth Coalition for Sexual and Reproductive Rights. Youth coalition for sexual and reproductive rights. Available at: http://www.youthcoalition.org. Accessed August 26, 2013.

      ].
      A lesson to draw from available literature is that having a youth program or youth project within an organization does not necessarily guarantee youth participation. Systems need to be in place to ensure that youth are integrated and contributing meaningfully within organizations, and this should be reflected in the evaluation of the projects [
      • Gurstein P.
      • Lovato C.
      • Ross S.
      Youth participation in planning: Strategies for social action.
      ]. Governance structures that involve youth in any capacity need to be evaluated to assess the level and quality of youth participation. These evaluations should point out how barriers for young people to meaningfully participate can be addressed [
      • Gurstein P.
      • Lovato C.
      • Ross S.
      Youth participation in planning: Strategies for social action.
      ]. Volunteerism and nonpaid or low-paid internships, although valuable for gaining experience, need to be reassessed, as they could demoralize young people. The lack of capacity of organizations to absorb young people as part-time or full-time employees after a period of volunteering should be evaluated in relationship to the lack of rotation in organizational leadership and managerial positions [
      • Ahumada C.
      • Dekkers K.
      • Mesman A.
      • et al.
      A step by step guide to creating sustainable youth-led organizations working on sexual and reproductive health and rights.
      ].

      Approaches for implementing, monitoring, and evaluating youth participation

      Commonly, youth participation is assessed based on two groups of indicators: (1) impact indicators (i.e., has youth involvement resulted in improved outcomes?) and (2) process indicators (i.e., to what degree have young people participated? Have they been involved in a meaningful way?). Typically, a human rights–based approach will focus more on the latter. The assumption is that meaningful participation of adolescents and young people in the development of laws, policies, and programs as a right will result in better-orchestrated responses for them; thus, it is essential to monitor both process and impact.
      There are a few methodologies to monitor and evaluate the impact of meaningful youth participation, and the ones presented here could serve as guides for the development and adaptation of SRH ones. Both peer-reviewed literature and gray literature have documented the use of these frameworks [
      • Cook P.
      Understanding the effects of adolescent participation in health programmes.
      ,
      • Senderowitz J.
      Youth participation: Aspects and effects.
      ].
      Miller et al. [
      • Miller G.
      • VanSant D.
      • Mullett J.
      Collaborative action research: A catalyst for enhancing the practice of community youth mapping.
      ] developed an evaluation framework for community youth development where youth participation should seek the ultimate goal of youth being active agents in their communities, confident, skilled, and connected. Adults need to avoid tokenism, imbalances of power, and negative youth stereotyping. This framework aims to challenge adult attitudes that characterize young people as incapable of taking on new roles, such as partnership and leadership positions within organizations and programs.
      The Western Australian Centre for Health Promotion Research developed the evaluation framework for peer-based youth programs, for youth most at risk [

      Western Australian Centre for Health Promotion Research. My-peer toolkit. My-Peer Toolkit Web site. Available at: http://mypeer.org.au/. Accessed August 25, 2013.

      ]. Youth participation is a component of this framework and is assessed by two dimensions: youth involvement and youth ownership of the program. Youth involvement is characterized as the role young people have in influencing program design and implementation and opportunities for genuine youth leadership, by taking primary responsibility for developing plans, carrying out decisions, and solving problems. Some proposed process indicators for youth involvement are the number of youth participating in program design, delivery, and evaluation activities; level of peer influence from experienced group members; and opportunities for experiential learning. Ownership of the program is described as a balance of power between staff and young people within the program and encouragement for participants to move up through the program when appropriate. Some proposed indicators are the authority of young people in decision making to influence program content and delivery and the active involvement of youth in program delivery, by becoming peer supporters, peer educators, peer leaders, or program facilitators [

      Western Australian Centre for Health Promotion Research. My-peer toolkit. My-Peer Toolkit Web site. Available at: http://mypeer.org.au/. Accessed August 25, 2013.

      ].
      Bohnert et al. [
      • Bohnert A.
      • Fredricks J.
      • Randall E.
      Capturing unique dimensions of youth organized activity involvement theoretical and methodological considerations.
      ] have proposed a conceptual model of participation in organized activities, with variables to predict youth participation (such as demographic, individual, family, peers, school, and neighborhood characteristics), qualities of the participation (breadth and intensity), type of youth engagement (behavioral, emotional, and cognitive), duration of intervention, and possible outcomes for youth (academic, psychological, social, or behavioral). These variables are mediated by the quality of the program, relationship with adults, peer affiliations, opportunities for skills building, activity type, norms, and the level of structure within the program.
      Other efforts have been to build instruments to measure adult attitudes toward young people [
      • Lofquist W.A.
      • Miller M.G.
      Inventory of adult attitudes and behavior. An instrument for examining the nature of adult/youth relationships.
      ] and youth participation in programs and interventions at the community level [
      • Tiffany J.S.
      • Exner-Cortens D.
      • Eckenrode J.
      A new measure for assessing youth program participation.
      ]. Tiffany et al. assessed six dimensions that contribute to meaningful youth participation: quality of program participation (measured by the TEPPS), intensity of the participation, duration of the intervention, breadth, family connectedness, and demographics. To the extent of our knowledge, the TEPPS is the only scale developed to quantitatively measure youth participation and there is not enough evidence yet to support its generalizability to different populations and contexts.
      Community-based participatory research (CBPR) is another field that has a lot of potential to promote active adolescent and youth participation at several points of the development of programs and policies [
      • Vaughn L.M.
      • Wagner E.
      • Jacquez F.
      A review of community-based participatory research in child health.
      ]. Under the umbrella of CBPR methodologies, we can find another set of approaches to promote and enable youth participation that have been developed in relation to health promotion and local community development. Youth-led Participatory Action Research (YPAR) includes training young people to identify problems or issues of concern in their communities, doing research to better understand the origin of those problems, and the movement from research to policy, by influencing policies and decisions to improve their living conditions [
      • Ozer E.J.
      • Douglas L.
      Assessing the key processes of youth-led participatory research: Psychometric analysis and application of an observational rating scale.
      ]. Seven central processes for the success of YPAR have been validated: (1) training and practice in research skills; (2) practice in strategic thinking and discussing strategies for influencing change; (3) building supportive networks by reaching out to stakeholders; (4) adults sharing power with young people in the research and action processes; (5) power-sharing among youth participants; (6) opportunities and guidance to work in groups to achieve goals; and (7) development of skills to communicate with other youth and adult stakeholders [
      • Ozer E.J.
      • Douglas L.
      Assessing the key processes of youth-led participatory research: Psychometric analysis and application of an observational rating scale.
      ,
      • Ozer E.J.
      • Douglas L.
      The impact of participatory research on urban teens: An experimental evaluation.
      ].
      Likewise, youth participatory evaluation (YPE) is the process of involving young people in the monitoring and evaluation of programs, organizations, agencies, and systems that have been designed to serve them. The YPE process can be completely youth driven or it can be conducted in partnership with adults. Either way, youth are provided with support to perform as evaluators who can create knowledge, shape their own evaluation questions and indicators, develop unique methods, analyze and interpret the data, and report findings [
      • Sabo-Flores K.
      Youth participatory evaluation: Strategies for engaging young people.
      ]. YPE holds promise in building youth capacity and skills, increasing community engagement, offering a space for self-reflection, and producing changes in their environments by building social capital through the evaluation process [
      • Sabo-Flores K.
      Youth participatory evaluation: Strategies for engaging young people.
      ]. The evidence for this approach is limited but does highlight the need to move youth from being subjects of interventions and research to stages where young people participate actively as consultants, partners, and directors in defining questions and instruments, collecting information, conducting analyses, and disseminating information [
      • Checkoway B.
      • Richards-Schuster K.
      Youth participation in community evaluation research.
      ,
      • Checkoway B.N.
      • Gutiérrez L.M.
      Youth participation and community change: An introduction.
      ].
      Photovoice is also a participatory action research method, based on the health promotion principles of community engagement and empowerment, and the theoretical literature on education for critical consciousness [
      • Wang C.C.
      Youth participation in photovoice as a strategy for community change.
      ,
      • Strack R.W.
      • Magill C.
      • McDonagh K.
      Engaging youth through photovoice.
      ,
      • Wilson N.
      • Dasho S.
      • Martin A.C.
      • et al.
      Engaging young adolescents in social action through photovoice the youth empowerment strategies (YES!) project.
      ]. The methodology entails providing cameras to participants to photograph the environments and communities in which they live and aim to promote critical dialog and knowledge about personal and community strengths and concerns and to reach policymakers.
      Community Youth Mapping (CYM) is a strategy to connect youth to their local setting and promote a deeper discussion on how people define their own communities [
      • Amsden J.
      • VanWynsberghe R.
      Community mapping as a research tool with youth.
      ]. This approach originated from the need to revitalize communities and engage youth with their local environments, to increase the connection to their home communities, and avoid the loss of youth from a community [
      • Miller G.
      • VanSant D.
      • Mullett J.
      Collaborative action research: A catalyst for enhancing the practice of community youth mapping.
      ]. CYM allows youth to explore their communities, to use information gathered to bridge gaps between what is needed and what is available, and to strengthen resources already in place. According to scholars, CYM has several potential benefits, including the enhancement of community engagement from multiple levels, increased collaboration among young people and the extended community, the encouragement of social action, increased understanding and commitment to the community by youth, empowerment to solve local problems, adoption of skills by youth, linking technology and community, and the active participation of youth in civic and public affairs [
      • Miller G.
      • VanSant D.
      • Mullett J.
      Collaborative action research: A catalyst for enhancing the practice of community youth mapping.
      ].
      YPAR, YPE, and photovoice have proven to be an effective way to develop and adapt youth friendly, culturally relevant, critical and socioecological SRHR interventions, curricula, and surveys [
      • Castle S.
      • Traore S.
      • Cisse L.
      (Re)defining reproductive health with and for the community: An example of participatory research from Mali.
      ,
      • Aronson R.E.
      • Rulison K.L.
      • Graham L.F.
      • et al.
      Brothers leading healthy lives: Outcomes from the pilot testing of a culturally and contextually congruent HIV prevention intervention for black male college students.
      ,
      • Gesink D.
      • Rink E.
      • Montgomery-Andersen R.
      • et al.
      Developing a culturally competent and socially relevant sexual health survey with an urban artic community.
      ,
      • Secor-Turner M.
      • Sieving R.
      • Garwick A.
      • et al.
      Culturally sensitive community engaged research with African American young women: Lessons learned.
      ,
      • Kubicek K.
      • Beyer W.
      • Weiss G.
      • Kipke M.D.
      Photovoice as a tool to adapt an HIV prevention intervention for African American young men who have sex with men.
      ,
      • Woods-Jaeger B.A.
      • Sparks A.
      • Turner K.
      • et al.
      Exploring the social and community context of African American adolescents' HIV vulnerability.
      ,
      • Markus S.F.
      Photovoice for healthy relationships: Community-based participatory HIV prevention in a rural American Indian community.
      ,
      • MacDonald J.A.
      • Gagnon A.J.
      • Mitchell C.
      • et al.
      Include them and they will tell you: Learnings from a participatory process with youth.
      ], create relevant STI-prevention messages [
      • MacDonald J.A.
      • Gagnon A.J.
      • Mitchell C.
      • et al.
      Include them and they will tell you: Learnings from a participatory process with youth.
      ,
      • MacDonald J.A.
      • Gagnon A.J.
      • Mitchell C.
      • et al.
      Asking to listen: Towards a youth perspective on sexual health education and needs.
      ], deliver sensitive SRHR messages and information to adolescents and young people [
      • Fredland N.M.
      Nurturing healthy relationships through a community-based interactive theater program.
      ], build academic–community partnerships to prevent HIV among young people and other at risk populations [
      • Lloyd S.W.
      • Ferguson Y.O.
      • Corbie-Smith G.
      • et al.
      The role of public schools in HIV prevention: Perspectives from African Americans in the rural south.
      ], and increase the leadership capacities of young leaders in HIV-related projects, including confidence and personal skills, increased knowledge and attitudes on SRHR topics and knowledge-sharing skills, role modeling skills, and program ownership [
      • Fongkaew W.
      • Fongkaew K.
      • Suchaxaya P.
      Early adolescent peer leader development in HIV prevention using youth-adult partnership with schools approach.
      ].
      Likewise, some researchers have also used multiple participatory methodologies (CYM and photovoice combined, for example) to be able to better understand community resources as well as adolescents' and young people's needs related to SRHR [
      • Decat P.
      • Nelson E.
      • De Meyer S.
      • et al.
      Community embedded reproductive health interventions for adolescents in Latin America: Development and evaluation of a complex multi-center intervention.
      ,
      • Mmari K.
      • Blum R.
      • Sonenstein F.
      • et al.
      Adolescents’ perceptions of health from disadvantaged urban communities: Findings from the WAVE study.
      ,
      • Abrahams N.
      • Mathews S.
      • Ramela P.
      Intersections of ‘sanitation, sexual coercion and girls’ safety in schools’.
      ]. A critical review of this body of research is out of the scope of this article, but it is a much-needed piece to assess to what extent these CBPR approaches have an impact on youth-related SRHR indicators.

      Discussion

      This review has several limitations. We only searched through English- and Spanish-language reports to identify relevant studies. We conducted searches in six electronic databases and on Internet sites of nongovernmental organizations and UN agencies but may have missed information in our literature review, particularly among the gray literature. For the peer education literature, and given the breadth of the literature in youth participation, we looked at meta-analysis articles and did not consult the original articles, thus we might have missed some of the fine details related to the topic of this article. Moreover, published reports may not represent fully all aspects of any given evaluation study or program, resulting in incomplete information.

      Limitations

      There are few attempts to systematically evaluate youth participation. The use of theoretical frameworks related to youth participation as well as systematic methodologies to monitor and evaluate youth participation is scarce. Only a few interventions have provided research data able to demonstrate that youth participation leads to better SRH outcomes or improved program impact. Those that have been able to demonstrate some impact are mostly applying CBPR methods.
      Interventions and programs implemented globally need to be documented and made available to global audiences, as a way to keep exchanging best practices and growth opportunities. Civil society organizations should, to a larger degree, try to bring their work to the academic publications. Donors of SRHR initiatives could also support an electronic library where civil society organizations could present their work and publish their reports to make them more accessible for researchers as well as the general public and policy makers.
      Cook [
      • Cook P.
      Understanding the effects of adolescent participation in health programmes.
      ] observed that there is little consensus on the effectiveness of adolescent participation in health programs. Nevertheless, participation is a right and should not only be evaluated in terms of effectiveness and impact. There is a need to keep pursuing meaningful youth participation. For this, strong evaluations and methodologies are needed to assess both processes and outcomes of where programs stand and where changes need to be made. In relation to outcomes and effects, it may be important to conduct measurements in such a way as to be able to (partially) assess whether the success of the program can be attributed to its participatory nature.
      Last, understanding youth participation is a dynamic right that touches areas of civil, political, cultural, and social rights and could potentially lead to the building of solid youth leadership in relation to not only youth issues but also the broader development agenda beyond 2014.

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