Adolescent & Youth Sexual & Reproductive Health Toolkit Essentials
Key Urban Youth Populations
Designing a youth-focused sexual and reproductive health (SRH) program starts with knowing about the young people in the area you serve.
- Who are they?
- Where do they live?
- What barriers do they face in accessing services and information?
- What factors shape their physical and social environments?
While they have things in common, it is important to keep in mind that “urban young people” are all individuals. Intersecting identities and factors related to age, marriage, education, economic status, family life, employment, sexual orientation, gender, parenthood, ethnicity, migrant status and much more shape their needs and experiences. There is no “one-size-fits-all” model for youth SRH programming. Program design must take all facets of young people’s lives into account, understand their realities and work in direct partnership with young people to fully meet their needs.
As a result of the diversity of young people, researching their SRH as a group is of limited use; research more typically focuses on the needs of vulnerable sub-groups, called “key populations.” These youth populations are not mutually exclusive. For example, a married young person may also be living with HIV and residing in a slum area.
Young People Residing in Slum Areas
Rapid migration to urban environments has fueled the growth of slum areas, which are characterized by poverty, housing insecurity, weak social networks and lack of access to public services. Compared to other urban young people, those residing in slums experience poorer sexual and reproductive health (SRH) outcomes including higher risk of HIV and unplanned pregnancy, due in part to engagement in high-risk sex and sexual debut at a young age (see Speizer, 2012, and Beguy et al., 2014).
Evidence on successful approaches can be drawn from several programs focused on young people residing in slum areas in Asia and Africa. The SAFE project – which focused on women and girls in four slum areas of Dhaka, Bangladesh – found violence and child marriage to be higher there than in rural and non-slum residing urban populations. A lack of public services meant that access to SRH care was lower than in other urban populations. The STEP UP program in Nairobi’s slum areas found that poverty constrained young people’s access to quality health services and information, and led to coercive sexual relationships.
Program designs for young people residing in slum areas should include multi-sectoral collaboration. Interventions that address the economic, education and gender dimensions of young people’s lives have been proven to have the most direct influence on their behavior (Beguy et al., 2014). The STEP UP program made the following key recommendations for working with young people residing in slum areas in Nairobi:
- Youth-friendly services that reach in- and out-of-school young people
- Enhancement of existing services to provide access to the full method mix of contraceptives, including long-acting reversible contraceptives (LARCs)
- Provision of comprehensive sexuality education (CSE)
- Addressing personal security and social support needs
- Transformation of male attitudes toward violence against women and girls
- Addressing education re-entry for pregnant girls
- Access to education and livelihood opportunities
Married Young People
Despite laws and policies banning child, early and forced marriage (CEFM) across the world, each year an estimated 15 million girls are married before the age of 18 (Girls Not Brides, 2017). In most places where CEFM is prevalent, male spouses are much older and have much greater control over decision-making in a range of areas. In Burkina Faso, for example, the 2010 Demographic and Health Survey (DHS) indicated that just 10% of girls in marriage reported taking part in decisions related to their health. Young, married women face significant pressure to begin childbearing soon after marriage, which carries major health risks for girls under 18 years old (Pathfinder, 2016).
While rural areas experience a higher prevalence of CEFM generally, it is clear that poor, urban married young women face additional disadvantages. In Senegal, for example, the vast majority of girls residing in urban environments who were married were also illiterate (Population Council, 2009). The STEP UP program in Dhaka, Bangladesh identified a higher proportion of unintended or mistimed pregnancies among married girls in slum areas (53%) compared to girls in non-slum areas (24%).
While there are not yet urban-specific interventions for working with married young people, there are generalized programmatic recommendations that are likely to apply. For example, Pathfinder has pointed to the importance of working with mothers-in-law and other “gatekeepers” to combat myths and misconceptions related to family planning, pregnancy and childbirth.
“Street-connected youth” is a term used to refer to young people who live on the streets (i.e., homeless young people) or are connected in some way to the population of young people who live on the streets. Street-connected youth are found mostly, if not exclusively, in urban environments.
The lives of street-connected youth are characterized by poverty, as well as vulnerability to sexual and reproductive health problems. Street-connected youth tend to have earlier sexual debut, have a higher number of sexual partners, are more vulnerable to coercive sexual encounters, use condoms inconsistently and receive inadequate information about sex. One result of these factors is that HIV rates among street connected youth are 10–25 times higher than for non-street youth. A study in Ethiopia found that only 15% of street connected youth in the study had accessed health services; for the other 85%, the barriers were too high, including cost of health services, the attitudes of service providers, inconvenient location of services, long waiting times, and fear of breaches of privacy. The same study pointed to the importance of peer-based interventions in reaching street connected youth, who typically place greater trust in information received from those of the same age and social situation (Brhane et al., 2014).
Young People Engaged in Transactional Sex
Transactional sex occurs when money, goods or gifts of any type are traded for sex. Not all young people who engage in transactional sex identify as sex workers. Relationships of this nature often involve a younger woman and an older man, which creates power differentials that can make it difficult for young women to negotiate the use of condoms. Young people may use the words “shuga daddies” or “blessers” to refer to the older men with whom they have sex.
In communities where poverty is prevalent, there is often increased pressure on young women to enter into sexual relationships to meet basic needs. Experts working in the field of adolescent health in the slums of Nairobi pointed to the need to ensure that young women are given access to financial education and asset-building opportunities to increase demand for SRH services (Austrian, 2017).
Young Domestic Workers
Domestic workers are a highly mobile and hard-to-reach population of young people, primarily young women. They are dependent on their employers for survival, frequently live and work under the same roof, and earn exceedingly low salaries for long hours of hard labor. Due to domestic workers’ social exclusion, they are vulnerable to sexual exploitation and poverty. They also lack access to services and justice to mitigate the consequences of their vulnerabilities (Medhin & Erulkar, 2017).
Programs and research targeting young domestic workers illustrate the challenges in accessing them but, also, their great need for SRH services and information. Reaching this population is not impossible. For example, one program in Addis Ababa, Ethiopia, reached approximately 1,500 child domestic workers through door-to-door recruitment, and provided them with opportunities to gain skills and build networks. Formative research and evaluation of the Filles Eveillees (“Girls Awakened”) program in Burkina Faso also showed that girls’ employers generally supported domestic workers’ involvement in opportunities for skills building.
Young People Outside the Formal Education System
Out-of-school young people in urban areas have unique vulnerabilities, due at least in part to their lack of access to comprehensive sexuality education. A Save the Children program for out-of-school youth in Kampala, Uganda, documented that they commence sexual activity at an early age, engage in transactional sex, use alcohol and have poor mental health outcomes. Similar to their in-school counterparts, they also lacked access to responsive SRH services (Save the Children 2015). A separate intervention with out-of-school youth in Uganda highlighted the importance of targeting them where they are, for example at adolescent clubs in their communities.
Young People Living with HIV (YPLHIV)
There are over 5 million young people living with HIV in the world today, and 45% of new HIV infections occur in those aged 15 to 24 years (UNICEF, 2011). HIV affects young women to a greater extent than young men. In Ethiopia, Malawi, United Republic of Tanzania, Zambia and Zimbabwe, for example, for every 15- to 19-year-old boy who is infected, there are five to six girls infected in the same age group (UNAIDS, 2002).
In major urban areas of eastern and southern Africa, studies show that 17% to 22% of girls aged 15 to 19 are already HIV infected due, in part, to more engagement in sexual activity (as compared with young people in rural areas), the “sugar daddy” effect and the prevalence of transactional sex in those contexts (UNAIDS, 2002). HIV has often been called an “urban epidemic,” which highlights the importance of working on prevention and the care and treatment of YPLHIV in urban environments.
Young people living with HIV have unique SRH needs, not least of which is the integration of HIV care and treatment with other SRH services. Contraceptive counseling with YPLHIV may also need to include discussions about disclosure of their HIV status, how to practice safer sex and increased vulnerability to sexually transmitted infections. As with any other client group, YPLHIV have the right to privacy and confidentiality, which may be of particular importance to them due to the stigma experienced by those living with HIV in many contexts.
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Compared to other urban young people, those residing in slums experience poorer sexual and reproductive health (SRH) outcomes including higher risk of HIV and unplanned pregnancy, due in part to engagement in high-risk sex and sexual debut at a young age.CorrectIncorrect
The STEP UP program made the following key recommendations for working with young people residing in slum areas:CorrectIncorrect
Due to young domestic workers’ social exclusion, they are vulnerable to sexual exploitation and poverty. They also often lack access to services and justice to mitigate the consequences of their vulnerabilities.CorrectIncorrect
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Tools Related to This Approach
- Meeting the Sexual and Reproductive Health Needs of Young Married Women and First-time Parents Toolkit, Pathfinder International, E2A Project
- Sexual and reproductive health needs and access to health services for adolescents under 18 engaged in selling sex in Asia Pacific, HIV Young Leaders Fund
- Healthy, Happy and Hot: A young person’s guide to their rights, sexuality and living with HIV, IPPF
- National Sexual Rights Law and Policy Database, Sexual Rights Initiative
- Sexual and reproductive health and rights, and HIV 101 workshop guide: A guide to facilitating a workshop on linking up HIV and sexual and reproductive health and rights with young key populations, International HIV/AIDS Alliance
- Family Planning and HIV Service Integration eLearning course, Global Health eLearning Center