Applying the ecological framework to adolescent sexual and reproductive health
- 1.At the individual level, there is a need to focus on empowering adolescents including through efforts such as those that build the economic and social assets as well as the resources of adolescents.
- 2.At the relationship level, there is a need to build relationships that support and reinforce positive health behaviors of adolescents. This may include interventions that target those close relationships which influence the sexual and reproductive experiences of adolescents, such as parents, intimate and other sexual partners, and peers.
- 3.At the community level, there is a need to create positive social norms and community support for adolescents to practice safer behaviors and access SRH information and services. This involves interventions aimed at broader community members and institutions outside the family—in neighborhoods, schools, and workplaces.
- 4.At the societal level, there is a need to promote laws and policies related to the health, social, economic, and educational spheres and to build broad societal norms in support of SRH and helping adolescents realize their human rights.
Key elements for creating enabling environments
Economic empowerment of girls
|Program and content (and references)||Design and objectives||Outcomes and achievements|
|Type of intervention: economic empowerment of girls: livelihoods, microcredit, cash transfers.|
The World Bank's Zomba conditional and unconditional cash transfer programs in Malawi.
Target population/participants: never-married women aged 13–22 years.
Baird et al.
2008, ‘Conditional cash transfers: A ‘Pathway to Women's Empowerment’?’ Pathways to Women's Empowerment Working Paper 5, Institute of Development Studies, Brighton Available at.
|Objective: reduce the risk of sexually transmitted infections in young girls and increase girls' school attendance.|
Design: paid girls' school fees as well as the girls and their parents monthly, on the condition of satisfactory school attendance, that is, if the girl attended for at least 75% of standard school hours. Another group got unconditional cash payments.
|Type of intervention: mentoring and economic empowerment.|
The Population Council and the K-Rep Development Agency's Tap and Reposition Youth (TRY) program in low-income and slum areas of Nairobi, Kenya.
Target population/participants: serving out-of-school adolescent girls and young women ages 16–22 years.
Erulkar et al.
|Objective: reduce adolescents' vulnerability to adverse social and reproductive health outcomes, including HIV infection, by improving their livelihoods options.|
Design: the program began with a basic model focused on savings and credit; by Phase II, the program had evolved to include elements of social support, which the organizers found was one of the most important program elements. Safe spaces came to be recognized as a core focusof all programs for young women.
|Type of intervention: life-skills training, SRH services, and social support.|
Shaping the Health of Adolescents in Zimbabwe. Implemented in periurban communities outside Harare, Zimbabwe.
Target population/participants: enrolled young women 16–19 years old who had been orphaned and who were currently out of school and not infected with HIV.
Dunbar et al.
|Objective: reduce risk and prevent HIV and STI.|
|Type of intervention: parental engagement and peer discussions.|
Somos Diferentes, Somos Iguales (SDSI) and PATH's Entre Amigas program in Nicaragua.
Target population/participants: young people ages 13–24 years.
Peña et al.
Solórzano et al.
|Objective: to reduce HIV risk and promote young people's rights and individual and collective empowerment in relation to sexual and reproductive health and HIV and to build intergenerational solidarity.|
Design: entertainment–education (edutainment) programs, social mobilization, and local capacity building. Distribution of communication materials to local groups, training for young people, and coordination with nongovernmental organizations and service providers. Intervention engaged girls in peer group discussions, mothers contributed to those peer groups, and the girls watched the carefully designed Sexto Sentido television series on ASRHR and related issues.
|Type of intervention: Life skills, critical reflection, gender awareness.|
Stepping Stones, South Africa. A community intervention program in 70 villages in the Eastern Cape province of South Africa.
Target population/participants: men and women aged 15–26 years who were mostly attending schools. Participants were mostly poor youth.
Jewkes et al.
A cluster randomized-controlled trial to determine the effectiveness of Stepping Stones in preventing HIV infections and promoting safer sexual behaviour amongst youth in the rural eastern cape, South Africa: Trial design, methods and baseline findings.
Trop Med Int Health. 2006; 11: 3-16
|Objective: the overall aim is to improve sexual health, gender-equitable norms, and communication and relationship skills.|
Design: training involves participatory learning to build knowledge, risk awareness, and communication skills and stimulate critical reflection about gender norms, power relationships with intimate partners, and other family and community members.
|Type of intervention: community intervention, education, critical reflection, gender awareness.|
Yari-Dosti: promoting gender equity as to reduce HIV risk and gender-based violence among young men in India. Adaptation of Program H in Brazil involving participatory education and a community campaign for promoting equitable gender norms.
Target population/participants: young men and women.
Khandekar et al.
Pulerwitz et al.
|Objectives: challenge and change inequitable gender attitudes among young men and women (respectively), to reduce risky sexual behavior and violence against women.|
Design: involves peer-led, participatory group education, hourly sessions held every week over 6 months.
Topics include gender equality and sexuality; STI/HIV risk and prevention; partner, family, and community violence; reproductive system; alcohol and risk; and HIV-related stigma and discrimination.
In Mumbai, a lifestyle social marketing campaign reached 100,000 residents, promoting messages of relationships without violence, egalitarian attitudes, a view of women and girls as deserving respect, and shared responsibility for SRH.
At 6-month follow-up, participants were compared with a control group.
A similar intervention was undertaken in Ethiopia, with a three-arm quasi-experimental design in three low-income regions of Addis Ababa with young men aged 15–24 years.
|Type of intervention: community intervention, work with community leaders.|
Berhane Hewan (“Light for Eve” in Amharic), a 2-year pilot project conducted in 2004–2006—a joint program of the Ministry of Youth and Sport and the Amhara Region Youth and Sport Affairs Bureau in Ethiopia.
Target population/participants: girls aged 10–19 years.
Karei and Erulkar
Erulkar and Muthengi
|Objective: aimed to reduce the prevalence of child marriage in rural Ethiopia. Its overall goal is to establish appropriate and effective mechanisms to protect girls at risk of forced early marriage and support adolescent girls who are already married.|
Design: a combination of group formation, support for girls to remain in school, and community awareness.
Held “community conversations,” bringing religious leaders, traditional healers, school administrators, and parents of adolescent girls together to discuss child marriage and other issues in the community. Participants developed an action plan and shared key messages from these meetings with other households in their communities.
|Type of intervention: strengthening the implementation of laws and policies through youth participation.|
Geração Biz in Mozambique, a national multisectoral and multicomponent program.
Target population/participants: in- and out-of-school youth and their social networks.
Pathfinder International and WHO
|Objective: to improve ASRH, increase gender awareness, reduce the incidence of unplanned pregnancies, and decrease young people's vulnerability to STIs, HIV, and unsafe abortion; create an enabling environment for youth SRH through advocacy (local and central) and policy development and implementation support, including technical training in ASRH; strengthen the capacities of institutional partners (government, nongovernmental organizations, and other facilitators/service providers) to plan, implement, monitor, and evaluate multisectoral ASRH interventions.|
Design: improved access to youth friendly health services, school based interventions, and community outreach activities. The Geração Biz project was designed and developed by youth.
Creating safe spaces for adolescent girls
Interventions at the relationship level
- Hargreaves J.
- Boler T.
Mentoring and positive role modeling
Population Council and UN Adolescent Girls Task Force. Girls' leadership and mentoring. Available at: http://www.popcouncil.org/pdfs/2012PGY_GirlsFirst_Leadership.pdf. Accessed February 1, 2014.
Interventions at the community level
Mobilization of adults and community leaders
Working with boys and men to promote gender-equitable norms
- Greene M.E.
- Gary B.
Interventions at the societal level
Promoting laws and policies and their implementation
Media campaigns and large-scale communication programs
- 1.The need to be holistic: making the environment more enabling requires working at multiple levels. For example, multicomponent programs targeting individuals as well as families or communities such as Berhane Hewan in Ethiopia and Yaari-Dosti in India highlighted the importance of working directly with the adolescents as well as communities.
- 2.The need to invest for the long term: changing the environment in terms of social norms, community support, and sustaining behavior change among adolescents and their families requires interventions that invest in long-term programming. For example, in the Stepping Stones intervention, male participants showed higher levels of violence perpetration reduction at 24 months than at 12 months after intervention.
- 3.The need to focus on positive messages: interventions to change social norms may need to focus on positive messages about alternate norms related to masculinity or femininity to connect with the intended audience. For example, the Yaari-Dosti intervention in India was premised on generating positive role models of masculinity.
- 4.The need for more interventions research that includes early adolescents (10–14 years). Several interventions either focused on 15- to 19-year-olds or even included 20- to 24-year-olds. There is increasing evidence that norms and attitudes toward gender and sexuality, which are the basis for sexual behaviors are formed earlier during childhood and adolescence.
- 5.There is also a need for interventions to disaggregate the impact of their interventions for 15- to 19-year-olds separate from 20- to 24-year-olds recognizing that the developmental needs and situations including legal of 10- to 14-year-olds are different from 15- to 19-year-olds and likewise from that of 20- to 24-year-olds.
- 6.The article recognizes the importance of creating enabling environment for both adolescent girls and boys. However, in several instances in the article and the program examples, there has been a larger emphasis on girls. This reflects both, the nature of where programming emphasis on ASRH particularly in low- and middle-income countries has been and the increased global attention to the specific needs of adolescent girls who face increased vulnerability because of gender inequalities. Therefore, there is a need to also strengthen programmatic research for creating enabling environments for boys' SRH in their own right as well as in promoting gender-equitable attitudes and relationships with girls.
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Joar Svanemyr was previously affiliated with the World Health Organization's Department of Reproductive Health and Research in Geneva, Switzerland.
Conflicts of Interest: The authors have no conflicts of interest to report.
Disclaimer: Publication of this article was supported by the World Health Organization (WHO). The opinions or views expressed in this paper are those of the author and do not necessarily represent the official position of WHO.
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