What Does Not Work in Adolescent Sexual and Reproductive Health: A Review of Evidence on Interventions Commonly Accepted as Best Practices

"Youth centers, peer education, and one-off public meetings have generally been ineffective in facilitating young people's access to sexual and reproductive health (SRH) services, changing their behaviors, or influencing social norms around adolescent SRH. Approaches that have been found to be effective when well implemented, such as comprehensive sexuality education and youth-friendly services, have tended to flounder as they have considerable implementation requirements that are seldom met. For adolescent SRH programs to be effective, we need substantial effort through coordinated and complementary approaches."

This commentary from the Global Health: Science and Practice Journal describe adolescent sexual and reproductive (ASRH) health interventions in the last 20 years, with the objective of separating the effective from the ineffective.  The review "suggests at least 5 thematic areas that challenge our ability to demonstrate significantly positive results in ASRH programming:

1. Significant numbers of adolescents are not adequately reached by the interventions intended for them.... [W]ithout  dedicated  outreach for specific subgroups of vulnerable adolescents (such as very young adolescents or married adolescents), the more advantaged (e.g., older and unmarried adolescents and youth) are more likely to be reached by traditional youth programs
2. Interventions that have been shown to be ineffective continue to be implemented....Three widely implemented  interventions - youth centers, peer education, and high-profile meetings on ASRH - have been shown to be ineffective....
3. Interventions that have been shown to be effective are delivered ineffectively....Comprehensive sexuality education (CSE) has been well-evaluated and has been shown to improve adolescent SRH knowledge, attitudes, and behaviors when implemented well." However, to achieve the results of improved knowledge, attitudes, practices, and behaviours (KAPB), programmes often do not contain enough information on "male/female condoms and contraception (including emergency contraception)" or "information about reproduction, sexually transmitted infections, abortion, and where to access condoms and sexual health services" or "attention to empowering young people, building agency, or teaching advocacy skills." In addition, ASRH services need to have: providers who have been trained to be non-judgmental; friendly facilities that are welcoming and appealing; communication and outreach to encourage adolescent use of services; and community member support.
4. "Interventions have limited effects because they are delivered piecemeal." Because ASRH behaviours and choices are dependent on a web of interrelated factors, focus on fragmented issues and interventions can have a negative effect, such as advocacy for laws on early and forced marriage that are not followed up with keeping girls in school and strengthening employment options.
5. "Interventions are delivered with inadequate dosage (i.e., they are of low intensity or for a short duration) resulting in limited or transient effects....Dosage matters. A review of behavioural interventions to reduce HIV, sexually transmitted infections, and pregnancy in adolescents showed that programs delivered with greater intensity or for a longer duration were more effective than shorter programs...."

The commentary suggests less focus on single behaviours and more consideration of the "co-occurrence of problem behaviors" so that there is better understanding of the overlap in predictors across many behaviours. Prevention research, now being applied in developed countries, uses the strategies of "identifying malleable risk and protective factors, assessing the efficacy and effectiveness of preventive interventions and identifying optimal means for dissemination and diffusion." A research base from developed countries, based upon controlled trials, is now being applied to low- and middle-income countries" by translating existing approaches and developing and testing new preventive interventions in lower-income contexts."

The commentary concludes that there are "gaps in knowledge and understanding of effective adolescent health programming, especially at scale." Scale-up of what works is urgent due to the growing youth population. However, authors warn: "...we must stop the implementation of ineffective interventions that waste human and financial resources and raise questions about the value of policies and programs that do not demonstrate results." They recommend using evidence-based approaches that "simultaneously address risk and protective factors for adolescents in lower- and middle-income countries. This should include the creation of a database that documents best and promising practices in prevention science and adolescent health."