This episode, we turn our attention to youth. Featuring guests from Benin, Ecuador, and Colombia, we will explore innovative strategies to provide essential family planning information and services to diverse groups of adolescents. From jewelry making to a unique method of engaging peer influencers, today’s episode will discuss what elements of successful programs can be replicated in other settings to improve access to contraception among young people.
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From Knowledge SUCCESS and the World Health Organization’s IBP Network, this is Season 2 of Inside the FP Story—a podcast with family planning professionals, for family planning professionals.
The international family planning field has generated a lot of data, a lot of reports, and a lot of lessons learned. But we don’t often have the opportunity to get behind that information, to hear directly from the people who implemented a program, or who did the analysis, and so we reinvent the wheel or miss the mark because we don’t know what could be really critical in a particular context. Inside the FP Story is that opportunity.
Each season, we hear directly from program implementers and decision makers from around the world on issues that matter to family planning programs. Through these honest conversations, we learn how we can improve our family planning programs as we work together to build a better future for all.
I’m Sarah Harlan, the Partnerships Team Lead for the Knowledge SUCCESS project. I’m pleased to welcome our narrator, Sakshi Sharma.
Narrator This season on “Inside the FP Story,” we’re partnering with the IBP Network to explore issues around implementing family planning programs. In our first two episodes this season, we heard about programs that focus on community engagement—both programs that reach people living in rural and remote areas, and programs integrating family planning services with other health areas and settings.
This episode, we turn our attention to youth. Featuring guests from Benin, Ecuador, and Colombia, we will explore innovative strategies to provide essential family planning information and services to diverse groups of adolescents. From jewelry making to a unique method of engaging peer influencers, today’s episode will discuss what elements of successful programs can be replicated in other settings to improve access to contraception among young people.
We will start out in Benin, where the Social Marketing Association, in partnership with USAID and Population Services International, started a Craft Academy for adolescent girls who are out of school or dropped out of school. Girls learn how to engage in income-generating activities, such as jewelry making, while obtaining contraceptive information and services.
To learn about this program, we spoke with Cyprien Zinsou, Director of the Research, Monitoring, and Evaluation Department at the Social Marketing Association of Benin.
Cyprien Zinsou I am Cyprien Zinsou, I am the Director of the Research and Monitoring and Evaluation department at the Beninese Association of Social Marketing in Benin which is part of the network of partner associations of PSI.
Narrator According to the most recent Demographic and Health Survey, the use of modern contraceptives in Benin is quite low overall, at 12%, and the government reports the rates among women ages 15 to 24 to be less than 6%. At the same time, 30% of 19 year olds have already had at least one child.
Among both boys and girls in Benin, early sexual debut is common, which is often unprotected and risks both unintended pregnancy and sexually transmitted infections. Due to gender norms, girls also have fewer economic opportunities and may engage in transactional sex to meet their financial requirements. They also receive less information about pregnancy or STI prevention due to high school drop-out rates—the World Bank estimates that about half of girls drop out of school by the last year of primary school. This leaves young people, and girls in particular, without the information and services they need to stay safe and healthy.
Designed to address both girls’ economic and reproductive health needs—Cyprien and his team piloted the Craft Academy in Dassa-Zoumè, Benin. Through weekly sessions, the girls learned to make beaded costume jewelry—like necklaces, bracelets, earrings, bags—while receiving lessons on reproductive health.
The program was designed for girls ages 15 to 24—particularly those not attending school, who are often not exposed to interventions designed to prevent STIs and pregnancy.
The Craft Academy allows girls in the program to quickly learn skills to help them generate income—during their weekly sessions, they receive training on jewelry making, using beads and fabric. At the end of these sessions, an outreach nurse or midwife provides reproductive health information and referrals to services.
Soon after piloting the program, word began to spread among girls in the community.
The initial 2017 three-month pilot in 2017 included 61 girls. In 2018, the Dutch Embassy, with a contribution from USAID, funded the operation of the Craft Academy in the commune of Savalou near Dassa. Sixty-two girls participated. In 2019, with USAID funding through the Transform/PHARE project, the Craft Academy was rolled out to four more communes in Benin, this time reaching 243 girls.
The program was a success. They saw huge increases in the girls' knowledge and attitudes related to family planning, over just a three month period. Further, between April and July 2019, nearly one-third of the girls in the group had adopted a modern contraceptive method.
Cyprien Zinsou In April 2019 in the baseline study in the four municipalities, there were 20.9% of the girls who could name at least three contraceptive methods. At the end, three months later in July 2019 in the same year, it went to 100%. From 20.9 to 100%. There were also rumors whether modern contraceptives can cause cancer or misconceptions such as the pill causes cancer etc. In the final study, 99% of girls could cite misconceptions about modern contraception.
Narrator The program also had an impact on the girls’ behavior—including speaking with their partner about family planning and using a modern method of contraception.
Cyprien Zinsou So we also wanted to measure the fact of telling some of them, those who had partners, the percentage of those who discuss FP with their partner. At the beginning it was 40.7%, and at the end it was 90.8%.
Narrator Comprehensive counseling includes support in choosing a method, countering myths, and understanding “side benefits” of contraception. For example, one “side benefit” is predictable menstruation.
Overall, the family planning knowledge provided through this program stuck with the girls.
Cyprien Zinsou Well, in the long run, one thing for sure is that girls' knowledge can't be taken away from them. Girls know the methods. We showed them packets of pills, injectables. Those who wanted to benefit from the methods went ahead on their own and those who didn't want a method always have that option in the future.
Narrator While services were not provided at the Craft Academy itself, in each district, the district public health center was selected to provide services to the girls who were part of the program.
Cyprien thought the most successful component of the program was the innovative combination of a trade with reproductive health. While all young people feel the need to make money, girls have fewer opportunities due to less access to skills and resources. So this program empowered them to make decisions that could affect their lives.
The Craft Academy adapted as they went along. For example, when implementation started, the biggest challenge in the program was the reluctance of parents to allow their children to participate. Parents expressed a desire to better understand the topics their daughters were learning. Therefore, the intervention expanded to include home visits to discuss sexual and reproductive health topics with both mothers and fathers.
Home visits with the mothers improved their own understanding of family planning—both for themselves and to share with their daughters. And over time, both the mothers and fathers began to appreciate both the education on family planning and the opportunities for income generation.
Cyprien Zinsou Most of the dads initially were very reluctant to have their children participate in sessions where we talk about reproductive health. But as soon as the girls came home with pearls around their necks, the attitudes changed.
Narrator To help with sustainability of the financial component of the training, they put all participants in contact with micro-credit groups or associations in the community.
Another recommendation that can be applied to other programs is to adapt programs to specific needs of adolescents.
Cyprien Zinsou Heath workers were trained before the program in specific care adapted to adolescents and young people, because the health workers in the public sector did not have this kind of training initially. So, people went, and noticed that it was important to have services responsive to adolescents. They feel more welcomed.
Narrator Adapting to adolescents involved developing the adolescent competency of providers, and making services responsive to their needs. At the beginning of the program, a workshop on providing health services tailored to adolescents and young people was organized for midwives or nurses in each of the program districts, so they were better prepared to serve young people.
It is also important to involve adolescents in program design—listening to their feedback at every step of the way. The Craft Academy, for example, incorporated feedback from the pilot phase into each subsequent phase of the program.
Finally, getting the support from authorities is another recommendation that can be applied to other programs tailored for adolescents and youth. In addition to getting support from the Ministry of Health early on, they also worked with mayors in the individual communities where the program was rolled out.
Cyprien Zinsou A piece of advice is to have the support of the local authorities, and not to be discouraged at the beginning if things seem to be difficult. Have patience, continue and it will eventually have an impact. At the national level, at the local level, look for influential people who can help to make the intervention visible. This is what I can suggest and then that the intervention responds as needed to the desire of the teenagers, on pearl jewelry design which is what the young girls here like.
Narrator Overall, this innovative model improved economic opportunities for girls in Benin, while also improving knowledge and access to life-saving sexual and reproductive health services.
We’ll now hear about another program that used a different innovative approach to reduce adolescent pregnancies—this time, in Ecuador.
Fundacion Octaedro, in collaboration with various partners, implemented a peer-to-peer program. Far from a typical peer education model, the program focused on supporting young influencers and integrating family planning, domestic violence prevention, gender, and youth empowerment activities.
We spoke with Irene Torres, Technical Director of Fundacion Octaedro, about their program.
Irene Torres I am Irene Torres, Technical Director of Fundacion Octaedro, or Octaedro Foundation, in Ecuador.
Narrator The program was implemented in Esmeraldas, a province that has been hit hard by natural disasters and poverty. There are also strong social norms to consider. For example, sexual violence, machismo, and the expectation that women should become mothers early in life are all social norms that discourage the use of family planning.
Irene Torres This is a very economically deprived region of Ecuador. It has been historically marginalized, not only in terms of infrastructure, but also education and health. And there has also been gender-based violence at home as well as norms that stimulate or incentivize violence against girls and adolescent girls. And also even incest is approved of—not publicly, but it is a social norm in that area, and also other coastal areas of Ecuador.
Narrator In this region of Ecuador, there are high rates of early marriage and cohabitation among young people—and low knowledge of family planning methods. There are also high rates of sexually transmitted infections, including HIV. Earlier national strategies to address adolescent pregnancy have focused on abstinence, rather than informed decision-making about contraception and family planning.
The Fundacion Octaedro program looked to improve knowledge and use of family planning among young people—while addressing social norms and stigma.
Irene Torres There is definitely a stigma around women who are sexualized from a young age. They’re stereotyped as, we could say, sexual objects and also as reproductive beings and not as whole beings with, for example, an outlook into the future to be independent, to hold a job outside the home.
Narrator There are also pervasive myths about reproductive health—for example, it is common for people to believe that eating lemon seeds prevents pregnancy. Meanwhile, peers are young people’s main source of information about sexual and reproductive health.
Young people across the country can have difficulty accessing reproductive health care, but particularly in Esmeraldas, where there are compounding factors of poverty and racism. Irene talked about this larger context of poverty, race, and gender—and how this affects young people and their reproductive lives.
Irene Torres They know that they're in an unequal relation of power with the rest of the country. Just one factor is that they are African Ecuadorians, largely. There is racism in Ecuador and it's not easy for them to get a job, hold a job. And in the balance of power, women have structurally in Ecuador, less power. They have less jobs with less leverage than men as a whole in Ecuador.
Narrator In addition to race and gender, these young people also have power imbalances related to their age—when interacting with parents and others in their households and communities. Because of deep-rooted power structures, in which youth often feel powerless and experience domestic violence, cohabiting and getting married at a young age is one of the few ways they feel that they can take charge over their own lives.
Irene Torres Young people do go live together at a very young age. They want to leave their home. If you have very little autonomy over the economic situation of your family, your community, your local city, very little autonomy at schools, where the voices of young people are not considered to make decisions, you have little autonomy if there is violence in your home and your local community. One of the threats of autonomy that are left in young people are precisely getting together and having a baby or at least getting together and then the baby ensues.
Narrator Afro-Ecuadorian youth also face high levels of poverty, and experience one of the highest pregnancy rates among young people in the country. However, previous reproductive health programs promoted abstinence—without addressing structural issues that these young people could not control.
Irene Torres Sex was not discussed. It was not talked about. And the school environment, which is the regular environment in which adolescents develop, learn, can discuss openly, it's not possible. So they are not discussing this openly. And they keep knowledge between peers with uninformed myths, uninformed stereotypes that are not helpful for them to make decisions.
Narrator The Intersectoral Policy for the Prevention of Pregnancy in Girls and Adolescents program began in Esmeraldas in late 2017, as the province was emerging from a devastating earthquake and resulting humanitarian crisis. Due to its high HIV prevalence among the general population, Esmeraldas was chosen as one of the first locations for program implementation.
Staff recognized early on that most adolescents received reproductive health information from their peers; so they identified and trained peer-to-peer influencers, using a proven peer-to-peer methodology.
The influencer methodology allows youth to become active communicators, and to pass down scientifically-accurate information to their peers—on contraception, prevention of sexually transmitted diseases, prevention of domestic violence, cervical cancer prevention, pregnancy, and childbirth. The program also helped young people open up and become more empowered to talk about sexual and reproductive health.
Irene Torres Adolescents can be very shy, very timid about talking about sex. So the best approach is in which influencers go to different schools and share this information that can organize activities. And that are models for other adolescents who are more timid or less experienced or less knowledgeable start becoming empowered to learn more, to transmit information that is scientific.
Narrator While this program did not have a direct service component, it contributed to decreases in HIV-related deaths and unintended pregnancies. One thing that has made the program so successful is that the program staff understands adolescents and how they prefer to learn and communicate.
Irene Torres If you know anything about adolescents, even in the mythical adolescent stereotype, they are rebellious. So this is an age at which if we want them to listen to adults only, we are going to be at a disadvantage because they are reaffirming themselves in contrast to the people who are always telling them what to do. They're telling them what to do at home. They're telling them what to do at the community. They’re telling them what to do at the health center, at the school. So they do want to learn in their own social circle, and also identities of adolescents depend a lot on the sense of belonging to that circle.
Narrator Another key to the program’s success was expanding beyond the health sector and working with the schools. The program wouldn’t have been possible without the training and services provided by the health sector—from pregnancy monitoring to HIV screening. And the support of the schools was important, for peer-to-peer education to take place as part of their extracurricular activities.
Irene recommends scheduling time for the program implementers to get to know the context and make sure you have enough information about your setting before starting the program.
During this buffer time, program implementers should learn more about adolescents and about the political and social context in which you’re working.
Irene Torres Well, to work with adolescents, I recommend reading about adolescence, about the adolescent mind, about adolescent identities. I don't think that implementers do that enough. They approach this commonly from a health perspective and they intuitively think they know how to work with adolescents. But I think it's very interesting to learn about how adolescents think, how they socialize.
Narrator Irene stressed that addressing social norms takes time—we can make changes, but we have to be patient.
Finally, Irene recommended engaging community leaders and becoming familiar with relevant policies before beginning your work.
Irene Torres To have strong local community participation is not only about engaging local community leaders or your local community youth, but you do need coordination between the different sectors—Ministry of Health, Ministry of Social Inclusion, Ministry of Education, UN agencies, for example, in this case. But especially a clear policy outlook. You need to know your policy.
Narrator Being familiar with these policies and these regulations helped this program’s success. In 2019 alone, the program worked directly with 430 students, 60 teachers and psychologists from 21 schools, and involved 80 health workers from 30 health centers. Indirectly, through collaboration and peer training, they reached thousands more.
This is a clear example of how strong local community participation, a clear policy outlook, and cooperation from partners can result in a highly effective reproductive health program. Within a challenging social context with high rates of teenage pregnancy, low knowledge of family planning, and harmful gender norms—engaging community groups and using peer-to-peer methodology was a successful strategy for beginning to shift harmful social norms and improve knowledge and use of family planning.
Narrator Continuing on the theme of addressing stigma and social norms, we will now hear about a program in Colombia that also involves a diverse range of youth in reproductive health programming.
Profamilia, in collaboration with a variety of partners, created a comprehensive program to promote the autonomy of people with disabilities in Colombia. The program includes training for Profamilia employees, the adoption of supportive guidelines and procedures for informed consent, conducting comprehensive sexuality education for youth with disabilities, and spearheading advocacy efforts to recognize the autonomy of people with disabilities in service provision.
To learn about this program, we spoke with Diana Moreno from Profamilia Colombia.
Diana Moreno I am Diana Moreno and I am currently the Director of Advocacy at Profamilia Colombia.
Since 2012, Profamilia has offered a comprehensive program of care for people with disabilities. We seek to adapt our services that are specialized in sexual and reproductive health to people with disabilities, especially people with cognitive and psychosocial disabilities.
Narrator Colombia has ratified international human rights conventions, including the Convention on the Rights of People with Disabilities, and incorporated them into the country’s laws. However, the greatest challenge is putting these laws into practice.
Diana Moreno In Colombia, it is estimated that 51.3 percent of the population with disabilities has experienced barriers in accessing health services. This includes everything from issues of physical accessibility and adjustments to information in order to be able to really understand, to barriers that are much more systematic and complex in the field of sexuality and reproduction. This includes the use of policies approving permanent and forced sterilizations on people with disabilities without their consent, through the authorization of judges or through the authorization of family members and health professionals.
Narrator In 2019, a law was passed that eliminated these policies in Colombia. However, such policies have a long history, so it will take time to make a cultural shift and ensure that these policy changes are implemented in practice.
In order to make strides in this area, Profamilia’s program provides accommodations for people with disabilities during their clinic visits, so they can make their own reproductive health decisions.
Diana Moreno I think it is very important for service providers to understand that a first step, both from a rights recognition perspective and from a practical health care delivery perspective, is to understand that people with disabilities—yes, just like us—are human beings and have the ability to make decisions.
And what happens is that some require supports that are different from what others require, to be able to understand the information and make the decision. For example, if I understand that it is the person with a disability who is my patient, who is called upon to make the decisions, then when the person comes and consults, I talk to her. I don't focus on what the mother, father, caregiver, companion wants, but I talk to her. I look her in the eyes.
Or, for example, they cannot communicate verbally, or they cannot communicate in writing. And that is precisely where something called support and adjustment assessment comes in.
Narrator Another suggestion she offered is to make sure clinic visits allow ample time to make sure that someone with cognitive or psychosocial disabilities understands the information they are given—practically, this may mean extending their counseling time beyond the usual few minutes.
Diana Moreno When a person with a disability comes in, the professional may take more time to get to know the person, to understand their way of communicating. And then yes, explaining what is happening is doing the validation of consent.
Narrator One aspect that has been key to this process has been the establishment of partnerships and alliances with disability advocacy groups—as well people with disabilities themselves.
Diana Moreno At the beginning we made an alliance thanks to the support of The Society Foundation with the Colombian Autism League and the Colombian Down Syndrome Association, both organizations of families of people with cognitive and psychosocial disabilities. And they were crucial to the understanding that we as a healthcare institution had about how to incorporate the vision of these people into our services. They helped us to assess and make tools that our providers could use. They also helped us carry out training on comprehensive sexuality education from a more holistic perspective.
At the beginning we were talking and doing groups only with people with disabilities and then we realized that it is important to generate an inclusive education, that is to say, one that includes both people with and without disabilities, because that is what really allows integration in society and also because it allows mutual learning of all people in the process.
Narrator As they realized how important this inclusive education was, they started to form youth groups in different cities—where young people gathered in a space to talk about different sexuality issues. These discussions and conversations covered disability rights as one of the topics.
Diana Moreno One of the things that is most important in promoting comprehensive education for inclusive sexuality is that, on the one hand, they are processes that prevent violence by allowing you to understand your body, how to relate to others, how to have healthy relationships, how to give consent, and they also allow you to denounce when all these things do not happen and when there is violence against your body. It is not sterilization that prevents violence. It is comprehensive education that does this.
Narrator We asked Diana what challenges the program encountered.
Diana Moreno In working with people with disabilities—prejudices and social stereotypes are reflected in everyone, including health professionals.
Especially with regard to sexuality, we always find the same kind of stereotypes. On the one hand, there is the idea that people with disabilities are always children, no matter how old they are. And in that sense, also in our minds, the idea that they should not live any sexuality, precisely because they are children. Paradoxically, the other stereotype is exactly the opposite of that idea, and it is the idea that people with disabilities are hyper-sexualized people, that they have no way to control their desires, that in that sense they are a danger to themselves and to others, and that therefore they should not exercise that sexuality either, but rather annul it, eliminate it.
In a way, both ideas have at their core is this idea that people with disabilities do not have the capacity to understand their sexuality and therefore, they do not have the possibility to exercise it.
Narrator The program has responded to these challenges by training young people and health professionals. To date, they have trained over 300 young people with and without disabilities, and have incorporated their groundbreaking program in Profamilia’s 45 clinics across Colombia. They also offer training for health professionals outside of the Profamilia network, and have provided them with skills and knowledge to better care for their clients with disabilities.
Beyond this training, their advocacy efforts have also left a great impact.
Diana Moreno A few years ago, forced sterilization was still permitted, and Profamilia intervened before the United Nations Human Rights Council. So, now in Colombia, people with disabilities cannot be sterilized without their consent. Also, the entire health system is obliged to provide reasonable accommodations and support.
Narrator Diana shared her insight on why working with young people—particularly those with disabilities—is so important.
Diana Moreno I believe that adolescents and young people are key because they are the generation that are beginning their reproductive age, so it is an intervention at a key moment. But secondly, they have the possibility of structuring the future of our societies. What they learn now, at this moment, will have a great impact not only on their lives, but also on their families, their communities and ultimately, on the country.
Narrator In this episode, we have heard about programs that reach youth using innovative techniques tailored to the needs of specific communities in Benin, Ecuador, and Colombia. They are diverse settings and programs, but what they have in common is that they all understand and address stigma and harmful social norms; they all recognize and value community engagement and multi-sectoral partnerships; and they involve youth in every step of their programs. We trust that you will learn from these recommendations and apply them to your programs—and ensure that a diverse range of adolescents have access to the family planning and reproductive health information and services they need.
Join us next time, when we examine three adolescent-responsive family planning programs, and hear about practical ways that we can better tailor our programs to meet young people where they are.
These stories are part of a series of 15 stories selected from a global competition hosted by IBP and Knowledge SUCCESS to highlight experiences implementing High Impact Practices and WHO guidelines. If this episode left you hungry for more, we encourage you to read the other stories on the IBP Network website and join us for episode four where we'll dive into strategies for working with and for adolescents and youth.
Inside the FP Story is a podcast produced by the Knowledge SUCCESS project and the World Health Organization’s IBP Network. This episode was written by Sarah Harlan and Anne Ballard Sara, and edited and mixed by Elizabeth Tully. It was supported by an additional team, including Nandita Thatte, Ados May, Carolin Ekman, Natalie Apcar, Michelle Yao, and Brittany Goetsch.
Special thanks to our guests: Cyprien Zinsou, Irene Torres, and Diana Moreno.
To download episodes and to find additional links and materials, please subscribe to Inside the FP Story on Apple Podcasts, Spotify, or Stitcher. You can also find Spanish and French transcripts at KnowledgeSuccess.org.
The opinions in this podcast do not necessarily reflect the views of USAID or the United States Government.
If you have any questions or suggestions for future episodes, feel free to reach out to us at info@knowledgesuccess.org.
Thank you for listening.