Adolescent and Youth Sexual and Reproductive Health

 

Welcome to the programmatic area on adolescent and youth sexual and reproductive health (AYSRH) within MEASURE Evaluation’s Family Planning and Reproductive Health Indicators Database. AYSRH is one of the subareas found in the sexual and reproductive health (RH) section of the database. All indicators for this area include a definition, data requirements, data source(s), purpose, issues and—if relevant—gender implications. There are nearly two billion young people in the world today who have specific health and development needs, and many face challenges that threaten their well-being, including poverty, a lack of access to health information and services, and unsafe environments (Fikree, 2017). Investments AYSRH focus on achieving one or more of four major goals: creating an enabling and supportive environment for young people; improving their knowledge, attitudes, skills and behaviors; increasing young people’s use of services; and increasing young people’s participation in programs. Key indicators to monitor and evaluate AYSRH can be found in the links at left.   Full Text More than 1.75 billion individuals in the world today are young people (aged 10-24 years) (WHO, 2008).  Adolescents (aged 10 to 19 years) have specific health and development needs, and many face challenges that threaten their well being, including poverty, a lack of access to health information and services, and unsafe environments.   Considering that youth aged 15 to 24 accounted for an estimated 45% of new HIV infections worldwide in 2007 and about 16 million girls aged 15 to 19 give birth every year (WHO, 2010), adolescents' and youths' sexual and reproductive health (AYSRH) needs --particularly girls -- deserve considerable attention and resources.    In the past decade, more programs have targeted AYSRH because: Existing human rights treaties, including the Convention on the Rights of the Child and the Convention on the Elimination of All Forms of Discrimination against Women, make it right, in principle. It is an effective way to consolidate and sustain global gains achieved in early and middle childhood since 1990 (e.g. reducing the under-five mortality rate, reducing gender gaps in primary school enrolment). Investing in adolescents can accelerate the fight against poverty, inequality and gender discrimination. Preconception care and contraceptive use can prevent unintended pregnancies, unsafe abortions and sexually-transmitted infections in adolescent girls and young women (Dean, Lassi, Imam and Bhutta, 2014). Young people need to be empowered and equipped with the skills and capacities to address pressing global challenges (e.g. climate change and environmental degredation, burgeoning urbanization and migration, frequent humanitarian crises). Although adolescents are commonly referred to as the "next" or "future generation", they require protection and care, services, opportunities, support, and recognition now (UNICEF, 2011). AYSRH programs may assume a variety of forms and may appear in a variety of settings. Among the more common program types are: AYSRH programs focus on achieving one or more of four major goals:  1. Creating an enabling and supportive environment for young people  2. Improving their knowledge, attitudes, skills, and behaviors 3. Increasing young people's use of services and  4. Increasing young people's participation in programs. Sexual-reproductive health or life-skills education programs in schools; Mass media-based behavior change and social marketing interventions; Programs to make reproductive health services more "youth- friendly"; Community-based non-formal education programs; Community mobilization campaigns;  Workplace-based reproductive health education programs; Youth clubs/organizations; Livelihood programs to generate economic opportunities for youth; and Advocacy campaigns to influence political and cultural leaders (and adults in general). It is worth noting some differences in terminology.  WHO defines adolescents as 10-19 years old, youth are 15-24 years old, and young people are 10-24 years old.  Most currently available data is for 15-24 year olds, or "youth".  Most of the indicators presented here are for adolescents and/or youth, which cumulatively captures the entire age range of young people. Methodological Challenges of Evaluating AYSRH Programs As they do in other areas of RH, program officials and evaluators face a number of formidable methodological challenges in assessing the performance of AYSRH programs. Together, these challenges make the evaluation of AYSRH programs among the more difficult types of RH programs. Specific methodological challenges include the following: A myriad of factors heavily influence adolescent behaviors.  Adolescent behaviors are influenced in important ways by a sizeable number of factors operating at the individual, family, school, community, and societal levels. Granted, these same factors influence adults, but because adolescents have not fully developed-- socially, psychologically, and physically -- they are perhaps more susceptible to "contextual" or "environmental" influences than are adults. This susceptibility requires that programs address a number of determinants or "antecedents" of adolescent behaviors simultaneously. Evaluators must measure and "control for" a sizeable number of factors in order to tease out the effects of specific AYSRH interventions. Furthermore, evaluators often find themselves beyond the bounds of their own disciplinary training in dealing with the range of factors (e.g., relationships with family, school, and community; selfesteem; self-efficacy). The intended effects of AYSRH interventions are long-term for some interventions, further complicating evaluation. The appropriate time-reference for measuring the impact of an AYSRH program is tricky. For some outcomes, (e.g., delayed age of sexual initiation), the desired result/ behavior is a short-term phenomenon an evaluator can accurately measure within the typical time-frames of most program evaluations (usually two to three years or less). For other outcomes, however, evaluators require longer periods of observation.  Further complicating matters is that, in some cases, program effects may be short-term or transitory in nature. For example, an evaluation of school-based AYSRH education programs in Jamaica found significant effects on knowledge, attitudes and behaviors when measured nine months after program implementation, but these effects had largely disappeared when measured again after 21 months (Eggleston et al., 2000). Thus, strong impact evaluations of AYSRH programs require evaluators to measure impact at several points in time after program implementation. Measuring the quality of AYSRH programs requires an understanding of cultural constructs in the local setting. Assessing the quality of AYSRH programs from the "client's perspective" requires the evaluator to elicit subjective interpretations, perspectives, and meanings from youth and others in the community. As a result, a combination of qualitative and quantitative data are generally required for the meaningful evaluation of AYSRH programs. AYSRH programs are often quite complex, multicomponent initiatives. Because AYSRH programs must simultaneously address multiple "risk" and "protective" factors, a sizeable and growing number of programs have complex designs and multiple components. For example, many programs have life-skills education, peer promotion, community mobilization, and access to RH services components. Measuring the impact of each of the separate components is especially difficult, and as a result, program evaluations often focus on the net or combined impact of the full "package" of interventions.  AYSRH programs produce effects at more than one level. Although AYSRH programs primarily focus on influencing adolescent behaviors and RH outcomes, programs often attempt to bring about change at more than one level. For example, some programs mobilize community support for and involvement in initiatives and activities for youth. Failure to garner such community involvement could greatly diminish the effectiveness of the program in changing the attitudes and behaviors of adolescents at the individual level. Without measuring change (or lack thereof) at the community level, the evaluator could not accurately interpret the lack of change at the individual level. Sensitivities to AYSRH programs and to issues of adolescent sexuality complicate measurement in many settings. Many societies regard the intended outcomes of AYSRH programs as personal and private. Some societies even prohibit discussions about sexual behavior and personal relationships. Program officials and evaluators may face parental and community resistance to asking adolescents questions about these topics. Because of the social sensitivities surrounding adolescent sexual behaviors, evaluators face more rigid informed/parental consent procedures for AYSRH programs than for other types of RH programs. AYSRH indicators overlap with other areas of RH. Some indicators described elsewhere in this database are relevant to AYSRH programs. For example, most or all of the cross-cutting indicators can apply to AYSRH programs as well as to other types of RH programs. However, the nuances involved in AYSRH programs necessitate several specific indicators even in these generic areas. It should be noted that evaluators should collect and report outcome indicators for adolescent programs by gender. There is not a universal definition of "youth". Unlike the various stages of pregnancy and infancy which have precise timelines and age ranges, the period of youth can vary by organization, project, and individual. WHO defines adolescence as 10-19 years, youth as 15-24 years, and young people as 10-24 year old.  The USAID Youth in Development Policy (2012) considers those age 10-29 as youth.  However programs  decide to define the age range for youth, it should be noted and tracked consistently. ____________ References: WHO. 10 facts on adolescent health. September, 2008.  Available at: http://www.who.int/features/factfiles/adolescent_health/en/index.html WHO.  Young people: health risks and solutions.  Fact sheet No 345.  August, 2010. UNICEF.  The State of the World's Children 2011: Adolescence - An Age of Opportunity.  NY, NY.  February, 2011. Dean SV, Lassi ZS, Imam AM, and Bhutta ZA. 2014. "Preconception care: promoting reproductive planning." Reproductive Health 11(Suppl 3):S2. Eggleston E, Jackson J, Rountree W, and Pan Z.  2000.  "Evaluation of Sexuality Education Program for Young Adolescents in Jamaica." Pan American Journal of Public Health 7, 2: 102-112.

Existence of supportive adolescent and youth sexual and reproductive health policies

Definition:

This indicator is a composite index measuring the ex­tent to which the overall policy environment in a coun­try supports adolescent and youth sexual and reproductive health (AYSRH) concerns. The index assesses the existence of:

Evaluators score the index by assigning a value of 2 when the policy environment fully satisfies a given con­dition, 1 when it partially satisfies the condition, and 0 when it fails to satisfy the condition.

Data Requirements:

Evidence of the presence or absence of each of the items included in the index.

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Government documents or other means of verifying the existence of relevant policies, legislation, or regulations; interviews with government officials and key informants

Purpose:

As is the case for family planning programs, a favor­able (or at least not hostile) policy environment is es­sential for the operation and expansion of AYSRH programs. Although few countries have explicitly restrictive policies, because of the so­cial sensitivity surrounding AYSRH issues, many coun­tries lack formal policies regarding the provision of RH information and services to youth. The absence of for­mal policies permits administrators and service provid­ers to impose restrictions based on their personal be­liefs that prohibit youth from gaining access to essen­tial information and services. This indicator measures whether formal policies that enable and support the pro­vision of RH information and services to youth have been enacted.

Issue(s):

Because educators and service delivery staff have personal biases toward and discom­fort in addressing AYSRH issues, the mere existence of policies does not guaran­tee the implementation of those policies. Evaluators may expand the indicator to include scores on the ex­tent to which each policy is actually being implemented. A separate indicator measures the actual availability of and access to relevant information and services by youth.

Adolescents are/were involved in the design of materials and activities and in the implementation of the program

Definition:

This qualitative (yes/no) indicator measures adolescent participation in a program. The evaluator assigns a “yes” score if adolescents participated in the program in a meaningful way.  This is assessed by determining if the participation included:

  1. program design (did adolescents from the intended audience participate in designing the program by com­municating their needs and preferences) and
  2. pro­gram implementation (did the adolescents help imple­ment the program).

Data Requirements:

Program documents or other evidence that (1) the pro­gram designers assessed the needs of the program‘s in­tended audience through a participatory process entail­ing significant input from youth in the program‘s in­tended audience, (2) the findings from the assessment helped shape program design and strategy development, and (3) youth play key roles in program management or in the delivery of services.

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Program records; interviews with program staff; inter­views with adolescents participating in the assessment and program design; interviews with youth involved in program implementation

Purpose:

Most adolescent reproductive health experts concur that youth participation in program design and implementation targeted toward addressing the needs of adolescents, enhances program appeal and effectiveness.  This indicator provides a qualitative measure of the extent of meaningful partici­pation by youth in the program‘s design and implemen­tation. Youth have "meaningful participation“ if they play a major role in carrying out the assessment, in de­riving conclusions from the assessment data gathered, in designing the program, and in managing and carry­ing out program activities.

Issue(s):

Although there is stated criteria for determining adolescent involvement in program design and implementation, determining "meaningful involvement" is still somewhat subjective and needs to be further defined by the evaluator.

Number of young people trained as peer educators

Definition:

This output level indicator measures the number of young people (10-24) who have completed a training course in adolescent and youth sexual and reproductive health (AYSRH) peer education. An individual should only be counted after they have completed the training. Individuals that are mid-way through a training course should be counted in the next reporting period. Individuals attending more than one peer education training during a reporting period should be counted only once.

Data Requirements:

Number of persons trained (based on an actual list of names for potential verification purposes) and training topic. Data can be disaggregated by gender, in school/out of school and urban/rural residence.

If targeting and/or linking to inequity, classify trainees by areas served (poor/not poor) and disaggregate by area served.

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Training sign-in sheets, training reports, program reports

Purpose:

This indicator serves as a crude measure of peer educator training programs.  Evaluators can use it for determining whether a program/project meets its training target and/or for tracking progress from one year to the next. When aggregated, it also represents human resource potential of peer educators who could assist in carrying out AYSRH education programs.

Peer education is the process whereby well-trained and motivated young people undertake informal and organized educational activities with peers who are similar in age, background or interests (UNAIDS 1999). Peer educators often serve as role models, demonstrating to their peers behaviors that promote risk-reduction. It is generally used in conjunction with other strategies such as media campaigns, youth-friendly services to reach young people with information and skills (Population Council 2000).

Peer education training consists of technical areas of SRH, as well as training methodologies, personal skills and confidence building (Pfiffner, 2005).

Issue(s):

Because this indicator does not capture the number of participants who become active peer educators it should be used in conjunction with Percent of young people trained as peer educators who are active during a reference period.  Furthermore, it does not indicate knowledge gained or what the quality of the training was.

Evaluators can further improve the measure in several ways:

Gender Implications:

Peer educator trainees can vary substantially by age and sex and evaluators should disaggregate data accordingly. Strategies to increase retention of a particular age bracket or sex may be necessary based on the results of this indicator.

In addition, if used with Percent of young people trained as peer educators who are active during a reference period, gender aggregated data from both indicators can help look at trends in training and subsequent retention of active peer educators.

Further, a gender perspective on evaluating training is available in the indicator Number of trainees by type of personnel and topic of training.

References:

Adamchak SE. Youth Peer Education in Reproductive Health and HIV/AIDS: Progress, Process, and Programming for the Future, 2006. Family Health International, YouthNet Program (Youth Issues Paper 7).

Population Council Horizons Project, 2000. Peer Education and HIV/AIDS: Past Experience, Future Directions.

UNAIDS, 1999. Joint United Nations Programme on HIV/AIDS. Peer education and HIV/AIDS: Concepts, uses and challenges. UNAIDS Best Practice Collection;UNAIDS/99.46E.

Pfiffner S editor 2005. Youth Peer Education Toolkit: Training of Trainers Manual. Second ed. New York, NY: United Nations Population Fund.

Percent of young people trained as peer educators who are active during a reference period

Definition:

This indicator measures retention of active peer educators after training within a given reference period. An active peer educator refers to a peer educator (aged 10-24) who has completed a training course in adolescent and youth sexual and reproductive health (AYSRH) and continues to conduct peer education activities on topics related to AYSRH including life skills. The definitions of ‘active peer educator’ and the ‘reference period’ must be operationally defined in terms specific to the project design and the monitoring system (e.g., a peer educator who attends at least 85% of supervision meetings and reports at least a set target number of peer contacts during a specific time interval).  The reference period selected (e.g., quarterly, biannually, annually) will significantly impact the measurement and results of this indicator and should be carefully considered when defining the indicator.

This indicator is calculated as:

(# of active peer educators / total # of peer educators trained) x 100

Data Requirements:

The definition of active peer educator, a reference time period, and a system for recording peer educators' activities must be determined prior to project initiation. Projects should record the total number of peer educators trained in order to determine the denominator of the indicator.

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Peer educator activity reporting forms or program activity attendance records for the given reference period.

Purpose:

This indicator measures peer educator retention (defined as a peer educator who is still actively conducting activities for which he/she was trained) over a specified amount of time post-training. Peer educator retention is a critical element of successful program implementation and contributes to program quality and sustainability. This indicator allows programs to actively monitor retention and develop and modify strategies to retain peer educators based on program needs.

Issue(s):

There are several key issues to be aware of. The indicator depends on a clear and consistent definition of ‘active peer educator’ that is applied throughout the life of the project. While the indicator should be consistent within a project, it will not necessarily be consistent across projects and is not designed to be used for comparison between projects unless the definition and reference period are the same.  Given that the indicator depends on definitions created by programs, one should be careful about inferring that a high retention rate means a program is successful or sustainable. In addition, the indicator does not measure the quality or content of peer educator counseling or other activities. It is also not designed to quantify the number of peer educator contacts or other monitoring information.

Gender Implications:

Peer educator retention can vary substantially by age and sex and evaluators should disaggregate data accordingly. Strategies to increase retention of a particular age bracket or sex may be necessary based on the results of this indicator.

Number/percent of health workers trained to provide adolescent and youth-friendly services

Definition:

The percent of program staff specifically trained to work with or provide information, education, or family plan­ning services to adolescents

This indicator is calculated as:

(# of program staff who have received specific training to provide education/ counseling or adolescent health care /Total # of program staff working with adolescents) x 100

Data Requirements:

Number of program staff working with adolescents, number (of these) who received specific training to pro­vide education/ counseling or adolescent health care.

If targeting and/or linking to inequity, classify trainees by areas served (poor/not poor) and disaggregate by area served.

Data Sources:

Program personnel files/records

Purpose:

Working with youth requires perspectives and skills often lacking in standard pre-service training. This in­dicator measures the extent to which program person­nel working with adolescents have received specific training to provide services to adolescents. Services may include outreach, information, education, counsel­ing, referral, and reproductive health services.

Issue(s):

This indicator only measures staff exposure to training; it does not measure the quality of the training or the staff competence in working with adolescents as a re­sult of the training.  A follow-up indicator could be Number/percent of trainees who have mastered relevant knowledge (found in the Training section of this database).

Percent service delivery points providing youth friendly services

Definition:

This indicator is a composite index measuring whether reproductive health services are “youth friendly.” Ser­vices are “youth friendly” if they “have policies and attributes that attract adolescents to the facility or pro­gram, provide a comfortable and appropriate setting for youth, meet the needs of adolescents, and are able to retain their adolescents for follow-up and repeat visits” (Senderowitz, 1999). Aspects of an “adolescent friendly” environment can include space or rooms dedi­cated to ARH services, policies and procedures to en­sure privacy and confidentiality, peer educators on site, nonjudgmental staff, and acceptance of drop-in clients.

Data Requirements:

Evidence as to whether reproductive health services satisfy standards for being “youth friendly.”  The fol­lowing characteristics make facilities/services “youth friendly:”

 

Evaluators create this index by assigning a score to each item: 2 points for complete fulfillment of the condition, 1 point for partial fulfillment of the condition, and 0 for lack of fulfillment. Evaluators may derive a total facil­ity score if they first sum the item scores and then di­vide that result by the total number of points possible (Nelson, MacLaren, and Magnani, 2000).

Data Sources:

Facility records; facility inventories; interviews with adolescent clients, providers, and managers at clinics; client exit interviews; interviews of youth in the com­munity

Purpose:

Because reproductive health services in most settings have been designed for older, married women, unmar­ried female and male adolescents face a variety of bar­riers to service use. Among these are policies that re­strict their access to services and information, negative community attitudes toward providing reproductive health services to unmarried adolescents, adolescent embarrassment at being seen at facilities, and fear that the facility will not honor privacy and confidentiality.

To overcome these barriers, a number of service-pro­viding organizations have sought to make their services more “youth friendly.” By offering more youth-friendly reproductive health services, programs may effectively attract young people and may provide quality reproduc­tive health services in a comfortable and responsive environment. Adolescents can receive services in a health facility, such as a clinic, health post or hospital, from trained personnel who provide services in a work­place or school setting, through community outreach workers or peer educators. Regardless of the venue, services must have special characteristics that attract, serve, and retain adolescent clients.

 This indicator is most appropriate for assessing facili­ties and services that were not specifically designed for adolescents (such as a family planning clinics, health posts, or pharmacies), because adolescent facilities were presumably designed with the characteristics of ado­lescent friendliness in mind. However, this indicator can also monitor the adolescent friendliness of adoles­cent-centered facilities over time. For example, after a baseline assessment, the program manager may plan to make changes in services over the next 6 months and may allow those changes to become part of the service-delivery protocols over the next 12 months. The pro­gram manager may then decide to undertake a follow-up assessment 18 months later to determine if the changes occurred. The follow-up assessment should measure the same characteristics it measured in the ini­tial assessment.

The Pathfinder International-developed Rapid Assessment of Youth Friendly Reproductive Health Services (2003) can be used for the initial assessment.  If a facility wishes to quantify its status as one that provides youth friendly services, the Certification Tool for Youth Friendly Services (Pathfinder, 2004) can be used.

Sexual and reproductive health education curriculum conformity to "best practices"

Definition:

This qualitative (yes/no) indicator measures the extent to which the program‘s sexual and reproductive health (SRH) education curriculum contains all (or most) of the features identified as “best practices“ or “key ele­ments“ of effective SRH programs.  Alternatively, the indicator can serve as an index or scale indicating the percent of best practices and key elements that the pro­gram has incorporated into it‘s curricula and materials.

Data Requirements:

Content analysis of the curriculum; accompanying ma­terials; and activities that permit an assessment of con­formity with “best practices”

Data Sources:

Content analysis of program curriculum, materials, and learning methodologies; observation of actual delivery; interviews or focus groups with youth; or self-reported questionnaires from youth who participated in the pro­gram

Purpose:

This indicator measures the quality of SRH education efforts focusing on curriculum content. The indicator reflects how well the program covers key aspects of SRH edu­cation and how appropriate the content is for the age-group of adolescents reached. A growing consensus requires that comprehensive sexuality education should cover, at minimum, the following four primary goals:

  1. Provide information about human sexuality, including human development, relationships, personal skills, sexual behavior, sexual health, and society and culture.
  2. Provide an opportunity to question, explore, and assess sexual attitudes in order to develop values, increase self-esteem, create insights concerning relationships with members of both genders, and understand obligations and responsibilities to others.
  3. Help develop interpersonal skills, including communication, decision-making, assertiveness, and peer refusal skills-and help to create satisfying relationships.
  4. Help create responsibility regarding sexual relationships, including addressing abstinence, resisting pressure to become prematurely involved in sexual intercourse, and encouraging the use of contraception and other sexual health measures.

 

Illustrative guidelines for sexuality edu­cation in the U.S. provided by SIECUS (1996) and Kirby (2001) enumerate ten characteristics that suc­cessful SRH education programs in the U.S. share:

Program delivery may be non-didactic and thus more effectively reach adolescents; for example, seminars, drama events, musical presentations, sports.

Issue(s):

Setting universally ap­propriate criteria is difficult because of cultural and socio-economic differences across and within countries. These criteria, developed from programs in the U.S., may not be appropriate in some other countries.

Number/percent of schools offering comprehensive sex education

Definition:

The number or percentage of primary and secondary schools with at least one teacher who has been trained in comprehensive sex education and who has taught the subject at least once in the last academic year (UNAIDS 2008).

According to SIECUS, Comprehensive Sexuality Education are sexuality education programs that operate throughout primary and secondary education which:

These programs should also cover information on a broad set of topics related to sexuality including:

Within each country “comprehensive sex education” is a term which needs to be operationally defined (UNESCO 2009). Some countries have national reproductive health policies, strategic plans or laws which dictate what should or cannot be included in the sexual health education offered at public, government run schools.

As a percentage, this indicator is calculated as:

(Number of schools with at least one teacher trained in, and regularly teaching, comprehensive sex education / Total number of schools surveyed) x 100

Data Requirements:

Responses to school-based surveys asking school administrators or principals if comprehensive sex education has been offered at their school the last academic year (UNAIDS 2008)

Principals/directors of a nationally representative sample of schools (including both private and public schools, and primary and secondary schools) should be briefed on the definition of comprehensive sex education and are then asked the following questions.

A “qualified teacher” is one who has participated in and successfully completed a training course focusing on the skills required that aim to develop knowledge, positive attitudes and skills (e.g. interpersonal communication, negotiation, decision-making and critical thinking skills and coping strategies) that assist young people in maintaining safe lifestyles.

“Throughout” means at least 5–15 hours of comprehensive sex education programming per year per grade of pupil.

The criterion of teaching “on a regular basis” is grounded in research showing that programs of high quality can produce good outcomes after 5–15 hours of life-skills based comprehensive sex education programming per year per grade of pupil.

The time dimension of “the last academic year” depends on the educational calendar in the country concerned (usually 9−10 months in one calendar year, designed to allow students to complete one educational level or grade) (UNAIDS 2008).

The data can be disaggregated by school type such as urban, rural, public private, primary, or secondary.   In addition, evaluators may wish to look at school attendance registers to get a crude estimate of how many students may have received comprehensive sex education.

Data Sources:

Institutional records, school-based survey, interviews with school principals or directors

Purpose:

This indicator is a measure of progress in implementing comprehensive sex education in schools.  It reflects coverage by school and estimates the proportion of schools that report having such programs.

Few individuals receive adequate, comprehensive education on sexuality. This leaves many potentially vulnerable to coercion, abuse and exploitation, unintended pregnancy and sexually transmitted infections (STIs), including HIV (Population Council, 2007). Many young people approach adulthood faced with conflicting and confusing messages about sexuality and gender.

Because there is no other government sponsored system which reaches as many individuals as the school system, it provides a crucial means for reaching adolescents with the information and skills that are a necessary part of stopping the spread of HIV and preventing unwanted pregnancy. There is strong evidence that school-based sex education can be effective in changing the knowledge, attitudes and practices that lead to risky behavior (UNESCO 2009).

With the increase in numbers of children who are completing primary education, there is an important opportunity to begin to work comprehensive sex education into standard curricula in primary and secondary education. Increased knowledge about how to reduce risk is also a major step toward achieving Millennium Development Goal # 6, target 6B, halting the spread of HIV by 2015. In addition, this indicator references sex education and is closely tied to the UNGASS indicator “By 2005: ensure that at least 90% and by 2010 at least 95% of young men and women, 15–24, have access to information, education including peer and youth-specific HIV education and services necessary to develop the life skills required to reduce their vulnerability to HIV infection, ” although it makes a point of including more comprehensive knowledge around issues of sex and sexuality.

Issue(s):

This is not a measure of quality of comprehensive sex education and therefore can be combined with the indicator, Sexual reproductive health education curriculum conformity to “best practices”. Single programs conducted by outside agencies or facilitators at the school should be excluded as they are generally done on an ad hoc basis. This indicator tracks the systematic inclusion of comprehensive sex education into the curriculum. The indicator may not capture the total effort of providing comprehensive sex education through schools, because students may be able to obtain some information from extracurricular sources (e.g. educational pamphlets, posters, special assemblies) (UNAIDS 2008).

Gender Implications:

This indicator does not track who is getting comprehensive sex education through the school system, only that it is being offered. Because of cultural norms in some countries that favor boys’ school attendance over girls’, collecting attendance rosters, disaggregated by sex, can help identify whether girls and boys are accessing comprehensive sexual education equally.

References:

UNAIDS, 2003 The HIV/AIDS Response by the Education Sector: A Checklist UNAIDS Inter-Agency Task Team for Education Working Group to Accelerate the Education Sector Response to HIV/AIDS. Washington DC: World Bank.

WHO, 2007 National AIDS programmes: a guide to indicators for monitoring and evaluating national HIV/AIDS prevention programmes for young people World Health Organization.

WHO/UNFPA, 2007. National-level monitoring of the achievement of universal access to reproductive health : conceptual and practical considerations and related indicators -- report of a WHO/UNFPA Technical Consultation, Geneva.

Learning to Live: Monitoring and Evaluating HIV/AIDS Programmes for Young People Save the Children Douglas Webb and Lyn Elliott, Abbreviated Version, 2002 With support from UNAIDS and DFID.

Guidelines for Comprehensive Sexuality Education 3rd Edition National Guidelines Task Force, Sexuality Information and Education Council of the United States 2004. http://www2.gsu.edu/~wwwche/Sex%20ed%20class/guidelines.pdf.

Percent of adults in community who have a favorable view of the program

Definition:

The percent of adults from the intended audience in the geographic area covered by the adolescent and youth sexual and reproductive health (AYSRH) program who report that they “like,” “support,“ or “agree“ with the goals, ob­jectives, and activities of the program

This indicator is calculated as:


# of adults who have a favorable view of the program x 100

_____________________________________________

Total # of adults surveyed

Data Requirements:

Responses to survey questions on adult views of the program

Data Sources:

Surveys of adults in the population covered by the pro­gram

Purpose:

Although a positive image among adolescents is the most crucial, parental and adult perceptions of AYSRH programs are also important to program success in view of the key role adults play in shaping adolescent atti­tudes and perceptions. If parents and adults in the com­munity disapprove of a program, their lack of support often influences the attitudes and behaviors of adoles­cents. The importance of adult perceptions and sup­port are demonstrated in a study in Zambia, which found that trends in adolescent use of SRH services were more strongly associated with adult acceptance of providing such services to youth than at­tributes of the services themselves were (Nelson, Magnani, and Bond, 2001).

Percent of adolescents aware of the program

Definition:

The percent of adolescents who report knowing of the adolescent and youth sexual and reproductive health (AYSRH) program's services and/or activities

The services and activities will be specific to each pro­gram. Thus, the indicator may refer to SRH or life-skills education in schools or work­places; RH services at clinics or youth centers; the existence of youth organizations, and radio or television programs for youth.

This indicator is calculated as:

(# of adolescents aware of the program/ Total # of adolescents surveyed) x 100

 

Data Requirements:

Responses to survey questions on awareness of the program‘s existence and activities by adolescents.  The preferred procedure is to first ask about program‘s ser­vices for youth without prompting; then, for adolescents who do not spontaneously report knowledge of the pro­gram, to identify the program and ask if the respondent has heard of it.  If the program has a discernable logo, the evaluators may want to show the logo and ask the respondent if s/he recognizes it or knows what it is for.

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Survey of adolescents in the program‘s intended popu­lation

Purpose:

Before adolescents can use a program, they must know it exists. This indicator provides program managers with a basis for assessing whether they must initiate promo­tional or awareness-raising activities as part of their youth initiative.

Number/percent of adolescents served or reached by the program

Definition:

The number of adolescents who have received program services, have participated in program activities, and have been exposed to program mass media messages

The evaluator can subdivide the total number exposed by the type of activity: school-based program, clinical services, youth center activity.  In addition, surveys (if used) can show the percent reached by mass media messages. The evaluation can also classify participants in these activities by relevant characteristics such as: age, gender, marital status, race/ethnicity, socio-eco­nomic status, school matriculation status, employment status, pregnancy history, history of sexually transmitted infections, and contracep­tive use history.

As a percentage, this indicator is calculated as:

(# of adolescents served or exposed to the program/ Total # of adolescents in the intended population) x 100

Data Requirements:

Program service statistics or comparable data indicat­ing the number and characteristics of adolescents served by the program; responses to survey questions on expo­sure to or participation in program activities. Where feasible, evaluators can collect comparable data on ado­lescents not served or reached by the program to verify that the program is reaching its intended audience and to identify under-served segments of the adolescent population.

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Program records or surveys of the program‘s intended population/audience In programs that provide differ­ent types of services (e.g., youth centers offering recre­ational, educational, and health services), evaluators should compile service statistics separately for each major type of service or activity.

Purpose:

This indicator measures the volume and characteristics of adolescent clients who participate in program activi­ties or use program services. The exact wording of the indicator will vary by type of program.

Evaluators can readily compile data on the number and characteristics of adolescents that attend program ac­tivities or seek clinical services at fixed sites. To mea­sure the reach of mass media and similar programs, evaluators can survey the intended audience and thus obtain counts or estimates of the percentage of adoles­cents “exposed“ to specific communication programs.

In addition to the number and percent of adolescents in the intended population served or reached by the pro­gram, the evaluator should ascertain if the program reaches key sub-groups of adolescents. For example, health facility-based programs that reach primarily older, married females who have previously been pregnant will likely have a very different population impact than will comparable programs that reach younger, unmarried adolescents of both genders. Similarly, —low-risk“ youth recruited as peer promoters who contact and engage other low-risk youth will likely have a very different population impact than will higher-risk youth recruited to contact other higher-risk youth.  In short, the evalua­tor needs to verify that the program is reaching the sub­groups of interest within the population at large.

Sexual and reproductive health knowledge

Definition:

This indicator is a composite indicator or index mea­suring adolescents‘ knowledge of key sexual and reproduc­tive health (SRH) topics and issues. The topics and issues included in the indicator should reflect those of primary importance for protecting the SRH of adolescents and/or those the program empha­sized.

Data Requirements:

Evidence of knowledge of key SRH issues, usually so­licited by means of personal interviews with or self-administered questionnaires completed by adolescents

The following is an illustrative list of topics that evalu­ators may include:

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Surveys of adolescent program participants or of ado­lescents in the program‘s intended population

Purpose:

Adolescents must have knowledge of key SRH topics and issues if they are to make in­formed decisions to protect their health and well being. Many adolescents get their RH information from poorly informed sources (i.e., peers). Inaccurate beliefs con­cerning levels of risk associated with particular behav­iors and/or the effectiveness and side-effects of differ­ent types of contraceptives can be strong enough to pre­vent adolescents from accurately perceiving the poten­tial consequences of their behaviors. This indicator is a composite measure that includes the SRH topics and issues of primary importance for protecting the RH of adolescents and/or those topics and issues the program emphasized.

Issue(s):

When interviewers question adolescents about these topics they should use local, non-scientific names to describe certain practices and conditions. Evaluators can and should analyze separately the individual topics and questions included in the composite index to deter­mine those specific topics requiring further emphasis by the program. Although adolescents need accurate knowledge of SRH topics for informed decision-mak­ing, adolescents may not act in a manner consistent with their knowledge, such that evaluators need to measure behavior separately.

Percent of adolescents who have "positive" attitudes toward key sexual and reproductive health issues

Definition:

This composite indicator or index measures adolescents' attitudes toward key sexual and reproductive health (SRH) topics and issues. “Positive" attitudes are those logi­cally expected to lead to positive SRH outcomes. The topics and issues included in the indicator should re­flect those of primary importance for protecting the RH of adolescents and/or those the pro­gram emphasized.

This indicator is calculated as:

(# of adolescents who have positive attitudes toward key SRH issues/ Total # of adolescents) x100

Data Requirements:

Evidence of the prevalence of “positive” attitudes to­ward key SRH issues, usually solicited by means of personal interviews with or self-administered question­naires completed by adolescents. Evaluators should tabulate data for this indicator by gender and age. The following items illustrate possible attitudes to measure:

Attitudes toward contraceptives/condoms:

 

Gender-role stereotypes:

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

 

Attitudes toward abstinence:

 

Perceived vulnerability:

Data Sources:

Surveys of adolescent program participants or of ado­lescents in the program‘s intended population

Purpose:

Developing "positive“ attitudes toward key SRH topics/issues is an important objec­tive of many adolescent and youth SRH programs.  This indicator is a com­posite measure that covers attitudes toward the SRH topics and issues of primary importance for protecting the RH of adolescents and/or those the program emphasized.

Issue(s):

As with knowledge, positive attitudes do not necessarily predict future be­haviors.  So this would be a weak indicator to use to predict actual healthy behaviors.

Percent of adolescents who are confident that they could refuse sex if they didn't want it

Definition:

The percent of adolescents reporting confidence that they could refuse sex if they did not desire it

This indicator is calculated as:

(# of adolescents reporting that they could refuse sex if they did not desire it / Total # of adolescents) x 100

 

Data Requirements:

Responses to survey questions on whether adolescents are “confident,“ “somewhat confident,“ “unsure,“ or “not confident“ that they could resist having sex when they did not want it

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Surveys of program clients/participants or adolescents in the program‘s intended population

Purpose:

This indicator measures the level of confidence or “per­ceived self-efficacy“ of adolescents to refuse sexual ad­vances when they do not want to have sexual relations. A growing consensus claims that adolescent and youth SRH education pro­grams are most successful when they address social pressures that influence sexual behaviors. Many pro­grams include exercises and “role-plays“ on how to re­sist pressure tactics and to escape situations that may lead to sex, through negotiation and other tactics. Thus, the indicator can measure the effectiveness of such skill-based educational programs in increasing adolescents‘ self-efficacy with regard to resisting unwanted sexual pressures and advances. This indicator measures per­ceived self-efficacy, which may or may not correspond to actual responses to real-life situations.

Because responses to sexual advances are likely to be context specific, the preferred measurement approach is to solicit responses to various situations that adoles­cents might find themselves in. For example, the inter­viewer may ask respondents how confident they are in their ability to refuse sex with:

Issue(s):

Although one may be confident they could refuse sex if they did not want it, when put in a situation where they are being forced or asked to have sex against their desires, the reality may be quite different.  Evaluators must be mindful that it is human nature to want to appear to be or believe you are more confident and in-control than what may actually be the case. 

Gender Implications:

Surveys indicate that for girls, the first ex­perience of sexual intercourse is often involun­tary (in some but not all developing countries). Forced sex (rape) is a form of gender-based vio­lence. Many girls are coerced into sex by older men who view younger partners as less likely to have an STI. Some men believe that sex with a virgin can cure them of HIV/AIDS.  Young girls say they lack the skills and self-confidence to refuse a more powerful and older male. Economic realities for many young girls makes refusing sex difficult and increases the likelihood that they will trade sex for money or gifts. In sub-Saharan Af­rica and other countries, these factors have led to new HIV infections among adolescent girls that are higher than those among boys and adults of either sex.

Percent of adolescents who are confident that they could get their partner(s) to use contraceptives/condoms if they desired

Definition:

The confidence or "self-efficacy“ of adolescents in their ability to negotiate contraceptive/condom use with their partner(s)

This indicator is calculated as:

(# of adolescents reporting ability to negotiate contraceptive/condom use with their partners/ Total # of adolescents) x 100

 

Data Requirements:

Responses to survey questions on whether adolescents are "confident,“ "somewhat confident,“ "unsure,“ or "not confident“ that they could convince their partner(s) to use a contraceptive/condom if desired

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Surveys of program clients and participants or adoles­cents in the program‘s intended population

Purpose:

This indicator measures the level of confidence or “per­ceived self-efficacy“ of adolescents desiring protec­tion to successfully negotiate contraceptive/condom use with their partner(s) if desired. Like the ability/ skill to resist social pressure to have sex, many adolescent and youth sexual and reproductive health (AYSRH) education programs emphasize negotiation skills with regard to contraceptive/condom use. This indicator is particularly important for girls in developing countries, because many have limited negotiation skills or power to convince sexual partners to use contraceptives/ condoms. The indicator can thus measure the effec­tiveness of such skill-based educational programs in increasing adolescents‘ self-efficacy at contraceptive use. Like the previous indicator, this indicator mea­sures perceived self-efficacy, which may or may not correspond to actual behaviors in real-life situations.

Because self-efficacy of contraceptive use is also likely to be context specific, the preferred measurement ap­proach is to solicit responses to various situations that adolescents may find themselves in. For example, an interviewer may ask respondents how confident they are in their ability to successfully negotiate contracep­tive/condom use with:

Issue(s):

Although one may be confident they could get their partner to use contraceptives/condoms, when put in a situation where their partner is refusing, the reality may be quite different.  Evaluators must be mindful that it is human nature to want to appear to be or believe you are more confident and in-control than what may actually be the case. 

Percent of youth who believe they could seek sexual and reproductive health information and services if they needed them

Definition:

This indicator measures the self-efficacy and perception of access to sexual and reproductive health (SRH) information and services among individuals aged 15-24 years. It is primarily a measure of self-efficacy.

Examples of SRH information and services can include:

This indicator is calculated as:

(Number of 15-24 year olds who believe they could obtain SRH information and services if they needed them / Total number of 15 to 24 year olds surveyed) x 100

Data Requirements:

Self-report from surveys indicating a yes/no response to whether or not they feel they could access SRH information and services.

This data could also be disaggregated by location, sex, socioeconomic status, marital status, and educational attainment. The questionnaire can ask about specific information and services (i.e. if the respondent felt they could obtain condoms or if they could attend a voluntary counseling and testing site to seek information  and/or testing on HIV).

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Self-reported responses from surveys; interviews with youth

Purpose:

Similar to the Demographic and Health Surveys/AIDS Indicator Survey (DHS/AIS) “perception of access to condoms by young people”, this indicator measures the prevalence of perceived access to SRH information and services among youth and is considered important to monitor as a determinant of SRH information and service use, as it assesses the reported self-efficacy of young people for accessing SRH information and service use if they were to need them (WHO 2007).  It is a useful intermediate measurement between knowledge of SRH information and services and their actual use as it could predict the behavior of SRH service utilization.

This can also be used as a measure of effectiveness of outreach from youth-friendly RH services, peer-education, or other communication aimed at educating adolescents have been in making their services known, available and accessible.  

Issue(s):

There is the possibility of reporting bias within this indicator because respondents feel obliged to answer in the affirmative. In addition, even if respondents feel they could obtain the services, it does not mean they actually will or can, due to personal issues as well as institutional barriers related to access and stigma. As with most indicators measuring attitudes and beliefs, the prevalence for perceived ability to access SRH information and services is expected to be higher than actual use (WHO 2007). 

Gender Implications:

In some cultures, unmarried adolescent girls have less access to SRH information and services than boys due to discriminatory policies limiting SRH services to unmarried women or girls, less exposure to mass media messages, lower rates of school attendance, lower literacy, and limited mobility outside the home. These factors may lead girls to feel they have less agency and limited ability to access these services if they needed them.  Married girls may also have limited mobility and access to services.

References:

Luszczynska, A., & Schwarzer, R., 2005 Social cognitive theory. In M. Conner & P. Norman (Eds.), Predicting health behaviour (2nd ed. rev., pp. 127-169). Buckingham, England: Open University Press.

Bandura, A., 1994 Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopedia of human behavior (Vol. 4, pp. 71-81). New York: Academic Press. (Reprinted in H. Friedman [Ed.], Encyclopedia of mental health. San Diego: Academic Press, 1998).

WHO, 2007 Introduction Access to Health Services for Young People for Preventing HIV and Improving Sexual and Reproductive Health.

Use of specified sexual and reproductive health services by young people

Definition:

The use of specified sexual and reproductive health (SRH) services by young people can be measured through either facility-based records (measuring service utilization only) or population-based methods such as surveys (which can give an estimate of the coverage of health services) (WHO, 2007).

Health services of particular interest include those concerned with HIV counseling, testing, and treatment; diagnosis and treatment or sexually transmitted infections (STIs); and counseling, provision, and referrals for contraceptives.  Evaluators may wish to specify other SRH services, including prenatal care, male circumcision services, counseling and treatment for victims of rape or sexual assault, abortion or postabortion care, treatment for obstetric fistula, etc.

This indicator generally refers to the use of facility-based SRH services only, however evaluators may choose to include SRH service provision from peer providers or community health workers.

At the facility level this indicator is calculated as:

(Number of young people aged 10-24 using an SRH service, disaggregated by service received, in a defined period / Total number of all clients using a specified SRH service in a defined period) x 100

At the population level this indicator is calculated as:

(Number of young people aged 10-24 who report receiving any of the specified SRH services in the preceding 12 months / Total number of young people surveyed who report being sexually active in a defined period) x 100

Data Requirements:

Facility-based data requires the total number of clients who sought specified SRH services in a given reporting period and the percentage of these clients who are aged 10-24.   Population-based data requires the number of young people reporting use of specified SRH services in the past year and the number who report having been sexually active in the past 12 months.

For both, data can be disaggregated by gender, age groups (10-14, 15-19, 20-24), in or out of school, marital status, urban/rural location and type of facility (WHO, 2007).

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Routine facility-based data collection; DHS or other nationally representative general population survey

Purpose:

This indicator tracks the number of young people seeking health services as an indication of care-seeking behavior, since such utilization appears to be low compared to the need (WHO, 2007). It also tracks the percent of all clients of health services who are young people and can be an estimate of the changes in care-seeking behavior among young people. Young people do not access health services in proportion to the health problems they experience (WHO,2004). A basic aim of an HIV/AIDS prevention program, therefore, is to increase the use of services by young people, specifically for STI testing and treatment, contraceptive use, and HIV counseling, testing and treatment.

Generally, an increase in the number and proportion of young clients is considered positive. However, the number and percentage must be interpreted together, as the percentage of clients who are young people may decrease if the overall use of SRH services by adults increases, even though the number of young clients may be increasing as well (WHO, 2004).

The correct interpretation of these numbers, moreover, requires some population-based estimates to understand the magnitude of need in order to interpret increases or decreases in specific services used. For example, if it is known that 40% of the population served by a particular health service are young people aged 20–24, and that in this population the prevalence of Chlamydia is 20%, an estimate can be obtained of the maximum number and percent of young clients who could, ideally, be expected to seek STI testing and treatment. In other words a ceiling is provided against which to gauge the increase or decrease in young clients(WHO, 2004).

At the population level this indicator estimates the proportion of sexually active young people who report seeking specified SRH services. In addition, if data are available on the proportion of young people in need of specific SRH services, either through epidemiological estimates or other surveys, this measure can be an estimate of the coverage of the specific health services. For example, if it is known that in a given region 50% of 15−19 females are sexually active; this provides a benchmark against which to gauge the number and percent of females aged 15−19 years that would theoretically need contraceptives. If more details are known about sexual risk behaviors (e.g. if, of the 50% who are sexually active, 40% report being with more than one partner in the preceding year and only 30% report frequent use of condoms) they can be benchmarks for the percent of girls aged 15-19 who would potentially need HIV testing services (WHO, 2004).

Issue(s):

An increase in the number of young people seeking services does not necessarily mean an increase in the percent of young people with SRH needs or issues. The increase may well be attributable to other factors, such as an information campaign advertising the services or a health promotion program that enables more young people to recognize the need for preventative or curative services, e.g. to recognize the symptoms of an STI or to increase the demand for contraceptives.  Changes in health seeking behavior are often attributed to changes in health policy as well, such as the instatement or removal of user fees.

A challenge with tracking this indicator is that it depends on facilities having well-maintained and accurate records and logbooks, including age-specific records or at least records in age brackets allowing for disaggregation of young people from adults (WHO, 2004). In many countries there may be no such records, or the recording of services in facilities may not be standardized. Furthermore, clients themselves may not know their exact age. Even where well-maintained clinical records exist, the way in which the information is recorded may limit the ability to collect data for this indicator.  Clients may seek multiple services at one visit and where services are not integrated, frequently the record keeping is decentralized, leading to problems in double counting. For example, they may come to a facility for flu like symptoms, but also receive SRH services in addition, and thus the reason for the visit may not reflect the use of SRH services.

Moreover, the measurement of service utilization provides no information about the quality of services.  In order to obtain a better understanding of the trends observed in utilization, these data should be complemented by measuring the quality and effectiveness of SRH services with additional indicators on Quality of Care/Service Provision Assessment.

Gender Implications:

Young women’s access to and use of SRH services may be limited by cultural gender norms and related barriers. Less mobility, fewer resources to pay for health services, and stigma associated with being a sexually active adolescent, and visiting facilities that offer HIV services may all contribute to young women not accessing care. Further, lack of female health care providers and or providers trained in youth-friendly services may deter women from accessing services. Young men may also be less likely to access services due to social norms around masculinity and not having a self-identified need.

References:

World Health Organization, 2004. National AIDS Programmes: A guide to indicators for monitoring and evaluating national HIV/AIDS prevention programmes for young people.

World Health Organization, 2007. Introduction Access to Health Services for Young People for Preventing HIV and Improving Sexual and Reproductive Health.

Age at first intercourse

Definition:

This indicator is a summary measure of the average age at which adolescents become sexually active. Evalua­tors may alternatively calculate the indicator as: (1) the mean age at first intercourse, (2) the median age at first intercourse, or (3) the percent of youth who have ever had intercourse by selected reference ages (e.g., age 13, 15, 17, 19).

1. Mean age at first intercourse

(Σ age of adolescents)/ Total # of adolescents

2. Median age of first intercourse1

MEDIAN= L+[(50-cf/f)*i]

Where:

L = the true lower limit of the class interval in which the median is located; 50 = the 50 percentile observation; cf = the cumulated frequency up to the median class interval;

f = the frequency within the median class interval; and

i = the class width.

1 Note: This formula is for use with grouped data consisting of percentage frequencies in each class. For ungrouped data, the median is the value of the observation falling at exactly the 50th percentile of the distribution of observations

3. Percent of youth who have had intercourse at refer­ence ages

# of adolescents of a reference age who report having had intercourse x 100
_________________________________________________________
Total # of adolescents of the reference age

 

Data Requirements:

Self-report by adolescents on whether they have ever had intercourse and, if so, their age at first intercourse. Obtaining current age is also useful for more refined measures (see below). Evaluators should measure the indicator for both married and unmarried youth.

Data Sources:

Surveys of program participants or adolescents in the program‘s intended population

 

Purpose:

The typical or average age at which adolescents in the program‘s intended population are initiating sex is an important parameter for program design purposes and a key outcome indicator for programs aimed at delay­ing onset of sexual activity.  The preferred form of the indicator is the median age at first intercourse, as this form avoids bias problems that arise in the use of the mean age in settings where sexual initiation typically occurs at later ages. If fewer than 50 percent of the sample is sexually active, the preferred form of the in­dicator is the proportion of adolescents who had initi­ated sex by specified reference ages among respondents who are the reference age or older (e.g., the percentage of adolescents 16 years of age or older who had initi­ated sex by age 15). Evaluators may compute median ages at first pregnancy or birth in a similar fashion.

Gender Implications:

Whereas menstruation is considered a sign of a young girl‘s passage into womanhood, in many societies, first sex marks a young man‘s initiation into manhood. Boys generally initiate sex earlier than girls, because many cultures tolerate or encourage sexual activity among adolescent males. In some places, a young man‘s masculinity is questioned if he has not had sexual intercourse by a certain age (McCauley and Salter, 1995).  Re­sponses to the question of age at first intercourse may thus be misreported because of cultural norms that may encourage boys to boast about early sexual experimentation, while having the opposite effect on girls, who may underreport sexual activity because of the great value placed on vir­ginity.

Percent adolescents who have ever had sex

Definition:

The percent of adolescents who have ever engaged in sexual intercourse (interpreted in most contexts to mean penile-vaginal intercourse)

This indicator is calculated as:

(# of adolescents who have ever had sexual intercourse/ Total # of adolescents) x 100  

 

Data Requirements:

Responses to a survey question asking whether they have ever had sexual intercourse

The question or questionnaire should specify penile-vaginal intercourse in order to minimize confusion as to the behavior the question referred to. The evaluators should disaggregate the indicator for married and un­married youth, males and females, and by age of respondent.

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Population-based surveys

Purpose:

This indicator determines the extent to which adoles­cents in a program‘s intended population are sexually initiated. The indicator is useful both for designing adolescent and youth sexual and reproductive health (AYSRH) programs and for evaluating the effectiveness of existing programs aimed at postponing age at sexual debut. Because of large differences in age of the part­ners, evaluators should tabulate the indicator by single years or by age groups to guarantee accurate interpreta­tion of the indicator.

Issue(s):

Evaluators may have problems arise in measuring this indicator in settings where sexual activity outside of marriage is stigmatized, because adolescents who have initiated sex may be reluctant to admit having done so. Given the sporadic nature of sexual activity among ado­lescents, especially younger adolescents, in many set­tings, the indicator may not reflect the number/percent of adolescents who have been sexually active in the re­cent past (e.g., the last 3 or 6 months).

Gender Implications:

Boys generally initiate sex earlier than girls, because many cultures tolerate or encourage sexual activity among adolescent males. In some places, a young man‘s masculinity is questioned if he has not had sexual intercourse by a certain age (McCauley and Salter, 1995).  Re­sponses to the question of having ever had sex may thus be misreported because of cultural norms that may encourage boys to boast about early sexual experimentation, while having the opposite effect on girls, who may underreport sexual activity because of the great value placed on vir­ginity.  Furthermore, since it is not uncommon for the first sexual experience among girls to be involuntary, adolescent girls - particularly young adolescents - may be reluctant to report having already had sexual intercourse because of the shame and pain associated with that experience.

Number/percent of adolescents who have experienced coercive or forced sex

Definition:

The number or percent of adolescents reporting some form of coerced or forced sex including: rape, date rape, domestic violence (resulting in sexual intercourse), sexual assault, sexual harassment, incest, and sexual mo­lestation (Kidman, 1993)

As a percent, this indicator is calculated as:

(# of adolescents reporting forced or coerced sex/ Total # of adolescents) x 100

Data Requirements:

Self-reports of adolescents of the occurrence of coerced or forced sex either in the immediate or distant past; data should be disaggregated by male and female

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Surveys of adolescents in a program‘s intended popula­tion; program "intake“ interviews; interviews during health service provision and/or in connection with edu­cational or counseling programs

Purpose:

Although most adolescent and youth sexual and reproductive health (AYSRH) programs emphasize self-efficacy and decision-making with regard to sexual relations and contraception, many adolescents, especially female ado­lescents, experience forced sexual encounters. At the 1994 International Conference on Population and De­velopment in Cairo and at the 1995 Fourth World Con­ference on Women in Beijing, discourse on sexual and reproductive rights appropriately characterized sexual coercion as a symptom of the limited life options of girls and young women. Thus, program models designed to reduce sexual activity among adolescents must not only offer information, but must also promote public acknowledgment of the prevalence of sexual coercion and of the gender inequality that fosters it. The plau­sible existence of a considerable amount of coerced sexual activity highlights the inadequacy of current AYSRH program models, which primarily assume that sexual activity among adolescents is voluntary (Mensch, Bruce, and Greene, 1998).

Issue(s):

This indicator provides a measure of the relative fre­quency of adolescents victimized by forced sex. For various reasons, incidents of coerced or forced sex are likely to be significantly under-reported in survey in­terviews, particularly among males. Evaluators can likely obtain more complete reporting in connection with counseling programs. How­ever, in many settings, such programs reach so few ado­lescents, that the actual incidence is likely to be seri­ously under-reported. Because of the sensitivity of this matter, interviewers must often ask questions about co­ercive sex repeatedly to offer adolescent respondents an opportunity to disclose their experience with forced sex. One potentially effective way of broaching the sub­ject is to ask the adolescent, "Did you have any upset­ting sexual experiences in childhood or adolescence?“ (Heise, Moore, and Toubia, 1995). Other researchers have also asked, "Did someone ever make you touch their breasts or genitals, or touch yours, when you did not want to?“ (Boyer and Fine, 1992). After receiving a positive response, researchers or counselors can probe more deeply by asking: the age at first abuse, the fre­quency of occurrence, the type of abuse, whether abused by one or more people, the relationship of abuser(s) to the respondent, the location of the abuse, and whether the respondent told anyone else about the abuse.

Gender Implications:

For various reasons, when people think of coercive or forced sex, a female victim often comes to mind.  However, it is a gross disservice to boys and men to not recognize that some of them have been sexually abused too.  Based on data from the U.S. and Canada, researchers estimate that one in six men have experienced unwanted or abusive sexual experiences before age 16.  It is important for evaluators to be mindful of this and treat the question of experience with coercive or forced sex with the same sensitivity toward young men and women, equally. 

Number of youth who have ever received money or other form of exchange for sex

Definition:

The number of males and females aged 15-24 years who have ever received money, favors, or gifts in exchange for sex.  

This indicator includes a broad range of exchanges for sex, including ”sex work”, which is defined by UNAIDS as “female, male and transgender adults and young people who receive money or goods in exchange for sexual services, either regularly or occasionally, and who may or may not consciously define those activities as income-generating.” Sex work can be categorized as either ‘formal’ or ‘informal’. Formal sex work includes an establishment to mediate sexual exchanges (i.e. nightclubs, brothels, and massage parlors) and is often found in Asia, while informal sex work requires finding the clients independently and is more common in Africa (UNAIDS, 2002). Those who have occasional commercial sexual transactions or where sex is exchanged for basic immediate needs such as food, shelter, or protection do not consider themselves linked with formal sex work (UNFPA, 2006).  Another term which is often used for more informal exchanges is transactional sex which the Demographic and Health Surveys (DHS) describes as “the exchange of sex for money, gifts or favors”.

“Other form of exchange” can take a wide variety of forms including small things such as rides, food, or clothing, to larger gifts such as payment of school fees, housing or money.  When surveying or interviewing youth, evaluators may need to give examples of other forms of exchange.

Evaluators may want to replace the word “ever” – which captures prevalence – with a time frame such as the past 12 months, as done in the DHS/AIS in order to get the incidence and track trends for programmatic reasons related to interventions around decreasing risky sexual behavior.

As a percentage, this indicator is calculated as:

(Number of individuals 15-24 who have received money or other exchange for sex/total number of individuals 15-24 surveyed who have had sexual intercourse) x 100

Data Requirements:

Self-reported data from survey respondents. Data can be disaggregated by sex, location, educational attainment, wealth quintile, etc. It can also be disaggregated for the age groups 10-14,15–19 and 20–24.

Data Sources:

Self-reported responses from surveys, interviews with youth, population based surveys

Purpose:

This indicator looks at the level of risk behavior for 15-24 year olds who have ever received something in exchange for sex. While both young men and women are involved in transactional sex and sex work, it is more commonly reported among women and girls. Studies indicate large majorities of adolescent girls have been involved in transactional sexual relations at some point (Luke, 2002). With young women in sub-Saharan Africa being three times more likely to be infected with HIV than young men of the same age (UNAIDS 2006), this indicator helps monitor a key path of HIV transmission.  

Because they often lack the power to negotiate condom use, there is a heightened risk for those engaged in transactional sex. In both formal and informal sex work, not using condoms may mean more money. Because informal sex work is often done irregularly and in order to meet short-term needs, the extra money can be lucrative (UNAIDS, 2002). In transactional sex in many parts of Africa, receiving a gift is expected, even though it reinforces the power differential between partners.

Due to a combination of factors, significantly higher rates of sexually transmitted infections (STIs), including HIV, have been documented among sex workers compared with the general population (UNAIDS, 2002).   Therefore, this indicator can be used to measure the impact of HIV prevention and life skills programs which seek to decrease the rates of transactional sex for young people.

There are a wide variety of motivations that drive transactional sex.  Studies from across the developing world indicate poverty and the need for economic gain and survival is overwhelmingly the core reason for bartering sex (Luke, 2002). A few studies have also documented wanting to find love and companionship.  For many people, especially women and girls, who are living in poverty, sex work may be the only employment or survival option. While some may freely choose sex work as their occupation, many more young girls, young boys and women are coerced through violence, trafficking, debt-bondage or the influence of more powerful adults. A wide variety of groups and individuals are directly involved in sex work in commercial sex establishments, or indirectly involved, for example as restaurant servers and escorts.

Issue(s):

In most parts of the developing world, sex work is illegal, and there is significant discrimination and stigma against male and female sex workers, which can lead to a high level of silence around the practice.  Furthermore, if someone is forced into sex work, there is an incredible amount of shame, which influences one’s decision to reveal this behavior.  Thus, if data is being collected through an interview, it needs to be conducted in a safe and sensitive manner in order to protect the young person from experiencing distress if s/he discloses her/his experience.

It is customary and expected for young women to receive gifts from boyfriends or sexual partners in many cultures.  Girls may see this as a token of affection from her partner and an expected part of romantic relationships and thus not report it as direct exchange (Luke, 2002). For example a study in Malawi found that in both mixed and same age relationships, monetary transactions are standard, and that girls found these to be both a symbol of men’s feelings as well as monetarily beneficial. The specific context of gift giving between partners is something that evaluators must consider closely when collecting this data.

Gender Implications:

The low status of women is a major driver of women entering sex work. In many parts of Africa girls do not complete secondary school, either because their families can’t afford it, don’t value girls’ education, or need her to work and bring in income for the family. However, in impoverished areas, there are few work opportunities, especially for women, and the jobs that are available – generally domestic help – are low paying. Sex work, on the other hand, can be relatively lucrative.

Male and female sex workers, both formal and informal, are generally seen as defying social norms and face multiple levels of discrimination. Women who ask for compensation for sex break traditional norms expected of women in many societies, and those who engage in transactional sex are still labeled as prostitutes. For male sex workers who have sex with men, the combination of homosexuality and engaging in sex work leads to extreme stigma, violence, and persecution, especially where homosexuality is illegal (UNFPA, 2004). For these groups, admitting their work could mean risking violence from police or pimps, abandonment by their families, and loss of social support.

References:

UNAIDS.Sex work and HIV/AIDS, UNAIDS Technical Update. 2002.

Hope R. Addressing Cross-Generational Sex: a Desk Review of Research and Programs. Population Reference Bureau (PRB) BRIDGE Project. 2007. http://www.igwg.org/pdf/addressing-CGsex.pdf.

Luke N. and Kurz K.M. Cross-generational and Transactional Sexual Relations in Sub-Saharan Africa: Prevalence of Behavior and Implications for Negotiating Safer Sexual Practices. ICRW and PSI as part of the AIDSMark Project, September 2002.

Feldman-Jacobs C., Worley H. Cross-Generational Sex: Risks and Opportunities. Population Reference Bureau (PRB). July 2008.

UNFPA Fact Sheet.  HIV/AIDS, Gender and Sex Work.  2006.  http://www.unfpa.org/hiv/docs/factsheet_genderwork.pdf.

Age mixing in sexual partnerships among young women

Definition:

 

The number or percent of female respondents aged 15-24 years who have had sex with a non-marital, non-cohabiting partner who was 10 or more years older than themselves.

Age mixing, age-disparate, intergenerational and cross-generational are terms that are used interchangeably to describe significant age differentials in relationships. Some researchers have expanded the definition to an age difference of five years because the smaller gap has also been clearly associated with increased risk of HIV transmission in young women (Hope, 2007). Demographic and Health Surveys (DHS) AIDS modules further define intergenerational sexual relationships as non-marital. Evaluators will want to make this distinction.

Since this indicator does not specify a time period when the partnerships have occurred, evaluators may want to specify if the relationships have taken place within a certain timeframe, such as the last 12 months.

As a percentage, this indicator is calculated as:

(Number of female respondents aged 15-24 years who have had sex (within timeframe) with a partner 10 or more years older than themselves / Total number of female respondents aged 15-24 surveyed who have had sex (within timeframe)) x 100

Data Requirements:

Self-reported data from survey respondents

 

In a general population survey respondents are first asked whether they have ever had sex. Those who answer in the affirmative are asked whether any of their partners were at least 10 years older than themselves.

Age mixing is culturally acceptable in many places, but taboo in others. When asking about this indicator evaluators will want to be sensitive to the particular context and ask the questions in an appropriate, sensitive way.

This indicator can be disaggregated for age groups 10-14, 15–19 and 20–24 year , in school/out of school status, as well as by urban and rural populations.

Data Sources:

UNAIDS general population survey; DHS AIDS mod­ule; FHI BSS (adult); self-reported responses from interviews with youth

Purpose:

 

Intergenerational sex has been practiced for centuries and is quite common in many communities and cultures in the developing world.  However, there has been an increased interest in age mixing in sexual relationships due to the feminization of the AIDS epidemic and evidence that age mixing has been shown to be one of the factors in the spread of HIV (Hope, 2007). Young women 15-24 in sub-Saharan Africa are three times more likely to be infected with HIV than young men of the same age (UNAIDS, 2006). There is a growing collection of research demonstrating a significant association between age and economic disparities, risk behaviors and HIV infection (Luke, 2002).

Older men are more likely to have (and have had) multiple partnerships, thus increasing their chances of contracting and spreading HIV to their partners (Hope, 2007). Growing evidence also shows that men who have sex with younger women engage in higher levels of risky sexual behavior than other men of the same age group (Evans, Delva and Pretorius, 2010). Young women are sometimes forced into these relationships while others actively pursue older male partners. No matter their level of volition younger women are expected to be obedient and respectful toward older men, which undermines their ability to resist older men’s advances and negotiate condom use.  Physiological reasons also make it more likely for younger women to become infected with HIV. For these reasons, each sexual act with an infected man carries a higher risk of infection for a young girl. (UNAIDS, 2004).  It also carries the risk of contracting other sexually transmitted infections (STIs) and unwanted and early pregnancy.

A related indicator is Number of youth who have reported receiving money or other form of exchange for sex, as cross-generational relationships often have a transactional component. A review of over 45 studies of cross-generational sex found a transactional component to sexual relationships for adolescent girls who were not engaged in commercial sex work (Feldman-Jacobs, 2008).

Issue(s):

 

One limitation of this indicator is that people often do not know their sex partner’s age. This is more likely to be true of casual partners than of spouses. In addition, the age difference constituting an elevated risk of exposure to HIV is not precisely known. When uncertain about a partner’s age, heaping or age clustering may occur, which is when respondents round up or down to a multiple of five or 10 (i.e. 15 or 20), which may distort the indicator. It should be noted, however, that the biases introduced through age clustering or age misreporting are unlikely to change greatly over time, so this may be of little consequence when time trends are being examined (WHO, 2004).

This measure cannot give an exact picture of patterns of age-mixing and does not show small changes in age gaps between partners. Nevertheless, it should show major changes in age-mixing of interest to HIV prevention and life skills programs, since women are unlikely to mistake a peer for a man much older than themselves. If women increasingly choose to have sex with their peers rather than with older men, or if older men become less likely to seek out substantially younger partners, these changes will be reflected in the indicator, regardless of errors in age-reporting (WHO, 2004).

Gender Implications:

 

Despite the risks involved with sexual relationships between older men and younger women, there are deeply rooted, gender-based cultural norms and personal motivations for why this practice is so common in many parts of the world. Young women’s motivations to be with older men are numerous and varied in different contexts. According to Luke and Kurz, the main motivation for cross-generational sex is financial gain, however finding a suitable marriage partner, wanting love and affection, and upward social mobility can also play a role. Girls often have fewer opportunities than older women and less access to pocket money from parents than boys, however there is an economic value to sex (Luke, 2002). In Ethiopia for example, young women described relationships with other men as “business opportunities” (Hope, 2007).

Older men seek younger women for a variety of reasons as well. Studies suggest enhanced prestige, enhanced access to sex on a regular basis, and domestic help. Further societal views on masculinity and polygamy perpetuate acceptability that men need multiple sexual partners in order to meet their desire for sexual gratification (Hope, 2007).

Family and societal pressures can make it normative for girls in sub-Saharan Africa, in particular, to engage in intimate relationships with older men (Luke, 2002).  In southern Africa, girls are encouraged to seek older men as partners and husbands because they are believed to be more stable partners than younger men. In other cases, girls are pushed into sexual relationships with older men by their families in order to earn income for the household.

The most common form of intergenerational sex occurs within marriages (Feldman-Jacobs, 2008) where it is also likely that husbands will transmit the disease to their wives because marital relationships are associated frequent sexual intercourse, greater exposure to infection and decreased likelihood of condom use (Luke 2002).

While cross generational sex is not stigmatized for men, it generally is for the young women they are involved with and thus girls might be hesitant to report being part of the relationship.

References:

 

Evans J., Delva W. and Pretorius C.  2010. “Condom use among young Swazi in mixed-age relationships.”  Exchange on HIV and AIDS, Sexuality and Gender.  Royal Tropical Institute, http://www.kit.nl/net/KIT_Publicaties_output/ShowFile2.aspx?e=1736 Accessed on July 30, 2011.

Feldman-Jacobs C., Worley H. 2008. Cross-Generational Sex: Risks and Opportunities, Population Reference Bureau (PRB).

Luke N., Kurz K.M. 2002. Cross-generational and transactional sexual relations in Sub-Saharan Africa: Prevalence of Behavior and Implications for negotiating safer sexual practices. ICRW and PSI as part of the AIDSMark Project.

Hope R. 2007.  Addressing Cross-Generational Sex: a Desk review of research and programs. (Washignton DC: Population Reference Bureau PRB  http://www.prb.org/igwg_media/AddressingCGSex.pdf

National AIDS programmes: a guide to indicators for monitoring and evaluating national HIV/AIDS prevention programmes for young people. World Health Organization. 2004 ISBN 92 4 159257 5.

Number of sexual partners among sexually active adolescents during a specified reference period

Definition:

The number of sexual partners during a specified refer­ence period (e.g., the last 3, 6, or 12 months) among sexually active adolescents

Data Requirements:

Responses to survey questions on number of sexual partners during the specified reference period.

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

 

Data Sources:

Surveys of program participants or adolescents in the program‘s intended population

Purpose:

Having multiple sexual partners increases the risk of transmission of STIs and HIV/AIDS. This indicator provides a measure of how prevalent this high-risk be­havior is in a program‘s intended population.  However, because consistent condom use greatly reduces the risk of STI transmission, evaluators must consider the indi­cator in conjunction with the indicators pertaining to condom use (Percent of sexually active young people who used a condom at first/last sex, Percent of sexually active, unmarried adolescents who con­sistently use condoms) in order to assess the prevalence of high-risk behaviors.

Issue(s):

Because the indicator deals with a sensitive topic, there is reason to be concerned about the accuracy of reported information. Unfortunately, little methodological re­search has been undertaken to assess how accurately numbers of partners are reported in different settings.

Percent of adolescents who were ever diagnosed and treated for an STI

Definition:

The percent of adolescents who have ever been diag­nosed as having a sexually transmitted infection (STI) and received treatment

This indicator is calculated as:

(# of adolescents ever diagnosed and treated for an STI/ Total # of adolescents) x 100

 

Data Requirements:

Responses to survey questions on whether adolescents had ever been diagnosed as having an STI and received treatment.  Questions include:

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Surveys of program participants or youth in the program‘s intended population

Purpose:

Along with reducing the incidence of adolescent preg­nancy, reducing the incidence of STIs among adoles­cents is an important objective of many adolescent and youth sexual and reproductive health (AYSRH) programs.  STIs, including HIV, are integrally linked to SRH. STIs (e.g., gonorrhea, syphilis, chlamydia, and HPV) constitute a significant health burden and can cause pregnancy-related complications, including spontaneous abortions, premature birth, stillbirth, congenital infections, pelvic inflammatory disease, cervical cancer and infertility. Next to complications of pregnancy and childbirth, STIs are the leading cause of health problems for women of reproductive age (UNFPA, 2011). STIs also increase the risk of transmission of HIV.

This indicator provides a relevant long-term outcome measure for programs addressing STIs, particularly among adolescents.

Issue(s):

Because the indicator is a "lifetime“ measure, it does not measure incidence or prevalence for specific reference periods, although evaluators can derive an incidence-like measure by ob­taining information on the dates of episodes of STIs. The measure is, however, crude and suffers from sev­eral biases. First, many STIs lack recognizable symp­toms; thus, the indicator will underestimate the true percent of adolescents who have ever contracted an STI. Second, those adolescents who were diagnosed with an STI, but never received treatment, will not be counted in this indicator.  Thirdly, because STIs imply that respondents have en­gaged in behaviors stigmatized in many settings, the indicator is prone to under-reporting in survey inter­view situations. Thus, the indicator will provide a lower-bound estimate in most settings.

References:

UNFPA, 2011, Breaking the Cycle of Sexually Transmitted Infections, New York: UNFPA. http://www.unfpa.org/rh/stis.htm

Percent of girls vaccinated with 2 doses of HPV vaccine by age 15 years

Definition:

The percent of 15 year old girls in target population who have completed the full two dose vaccination schedule for the human papillomavirus (HPV).

This indicator is calculated as:

(Number of girls aged 15 in target population who have received two doses of the HPV vaccine / Total number of 15 year old girls in target population) x 100

Depending on the type of HPV vaccine, WHO recommends vaccinating girls ages 9-14. The key point is that the girl receives two doses before she becomes exposed to HVP through sexual contact.  Although this can occur before 15 years of age, this is the most commonly used lower age limit for when girls typically become sexually active.

Only girls who have completed both doses of the HPV vaccines should be counted in this indicator.

Data Requirements:

Total number of girls in target population; age of girl; response to survey questions on HPV vaccination; vaccine program service statistics

Data Sources:

Population-based surveys; service statistics; vaccine registers

Purpose:

In 2010 alone, approximately 200,000 women died from cervical cancer with the majority of these deaths having occurred in low-income countries, where HPV vaccinations and comprehensive cervical cancer screening programs are lacking (IHME, 2011). Nearly all cervical cancer cases are linked to HPV which is the most common sexually transmitted infection (WHO, 2006). The bivalent vaccine, which protects against HPV types 16 and 18, and the quadrivalent vaccine, which protects against HPV types 6, 11, 16, and 18 - the most common cancer-causing strains of HPV - have both been proven to be safe and effective in preventing cervical cancer, with the quadrivalent vaccine also effective in preventing genital warts in women and men.

HPV is highly transmissible through sexual contact, so vaccinating girls before sexual activity is initiated is a key strategy to prevent cervical cancer. The peak of HPV incidence occurs between the ages of 16 and 20 years old (GAVI 2007).

Although addressing cervical cancer is still in the initial stage in developing countries due to lack of resources for prevention, screening, and treatment, the HPV vaccine is slowly being added to national immunization programs. This indicator can be used to track the impact of comprehensive HPV and cervical cancer prevention programs and marketing campaigns aimed at increasing the use and coverage of the vaccine in girls under 15 years of age.

Issue(s):

Based on a pilot program in Uganda, PATH found it challenging to identify eligible girls based on their age. Selecting girls based on grade/class in school was more feasible, but presented challenges for age focused reporting and evaluation (PATH, 2011).

If this data is being collected through population-based surveys, girls may not know if they have received the full three doses for HPV, nor may they recall if it was an HPV vaccine they received.

Service statistics have the disadvantage that they may be incomplete or inaccurate (WHO, 1999). They are also subject to a selection bias and are not representative of the general population. However, they provide the only way of monitoring coverage on an annual basis and may be more reliable than self-reported data.

Girls who are 15 or older at the time of first dose should receive 3 doses of HPV. A 3-dose schedule remains necessary, even for those under the age of 15, if known to be immunocompromised and/or HIV-infected. This indicator does not capture that population of girls.

Gender Implications:

 

School-based immunization programs have had some success with achieving widespread vaccination coverage. However in many parts of the world, girls from poorer households are more likely to no longer be in school by the time they reach early adolescence (Kane, 2006). It is common in many parts of Africa for girls to stay home when they are menstruating.  In both cases, young women will be at a disadvantage for getting fully or even partially vaccinated against the HPV vaccine.

Because HPV is a sexually transmitted virus, more conservative countries have shown some resistance to vaccinating young girls, saying that giving the vaccination will give them permission for sexual promiscuity or that it is unnecessary since sexual activity is "not supposed to" take place outside of marriage. In other cases, the myth that the HPV vaccine is designed to sterilize young women has also been cited (Kane, 2006).

References:

 

Agosti JM, Goldie SJ (2007). Introducing HPV vaccine in developing countries–key challenges and issues. N Engl J Med 356:1908–1910.

Institute for Health Metrics and Evaluation (IHME). The Challenge Ahead: Progress and setbacks in breast and cervical cancer. Seattle, WA: IHME, 2011. http://www.healthmetricsandevaluation.org/sites/default/files/policy_report/2011/The_Challenge_Ahead_IHME_Policy_Report_0911.pdf

GAVI Alliance. HPV (Human papillomavirus) Fact Sheet. GAVI alliance in collaboration with PATH.

Kane, M.A., Sherris, J., Coursaget, P., Aguado, T. and Cutts, F. (2006). Chapter 15: HPV vaccine use in the developing world. Vaccine, 24 (Suppl. 3), S132–S139.

PATH. HPV Vaccination in Africa Lessons Learned From a Pilot Program in Uganda. January 2011. http://www.rho.org/files/PATH_HPV_lessons_learned_Uganda_2011.pdf

WHO Position Paper: Weekly epidemiological record. p. 118-132 April 2009.   http://www.who.int/wer/2009/wer8415.pdf?ua=1 

WHO, 2006.  Preparing for the Introduction of HPV vaccines: policy and programme guidance for countries.

HIV prevalence among young people (15-24)

Definition:

 

The percent of young people aged 15-24 who have been tested for HIV and have positive test results.

As a percentage, this indicator is calculated as:

(Number of young people aged 15-24 tested whose HIV test results are positive / Number of young people aged 15-24 tested for HIV)  X 100

Data Requirements:

 

Nationally or regionally representative community-based survey tools with the necessary questions to determine whether respondents have been tested for HIV and if they know their status. Community-based surveys can be the most accurate source of data on HIV prevalence for young people in the general population. For cost and efficiency reasons this method is best used if there is a generalized HIV epidemic with prevalence at or above 5% (WHO 2004).

Evaluators can also count the total number of all individuals who received HIV testing and know their results from any service delivery point, including fixed health care facilities such as hospitals; public and private clinics; specialized care sites (e.g., antenatal care, preventing mother-to-child transmission, male circumcision or TB sites); stand-alone sites not associated with medical institutions; and mobile testing, such as outreach, door-to-door services, and workplace testing events (PEPFAR, 2009).

Data should be collected, reviewed, and cleaned continuously at the facility or community level. The indicator should be further disaggregated by sex and age subgroups (15-19, 20-24, etc.) and, where data are available, by type of test, test result (positive or negative), and, in areas of concentrated epidemics, membership in other most-at-risk subpopulations.

Data Sources:

 

Nationally or regionally representative community-based surveys, population-based surveys such as (DHS/AIS), behavioral surveillance survey (BSS), clinic or facility testing records

Purpose:

 

This indicator allows assessment of progress toward eradicating HIV infection because the highest rates of new HIV infections typically occur among young adults (PEPFAR 2009).

 Patterns in HIV prevalence for young people are a better indication of recent trends in HIV incidence and risk behavior. In older populations shifts in HIV prevalence are slow to reflect changes in the rate of new infections because the average duration of infection is long. Furthermore, declines in HIV prevalence can reflect saturation of infection among those individuals who are most vulnerable and rising mortality, rather than behavior change. Thus, reductions in HIV incidence associated with genuine behavior change should first become detectable in HIV prevalence figures for 15–19-year-olds. Where available, parallel behavioral surveillance survey data should be used to aid interpretation of trends in HIV prevalence (PEPFAR 2009).

Other indicators which are also used to capture the rates of new infection are HIV prevalence among pregnant women 15-24 years old.

Issue(s):

 

There is the potential for participation bias within community-based surveys. People at higher risk of HIV infection have an increased likelihood of being missed by community and population-based surveys. Most-at-risk populations such as intravenous drug users, sex workers, truck drivers, and military or police may not be counted because they live outside of households.  For facility-based monitoring, there may be potential participation bias since those who present at clinics to get tested may not be representative of the population.

There is also the risk of a lack of continuity in community-based surveys, as they are costly and time consuming to deliver, which can lead to variation in the scope and format of successive surveys. This can lead to the inability to compare data on the same population (WHO 2004).

Gender Implications:

 

Young women’s access to and use of voluntary counseling and testing services may be limited by cultural gender norms and related barriers. Less mobility, fewer resources to pay for health services, fear the stigma associated with being a sexually active adolescent and visiting facilities that offer HIV services may all contribute to young women not seeking HIV testing. Further, lack of female health care providers may deter women from accessing services.  Women who are married or believe they are in a monogamous relationship may have low perceived risk of exposure to HIV. Furthermore, positive test results for women may have serious repercussions ranging from partner violence, social and economic isolation, to outright abandonment. Women who test positive for HIV also may not be compliant with prophylaxis, treatment, and approaches for preventing mother-to-child transmission for fear of being stigmatized as having HIV.  The UNAIDS (2010) agenda for women, girls, and gender equality calls for increasing access and networks for women, particularly targeting women at the community level to strengthen HIV prevention efforts that include voluntary testing and counseling.

References:

 

HIV/AIDS Survey Indicators Database,  http://hivdata.dhsprogram.com/  
Accessed July 27, 2011.

United Nations, 2003. Indicators for Monitoring the Millennium Development Goals: Definitions, Rationale, Concepts, and Sources, New York.

World Health Organization.  National AIDS Programmes.  A guide to indicators for monitoring and evaluating national HIV/AIDS prevention programmes for young people. 2004.

PEPFAR, 2009, The President’s Emergency Plan for AIDS Relief: Next Generation Indicators Reference Guide, Washington, DC: USAID/PEPFAR.  http://pdf.usaid.gov/pdf_docs/Pcaac330.pdf

UNGASS Online Indicator Registry (for HIV/AIDS), http://indicatorregistry.org/.

Condom availability for young people (15-24)

Definition:

 

The percent of randomly selected sites and venues typically accessed by young men and women aged 15-24 years which have condoms in stock at the time of the survey.

Sites and venues that are typically accessed by young people must be operationally defined through key informant interviews or responses on a youth survey to questions on where young people get condoms or where they prefer to get them. These venues should primarily include retail outlets, youth centers, health clinics, school clinics, and pharmacies. Additional sites could be as diverse as bus stops, barbers’ shops, hair salons, night clubs, bars, food shops, kiosks, markets, petrol stations, and other community-based distributors.

This indicator is calculated as:

(Number of retail outlets and service delivery points that are typically accessed by young people aged 15-24 years that have condoms in stock at the time of the survey / Number of retail outlets and service delivery points typically accessed by young people) x 100

Data Requirements:

 

Inventories, responses to surveys that demonstrate condom availability. The sampling frame should be stratified in order to ensure geographical, demographic, and socioeconomic  diversity (e.g. rural/urban). It is better to limit the type of venue that could or should provide condoms to young people, and to focus on a defined set that must consistently provide them. Accordingly, this indicator should focus mainly on the priority venues and include additional ones as resources permit.

The data can be disaggregated by condom type (male/female), geographical location (e.g. region, state, district, county or ward), outlet type and if the condoms were available behind the counter or available where people did not need to ask for them.  Data disaggregated by outlet type provide invaluable information for program managers and for persons seeking to improve the marketing of condoms.

Data Sources:

 

Condom inventories and purchase records for sites and venues, or the MEASURE Evaluation/WHO/ PSI compiled condom availability and quality protocol retail survey.

Purpose:

 

This indicator helps measure the supply and accessibility of condoms for young people by monitoring the distribution of condoms at venues where youth will typically access them. It highlights programs and efforts to increase the distribution of condoms so they are available at the types of locations young people prefer. Because of the stigma around adolescent sexual activity many young people do not feel comfortable purchasing condoms in places where they know people or fear judgment.

While condom availability is considered important component of a program aimed at increasing access and usage there is no clear link to between condom availability alone and their subsequent usage, particularly by young people (WHO, 2004). Thus, combining this indicator with other indicators such as Percent of sexually active, unmarried adolescents who consistently use condoms  can give a powerful picture of the adequacy of condom provision.

Issue(s):

 

This indicator does not measure cost or if condoms are available at the right time. However, barriers to accessibility other than simple absence of condoms are often subjective and therefore difficult to measure (WHO, 2004).

It may be difficult and costly to obtain a full list of all possible sites where young people obtain condoms. For this reason, criteria should be developed for the types of venues to be included, focusing on venues that, in the particular national context, must consistently provide condoms for young people (WHO, 2004).

Where condom promotion activities center around mar­keting condoms at subsidized prices to people likely engaging in risky sex (social marketing), sales of par­ticular brands of condoms can also provide a useful in­dicator of program success. Organizations responsible for the social marketing of condoms typically keep records of condoms distributed down to the retail level. Although these data tell only part of the story of condom availability, they provide a very low-cost source of information.

References:

 

WHO, 2004. National AIDS programmes : a guide to indicators for monitoring and evaluating national HIV/AIDS prevention programmes for young people.

Percent of sexually active young people who used a condom at first/last sex

Definition:

Among young people reported to be sexually active, those that used a condom during first and/or last sexual intercourse

This indicator is calculated as:

(# of adolescents who report having used a condom at first/last sex/ Total # of adolescents) x 100

 

Data Requirements:

Reports of condom use at first and last sexual encoun­ters

Data should be disaggregated by male, female, married and unmarried

Data Sources:

Surveys of adolescent program participants or adoles­cents in the intended population for the program

Purpose:

This indicator measures the prevalence of condom use at two important reference points. Reported use at first intercourse indicates the effectiveness of program mes­sages encouraging the use of condoms among youth who become sexually active - an especially important mes­sage for programs focusing on younger adolescents. Condom use at last intercourse approximates the cur­rent condom prevalence rate among adolescents (assum­ing that last sexual encounters occurred in the recent past). Given that most adolescents need non-perma­nent methods that provide dual protection against preg­nancy and STI transmission, this indicator specifies condoms. However, evaluators may include questions on the use of other contraceptive methods to capture the use of other protective methods. Ideally, evaluators will tabulate the indicator separately for married and unmarried adolescents, because the circumstances sur­rounding contraception and choice of method are quite different for each group. 

Issue(s):

Reports of condom use (or the use of other contraceptives) do not necessar­ily reflect consistent use, measured by Percent of sexually active, unmarried adolescents who consistently use condoms.

Percent of sexually active, unmarried adolescents who consistently use condoms

Definition:

The percent of sexually active, unmarried adolescents who report using a condom in all sexual encounters during a defined reference period (e.g., last 6 or 12 months)

Because condom use varies by partner in some settings, the preferred approach is to ask about respondent‘s regu­lar partner and recent non-regular partners (if any). The indicator measures only unmarried adolescents because of potentially confounding issues surrounding the use of condoms by married couples.

This indicator is calculated as:

(# of unmarried adolescents who report using condoms in all sexual encounters in a reference period/ Total # of unmarried adolescents)  x 100 

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24

Data Requirements:

Reports of condom use during recent sexual encoun­ters

Data Sources:

Surveys of program participants or youth in the geo­graphic area of the program To measure this indicator, evaluators can use responses to questions asking whether youth “always,“ “most of the time,“ “sometimes,“ or “never“ use condoms.

Purpose:

Because condoms protect against both pregnancy and transmission of sexually transmitted infections, including HIV, and are readily available from non-clinic sources in most settings, many adolescent and youth sexual and reproductive health (AYSRH) programs promote condoms as the contraceptive method of choice for adolescents. However, prior research indicates that adolescents tend to be inconsistent contraceptive/con­dom users and/or to use condoms with non-regular part­ners but not necessarily with regular partners. Also, some evidence shows that the regularity of condom use tends to decline as the duration of sexual relationships increases. In view of these findings, many AYSRH pro­grams counsel condom use in all sexual encounters, ir­respective of the partner and duration of relationship. This indicator measures the prevalence of this “pre­ferred” practice in a program‘s intended population.

Percent of adolescents who regularly use drugs/alcohol

Definition:

The percent of adolescents reporting that they use drugs and/or alcohol regularly

Evaluators may allow adolescents to define "regular use“ or may define regular use in terms of number of times used during a specified reference period (e.g., the last month).

This indicator is calculated as:

(# of adolescents who report regular use of drugs and alcohol /Total # of adolescents) x 100

 

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Requirements:

Responses to survey questions on drug and alcohol use. Specific questions may include:

Data Sources:

Surveys of program participants or youth in the program‘s intended population

Purpose:

Studies in both the U.S. and developing countries have shown that drug and alcohol use among adolescents is associated with a higher prevalence of risky sexual be­haviors (e.g., unprotected sex, multiple sexual partners). This indicator thus measures the prevalence of these non-sexual risk factors for adverse sexual and reproductive health outcomes in the program‘s intended population.  Where the prevalence is high, programs may need to directly address substance abuse as a proximate cause of adverse SRH outcomes along with sexual and contraceptive behaviors.

Issue(s):

Universally, there's a general understanding that regular drug/alcohol use among adolescents is frowned upon.  Therefore, evaluators may see under-reporting if the respondants are reluctant to report on their actual behavior because they understand it to be socially unacceptable.

Percent of adolescents who feel "connected" with their parents/family

Definition:

The degree to which adolescents feel “connected“ with their parents/family

Evaluators measure connections in terms of the close­ness of relationships between adolescents and parents or other adult family members or caretakers.

This indicator is calculated as:

(# of adolescents who report feeling connected to their parents/families/Total # of adolescents) x 100

Data Requirements:

Responses to survey questions on the degree of family "connectedness“ among adolescents. Evaluators may include the following types of items in indices of con­nectedness:

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

Surveys of program participants or youth in the program‘s intended population

Purpose:

Studies in both the U.S. and developing countries have shown that feeling “connected“ with parents and/or adult family members protects adolescents against risky sexual behaviors and thus against adverse sexual and reproductive health outcomes (Resnick et al., 1997). This indicator thus measures the degree of connections between adolescents in the program‘s intended population and their parents/fami­lies. For diagnostic purposes, the indicator measures the percent of adolescents in the program‘s intended population that may be vulnerable to negative influences and to adverse outcomes. In settings where the level of connectedness is low, programs for parents and/or the provision of alternative mentors may be called for.  In such programs, evaluators may also use the indicator as an intermediate outcome indicator to measure improve­ments in the social environment for adolescents in the program‘s intended population.

Percent of sexually active young people who used contraception at first/last sex

Definition:

The percent of respondents aged 15-24 years who say they used contraception the first or last time they had sex of those who have had sex in the last 12 months.  Evaluators must decide whether to look singly at first or last sex or both indicators.  “Contraception” refers to modern methods of family planning (FP) (e.g. condoms, injectables, implants, pills, etc.).

This indicator is calculated as:

(The number of respondents aged 15-24 who report using contraception the first/last time they had sex / Total number of respondents who report that they had sex in the last 12 months) X 100

Data Requirements:

Self-reported data from survey respondents.

The indicator should be presented as separate percentages for males and females and can be disaggregated by age (or age groups) and other characteristics such as urban/rural and in or out of school.

Evaluators may include questions on the type of contraceptive methods used to capture the method mix among young people. Ideally, evaluators will tabulate the indicator separately for married and unmarried adolescents, because the circumstances sur­rounding contraception and choice of method are quite different for each group.

Evaluators may want to disaggregate by the following age ranges: 10-14, 15-19, and 20-24.

Data Sources:

UNAIDS general population survey; DHS AIDS Module; FHI BSS- youth survey

Purpose:

This indicator measures the prevalence of contraceptive use among 15 – 24 year olds at two important reference points. Reported use at first intercourse indicates the effectiveness of programs encouraging the use of contraception among youth who become sexually active - an especially important mes­sage for programs focusing on younger adolescents. Contraception use at last intercourse approximates the cur­rent contraceptive prevalence rate among young people (assum­ing that last sexual encounters occurred in the recent past).

This indicator measures progress towards establishing safe behavior from the outset of people's sexually active lives. It is generally believed that it is easier to maintain safe behaviors established from the onset of sexual activity than to change risky behaviors once they have become habitual.

Although most people become sexually active during adolescence, young people often have limited access to FP services and education and are therefore at high risk for unwanted pregnancy.  This indicator can track the impact of programs aimed at increasing access to modern FP methods, promoting youth-friendly health services, and other campaigns aimed at destigmatizing adolescent sexual activity.

Issue(s):

Reports of contraceptive use do not necessar­ily reflect consistent and correct use, measured by Percent of sexually active, unmarried adolescents who consistently use condoms, where contraceptives can be substituted for condoms in the indicator.  Also, in areas where there have been major campaigns promoting FP or healthy timing and spacing of pregnancy, youth may be more likely to report contraceptive use at last sexual intercourse when, in fact they did not use contraception. It is not

uncommon for young people to have more than one partner and patterns of contraceptive use may differ with different partners—e.g. a girls having sex with an older partner where sex is transactional may have trouble negotiating contraceptive use, compared to regular partner or vice versa, so further questions about the nature of the relationship with their first/last sexual partner may be useful in showing trends in contraceptive use among different types of partners.

Gender Implications:

Young women’s knowledge about, access to and ability to negotiate use of contraception, including condoms) may be limited by cultural gender norms affecting women’s mobility, exposure to media and FP information, access to health care services, resources to purchase contraception, and unbalanced power dynamics within sexual relationships. Women may be less informed about their fertile times of the month and different family planning options, especially in more rural areas, and may be reluctant to seek out information that could make them look sexually active (if unmarried) or promiscuous. Health care workers may not discuss contraception with women clients and, where rates of female literacy are low, women may not benefit from media and communication strategies that rely on printed materials.   

Contraceptive prevalence rate among young people

Definition:

The percent of young women aged 15-24 years who are currently using (or whose sexual partner is using) a contraceptive method.  “Currently” is defined as within the past three months.  The contraceptive prevalence rate (CPR) is usually reported for women married or in sexual union, but this can be defined by the evaluator based on the local context.

Generally, the measure includes all contraceptive methods (modern and traditional), but it may include modern methods only. Contraceptive methods include condoms, female and male sterilization, injectable and oral hormones, intrauterine devices, diaphragms, spermicides and fertility awareness methods such as lactational amenorrhea and the standard days method. Because only condoms are effective in preventing HIV infections among methods of contraceptives, specific indicators on condom use are also considered.

The indicator is calculated as follows:

(Number of currently sexually active women 15-24 using a contraceptive method / Total number of currently sexually active women 15-24) x 100

Illustrative example based on Uganda DHS 2006 numbers

All women 15-24
Women currently married or in union 15-24
CPR = 490/3646) x 100 = 13.4%
CPR = (292/1528) x 100 = 19.1%